Pustular Psoriasis Symptoms and Treatment

Pustular psoriasis is a rare form of psoriasis affecting people. As the name indicates it is a type of psoriasis with pus-filled yellowish pustules spread over a reddish erythematous skin. They can be confined to certain locations or spread all over the body. We will further talk over more of its disease pattern, types, and treatment norms later in this. 

pustular psoriasis

To start with the prevalence of the disease, It is seen from very early infancy called juvenile pustular psoriasis and also appears in adults in the fifties and sixties. The male to female ratio being influenced by pustular psoriasis is 1:1 in the United States. All over the world and in Asians female dominance is seen.

Even in children, female preeminence is noted with a 3:2 female to male ratio. Although female dominance remains for every type of pustular psoriasis, each of their prevalences varies. Their ages of onsets also differ individually. As in the generalized pustular psoriasis onsets at the age of 31 years in an individual.

Palmoplantar pustular psoriasis may turn on after 43 years and the acrodermatitis continua of hallopeau after fifty years. Annular pustular psoriasis onsets at an average of six years. Infantile or juvenile pustular psoriasis starts as early as 6 weeks onwards. A generalized pustular psoriasis case was noted in an infant of six weeks old.

There are various rare and more common subtypes of pustular psoriasis, which are:

  1. Generalized pustular psoriasis
  2. Annular or circinate type, subacute generalized pustular psoriasis
  3. Palmoplantar pustulosis
  4. Acrodermatitis continua of hallopeau
  5. Juvenile pustular psoriasis
  6. pregnancy-associated impetigo herpetiformis
  7. Acute generalized exanthematous pustulosis

Out of these, we will take a deeper look at a few.

Generalized pustular psoriasis:

Generalized-pustular-psoriasis

About the disease and its symptoms:

  • Generalized pustular psoriasis is the most acute form of pustular psoriasis. It is also called von zambush. 
  • It is rare and with more acute intermittent flares, which are severe and regularly come back.
  • Generalized pustular psoriasis is a severe and chronic kind of psoriasis existing. In the poorest cases of this disease, it is life-threatening.
  • As this disease has a high morbidity rate of up to 30 percent and serious complications the treatment is activated with no delay.
  • It is severe, affecting multiple locations of the body. 
  • Often untreated and undiagnosed generalized pustular psoriasis can end in a serious failure of multiple organs, heart disease, renal failure, acute respiratory disease, and sepsis.
  • A person affected with this variant of pustular psoriasis has the characteristic erythematous skin which is reddish skin that looks like a skin rash. 
  • Edematous erythema is the next specific symptom of generalized pustular psoriasis.
  • The skin turns to become fiery red, and tender.
  • There will be a persistent accumulation of the neutrophils as pus which is erupted as pustules all over the body.
  • Pustules develop on this as a base. They are painful, sterile, and numerous. They do not confine to a location but can start from any and spread to any part of the body.
  • Within no time, they emerge on the skin in a diffuse pattern.
  • It is frequently relapsing, beginning with a skin rash and pustules covering other parts of the body than the palms, soles, fingers, arms, and toes. 
  • Each time it comes it can last from days to weeks.
  • There may or may not be the presence of any plaques. 
  • It is a severe and chronic kind of psoriasis. 
  • There may be the presence of psoriasis symptoms alongside instances. 
  • Systemic symptoms like fever, discomfort, fatigue, chills, pain in the joints, hunger issues, nausea, headache, and pain also can be present. 
  • However, the presence of psoriasis symptoms, inflammation, and systemic symptoms is not standard for the diagnosis of generalized pustular psoriasis. 

The prevalence of generalized pustular psoriasis:

  • Unneeded to say, it has its dominance in females more than in males. 
  • It can appear in any age group from birth but is more frequent in adults from over forty to fifty of age. 
  • Generalized pustular psoriasis is more prevalent in Asian communities than in Americans. For example, it is way more prevalent in Japan than in the United States of America. 
  • When the actual psoriasis prevalence is compared to the generalized pustular psoriasis in Malaysia it is one percent of the total psoriasis cases. In Japan, 1.3 percent of total psoriasis cases exist in the country as per the research carried out.
  • Plaque psoriasis has a good association of as tiny as 25 to as big as 65 percent with generalized pustular psoriasis.
  • The juvenile generalized pustular psoriasis has male domination and also pediatric generalized pustular psoriasis includes almost 7 percent of the total psoriasis cases.
  • Patients living with this lifelong disease complain of not less than two acute flares each year.
  • Skin gets enraged and painful during this flare. Once the pustules are fixed, a lot of scaling is seen. 

