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Proactive treatment in childhood psoriasis

Traitement proactif du psoriasis de l’enfant

J. Lavaud , E. Mahé ∗

Dermatology Department, hôpital Victor-Dupouy, 69, rue du Lieutenant-Colonel Prud’hon,

95100 Argenteuil, France

Received 18 January 2019; accepted 11 July 2019

KEYWORDS Summary Psoriasis affects 0.5% of children. The current therapeutic arsenal includes local
Psoriasis; treatments, phototherapies and systemic treatments (conventional systemic therapy and
Child; biotherapy), which, in most cases, are sufficient to control this skin disease. Subsequent mana-
Adolescent; gement of these children should focus on maintaining therapeutic efficacy and preventing
Treatment; relapse by reducing any treatment-related toxicity in order to improve their quality of life.
Proactive treatment It would therefore appear useful to adopt a ‘‘proactive’’ attitude. To be proactive is to antici-
pate disease progression in order to limit both the severity and the incidence of new flare-ups.
This approach must be distinguished from reactive support. Based on our experience of atopic
dermatitis and data on adult psoriasis, in the absence of publications specific to childhood-onset
psoriasis, herein we propose to provide an overview of this proactive approach in paediatric
psoriasis. This proactive management approach concerns four key precepts: therapeutic edu-
cation: explanation of the disease, its pathophysiology and the various possible therapeutic
approaches; prevention of factors triggering flare-ups or worsening psoriatic infections, such
as stress, trauma, diet (mainly reduction of obesity); a proactive approach to topical therapy:
skin hygiene and use of emollients, but also limitation of active therapies, use of dosing inter-
vals and ‘‘weekend therapy’’ to reduce the risk of relapse; a proactive approach to systemic
therapies: improved therapeutic safety, reduced cumulative doses, through reduced doses, use
of dosing intervals and weekend therapy. Care for children with psoriasis must be comprehen-
sive and include their environment. The concept of ‘‘proactive’’ treatment in childhood-onset
psoriasis can help limit the duration and severity of flare-ups while improving quality of life.
Simple measures can in fact ensure effective maintenance of treatments over the long term.
© 2019 Elsevier Masson SAS. All rights reserved.

∗ Corresponding author.
E-mail address: emmanuel.mahe@ch-argenteuil.fr (E. Mahé).

https://doi.org/10.1016/j.annder.2019.07.005
0151-9638/© 2019 Elsevier Masson SAS. All rights reserved.

Please cite this article in press as: Lavaud J, Mahé E. Proactive treatment in childhood psoriasis. Ann Dermatol Venereol
(2019), https://doi.org/10.1016/j.annder.2019.07.005
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2 J. Lavaud, E. Mahé

MOTS CLÉS Résumé Le psoriasis touche 0,5 % des enfants. L’arsenal thérapeutique actuel comprend les
Psoriasis ; traitements locaux, les photothérapies et les traitements systémiques (systémiques conven-
Enfant ; tionnels et biothérapies), et il permet le plus souvent de contrôler cette dermatose. La prise
Adolescent ; en charge de ces enfants devra alors se concentrer sur maintenir l’efficacité thérapeutique,
Traitement ; et prévenir les rechutes en réduisant toute toxicité thérapeutique, afin d’améliorer la qualité
Traitement proactif de vie de ces enfants. Il semble donc intéressant d’adopter une attitude « proactive ». Être
proactif c’est anticiper l’évolution de la maladie afin de limiter sa sévérité et la survenue de
nouvelles poussées. Cette attitude est à différencier d’une prise en charge réactive. À par-
tir de l’expérience de la dermatite atopique et des données dans le psoriasis de l’adulte, à
défaut de publications spécifiques à l’enfant psoriasique, nous proposons ici de faire un point
sur cette approche proactive dans le psoriasis de l’enfant. Quatre grands axes interviennent
dans cette prise en charge proactive : l’éducation thérapeutique : explication de la maladie, de
sa physiopathologie et des différentes thérapeutiques ; la prévention des facteurs déclenchant
les poussées ou aggravant le psoriasis : infections, stress, traumatismes, régime (réduction de
l’obésité notamment) ; être proactif avec les traitements locaux : hygiène cutanée et utilisation
des émollients, mais aussi épargne des thérapeutiques actives : espacement des doses, week-
end therapy, afin de réduire le risque de rechutes ; être proactif avec les traitements généraux :
amélioration de la tolérance des traitements, réduction des doses cumulées : réduction des
doses, espacements des prises, « week-end therapy ». La prise en charge des enfants atteints
de psoriasis doit être globale et intégrer l’entourage. Le concept de traitement « proactif » dans
le psoriasis de l’enfant permet à la fois de limiter les poussées dans le temps et la gravité de
celles-ci, et d’améliorer la qualité de vie. Des mesures finalement simples peuvent permettre
le maintien au long cours de traitements efficaces.
© 2019 Elsevier Masson SAS. Tous droits réservés.

