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Pustular Psoriasis
A positive approach
to psoriasis and
psoriatic arthritis
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What are the aims of this leaflet?
This leaflet has been written to help you understand more
about different types of pustular psoriasis, including
treatments.
What is psoriasis?
Psoriasis (sor-i’ah-sis) is a long-term (chronic) scaling disease
of the skin, which affects 2% to 3% of the UK population. IT
IS NOT CONTAGIOUS. It appears as red, raised, scaly
patches known as plaques. Any part of the skin surface may
be involved, but the plaques most commonly appear on the
elbows, knees and scalp. It can be itchy, but is not usually
painful. Nail changes, including pitting and ridging, are present
in 40% to 50% of people with psoriasis and 10% to 20% of
people with psoriasis will develop psoriatic arthritis. There are
many different types of psoriasis, including chronic plaque
psoriasis, and there are also many types of pustular psoriasis
(see below), guttate psoriasis, scalp psoriasis, flexural
psoriasis, napkin psoriasis, nail psoriasis and erythrodermic
psoriasis – see our What is Psoriasis? leaflet.
What happens?
Normally a skin cell matures in 21 to 28 days and during this
time it travels to the surface, where it is
lost in a constant invisible
shedding of dead cells. In
patches of psoriasis the
turnover of skin cells is
much faster, around 4 to 7
days, and this means
that even live cells can
reach the surface and
accumulate with dead
cells. The extent of
psoriasis and how it affects
an individual varies from
Plaque psoriasis
person to person. Some may be
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mildly affected, with a tiny patch hidden away on an elbow
which does not bother them, while others may have large
visible areas of skin involved that significantly affect daily life
and relationships. This process is the same wherever it occurs
on the body.
Pustular psoriasis tends not to look like plaque psoriasis,
although plaque and pustular psoriasis can coexist or one
may follow the other.
The main distinguishing feature of pustular psoriasis is the
appearance of pus spots surrounded
by red skin. This doesn’t mean
that there is any infection
present. The spots simply
show that the skin has
been invaded by the
same white blood cells
that would be seen if
there were to be an
infection present.
It can be triggered by
some internal medications,
irritating topical agents,
Pustular psoriasis
u l t r a v i o l e t l i g h t o v e rd o s e s ,
pregnancy, systemic steroids (especially sudden withdrawal
of systemic or topical steroids), infections, perspiration or
emotional stress.
Generalised pustular psoriasis
Generalised pustular psoriasis is a rarer form of the condition,
and especially rare in children. It can be abrupt, and triggered
by an infection, pregnancy, low thyroid activity or any of a
number of different drugs. It can cause fever, chills, severe
itching, rapid pulse rate, exhaustion, anaemia, weight loss,
muscle weakness and/or joint pain. Sometimes these attacks
are followed by milder outbreaks of psoriasis. With this type,
the pustules occur all over the body – patients can often
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© Bernard Cohen MD, Dermatlas http://www.dermatlas.org
Pustular psoriasis
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become quite unwell and, as such, generalised pustular
psoriasis often requires hospital in-stay treatment. Please do
note that this is a rare form of psoriasis.
Another form of pustular psoriasis, palmer-plantar pustulosis,
causes pustules on the palms and soles of
the feet. It tends to occur in people
between the ages of 20 and
60, and is more common in
people who smoke.
Infection and stress
are suspected trigger
factors. PPP is normally
recognisable by large
yellow pustules up to
5cm in diameter in fleshy
areas of hands and feet,
such as the base of the thumb
and the sides of the heels. It may
PPP
be painful. The pustules then turn
brown and drop off or peel. PPP is usually cyclical with new
crops of pustules followed by periods of low activity. This form
of psoriasis affects approximately 5% of people with
psoriasis.
It tends to go in cycles of:
● erythema (reddening of the skin) followed by
● formation of pustules; and
● scaling of the skin.
Topical therapies are usually a first-line treatment. PUVA and
methotrexate are also sometimes used to clear the attack.
However this type of psoriasis can be a little more difficult to
manage.
In most episodes of pustular psoriasis these will last for a
few weeks then disappear or return to erythrodermic psoriasis.
