PAEDI ATRI C DERMATOLOGY

BJD
British Journal of Dermatology
Epidemiology and comorbidity of psoriasis in children
M. Augustin, G. Glaeske,* M.A. Radtke, E. Christophers, K. Reich and I. Schafer
CVderm German Center for Health Services Research in Dermatology, Department of Dermatology, University Clinics of Hamburg, Martinistrasse 52, 20246
Hamburg, Germany
*Zentrum fur Sozialpolitik, University of Bremen, Germany
Dermatology Practice am Tibarg, Hamburg, Germany
Dermatologikum, Hamburg, Germany
Correspondence
Matthias Augustin.
E-mail: m.augustin@derma.de
Accepted for publication
1 November 2009
Key words
children, comorbidity, epidemiology, health care,
psoriasis
Conicts of interest
This study was supported by research grants from
Merck Pharma GmbH (Darmstadt, Germany) and
from Janssen-Cilag GmbH (Neuss, Germany).
M.A., K.R. and M.A.R. have received funding
from Merck Serono and Janssen-Cilag for research
and were invited speakers and consultants for both
companies. E.C. has received funding from Merck
Serono and Janssen-Cilag for consulting and oral
presentations. G.G. and I.S. have no conicts of
interest to declare.
DOI 10.1111/j.1365-2133.2009.09593.x
Summary
Background Psoriasis is a common disease affecting all age groups. In contrast to
adult psoriasis, only few studies on the epidemiology of childhood psoriasis have
been published.
Objectives Assessment of prevalence and comorbidities of juvenile psoriasis in Ger-
many based on health insurance data.
Methods Data were collected from a database of about 13 million nonselected
individuals from a German statutory health insurance organization which covers
all geographical regions. Individuals with psoriasis were identied by ICD-10
codes applied to all outpatient and inpatient visits. The present analysis consists
of all patients who were enlisted throughout the year 2005. The diagnosis of
psoriasis was registered whenever there was at least one documented patient
contact using code L40.* and subcodes. Comorbidities were also evaluated by
ICD-10 diagnoses.
Results In total, 33 981 patients with the diagnosis of psoriasis were identied.
The prevalence in 2005 was 25%. The total rate of psoriasis in children younger
than 18 years was 071%. The prevalence rates increased in an approximately lin-
ear manner from 012% at the age of 1 year to 12% at the age of 18 years. The
overall rate of comorbidity in subjects with psoriasis aged under 20 years was
twice as high as in subjects without psoriasis. Juvenile psoriasis was associated
with increased rates of hyperlipidaemia, obesity, hypertension, diabetes mellitus,
rheumatoid arthritis and Crohn disease.
Conclusions Psoriasis is a common disease in children. Like in adults, it is associated
with signicant comorbidity. Increased attention should be paid to the early
detection and treatment of patients affected.
Psoriasis is a frequent and burdensome disease in children and
adults.
1,2
Family history of psoriasis predicts early disease
onset.
3,4
Among children (018 years) the median age at
onset of psoriasis was found to be between 7 and 10 years.
58
Features of juvenile psoriasis have been reported in recent
studies, including an increased rate of guttate psoriasis and
relapses following infections.
9
Like in adults, nail psoriasis is
common.
7,10
Spontaneous remissions are more frequent in
children.
9
However, these studies have been performed in special-
ized psoriasis centres and therefore represent selected patient
cohorts. The only comprehensive prevalence analysis of
juvenile psoriasis to date showed a prevalence in the U.K.
of about 06% in children aged 09 years and 14% in chil-
dren aged 1019 years.
11
The aim of the present study was
to analyse the prevalence of psoriasis in children. Also the
frequency of comorbidities was evaluated, as up to now no
data on comorbidities in juvenile psoriasis have been avail-
able.
Materials and methods
Study design and patients
Patient data were gained from a database of about 13 million
nonselected persons enlisted in a German statutory health
insurance organization (Gmunder Ersatzkasse, GEK) which
covers all geographical regions in Germany. Individuals with
psoriasis were identied by ICD-10 codes applied to all
patients (inpatients and outpatients). The present analysis
2009 The Authors
Journal Compilation 2009 British Association of Dermatologists British Journal of Dermatology 2010 162, pp633636 633
includes all patients insured by the GEK throughout the year
2005.
The diagnosis of psoriasis was registered whenever there
was at least one documented patient contact using the code
L40.* and subcodes. In addition, prevalence rates of comor-
bidities were evaluated by ICD-10 diagnoses. These included
Crohn disease (CD), hyperlipidaemia, diabetes mellitus, arte-
rial hypertension, rheumatoid arthritis, obesity, ischaemic
heart disease, ulcerative colitis and metabolic syndrome. For
technical reasons, the data on comorbidities were presented in
the age group 020 years.
Statistics
Data analyses were descriptive and performed with the statis-
tical program SAS by Pharmafacts Research Institute Berlin,
Germany. For comorbidities prevalence ratios were calculated
by comparing the prevalence rate in patients with psoriasis
with the corresponding rate in the nonpsoriatic group. The
corresponding 95% condence intervals were computed by a
general method based on constant v
2
boundaries.
Results
Prevalence
Among n = 1344 071 insured subjects, 33 981 individuals
with the diagnosis of psoriasis were identied. The overall
1-year prevalence was 253%. The total prevalence of psoriasis
in children up to 18 years was 071% (boys 066%, girls
076%). The prevalence increased in an approximately linear
manner from 012% at the age of 1 year to 124% at the age
of 18 years (Fig. 1). Hence, the prevalence of juvenile psoria-
sis rose more than 10 times between patients aged 1 year and
patients aged 18 years.
