Quiz
Mixed diagnoses – 10 cases (2 of 11)

The image shows profuse scaly erythematous papules and small plaques on the back and upper limbs.

This is acute guttate psoriasis affecting an adult woman.

Guttate psoriasis tends to start very abruptly a week or two after streptococcal pharyngitis. However, streptococcal infection is not confirmed in every case.

Guttate psoriasis presents with numerous small erythematous plaques on the whole body, often most severe on the trunk. Guttate psoriasis does not usually cause much in the way of symptoms, but the plaques may sting, burn or itch intensely. The patient may also be fairly alarmed!
The patient is generally quite well at the time of the rash.

In typical cases no specific investigations are required, as they do not change management. However, throat swab may be worthwhile, and occasionally a skin biopsy is performed in case of clinical doubt.

Antibiotics should only be prescribed if persisting streptococci are cultured from the throat.
Management depends on severity and symptoms and may include:

• Emollients
• Mild topical steroid lotions or creams
• Coal tar baths
• Phototherapy
• Rarely, methotrexate

In many cases, the psoriasis completely resolves within 3-4 months. However, it may lead to chronic plaque psoriasis or recur next time the patient suffers a sore throat.