A 42-year-old man with a significant history of psoriasis presented with cutaneous lesions evolving over 10 days. The patient's history revealed well-controlled plaque psoriasis under the care of his family physician, treated with a weekly dose of 12.5mg methotrexate and a combination cream of betamethasone and calcipotriol on specific occasions. As a result, he had been lesion-free in recent years, maintaining a well-controlled psoriasis with a Psoriasis Activity and Severity Index (PASI), body surface area (BSA), and Dermatology Life Quality Index (DLQI) all at 0. However, due to a family issue, the patient discontinued treatment 2–3 months earlier, remaining asymptomatic. Based on a presumed cutaneous allergy, he was prescribed prednisone 30mg/day for 7 days. Upon abrupt discontinuation of treatment, he developed a cutaneous clinical presentation, leading to an urgent hospital emergency consultation. Examination (Fig. 1) revealed a generalized symmetric exanthem, characterized by confluent erythematous-scaly plaques predominantly on the trunk and limbs. The plaques displayed a wine-red color, with some having peripheral pustules and others showing a raised rupioid appearance. Systemic symptoms included fever, thermal sensation, and overall discomfort. Given the severe clinical presentation, hospital admission was initiated with a presumptive diagnosis of generalized pustular psoriasis (GPP). The patient was stabilized, and dermatology-initiated treatment with cyclosporine as a bridging therapy, followed by ixekizumab, resulted in a complete response within one month of treatment. Subsequently, a joint follow-up was carried out between his family doctor and dermatology.
GPP is a rare and severe form of psoriasis characterized by the development of generalized pustular plaques.1 These pustules are distinctive and often surround areas of red and inflamed skin, creating a striking and often painful appearance. Patients with generalized pustular psoriasis often experience systemic symptoms such as fever, chills, and general discomfort, indicating a more extensive inflammatory response in the body.1,2 This form of psoriasis can be triggered by genetic and environmental factors. Notably, it can be precipitated by the abrupt cessation of drugs, especially systemic corticoids.3 Management may require a multidisciplinary approach involving topical and systemic treatments, and in some cases, hospitalization to manage severe symptoms.1,3 Such was the case with our patient, where an abrupt discontinuation of systemic corticoids triggered a sudden clinical manifestation in a patient with underlying psoriasis. At times, the treatment of generalized pustular psoriasis can be challenging, as not all patients respond uniformly to conventional therapies. Specialized medical attention is necessary to evaluate and adapt the therapeutic approach based on individual patient needs and the severity of the disease.3,4
In summary, GPP is characterized by the emergence of generalized erythematous-scaly pustular plaques, and in some cases, it may affect vital organs. Early recognition of this evolving entity is crucial for all family physicians for proper management and to prevent potential complications, as it can occasionally jeopardize the patient's life.
Ethical approvalProcedures followed here were in accordance with the ethical standards of the responsible committee on human experimentation and with the Helsinki Declaration of 1975, as revised in 1983. We have not use patients’ names, initials, or hospital numbers.
FundingThis article has no funding source.
Authors’ contributionsAll authors had access to the data and played a role in writing this manuscript.
Miguel Mansilla-Polo managed clinical treatment and procedures, contributing to the development of this paper.
Daniel Martín-Torregrosa supervised the work.
Informed consentOral and written consent was obtained to publish this image.
Conflicts of interestThe authors have declared no conflicts of interest.
