Laboratory Studies

Findings include the following:

Complete blood cell (CBC) count with absolute lymphopenia coinciding with polymorphonuclear leukocytosis up to 40,000/µL
Elevated erythrocyte sedimentation rate (ESR)
Elevated C-reactive protein (CRP) ^[1]
Serum chemistries - Increased plasma globulins; decreased albumin, calcium, and zinc; elevated BUN and creatinine if the patient is oligemic; elevated liver enzymes (aspartate transaminase [AST], alanine transaminase [ALT]) if liver damage has occurred
Urinalysis - Positive albumin; positive casts
Bacterial cultures and sensitivities of pustules - Negative in the absence of secondary infection, as are Tzanck preparations and viral cultures; loss of the cutaneous barrier may result in bacteremia

Histologic Findings

The overall architecture of the epidermis is similar to patients with psoriasis vulgaris, exhibiting parakeratosis, elongation of rete ridges, and thinning of the suprapapillary epidermis. The superficial dermis shows a mononuclear infiltrate and numerous neutrophils migrating from papillary capillaries to the epidermis. Neutrophils in the epidermis can aggregate between keratinocytes, where there is also spongiosis, forming pustules known as spongiform pustules of Kogoj, a characteristic histologic feature.^[28]

Treatment & Management

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Media Gallery

Note the clearly defined, raised bumps on the skin that are filled with pus (pustules). The skin under and around these bumps is reddish. Courtesy of Hon Pak, MD.
Palmoplantar pustular psoriasis, a type of pustular psoriasis that appears on the palms of the hands or the soles of the feet. Courtesy of Hon Pak, MD.

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Author

Clay J Cockerell, MD President and Owner, Cockerell Dermatopathology; Adjunct Clinical Professor, Department of Internal Medicine (Dermatology), Division of Dermatopathology, University of North Texas Health Science Center at Forth Worth

Clay J Cockerell, MD is a member of the following medical societies: American Academy of Dermatology, American Academy of HIV Medicine, American College of Osteopathic Family Physicians, American College of Physician Executives, American Contact Dermatitis Society, American Dermatological Association, American Medical Association, American Society for Clinical Pathology, American Society for Dermatologic Surgery, American Society of Dermatology, American Society of Dermatopathology, California Society of Dermatology and Dermatologic Surgery, College of American Pathologists, Dallas County Medical Society, Dermatology Foundation, International Academy of Pathology, International AIDS Society, International Society of Dermatology, Louisiana Dermatological Society, Noah Worcester Dermatological Society, North American Clinical Dermatologic Society, Pacific Dermatologic Association, Physicians Association for AIDS Care, Society for Investigative Dermatology, Southern Medical Association, Texas Dermatological Society, Texas Medical Association, Texas Society of Pathologists, United States and Canadian Academy of Pathology, Women's Dermatologic Society

Disclosure: Nothing to disclose.

Specialty Editor Board

David F Butler, MD Former Section Chief of Dermatology, Central Texas Veterans Healthcare System; Professor of Dermatology, Texas A&M University College of Medicine; Founding Chair, Department of Dermatology, Scott and White Clinic

David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, Association of Military Dermatologists, Phi Beta Kappa, Texas Dermatological Society

Disclosure: Nothing to disclose.

Christen M Mowad, MD Professor, Department of Dermatology, Geisinger Medical Center

Christen M Mowad, MD is a member of the following medical societies: Alpha Omega Alpha, Noah Worcester Dermatological Society, Pennsylvania Academy of Dermatology, American Academy of Dermatology, Phi Beta Kappa

Disclosure: Nothing to disclose.

Chief Editor

William D James, MD Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

William D James, MD is a member of the following medical societies: American Academy of Dermatology, Society for Investigative Dermatology

Disclosure: Received income in an amount equal to or greater than $250 from: Elsevier; WebMD<br/>Served as a speaker for various universities, dermatology societies, and dermatology departments.

Additional Contributors

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: Received none from Amgen for consultant & investigator; Received none from Novartis for consultant & investigator; Received none from Pfizer for consultant & investigator; Received none from Celgene Corporation for consultant & investigator; Received none from Clinuvel for consultant & investigator; Received none from Eli Lilly & Co. for consultant & investigator; Received none from Janssen Ortho Biotech for consultant & investigator; Received none from LEO Pharmaceuticals for consultant & inves.

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, International Society of Dermatopathology

Disclosure: Nothing to disclose.

Annie O Morrison, MD Fellow in Dermatopathology, Cockerell Dermatopathology

Annie O Morrison, MD is a member of the following medical societies: Academy of Clinical Laboratory Physicians and Scientists, American Society for Clinical Pathology, American Society of Dermatopathology, College of American Pathologists, Digital Pathology Association, International Society of Dermatopathology, Phi Beta Kappa, United States and Canadian Academy of Pathology

Disclosure: Nothing to disclose.

Christie A Riemer, MD, (NRM) Resident Physician, Department of Dermatology, Mayo Clinic School of Graduate Medical Education

Christie A Riemer, MD, (NRM) is a member of the following medical societies: American Academy of Dermatology, American Medical Student Association/Foundation

Disclosure: Nothing to disclose.

Cooper Benjamin Tye University of Texas Health Science Center at San Antonio School of Medicine

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Drugs & Diseases gratefully acknowledge the contributions of previous authors Elma Baron, MD; Charles R Taylor, MD; John D Wilkinson, MD, MBBS, MRCS, FRCP; John Reed, MBBS, MRCP; Sarah E Dick, MD; and Abby S Van Voorhees, MD, to the development and writing of the source articles.

Pustular Psoriasis Workup

Laboratory Studies

Histologic Findings

References

Tables

Contributor Information and Disclosures

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