Acrodermatitis Continua Of Hallopeau Research Articles

A retrospective analysis of 65 patients with acrodermatitis continua of Hallopeau.

There are limited data on acrodermatitis continua of Hallopeau (ACH), particularly among Asian populations. The primary aim was to evaluate the clinical features of ACH and treatment approaches in a sizeable multicentre Asian cohort. We analysed data from adult patients diagnosed with ACH. Of 65 patients with ACH, seven patients had ACH with GPP. Females were more frequently affected in both conditions. Five (71.4%) developed GPP 5-33 years after ACH onset, while two (28.6%) developed GPP concurrently with ACH. The onset age for ACH with GPP (27.9 ± 13.6 years) was earlier than that of isolated ACH (39.8 ± 17.3 years). Metabolic comorbidities were common. ACH exhibited a chronic persistent course. Among systemic non-biologics, acitretin was the most frequently prescribed, followed by ciclosporin and methotrexate. Acitretin and ciclosporin demonstrated similar marked response rates, which surpassed that of methotrexate. Regarding biologics, a marked response was more commonly observed with interleukin-17 inhibitors than with tumour necrosis factor inhibitors. Females are predominant in both conditions. The onset age for ACH among Asian patients is earlier (late 30s) than that for Caucasian patients (late 40s). Interleukin-17 inhibitors may be more effective than tumour necrosis factor inhibitors in managing ACH.

Low grade of satisfaction related to the use of current systemic therapies among pustular psoriasis patients: a therapeutic unmet need to be fulfilled.

Pustular psoriasis is considered a separate entity from plaque psoriasis and can be categorized as generalized pustular psoriasis (GPP), acrodermatitis continua of Hallopeau, or palmoplantar pustulosis (PPP). Current guidelines mostly include treatment options that have not been specifically developed for the treatment of pustular psoriasis. The majority of them does not have indication for the treatment of pustular psoriasis. Their effectiveness and safeness have been described in small cohort-based studies or case series with a low level of evidence. Previous studies evaluated treatment response through physician-based assessment but none reported patient satisfaction to treatment, quality of life and patient perception of disease severity during systemic therapies, particularly with biologics commonly used in plaque psoriasis. This study aimed to investigate patient satisfaction to treatment and patients' quality of life during treatment, correlating patient-reported outcomes with residual disease severity. A cross-sectional, cohort-based, single center study included patients affected by pustular psoriasis undergoing treatment with systemic agents. Demographic, clinical characteristics were collected. Treatment satisfaction as well as disease severity were assessed through dedicated assessment scores. A total of 31 patients affected by GPP or PPP were included. Despite biologic treatment, 80.6% of patients continued to experience mild-to-severe disease activity, with discrepancies between patient and physician assessments. Patients reported a substantial impairment in their quality of life, with notable limitations in physical activity and emotional distress. Mental health conditions, such as depression and anxiety disorders, were common. Treatment satisfaction varied, with moderate scores for effectiveness and convenience. Only a small proportion of patients (41.9%) reported complete or high overall treatment satisfaction. GPP and PPP subcohorts exhibited similar quality of life and treatment satisfaction levels. This study highlights the suboptimal control of PP despite biologic therapies, resulting in a significant impact on patients' quality of life and treatment satisfaction. The findings highlight the need for specific therapies and standardized guidelines for managing PP. New targeted therapies, such as spesolimab, hold promise for optimizing treatment satisfaction and improving patients' quality of life in this challenging condition. Future research should focus on refining treatment strategies to address the unmet needs of PP patients comprehensively.

Anti-Interleukin-17s for successful management of pustular psoriasis

Generalised pustular psoriasis (GPP) and acrodermatitis continua of Hallopeau (ACH) are two rare entities included in the spectrum of pustular psoriasis (PP). Due to the lack of randomised controlled clinical trials and standardized guidelines, their treatment remains a challenge for clinicians. Thus, herein we report our centre experience with the successful use of interleukin (IL)-17 inhibitors in three patients affected by PP. We also provide a brief overview of the current knowledge concerning the role of IL-17 in PP pathogenesis and of the use of IL-17 inhibitors in the treatment of PP. Based on our experience, anti-IL-17 molecules may represent a valuable therapeutical option for patients affected by different PP subtypes.

