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Pustular psoriasis: Treatment options

physician at laptop
If you develop pustular psoriasis, you may be referred to a board-certified dermatologist for treatment.
If you have pustular (pus-choo-lar) psoriasis, pus-filled bumps called pustules (pus-choo-ules) form.

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 your:

  • Type of pustular psoriasis

  • Symptoms

  • Age

  • Other medical conditions

  • Medications that you take to treat another condition

  • Flare-up intensity (mild, moderate, or severe)

The type of pustular psoriasis you have is one of the first considerations because certain treatments are considered the best choice for each type. The following describes the first choices for each type of pustular psoriasis.

Pustular psoriasis

On their hands and feet, people develop painful pus-filled blisters and thick, scaly skin that cracks easily.

Pustular psoriasis
What is pustular psoriasis?

This type of psoriasis causes reddish, scaly, pus-filled bumps.

Anyone who has pus-filled bumps over much of the body needs immediate medical care. When widespread, pustular psoriasis can be life-threatening.

The pus-filled bumps are called pustules. They can form on the skin, inside the mouth, or beneath a nail.

About 24 to 48 hours after the pus-filled bumps appear, they join together and burst open.

As the pus dries, the area turns red and glazed. It often feels raw and tender.

On the red, glazed area, new pustules can form. These, too, will join together and burst open.

Generalized pustular psoriasis (GPP)

This type of pustular psoriasis causes widespread pus-filled bumps and requires immediate medical care.

Symptoms of GPP include fever, chills, dehydration, and a rapid pulse.

Generalized pustular psoriasis

Rare and very serious, this type of psoriasis requires emergency medical care. It begins with dry, red, and tender skin. Within hours, widespread pus-filled blisters appear.

Generalized pustular psoriasis

Treatment for GPP in adults: A dermatologist may prescribe one of the following medications to get the psoriasis under control.

  • Oral retinoid

  • Infliximab: This is a biologic, which can decrease inflammation (and bumps) quickly. Because patients often respond rapidly, some experts believe this may be the first choice when GPP is severe.

Because the above are potent medications, they may not be suitable for some patients. Another medication may be used to get the psoriasis under control. Possible psoriasis medications that may be prescribed include:

To get GPP under control, a dermatologist may prescribe two medications. Options include using etanercept (a biologic) and cyclosporine, infliximab (a biologic) and methotrexate, or infliximab followed by etanercept.

Knowing how to prescribe these combinations requires in-depth expertise in treating pustular psoriasis.

GPP in children: While rare, this condition can develop before someone turns 18 years of age. When it does, the first choices for treating it follow.

  • Cyclosporine: This may be the first choice because it works quickly. It usually takes two to four weeks to see an improvement.

  • Etanercept: This is a type of medication called a biologic. It is used to treat severe plaque psoriasis in children aged 4 to 17 years old. Some experts believe that this may be the first choice for treating a child who has pustular psoriasis. It is typically given twice weekly for two months because it takes time to see improvement.

  • Methotrexate: A low dose may be given to a child as young as 2 years old. It often takes about two weeks to see an improvement in a child, but it can take longer.

Other psoriasis medications and treatments may also be an option, including phototherapy or another biologic.

Impetigo herpetiformis

Developing only in pregnant women during their last trimester, this type of pustular psoriasis begins with pus-filled bumps that form in the inner thighs and groin. As the pustules join together and spread, the pus-filled bumps cover a large, widespread area.

Pus-filled bumps can develop inside the mouth and under the nails.

Because this condition is rare, it’s still unknown whether this is actually a different type of pustular psoriasis. This may be GPP.

While the psoriasis can cover a large area of your body, treatment options differ from those listed above for GPP. For example, pregnant women should not take an oral retinoid.

A treatment plan for treating impetigo herpetiformis often begins with psoriasis medication that you apply to your skin. A dermatologist may prescribe:

If stronger treatment is required to get the psoriasis under control, a dermatologist may prescribe:

If you have severe or life-threatening psoriasis, your dermatologist may prescribe one of the following to get the psoriasis under control:

  • Cyclosporine

  • A biologic

To reduce possible side effects, your dermatologist may prescribe more than one medication. This may sound strange, but it can be an effective strategy when the doctor has expertise in this area.

Palmopustular psoriasis

This type of pustular psoriasis causes pus-filled bumps to form only on the palms, soles, or both. Often, one of the following is used to treat this type of pustular psoriasis:

  • Corticosteroid (apply to the skin)

  • Synthetic vitamin D (apply to the skin)

  • Phototherapy (light treatments)

  • Corticosteroid and salicylic acid (apply to the skin)

The above treatments are often effective for treating mild disease. To strengthen 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:

  • An oral retinoid

  • A biologic

Acrodermatitis continua of Hallopeau

This type of pustular psoriasis is rare. It causes pus-filled bumps on the fingertips, toes, or both. The disease 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 the 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 that involves taking a medication called psoralen before getting UVA light treatments on the affected skin.

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 role in determining which treatment is best for you.

Getty Images

Fitzpatrick JE. “Pustular eruptions.” In: Fitzpatrick JE and Aeling JL. Dermatology Secrets. Hanley & Belfus, Inc., Philadelphia, 1996:66-7.

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.