Psoriasis is a chronic inflammatory dermatosis that pro-
gresses by flare-ups which affects 0.5 to 1% of children in
Europe. The first manifestations of the disease begin in
childhood in around 30% of psoriasis patients [1—3]. The
most common form in children is plaque psoriasis. Cer-
tain functionally severe skin conditions, such as generalized
plaque psoriasis, erythrodermic psoriasis, pustular psoria-
sis and palmoplantar psoriasis, as well as psoriatic arthritis,
warrant rapid institution of systemic therapy [1]. In France,
such severe forms affect 16% of psoriatic children seen in
private practice and 32% of those seen in hospitals [4,5].
The therapeutic objectives for a psoriatic child are mul-
tidimensional: management of flare-ups (clinical aspect and
quality of life), prevention of relapse and maintenance
of remission, and prevention of long-term complications.
These different phases of care are often interconnected.
The prevention of long-term complications is currently of
less importance due to the reassuring nature of long-term
data on outcomes for psoriatic children: onset before the
age of 18 years does not increase the risk of developing
severe psoriasis, psoriatic rheumatism, cardiovascular or
metabolic comorbidities, addictions or even desocialization
[3,6—8]. Therapy must thus focus on management of flare-
ups, maintenance of therapeutic efficacy, and prevention of
relapses.
The therapeutic arsenal has progressed considerably in
recent years, with better control of relapses and significant
improvement in the quality of life of patients of all ages.
The treatment of flare-ups consists mainly of the application
of local treatments such as topical corticosteroids or vita-
min D derivatives, but it may also include phototherapy or
systemic drugs [1,9]. The short-term benefits of this
approach are well known, but long-term remission between
flare-ups is difficult to achieve, making long-term treat-
ment strategies to prevent relapse necessary. Adopting
a ‘‘proactive’’ approach appears beneficial in terms of
improving the quality of life of children with psoriasis
[10,11].
Proactive patient management means anticipating dis-
ease progression in order to limit its severity and the
occurrence of new flare-ups. This approach must thus
be distinguished from ‘‘active or reactive’’ management
given at the time of the active episode, and also from
‘‘prophylactic’’ management, conducted before onset of
the disease. This concept has been developed primarily
in atopic dermatitis, where proactivity is the daily norm
[12,13].
Based on experience of atopic dermatitis and on data
concerning adult psoriasis, and in the absence of publica-
tions specific to the psoriatic child, we propose herein to
provide an overview of this proactive approach in childhood-
onset psoriasis.
Remission — the therapeutic goal of initial
treatment
Rather than targeting cure, the aim of initial therapy is to
reduce the severity of the episode and achieve whitening
or near-whitening of lesions while improving the quality of
life of the child. Often this goal will be achieved after sev-
eral weeks or months of local or systemic treatment [1,9]. In

Please cite this article in press as: Lavaud J, Mahé E. Proactive treatment in childhood psoriasis. Ann Dermatol Venereol
(2019), https://doi.org/10.1016/j.annder.2019.07.005
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Proactive treatment in childhood psoriasis 3

