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adalimumab and infliximab was helpful inside the management of refractory PPP in 1 case203. Caution has to be exercised with the administration of TNF inhibitors as paradoxical induction of psoriasis, pustulosis and PPP have been reported with these agents204, 205. Far more recently, ustekinumab resulted in disease clearance in six of 9 PPP patients111. Acropustulosis of infancy--Acropustulosis of infancy (AI) is among the most common forms of pustular psoriasis presenting in childhood75, 136, 206. This situation predominates in male young children of African descent, nonetheless may possibly take place in both sexes and in all races207, 208. A single series reported acropustulosis in 4.7 of juvenile psoriasis sufferers, with approximately two-thirds of circumstances occurring in children much less than 5 years of age206. AI is characterized by intermittent crops of intensely pruritic vesiculopustules occurring around the acral surfaces. Vesiculopustules do not coalesce. Illness onset normally happens before ten months of age, and lesions usually persist for about two years, resolving by age 3 207, 208. Though AI will spontaneously remit, potent topical steroids are beneficial for illness management. Pustular lesions show a striking response to sulfones, specifically dapsone,208 nevertheless the risks of methemoglobinemia and also other hematologic adverse events may well outweigh its benefit to get a self-limited situation. Histopathology of pustular psoriasis and variants Neutrophils are the predominant function upon histopathologic examination of pustular psoriasis and its variants in both kids and adults. The epidermis is notable for variable hyperplasia, absent granular layer, parakeratosis, suprapapillary thinning, intracorneal aggregates of neutrophils (Munro microabscesses) and epidermal spongiosis with neutrophils (spongiform pustules of Kogoj). Prominent and dilated vessels are noted within the superficial dermis, with sparse mononuclear cell infiltrate and scattered neutrophils within the dermis161. Unique stains for bacteria or fungal elements are unfavorable. In annular pustularDermatol Clin. Author manuscript; obtainable in PMC 2014 July 01.NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author ManuscriptNaik and CowenPagepsoriasis, subcorneal pustules may well be observed136. In SCPD, subcorneal neutrophils accumulate atop fairly regular appearing epidermis in which spongiosis, spongiform pustules, microabscesses, acanthosis and acantholysis are absent144. In palmoplantar pustulosis, eosinophils and mast cells may possibly be noticed surrounding pustules within the upper dermis, and also the typical spiral columnar architecture of eccrine ducts is absent 182. In acropustulosis of infancy, both neutrophils and eosinophils may perhaps be observed inside intraepidermal vesicles both on histopathology and smear208. Differential diagnosis of pustular psoriasis and variants The differential diagnosis for generalized pustular psoriasis involves acute generalized exanthematous pustulosis (AGEP), subcorneal pustular dermatosis (SCPD), reactive arthritis and cutaneous infections such as impetigo, folliculitis, miliary tuberculosis and generalized candidiasis. Additionally, tinea corporis and gyrate erythemas must be viewed as within the differential diagnosis of annular pustular psoriasis. In kids, childhood bullous dermatosis, miliaria pustulosa, staphylococcal scalded skin syndrome and generalized seborrheic dermatitis ought to also be regarded as. IgA pemphigus, pemphigus foliaceus and dermatitis herpetiformis really should be thought of on the