Psoriasis is a life-long skin disease that often begins during childhood and affects about 3.5% of the population.1 It is associated with the immune system and causes skin cells to reproduce rapidly. This results in an over-accumulation of skin cells on the surface, which can form painful, red itchy lesions.
In greater than 33% of patients, the initial presentation of psoriasis occurs before a person turns 20.2-5 It is estimated that 10% of patients develop psoriasis before the age of 10.6
In some cases, children’s psoriasis can differ in presentation than adult psoriasis. For infants, psoriasis tends to appear as diaper rash. Some children may develop a patch of psoriasis where skin has been injured, or after a bout of bacterial infections such as “Strep throat.” Often times, children’s psoriasis presents itself on highly visible areas of skin, such as the face and scalp.
For children and young adults that are in the budding stages of developing their own personal “sense of self”, this skin condition can be very emotionally distressing and lead to feelings of anxiety and embarrassment.
This article will look at the way psoriasis affects children, triggers for flare-ups, and the recommended treatment options that are currently available.
Types of Psoriasis Seen In Children
Plaque Psoriasis: This is the most common type of psoriasis that affects children. It’s characterized by raised, inflamed, red lesions on the skin, covered by silvery white scales. Plaque psoriasis routinely affects the scalp, which in some cases, can lead to temporary hair loss.2,8 Plaque psoriasis can also affect the face, as well as outer and inner sides of the knees and elbows.2,9
Psoriatic Diaper Rash: This is next most common form of psoriasis in children. Psoriatic diaper rash features a bright red, well-demarcated, glazed, diaper rash that may be followed by the appearance of small psoriasis-like lesions.2 Although the rashes typically appear in the groin area, they can also spread elsewhere on the body. This type of diaper rash can be differentiated from irritant diaper dermatitis by its unique presentation and poor response to conventional treatment for diaper dermatitis.2
Guttate Psoriasis: This form of psoriasis appears as small, red, individual spots on the skin and affects the skin on the trunk, abdomen, and back.8 These spots are not usually as thick as plaque lesions and can flare up quite suddenly.
Pustular and erythrodermic psoriasis are less frequently seen in children than adults.2,9
Pustular Psoriasis: This type of psoriasis is characterized by the appearance of white, puss-filled blisters that are surrounded by red skin.
Erythrodermic Psoriasis: This type of psoriasis is characterized by the appearance of fiery red and inflamed patches of skin that cover most of the body. The shedding of scales often occurs in sheets, rather than smaller flakes. The reddening and shedding of the skin are often accompanied by intense itching and pain.
Factors that can Induce/Aggravate Psoriasis
Psoriasis in children and adults is a complicated disease. The exact causes of psoriasis are not well understood, but are known to be multifactorial, having both genetic and environmental influences.9
A variety of factors, such as upper respiratory infection, emotional stress, skin injury, and drugs, can trigger flare-ups and worsen psoriasis in children.2,6,8,13 In childhood, certain infections such as Strep throat can trigger psoriasis flare-ups.2,7,8 The frequency of sore throats and skin trauma leading to the worsening of psoriasis is greater in children than adults with psoriasis.5,13 The appearance of new lesions in times of emotional stress is also more common in pediatric patients.13 Injury or irritation of normal skin can induce new psoriatic lesions, known as the Koebner phenomenon.
71% of children with psoriasis have a positive history for psoriasis in a first degree relative.7
Treatment
When treating children with psoriasis, it is important both children and parents to be fully educated about the nature of the disease. It must be made clear that psoriasis is a chronic skin disorder without a permanent cure and, therefore, the goal of treatment is to establish disease control and prolong periods between flares.23
Topical Medications
Topical medications are the first choice therapy for children with psoriasis. Systemic agents are used to treat more severe cases.
