Re: Pustular Psoriasis Treatment Pdf Download
Vida Hubbert
Pustular (pus-choo-lar) psoriasis causes pus-filled bumps called pustules (pus-choo-ules). Depending on the type of pustular psoriasis you have, the pustules form on your skin, and sometimes inside your mouth or beneath a nail.
Because the above are potent medications and may have side effects, they may not be suitable for some patients. Another medication may be used to get GPP under control. Psoriasis medications that may be prescribed include:
To get GPP under control, a dermatologist may prescribe two medications. For example, your dermatologist may prescribe etanercept (a biologic) and cyclosporine, infliximab (a biologic) and methotrexate, or infliximab followed by etanercept (both biologics).
While this type of pustular psoriasis can cover a large area of your body, treatment options differ from those listed above for generalized pustular psoriasis. For example, oral retinoids should not be taken during pregnancy because of the potentially harmful effects on the baby.
The above treatments are often effective for treating mild disease. To strengthen a medication that you apply to your skin, your dermatologist may tell you to apply the medication and then cover it with a gauze bandage or other dressing.
Often beginning on one finger or toe, new pus-filled bumps may continue to appear. When this happens, new pustules can develop on more than the fingers and toes. In rare cases, the pus-filled bumps can slowly spread up the arms or legs.
While the above describes what treatment may be used for each type of pustular psoriasis, your treatment plan may include different medications. Your age, other medical conditions (if any), and general health also play key roles in determining which treatment is best for you.
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Background: A task force of the National Psoriasis Foundation Medical Board was convened to evaluate treatment options for pustular psoriasis. Meetings were held by teleconference. Consensus on treatment of pustular psoriasis was achieved. Pustular psoriasis has been classified into localized and generalized forms. There are a number of treatment modalities, but there is little evidence-based information to guide the management of this type of psoriasis.
Results: Overall the quality of the literature about the treatment of pustular psoriasis is weak. Treatment should be governed by the extent of involvement and severity of disease. Acitretin, cyclosporine, methotrexate, and infliximab are considered to be first-line therapies for those with generalized pustular psoriasis. Adalimumab, etanercept, and psoralen plus ultraviolet A are second-line modalities in this setting. Pustular psoriasis in children, in pregnant women, and in localized forms alter which agents are first-line modalities as concerns such as teratogenicity need to be factored into the decisionmaking for the individual patient.
Conclusions: Treatment of patients with pustular psoriasis depends on the severity of presentation and patient's underlying risk factors. The data are extremely limited for this type of psoriasis and we encourage further exploration.
The Department of Dermatology at Mount Sinai is a leader in pustular psoriasis treatment and research. We have been at the forefront of developing new and dramatically effective therapies for pustular psoriasis, and we are currently leading the development of additional treatment options. Although pustular psoriasis is a rare condition, our specialists have extensive experience designing a safe and effective treatment plan for each patient.
The pus involved in pustular psoriasis is caused by inflammation. This condition can develop at any age, but it is often seen in older adults. There are a number of factors that could trigger pustular psoriasis, including the following:
As a world leader in the treatment of psoriasis, our Department of Dermatology understands the importance of research in pustular psoriasis and is committed to developing safe and effective therapies for this condition.
