Subacute annular generalized pustular psoriasis treated with etanercept and cyclosporine combination

We present a case of a 36-year-old man with a 20-year history of stable plaque psoriasis admitted to our inpatient dermatology unit with subacute annular pustular psoriasis. Two weeks prior to admission the patient's dermatologist discontinued the use of 5 lbs (2.3 kg) of triamcinolone 0.1% cream, which the patient had been applying to his skin weekly over the last 8 years. The patient subsequently developed generalized erythematous annular and irregularly shaped, well-defined plaques and confluent pustules. Approximately 80% of his total body surface area was involved, sparing the face and the genitals. Initial therapy included cyclosporine 300 mg twice daily, topical hydrocortisone 1% ointment to affected areas, acetaminophen/oxycodone 10/325 mg every 4 hours for pain as needed, and subcutaneous etanercept 50 mg twice weekly. The patient was discharged on day 7 with significant improvement of skin lesions. On discharge the cyclosporine was increased to 400 mg twice daily. The patient continued etanercept 50 mg twice weekly. One month after discharge the patient was clear with only postinflammatory changes.