Causes of generalized pustular psoriasis: 

  • The studies carried on by far indicated that the base of generalized pustular psoriasis is plaque psoriasis. It has been explained by many reasons
  • Stress, inflammation, pregnancy, withdrawals of corticosteroid treatment, etc.
  • Withdrawal of systemic corticosteroid therapy is a trigger for this. Also, topical therapy, with any of the potent corticosteroids can get complicated in the flares. Cyclosporin, propranolol, bupropion, lithium, salicylates, etc are a few responsible for causing generalized pustular psoriasis.
  • Pregnancy and generalized pustular psoriasis: the variant of generalized pustular psoriasis that happens during pregnancy is named impetigo herpetiformis. It onsets with a centripetal diffusion of the pustules at the flexible parts of the body like knees, arms, hands, elbows, knees, and groins. 
  • There was an assertion for a long time that both generalized pustular psoriasis and impetigo herpetiformis are closely related. A piece of strong evidence to establish that impetigo herpetiformis and generalized pustular psoriasis are closely connected is the gene IL36RN. It is seen undergoing the same mutation that encodes receptor IL36, same as in generalized pustular psoriasis. Also, generalized pustular psoriasis is followed by impetigo herpetiformis during pregnancy. 

Diagnosis and Treatments for generalized pustular psoriasis:

  • Diagnosis evaluations entail elevated erythrocyte sedimentation rate, increased C reactive protein, and decreased calcium, zinc, and albumin.
  • The patient is kept on fluid and protein intake, and an antibiotic is stipulated for the infection, monitored closely.
  • Topical medications such as diluted corticosteroids, anthralin, and coal tar as in psoriasis are recommended for patients with unstable or shifting kinds of generalized pustular psoriasis.
  • Acitretin, cyclosporin, methotrexate, prednisone, adalimumab, etanercept, and infliximab are next-line drugs used. However excluded pregnant, also pregnancy is terminated if it poses a risk to the maternal life. 

Annular or circinate type pustular psoriasis:

About the disease and its symptoms

  • The annular or circinate type of pustular psoriasis is the most predominant pustular psoriasis that runs in childhood. It has less predominant symptoms and less severe manifestations of the disease. 
  • In children, skin all over turns red with plaques and lesions cultivated on it. It goes on scattering all over the body. Scaling is seen on the peripheral areas of the affected skin. As the disease unfolds to the peripheral sides, the central part of the disease gets to heal over hours to days. 
  • Annular lesions are seen along with pustules and scaling along the peripheral advancing ends. It gives the appearance of rounded lesions with clear centers. Because of its appearance, it is mistaken for fungus. 
  • Well-defined lesions, plaques, and gradation of the scaling define the severity of the disease. Plaque-type psoriasis without pustules is defined as the primary annular type of psoriasis. 
  • The annular type of pustular psoriasis is related to facial involvement and psoriasis arthritis in rare instances. 

