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Management of Pediatric Psoriasis Tina Bhutani, MD; Faranak Kamangar, Bsc; and Kelly M

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Management of Pediatric Psoriasis Tina Bhutani, MD; Faranak Kamangar, Bsc; and Kelly M CM E Management of Pediatric Psoriasis Tina Bhutani, MD; Faranak Kamangar, BSc; and Kelly M. Cordoro, MD soriasis is a chronic inflamma- More than one-third of patients pres- children10 but, when present, are typi- tory disease of the skin, nails, ent before age 20.5-9 cally accompanied by systemic signs, Pand joints. Overall prevalence The pattern of psoriasis presenta- including fever, chills, malaise, and in the US is 2.5%.1-3 Among children tion in children can vary from what is subsequent dehydration and toxicity. aged 0 to 18 years, prevalence is 1% classically observed in adults. Children Nail involvement such as pitting, ony- and incidence is 40.8 per 100,000.4 have increased involvement of the face cholysis, and subungual debri can oc- and anogenital regions, and pruritus cur with all types of psoriasis and can CM E EDUCATIONAL OBJECTIVES is common.10 Plaque-type psoriasis is serve as a diagnostic clue (Figure 1e, 1. Provide a practical approach to the most common (73.7%)4 and presents as see page e2). management of psoriasis in the pediatric primary care setting. erythematous plaques with silvery-white The differential diagnosis for pso- scales typically involving the scalp, riasis in children depends on the site 2. Review the proper selection and utilization of topical agents for the postauricular region (Figure 1a, see page of involvement. Scalp psoriasis pres- management of pediatric psoriasis. e2), elbows, knees, umbilicus, and but- ents with discrete or confluent red 3. Recognize moderate-to-severe tocks (Figure 1b, see page e2). patches with silvery scale. The scale psoriasis and when referral to a Guttate psoriasis is the next most may become very thick and mat the dermatologist for advanced man- common type (13.7%);4 it is composed hair down in clusters. This is referred agement is indicated. of few to numerous small (less than 1 to as pityriasis amiantacea (Figure 1a, Tina Bhutani, MD, is Clinical Research cm), drop-like erythematous scaly pap- see page e2). The differential for scalp Fellow, UCSF Psoriasis and Skin Treatment ules (Figure 1c, see page e2). Guttate psoriasis includes: seborrheic derma- Center, UCSF Department of Dermatology. psoriasis has a documented association titis in infants and adolescents; atopic Faranak Kamangar, BSc, is Clinical Research with pharyngeal — and less commonly dermatitis (usually accompanied by Associate, UCSF Psoriasis and Skin Treatment — perianal, streptococcal infection.11 other signs, symptoms, or a family Center UCSF Department of Dermatology. Other common types are inverse history of atopy); and tinea capitis, Kelly M. Cordoro, MD, is Assistant Professor psoriasis, involving the skin folds and which should be ruled out with a fun- of Clinical Dermatology and Pediatrics, Uni- flexures (neck, axillae, groin), and gal culture. versity of California, San Francisco. psoriasis in the anogenital area (diaper Plaque and guttate psoriasis may Address correspondence to: Kelly M. Cor- or “napkin” psoriasis). Diaper psoria- be confused with nummular atopic doro, MD, University of California, San Fran- sis is especially common in children dermatitis, a form of atopic dermatitis cisco; fax: 415-353-7478; email: cordorok@ younger than 2 years of age and pres- presenting with coin-shaped lesions. derm.ucsf.edu. ents as bright- to dull-red smooth or This also is typically accompanied by Dr. Bhutani and Ms. Kamangar have dis- slightly scaly erythema in the diaper a personal or family history of atopy, closed no relevant fi nancial relationships. area, which may be accompanied by and pityriasis rosea, a viral exanthem Dr. Cordoro has disclosed the following more typical psoriasis in other loca- that follows Langer’s lines on the skin relevant fi nancial relationships: consulting fees, Topaz Pharmaceuticals. tions (Figure 1d, see page e2). and thus is distributed in the classic doi: 10.3928/00904481-20111209-08 Pustular and erythrodermic psoria- “Christmas tree” pattern on the trunk sis are uncommon subtypes in young and proximal extremities. Diaper pso- PEDIATRIC ANNALS 41:1 | JANUARY 2012 www.PediatricSuperSite.com | e1 PPED0112Cordoro-olo.inddED0112Cordoro-olo.indd ee11 112/30/20112/30/2011 22:03:03:03:03 PPMM CM E abc def Figure 1. (a) scalp psoriasis; (b) typical plaque psoriasis; (c) guttate psoriasis; (d) diaper psoriasis; (e) nail psoriasis (pits); (f) adolescent with atrophy and striae after using a highly potent topical steroid (clobetasol) twice daily for 6 months. Source: a-e, Cordoro KM; f, Sugarman J. Reprinted with permission. riasis must be differentiated from ir- cardiovascular risk. Psoriasis is also an individual basis. Counseling for