Transcript
Announcer:
You’re listening to DermConsult on ReachMD, and this episode is sponsored by Leo Pharma Inc. Here’s your host, Dr. Brian McDonough.
Dr. McDonough:
This is DermConsult on ReachMD, and I'm Dr. Brian McDonough. Here with me today is Dr. Saakshi Khattri, who's an Associate Professor of Dermatology at the Icahn School of Medicine at Mount Sinai in New York. She'll be talking about how we can recognize generalized pustular psoriasis and differentiate it from plaque psoriasis and other inflammatory skin conditions. Dr. Khattri, welcome to the program.
Dr. Khattri:
Thank you so much for having me.
Dr. McDonough:
Well, to start us off, Dr. Khattri, can you tell us about some of the ways generalized pustular psoriasis can present and why it can be difficult to recognize?
Dr. Khattri:
So I always start by saying that for generalized pustular psoriasis, or GPP for short—and I'm going to use GPP going forward—the pustules are the textbook image that we associate with GPP, and that is what we see in our dermatology textbooks or any textbooks talking about GPP as a matter of fact.
But patients can present with diffuse erythema scaling. So just showing a pustular eruption on the skin does a disservice to GPP because it is not just one picture. And in between flares, patients can have what might even look like plaque psoriasis or other inflammatory diseases as you mentioned in your opening sentence.
So a static textbook description allows for recognition to lag in the community setting or in the derm setting in general.
Dr. McDonough:
As a follow-up to that, we're also starting to understand that the appearance of generalized pustular psoriasis can change over time. So how does that variability influence the way you evaluate patients from visit to visit?
Dr. Khattri:
So at any visit when we are seeing patients in our practice or any healthcare interaction, we are only capturing a snapshot of what their GPP looks like at that point in time. So it's a very static representation. But what we have to think of is what's happening in between those snapshots because this disease is extremely variable.
Patients cycle between stability and worsening of their symptoms, and the morphology of the key features that we look for in GPP might be very transient in nature. So following patients longitudinally or looking at it from a more longitudinal perspective is certainly more helpful than just a single exam.
So I do think we have to, as clinicians, keep an open mind that perhaps that point in time that you're interacting with the patient might not be enough of a holistic picture of what their GPP really looks like or feels to them.
Dr. McDonough:
Now, let's say you're seeing a patient who's been diagnosed with plaque psoriasis but isn't responding to therapy as expected. What clinical clues would prompt you to reconsider whether generalized pustular psoriasis could be part of the differential diagnosis?
Dr. Khattri:
We have excellent therapies in 2026 for plaque psoriasis. Certainly, if a patient is on systemic therapy—for example, an IL-23 blocker—we expect that medicine to work really well for their plaque psoriasis. So if a patient is not all or almost clear or he or she underperforms on appropriate therapy for their plaque psoriasis, then it's not a dosing issue.
I really think that we should then start to think, "Is this something else that the patient has?" So if there’s limited or inconsistent response to adequate plaque psoriasis therapy or if a patient endures rapid worsening of symptoms or maybe a history of a pustular episode or any systemic symptoms, then I do think we should reassess. Whether it's by doing a biopsy or going back into their history and questioning them a lot more, we should second-guess whether the plaque psoriasis diagnosis is indeed correct.
Dr. McDonough:
For those just tuning in, this is DermConsult on ReachMD. I'm Dr. Brian McDonough, and I'm speaking with Dr. Saakshi Khattri about identifying the variable features of generalized pustular psoriasis.
Looking beyond differences in appearance, Dr. Khattri, generalized pustular psoriasis is often described as an unpredictable disease. So what do we need to understand about how flares can progress and how severity may vary from one episode to the next?
Dr. Khattri:
Right. GPP is notoriously unpredictable, and flares can escalate rapidly over days or even hours. And that pace of disease escalation or flare has real consequences for patients. Rapid progression over hours to days really equates to worsening severity of their disease.
And such patients can then eventually present to the ER or be admitted to an ICU and can rapidly destabilize to a point of increased morbidity and mortality. So we do really have to be cognizant of the fact that GPP does have flares associated with it, which can really escalate the burden of the disease for patients.
Dr. McDonough:
And during those flares, systemic symptoms like fever and malaise can sometimes accompany cutaneous findings. How do these features help inform your clinical assessment, and at the same time, what are the limitations of relying on them alone?
Dr. Khattri:
So systemic signs support but don't necessarily gatekeep the diagnosis of GPP. The presence of fever, malaise, or other systemic symptoms is certainly useful when we're making a diagnosis of GPP. But their absence really doesn't mean anything. Because we as dermatologists and as clinicians dealing with GPP have seen patients having a flare of their GPP with or without systemic symptoms.
So I really want to make sure that the audience understands that the presence or absence of systemic symptoms is not really a diagnostic marker or criteria for GPP. Certainly, systemic features signal broader inflammatory activity during flares. And again, the absence of it does not exclude that a patient has GPP.
So we really need to integrate what we are seeing clinically on the skin, what the history has been, and whether they have systemic symptoms or not when we are making that diagnosis.
Dr. McDonough:
As we come to a close, Dr. Khattri, can you share some practical strategies that can help clinicians identify generalized pustular psoriasis when a patient's disease course doesn't fit the expected pattern?
Dr. Khattri:
First of all, be mindful that just having pustules on the skin is not the entire picture of GPP. So that's one thing. The second thing is GPP is a very variable disease as patients can be asymptomatic one day and then have a flare the next, and that flare can rapidly escalate.
If there is a thought or if they've been considered as having plaque psoriasis historically and if they're refractory to systemic therapies or even therapies which we expect to work very well for plaque psoriasis, please re-question the diagnosis. Certainly, we can have GPP patients with overlapping plaque psoriasis, and that's a different story altogether. But just question if a patient does not respond to treatment the way we'd hope them to.
And when in doubt, doing a skin biopsy is such an easy tool that we have in our armamentarium, so we should use that.
Dr. McDonough:
With those key strategies in mind, I want to thank my guest, Dr. Saakshi Khattri, for joining me to share her insights on improving the recognition of generalized pustular psoriasis. Dr. Khattri, it was great having you on the program.
Dr. Khattri:
Thank you so much for having me.
Announcer:
This episode of DermConsult was sponsored by Leo Pharma Inc. To access this and other episodes in our series, visit DermConsult on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening!
