CASES 4A AND 4B: Guttate Psoriasis

4A:Small, slightly pruritic, salmonpink papules with thick white scalehave arisen over the past 5 days onthe trunk and arms of a 24-year-oldman. The patient has a history ofvery mild psoriasis vulgaris of the elbows,knees, and scalp; he deniesstreptococcal pharyngitis or other recentinfections. Guttate psoriasis isdiagnosed.(Case and photographs courtesy of Joe Monroe, PA-C.)4B:The abrupt onset of a generalizedexanthem of multiple small,scaly papules sends a 19-year-oldwoman for medical evaluation. Thepatient had a sore throat 2 weeks earlier.She uses no medications and hasno allergies.Scattered, discrete, 0.2- to 1.0-cm,salmon pink, scaling papules involvemost of the body symmetrically; thepalms and soles are spared. All laboratorytest results are normal except for an elevated antistreptolysin-O titer.The clinical picture and history suggestguttate psoriasis.(Case and photograph courtesy of Drs Tausif Zar andClaudia McClintock.)What strategies would youpursue in these patients?A REVIEW OF THE OPTIONSGuttate psoriasis is characterizedby teardrop-size pink papules thatoften develop in response to a streptococcalor other upper respiratorytract infection. The lesions are muchsmaller than those of psoriasis vulgaris;however, this usually shortlivedcondition can evolve into chronicpsoriatic disease.Generally, guttate psoriasisclears quickly; when lesions are widespread,UV-B therapy may be recommendedto accelerate clearing. Considerantibiotic therapy when the patient'sthroat culture is positive orwhen episodes of guttate psoriasisrecur. Penicillin, cephalosporin,erythromycin, or rifampin can beused to eradicate group A β -hemolyticstreptococci and, in turn, help treatguttate psoriasis.CASE 4A:APPROACH AND OUTCOMEUV-B therapy successfullycleared the guttate psoriasis in this24-year-old man.CASE 4B:APPROACH AND OUTCOMENo treatment was offered; thepatient recovered spontaneously in 1month. There were no residual signsof papules; a second antistreptolysin-O titer indicated no infection.