Pustular psoriasis: Treatment
Pustular (pus-tyu-lar) psoriasis is a type of psoriasis that causes pus-filled bumps called pustules (pus-tules). Depending on the type of pustular psoriasis you have, the pustules form on your skin, and sometimes inside your mouth or beneath a nail.
If the pustules cover large areas of your body, you may have generalized pustular psoriasis. Not everyone develops widespread pustules. Sometimes, the pustules develop in a specific area, such as on your fingers and toes.
If you have pustules over much of your skin along with fever or chills, get immediate medical care from a board-certified dermatologist
Fever, chills, or both can be signs that pustular psoriasis is becoming life-threatening.
A variety of medications are used to treat the pustules. A board-certified dermatologist will create a treatment plan with the following goals in mind:
Reduce (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 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
Flare-ups of generalized pustular psoriasis can occur suddenly, causing widespread pus-filled bumps that come together and break open. When the bumps break open, they leave pus (often called “lakes of pus”) on the skin. As the skin dries out, you usually see a red (lighter skin tones) or purplish (darker skin tones) color develop. Skin shedding follows.
Generalized pustular psoriasis is the most serious type of pustular psoriasis. Symptoms include fever, chills, dehydration, and a rapid pulse.
Generalized pustular psoriasis
A flare-up causes widespread pus-filled bumps over large areas of the body. The bumps are usually white or yellow. On lighter skin tones, the skin is often red (A). On darker skin tones, you may not see a change in skin color (B), a purplish discoloration, or a color that’s darker than your natural skin tone.
Treatment for generalized pustular psoriasis
It's important to treat generalized pustular psoriasis. Your dermatologist will consider your age, other medical conditions (if any), and general health when determining how to treat generalized pustular psoriasis. Your treatment plan may include:
Spesolimab (Spevigo): This biologic is the only medication approved by the U.S. Food and Drug Administration (FDA) to treat generalized pustular psoriasis. It’s approved to treat adults and children aged 12 or older who weigh at least 40 kilograms (a little than 88 pounds). Spesolimab may be given intravenously (by IV) or as an injection you give yourself at home.
Treatment for generalized pustular psoriasis flares
A sudden flare-up of generalized pustular psoriasis requires immediate medical care. Without treatment, this psoriasis can become life-threatening. Here’s how your dermatologist may treat a sudden flare-up.
Spesolimab: This biologic is also the only medication that the FDA has approved specifically to treat flares.
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 this type of psoriasis under control.
Because the above are potent medications and may cause side effects, they may not be suitable for some patients. Other medications may be used to get the psoriasis under control. These medications include:
Another biologic, such as ixekizumab or secukinumab
Sometimes, your dermatologist will prescribe more than one medication. Using two medications may be the most effective way to get generalized pustular psoriasis under control.
Pustular psoriasis of pregnancy
This is a rare type of psoriasis. It most commonly occurs during the third trimester and may be life threatening for both mother and baby.
Also called impetigo herpetiformis, this type of psoriasis 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 pustular psoriasis of pregnancy often begins with psoriasis medications that you apply to your skin. A dermatologist may prescribe:
A corticosteroid cream (applied to the skin)
Synthetic vitamin D (applied to the skin)
If stronger treatment is required to get the psoriasis under control, a dermatologist may prescribe:
An oral corticosteroid 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.
Palmoplantar pustulosis
This type of pustular psoriasis causes pus-filled bumps that form on the hands, feet, or both.
Palmoplantar pustulosis on the side of a patient’s foot
On the affected skin, you’ll see pus-filled bumps. The skin may also be discolored, thick, scaly, and painful.
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. Only cover the medication if your dermatologist tells you to.
If you need stronger medication, your dermatologist may prescribe:
Acrodermatitis continua of Hallopeau
A rare type of pustular psoriasis, this condition causes painful 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: Getty Images
Images 2, 3: Reproduced with permission from ©DermNet www.dermnetnz.org 2024.
Image 4: 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.
Cockerell CJ (author), James WD (Chief Editor). “Pustular psoriasis treatment & management.” Medscape. Last updated Jul 1, 2024. Last accessed Aug 1, 2024.
Genovese G, Moltrasio C, et al. “Pustular psoriasis: From pathophysiology to treatment.” Biomedicines. 2021 Nov 23;9(12):1746.
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.
Navarini AA, Burden AD, et al. “European consensus statement on phenotypes of pustular psoriasis.” J Eur Acad Dermatol Venereol. 2017 Nov;31(11):1792-9.
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:
Elan M. Newman, MD, FAAD
Megan H. Noe, MD, MPH, FAAD
Rajiv I. Nijhawan, MD, FAAD, FACMS
Brittany Oliver, MD, FAAD
Last updated: 8/29/24