What Is Pustular Psoriasis?

Pustular psoriasis is a rare form of psoriasis (a type of inflammatory skin disorder), which causes white or yellow pus-filled bumps to form on inflamed skin. These bumps are called pustules and accompany other symptoms of pustular psoriasis such as itching, burning, fever, and chills. This condition develops due to an overactive immune system—and factors like stress, infections, and certain medications can also trigger symptoms.

About 3% of people with psoriasis experience pustular psoriasis flares, but people without a history of psoriasis can also develop the condition. Pustular psoriasis can develop anywhere on the body but most commonly affects the palms of the hands and soles of the feet. While this condition can be painful, itchy, and challenging to live with, fortunately, treatments are available to manage the condition and relieve symptoms.

Types of Pustular Psoriasis 

The type of pustular psoriasis you have will depend on where the pustules develop. While all types of pustular psoriasis involve blisters filled with pus on the skin, each type presents with unique symptoms and requires different treatment approaches. There are three primary types, including:

• Palmoplantar pustular psoriasis (PPPP): Also known as palmoplantar pustulosis, PPPP is the most common type of pustular psoriasis and affects the palms of the hands and soles of the feet. PPPP is a chronic condition that can be difficult to treat, though periods of remission (when symptoms disappear) are possible.
• Generalized pustular psoriasis (GPP): Sometimes called von Zumbusch psoriasis, GPP involves widespread pustules all over the skin. Symptoms like fever, chills, fatigue, and joint pain also occur with GPP. Most people with this type experience sudden flares (when symptoms appear) followed by remission (when symptoms partially or completely resolve).
• Acrodermatitis continua of Hallopeau (ACU): This is a rare form of pustular psoriasis that causes persistent, chronic bumps on the tips of the fingers and toes. ACH typically starts on one finger or toe and later spreads. New pustules can appear on other fingers and toes and underneath the nails.
  

Symptoms

Clusters of non-infectious, pus-filled bumps that usually develop on top of discolored and swollen skin are the primary symptom of all types of pustular psoriasis. The bumps and surrounding area are tender or painful and can be extremely itchy. The pustules can burst open, leaving the skin underneath raw and scaly.

With pustular psoriasis, your skin may appear like the photo below—especially when pustules open and dry out.

This photo contains medical imagery.

See Image

Symptoms of pustular psoriasis typically develop suddenly. But your exact symptoms will depend on the type of pustular psoriasis you have.

Palmoplantar Pustular Psoriasis Symptoms 

PPPP affects the palms of the hands and soles of the feet, causing symptoms like:

• Large yellow or white-colored pustules that develop on inflamed skin
• Burning sensations
• Itchiness
• Scaly skin patches if the pustules break open
• Cracked or painful skin
  

These symptoms can also make it difficult for people with PPPP to use their hands for performing daily tasks or walking.

Generalized Pustular Psoriasis Symptoms

GPP causes widespread pustules that cover the skin all over your body. Symptoms of GPP are often severe and include:

• Fever
• Chills
• Rapid heart rate 
• Headache
• Loss of appetite 
• Nausea
• Muscle weakness

People with GPP have flares that develop suddenly and last for weeks at a time, which are usually followed by remission periods when symptoms partially or entirely disappear.

Acrodermatitis continua of Hallopeau Symptoms

ACH typically causes pustules that usually develop on just one finger or toe. These pustules often develop under the nail bed of the affected finger or toe. As ACH progresses, you may experience the following symptoms:

• Pustules that spread to other fingers and toes 
• Changes in the shape, color, and texture of fingernails or toenails
• Thickened skin with scaly patches on the fingers and toes
  

When pustules rupture, the underlying skin can become red, inflamed, shiny, and smooth. ACH is chronic (long-term), and new pustules often form in the same location as previous ones. When pustules under the nail rupture, people with ACH may lose one or all of their fingernails. 

Causes

Like psoriasis and other autoimmune disorders, an overactive immune system that mistakenly attacks healthy skin cells also causes pustular psoriasis. This misdirected attack triggers an overproduction of neutrophils and macrophages (which are types of white blood cells) that accumulate in the outer layers of the skin. When these white blood cells start to develop, inflammation and the formation of pustules occur.

Experts aren't sure exactly what causes this overactive immune response, but recent research suggests genetics may play a role. People with inherited gene mutations (changes) in the IL36RN gene, which provide instructions for making a protein that regulates skin inflammation, may play a role in how pustular psoriasis develops. 

Risk Factors 

Some factors can also trigger symptoms of pustular psoriasis to develop, such as:

• Stress
• Overexposure to ultraviolet (UV) rays 
• Bacterial infections
• Reactions to medications
• Stopping certain immunosuppressant medications (e.g., corticosteroids) 
• Pregnancy
• Smoking

Additionally, certain risk factors can increase your chances of developing specific types of pustular psoriasis. For example, an injury to the fingers or toes may trigger ACH. Menstruation can play a role in triggering GPP. And, coming into contact with allergic metals may lead to PPPP. It's also worth noting that people with plaque psoriasis (the most common type of psoriasis) are more likely to develop pustules than those who do not have a history of psoriasis.

