Topical Treatment for Acute Generalized Exanthematous Pustulosis (AGEP)
Topical corticosteroids are the first-line treatment for AGEP and should be initiated immediately after discontinuing the offending drug, with potent to very potent formulations (such as clobetasol propionate 0.05%) applied to affected areas. 1
Primary Topical Management
- Apply potent topical corticosteroids (betamethasone valerate 0.1% or clobetasol propionate 0.05%) to pustular and erythematous areas once the causative drug is stopped 1, 2
- Pustules typically cease developing within 24 hours of topical steroid application, with complete resolution occurring within 7 days in most cases 1
- Group D corticosteroids (betamethasone dipropionate or hydrocortisone-17-butyrate) are effective alternatives if group A corticosteroids are contraindicated or caused the AGEP 2
Supportive Topical Care
- Use emollients and moisturizers liberally (200-400 g per week) to manage the desquamative phase that follows pustule resolution 3, 4
- Apply petrolatum-based emollients to prevent moisture loss and support skin barrier recovery 3
- Avoid greasy occlusive creams during the acute pustular phase as they may worsen folliculitis 3
Important Caveats
- Systemic corticosteroids themselves can paradoxically induce AGEP, making topical therapy particularly valuable as first-line treatment 1, 2
- Topical treatment alone is sufficient for most cases without systemic involvement 1, 5
- If mucous membrane involvement or skin sloughing >10% body surface area occurs, this suggests Stevens-Johnson syndrome/toxic epidermal necrolysis overlap and requires immediate hospitalization with systemic therapy 3
When Topical Therapy Is Insufficient
- Severe or recalcitrant AGEP not responding to topical corticosteroids within 48-72 hours requires escalation to systemic therapy 6
- Cyclosporine 3-5 mg/kg/day divided twice daily is recommended for severe cases requiring rapid disease control 7
- Systemic corticosteroids (methylprednisolone 0.5-1 mg/kg IV) are reserved for grade 3-4 toxicity with systemic involvement 3