Treatment of Pustular Lesions in Children

Non-Infectious Pustular Psoriasis

The American Academy of Dermatology recommends beginning with topical calcineurin inhibitors (tacrolimus 0.1%) for facial and genital involvement in mild to moderate pustular psoriasis, as these show excellent improvement within 30 days without the risk of skin atrophy 1
Combination therapy with topical vitamin D analogs and topical corticosteroids is effective for plaque-type pustular psoriasis 1
Moderately potent (class III) topical corticosteroids should be used for body lesions to balance efficacy with safety 2
High-potency or ultra-high-potency corticosteroids should be avoided in children 0-6 years due to high risk of HPA axis suppression from their elevated body surface area-to-volume ratio 1

Acitretin is recommended as the first-line systemic therapy for pustular psoriasis in children at 0.1-1 mg/kg/day, with response typically seen within 3 weeks 3, 4
Acitretin combined with narrowband UVB phototherapy is synergistic and allows dose reduction of both agents 3, 4
Acitretin should be avoided in female adolescents approaching childbearing potential, as it remains stored in the body for up to 3 years when reverse-esterified to etretinate in the presence of alcohol 3, 2
Cyclosporine 2-5 mg/kg/day achieves skin clearance in approximately 4 weeks and is excellent for crisis management and rapidly progressive disease 5

Infliximab 5 mg/kg IV at weeks 0, 2, and 6, then every 8 weeks is recommended for severe pustular psoriasis unresponsive to other systemic medications, rapidly progressive, unstable, or life-threatening disease 3, 6

Routine clinical and laboratory monitoring is mandatory during systemic therapy with acitretin, cyclosporine, or biologics 3, 4
Methotrexate should be avoided in female adolescents without reliable contraception due to teratogenicity (pregnancy category X) 5
Infants and children 0-6 years require extreme caution with topical corticosteroids and limited quantities with clear application instructions 1
Adolescents approaching childbearing potential should avoid acitretin and use methotrexate only with reliable contraception 3, 2