The choice of treatment for guttate psoriasis is hampered by the lack of controlled trials for the available therapies, as Drs Caroline Owen and Robert Chalmers report
Guttate psoriasis is a distinctive form of psoriasis which characteristically occurs in children and young adults. It may arise on its own (acute guttate psoriasis) or may complicate existing, often quite limited, chronic plaque psoriasis (guttate flare of chronic psoriasis).
It is strongly associated with preceding or concurrent streptococcal infection, evidence of which can be found in the majority of affected patients.1 Typically, showers of tiny red papules (likened to rain-drops or guttae) erupt over large areas of the skin surface 1–2 weeks after an episode of acute tonsillitis.
In the early stages, before the typical scale has had a chance to develop, guttate psoriasis can be mistaken for a drug eruption, especially in people given an antibiotic for the associated streptococcal infection.
The true diagnosis, which is a clinical one, soon becomes apparent as characteristic psoriatic scaling develops on the surface of the papules.
If left untreated, guttate psoriasis may clear spontaneously or develop into chronic plaque psoriasis. Guttate psoriasis may recur although the risk is not well defined.2
There is no consensus on the best treatment for guttate psoriasis. Topical therapies commonly used include simple emollient therapy, corticosteroids, tar formulations and, more recently, vitamin D analogues. Phototherapy is often used for extensive guttate psoriasis. In view of the link with streptococcal infection, antistreptococcal antibiotics have been recommended.
In recent systematic reviews of treatments for guttate psoriasis undertaken for the Cochrane Collaboration, no randomised controlled trials of topical therapy or phototherapy were found,3 and the limited evidence available suggests that antibiotics are of no benefit.4
Explanation and reassurance
Acute guttate psoriasis develops rapidly, and can cause great anxiety in someone without any history of psoriasis. Explanation of the disease and its natural history is an important aspect of treatment.
Emollient therapy alone can help with the discomfort associated with guttate psoriasis. As guttate psoriasis is usually widespread, it is important to prescribe sufficient quantities to allow it to be applied generously twice daily.
There is no evidence to support one form of active topical therapy over another, nor any firm evidence to demonstrate that active topical treatments are more efficacious than emollient therapy alone.
Mild tar preparations have been used over many decades for treating guttate psoriasis and are generally well tolerated.
Vitamin D analogues are well tolerated and have the advantage over topical corticosteroids that they do not cause skin atrophy. They can be prescribed twice daily or, if irritation proves to be a problem, once daily in conjunction with a mild or moderately potent topical corticosteroid cream at night.
The disadvantages of topical corticosteroids are well known, but mild to moderate preparations may be used for up to 4 weeks at a time. Hydrocortisone cream 1% is particularly useful for the face where other preparations may cause irritation.
It is not known which of the above preparations is most likely to result in rapid resolution of guttate psoriasis.
Traditionally, UVB phototherapy, often in association with tar, has been used for treating guttate psoriasis in patients referred to hospital clinics.
Photochemotherapy (psoralens with UVA; PUVA), with or without acetretin, is usually reserved for chronic plaque psoriasis, or extensive or recalcitrant guttate psoriasis.
There is very little guidance, even from uncontrolled studies, on either form of phototherapy.
A large uncontrolled study of 1308 patients receiving PUVA5 included over 120 patients with guttate psoriasis. A good response to therapy was observed in all groups, but guttate psoriasis patients required fewer treatments to achieve clearance than those with chronic plaque disease or erythroderma. However, as guttate psoriasis is commonly self-limiting, it is difficult to draw firm conclusions from this study.
Although it is well known that guttate psoriasis may be precipitated by streptococcal infection, there is no firm evidence to support the use of antibiotics either in the management of established guttate psoriasis or in prophylaxis against the development of guttate psoriasis following streptococcal sore throat.
