CLINICAL DESCRIPTION

A 28-year-old woman presented with two days of painful pustules on her chest and back. She also had fever and chills but denied cough or dyspnea. On examination, the temperature was 38.6°C, blood pressure was 93/51 mm Hg, and pulse was 130 beats per minute. Examination of her back (Fig. 1) and ear (Fig. 2) revealed erythematous plaques mixed with scattered pustules. IV fluid and vancomycin were given for possible septic shock. Punch biopsy of the skin was compatible with a clinical diagnosis of generalized pustular psoriasis (GPP).

Figure 1
figure 1

Photograph demonstrating erythematous plaques mixed with scattered pustules on her back.

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Figure 2
figure 2

Photograph demonstrating scaly plaques mixed with small pustules on her ear and cheek.

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GPP is a rare subtype of psoriasis. It is characterized by acute, generalized pustules on erythematous or scaly skin.1 It is considered the most severe type of psoriasis. The pustules are aseptic; therefore, therapeutic or prophylactic antimicrobial therapies are not indicated.1 This subtype of psoriasis can be fatal and requires immediate medical care. The differential diagnosis includes acute generalized exanthematous pustulosis, subcorneal pustular dermatosis and IgA pemphigus, which can present with pustular lesions. Rehydration and supportive skin care are usually indicated for most cases. The National Psoriasis Foundation has recommended using acitretin, cyclosporine, or methotrexate as first-line therapy.2 Systemic steroids should be avoided in the treatment of psoriasis because of the risk of worsening psoriasis.