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Problems associated with clinical forms of psoriasis

4.1. Pustular psoriasis (photo 100)

Photo 100. Pustular psoriasis of the Zumbusch type responds remarkably to retinoids at doses approaching 1 mg/kg/j, the retinoids having a resolvent effect on attacks in seven to ten days at this dose.
In women in child-bearing age, Soriatane® is replaced with Roaccutane® in order to avoid the restrictions imposed by overly lengthy contraception. After 7 to 10 days the daily dose of retinoids must be reduced to 10 or 20 mg in order to avoid side effects.
Zumbusch-type pustulosis resistant to retinoids presents difficult therapeutic problems. Methotrexate and cyclosporine can be of help.
Anti-TNF?drugs are very effective.

4.2. Erythrodermic psoriasis

Like any erythroderma, psoriatic erythroderma is a metabolic emergency that can jeopardize the life of fragile subjects. Cardiac flow increase by two- or threefold, the calorific loss associated with vasodilation involves intense protein catabolism, trans epidermal water loss is severe - involving a risk of dehydration - and the accelerated rate of skin turnover increases moreover the protein catabolism.
Hydration is necessary. Strength 4 topical steroids must be used whenever there is a metabolic emergency, bearing in mind that a long-term treatment needs to be started simultaneously in order to avoid ending up in a situation of cortico-dependence or, even worse, rebound.

The long-term treatments may be:

  1. retinoids, never exceeding 20 mg/j as higher doses run the risk of producing particularly serious weeping erythroderma;
  2. methotrexate in small doses, taking into consideration frequent hypoalbuminemia and generally starting treatment at 10 mg/week intramuscularly;
  3. cyclosporine has not been assessed in psoriatic erythroderma. Metabolic disturbances and the frequent reduction in renal perfusion caused by dehydration should dictate caution, starting off at weak doses in the order of 2 or 2.5 mg/kg/j;
  4. Phototherapy is contraindicated in erythroderma because it is practically always poorly tolerated and a source of aggravation.

Substantial improvements have been sometimes observed in psoriatic erythroderma after taking vitamin D, but the results are very fickle and remain to be assessed.
Anti-TNF?are very effective.

[|4.1 Pustular Psoriasis and 4.2 Erythrodermic Psoriasis - Response to infliximab, in both these forms of psoriasis, is frequently more dramatic than even ciclosporin. |auteur215]

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