adults, the goal of psoriasis management is clearing or near-

Table 1 Proactive treatment.
clearing, and values are assigned quantifying this notion:
PASI 75 (a 75% reduction in Psoriasis Area Severity Index), Education Explain the pathophysiology and
PASI 90 or PASI 100, absolute PASI, or PGA 0-1 (Physician course of psoriasis
Global Assessment of 0 or 1), associated with an improve- Choose treatment (pharmaceutical
ment in quality of life (DLQI — Dermatology Life Quality forms) together with the child and
Index of 3 or 5) [14,15]. In children, neither these scores nor parents
the goals have been validated. Psoriasis is often less inflam- No restrictions concerning diet,
matory, occurring in smaller plaques that are less thick and vaccination or sports
less scaly [1], and these scores and therapeutic goals are Avoid factors that Avoid injury (onychophagia,
therefore difficult to extrapolate to children [16] and thus aggravate/trigger pruritus, poor hygiene in nappy
rarely used in all cases [17]. A simple clinical objective, flare-ups area, poor shoe fit)
‘‘clearing or near-clearing’’ of the lesions, corresponding Up-to-date vaccines (adaptation in
to PGA 0 or 1, seems reasonable, even if this approach case of vaccine-related flare-ups)
has not been validated in children. The treatment aims are Tonsillectomy, antibiotic
also expressed simply as straightforward clinical and social prophylaxis
goals: resumption of sport, ability to go swimming, etc. Such Psychological support
goals frequently take a long time to attain, and this must be Management of obesity
explained to the child and parents. Once consent has been Mediterranean diet
obtained, proactive treatment can be initiated. Topical therapy Emollients
This proactive treatment is based on several approaches: Very gradual decline in topical
education, prevention of aggravating/triggering factors, and corticosteroids
adaptation of therapy. The key principles are set out in detail Weekend therapy (topical
in Table 1. corticosteroids—calcipotriol,
tacrolimus)
Early treatment of flare-ups
Education (topical corticosteroids -
calcipotriol)
Education about treatment, whether formal (hospital edu- Systemic therapy Subcutaneous treatments: local
cation sessions) [18] or informal (performed on a day-to-day anaesthetic
basis at visits) must be fully integrated into patient care Acitretin: mucous, semi-mucous,
to ensure that all patients understand their disease (patho- dermal hydration
physiology, course, etc.) and its management, thereby Methotrexate: folic acid
optimizing overall compliance with the therapeutic project. Effective minimum dose (acitretin,
The key messages given to parents are not limited to treat- cyclosporin, methotrexate)
ment. It is essential to be able to explain what the disease Dosing intervals (adalimumab,
is, its course and the types of treatment that may be given. ustekinumab)
Weekend therapy (cyclosporin)
Simple explanation of pathophysiology (‘‘it’s Intermittent treatment
not in the head’’) (cyclosporin, etanercept)

Explain that genetic and immunological predispositions for

the disease exist, and that environmental factors (including
stress) play a part in flare-ups. Parents should not be made
to feel guilty in any way, particularly in cases of a famil-
ial history, and it should be stressed that the disease is not
contagious.
Course of the disease
Explain that the disease is not fatal, and that in children
there is no excess risk of developing comorbidities or psori-
atic arthritis. It should be stated that the disease is chronic,
that progression occurs through flare-ups, and that remis-
sions can occur either spontaneously or with treatment.
form) must be adapted to the site of the lesions, and to
their extension and semiological appearance (more or less
squamous, differing degrees of inflammation). Finally, it is
important to dispel any fear of corticosteroids.
The anonymous and free educational game ‘‘Theo and
the Psorianautes’’ in book form (target age group: 5—8
years) (Fig. 1A) and digital form - theoetlespsorianautes.fr
(target age group: 6—12 years) (Fig. 1B), developed by the
‘‘France Psoriasis’’ patient association, is of great assis-
tance in explaining the disease to children and their parents.
It allows the children themselves, but also their entourage,
siblings and parents, to better understand their dermatosis.

Treatments
It should be pointed out that psoriasis does not require any
restrictions with regard to diet, sporting activity or vac-
cines. There is no cure, but relapse can be controlled via
therapy. Indicate that the treatment (type, pharmaceutical
Preventing triggers for flare-ups or
worsening of psoriasis
The main triggers for psoriasis flare-ups are infections, phys-
ical trauma, stress and medications [1]. Another important

Please cite this article in press as: Lavaud J, Mahé E. Proactive treatment in childhood psoriasis. Ann Dermatol Venereol
(2019), https://doi.org/10.1016/j.annder.2019.07.005
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Figure 1. Theo and the Psorianauts. An anonymous and free educational game created by the France Psoriasis association. A. The book
form (made with the support of Laboratoire Abbvie). B. The homepage of the digital version (theoetlespsorianautes.fr).

