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SYMPOSIUM
Year : 2012  |  Volume : 13  |  Issue : 1  |  Page : 17-20

Quality of life issues in pediatric psoriasis


Department of Dermatology, Kasturba Medical College, Manipal University, Manipal, Karnataka, India

Date of Web Publication23-Oct-2012

Correspondence Address:
Shrutakirthi D Shenoi
Professor and Head, Department of Dermatology, Kasturba Medical College, Manipal University, Manipal, Karnataka
India
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Source of Support: None, Conflict of Interest: None


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  Abstract 

'Childhood Psoriasis - A challenge for all' was the slogan of World Psoriasis Day 2010. This entity was aptly recognized as a problem more than skin deep as children are very sensitive to public opinion and peer pressure. Children with psoriasis also face emotional trauma as a result of bullying, discrimination and self-consciousness due to the easy visibility of disease. Severe forms of the disease like erythroderma, and facial involvement which is more in children may further negatively impact the child's psyche. The few studies conducted so far on Quality of life issues in childhood psoriasis equivocally state that there is negative impact on Quality of Life which moderately correlates with PASI scores and Physicians Global Assessment.

Keywords: Quality of life, childhood, psoriasis


How to cite this article:
Prabhu S, Shenoi SD. Quality of life issues in pediatric psoriasis. Indian J Paediatr Dermatol 2012;13:17-20

How to cite this URL:
Prabhu S, Shenoi SD. Quality of life issues in pediatric psoriasis. Indian J Paediatr Dermatol [serial online] 2012 [cited 2020 Jul 6];13:17-20. Available from: http://www.ijpd.in/text.asp?2012/13/1/17/102803


  Introduction Top


'Childhood Psoriasis - A challenge for all' was the slogan of World Psoriasis Day 2010. This entity was aptly recognized as a problem more than skin deep as children are very sensitive to public opinion and peer pressure and are more prone for depression and anxiety, especially so in a disfiguring disease like psoriasis. The physical symptoms can limit childhood activities such as outdoor exercise, swimming and sports. Psoriasis in sensitive areas, such as the palms, soles or genitalia, can cause pain or discomfort for children in the classroom leading to concentration issues and difficulties in participating in learning activities. Children with psoriasis also face emotional trauma as a result of bullying, discrimination and self-consciousness due to the visible manifestation of disease. The perception of quality of life may differ among children and adults. There are few large scale studies on the impairment of quality of life in children with psoriasis, though studies indicate that psoriasis in young people impacts health related quality of life more than other childhood conditions including other skin diseases, epilepsy, diabetes and alopecia.

Childhood Psoriasis: Epidemiology, Co-morbidities and Health Issues

Psoriasis is a relatively common papulosquamous disease affecting approximately 2.5% of world's population, [1] which due to its disfiguring nature adversely affects the quality of life in adults. Psoriasis may affect children also (worldwide incidence of juvenile psoriasis being 0.7%); however, the psychological impact on children is little known. The peak age of onset varies. About 10% of psoriatic patients develop the disease in the first decade of life and 25%in the first 16 years. [2] Childhood psoriasis is more common in females (52-58%) worldwide, except in India and Australia. [3] The course of the disease may be more severe than in adults. [4] In India, a retrospective large scale analysis of childhood psoriasis in 419 children by Bhushan Kumar et al showed a slightly higher male preponderance(52.2%), and comprised 12.5% of all psoriatic cases. [5] Childhood psoriasis has slight variations from adult psoriasis. Though severe forms of psoriasis are considered to be rare in children, psoriatic erythroderma constituted upto 15% of all pediatric erythroderma as reported by Sarkar et al, from Delhi, India. [6] Moreover, facial involvement, though uncommon in adults, is an established feature of pediatric psoriasis [7] and upto 20% of childhood arthritis which may cause irreversible joint destruction is attributed to psoriasis. A study of 198 children less than 14 years old conducted in Tashkent Medical Institute in Uzbekistan showed that there was female predominance (58.1%) and 88.8% had disseminated disease, the younger the age, more widespread the disease in later life. [1] These factors further contribute to the emotional vulnerability in children. The overall rate of co-morbid chronic conditions in psoriasis patients under age 20 is double that of their peers who do not have psoriasis. Increased rates of diabetes, arthritis, Crohn's disease, obesity, hypertension and high cholesterol were associated with juvenile psoriasis. [8] Thirty two percent of children with moderate to severe psoriasis, and 41 percent of adolescents, are overweight; these being significantly higher rates than the general pediatric population. Obesity in early adulthood may increase the risk for developing psoriatic arthritis later in life. [9]

Treatment options; [10] Treatment objectives include control of the disease as well as minimizing the psychosocial trauma experienced by the child and limiting adverse effects of drugs on future growth and development. The expectations should be realistic and the parents and patient should be counseled. Precipitating factors like trauma and infections are more significant in children than in adults, and these have to be dealt with. Randomized trials in children have been conducted only for corticosteroids and calcipotriol. Systemic therapy is to be considered only in those who do not respond to topical and phototherapy and those who have moderate to severe disease. Topical agents like emollients, keratolytics, coal tar, dithranol, corticosteroids, tazarotene, tacrolimus may be safely used in children. Though no systemic agent is approved for childhood psoriasis, retinoids, methotrexate and cyclosporine have been used with caution.

