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Pustular psoriasis

Published by Bupa's health information team, September 2008.

This factsheet is for people who have pustular psoriasis, or who would like information about it.

Psoriasis is a common skin condition causing patches of inflamed skin. Pustular psoriasis is a rare, severe form of the condition, in which small pus-filled spots (pustules) develop on the skin. It is not contagious.

About pustular psoriasis
Symptoms of pustular psoriasis
Complications of pustular psoriasis
Causes of pustular psoriasis
Diagnosis of pustular psoriasis
Treatment of pustular psoriasis
Prevention of pustular psoriasis
Further information
Questions and answers
Related topics
Sources

About pustular psoriasis

In psoriasis, the rate at which your skin is replaced is greatly increased.

Your skin is constantly shedding old cells and being replaced with new ones from underneath, in a cycle that usually takes about 28 days. In psoriasis, this process speeds up, only taking about three to four days. New skin cells move rapidly to the surface before they have properly matured, and accumulate on the surface of the skin, forming thick patches called plaques. There is also a build-up of a type of white blood cell (called T-cells) under the skin, which causes inflammation.

In pustular psoriasis, the white blood cells collect on the surface of your skin in small spots, known as pustules. If this happens all over your body, it is called generalised pustular psoriasis - also sometimes known as von Zumbusch pustular psoriasis. This can be a very serious, life-threatening condition.

Another type of pustular psoriasis which isn't so serious is known as palmo-plantar psoriasis. This type only affects the hands and feet.

The pustules are not contagious and can't be spread to anyone else.

Symptoms of pustular psoriasis

In generalised pustular psoriasis:

small, yellowish pustules may develop anywhere on your body
the skin around the pustules becomes very red and hot
the pustules can come on very quickly and spread rapidly
you may also feel unwell and have a fever

You should seek immediate medical attention if you get these symptoms.

In palmo-plantar psoriasis:

pustules may be yellow or brown and limited to the palms of your hands and soles of your feet
the affected areas of skin may become red and scaly, and are often painful
the pustules may erupt repeatedly over months or even years

If you have any of these symptoms, you should see your GP.

Complications of pustular psoriasis

You may have relapses of pustular psoriasis over a number of years (the psoriasis may keep coming back).

Causes of pustular psoriasis

It is thought that substances produced by your immune system cause your skin to start producing new cells faster in psoriasis, as well as causing the build up of T-cells.

You are more likely to develop generalised pustular psoriasis if you have a history of plaque psoriasis, but some people develop it who have never had the disease. Certain factors may trigger a flare-up of the condition, including:

an infection
suddenly stopping treatment with steroid creams or pills
pregnancy
some prescription medicines

Palmo-plantar psoriasis may be triggered by:

cigarette smoking - this type of psoriasis has a strong association with smoking
an infection
stress

Diagnosis of pustular psoriasis

If you go to your GP with symptoms of palmo-plantar psoriasis, he or she will examine you and ask you about your medical history. He or she may refer you to a dermatologist for some types of treatment. A dermatologist is a doctor specialising in conditions affecting the skin.

If you have generalised pustular psoriasis, you will often need to be admitted to hospital until the condition has stabilised. In hospital, a dermatologist will examine you and may carry out some tests, such as a blood test.

Treatment of pustular psoriasis

Standard treatment for palmo-plantar pustular psoriasis includes creams and ointments that you apply to your skin, and light therapy. You will usually be treated as an outpatient at a hospital dermatology department.
Generalised pustular psoriasis is usually treated in hospital, where you will be monitored until you recover and receive treatment to maintain your fluid levels. You will also be given medicines to treat your psoriasis.

Topical treatment

If you have palmo-plantar psoriasis, your GP will usually suggest that you try medicated topical preparations first (treatments that are applied directly to your skin). These may include creams and ointments containing:

steroids
emollients (moisturisers)
a vitamin D derivative (eg, calcipotriol) - these preparations can be easier to use than some of the other products
coal tar or dithranol

Palmo-plantar psoriasis doesn't always respond to these treatments, however your GP may suggest you try them as they can give some benefit to some people.

Light therapy

Treatment with ultraviolet light is often used for palmo-plantar pustular psoriasis if creams and ointments haven't worked. It can also be used for generalised pustular psoriasis, once the severe stage has passed. Light therapy can only be given by a dermatologist in a hospital. It includes the following.

Psoralen and ultraviolet A light treatment (also called PUVA). This is the most common type of light therapy used for pustular psoriasis, and involves combining a medicine which sensitises the skin to sunlight (psoralen) with a controlled dose of ultraviolet A (UVA) light. You can have psoralen as a tablet, but for palmo-planter pustular psoriasis, it may be applied directly to your skin like a paint. The UVA light is given in a machine that looks similar to a shower cabinet, containing fluorescent tubes. You usually have the treatment twice a week, for several weeks.
Ultraviolet B (UVB) light therapy. UVB light occurs naturally in sunlight. This therapy involves shining artificial UVB light onto your skin. You will usually have the therapy two to three times a week for several weeks.

Oral medicines

You may be given the following medicines while in hospital for generalised pustular psoriasis:

acitretin
ciclosporin
methotrexate

You may also need antibiotics.

You may also be prescribed acitretin or methotrexate if you have very severe palmo-plantar pustular psoriasis that doesn't respond to other treatments.

If you are a woman, you will be warned not to become pregnant for some time after having these medicines. Men may also be advised they shouldn't get their partner pregnant for some time after taking some of the medicines. This is because they can cause serious damage to an unborn baby.

You may also be offered a newer type of medicine called a biological agent. Biological agents are newer treatments for psoriasis that can be very effective, but tend to be restricted to people with severe psoriasis. They are given as an injection into your skin, or through a drip into a vein in your arm.

Your dermatologist can discuss these treatments with you. You will need to have various pre-treatment tests before you can try these medicines, and you will be monitored with blood tests while you are receiving the treatment.

Prevention of pustular psoriasis

If you have a history of psoriasis, you can reduce your chance of having another episode of pustular psoriasis by ensuring you use any treatment you have been given as prescribed. If you notice your psoriasis worsening, see your GP without delay. Some types of medicine can provoke pustular psoriasis; however, you should not stop taking any treatment without advice from a doctor.

As palmo-plantar pustular psoriasis has a strong association with smoking, stopping smoking reduces your chance of getting this form of the disease.

Further information

The Psoriasis Association
0845 676 0076
www.psoriasis-association.org.uk