ARTICLE IN PRESS

Current Paediatrics (2003) 13, 418 -- 422

c 2003 Published by Elsevier Ltd.
doi:10.1016/S0957-5839(03)00084- 8

Recognition and treatment of psoriasis in children

J.A. Leman and A.D. Burden

Department of Dermatology, Royal Hospital for Sick Children, Glasgow, G3 8SJ, UK

KEYWORDS
childhood psoriasis; genetic
factors; environmental
triggers; clinical forms;
management strategies
Summary Psoriasis frequently presents in childhood and is usually easily recognized.
Mild disease or an atypicalpresentation maypresentdiagnostic diff|culty.There are many
clinical patterns, and anogenital, facial and guttate lesions are particularly well recog-
nized in this age group. Education of children and parents about disease chronicity and
treatment options is essential for successful management. Most patients respond to to-
pical treatment with emollients, coal tar, dithranol or calcipotriol. Supervision of the ap-
plication of topical medicaments in a daycare setting, or admission to a ward, may be
necessary if response to outpatienttreatment is disappointing.Phototherapy with ultra-
violet B may be combined with topical treatment in older children with more extensive
disease. A minorityof childrenwith particularly severe disease require systemic therapy.
Retinoids are the most commonly used agents.There are few published data regarding
methotrexate or cyclosporin in childhood psoriasis, although these agents appear to
have a role in those most severely affected.
c 2003 Published by Elsevier Ltd.

