Guttae Psoriasis | Visual Dermatology Atlas

General info +

AKA: Guttate psoriasis / Eruptive psoriasis

• Acute variant of psoriasis characterized by the sudden eruption of numerous small, erythematous, scaly “drop-like” papules.
• Most commonly occurs in children, adolescents, and young adults.
• Frequently triggered by a streptococcal infection, particularly pharyngitis caused by group A Streptococcus pyogenes.
• The eruption classically develops 1–3 weeks after an upper respiratory tract infection.
• Other infections may also act as triggers.
• May represent the first manifestation of psoriasis or occur in a patient with a personal or family history of psoriasis.
• May resolve spontaneously within weeks to months, although some patients subsequently develop chronic plaque psoriasis.

Symptoms / presentation +

• Acute, rapidly disseminating eruption of numerous small lesions.
• Frequently preceded by a recent sore throat or respiratory infection.
• Lesions may be asymptomatic or associated with variable pruritus.
• Individual lesions are considerably smaller and more numerous than typical plaque psoriasis lesions.
• Recurrences may occur following subsequent streptococcal infections.

Clinical exam +

• Multiple erythematous or salmon-pink papules, typically measuring a few millimeters to approximately 1 cm.
• Well-demarcated, round or oval, “drop-like” lesions.
• Covered by fine white or silvery scales, which may be subtle early in the eruption.
• Numerous lesions may produce the appearance of a widespread exanthem.
• Auspitz sign may occur: pinpoint bleeding after removal of scale, although this finding is neither required nor specific for the diagnosis.
• Variable pruritus.

Distribution +

• Trunk +++
• Proximal upper and lower extremities
• Scalp may be involved
• Face is usually less prominently affected
• Palms and soles are generally spared
• Distribution is often bilateral and symmetric

Dermoscopy +

• Regularly distributed dotted vessels on an erythematous background.
• Diffuse white scaling.
• Relatively uniform and symmetric vascular distribution.
• These findings can help distinguish psoriasis from other papulosquamous disorders.

Diagnostic +

• Primarily a clinical diagnosis based on characteristic morphology and distribution.
• Assess for a recent streptococcal infection, particularly when pharyngeal symptoms are present.
• Rapid antigen testing or throat culture if active streptococcal pharyngitis is suspected.
• ASO or anti-DNase B titers may occasionally help document a recent streptococcal infection when clinically relevant.
• Skin biopsy is rarely required but may be considered for an atypical presentation or diagnostic uncertainty.

Differential diagnosis +

• Pityriasis rosea
• Morbilliform drug eruption
• Secondary syphilis
• Pityriasis lichenoides
• Generalized lichen planus
• Multifocal dermatophytosis
• Other infectious or drug-related exanthems depending on the clinical context

Treatment plan +

• Mild disease may resolve spontaneously and require primarily symptomatic treatment.
• Emollients to reduce dryness and scaling.
• Topical corticosteroids of appropriate potency may be used for symptomatic or inflammatory lesions.
• Avoid prolonged application of superpotent topical corticosteroids over large body surface areas.
• Widespread disease: narrowband UVB (NB-UVB/TL01) phototherapy is commonly preferred when phototherapy is indicated.
• A confirmed active streptococcal infection should be treated according to standard recommendations for streptococcal pharyngitis.
• Antibiotics are not an established treatment for the psoriatic eruption itself once an active streptococcal infection is no longer present.
• Systemic psoriasis therapy is rarely necessary for an isolated episode but may be considered for persistent, severe disease or progression to chronic psoriasis.

References +

DermNet — Guttate psoriasis.
American Academy of Dermatology (AAD) — Psoriasis clinical guidelines.
UpToDate — Guttate psoriasis.
Bolognia JL, Schaffer JV, Cerroni L. Dermatology. Elsevier.