Generalized Pustular Psoriasis: Symptoms, Causes, Treatment

Written by Matt McMillen
Medically Reviewed by Stephanie S. Gardner, MD on July 17, 2025
12 min read

Generalized pustular psoriasis (GPP) is the rarest form of psoriasis, a chronic autoimmune skin condition. GPP can be severe, even life-threatening.

The disease causes flares of widespread inflammation of the skin, leading to red patches and pustules on large parts of your body. That inflammation usually comes with other symptoms. Sometimes, those symptoms only affect the skin, causing itching and a burning sensation, but the disease can affect your whole body, bringing with it fever, fatigue, muscle weakness, and more. Severe flares can lead to kidney, heart, or respiratory failure.

GPP affects about 1 in 10,000 people in the U.S. While it can develop at any age, you’re most likely to get it between the ages of 40 and 59. People assigned female at birth (AFAB) have a slightly higher risk of getting the disease than people assigned male at birth (AMAB). Just over half of people with GPP also have plaque psoriasis, the most common type of psoriasis.

The symptoms of GPP occur when the disease flares up. This usually happens suddenly.

GPP symptoms can vary, but you can expect the disease to cause large areas of reddened skin covered with tiny, painful white bumps filled with sterile pus. That means the pus does not harbor infection and is not contagious. These pustules also can form in your mouth, while reddish, smooth patches may develop on your tongue.

The symptoms of GPP usually follow this course:

  • A burning sensation develops on your skin, which becomes tender and dry.
  • A high fever starts, accompanied by a general feeling of being unwell.
  • Areas of skin previously affected by the disease become covered with pustules.
  • Redness of your skin, caused by inflammation, gets worse.
  • Pustules begin to cover previously healthy skin, particularly in skin folds and around your genitals. These can be individual pustules or pustules that merge together to form what are called “lakes of pus.”
  • Pustules may form within circular skin lesions, on areas of reddish raised skin called plaques, or as part of widespread redness on your skin.
  • Finally, the pustules usually will dry up, forming scales and redness before they fall off.

While the above symptoms mostly involve your skin, GPP causes other symptoms, including:

  • Fever
  • Fatigue
  • Headache
  • Chills
  • Nausea and diarrhea
  • Pain in your joints
  • Weakening of your muscles
  • Swelling (edema) of your legs if heart failure develops
  • Inflammation of your eyes
  • Faster than normal pulse
  • Low blood pressure
  • Jaundice, a yellowing of the skin and the whites of the eyes
  • Intense itching

How long do symptoms last?

Once a flare begins, skin symptoms take about a week to fully spread. Flares usually last a few weeks but can continue for months before the disease settles down and goes into remission. In some cases, the pustules that form during a flare will remain on your skin between flares.

There’s no widely agreed upon classification of the different types of GPP, which include:

Von Zumbusch, or acute GPP

This is the most common type of GPP and the most dangerous, as it can lead to life-threatening complications such as sepsis. It comes in acute flares followed by periods in which the disease causes few or no symptoms.

Annular GPP

This type is more common in children than adults; it’s also less severe. It causes symptoms on the skin, such as ring-shaped (annular) plaques, which are thick, raised areas of skin surrounded by red, scaly skin or pustules. It typically does not cause fever or other concerning complications. However, in some cases it has developed into acute GPP. Unlike acute GPP, the symptoms of annular GPP can be chronic or longer lasting, but they usually respond well to treatment.

Pustular psoriasis of pregnancy

Also known as impetigo herpetiformis, this type usually occurs in the third trimester, though in some cases it has developed as early as the first month. It often lasts until the child is born, though it may continue after childbirth. Like Von Zumbusch GPP, this type of GPP can be deadly. In fact, some experts say that this is the same disease as Von Zumbusch. If you develop it during pregnancy, it likely will return in future pregnancies. It also may be triggered by using oral contraceptives.

Experts don’t yet know for sure why GPP occurs, but several factors likely play a part, either in the development of the disease or as triggers that lead to flares of GPP. These include your genes, your immune system, and your environment. Certain medications and infections also have been linked to GPP. Pregnancy is another known risk factor; it can trigger a form of GPP called pustular psoriasis of pregnancy.

Your genes and your immune system

You have a gene called IL36RN, which helps to keep inflammation under control by enabling the production of an immune system cell called an IL-36 receptor agonist. If you have a faulty version of this gene, you will be more likely to develop GPP and to develop it in childhood rather than in middle age, when it most commonly starts. If you are having GPP symptoms in your mouth and you don’t have plaque psoriasis, you may have this gene mutation, also called a gene variant.

