Our skin acts as a primary barrier to protect us from the external environment and pathogens. The skin has various skin cells comprising immune cells such as neutrophils and sentinel dendritic cells. They help in maintaining the balance of immune response. Under certain circumstances, these cells trigger an irregular activation that releases some of the cytokines involved in causing an inflammatory reaction, causing severe guttate psoriasis to develop.
Psoriasis is a skin-related inflammatory condition and an interplay between the cells of the immune system located within the skin. Around 2% of the world’s population is afflicted with psoriasis. Amongst 30% of its subtype is Guttate psoriasis. Guttate psoriasis is a chronic inflammatory skin condition identified by the presence of erythematous plaques usually affecting the young adult of age groups between 15 to 20 and mid 55-60s age group. Patients suffer from erythematous plaques on the elbows, knees, scalp, umbilicus, lower back and palms. The released cytokines from the immune skin cell widen the blood vessels, followed by the accumulation of keratinocytes and neutrophils making the outer skin very thick. In a healthy person, it takes nearly 3-4 weeks for the skin to undergo turnover while in the case of psoriatic patients the outermost skin grows quickly forming a thick layer of skin buildup, blood flush, plaque dry scales resembling that of a pink water droplet. It is a chronic recurrent disease accompanied by cutaneous (skin disease) and inflammatory joints.1
Different variants of psoriasis are:
- Plaque psoriasis: It is the common type of psoriasis also called psoriasis vulgaris. The main feature is the plaque, a circular lesion of raised bump of 1cm. They are erythematous plaques made of reddened superficial and thick silver scales. They are found on the extensor surface such as the outside of the joints of the elbow and knee, on the scalp (scalp psoriasis), lumbosacral area of the lower back, and intergluteal cleft which is the groove between the buttocks.
- Inverse psoriasis or flexural psoriasis: They are present on the body folds such as the inframammary fold which is the lower boundary of the breast, on the perineal fold space between the anus and genitals, and axillary area such as the armpit. These plaques are often characterised as shiny red lesions without any scales. As these areas are sensitive they are prone to fungal infections (dermatophytes, yeast, lichen planus), bacterial (erythrasma) and allergic contact dermatitis.
- Guttate psoriasis: Acute guttate psoriasis are small lesions of 2-10 mm found on the trunk skin often seen after a streptococcal infection.
- Erythrodermic psoriasis: Psoriasis affects the majority of the skin and is the deadliest among the types. The complete skin from head to toe is covered with plaque that merges later typically appearing as red skin. Erythrodermic psoriasis is associated with systemic complications as you would see symptoms such as chills, fatigue, malaise, electrolyte imbalance, peripheral oedema, heart failure, renal failure, difficulties with thermoregulation, and superinfection.
- Pustular psoriasis: The psoriatic plaque is filled with pus that is found to be sterile without any microbial growth or infection.
Causes of guttate psoriasis
The various risk factors associated with plaque psoriasis are:
- Environmental factors
- Genetic susceptibility of HLA-Cw6 allele
- Lifestyle factors such as alcoholism, stress, smoking
- Prior surgery
- Strep infection
- Trauma of skin
- Insect bites
- Scratches and sunburn
- Medications such as antimalarial drugs and beta blockers
- Flu, sinus and upper respiratory infections
There is a close correlation between streptococcal infection and psoriasis association. Our skin consists of enormous bacteria that play a role in protecting the skin from invaders. Changes in these skin cutaneous microbiota are the primary feature you observe in psoriasis. A high proportion of patients experience sore throat and tonsillitis (streptococcal pharyngitis) two weeks before the development of skin eruption, indicating it to be a triggering factor in acute guttate psoriasis and the condition deteriorates in chronic plaque psoriasis. In post-infection, the streptococcus bacteria pyogenes reside within the epithelial cells (lines the inner and outer surface of the body).Within the cell, streptococcal antigen triggers the formation of cutaneous lesions of psoriasis. To put it simply, it resembles enemies invading a territory and building their weapons for destruction.
Furthermore, the viral infection and fungal infection contributes towards psoriasis.
