Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 27 Aug 2026Clinical review pending
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Generalised pustulation or erythroderma
Widespread sterile pustules or inflammation affecting most skin can cause temperature dysregulation, fluid and protein loss, electrolyte disturbance, infection, high-output cardiac strain and multiorgan deterioration.
Action: Arrange immediate same-day specialist assessment and likely admission, perform ABCDE and sepsis evaluation, monitor fluid balance and temperature, and avoid delay for histology or outpatient treatment trials.
Synopsis
Recognise unstable pustular or erythrodermic psoriasis, distinguish sterile inflammation from infection and drug reactions, stabilise physiological threats, and support immediate specialist-directed treatment.
Generalised pustular psoriasis causes widespread tender erythema studded with superficial sterile pustules; erythroderma means near-generalised inflammation and scale with systemic barrier failure.
NICE requires immediate same-day specialist assessment and treatment for generalised pustular psoriasis or erythroderma.
Perform ABCDE, full observations, core temperature, fluid balance and urine output; assess sepsis, cardiac strain and venous thromboembolism risk in parallel.
Key red flags
Fever, tachycardia, hypotension, reduced urine output, confusion, shivering, oedema or breathlessness indicates physiological compromise and requires emergency assessment.
Generalised sterile pustules
Sheets of small superficial non-follicular pustules develop on hot tender inflamed skin and may merge. Pustule contents are not assumed infectious, but fever and neutrophilia cannot distinguish sterile inflammation from sepsis.
Investigation priorities
01
First-line physiological assessmentFirst stepFirst line
Detect shock, respiratory compromise, temperature disturbance, acute kidney injury and fluid loss immediately.
Management branches
ImmediateSame-day admission and stabilisation
Generalised pustulation or near-total inflammation, particularly with systemic symptoms or abnormal observations.
Call dermatology and acute medical services immediately, use ABCDE, establish monitoring and assess whether higher-acuity care is required.
Measure input-output, urine, electrolytes, albumin, temperature and weight; give carefully titrated fluid and electrolyte replacement with cardiac and renal reassessment.
DischargePrevent rebound and readmission
Physiology stable, skin improving and a safe ongoing plan agreed.
Key medicines
Ciclosporin for rapid specialist controlNICE uses 2.5 to 3 mg/kg/day orally in 2 divided doses; increase towards 5 mg/kg/day after 4 weeks only for non-response, or earlier when rapid control is necessary in severe unstable disease.
Acitretin for pustular psoriasisNICE targets 25 mg orally once daily using incremental dosing and permits escalation to a maximum 50 mg daily only when no other treatment option is available; assess response by 4 months.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.