Another gene thought to play a role in GPP is CARD14. It also is involved in your immune system and in managing inflammation. Mutations in this gene have been tied to GPP in both adults and children. Problems with other genes also have been linked to GPP. These genes include:

  • AP1S3
  • MPO
  • SERPINA3

Your environment

Things you do and things happening around you can act as triggers of GPP. These include:

  • Smoking
  • UV radiation from sunlight as well as sunburns
  • Emotional stress

Medications

A number of different medications have been linked to GPP. One of the most common triggers reported: stopping corticosteroid medications, either in pill form or if you’ve been taking a strong topical corticosteroid. These drugs suppress the immune system and are typically prescribed for short periods to control inflammation. Other immunosuppressant drugs that may trigger GPP include:

  • Cyclosporine (Gengraf)
  • Methotrexate, usually prescribed for rheumatoid arthritis, psoriasis and some cancers. It can trigger GPP in rare cases. 
  • Rituximab (Rituxan)
  • Ustekinumab (Stelara), it can trigger GPP in rare cases.
  • Medications called tumor necrosis factor alpha (TNF alpha) inhibitors and interleukin-17 (IL-17) inhibitors, prescribed for plaque psoriasis, rheumatoid arthritis, and Crohn’s disease

Other types of drugs linked to GPP

  • The antibiotics amoxicillin, ceftriaxone, and oxacillin
  • Aspirin
  • Codeine, a pain medication
  • Hydroxychloroquine
  • Lithium
  • Progesterone
  • Salicylates, a naturally occurring organic acid that is found in fruits and vegetables like blueberries, mushrooms, and avocados
  • Terbinafine, an antifungal medication

Infections

The following infections have been associated with GPP:

  • Cytomegalovirus (a type of herpes)
  • Chickenpox and shingles (varicella zoster virus)
  • Strep throat (streptococci infection)
  • Mono (mononucleosis, caused by the Epstein-Barr virus)
  • COVID-19 (SARS-CoV-2)

Diagnosing GPP can be difficult. For one thing, the disease is quite rare, so your doctor may not expect it. It also causes a great number of symptoms that can vary from person to person, making it tough to identify and easy to confuse with other conditions. Experts also have not established standardized criteria for making a diagnosis, further complicating the diagnostic process.

When you see your doctor, you will discuss your symptoms, what was going on when your symptoms began, such as the types of medications you were or are taking, and your medical history. For example, if you have plaque psoriasis, that can be a clue that GPP explains your symptoms.

Tests for generalized pustular psoriasis

In addition to a physical exam, your doctor will order several tests. While there’s no blood test to diagnose GPP, blood tests can help to confirm your doctor’s suspicions that you have GPP and rule out other causes. Blood tests also help evaluate how the disease is affecting you. These tests include checks of:

  • Erythrocyte sedimentation rate, a measure of inflammation
  • C-reactive protein, a measure of inflammation
  • Albumin, zinc, and calcium levels
  • White blood cell levels
  • Liver enzyme levels
  • Antistreptolysin antibodies, which help fight group A streptococcus, the bacteria that cause strep throat
  • Lipid, or blood fat, levels
  • Genetic testing for IL36RN, though this is not often done

A skin biopsy also can help to diagnose GPP, though it may be unnecessary. To do a biopsy, your doctor will take a small skin tissue sample to be tested in a lab.

Care for your generalized pustular psoriasis will be overseen by a dermatologist, a doctor who specializes in skin conditions. Your primary care doctor will also be involved in your care. 

Other specialists who may be part of your care team include:

  • Immunologists and allergists, who help manage the involvement of your immune system in GPP
  • Rheumatologists, who treat arthritis, a common complication in people with GPP
  • Psychiatrists, who can help manage your emotional and psychological health as you live with this chronic condition
  • Geneticists and genetic counselors, if your GPP has been linked to a gene like IL36RN

Questions for your doctor

You and your doctor will discuss your diagnosis and care in detail. Be sure to ask the following questions:

  • What’s the right medication for me and how soon will it start to work?
  • What options are there if my medication does not work?
  • How can I prevent flares? How can I identify what triggers my flares?
  • Can lifestyle changes, such as diet, help?
  • What should I do if I have a flare? Should I call my doctor or go right to the hospital?
  • What should I do if a flare starts while I am traveling?

If your GPP was caused by a medication that you take, your doctor will have you stop taking it, if possible.

Your treatment will depend on the severity of your disease. If you have severe GPP, you’ll receive treatments to get flares under control. After that, you likely will need ongoing treatment to help prevent the disease from coming back. You also may need to be hospitalized when you first develop symptoms or when you have a flare, particularly if your blood pressure, heart rate, body temperature, or other vital signs are cause for concern. While in the hospital, your doctor will monitor you closely for any potentially life-threatening complications, such as sepsis.

