Symptoms dictate treatment strategies
Guttate psoriasis is usually self-limiting and resolves within a few weeks to months. One small study, however, suggests that 33% of patients will eventually develop chronic plaque disease.6 A systematic review of treatments for guttate psoriasis failed to show firm evidence in favor of any specific treatment.7 Treatment strategies are thus based on symptomatology and may include emollients or, less commonly, low-potency topical corticosteroids.
Phototherapy, via direct sunlight exposure or by a short course of UV-B phototherapy, has been used to help clear lesions, but care must be taken to avoid burns, which can exacerbate the eruption. More resistant cases may benefit from oral psoralen plus exposure to ultraviolet A radiation.7
Due to the clear association between guttate psoriasis and streptococcal disease, appropriate testing should be done and antistreptococcal antibiotics initiated. While erythromycin and penicillin VK have been used in the past as first-line agents (with the addition of rifampin usually reserved for more resistant cases or chronic carrier states), a small case-controlled study failed to find statistically significant improvement with a course of penicillin or erythromycin.8 For patients with recurrent or chronic guttate psoriasis, tonsillectomy for poststreptococcal tonsillitis may be offered, although a systematic review failed to show a benefit.9
A chronic problem for our patient
We initially treated our patient with a 10-day course of penicillin VK and UV-B phototherapy. Eight weeks later, she had 90% resolution of her lesions. However, our patient subsequently experienced a flare, suggesting that she might go on to develop chronic plaque psoriasis.
CORRESPONDENCE
Christopher R. Worley, DO, LT, MC, USN, Naval Hospital Jacksonville, 2080 Child Street, Jacksonville, FL 32214; christopher.r.worley@med.navy.mil