Pustular Psoriasis is when crops of spots filled with yellow pus appear on the palms of the hands or soles of the feet. The pus in these spots is not a sign of infection, nor are they contagious. This condition can be quite painful; the skin is usually very red and can crack, which impedes walking and other everyday activities. PPP can be caused by any of the common psoriasis triggers, although there is also an association between PPP and smoking.
Topical treatments such as steroids or coal tar are most often used to treat PPP, although it can prove to be stubborn. Where this is the case, a patient with PPP may also be prescribed PUVA therapy or certain systemic medications.
Generalised pustular psoriasis also features pus-filled spots, but on any area of the body. This condition can come on fairly quickly, and can be quite serious. The skin is usually red and hot, and the patient may become feverish and suffer from a loss of heat and fluids. Generalised pustular psoriasis can be triggered by an infection, certain prescription drugs, or by abrupt withdrawal from topical steroids. It’s important to get medical help immediately in the case of someone with generalised pustular psoriasis, as they may need to be hospitalised for rehydration and swift treatment with systemic medications.
It is important to note that pustular psoriasis, like any other form of psoriasis, is not catching in any way.
What is it?
Pustular psoriasis is an uncommon form of psoriasis consisting of widespread pustules on an erythematous background. It is characterized by white pustules (blisters of noninfectious pus) surrounded by red skin. The pus consists of white blood cells. It is not an infection, nor is it contagious.
Classifications of Pustular Psoriasis
Generalized Pustular psoriasis
Von Zumbusch can appear abruptly on the skin. It is characterized by widespread areas of reddened skin, which then become painful and tender. Within hours, the pustules appear. Over the next 24 to 48 hours, the pustules dry leaving the skin with a glazed and smooth appearance. Von Zumbusch is rarely seen in children, although when it does, it is often the first psoriasis flare and may have a better outcome than in adults. This form can be life-threatening and requires immediate medical care. People with von Zumbusch pustular psoriasis often need to be hospitalized for rehydration and start topical and systemic treatment, which typically includes antibiotics. Von Zumbusch is associated with fever, chills, severe itching, dehydration, a rapid pulse rate, exhaustion, anemia, weight loss and muscle weakness.
Localized Pustular psoriasis
- Palmoplantar pustulosis (PPP) causes pustules on the palms of the hand and soles of the feet. It commonly affects the base of the thumb and the sides of the heels. Pustules initially appear in a studded pattern on top of red plaques of skin, but then turn brown, peel and become crusted. PPP is usually cyclical, with new crops of pustules followed by periods of
- Acropustulosis (acrodermatitis continua of Hallopeau) is a rare type of psoriasis characterized by skin lesions on the ends of the fingers and sometimes on the toes. The eruption occasionally starts after an injury to the skin or infection. Often the lesions are painful and disabling, producing deformity of the nails. Occasionally bone changes occur in severe
Who gets it?
It is equally appear both women and men and rarely in young children.
Is it contagious?
Pustular Psoriasis is not contagious.
- Folate deficiency – patients with severe psoriasis have a risk of developing folate deficiency. Folate is a B vitamin that is vital for proper nerve function; it also prevents birth defects. Folate also prevents high levels of homocysteine, which increase the risk of heart disease.
- Cancers – patients with severe psoriasis who received systemic medications (those that affect the whole body) have a higher risk of developing skin cancers and lymphomas.
- Heart problems, obesity and diabetes – a higher percentage of individuals with psoriasis develop heart problems, diabetes and/or obesity. Experts do not know whether there is a genetic link between these conditions and psoriasis. People with moderate-severe psoriasis, ideally should be tested for these conditions. Experts from UC Davis explained in Archives of Dermatology that fat cells in patients with psoriasis secrete cytokines that raise insulin resistance in the liver and muscle, which initiates the destruction of the insulin-producing beta cells in the pancreas.
- Bad body temperature regulation – patients with erythrodermic psoriasis may have abnormalities in the body’s ability to control temperature.
- Zumbusch psoriasis – this is a combination of erythrodermic and pustular psoriasis. The condition may develop suddenly. The patient may experience fever, chills, muscle weakness and weight loss. Sometimes there may be an over-accumulation of fluids, protein loss, and electrolyte imbalances; in such cases the patient may need to be hospitalized until fluid, chemical balances and body temperature are normalized. Zumbusch psoriasis is especially dangerous if the patient is elderly.
- Psoriatic arthritis – in the majority of cases, psoriatic arthritis symptoms are mild. However, the following complications are possible:
- Arthritis mutilans – an extremely severe form of chronic rheumatoid arthritis, in which the bones are reabsorbed, resulting in the collapse of soft tissue. When the hands are affected it can cause a phenomenon called telescoping fingers; the feet may also be affected. Patients with other arthritic conditions, such as osteoarthritis or rheumatoid arthritis in the joints of the fingers have a higher risk.
- Risk of developing psoriatic arthritis – it is estimated that between 10% and 20% of all patients with psoriasis develop psoriatic arthritis; in about 20% of these people the arthritis symptoms occur before the psoriasis ones.
- Psychological and emotional consequences – living with psoriasis often has emotional and social consequences.
Occasionally, acute respiratory distress syndrome may complicate generalized pustular psoriasis.
Other complications in pustular psoriasis may include the following:
- Secondary bacterial skin infections, hair loss (telogen effluvium), and nail loss
- Hypoalbuminemia secondary to loss of plasma protein into tissues
- Renal tubular necrosis as a result of oligemia
- Liver damage as a result of oligemia and general toxicity
- Malabsorption and malnutrition
Signs and Symptoms
In the generalized type, the skin is initially fiery red and tender. You may have symptoms such as headache, fever, chills, joint pain, a feeling of general discomfort or uneasiness, decreased appetite, and nausea. Within hours, you may see clusters of pustules.
