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Improving treatment options for childhood psoriasis
Declaration of sponsorship Novartis Pharma AG

What's wrong with Mia?

Declaration of sponsorship Novartis Pharma AG
Read time: 40 mins
Last updated:12th Feb 2021
Published:4th Jul 2020
  • Join Mia on her animated journey to appreciate how you can improve the lives of young people like her
  • Appreciate the burden of psoriasis to help those living with its challenges

What is life like for Mia and her family?

Let’s meet our patient Mia and her family who are going to help us understand the impact of moderate to severe psoriasis for all the family. 

Note: Mia is an expert-reviewed theoretical case for educational purposes only.  

In this introductory animation, Mia’s worried parents take her to see a new paediatric dermatologist. Mia has continued to put on weight and become increasingly withdrawn at school and depressed and so she has been referred by her primary care physician.

Find out about the treatments that Mia has tried in the past in the next section of the Learning Zone

Keep reading to find out about the complexities of diagnosing and treating childhood psoriasis.

What's wrong with Mia?

Psoriasis is common in children and they may need lifelong treatment

The prevalence of psoriasis in children is difficult to determine as many cases are either missed or misdiagnosed and it varies by age, gender, psoriasis definition, study design and geographical region1.

PaedDerma_Pt1_Fig1.png

Figure 1. Range of childhood psoriasis prevalence (percentage of population) (adapted from Burden-Teh et al.2).

Around 30% of patients present with the first symptoms of psoriasis during childhood and adolescence3 and psoriasis appears more common after (0.6–1.3%) than before puberty (0.1–0.5%)2. The incidence of paediatric psoriasis is growing. Published incidence rates more than doubled between 1970–74 and 1995–991 and currently ~20,000 children under 10 are diagnosed with psoriasis every year4. With psoriasis patients making up 0.7–6.2% of the patients in paediatric dermatology clinics2, and a prevalence of 2–3% in adults3, dermatologists need to consider long-term treatment options for their paediatric patients given that psoriasis is a lifelong chronic inflammatory condition.

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Diagnosing psoriasis and measuring QoL is more difficult in children

Diagnosis

Although the clinical subtypes of psoriasis in children are similar to adults, diagnosis in children is more challenging.

In a study of 887 patients <18 years, the most common subtypes of psoriasis were6:

  • plaque psoriasis (73.7%)
  • guttate psoriasis (13.7%)
  • scalp psoriasis (7.6%)
  • pustular psoriasis (1.1%)

Lesions in children may be thinner, softer, less scaly, less well defined than in adults7 and the clinical symptoms at presentation also vary according to the age group8. In addition, skin biopsy is performed less often in younger patients compounding the difficulty9.

Professor Vakirlis describes the dermatoscopic findings that define childhood psoriasis.

Childhood psoriasis is also sometimes misdiagnosed because it is confused with other skin diseases such as atopic or nummular dermatitis, otitis externa, pityriasis rosea, or superficial fungal infections5. Figure 2 details the clinical features of psoriasis to look out for in children of different ages.

PaedDerma_Pt1_Fig2.png

Figure 2. Clinical features of paediatric psoriasis by age (adapted from Pinson et al.9).

Find out from Professor Vakirlis more on the challenges of diagnosing childhood psoriasis and the dangers of under- or misdiagnosis.

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Comorbidities are often present in childhood psoriasis

Children with psoriasis are at greater risk of obesity, diabetes, anxiety and depression and show marked impairment in emotional, social and school functions24–26.

Professor Vakirlis describes the common comorbidities he sees in his paediatric patients with psoriasis.

Professor Vakirlis describes the common comorbidities he sees in his paediatric patients with psoriasis.

Psoriatic arthritis

While the prevalence of psoriatic arthritis is lower than that in adults affected by psoriasis, there is still an estimated prevalence of 0.7% for all children with psoriasis, rising to 1.2% of patients with psoriasis by 18 years. Indeed, psoriatic arthritis is estimated to account for 6–8% of all inflammatory arthritis cases in children27.

Obesity and metabolic syndrome

While information about the incidence of comorbidities among children with psoriasis is more limited than that in adults, studies have shown increased risk of obesity and cardiovascular risk factors among children with psoriasis compared with those without28,29 (Figure 3).PaedDerma_Pt1_Fig3.png

Figure 3. Increased risk of comorbidities in childhood psoriasis from a German (Augustin et al.28) and US study2 (Paller et al.5).
NS; not significant.

