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Psoriasis
Practical Approach to Treating Children with Psoriasis
Mona Ståhle
1
and Josefin Lysell
2
1. Professor; 2. Resident in Dermatology and Venereology, Unit of Dermatology, Department of Medicine, Karolinska Institute
Abstract
Psoriasis can occur at all ages but roughly half of those who develop the disease have their onset below 25 years of age. Onset of psoriasis
prior to puberty is less common and the phenotype may differ from that of adults. In infants a nappy rash may be the first manifestation
and the diagnosis may not be obvious. The genetic contribution to psoriasis is strong and especially in children a positive family history
may be helpful. Guttate psoriasis is a distinct acute form of psoriasis commonly affecting young adolescent patients in association with a
throat infection. Other phenotypes such as chronic plaque psoriasis, nail psoriasis and psoriatic arthritis also occur in children. Paediatric
psoriasis is not well characterised and only a limited number of studies focus on children. Treatment of childhood psoriasis follows that of
adults, with some exceptions: ultraviolet (UV) therapy is used only with great caution. In this article we discuss various treatment modalities
including the recently launched anti-tumour necrosis factor (TNF) treatment for children, etanercept.
Keywords
Psoriasis, childhood psoriasis, topical treatment, systemic treatment, anti-tumour necrosis factor (TNF)
Disclosure: Mona Ståhle has given several lectures in symposia sponsored by Abbott, Wyeth and Schering-Plough and has served on Advisory Boards for these companies.
She is a founder of Lipopeptide AB. Josefin Lysell has no conflicts of interest to declare.
Received: 7 October 2008 Accepted: 16 November 2008
mona.stahle@ki.se
Treating psoriasis in childhood is a challenge. Whereas psoriasis in adults The phenotypic presentation of psoriasis varies widely, but some
is one of the most prevalent inflammatory dermatoses, psoriasis is less phenotypes are more common in childhood. The diagnosis relies on
frequent in pre-pubertal children, and in paediatric dermatology clinics clinical examination and there is still no laboratory test to confirm
these patients are vastly outnumbered by patients diagnosed with other diagnosis. Tissue histopathology can support the diagnosis, but usually
skin diseases such as atopic dermatitis. Novel treatments are usually reflects the clinical presentation and, if a trained dermatologist remains
first introduced into the adult psoriatic population and implementation uncertain, the micromorphology may be equally uncertain. There seems
in paediatric patients is slower, if it happens at all. Also, children are by to be no apparent gender difference; psoriasis appears to be roughly
no means small adults and special consideration and caution must be equally common in both sexes. Females typically have their onset one
exercised when treating an individual who is not yet fully developed and to two years before males, reflecting the earlier onset of puberty.
1
who will likely require long-term therapy. However, the up-side is that
there may be a theoretical potential to interfere with the natural course In infants, the first manifestation of psoriasis is commonly nappy rash,
of the disease by intervening at an early stage of the disease process. sometimes with disseminated lesions. The diagnosis at this stage can be
We are not yet there, but the rapid progress in our understanding of uncertain and sometimes the psoriasis diagnosis is established in
psoriasis pathophysiology means there is reason for optimism. retrospect. In addition to nappy rash, the two most common phenotypes
in pre-pubertal children appear to be plaque psoriasis and psoriasis of
There is substantial variation across – and even within – countries in the scalp (see Figure 1). A positive family history of psoriasis can be very
terms of who manages children with psoriasis: paediatricians, general helpful in children since the genetic background is much stronger in
practitioners and dermatologists may all be involved and, if joint early-onset psoriasis compared with late-onset psoriasis. Guttate
problems are present, these children will generally be managed within psoriasis is a distinctive phenotypic presentation of acute widespread
paediatric rheumatology. Obviously, therapy traditions and treatment droplet psoriasis lesions usually occurring in young adolescent patients.
choices may differ depending on where the patient is being monitored. The guttate phenotype is strongly associated with concurrent throat
infections where streptococci is commonly isolated from swabs. In some
Clinical Presentation patients, recurrent throat infections are associated with exacerbations
The onset of psoriasis can occur at all ages, but there is a peak in of the disease.
2–4
These patients should receive antibiotics to eradicate
adolescence, with onset before 25 years of age seen in roughly 50% of their throat infection, which may have a beneficial effect on their skin
patients. Manifestations of psoriasis prior to puberty are less common lesions.
5,6
Tonsillectomy is claimed to help some patients with frequent
and the diagnosis can be uncertain at an early age. Lesions are typically flares;
6–8
the hypothesis is that there is molecular mimicry, with T cells in
less infiltrated and less scaly, and can easily be mistaken for eczema. the tonsils and in the skin sharing receptor re-arrangement and reacting
© TOUCH BRIEFINGS 2009 7
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