The most common places these pustules appear are the anal and genital areas and bends and folds in your skin. Pustules may appear on the face, but this is unusual. Pustules can appear on the tongue, which may make it difficult to swallow. They can also occur under your nails and cause your nails to come off.
Within a day, the pustules fuse together and form “lakes” of pus that dry and peel off in sheets. The skin underneath is a smooth reddish surface, on which new pustules can appear. These episodes of pustules appearing, fusing and peeling, and reappearing can last for days to weeks. They can make you uncomfortable and exhausted. In two to three months, a phase involving hair loss can occur.
Once the pustules improve, most of your other symptoms (such as headache and fever) will usually disappear. However, in some people, the skin may remain bright red, and skin symptoms of classical psoriasis may continue.
The ring-shaped type is more common in young children. This type tends to be subacute or chronic, and the symptoms are less severe than in the generalized type. Ring-shaped plaques (elevated areas) appear and are often recurrent. Pustules may appear at the edges of the ring. These areas of skin symptoms appear mostly on the trunk but also on the arms and legs. The edges expand, and the center heals. Other symptoms are either absent or mild.
The juvenile, or infantile, type of pustular psoriasis is usually mild. Other symptoms besides skin symptoms are seldom present. The condition often resolves on its own.
Pustular psoriasis of the palms and soles is usually chronic and may be associated with bone or joint inflammation. The palms or soles are red with white or yellow pustules.
Over the counter treatment
Medical treatment of Pustular Psoriasis can be divided into two:
- Vitamin D: Calcipotriene (Dovonex) is a form of vitamin D-3 and slows the production of excess skin cells. It is used in the treatment of moderate psoriasis. This cream, ointment, or solution is applied to the skin two times a day.
- Coal tar: Coal tar (DHS Tar, Doak Tar, Theraplex T) contains literally thousands of different substances that are extracted from the coal carbonization process. Coal tar is applied topically and is available as shampoo, bath oil, ointment, cream, gel, lotion, ointment, paste, and other types of preparations. The tar decreases itching and slows the production of excess skin cells.
- Corticosteroids: Clobetasol (Temovate), fluocinolone (Synalar), and betamethasone(Diprolene) are commonly prescribed corticosteroids. These creams or ointments are usually applied twice a day, but the dose depends on the severity of the psoriasis.
- Tree bark extract: Anthralin (Dithranol, Anthra-Derm, Drithocreme) is considered to be one of the most effective antipsoriatic agents available. It does have potential to cause skin irritation and staining of clothing and skin. Apply the cream, ointment, or paste sparingly to the patches on the skin. On the scalp, rub into affected areas. Avoid the forehead, eyes, and any skin that does not have patches. Do not apply excessive quantities.
- Topical retinoid: Tazarotene (Tazorac) is a topical retinoid that is available as a gel or cream. Tazarotene reduces the size of the patches and the redness of the skin. This medicine is sometimes combined with corticosteroids to decrease skin irritation and to increase effectiveness. Tazarotene is particularly useful for psoriasis of the scalp. Apply a thin film to the affected skin every day or as instructed. Dry skin before using this medicine. Irritation may occur when applied to damp skin. Wash hands after application. Do not cover with a bandage.
Systemic medications (those that circulate throughout the body)
- Acitretin (Soriatane) or isotretinoin (Accutane, Amnesteem, Claravis, Sotret) are both vitamin A-like drugs available orally. These drugs are generally used immediately to control the acute pustular eruption and then followed by more long-term medications and therapies as noted below.
- Methotrexate (Rheumatrex): This drug suppresses the immune system and slows the production of skin cells. Methotrexate is taken by mouth (tablet) or as an injection once per week. Women who are planning to become pregnant or who are pregnant should not take this drug. Men must not take this drug if there is a possibility that they will impregnate their partners because it can go into the sperm. The doctor will order blood tests to check your blood cell count and liver and kidney function on a regular basis while on this medicine.
- Etanercept (Enbrel): This drug is a manmade protein that works with the immune system to reduce inflammation. It is FDA approved for psoriatic arthritis. Etanercept is given as an injection two times per week. The drug can be injected at home. Rotate the site of injection (thigh, upper arm, abdomen). Do not inject into bruised, hard, or tender skin. Enbrel affects your immune system and is rarely associated with heart failure.
- Adalimumab (Humira): An antibody that binds to TNF, a key mediator of inflammation. Adalimumab is injected every two weeks and is not used in persons with significant heart failure or active infections.
- Cyclosporine (Sandimmune, Neoral): This drug suppresses the immune system and slows the production of skin cells. Cyclosporine is taken by mouth once a day. Your doctor will order tests to check your kidney and liver function and levels of cyclosporine in your blood while you are on this medicine. Cyclosporine may increase the risk of infection or lymphoma, and it may cause high blood pressure.
- Alefacept (Amevive): In 2003, the FDA approved this drug for the treatment of psoriasis. It suppresses the immune system to slow down the production of skin cells. Alefacept is given as an injection once per week. Women who become pregnant while taking alefacept should be enrolled in the manufacturer’s pregnancy registry by calling 866-263-8483. Alefacept may increase the risk of malignancy or infection, may cause allergy or swelling of the throat or tongue, and may cause a hard lump, inflammation, or bleeding at the injection site.
- Ultraviolet light therapy