Mount Sinai specialists are skilled in customizing the right treatment plan based on the type of pustular psoriasis you have, as well as factors such as the severity of your symptoms, age, and other medical conditions. Treatment options include:
Current recommendations include initiation of systemic medications together with the proper supportive measures. Oral retinoids (acitretin, isotretinoin), methotrexate, cyclosporine, and infliximab are considered first-line therapies by the National Psoriasis Foundation Medical Board. [29] Hydroxyurea and 6-thioguanine have also been used with success. [30, 31]
Second-line therapies include biologic agents (etanercept, adalimumab, ustekinumab, secukinumab) or topical treatments (corticosteroids, calcipotriene, tacrolimus) for more localized disease on the palms and soles. [29] An example of the palmoplantar condition is seen in the image below. [32] Guidelines regarding these second-line therapies are needed, as anecdotal reports describe paradoxical induction of pustular psoriasis with some biologics. [33, 34]
The study of IL35RN gene mutations in the pathogenesis of generalized pustular psoriasis has led to new advances in treatment. Case reports have documented success with IL-1 receptor antagonists (eg, anakinra), and clinical trials are currently underway. [35, 36]
Several case reports discuss treatment of pustular psoriasis in pregnancy. Cyclosporine has been used with success in such cases, as well as infliximab (5 mg/kg). [40] The woman on infliximab delivered a healthy female baby via cesarean delivery. The neonate breastfed for 1 month and developed normally. No detectable adverse effects were noted, despite potential exposure to infliximab throughout gestation and breastfeeding. [41]
Patients usually have too much systemic toxicity and erythema during a flare to tolerate oral psoralen plus ultraviolet-A (PUVA). Treatment also requires frequent clinic visits (up to 4 d/wk), which is logistically difficult.
However, several studies have reported that PUVA is safe and effective in controlling flares of pustular psoriasis. Typically, PUVA is started once the patient has been stabilized on acitretin. PUVA has also successfully been used in combination with oral cyclosporine. [29]
While little is written regarding the use of phototherapy for pustular psoriasis, [42] narrow-band UV-B may be a reasonable choice since it has achieved therapeutic effects similar to those of PUVA in other forms of psoriasis.
Acitretin is administered first at 0.2-0.5 mg/kg for 7 days, and then PUVA is added 3 times per week. As lesions resolve, acitretin can be withdrawn, and maintenance phototherapy with PUVA or narrowband UV-B can be continued as needed.
Patients with generalized pustular psoriasis eruptions may require hospitalization to ensure adequate hydration, bed rest, and avoidance of excessive heat loss. Supportive therapy with bland topical compresses and saline or oatmeal baths helps sooth and debride affected areas.
Clay J Cockerell, MD President and Owner, Cockerell Dermatopathology; Adjunct Clinical Professor, Department of Internal Medicine (Dermatology), Division of Dermatopathology, University of North Texas Health Science Center at Forth Worth
Clay J Cockerell, MD is a member of the following medical societies: American Academy of Dermatology, American Academy of HIV Medicine, American College of Osteopathic Family Physicians, American College of Physician Executives, American Contact Dermatitis Society, American Dermatological Association, American Medical Association, American Society for Clinical Pathology, American Society for Dermatologic Surgery, American Society of Dermatology, American Society of Dermatopathology, California Society of Dermatology and Dermatologic Surgery, College of American Pathologists, Dallas County Medical Society, Dermatology Foundation, International Academy of Pathology, International AIDS Society, International Society of Dermatology, Louisiana Dermatological Society, Noah Worcester Dermatological Society, North American Clinical Dermatologic Society, Pacific Dermatologic Association, Physicians Association for AIDS Care, Society for Investigative Dermatology, Southern Medical Association, Texas Dermatological Society, Texas Medical Association, Texas Society of Pathologists, United States and Canadian Academy of Pathology, Women's Dermatologic Society
Disclosure: Nothing to disclose.
David F Butler, MD Former Section Chief of Dermatology, Central Texas Veterans Healthcare System; Professor of Dermatology, Texas A&M University College of Medicine; Founding Chair, Department of Dermatology, Scott and White Clinic
David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, Association of Military Dermatologists, Phi Beta Kappa, Texas Dermatological Society
Disclosure: Nothing to disclose.
Christen M Mowad, MD Professor, Department of Dermatology, Geisinger Medical Center
Christen M Mowad, MD is a member of the following medical societies: Alpha Omega Alpha, Noah Worcester Dermatological Society, Pennsylvania Academy of Dermatology, American Academy of Dermatology, Phi Beta Kappa
Disclosure: Nothing to disclose.
William D James, MD Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine
William D James, MD is a member of the following medical societies: American Academy of Dermatology, Society for Investigative Dermatology
Disclosure: Received income in an amount equal to or greater than $250 from: Elsevier; WebMD
Served as a speaker for various universities, dermatology societies, and dermatology departments.