|Year : 2014 | Volume
| Issue : 3 | Page : 163-165
Pustular psoriasis in lactating female: A successful challenge
Sonia P Jain1, Pramod A Jain2, Vitaladevuni B Shivkumar3
1 Department of Skin and Venereal Diseases, Mahatma Gandhi Institute of Medical Sciences, Sewagram, Maharashtra, India
2 Department of Orthopedics, Mahatma Gandhi Institute of Medical Sciences, Sewagram, Maharashtra, India
3 Department of Pathology, Mahatma Gandhi Institute of Medical Sciences, Sewagram, Maharashtra, India
|Date of Web Publication||7-Oct-2014|
Sonia P Jain
Department of Skin and Venereal Diseases, Mahatma Gandhi Institute of Medical Sciences, Sewagram - 442 102, Maharashtra
Source of Support: None, Conflict of Interest: None
Psoriasis is an immune mediated genetically determined dermatological disorder affecting skin, nails, joints along with systemic associations. It is associated with high impact on the health-related quality of life and considerable cost. This disease is characterized by multiple remissions and relapses. Among various types of psoriasis, pustular psoriasis is rare. There are many triggering factors for pustular psoriasis including pregnancy also termed as impetigo herpetiformis. Here we report a female with triggering of pustular psoriasis during her postpartum period who recovered after the combination therapy of Narrow Band UltraViolet B (NB-UVB) phototherapy and Azathioprine
Keywords: Azathioprine, impetigo herpetiformis, lactating female, narrow band, pustular psoriasis, ultraviolet B
|How to cite this article:|
Jain SP, Jain PA, Shivkumar VB. Pustular psoriasis in lactating female: A successful challenge. Saudi J Health Sci 2014;3:163-5
| Introduction|| |
Psoriasis is a chronic inflammatory papulosquamous disease characterized by multiple remissions and relapses. Prevalence of psoriasis varies in different parts of the world, ranging from 0.5% to 2.5%.  Pustular psoriasis is characterized by white pustules (blisters of noninfectious pus) surrounded by red skin consisting of white blood cells. Two main types of pustular psoriasis are localized pustular psoriasis, including palmoplantar pustulosis and acrodermatitis continua. Generalized pustular psoriasis (GPP) includes acute type due to pregnancy known as impetigo herpetiformis (IH), infantile and juvenile, and circinate and localized (not hands and feet). 
GPP is characterized by an acute, subacute, or chronic eruption with sterile pustulosis. IH is considered as a distinct pregnancy dermatosis, a variant of GPP triggered by pregnancy.  IH was first described by von Hebra in 1872.  It's onset is usually in the last trimester of pregnancy. The disease tends to persist until the child is born, resolving in postpartum. Characteristically, the disease recurs in subsequent pregnancies. Histopathology shows typical psoriasiform hyperplasia, parakeratosis along with macropustule.  Constitutional disturbance is characteristically severe. This case is rare as treatment of lactating female with resistant pustular psoriasis with NB-UVB therapy and azathioprine has not been reported as yet.
| Case report|| |
A multiparous 27-year-old woman presented with complaints of multiple erythematous scaly patches, with pustules all over the body since two and half months. On examination, she had multiple erythematous scaly, circinate patches, plaques ranging from 2 cm × 3 cm to 8 cm × 10 cm over her neck, chest, abdomen, back, and both upper and lower limbs. There were similar lesions along flexures of both axillae, inframammary, and groins [Figure 1] and [Figure 2]. Patches and plaques had multiple pustules with lakes of pus appearance. Her face, scalp, nails, palms, and soles were normal. Oral and genital mucosa were also normal.
|Figure 2: Scaly erythematous plaques and pustules over the chest and abdomen|
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She had normal vaginal delivery of a male baby one and half months back. Lesions appeared as erythematous patches all over body in her last trimester, associated with itching. Postpartum lesions got aggravated. New lesions appeared increasing in size, with multiple pustules all over the body. She had no history of drug intake, positive family history of psoriasis, joint pains, fever, or any constitutional symptoms. She had past history of similar lesions three years back during her postpartum period after normal vaginal delivery of a female child. She was diagnosed as pustular psoriasis (impetigo herpetiformis, IH), which responded to treatment with oral steroids and NB-UVB therapy.
She had leukocytosis with normal blood sugar, serum calcium, vitamin D level, and liver and kidney function tests. She was found to be nonreactive for HIV testing using Combi-AIDS kit. Blood culture and Gram staining from pus revealed no microbes. Skin biopsy showed features of pustular psoriasis showing intra-epidermal pustule (shown with help of arrow) with psoriasiform hyperplasia [Figure 3].
|Figure 3: Photomicrograph showing intra-epidermal pustule shown with help of arrow) with psoriasiform hyperplasia; blood vessels of the papillary dermis showing perivascular cuffing of lymphocytes are also seen. (H and E, ×100)|
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Oral prednisolone (60 mg/day) in tapering dose of reducing 10 mg every week and 100 mg Dapsone was started. However, no response was noticed after one month of continuous therapy. Later, oral steroids and dapsone were stopped. After adequate blood analysis of mother and baby and after obtaining written informed consent, oral azathioprine daily (100 mg/day) and NB-UVB phototherapy was started alternate day with the starting standard dose of 280 mj/cm 2 with stepwise increase (20%).  Opthalmic examination before and after phototherapy was carried out. The baby was kept on exclusive breast feed. She was supplemented with oral calcium and iron therapy. Regular weekly monitoring of blood indices of mother and baby was carried out with watch on hepatic derangement. A pediatrician was also consulted to take care of the child. Within a week of combined therapy, she responded and showed clearing of plaques and significant reduction in pustules, scaling, and redness [Figure 4] and [Figure 5]. The treatment was continued for further three weeks with regular monitoring of blood indices of both mother and child. After three weeks, azathioprine was stopped. NB-UVB therapy was also stopped after four weeks. The patient still follows up without any symptoms.
| Discussion|| |
Psoriasis is a genetically determined, inflammatory, and proliferative chronic intractable disease of the skin, affecting about 2% of population.  Retinoids are probably the treatment of choice for pustular psoriasis.  Recent survey reported acitretin to be effective in more than 80% of cases.  A combination of etretinate and PUVA is beneficial.  Control of GPP has been achieved with methotraxate and high dosage of ciclosporin (9-12 mg/kg/day). Colchicine and hydroxyurea are less effective.  In subacute and chronic forms of GPP, dapsone (50-200 mg/day) can be considered.  Oral corticosteroid forms the mainstay of treatment in the management of pustular psoriasis of pregnancy. Biological agents used occasionally have excellent effect.  Other therapies include azathioprine and NB-UVB phototherapy.
Azathioprine has a relatively high safety profile. It has been vastly used in various dermatological conditions. Its major drawback is myelosuppression, which can be guarded against by regular blood counts. Moreover, susceptibility to bone marrow toxicity is due to genetically determined metabolic defect occurring in frequency of 1 in 300.  Previously, it was found to be effective in psoriasis but no large-scale controlled study was conducted. According to a study, azathioprine should be considered as an alternative treatment in selected patients of chronic recalcitrant psoriasis when methotrexate cannot be used. 
NB-UVB therapy has been used successfully in pregnant females, with GPP being the first case report.  In our case, a combination of oral azathioprine and NB-UVB therapy proved to be a good treatment option for pustular psoriasis in lactating female, where treatment options become limited. To the best of our knowledge, there are no case reports of treatment of IH using a combination of azathioprine and NB-UVB therapy in lactating female.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]