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ISSN: Print -2349-0977, Online - 2349-4387


 
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ORIGINAL CONTRIBUTION - CLINICS IN PEDIATRIC DERMATOLOGY
Year : 2016  |  Volume : 3  |  Issue : 1  |  Page : 6-11

Clinical features and management of childhood psoriasis: Retrospective analysis among 171 children from North India


1 Department of Dermatology and STD, Lady Hardinge Medical College, New Delhi, India
2 Department of Dermatology and STD, Ambedkar Hospital, New Delhi, India

Date of Web Publication20-Oct-2016

Correspondence Address:
Soumya Agarwal
Department of Dermatology and STD, Lady Hardinge Medical College, New Delhi - 110 001
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2349-0977.192704

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  Abstract 

Introduction: Psoriasis is a common chronic inflammatory disease of the skin which is relatively less studied in children. Materials and Methods: A retrospective analysis of records of children (≤18 years of age) with psoriasis over a period of 5 years was conducted in the department of Dermatology of a tertiary care center. The results were described as percentages. Results: Out of a total of 1350 cases of psoriasis attending the Dermatology department, there were 171 (12.7%) children ≤ 18 years of age. Mean age of the cases was 12.0 ± 5.0 years. Mean duration of illness was 24.7 ± 32.9 weeks. Infection was the most common (8.8%) aggravating factor. Plaque-type psoriasis (60.2%) was the most common type of psoriasis, followed by guttate psoriasis (11.7%). Erythrodermic and pustular psoriasis were seen in 5.8% and 2.3% of the patients, respectively. Lower limb (67.2%) was the most commonly involved site followed by upper limb (55.5%). Nails were involved in 38% of the patients, pitting being the most common finding. Joint involvement was present in 3.5% of the patients. The body surface area involvement ranged from 0.3 to 95% (10.5 ± 21.9). The psoriasis area and severity index ranged from 0.3 to 39.2 (6.5 ± 7.9). Most of the patients (37.4%) were managed with topical therapy alone. Systemic therapy was used in the form of methotrexate in 5.3% patients and oral antibiotics in 4.6% patients. Conclusion: Psoriasis in children is not very common. In children also, plaque-type psoriasis is the most common presentation. Severe forms of psoriasis and joint involvement are less frequent. In general, psoriasis is relatively mild in children. Topical treatment is sufficient to control the disease in most of the cases.

Keywords: Psoriasis, children, clinical features


How to cite this article:
Garg T, Agarwal S, Yadav P, Rao A, Chander R, Mendiratta V. Clinical features and management of childhood psoriasis: Retrospective analysis among 171 children from North India. Astrocyte 2016;3:6-11

How to cite this URL:
Garg T, Agarwal S, Yadav P, Rao A, Chander R, Mendiratta V. Clinical features and management of childhood psoriasis: Retrospective analysis among 171 children from North India. Astrocyte [serial online] 2016 [cited 2022 Jan 22];3:6-11. Available from: http://www.astrocyte.in/text.asp?2016/3/1/6/192704


  Introduction Top


Psoriasis is a common, chronic, disfiguring, inflammatory condition of the skin characterized by complex alterations of epidermal proliferation and differentiation, in which both genetic and environmental influences play a critical role. It commonly occurs in children. In approximately one-third of the patients, psoriasis begins in the first two decades of life.[1] Psoriasis has a profound impact on the physical, social, emotional, and psychological well-being of children, and can considerably hamper their quality of life. This highlights the importance of early recognition and management of psoriasis at an early age. Childhood psoriasis is known to differ in the epidemiology, clinical features, management, and long-term clinical and psychological outcome.


  Material and Methods Top


Analysis of records of children (≤18 years' age) with psoriasis registered at the department of Dermatology of a tertiary care center from 2009 to 2014 was conducted. Various parameters including age, gender, type of psoriasis, family history in a first-degree relative, areas of body involved, nail and joint involvement, seasonal exacerbations, and aggravating factors were recorded. The history of treatment in the past and treatment given at our center was also recorded. Severity of psoriasis was recorded in terms of body surface area (BSA) and psoriasis area severity index (PASI). The data was statistically analyzed using the SPSS version 17 (Chicago, USA) was used for statistical analysis. The results were described as percentages.


