|Year : 2012 | Volume
| Issue : 1 | Page : 12-16
Management of childhood psoriasis
Vibhu Mendiratta, Saurabh Mittal
Department of Dermatology and STD, Lady Hardinge Medical College, Shahid Bhagat Singh Marg, New Delhi, India
|Date of Web Publication||23-Oct-2012|
Department of Dermatology and STD, Lady Hardinge Medical College, Shahid Bhagat Singh Marg, New Delhi - 110 001
Source of Support: None, Conflict of Interest: None
Childhood psoriasis although a well known entity, isn't a frequently reported one. Childhood psoriasis has a better prognosis as compared to adult onset psoriasis. Management of psoriasis in children is almost on similar lines as that for adults. But management of generalized disease remains a challenge as systemic therapies are to be used with caution in children. The medicines used most commonly for the management of psoriasis are highly toxic and thus require stringent monitoring. This article will discuss the various treatment modalities used for the management of juvenile psoriasis.
Keywords: Juvenile, psoriasis, biologics
|How to cite this article:|
Mendiratta V, Mittal S. Management of childhood psoriasis. Indian J Paediatr Dermatol 2012;13:12-6
| Introduction|| |
Childhood psoriasis is a well-recognized entity but its true prevalence is not known. 20-35% of patients with psoriasis have their disease onset before the age of 20 years. , In a study of childhood psoriasis patients from North India, it constituted 0.3% of all the dermatology outpatients and 12.5% of the total psoriasis patients.  Psoriasis comprised 1.4% of all pediatric dermatoses seen in patients less than 14 years of age at a referral hospital in South India.  In a study of erythroderma in children (less than 12 years of age) in Delhi, India, psoriasis was the underlying cause in 15% of all cases.  The peak age of onset in childhood psoriasis varied in different studies. In surveys from India and Denmark, most patients developed first symptoms at the ages of 6 to 10 years , whereas other studies from the Middle East and Australia reported a peak of onset at the ages of up to 4 years. ,
Psoriasis has a bimodal age of onset: Type I, which has an age of onset between 15-40 years; accounts for majority of cases (>75%) of cases; shows a higher degree of familial aggregation; strong association with HLA Cw6, and Type II that begins after 40 years of age and tends to be less severe.
Childhood psoriasis is more frequently pruritic, has female preponderance, and the lesions are relatively thinner, softer, and less scaly.  Certain clinical variants such as erythroderma, arthropathy and pustular forms are rarer in children. ,,,,, Infections and physical and psychological trauma as precipitating factors, are more frequently seen in children than in adults. ,,, Remission is more frequently seen in juvenile onset than in adult onset psoriasis. 
Recent years have witnessed the use of many new molecules for the treatment of psoriasis but curative treatment of psoriasis is still a distant goal. This review overviews various modalities of treating childhood psoriasis.
| Topical Therapies|| |
Topical therapies [Table 1] are the mainstay of treatment for mild or localized disease. Mild disease is defined as having a Psoriasis Area and Severity Index (PASI) of <10 or involvement of body surface area (BSA) of <20%. Besides being used for localized disease, topical therapies are also used as an adjunct to systemic modalities in generalized or severe disease. Evidence-based guidelines describing the preferential order of treatments used for childhood psoriasis are not available.  The choice depends upon the age of the patient, type of psoriasis, site, individual patient's tolerability and affordability.
Emollients constitute the cornerstone of management of childhood psoriasis. Emollients, such as white soft paraffin, are especially useful in the common scaly type  where they help in reducing transepidermal water loss (TEWL), soothe irritated skin, increase softness of the skin and decrease scaling. They improve the barrier function and stratum corneum hydration, making the epidermis less amenable to trauma and stress, thereby reducing the induction of Koebner phenomenon.  Pretreatment with emollient like mineral oil or Vaseline, enhances the therapeutic efficacy of NB-UVB (Narrow Band Ultraviolet B) therapy, probably because the oil allows an optical matching which increases the UV transmission. 
Keratolytics, such as salicylic acid and urea, are used mostly in thick hyperkeratotic lesions. They help in reducing hyperkeratosis, reduce scaling and enhance absorption of other drugs. Salicylic acid is mostly used in lesions over the scalp, palms and soles in children older than 6 years. It is to be avoided in younger children because of the risk of percutaneous salicylate absorption leading to salicylism.  Topical salicylic acid reduces the efficacy of UVB phototherapy because of a filtering effect.
