Pustular Psoriasis When Nonbiologic Systemic Therapy Has Not Worked

Pustular psoriasis is a severe variant of psoriasis requiring active systemic management. When an initial course of nonbiologic systemic therapy fails to produce adequate improvement, a defined next-line protocol applies.

Previous Treatment & Escalation Trigger

The prior line employed nonbiologic systemic therapy — agents such as methotrexate, cyclosporine, or acitretin. The goal was meaningful improvement of pustular psoriasis; when that threshold is not reached, this protocol becomes the appropriate next step.

Next-Line Approach

For pustular psoriasis that is unresponsive to nonbiologic systemic therapy, the next step involves infliximab — a biologic therapy administered intravenously — used either as monotherapy or in combination with another systemic agent. The complete dosing schedule and combination criteria are in the full structured regimen.

Instant Access to Structured Evidence-Based Regimens

References

DOI: 10.1016/j.jaad.2019.08.049

Methotrexate is recommended as an effective systemic therapy for pustular psoriasis in children.
Infliximab can be recommended as monotherapy or in combination with methotrexate for use in pediatric patients with severe plaque or pustular psoriasis that is unresponsive to other systemic medications, rapidly progressive, unstable, and/or life threatening.
The starting dose of infliximab is an infusion of 5 mg/kg administered on weeks 0, 2, and 6 and then every 8 weeks.

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