- Stephanie Mehlis, MD
Stephanie Mehlis, MD
- Clinical Instructor, Division of Dermatology
- University of Chicago, Pritzker School of Medicine
Psoriasis is a common skin disorder characterized by the development of inflammatory plaques on the skin. The spectrum of clinical manifestations of psoriasis is wide, and includes chronic plaque, guttate, inverse, erythrodermic, pustular, and nail variants of the disease. (See "Epidemiology, clinical manifestations, and diagnosis of psoriasis", section on 'Clinical manifestations'.)
Patients with guttate psoriasis typically present with the acute onset of numerous small, inflammatory, scaly plaques on the trunk and extremities (picture 1A-B). Guttate psoriasis is most common among children and young adults, and a preceding history of streptococcal infection is often present.
The epidemiology, clinical manifestations, and treatment of guttate psoriasis will be reviewed here. Other manifestations of psoriasis are discussed separately. (See "Epidemiology, clinical manifestations, and diagnosis of psoriasis" and "Treatment of psoriasis".)
Psoriasis occurs in 0.6 to 4.8 percent of the general population , with chronic plaque psoriasis as the most common clinical presentation. Estimates of the proportion of patients with psoriasis who develop guttate disease vary widely; many studies cite a prevalence of less than 30 percent among patients with psoriasis [2-6].
Guttate psoriasis is most frequently diagnosed in children and young adults under the age of 30; however, older individuals may also be affected [7-9]. As an example, in a Spanish study that compared 1092 patients in whom psoriasis began between the ages of 0 and 30 years to 662 patients with disease onset later in life, patients in the younger-onset group were significantly more likely to have the guttate variant (15 versus 7 percent) .
- Naldi L. Epidemiology of psoriasis. Curr Drug Targets Inflamm Allergy 2004; 3:121.
- Rigopoulos D, Gregoriou S, Katrinaki A, et al. Characteristics of psoriasis in Greece: an epidemiological study of a population in a sunny Mediterranean climate. Eur J Dermatol 2010; 20:189.
- Kundakci N, Türsen U, Babiker MO, Gürgey E. The evaluation of the sociodemographic and clinical features of Turkish psoriasis patients. Int J Dermatol 2002; 41:220.
- Valenzuela F, Silva P, Valdés MP, Papp K. Epidemiology and quality of life of patients with psoriasis in Chile. Actas Dermosifiliogr 2011; 102:810.
- Fan X, Yang S, Sun LD, et al. Comparison of clinical features of HLA-Cw*0602-positive and -negative psoriasis patients in a Han Chinese population. Acta Derm Venereol 2007; 87:335.
- Kwon HH, Na SJ, Jo SJ, Youn JI. Epidemiology and clinical features of pediatric psoriasis in tertiary referral psoriasis clinic. J Dermatol 2012; 39:260.
- Ko HC, Jwa SW, Song M, et al. Clinical course of guttate psoriasis: long-term follow-up study. J Dermatol 2010; 37:894.
- Ferrándiz C, Pujol RM, García-Patos V, et al. Psoriasis of early and late onset: a clinical and epidemiologic study from Spain. J Am Acad Dermatol 2002; 46:867.
- Kwon HH, Kwon IH, Youn JI. Clinical study of psoriasis occurring over the age of 60 years: is elderly-onset psoriasis a distinct subtype? Int J Dermatol 2012; 51:53.
- Mallon E, Bunce M, Wojnarowska F, Welsh K. HLA-CW*0602 is a susceptibility factor in type I psoriasis, and evidence Ala-73 is increased in male type I psoriatics. J Invest Dermatol 1997; 109:183.
- Wu D, Wu Y, Liu JL, et al. Association between HLA-Cw*0602 polymorphism and psoriasis risk: a meta-analysis. Genet Mol Res 2011; 10:3109.
- Holm SJ, Sakuraba K, Mallbris L, et al. Distinct HLA-C/KIR genotype profile associates with guttate psoriasis. J Invest Dermatol 2005; 125:721.
- Mallbris L, Wolk K, Sánchez F, Ståhle M. HLA-Cw*0602 associates with a twofold higher prevalence of positive streptococcal throat swab at the onset of psoriasis: a case control study. BMC Dermatol 2009; 9:5.
- Gudjonsson JE, Karason A, Runarsdottir EH, et al. Distinct clinical differences between HLA-Cw*0602 positive and negative psoriasis patients--an analysis of 1019 HLA-C- and HLA-B-typed patients. J Invest Dermatol 2006; 126:740.