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Treatment data and options are more limited in childhood psoriasis

There are a plethora of treatments available for adults with moderate-to-severe-psoriasis but a lack of efficacy and safety data in paediatric populations means there are far fewer approved treatments available to children and widespread off-label use33. 

Topical treatments

Topical treatments are considered first-line therapy in children with mild psoriasis. However, most topical medications are not approved for paediatric use, especially in children under 12 years, and so are extensively used off-label34. Topical treatments included in paediatric guidelines include corticosteroids, calcineurin inhibitors, vitamin D analogues (and various combinations), tazarotene, anthralin and coal tar10.

Professor Paller describes a typical topical treatment regime and why topical treatments are not popular with adolescent patients.

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References

  1. Bronckers IMGJ, Paller AS, van Geel MJ, van de Kerkhof PCM, Seyger MMB. Psoriasis in children and adolescents: Diagnosis, management and comorbidities. Pediatric Drugs. 2015;17(5):373–384.
  2. Burden-Teh E, Thomas KS, Ratib S, Grindlay D, Adaji E, Murphy R. The epidemiology of childhood psoriasis: a scoping review. British Journal of Dermatology. 2016;174(6):1242–1257.
  3. Paller AS, Singh R, Cloutier M, Gauthier-Loiselle M, Emond B, Guérin A, et al. Prevalence of psoriasis in children and adolescents in the United States: A claims-based analysis. J Drugs Dermatology. 2018;17(2):187–194.
  4. National Psoriasis Foundation. About Psoriasis in Children. Available at: https://www.psoriasis.org/parents/about-psoriasis. Accessed 11 May 2020.
  5. Eichenfield LF, Paller AS, Tom WL, Sugarman J, Hebert AA, Friedlander SF, et al. Pediatric psoriasis: Evolving perspectives. Pediatr Dermatol. 2018;35(2):170–181.
  6. Tollefson MM, Crowson CS, McEvoy MT, Maradit Kremers H. Incidence of psoriasis in children: A population-based study. J Am Acad Dermatol. 2010;62(6):979–987.
  7. Cordoro KM. Management of childhood psoriasis. Advances in Dermatology. 2008;24(C):125–169.
  8. Mercy K, Kwasny M, Cordoro KM, Menter A, Tom WL, Korman N, et al. Clinical manifestations of pediatric psoriasis: Results of a multicenter study in the United States. Pediatr Dermatol. 2013;30(4):424–428.
  9. Pinson R, Sotoodian B, Loretta Fiorillo L. Psoriasis in children. Psoriasis Targets Ther. 2016;Volume 6:121–129.
  10. Menter A, Cordoro KM, Davis DMR, Kroshinsky D, Paller AS, Armstrong AW, et al. Joint American Academy of Dermatology–National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients. J Am Acad Dermatol. 2020;82(1):161–201.
  11. Caroppo F, Zacchino M, Milazzo E, Fontana E, Nobile F, Marogna C, et al. Quality of life in children with psoriasis: results from a monocentric study. G Ital Dermatol Venereol. 2019. doi:10.23736/S0392-0488.19.06368-5.
  12. Raychaudhuri SK, Maverakis E, Raychaudhuri SP. Diagnosis and classification of psoriasis. Autoimmunity Reviews. 2014;13(4–5):490–495.
  13. De Jager MEA, Van De Kerkhof PCM, De Jong EMGJ, Seyger MMB. A cross-sectional study using the Childrens Dermatology Life Quality Index (CDLQI) in childhood psoriasis: Negative effect on quality of life and moderate correlation of CDLQI with severity scores. Br J Dermatol. 2010;163(5):1099–1101.
  14. Beattie PE, Lewis-Jones MS. A comparative study of impairment of quality of life in children with skin disease and children with other chronic childhood diseases. Br J Dermatol. 2006;155(1):145–151.
  15. Lewis-Jones MS, Finlay AY. The Children’s Dermatology Life Quality Index (CDLQI): initial validation and practical use. Br J Dermatol. 1995;132(6):942–949.
  16. Gelfand JM, Weinstein R, Porter SB, Neimann AL, Berlin JA, Margolis DJ. Prevalence and treatment of psoriasis in the United Kingdom: A population-based study. Arch Dermatol. 2005;141(12):1537–1541.
  17. Oostveen AM, De Jager MEA, Van De Kerkhof PCM, Donders ART, De Jong EMGJ, Seyger MMB. The influence of treatments in daily clinical practice on the Children’s Dermatology Life Quality Index in juvenile psoriasis: A longitudinal study from the Child-CAPTURE patient registry. Br J Dermatol. 2012;167(1):145–149.
