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CME Article

PSORIASIS IN CHILDREN: AN INSIGHT

Sandipan Dhar, Raghubir Banerjee, Nilesh Agrawal1, Sharmila Chatterjee,
Rajib Malakar2
Abstract

Onset of psoriasis in childhood is quite common. Chronicity, inflammation and hyperproliferation are the cardinal features
by which the condition establishes its uniqueness. Clearance of disease may be farfetched in most patients and relapse is
frequent. Early recognition and management of psoriasis in children and adolescents is vital in therapy in children.

Key Words: Pediatric psoriasis, relapse, therapy

Introduction pathogenesis. Two types of psoriasis have been

Psoriasis is an inherited papulosquamous disorder with
a variable clinical spectrum. As much as 40% of adult
patients with psoriasis have reported manifestations of
this condition in childhood, with at least one-third of the
patients demonstrating features of psoriasis before the age
of 16.1 years. The psychosocial impairment, in addition
to the physical affliction that can result from psoriasis,
is a reminder that early recognition and management of
psoriasis in children and adolescents is crucial.[1]
Epidemiology
A definitive paucity of studies exists in the epidemiological
backdrop of childhood psoriasis. A study of 419 patients from
North India revealed the pattern and prevalence of childhood
psoriasis in patients less than 14 years of age. The peak age
of onset in boys was in the 610-year age group, whereas
the majority of girls showed an onset of psoriasis between
the ages of 10 and 14 years. A positive family history was
present in only 19 (4.5%) patients. These findings differ
from those of previous studies in showing a delayed onset,
equal sex distribution and a less frequent history of familial
occurrence.[2] In a recent study of 137 patients from China,
aged between 3 and 14 years, 64 were males (46.7%)
and 73 were females (53.3%). Eleven patients (8%) had a
family history of psoriasis. Infection was the most common
precipitating factor (39, 28.5%). Seasonal influence was
found in 57 patients (41.6%). Exacerbations in winter and
spring were noted in 29 and 16 patients, respectively.[3]
Multifactorial nature of the disease and epidemiological
evidence point to genes playing a key role in the
From the Department of Pediatric Dermatology, Institute of Child
Health, Kolkata, India, 1Department of Paediatrics, Bedford Hospital
NHS Trust, Bedfordshire, UK, 2Department of Epidemiology, School
of Public Health and Health Services, The George Washington
University, Washington DC, USA. Address for correspondence:
Dr. Sandipan Dhar, Flat 2A2, Block 2, 5, NSC Bose Road, Kolkata -
700 040, India. E-mail: drsandipan@gmail.com
distinguished considering the onset age. Type I (onset 15
40 years) accounts for the majority of cases (>75%) and
shows a high degree of familial aggregation and strong
association with HLA Cw6. Correspondingly, type II begins
after the age of 40 years. Familial prevalence is observed to
be greater in childhood psoriasis than in adults, with 37%
of adult-onset patients and 49% of pediatric-onset patients
having first-degree family members affected with psoriasis.
Some studies have reported familial incidence to be as high
as 89% in childhood cases of psoriasis.[4,5]
The epidermis of any individual with the psoriatic phenotype
has the capacity to express clinical disease. Expression is
linked to a complex interaction of cells of the epidermis,
cells of the dermis, cells of the immune system, and possibly,
other noncellular humoral elements. The keratinocytes
of psoriatic patients are unique in that the inherent
phenotype has a capacity for hyperproliferation and altered
differentiation. Proliferation and differentiation are controlled
at the level of the gene. Thus, it is important to consider not
only cytokines and growth factors released by the various
cell types, but also the role of regulators of transcription,
translation, and the modification of the cytokines and growth
factors. The large number of alterations of cytokine and
growth factor profiles within psoriasis causes us to postulate
that the genetic aberration in psoriasis is quite basic, that
is, it is proximal to the common element in the cascade
of inflammatory events that lead to a lesion of psoriasis.
About 20 genetic loci associated with psoriasis have been
reported from linkage-based studies; only one of these
linkage-based loci, PSORS1, that includes the HLA-C gene
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DOI: 10.4103/0019-5154.82477

