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Treatment of acute pustular psoriasis

Authoring team

Treatment

Patients with erythrodermic or generalised pustular psoriasis often require admission to the hospital and use of systemic therapy from the outset (1).

Disease-specific medications include systemic retinoids (acitretin, isotretinoin), methotrexate, cyclosporine, and infliximab (2)

  • methotrexate and cyclosporin usually provide the most rapid response (1)
    • methotrexate can be used
      • as a short term treatment method
      • to control the disease before starting other methods of treatment
      • frequently as long term maintenance treatment method (1)

In the paediatric age group, acitretin, cyclosporine, methotrexate, and etanercept are considered the first line options (1).

Second line options:

  • include systemic treatments like etanercept and adalimumab or topical treatments like corticosteroids, calcipotriene, and tacrolimus
    • all of these options can be monotherapy choices or in combination with the first line options
    • phototherapy is another treatment option
    • early delivery is recommended in pregnant patients with impetigo herpetiformis
    • there are reports that indicate the successful use of L-1 receptor antagonists (e.g., anakinra) and IL-36 receptor antagonists in treating pustular psoriasis
      • tocilizumab, a monoclonal antibody against the IL-6 receptor, has also shown efficacy in some recalcitrant cases of pustular psoriasis

Attention must be given to fluid balance and body temperature.

References:

  1. van der Kraaij GE, Balak DMW, Busard CI, et al. Highlights of the updated Dutch evidence- and consensus-based guideline on psoriasis 2017. Br J Dermatol. 2019 Jan;180(1):31-42.
  2. Shah M, Al Aboud DM, Crane JS, et al. Pustular Psoriasis. [Updated 2019 Jul 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-.

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