- Mallon E, Bunce M, Savoie H, et al. HLA-C and guttate psoriasis. Br J Dermatol 2000; 143:1177.
- Gudjónsson JE, Kárason A, Antonsdóttir AA, et al. HLA-Cw6-positive and HLA-Cw6-negative patients with Psoriasis vulgaris have distinct clinical features. J Invest Dermatol 2002; 118:362.
- NORRLIND R. Psoriasis following infections with hemolytic streptococci. Acta Derm Venereol 1950; 30:64.
- Prinz JC. Psoriasis vulgaris--a sterile antibacterial skin reaction mediated by cross-reactive T cells? An immunological view of the pathophysiology of psoriasis. Clin Exp Dermatol 2001; 26:326.
- Telfer NR, Chalmers RJ, Whale K, Colman G. The role of streptococcal infection in the initiation of guttate psoriasis. Arch Dermatol 1992; 128:39.
- Mallbris L, Larsson P, Bergqvist S, et al. Psoriasis phenotype at disease onset: clinical characterization of 400 adult cases. J Invest Dermatol 2005; 124:499.
- Mercy K, Kwasny M, Cordoro KM, et al. Clinical manifestations of pediatric psoriasis: results of a multicenter study in the United States. Pediatr Dermatol 2013; 30:424.
- Patrizi A, Costa AM, Fiorillo L, Neri I. Perianal streptococcal dermatitis associated with guttate psoriasis and/or balanoposthitis: a study of five cases. Pediatr Dermatol 1994; 11:168.
- Herbst RA, Hoch O, Kapp A, Weiss J. Guttate psoriasis triggered by perianal streptococcal dermatitis in a four-year-old boy. J Am Acad Dermatol 2000; 42:885.
- Veraldi S, Lunardon L, Dassoni F. Guttate psoriasis triggered by chickenpox. G Ital Dermatol Venereol 2009; 144:501.
- Ito T, Furukawa F. Psoriasis guttate acuta triggered by varicella zoster virus infection. Eur J Dermatol 2000; 10:226.
- Elewski B. Does pityrosporum ovale have a role in psoriasis? Arch Dermatol 1990; 126:1111.
- Sandhu K, Jain R, Kaur I, Kumar B. Role of Pityrosporum ovale in guttate psoriasis. J Dermatol 2003; 30:252.
- Horner KL, Chien AJ, Edenholm M, Hornung RL. Winnie the Pooh and psoriasis too: an isomorphic response of guttate psoriasis in a tattoo. Pediatr Dermatol 2007; 24:E70.
- Guerra I, Algaba A, Pérez-Calle JL, et al. Induction of psoriasis with anti-TNF agents in patients with inflammatory bowel disease: a report of 21 cases. J Crohns Colitis 2012; 6:518.
- Brigant F, Clavel G, Chatelain D, et al. Letter: A case of generalized guttate psoriasis induced by etanercept with relapse after abatacept. Dermatol Online J 2011; 17:11.
- Collamer AN, Battafarano DF. Psoriatic skin lesions induced by tumor necrosis factor antagonist therapy: clinical features and possible immunopathogenesis. Semin Arthritis Rheum 2010; 40:233.
- Laga AC, Vleugels RA, Qureshi AA, Velazquez EF. Histopathologic spectrum of psoriasiform skin reactions associated with tumor necrosis factor-α inhibitor therapy. A study of 16 biopsies. Am J Dermatopathol 2010; 32:568.
- Costa-Romero M, Coto-Segura P, Suarez-Saavedra S, et al. Guttate psoriasis induced by infliximab in a child with Crohn's disease. Inflamm Bowel Dis 2008; 14:1462.
- Valdimarsson H, Thorleifsdottir RH, Sigurdardottir SL, et al. Psoriasis--as an autoimmune disease caused by molecular mimicry. Trends Immunol 2009; 30:494.
- Johnston A, Gudjonsson JE, Sigmundsdottir H, et al. Peripheral blood T cell responses to keratin peptides that share sequences with streptococcal M proteins are largely restricted to skin-homing CD8(+) T cells. Clin Exp Immunol 2004; 138:83.
- Christophers E, Kiene P. Guttate and plaque psoriasis. Dermatol Clin 1995; 13:751.
- Krishnamurthy K, Walker A, Gropper CA, Hoffman C. To treat or not to treat? Management of guttate psoriasis and pityriasis rosea in patients with evidence of group A Streptococcal infection. J Drugs Dermatol 2010; 9:241.
