a dermatologist examining a person's feet

What Makes Pustular Psoriasis Different from Other Types

By Corinne O'Keefe Osborn
February 10, 2022

If you or a loved one has pustular psoriasis, you probably want to know more about what makes this type different, including how best to treat it. Here, we’ve answered your biggest questions about living with pustular psoriasis.

What Is Pustular Psoriasis?

Pustular psoriasis is a very rare type of psoriasis characterized by small white pustules that spread rapidly across inflamed skin. It affects only up to nine people in one million. Some cases of pustular psoriasis are more serious than others, and unfortunately, pustular psoriasis can be extremely debilitating and even life-threatening when left untreated.

What Are the Symptoms of Pustular Psoriasis?

During flare-ups, people with this type of psoriasis get widespread pustules, which are tiny white blisters resembling pimples. Pustules can form anywhere on the skin, inside the mouth, and beneath or around the fingernails. The pustules begin joining together about 24 to 48 hours after they first appear, at which point they burst open. As the pus dries on inflamed skin, the area may appear crusty, red, brown, or glazed. New pustules develop and the process repeats.

There are several different subtypes of pustular psoriasis. In each of them, symptoms appear slightly differently and at different severity levels.

Palmoplantar pustulosis (PPP) is a type of pustular psoriasis that affects the palms of the hands, the soles of the feet, or both. It can also present around the base of the thumbs and heels. It first resembles small white studs on top of red plaques, but later becomes crusted and peels. PPP typically comes and goes in a cyclical pattern.

Generalized pustular psoriasis (GPP), also known as von Zumbusch psoriasis, is a rare and serious condition characterized by severely itchy pustules covering large portions of the body. It may begin with large areas of reddened, painful skin. Pustules then cover the skin in a matter of hours. It is typically accompanied by fever, chills, rapid heart rate, and nausea.

“If pustular psoriasis involves your entire body, it can become life-threatening. The high degree of inflammation can lead to rapid temperature shifts, an increased risk of dehydration (which can lead to electrolyte imbalance), and increased risk of infection,” explains Peterson Pierre, M.D. of the Pierre Skin Care Institute in Westlake Village, California.

Acropustulosis is one of the rarest forms of psoriasis. People with this subtype develop pustules on the tips of their fingers and toes. These eruptions are extremely painful, making it difficult to walk and grasp things. It often starts on one finger or toe and then progresses to others. It has also been known to cause damage to the joints and nails.

Pustular psoriasis of pregnancy occurs during the third trimester of a woman’s pregnancy. It resembles GPP, but often begins with pustules forming on the inner thighs and groin. Pustules may become widespread, even forming inside the mouth and under the nails.

“Pustular psoriasis of pregnancy, or impetigo herpetiformis, is a rare and serious condition that has potential serious consequences for both the mother and fetus,” says Dr. Paola De Mozzi, a dermatologist based in London, England. “Early recognition and treatment are paramount.”

Who Gets Pustular Psoriasis?

Pustular psoriasis is very rare, and it can develop in people with other types of psoriasis. With generalized pustular psoriasis, the average age of onset is about 40, although it tends to affect women a bit earlier than men. About 65 percent of people with generalized pustular psoriasis have a history of psoriasis, but this is not necessarily the case in the other forms. Pustular psoriasis of pregnancy affects pregnant women in their third trimester and PPP occurs almost entirely in people who smoke.

What Triggers Pustular Psoriasis?

According to De Mozzi, “There are potential triggers for pustular psoriasis, for example, stress (physical or emotional), infections, certain drugs, sudden withdrawal of steroid medications, excessive UV exposure, pregnancy, and excessive alcohol consumption.”

Many of these triggers are unavoidable, but some are within your control. For example, if you regularly take steroid medications for your psoriasis, you can work with your doctor to taper down your dose, rather than stopping it abruptly. Also, if you’re a smoker, working with your doctor to develop a plan to quit smoking can decrease your risk of developing PPP.

What Treatments Work for Pustular Psoriasis?

Pustular psoriasis always requires medical attention, as it can become life-threatening if it becomes severe. Recommended treatment is often similar to the treatment of plaque psoriasis. “This includes topical treatments for milder forms and systemic treatments for more severe and extensive forms,” says De Mozzi. But the subtype and extent of pustular psoriasis will often be factors.

Treatment options include:

  • Oral retinoids (like Acitretin)
  • Biologics (like Infliximab)
  • Corticosteroids
  • Synthetic vitamin D
  • Phototherapy
  • Psoralens dtogether with ultraviolet light (PUVA)
  • Apremilast
  • Methotrexate
  • Cyclosporine

According to Pierre, special care must be taken when treating pregnant women to ensure the treatment is safe. “During pregnancy, the following drugs are used: oral steroids, narrow band UVB, cyclosporine, oral antibiotics, and infliximab.” An OB/GYN will also need to oversee treatment to ensure the safety of both mother and baby.

Living with Pustular Psoriasis

Living with recurring pustular psoriasis isn’t easy, but there is hope. Treatment can involve some trial and error, but a good dermatologist will stick by you until you find a medication and plan that works for you. It’s also a good idea to keep your primary care doctor in the loop. They can help coordinate your care team and stay on top of any hospitalizations to help you get well.

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