PUSTULAR PSORIASIS: Types, Triggers and Treatments

pustular psoriasis

Psoriasis is a chronic and common skin condition. The disease speeds up the life cycle of skin cells and causes them to build up rapidly on the surface of the skin. These extra skin cells form scales and red patches that are itchy and may be painful. There is no cure, but symptoms of psoriasis can be managed.

Psoriasis presents itself in several different forms, with plaque psoriasis and guttate psoriasis accounting for 90% of the cases. A more uncommon – but more serious form – of the condition is called pustular psoriasis. Pustular psoriasis develops quickly and may precede, accompany or follow plaque psoriasis.


Pustular psoriasis is characterized by well-defined and raised pus-filled blisters that develop within hours of your skin becoming red, tender and inflamed. The pustules will be surrounded by the red skin. The condition is not an infection, nor is it contagious. The pus-filled blisters contain white blood cells.

Pustular psoriasis can occur in widespread patches or in smaller areas on your hands, feet or fingertips. The blisters may appear and disappear frequently.


There are three different types of pustular psoriasis, based on where the blisters occur and how fast they show up.

Palmoplantar pustulosis (PPP) – This type of pustular psoriasis occurs when blisters form on small areas of your body, typically your palms or the soles of your feet. It commonly affects the base of your thumb and the sides of the heels. The pus-filled bumps initially appear in a studded pattern on top of red plaques of skin, but then they may turn brown, peel or crust over. They can also cause your skin to crack. This type may come and go often, with new pustules forming followed by periods of low activity. Those who smoke are more likely to acquire palmoplantar pustulosis.

Acropustulosis (Acrodermatitis continua of Hallopeau) – This rare type leads to small, very painful lesions popping up on your fingertips or toes. The eruptions may start after an injury or skin infection. The pain can be so severe that it may become difficult to use your fingers or toes. In rare cases, it can cause nail deformity or even bone damage.

Generalized or Von Zumbusch – This type of the disease is characterized by red, painful and tender skin blotches that can appear abruptly over a large area of your body. Soon after, the white, pus-filled blisters appear. Over a period of 24 to 48 hours, the pustules dry, leaving the skin with a glazed and smooth appearance. Your skin may be very itchy, but even worse, you may experience fever, chills, weakness, fatigue, dehydration, nausea, headaches and joint pain.

This condition is rare, but very serious and may become life-threatening. It requires immediate medical care. People with von Zumbusch pustular psoriasis often need to be hospitalized for rehydration and systemic treatment, including antibiotics.

There is a juvenile, or infantile type, of pustular psoriasis, but it occurs much less common than in adults. Pustular psoriasis can also occur during pregnancy (impetigo herpetiformis) and may occasionally be life-threatening.


Pustular psoriasis occurs in all races. It affects men and women equally. In children, it affects boys somewhat more often than girls. The age range is between 20 and 60 years, with the average age at 50 years. Children as young as two can be affected, but it is a rare occurrence.


There are a number of factors that may trigger pustular psoriasis, including:

  • Certain medications
  • Irritating topical agents
  • Overexposure to UV light
  • Pregnancy
  • Systemic steroids
  • Infections
  • Emotional stress
  • Sudden withdrawal of systemic medications or potent steroids


Dermatologists may be able to diagnose pustular psoriasis by looking at the lesions on the skin and where they are located. However, testing can confirm the diagnosis and identify possible complications. These tests include:

  • Laboratory tests for bacterial infection
  • Skin biopsy
  • Blood count
  • Kidney and liver function
  • Levels of electrolytes and minerals


The treatment for all types of pustular psoriasis includes topical steroid creams or emollients, which are applied to the affected area and systemic medications, which are taken by mouth or injection. Typically, doctors may combine or rotate treatments due to the potential side effects of systemic medications. Methotrexate is one such systemic medication, however, each type of the condition has slightly different treatments.

