Distinguishing pustular psoriasis and acute generalized exanthematous pustulosis (AGEP) on the basis of plasmacytoid dendritic cells (PDCs) and MxA protein

Background

Distinguishing acute generalized exanthematous pustulosis (AGEP) and pustular psoriasis (PS) can be challenging. Staining for plasmacytoid dendritic cells, or PDCs (producer of IFN‐α/β),[1] and MxA (an IFN‐α/β inducible protein)[2] may help discriminate these entities.

Methods

Forty‐three cases of AGEP and PS were compiled from two academic institutions. All cases were examined for CD123+ PDCs, eosinophils, acanthosis, papillomatosis, suprapapillary plate thinning, tortuous dilated capillaries, single necrotic keratinocytes, papillary dermal edema, vasculitis, eosinophil exocytosis, intraepidermal pustules, and subcorneal pustules. A subset of cases (n=26) was stained with MxA.

Results

Perivascular and intraepidermal PDCs, dilated tortuous vessels and MxA expression in the dermal inflammatory infiltrate, were significantly (p<0.05) in favor of a diagnosis of PS. The absence of PDCs and presence of eosinophils favored a diagnosis of AGEP (p<0.05).

Conclusions

We found compelling evidence for the use of CD123 to highlight PDCs in these cases. The presence of PDCs and expression of MxA in dermal inflammatory infiltrate, as well as absence of eosinophils and presence of tortuous dilated capillaries favored a diagnosis of PS. Expression of MxA in the dermal infiltrate corresponds with a Th1 pathway in PS, and may indicate a Th1 component in the early initial phase of AGEP.

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