- Martin BA, Chalmers RJ, Telfer NR. How great is the risk of further psoriasis following a single episode of acute guttate psoriasis? Arch Dermatol 1996; 132:717.
- Williams RC, McKenzie AW, Roger JH, Joysey VC. HL-A antigens in patients with guttate psoriasis. Br J Dermatol 1976; 95:163.
- Chalmers RJ, O'Sullivan T, Owen CM, Griffiths CE. A systematic review of treatments for guttate psoriasis. Br J Dermatol 2001; 145:891.
- Chalmers RJ, O'Sullivan T, Owen CM, Griffiths CE. Interventions for guttate psoriasis. Cochrane Database Syst Rev 2000; :CD001213.
- Menter A, Korman NJ, Elmets CA, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis: Section 5. Guidelines of care for the treatment of psoriasis with phototherapy and photochemotherapy. J Am Acad Dermatol 2010; 62:114.
- Lapolla W, Yentzer BA, Bagel J, et al. A review of phototherapy protocols for psoriasis treatment. J Am Acad Dermatol 2011; 64:936.
- Walters IB, Burack LH, Coven TR, et al. Suberythemogenic narrow-band UVB is markedly more effective than conventional UVB in treatment of psoriasis vulgaris. J Am Acad Dermatol 1999; 40:893.
- Kirke SM, Lowder S, Lloyd JJ, et al. A randomized comparison of selective broadband UVB and narrowband UVB in the treatment of psoriasis. J Invest Dermatol 2007; 127:1641.
- Yones SS, Palmer RA, Garibaldinos TT, Hawk JL. Randomized double-blind trial of the treatment of chronic plaque psoriasis: efficacy of psoralen-UV-A therapy vs narrowband UV-B therapy. Arch Dermatol 2006; 142:836.
- Gökdemir G, Kivanç-Altunay I, Köşlü A. Narrow-band ultraviolet B phototherapy in patients with psoriasis: for which types of psoriasis is it more effective? J Dermatol 2005; 32:436.
- Mason AR, Mason J, Cork M, et al. Topical treatments for chronic plaque psoriasis. Cochrane Database Syst Rev 2009; :CD005028.
- Wilson JK, Al-Suwaidan SN, Krowchuk D, Feldman SR. Treatment of psoriasis in children: is there a role for antibiotic therapy and tonsillectomy? Pediatr Dermatol 2003; 20:11.
- Owen CM, Chalmers RJ, O'Sullivan T, Griffiths CE. A systematic review of antistreptococcal interventions for guttate and chronic plaque psoriasis. Br J Dermatol 2001; 145:886.
- Owen CM, Chalmers RJ, O'Sullivan T, Griffiths CE. Antistreptococcal interventions for guttate and chronic plaque psoriasis. Cochrane Database Syst Rev 2000; :CD001976.
- Rachakonda TD, Dhillon JS, Florek AG, Armstrong AW. Effect of tonsillectomy on psoriasis: a systematic review. J Am Acad Dermatol 2015; 72:261.
- Hone SW, Donnelly MJ, Powell F, Blayney AW. Clearance of recalcitrant psoriasis after tonsillectomy. Clin Otolaryngol Allied Sci 1996; 21:546.
- Rosenberg EW, Noah PW, Zanolli MD, et al. Use of rifampin with penicillin and erythromycin in the treatment of psoriasis. Preliminary report. J Am Acad Dermatol 1986; 14:761.
- Polat M, Lenk N, Yalcin B, et al. Efficacy of erythromycin for psoriasis vulgaris. Clin Exp Dermatol 2007; 32:295.
- Komine M, Tamaki K. An open trial of oral macrolide treatment for psoriasis vulgaris. J Dermatol 2000; 27:508.
- Tsankov N, Grozdev I. Rifampicin in the treatment of psoriasis. J Eur Acad Dermatol Venereol 2009; 23:93.
- 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.
- RISK FACTORS
- Streptococcal infection
- Other infections
- CLINICAL MANIFESTATIONS
- Laboratory tests
- Differential diagnosis
- CLINICAL COURSE
- First-line therapies
- - Phototherapy
- - Topical corticosteroids and vitamin D analogs
- Refractory disease
- - Tonsillectomy
- - Systemic psoriasis therapies
- Other interventions
- - Systemic antibiotics
- SUMMARY AND RECOMMENDATIONS