PRACTICE POINTS
* Childhood psoriasis can usually be suppressed ade-
quately with topical agents
* Adequate disease control requires a high degree of
parental motivation
* In severe psoriasis, phototherapy or systemic ther-
apy can be highly effective
INTRODUCTION
Psoriasis is an inherited, chronic, inflammatory condition
of the skin that affects about 2% of the population and
often presents in childhood.The clinical course is unpre-
dictable, characterized by remissions and relapses. On
histological examination, plaques reveal hyperprolifera-
tion and abnormal differentiation of keratinocytes, vas-
cular endothelial proliferation and inflammatory cell
inf|ltration. The aetiology and pathogenesis of psoriasis
remain enigmatic. It is likely that there is interplay be-
tween genetic and environmental factors. T cells play a
pivotal role, and the cytokine pattern is skewed towards
Th1.There is compelling evidence of a genetic predisposi-
Correspondence to: JAL.Tel.: +44(0)141211 6259;
E-mail: Joyce.leman.wg@northglasgow.scot.nhs.uk.
tion with lifetime risks of 4%, 28% and 65% if neither, one
or both parents, respectively, are affected.1 Nine named
genetic susceptibility loci (PSORS1--PSORS9) have been
detected by linkage analysis, but the genetic determi-
nants at these loci have not yet been identif|ed. The sus-
ceptibility locus with the greatest genetic effect
(PSORS1) lies on chromosome 6p21.3 in the region of
the major histocompatability complex.2 Psoriasis has
been subdivided by age of onset.3 Type 1 psoriasis has an
age of onset o40 years, is often familial and is strongly
associated with HLA Cw6. In contrast, presentation la-
ter in life (type 2 psoriasis) is less often familial and is
not associated with the Cw6 allele.
CLINICAL FEATURES
Psoriasis is diagnosed prior to the age of 2 years in 2% of
cases and before10 years in10% of cases.The age at onset
is younger in girls than boys. Establishing the diagnosis in
infancy can be challenging because of limited involve-
ment or an atypical appearance. Under these circum-
stances, observing the natural history as it evolves is
often more helpful than taking a skin biopsy in reaching
a diagnosis.
All of the clinical variants of psoriasis described in
adults are recognized in childhood.4 Different forms
may occur in the same patient at different times. Plaque
 ARTICLE IN PRESS
RECOGNITION ANDTREATMENTOF PSORIASIS
psoriasis is the most common variant encountered in
children.Typical lesions are 5--10 cm in diameter, symme-
trically located over extensor surfaces of the limbs.Facial
involvement appears to be particularly common in chil-
dren compared with adults (Fig.1).The scalp is frequently
involved, and this must be distinguished from sebor-
rhoeic dermatitis or tinea capitis.
The involvement of flexural surfaces is particularly
common in young children.The napkin area is frequently
the f|rst site affected, with well-def|ned erythema devoid
of scale. At this site, psoriasis must be differentiated
from irritant contact dermatitis and seborrhoeic derma-
titis. Napkin seborrhoeic dermatitis is a particular diag-
nostic problem as a signif|cant proportion of affected
children develop psoriasis in adulthood.5 Psoriatic nail
changes (often misdiagnosed as fungal infection) are
characterized by superf|cial pits, onycholysis and subun-
gal hyperkeratosis.
Guttate psoriasis develops suddenly, often in response
to a streptococcal infection of the throat or skin. It is
characterized by the eruption of multiple papules 0.5--
1cm in diameter over the face, trunk and limbs (Fig. 2).
Infection may be conf|rmed by culturing a throat swab
and by measuring the serum antistreptolysin O titre.
Although most clinicians will treat any associated infec-
tion, evidence that this will ameliorate the psoriasis is
lacking.6 Lesions typically persist for a few months before
resolving spontaneously. However, many patients
experience a recurrence of either guttate or plaque
Figure 1 Involvement of the face by psoriasis is a particularly
common problem in children.
419
Figure 2 Guttate psoriasis is characterized by the eruption of
small papules of psoriasis, often related to a streptococcal sore
throat.
psoriasis over the next few years. Pityriasis rosea and
discoid eczema may cause diagnostic confusion.
Erythrodermic and pustular variants of psoriasis are
rare in childhood. Erythrodermic psoriasis may be preci-
pitated by drugs such as antimalarials. Pustular psoriasis,
a potentially life-threatening disorder in adults, often fol-
lows a more benign course in childhood. It may be preci-
pitated by infection, corticosteroids or ultraviolet B
exposure.The pustules, which are superf|cial and sterile,
may be generalized or localized.General malaise, pyrexia
and anorexia are frequent accompaniments. Pustular
psoriasis may be the f|rst presentation of psoriasis. In
about one-third of cases, there is a preceding history of
seborrhoeic dermatitis or napkin dermatitis.
Psoriatic arthropathy, a seronegative inflammatory ar-
thritis, is uncommon in childhood. The long-term prog-
nosis is usually favourable. Distinction should be made
from juvenile rheumatoid arthritis and ankylosing spon-
dylitis.7
TREATMENT
For the majority of patients, psoriasis is mild and easy to