Impact of Psoriasis on Child's Emotional Well Being

Children who have psoriasis may find it difficult to cope with the realities of the disease. Children often rely on their parents to find solace from the symptoms of the disease as well as the emotional challenges of having erythematous, inflamed skin. Very few children escape from emotional trauma. Most often feel embarrassed, angry or depressed; they become anxious about the recurring episodes, worsening of lesions and being socially rejected by their peer. Children's reactions are usually unpredictable and they have swinging moods and reactions. Having a disfiguring skin disease at a young age also considerably impairs their body image, more so than in adults. One of the biggest challenges for children with psoriasis is living in anticipation, anxiety, and fear of the next psoriasis flare-up. A health survey poll of US parents with children with psoriasis found that 44% had been bullied at school, and bullying caused anxiety in 60% and decreased academic performance and sleep problems in 23.5%, each. [11] Reports of a survey in Boston on the risk of psychiatric disorders in psoriatic children, presented at the 68 th annual American Academy of Dermatology meeting showed that that patients with psoriasis had a 25% higher risk of developing any psychiatric disorder, a 23% higher risk of developing depression, a 32% higher risk of developing anxiety, a 47% higher risk of using any medication to treat these disorders, and a 62% higher risk of using tricyclic antidepressants. [12]


  QOL Studies in Childhood Psoriasis Top


The Psoriasis Quality of Life (PQOL) questionnaire covers self-consciousness, helplessness, embarrassment, anger/frustration, emotional well-being, capacity to enjoy life, itching, physical irritation, pain/soreness, and influence on choice of clothing. [13] Findings have shown adequate validity and reliability for the abbreviated questionnaire, although it doesnot correlate well with the Psoriasis Area and Severity Index (PASI) and other instrument scores. QOL has been modified in children to suit their needs to form childhood dermatology life quality index (CDLQI)

Studies have shown that Quality of Life (QOL) in children with psoriasis is worse than in children with epilepsy and diabetes mellitus. de Jager et al studied 39 children with chronic plaque psoriasis and found that disease severity measures calculated by physicians global assessment (PGA) and psoriasis area severity index (PASI) moderately correlated with CDLQI. [14] They ascribe the moderate correlation to the fact that perception of quality of life depends on other factors like age, gender, social setup, cultural and ethnical factors, level of education and innate anxiety and personality of the patient. In adults, quality of life scores improve with improvement in disease, but there are no such studies in children.

A comparative study of impairment of quality in life in 379 children with various dermatological diseases showed that according to children psoriasis and atopic dermatitis caused the greatest impairment (CDLQI scores of 30.6% and 30.5%), followed by urticaria (20%) and acne (18%). Using the generic CLQI (scored 0-36), from the parental perspective the highest score was for AD (33%), followed by urticaria (28%), psoriasis (27%) and alopecia (19%). [15]

de Jager et al conducted another large scale study of 1762 psoriatic patients comparing the quality of life (QOL) in childhood as well as in adulthood where they retrospectively analyzed the impact of childhood psoriasis on daily life, the influence of psoriasis as experienced in childhood as compared to the current quality of life and compared the current quality of life in patients with childhood psoriasis and adult psoriasis and found that QOL in childhood was much less compared to the current QOL. Upto 30% had highly limited social and recreational life in childhood leading to impairment of social development, a major milestone of childhood development. [16]

In a recent study sponsored by Abbott laboratories, which involved review of 7404 pediatric medical case sheets, it was found that psychiatric disorders like depression and anxiety were more in childhood psoriatics, comprising to about 5% of total childhood psoriatics, as compared to children without psoriasis. It is deducted that a child with psoriasis has a 25-47% risk of future mental health problems. [17] Moreover, children with psoriasis are relentlessly alienated, teased and bullied at school. To prevent this educating the public as well as school children, along with emotional supportive care of the psoriatic child is a must. For furthering this aim, the National Psoriasis Foundation has dedicated a website to pediatric sufferers of psoriasis: PsoMe- 'the place for kids with psoriasis to connect for a cure'. [18]

How to Combat Emotional and QOL Issues in Childhood Psoriasis?

A support network is important for a child to cope with the realities of the disease. The chronic nature of the disease and the possibility of repeated relapses should be gently stressed upon. Parents have a great role in improving the quality of life of psoriatic children. They should be taught to be open, supportive and willing to answer questions. They should educate and comfort their child at various phases, and even repeatedly, if needed. Encouraging messages should be put forth to the child: [19]

  • psoriasis is not life threatening; you can live with the disease, there are excellent medications to control the disease
  • you are not alone, there are millions of people who suffer from this disease
  • it is not contagious; your friends will not catch it from you
  • it is not your or your parents fault that you have this disease, it can happen to anyone at any time
Parents should enforce the importance of compliance to medications and lifestyle modifications. The child should be encouraged to seek support whenever needed and support should be ensured when the child seeks it. The child's feeling should be validated by saying it is okay to be angry or sad. Empowering the children with education and support helps them to survive difficult recurrences.