  Results Top


The age of the study patients ranged from 1 to 18 years, with a mean age of 12.0 ± 5.0 years. There were 90 (52.6%) males and 81 (47.4%) females (M:F = 1:0.9). Duration of illness ranged from 1 week to 16 years, with a mean duration of 24.7 ± 32.9 weeks. Maximum number of patients, 68 (39.7%), had a duration of illness less than 6 months. A total of 36 (21%) patients had a duration of illness of more than 36 months followed by 7–12 months (34 patients, 19.8%).

There was a family history of psoriasis in 12 (7.1%) patients. History of psoriasis in first-degree relative was present in 9 (5.3%) patients. Infection was the most common (8.8%) aggravating factor. It included, sore throat (4.7%), rhinitis, urinary tract infection, chicken pox, and dengue. Other aggravating factors included change of place (0.6%) and stress (0.6%). There was no history of preceding drug intake in any of the patients. A total of 54 (31.6%) patients had a history of winter aggravation whereas 16 (9.4%) had summer aggravation. A total of 101 (59.1%) patients had no history of seasonal variation.

Plaque-type psoriasis (60.2%) was the most common type of psoriasis, followed by guttate (11.7%) psoriasis. Erythrodermic and pustular psoriasis were seen in 10 (5.8%) and 4 patients (2.3%), respectively. Lower limb (67.2%) was the most commonly involved site followed by upper limb (55.5%), trunk (49.7%), and scalp (49.1%). Nail involvement was seen in 65 (38%) patients. In most of the patients, a conglomeration of findings was noted. Most common pattern of nail involvement was pitting (19.8%), followed by subungual hyperkeratosis (6.4%) and longitudinal ridging (5.2%). Joint involvement was seen in 6 (3.5%) patients. Knee joint was the most commonly involved joint followed by ankle [Table 1].
Table 1: Clinical Features

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BSA assessment was available for 141 patients. It ranged from 0.3% to 95%, with a mean of 10.5 ± 21.9. Majority of patients had ≤1% BSA involvement. A total of 55 (39.0%) patients had BSA involvement of 1–10%.

PASI records were available for 69 patients, and ranged from 0.3 to 39.2, with a mean PASI of 6.5 ± 7.9. Maximum number of patients (62.3%) had a PASI score of 1–10 [Table 2].
Table 2: Severity of Psoriasis

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A total of 89 (52.1%) patients had not taken any treatment for psoriasis in the past. Eighty-two (47.0%) patients gave a history of treatment in the past; however, the nature of treatment was not known in 17 (10.0%) patients. Most of the patients (16.3%) had received topical treatment. Among the systemic therapies, methotrexate (9.3%) was the most common agent followed by oral steroids (4.6%) and acitretin (3.5%). We managed most of the patients (37.4%) with topical therapy alone. Systemic therapy was used in the form of methotrexate in 5.3% patients and oral antibiotics in 4.6% patients [Table 3].
Table 3: Treatment Received by Patients

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  Discussion Top


There is a paucity of studies pertaining to the epidemiology of psoriasis in children in the medical literature, and therefore the exact prevalence of childhood psoriasis is not known. Few large studies have reported that 20–35% of all psoriasis patients have onset of their disease before the age of 20 years.[2],[3] The worldwide prevalence ranges 0.1–3%. The prevalence of disease in children increases linearly from 0.095 at 1 year to 0.825 at 18 years.[4] In a study from north India, childhood psoriasis was seen in 0.3% of all Dermatology outpatients and 12.5% of the total psoriasis patients at a tertiary care hospital.[5] The point prevalence of psoriasis was found to be 0.02% in a study of various dermatoses in school children aged 6–14 years from north India.[6] Psoriasis constituted 1.4% of all pediatric dermatoses seen in patients less than 14 years of age at a referral hospital in South India.[7] A study from Delhi, India reported that psoriasis was the underlying etiology in 15% of all cases of erythroderma in children less than 12 years of age.[8] In our study, there were 171 cases (12.7%) of childhood psoriasis. Maximum number of patients were seen between 16 and 18 years (32.1%), followed by 10–12 years (23.3%). The peak age of onset in childhood psoriasis has been variably reported in previous studies. In approximately one-third of patients, psoriasis begins in the first two decades of life.[9] In surveys from India and Denmark, majority of patients had the onset of disease at the ages of 6 to 10 years,[5],[10] whereas other studies from the Middle East and Australia documented the same at the ages of up to 4 years.[11],[12] Studies from Denmark and Middle East have observed a female preponderance,[10],[11] however, reports from India and Australia have reported equal sex predisposition.[5],[12],[13] We observed slight male preponderance, with 90 males and 81 females (M:F = 1:0.9) in our study.