control. In a minority, the disease presents a challenging
management problem. Customising treatment to reflect
patient age, extent, severity and location is imperative. In
younger patients, compliance often reflects parental mo-
tivation. From the outset, it should be emphasized that a
realistic objective is to control rather than cure the dis-
ease. The possibility that factors such as streptococcal
infection, psychological stress or trauma (the Koebner
or isomorphic phenomenon) could be contributing to
ongoing activity or flares should be considered.
Topical treatment
Most childhood psoriasis will respond well to topical
agents. Cosmetic acceptability of agents should be con-
sidered as this can greatly influence patient compliance.
 ARTICLE IN PRESS
420
Most patients can apply topical treatments at home un-
der parental supervision. Initial demonstration of appli-
cation of treatments by skilled dermatology nurses may
be helpful. If response to therapy is poor or disease is
particularly extensive, attendance at a day treatment
centre or admission to an inpatient facility may be helpful
if available.
Emollients
The application of an emollient reduces scaling and re-
lieves itch. They are inexpensive and well tolerated. In
mild disease, this may be the only therapy required.
Topical corticosteroids
Topical corticosteroids are particularly useful when itch
is a major symptom. Their lack of odour and ease of ap-
plication make them popular with patients. They have
anti-inflammatory and antiproliferative effects, reducing
erythema and scaling of plaques. They may be used as
monotherapy on the flexures, face or scalp-sites prone
to irritation from other topical preparations. On stable
plaque disease, they are often combined with other
agents such as calcipotriol. In general, the least potent
topical corticosteroid should be used for the shortest
possible time to minimize the risks of long-term sequelae
such as striae and telangiectases. Application under oc-
clusion may be clinically benef|cial but does lead to en-
hanced penetration and therefore potentiation of
adverse effects. Extensive application can lead to sup-
pression of the hypothalamic--pituitary--adrenal axis. Re-
bound flare of disease is well recognized if topical
corticosteroids are withdrawn abruptly. A gradual
reduction is advocated.
Tars
Tars are widely used in the treatment of psoriasis, but
their odour and tendency to stain limit their acceptabil-
ity to patients.They have antiproliferative and antipruri-
tic effects. Irritancy is low and tars such as coal tar or
ichthyol may be prescribed for sensitive sites such as the
face and flexures, as well as plaques on trunk and limbs.
Combining tar and ultraviolet B (Goeckerman regimen)
may be helpful, especially for extensive plaque or guttate
disease.
Dithranol (Anthralin)
Dithranol is an effective treatment, particularly for
large, thick plaques. In a study of children aged 5--10
years, remission was achieved using dithranol in 47 of 58
(81%) children.8 The application of dithranol (0.1% up to
3%) washed off after 30 -- 45 min maintains eff|cacy but
reduces side effects. A cream base preparation is avail-
able for home use. Daycare patients and inpatients are
often treated with dithranol in Lassars paste which is
more effective but less cosmetically acceptable. Dithra-
nol stains skin and clothing, has a propensity to irritate
CURRENT PAEDIATRICS
flexural, face and genital lesions, and burns healthy peri-
lesional skin. Parental supervision of application and the
use of a protective greasy emollient around plaques are
advocated.
Vitamin D analogues
Vitamin D stimulates differentiation and inhibits DNA
synthesis and cell proliferation in cultured keratinocytes.
In addition, a role in immunomodulation is postulated.
However, effects on calcium homeostasis restrict the
clinical use of vitamin D3.Calcipotriol, a synthetic analo-
gue of vitamin D3, has a lesser effect on calcium home-
ostasis. Patient acceptability is high as the preparation is
clean and odour free. In a UK multicentre open study of
66 children, calcipotriol 50 mg/g was applied twice daily
for up to 8 weeks (maximum 45 g/week/m2). Clinical
clearance or marked improvement was documented in
65% of cases, and the psoriasis area and severity index
(PASI, a standard measure of disease extent) was signif|-
cantly reduced.9 An international, double-blind, parallel
group study in 77 children compared calcipotriol 50 mg/
g twice daily with placebo over an 8 -week period.10 Tol-
erability of the treatment was conf|rmed but the fall in
PASI was not signif|cantly different in the two groups.
Calcipotriol may cause irritation if applied to the face,
napkin or genital areas. In the UK, calcipotriol 50 mg/g is
licensed for use in children at a maximum dose of 50 g/
week in those aged over 6 years and 75 g/week in those
aged over 12 years. Tacalcitol and calcitriol are also
vitamin D analogues that are commercially available,
but there are no published data concerning their use in
children.
Topical retinoids
Tazarotene is a receptor-specif|c topical retinoid licensed
for use in adults. However, it remains untested in child-
hood psoriasis. In adults, local irritation is commonly
