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ORIGINAL ARTICLE
Year : 2018  |  Volume : 19  |  Issue : 4  |  Page : 321-325

A hospital-based clinical study of childhood psoriasis in a tertiary care center of Northeast India


Department of Dermatology, Gauhati Medical College and Hospital, Guwahati, Assam, India

Date of Web Publication28-Sep-2018

Correspondence Address:
Dr. Seujee Das
Department of Dermatology, Gauhati Medical College and Hospital, Guwahati - 781 032, Kamrup (M), Assam
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpd.IJPD_86_17

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  Abstract 


Background: Childhood psoriasis has been reported to differ from that among adults. There are a limited number of studies on childhood psoriasis and none from the north-eastern part of India. A detailed clinical study will help to understand better the disease profile in children, thereby assisting in better diagnosis and treatment. Objective: The objective of this study was the clinical profile of childhood psoriasis. Materials and Methods: The present observational study was conducted in the Dermatology Outpatient Department of Assam Medical College and Hospital, Dibrugarh, during 12 months from June 2014 to May 2015. All children up to 13 years presenting with psoriasis during 1 year were taken as study participants after obtaining the written consent from the sole guardian. A detailed examination and relevant investigations were done, whenever necessary. The findings were recorded in a pro forma for the analysis and interpretation of data. Results: A total of 26 cases of childhood psoriasis were recorded during the study. The prevalence of childhood psoriasis in our outpatient pediatric population was 1.24%. Female cases (19; 73.08%) outnumbered male cases (7; 26.92%). A maximum number of cases were noted in 9–13 years of age group. The lower extremities (11; 42.31%) were the most common site of onset. Plaque type (14; 53.85%) was found to be the most common type. About 7.69% cases had a positive family history. Conclusion: Frequent involvement of soles was noted in childhood psoriasis similar to other parts of India but unlike other parts of the world. Pediatric patients had significantly more involvement of the trunk, face, and groin than did adult patients.

Keywords: Childhood psoriasis, inflammatory, papulosquamous disorder


How to cite this article:
Das S, Adhicari P. A hospital-based clinical study of childhood psoriasis in a tertiary care center of Northeast India. Indian J Paediatr Dermatol 2018;19:321-5

How to cite this URL:
Das S, Adhicari P. A hospital-based clinical study of childhood psoriasis in a tertiary care center of Northeast India. Indian J Paediatr Dermatol [serial online] 2018 [cited 2018 Oct 16];19:321-5. Available from: http://www.ijpd.in/text.asp?2018/19/4/321/242418




  Introduction Top


Psoriasis is a chronic, immune-mediated, inflammatory, and proliferative condition involving the skin, nails, and joints having both genetic and environmental influences. It is a papulosquamous disorder, the most characteristic lesions being discrete, erythematous, scaly, sharply demarcated, indurated plaques, present particularly over extensor surfaces, and scalp. It affects 2%–3% of the global population.[1] Childhood psoriasis has been reported to differ from that among adults being more frequently pruritic; plaque lesions are relatively thinner, softer, and less scaly; face and flexural involvement is common. Psoriasis can have a profound impact on physical, emotional and social functioning, and overall quality of life in children leading to a great amount of stress and anxiety among the concerned parents.

There are a limited number of studies on childhood psoriasis and none from this part of India. Therefore, a detailed clinical study will help us understand better the disease profile in children of this part of the country.

Objective

The objective of this study was the clinical profile of childhood psoriasis.


  Materials and Methods Top


The present observational study was conducted in the Department of Dermatology, Assam Medical College and Hospital, Dibrugarh, during 12 months from June 2014 to May 2015, after due approval from the Institutional Ethics Committee. All children up to 13 years presenting with psoriasis in the Dermatology Outpatient Department of Assam Medical College and Hospital, Dibrugarh, for 1 year were taken as study participants. A detailed general, systemic, and cutaneous examination was done. Relevant investigations were carried out whenever necessary. The findings were recorded in a pro forma for analysis and interpretation of data.