BH05 Successful treatment of acrodermatitis continua of Hallopeau with methotrexate

Abstract A 39-year-old woman was referred with a 3-month history of brittle nails, painful fingertips and psoriasiform plaques affecting her torso and limbs. She had a past medical history of macrocytic anaemia secondary to dietary B12 and folate deficiencies, which required inpatient transfusions. She had no previous dermatological concerns, and there was no history of infection or trauma to the affected sites. On examination of her hands and feet, there was evidence of nailbed pustulation, subungual hyperkeratosis, onychodystrophy, anonychia of multiple nails and dactylitis, consistent with acrodermatitis continua of Hallopeau (ACH) with associated psoriasis. At diagnosis, the patient’s Dermatology Life Quality Index (DLQI) was 16, she had a Psoriasis Area and Severity Index (PASI) score of 18 and a Psoriasis Epidemiology Screening Tool (PEST) score of 4. Nail fungal culture was negative. Plain radiographs of the hands and feet demonstrated a flexion deformity of the left fifth finger distal interphalangeal joint, with otherwise normal bone texture, alignment and joint spaces. The patient was initially treated with potent topical corticosteroids and vitamin D analogues, with little improvement. The patient was commenced on 15 mg subcutaneous methotrexate (MTX), with close monitoring of serum and red cell folate given her background of folate deficiency, which was being actively replaced. Within 3 months of starting MTX monotherapy, the patient’s hands had dramatically improved with skin and fingernail changes largely resolved, and an improvement in manual dexterity (DLQI 11, PASI 3, PEST 5). MTX was increased to 20 mg once weekly and the patient was also started on sulfasalazine 500 mg twice daily by her rheumatologist for psoriatic arthritis. ACH is a chronic pustular eruption initially affecting distal phalanges with gradual proximal progression and the potential development of generalized pustular psoriasis. ACH is considered a variant of palmoplantar pustulosis, commonly affecting adult females with localized trauma and infection as possible triggers. Given the rarity of ACH, the evidence base for therapy is limited to case reports and series, with no standardized treatment guidelines. Topical therapies include corticosteroids, calcineurin inhibitors and vitamin D analogues. Local phototherapy and systemic therapy with acitretin, MTX and ciclosporin have been described, with wide-ranging results. In severe cases such as this, patients typically receive biologic therapy, with variable responses reported with tumour necrosis factor-α inhibitors, anti-interleukin (IL)-6 therapy, and anti-IL-12/IL-23 and anti-IL-17 therapy. We present a rare case of severe ACH and psoriasis, treated with MTX monotherapy, which was not only clinically effective but also cost-effective.

Acrodermatitis continua of Hallopeau with psoriatic arthritis treated with biologics and apremilast

AbstractAcrodermatitis continua of Hallopeau (ACH) is a rare variant of acral pustular psoriasis, exclusively involving the distal phalanges and nails of the hands and feet. We herein report a rare case of concurrent ACH and psoriatic arthritis sine psoriasis presenting with dactylitis. The patient was successfully treated with biologics and apremilast.

Acrodermatitis continua of Hallopeau and generalised pustular psoriasis: Should they be the same or different entities?

