Pustular psoriasis

Etretinate 0 i COOR Oral 0.25-1.0 mg/kg/d Generalized pustular psoriasis, exfoliative psoriasis, plaque psoriasis ... 

Pustular psoriasis may be localized or generalized and may be an acute emergency requiring systemic therapy. Generalized pustular psoriasis is characterized by disseminated deep-red erythematous areas and pustules, which may merge to become "lakes of pus."... 

Acitretin is most useful for the treatment of severe psoriasis, particularly the pustular and erythrodermic variants. Psoriatic nail changes and arthritis also may respond. Combining the drug with ultraviolet light therapy (Re-UVB, in the case of ultraviolet B radiation, or Re-PUVA, with psoralen plus ultraviolet A radiation) permits the use of lower doses of both acitretin and ultraviolet radiation. Other conditions for which the drug may be especially useful include congenital and acquired hyperkeratotic disorders, such as the ichthyoses and palmoplantar keratodermas, and severe lichen planus. 

Acitretin (Soriatane), a metabolite of the aromatic retinoid etretinate, is quite effective in the treatment of psoriasis, especially pustular forms. It is given orally at a dosage of 25-50 mg/d. Adverse effects attributable to acitretin therapy are similar to those seen with isotretinoin and resemble hypervitaminosis A. Elevations in cholesterol and triglycerides may be noted with acitretin, and hepatotoxicity with liver enzyme elevations has been reported. Acitretin is more teratogenic than isotretinoin in the animal species studied to date, which is of special concern in view of the drug s prolonged elimination time (more than 3 months) after chronic administration. In cases where etretinate is formed by concomitant administration of acitretin and ethanol, etretinate may be found in plasma and subcutaneous fat for many years. 

Erythrodermic psoriasis results in a widespread erythema that affects most of the body. It is often associated with pustular psoriasis. Oedema, particularly around the ankles, is common, as is excessive exfoliation of the skin and severe itching and/or pain. 

Pustular psoriasis manifests itself as a series of white blisters, surrounded by reddened skin, which usually contain white blood cells. It is normally localised to the hands and feet. Normally the skin reddens and this is then followed by the formation of pustules and associated scaling. 

Topical corticosteroids are usually given in combination with other topical treatments for the treatment of chronic plaque psoriasis. Sensitive areas, such as the face, should be treated with a mild corticosteroid and other areas, such as the scalp, with moderate to potent corticosteroids. In general, use should be maintained as early improvements in the condition are not maintained if use is halted. Such a pattern of use may worsen the condition, possibly causing a deterioration of the condition to unstable forms, such as erythrodermic or pustular psoriasis. Co-administration of topical medicaments usually involves alternating administration of each product. Scalp psoriasis is normally treated with softening emollients in combination with salicylic acid with coal tar or sulphur. 

Notes Drugs associated with the exacerbation of psoriasis include lithium, beta-adrenergic receptor blocking agents and antimalarials. Withdrawal of corticosteroid therapy may activate pustular psoriasis. NSAIDs, such as ibuprofen... 

Trazodone has caused generalized erythematous maculo-papular eruptions (24), erythema multiforme (although the patient was also taking lithium) (25), and generalized pustular psoriasis in a patient who had had stable plaque psoriasis for 19 years (26). 

Barth JH, Baker H. Generalized pustular psoriasis precipitated by trazodone in the treatment of depression. Br J Dermatol 1986 115(5) 629-30. 

Pustular drug eruptions due to penicillin (195), amoxicillin (196), ampicillin (197), bacampicillin (198), cefazo-hn (199,200), cefradine (201), cefalexin (202), cefaclor (203), or imipenem -I- cilastin (204) seem to form a distinct chnical entity that has to be differentiated from pustular psoriasis, which can be drug-induced as well (204). A history of drug exposure, rapid disappearance of the eruption after the drug is stopped, and eosinophils in the inflammatory infiltrate argue in favor of pustular drug eruptions. 

Katz M, Seidenbaum M, Weinrauch L. Penicillin-induced generalized pustular psoriasis. J Am Acad Dermatol 1987 17(5 Pt 2) 918-20. 

Spencer JM, Silvers DN, Grossman ME. Pustular eruption after drug exposure is it pustular psoriasis or a pustular drug eruption Br J Dermatol 1994 130(4) 514-19. 

