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Psoriasis
Figure 1: 13-year-old Boy with Severe Plaque problem in chronic disease. Parent education and ‘psoriasis schools’
Psoriasis with Scalp Involvement
play an important role in establishing and maintaining disease control.
For decades, tar compounds were the standard treatment for psoriasis
as well as for eczema. With the advent of topical corticosteroids,
treatment with tar compounds became the exception, but they are still
used occasionally. The effect seems moderate, but tar-containing
shampoos in particular are popular with some patients. The
characteristic odour may be a limiting factor in some patients.
Anthralin (dithranol) is an established and effective antipsoriatic
treatment for stable plaque psoriasis.
12
In outpatients it is used as
short-contact therapy for 10–60 minutes to control side effects such
as irritation and staining of clothes and surrounding skin. Anthralin is
Figure 2: Five-year-old Boy with Facial
available in different concentrations, and to obtain optimal effect the
Involvement of Psoriasis
concentration should be increased every few days. As athralin treatment
requires detailed hands-on instruction for compliance and is rather
cumbersome and time-consuming, it is less commonly used today.
Topical steroids have changed the lives of psoriasis and eczema
patients. Onset of the anti-inflammatory effect is rapid and, if present,
itching is relieved. However, continuous treatment is usually needed,
and when treating psoriasis high-potency steroids are required, which
carry a risk of skin atrophy and also the potential for systemic effects
with suppression of the hypothalamic–pituitary–adrenal axis if an
extensive body area is involved. Upon abrupt discontinuation of topical
steroids there is usually rather quick recurrence of lesions, which may
require slow tapering of the application frequency. Still, topical
corticosteroids are valuable, and for some body locations where
medium-potency rather than high-potency corticosteroids should be
used – such as intertriginous areas, the genitals and the face – there
are few if any effective alternatives. Fixed combinations of
corticosteroids with topical vitamin D
3
analogues are more efficacious
and have become a popular and convenient therapy in adult psoriasis.
to a hitherto unknown antigen.
9
The prognosis of guttate psoriasis may The advantage is that only one application per day is required, which
be more favourable, but a proportion of patients will develop chronic likely improves compliance and reduces the need for several different
plaque lesions.
10
However, reliable structured long-term follow-up of ointments/creams. However, in children the combination is only
these patients is lacking. starting to be used, and long-term safety using the high-potency
corticosteroid in combination needs monitoring and close surveillance.
General Therapeutic Considerations
Paediatric patients are quite a heterogenous population, comprising Today, the vitamin D
3
analogues calcipotriol, tacalcitol and calcitriol are
diverse biological ages from infancy up to adolescence, which likely first-line topical treatments, particularly in plaque psoriasis. Calcipotriol
encompass different attitudes to the disease and require distinct in particular has been thoroughly evaluated in children with psoriasis. In
treatment modalities. Also, within the same age group, disease severity a controlled trial using the ointment base as comparator, a 52%
varies considerably. In the subpopulation of children with severe reduction of Psoriasis Area and Severity Index (PASI) was established
psoriasis, there is increased awareness of the need to control disease using calcipotriol versus a 37% PASI reduction in the control group.
13
activity to hopefully limit subsequent complications and co-morbidities. Calcipotriol should be applied twice daily and is available as a cream and
In these patients, systemic treatments should be considered. an ointment. The cream is more attractive for use during the day, while
Established treatment guidelines are missing for childhood psoriasis. the ointment is preferably applied at night. The ointment is effective in
removing scales, which reduces exfoliative pre-treatment. A major
Topical Treatments concern with calcipotriol, especially in children, was the potential impact
Topical treatments are central in paediatric psoriasis care. Most on serum calcium. However, trials have shown that when applying the
patients can be managed with topical treatments, although compliance treatment twice daily, a dose of 45g/week/m
2
is safe in children between
may be a limiting factor. Emollients and moisturisers by themselves two and 14 years of age.
14
Calcipotriol can be combined with ultraviolet
have a marginal yet beneficial effect in reducing redness and scaling of (UV) treatment, which enhances its efficacy. Side effects include burning
the skin lesions in most patients. In cases of thick severe scaling, and irritation, especially in sensitive skin areas such as intertriginous
salicylic acid preparations are helpful; however, they should be avoided regions and the face. Topical retinoids are not widely used in childhood
in infants and small children, since percutaneous salicylate intoxication psoriasis. Tazarotene is approved for adult psoriasis, but seems not to
with serious complications can occur.
11
Thus, general skin care is have gained popularity in the paediatric population, possibly due to only
important, but, as with all topicals, compliance in children may be a moderate efficacy and a tendency for local irritation.
8 EUROPEAN DERMATOLOGY
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