Vitamin D Analogues
Calcipotriol, calcitriol, maxacalcitol and tacalcitol are the various vitamin D analogues which are used for the treatment of psoriasis because of their anti-inflammatory, induction of keratinocyte differentiation and inhibition of epidermal proliferation actions. These are one of the first lines and widely used topical agents for psoriasis. These can be used safely in children and for all types of psoriasis. A combination ointment containing calcipotriol and betamethasone used as once daily application is more effective than either agent alone.  UVB phototherapy increases the efficacy of calcipotriol, although the same has yet not been proven in children.  The most common adverse events are burning and stinging sensation, especially over the face and flexures. Recommended dose for calcipotriol 50 μg/g ointments is less than 75g/week for children above 12 years and 50g/week for children between 6-12 years. It may rarely cause hypercalcemia if the recommended dose is exceeded.
Topical steroids remain among the first line agents for treatment of psoriasis among all age groups.  They are available in many strengths and formulations, which allows for versatility of use. The mechanisms of action of corticosteroids include anti-inflammatory, antiproliferative, immunosuppressive, and vasoconstrictive effects. The choice of the appropriate potency corticosteroid and its vehicle should take into consideration the disease severity, the location being treated, patient preference, as well as the age of the patient. High potency ointment preparations are usually preferred for thick hyperkeratotic lesions such as on the palms and soles whereas low to mid potency cream formulations are preferred for the face, flexures and genitals. Lotions are suitable for scalp psoriasis. They can also be combined with other topicals such as calcipotriol and tazarotene to enhance efficacy and reduce their irritation potential. Their long term use can lead to local cutaneous side effects such as skin atrophy, telangiectasia, striae distensae, acne, folliculitis, and purpura; may exacerbate pre-existing dermatoses such as rosacea, perioral dermatitis, and tinea infections and may on occasion cause contact dermatitis. Other possible concerns with the use of topical steroids is rebound, wherein the disease recurs worse than the pretreatment baseline and tachyphylaxis,  which is defined as the loss of efficacy on continued application. Systemic side effects are rarely seen with judicial use but children are at a higher because of a higher skin surface/body mass ratio.
Coal tar, a distillation product of coal, has been used for over a century for the treatment of psoriasis. Coal tar has antiproliferative effects by suppressing DNA synthesis,  and also has anti-pruritic and anti-inflammatory effects.  Although effective, it is avoided in children <12 years of age as its safety for this age group has not been established.  It can be used alone or in combination with other agents such as corticosteroids, salicylic acid and UV therapy. However it is not to be used on face and flexures, as it causes irritation.
Dithranol, also known as anthralin, like coal tar, has also been used for over a century for the topical treatment of psoriasis. But its use has declined in the recent years because of the availability of cosmetically more acceptable formulations. Recent studies suggest that its ability to prevent T-lymphocyte activation and normalize keratinocyte differentiation may occur by a direct effect on mitochondria, leading to anti-inflammatory and anti-proliferative effect.  "Short contact therapy" is the preferred method these days in which increasing concentrations of anthralin are applied for a short period (10-30 minutes) till a slight irritation develops, after which the dose and time are held constant till lesions clear.  In an open study of 58 children aged 5-10 years treated with dithranol at concentrations up to 1%, remission was achieved in 47 (81%) patients.  It can be combined with UVB phototherapy, as in Ingram regimen, to improve the response.
Tazarotene is a third generation retinoid that has recently been approved for topical use in adults with psoriasis  . Data on the efficacy and safety in children is as yet not available. It functions by normalizing abnormal keratinocyte differentiation, diminishing hyperproliferation, and by decreasing expression of inflammatory markers. Skin irritation is the most common side effect and its use is thus usually restricted to thicker plaques in the non-intertriginous sites. Tazarotene 0.05% gel has been successfully used to treat nail psoriasis in a child in a single case report. 
Tacrolimus (0.03%, 0.1%) ointment and pimecrolimus (1%) cream are two drugs belonging to this class, which act as nonsteroidal immunomodulatory drugs. They act by blocking the enzyme calcineurin thereby inhibiting the production of IL-2 and subsequent T-cell activation and proliferation. Although not FDA approved, but their efficacy has recently been documented for treatment of childhood psoriasis. , They can be used as steroid sparing agents and are also useful for sequential and rotational regimens, so as to avoid long term adverse effects of topical steroids. They are particularly useful for sites such as face, flexures and anogenital region.
| Systemic Therapies|| |
Various indications for the use of systemic therapy in cases of psoriasis are outlined in [Table 2]. Their use is restricted because of their adverse effects which make them all the more unfit to be used in children. The choice of systemic agent to be employed depends upon the type of psoriasis, the efficacy of the drug, its adverse effect profile and if there are any associated complaints of illnesses. Experience of the treating physician with regards to a particular drug, at times, also determines its application. Systemic agents currently being tried for use in childhood psoriasis are outlined in [Table 3].
