Types of Psoriasis – GUTTATE PSORIASIS (GP)

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Guttate means “drop” in Latin (also known as Teardrop Psoriasis, Raindrop Psoriasis or Psoriasis Exanthematic), and is the second most common type of psoriasis. Guttate psoriasis (GP), is an important clinical variant which occurs more commonly in adolescents and young adults. It is characterized by the sudden onset of widely dispersed small red scaly plaques – 0.2 – 2.0 cm’s in diameter, mainly over the trunk and proximal limbs. The symptoms of GP are numerous small, bright red or salmon coloured, drop-like spots which cover a large portion of the skin. Spots have an abundant fine scaling. The lesions are usually located on the trunk, arms, legs and scalp and spares the face, palms and soles.1

GP represents approximately 2% of psoriasis patients and 30% of guttate patients have a first degree family member with psoriasis 2. Among patients with acute guttate psoriasis, 56–98% experienced a streptococcal infection (e.g. tonsillitis, viral respiratory infections, laryngitis etc.) within a 2-3 weeks period prior to the eruption and, it is theorized that psoriasis may be induced in susceptible individuals by streptococcal superantigens. In children perianal streptococcal infections (or chronic pruritus of the anus) have also been associated with GP 3.

Because some cases of GP in childhood may be triggered or exacerbated by streptococcal pharyngeal infections, the role of tonsillectomy as a treatment option in severe refractory GP has been studied. However, the results remain controversial and at best non conclusive. In a Cochrane review the conclusion that tonsillectomy may be a successful treatment modality in selected patients with recalcitrant GP is suspect due to the fact that many of the studies were not of a high enough standard for the conclusions to be definitive.5 A study in 2012 which was a blind study found that patients with chronic GP and a history of disease exacerbation in association with sore throat, generally improved after a tonsillectomy.6

Many other infectious agents have also been implicated, although the exact frequency of GP associated with these infections/diseases is unknown.

They include the following:

  • Bacteria – other than Staphylococcus aureus – Enterococcus faecalis, Escherichia coli, Pseudomonas and Proteus species, or the bacterium implicated in duodenal ulceration, Helicobacter pylori.5
  • Fungi – Malassezia, Candida
  • Viruses – Flu, Human papillomavirus (HPV), varicella-zoster virus, human endogenous retroviruses (HERVs) e.g. cytomegalovirus and vaccinations 7.
  • Drugs (including biologic agents) sometimes cause a guttate-type flare.

The most commonly implicated drugs in association with either the initiation or exacerbation of GP include lithium, beta-blockers, antimalarial, and non steroidal anti-inflammatories. 

Immunomodulatory drugs such as infliximab, etanercept, imatinib, and adalimumab have also been reported to initiate GP. The Koebner Phenomenon e.g. tattoos, insect bites scratches etc. can trigger GP.

Approximately 70% of patients with GP will go on to develop chronic plaque psoriasis within a 10 year time frame.

For more information read Our BLOG “PSORIASIS – THE RELATIONSHIP WITH VIRAL, BACTERIAL AND FUNGAL INFECTIONS?”

Guttate with fine scale                        Guttate with no scale

Figure 1. Scattered drop like lesions                                Figure 2. Reddish – scattered drop like lesions

ranging from 0.5 to 2.0 cm, with slight scale.                   ranging from 0.2 to 1.0 cm with no scale.

Coalesing Guttate 4                     Coalesing Guttate 3

Figure 3. Note the fine scale and the                              Figure 4. Note the fine scale and the complete

coalescing (merging) of the lesions.                               merging of the lesions.

Coalesing Guttate                      Coalesing Guttate 2

Figure 5. Reddish lesions – where the                                      Figure 6. Salmon pink lesions – where the             

majority of the lesions have merged.                                       majority of the lesions have merged.

