eMedicine Specialties > Dermatology > Papulosquamous Diseases

Psoriasis, Pustular: Differential Diagnoses & Workup

Author: Carlos Ricotti, MD, Fellow, Department of Dermatology, Division of Dermatopathology, University of Texas Southwestern School of Medicine
Coauthor(s): Clay J Cockerell, MD, Director, Clinical Professor, Department of Dermatology, Division of Dermatopathology, University of Texas Southwestern Medical Center
Contributor Information and Disclosures

Updated: Dec 29, 2009

Differential Diagnoses

Subcorneal Pustular Dermatosis

Other Problems to Be Considered

Acute generalized exanthematous pustulosis (drug eruption)
Gram-negative septicemia
Infected generalized atopic dermatitis and/or seborrheic dermatitis

Workup

Laboratory Studies

  • CBC count reveals absolute lymphopenia coinciding with polymorphonuclear leukocytosis up to 40,000/µL.
  • Erythrocyte sedimentation rate is elevated.
  • Serum chemistry shows increased plasma globulins and decreased albumin, calcium, and zinc. If the patient is oligemic, BUN and creatinine also are increased.
  • If renal tubular necrosis occurs, urinalysis may show albumin and casts.
  • Culture and sensitivity of a pustule's contents prove negative, as do blood cultures. Loss of cutaneous barrier to infection may result in bacteremia. Tzanck preparation and viral culture are negative.

Histologic Findings

Epidermal changes are similar to those of psoriasis vulgaris, with parakeratosis and elongation of rete ridges. The upper dermis shows a mononuclear infiltrate and numerous neutrophils migrating from papillary capillaries to the epidermis. Those already in the epidermis are arranged in a network of degenerated and flattened keratinocytes, forming a macropustule that is the characteristic histologic lesion and is termed the spongiform pustule of Kogoj.7

More on Psoriasis, Pustular

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

  1. Zelickson BD, Pittelkow MR, Muller SA, Johnson CM. Polymorphonuclear leukocyte chemotaxis in generalized pustular psoriasis. Acta Derm Venereol. 1987;67(4):326-30. [Medline].

  2. Chao PH, Cheng YW, Chung MY. Generalized pustular psoriasis in a 6-week-old infant. Pediatr Dermatol. May-Jun 2009;26(3):352-4. [Medline].

  3. Hubler WR Jr. Lingual lesions of generalized pustular psoriasis. Report of five cases and a review of the literature. J Am Acad Dermatol. Dec 1984;11(6):1069-76. [Medline].

  4. Brenner M, Molin S, Ruebsam K, Weisenseel P, Ruzicka T, Prinz JC. Generalized pustular psoriasis induced by systemic glucocorticosteroids: four cases and recommendations for treatment. Br J Dermatol. Oct 2009;161(4):964-6. [Medline].

  5. Tobin AM, Langan SM, Collins P, Kirby B. Generalized pustular psoriasis (von Zumbusch) following the use of calcipotriol and betamethasone dipropionate ointment: a report of two cases. Clin Exp Dermatol. Jul 2009;34(5):629-30. [Medline].

  6. Cassandra M, Conte E, Cortez B. Childhood pustular psoriasis elicited by the streptococcal antigen: a case report and review of the literature. Pediatr Dermatol. Nov-Dec 2003;20(6):506-10. [Medline].

  7. Heng MC, Heng JA, Allen SG. Electron microscopic features in generalized pustular psoriasis. J Invest Dermatol. Aug 1987;89(2):187-91. [Medline].

  8. Lee CS, Koo J. A review of acitretin, a systemic retinoid for the treatment of psoriasis. Expert Opin Pharmacother. Aug 2005;6(10):1725-34. [Medline].

  9. Rosenbaum MM, Roenigk HH Jr. Treatment of generalized pustular psoriasis with etretinate (Ro 10-9359) and methotrexate. J Am Acad Dermatol. Feb 1984;10(2 Pt 2):357-61. [Medline].

  10. Wolska H, Jablonska S, Bounameaux Y. Etretinate in severe psoriasis. Results of double-blind study and maintenance therapy in pustular psoriasis. J Am Acad Dermatol. Dec 1983;9(6):883-9. [Medline].

  11. Hazarika D. Generalized pustular psoriasis of pregnancy successfully treated with cyclosporine. Indian J Dermatol Venereol Leprol. Nov-Dec 2009;75(6):638. [Medline].

  12. Manni E, Barachini P. Psoriasis induced by infliximab in a patient suffering from Crohn's disease. Int J Immunopathol Pharmacol. Jul-Sep 2009;22(3):841-4. [Medline].

  13. Puig L, Barco D, Alomar A. Treatment of Psoriasis with Anti-TNF Drugs during Pregnancy: Case Report and Review of the Literature. Dermatology. Nov 25 2009;[Medline].

  14. Ghate JV, Alspaugh CD. Adalimumab in the management of palmoplantar psoriasis. Dermatol Online J. Jul 15 2009;15(7):15. [Medline].

  15. Honigsmann H, Gschnait F, Konrad K, Wolff K. Photochemotherapy for pustular psoriasis (von Zumbusch). Br J Dermatol. Aug 1977;97(2):119-26. [Medline].

  16. Amin S, Maibach H. Pustular psoriasis: generalized and localized. In: Maibach H, Roenigk HH, eds. Psoriasis. 3rd ed. Marcel Dekker Inc; 1998:13-39.

  17. Lindgren S, Groth O. Generalized pustular psoriasis. A report on thirteen patients. Acta Derm Venereol. 1976;56(2):139-47. [Medline].

  18. Sauder DN, Steck WD, Bailin PB, Krakauer RS. Lymphocyte kinetics in pustular psoriasis. J Am Acad Dermatol. Apr 1981;4(4):458-60. [Medline].

  19. Toussaint S, Kamino H. Noninfectious erythematous papular and squamous diseases. In: Elder D et al, eds. Lever's Histopathology of the Skin. 8th ed. Lippincott-Raven Publishers; 1997.

  20. Umezawa Y, Ozawa A, Kawasima T, et al. Therapeutic guidelines for the treatment of generalized pustular psoriasis (GPP) based on a proposed classification of disease severity. Arch Dermatol Res. Apr 2003;295 Suppl 1:S43-54. [Medline].

  21. Zelickson BD, Muller SA. Generalized pustular psoriasis in childhood. Report of thirteen cases. J Am Acad Dermatol. Feb 1991;24(2 Pt 1):186-94. [Medline].

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Further Reading

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Keywords

psoriasis, pustular psoriasis, von Zumbusch psoriasis

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Contributor Information and Disclosures

Author

Carlos Ricotti, MD, Fellow, Department of Dermatology, Division of Dermatopathology, University of Texas Southwestern School of Medicine
Carlos Ricotti, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, American Society of Dermatopathology, and International Society of Dermatopathology
Disclosure: Nothing to disclose.

Coauthor(s)

Clay J Cockerell, MD, Director, Clinical Professor, Department of Dermatology, Division of Dermatopathology, University of Texas Southwestern Medical Center
Clay J Cockerell, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, International Academy of Pathology, International AIDS Society, International Society for Dermatologic Surgery, North American Clinical Dermatologic Society, Society for Investigative Dermatology, and Southern Medical Association
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 M Quirk, MD, Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania
Catherine M 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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