Pustular psoriasis is characterised by eruptions of neutrophilic sterile pustules. The European Rare and Severe Psoriasis Expert Network consensus defines pustular psoriasis into three subtypes; generalised pustular psoriasis (GPP), palmoplantar pustulosis and acrodermatitis continua of Hallopeau (ACH). Mixed forms are categorised according to their predominant features. However, the Japanese Dermatological Association includes ACH under the diagnosis of GPP. This article aims to review the similarities and differences between ACH and GPP. Based on our review, interleukin (IL)-36RN mutations, the most frequent genetic findings in pustular psoriasis are found most commonly in GPP, followed by ACH. Genotypes of IL-36RN mutations among GPP patients and ACH patients are different between European and Asian ethnicities. IL-36 signalling pathway is the main mechanism. Metabolic diseases are common comorbidities and joint involvement can occur in 20.5%-36.4% of both conditions. Associated plaque psoriasis is more common in GPP than in ACH. Generally, ACH, even the generalised type, does not have systemic inflammation whereas GPP can occur with or without systemic inflammation. ACH can occur before, simultaneously, or after the development of GPP. However, response to treatment for GPP and ACH even in the same patients appear to be different. ACH seemed to be more recalcitrant to treatment than GPP but severe flare of GPP can lead to morbidity and mortality. Although GPP and ACH share genotypes and pathogenesis, we believe that ACH should be classified separately from GPP, and not under diagnosis of GPP. Future research is warranted to satisfactorily distinguish the two conditions.

Acrodermatitis continua of Hallopeau with insufficient response to ixekizumab and infliximab, successfully treated with a combination of ustekinumab and tofacitinib.

Acrodermatitis continua of Hallopeau with insufficient response to ixekizumab and infliximab, successfully treated with a combination of ustekinumab and tofacitinib.

Deficiency of interleukin-36 receptor antagonist (DITRA): An analysis of 58 Chinese patients in a tertiary hospital in Taiwan.

DITRA, acronym for deficiency of interleukin-36 receptor antagonist (IL36RN), leads to unopposed pro-inflammatory signalling which typically manifests as pustular psoriasis. In Asian patients, c.115 + 6 T > C mutation is the most common and important single-nucleotide variant in DITRA. We present the largest case series consisting of 58 DITRA patients carrying heterozygous or homozygous c.115 + 6 T > C mutation. The mean age of onset (±SD) was 20.74 (±20.86), and the median age of onset was 13 years old. Twelve patients (20.7%) had disease onset before the age of two. Twenty-two patients (37.9%) had disease onset between the ages of 2-18. Main clinical phenotype was generalized pustular psoriasis (GPP) with systemic symptoms (33 patients, 56.9%), followed by acrodermatitis continua of Hallopeau (ACH) (16 patients, 27.6%). Nearly half of our patients (27 patients, 46.6%) ever had ACH, and only three of them are free of ACH currently, which indicates that the development of ACH is relatively persistent and irreversible. Thirty-four patients (58.6%) had recurrent GPP and 29 patients (50%) have been admitted due to GPP flare. Compared to those with heterozygous (C/T) mutation, more patients carrying homozygous mutation (C/C) have recurrent episodes of GPP (C/T vs. C/C: 25.53 vs. 76.47%, p=0.0367). Two patients with squamous cell carcinomas arising from the pustular psoriasis skin lesions were noted. Two patients had elevated serum IgG4 levels.

Acrodermatitis Continua of Hallopeau: A Diagnostic Challenge.

Acrodermatitis Continua of Hallopeau: A Diagnostic Challenge.

Dermoscopy of Acrodermatitis Continua of Hallopeau.

