CASE 8: Erythrodermic or Pustular Psoriasis

A 60-year-old man with a long history of psoriasis vulgaris required a systemic corticosteroid for a severe exacerbation of asthma. Soon after theErythrodermic or Pustular Psoriasis corticosteroid was discontinued, generalized erythema and scaling of the skin developed. (Case and photograph courtesy of Drs Marti Jill Rothe and Jane M. Grant-Kels.)What therapies do you consider?
A REVIEW OF THE OPTIONSErythrodermic psoriasis features diffuse erythema and scaling. Generalized pustular psoriasis is characterized by waves of sterile pustules on an erythematous base that leads to desquamation and often evolves into an erythroderma. These highly labile forms of psoriasis can be precipitated by infection, including HIV disease; withdrawal of systemic or ultrapotent topical corticosteroids; and cutaneous drug reactions. A history of psoriasis may exist, or erythrodermic or pustular disease may be the initial presentation of psoriasis. Patients often appear toxic and present with fever, chills, malaise, and fatigue. Potential complications include deep venous thrombosis and pulmonary embolism caused by confinement to bed and inactivity, high output cardiac failure from shunting of blood to the skin, peripheral edema from negative nitrogen balance induced by protein loss through shed scale, fluid and electrolyte imbalance, and sepsis from secondary cutaneous infection. Patients are treated initially with gentle and bland topical therapy, including oatmeal baths, wet dressings, emollients, and low-potency topica corticosteroids; antihistamines and antibiotics can be given for secondary infection. When local measures fail to ameliorate the condition, consider systemic therapy with cyclosporine, methotrexate(, or retinoids. Cyclosporine can rapidly clear either of these 2 forms of psoriasis within 1 to 3 weeks; retinoids clear pustular psoriasis within 1 to 2 weeks, but these agents are slow to achieve improvement in patients with erythrodermic psoriasis. The gradual onset of action of methotrexate takes from 3 to 6 weeks. The premarketing research data from the biologic agents discussed in the Quick Take on page 890 indicate that these drugs may offer relief for patients with erythrodermic or pustular psoriasis.CASE 8:
APPROACH AND OUTCOMEAfter 2 weeks of gentle and conservative skin care, the erythroderma began to clear and the patient's psoriasis reverted to stable plaque disease. [Editor's note: Although our policy is to use generic names whenever possible, some trade names have been used to distinguish between certain agents and formulations.]