A prospective, observational study on the epidemiology, disease characteristics and treatment outcomes for generalized pustular psoriasis in India

Background Generalized pustular psoriasis (GPP) is a rare, severe inflammatory skin disease marked by widespread sterile pustules on erythematous skin. It poses clinical challenges due to its systemic involvement, unpredictable course, and risk of serious complications. This study evaluates the clinical features, disease severity, triggers, treatment outcomes, and quality of life (QOL) in GPP patients in India. Methods A prospective observational study was conducted at a tertiary care hospital in North India from March 2022 to March 2025. Patients diagnosed with GPP were assessed for disease severity (GPPASI), triggers, treatment response, flares, and QOL (DLQI). Clinical data, lab findings, and comorbidities were analyzed. Results Of 857 new psoriasis patients, 46 (5.3%) had GPP (mean age: 36.2±16.7 years; 63% male). The median inpatient stay was 12 days; average flare count was 3.1±2.5. Common triggers included medications (complementary therapies, NSAIDs, antibiotics), infections, hypocalcemia, pregnancy, and COVID-19. The average latency from trigger to flare was 10.4±8.5 days. Systemic inflammation was reflected in lab markers. Treatment included acitretin (n=20), methotrexate (n=12), cyclosporine (n=6), and biologics (n=4), with combination therapy in some cases. Early remission (≥50% GPPASI reduction in 5 days) occurred in 75% on biologics, 66.7% on cyclosporine, and 65% on acitretin. Sustained remission at 3 months was seen in 60% (biologics), 55% (cyclosporine), and 52% (acitretin). Twelve patients (26.1%) relapsed, and 6 (13%) had persistent disease. Early responders (n=28) showed significantly better sustained remission than non-responders (p=0.032). GPPASI scores improved from 25.4±16.9 to 19.1±13.7 by day 3, with parallel QOL improvement. There were three deaths, two COVID-19-related. Conclusion In resource-limited settings, early trigger identification and personalized treatment can optimize GPP outcomes. Conventional agents like methotrexate, acitretin and cyclosporine remain effective and affordable alternatives to biologics for short-term disease control.