A 29-year-old female presented with recurrent episodes of painful pustules over the right thumb for the past 8 months. She was treated with oral antibiotics along with avulsion of the nail plate, but it did not improve her condition. She had no history of other skin disorders. On examination, the nail plate was absent. Erythematous plaque with scaling and few areas of crusting were present involving the nail bed and pulp of the right thumb [Figure 1a] along with a single pustule on the right thumb [Figure 1b]. Dermoscopy (Polarized contact light dermoscopy; Dermlite DL4; 10×) revealed yellowish-white scales and linear blood vessels over the nail bed along with few hemorrhagic spots [Figure 2a]. Additionally, yellow globules were seen on the lateral nail fold and dotted vessels arranged in a regular pattern were seen over the pulp area [Figure 2b]. A Gram stain was done from the pustule, which was sterile and showed only neutrophils. A diagnosis of acrodermatitis continua of Hallopeau (ACH) was made based on the clinical and dermoscopic correlation. She was treated with oral cyclosporine and topical calcipotriol with good improvement in 2 weeks [Figure 3a and b].Figure 1: (a) The nail plate is absent. Erythematous plaque with scaling and few areas of crusting is seen involving the nail bed and pulp of the right thumb. (b) A single pustule is seen on the right thumbFigure 2: (a) Dermoscopic image showing yellowish-white scales (black arrow) and linear blood vessels over the nail bed (blue arrow) along with few hemorrhagic spots (red arrow). (b) Dermoscopic image showing dotted vessels arranged in a regular pattern (yellow arrows) over the pulp area. (Polarized contact light dermoscopy; Dermlite DL4; 10×)Figure 3: Clinical (a) and dermoscopic (b) images showing near-complete resolution of the lesions after 2 weeks. (Polarized contact light dermoscopy; Dermlite DL4; 10X)ACH, a variant of pustular psoriasis, is a rare, sterile pustular eruption of the distal fingers and/or toes. It is a chronic and progressive condition and can lead to irreversible complications including onychodystrophy and osteitis, which may result in anonychia and distal phalanx osteolysis, respectively; hence, an early and prompt diagnosis is required.[1] Dermoscopy of pustular psoriasis reveals yellow globules and regularly distributed dotted vessels which on histology correspond to nonfollicular superficial pustules and dilated vessels in homogenously elongated dermal papillae, respectively.[2] E. Errichetti et al. described dermoscopic findings in two cases of ACH which showed whitish-yellowish hyperkeratosis/scaling along with single or multiple pustules, dotted and linear vessels, and hemorrhagic spots.[3] These findings aid in differentiating ACH from other localized conditions such as onychomycosis, nail lichen planus, acral hand eczema, and psoriatic onychopathy.[3] We report our case to highlight the dermoscopic features of ACH which can help in the preliminary evaluation, thus reducing the diagnostic delay. As biopsy over the distal digits is often distressing and difficult, dermoscopy can be considered a valuable tool in such cases. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Epidemiological survey of patients with pustular psoriasis in the Japanese Society for Psoriasis Research from 2017 to 2020.

The Japanese Society for Psoriasis Research (JSPR) has been conducting annual epidemiological surveys of patients with pustular psoriasis in Japan since 2017. This study aimed to conduct a recent epidemiological analysis of patients with pustular psoriasis who were enrolled in the JSPR from 2017 to 2020. A total of 291 patients from 131 medical institutions were enrolled, of which 47.4% (138 cases) were males and 52.6% (153 cases) were females. The mean ± standard deviation (SD) age of the patients was 57.4 ± 20.3 years (males, 61.2 ± 17.3 years; females, 54.1 ± 22.1 years). The mean ± SD age of the patients at disease onset was 48.5 ± 22.5 years (males, 50.8 ± 20.6 years; females, 46.4 ± 24.0 years). The types of pustular psoriasis observed included the von Zumbusch type (59.8%), annular pustular psoriasis (8.2%), impetigo herpetiformis (6.5%), and acrodermatitis continua of Hallopeau (4.8%), of which, the majority of the patients with impetigo herpetiformis were female. Among the patients, 58.4% were treated with oral medications and 44.0% were treated with biologics. The most common oral medication prescribed was etretinate (52.4%), followed by corticosteroids (24.7%) and cyclosporin (22.9%). The most common biologics used were IL-17 inhibitors (ixekizumab [28.1%] and secukinumab [22.7%]), followed by tumor necrosis factor (TNF) inhibitors (infliximab [15.6%]) and IL-23 inhibitors (guselkumab [14.8%] and risankizumab [10.2%]). This survey thus provides new and significant information regarding the recent perspective of pustular psoriasis, such as patient characteristics and treatment trends, in Japan.

