CASE 8: Erythrodermic or Pustular Psoriasis

A 60-year-old man with a long historyof psoriasis vulgaris required a systemiccorticosteroid for a severe exacerbationof asthma. Soon after theErythrodermic or Pustular Psoriasiscorticosteroid was discontinued, generalizederythema and scaling of theskin developed.(Case and photograph courtesy of Drs Marti Jill Rotheand Jane M. Grant-Kels.)What therapies do you consider?A REVIEW OF THE OPTIONSErythrodermic psoriasis featuresdiffuse erythema and scaling. Generalizedpustular psoriasis is characterizedby waves of sterile pustules onan erythematous base that leads todesquamation and often evolves intoan erythroderma. These highly labileforms of psoriasis can be precipitatedby infection, including HIV disease;withdrawal of systemic or ultrapotenttopical corticosteroids; and cutaneousdrug reactions.A history of psoriasis may exist,or erythrodermic or pustular diseasemay be the initial presentation of psoriasis.Patients often appear toxic andpresent with fever, chills, malaise, andfatigue. Potential complications includedeep venous thrombosis andpulmonary embolism caused by confinementto bed and inactivity, highoutput cardiac failure from shuntingof blood to the skin, peripheraledema from negative nitrogen balanceinduced by protein loss throughshed scale, fluid and electrolyte imbalance,and sepsis from secondarycutaneous infection.Patients are treated initially withgentle and bland topical therapy, includingoatmeal baths, wet dressings,emollients, and low-potency topicacorticosteroids; antihistamines andantibiotics can be given for secondaryinfection. When local measures fail toameliorate the condition, consider systemic therapy with cyclosporine,methotrexate, or retinoids. Cyclosporinecan rapidly clear either of these 2forms of psoriasis within 1 to 3 weeks;retinoids clear pustular psoriasis within1 to 2 weeks, but these agents areslow to achieve improvement in patientswith erythrodermic psoriasis.The gradual onset of action of methotrexatetakes from 3 to 6 weeks.The premarketing research datafrom the biologic agents discussed inthe Quick Take on page 890 indicatethat these drugs may offer relief forpatients with erythrodermic or pustularpsoriasis.CASE 8:APPROACH AND OUTCOMEAfter 2 weeks of gentle andconservative skin care, the erythrodermabegan to clear and the patient'spsoriasis reverted to stableplaque disease.[Editor's note: Although our policy isto use generic names whenever possible,some trade names have beenused to distinguish between certainagents and formulations.]