Psoriasis in Children - Clinicals, Diagnosis, and Management

Dermatology

Clinicals - History

Fact Explanation
Skin lesions with pruritus, burning and irritation This is seen due to inflammatory changes of the skin. Burning and irritating sensation are not common . Skin lesions with pruritus, burning and irritation
This is seen due to inflammatory changes of the skin. Burning and irritating sensation are not common .
History of precipitating factors Infection by streptococcus (sore throat) as a precipitating factor is seen more in Guttate psoriasis than in other types of psoriasis .
Other factors are trauma, drugs, vaccination and emotional factors .
Drugs include antimalarials and steroids.
These factors activate the immune system and enhance keratinocyte proliferation .
History of precipitating factors
Infection by streptococcus (sore throat) as a precipitating factor is seen more in Guttate psoriasis than in other types of psoriasis .
Other factors are trauma, drugs, vaccination and emotional factors .
Drugs include antimalarials and steroids.
These factors activate the immune system and enhance keratinocyte proliferation .
Family history of psoriasis Due to genetic susceptibility. HLA genes are thought to be involved in the pathogenesis . Psoriasis in a first degree relative is seen in more than 50% of patients . Family history of psoriasis
Due to genetic susceptibility. HLA genes are thought to be involved in the pathogenesis . Psoriasis in a first degree relative is seen in more than 50% of patients .
Joint symptoms Pain/ swelling/ erythema of distal interphalangeal joints, shortening of fingers due to arthritis mutilans, back pain and buttock pain due to sacroileitis and ankylosing spondylitis are manifestations of psoriatic arthritis. This is seen in 1% of children with psoriasis . Joint symptoms
Pain/ swelling/ erythema of distal interphalangeal joints, shortening of fingers due to arthritis mutilans, back pain and buttock pain due to sacroileitis and ankylosing spondylitis are manifestations of psoriatic arthritis. This is seen in 1% of children with psoriasis .
Eye symptoms (pain/ redness/ blurring of vision/ tearing) Occurs due to associated uveitis, conjunctivitis or episcleritis . Eye symptoms (pain/ redness/ blurring of vision/ tearing)
Occurs due to associated uveitis, conjunctivitis or episcleritis .

Clinicals - Examination

Fact Explanation
Skin lesions: plaque psoriasis Pink plaques with silvery scales on extensor/ flexor surfaces, lower back, ears and scalp. Involvement of the frontal hairline, gluteal cleft, axillae, inguinal creases and perineum can also be seen . Skin lesions: plaque psoriasis
Pink plaques with silvery scales on extensor/ flexor surfaces, lower back, ears and scalp. Involvement of the frontal hairline, gluteal cleft, axillae, inguinal creases and perineum can also be seen .
Skin lesions: Guttate psoriasis Commonly seen in children. Small 'rain-drop' like circular/oval plaques appear abruptly on the back, often following streptococcal infection . Skin lesions: Guttate psoriasis
Commonly seen in children. Small 'rain-drop' like circular/oval plaques appear abruptly on the back, often following streptococcal infection .
Skin lesions: Infantile psoriasis Lesions are seen in the skin folds including the diaper area, face, scalp, periumbilical area, palms & soles in infants . Skin lesions: Infantile psoriasis
Lesions are seen in the skin folds including the diaper area, face, scalp, periumbilical area, palms & soles in infants .
Skin lesions: Pustular psoriasis Lesions contain pustules with erythema and desquamation . Skin lesions: Pustular psoriasis
Lesions contain pustules with erythema and desquamation .
Koebner phenomenon New psoriatic plaques develop at the sites of trauma . Koebner phenomenon
New psoriatic plaques develop at the sites of trauma .
Nail changes T cell mediated enhanced keratinocyte proliferation leads to nail changes. Most common feature is pitting. Others include discoloration, oil spotting, distal subungual debri formation and onycholysis . Nail changes
T cell mediated enhanced keratinocyte proliferation leads to nail changes. Most common feature is pitting. Others include discoloration, oil spotting, distal subungual debri formation and onycholysis .
Psoriatic arthritis Swollen, tender, erythamatous joints are seen due to inflammatory changes brought by the activated immune system. Psoriatic arthritis
Swollen, tender, erythamatous joints are seen due to inflammatory changes brought by the activated immune system.