factor is the link between obesity and severity of psoriasis

in children [4,5].
Infections frequently induce outbreaks but are difficult to
avoid. This is true for beta-haemolytic streptococci (throat
and other sites), but also staphylococci, viral infections and
vaccinal reactions [19—21]. Psoriasis is obviously not a con-
traindication to vaccines, even if vaccination can trigger
flare-ups of psoriasis. The vaccine schedule must be kept up-
to-date. Caution must be exercised in the event of a severe
flare-up after certain vaccines. In this case, the benefit-
risk ratio of boosters should be discussed (consideration of
residual levels of antibodies may be useful in deciding).
Streptococcal infections can cause recurrent guttate psoria-
sis as well as flare-ups of plaque psoriasis. Although its value
has not been validated, antibiotic prophylaxis may be pro-
posed as in recurrent erysipelas [22]. Similarly, some authors
suggest preventive tonsillectomy in cases of recurrent throat Figure 2. Psoriatic onychopathy in a 14-year-old footballer. Con-
infection that trigger flare-ups of psoriasis [23,24]. While the sider adapting shoe form/size to reduce ungual trauma.
value of this approach has not been confirmed in systematic
literature reviews, it may nevertheless be discussed with the
paediatrician on a case-by-case basis.
Physical trauma is a source of worsening psoriasis and
possibly Koebner’s phenomenon. Children should be made
aware of this factor: they must avoid biting their nails and
scratching (the application of emollient creams is to be pre-
ferred in the case of pruritus for example). For psoriatic
onychopathy of the toes it is necessary to check that suit-
able footwear is being worn, especially in young footballers
(Fig. 2) and young dancers. Particular attention must be
paid to cleansing of the nappy area in the event of nappy
rash (Fig. 3). Nappy rash is often considered a Koebner
phenomenon occurring on an irritated nappy area. Simple
instructions concerning cleansing of this area will prevent
relapses: ‘‘cleaning with super-fat soap or syndet soap, Figure 3. Nappy rash. Insist on the importance of good hygiene
rinsing, drying’’ with each nappy change. Avoiding drying of the nappy area to avoid maceration and relapse.
agents (e.g. eosin, water paste, etc.), oil-limestone lini-
ment, cleansing wipes, and so on [25,26].
Stress is very common in children: the birth of a younger support may be warranted, and its implementation must be
sibling, entry into first school classes, parental separation, discussed with the paediatrician.
and so on. Studies suggest that the stress factor plays a Medications rarely appear to be involved in psoriasis
greater role in children than in adults in the onset of flare- flare-ups in children. Although a case has recently been
ups [2]. This stress is often minor and does not warrant reported [27], it would appear that the wide use of propra-
specific therapy. In some children, however, psychological nolol for instance in haemangiomas does not cause psoriasis

