Guttate psoriasis Signs, symptoms and Treatment

Guttate psoriasis is also termed eruptive psoriasis because of its appearance. The skin lesions look like a drop giving the guttate impression, for which it is called also. It is more likely in children and younger ones within 30 years of age.

Both genders have an equal share of prevalence for this disease. All the races also are equally affected. Children and adolescents share a fair share of the disease. It is the second most common type of psoriasis in children, the first being plaque psoriasis.

Guttate psoriasis accounts for about 30 percent of all the psoriasis cases in the world. It’s not too often as other ones and also not fatal as erythrodermic psoriasis.

Guttate psoriasis in our country is no exemption, and various research has been done on it as a way of eradication and treatment.  In the United States of America, the disease constitutes 8 percent of the psoriasis population.

A worldwide range of prevalence of 1.6 to 44 percent However the spread of guttate psoriasis also pertains to the dispersion and mortality of streptococcal breakouts.

Signs and symptoms of the guttate psoriasis

Guttate psoriasis
  • Guttate psoriasis is defined by skin lesions. What makes them differ from other psoriasis lesions is that they appear to drop like, and all of them are monomorphic. This means all the lesions come in a similar shape and size. 
  • These skin lesions are said to be dispersed centripetally, over the extremities, covering all over the body, abdomen, neck to the limbs. 
  • Also, this may have a generalized spread. They develop as multiple papules, discrete, separate from one other. In the first month of the disease, the onset with acute small lesions of 1-10 millimeter diameter in a salmon pink tint. 
  • And they go dormant in the second month, remaining stable. Again in the third month of the disease, they begin a remission. As the disease progresses, a fine scale can be seen along with the lesions. 

Causes and triggers of Guttate psoriasis

  • It is widely stated that guttate psoriasis develops after an infection by the streptococcus. 
  • Streptococcus pyogenes is a bacteria that causes upper respiratory tract infection. In general a pharyngeal disease.
  • The exact mechanism behind the infection is not determined. It is stated as a result of an immune reaction followed by the infection by streptococcus. 
  • As many as 80 percent of the patients infected with guttate psoriasis show signs of streptococcal infections.
  • It is more likely to infect people who are genetically more susceptible.
  • The people which are already positive for psoriasis are more likely to develop the guttate variant of psoriasis too.
  • Patients with existing acute plaque psoriasis for a long time can see a sudden appearance of lesions.
  • It can also be the first form to manifest psoriasis, in a previously completely healthy individual after the streptococcal infection.
  • Lymphocytes and cytokines are responsible for causing the inflammatory changes. They also increase in a number of patients. 
  • Some studies also stated that guttate psoriasis can also be an autoimmune reaction, showing a reaction in the epidermis
  • As we talked about above, the lesions show cell degradation in the early growth.
  • Despite the bacterial infections, it is sometimes induced by viral infections and medications.
  • Genetic predisposition also plays a role in the flares. Certain antigens responsible for psoriasis arthritis are found to be high in people living with guttate psoriasis.
  • Patients with higher HLA-C (human leukocyte gene) expression have been detected with a higher frequency of psoriasis flares.

Pathophysiology of guttate psoriasis

Guttate Psoriasis
image source wiki
  • When observed under the microscope, the cells revealed the activation of T cells and cytokines as an immune response to the respiratory infection by streptococcal bacteria. This facilitates the rapid cell divisions in the epidermis. 
  • Also, the immune cells such as endothelial cells, macrophages, mast cells, etc get activated. All these are found increasingly high in number in guttate psoriasis. Lymphocytes specific to Streptococcal antigens, exotoxins, are produced. These T cell receptors induce the expansion of certain white blood cells, mainly in the epidermis and dermis of the skin lesions. These are more strongly increased in the epidermis than in the blood and skin of a normal individual. 
  • In addition to the dermal cell changes, there is dilation of blood vessels and an increase in the thickness of skin cells.
  • Neutrophils are seen discreetly in the upper layers
  • The immune response of the patients with guttate psoriasis to the streptococcal is stronger than that of a normal individual to the same.
  • Autoantibodies of guttate psoriasis only react with the own skin cells of people with guttate psoriasis and not with any lesional cells who don’t have psoriasis.
  • Langerhans cell migration has been noticed in people living with guttate psoriasis.
  • The therapies used to block the tumor cells also worsen or trigger the guttate lesions.
  • Perianal streptococcal infections around the anus, streptococcal vaginal or vulval infections in children also cause guttate psoriasis.