Investigations - Diagnosis

Fact Explanation
Histology of the skin lesions Shows epidermal hyperplasia, thinned out granlar layer, parakeratosis, intracorneal and intraepidermal neutrophils, perivascular lymphocytic infiltrate and dilated dermal capillaries with mild erythrocyte extravasation.
Note: Psoriasis is an essentially clinically diagnosis, made on the typical appearance of the skin lesions. Histology can be used when there is diagnostic uncertainity .
Histology of the skin lesions
Shows epidermal hyperplasia, thinned out granlar layer, parakeratosis, intracorneal and intraepidermal neutrophils, perivascular lymphocytic infiltrate and dilated dermal capillaries with mild erythrocyte extravasation.
Note: Psoriasis is an essentially clinically diagnosis, made on the typical appearance of the skin lesions. Histology can be used when there is diagnostic uncertainity .
KOH examination Used to exclude tinea/ candida infections giving rise to similar skin lesions of psoriasis, commonly in the inguinal region & nails . KOH examination
Used to exclude tinea/ candida infections giving rise to similar skin lesions of psoriasis, commonly in the inguinal region & nails .
Investigations for streprococcal infection: Antistreptolysin titre & throat cultre Increased antistreprolysin titre is sometimes seen in acute guttate psoriasis, as streptococcal infection acts as a triggering factor for acte guttate psoriasis. Throat culture for group A beta haemolytic streptococcus also supports in making the diagnosis . Investigations for streprococcal infection: Antistreptolysin titre & throat cultre
Increased antistreprolysin titre is sometimes seen in acute guttate psoriasis, as streptococcal infection acts as a triggering factor for acte guttate psoriasis. Throat culture for group A beta haemolytic streptococcus also supports in making the diagnosis .

Management - Supportive

Fact Explanation
Patient education and counselling Explaining the child and the parents about the chronic course of the disease, possibility of relapses even with medication, and about the triggering factors will help to cope with the disease well with minimal exacerbations . Patient education and counselling
Explaining the child and the parents about the chronic course of the disease, possibility of relapses even with medication, and about the triggering factors will help to cope with the disease well with minimal exacerbations .

Management - Specific

Fact Explanation
Tar preparations Preparations like anthralin, liquor picis carbonis are good for children as they are safe for long term use and less likelihood of relapse once termination of treatment.
Important: these preparations can be irritants to infants, and to any age when applied over the face & other sensitive areas .
Tar preparations
Preparations like anthralin, liquor picis carbonis are good for children as they are safe for long term use and less likelihood of relapse once termination of treatment.
Important: these preparations can be irritants to infants, and to any age when applied over the face & other sensitive areas .
Calcipotriol This is a synthetic derivative of vitamin D, effective in treatment of childhood psoriasis on long term.
Important: It is recommended to monitor vitamin D metabolites level during the treatment as calcipotriol may reduce the endogenous synthesis of vitamin D .
Calcipotriol
This is a synthetic derivative of vitamin D, effective in treatment of childhood psoriasis on long term.
Important: It is recommended to monitor vitamin D metabolites level during the treatment as calcipotriol may reduce the endogenous synthesis of vitamin D .
Topical immunomodulators: tacrolimus, pimecrolimus These act by inhibiting cytokine production and thereby suppressing the immune activity. Very effective mode of treatment for psoriasis in children. Can be applied safely to face and intertriginous areas, unlike steroids . Topical immunomodulators: tacrolimus, pimecrolimus
These act by inhibiting cytokine production and thereby suppressing the immune activity. Very effective mode of treatment for psoriasis in children. Can be applied safely to face and intertriginous areas, unlike steroids .
Steroids Effective treatment mode for plaque type psoriasis . However, the side effect profile is high with cutaneous atrophy and stunting, and cannot be used for sensitive areas such as face and genitals . Steroids
Effective treatment mode for plaque type psoriasis . However, the side effect profile is high with cutaneous atrophy and stunting, and cannot be used for sensitive areas such as face and genitals .
Phototherapy Ultraviolet B and psoralin Ultraviolet A (PUVA) are effective in treatment . Most common side effect is erythema. Other effects include burning, pruritus and xerosis that last only for a short term . It is Important to note that oral PUVA is not recommended for children under 11 years of age, topical PUVA is a good treatment option for them . Phototherapy
Ultraviolet B and psoralin Ultraviolet A (PUVA) are effective in treatment . Most common side effect is erythema. Other effects include burning, pruritus and xerosis that last only for a short term . It is Important to note that oral PUVA is not recommended for children under 11 years of age, topical PUVA is a good treatment option for them .
Systemic therapy with methotrexate, cyclosporin and retinoids Effective for severe disease . Methotrexate causes nausea and vomiting most commonly, while fibrotic changes in the liver can be induced on long term use. Use of oral retinoids for long term can cause stunting in children by premature ossification of epiphyses . Systemic therapy with methotrexate, cyclosporin and retinoids
Effective for severe disease . Methotrexate causes nausea and vomiting most commonly, while fibrotic changes in the liver can be induced on long term use. Use of oral retinoids for long term can cause stunting in children by premature ossification of epiphyses .

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