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Psoriasis - TeachMePaediatrics
Psoriasis - TeachMePaediatrics
Introduction
Psoriasis is a common, chronic, inflammatory condition affecting the skin. It can occur at any age, with about 1/3rd of cases developing before 20 years
of age (1, 2).
Pathophysiology
The exact pathophysiology is unknown. It is thought to be multifactorial, with environmental, genetic, and immunological factors involved (3). There is T
cell infiltration of the epidermis, secreting substances that activate the uncontrolled proliferation of keratinocytes. This means the skin cells proliferate
around 10x faster than normal, which leads to characteristic thick and scaly plaque formation on the skin (2, 4).
Risk factors
Some risk factors for psoriasis flare include: (3)
Family history
Drug induced
*Koebner phenomenon is the appearance of new lesions on previously unaffected areas of skin, secondary to trauma (3)
Guttate psoriasis
Flexural psoriasis
Pustular psoriasis
Erythrodermic psoriasis
Sore
Burning
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present, history of an infection or of mechanical skin injury.
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Clinical features from examination
Chronic plaque psoriasis:
Symmetrical distribution
Auspitz sign*
*Auspitz sign is pin-point bleeding of the skin after a psoriatic scale is scratched/ lifted (6)
Guttate psoriasis:
Figure 4: Guttate psoriasis on the trunk. The lesions resemble raindrops. (5)
+
Involvement can vary across different age groups:
In infants, involvement of the genital/nappy area is common.
In young children, involvement of the scalp, face and flexural areas is common (e.g., arm and knee flexures).
In older children, involvement of the face, ears and nails may be noted.
Differential diagnosis
Juvenile psoriatic arthropathy (1)
Inflammation and swelling of the joints. Skin and nail changes may be present.
Eczema (8)
Eczema is typically seen in flexures, whereas typical psoriasis is seen on the extensors. This can be difficult to differentiate in flexural psoriasis.
Psoriasis is typically very well defined with a thick scale, whereas eczema is erythematous and may have excoriation marks, oozing blood or pus due
to the intense itching.
A characteristic feature of pityriasis rosea is the presence of a ‘herald patch’ appearing 1-20 days before the generalized rash.
Investigations (2,5)
Psoriasis is usually a clinical diagnosis.
Sometimes, a skin biopsy may be needed to distinguish psoriasis from other similar conditions.
A PASI (psoriasis area and severity index) score can be calculated to assess the severity and psychological impact of the condition, which helps
guide management.
Management
There is no cure for psoriasis, however lots of treatment options are available.
Topical corticosteroids
Dithranol
Coal tar preparations e.g., shampoos (particularly useful for scalp psoriasis)
These would be first-line treatment options that may be offered by a GP. Further treatment options below would require referral to a specialist in
dermatology or paediatrician.
Phototherapy (5)
Ultraviolet light B (UVB) and PUVA (psoralen and ultraviolet light A) therapy to those >10 years of age for 6-12 weeks.
Methotrexate (5)
Off label use, given once a week to those who have not responded to topical therapy and UV therapy. Regular blood tests are required.
Complications
Juvenile psoriatic arthritis
Impact on quality of life including mental health problems (depression and anxiety)
Prognosis
This (5)
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Children with psoriasis may clear the condition completely, particularly if it was triggered by infection.
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Others may go on to have life-long chronic psoriasis.
References
1. Pinson R, Sotoodian B, Loretta Fiorillo L. Psoriasis in children. Psoriasis: Targets and Therapy. 2016; 6:121-129.
British Association of Dermatologists. Psoriasis in children and young people. [Internet]. Bad.org.uk. 2020 [Accessed 6 March
2.
2021].
Kamiya K, Kishimoto M, Sugai J, Komine M, Ohtsuki M. Risk Factors for the Development of Psoriasis. International Journal of
3.
Molecular Sciences. 2019; 20(18):4347.
4. Rendon A, Schäkel K. Psoriasis Pathogenesis and Treatment. International Journal of Molecular Sciences. 2019; 20(6):1475.
5. Brown E. Paediatric psoriasis. DermNet NZ [Internet]. Dermnetnz.org. 2013 [Accessed 6 September 2021].
Stanway A. Erythrodermic psoriasis. DermNet NZ [Internet]. Dermnetnz.org. 2004 [cited 6 March 2021]. Available from:
6.
https://dermnetnz.org/topics/erythrodermic-psoriasis/
7. Hsu C. Global Dermatology. Psoriasis: Auspitz Sign [Internet]. Genevadermatology.ch. 2021 [Accessed 6 March 2021].
8. Paller A. What’s the difference between eczema and psoriasis? [Internet]. Aad.org. 2021 [Accessed 21 October 2021]
9. British Association of Dermatologists. Lichen planus [Internet]. Bad.org.uk. 2021 [Accessed 6 March 2021].
10. Oakley A. Pityriasis rosea. DermNet NZ [Internet]. Dermnetnz.org. 2014 [Accessed 6 March 2021].
11. NICE. Psoriasis overview [Internet]. Pathways.nice.org.uk. 2021 [Accessed 6 September 2021].