What is the immediate treatment for pustular psoriasis in an Intensive Care Unit (ICU) setting?

Immediate Treatment of Pustular Psoriasis in the ICU

For generalized pustular psoriasis requiring ICU admission, immediately initiate systemic therapy with either cyclosporine 2.5 mg/kg/day or infliximab 5 mg/kg, while avoiding systemic corticosteroids which can precipitate life-threatening flares upon withdrawal. 1, 2

Initial Assessment and Stabilization

Upon ICU admission, immediately assess for:

• Hemodynamic instability - Monitor for hypotension, fever, and signs of high-output cardiac failure 3, 4
• Metabolic complications - Check for hypocalcemia, fluid/electrolyte abnormalities, and signs of systemic inflammation 1, 5
• Extent of skin involvement - Document body surface area affected and presence of sterile pustules on erythematous base 6, 4
• Superinfection risk - Rule out bacterial or fungal superinfection, which occurs in approximately 25% of hospitalized cases 5

First-Line Systemic Therapy Options

Preferred Agents for Severe Disease

Infliximab is the most rapidly effective option for life-threatening generalized pustular psoriasis:

• Dosing: 5 mg/kg IV at weeks 0,2, and 6, then every 8 weeks 2
• Efficacy: Demonstrates rapid and often complete disease clearance in severe cases 2
• Dose intensification: May increase to 10 mg/kg and/or shorten intervals to every 4 weeks if needed 2
• Combination: Can be combined with methotrexate for augmented efficacy (Grade B recommendation) 2

Cyclosporine is an alternative rapid-acting systemic agent:

• Dosing: Initial dose 2.5 mg/kg/day divided twice daily 1, 2
• Titration: Can increase to 5 mg/kg/day if inadequate response 1
• Monitoring: Measure blood pressure and serum creatinine before treatment and regularly thereafter 1
• Contraindications: Abnormal renal function, uncontrolled hypertension, previous malignancy 1, 7

Alternative Systemic Options

Acitretin (particularly effective for pustular variants):

• Dosing: 0.1-1 mg/kg/day with response as early as 3 weeks 2, 7
• Efficacy: 84% improvement rate in generalized pustular psoriasis 7
• Critical caveat: Absolutely contraindicated in women of childbearing potential unless strict contraception for 2 years after stopping 1, 7

Methotrexate (especially useful in acute generalized pustular psoriasis):

• Indication: Particularly effective for acute flares and psoriatic erythroderma 1, 7
• Monitoring: Requires full blood count, liver function tests, and avoidance of interacting drugs 1
• Contraindications: Pregnancy, breastfeeding, significant hepatic damage, blood disorders 1, 7

Critical Management Pitfalls to Avoid

Systemic Corticosteroids - AVOID

Systemic corticosteroids are contraindicated as primary therapy and can precipitate life-threatening complications:

• Risk of rebound: Stopping systemic steroids precipitates erythrodermic psoriasis, generalized pustular psoriasis, or very unstable disease 1, 8
• Limited exceptions: Only use for persistent uncontrollable erythroderma causing metabolic complications, von Zumbusch type when other drugs contraindicated, or hyperacute psoriatic polyarthritis threatening irreversible joint damage 1
• If patient is already on steroids: Do NOT abruptly discontinue; implement controlled taper over several weeks while initiating appropriate psoriasis-specific therapy 8

Phototherapy Cautions

Ultraviolet B radiation and PUVA must be used with extreme caution:

• Risk: May exacerbate pustular psoriasis despite efficacy in plaque psoriasis 1, 5
• PUVA considerations: Generally considered least toxic systemic option for stable disease, but 45.7% efficacy rate in generalized pustular psoriasis is lower than biologics 2
• Contraindication: Should not be used during acute, unstable flares requiring ICU admission 5

Supportive Care Measures

Topical therapy as adjunct:

• High-potency topical corticosteroids can be combined with systemic therapy (Grade B recommendation) 2
• Topical emollients for skin barrier support 1
• Wound care for areas of skin sloughing or erosions 1

Monitoring requirements:

• Daily assessment of body surface area involvement, pustule formation, and systemic symptoms 1
• Serial clinical photography to document progression or improvement 1, 8
• Laboratory monitoring based on chosen systemic agent - renal function for cyclosporine, liver function for methotrexate/acitretin 1, 7

Emerging Targeted Therapy

Spesolimab (IL-36 receptor antagonist) - FDA-approved specifically for GPP flares:

• Indication: Life-threatening GPP flares resistant to conventional treatments 3
• Dosing: 900 mg IV, can repeat one week apart 3
• Efficacy: Rapid resolution of pustules and systemic symptoms in severe cases 3, 4
• Availability: Currently the only GPP-specific treatment approved in the United States 4

Treatment Algorithm Summary

1. Immediate stabilization: Address hemodynamic instability, metabolic derangements, and rule out infection 3, 4, 5
2. First-line systemic therapy: Initiate infliximab 5 mg/kg IV OR cyclosporine 2.5 mg/kg/day PO 1, 2
3. Adjunctive topical therapy: High-potency corticosteroids to affected areas 2
4. If inadequate response: Consider dose intensification of infliximab, addition of methotrexate, or transition to spesolimab if available 2, 3
5. Avoid: Systemic corticosteroids, abrupt medication changes, and phototherapy during acute phase 1, 5