  Results Top


During the study, 2094 pediatric patients attended the Dermatology Outpatient Department, of which 26 of them had psoriasis. Thus, the prevalence of childhood psoriasis in our outpatient pediatric population was 1.24%. Female cases of psoriasis (19; 73.08%) outnumbered male cases (7; 26.92%) with a ratio of 2.71:1. The age and sex distribution of childhood psoriasis is shown in [Table 1]. A maximum number of cases were seen in patients from 9 to 13 years of age (15; 57.69%), followed by cases in 5–8 years (7; 26.92%) which was followed by cases in 0–4 years (4; 15.38%). Mean age of onset was found to be 8.4 years. The youngest patient in our study was 1 year old. A maximum number of cases were reported in the spring months (34.62% cases) followed by autumn (26.92% cases). The season-wise distribution of childhood psoriasis is shown in [Table 2]. The lower extremities (11; 42.31%) were the most common site of onset in psoriasis, followed by scalp (9; 34.62%), upper extremities (4; 15.38%), and trunk (2; 7.69%) [Table 3]. Extremities (17; 65.38%) were the most common sites to be involved in psoriasis followed closely by scalp (15; 57.69%) which was followed by trunk and face with an equal number of cases (7; 26.92%) in each. Intertriginous areas were involved in only 1 case (3.85%) [Table 4]. Plaque type (14; 53.85%) was the most common type of psoriasis, followed by plantar psoriasis (8; 30.77%) and scalp psoriasis (4; 15.38%). There were no cases of pustular, guttate, erythrodermic psoriasis, or psoriatic arthropathy. Family history was positive in two cases constituting 7.69% of the total cases of psoriasis. Nail involvement was noted in four cases constituting 15.38% of all the cases with psoriasis. Pruritus was found to be present in 24 cases constituting 92.31% of all the cases with psoriasis.
Table 1: Age and sex distribution in childhood psoriasis

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Table 2: Season-wise distribution in childhood psoriasis

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Table 3: Site of onset in psoriasis

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Table 4: Sites involved in psoriasis

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  Discussion Top


Childhood psoriasis is relatively common, but only limited epidemiologic data are available. The prevalence of childhood psoriasis in our outpatient pediatric population was 1.24%.

In an epidemiological study of various dermatoses in school children aged 6–14 years from North India by Dogra and Kumar,[2] the point prevalence of psoriasis was found to be 0.02%. In a study by Karthikeyan et al.,[3] psoriasis comprised 1.4% of all pediatric dermatoses seen in patients <14 years of age at a referral hospital in South India. In a study by Gül et al.,[4] the incidence of psoriasis in children was 5.4%. In a study of various dermatoses in children conducted at a tertiary care referral center in India by Sardana et al.,[5] psoriasis constituted 0.54% of all dermatoses. Tollefson et al.[6] reported the prevalence of psoriasis in children to be as high as 3.8%.

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 6–10 years,[7] but according to some authors, peak age of onset is 15–25 years.[8] In a study from Denmark by Nyfors and Lemholt [9] the mean age of onset was 8.1 years. Morris et al.[10] reported a peak of onset at the ages of 0–2 years. In the study by Kumar et al.[11] reported that the age of onset ranged from 4 days to 14 years, the mean age of onset being 8.1 ± 2.1 years in boys and 9.3 ± 2.3 years in girls. Tollefson et al.[6] reported the mean age of onset to be 10.6 years. Two other recent studies reported the mean age of onset to be 9.96 years and 11 years.[12],[13] In our study, the peak age of onset was 9–13 years and the mean age of onset was 8.4 years which is quite similar to other studies. The youngest patient was 1 year old in our study.

It is commonly found that girls with psoriasis outnumber boys. In our study, female cases of psoriasis (19; 73.08%) outnumbered male cases (7; 26.92%) with a ratio of 2.71:1 which is almost consistent with most other studies.[14],[15] Nanda et al.[16] did not observe a female preponderance in childhood. Morris et al.[10] observed a male-to-female ratio of 0.9:1.0, whereas in a study by Kumar et al.[11] the male-to-female ratio was 1.09:1.0. In a study of 137 patients from China, aged between 3 and 14 years by Wu et al.,[17] 46.7% were male and 53.3% were female. Tollefson et al.[6] reported that girls and boys were almost equally affected in childhood.

Wu et al.[17] reported exacerbations of the disease in spring and winter months. In our study, a maximum number of cases with childhood psoriasis presented in the spring and autumn months, thereby indicating an exacerbation of the disease process during this time of the year.