Diagnosis of the guttate psoriasis

  • The diagnosis of Guttate psoriasis does not necessarily need a skin biopsy, it can be usually made on the grounds of clinical history.
  • The history of drugs taken, such as beta-blockers, lithium, etc 
  • A histopathological finding of the skin lesions is enough, if not skin biopsy is the single certain test useful.
  • Early lesions show inflammation, dilated vessels, and edema. Later lesions show parakeratosis.
  • The elevated presence of streptococcus specific antigens, hyaluronidase, nuclear B, and increased immunogenic cells in the skin also directs toward guttate psoriasis.
  • It is seen in more than half of the patients with guttate psoriasis.
  • Differential diagnosis includes cutaneous t cell lymphoma, lymphoid papulosis, parapsoriasis, and pediatric syphilis. All these diseases show increased t cell proliferation in the skin cells.
  • Throat cultures are done to diagnose streptococcal pharyngeal infections.
  • Although screenings for asymptomatic patients are not right, it should be better to check if there is an existing streptococcal disease.
Guttate Psoriasis
image source wiki

Treatments and therapies for guttate psoriasis

  • Guttate psoriasis usually resolves within a few weeks to a rarely months.
  • The treatment is prescribed based on the individual health, severity, habits, and choices.
  • Topical corticosteroids are always the first line. But with the extensive spread of the disease, the application can become cumbersome. 
  • The formulation of the topical applications must be anti-inflammatory, immunosuppressive, and vasoconstriction.
  • Low potent corticosteroids are used on the sensitive areas and higher potency ones on the other parts of the body.
  • Cephalexin, amoxicillin, erythromycin, rifampin, and penicillin are the antimicrobials used as antibiotic therapy in managing the disease.
  • More resistant cases of guttate psoriasis can benefit from oral psoralen plus exposure to ultraviolet A rays. 
  • Still narrowband is considered effective over the PUVA 
  • Narrowband ultraviolet B phototherapy is prescribed for adults who are also dealing with plaque psoriasis. Depending on the erythema the dosage should be altered in the adults 
  • Substitute to the narrowband is the broadband ultraviolet B phototherapy. Although it is less efficient than both narrowband and psoralen plus exposure, it can be done when no option is left.
  • PUVA therapy is used to treat localized plaque psoriasis in adults. Although oral PUVA is highly recommended, topical therapy is also deemed superior.
  • Vitamin D analogs, fish-derived fatty acid infusion, and topical retinoids are the additional therapies to go in certain cases of guttate psoriasis. 
  • Should guttate psoriasis develop resistance to the above therapies, it can develop into chronic plaque psoriasis.
  • Targeted biologic therapy is reserved for 40 percent of guttate skin lesions which are on edge of developing into plaque psoriasis.
  • Rarely but some people go for surgical removal of tonsils in chronic guttate psoriasis.

Reference:

  1. https://emedicine.medscape.com/article/1107850-overview
  2. https://www.sciencedirect.com/science/article/abs/pii/S1083318814003660
  3. https://en.wikipedia.org/wiki/Guttate_psoriasis
  4. https://www.ncbi.nlm.nih.gov/books/NBK482498/
  5. https://www.psoriasis.org/guttate/
  6. https://pubmed.ncbi.nlm.nih.gov/29494104/
  7. https://emedicine.medscape.com/article/1107850-overview#a16
  8. https://emedicine.medscape.com/article/2139720-overview.
  9. https://emedicine.medscape.com/article/1098954-overview
  10. https://emedicine.medscape.com/article/1107425-overview
  11. https://emedicine.medscape.com/article/1099078-overview
  12. https://emedicine.medscape.com/article/969023-overview
  13. https://ijdvl.com/treatment-of-acute-guttate-psoriasis-with-rifampicin/