Diagnosis and treatment of annular type psoriasis

  • Treating children for psoriasis has a different approach nearer to adults. Firstly the severity is measured with an estimation. 
  • The body surface area (BSA) measures the severity of the disease. It acts as a measuring tool. While treating children, there can be two ways to do it. The traditional use utilizes the old medications ready or uses the novel ones. 
  • As there is no one right option to treat, it is in general personalized and individualized per need, the severity of the disease and acceptability of the child, feasibility, formulation of the drug, and availability of the drugs. 
  • All systemic therapies can be considered to approach children, with severe to moderate disease. Although the threshold for initiating systemic therapies varies with age and intensity of the disease in pediatric treatments, as it pertains to children. Conventional treatment options like methotrexate, cyclosporin, acitretin, phototherapy UVA and UVB, etc have always been helpful and still put into use. 
  • Nevertheless, new approaches to target therapies with inhibitors are being more efficient. They proved to be more convenient. Trials of such targeted therapies include risankizumab, apremilast, brodalumab etc. 
  • Treating a child with pediatric psoriasis is a challenge. The decision to take on systemic therapies should be a total decision of the drug and patient history. Not just that but also the complications and existing diseases associated. 
  • In recalcitrant annular psoriasis arthritis and spondylitis are diagnosed also with the signs of the disease. Methotrexate, cyclosporine, etc are used in such cases
  • Topical corticosteroids are adequate for milder infections of the disease. For a more severe disease that is if the body is affected more than 5 percent then the treatment is boosted to phototherapy, systemic therapy with biologics. 
  • Sekunimubab, acitretin, etanercept, ustekinumab, calcipotriene, tacrolimus, UVA  and UVB phototherapy, retinoids, and more are opted for in planning the treatment. 

Acrodermatitis continua hallopeau:

About the acrodermatitis disease and its symptoms:

  • The acrodermatitis continua hallopeau is the variant of psoriasis that confines the distal part of the toes and toes. It is a rare, chronic, sterile, and relapsing form of psoriasis. Acrodermatitis continua hallopeau is a localized pustular psoriasis condition. It also has nail involvement in rare cases.  
  • Acrodermatitis continua hallopeau is highly resistant and non-yielding to the very few treatment choices available. It is also a less common disease of them all. 
  • The skin becomes red with tender pustules, and the tips of the digit and fingers but not on the toes. It is considered the most local form of pustular psoriasis.
  • The exact etiology of the disease is not found, but it usually starts after a trauma or infection is caused. It advances as a lifelong and progressive disease with so many complications adding on the years. 
  • The irreversible difficulties of acrodermatitis are anonychia, onychodystrophy, osteolysis, and osteitis of the distal phalanges. 

Treatment of the acrodermatitis continua hallopeau:

  • Besides the traditional conventional first-line and second-line treatments, biologics have revolutionized the treatments in acrodermatitis continua hallopeau. The use of targeted therapy has become a promising treatment for this disease, among the elderly too. 
  • Secukinumab, infliximab, adalimumab, etanercept which are IL-11 inhibitors, and anakinra which is an IL-7 inhibitor that acts on the targets are the biologics employed. 
  • As the disease is causing underlying issues in both the bones and joints acrodermatitis is a refractory and unyielding disease.

Palmoplantar pustular psoriasis:

Palmoplantar-pustular-psoriasis

About and prevalence of palmoplantar pustular psoriasis:

  • Palmoplantar pustular psoriasis is a chronic and challenging disease, persistent with no gold standard therapy of treatment. It is psoriasis that arises on the palms and soles of a person. It is all about sterile pustules that revert very often. 
  • It is more associated with plaque psoriasis in almost 20 percent of the cases. Females get affected in their sixties and seventies which is more common in women that have an addiction to cigarette smoking. In men, it onsets after the fifties, but more common in women in general. The prevalence ranges up to 0.05 percent in Europe and 0.12 percent in Japan. 
  • The symptoms and signs linked with this disease are most likely pustular psoriases. 
  • The redness of the skin also called erythema, and accumulation of neutrophils filled with pus in them, hyperkeratosis, an enormous number of increase in the cells, tortuous dermal capillaries, scaling and discoloration of the skin, pain, sterile pustules, etc and other symptoms of palmoplantar pustular psoriasis. A modern study of DNA in palmoplantar pustular psoriasis showed bacterial microbes in the pustules, moderately than being sterile.
  • The fresh sterile yellow pustules get dried up to form brown discoloration later on the skin. As the affected areas are mainly the soles and palms, this results in immense pain in weight-bearing. As the fissuring unfolds a severe itch and burning sensation persists on the skin. 
  • Chronic lesions can spread all over the body as it gets worse. Palmoplantar pustular psoriasis significantly impairs life with debilitating skin conditions, and pain and impacts the quality of life significantly. 