Treatments for specific types of pustular psoriasis include:

Palmoplantar pustulosis – PPP may be stubborn to treat, so doctors usually prescribe topical treatments first, and then consider other options, including PUVA and UVB light therapy, acitretin, methotrexate or cyclosporine. Topical treatments include:

  • Corticosteroids
  • Synthetic vitamin D
  • Coal Tar
  • Corticosteroids combined with salicylic acid

Coal tar or salicylic acid may help with scaling, and regularly applying emollients can help prevent cracking, keeping the palms and soles more flexible. However, people may find that applying topical creams to their hands and feet make working and other activities difficult, so light therapy or oral medications may be given.

Acropustulosis – Traditionally this form of pustular psoriasis has been hard to treat. There has been some success using systemic medications to clear lesions and restore the nails. Combination therapy tends to work well, and the first choice of treatment is synthetic vitamin D paired with a strong corticosteroid. Also the light therapy PUVA, involving taking the medication psoralen combined with UVA treatments, can be effective.

Generalized or Von Zumbusch – People affected by this type of pustular psoriasis will suffer with skin that is very sore and fragile during outbreaks. Immediate medical attention is necessary and hospitalization may happen. Treatment aims to restore the skin’s protective function and chemical balance, prevent fluid loss and stabilize the body’s temperature. This condition can be life-threatening as chemical imbalances may put additional strain on the heart and kidneys. Medications include:

  • Antibiotics for infection
  • Acitretin
  • Systemic corticosteroids
  • Cyclosporin – used to control symptoms quickly
  • Colchicine
  • Biologic agents, such as Infliximab, to reduce inflammation

Generalized pustular psoriasis in children – Even though it’s rare, the condition can develop before the age of 18. When it does occur, the preferred treatments are:

  • Cyclosporine – This works quickly, usually taking two to four weeks to see improvement.
  • Etanercept – A biologic used to treat severe plaque psoriasis in children.
  • Methotrexate – A low dose may be given to children as young as two years.

Impetigo herpetiformis – Developing only in pregnant women during the last trimester, this type of pustular psoriasis presents with pustules on the inner thighs and groin. The bumps join together and spread, covering a larger area.

A treatment plan has to take the pregnancy in account, and often begins with topical medication applied to the skin. This may include:

A treatment plan has to take the pregnancy in account, and often begins with topical medication applied to the skin. This may include:

  • Corticosteroids
  • Synthetic vitamin D

If stronger treatment is required, a dermatologist may prescribe phototherapy (light treatments).


Medical treatment is recommended for people who are affected by pustular psoriasis. However, some natural home remedies may be beneficial. These treatments can help to soothe and heal the affected areas. They can also help relieve itching. These include:

  • Tree bark extract
  • Compresses using non-irritating medications
  • Salt water solutions or salt water baths
  • Oatmeal baths
  • Aloe vera gel
  • Oil-rich moisturizers

Skin care is important when dealing with pustular psoriasis. The blisters can enable germs and bacteria to enter the skin. Keeping the skin area clean and moisturized can help reduce the risk of infection.


You may not be able to prevent pustular psoriasis, and there is no cure, but you can take steps to reduce the risk of getting this potentially serious condition. These steps include:

  • Maintain a healthy weight – Many people with psoriasis are obese. Some may gain weight after becoming affected by the disease. People who carry extra pounds tend to have more severe cases of pustular psoriasis, and the treatments don’t work as well.
  • Quit smoking – People who smoke are more likely to get psoriasis. The habit may trigger pustular psoriasis in some people. Treatments don’t work as well on smokers, and they are less likely to have symptom-free periods between flare-ups.
  • Limit beer, wine and all liquor – If you have psoriasis, you should avoid alcohol. People who drink have more flare-ups, and treatments don’t work as well. Men who drink are also more likely to get pustular psoriasis.
  • Lower your stress level – Take measures to relax and de-stress at work, home and in all areas of your life. Try exercise or meditation to relieve stress, and make sure to get a full night’s sleep.
  • Don’t sunbathe – Some people have flare-ups of pustular psoriasis after getting too much UV light from spending too much time outdoors or using a tanning bed. If you are prone to pustular psoriasis, avoid all-day visits to the beach or park and stay away from tanning salons. Always remember to protect your skin with clothing and proper sunscreen.

If you found this article informative then you may also be interested in reading Natural Treatments & Home Remedies for Psoriasis.