Indian Journal of Dermatology 2011; 56(3) 262

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Dhar, et al.: Psoriasis in children
on chromosome 6p21, has been universally confirmed and
is considered to confer susceptibility to early-onset psoriasis.
Accumulating evidence points to triggers like infections
(Streptococcus), cold, stress, and drugs (Chloroquine and
systemic Corticosteroids) either precipitating or worsening
the disease in children.[6,7]
Clinical Features
Pediatric psoriasis consists of three age groups of psoriatic
patients like infantile psoriasis, a self-limited disease of
infancy, psoriasis with early onset, and pediatric psoriasis
with psoriatic arthritis. The varied clinical presentations
in childhood include plaque-type, guttate, erythrodermic,
napkin, and nail-based disease. Like all forms of auto-
immunity, susceptibility is likely genetic, but environmental
triggers are required to initiate disease activity.
How Different is the Presentation in Children?
The disease in children is more pruritic, common in girls,
and the lesions are relatively thinner, softer, and less
scaly. Plaque type is the most common form of disease,
but certain clinical variants are rare in children like
erythroderma, arthropathy, and localized and generalized
pustular psoriasis. Psoriasis in children is more frequently
precipitated by infections and manifests as acute guttate
psoriasis. However, Indian studies show that children
manifest the established plaque type of disease more
often, rather than the guttate variety. Facial involvement
in children is a frequent observation in majority of the
reports, which varies from 18 to 46%, whereas mucosal
involvement has been rare in Indian children.[8]
A study from North India reported that extensors of
the legs were the most common initial site affected
[105 (25%) cases], followed by the scalp [87 (20.7%)].
Classical plaque psoriasis was the most frequent clinical
presentation [254 (60.6%) patients], followed by plantar
psoriasis [54 (12.8%)]. Nail involvement was observed
in 130 (31%) cases. Pitting was the most common nail
change, followed by ridging and discoloration. Five
children (1.1%) (three girls and two boys) had psoriatic
arthropathy. Koebnerization was observed in 27.9% of
patients.[9]
Another study showed that plaque psoriasis was the most
common type (52.6%), followed by guttate psoriasis
(25.5%), psoriasis pustulosa (10.9%), and psoriasis
erythroderma (5.1%). Scalp was the most common initial
site affected (50.3%), nail changes were found in 25.5%,
but no mucosal involvement was observed.[3]
Associated Skin Conditions
The co-morbidities of childhood psoriasis include allergic
contact dermatitis, eczema, vitiligo and alopecia areata.
Psoriasis is sometimes misdiagnosed as dermatitis
seborrheica, neurodermatitis and balanitis.
263
Natural History of the Disease and Triggers
The goal of control versus cure is a more practical outcome
of treatment. Many randomized controlled clinical trials
involving children under the age of 12 years have reported
on two topical treatments: calcipotriol and corticosteroids.
Avoidance of triggers like trauma (Koebner phenomenon),
including physical, surgical, or inflammatory trauma,
should be borne in mind in this age group. A strong
association between pharyngitis by group A beta-hemolytic
streptococci and the clinical activity of psoriasis (guttate
psoriasis) is now well established and should be properly
investigated where relevant.[4,10]
Management Strategies
Many studies have investigated the use of standard
psoriasis therapies in children with psoriasis, including
topical treatments, phototherapy, and systemic therapies.
Inflammatory nature of psoriasis has initiated study of
the use of biologic agents in children, where targeted
treatments have a better safety profile.
Topical Therapy
Moisturizers have a role in normalizing hyperproliferation,
and they exert anti-inflammatory effects by way of the
physiologic lipids. An improved barrier function and
hydration makes the epidermis less vulnerable to external
trauma, thereby reducing the induction of Koebnerization.
Pretreatment with emollients like mineral oil or vaseline
augments the therapeutic efficacy of narrow-band
ultraviolet-B therapy, possibly because it penetrates the
intercellular space, producing an optical matching effect
which enhances the UV transmission.[11]
Salicylic acid (6% ointment and 3% shampoo) is a
keratolytic agent that can be used for small plaques on the
