Childhood psoriasis: Analytic retrospective study in Saudi patients

Journal of the Saudi Society of Dermatology & Dermatologic Surgery (2011) 15, 57 61 King Saud University Journal of the Saudi Society of Dermatology & Dermatologic Surgery www.ksu.edu.sa www.jssdds.org www.sciencedirect.com ORIGINAL ARTICLE Childhood psoriasis: Analytic retrospective study in Saudi patients Sami N. Alsuwaidan * Department of Dermatology, Psoriasis Research Chair, College of Medicine, King Saud University, P.O. Box 2925, Riyadh 11461, Riyadh, Saudi Arabia Received 20 December 2010; accepted 20 February 2011 Available online 20 May 2011 KEYWORDS Psoriasis; Guideline; Saudi Abstract Psoriasis is a genetically determined chronic inflammatory and immunologically mediated disease. At an early age, the presentation of psoriasis may be atypical. Among all types of childhood psoriasis, plaque type is the most common. In this article, we report our data analysis on the main clinical aspects of childhood psoriasis, its onset, risk factors, demographics and therapeutic options. A total of 36 patients with childhood psoriasis were evaluated at the dermatology out-patient clinic in the college of medicine at King Saud University during the period from April 2002 to June 2007. All patients were diagnosed based on clinical findings. Of the 36 patients, 24 (66.67%) had generalized plaque type psoriasis, 8 (22.2%) had guttate psoriasis, 4 (11.1%) had mixed plaque type and guttate psoriasis, 6 (16.67%) had localized plaque type (on elbows and knees), 4 (11.11%) had palmoplanter psoriasis and 1 (2.77%) had scalp psoriasis. Among those, one patient had congenital psoriasis. The age of patients ranged from 8 months to 18 years (mean = 11.3 years). There were 15 males and 21 females. The mean duration of the disease was 3.04 years and family history was positive in 10 patients (27.78%). All patients were treated by topical medications and/or narrow-band ultraviolet-b phototherapy. Apart from prolonged tanning no significant adverse effects were reported. Of particular interest, skin cancer was not detected in this series of children even after repeated courses. In conclusion, childhood psoriasis is more common in girls with plaque type psoriasis being the most common type. Topical therapy is the mainstay treatment for localized disease and narrow-band ultraviolet-b phototherapy is considered safe and effective for moderately severe conditions. More studies are required to define the safety of systemic therapy and biologic treatment in this age group of psoriasis. ª 2011 King Saud University. Production and hosting by Elsevier B.V. All rights reserved. * Tel.: +966 1 4691426; fax: +966 1 4691432. E-mail address: salsuwaidan@ksu.edu.sa. 2210-836X ª 2011 King Saud University. Production and hosting by Elsevier B.V. All rights reserved. Peer review under responsibility of King Saud University. doi:10.1016/j.jssdds.2011.04.005 Production and hosting by Elsevier 1. Introduction Psoriasis is a genetically determined chronic inflammatory disorder seen in 3.5% of US population (Kurd and Gelfand, 2009). The incidence in Saudi Arabia has not been precisely defined. It is mainly classified into two age groups: childhood psoriasis that develops below the age of 18 years and adulthood psoriasis that develops after the age of 18 years. Childhood psoriasis is broadly sub-classified into three age groups:

58 S.N. Alsuwaidan infantile psoriasis (onset within the first year of age), pediatric psoriasis and pediatric psoriasis with psoriatic arthritis (Silverberg, 2009). Moreover, Congenital psoriasis (psoriasis since birth), a distinct entity of psoriasis associated with lower prevalence of family history, different pattern of anatomic involvement, higher fraction of erythrodermic, pustular or linear subtypes and poor prognosis has been described. It has been suggested that congenital psoriasis should be considered in the category of erythematous, scaly, or pustular eruptions in the newborn (Lehman and Rahil, 2008). The aim of this article is to look over the clinical aspects, risk factors and therapeutic options of childhood psoriasis in Saudi patients. 