A pustular psoriasis is an uncommon form of psoriasis. Pustular psoriasis appears as clearly defined, raised bumps that are filled with a white, thick fluid composed of white blood cells. This purulent exudate is commonly called pus. The skin under and around these bumps is red. Although pus is often a sign of infection, there is no evidence that infection plays any role in pustular psoriasis.
Pustular psoriasis may precede, accompany, or follow the standard form of plaque-type psoriasis.
Pustular psoriasis is classified into one of several types, depending on symptoms. Symptoms may be sudden and severe (acute), long-term (chronic), or somewhere in between (subacute). Widespread pustular psoriasis (von Zumbusch type) affects large areas of the skin and can produce a systemic febrile illness. A ring-shaped (annular, or circinate) type has also been described. It is usually subacute or chronic, and people with this type do not usually have symptoms aside from skin involvement. Pustules may be localized to the palms and soles (palmoplantar pustulosis) or to the fingertips and nails (acrodermatitis continua of Hallopeau). Less common is the juvenile, or infantile type, which occurs in children. Pustular psoriasis in pregnancy (impetigo herpetiformis) is occasionally life-threatening.
Pustular psoriasis is not a common disease. Far more common forms of psoriasis are plaque psoriasis and guttate psoriasis, which account for over 90% of psoriasis. Pustular psoriasis affects all races. In adults, it affects men and women equally. In children, it affects boys somewhat more often than girls. The average age of people with pustular psoriasis is 50 years. Children 2-10 years of age can be affected by the disease, but this is rare.
To understand pustular psoriasis, one must recognize aspects of classical plaque-type psoriasis. It is generally agreed that a combination of genetics and environment induces psoriasis, including this pustular subtype. Below is a list of factors that are known to exacerbate pustular psoriasis:
In most people, a trigger for the disease is never identified.
In the generalized form, the skin is initially fiery red and tender. Someone may have symptoms such as headache, fever, chills, joint pain, a feeling of general discomfort or uneasiness, decreased appetite, and nausea. Within hours, one may see clusters of pustules.
The most common places these pustules appear are the anal and genital areas and the skin folds in the 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 the nails and cause the nails to come off.
Within a day, the pustules coalesce to 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 may recur for days to weeks. They can make someone uncomfortable and exhausted.
Once the pustules improve, most of your other symptoms (such as headache and fever) will usually disappear. Occasionally, the skin may remain bright red, and classical plaque-type disease may follow.
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 without systemic symptoms. The condition often resolves on its own.
Pustular psoriasis of the palms and soles is usually chronic and is often associated with bone or joint inflammation (psoriatic arthritis). The palms or soles are red with white or yellow pustules.
An individual should visit a physician if he or she has a rash of raised, pus-filled bumps on the skin, especially if he or she has generalized symptoms such as headache, fever, chills, joint pain, a feeling of general discomfort or uneasiness, decreased appetite, and nausea. It is important for a physician to evaluate the individual for a potentially curable health condition caused by an infectious organism as well as consider whether or not one may have another associated chronic problem. A dermatologist is a skin specialist with a particular expertise in evaluating and treating pustular psoriasis.
Visit a doctor anytime one has sores of any type in the mouth or throat that make it difficult to breathe or swallow.
A doctor may perform blood tests, including the following, in order to make a diagnosis:
A doctor may take a small sample of a pustule's contents to perform a culture. The results from these cultures and blood cultures are usually negative (no sign of infection). Since the skin is damaged, it may become infected, and the cultures are important. Occasionally, a biopsy of the skin can be examined by a pathologist to help confirm the diagnosis.
People with the generalized form of pustular psoriasis are occasionally admitted to the hospital to make sure they have adequate fluid intake and bed rest and don't lose too much heat or have too much strain on the heart. Bland compresses are applied to the patient's skin, and saline (saltwater) solutions and oatmeal baths help to soothe and heal affected areas. In children with pustular psoriasis, this treatment is often all that's needed.
There are two basic types of treatments for psoriasis: (1) topical therapy (drugs used on the skin) and (2) systemic therapy (drugs taken into the patient's body). All of these treatments may be used alone or in combination.
The goals of medications are to reduce symptoms and prevent complications. In general, topical treatment is of limited use in treating extensive pustular psoriasis. Options to be considered for the limited disease include bland emollients and topical steroids, substances unlikely to produce any local irritation or inflammation. The main topical treatments are corticosteroids, vitamin D-3 derivatives, coal tar, anthralin, or retinoids. Generic drug names are listed below with examples of brands in parentheses.
For the most part, alternative therapies have not been tested with clinical trials, and the FDA has not approved dietary supplements for the treatment of psoriasis. However, the National Psoriasis Foundation does discuss some other therapies on its website. Individuals should check with their doctors before starting any therapy.
Complications may include the following:
The von Zumbusch type (with fever and toxicity) can cause death if it is not treated during the acute phase. In the elderly and those with compromised cardiopulmonary function, pustular psoriasis can be a very serious condition.
Occasionally, acute respiratory distress syndrome can complicate generalized pustular psoriasis. People who have typical psoriasis before they experience a generalized pustular episode tend to do better than people with unusual forms of psoriasis before the pustular flare-up.
Children tend to recover well as long as serious skin infections are avoided.
Education is one of the foundations for managing this chronic and typically relapsing condition. People with psoriasis should be familiar with the treatment options in order to make proper informed decisions about therapy. The National Psoriasis Foundation is an excellent organization that provides support to people with psoriasis.
American Academy of Dermatology
American Academy of Dermatology, PsoriasisNet
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For generalized pustular psoriasis, systemic agents such as retinoids may be required from the beginning of treatment. This may be followed by PUVA treatment. For milder and chronic forms of pustular psoriasis, topical treatment or light treatment may be tried first.