scalp, palms, and soles in children older than 6 years.[12]
Coal tar is antiproliferative and can be used as ointment,
cream or solution in concentrations from 0.5 to 20%. Tar
is safe and effective for childhood psoriasis, mainly for
plaque type lesions. It can be used in combination with
other medications like topical corticosteroids, salicylic acid
and with UV irradiation. It is irritating on the face and
flexures in children. Anthralin (dithranol) is a potent anti-
inflammatory and antiproliferative agent used as "short-
contact" or "minute" therapy, to reduce side effects like
irritation and temporary perilesional staining of the skin.
In an open study of 58 children aged 510 years treated
with dithranol at concentrations up to 1%, remission was
achieved in 47 (81%) patients.[13]
Goeckerman therapy for psoriasis was first described
at the Mayo Clinic in 1925, and in a study undertaken,
the responses were excellent (62% of patients had 90%
clearance or greater, 23% had 8089% clearance of
lesions), hence proving it as an option for children with
moderate to severe psoriasis.[14]
Indian Journal of Dermatology 2011; 56(3)
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Dhar, et al.: Psoriasis in children
Corticosteroids still remain the mainstay topical treatment
of psoriasis, as they have anti-inflammatory and
antiproliferative properties and reduce erythema, scaling,
and pruritus. Topical corticosteroids are used in chronic
plaque type psoriasis as monotherapy or in combination
with topical treatments like calcipotriol and tazarotene.
Lower potency preparations are indicated for facial, genital
and intertriginous skin areas, whereas thick hyperkeratotic
areas, such as the palms and soles, require high potency
agents. Halobetasol cream 0.05% and clobetasol propionate
emulsion 0.05% seem to be efficacious treatments in
childhood plaque psoriasis. Reported side effects were
relatively mild in the treatment period of 2 weeks. A case
report described the use of hydrocortisone 1% ointment in
a 2-year-old child with pustular psoriasis.[15,16]
Calcipotriene (calcipotriol) is a nonsteroidal alternative in
the treatment of mild to moderate plaque type psoriasis
and has utility as monotherapy, as well as in combinations
with topical steroids. Oranje performed a randomized
double-blind study in 77 juvenile patients with twice daily
applications for 8 weeks. The investigators reported a
decrease in psoriasis area-and-severity index (PASI) score
of 52% in the vitamin D group. The amount for use in
children is a maximum dose of 75 g/week for children aged
over 12 years and 50 g/week for those aged 612 years.[17]
Topical tacrolimus (0.03%, 0.1%) ointment and pimecrolimus
(1%) cream are nonsteroidal immunomodulating
macrolactams which block the enzyme calcineurin, thereby
inhibiting the production of IL-2 and subsequent T-cell
activation and proliferation. In two nonrandomized clinical
trials, treatment of facial and flexural psoriasis with
tacrolimus 0.1% was evaluated in which all patients showed
clearance after a treatment period varying from 2 to 30 days.
Tacrolimus 0.1% was also used in one case report in which
facial psoriasis cleared totally.[18]
Phototherapy is preferred in older children and adolescents
with moderate to severe disease in which topical treatments
have failed. Guttate and thin plaque type lesions respond
best to phototherapy. NB-UVB shows good results in the
treatment of plaque and guttate psoriasis in childhood and has
comparatively milder side effects for the treatment duration
studied. Two open-label studies were performed. Jain et al.
examined NB-UVB treatment for 12 weeks. PASI 90 was
achieved in 60% of patients. It needs to be mentioned that
all the patients had skin type IV.[19] Tay et al. also studied
NB-UVB treatment, where after a mean treatment of 11.9
weeks, clearance was reached in all the patients.[20]
Systemic Agents
Role of oral antibiotics remains controversial. In one study,
thiamphenicol was used and there was less than 50%
clearance of lesions. Four patients in a case series were
treated with erythromycin (50 mg/kg/d) for 2 weeks; in all
the patients, the psoriasis lesions disappeared completely. A
Indian Journal of Dermatology 2011; 56(3)
patient with guttate psoriasis was treated with amoxicillin/
clavulanic acid (50 mg/kg/d), which cleared all lesions
after 20 days.[21,22]
Methotrexate (MTX) is an antimetabolite agent with
immunomodulatory and anti-inflammatory properties, and