REFERENCES

  • Zangeneh F.Z., Shooshtary F.S.; Psoriasis — Types, Causes and Medication – Chapter 1; http://cdn.intechopen.com/pdfs-wm/44173.pdf
  • Mallbris et al.: Psoriasis Phenotype at Disease Onset: Clinical Characterization of 400 Adult Cases; Journal of Investigative Dermatology; Volume 124, Issue 3, March 2005, Pages 499–504
  • Honig J.; Guttate psoriasis associated with perianal streptococcal disease; Clinical and laboratory observations The Journal of Pediatrics December 1988
  • Telfer NR,Chalmers RJ, Whale K, Colman G. The role of streptococcal infection in the initiation of guttate psoriasis. Archives of Dermatology 1992;128(1):39-42.
  • Antistreptococcal interventions for guttate and chronic plaque psoriasis (Review) 8 Copyright © 2016 The Cochrane Collaboration. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001976/epdf
  • Thorleifsdottir R.H. et al.; Improvement of Psoriasis after Tonsillectomy Is Associated with a Decrease in the Frequency of Circulating T Cells That Recognize Streptococcal Determinants and Homologous Skin Determinants; The Journal of Immunology; April 9, 2012, doi:10.4049/jimmunol.1102834
  • Moon Seub Shin et al; New Onset Guttate Psoriasis Following Pandemic H1N1 Influenza Vaccination; Ann Dermatol. 2013 November; 25(4): 489–492.

What is the Koebner Phenomenon?

The Koebner phenomenon was first described by Heinrich Koebner (1838-1904), one of the outstanding dermatologists of the 19th century. His initial observations and studies resulted from having seen patients who had developed psoriasis at sites of excoriations, horse bites, and tattoos and he first published his findings in 1876. However, the definition has been extended to include lesions developed after trauma in people with no pre-existing dermatosis. Several other skin diseases e.g. lichen planus, vitiligo and Darier disease, can also present with Koebner phenomenon. Koebner phenomenon occurs in about 25% of people with psoriasis after various traumatic injuries, but this may be much higher as patients may not recognize the original traumatic episode (e.g. insect bite) and therefore the Koebner effect may go unreported. 1

Koebner response may follow:
(1)     mechanical or thermal trauma – due to animal bites, burns, electrodessication, excoriation, freezing, friction, gunshot wounds,            insect bites, lacerations, nail manicuring, poor fitting shoes, pressure, shaving, surgical grafts, surgical incision, tape stripping,                  thumb sucking, x-rays, sunburn, tattoos (injury). 2

Bellybutton PsoriasisTattoo psoriasisPsoriasis after surgery

         Psoriasis after Belly Ring Piercing                                          Psoriasis after a Tattoo                                       After removal of Benign Growth

 

(2)  dermatoses – skin conditions e.g. carbuncles/furuncles (boils and/or cysts), dermatitis, dermatitis herpetiformis, dermatophytosis,          diaper dermatitis secondary to Candida infection, eczema, epidermal inclusion cyst, folliculitis, herpes simplex, herpes zoster,                   lichen planus, lymphangitis, measles, miliaria, perianal neuro   dermatitis, pityriasis rosea, psoriasis, scabies, seborrheic dermatitis,              varicella, vitiligo. 2

Psoriasis after Herpes Zoster

                  Psoriasis after herpes Zoster     

    

(3)     allergic or irritant reactions – following Bacillus Calmette–Guérin (BCG) vaccination (tuberculosis), tuberculin skin test, hair                   spray, hair tints, influenza   vaccination, photosensitivity, positive patch testing, scratch skin test, tattoos (allergic reaction to ink),                 urticaria 2 , and

(4)     therapy – such as Grenz ray therapy – “ultrasoft” or “soft” radiation, roentgen radiation therapy, iodine application, ultraviolet light            (PUVA). 2

Psoriatic lesions usually form within 10-20 days of the wounding event (but may range from 3 days to 2 years). However, it usually coincides with the duration of the wound healing phase. This strongly suggests that skin in predisposed individuals may continue to develop normally right up until the substantial triggering skin trauma. 3,4

 

REFERENCES

  • Arias-Santiago A. et al.; The Koebner phenomenon: psoriasis in tattoos; CMAJ, April 16, 2013, 185(7)
  • Thappa DM. The isomorphic phenomenon of Koebner. Indian J Dermatol Venereol Leprol 2004;70:187-9
  • Matovi? L. et al.; The Koebner phenomenon, a prognostic sign of PUVA therapy effectiveness in patients with     psoriasis vulgaris–yes or no?; Med Pregl. 1999 Nov-Dec;52(11-12):437-40.
  • Chee Ren Ivan Lam et al.; Wound Repair Studies Reveal New Insights to Psoriasis; http://www.intechopen.com/