UMEM Educational Pearls


A 56-year-old woman with a history of psoriasis presents with fever, nausea, and painful pin-point pustules on an erythematous base. Her dermatologist recently reduced her prednisone dose. What's the diagnosis?


Answer: Pustular psoriasis

Pustular psoriasis

Occurs in patients with psoriasis, classically occurring after a decrease in dose or cessation of systemic steroids

Symptoms include:

  • Acute eruption of painful small pustules (2-3 mm in diameter) that rapidly become confluent into large “lakes of pus”
  • Systemic symptoms may also occur (e.g., fever, malaise, nausea, or arthritis).

These lesions can eventually drain and desquamate, leaving large patches of exposed dermis.

Complications include:

  • Super-infection (most common)
  • ARDS
  • AKI
  • Hypothermia secondary to loss of epidermis
  • Hypovolemia secondary to fluid losses from the skin

Patients may be admitted for supportive care and treatment with disease-modifying antirheumatic drugs (DMARDs) such as cyclophosphamide or methotrexate.



L Naldi, D Gambini, The clinical spectrum of psoriasis, Clinics in Dermatology, Volume 25, Issue 6, November–December 2007, Pages 510-518


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