Pustular psoriasis: Treatment options
Pustular (pus-choo-lar) psoriasis causes pus-filled bumps called pustules (pus-choo-ules). Depending on the type of pustular psoriasis you have, the pustules form on your skin, and sometimes inside your mouth or beneath a nail.
A variety of psoriasis medications are used to treat the pustules. A board-certified dermatologist will create a treatment plan with the following goals in mind:
Lessen (or clear) your pus-filled bumps.
Alleviate your symptoms, such as pain, itching, fever, or chills.
Reduce your risk of developing complications.
To achieve these goals, a dermatologist will consider:
The type of pustular psoriasis you have
Where you have pustules on your body and how many pustules you have
Your symptoms, age, and other medical conditions
The medications that you take
Whether your flare-up is mild, moderate, or severe
The following describes how board-certified dermatologists treat the different types of pustular psoriasis.
Generalized pustular psoriasis (GPP)
Generalized pustular psoriasis causes sudden, widespread pus-filled bumps that come together and break open
Symptoms include fever, chills, dehydration, and a rapid pulse.
This type of pustular psoriasis requires immediate medical care. Without treatment, GPP can become life-threatening. Here’s how your dermatologist may treat it.
Treatment for GPP in adults: Your dermatologist may prescribe one of the following medications to get this pustular psoriasis under control.
Spesolimab (Spevigo®): This biologic is the only medication that the U.S. Food and Drug Administration (FDA) has approved specifically to treat flares of GPP in adults.
Spesolimab is given intravenously (by IV), so you’ll need to go to a treatment center that offers infusions, like your dermatologist’s office, a hospital, or an infusion center. The infusion usually takes about 90 minutes. A second infusion can be given a week later if needed.Infliximab: This is a biologic medication. It can decrease inflammation (and bumps) quickly.
Oral retinoid: This type of medication comes from vitamin A. These pills have been used for years to help get GPP under control.
Because the above are potent medications and may have side effects, they may not be suitable for some patients. Another medication may be used to get GPP under control. Psoriasis medications that may be prescribed include:
Another biologic, such as adalimumab or etanercept
To get GPP under control, a dermatologist may prescribe two medications. For example, your dermatologist may prescribe etanercept (a biologic) and cyclosporine, infliximab (a biologic) and methotrexate, or infliximab followed by etanercept (both biologics).
Knowing how to prescribe these combinations requires in-depth expertise in treating pustular psoriasis.
Impetigo herpetiformis
When generalized pustular psoriasis occurs during pregnancy, it’s called impetigo herpetiformis. A rare type of psoriasis, it most commonly occurs during the third trimester and can have life-threatening effects on both mother and baby.
Impetigo herpetiformis begins with pus-filled bumps that develop on the mother’s inner thighs and groin. As the pustules come together and spread, the pus-filled bumps cover a large, widespread area.
Pus-filled bumps can also develop inside the mouth and under the nails.
While this type of pustular psoriasis can cover a large area of your body, treatment options differ from those listed above for generalized pustular psoriasis. For example, oral retinoids should not be taken during pregnancy because of the potentially harmful effects on the baby.
A treatment plan for treating impetigo herpetiformis often begins with psoriasis medications that you apply to your skin. A dermatologist may prescribe:
A corticosteroid cream (applied to the skin)
If stronger treatment is required to get the psoriasis under control, a dermatologist may prescribe:
A steroid medication, such as prednisone
Phototherapy (light therapy)
If you have severe or life-threatening psoriasis, your dermatologist may prescribe one of the following to get the psoriasis under control:
To reduce possible side effects, your dermatologist may prescribe more than one medication. This can be an effective strategy when the doctor has expertise in this area.
Palmoplantar pustular psoriasis
This type of pustular psoriasis causes pus-filled bumps that form only on the palms, soles, or both.
One of the following is often used to treat this type of pustular psoriasis:
Corticosteroid (applied to the skin)
Synthetic vitamin D (applied to the skin)
Phototherapy (light treatments)
Corticosteroid and salicylic acid (applied to the skin)
The above treatments are often effective for treating mild disease. To strengthen a medication that you apply to your skin, your dermatologist may tell you to apply the medication and then cover it with a gauze bandage or other dressing.
If you have many pus-filled bumps, your dermatologist may prescribe:
Acrodermatitis continua of Hallopeau
A rare type of pustular psoriasis, this causes pus-filled bumps on the fingertips, toes, or both. Pus-filled bumps can also develop underneath the nails.
Often beginning on one finger or toe, new pus-filled bumps may continue to appear. When this happens, new pustules can develop on more than the fingers and toes. In rare cases, the pus-filled bumps can slowly spread up the arms or legs.
Anyone who has pus-filled bumps over much of their skin needs immediate medical care. When widespread, pustular psoriasis can be life-threatening.
The first choice for treating this type of pustular psoriasis often includes the following.
Synthetic vitamin D combined with a strong corticosteroid: This combination is applied to the skin.
PUVA: This is a type of light treatment. It involves taking a medication called psoralen before getting light treatment known as UVA therapy.
While the above describes what treatment may be used for each type of pustular psoriasis, your treatment plan may include different medications. Your age, other medical conditions (if any), and general health also play key roles in determining which treatment is best for you.
Images
Image 1: Used with permission of DermNet NZ.
Image 2: Used with permission of the American Academy of Dermatology National Library of Dermatologic Teaching Slides.
References
Blair HA. “Spesolimab: First approval.” Drugs. 2022 Nov;82(17):1681-6. Erratum in: Drugs. 2023 Jan;83(1):103.
Gudjonsson JE, Elder JT. “Psoriasis.” In: Kang S, et al. Fitzpatrick’s Dermatology. (ninth edition) McGraw Hill Education, United States of America, 2019:461-63.
Jeon C, Nakamura M, et al. “Generalized pustular psoriasis treated with apremilast in a patient with multiple medical comorbidities.” JAAD Case Rep. 2017;3(6): 495-7.
Robinson, A Van Voorhees AS, et al. “Treatment of pustular psoriasis: From the Medical Board of the National Psoriasis Foundation.” J Am Acad Dermatol 2012;67:279-88.
Sussman M, Napodano A, et al. “Pustular psoriasis and acute generalized exanthematous pustulosis.” Medicina (Kaunas). 2021 Sep 23;57(10):1004.
Written by:
Paula Ludmann, MS
Reviewed by:
Elisa Gallo, MD, FAAD
Laurel Geraghty, MD, FAAD
Last updated: 10/4/23