eMedicine Specialties > Dermatology > Papulosquamous Diseases

Psoriasis, Guttate: Differential Diagnoses & Workup

Author: Charles R Taylor, MD, Assistant Professor of Dermatology, Harvard Medical School; Director of Phototherapy Unit, Department of Dermatology, Massachusetts General Hospital
Contributor Information and Disclosures

Updated: Aug 3, 2009

Differential Diagnoses

Cutaneous T-Cell Lymphoma
Pityriasis Rosea
Lymphomatoid Papulosis
Syphilis
Nummular Dermatitis
Parapsoriasis
Pityriasis Lichenoides

Other Problems to Be Considered

Psoriasiform drug eruption
Viral exanthem

Workup

Laboratory Studies

  • Serology:Levels of antibodies to streptolysin O, hyaluronidase, and deoxyribonuclease B may be elevated in more than half the patients with guttate psoriasis. Significant elevations of antistreptococcal M6 protein have been documented.
  • Cultures: A bacteriologic culture of the throat or the perianal area may be helpful to isolate the organism in selected cases.
  • Urinalysis: Urine results are usually negative, although blood and protein have been detected in rare cases associated with a concomitant poststreptococcal acute glomerulonephritis.

Histologic Findings

Because the clinical appearance is so characteristic, biopsies are seldom necessary to confirm the diagnosis. Histopathologic changes may not be diagnostic when samples of early-stage papules are obtained at biopsy. The epidermis shows hyperplasia and small foci of parakeratosis with absence of the granular layer. Dermal changes consisting of capillary dilatation and edema may be more pronounced, and an infiltrate consisting of lymphocytes and macrophages is seen mostly in the upper dermis. A few polymorphonuclear leukocytes may be found at all levels.

In fully developed guttate lesions, vacuolated keratinocytes eventually disappear, leaving areas of agranulosis with overlying parakeratosis. Degenerated polymorphonuclear leukocytes on an otherwise orthokeratotic stratum corneum may be the earliest presentation of Munro microabscesses. The term squirting papillae has been used to describe a phenomenon wherein neutrophils are discharged from the papillary capillaries resulting in collections of neutrophils in association with parakeratotic mounds. In some cases, marked exudation may lead to the formation of the highly diagnostic spongiform pustule of Kogoj, which is seen in psoriasiform variants.

More on Psoriasis, Guttate

Overview: Psoriasis, Guttate
Differential Diagnoses & Workup: Psoriasis, Guttate
Treatment & Medication: Psoriasis, Guttate
Follow-up: Psoriasis, Guttate
Multimedia: Psoriasis, Guttate
References
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References

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Further Reading

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Keywords

psoriasis, guttate psoriasis, perianal streptococcal infection, Streptococcus pyogenes, S pyogenes, upper respiratory infection

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Contributor Information and Disclosures

Author

Charles R Taylor, MD, Assistant Professor of Dermatology, Harvard Medical School; Director of Phototherapy Unit, Department of Dermatology, Massachusetts General Hospital
Charles R Taylor, MD is a member of the following medical societies: American Academy of Dermatology, American Society for Laser Medicine and Surgery, Massachusetts Medical Society, New England Dermatological Society, and Society for Investigative Dermatology
Disclosure: Nothing to disclose.

Medical Editor

Mark G Lebwohl, MD, Chairman, Department of Dermatology, Mount Sinai School of Medicine
Mark G Lebwohl, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Abbott Laboratories Honoraria Consulting; Actelion Honoraria Consulting; Amgen Honoraria Consulting; Astellas Honoraria Consulting; Centocor Honoraria Consulting; DermiPsor Honoraria Consulting; Galderma  Consulting; Genentech Honoraria Consulting; Helix BioMedix Honoraria Consulting; Medicis Honoraria Investigator

Pharmacy Editor

David F Butler, MD, Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic, Northside Clinic
David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Managing Editor

Christen M Mowad, MD, Associate Professor, Department of Dermatology, Geisinger Medical Center
Christen M Mowad, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, and Phi Beta Kappa
Disclosure: Nothing to disclose.

CME Editor

Catherine Quirk, MD, Clinical Assistant Professor, Department of Dermatology, Brown University
Catherine Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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