Streptococcus (strep) infections are a literal pain. There’s a sense of triumph that comes from taking the last dose of antibiotics and putting the symptoms behind you. It can be confusing and even frightening when, weeks later, a red, scaly rash erupts over the body.
This is a complication of strep, not antibiotic therapy. It’s a distressing but often temporary and self-limiting condition called guttate psoriasis.
A Different Kind of Psoriasi
Guttate psoriasis is one variant among many of psoriasis. Its red, tear-drop shaped (guttate is derived from the Latin word for “drop") lesions are scattered diffusely over the trunk and the limbs, unlike the large, scaly, localized patches seen in plaque psoriasis. Guttate psoriasis rashes consist of small, well-defined circular plaques and small papules. It does not affect the palms of the hand, the soles of the feet, or the nail beds.
On light skin, the papules are usually red, violet, or pink with white or silverish scales. On darker skin, the lesions can look like purple spots with greyish scales.
A Rare Disorder
Guttate psoriasis is relatively rare, accounting for only four percent of psoriasis cases in the United States. However, it is the second most common form of psoriasis in children.
The first symptom of guttate psoriasis is often a generalized itch; a day or so later, one or more raised, red lesions might erupt on the irritated skin. In the days that follow, dry white or silvery scales may form over the lesion. The palms of the hands, the soles of the feet, and the nail bed are generally unaffected
You might notice that lesions erupt around small injuries to the skin–this is called Koebner’s phenomenon, and it can occur with most variants of psoriasis. If the patient has a pre-existing skin condition or develops one during a flare, papules may develop around those eruptions.
Guttate psoriasis most often develops subsequent to streptococcal infection in the throat, upper respiratory system, or perianal area. It can erupt after certain viral illnesses, as well, including Covid 19 and coxsackie virus (hand foot and mouth disease). Medications, most notably methotrexate and malarials, can also trigger the development of guttate psoriasis. In very rare cases, it develops independently of any identifiable trigger.
Symptoms usually resolve within two weeks to four months. It does not usually recur, although exposure to Streptococci can sometimes trigger recurrences. These recurrences typically resolve on their own. It’s important to have strep screens repeated to ensure that there is not a carrier state of chronic strep infections going on.
About 40 percent of guttate psoriasis patients “convert” from guttate psoriasis to plaque psoriasis, which is chronic. In a much smaller percentage of cases, guttate psoriasis becomes chronic, itself.
Guttate psoriasis lesions do not scar, but they sometimes leave behind spotty areas of depigmentation, which usually fade over time. It should be noted that depigmentation caused by guttate psoriasis is not the same thing as idiopathic guttate hypomelanosis, a loss of pigment associated with age and sun exposure. The relationship between these disorders begins and ends with the word “guttate,” which denotes the speckled, “drop-like” effects of each.
Diagnosing Guttate Psoriasis
There are a number of skin disorders and diseases that cause papular rashes: pityriasis rosea, ringworm, nummular eczema, and secondary syphilis are but a few. Doctors can usually eliminate these other disorders by visually examining the rash and taking a thorough history.
In less straightforward cases, the doctor might order a skin scraping or a biopsy. Examining this tissue under microscopes allows physicians to look for the distinct properties of guttate psoriasis.
Why does strep trigger guttate psoriasis?
We know that streptococcal infections trigger guttate psoriasis, as can certain viruses and medications. We aren’t as certain about the mechanisms by which this happens. Most clues point to a combination of genetic predisposition and environment.
An allele (a variation of a gene) called HLA-Cw6 has been found to correlate strongly with guttate psoriasis. Genome-wide association studies of guttate psoriasis patients in Europe found the allele in 73% of Finnish cases, 100% percent of British cases, and 86% of Irish cases.
People carrying HLA-Cw6 are more likely to develop guttate psoriasis and to experience Koebner's phenomenon. They are also more likely to contract streptococcal pharyngitis, the infection most often implicated in guttate psoriasis. Some hypothesize that environmental triggers, such as streptococcal infection, cause HLA-Cw6 acts upon the innate and adaptive immune systems of those who carry the allele to cause inflammation in the skin cells.
Treatment Options For Guttate Psoriasis
Guttate psoriasis cannot be cured. Treatments are chosen based upon the duration and severity of the disorder, as well as any comorbidities.
Topical corticosteroids are the first-line treatment for mild cases. Topical anthralin, which slows the production of skin cells, is sometimes prescribed to people who cannot use corticosteroids. Other topical treatments include calcipotriene (a form of vitamin D, available by prescription) and calcineurin inhibitors. Severe scaling is sometimes addressed with topical treatments of either retinoids (tazarotene) or salicylic acid products; these treatments help the epidermis shed its dead cells more rapidly, thereby minimizing thickening of the skin.
Phototherapy involves exposing the affected skin to ultraviolet light, and it is frequently prescribed for moderate to severe cases. Phototherapy is done in a doctor’s office with a specialized UVA or UVB lamp. It is sometimes augmented by the application of psoralen, a plant-based compound that enhances the effects of UVA lamps (PUVA).
