Putu Natasha Arivia Candra Nugraha, Ni Wayan Wendy Rinawati, Verika Christabela Tansuri, Ni Made Adhiswari Mardhana

Generalized pustular psoriasis in a 36-year-old female: clinical presentation and management

Introduction

Generalized pustular psoriasis in a 36-year-old female: clinical presentation and management. Generalized pustular psoriasis (GPP) case: a 36-year-old female's clinical presentation, diagnosis, and complex management, including metabolic comorbidities.

Abstract

Introduction: Psoriasis is a chronic inflammatory skin disease with a strong genetic component. Pustular psoriasis is a rare variant characterized by sterile pustules on erythematous skin, with Generalized Pustular Psoriasis (GPP) representing its most severe form. GPP is driven by dysregulated IL-36–mediated inflammation and may occur independently or with plaque psoriasis. It is often accompanied by systemic symptoms such as fever, malaise, and pain, and may require urgent medical management. Although its exact etiology remains unclear, various triggers, including infections, corticosteroid withdrawal, stress, and medications, have been implicated. This report aims to evaluate the clinical approach to managing a patient with pustular psoriasis and coexisting comorbidities. Case description: A 36-year-old woman presented with a two-week history of worsening bilateral leg pain and progressive pustular skin lesions initially on the lower extremities, later spreading to the trunk. Symptoms developed after the patient experienced hypercholesterolemia and received treatment. Examination revealed widespread pustules on erythematous plaques, some forming “lakes of pus,” without nail or joint involvement. Laboratory findings showed neutrophilia and an elevated neutrophil-to-lymphocyte ratio (4.2), with otherwise normal results. A diagnosis of generalized pustular psoriasis was made. The patient received supportive and symptomatic treatment during a two-day hospitalization, resulting in clinical improvement and no new lesions, and was discharged for outpatient care with continued recovery. Conclusion: This case highlights the complexity of generalized pustular psoriasis management in a patient with metabolic comorbidities and recurrent pustular flares. Management focused on a combination of supportive, systemic, and topical therapies. Although not a confirmed trigger, hypercholesterolemia may have contributed as a comorbidity.

Review

The case report titled "Generalized pustular psoriasis in a 36-year-old female: clinical presentation and management" effectively highlights a challenging and severe variant of psoriasis. The abstract provides a concise introduction to Generalized Pustular Psoriasis (GPP), emphasizing its inflammatory basis, systemic manifestations, and the urgency often required in its management. The description of the 36-year-old woman's presentation, including widespread pustular lesions, leg pain, and the onset after hypercholesterolemia treatment, offers a clear clinical picture of a complex case requiring careful consideration. A key strength of this report lies in its focus on the practicalities of managing GPP in a patient with metabolic comorbidities and recurrent flares. However, the abstract's description of the "management focused on a combination of supportive, systemic, and topical therapies" in the conclusion could benefit from greater specificity. While "supportive and symptomatic treatment" during the 2-day hospitalization is mentioned, the exact nature of the "systemic therapies" is not detailed, which is crucial for a condition as severe as GPP. Furthermore, the role of hypercholesterolemia and its treatment as a potential contributor or comorbidity warrants a more explicit and thoroughly explored discussion, as the abstract only vaguely touches upon its temporal association with symptom onset. Overall, this case report holds significant value for clinicians, offering insights into the diagnostic pathway and initial management of GPP in a nuanced clinical context. The rarity and severity of GPP, coupled with the presence of comorbidities and suggested recurrent flares, make this a compelling case study. To maximize its impact, a more detailed account of the specific systemic treatments employed and a deeper exploration of the interplay between hypercholesterolemia and disease presentation would enhance its contribution to the dermatological literature.

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