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Practical Approach to Treating Children with Psoriasis
Phototherapy Figure 3: Nine-year-old Boy with Pustular Psoriasis
Phototherapy has been and still is a core treatment for psoriasis in the
adult population. Over the years, substantial efforts have been
undertaken to optimise the antipsoriatic effect from UV light,
culminating (so far) in psoralen UVA (PUVA), which was used
extensively during the 1980s. PUVA combines UVA with the
photosensitising chemical psoralen; this treatment is highly efficacious
in controlling psoriasis in the majority of patients. However, the effect
comes at the cost of a high risk of skin cancer after a certain
accumulated dose. PUVA was hardly ever used in children due to the
cancer risk, which was perceived to be even higher in the young. Today,
the standard phototherapy in psoriasis is narrow-band UVB, making
optimal use of the UV wavelengths that have a maximal effect on
psoriasis lesions. When starting a course of UV therapy, treatments
should be given two to three times a week to obtain maximal effect,
and the result should be evaluated after 20–30 treatments. Generally,
Figure 4: Same Patient as in Figure 3 After
UV is used with caution in children. In the very young it is simply not Three Months of Acitretin 0.5mg/kg/day
practical to administer UV treatment. Even in older children there is risk
that extensive UV exposure may prime the skin to photoageing and
subsequent cancer development. This is particularly valid in severe
disease, where there may be a need for systemic immunosuppressive
therapy. However, in children who do not have an apparent risk
phenotype for skin cancer (freckles, red hair and fair skin), UV treatment
may be used by itself and in combination with topical treatments such
as calcipotriol.
15
Psoriasis on the Face
The face is not considered a predilection site for psoriasis, but appears
to be more commonly affected in children than in adults and can
present as rather infiltrated plaques around the eyes (see Figure 2). Also,
in association with guttate psoriasis, involvement of the face is
commonly seen with less demarcated and thinner lesions. Treatment of
facial lesions represents particular problems: the incentive to treat is
usually high because of the visible location, but first-line topical
treatment with calcipotriol is not suitable due to irritation and risk of
eczematous flare. Here, corticosteroids of medium potency remain the
Figure 5: 10-year-old Boy with Plaque Psoriasis and
Involvement of All Fingernails
most commonly used topical agents. During recent years, a new class of
immunomodulatory agent, calcineurin inhibitors, has been launched for
topical treatment of atopic eczema, and facial involvement is a primary
indication. These compounds – tacrolimus and pimecrolimus – are now
also being used in the treatment of psoriasis, particularly in facial
lesions.
16,17
However, even though these drugs do not cause skin atrophy
and constitute a valuable addition to our treatment options, a word of
warning may be appropriate. According to the label, these drugs should
not be combined with phototherapy and sun exposure since long-term
effects on immune surveillance in the skin are unknown.
The patient had an extremely strong family history of psoriasis and psoriatic arthritis in
first-degree relatives.
Systemic Treatments
In severe disease that cannot be sufficiently controlled with topical
Figure 6: Same Patient as in Figure 5 After Five Months
of Subcutaneous Etanercept Treatment
treatment, systemic therapy must be considered. Admittedly,
assessment of disease severity does not rely on absolute
measurements, but entails an integration of the extent and
management of skin lesions, associated joint disease and a review of
the impact of the disease on the child’s quality of life and development.
Systemic antipsoriatic drugs established for psoriasis in adults are also
used in children even though controlled clinical trials are scarce.
Retinoids
The retinoid compounds acitretin and etretinate were introduced more
Excellent clinical response – complete remission of skin lesions (not shown) and
than two decades ago and were initially widely prescribed in severe
nail dystrophy.
EUROPEAN DERMATOLOGY 9
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