Diagnosis

A dermatologist (a doctor specializing in diagnosing and treating conditions affecting the skin, hair, and nails) can diagnose pustular psoriasis. If you are experiencing skin changes or notice symptoms of pustular psoriasis, it's important to see your healthcare provider for proper testing.

During your appointment, your provider will ask about your personal medical history, lifestyle habits, symptoms, medications, and any triggers you may have been exposed to. They will also perform a physical exam to check for signs of pustules, inflammation, scaling, or nail changes.

In some cases, a physical exam is enough to diagnose pustular psoriasis. To confirm the diagnosis and rule out other conditions that can cause similar symptoms, your healthcare provider may also order diagnostic tests such as:

• Blood test: Measures blood cell counts (e.g., white blood cells) and inflammatory markers to confirm the diagnosis and check for complications
• Skin or nail culture: Swabs the skin or nails to collect a pus sample and sends it to the lab to check for infection.
• Skin biopsy: Uses a scalpel or razor to collect a small sample of the affected skin to examine it under a microscope and rule out other conditions.
  

Pustular Psoriasis Treatment

Treatment for pustular psoriasis focuses on relieving symptoms, reducing or clearing pustules from the skin, and lowering the risk of complications. Treatments vary depending on the severity and type of pustular psoriasis.

Palmoplantar Pustular Psoriasis Treatment

Treatment for mild cases of PPPP generally includes topical medications that you can apply directly to the affected skin. Your healthcare provider may also recommend covering the affected area with gauze or bandages to strengthen the medication and ensure it absorbs into the skin. Topical medications may include topical corticosteroids to relieve itching, synthetic vitamin D to remove scaly skin patches, and salicylic acid to improve inflammation.

However, moderate to severe PPPP may require stronger medications and additional treatments, such as: 

• Light therapy or phototherapy: Slows the growth of skin cells and suppresses an overactive immune system to reduce inflammation, relieve itchiness or pain, and promote healing
• Vitamin A oral retinoids: Helps slow down skin cell growth, reduces inflammation, and improves swelling
  

Generalized Pustular Psoriasis Treatment 

GPP requires immediate medical treatment to prevent life-threatening complications. Because GPP symptoms are often severe, many people require hospitalization for treatment and monitoring. With treatment, most cases of GPP resolve within days or weeks, but recurring flares are common.

Your healthcare provider may prescribe one or more medications to treat GPP, such as:

• Biologics: Spevigo (spesolimab) is an FDA-approved biologic drug that treats GPP symptoms in adults. These medications help reduce inflammation and clear your skin. Some healthcare providers prescribe other biologic drugs, such as Humira (adalimumab) or Remicade (infliximab), to reduce inflammation and the presence of pustules.
• Oral retinoids: Made from vitamin A, oral retinoids help control inflammation and reduce GDD symptoms.
• Immunosuppressants: Biologics and retinoids are potent drugs that some people may not tolerate. Instead, healthcare providers may prescribe immunosuppressant medicines, such as Rheumatrex (methotrexate) or Gengraf (cyclosporine), to suppress the overactive immune response and manage GPP symptoms.

Acrodermatitis continua of Hallopeau Treatment

Treatment for ACH is similar to PPPP treatment. It's worth noting that ACH is chronic and more difficult to treat, so you may require multiple treatment options before finding an effective approach. Common ACH treatments include topical corticosteroids to reduce inflammation, synthetic Vitamin D to slow down skin cell growth and reduce scaly skin patches, and PUVA (a type of light therapy that uses a medication called psoralens to help clear out pustules.

How to Prevent Flares

While there's no definitive way to prevent pustular psoriasis, there are steps you can take that may help reduce the frequency and severity of flare-ups. Consider the following strategies:

• Reducing stress through breathing exercises, meditation, and spending time in nature or with loved ones
• Maintaining a proper skincare routine by moisturizing your skin with fragrance-free products to keep it hydrated and healthy
• Avoiding soaps with added fragrances
• Limiting how often you scrub or scratch your skin
• Quitting smoking
• Identifying and avoiding personal triggers that can cause your symptoms to flare up
  

Related Conditions

People with pustular psoriasis are also more likely to develop other health conditions that co-occur at the same time. These conditions include:

• Psoriatic arthritis (PsA): An inflammatory form of arthritis that causes joint pain, stiffness, and swelling. About 26% of people with GPP also have PsA.
• Inflammatory bowel disease (IBD): People with all types of psoriasis have a 1.6 times higher likelihood of developing IBD (such as Crohn's disease or ulcerative colitis). Research suggests overactive immune responses and genetics play a role in the connection between these conditions.
• Anxiety and depression: Living with a chronic, sometimes debilitating condition like pustular psoriasis can cause emotional stress and increase the risk of developing anxiety and depression. In some cases, depression and stress can also trigger pustular psoriasis flares.
  

Living With Pustular Psoriasis

Pustular psoriasis can be difficult to live with, both physically and emotionally. While there's no cure, there are effective treatments that can provide symptom relief and help manage the condition. Researchers are actively developing new and improved treatment options, offering hope for even better treatments in the future. You can live a fulfilling, active life by working closely with your healthcare provider, avoiding triggers, and following your treatment plan.