Interestingly, Augustin et al. The prevalence of psoriasis patients with an affected family member is observed to be greater in early-onset psoriasis defined as psoriasis onset before the age of 16 than in adult-onset psoriasis defined as psoriasis onset after the age of 16 [ 5 , 29 , 31 , 32 ]. Chiam et al. A positive family history of psoriasis was reported in These differences point to the role of genetic background within each population of patients with juvenile psoriasis [ 23 , 28 ].
Although children present with the same clinical subtypes of psoriasis seen in adults, lesions may differ in distribution and morphology, and their clinical symptoms at presentation may vary from those reported by adults. In childhood, typical erythematous plaques with overlying white scale are often thinner and smaller and psoriasis lesions tend to develop more often on the face and flexural areas. These lesions are characterized by maceration and less prominent scale [ 22 , 28 ].
Despite these predilection sites, psoriasis papules and plaques can develop on any skin area and are usually symmetrically distributed [ 33 ]. Young children usually present with a diaper rash that is unresponsive to irritant diaper dermatitis treatment. Psoriatic diaper rash is seen in young infants and is characterized by sharply demarcated, minimally elevated erythematous plaques in the diaper area, involving the inguinal folds.
Psoriasis in Children and Adolescents: Diagnosis, Management and Comorbidities
Morris et al. Diaper psoriasis can be particularly difficult to treat [ 23 ]. This is the most common type of psoriasis in children and adults and is characterized by well defined erythematosquamous papules or plaques with overlying silvery-white scale. The lesions vary in size and develop primarily on the scalp, face and extensor surfaces of the elbow and knee.
The scalp is the most frequently involved area and often the first site of presentation in children [ 29 , 35 ]. Guttate psoriasis is the second most common type of psoriasis in children [ 21 , 29 ]. It has been reported that a proportion of individuals with guttate psoriasis eventually develop plaque psoriasis [ 22 , 24 , 25 , 36 , 37 ].
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Mercy et al. Prospective cohort studies are needed to further determine features and percentages of children with guttate psoriasis who develop plaque psoriasis.
Pustular psoriasis is seen in only 1. In a minority of these patients, mutations of the interleukin IL receptor antagonist IL36RN gene and subsequent upregulation of IL-1 production have been identified [ 38 ]. Pustular psoriasis is characterized by localized or generalized superficial sterile pustules and can be accompanied by fever, malaise and arthralgias in the case of classical von Zumbusch type. Although pustular psoriasis is more common in adults, von Zumbusch pustular psoriasis and pustular psoriasis with an annular configuration occur more frequently in childhood [ 31 , 39 ].
Other less common subtypes of psoriasis are inverse psoriasis, palmoplantar psoriasis, isolated facial psoriasis, linear psoriasis and erythrodermic psoriasis [ 17 ]. The condition is extremely rare in children and can be life-threatening because of severe hypothermia, hypoalbuminemia and cardiac failure [ 17 , 32 ].
Psoriasis of the skin can be accompanied by changes of the nail plate and nail bed.
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Nail changes can precede, coincide with, or develop after skin psoriasis. Whether these changes relate to patient age or disease severity vary among studies [ 25 , 40 ]. The most common presentation is pitting of the nail plate.
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Other characteristics include oil spots, onycholysis distal separation of the nail plate from the nail bed , subungual hyperkeratosis, onychodystrophy and splinter hemorrhages [ 41 ]. Juvenile psoriatic arthritis JPsA is another manifestation of psoriasis in children. The peak of onset in childhood is between ages 9 and 12, and the skin psoriasis often precedes psoriatic arthritis.
Although a relationship between nail involvement and psoriatic arthritis in adults has been suggested, recent studies in both children and adults do not support this correlation [ 25 , 32 , 50 ]. In addition to the clinical features described above, children often present with a thinner surface scale compared with adults. When scraping off scales, punctuate bleeding spots occur, a phenomenon known as the Auspitz sign.
The occurrence of lesions in areas of trauma, also called isomorphic response or Koebner phenomenon, and residual pigmentation following healing of lesions are other typical diagnostic features of psoriasis [ 34 ]. Although the diagnosis of psoriasis is primarily based on clinical features, biopsy can help to confirm the diagnosis in children with atypical presentations. Histological features of psoriasis include parakeratosis, loss of the granular cell layer, elongation of the rete ridges, neutrophilic aggregates within the epidermis microabscesses of Munro , dilated blood vessels in the dermis, and perivascular lymphocytic infiltrates [ 17 , 51 , 52 ].