has advantages of efficacy, affordability and convenient
weekly oral dose. In children, 0.20.4 mg/kg/wk orally is
recommended. A review of 10 cases of childhood psoriasis
treated with MTX showed a complete clearance in 20%
cases, almost complete clearance in 60% cases, and no
response in 10% of cases. MTX was given at an initial
dose of 0.030.24 mg/kg/wk and was increased according
to the patients response to 0.100.41 mg/kg/wk; duration
of treatment was from 6 to 178 weeks. A study revealed
the treatment results in childhood psoriasis with MTX in
seven children (four boys, three girls) over 7.5 years. Their
ages and duration of disease varied from 3.5 to 16 years
(mean 12.14 years) and from 4.8 months to 5 years (mean
2.2 years), respectively. Psoriatic erythroderma was seen
in three patients, generalized pustular psoriasis in two, and
recalcitrant psoriasis and psoriatic arthropathy in one each.
Pre-MTX liver biopsy performed in four children showed
grade I changes. MTX was given in a single weekly oral
dose of 3.7525 mg (mean 16.6 mg). The duration of
treatment necessary to control the disease varied from 6
to 10 weeks (mean 7.9 weeks). Total duration of MTX
therapy was from 31.2 to 46.4 weeks (mean 38.8 weeks).
Post-therapy disease-free interval ranged between 14.4 and
16.8 weeks (mean 15.5 weeks). Follow-up after withdrawal
of MTX was from 16 to 28 weeks (mean 22.3 weeks).
Total cumulative MTX dose ranged from 390 to 960 mg
(mean 683.6 mg). Side effects were nausea and vomiting
reported in three patients.[23,24]
Acitretin is an aromatic retinoid that acts in psoriasis by
its anti-inflammatory activity. Treatment should be initiated
and maintained at dosages at or below 0.51 mg/kg/d to
limit short- and long-term toxicities and therapy should
be continued for about 2 months after clinical remission.
Major limitation of oral retinoids (acitretin) in children is
the risk of growth retardation due to premature closure
of epiphyses on long-term use. In the open-label study,
three patients with psoriasis erythroderma were treated
with etretinate in a dosage ranging from 0.5 to 0.9 mg/
kg/d. After 45 months of treatment, they all had complete
clearance of erythema and scaling.[25] Etretinate was used as
a treatment for plaque psoriasis in two children where both
the patients had an excellent response.[26]
Cyclosporine primarily acts by inhibiting T-cell function
and interleukin (IL)-2 and is effective in severe forms
of psoriasis such as pustular or erythrodermic psoriasis
or when other therapies are ineffective. Three patients
with pustular psoriasis have been described in whom the
administered dose was from 1 to 2 mg/kg/d. Complete
disappearance of lesions was seen in two patients who were
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Dhar, et al.: Psoriasis in children
treated for 12 and 6 months, and the third patient showed
a significant improvement after 5 months of treatment.[27]
The inflammatory nature of psoriasis has also prompted
further study of the use of biologic therapeutics in
children, where targeted treatments may offer a safer
option. Biologics are drugs including antibodies and fusion
proteins targeting cytokines like tumor necrosis factor that
plays an important role in psoriasis.[28] Etanercept has been
found to be overall effective and well tolerated in children
and adolescents with moderate-to-severe plaque psoriasis.
In a 48-week study, 211 patients with psoriasis (417 years
of age) were initially randomly assigned to a double-blind
trial of 12 once-weekly subcutaneous injections of placebo
or 0.8 mg of etanercept per kilogram of body weight (to
a maximum of 50 mg), followed by 24 weeks of once-
weekly open-label etanercept. At week 36, 138 patients
underwent a second randomization to placebo or etanercept
to investigate the effects of withdrawal and retreatment.
The primary end point was 75% or greater improvement
from baseline in the PASI 75 at week 12.[29]
Counseling
This chronic disease, punctuated by remissions and
exacerbations, has a profound impact on the quality of life
of the child. The family must learn to deal with the illness,
considering the psychological burden on the child.
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How to cite this article: Dhar S, Banerjee R, Agrawal N, Chatterjee
S, Malakar R. Psoriasis in children: An insight. Indian J Dermatol
2011;56:262-5.
Received: March 2011. Accepted: March 2011.
Source of support: Nil, Conflict of Interest: Nil.
Indian Journal of Dermatology 2011; 56(3)