Corticosteroids
Topical corticosteroids are the first choice treatment of childhood psoriasis. Corticosteroids have anti-inflammatory and antiproliferative (helps stop spreading) properties that reduce redness, scaling, and itching.5,9 Side-effects of topical steroids include skin degeneration, marks on the skin similar to stretch marks, broken blood vessels and acne-like eruptions
Coal Tar
Coal tar is a by-product of oil production that has been found to be an effective ingredient in skin care preparations. It works by slowing the rapid growth of skin cells, reducing inflammation and itching and scaling. The use of coal tar is limited by its strong odor and ability to stain. Coal tar is less irritating than calcipotriene and anthralin on the face and skin folds, sites commonly affected in children.25
Anthralin
Anthralin (dithranol) is a medication that works by slowing down the growth of skin cells. It also has potent anti-inflammatory properties..5 Anthralin’s use is limited due to its tendency to stain skin and clothing and irritate healthy skin. It is not recommended for application on the face, in skin folds and genitalia, and should not be used in erythrodermic or pustular psoriasis.9 In an open study of 58 children ages 5-10 years, remission was achieved in 47 patients (81%) using dithranol.28
Calcipotriene
Calcipotriene (calcipotriol) is considered to be a successful and safe treatment for children with mild to moderate plaque psoriasis that affects more than 30% of the body surface.2Calcipotriene is a derivative of Vitamin D, and works by controlling the rapid growth of skin cells. It is non-staining and odorless.9 Potential side-effects include skin tenderness and irritation.8
Topical Calcineurin Inhibitors
Tacrolimus and pimecrolimus are non-steroidal medications that work by blocking the immune system’s inflammatory process, so they reduce inflammation of the affected skin as well the itch and rash associated with psoriasis.5 They are particularly useful for treating pediatric psoriasis in areas where atrophy is a risk, such as the face, areas where skin rubs together, and the groin.9
Salicylic Acid
Salicylic acid is recommended for use on thick localized plaques.2,5 However, salicylic acid should be avoided in infants and children less than 6 years of age, or otherwise used with caution, as there is a risk of salicylate intoxication.2,5
Phototherapy
Phototherapy is extensively used in adults and is a treatment option for children with widespread plaques.2 Narrowband UVB (NB-UVB) phototherapy may be combined with topical therapies to enhance the effectiveness of both treatments and to reduce the carcinogenic risks.2,5 Psoralen + UVA (PUVA) therapy is not generally recommended in young children, but may be used in adolescents with caution.5,9,25 NB-UVB is considered the first-line phototherapy because it is as effective as PUVA, more convenient, and less carcinogenic.5,29
Systemic Medications
Acitretin
Acitretin, a retinoid, is an effective treatment for severe plaque, pustular, and erythrodermic psoriasis in adolescents.5 It can be used as single therapy or in combination with topical medications and NB-UVB phototherapy. Side-effects includecheilitis, itchiness, and hair loss.2
Acitretin should be used with caution in girls of childbearing age and must be accompanied by oral contraceptive therapy, as well as counseling, to avoid pregnancy during and 3 years after the completion of treatment.30 Serious birth-defects may be a possible side effect of taking this drug. Long-term use can lead to premature epiphyseal closure (discontinued growth of long bones) and radiologic bone evaluations may be required.30
Methotrexate
Methotrexate, is rarely used in children and reserved for severe psoriasis unresponsive to other treatments.30,31 This medication treats psoriasis by slowing the growth of skin cells to stop scales from forming. Side-effects include nausea, headache and gastrointestinal upset, which can be minimized with folic acid supplements.9
Cyclosporine
Cyclosporine is an immunosuppressant that can be used to treat extremely severe cases of pediatric psoriasis. Close monitoring by a physician is necessary due to major risks of hypertension and kidney dysfunction.
Antibiotics
Antibiotics may be prescribed to treat recurring or flares of guttate psoriasis, caused by strep bacteria infections.30
A chronic, visible condition like psoriasis can have a significant impact on children’s psychosocial development.24 Through school years and adolescence, children should be given substantial family and professional support to cope with the psychological and social consequences of psoriasis, particularly the negative reactions of other children.25 In order to correctly diagnose and treat children and adolescents, it is important to recognize the different presentations of the disease. Children with psoriasis, including their parents and caregivers, should be educated about the natural history of the disease and the factors responsible for flare-ups, as well as receive support and counseling to help cope with their condition.
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