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© Shahbaz A Janjua MD, Dermatlas http://www.dermatlas.org
Palmer-plantar pustulosis
(PPP)
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Acrodermatitis continua of
Hallopeau
© Shahbaz A Janjua MD, Dermatlas http://www.dermatlas.org
Another rare type of palmar-plantar pustular psoriasis,
acrodermatitis continua of Hallopeau is characterised by
skin lesions on the ends of the fingers and sometimes on the
toes. The eruption occasionally starts after local trauma. Often
the lesions are painful and disabling, with the nails often
deformed, and bone changes may occur. This condition is
quite hard to treat satisfactorily.
Treatment
Pustular psoriasis and PPP are usually treated with topical
treatments. Sometimes topical steroids under thin dressings
are prescribed. Pustular psoriasis can be stubborn to treat so
sometimes other treatment regimes typically used for plaque
psoriasis may be tried. Although not completely proven, for
those who smoke, quitting appears to reduce the number of
pustules as well as significantly reducing the erythema
(redness) and desquamation (shedding of skin).
The main aims of the treatment of generalised pustular
psoriasis are to restore the skin’s barrier function, prevent
further loss of fluid, stabilise the body’s temperature and
restore the skin’s chemical balance. Imbalances, which can
occur, might put added strain on the heart and kidneys,
especially in older people. Because of possible complications
with this form of psoriasis, if you’re affected you should seek
medical care immediately. The likelihood of hospitalisation for
a short period of time depends on the severity of the outbreak.
When hospitalised, bed rest, mild sedation, bland topical
therapy, rehydration and avoiding excessive heat loss can
improve the situation. It is important to remove as many of the
potential trigger factors as possible. In some cases antibiotics
are prescribed just in case an infection is also present. In
severe cases, where the patient has become exhausted, other
medications may be needed.
Methotrexate is the most common treatment for generalised
pustular psoriasis. Ciclosporin is also used if your doctor
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needs to control the symptoms quickly. Oral steroids are often
prescribed for those who do not respond to other forms of
treatment or who have become very ill, but their use is very
controversial. PUVA (the photsensitising drug psoralen plus
UVA light) may also be used in the treatment of this condition
after it has subsided.
Acrodermatitis continua of Hallopeau tends to be resistant
to both topical and systemic treatments for psoriasis, so
combinations of therapy may be tried. Most episodes of
pustular psoriasis will last for a few weeks then disappear or
remit to erythrodermic psoriasis.
Summary
● Pustular psoriasis is a rare form of psoriasis
● Severe cases need urgent referral
● Be aware of the trigger factors
● PPP is more common in people who smoke
● It tends to go in cycles
● Where pustules exist they may not necessarily be
infectious
● Like psoriasis, the pustular version is not contagious.
Always consult your doctor or healthcare provider.
About this information
This material was produced by PAPAA. Please be aware that
treatments and research is ongoing. References and sources
of evidence for this leaflet are available upon request or can
be found on our website. For the latest information or any
amendments to this material please contact us or visit our
website. The site contains information on treatments and
includes patient experiences and case histories.
Original text written by David and Julie Chandler 1996.
Reviewed/revised April 2004, June 2009, March 2011.
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This edition reviewed and revised by Dr Jennifer Crawley,
Clinical Fellow in Medical Dermatology, St John’s Institute of
Dermatology, London March 2012.
A lay and peer review panel has provided key feedback on
this leaflet. The panel includes people with or affected by
psoriasis and/or psoriatic arthritis.
Published: June 2012
Review date: March 2014
© PAPAA
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®
The charity for people
with psoriasis and
psoriatic arthritis
PAPAA, the single identity of the
Psoriatic Arthropathy Alliance and the
Psoriasis Support Trust.
The organisation is independently funded and is a
principal source of information and educational
material for people with psoriasis and psoriatic
arthritis in the UK.
PAPAA supports both patients and professionals by
providing material that can be trusted (evidencebased), which has been approved and contains no
bias or agendas.
PAPAA provides positive advice that enables people
to be involved, as they move through
their healthcare journey, in an informed way
which is appropriate for their needs and any
changing circumstances.
Contact:
PAPAA
PO Box 111 St Albans Herts AL2 3JQ
Tel: 01923 672837
Fax: 01923 682606
Email: [email protected]
www.papaa.org
ISBN 978-1-906143-19-0
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registered in England and Wales No. 6074887
Registered Charity No. 1118192
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