Medications that treat generalized pustular psoriasis

Several medications that target your immune system can help ease flares and prevent them from recurring. The newest, approved by the FDA in 2022, is a biologic called spesolimab (Spevigo). It’s the first drug to target an immune system cell called the IL-36 receptor. This drug quickly stops flares and prevents recurrences of GPP. It’s delivered via monthly IV infusions or an injection you give yourself.

Spesolimab has become the drug of choice for treating GPP because it’s both safer and more effective than other drugs that have been used for GPP. In fact, it eventually may replace the other immune system drugs typically prescribed to treat GPP, such as:

Infliximab (Remicade), a TNF alpha inhibitor delivered intravenously.

Cyclosporine, an oral drug typically given for short periods because of its serious side effects from long-term use.

Monoclonal antibodies, a type of injectable drug that includes IL-17and IL-23 inhibitors such as secukinumab (Consentyx) and ustekinumab (Stelara).

Acitretin (Soriatane) and methotrexate (Rheumatrex and other brand names), which are typically given for milder GPP or for maintaining remission after a flare has been effectively treated. Both drugs can cause birth defects, so talk to your doctor before you take them if you are or plan to become pregnant.

It’s not yet known whether it’s safe to take spesolimab during pregnancy. If you develop GPP while pregnant, your treatment options include:

  • Systemic corticosteroids
  • Cyclosporine
  • Antibiotics
  • Narrow-band ultraviolet B light therapy

Your doctor may prescribe topical medications if the drugs you take do not fully clear up your skin. These include:

  • Topical corticosteroids
  • Topical vitamin D analogs
  • Topical tacrolimus (Protopic)

In addition to prescription topical medications, moisturizing creams, oatmeal baths, and wet wraps also can help to relieve skin symptoms.

Generalized pustular psoriasis is a chronic condition. That means it will never entirely go away. You can expect the disease to flare up from time to time. These flares usually last for a few weeks, followed by periods of remission, in which you have few or no symptoms. Sometimes, flares can last for more than three months.

Your doctor won’t be able to predict how GPP will affect you, as it varies from person to person. Some people have several flares a year while others may have a flare every few years.

The flares you experience can be different each time. Some may be severe, causing widespread skin problems as well as harmful symptoms like inflammation throughout your body. Other flares may be mild, with no accompanying symptoms of concern. An estimated 50% of flares lead to a hospital stay, and it’s likely that you will need to be hospitalized for a flare at least once every five years.

For most people with GPP, skin symptoms don’t entirely clear up between flares. However, 9 out of 10 people with GPP respond to medications that get their flares under control.

GPP flares can be life-threatening. Potentially fatal complications include:

  • Sepsis
  • Heart failure
  • Kidney failure
  • Liver failure
  • Respiratory failure

Other serious complications that can occur during a GPP flare include:

  • High fever
  • Low blood pressure
  • Swelling in the legs
  • Uveitis, a type of inflammation in the eyes
  • Arthritis

GPP is a chronic, unpredictable, and potentially life-threatening disease. That sounds scary, but there are things you can do to take care of yourself, both during a flare and between flares.

Helping yourself during a flare

  • Stay hydrated by drinking plenty of fluids.
  • Keep your skin moisturized.
  • Try to stay calm. Meditation, yoga, and other relaxing activities can help.
  • Make it a priority to rest and sleep.
  • Ask for help from friends and family.
  • Stick to your treatment plan.

Helping yourself between flares

  • Minimize the time you spend in the sun and wear sunscreen.
  • Stay physically active.
  • Curb the amount of alcohol you drink.
  • Eat a healthy diet.
  • Quit smoking.

Having GPP can be stressful, to say the least. And stress happens to be a major trigger of GPP flares. Finding ways to manage your stress — and other aspects of your mental and emotional health — is critical. Your doctor can help with referrals to counseling and other resources. Also, try the following:

  • Practice mindfulness and meditation with the help of an app.
  • Establish a yoga or light exercise routine.
  • Find relaxing activities that you enjoy, like reading, listening to music, and watching a funny movie.
  • Hang out with friends and family. Staying social can improve your mood.

To connect with others with GPP, check out the National Psoriasis Foundation, which offers both online and in-person ways to be part of the support community.

Generalized pustular psoriasis is very rare but very serious, even life-threatening. 

If you develop this disease, follow your treatment plan carefully to get your flares under control and to help prevent future flares. Call your doctor at the first sign of symptoms even if you normally have mild flares. 

The disease is unpredictable, and any flare can be quite serious.

How serious is generalized pustular psoriasis?

Very serious. A GPP flare can be life-threatening.

What is most likely to cause a generalized pustular psoriasis flare?

The most common triggers of GPP flares include stress, infections, stopping a corticosteroid medication, and pregnancy.

How can you stop pustular psoriasis from spreading?

The drug spesolimab (Spevigo) has been shown to stop flares quickly. Other medications also can be effective for GPP flares.

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