Given that the diagnosis is usually made on the basis of morphology and distribution, a biopsy is virtually never performed, especially not in children. In atypical cases in which a diagnosis is required, topical therapy should ideally be discontinued prior to biopsy to avoid alteration of histological features [ 53 ]. Dermoscopy has become a standard diagnostic tool in dermatology. Although this technique permits visualization of morphological structures invisible to the naked eye, it is not commonly used in the diagnosis of psoriasis.
Lallas et al. Dotted vessels regularly distributed over a light red background and diffuse superficial white scales are typical dermatoscopic characteristics of a psoriasis plaque [ 54 , 55 ]. Further research is warranted to determine the added value of dermoscopy in diagnosis and predicting response to treatment. Treating pediatric psoriasis can be challenging and requires careful compliance to a specific treatment regimen. Poor treatment adherence is rampant in psoriasis, in particular to topical agents [ 56 , 57 ]. Educating the patient and family on the chronicity of psoriasis, triggering factors, and treatment modalities is important, in addition to prescribing treatment.
Timing of the first return visit may be a practical tool to enhance patient adherence [ 29 ]. Psychosocial support is another important component of therapy for children with psoriasis [ 7 ].
Psoriasis in Children and Adolescents: Diagnosis, Management and Comorbidities | SpringerLink
To date, treatment is primarily based on published case reports, guidelines for adult psoriasis, expert opinions and experience with these drugs in other pediatric disorders. The range of psoriasis treatments has been expanded during the past several years, and multiple topical agents, phototherapy and systemic and biological agents are available to date [ 53 ]. Several factors need to be taken into account when selecting a specific treatment, e. The majority of children with psoriasis can be managed with topical treatment, which is considered first-line therapy in psoriasis.
However, most are not approved for pediatric use, requiring off-label prescribing [ 61 ]. The most commonly used topical agents will be reviewed below. The vehicle for treatment is important and depends on the location of psoriasis, lesional characteristics, and patient preference [ 62 ].
Available vehicles include creams, ointments, foams, gels and lotions. Topical steroids are the most commonly prescribed medications to treat psoriasis in all age groups. Steroids are available in a wide variety of strengths and vehicles. In adults, low- to mid-potency corticosteroids are used in facial, flexural and genital lesions, with use of high-potency corticosteroids in combination with penetration enhancers in areas of thick skin, such as the palms and the soles.
In a systematic review on treatments in childhood psoriasis, three studies on the efficacy and safety of topical corticosteroids were reported [ 63 ]. Based on these studies, it was concluded that halobetasol cream 0.
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Apart from these studies with the strongest steroids available, no reports on the efficacy and safety of topical corticosteroids in pediatric psoriasis were found. Therefore, corticosteroids should be used with caution through intermittent or rotational use to limit possible side effects [ 29 , 32 ]. Studies with topically administered calcipotriol and calcitriol have shown efficacy in pediatric psoriasis patients with only mild side effects [ 63 ].
Localized skin irritation and pruritus are the most common side effects, and use of these preparations is therefore avoided on areas with thinner skin, such as the face, genital and flexural areas [ 53 ]. However, calcitriol ointment has been found to be less irritating than calcipotriol ointment if used in intertriginous psoriasis [ 29 , 62 ].
Systemic absorption of vitamin D and increasing calcium levels could theoretically occur, but are unlikely if used appropriately [ 34 ]. Although vitamin D analogs may be used as monotherapy, they are often prescribed in combination with topical corticosteroids, leading to drug synergy and a steroid-sparing effect [ 32 , 68 ].
In order to avoid separate applications and to enhance patient compliance, a commercially available compounded formulation containing calcipotriol and betamethasone dipropionate has been developed. Three studies describe the efficacy and safety of this formulation in pediatric psoriasis [ 69 , 70 , 71 ].
Continued treatment seemed to stabilize psoriasis in these children. Five children reported an adverse event, most commonly the development of striae [ 69 ]. A multicenter, open-label study by Gooderham et al. Oostveen et al. Striae of the skin arms, trunk and legs were described in three patients [ 71 ]. In adults, tacrolimus 0.
The efficacy and safety of tacrolimus 0. The only reported adverse effect was pruritus in one patient [ 73 , 74 ]. Concomitant treatment with phototherapy and excessive sun exposure should be avoided because of the possible increased risk for skin cancer and lymphoma.
However, further research is warranted to study possible long-term adverse effects [ 60 ]. Dithranol, also referred to as anthralin, is a topical agent with both anti-inflammatory and anti-proliferative properties and no significant systemic absorption. It is an effective and safe treatment option for pediatric psoriasis [ 32 , 36 ]. Short-contact dithranol at higher concentrations 0.