Psoriasis involves a T-cell mediated autoimmune response against an unknown self-antigen triggered by an environmental factor in a genetically susceptible individual.[14] There is overwhelming evidence that psoriasis has a significant genetic component. Familial prevalence is greater in childhood psoriasis than in adult-onset psoriasis. Compared with 37% in adult-onset patients, 49% of pediatric-onset patients had first-degree family members affected with psoriasis.[15] Based on the population data, several researchers have calculated the risk for a child to develop psoriasis. In a German study, the risk was 14% if one parent was affected, 41% if both parents were affected, and 6% if one sibling was affected, compared to 2% when no parent or sibling was affected.[16] The most convincing data supporting a genetic basis to psoriasis comes from studies examining the concordance for the disease in twins. Twin studies yielded a concordance in monozygotic twins of 35–75%.[17] Although approximately 20 genetic loci associated with psoriasis have been reported from linkage-based studies, by far the major psoriasis genetic determinant is PSORS1, which probably accounts for 35–50% of the heritability of the disease and is located on the HLA-C gene on chromosome 6p21.[18] We observed positive family history of psoriasis in 7% of our patients. The reported frequency of family history in Indian studies has been low (4.5–9.8%) possibly due to ignorance of skin lesions, nondisclosure due to social reasons, or actual absence at the time of inquiry.[19] Many environmental factors have been linked to psoriasis, and have been implicated in the initiation of the disease process and exacerbation of pre-existing disease. These include trauma, infection, drugs (lithium salts, antimalarials, beta-adrenergic blocking agents, nonsteroidal anti-inflammatory drugs, angiotensin-converting enzyme inhibitors, and the withdrawal of corticosteroids), sunlight, and stress. Psoriasis in children is more commonly precipitated by infections and physical and psychological trauma than it is in adults.[1],[5],[7],[20] The analysis of environmental risk factors has suggested a possible role of high body mass index (BMI), exposure to smoking at home, and stressful life events in childhood psoriasis.[21] In our study, infection was the most common aggravating factor (8.8%).

Childhood psoriasis is more pruritic, with relatively thinner, softer, and less scaly lesions when compared to adults.[19] Similar to adults, plaque type is the most common form of disease but certain clinical variants are rare in children, such as erythroderma, arthropathy, and localized and generalized pustular psoriasis.[1], 2, [5],[6],[7] Guttate psoriasis is typically seen in children and adolescents, often precipitated by acute streptococcal infection. However, Indian studies suggest that children tend to manifest the established plaque type of disease more often, rather than the transient guttate form [Figure 1].[5],[13] Facial involvement in psoriasis appears more common in children than adults.[22] In an Australian study of 1261 children with psoriasis, 26% had a psoriatic rash in the napkin area and 38% had facial involvement.[12] However, involvement of the face is reported as low as 4.71% from India where tropical climatic conditions lead to a greater exposure of children to the ultraviolet (UV) rays of the sun, and hence they have less frequent involvement of sun-exposed sites.[5] The scalp involvement often presents as pityriasis amiantacea (thick, adherent white scales that encase the hair shaft), however, palms and soles are less commonly affected.[20] Pustular [Figure 2] and erythrodermic psoriasis are less common in children. Although localized pustular psoriasis is extremely rare in children, parakeratosis pustulosa is usually a manifestation of psoriasis in children. The von Zumbusch pustular psoriasis is more common in infancy and annular forms appear later. Erythrodermic psoriasis may be intractable for years and may or may not become pustular.[23] In our study, majority of children presented with plaque-type psoriasis (60.2%). Erythrodermic and pustular psoriasis were less common. The common sites of involvement in children, as documented by Kumar et al.,[5] are lower legs, scalp, soles, and arms. Similarly, lower legs (67.2%) were the most commonly involved site involved in our patients followed by upper limbs (55.5). In a previous study from Australia, plantar involvement was reported in only 4%.[12] Higher incidence of involvement of soles in Indian patients could be explained by the habit of walking barefoot or wearing open sandals, leading to koebnerization at these friction-prone sites, especially in more active children [Figure 3].[24] Psoriatic arthropathy is very uncommon in children, and constitutes 0–4% of pediatric psoriasis cases.[12],[25] It is preceded by skin lesions in approximtely 80% of the patients. We observed joint involvement in 3.5% of patients. Knee joint was the most commonly involved joint. Nail involvement was seen in one-third of the patients.[1],[5],[11],[13] Nail pitting, distal onycholysis, subungual hyperkeratosis, and nail discoloration were the most common findings [Figure 4].[11],[13],[26] We found nail involvement in 38% of patients. Most common pattern of nail involvement was pitting (19.8%), followed by subungual hyperkeratosis (6.4%) and longitudinal ridging (5.2%). Most children with psoriasis usually have a mild form of the disease with a BSA involvement of <20%.[5],[11],[13] We also observed that, out of 141 patients, the majority of patients (43.3%) had ≤1% BSA involvement, and 39% patients had a 1–10% involvement. Out of 69 patients, the mean PASI score was 6.5 ± 7.9. Maximum number of patients (62.3%) had a PASI score of 1–10, followed by ≤1 in 17.4% of the patients.
Figure 1: Erythematous, scaly rain-drop like plaques in guttate psoriasis.