2. Demographics and onset of the disease In this study a total of 36 patients with childhood psoriasis were evaluated at the dermatology out-patient clinic in the college of medicine at King Saud University during the period from April 2002 to June 2007. The age of patients ranged from 8 months to 18 years (mean = 11.3 years). The mean duration of disease was 3.04 years. Male patients were 15 (41.67%) and females were 21 (51.33%) (see Table 1). The incidence of childhood psoriasis is unknown (Marcoux and Prost, 2002), but it has been reported that 10% of all cases occurred before the age of 10 years and 2% at less than 2 years of age (Burden, 1999). The differences of the onset between females and males have varied from region to region (Morris et al., 2001). In a study from India, the age of onset of the disease ranged from 4 days to 14 years. The mean age of onset in boys was 8.1 ± 2.1 years and in girls was 9.3 ± 2.3 years. (Kumar et al., 2004). In another report from china, a study was carried out in 277 childhood psoriatic patients where the mean age of onset was found to be 11 years. The male: female ratio was 1:1.13. The median age of onset of disease was 10 years (Fan et al., 2007). Furthermore, a population based study was performed in USA to assess the incidence of childhood psoriasis which revealed that the annual incidence was 40.8 per 100,000. Authors concluded that the incidence of pediatric psoriasis increased with age and both males and females suffer equally (Tollefson et al., 2010). In a retrospective analysis from Turkey, 61 children with psoriasis under age of 18 years were evaluated. Twenty three (37.70%) were males and 38 (62.30%) were females. The mean age of patients was 9.28 ± 4.02% for females and 11.18 ± 3.85% for males. The mean age of onset of the disease in females was 6.81 ± 4.11 years and 7.03 ± 4.28 years in males (Seyhan et al., 2006). the triggering factors were respiratory tract infections (14.8%) and positive throat culture for group A-beta hemolytic streptococci (21.3%). Also, the frequency of emotional stress and psychiatric morbidity was 54% and 9.8%, respectively. It is suggested that stress and upper respiratory tract infections are the most important triggering factors in childhood and adult psoriasis. They also reported a positive family history in 14 cases (23%) (Seyhan et al., 2006). Apart from positive family history in one third of our patients, we did not find any other significant associated factors. This might be explained by the small number of patients in our study. 4. Clinical patterns In our study, all patients were diagnosed based on clinical findings. Of the 36 patients, 24 (66.67%) had generalized plaque type psoriasis, 8 (22.2%) had guttate psoriasis, 4 (11.1%) had mixed plaque type and guttate psoriasis (see Fig. 1), 6 (16.67%) had localized plaque type (on elbows and knees), 4 (11.11%) had palmoplanter psoriasis and 1 (2.77%) had scalp psoriasis. Among those, one patient had congenital psoriasis (see Table 1). Most children with psoriasis manifest with the plaque type disease (68.6%) in similar patterns to adult patients, with lesions being localized to the scalp, post auricular region, elbows, and knees. Guttate disease is more common in pediatric than in adult patients. It was present in 28.9% of 277 children in a Chinese survey. Other patterns in childhood psoriasis include erythroderma (1.4%), pustular disease including palmoplantar pustular psoriasis (1.1%), and mucosal glossitis (1.1%) (Fan et al., 2007). Another study has shown that the most frequent clinical type of childhood psoriasis is plaque type in 1302 patients (68.1%), followed by guttate psoriasis in 727 patients (38.0%). Erythrodermic psoriasis and pustular psoriasis were only seen in 7.3% and 5.0% of patients, respectively (Jager and Jong, 2010). Though generalized pustular psoriasis in children is uncommon, it may present as a severe and potentially life-threatening disorder. Four clinical patterns of pustular psoriasis have been described in children: generalized pustular psoriasis, annular pustular psoriasis, exanthematous pustular psoriasis, and localized pustular psoriasis. Mixed variants of these patterns are also possible. 3. Risk factors In a recent report, there was no evidence to support that getting affected by psoriasis before the age of 18 years influences disease activity in later life or type of treatments used (Jager and Jong, 2010). The association of childhood obesity and psoriasis is of significance. A study was conducted to observe the influence of obesity on childhood psoriasis, it was concluded that being overweight is an important risk factor for the onset of childhood psoriasis (Boccardi and Menni, 2009). It is suggested that psoriasis should be added to the adverse consequences of childhood obesity (Naldi et al., 1996). Seyhan et al, from Turkey found that in most of their 61 patients Figure 1 Child with mixed guttate and plaque type psoriasis.

