🚨 Erythrodermic psoriasis (psoriasis affecting >80% BSA) and generalised pustular psoriasis (widespread erythema with sterile pustules coalescing into “lakes of pus”) are dermatological emergencies.
➡️ Both require urgent referral to a dermatologist and usually inpatient management.
📖 About
- Life-threatening forms of psoriasis requiring hospital admission.
- Systemic involvement includes fluid/electrolyte imbalance, protein loss, infection risk, and thermoregulation failure 🌡️.
🩺 Clinical Features
- Often a prior history of psoriasis (plaque type or guttate).
- Erythrodermic psoriasis:
- >80% body surface area affected.
- Widespread erythema, scaling, intense pruritus.
- Systemic upset: fever, malaise, dehydration.
- Generalised pustular psoriasis:
- Sheets of erythema studded with sterile pustules 🟡.
- Pustules coalesce into “lakes of pus.”
- Systemic toxicity: fever, tachycardia, hypocalcaemia, risk of sepsis.
⚡ Differentials
- Severe atopic or contact eczema.
- Drug reactions (e.g. AGEP – acute generalised exanthematous pustulosis).
- Cutaneous T-cell lymphoma (erythroderma).
🔍 Investigations
- Diagnosis is largely clinical.
- Bloods: FBC (look for neutropenia), U&E (renal compromise), LFTs (drug monitoring), CRP/ESR.
- Consider skin biopsy if diagnosis uncertain.
- Screen for infection (blood cultures, swabs) before immunosuppressive therapy.
💊 Management
- 🏥 Admit under dermatology; involve ITU if unstable.
- Supportive:
- ABC assessment, IV fluids & electrolyte correction.
- Temperature regulation, nutritional support.
- Good skin care: emollients, wet wraps, gentle cleansing.
- Meticulous oral and eye care (risk of mucosal involvement).
- Systemic therapy:
- Methotrexate (oral/weekly, 5–7.5 mg/wk initially). Monitor for neutropenia & hepatotoxicity.
- Ciclosporin (short-term, rapid clearance option).
- Retinoids (acitretin) are first-line for severe pustular psoriasis.
- Biologics (e.g. infliximab, adalimumab, secukinumab) if refractory to standard agents.
- ⚠️ Systemic corticosteroids should be avoided: they may precipitate unstable rebound pustular psoriasis.
- Topical coal tar and dithranol (useful for plaque psoriasis) are contraindicated here as they worsen erythroderma.
🧾 Clinical Case – Erythrodermic Psoriasis
A 48-year-old man with a long history of chronic plaque psoriasis presents with
widespread erythema, scaling, and severe pruritus covering >90% of his body surface.
He is febrile, tachycardic, and reports chills and malaise.
Labs reveal raised inflammatory markers and electrolyte imbalance.
Diagnosis: Erythrodermic psoriasis, a life-threatening flare often triggered by
sudden steroid withdrawal. He required urgent hospital admission, fluid/electrolyte correction,
emollients, systemic therapy (cyclosporin), and infection monitoring.
📚 References
