Pustular psoriasis
Primarily seen in adults, pustular [PUHS-choo-ler] psoriasis is characterized by white pustules (blisters of noninfectious pus) surrounded by red skin. The pus consists of white blood cells. It is not an infection, nor is it contagious. It may be localized to certain areas of the body–for example, the hands and feet. Pustular psoriasis also can be generalized, covering most of the body. It tends to go in a cycle–reddening of the skin followed by formation of pustules and scaling.
Pustular psoriasis reportedly may be triggered by internal medications, irritating topical agents, overexposure to UV light, pregnancy, systemic steroids, infections, emotional stress and sudden withdrawal of systemic medications or potent topical steroids.
It is not unusual for doctors to combine or rotate treatments for pustular psoriasis due to the potential side effects of systemic medications and phototherapy.
More than one study has shown that Soriatane (also known by its generic name acitretin) and methotrexate in combination produced a rapid remission in the acute state of pustular psoriasis and an eventual clearing of the skin.
Types of pustular psoriasis
Von Zumbusch
The onset of von Zumbusch pustular psoriasis can be abrupt. Widespread areas of reddened skin develop, and the skin becomes painful and tender. Within a few hours, the pustules appear. The pustules then dry and peel over the next 24 to 48 hours, leaving the skin with a glazed, smooth appearance. A fresh crop of pustules may then appear. Eruptions often come in repeated waves that last days or weeks.
Von Zumbusch pustular psoriasis rarely appears in children, although when it does, the prospect of improvement may be much better than for adults.
Von Zumbusch pustular psoriasis can be triggered by an infection; sudden withdrawal of topical or systemic steroids; pregnancy; and drugs such as lithium, propranolol (brand name Inderal) and other high blood pressure drugs, iodides and indomethacin (brand name Indocin).
Von Zumbusch pustular psoriasis is associated with fever, chills, severe itching, dehydration, a rapid pulse rate, exhaustion, anemia, weight loss and muscle weakness. The goal of treatment is to restore the skin's barrier function, prevent further loss of fluid, stabilize the body's temperature and restore the skin's chemical balance. Chemical imbalances can put excessive stress on the heart and kidneys, especially in older people.
Because this form can be life-threatening, medical care must begin immediately. If you can't get in to see your doctor, you should go to the emergency room to get treatment. People with von Zumbusch pustular psoriasis often require hospitalization for rehydration and initiation of topical and systemic treatments, which typically include antibiotics.
Soriatane, cyclosporine or methotrexate are often prescribed. Some doctors may prescribe oral steroids for those who do not respond to other treatments or who have become very ill, but their use is controversial because von Zumbusch pustular psoriasis can be triggered by the sudden withdrawal of steroids. PUVA may be used once the severe stage of pustule development and redness has passed.
Palmo-plantar pustulosis
Palmo-plantar pustulosis (PPP) is a type of pustular psoriasis that causes pustules on the palms of the hands and soles of the feet. PPP is characterized by multiple pencil eraser-sized pustules in fleshy areas of the hands and feet, such as the base of the thumb and the sides of the heels. The pustules appear in a studded pattern throughout reddened plaques of skin, then turn brown, peel and become crusted. The course of PPP is usually cyclical, with new crops of pustules followed by periods of low activity.
Those who are at risk for PPP should seriously consider not smoking, as some studies suggest that these patients may have an abnormal response to nicotine which can trigger flares of PPP.
Topical treatments are usually prescribed first, but PPP often proves stubborn to treat. PUVA, UVB, Soriatane, methotrexate or cyclosporine may be used to clear this form.
Acropustulosis (acrodermatitis continua of Hallopeau)
This rare type of psoriasis is characterized by skin lesions on the ends of the fingers and sometimes on the toes. The eruption occasionally starts after an injury to the skin or infection. Often the lesions are painful and disabling, producing deformity of the nails. Occasionally bone changes occur in severe cases. This form has traditionally been hard to treat. Topical preparations that are occluded may help some patients. Systemic medications have been used with some success in clearing the lesions and restoring the nails.
Updated December 2005
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