Pustular Psoriasis Treatment Guidelines

Introduction to Pustular Psoriasis Treatment

The British Medical Journal recommends avoiding systemic corticosteroids in pustular psoriasis due to the risk of disease exacerbation 2
Systemic corticosteroids (including potent topical preparations that can be systemically absorbed) can precipitate erythrodermic psoriasis, generalized pustular psoriasis, or very unstable psoriasis when discontinued 1, 2

Fluoridated hydrocortisone should not be used in the treatment of pustular psoriasis due to the risk of exacerbating the condition upon discontinuation and potential for triggering disease flares 1, 2
Systemic corticosteroids should only be used in rare specific conditions: persistent uncontrollable erythroderma causing metabolic complications, generalized pustular psoriasis of the von Zumbusch type when other drugs are contraindicated, or hyperacute psoriatic polyarthritis threatening severe irreversible joint damage 1

The American Academy of Dermatology recommends acitretin as first-line therapy for generalized pustular psoriasis, particularly since it is not immunosuppressive 3, 4
Acitretin is particularly effective for pustular psoriasis, with response seen as early as 3 weeks and improvement reported in 84% of patients with pustular psoriasis 3

Combination therapy should be approached with extreme caution as toxicity is at least additive 2, 5
All systemic treatments require appropriate pretreatment assessment and ongoing monitoring, including regular blood tests, liver function tests, and serum creatinine monitoring depending on the agent used 5, 6
Combination therapy: Acitretin with narrowband UVB for synergistic effects 2, 3

Pregnancy: All commonly used systemic agents are absolutely contraindicated in pregnancy, requiring strict contraception 5, 6
Phototherapy (PUVA) is generally considered the systemic treatment of first choice with the least toxicity for many forms of psoriasis, but must be used with caution in pustular forms 2, 5