Please cite this article in press as: Lavaud J, Mahé E. Proactive treatment in childhood psoriasis. Ann Dermatol Venereol
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Proactive treatment in childhood psoriasis
in infants. There does not appear to be any absolute con-
traindication to medication in children with psoriasis.
Obesity is linked to the existence of psoriasis and the
severity thereof in both children and adults [3,28,29]. In
adults, weight reduction improves psoriasis, psoriatic arthri-
tis and treatment response [30]. It follows then that it is
important to manage excess weight in the psoriatic child,
working closely with the paediatrician.
There are also no dietary restrictions in psoriasis. Recent
studies have suggested that in adults a ‘‘Mediterranean
diet’’ (i.e. rich in fruits, vegetables, beans, cereals, herbs
and olive oil, with moderate consumption of dairy prod-
ucts and eggs, limited consumption of fish and low intake of
meat) seems to have a favourable effect on psoriasis, par-
ticular regarding disease severity [31,32]. Despite the lack
of certainty as to its efficacy on psoriasis, it may also be
proposed in children. Even if not effective, this type of diet
is nevertheless balanced and promotes weight loss.
Proactive topical treatment
Emollients are essential in the long run. As in atopic der-
matitis, emollient treatment of the areas usually affected
reduces the frequency of relapse [33]. In addition, by redu-
cing pruritus, it limits the risk of scratching and of Koebner
phenomenon on dry skin. The choice of emollient, which
may contain urea, will obviously be made with the child and
its parents in order to determine the product that is most
comfortable for the child [34].
Treatment of the active phase—with topical corticos-
teroids, vitamin D analogues, tacrolimus (non-label use)
— [1] has its place in proactive treatment based on all
available pharmaceutical forms suitable for psoriasis sites.
Several alternatives may be proposed, and feasibility should
be assessed with the parents. These alternatives are suit-
able for mild psoriasis with plaques always occurring at the
same site. The first is the classic ‘‘gradual withdrawal’’ of
treatment over a period of several months to avoid any
early rebound. In practice (based on our personal expe-
rience), this is quite difficult to achieve, and compliance
is generally poor. The alternative is weekend therapy, by
analogy to what has been proposed in atopic dermatitis
and adult psoriasis [35,36]. This approach involves applying
topical treatment to the areas usually affected on Satur-
day and Sunday only (or on two separate weekdays), which
reduces the frequency of flare-ups. A further alternative is
‘‘on-demand’’ treatment, i.e. early treatment of flare-ups,
from the first symptoms, which seems equally effective,
even if this approach is not strictly proactive treatment
[37].
Proactive systemic treatment
Conventional systemic treatments (acitretin, methotrexate
and ciclosporin) and biotherapies (etanercept, adalimumab
and ustekinumab), when effective, are generally utilised for
more than a year. The fear of prescribers regarding all long-
term treatments is the risk of cumulative toxicity, especially
since subjects are young and may require treatment for the
rest of their life. In addition, ease of use and good safety
Please cite this article in press as: Lavaud J, Mahé E. Proactive treatment in childhood psoriasis. Ann Dermatol Venereol
(2019), https://doi.org/10.1016/j.annder.2019.07.005
5
contribute to good compliance. The aim of proactive treat-
ment is to maintain therapeutic efficacy while minimising
treatment.
In order to improve the safety of medication, it is impor-
tant that for all treatments given by subcutaneous injection
(methotrexate, etanercept, adalimumab and ustekinumab),
allowance should be made for pain, which is not always
verbally signalled by the child. Intervention by a nurse,
especially in small children (injections by parents create
an ambiguous relationship with the child and should thus
be avoided), a calm atmosphere, and prior application of
anaesthetic cream such as lidocaine/prilocaine will avoid
the potential physical and psychological trauma of repeated
‘‘pricks’’ [38]. Acitretin should be avoided in adolescent
maintenance therapy due to the strict and difficult-to-
implement rules imposed on account of the teratogenicity of
the drug [39]; it must be accompanied over the long term by
hydration of the mucous membranes (ophthalmic gel), semi-
mucous membranes (lip stick) and skin (emollient), the type
of which must be chosen with the child and parents [40]. Sys-
tematic use of folic acid associated with methotrexate has
been shown to reduce digestive intolerance in both adults
and children, although its impact on therapeutic efficacy has
not been demonstrated [41—43]. Folic acid at a dose of 5 to
10 mg should be routinely proposed 48 h after methotrexate
use.
To reduce cumulative toxicity, proactive treatment
seeks to reduce the therapeutic dose by means of three
approaches: seeking to determine the minimum effective
dose, weekend therapy, and intermittent treatment. The
search for the effective minimum dose can be achieved
either by reducing the dose (acitretin, methotrexate,
ciclosporin) [41] or by spacing intakes (adalimumab, ustek-
inumab) [44,45]. The search for this minimum dose is
undertaken gradually in stages, usually after several months
of treatment at full dose.
Weekend therapy has been studied for ciclosporin in
atopic dermatitis and adult psoriasis [46—48]. It consists
of giving the initial dose on Saturday and Sunday only. This
reduces the frequency and intensity of subsequent flare-ups
with very low doses of treatment.
Intermittent treatment consists of stopping treatment
once remission has been achieved and consolidated, and
then resuming it early in the event of relapse. It is of value
if the treatment is rapidly effective and no loss of effi-
cacy is noted upon resumption. This alternative has been
proposed in psoriasis for ciclosporin and etanercept and it
may therefore be proposed in children. Its value in adults is
debatable, however, and it appears to be infrequently used
in paediatrics [49,50].
Conclusion
The management of children with psoriasis must be com-
prehensive and take their environment into account. The
concept of ‘‘proactive’’ treatment in childhood-onset pso-
riasis limits flare-ups in terms of duration and severity while
improving patients’ quality of life. Finally, simple measures
can enable effective treatment to be maintained over the
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ANNDER-2769; No. of Pages 7 ARTICLE IN PRESS
6 J. Lavaud, E. Mahé
long term. In addition, the management of trigger factors
and obesity should not be overlooked.
Appendix A. Supplementary data
Supplementary data associated with this article can be
found, in the online version, at https://doi.org/10.1016/j.
annder.2019.07.005.
Disclosure of interest
E. Mahé is a consultant and investigator and has received
fees as a speaker from Abbvie, Amgen, Boehringer-
Ingelheim, Celgene, Janssen Cilag, Leo Pharma, Lilly, Pfizer
and Novartis.
The other author declares that he has no competing inter-
est.
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