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Pustular Psoriasis - Causes, Symptoms and Treatment


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Pustular psoriasis is an uncommon form of psoriasis. It is also known as acute generalised pustular psoriasis of von Zumbusch. In adults, it affects men and women equally. In children, it affects boys somewhat more often than girls. The average age of people with pustular psoriasis is 50 years. Children aged 2-10 years can be affected, but this is rare. The disease usually becomes much less active for a while after peeling. It can be life-threatening especially in the elderly. It is characterized by the development of pustules in the flexural areas -the backs of the knees, the insides of the elbows, the armpits and the groin. Pustular psoriasis also can be generalized, covering most of the body. In many patients no identifiable cause can be found for the altered pattern of disease i.e. the generalised pustular psoriasis is idiopathic. It may be triggered by internal medications, irritating topical agents, pregnancy, systemic steroids, infections, emotional stress and sudden withdrawal of systemic medications or potent topical steroids. Some individuals have even reported outbreaks of psoriasis after reacting to a vaccination as a child or in later life or reacting to certain medications.

Pustular psoriasis can be either localised or generalised on the skin and can be preceded in appearance by chronic plaque psoriasis. When pustular psoriasis is referred to without any further description, however, it usually means a much rarer and serious from of the disease where pustules are visible at other sites, this is often referred to as generalised pustular psoriasis or von Zumbusch pustular psoriasis. When pustules are visible in areas other than the palms and soles it very often means that psoriasis is in an unstable stage, and spreading very rapidly, this may make the patient feel quite ill from loss of heat and fluid resulting in feverish type symptoms. Oral steroids in psoriasis patients are actually dangerous. They do clear up the psoriasis while the patient is taking them, but after the patient stops, the psoriasis often comes back even worse. 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.

Causes of Pustular psoriasis

In most patients no identifiable cause can be found i.e. the generalised pustular psoriasis is idiopathic. In many patients no identifiable cause can be found for the altered pattern of disease i.e. the generalised pustular psoriasis is idiopathic. Psoriasis can be triggered by infections, the most common being a sore throat or upper respiratory tract infection. A type of psoriasis called guttate psoriasis can follow this type of infection. Major life events such as stress, a close bereavement, menopause, pregnancy, marital problems and change of lifestyle have been considered triggers for some patients.

Common causes and risk factors of Pustular psoriasis:

  • A history of chronic plaque psoriasis.
  • Psychological stress.
  • Sunlight or photo therapy.
  • Hypocalcemia.
  • Excessive alcohol intake.

Signs and Symptoms of Pustular psoriasis

Psoriasis patches can range from a few spots of dandruff-like scaling to major eruptions that cover large areas. Mild cases of psoriasis may be a nuisance. But more severe cases can be painful, disfiguring and disabling. The most common places these pustules appear are the anal and genital area and bends and folds in your skin. Pustules may appear on the face, but this is unusual. Pustules can appear on the tongue, which may make it difficult to swallow. Psoriasis of the scalp can be difficult to distinguish from a severe case of cradle cap, and sometimes the two occur simultaneously. An outbreak of psoriasis often leads to lesions on the face.

Sign and symptoms may include the following :

  • Thickening and reddening of patches.
  • Itching.
  • Skin can split and bleed in the affected areas, especially when over joints or on the palms or feet.
  • Nail changes.

Treatment for Pustular psoriasis

Psoriasis treatments aim to interrupt the cycle that causes an increased production of skin cells, thereby reducing inflammation and plaque formation. Generalised pustular psoriasis can be life threatening so hospitalisation is usually required. Antibiotics may be prescribed if infection has occurred. In severe cases or cases where recurrent outbreaks have exhausted the patient, systemic medications are used. Oral treatment with immunosuppressants such as ciclosporin, or methotrexate or the vitamin A derivative acitretin may be used for patients with severe, widespread or unresponsive psoriasis. Occasionally, corticosteroid-containing ointments are used for a short time.

Treatment may include:

  • Acitretin is the most commonly prescribed retinoid for the treatment of pustular psoriasis.
  • UVB radiation is effective for both chronic pustular and guttate psoriasis.
  • Steroid creams is the most widely used treatment, and can reduce inflammation and plaques.
  • Hydroxyurea is an effective treatment for patients with chronic plaque psoriasis.
  • Vitamin A derivatives, in tablet form are very effective in the treatment of pustular psoriasis.
  • Sometimes it is necessary to restart corticosteroids, usually temporarily.