Treatment of Pustular Psoriasis

Immediate Treatment Approach

• The American Academy of Dermatology recommends acitretin, cyclosporine, methotrexate, and infliximab as first-line systemic therapies for generalized pustular psoriasis, with hospital admission typically required for initial management 1, 2
• For localized pustular psoriasis, the British National Formulary suggests applying moderately potent topical corticosteroids (grade III) as first-line therapy for symptom relief 3

Systemic Therapies

• Acitretin is particularly effective for pustular psoriasis, with response as early as 3 weeks and 84% of patients showing improvement, at a dose of 0.1-1 mg/kg/day (10-50 mg daily in adults) 1, 2, 4, 5
• The American Academy of Dermatology gives a grade C recommendation for infliximab in pustular psoriasis subtypes, with standard dosing at 5 mg/kg infused at weeks 0, 2, and 6, then every 8 weeks 2

Critical Management Principles

• Systemic corticosteroids should be avoided as routine treatment for pustular psoriasis, as they can precipitate erythrodermic psoriasis, generalized pustular psoriasis, or very unstable psoriasis when discontinued 2, 4, 6
• All systemic treatments require pretreatment assessment and ongoing monitoring, including regular blood tests, liver function tests, and serum creatinine 2, 4

Combination Therapy Considerations

• Combination therapy should be approached with extreme caution, as toxicity is at least additive, but acitretin combined with narrowband UVB shows synergistic effects and is a reasonable approach 1, 2, 4
• Infliximab may be combined with methotrexate or topical high-potency corticosteroids 2