ERYTHRODERMIC PUSTULAR PSORIASIS TRIGGERED BY RED LIGHT/LASER THERAPY

Document Type

Conference Proceeding

Publication Date

7-17-2025

Publication Title

J Gen Intern Med

Keywords

acitretin, C reactive protein, celecoxib, cyclosporine, infliximab, methotrexate, adult, arthralgia, blood culture, body surface, case report, clinical article, conference abstract, dermatitis, diagnosis, drug therapy, erythema, erythroderma, erythrodermic psoriasis, female, first-line treatment, generalized edema, hand edema, hand swelling, human, human tissue, immunosuppressive treatment, laser therapy, leukocyte count, leukocytosis, lymphocytopenia, myalgia, pruritus, psoriasis, pustular psoriasis, pustule, rash, red light, tachycardia, therapy, topical treatment, urinalysis

Abstract

CASE: We report a 47-year-old female with a 25-year history of psoriasis, previously stable without treatment for 13 years, presenting with a flare following a first-time session of red light/laser therapy (RLLT). Initial symptoms of joint pain and localized plaques became widespread following RLLT. The thick, scaly plaques, bright red patches, and pustules on her palms, fingers, and toes covered 90% body surface area. She also experienced generalized edema and pruritus. Aside from RLLT, she had no new exposures. Upon admission, the patient was febrile (102°F) and tachycardic (HR 115). Lab results showed leukocytosis (WBC 19,000/μL), lymphopenia, elevated CRP (40.1 mg/L), ESR (87 mm/hr). Blood cultures, urinalysis, infectious, and autoimmune workups were unremarkable. She was treated with infliximab 5 mg/kg, topical therapies, and celebrex for joint pain. Within two days the patient experienced significant improvement of erythema, pustules, and joint pain. IMPACT/DISCUSSION: Psoriasis is an immune mediated inflammatory skin condition with various presentations. Pustular psoriasis (PP) is characterized by sterile pustules on background erythema. Erythrodermic psoriasis (EP) is rare and life-threatening, presenting with systemic symptoms and an erythematous scaly rash on 75% of the body. Due to this patient's symptoms she was determined to have a very rare presentation of EP with concomitant PP. First-line therapy of PP is potent topical steroids or, if severe, cyclosporine or infliximab. Treatments for EP are cyclosporine and infliximab in unstable patients or acitretin and methotrexate in stable patients. Unlike for PP, steroids are highly contraindicated for EP due to the potential for severe withdrawal rebound of symptoms. In this case infliximab was chosen over cyclosporine due to less immunosuppressive effects given the initial concern for infection. Although RLLT has shown as a promising treatment for plaque psoriasis, this case seemed to have triggered a cascade of worsening symptoms, indicating possible Koebner phenomenon. This phenomenon describes the appearance of new lesions on previously unaffected areas of the body following trauma or injury to that area. The patient had been experiencing bilateral hand edema and muscle aches prior to the full-body RLLT, suggesting a flare-up during the RLLT session, thus triggering koebnerization and explaining the full-body severity. CONCLUSION: PP and EP are rare, severe variants and seldomly cooccur. This case illustrates a severe psoriasis flare likely triggered by RLLT, with significant systemic inflammatory symptoms that required prompt biologic intervention and a multidisciplinary approach. The patient's response to Infliximab highlights the importance of timely treatment in managing severe psoriasis with systemic involvement. Although RLLT has shown potential for treating psoriasis, clinicians must consider the risk of novel therapies triggering a worsening of symptoms and the potential for Koebner phenomenon.

Volume

40

First Page

S208

Last Page

S209

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