Childhood psoriasis: Analytic retrospective studyin Saudi patients 59 Generalized pustular psoriasis has been reported in a 6-weekold infant (Chao et al., 2009). In regard to congenital psoriasis, erythrodermic and pustular variants are common presentations (Lehners-Weber et al., 1996; Al-Fouzan et al., 1990; Lerner and Lerner, 1972; Henriksen and Zachariae, 1972). 5. Therapy Topical treatment is the first line therapy in childhood psoriasis for a limited disease. In a more severe disease, systemic therapy and phototherapy are considered to control the disease. Well-designed studies on systemic therapeutic modalities for psoriasis in pediatric age group are meager and children are treated with the support of data extrapolated from those in adults (Burden, 1999). 6. Topical treatment There are various agents frequently used as topical therapies for childhood psoriasis. Topical corticosteroids are usually prescribed. Mild forms of topical corticosteroids are used for the face, whereas, moderate to potent forms are used for the body and scalp. More than 40% of our patients were treated by either topical corticosteroids or calcipotriene. Topical Calcipotriene was proved to be efficacious in childhood psoriasis treatment in 43 children (Oranje et al., 1997). Anthralin 1% is rarely used in childhood psoriasis because of localized irritation (Farber and Nall, 1999). Other topical agents described in the treatment of childhood psoriasis are topical calcineurin inhibitors, tacrolimus 0.3% ointment, and pimecrolimus 1% cream (Stefanakiet al., 2010). 7. Phototherapy Phototherapy is considered a safe and effective treatment for children. Generalized or hand-foot therapy, either narrowband ultraviolet-b (NB-UVB), broadband UVB (BB-UVB) or psoralen and UVA (PUVA) can be used. More than 60% of our patients were treated with NB-UVB and satisfactory results were observed (see Table 1). In one report, 12 weeks treatment with NB-UVB, PASI 90 was achieved in 60% of patients, however, 10% had less than 50% improvement (Jain et al., 2007). A series of 113 children were treated by various phototherapy methods. Positive response was observed in 92.9% of psoriatic patients treated by NB-UVB, in 83.3% of those treated with PUVA and in 93.3% of those treated with BB-UVB (Ersoy- Evans et al., 2008). NB-UVB and PUVA therapies have shown satisfactory results in treating childhood guttate and plaque psoriasis as marked improvement was found in 88% of 25 patients treated with these two modalities (Al-fouzan and Nanda, 1995). In another study conducted on 35 patients of childhood psoriasis, clearance of disease was found in 63% of cases (Jury et al., 2006). Only few cases are reported to develop erythema and anxiety during phototherapy, otherwise, treatment is being well tolerated (Tay et al., 1996). From our experience, phototherapy is considered safe and effective treatment of childhood psoriasis where NB-UVB is favored over PUVA due to increased safety profile and convenience for patients. During Phototherapy, Our patients encountered tanning effect, pruritus and dryness that might be aggravated by local climate nature. In our data no single case of skin cancer was reported over 10 year experience with phototherapy. Although phototherapy is a simple, safe and effective treatment, both children and their parents must be educated for the possible adverse effects and the associated hazards of overexposure. 