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Figure 2: Annular erythematous plaques on trunk showing pustules at the periphery in pustular psoriasis.

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Figure 3: Soles showing well defined erythematous scaly plaques in plantar psoriasis.

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Figure 4: Coarse pits and onycholysis involving finger nail.

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The management of childhood psoriasis is mostly conservative because of the benign course and milder disease. However juvenile psoriasis can be associated with increased rates of hyperlipidaemia, obesity, hypertension and diabetes mellitus. Increased attention should be paid to the early detection and treatment of affected patients.[27] Because the long-term safety data on drugs and evidence-based data in pediatric psoriasis is limited, the treatment guidelines for adults are usually extrapolated for children. Therapeutic modality should consider the patient's and the parents' attitude toward the disease; the type, severity, extent, and sites of psoriasis; as well as the safety concerns and accessibility of treatment.[20],[28],[29] Because the treatment is required for a long-term in children, the management strategy should be tailored individually by involving children and parents in decision making.[30] Topical therapies are the mainstay of treatment for mild or localized disease. Mild disease is defined as having a PASI score of <10 or involvement of BSA of <20%. Topical therapies also constitute an important adjunct to systemic modalities in generalized or severe disease. Emollients, keratolytics, vitamin D analogues, and corticosteroids are considered to be the first-line agents. Coal tar and dithranol are the second-line agents, whereas retinoids and calcineurin inhibitors could be resorted to as third-line agents.[14],[31],[32] The use of systemic drugs in children is restricted because of their adverse effects, lack of evidence, lower tolerability, and cumulative toxicities. The choice of systemic agent to be employed depends upon the type of psoriasis, drug efficacy, adverse effect profile, experience of clinician, and affordability. The first-line drugs in children are retinoids and methotrexate, whereas the second-line agents include cyclosporine, phototherapy, and biologics.[31],[32] In our study, 47.0% patients gave a history of treatment in the past, with the majority (16.3%) having received topical treatment. Among the systemic therapies, methotrexate (9.3%) was the most commonly used drug followed by oral steroids (4.6%) and acitretin (3.5%). NBUVB and PUVA phototherapy had been received by 2.3% and 1.7% patients, respectively. Most of the patients (37.4%) were managed with topical therapy alone for the current episode. Systemic therapy was used in the form of methotrexate (5.3%), oral antibiotics (4.6%), acitretin (1.7%), NBUVB (1.7%), vitamin A (0.6%), azathioprine (0.6%), cyclosporine (0.6%), and hydroxyurea (0.6%).


  Conclusion Top


Childhood psoriasis embodies a special challenge to dermatologists. Although psoriasis in children and adolescents is not very common, it is crucial to recognize the different presentations of the disease in this cohort for the timely diagnosis and management. In children also, plaque type of psoriasis is the most common presentation. Psoriasis in children usually presents as a mild disease. The nail and joint involvement, as well as severe manifestations (erythrodermic and pustular variants), are less frequent than adults. The majority respond well to topical therapy alone. Importantly, supportive care and quality of life issues such as psychosocial stigmas should also be adequately addressed in addition to proper treatment. New advances in topical and systemic therapy, phototherapy, and biologicals may provide encouraging future in psoriasis therapeutic armamentarium.

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Conflicts of interest

There are no conflicts of interest.

 
  References Top

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
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