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SYMPOSIUM
Year : 2012  |  Volume : 13  |  Issue : 1  |  Page : 12-16

Management of childhood psoriasis


Department of Dermatology and STD, Lady Hardinge Medical College, Shahid Bhagat Singh Marg, New Delhi, India

Date of Web Publication23-Oct-2012

Correspondence Address:
Vibhu Mendiratta
Department of Dermatology and STD, Lady Hardinge Medical College, Shahid Bhagat Singh Marg, New Delhi - 110 001
India
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Source of Support: None, Conflict of Interest: None


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  Abstract 

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

How to cite this URL:
Mendiratta V, Mittal S. Management of childhood psoriasis. Indian J Paediatr Dermatol [serial online] 2012 [cited 2020 Jul 6];13:12-6. Available from: http://www.ijpd.in/text.asp?2012/13/1/12/102801


  Introduction Top


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. [1],[2] 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. [3] Psoriasis comprised 1.4% of all pediatric dermatoses seen in patients less than 14 years of age at a referral hospital in South India. [4] 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. [5] 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 [3],[6] whereas other studies from the Middle East and Australia reported a peak of onset at the ages of up to 4 years. [7],[8]

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. [9] Certain clinical variants such as erythroderma, arthropathy and pustular forms are rarer in children. [1],[2],[3],[4],[10],[11] Infections and physical and psychological trauma as precipitating factors, are more frequently seen in children than in adults. [3],[4],[10],[12] Remission is more frequently seen in juvenile onset than in adult onset psoriasis. [13]

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 Top


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. [14] The choice depends upon the age of the patient, type of psoriasis, site, individual patient's tolerability and affordability.
Table 1: Topical agents in psoriasis

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Emollients

Emollients constitute the cornerstone of management of childhood psoriasis. Emollients, such as white soft paraffin, are especially useful in the common scaly type [15] 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. [9] 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. [16]

Keratolytics

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. [15] 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. [17] UVB phototherapy increases the efficacy of calcipotriol, although the same has yet not been proven in children. [18] 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.

Corticosteroids

Topical steroids remain among the first line agents for treatment of psoriasis among all age groups. [19] 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, [20] 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

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, [21] and also has anti-pruritic and anti-inflammatory effects. [22] Although effective, it is avoided in children <12 years of age as its safety for this age group has not been established. [23] 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

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. [24] "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. [17] 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. [25] It can be combined with UVB phototherapy, as in Ingram regimen, to improve the response.

Retinoids

Tazarotene is a third generation retinoid that has recently been approved for topical use in adults with psoriasis [9] . 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. [26]

Calcineurin Inhibitors

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. [27],[28] 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 Top


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].
Table 2: Indications for systemic agents in psoriasis

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Table 3: Systemic agents for childhood psoriasis

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Retinoids

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. [9] 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, [29] 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. [29] Their major limitation in children is the risk of growth retardation due to premature closure of epiphysis.

Methotrexate

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. [30] There are various studies documenting the successful use of methotrexate in various forms of juvenile psoriasis. [31],[32],[33],[34] 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. [35]

Cyclosporine

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. [36],[37] 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.

Biologics

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. [38],[39],[40] 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. [41],[42],[43],[44]

Phototherapy

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. [45] 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. [45] . A pilot study has reported 308 nm excimer laser to be a safe and effective treatment for localized psoriasis in children as in adults. [46]


  Conclusions Top


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 Top

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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.  Back to cited text no. 46
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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Introduction
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Conclusions
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