8. Oral antibiotics Multiple studies implicate subclinical or recurrent streptococcal infection as a trigger or maintenance factor in the pathogenesis of psoriasis in children. In one study reviewing studies and reports examining this particular relationship concluded that the percentage of psoriasis patients who experienced disease clearance with antibiotic therapy ranged from 0% to 55%, with no patients experiencing disease worsening during treatment. The available evidence does not demonstrate the efficacy of antibiotic therapy in the treatment of childhood psoriasis. Because these treatments are relatively benign compared to other treatments for severe psoriasis, the use of antibiotic therapy may still be worth considering, especially for those patients with recurrent streptococcal infections that seem to trigger or maintain their skin disease (Wilson et al., 2003). A controlled study revealed mixed results of oral antibiotics therapy in childhood psoriasis (Dogan et al., 2008). In our experience the response to oral antibiotics in children with psoriasis was variable with majority being none responsive. 9. Systemic treatment Systemic treatment is the ultimate option in severe and uncontrolled cases. Systemic therapeutic options may include cyclosporine (Cordoro, 2008; Mahe et al., 2001), systemic retinoids (Davis and Krafchik, 1993; Rosinska et al., 1988) and methotrexate (Collin et al., 2006; Kumar et al., 1994). Limited resources and studies are available to assess appropriately the efficacy and safety of these treatments in childhood psoriasis. We have not tried such modalities in our series and no further comments can be made. 10. Biologics The biologic therapy namely Tumor Necrosis Factor-alpha (TNF-alpha) blockers like etanercept and infliximab has been used recently in pediatric auto immune diseases like rheumatoid arthritis, TNF-a receptor 1-associated periodic syndrome without fever (TRAPS), juvenile idiopathic arthritis and crohn s disease. Safety and efficacy of etanercept therapy have been recognized in juvenile rheumatoid arthritis patients (Lovell et al., 2008). In a placebo-controlled randomized double-blind trial, 211 children with plaque psoriasis were treated with once-weekly subcutaneous injections of etanercept (0.8 mg/kg), with a maximum dose of 50 mg. At week 12, 27% of patients treated with etanercept reached PASI 90, in contrast to 7% of patients treated with placebo (Paller et al., 2008). Further reports manifest the positive response of etanercept (Safa et al., 2007; Papoutsaki et al., 2006). In one case report one child with psoriasis was successfully treated with Infliximab after failure of etanercept (Farnsworth et al., 2005). We did not use these drugs in our patients at this stage. But we stress that these drugs cannot be used frequently until more data are available about the risk-benefit ratio of these treatments in childhood psoriasis. With future studies proper

60 S.N. Alsuwaidan Table 1 Childhood psoriasis: patients series of 36 patients. Serial No. Age (yr) Sex Duration of disease (yr) Pattern of the disease Family history Mode of treatment 1 7 f 4 Generalized (plaque type) Negative NB-UVB 2 7 f 2 Generalized (plaque type) Positive NB-UVB 3 11 f 2 Guttate type Positive NB-UVB 4 6 m 1 Mixed guttate and plaque Negative NB-UVB 5 7 m 2 Generalized (plaque type) Negative NB-UVB/Corticosteroids 6 12 f 1 Guttate type Negative NB-UVB 7 11 f 2 Mixed guttate and plaque Negative NB-UVB 8 10 f 1.5 Localized e/k (plaque type) Positive Corticosteroids 9 9 f 4 Localized e/k (plaque type) Negative Calcipotriene 10 10 f 3 Generalized (plaque type) Positive NB-UVB 11 18 f 1 Palmoplantar Negative Corticosteroids 12 15 f 2 Localized e/k (plaque