Guttate Psoriasis Causes, Symptoms and Treatment

Authored by , Reviewed by Dr Hayley Willacy | Last edited | Meets Patient’s editorial guidelines

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Read COVID-19 guidance from NICE

Treatment of almost all medical conditions has been affected by the COVID-19 pandemic. NICE has issued rapid update guidelines in relation to many of these. This guidance is changing frequently. Please visit https://www.nice.org.uk/covid-19 to see if there is temporary guidance issued by NICE in relation to the management of this condition, which may vary from the information given below.

Guttate psoriasis is a distinctive acute skin condition characterised by small drop-like, salmon-pink papules which usually have a fine scale. This variant primarily occurs on the trunk and the proximal extremities but it may have a more generalised distribution. A history of an upper respiratory infection secondary to group A beta haemolytic streptococci often precedes the eruption by 2-3 weeks. Guttate psoriasis may be chronic and unrelated to streptococcal infection.

  • It is more common in individuals younger than 30 years[1].
  • Genetic predisposition: guttate psoriasis has been linked with HLA-BW17, HLA-B13, HLA-CW6[2, 3].
  • It is most often associated with streptococcal infection - two thirds have evidence of a recent strep throat infection - but may also be associated with stress, trauma (Köbner's phenomenon) or drugs - eg, antimalarials, lithium, non-steroidal anti-inflammatory drugs, beta-blockers[4].
  • In most cases there is a history of an antecedent streptococcal infection, usually of the upper respiratory tract, such as pharyngitis or tonsillitis, 2-3 weeks prior to the eruption.
  • There may be a positive family history of psoriasis.
  • The onset of the skin lesions is often acute, with multiple papules erupting on the trunk and the proximal extremities.
  • Lesions may sometimes spread to involve the face, the ears and the scalp.
  • The palms and the soles are rarely affected.
  • The rash is often associated with mild itching.
  • Like other forms of psoriasis, guttate psoriasis tends to improve during the summer and worsen during the winter.
  • Examination of the skin reveals characteristic lesions consisting of multiple, discrete drop-like salmon-pink papules. A fine scale may be seen on established lesions.

    Guttate psoriasis hands

    Guttate psoriasis hands
    Mohammad2018, CC BY-SA 4.0, via Wikimedia Commons
    By Mohammad2018, CC BY-SA 4.0, via Wikimedia Commons
           
  • Nail changes characteristic of chronic psoriasis (eg, pits, ridges and the oil-drop sign) are usually absent.
  • Diagnosis is clinical and biopsy is usually not required.
  • Dermoscopy may be useful in differentiating guttate psoriasis from chronic pityriasis lichenoides[5].
  • Serology: levels of antibodies to streptolysin O (ASO) may be elevated.
  • Cultures: bacterial culture of the throat or perianal area.

Treatment of acute guttate psoriasis is not based on trial evidence; rather, it is guided by expert opinion.

  • Usually, the rash resolves within a few weeks to months without treatment for guttate psoriasis, so simple reassurance and emollients may therefore be sufficient.
  • Clearance of guttate lesions can be accelerated by judicious exposure to sunlight or by a short course of narrow-band ultraviolet B (UVB) phototherapy, so consider early referral in those who do not respond to topical treatment[7].
  • Topical treatment with a vitamin D preparation, topical corticosteroid, or coal tar preparation can be considered but may be difficult due to the extent, size and wide distribution of lesions.
  • Antibiotic treatment has often been given because of the association between guttate psoriasis and streptococcal infection. However a Cochrane review did not find convincing evidence of benefit and recommended further trials[8].
  • A prospective study reported that the use of tonsillectomy for patients with chronic guttate psoriasis may be beneficial[9].
  • Targeted therapy may result from research exploiting the role of the cytokine interleukin (IL)-17 in the pathogenesis of guttate and several other forms of psoriasis[10].

Complications are largely iatrogenic:

  • Steroid-induced cutaneous atrophy, telangiectasia, hypopigmentation.
  • PUVA side-effects - eg, nausea and vomiting, photosensitivity.
  • Guttate psoriasis often runs a self-limited course over several weeks to a few months with complete remission in about 60%. Other patients go on to develop chronic plaque-type psoriasis. Good prognosis is associated with younger age and high ASO titres, whilst poorer prognosis is associated with a family history of psoriasis[11].
  • Scarring is not a problem.
  • Previously affected areas may show post-inflammatory hypopigmentation or hyperpigmentation.
  • Recurrent episodes may occur, especially with pharyngeal carriage of streptococci.

Further reading and references

  1. Weigle N, McBane S; Psoriasis. Am Fam Physician. 2013 May 187(9):626-33.

  2. Umapathy S, Pawar A, Mitra R, et al; Hla-a and hla-B alleles associated in psoriasis patients from mumbai, Western India. Indian J Dermatol. 2011 Sep-Oct56(5):497-500. doi: 10.4103/0019-5154.87128.

  3. Cafardi J; Guttate HLA-B13, The Manual of Dermatology, 2012.

  4. Nahary L, Tamarkin A, Kayam N, et al; An investigation of antistreptococcal antibody responses in guttate psoriasis. Arch Dermatol Res. 2008 Sep300(8):441-9. Epub 2008 Jul 22.

  5. Errichetti E, Lacarrubba F, Micali G, et al; Differentiation of pityriasis lichenoides chronica from guttate psoriasis by dermoscopy. Clin Exp Dermatol. 2015 Oct40(7):804-6. doi: 10.1111/ced.12580. Epub 2015 Feb 16.

  6. Cunliffe D; Guttate Psoriasis, Primary Care Dermatology Society

  7. Diagnosis and management of psoriasis and psoriatic arthritis in adults; Scottish Intercollegiate Guidelines Network - SIGN (October 2010)

  8. Dupire G, Droitcourt C, Hughes C, et al; Antistreptococcal interventions for guttate and chronic plaque psoriasis. Cochrane Database Syst Rev. 2019 Mar 53:CD011571. doi: 10.1002/14651858.CD011571.pub2.

  9. Harabuchi Y, Takahara M; Recent advances in the immunological understanding of association between tonsil and immunoglobulin A nephropathy as a tonsil-induced autoimmune/inflammatory syndrome. Immun Inflamm Dis. 2019 Jun7(2):86-93. doi: 10.1002/iid3.248. Epub 2019 Apr 7.

  10. Lee E, Zarei M, LaSenna C, et al; Psoriasis Targeted Therapy: Characterization of Interleukin 17A Expression in Subtypes of Psoriasis. J Drugs Dermatol. 2015 Oct 114(10):1133-6.

  11. Ko HC, Jwa SW, Song M, et al; Clinical course of guttate psoriasis: long-term follow-up study. J Dermatol. 2010 Oct37(10):894-9. doi: 10.1111/j.1346-8138.2010.00871.x.

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