A Canadian group examined 20 patients with predominantly guttate psoriasis and cultural or serological evidence of beta-haemolytic streptococcal colonisation randomly allocated to two treatment groups.6 Group A received oral phenoxymethyl penicillin or oral erythromycin for 14 days plus a placebo for the last 5 days of the 14 days, and group B received oral phenoxymethylpenicillin or oral erythromycin for 14 days plus oral rifampin for the last 5 of the 14 days. No benefit was shown in either treatment group.
A further study7 looking at oral fucidin vs placebo likewise showed no benefit in the active treatment group.
In view of the link between streptococcal infection and psoriasis, it has been proposed that tonsillectomy can be beneficial for patients with guttate psoriasis exacerbated by recurrent tonsillitis.
Hone et al in 1996 investigated 13 patients with either recurrent guttate psoriasis or chronic plaque psoriasis exacerbated by tonsillitis. In this group, psoriasis cleared completely after tonsillectomy in five of six patients with guttate psoriasis and two of seven with chronic plaque psoriasis.8
Rosenberg and colleagues reported clearing of psoriasis in nine of 14 patients (all of whom had evidence of streptococcal colonisation) following tonsillectomy.9
McMillin et al found that two children with recurrent streptococcal pharyngitis or tonsillitis complicated by recurrent guttate psoriasis were completely free of psoriasis 16 months after adenotonsillectomy.10
All of the above three studies were uncontrolled.
|There is no firm evidence to guide doctors or their patients on the optimal method of treatment of guttate psoriasis.|
In general, topical agents as described above should be used in the first instance. Many patients can be managed adequately in primary care.
|Despite the well-established link between streptococcal infection and guttate psoriasis, there is to date no evidence that antistreptococcal antibiotics are of benefit.|
|The main indication for specialist referral is extensive or recalcitrant disease, for which phototherapy may be appropriate.|
|There is no robust evidence to support the use of tonsillectomy for guttate psoriasis and this should not be considered without referral to a dermatologist.|
|Studies comparing standard treatment modalities, including topical regimens and phototherapy, are required to enable informed decisions on treatment choices to be made.|
- Telfer NR, Chalmers RJG, Whale K, Colman G. The role of streptococcal infection in the initiation of guttate psoriasis. Arch Dermatol 1992; 128: 39-42.
- Martin BA, Chalmers RJG, Telfer NR. How great is the risk of further psoriasis following a single episode of acute guttate psoriasis? Arch Dermatol 1996;132:717.
- Chalmers RJG, O'Sullivan T, Owen CM, Griffiths CEM. Interventions for guttate psoriasis (Cochrane Review). In: The Cochrane Library, Issue 1, 2000. Oxford: Update Software.
- Owen CM, Chalmers RJG, O'Sullivan T, Griffiths CEM. Antistreptococcal interventions for guttate and chronic plaque psoriasis (Cochrane Review). In: The Cochrane Library, Issue 1, 2000. Oxford: Update Software.
- Melski JW, Tannenbaum L, Parrish JA, Fitzpatrick TB, Bleich HL. Oral methoxsalen photochemotherapy for the treatment of psoriasis: a cooperative clinical trial. J Invest Dermatol 1997; 68: 328-35.
- Vincent F, Ross JB, Dalton M, Wort AJ. A therapeutic trial of the use of penicillin V or erythromycin with or without rifampin in the treatment of psoriasis. J Am Acad Dermatol 1992; 26: 458-61.
- Nyfors A. Fucidin in psoriasis. A double-blind study of 20 psoriatics over two periods of four weeks each. Dermatologica 1973; 146(5): 281-4.
- Hone SW, Donnelly MJ, Powell F, Blayney AW. Clearance of recalcitrant psoriasis after tonsillectomy. Clin Otolaryngol Allied Sci 1996; 21: 546-7.
- Rosenberg EW, Duberstein LE, Duberstein AJ et al. Effect of tonsillectomy and other otorhinolaryngologic surgery on psoriasis. In: Society of Investigative Dermatology Annual Meeting, April 27-30, 1994, Baltimore, MD (poster).
- McMillin BD, Maddern BR, Graham WR. A role for tonsillectomy in the treatment of psoriasis? Ear, Nose Throat J 1999; 78(3): 155-8.