Pustular Psoriasis Clinical Presentation

Updated: Oct 08, 2021
  • Author: Clay J Cockerell, MD; Chief Editor: William D James, MD  more...
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In generalized pustular psoriasis, the skin initially becomes fiery red and tender. Constitutional signs and symptoms include headache, fever, chills, arthralgia, malaise, anorexia, and nausea. Within hours, clusters of nonfollicular, superficial, 2- to 3-mm pustules may appear in a diffuse pattern.

Flexural and anogenital areas are most commonly involved in pustular psoriasis. Less often, facial lesions occur. Pustules can appear on the tongue and develop subungually, resulting in dysphagia and nail shedding, respectively. [26] Pustules coalesce within 1 day to form lakes of pus that dry and desquamate in sheets, leaving behind a smooth, erythematous surface on which new crops of pustules may recur.

Episodes of pustulation occur for days to weeks, causing the patient severe discomfort and exhaustion. A telogen effluvium type of hair loss may develop in 2-3 months.

Upon remission of pustules, most systemic symptoms disappear. However, patients can experience an erythrodermic state or residual lesions of psoriasis vulgaris. Patients with a history of psoriasis may show a predilection for particular pustular psoriasis subtypes, particularly generalized pustular psoriasis and acrodermatitis of Hallopeau [4] ; however, a preceding history of psoriasis is not a requirement. [14]

Circinate or annular-type pustular psoriasis predominates in childhood and runs a more subacute course with less severe manifestations. Often, recurrent episodes of annular or circinate erythematous plaques are seen, with pustules and scaling along the periphery. [3] These lesions appear primarily on the trunk and undergo peripheral expansion with central healing over hours to days. Other systemic signs and symptoms are either mild or absent.

The juvenile/infantile type of pustular psoriasis typically has a benign course. Systemic involvement is not common, and spontaneous remissions frequently occur.


Physical Examination

Patients appear distressed, often tachypneic, tachycardic, and febrile. The oropharyngeal mucosa may be hyperemic, and a geographic tongue or fissured tongue may be appreciated. Skin findings include a generalized or patchy erythema studded with interfollicular pustules that may have an annular or generalized/nonspecific configuration. 

Lesions appear on the trunk, extremities, and, rarely, on the face. Flexural and anogenital accentuation may be present. Pustulation may also involve the nail beds, resulting in onychodystrophy, onycholysis, and defluvium unguium.

Peripheral scaling may be observed, especially in areas that have undergone pustulation. The rest of the physical examination depends on systemic complications.



Occasionally, acute respiratory distress syndrome may complicate generalized pustular psoriasis.

Other possible complications in pustular psoriasis include the following:

  • Secondary bacterial skin infections, hair loss ( telogen effluvium), and nail loss
  • Hypoalbuminemia secondary to loss of plasma protein into tissues
  • Hypocalcemia
  • Renal tubular necrosis as a result of oligemia
  • Osteoarthritis
  • Uveitis
  • Neutrophilic cholangitis
  • Liver damage as a result of oligemia, neutrophilic cholangitis, [27] and general toxicity
  • Malabsorption and malnutrition