Synopsis
Recognise a generalised pustular psoriasis flare as a potentially fatal neutrophilic emergency, exclude infection and drug pustulosis, stabilise systemic complications, and apply current specialist systemic and spesolimab criteria safely.
- Generalised pustular psoriasis causes widespread visible or superficial non-follicular pustules on inflamed skin with systemic illness; pustules are sterile unless secondary infection complicates them.
- Pustules may be conspicuous cream-yellow in any skin tone, while background erythema can look red, violaceous, grey-brown or dusky and is assessed with warmth, tenderness and swelling.
- Ask about established plaque or pustular psoriasis, previous flares, pregnancy, infection, hypocalcaemia, medicine exposure and abrupt withdrawal of systemic corticosteroid or other psoriasis treatment.
Key red flags
Hypotension, hypoxia, confusion, oliguria, rapidly spreading painful pustulation, hypothermia or high fever, severe oedema, tetany, mucosal involvement, pregnancy, childhood, frailty, neutropenia, suspected sepsis or respiratory symptoms requires critical-care-level reassessment and urgent specialist treatment.
Hypotension, hypoxia, confusion, oliguria, marked calcium disturbance, tetany, extensive erosion or rapidly escalating oxygen and fluid need indicates critical illness.
Investigation priorities
Quantify neutrophilic inflammation and identify eosinophilia, cytopenia or infection risk.
Management branches
Widespread pustulation is accompanied by systemic symptoms, rapid progression or diagnostic uncertainty.
- Assess ABCDE, core temperature, haemodynamics, oxygen need, mental state, pain, extent, mucosae and urine output and involve dermatology immediately.
- Obtain full blood count, renal, liver, albumin, calcium, magnesium, CRP and appropriate cultures, biopsy a fresh lesion and document the complete medicine timeline.