reported and may be ameliorated by the additional use
of a topical steroid.
Topical immunomodulators
Tacrolimus inhibits T-cell activation and has been shown
to be effective when administered orally in adults with
chronic plaque psoriasis. In pilot studies, non-occluded
topical application is no more effective than placebo. This
may reflect poor penetration into thick psoriatic pla-
ques. In childhood, facial psoriasis is common and the
stratum corneum at this site is thin. Topical tacrolimus
0.1%, applied twice daily for 4 weeks to facial lesions, has
been reported to be effective in 10 of 11 adult patients.11
Phototherapy
Ultraviolet B (UVB) phototherapy is highly effective in
inducing a remission in widespread psoriasis. The dura-
tion of remission is variable between patients but can last
 ARTICLE IN PRESS
RECOGNITION ANDTREATMENTOF PSORIASIS
for months or even years. Increasingly, fluorescent tubes
that emit a wavelength of 31172 nm (narrow-band UVB)
are used as this appears to be more effective than pre-
viously used broad-band UVB. Treatment is usually given
three times a week for about 6 weeks with increasing
doses as tolerated. Combining UVB and topical prepara-
tions such as tar or calcipotriol is benef|cial. Side effects
of UVB include immediate burning and delayed photocar-
cinogenicity. Particular concerns about increased photo-
carcinogenesis in children limit the use of UVB in this age
group, as do the practical diff|culties of administering the
treatment in young children.12
Systemic therapy
In adults with psoriasis, retinoids, cyclosporin and meth-
otrexate are the most frequently used agents but data
relating to their use in childhood psoriasis are lacking.
Only in the most severe cases of psoriasis (pustular, ery-
throdermic, arthropathic and extensive resistant plaque
psoriasis) are such agents appropriate. Their introduc-
tion should be made under the supervision of an experi-
enced dermatologist, and parents must be advised of
possible adverse effects and the need for monitoring.
Retinoids
Acitretin (0.25-- 0.6 mg/kg) is the most commonly used
agent. Only case reports and small case series support
its use in childhood psoriasis,13,14 although retinoids have
been used extensively in inherited disorders of keratini-
zation. Measurements of baseline lipid prof|le and liver
enzymes are required, repeated at 3-monthly intervals.
Girls of childbearing age must be counselled of the abso-
lute necessity of avoiding pregnancy during and for
2 years after cessation of the drug. Dryness of the
skin and mucous membranes and myalgia are common
adverse effects.
Methotrexate
Methotrexate has a direct effect on T lymphocytes as
well as on the keratinocyte cell cycle.There are few pub-
lished studies on its use in childhood psoriasis.15,16 Seven
children, aged between 3 and 16 years, with erythroder-
mic, generalized pustular psoriasis or psoriatic arthropa-
thy tolerated doses of 0.2-- 0.4 mg/kg without
biochemical or haematological upset. Gastrointestinal
upset was common but responded to folic acid.16 Bone
marrow suppression is dose dependent and occurs early.
Hepatotoxicity is thought to be related to the total cu-
mulative dose. Baseline full blood count, liver enzymes
and renal function are required. Initially, these assays are
repeated weekly, then monthly and eventually 3-
monthly. Some guidelines recommend monitoring by re-
peated liver biopsy because of the lack of sensitivity of
elevated liver enzymes in detecting hepatic f|brosis.
421
Non-invasive techniques such as serial measurement of
serum procollagen III peptide are under investigation.
Cyclosporin
Cyclosporin is a potent inhibitor of IL-2 production from
T lymphocytes. Literature on its use in childhood psoria-
sis is sparse but there is considerable experience in child-
hood atopic eczema and in adult psoriasis. Cyclosporin is
best used to achieve remission rather than for mainte-
nance therapy.
A single case was reported of a 9-year-old boy with
generalized pustular psoriasis who responded to cyclos-
porin 3 mg/kg/day.17 However, four patients with eythro-
dermic or pustular psoriasis failed to respond adequately
to cyclosporin (2.5--7.5 mg/kg/day).18 In one of these four
patients, cyclosporin was accidentally given at 10 mg/kg/
day and was effective at this dose.The use of cyclosporin
in the paediatric transplant population suggests that
children may require a relatively higher dose or a more
frequent dosing regimen than adults. 19
CONCLUSIONS
Parental and physician attitudes can have a major impact
on the disability caused by psoriasis. The disease can
usually be well controlled with the use of topical agents,
but modern treatment remains suppressive rather than
curative or disease-modifying.Only the most severely af-
fected are likely to require second-line agents, which
should be introduced only by experienced dermatolo-
gists and require monitoring for the duration of treat-
ment. The dramatic response of psoriasis to anti-TNFa
therapy raises the possibility of newer, more effective
treatments.20 The development of more selective immu-
nomodulatory drugs for psoriasis is an area of very ac-
tive research and development.
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