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Woman sitting on ground with feet facing the viewer with Pustular Psoriasis on her foot.

Are There Different Types of Pustular Psoriasis?

Psoriasis is a relatively common skin condition that affects people all over the world. In the United States, about 3.2% of adults are affected.1 The most common type of psoriasis is called plaque psoriasis. It accounts for about 85-90% of psoriasis cases and can occur just about anywhere on the body.2 Pustular psoriasis is a different, much more rare, form of the disease.

What does plaque psoriasis look like?

Plaque psoriasis generally appears as red, raised, scaly, and often itchy patches on the skin. These symptoms are caused by an overactive immune system, which causes skin cells to grow abnormally quickly.3

What does pustular psoriasis look like?

Pustular psoriasis appears as small white or yellow fluid-filled blisters that form on top of very red skin. The fluid inside the blisters is made up of a special kind of white blood cell. White blood cells are part of our body’s immune system, which detects and fights off invaders and infections.

What are some common elements of pustular psoriasis?

There are three main sub-types of pustular psoriasis. They all look slightly different, and they show up on different parts of the body. Like plaque psoriasis, pustular psoriasis generally ebbs and flows, becoming more or less serious at different times. Periods, when the disease is more severe, are known as “flare-ups.”

As with plaque psoriasis, people with pustular psoriasis are prone to other illnesses too. These are often called “comorbidities.” For people with pustular psoriasis, common comorbidities include diabetes and high blood pressure, which is a risk factor for heart disease. People with pustular psoriasis often have plaque psoriasis as well, although some sub-types occur more frequently with plaque psoriasis than others.5

One of the main risk factors for all types of pustular psoriasis is smoking. Pustular psoriasis can also be triggered by:6

  • Treatment with certain medications
  • Steroid medicines
  • Irritating topical agents
  • Sudden discontinuation of a steroid or other strong medication
  • Infection
  • Pregnancy
  • Skin injury
  • Stress
  • Overexposure to sunlight

What are the main sub-types of pustular psoriasis?

Although there are similarities among the sub-types of pustular psoriasis, they are also very different in their clinical and genetic characteristics.

Palmoplantar pustulosis (PPP)

This type of psoriasis affects about 5% of people with psoriasis.3 It appears only on the palms of the hands and soles of the feet. It can be quite painful, enough to affect daily life. PPP starts later than other types of psoriasis, with a mean age of onset at 44. It is also most affected by smoking and seems to occur more frequently in women than in men, compared to other subtypes.4

PPP can be hard to treat, so people with this condition should check with their health care provider for guidance. Treatment often begins with creams and other topical medicines, including strong topical steroids. Coal tar or salicylic acid may help prevent scaly skin, and applying cremes frequently can help prevent skin from cracking. This is important to prevent infection.3

Generalized pustular psoriasis (GPP), also known as von Zumbusch

Generalized pustular psoriasis occurs over the entire body. GPP can often come on quite suddenly, and it can be dangerous or even life-threatening.3,5 The mean age of onset for GPP is relatively young-31-compared to other types of pustular psoriasis.4

People experiencing a flare-up of GPP generally need to go to the hospital for supervised care. Important treatments include restoring the protective function of the skin and preventing fluid loss and dangerous chemical imbalances that can result from dehydration.5,6

People with GPP often get other serious symptoms, in addition to the outbreak of red rash and pustules. These include:5

  • Fever
  • Chills
  • Severe itching
  • Rapid pulse
  • Dehydration
  • Exhaustion
  • Joint pain
  • Muscle weakness
  • Lack of red blood cells
  • Weight loss

Most of the treatments for GPP are prescription medications, including biologics. People with GPP often need antibiotics as well, to prevent or treat infection.

Acrodermatitis continua of Hallopeau (ACH)

This is a very rare type of pustular psoriasis that occurs only on the ends of the fingers and sometimes the toes. The problems often occur after damage or trauma to the area. ACH is most common among middle-aged women.7 It is typically painful and can cause discoloration and damage to the nails or, in rare cases, the bone.5

Doctors generally prescribe a combination of systemic or topical medicines for ACH as well as other hard-to-treat types of pustular psoriasis. Systemic medications are taken by mouth or injection and affect the whole body. Topical medications are lotions or creams that you apply directly to your affected skin.

  1. Craig Elmets, Craig Leonardi, Dawn Davis, et al. Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with awareness and attention to comorbidities. April 2019 Volume 80, Issue 4, Pages 1073–1113 Available at https://www.jaad.org/article/S0190-9622(18)33002-0/fulltext Accessed March 17, 2019.
  2. Palfreeman AC, McNamee KE, McCann FE (March 2013). New developments in the management of psoriasis and psoriatic arthritis: a focus on apremilast. Drug Des Devel Ther. 7: 201–210. Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3615921/. Accessed March 15, 2018.
  3. About Psoriasis. National Psoriasis Foundation. Available at https://www.psoriasis.org/about-psoriasis. Accessed March 15, 2018.
  4. Brian Wu. Pustular psoriasis: What you need to know. January 1, 2016. Medical News Today. Available at: https://www.medicalnewstoday.com/articles/314940.php Accessed May 27, 2019.
  5. Sophie Twelves, Alshimaa Mostafa, Nick Dand, et al. Clinical and genetic differences between pustular psoriasis subtypes. J Allergy Clin Immunol. 2019 Mar; 143(3): 1021–1026. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6403101/ Accessed May 27, 2019.
  6. Pustular Psoriasis. National Psoriasis Foundation. Available at: https://www.psoriasis.org/about-psoriasis/types/pustular. Accessed May 27, 2019.
  7. Katie Benjegerdes, Kimberly Hyde, Dario Kivelevitch, et al. Pustular psoriasis: pathophysiology and current treatment perspectives. Psoriasis (Auckl). 2016; 6: 131–144. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5683122/ Accessed May 27, 2019.

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