In order to compare the prevalence of juvenile psoriasis in
Germany with the data published from the U.K.,
11
the patients
were grouped into age decades. In the rst two decades,
psoriasis was slightly more prevalent in the British cohort
(age 09 years, 037% in Germany vs. 055% in the U.K.; age
1019 years, 101% in Germany vs. 137% in the U.K.).
Comorbidities
The overall rate of comorbidities in psoriatic patients younger
than 20 years was twofold compared with persons without
psoriasis (144% vs. 72%; Table 1). Juvenile psoriasis was as-
sociated with increased rates of hyperlipidaemia, obesity,
hypertension, diabetes mellitus, rheumatoid arthritis and CD.
Interestingly, CD occurred 34 times more often in patients
with psoriasis as compared with controls. Also, hyperlipida-
emia, diabetes and hypertension were seen twice as often in
patients with psoriasis. Prevalences of ischaemic heart disease
and ulcerative colitis were also higher in patients with psoria-
sis, but differences were not signicant.
Discussion
The present study aimed at gaining rst data on two major ques-
tions in psoriasis research, namely its prevalence and the pres-
ence of comorbidities in juvenile patients with psoriasis. For
this purpose, the database of a German national health insurance
company (GEK) was used. GEK insures patients irrespective of
income and social status. Reliability of the database has been
proven in previous studies for different indications.
12
In the present study, 071% of children between the age of
0 and 18 years were found to be affected by psoriasis. Inter-
estingly, this prevalence shows a constant increase throughout
the years 0 to 18 so that at the age of 18 years 10 times more
individuals are affected by psoriasis (Fig. 1). These data cover
all forms of the psoriatic disease spectrum, including guttate
psoriasis which may be transient. Therefore, there may be an
over-representation of guttate psoriasis within the overall esti-
mate as presented here. This, however, seems not to produce
a major change as prevalence of guttate psoriasis is far below
the prevalence of plaque-type psoriasis: data from China and
India have revealed that in juvenile psoriasis, 2629% of the
patients showed guttate psoriasis.
5,8
012
022
024
020
030
040
041
056
055
056
079
072
083
100
104
122
112
117
124
000
020
040
060
080
100
120
140
<1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
P
r
e
v
a
l
e
n
c
e

(
%
)
Age
Fig 1. Prevalence of juvenile psoriasis
according to age groups (n = 306 020).
Physician-recorded ICD-10 codes were
computed from a database comprising 13
million persons. Persons identied as patients
with psoriasis (n = 2549) were studied. There
is an almost linear increase in prevalence rates
with age.
2009 The Authors
Journal Compilation 2009 British Association of Dermatologists British Journal of Dermatology 2010 162, pp633636
634 Epidemiology and comorbidity of psoriasis in children, M. Augustin et al.
Our prevalence data correspond to results of a study recently
published by Gelfand et al.
11
In this study prevalence rates
were investigated according to age decades. It was shown that
within the rst decade the prevalence in the U.K. was 055%
which is comparable with our data (037%). Also, psoriasis
diagnosed within the second decade of life (137% in the U.K.
vs. 101% in Germany) showed no major differences in preva-
lence. This emphasizes that psoriasis appears to be a common
disease also in childhood.
Identication of disorders associated with psoriasis (comor-
bidities) was a further objective of this study. As a signicant
nding, our data demonstrate that a distinct group of comor-
bidities previously known to be associated with adult psoria-
sis
1319
is also noted in childhood psoriasis.
It is intriguing to note that CD is four times more prevalent
in children with psoriasis as compared with children without
psoriasis. As no data for the simultaneous occurrence of CD
and psoriasis in children have been published so far, this com-
pares with data on CD disease association in adult patients
with psoriasis.
2023
Also, hyperlipidaemia, diabetes, hypertension, obesity and
ischaemic heart disease were noted markedly more often as
compared with nonpsoriatic controls. These ndings suggest
that signs of the metabolic syndrome may occur indepen-
dently of patient age and duration of psoriasis as an inamma-
tory disease. They further indicate that there may be separate
mechanisms leading to clinical disease in psoriasis as well as
in metabolic syndrome.
24,25
Finally, rheumatoid arthritis, ulcerative colitis and CD have
been suggested as being caused by underlying immune mech-
anisms similar to psoriasis.
23,2630
The present data are in sup-
port of this hypothesis.
A limitation of the present study is the fact that the analysis
is based completely on data derived from ofce-based phys-
icians including only a limited number of dermatologists.
Accordingly, means of controlling the correct diagnosis were
impaired. The overall 1-year prevalence of psoriasis in the
present study (25%) compares well with point prevalence
rates of 21% as determined in a nationwide population-based
study.
31
This suggests that the diagnoses may be reliable. Fur-
thermore, the data derived from the health insurance company
do not include any specic clinical details such as psoriasis
severity. For this, the data presented cannot be used for com-
plex multivariate analysis which would have been convenient
for detecting potential residual confounding factors.
Finally, a diagnostic bias as described by Nijsten and Wak-
kee
32
cannot be exluded. This potential bias refers to the pos-
sibility that patients with psoriasis visit the doctor more often
than unaffected persons, which may lead to a higher possibil-
ity of detecting comorbidity. However, the comparison group
of patients without psoriasis also includes a considerable pro-
portion of persons with further diseases which may also cause
them to seek medical care.
In summary, the present data show that childhood psoriasis
is more prevalent than expected and represents a signicant
burden of disease at this age. Also, the signicant prevalence
rates of comorbidity seen in juvenile psoriasis suggest that we
should investigate our young patients more carefully for
underlying diseases. Interdisciplinary management including
cooperation with pediatricians and rheumatologists is advised.
Patient registries for the long-term outcomes of psoriasis and
psoriasis treatment in children will be of particular value.
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