The family history was positive in 7.69% of the total cases of psoriasis in the present study. Positive family history noted in different studies is shown in [Table 5]. Morris et al.[10] reported a much higher rate of positive family.
Table 5: Positive family history in various studies

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Childhood psoriasis is often precipitated by infections and commonly manifests as acute guttate psoriasis. However, most Indian studies report that the established plaque type of disease is more common in children than the guttate variety [Table 6].[16] In our study, plaque type (14; 53.85%) was the most common type of psoriasis at presentation, followed by plantar psoriasis (8; 30.77%), and scalp psoriasis (4; 15.38%). Morris et al.[10] reported that plaque psoriasis was the most common type overall, affecting 34% patients. A study from North India by Kumar et al.[11] reported that plaque psoriasis was the most frequent clinical presentation (60.6%), followed by plantar psoriasis (12.8%). Tollefson et al.[6] reported that chronic plaque psoriasis was the most common type (73.7%) followed by guttate psoriasis (14%). Another study by Wu et al.[17] showed that plaque psoriasis was the most common type (52.6%), followed by guttate psoriasis (25.5%), pustular psoriasis (10.9%), and psoriatic erythroderma (5.1%). Lysell et al.[20] reported plaque psoriasis to be the most common in 71% cases followed by guttate psoriasis in 26% cases [Figure 1], [Figure 2], [Figure 3].
Table 6: Occurrence of plaque psoriasis in various studies

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Figure 1: Plaque type psoriasis

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Figure 2: Scalp psoriasis

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Figure 3: Plantar psoriasis

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Kumar et al.[11] reported that extensors of the legs (25% cases) were the most common initial site affected, followed by the scalp (20.7%). Wu et al.[17] reported that scalp was the most common initial site affected (50.3%). Our study showed that the lower extremities (11; 42.31%) were the most common site of onset in psoriasis, followed by scalp (9; 34.62%); while extremities (17; 65.38%) were the most common sites to be involved in psoriasis followed closely by scalp (15; 57.69%) which is consistent with the study by Tollefson et al.,[6] who reported that the most commonly involved sites were the extremities (59.9%) and the scalp (46.8%). A majority of the past studies done in pediatric patients found that the scalp and extremities were the two most common sites to be involved in psoriasis, with some reporting extremities more common than scalp disease [11],[12],[13] while others found scalp involvement to be more common than extremities.[14],[16] In childhood psoriasis, the involvement of the face is a frequent observation, which varies from 18% to 46% in various reports whereas mucosal involvement is found to be rare in Indian children.[16] About 26.92% cases were found to have facial involvement in our study.

In a study from North India by Kumar et al.,[11] nail involvement was observed in 31% cases. Tollefson et al.[5] reported that nail involvement was present in 17% cases. Wu et al.[17] reported nail changes in 25.5% cases. Our study recorded nail involvement in childhood psoriasis in 15.38% of the cases.

Kumar et al.[11] reported that pruritus was the most frequent symptom and was present in 87.1% children. The present study recorded pruritus in 92.31% of all the cases with childhood psoriasis.

In the study by Kumar et al.,[11] the soles were the most frequent site of onset in 12.8% of children after the legs and scalp, whereas Morris et al.[10] reported plantar involvement in only 4%. Our study reported a much higher plantar involvement in 30.77% of the cases with childhood psoriasis. Higher incidence of plantar involvement in Indian children is suggested to be due to the habit of walking barefoot and often wearing open sandals which lead to koebnerization and thereby manifestation of the disease.


  Conclusion Top


Childhood psoriasis was found to be more common in females than males unlike the adult-onset form. More frequent involvement of soles was reported in childhood psoriasis in our study similar to other parts of India, but unlike other parts of the world. Chronic plaque type was the most common type in childhood psoriasis. Furthermore, pediatric patients had significantly more involvement of the trunk, face, and groin than did adult patients, thus indicating that the practitioners must keep a high level of suspicion for psoriasis while encountering rashes in these locations in children. Long-term clinico epidemiological studies are required for better understanding of childhood psoriasis and to note the differences in clinical findings from the adult-onset form, as well as to know better about the geographical and genetic influences in the manifestation of the disease in children.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Pariser DM, Bagel J, Gelfand JM, Korman NJ, Ritchlin CT, Strober BE, et al. National psoriasis foundation clinical consensus on disease severity. Arch Dermatol 2007;143:239-42.  Back to cited text no. 1
    