The most commonly use systemic retinoids for psoriasis belongs to second generation retinoids, i.e. etretinate and acitretin. They mainly act by modulating the epidermal proliferation and differentiation and also have anti- inflammatory activity.  Treatment is usually initiated at a low dose such as 0.5 mg/kg/day and then increased to a maximum of 1 mg/kg/day to avoid short and long term toxicities. With improvement, the dose is further tapered down to 0.2 mg/kg/day and continued for around 2-3 months post-remission. Absorption is increased by milk or fatty foods,  and thus the capsule can be dissolved in edible oils for administration in younger age groups (syrup or suspension preparations being currently unavailable). The most common adverse effects are mucocutaneous (xerosis, cheilitis, epistaxis) and reversible alteration in liver enzymes and serum lipids, rarely necessitating cessation of therapy.  Their major limitation in children is the risk of growth retardation due to premature closure of epiphysis.
It is an antimetabolite agent and one of the most commonly used systemic agent for the treatment of psoriasis, because of its efficacy, affordability and convenient dosing. It's usually given in a dosage of 0.2-0.4 mg/kg/week.  There are various studies documenting the successful use of methotrexate in various forms of juvenile psoriasis. ,,, Most of the children tolerate the drug well except for the minor gastrointestinal symptoms such as nausea, vomiting which can be abated with co-prescription of folic acid. Serious adversities are a rare occurrence. The advantages of methotrexate over other systemic agents are that it's an effective, cheap, easily available and reasonable safe drug. Vigilant clinical and laboratory monitoring, especially liver functions, is a mandate. 
It's an immunosuppressive drug that primarily acts by inhibiting T-cell function and interleukin (IL)-2. It is a second line drug in severe forms of psoriasis such as pustular and erythrodermic. , It's prescribed in a dose range of 3-5mg/kg and is variably effective, thus is reserved for severe cases. Its toxicity also limits its use in children. It has the risk of nephrotoxicity, hypertension and immunosuppression apart from other mucocutaneous side effects.
These are a group of drugs including antibodies and fusion proteins targeting cytokines that play an important role in the pathogenesis of psoriasis. These are again reserved for refractory cases. Etanercept, an anti-TNF α fusion protein, has been the one studied most extensively. It has been found to be effective and well tolerated in children and adolescents with moderate-to-severe plaque psoriasis. ,, There are 4 case reports of the use infliximab in childhood psoriasis with good results, but the paucity of data hinders any conclusive status of its efficacy. ,,,
Three main types of therapeutic light options exist: broadband UVB (BB-UVB, 290 -320 nm), narrowband UVB (NBUVB, 311 ±2 nm) and UVA (320-400 nm). They are useful in psoriasis by their action of inhibiting DNA synthesis and epidermal keratinocyte proliferation, induce T-cell apoptosis and immunosuppressive and anti-inflammatory cytokines.  Guttate and thin plaque type lesions respond best to phototherapy. In children, NBUVB is a much safer option and can be in patients as young as 6 years, whereas UVA or PUVA (psoralens and UVA) therapy can only be used in patients older than 12 years. NB-UVB is now considered first-line phototherapy in pediatric age group for psoriasis.  . A pilot study has reported 308 nm excimer laser to be a safe and effective treatment for localized psoriasis in children as in adults. 
| Conclusions|| |
Juvenile psoriasis although an uncommon entity, is not rare. Topical therapy is the most patient friendly approach in childhood psoriasis, more so in the younger age group. Most of the research on topicals is currently available for adult cases but guidelines for treatment in children are yet not available for most of the topical agents. Currently there are no FDA approved systemic agents for the treatment of juvenile psoriasis as there is lack of randomized controlled trials (RCTs). Agents such as NBUVB, retinoids, methotrexate and Etanercept have proven to be safe as compared to other systemic agents in initial trials, but further exploration is still required.