type) Negative Calcipotriene 13 4 m 1.5 Guttate type Negative NB-UVB/oral antibiotic 14 0.8 m Since birth Congenital Negative Corticosteroids 15 11 m 6 Palmoplantar Negative Calcipotriene 16 4 m 1 Guttate type Negative NB-UVB/ oral antibiotic 17 8 f 2 Guttate type Positive NB-UVB 18 18 f 6 Generalized (plaque type) Negative NB-UVB/Corticosteroids 19 17 f 6 Mixed guttate and plaque Negative NB-UVB 20 12 f 0.3 Generalized (plaque type) Negative NB-UVB 21 16 f 5 Guttate type Negative NB-UVB 22 4 f 1 Scalp psoriasis Negative Corticosteroids 23 16 m 8 Generalized (plaque type) Negative NB-UVB/Corticosteroids 24 13 m 4 Localized e/k (plaque type) Negative Calcipotriene 25 12 m 0.2 Localized e/k (plaque type) Negative Corticosteroids 26 14 f 6 Palmoplantar Positive Corticosteroids 27 8 f 4 Generalized (plaque type) Negative NB-UVB 28 15 f 2 Palmoplantar Negative Corticosteroids 29 9 m 2 Guttate type Positive NB-UVB/ oral antibiotic 30 14 m 5 Generalized (plaque type) Positive NB-UVB 31 18 m 11 Generalized (plaque type) Positive NB-UVB/Corticosteroids 32 17 f 0.3 Mixed guttate and plaque Negative NB-UVB 33 6 f 1.5 Generalized (plaque type) Negative NB-UVB 34 17 m 3 Guttate type Negative NB-UVB 35 18 m 1.3 Generalized (plaque type) Positive NB-UVB/Corticosteroids 36 11 m 1 Localized e/k (plaque type) Negative Corticosteroids e/k: Elbows and knees. positioning of biologics in the therapeutic ladder of psoriasis in children might be possible. 11. Conclusion With evaluation of our series of children with psoriasis we conclude that childhood psoriasis is more common in females with plaque type psoriasis being the most common type. Topical therapy is the mainstay treatment for localized disease. At present, NB-UVB phototherapy is a safe and effective modality for moderately severe cases particularly in children with poor response to topical therapeutic protocols. Systemic therapy and biologics should be reserved for severe and uncontrolled cases. More clinical studies are required to define the safety levels of systemic therapies and biologic treatments to properly define their position in the therapeutic ladder of childhood psoriasis. References Al-fouzan, AS., Nanda, A., 1995. UVB phototherapy in childhood psoriasis. Pediatr. Dermatol. 12, 66. Al-Fouzan, S.A., Hassab-El-Nabi, H.M.M., Nanda, A., 1990. Congenital linear psoriasis: a case report. Pediatr. Dermatol. 7, 303 306. Boccardi, D., Menni, S., Vecchia, CLA., Nobile, M., Decarli, A., Volpi, G., Ferraroni, M., 2009. Br. J. Dermatol. 161, 484 486. Burden, A.D., 1999. Management of psoriasis in childhood. Clin. Exp. Dermatol. 24, 341 345. Burden, A.D., 1999. Management of psoriasis in childhood. Clin. Exp. Dermatol. 24, 341 345. Chao, P., Cheng, Y., Chung, M., 2009. Generalized pustular psoriasis in a 6-week-old infant. Pediatr. Dermatol. 26 (3), 352 354. Collin, B., Ogboli, M., Moss, C., 2006. Methotrexate therapy in 10 children with severe plaque psoriasis: P-29. Br. J. Dermatol. 155 (Suppl), 33. Cordoro, K.M., 2008. Systemic and light therapies for the management of childhood psoriasis: part II. Skin Ther. Lett. 13, 1 3. Davis, A., Krafchik, B.R., 1993. New drugs in pediatric dermatology. Curr. Opin. Pediatr. 5, 212 215. Dogan, B., Karabudak, O., Harmanyeri, Y., 2008. Antistreptococcal treatment of guttate psoriasis: a controlled study. Int. J. Dermatol. 47, 950 952. Ersoy-Evans, S., Altaykan, A., Sahin, S., Kolemen, F., 2008. Phototherapy in childhood. Clinical and laboratory investigations. Pediatric Dermatol. 25 (6), 599 605.

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