Clinical Characteristics of Patients with Pustular Psoriasis: A Single-Center Retrospective Observational Study

Clinical and epidemiologic data on pustular psoriasis are scarce. To investigate the phenotypes of pustular psoriasis and the patients’ characteristics observed in a real-life retrospective observational study. The number of incident cases of pustular psoriasis registered in the period 2005–2021 was retrieved from the electronic medical records of the University Hospital of Verona. One hundred and forty cases of pustular psoriasis were collected. Ninety-one out of 140 patients (65%) were females, with a median (IQR) age of 57 (43–66) years. According to the ERASPEN classification criteria, 116 patients (83%) had palmoplantar pustulosis (PPP), 13 (9%) generalized pustular psoriasis (GPP), and 11 (8%) acrodermatitis continua of Hallopeau (ACH). Gender distribution and median age were consistent among the three groups. The prevalence of psoriatic arthritis in GPP, ACH, and PPP was 8%, 36%, and 28%, respectively. During the same period, a total of 4718 cases of plaque psoriasis were retrieved, with a 1:34 ratio of pustular over plaque psoriasis. Pustular psoriasis is much rarer than plaque psoriasis, with PPP being the more common subtype.

Line-field confocal optical coherence tomography: a new tool for non-invasive differential diagnosis of pustular skin disorders.

BackgroundThe spectrum of pustular skin disorders (PSD) is large and particularly challenging, including inflammatory, infectious and amicrobial diseases. Moreover, although pustules represent the unifying clinical feature, they can be absent or not fully developed in the early stage of the disease. The line‐field confocal optical coherence tomography (LC‐OCT) is a recently developed imaging technique able to perform a non‐invasive, in vivo, examination of the epidermis and upper dermis, reaching very high image resolution and virtual histology.ObjectivesWe aimed to investigate the potentialities of LC‐OCT in the non‐invasive differential diagnosis of a series of 11 PSD with different aetiology, microscopic features, body location and incidence rates.Materials and MethodsComplete LC‐OCT imaging (i.e. 2D/3D frames, videos) was performed on a total of 19 patients (10 females and 9 males) aged between 35 and 79 years. Images were blindly evaluated and compared with corresponding histopathologic findings.ResultsThe LC‐OCT imaging was able to detect with high accuracy the pustule structure including shape, margins, morphology and cellular content, along with peculiar epidermal and adnexal alterations in each condition, including: Acute Generalized Exanthematous Pustulosis, Generalized pustular psoriasis, Generalized pustular figurate erythema, Subcorneal Pustular Dermatosis, Intraepidermal IgA pustulosis, Palmoplantar pustulosis, Palmoplantar pustular psoriasis. Herpetic whitlow, Acrodermatitis continua of Hallopeau, Vesicopustular Sweet syndrome and Vesicopustular Eosinophilic cellulitis, with pustular appearance, were also compared.ConclusionsThe new LC‐OCT can represent a rapid, non‐invasive and painless tool which can help differentiating among PSD of different aetiology and microscopic morphology in clinical mimickers in daily practice.

Palmoplantar pustulosis and acrodermatitis continua of Hallopeau: demographic and clinical comparative study in a large multicentre cohort.

BackgroundAcral pustular disease within the pustular psoriasis/psoriasis‐like spectrum mainly includes palmoplantar pustulosis (PPP) and acrodermatitis continua of Hallopeau (ACH). Scarce data argue for a distinction between these two entities, but no study has compared the clinical and epidemiologic characteristics of ACH and PPP.ObjectivesWe aimed to perform a comparative description of the epidemiological and clinical characteristics of PPP and ACH in a multicentre retrospective cohort.MethodsIn this multicentre national retrospective cohort study, we compared the epidemiological characteristics, comorbidities and psoriasis characteristics of patients with PPP and ACH.ResultsA total of 234 patients were included: 203 (87%) with PPP, 18 (8%) with ACH and 13 (6%) with both, according to 2017 ERASPEN criteria. As compared with ACH, PPP was associated with female sex, smoking activity and higher median BMI (P = 0.01, P = 0.02 and P = 0.05 respectively). A family background of psoriasis was more frequent in PPP than ACH. Age of onset of palmoplantar disease was similar between PPP and ACH patients, median age 44 and 48 years respectively. Peripheral joint inflammatory involvement was the only rheumatic disease associated with ACH. The association with another psoriasis type was similar in PPP and ACH (57.6% and 61.1% respectively).ConclusionOur study confirms in a large PPP cohort the predominance of females and a high prevalence of smoking and elevated body mass index but also shows an association of these features in PPP as compared with ACH. In addition, it highlights peripheral arthritis as the only arthritis endotype associated with ACH. Increased knowledge of the immunogenetic backgrounds underlying these two entities is warranted to better stratify pustular psoriasis or psoriasis‐like entities for precision medicine.

