Treatment of acute pustular psoriasis

Treatment

Patients with erythrodermic or generalised pustular psoriasis often require admission to the hospital and use of systemic therapy from the outset (1,2,3).

Disease-specific medications include systemic retinoids (acitretin, isotretinoin), methotrexate, cyclosporine, and infliximab (3)

• methotrexate and cyclosporin usually provide the most rapid response (1,2)
  • 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 (3).

Second line options (3):

• 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.

Reference:

• 1. The British Association of Dermatologists 2006. General management of Psoriasis -Specific sites
• 2. The British Association of Dermatologists 2006. General management of Psoriasis -Methotrexate
• 3. 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-.