Guttate psoriasis is a type of psoriasis, the distinctive features of which are the absence of damage to the nail plates and the spontaneous unpredictable spread of skin rashes associated with the presence of infection in the body. The primary element is a pink guttate papule. The appearance of papules is accompanied by itching. Initially, the rash is localized on the trunk and extremities, but subsequently spreads throughout the skin with the exception of the palms and soles. The disease is diagnosed clinically when a psoriatic triad is detected, histology data is used. The most effective methods of treatment are PUVA therapy and plasmapheresis.
Guttate psoriasis is a fairly rare form of scaly lichen of autoimmune coloration with a chronic course. Dermatosis has no gender or racial differences, does not have a clear seasonality, is not endemic. Most often, guttate psoriasis is diagnosed in school-age children, young men and women. In the world, more than 4% of the population suffer from psoriasis, the share of guttate accounts for about 2 million people. Guttate psoriasis is organ-specific, often combined with somatic pathology, acute or aggravated chronic infections. It is assumed that such combinations are caused by a violation of the protective properties of the skin and the easy penetration of infectious agents into the body, which are one of the main triggers in the trigger mechanism of the development of the disease.
It is believed that disseminated guttate psoriasis shortens the life of a woman by 3 years, a man by 1.5 years. Autoimmune disorders become the reason for shortening the life span. The development of guttate psoriasis is adversely affected by bad habits, especially smoking and a high atherogenic nutrition profile. Smoking a pack of cigarettes a day increases the risk of developing guttate psoriasis by 2 times. Eating a large amount of fish (a natural source of polyunsaturated fatty acids) reduces the likelihood of the disease by 3 times. The urgency of the problem is associated with the severe course of the psoriatic process, which significantly worsens the quality of life of patients.
The vast majority of dermatologists consider the main cause of the development of guttate psoriasis to be an infection of any etiology: influenza, sore throat, pneumonia, acute respiratory diseases of the upper respiratory tract, candidiasis of the mucous membranes. The infectious theory is supported by the presence of pathogenic pathogens in the scraping from the guttate plaque. An infectious disease either leads to the onset of pathology, or exacerbates the course of other forms of psoriasis and stimulates their transformation into guttate psoriasis. The background of pathological changes is stress, fatigue, decreased immunity, hereditary predisposition or a combination of several listed factors. Despite the fact that a pathogenic pathogen is detected in scrapings from plaques, guttate psoriasis is not an infectious disease, it is not contagious.
Autoimmune reactions play a leading role in the pathogenesis of the development of guttate psoriasis. The presence of infection activates the genes responsible for the development of the disease, stress affects neuropeptides that can stimulate keratinocytes, which, in turn, secrete cytokines. Cytokines activate lymphocytes of the immune system and histiocytes of the connective tissue component of the skin, attracting eosinophils. There are three stages of the development of guttate psoriasis: sensitization, latent existence and effector. In the first phase, the mechanism of the antigen-antibody reaction is triggered, where pathogenic microorganisms invading the skin act as antigen, and the cells of the immune and reticuloendothelial system act as antibodies. In the second phase, there is a latent accumulation of antibodies produced by dermal cells and lymphocytes of the immune system. Antibodies, due to an overabundance, bind not only foreign particles, but also endogenous skin structures.
Finally, in the third phase, a manifest rash of primary elements begins on the surface of the skin. The time of the beginning of the final phase cannot be predicted, since the duration of the latent period depends on the virulence of the pathogen or the cytotoxicity of another pathogenic origin, its quantity and the body’s resistance. It should be noted that in the case of guttate psoriasis, genetic predisposition does not play a decisive role, since there are many genes responsible for the development of guttate psoriasis, and the genetic transmission of any form of psoriasis does not obey Mendel’s laws. It is impossible to consider guttate psoriasis as a genodermatosis, we can only talk about a genetically determined heterogeneous disease.
In dermatology, it is customary to classify guttate psoriasis by severity, taking into account the prevalence of skin lesions. Distinguish:
- Mild guttate psoriasis – rashes are represented by single primary elements on an area occupying less than 3% of the skin. The elements appear acutely 2-3 weeks after the infection and require urgent medical attention. They are localized on the trunk and limbs, regress with hyperpigmentation phenomena.
- Moderate guttate psoriasis – multiple rashes, prone to peripheral growth, skin lesions from 3% to 10%. The general condition is disturbed, skin itching is noted, the patient needs inpatient medical care. The elements of the rash can resolve themselves or transform into a disseminated form.
- Severe guttate psoriasis is a common rash that occupies more than 10% of the skin. They are localized everywhere, seriously disrupt the patient’s condition, require medical intervention in a specialized hospital and treatment according to an individual program until the primary psoriatic elements completely regress.
The disease has a wave-like course, relapses come to replace remission, especially frequent in the autumn-winter period. Clinical manifestations of guttate psoriasis occur spontaneously. The primary element is a bright red guttate papule from 3 to 10 mm in diameter, covered with silver scales. Papules grow on the periphery, merge and turn into plaques. When traumatized, the elements are prone to ulceration and transformation into exudative psoriasis. The appearance of a rash is accompanied by itching. The rash is located on the trunk and extremities – this is a typical localization of the primary elements of guttate psoriasis. The face almost always remains free, the nail plates are not affected. The rash may resolve on its own or transform into a more severe form of psoriasis. The disappearance of the rash is not a guarantee of recovery.
When making a diagnosis of “guttate psoriasis”, data on a recent infection, complaints and the presence of a specific diagnostic triad are taken into account: stearin stain, terminal film, bleeding “dew drops”. In the blood test, increased ESR and leukocytosis are determined, according to biochemistry, the presence of rheumatoid factor is detected. Children who have suffered a streptococcal infection are serologically tested to detect an increased titer of antistreptolysin-O and antideoxyribonuclease, a nasopharyngeal smear is taken with a bacteriological examination for hemolytic streptococcus.
Histology is typical for drip psoriasis, morphological changes indicate the immaturity of epidermal cells, the presence of T-lymphocytes in the biopsy and the phenomena of hyperkeratosis. The disease is differentiated with other types of psoriasis, pink lichen, secondary syphilis, drug toxicoderma, dermatitis and viral exanthema.
Guttate psoriasis treatment
Dermatosis is resistant to therapy, requires patience from both the patient and the dermatologist. Complex treatment, depending on the severity of the process, is carried out in outpatient or inpatient conditions. First of all, the foci of chronic infection are sanitized, residual phenomena of acute forms of acute respiratory infections and acute respiratory infections are treated, and concomitant somatic pathology is corrected. The dermatologist selects an individual program of anti-atherogenic nutrition profile with the use of polyunsaturated fatty acids. At the same time, symptomatic therapy is carried out. With guttate psoriasis, PUVA therapy is most effective, prescribed in small doses under the supervision of a doctor. The use of plasmapheresis reduces the frequency of relapses.
Medications for guttate psoriasis are used for different purposes and in accordance with different therapeutic schemes. For example, hormonal ointments, taking into account the area of the skin lesion, are used only in short courses; antibacterial therapy against seeded hemolytic streptococcus is carried out by prescribing long cycles of antibiotic therapy using cephalosporins. The longest time is the reception of immunomodulators.
Vitamin therapy (A, D, C, E, group B) and preparations containing monoclonal antibodies are indicated. If the overgrowth of the primary elements is significant and continues to progress, retinoids are used internally and ointments with calcitriol externally. Sedative, antipruritic and antihistamine therapy are prescribed. Bran baths give a good effect. The prognosis is relatively favorable, taking into account the wave-like course of guttate psoriasis and a decrease in the quality of life of patients.