2.
Dogra S, Kumar B. Epidemiology of skin diseases in school children: A study from Northern India. Pediatr Dermatol 2003;20:470-3.  Back to cited text no. 2
    
3.
Karthikeyan K, Thappa DM, Jeevankumar B. Pattern of pediatric dermatoses in a referral center in South India. Indian Pediatr 2004;41:373-7.  Back to cited text no. 3
    
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Gül U, Cakmak SK, Gönül M, Kiliç A, Bilgili S. Pediatric skin disorders encountered in a dermatology outpatient clinic in Turkey. Pediatr Dermatol 2008;25:277-8.  Back to cited text no. 4
    
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Sardana K, Mahajan S, Sarkar R, Mendiratta V, Bhushan P, Koranne RV, et al. The spectrum of skin disease among Indian children. Pediatr Dermatol 2009;26:6-13.  Back to cited text no. 5
    
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Tollefson MM, Crowson CS, McEvoy MT, Maradit Kremers H. Incidence of psoriasis in children: A population-based study. J Am Acad Dermatol 2010;62:979-87.  Back to cited text no. 6
    
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Mallory SB, Bree A, Chern P, editors. Papular and papulosquamous disorders. In: Illustrated Manual of Pediatric Dermatology. 1st ed. Oxon: Taylor and Francis; 2005. p. 33-48.  Back to cited text no. 8
    
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Nyfors A, Lemholt K. Psoriasis in children. A short review and a survey of 245 cases. Br J Dermatol 1975;92:437-42.  Back to cited text no. 9
    
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Morris A, Rogers M, Fischer G, Williams K. Childhood psoriasis: A clinical review of 1262 cases. Pediatr Dermatol 2001;18:188-98.  Back to cited text no. 10
    
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Kumar B, Jain R, Sandhu K, Kaur I, Handa S. Epidemiology of childhood psoriasis: A study of 419 patients from Northern India. Int J Dermatol 2004;43:654-8.  Back to cited text no. 11
    
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Seyhan M, Coşkun BK, Sağlam H, Ozcan H, Karincaoğlu Y. Psoriasis in childhood and adolescence: Evaluation of demographic and clinical features. Pediatr Int 2006;48:525-30.  Back to cited text no. 12
    
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Fan X, Xiao FL, Yang S, Liu JB, Yan KL, Liang YH, et al. Childhood psoriasis: A study of 277 patients from China. J Eur Acad Dermatol Venereol 2007;21:762-5.  Back to cited text no. 13
    
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Raychaudhuri SP, Gross J. A comparative study of pediatric onset psoriasis with adult onset psoriasis. Pediatr Dermatol 2000;17:174-8.  Back to cited text no. 14
    
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Farber EM, Carlsen RA. Psoriasis in childhood. Calif Med 1966;105:415-20.  Back to cited text no. 15
    
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Nanda A, Kaur S, Kaur I, Kumar B. Childhood psoriasis: An epidemiologic survey of 112 patients. Pediatr Dermatol 1990;7:19-21.  Back to cited text no. 16
    
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Wu Y, Lin Y, Liu HJ, Huang CZ, Feng AP, Li JW, et al. Childhood psoriasis: A study of 137 cases from central China. World J Pediatr 2010;6:260-4.  Back to cited text no. 17
    
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Al-Fouzan AS, Nanda A. A survey of childhood psoriasis in Kuwait. Pediatr Dermatol 1994;11:116-9.  Back to cited text no. 18
    
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Uber M, Abagge KT, Robl R, Carvalho VO, Marinoni LP. Nail changes in psoriatic children. Indian J Dermatol Venereol Leprol 2016;82:314-6.  Back to cited text no. 19
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Lysell J, Tessma M, Nikamo P, Wahlgren CF, Ståhle M. Clinical characterisation at onset of childhood psoriasis – A cross sectional study in Sweden. Acta Derm Venereol 2015;95:457-61.  Back to cited text no. 20
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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