ritant diaper dermatitis (which spares associated with increased rates of patients with severe psoriasis is ap- the folds) or candidal diaper dermatitis depression and decreased quality of propriate, since adult and preliminary (“beefy” red plaques with characteris- life.13 Comorbidities in the pediatric pediatric data show that the risk for tic satellite papules and pustules).12 population are less well defined, but comorbidities, especially obesity, hy- data are emerging linking psoriasis to pertriglyceridemia, and hyperglyce- ENVIRONMENTAL TRIGGERS obesity and depression in children.14 mia, increases with disease severity.17 A thorough history and physical Psoriatic arthritis in children is well should be performed to identify poten- documented, with a prevalence rang- TREATMENT tial disease triggers. These include trau- ing from 5% to 40%.10,15 Onset age of Topical Therapy ma (Koebner phenomenon), infections psoriatic arthritis in children is usually Available topical treatment ve- (especially pharyngeal and perianal between 9 and 12 years. Severe nail hicles include creams, ointments, group A beta-hemolytic streptococci and and digital disease is a clinical predic- foams, gels, lotions, liquid solutions, viruses including HIV), drugs (particu- tor of joint disease.16 However, cor- sprays, oils, and drug-impregnated larly recent oral steroid withdrawal), and relation between the severity of skin tapes. Thicker vehicles such as oint- physical or psychological stress.10 disease and arthritis is usually poor.15 ments (usually petrolatum) are more Since the true risk in this popula- occlusive and therefore often more COMORBIDITIES tion is insufficiently investigated, effective than creams and lotions. Psoriasis is a chronic inflamma- whether pediatricians and dermatolo- Choice of vehicle is based on the lo- tory disease that may not be limited gists should screen youths with psori- cation of the psoriasis and patient to the skin. Studies in adults have asis for the presence of comorbid con- preference. Plaques on the extremities demonstrated an association between ditions remains to be established. A call for ointments or creams, where- psoriasis and metabolic syndrome reasonable approach is a detailed his- as hair-bearing sites (scalp) require (hypertension, obesity, dyslipidemia, tory and physical examination, with thinner preparations such as liquids, and hyperglycemia)12 and increased directed investigations performed on gels, lotions, sprays, oils, or foams.18 e2 | www.PediatricSuperSite.com PEDIATRIC ANNALS 41:1 | JANUARY 2012 PPED0112Cordoro-olo.inddED0112Cordoro-olo.indd ee22 112/30/20112/30/2011 22:03:03:03:03 PPMM CM E Twice-daily application is required for Face/Anogenital: Scalp: maximum effect of most topical medi- · Low-potency TCS · Low- to high-potency TCS or shampoo cations. The traditional dogma that · TCI · Calcipotriene solution · 3% LCD (in emollient or 1% HC) · Tar/LCD lotion, foam, or shampoo ointments are more effective must be · Emollient · Keratolytics (salicylic acid gel or shampoo; lactic acid, urea) reconciled with patient preference to Eyelids: · Anthralin · 1% HC ointment or TCI select vehicles that the patient will ac- · Emollient Trunk/Extremities: tually apply. Adolescents often object · Low- to high-potency TCS · Calcipotriene to greasy ointments on the body and Palms/Soles: · 5% to 20% LCD in low-mid TCS · Mid- to high-potency TCS · Tazarotene (thick plaques) prefer creams, lotions, or foams. An ef- · 5% to 20% LCD in TCS · Keratolytics prn · Salicylic acid (>6 y/o) fective compromise is to prescribe cos- · Urea 10% to 40% metically acceptable vehicles for day- · Tazarotene Nails: · Calcipotriene · Tazarotene time use and reserve oils and ointments · TCI (esp. for pustular variants) for nighttime use. · Calcipotriene TCS: topical corticosteroids · TCS (beware of digital atrophy) HC: hydrocortisone · Keratolytics prn LCD: liquor carbonis detergens Corticosteroids Keratolytics: salicylic or lactic Topical corticosteroids (TCS) are the acid; urea 10% to 40% fi rst-line agents for treatment of psoria- Figure 2. Guide to site-based topical therapy for psoriasis. Source: Cordoro KM. Reprinted with permission. sis in all age groups and all body sites. They are anti-infl ammatory, anti-prolif- erative, and reduce erythema, scaling, avoided or used sparingly in infants. There are a multitude of TCS formu- and pruritus.19 TCS range in potency To decrease the risk of potential ad- lations and potencies (see Table, page from the very weak Class VII to high- verse effects, such as cutaneous atro- e4). For practical purposes, start with a ly potent Class I agents.20 In general, phy, combine or rotate topical steroids short list of at least one generic medi- psoriasis on sensitive or occluded sites with steroid-sparing alternatives, such cation from each of the potency class- (face, neck, genitalia/diaper
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