|Year : 2012 | Volume
| Issue : 1 | Page : 9-11
Treatment plan of juvenile psoriasis
Department of Dermatology, Venereology & Leprosy Unit-1 & Pediatric Dermatology, Christian Medical College, Vellore, Tamil Nadu, India
|Date of Web Publication||23-Oct-2012|
Department of Dermatology, Venereology & Leprosy Unit-1 & Pediatric Dermatology, Christian Medical College, Ida Scudder Road, Vellore, Tamil Nadu 632004
Source of Support: None, Conflict of Interest: None
The treatment of juvenile psoriasis is challenging. The article addresses the various aspects of management including the laboratory diagnosis and general principles. The treatment of the different types of psoriasis is outlined.
Keywords: Juvenile psoriasis, treatment, plan
|How to cite this article:|
George R. Treatment plan of juvenile psoriasis. Indian J Paediatr Dermatol 2012;13:9-11
| Introduction|| |
The treatment of juvenile psoriasis is addressed in three recent articles. ,, In general, a treatment modality that is affordable, effective and one that does not cause a major disruption in the school schedule should be advocated.
| Treatment of Juvenile Psoriasis|| |
- Microbial swabs of the throat may be done in patients with guttate psoriasis who present with concurrent throat infection and Antistreptolysin O titres in those who present with a past history of throat infection
- The lipid profile and blood sugar estimation are indicated in obese children with psoriasis
- Autoimmune thyroiditis should be excluded in those with psoriasis and vitiligo
- Biopsies are not routinely performed
- Relevant laboratory tests should be ordered prior to starting systemic therapy.
Plaque Type of Psoriasis (1-2 % BSA)
- Counseling and support
- Parent and patient education on all aspects of the disease including the course of the disease, triggers, common side effects of medications and the possible psychosocial impact on the child
- Avoid use of medicated soaps, strong perfumed deodorants in cases of flexural psoriasis and ill-fitting footwear in patients with plantar psoriasis.
- A realistic target should be set as far as results of treatment go and search for an elusive cure should be discouraged.
- Curb obesity, encourage exercise and outdoor activities. Treat co-existent vitamin D deficiency.
- Liberal use of emollients should be encouraged (usually after school hours).
- Topical steroids are used for short periods for localized/limited disease. The effect of topical steroids can be optimized by using it under occlusion e.g. cling film for lesions on the palms and soles.
- Calcineurin inhibitors are not recommended for use in children < 2 years of age.
- Salicylic acid preparations should be used with caution in infant and toddlers. It should not be applied over large areas of inflamed skin.
- Narrow band UVB therapy is effective but interference with school schedule is a major limiting factor.
- The factors that influence the choice of treatment include 1) sites of involvement, type and extent of disease (the body surface area affected), 2) presence of joint involvement and other comorbidities 3) psychological impact and 4) cost of treatment.
Face, flexures and anogenital areas
Chronic plaque psoriasis (< 10 % body surface area (BSA) on the trunk and extremities
- Tacrolimus ointment 0.03% twice daily
- Pimecrolimus ointment 1% twice daily
- Hydrocortisone 1% cream, clobetasone 0.05%
- Topical steroid+ antifungal agent like miconazole (fixed combination) for napkin psoriasis
- Topical calcipotriol + topical steroid (fixed combination for ease of application) for short term use. It should be used with caution on the face and flexures
- *Modified Goeckerman regime + topical steroids (fluticasone/mometasone/betamethasone/clobetasone)
- Short contact dithranol (applied for 30 minutes) + topical steroids (fluticasone/mometasone/betamethasone/clobetasone)
- Tazarotene cream once daily for thick plaques + topical steroids
*Modified Goeckerman regime + Topical steroid and salicylic acid combination
The steroid-salicylic acid combination can be used under a cling film to optimize its action for 7-10 days. During the maintenance phase, the same may be done with salicylic acid ointment (without the steroid).
Psoriasis vulgaris (>10% BSA)
- *Modified Goeckerman regime
- Azithromycin or roxithromycin
- Methotrexate if there is no response to the above therapy
- Narrow band UVB thrice weekly if it does not interfere with the school schedule
- Methotrexate may be combined with narrow band UVB therapy in resistant cases
Modified Goeckerman regime can be used in combination with any of the above if the lesions are not inflamed
- N/B UVB + ** acitretin or methotrexate
- ** Acitretin as monotherapy
- Salycilic acid based preparation (e.g.sulfur salicylic acid) at night and shampooed off with either a tar based or steroid based shampoo in the morning.
- Thick plaques: Sulphur salicylic acid preparation under a shower cap, shampooed off with a tar based or steroid based shampoo in the mornings
- N/B UVB / Targeted phototherapy can be combined with the above if feasible
Generalized pustular psoriasis
Localized pustular psoriasis
- Oral steroids (if unresponsive to the above/in fulminant cases)
- Topical steroids
*Modified Goeckerman Regimen
- Calcipotriol under occlusion with a plastic film at night- to be applied to the nail folds, plate, and under the nail plate
- Tazarotene .05% - 0.1% cream/gel - application as above
Modified Goeckerman regimen consists of the use of crude coal tar paste applied on the lesions followed by UVB exposure. 
For convenience we advice our patients to apply the tar ointment and leave it on for at least 1 hour, after which they are advised to expose the affected area to sunlight after wiping off the excess tar ointment with a gauze/muslin/or any clean soft cotton cloth dipped in liquid paraffin/vegetable oil. The advantage is that it is safe, can be done at home, and usually results in long remissions. Avoid application on the face, flexures and anogenital region.
**Isotretinoin may used instead of acitretin in adolescent girls
| References|| |
|1.||Silverberg NB. Pediatric psoriasis: An update. Ther Clin Risk Manage 2009;5:849-56. |
|2.||Stahle M, Atakan N, Boehncke WH, Chimenti S, Dauden AG, Hoeger P, et al. Juvenile psoriasis and its clinical management: A European expert group consensus. J Dtsch Dermatol Ges 2010;8:812-8. |
|3.||de Jager ME, de Jong EM, van de Kerkhof, Seyger MM. Efficacy and safety of treatments for childhood psoriasis: A systematic literature review. J Am Acad Dermatol 2010;62:1013-30. |
|4.||Kortuem KR, Davis MD, Witman PM, McEvoy MT, Farmer SA. Results of Goeckerman treatment for psoriasis in children: A 21- year retrospective review. Pediatr Dermatol 2010;27:518-24. |