Systemic immune-suppressing oral treatments such as methotrexate, cyclosporine, or apremilast are prescribed for especially severe or persistent cases. While several targeted or biologic therapies have emerged in the treatment of plaque psoriasis, they have not yet been thoroughly researched for treating guttate psoriasis. Ustekinumab has shown promise for treating severe, long-lasting cases.
Along with checking for strep reinfection, reducing stress is important.
SmartLotionⓇ Can Help
Like all variants of psoriasis, guttate psoriasis can be draining and frustrating to treat.There is no one-size-fits-all treatment plan, and some symptoms can persist with even the best treatments.
Fortunately, guttate psoriasis sufferers have a safe and effective tool to address those persistent symptoms–even in those cases where it becomes chronic.
SmartLotionⓇ is the brainchild of Steve Harlan, MD, a board-certified dermatologist who saw the toll that chronic skin conditions–and the side-effects of long term corticosteroid treatments–took on his patients.
With SmartLotionⓇ eczema cream, Dr. Harlan combined the anti-inflammatory properties of 0.75% hydrocortisone with a unique, prebiotic formula that promotes the restoration of the skin’s barrier function.. By addressing the skin’s underlying health, SmartLotionⓇ can effectively address symptoms like itching and redness without the risk of topical steroid withdrawal.
Most guttate psoriasis patients can safely add SmartLotionⓇ to their prescription treatments under their physician’s guidance. Dr. Harlan has his adult guttate patients apply SmartLotion® 3-4 times per day for up to 4 weeks. After that, patients can safely apply it once or twice a day as needed. He recommends applying SmartLotionⓇ after moisturizing the skin.
A brief stinging sensation can accompany the initial applications; this can be alleviated with cool compresses. The stinging subsides after the first few applications.
Self-Care for Guttate Psoriasis
Beyond the treatments outlined above, there are self-care practices that can help you manage guttate psoriasis symptoms better.
- Wash regularly… Shower every day, using lukewarm water and gentle bath products. Do not use hot water, and do not stay in the shower for more than 20 minutes. Alternatively, take a warm (not hot!), 15-minute soak after adding oatmeal to the water (you can use rolled oats from your pantry or get a specially-formulated oatmeal bath)
- …But not too frequently. Believe it or not, frequent baths strip oils from the skin and contribute to dryness. They also intensify itching. Bathe no more than once a day unless absolutely necessary.
- Moisturize!! Apply moisturizer twice a day (at least! Moisturize as frequently as you can). Always moisturize after washing; gently pat your skin dry and apply your moisturizing cream or lotion while your skin is still damp. Ointment-based moisturizers like Aquaphor Healing OintmentⓇ are sometimes better for extremely dry skin, because they prevent rapid evaporation of moisture.
Use dermatologist-recommended moisturizers such as CeraVeⓇ, which produces a lotion specifically formulated for psoriasis–it rehydrates the skin and seals in moisture while reducing redness and scaling.
- Don’t scratch! Scratching exacerbates psoriasis, it exposes vulnerable skin to infection, and for those with Koebner phenomenon, it creates new areas for papules to form. Frequent applications of moisturizer prevent dryness and facilitate the removal of dead skin cells to alleviate itchiness. For lesions on the scalp, try shampoos containing coal tar. An over-the-counter hydrocortisone treatment like SmartLotionⓇ can help with itch.
- Catch some rays! Most variants of psoriasis benefit from a moderate amount of natural sunlight. This calls for controlled conditions:
- Speak to your doctor first. Excessive sunlight can sometimes exacerbate psoriasis, and some medications can make skin more sensitive to sunlight.
- Wear sunscreen with a minimum SPF of 30 on the face.
- Limit exposure to 20 minute increments.
- Avoid peak daylight hours (between 10 AM to 5 PM)
- Avoid sun exposure if you are doing phototherapy or PUVA (psoralen plus UVA therapy).
- Take vitamin D. Its effects on psoriasis are not clear, but it has a number of documented health benefits, and sunlight helps us make more of it. The FDA recommends a daily intake of 400 international units (IU) for children under 12 months, 600 IU for people between the ages of 1 and 70 years, and 800 IU for people over 70. Discuss all supplements with your doctor.
- Do not use tanning beds! Not all UV radiation is the same. The wavelength used in tanning beds is of negligible benefit to psoriatic skin. In fact, it is more likely to dry the skin and exacerbate symptoms–and it increases your risk of developing skin cancer.
- Avoid anything that worsens your guttate psoriasis lesions or triggers other skin disorders. Even small injuries can worsen guttate psoriasis locally. Avoid exposure to known eczema or plaque psoriasis triggers. Prevent sunburns, and protect your hands with gloves if you are gardening or doing other tasks that expose you to scratches or irritating chemicals.
- Manage your stress. Stress intensifies itchiness and pain. Take stock of the stressors you can realistically eliminate. Punctuate your work hours with calming, enjoyable activities, and spend time with friends when you can. Try to improve the quality of your sleep. Guttate psoriasis is stressful enough in and of itself.
Guttate psoriasis cannot be cured. Fortunately, many excellent treatments are available to address the symptoms–and when symptoms persist, SmartLotionⓇ, our eczema cream, will be there to give your treatment plan a leg-up.
Steven Harlan MD
Board Certified Dermatologist
Inventor of SmartLotion®