Calcipotriol can occasionally convert psoriasis vulgaris into pustular psoriasis (SEDA-19,165). 

Acute generalized pustular psoriasis occurred 1 week after ciclosporin withdrawal in a 32-year-old woman... 

Mahendran R, Grech C. Generalized pustular psoriasis following a short course of cyclosporin (Neoral). Br J Dermatol 1998 139(5) 934. 

The first reports of psoriasis in cancer patients treated with high-dose interferon alfa were followed by a controversial debate (295,296). However, numerous cases have confirmed that interferon alfa can either induce typical psoriasis or worsen pre-existing psoriasis (SED-13,1095) (297), an observation that is compatible with interferon aHa-induced imbalance toward an increased Thl response. This was particularly exemplified by the reversibility of the lesions after withdrawal of treatment and the prompt recurrence of symptoms after interferon aha readministration. Exacerbation of psoriasis usuaUy occurred within the first month, whereas a minimum of 2-3 months of treatment was required in patients without a past history of psoriasis (297). Psoriatic lesions at the sites of injection were suggested to be potential indicators for further generalization of psoriasis. In more severe cases, there was concomitant development of monoarticular or polyarticular joint symptoms (SED-13, 1095) (SEDA-21, 372). Pustular psoriasis with balanitis and erosive monoarthritis, suggesting incomplete Reiter s sjmdrome, was also reported in one patient with HLA-B27 (298). 

Webster GF, Knobler RL, Lublin FD, Kramer EM, Hochman LR. Cutaneous ulcerations and pustular psoriasis flare caused by recombinant interferon beta injections in patients with multiple sclerosis. J Am Acad Dermatol 1996 34(2 Pt 2) 365-7. 

Sendagorta E, Allegue F, Rocamora A, Ledo A. Generalized pustular psoriasis precipitated by diclofenac and indomethacin. Dermatologica 1987 175(6) 300-1. 

Isogai Z, Sunohara A, Tsuji T. Pustular drug eruption due to bacampiciUin hydrochloride in a patient with psoriasis. 

Psoriasis of the nails Pustular psoriasis PUVA keratoses (26)... 

Severe pustular psoriasis provoked de novo by oral terbinafine has been reported in a 65-year-old man 2 weeks after the start of therapy for onychomycosis (52). Treatment of psoriasis was complicated and ultimately required continuous systemic and topical antipsoriatic therapy. 

Wilson NJ, Evans S. Severe pustular psoriasis provoked by oral terbinafine. Br J Dermatol 1998 139(1) 168. 

In 1990, etretinate (Tigason) was replaced by acitretin (Neo-Tigason), an aromatic retinoid, a carboxylic acid metabolite of etretinate (15). It is effective in pustular psoriasis and psoriatic palmoplantar keratoderma and in combination with PUVA or topical therapy (calci-potriol or glucocorticoids) in the treatment of other forms of psoriasis. It has also been used to treat disorders of keratinization (ichthyosis, palmoplantar keratoderma, Darier s disease) and severe cutaneous forms of lichen planus. It prevents new skin carcinomas in patients with xeroderma pigmentosum and those who are immunosuppressed. The main advantage of acitretin is its short half-life of 50 hours, compared with over 80 days for etretinate (16). 

Etretinate (Tegison) Treats pustular psoriasis suppresses cell growth used when other medications fail... 

Yamamoto T+,Acta Derm Venereol (Stockh) 77, 168 (in a patient with pustular psoriasis)... 

Acitretin, an oral retinoid, is the active metabolite of etretinate and has demonstrated clinical effects similar to etretinate, but with fewer adverse effects. Acitretin is indicated for the treatment of severe psoriasis, including erythrodermic and generalized pustular types, but is more useful as an adjunct in the treatment of plaque psoriasis. In contrast to the fast-acting cyclosporine and methotrexate, acitretin resolves psoriatic lesions more slowly. 

Psoriasis occurs in several other forms. A form particularly difficult to treat is palmo-plantar psoriasis (PPP), which manifests as pus-fllled spots (pusmles) on the hands and feet. Pustular and erythrodermic psoriasis are two rare forms of the disease, which present as medical emergencies. Both types cover the entire body, as either pus-fllled spots (pustular) or red patches with skin shedding (erythrodermic). 

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