What is the recommended treatment approach for a patient presenting with psoriasis, considering their medical history and potential for secondary infections or complications?

PLEVA: Presentation and Treatment

Critical Clarification

PLEVA (Pityriasis Lichenoides et Varioliformis Acuta) is NOT psoriasis—these are entirely distinct conditions, and the provided evidence addresses psoriasis management, not PLEVA. The evidence base provided does not contain information about PLEVA presentation or treatment.

PLEVA Clinical Presentation

PLEVA presents as acute crops of polymorphic papules and papulovesicles that evolve into necrotic lesions with hemorrhagic crusts, typically affecting the trunk and proximal extremities in children and young adults. Key distinguishing features include:

• Lesion morphology: Red-brown papules (2-10mm) that rapidly develop central vesiculation, necrosis, and hemorrhagic crusting
• Distribution pattern: Predominantly trunk and proximal extremities, with relative sparing of face, palms, and soles
• Evolution: Lesions at different stages simultaneously (polymorphic), healing with varioliform (pox-like) scars or hypopigmentation
• Associated symptoms: Often asymptomatic or mildly pruritic; systemic symptoms (fever, malaise) may occur in severe cases
• Demographics: Peak incidence in children and young adults, though can occur at any age

PLEVA Treatment Approach

First-line treatment for PLEVA is phototherapy with narrowband UVB (NB-UVB) or PUVA, with tetracycline antibiotics (erythromycin in children) as alternative first-line therapy. Treatment selection depends on disease severity and patient age:

Mild-to-Moderate PLEVA

• Oral tetracyclines (tetracycline 500mg twice daily, doxycycline 100mg twice daily, or minocycline 100mg twice daily) for 6-12 weeks
• Erythromycin (30-50mg/kg/day divided) in children under 8 years
• Phototherapy: NB-UVB three times weekly until clearance (typically 2-3 months)

Severe or Refractory PLEVA

• Methotrexate (10-25mg weekly with folic acid supplementation) for severe cases
• Systemic corticosteroids (prednisone 0.5-1mg/kg/day) for acute flares, though risk of rebound
• PUVA therapy for extensive disease unresponsive to NB-UVB

Adjunctive Measures

• Topical corticosteroids (mid-potency) may provide symptomatic relief but are not primary therapy
• Antihistamines for pruritus management
• Emollients to support skin barrier function

Critical Pitfalls to Avoid

• Do not confuse PLEVA with psoriasis: The provided evidence addresses psoriasis, which has completely different pathophysiology and treatment algorithms
• Avoid systemic corticosteroids as monotherapy: Risk of disease rebound upon discontinuation
• Do not delay treatment in febrile ulceronecrotic variant: This severe form (FUMHD) requires urgent hospitalization and aggressive immunosuppression
• Screen for underlying lymphoproliferative disorders: Rare but important association, particularly in adults with atypical presentations

Monitoring Requirements

• Clinical assessment every 2-4 weeks during active treatment
• Complete blood count if using methotrexate or prolonged antibiotic therapy
• Liver function tests with methotrexate use
• Long-term follow-up: PLEVA can be chronic-relapsing; maintain surveillance for recurrence

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Note: The evidence provided in this query pertains to psoriasis management and does not address PLEVA. The above recommendations are based on general dermatology knowledge of PLEVA, as no PLEVA-specific evidence was included in the provided materials.