Signs and symptoms of guttate psoriasis
Psoriasis symptoms may vary between individuals. Some patients experience rashes in patches, dry scales like dandruff, or red bumps with silver scaling on the surrounding area. They may appear as rashes of brown, pink or purple. Some would manifest macerated dry skin with bleeding, stinging, burning sensation and pain. Guttate psoriasis appears as drop-shaped plaque all over the limb and trunk.2
Before the appearance of Guttate psoriasis symptoms, patients are susceptible to strep throat or sore throat infection and perianal streptococcal dermatitis. The most frequent type is chronic plaque psoriasis which is found with comorbidities like psoriatic arthritis and nail infection. Nearly 1/3rd of the patients are infected with nail and cuticle psoriasis. Nails get worn off, crumbled, discoloured and flushed which gets separated from the nail bed. 30% of patients are affected with psoriatic arthritis. Psoriatic arthritis has 5 various types. Distal oligoarthritis is the most common one that affects the joints. The other types are rheumatoid factor–negative polyarthritis, arthritis mutilans, sacroiliitis, and ankylosing spondylitis.
Severe psoriasis also increases the risk of cardiovascular diseases and metabolic disorders. Metabolic syndrome, a cluster of diseases leading to cardiovascular impact, is associated with psoriasis. These comorbid conditions include chronic obstructive pulmonary disease, nonalcoholic fatty liver disease, coronary artery disease, celiac disease and HIV.3
Moreover, these physical symptoms and pain affect the mental health of the patient.
A physical examination and patient history are performed by a doctor for lesions on the skin, scalp, nails and other common areas that are typical of psoriasis. Visualisation of two signs: Auspitz sign and Koebner phenomenon will provide clues on the diagnosis.
- Auspitz sign is the clustered blood spots you see when the psoriatic sites are abraded from cloth or object. The cells underlying the psoriatic skin are not matured and when they are scratched, the blood vessels are broken.
- Koebner phenomenon are psoriatic lesions in an area that is not usually affected by psoriasis
Skin Biopsy is rarely required but can further clarify the diagnosis or can differentiate from another kind of skin condition based on the histopathological features - in the case of erythrodermic psoriasis biopsy is normally done.
Plaque psoriasis is graded based on three factors:
- Area and Severity Index (PASI)
- Body surface area (BSA)
- Dermatology Life Quality Index
A score greater than 10 in each of the mentioned factors implies moderate to severe guttate psoriasis. Severe cases of chronic plaque psoriasis can increase the chances of developing cancer.
Management and treatment for guttate psoriasis
The type of treatment relies on the location of plaque, itching, related psoriatic arthritis, functional limitations and psychosocial limitations of the patient. Findings on Guttate psoriasis treatment are very much limited and require further scientific investigations.
Guttate psoriasis treatment is through:
- Retinoids - a topical treatment to manage the symptoms, slow down and reduce inflammation
- Methotrexate and/or Cyclosporine - treats moderate-to severe psoriasis. They can either be given as a single treatment or in combination.4
- TNF-alpha inhibitors
- Topical corticosteroids - applied directly to the skin to reduce inflammation. Mild or acute forms of psoriasis are treated. Inverse psoriasis can be treated with low potency corticosteroids
- Phototherapy - Exposure of skin to UV B penetrates the skin and kills unwanted skin cells. It is done under the supervision of clinicians.
- Topical non-steroidals - anthralin, synthetic vitamin D3, and vitamin A for chronic plaque psoriasis.
- FDA-approved ingredients like salicylic acid and coal tar are used in the form of lotions, foams, tars, bath solutions, and shampoos.
- Aloe vera, jojoba, zinc pyrithione, and capsaicin - moisturise, soothe, remove scale, or relieve itching.
- Emollient moisturisers - prevent hyperkeratinization and scales
- Keratolytic agents such as urea, salicylic acid, and α-hydroxy acid - decrease the thickness of scales and excess keratinisation
- Tonsillectomy - systematic reviews show reduced skin lesions after tonsillectomy in patients with severe psoriasis. Thus tonsillectomy could be used as an adjunct for guttate psoriasis treatment.5
Half of the patients diagnosed with psoriasis may also have scalp psoriasis. The scalp needs to be examined along with the skin. Usually, the same topical application of skin is effective against scalp psoriasis but patients prefer lotions and gels over thicker creams and ointments. Keratolytic and tar-based shampoo for 10- 20 min is recommended.