Acrodermatitis continua of Hallopeau: historical perspectives and modern management.

Acrodermatitis continua of Hallopeau is a sterile pustular dermatosis primarily of the digits. Often considered a type of pustular psoriasis, it may be difficult to diagnose and even more difficult to treat. Initial involvement of a distal finger or toe may appear as erythema which should not be confused with the chilblains-like findings potentially associated with COVID-19 infection. We review the clinical manifestations of and explore potential therapeutic options for this uncommon, clinically striking dermatosis.

Pustular Psoriasis: From Pathophysiology to Treatment.

Pustular psoriasis (PP) is a clinicopathological entity encompassing different variants, i.e., acute generalized PP (GPP), PP of pregnancy (impetigo herpetiformis), annular (and circinate) PP, infantile/juvenile PP, palmoplantar PP/palmoplantar pustulosis, and acrodermatitis continua of Hallopeau (ACH), which have in common an eruption of superficial sterile pustules on an erythematous base. Unlike psoriasis vulgaris, in which a key role is played by the adaptive immune system and interleukin (IL)-17/IL-23 axis, PP seems to be characterized by an intense inflammatory response resulting from innate immunity hyperactivation, with prominent involvement of the IL-36 axis. Some nosological aspects of PP are still controversial and debated. Moreover, owing to the rarity and heterogeneity of PP forms, data on prognosis and therapeutic management are limited. Recent progresses in the identification of genetic mutations and immunological mechanisms have promoted a better understanding of PP pathogenesis and might have important consequences on diagnostic refinement and treatment. In this narrative review, current findings in the pathogenesis, classification, clinical features, and therapeutic management of PP are briefly discussed.

Pustular Psoriasis: A Narrative Review of Recent Developments in Pathophysiology and Therapeutic Options.

Pustular psoriasis is an unusual form of psoriasis that frequently presents clinical challenges for dermatologists. The condition presents with pustules on an erythematous background and has two distinct subtypes: localized disease on the palms and soles, called palmoplantar pustulosis (PPP), and generalized pustular psoriasis (GPP). The involvement of the fingers, toes, and nails is defined as a separate localized variant, acrodermatitis continua of Hallopeau, and is now thought to be a subset of PPP. The rarity of pustular psoriasis frequently makes the correct diagnosis problematic. In addition, treatment is limited by a relative lack of evidence-based therapeutic options. Current management is often based on existing therapies for standard plaque psoriasis. However, there remains a need for treatments with high, sustained efficacy and a rapid onset of action in pustular psoriasis. Recent advances in understanding of the pathogenesis of pustular psoriasis have provided insights into potential therapies. Treatment of pustular psoriasis is generally determined by the extent and severity of disease, and recent years have seen an increasing use of newer agents, including biologic therapies. Current classes of biologic therapies with US Food and Drug Administration and European Medicines Agency approval for treatment of moderate-to-severe plaque psoriasis in the USA (and elsewhere) include tumor necrosis factor alpha inhibitors (adalimumab, certolizumab pegol, etanercept, infliximab), interleukin (IL)-17 inhibitors (brodalumab, ixekizumab, secukinumab), an IL-12/23 inhibitor (ustekinumab), and IL-23 inhibitors (guselkumab, risankizumab, tildrakizumab). Recently, specific inhibitors of the IL-36 pathway have been evaluated in GPP and PPP, including spesolimab, an IL-36 receptor inhibitor which has shown promising results in GPP. The emerging drugs for pustular psoriasis offer the possibility of rapid and effective treatment with lower toxicities than existing therapies. Further research into agents acting on the IL-36 pathway and other targeted therapies has the potential to transform the future treatment of patients with pustular psoriasis. This article reviews the clinical features of PPP and GPP, and current understanding of the genetics and immunopathology of these conditions; it also provides an update on emerging treatments.Supplementary InformationThe online version contains supplementary material available at 10.1007/s13555-021-00612-x.