  18. Gupta MA, Gupta AK. Evaluation of cutaneous body image dissatisfaction in the dermatology patient. Clinics in Dermatology. 2013;31(1):72–79.
  19. Holme SA, Man I, Sharpe JL, Dykes PJ, Lewis-Jones MS, Finlay AY. The children’s dermatology life quality index: Validation of the cartoon version. Br J Dermatol. 2003;148(2):285–290.
  20. Rasmussen GS, Kragballe K, Maindal HT, Lomborg K. Caring for young people with moderate to severe psoriasis: an interpretive description of parental perspectives. J Dermatolog Treat. 2020;31(3):227–234.
  21. Christin A, Akre C, Berchtold A, Suris JC. Parent-adolescent relationship in youths with a chronic condition. Child Care Health Dev. 2016;42(1):36–41.
  22. Tollefson MM, Finnie DM, Schoch JJ, Eton DT. Impact of childhood psoriasis on parents of affected children. J Am Acad Dermatol. 2017;76(2):286-289.e5.
  23. Salman A, Yucelten AD, Sarac E, Saricam MH, Perdahli-Fis N. Impact of psoriasis in the quality of life of children, adolescents and their families: A cross-sectional study. An Bras Dermatol. 2018;93(6):819–823.
  24. Busch AL, Lieberman AF. Mothers’ adult attachment interview ratings predict preschool children’s iq following domestic violence exposure. Attach Hum Dev. 2010;12(6):505–527.
  25. de Moll EH, Chang MW, Strober B. Psoriasis in adults and children: Kids are not just little people. Clin Dermatol. 2016;34(6):717–723.
  26. Osier E, Wang AS, Tollefson MM, Cordoro KM, Daniels SR, Eichenfield A, et al. Pediatric psoriasis comorbidity screening guidelines. JAMA Dermatology. 2017;153(7):698–704.
  27. Ogdie A, Weiss P. The epidemiology of psoriatic arthritis. Rheumatic Disease Clinics of North America. 2015;41(4):545–568.
  28. Augustin M, Glaeske G, Radtke MA, Christophers E, Reich K, Schäfer I. Epidemiology and comorbidity of psoriasis in children. Br J Dermatol. 2010;162(3):633–636.
  29. Paller AS, Schenfeld J, Accortt NA, Kricorian G. A retrospective cohort study to evaluate the development of comorbidities, including psychiatric comorbidities, among a pediatric psoriasis population. Pediatr Dermatol. 2019;36(3):290–297.
  30. Kimball AB, Wu EQ, Guérin A, Yu AP, Tsaneva M, Gupta SR, et al. Risks of developing psychiatric disorders in pediatric patients with psoriasis. J Am Acad Dermatol. 2012;67(4):651-657.e2.
  31. Todberg T, Egeberg A, Jensen P, Gislason G, Skov L. Psychiatric comorbidities in children and adolescents with psoriasis: a population-based cohort study. British Journal of Dermatology. 2017;177(2):551–553.
  32. Paller AS, Mercy K, Kwasny MJ, Choon SE, Cordoro KM, Girolomoni G, et al. Association of pediatric psoriasis severity with excess and central adiposity: An international cross-sectional study. JAMA Dermatology. 2013;149(2):166–176.
  33. Cline A, Bartos GJ, Strowd LC, Feldman SR. Biologic treatment options for pediatric psoriasis and atopic dermatitis. Children. 2019;6(9):103.
  34. Bhutani T, Kamangar F, Cordoro KM. Management of pediatric psoriasis. Pediatr Ann. 2012;41(1):e1-7.
  35. Relvas M, Torres T. Pediatric psoriasis. American Journal of Clinical Dermatology. 2017;18(6):797–811.
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  44. Taltz 80 mg solution for injection in pre-filled syringe - Summary of Product Characteristics (SmPC). Available at: https://www.medicines.org.uk/emc/product/7233/smpc. Accessed 13 January 2021.
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  1. World Health Organization. Psoriasis. 2016. Available at: https://www.who.int/publications-detail/global-report-on-psoriasis. Accessed 27 April 2020.
  2. Paller AS, Singh R, Cloutier M, Gauthier-Loiselle M, Emond B, Guérin A, et al. Prevalence of psoriasis in children and adolescents in the United States: A claims-based analysis. J Drugs Dermatology. 2018;17(2):187–194.
  3. Bronckers IMGJ, Paller AS, van Geel MJ, van de Kerkhof PCM, Seyger MMB. Psoriasis in children and adolescents: Diagnosis, management and comorbidities. Pediatric Drugs. 2015;17(5):373–384.
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