Psoriasis (Ps) is a long term (chronic) scaling disease of the skin, which affects 2% – 3% of the UK population. It appears as red, raised scaly patches known as plaques. Any part of the skin surface may be involved but the plaques most commonly appear on the elbows, knees and scalp. It can be itchy but is not usually painful. Nail changes are present in 50% of people and 10%-20% of people will develop psoriatic arthritis.


Normally a skin cell matures in 21 – 28 days and during this time it travels to the surface, where it is lost in a constant invisible shedding of dead cells. In patches of psoriasis the turnover of skin cells is much faster, around 4 – 7 days, and this means that even live cells can reach the surface and accumulate with dead cells. The extent of psoriasis and how it affects an individual varies from person to person. Some may be mildly affected with a tiny patch hidden away on an elbow which does not bother them, while others may have large visible areas of skin involved that significantly affect daily life and relationships. This process is the same wherever it occurs on the body. Psoriasis is not contagious.


Pustular psoriasis tends not to look like plaque psoriasis although plaque and pustular psoriasis can coexist or one may follow the other.

The main distinguishing feature of pustular psoriasis is the appearance of pus spots surrounded by red skin. However this does not mean that there is any infection present. They simply show that the skin has been invaded by the same white blood cells that would be seen if there were to be an infection present.

It can be provoked by some internal medications, irritating topical agents, ultraviolet light overdoses, pregnancy, systemic steroids, especially sudden withdrawal of systemic or topical steroids, infections, perspiration or emotional stress.


A rare type is generalised pustular psoriasis also known as Von Zumbusch’s disease, which can be abrupt, and can be triggered by an infection, pregnancy, low thyroid activity and drug involvement. It can cause fever, chills, severe itching, rapid pulse rate, exhaustion, anaemia, weight loss, muscle weakness and/or joint pain. Sometimes these attacks are followed by milder outbreaks of psoriasis. With this type, which can also rarely appear in children, the pustules occur all over the body – this type often requires hospital in-stay treatment. It must be stressed that generalised pustular psoriasis is a rare form of psoriasis.


Another form of pustular psoriasis which can occur in people between the ages of 20 and 60, which causes pustules on the palms and soles of the feet. Infection and stress are suspected trigger factors. PPP is normally recognisable by large yellow pustules up to 5cms in diameter, in fleshy areas of hands and feet, such as the base of the thumb and the sides of the heels. They then turn brown and drop-off or peel. PPP is usually cyclical with new crops of pustules followed by periods of low activity. This form of psoriasis affects approximately 5% of people with psoriasis.

It tends to go in cycles of:

1. Erythema (reddening of the skin) followed by
2. Formation of pustules and
3. Scaling of the skin.

Topical treatments are usually a first line treatment. PUVA and methotrexate are also sometimes used to clear the attack.

In most episodes of pustular psoriasis these will last for a few weeks then disappear or return to erythrodermic psoriasis.


Another rare type of palmar-plantar pustular psoriasis characterised by skin lesions on the ends of the fingers and sometimes on the toes. The eruption occasionally starts after local trauma. Often the lesions are painful and disabling, with the nails often deformed, and bone changes may occur. This condition is quite hard to treat satisfactorily.


Pustular psoriasis and PPP are usually treated with topical treatments. Sometimes topical steroids under occlusion dressings are prescribed. Pustular psoriasis can be stubborn to treat therefore other treatment regimes used in plaque psoriasis may be tried.

The main aims of the treatment of generalised pustular psoriasis is to restore the skin's barrier function, prevent further loss of fluid, stabilise the body's temperature and restore the skin's chemical balance. Imbalances, which can occur, might put added strain on the heart and kidneys, especially in older people. Because of possible complications with this form of psoriasis medical care must be sought immediately, with the likelihood of hospitalisation for a short period of time, depending on the severity of the outbreak.

When hospitalised, bed rest, mild sedation, bland topical therapy, rehydration and avoidance of excessive heat loss can improve the situation. In some cases antibiotics are prescribed just in case an infection is also present. In severe cases, where the patient has become exhausted, other medications may be needed.

Methotrexate is the most common treatment for generalized pustular psoriasis. Oral steroids are often prescribed for those who do not respond to other forms of treatment, or have become very ill, but their use is very controversial. PUVA (the photsensitizing drug psoralen plus UVA light) may also be used in the treatment of this condition after it has subsided. Ciclosporin is also a medication that is used.

Acrodermatitis Continua of Hallopeau often tends to be resistant to both topical and systemic treatments for psoriasis, therefore combinations of therapy may be tried. Most episodes of pustular psoriasis will last for a few weeks then disappear or remit to erythrodermic psoriasis.


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