087 International Rare and Severe Psoriasis Expert Network (IRASPEN) – A prospective multi-centre pustular psoriasis registry with genotype-phenotype correlation

Pustular psoriasis (PP) encompasses a range of well-defined, severe inflammatory conditions characterized by production of sterile pustules. Our understanding of this rare disease’s pathophysiology, clinical course and optimal treatment is as yet limited. The goal of this prospective international registry is to describe the natural course of disease in different subtypes of PP and create phenotype-genotype correlations as well as elucidate therapeutic molecular pathways. The IRASPEN registry plans to include at least 180 patients at approximately 15 sites world-wide, aiming for minimum numbers of 140 Palmoplantar Psoriasis (PPP), 20 Generalized Pustular Psoriasis (GPP) and 20 Acrodermatitis Continua of Hallopeau (ACH) patients and up to 360 non-affected first degree relatives.

Epidemiology and clinical features of pustular psoriasis: A 15-year retrospective cohort.

Pustular psoriasis (PuP) is a rare variant of psoriasis with a unique immunopathogenesis, unlike its more prevalent plaque-type counterpart. However, data available are limited due to its low prevalence. This study aimed to describe the demographic profile, precipitating factors, clinical presentations, and treatments among patients with different PuP subtypes from a 15-year retrospective cohort study in Thailand. A total of 60 patients were included in this study. There was female predominance (73.3%) and mean age of onset was 38.1±17.6years. Generalized PuP (GPP) was the most prevalent subtype (80.0%), followed by acrodermatitis continua of Hallopeau (13.3%) and palmoplantar pustulosis (6.7%). Precipitating factors included corticosteroid withdrawal, upper respiratory tract infection, and pregnancy. One-third of PuP occurred concomitantly with other psoriasis variants, especially the plaque type. The most prescribed systemic and topical treatments were oral acitretin (60.0%) and topical corticosteroids (98.3%), respectively. Only two patients were treated with narrow-band ultraviolet B. In conclusion, four out of every five PuP patients in this center had GPP. Corticosteroid withdrawal, upper respiratory tract infection, and pregnancy are important precipitating factors. Coexistence with other psoriasis variants was identified in one out of every three patients. Acitretin remains the mainstay of systemic treatment.

COVID‐19 and exacerbation of dermatological diseases: A review of the available literature

Since the emergence of the new coronavirus disease 19 (COVID‐19) pandemic, there has been a concern for the patients with chronic autoimmune diseases including dermatological conditions over the potential exacerbation of these underlying conditions after infection with severe acute respiratory syndrome coronavirus‐2 (SARS‐CoV2). We performed a systematic review to evaluate presentations, postinfection change in the manifestation, diagnosis, and management of flare‐ups of underlying dermatologic disease in patients with COVID‐19. A total of 17 articles were recovered reporting on flare‐ups of dermatological disease including pemphigus vulgaris, psoriasis, subacute cutaneous lupus erythematosus, acrodermatitis continua of Hallopeau, systemic sclerosis sine scleroderma, and Sézary syndrome (SS). Out of these, psoriasis and alopecia areata were the most common conditions. However, most cases of psoriasis could have been attributed to either antimalarial agents that were initially used for the treatment of COVID‐19 or discontinuation of treatment following SARS‐CoV2 infection.