| References|| |
|1.||Faber E, Nall M. The natural history of psoriasis in 5600 patients. Dermatologica 1974;148:1-18. |
|2.||Swanbeck G, Inerot A, Martinsson T, Wahlstrom J, Enerback C, Enlund F, et al. Age at onset and different types of psoriasis. Br J Dermatol 1995;133:768-73. |
|3.||Kumar B, Jain R, Sandhu K, Kumar B. Epidemiology of childhood paoriasis: A study of 419 patients from Northern India. Int J Dermatol 2004;43:654-8. |
|4.||Karthikeyan K, Thappa DM, Jeevankumar B. Pattern of pediatric dermatoses in a referral centre in South India. Indian Pediatr 2004;41:373-7. |
|5.||Sarkar R, Sharma RC, Korrane RV, Sardana K. Erythroderma in children: A clinic-etiological study. J Dermatol 1999;26:507-11. |
|6.||Nyfors A, Lemholt K. Psoriasis in children. A short review and survey of 245 cases. Br J Deramtol 1975;92:437-42. |
|7.||Al-Fouzan AS, Nanda A. A survey of childhood psoriasis in Kuwait. Pediatr Dermatol 1994;11:116-9. |
|8.||Morris A, Rogers M, Fischer G, Williams K. Childhood psoriasis: A clinical review of 1262 cases. Pediatr Dermatol 2001;18:188-98. |
|9.||Dogra S, Kaur I. Childhood psoriasis. Indian J Dermatol Venereol Leprol 2010;76:357-65. |
|10.||Hamm H, Benoit S. Childhood psoriasis. Clin Dermatol 2007;25:555-62. |
|11.||Dogra S, Kumar B. Epidemiology of akin diseases in school children: A study from Northern India. Pediatr Dermatol 2003;20:470-3. |
|12.||Cordoro KM. Management of childhood psoriasis. Adv Dermatol 2008;24:125-69. |
|13.||Raychaudhury SP, Gross J. A comparative study of pediatric onset psoriasis with adult onset psoriasis. Pediatr Dermatol 2000;17:174-8. |
|14.||de Jager ME, de Jong EM, van de Kerkhof PC, Seyger MM. Efficacy and safety of treatments for childhood psoriasis: A systematic literature review. J Am Acad Dermatol 2010;62:1013-30. |
|15.||Fluhr JW, Cavallotti C, Berardesca E. Emollients, moisturisers and keratolytic agents in psoriasis. Clin Dermatol 2008;26:380-6. |
|16.||Jain VK, Bansal A, Aggarwal K, Jain K. Enhanced response of psoriasis to UVB therapy after pretreatment with a lubricating base. A single blind controlled study. Pediatr Dermatol 2008;25:559-64. |
|17.||Lebwohl M, Ali S. Treatment of psoriasis. Part 1. Topical therapy and phototherapy. J Am Acad Dermatol 2001;45:487-98. |
|18.||Rim JH, Choe YB, Youn JI. Positive effect of using calcipotriol ointment with narrow-band Ultraviolet B phototherapy in psoriatic patients. Photodermatol Photoimmunol Photomed 2002;18:131-4. |
|19.||Owen CM, Chalmers RJ, O′Sullivan T, Griffiths CE. Antistreptococcal interventions for Guttate and chronic plaque psoriasis. Cochrane Database Syst Rev 2000;2:CD001976. |
|20.||Miller JJ, Roling D, Margolis D, Guzzo C. Failure to demonstrate therapeutic tachyphylaxis to topically applied steroids in patients with psoriasis. J Am Acad Dermatol 1999;41:546-9. |
|21.||Smith CH, Jackson K, Chinn S, Angus K, Barker JNWN. A double blind, randomized, controlled clinical trial to assess the efficacy of a new coal tar preparation (Exorex® ) in the treatment of chronic, plaque type psoriasis. Clin Exp Dermatol 2000;25:580-3. |
|22.||Thami GP, Sarkar R. Coal tar: Past, present and future. Clin Exp Dermatol 2002;27:99-103. |
|23.||McEvoy GK, editor. Keratoplastic agents: coal tar preparations. AHFS drug information (2007). Available from: http://online.statref.com/document.aspx?fxid=1anddocid=1. [Last accessed on 2007 Sept 6]. |
|24.||McGill A, Frank A, Emmett N, Turnbull DM, Birch-Machin MA, Reynolds NJ. The anti-psoriatic drug anthralin accumulates in keratinocyte mitochondria, dissipates mitochondrial membrane potential, and induces apoptosis through a pathway dependent on respiratory competent mitochondria. FASEB J 2005;19:1012-4. |