Erythrodermic psoriasis often requires hospitalisation and systemic treatments. Systemic corticosteroids and phototherapy should be avoided since they are photosensitive and can trigger the condition. The pain, itching and burning sensation of the plaque can be managed by using pain analgesics. Psoriasis is an immune-mediated skin condition whereby cytokines play an adversary role, thus cytokine blockers are used for guttate psoriasis treatment.6
How is guttate psoriasis diagnosed?
A thorough physical examination by the dermatologist can determine the condition. tTo prevent misdiagnosis the physician might suggest a skin biopsy.
How can I prevent guttate psoriasis?
- Keep the skin moist to prevent plaque formation
- Avoid products that cause skin irritation
- Abstain from alcohol and smoking
- Take a bath in lukewarm water to get rid of itching and scales
- In case any skin trauma take appropriate treatment and avoid scratching as it may cause psoriatic lesions
Is guttate psoriasis contagious?
Psoriasis is an autoimmune condition. It is not contagious and does not spread via water, air and touch.
Who are at risk of guttate psoriasis?
Patients who had a strep infection, sore throat, or fungal and viral infection are at risk of developing guttate psoriasis. While other risk factors include trauma, lifestyle factors, gene susceptibility, strep infection, and viral and fungal infection are also at risk of developing guttate psoriasis.
How common is guttate psoriasis?
Around 2-4% of the total population is affected with psoriasis.7
When should I see a doctor?
As the lesions develop and start spreading as well as causing pain and burning sensation, it is advisable to visit a doctor.
Guttate psoriasis is a skin-related inflammatory condition usually manifested as drop-like plaques on the trunk and extremities including scalp and nail cuticles. Young adult and mid-aged groups are affected. Psoriasis affects the physical, emotional and mental health of patients. The causative factor is yet to be understood and this area of research is ongoing. Guttate psoriasis treatment includes topical corticosteroids, phototherapy and systemic treatments to reduce inflammation. By regularly using the medications as prescribed by your doctor, you should expect to see an improvement in your skin. Psoriasis patients often deal with low self-esteem, depression or anxiety. It’s important to discuss your concerns with your doctor or dermatologists as they understand what you’re experiencing.
- Saleh D, Tanner LS. Guttate psoriasis. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 [cited 2023 Mar 16]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK482498/
- Dhabale A, Nagpure S. Types of psoriasis and their effects on the immune system. Cureus [Internet]. [cited 2023 Mar 16];14(9):e29536. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9592057/
- Chen L, Tsai TF. hla-cw6 and psoriasis. British Journal of Dermatology [Internet]. 2018 Apr 1 [cited 2023 Mar 17];178(4):854–62. Available from: https://academic.oup.com/bjd/article/178/4/854/6602682
- Sandhu K, Kaur I, Kumar B, Saraswat A. Efficacy and Safety of CyclosporineversusMethotrexate in Severe Psoriasis: A Study from North India. The Journal of Dermatology [Internet]. 2014 Jul [cited 2023 Sep 10];30(6):458–63. Available from: https://onlinelibrary.wiley.com/doi/10.1111/j.1346-8138.2003.tb00416.x
- Zhou S, Yao Z. Roles of infection in psoriasis. Int J Mol Sci [Internet]. 2022 Jun 23 [cited 2023 Mar 17];23(13):6955. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9266590/
- Brandon A, Mufti A, Gary Sibbald R. Diagnosis and management of cutaneous psoriasis: a review. Advances in Skin & Wound Care [Internet]. 2019 Feb [cited 2023 Mar 17];32(2):58. Available from: https://journals.lww.com/aswcjournal/Fulltext/2019/02000/Diagnosis_and_Management_of_Cutaneous_Psoriasis__A.3.aspx
- Papp KA, Gniadecki R, Beecker J, Dutz J, Gooderham MJ, Hong CH, et al. Psoriasis prevalence and severity by expert elicitation. Dermatol Ther (Heidelb) [Internet]. 2021 Apr 22 [cited 2023 Mar 17];11(3):1053–64. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8163919/