Name:
When should a PCP refer a patient with pustular psoriasis to a dermatologist?
Description:
When should a PCP refer a patient with pustular psoriasis to a dermatologist?
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T00H06M23S
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Upload Date:
2021-08-12T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
[MUSIC PLAYING]
SPEAKER: What is pustular psoriasis? When should a primary care provider refer a patient with pustular psoriasis to a dermatologist? Pustular psoriasis is a heterogeneous group of chronic inflammatory skin disorders, and may present as either widespread or localized disease. Generalized pustular psoriasis or GPP, presents as widespread disease in many patients, but in other patients it can be confined to certain areas of the body.
SPEAKER: Localized forms of pustular psoriasis include; palmoplantar pustulosis or PPP, and acrodermatitis continua of Hallopeau, or ACH. The diagnosis of pustular psoriasis is predominantly clinical, and is based upon the patient's medical history and presenting clinical features. Individuals should be asked about a history or family history of pustular psoriasis or plaque psoriasis.
SPEAKER: Recent medication history should also be determined. For example, sudden withdrawal of corticosteroid treatment is a precipitating factor for GPP flare in some people. Has any new medication been used lately that might have triggered acute generalized exanthematous pustulosis or AGEP? A GPP flare is characterized by the rapid and widespread eruption of superficial pustules, usually affecting skin on the trunk and limbs.
SPEAKER: Systemic symptoms are also common, particularly fever and pain from skin lesions. GPP should be suspected in any individual with sudden onset of erythema and pustulosis. GPP may be potentially life-threatening if left untreated due to complications such as sepsis and multisystem organ failure. In the absence of a history of psoriasis, other conditions may need to be considered, and a skin biopsy may be helpful.
SPEAKER: The main diagnosis to exclude is AGEP. Although, in practice, it may be very difficult to distinguish this condition from GPP. The vast majority of cases of AGEP are associated with recent drug ingestion. PPP is the most common subtype of pustular psoriasis. It presents as a sudden eruption of pustules on the palms and/or the soles of the feet, often accompanied by pain and itching.
SPEAKER: The main differential diagnosis is pompholyx also known as dyshidrotic eczema. In PPP, the nails may be affected, which can make it difficult to differentiate clinically between PPP and ACH. ACH presents with painful pustules on the tip of one or more digits, affecting the fingers more often than the toes.
SPEAKER: There is always nail involvement and the disease may result in progressive destruction of the nail apparatus, and lead eventually to bone damage. The main differential diagnosis is nail infection caused by bacterial, fungal, or viral agents. Individuals with suspected pustular psoriasis of any subtype should be referred to a dermatologist if there is any question about the diagnosis.
SPEAKER: Due to the potential complications of widespread disease, individuals with GPP should be referred to a dermatologist, whether the case is suspected or confirmed. The same applies to suspected or confirmed cases of ACH due to the risk of irreversible nail damage and in a minority of cases, bone damage.
SPEAKER: Individuals with PPP and whom initial topical treatment has been ineffective should be referred to a dermatologist. Once the diagnosis of pustular psoriasis is made, treatment should be started promptly to minimize disease severity and reduce the risk of complications. Individuals should be referred to a dermatologist to facilitate management as treatment options are not straightforward.
SPEAKER: Several agents are approved in Japan for the treatment of GPP. And in Europe, some medications licensed under national procedures can be used in pustular psoriasis. Such as methotrexate or corticosteroids. But no GPP-specific treatment has been approved by the FDA and the United States, or the EMA in Europe. Thus the current range of treatment options for GPP is limited, and generally involves agents used to treat plaque psoriasis.
SPEAKER: Options include: topical agents, phototherapy, systemic therapies, and/or biological therapies. Systemic corticosteroids should be used with care as their non-tapered withdrawal in individuals with plaque psoriasis may precipitate a pustular psoriasis flare. Once the treatment is underway, individuals with any subtype of pustular psoriasis should see their dermatologist regularly for follow-up.
SPEAKER: Other specialists may also be required, such as a rheumatologist to monitor any related joint and/or bone disease. Individuals may also benefit from receiving appropriate educational information on pustular psoriasis and referral to pustular psoriasis support groups. In summary, a dermatologist can assist the primary care team with diagnosis of pustular psoriasis subtypes, implementation of prompt and effective treatment, and ongoing disease management.
SPEAKER:
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