Diagnosis and treatment of palmoplantar pustular psoriasis: 

  • A patient should be suspected of palmoplantar pustular psoriasis if he has red skin and pustules on the body. A physical examination is done and family history is obtained to learn more about the patient. 
  • The absence of systemic symptoms can not potentially exclude the presence of the disease. An immediate necessity for hospitalization, stabilization should be checked to avoid the risk of complications. The treatments for this disease are not distinct but prefer the line of any other psoriasis subtype. The differential diagnosis includes eczema, arthritis, and fungal infections. 
  • A punch biopsy is taken to assess for the pustules. The treatment utilizing topical corticosteroids can do the work, but systemic inhibitors and biologics can be wanted in the worst cases. The most effective treatment approach comprised a topical therapy with high potency topical steroids. Vitamin D analogues along with oral acitretin and methotrexate come under the same. Narrowband UVB and UVA, adalimumab, ustekinumab, secukinumab, placebo, etanercept, infliximab, apremilast, etc are the other options usable going up the ladder.

Pregnancy-associated impetigo herpetiformis:

About the disease and its prevalence:

  • The name indicates a bacterial infection, but it is a variant of pustular psoriasis. In explicit words, it is a flare of an acute generalized pustular psoriasis that affects pregnant women. 
  • Never before in life does it appear, and go away after gestation. It does not start with very early pregnancy, instead, it turns on in the third trimester, and leaves off after gestation. Postpartum, no flares are argued by any patient. 
  • But in case of using any oral contraceptives or in case of subsequent pregnancies the flares start earlier.
  • Although a family history of this disease is not recorded, hypocalcemia is discerned to be a trigger for this disease. Also, the mutation resulting in the gene IL36RN for which certain cytokines are accountable is the key factor too. The underlying issues that come with low vitamin D levels such as hypothyroidism, and hypoalbuminemia can accelerate the disease. 

Symptoms and complications of impetigo herpetiformis:

  • On the base of red erythematous skin, white, sterile, and painful pustules appear. The pustules emerge around the unduned areas such as the shoulder joint, groins, gluteal areas, navel, rarely on hands and nails, etc. they rupture and leave stiffened crust over the skin. 
  • The pathological studies of these pustules of the impetigo demonstrated subcorneal pustules not just with neutrophils but also with keratinocytes
  • High count of peripheral white blood cells
  • Systemic symptoms are fever, chills, diarrhea, vomiting, and nausea. Rarely tetany, delirium, seizures, and other difficulties associated with hypocalcemia, deaths with cardiac or renal failure may happen. Which are quite unusual.
  • There are certain complications led by this impetigo herpetiformis. Fetal mortality risks were elevated for pregnant women with this disease, because of placental insufficiency. Fetal anomalies and neonatal deaths are also caused. 
  • Placental insufficiency ensues because of the restricted nutrition by the placenta to the fetus. Thus concluding in fetal deaths. Septicemia caused by the disease can be another reason for the deaths.
  • Difficulties related to impetigo herpetiformis,  include hypoparathyroidism, hypocalcemia, and hyperparathyroidism also present in a few cases. Electrolyte imbalance in the body, iron deficiency anemia, hypoalbuminemia, premature rupture of the membranes of the womb, stillbirths, decreased vitamin D, increased erythrocyte sedimentation rate, hypophosphatemia, leukocytosis, nail atrophy. 

Treatment options for impetigo herpetiformis:

  • Treating with prednisone of only 20 to 40mg per day is allowed, an adrenal corticosteroid during pregnancy to withstand the thyroid and parathyroid issues. Corticosteroids of restricted usage as in 15 to 20 mg per day and higher doses up to 80 mg per day are permitted. Also, impetigo herpetiformis attacks in the third-trimester use of corticosteroids are safe. Topical use of corticosteroids is not advised because of the fetal growth restriction. Cyclosporine is recommended for those the corticosteroids could not help treat a 2.5 to 7 mg per day following prednisone use. It has successful clearance cases in the patients. 
  • Antibiotics used for ampicillin, macrolide, etc, and biologic agents infliximab and adalimumab, methotrexate, and clofazimine are given postpartum for recalcitrant impetigo herpetiformis. Narrowband UVB and PUVA are also other treatment options. 

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