|25.||Zvulunov A, Anisfeld A, Metzker A. Efficacy of short-contact therapy with dithranol in childhood psoriasis. Int J Dermatol 1994;33:808-10. |
|26.||Diluvio L, Campione E, Paternò EJ, Mordenti C, El Hachem M, Chimenti S. Childhood nail psoriasis: A useful treatment with tazarotene 0.05%. Pediatr Dermatol 2007;24:332-3. |
|27.||Brune A, Miller DW, Lin P, Cotrim-Russi D, Paller AS. Tacrolimus ointment is effective for psoriasis on the face and intertriginous areas in pediatric patients. Pediatr Dermatol 2007;24:76-80. |
|28.||Mansouri P, Farshi S. Pimecrolimus 1 percent cream in the treatment of psoriasis in a child. Dermatol Online J 2006;12:7. |
|29.||Pang ML, Murase JE, Koo J. An updated review of acitretin-a systemic retinoid for the treatment of psoriasis. Expert Opin Drug Metab Toxicol 2008;4:953-64. |
|30.||Cordoro KM. Topical therapy for the management of childhood psoriasis: Part I. Skin Therapy Lett 2008;13:1-3. |
|31.||Kumar B, Dhar S, Handa S, Kaur I. Methotrexate in childhood psoriasis. Pediatr Dermatol 1994;11:271-3. |
|32.||Dogra S, Kumaran MS, Handa S, Kanwar AJ. Methotrexate for generalized pustular psoriasis in a 2-year old child. Pediatr Dermatol 2005;22:85-6. |
|33.||Kaur I, Dogra S, De D, Kanwar AJ. Systemic methotrexate treatment in childhood psoriasis: Further experience in 24 children from India. Pediatr Dermaatol 2008;25:184-8. |
|34.||Garg T, Chander R, Mittal S. Familial juvenile generalized pustular psoriasis: Response to methotrexate. Skinmed 2011;9:190-1. |
|35.||Kalb RE, Strober B, Weinstein G, Lebwohl M. Methotrexate and psoriasis: 2009 National Psoriasis Foundation Consensus Conference. J Am Acad Dermatol 2009;60:824-37. |
|36.||Alli N, Góngφr E, Karakayali G, Lenk N, Artóz F. The use of cyclosporin in a child with generalized pustular psoriasis. Br J Dermatol 1998;139:754-5. |
|37.||Pereira TM, Vieira AP, Fernandes JC, Sousa-Basto AJ. Cyclosporin A treatment in severe childhood psoriasis. Eur Acad Dermatol Venereol 2006;20:651-6. |
|38.||Kress DW. Etanercept therapy improves symptoms and allows tapering of other medications in children and adolescents with moderate to severe psoriasis. J Am Acad Dermatol 2006;54:S126-8. |
|39.||Paller AS, Siegfried EC, Langley RG, Gottlieb AB, Pariser D, Landells I, et al. Etanercept treatment for children and adolescents with plaque psoriasis. N Engl J Med 2008;358:241-51. |
|40.||Trueb RM. Therapies for childhood psoriasis. Curr Probl Dermatol 2009;38:137-59. |
|41.||Pereira TM, Vieira AP, Fernandes JC, Antunes H, Basto AS. Anti-TNF-alpha therapy in childhood pustular psoriasis. Dermatology 2006;213:350-2. |
|42.||Farnsworth NN, George SJ, Hsu S. Successful use of infliximab following a failed course of etanercept in a pediatric patient. Dermatol Online J 2005;11:11. |
|43.||Menter MA, Cush JM. Successful treatment of pediatric psoriasis with infliximab. Pediatr Dermatol 2004;21:87-8. |
|44.||Weishaupt C, Metze D, Luger TA, Stander S. Treatment of pustular psoriasis with infliximab [German]. J Dtsch Dermatol Ges 2007;5:397-9. |
|45.||Holme SA, Anstey AV. Phototherapy and PUVA photochemotherapy in children. Photodermatol Photoimmunol Photomed 2004;20:69-75. |
|46.||Pahlajani N, Katz BJ, Lozano AM, Murphy F, Gottlieb A. Comparison of the efficacy and safety of the 308 nm excimer laser for the treatment of localized psoriasis in adults and in children: A pilot study. Pediatr Dermatol 2005;22:161-5. |
[Table 1], [Table 2], [Table 3]