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SYMPOSIUM
Year : 2012  |  Volume : 13  |  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 Publication23-Oct-2012

Correspondence Address:
Renu George
Department of Dermatology, Venereology & Leprosy Unit-1 & Pediatric Dermatology, Christian Medical College, Ida Scudder Road, Vellore, Tamil Nadu 632004
India
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Source of Support: None, Conflict of Interest: None


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  Abstract 

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

How to cite this URL:
George R. Treatment plan of juvenile psoriasis. Indian J Paediatr Dermatol [serial online] 2012 [cited 2020 Jul 6];13:9-11. Available from: http://www.ijpd.in/text.asp?2012/13/1/9/102800


  Introduction Top


The treatment of juvenile psoriasis is addressed in three recent articles. [1],[2],[3] 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 Top
[1],[2],[3]

Laboratory Investigations

  1. 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
  2. The lipid profile and blood sugar estimation are indicated in obese children with psoriasis
  3. Autoimmune thyroiditis should be excluded in those with psoriasis and vitiligo
  4. Biopsies are not routinely performed
  5. Relevant laboratory tests should be ordered prior to starting systemic therapy.
General Principles

  1. Counseling and support
  2. 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
  3. Avoid use of medicated soaps, strong perfumed deodorants in cases of flexural psoriasis and ill-fitting footwear in patients with plantar psoriasis.
  4. A realistic target should be set as far as results of treatment go and search for an elusive cure should be discouraged.
  5. Curb obesity, encourage exercise and outdoor activities. Treat co-existent vitamin D deficiency.
  6. Liberal use of emollients should be encouraged (usually after school hours).
  7. 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.
  8. Calcineurin inhibitors are not recommended for use in children < 2 years of age.
  9. Salicylic acid preparations should be used with caution in infant and toddlers. It should not be applied over large areas of inflamed skin.
  10. Narrow band UVB therapy is effective but interference with school schedule is a major limiting factor.
  11. 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.
Plaque Type of Psoriasis (1-2 % BSA)

Face, flexures and anogenital areas


  1. Tacrolimus ointment 0.03% twice daily
    OR
  2. Pimecrolimus ointment 1% twice daily
    OR
  3. Hydrocortisone 1% cream, clobetasone 0.05%
  4. Topical steroid+ antifungal agent like miconazole (fixed combination) for napkin psoriasis
Chronic plaque psoriasis (< 10 % body surface area (BSA) on the trunk and extremities

  1. 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
    OR
  2. *Modified Goeckerman regime + topical steroids (fluticasone/mometasone/betamethasone/clobetasone)
    OR
  3. Short contact dithranol (applied for 30 minutes) + topical steroids (fluticasone/mometasone/betamethasone/clobetasone)
  4. Tazarotene cream once daily for thick plaques + topical steroids
Palmoplantar psoriasis

*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).

Guttate psoriasis

  1. *Modified Goeckerman regime
  2. Azithromycin or roxithromycin
  3. Methotrexate if there is no response to the above therapy
    OR
  4. Narrow band UVB thrice weekly if it does not interfere with the school schedule
  5. Methotrexate may be combined with narrow band UVB therapy in resistant cases
Psoriasis vulgaris (>10% BSA)

  1. Methotrexate
    OR
  2. Cyclosporine
    OR
  3. N/B UVB + ** acitretin or methotrexate
    OR
  4. ** Acitretin as monotherapy
Modified Goeckerman regime can be used in combination with any of the above if the lesions are not inflamed

Scalp psoriasis

  1. 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.
  2. Thick plaques: Sulphur salicylic acid preparation under a shower cap, shampooed off with a tar based or steroid based shampoo in the mornings
  3. N/B UVB / Targeted phototherapy can be combined with the above if feasible
Erythrodermic psoriasis

  1. Methotrexate
    OR
  2. **Acitretin
    OR
  3. Cyclosporine
Generalized pustular psoriasis

  1. **Acitretin
    OR
  2. Methotrexate
    OR
  3. Dapsone
    OR
  4. Oral steroids (if unresponsive to the above/in fulminant cases)
Localized pustular psoriasis

  1. Topical steroids
  2. Dapsone
  3. **Acitretin
Nail psoriasis

  1. Calcipotriol under occlusion with a plastic film at night- to be applied to the nail folds, plate, and under the nail plate
    OR
  2. Tazarotene .05% - 0.1% cream/gel - application as above
*Modified Goeckerman Regimen

Modified Goeckerman regimen consists of the use of crude coal tar paste applied on the lesions followed by UVB exposure. [4]

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 Top

1.Silverberg NB. Pediatric psoriasis: An update. Ther Clin Risk Manage 2009;5:849-56.  Back to cited text no. 1
[PUBMED]    
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.  Back to cited text no. 2
    
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.  Back to cited text no. 3
    
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.  Back to cited text no. 4
[PUBMED]    




 

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