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Psoriasis, Guttate: Treatment & Medication
Updated: Aug 3, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
Usually, this type of psoriasis spontaneously disappears in a few weeks without treatment. Simple reassurance and emollients may be sufficient care. As in other conditions, the choice of treatment should be tailored to the individual. For example, applying topical steroids, although effective, could be cumbersome, especially when the eruption is extensive as in most cases of guttate psoriasis.
- Antimicrobials: Because of the clear association between guttate psoriasis and streptococcal infection in most cases, obtaining a throat culture for each bout of pharyngitis in patients with a known history of psoriasis and immediately starting the proper antibiotic treatment depending on the culture results are imperative. See Medication below for specific drugs.
- Phototherapy: The clearance of guttate lesions can be accelerated by judicious exposure to sunlight or by a short course of either broadband UV-B or narrowband UV-B phototherapy. More resistant cases may benefit from oral psoralen plus exposure to ultraviolet A radiation (PUVA). The suit PUVA technique has been used in this setting. Aside from the usual mechanisms by which UV light is believed to exert its beneficial effects in psoriasis, a specific fibrosing response to PUVA via increased mast cell activation has been observed in guttate psoriasis and might underlie the mechanism of action behind UV-induced resolution of the lesions.12 However, considering the developments in photomedicine over the last several years, particularly regarding the clinical efficacy of narrowband UV-B phototherapy, versus the risk of cutaneous malignancies with PUVA, treatment with narrowband UV-B is favored over treatment with PUVA.
A guideline summary from the American Academy of Dermatology, Guidelines of care for the management of psoriasis and psoriatic arthritis: Section 1. Overview of psoriasis and guidelines of care for the treatment of psoriasis with biologics, may be helpful.13
Surgical Care
Although unproven by large controlled clinical trials, tonsillectomy for patients with recurrent or chronic guttate psoriasis associated with poststreptococcal tonsillitis may be helpful.14
Medication
Many physicians have questioned the usefulness of antibiotics in the management of psoriasis. For example, Dogan et al found no statistically significant improvement in streptococcal guttate psoriasis after treatment with penicillin or erythromycin or with no treatment.15 Nevertheless, some experts have used empiric therapy with the following antimicrobials in streptococcal-related guttate psoriasis. Azithromycin, which is commonly prescribed for community-acquired pneumonia, is likewise an option.
Antimicrobials
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.
Erythromycin (E.E.S., E-Mycin, Ery-Tab)
DOC for pregnant patients. Has the added advantage of being a good anti-inflammatory agent by inhibiting migration of polymorphonuclear leukocytes.
Adult
>1 g/d PO for 7-14 d
Pediatric
30-50 mg/kg/d PO for 7-14 d
Coadministration may increase toxicity of theophylline, terfenadine, digoxin, carbamazepine, astemizole, and cyclosporine; may potentiate anticoagulant effects of warfarin; coadministration with lovastatin and simvastatin increases risk of rhabdomyolysis
Documented hypersensitivity; hepatic impairment
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in liver disease; estolate formulation may cause cholestatic jaundice; GI adverse effects are common (give doses pc); discontinue use if nausea, vomiting, malaise, abdominal colic, or fever occur
Penicillin VK (Veetids, Beepen-VK)
Inhibits biosynthesis of cell wall mucopeptide and is effective during active multiplication. Inadequate concentrations may produce only bacteriostatic effects.
Adult
>1 g/d PO for 10-14 d
Pediatric
30-50 mg/kg/d PO for 10-14 d
Probenecid can increase effects by decreasing clearance; coadministration of tetracyclines can decrease effects
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in impaired renal function
Rifampin (Rifadin, Rimactane)
Recommended for resistant cases that may progress to chronic carrier state. Usually given in addition to either erythromycin or penicillin.
Adult
600 mg/d PO for 5 d
Pediatric
10-20 mg/kg PO/IV; not to exceed 600 mg/d
Induces microsomal enzymes, which may decrease effects of acetaminophen, oral anticoagulants, barbiturates, benzodiazepines, beta-blockers, chloramphenicol, oral contraceptives, corticosteroids, mexiletine, cyclosporine, digitoxin, disopyramide, estrogens, hydantoins, methadone, clofibrate, quinidine, dapsone, tazobactam, sulfonylureas, theophyllines, tocainide, and digoxin; blood pressure may increase with coadministration of enalapril; coadministration with isoniazid may result in higher rate of hepatotoxicity than with either agent alone (discontinue 1 or both agents if alterations in LFTs occur)
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Obtain CBC counts and baseline clinical chemistries prior to and throughout therapy; in liver disease, weigh benefits against risk of further liver damage; interruption of therapy and high-dose intermittent therapy are associated with reversible thrombocytopenia if therapy is discontinued as soon as purpura occurs; if treatment is continued or resumed after appearance of purpura, cerebral hemorrhage or death may occur
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
Keywords
psoriasis, guttate psoriasis, perianal streptococcal infection, Streptococcus pyogenes, S pyogenes, upper respiratory infection
