Guttate Psoriasis in a 33 year old male patient with type 2 skin
Contributed by Dr. Anna Chacon
Guttate Psoriasis
Author: Robin Olanonipekun, MS3, Y, Miller-Monthrope, Dermatologist/Dermatopathologist, Toronto, Canada, 2024
Definition: Guttate Psoriasis (GP) is a distinct variant of acute psoriasis characterized by a wide-spread eruption of “drop-like”, red, purple or brown (depending on the person’s skin tone), scaly, well-defined papules and/or plaques. GP is classically triggered by a previous upper respiratory tract or perianal infection (1, 3).
Etiology: Risk factors for developing GP include infections caused by Group A, Beta-hemolytic streptococci or viruses such as coxsackievirus and SARS-CoV-2 (1). Infection usually precedes the first presentation of GP lesions by 1-3 weeks.
Epidemiology: GP accounts for less than 30% of total psoriasis cases. Onset is described as bimodal- with peak onset ages of 20- 30 and 50 – 60 years of age (3). GP is more common in children and adolescents and occurs equally in males and females and in all races. (1, 3).
Signs/Symptoms: GP typically manifests with numerous “drop-like”, scaly, scattered papules <6mm over the scalp, trunk, arms, back or peri-anal area. In lighter skin tones (Fitzpatric 1-3), GP appears as erythematous or salmon-colored papules with a white or silvery scale. In deeper skin tones, GP tends to be deep red-purple or dark-brown papules with a greyish scale.
Course: GP manifests 1-3 weeks after an acute infection and a persistent disease course is common, often lasting for over 1 year (5). GP may be self-limiting however typically clearing after 4 months without treatment (1).
Diagnosis: A thorough patient history and physical exam are paramount when suspecting GP. (1,3,5). GP is a clinical diagnosis based on patient history and histological findings from a skin biopsy. Dermoscopy will show a red background with spot-like, diffuse vessel distribution and white/ silver scales (4). Investigations directed towards the search for a streptococcal infection include swabs and cultures from the appropriate site (eg: tonsil or perianal), PCR (SARS-CoV-2 infection) and blood tests, such as Anti-streptolysin O and anti-D-Nase B titre (1, 3,4).
Treatment: The preceding infection to GP should be treated, however, this will not treat the papules associated with GP. First-line treatment of mild GP papules involves topical corticosteroids, particularly in ointment form. For more prominent GP, nbUVB is often successful. Therapy with biologic agents is typically reserved for the 40% of GP lesions that are expected to progress to plaque psoriasis (3).
References:
Raharja A, Mahil SK, Barker JN. Psoriasis: a brief overview. Clin Med (Lond). 2021;21(3):170-173. doi:10.7861/clinmed.2021-0257
Stanway A. Guttate psoriasis | DermNet NZ. dermnetnz.org. Published October 2021. https://dermnetnz.org/topics/guttate-psoriasis
Garritsen FM, Kraag DE, de Graaf M. Guttate psoriasis triggered by perianal streptococcal infection. Clin Exp Dermatol. 2017;42(5):536-538. doi:10.1111/ced.13129
Saleh D, Tanner LS. Guttate Psoriasis. In: StatPearls. Treasure Island (FL): StatPearls Publishing; July 31, 2023.
Leung AK, Barankin B, Lam JM, Leong KF. Childhood guttate psoriasis: an updated review. Drugs Context. 2023;12:2023-8-2. Published 2023 Oct 23. doi:10.7573/dic.2023-8-2
Galili E, Levy SR, Tzanani I, et al. New-Onset Guttate Psoriasis: A Long-Term Follow-Up Study. Dermatology. 2023;239(2):188-194. doi:10.1159/000527737