Multiple Triggering Factors Of Generalized Pustular Psoriasis: A Case Report
DOI:
https://doi.org/10.12928/admj.v6i2.14209Keywords:
Acute infection, Generalized Pustular Psoriasis, NSAID, Overweight, Triggering factorsAbstract
Generalized Pustular Psoriasis (GPP) is a rare, severe systemic inflammatory disorder driven by dysregulation of the interleukin-36 (IL-36) pathway. Flares are often precipitated by multiple triggering factors, including infections, medication and underlying comorbidities. A 40-year-old overweight male with a history of pustular psoriasis and poor treatment adherence presented with a severe flare of widespread, painful pustules. The presentation was complicated by consumption of diclofenac and multiple infections, including cellulitis and untreated dental caries, which progressed to septic shock and acute kidney injury (AKI). He was managed with intravenous antibiotics and systemic immunomodulators (cyclosporine, then methotrexate), leading to significant clinical improvement. Host factors like obesity and non-adherence created a pro-inflammatory state, while acute infections and non-steroidal anti-inflammatory drugs (NSAID) acted as potent triggers for IL-36 upregulation, igniting a severe inflammatory cascade. This convergence led to life-threatening systemic complications, underscoring the complexity of the disease. Severe GPP flares are often triggered by a convergence of overweight status, NSAID and acute infections. Effective management requires a holistic, multidisciplinary approach that aggressively identifies and treats all contributing triggers to improve outcomes.
References
Lee JY, Kang S, Park JS, Jo SJ. Prevalence of Psoriasis in Korea: A Population-Based Epidemiological Study Using the Korean National Health Insurance Database. Ann Dermatol. 2017;29:761.
Prinz JC, Choon SE, Griffiths CEM, Merola JF, Morita A, Ashcroft DM, et al. Prevalence, comorbidities and mortality of generalized pustular psoriasis: A literature review. Vol. 37, Journal of the European Academy of Dermatology and Venereology. John Wiley and Sons Inc; 2023. p. 256–73.
Rivera-Díaz R, Daudén E, Carrascosa JM, Cueva P de la, Puig L. Generalized Pustular Psoriasis: A Review on Clinical Characteristics, Diagnosis, and Treatment. Vol. 13, Dermatology and Therapy. Adis; 2023. p. 673–88.
Navarini AA, Burden AD, Capon F, Mrowietz U, Puig L, Köks S, et al. European consensus statement on phenotypes of pustular psoriasis. Journal of the European Academy of Dermatology and Venereology. 2017;31:1792–9.
Ly K, Beck KM, Smith MP, Thibodeaux Q, Bhutani T. Diagnosis and screening of patients with generalized pustular psoriasis. Psoriasis: Targets and Therapy. 2019;Volume 9:37–42.
Marrakchi S, Puig L. Pathophysiology of Generalized Pustular Psoriasis. Am J Clin Dermatol. 2022;23:13–9.
Liu ZJ, Tian YT, Shi BY, Zhou Y, Jia XS. Association between mutation of interleukin 36 receptor antagonist and generalized pustular psoriasis. Medicine. 2020;99:e23068.
Wang H, Jin H. Update on the aetiology and mechanisms of generalized pustular psoriasis. European Journal of Dermatology. 2021;31:602–8.
Barros G, Duran P, Vera I, Bermúdez V. Exploring the Links between Obesity and Psoriasis: A Comprehensive Review. Vol. 23, International Journal of Molecular Sciences. MDPI; 2022.
Buhl AL, Wenzel J. Interleukin-36 in infectious and inflammatory skin diseases. Vol. 10, Frontiers in Immunology. Frontiers Media S.A.; 2019.
Kwak EJ, Choi YJ, Kim HN, Kim KE, Jeon J, Baek YS. Increased dental comorbidities in patients with psoriasis: a nationwide population-based cohort study in Korea. Clin Exp Dermatol. 2023;48:1347–53.
Mansouri B, Benjegerdes K, Hyde K, Kivelevitch D. Pustular psoriasis: pathophysiology and current treatment perspectives. Psoriasis: Targets and Therapy. 2016;Volume 6:131–44.
Agustinus OP. Patomekanisme dan Manifestasi Infeksi COVID-19 pada Kulit. Cermin Dunia Kedokteran. 2022;49:427–30.
Coscarella G, Falco GM, Palmisano G, Ippoliti E, De Luca E, Gori N, et al. Low grade of satisfaction related to the use of current systemic therapies among pustular psoriasis patients: a therapeutic unmet need to be fulfilled. Front Med (Lausanne). 2024;10.
Teshima R, Saito-Sasaki N, Sawada Y. Generalized Pustular Psoriasis and Systemic Organ Dysfunctions. Int J Mol Sci. 2024;25:6270.
Puig L, Choon SE, Gottlieb AB, Marrakchi S, Prinz JC, Romiti R, et al. Generalized pustular psoriasis: A global Delphi consensus on clinical course, diagnosis, treatment goals and disease management. Journal of the European Academy of Dermatology and Venereology. 2023;37:737–52.
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