  Conclusion Top


Pediatric patients with psoriasis deserve a normal childhood. The National Psoriasis Foundation has serious concerns that children with psoriasis and psoriatic arthritis do not have access to the therapies they need. In addition to facing significant emotional and social challenges in their childhood, they are at an increased risk of developing serious, chronic comorbid health conditions in their later years. [12]

 
  References Top

1.Khaitov K, Mannanov A, Turakhodjaeva F. Clinical analysis of psoriasis course in children. Med Health Sci J 2010;48-50.  Back to cited text no. 1
    
2.Christophers E. Psoriasis - epidemiology and clinical spectrum. Clin Epidem Dermatol 2002;26:314-20.  Back to cited text no. 2
    
3.Morris A, Rogers M, Fischer G, William K. Childhood psoriasis: A review of 1262 cases. Pediatr Dermatol 2001;18:188-98.  Back to cited text no. 3
    
4.Farber EM, Carlsen RA. Psoriasis in childhood. California Med 1966;105:415-20.  Back to cited text no. 4
[PUBMED]    
5.Kumar B, Jain R, Sandhu K, Kumar B. Epidemiology of childhood psoriasis: A study of 419 patients from northern India. Int J Dermatol 2004;43:654-8.  Back to cited text no. 5
[PUBMED]    
6.Sarkar R, Sharma RC, Koranne RV, Sardana K. Erythroderma in children: A clinico-etiological study. J Dermatol 1999;26:507-11.  Back to cited text no. 6
[PUBMED]    
7.Asboe Hansen G. Psoriasis in childhood. In: Farber EM, Cox AJ, editors. Psoriasis: Proceedings of the International Symposium. Stanford, CA: Stanford University Press; 1971. p. 53-9.  Back to cited text no. 7
    
8.Augustin M, Glaeske G, Radtke MA, Christophers E, Reich K, Schafer I. Epidemiology and comorbidity of psoriasis in children. Br J Dermatol 2010;162:633-6.  Back to cited text no. 8
    
9.Soltani-Arabshahi R, Wong B, Feng BJ, Goldgar DE, Duffin KC, Krueger GG. Obesity in early adulthood as a risk factor for psoriatic arthritis. Arch Dermatol 2010;146:721-6.  Back to cited text no. 9
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10.Dogra S, Kaur I. Childhood psoriasis. Ind J Dermatol Venereol Leprol 2010;76:357-65.  Back to cited text no. 10
    
11.American Academy of Dermatology (AAD) 68 th Annual Meeting: Abstract P505. Presented March 8, 2010.  Back to cited text no. 11
    
12.National Psoriasis Foundation children issue brief. January 2011. Available from: http://www.psoriasis.org/NetCommunity/Document.Doc?id=348 [Last accessed on 2011June 4].  Back to cited text no. 12
    
13.Koo J, Kozma C, Menter A, Lebwohl M. Development of the 12-item psoriasis quality of life questionnaire. Program of the 61 st Annual Meeting of the American Academy of Dermatology; March 22-26, 2003; San Francisco, California. Poster 606.  Back to cited text no. 13
    
14.de Jager ME, van de Kerkhof PC, de Jong EM, Seyger MM. A cross-sectional study using the Children′s Dermatology Life Quality Index (CDLQI) in childhood psoriasis: Negative effect on quality of life and moderate correlation of CDLQI with severity scores. Br J Dermatol 2010;163:1099-101.  Back to cited text no. 14
[PUBMED]    
15.Beattie PE, Lewis-Jones MS. A comparative study of impairment of quality of life in children with skin disease and children with other chronic childhood diseases. Br J Dermatol 2006;155:145-51.  Back to cited text no. 15
[PUBMED]    
16.de Jager ME, de Jong EM, van de Kerkhof PC, Evers AW, Seyger MM. An intrapatient comparison of quality of life in psoriasis in childhood and adulthood. J Eur Acad Dermatol Venereol 2010;25:828-31.  Back to cited text no. 16
[PUBMED]    
17.Worcestor S. Psoriasis linked with risk of increased psychiatric disorders in children. Available from: http://www.medconnect.com.sg/tabid/92/s19/Psychiatry/ct1/c36095/Psoriasis-Linked-with-Increased-Risk-of-Psychiatric-Disorders-in-Children/Default.aspx [Last accessed on 2011 June 6].  Back to cited text no. 17
    
18.Available from: http://www.psoriasis.org/NetCommunity/psome [Last accessed on 2011 June 6].  Back to cited text no. 18
    
19.Melville NA. Kids can get psoriasis too. Available from: http://beatpsoriasis.com/psoriasis-children.htm [Last accessed on 2011 June 6].  Back to cited text no. 19
    




 

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