Psoriasis in Children—An Overview of Current Treatment Options
For as many as 30% to 45% of adults suffering with psoriasis, their first experience with the disease began before 16 years of age. Although very rare in neonatal infants, psoriasis has been seen in children as young as one year old, albeit to a much lesser extent than in older children. Psoriasis is evenly distributed between the sexes in adults, and the same holds true for children.
Plaque psoriasis is the most common type of psoriasis in children, and in the exceptionally young quite a few first manifest psoriasis as a psoriatic diaper rash. Afflicting the diapering area, this manifestation differs in appearance than the contact dermatitis typical of diaper rash. Margins of the lesions are more clearly defined, folds of skin are frequently involved, and pruritus (itch) may or may not accompany the bright, reddish lesions. Conventional topical treatments for contact diaper rash typically have little effect on psoriatic diaper rash. From the onset of this condition in the infant, within a couple of weeks classical plaque lesions may develop in other areas of the body, such as face, trunk, or limbs.
Genetics and Psoriasis in Children
Nearly half the children who develop psoriasis at a young age have a parent who has psoriasis. Identical twins with psoriasis share the affliction nearly three-quarters of the time, an indication of the genetic component lending susceptibility to this immunologically-mediated inflammatory disease. As many as 179 unique genes have been identified that show altered expression products in the "uninvolved" skin of psoriasis patients compared to the skin of normal individuals. Much is yet to be learned about this difference in gene expression, but the proteins these genes encode are involved in lipid metabolism, skin differentiation, antimicrobial defenses, and regulation of capillary formation in skin.
Dietary Options for Children with Psoriasis
Children present more of a challenge to treat than adults, especially for more severe cases, as their developing systems are more vulnerable and many of the FDA-approved therapeutic remedies are not approved for children. For mild psoriasis in children the common topical treatments effective in adults are frequently effective in children. Including probotics, fish oils, fish, foods rich in vitamin D, and vitamin supplements in a child's diet offers systemic support for improving homeostasis and skin maintenance.
Topical Psoriasis Treatments
Topical treatments such as corticosteroids are often the treatment of choice for most patients of any age, and provide relief for mild cases. High-potency formulations of corticosteroids are not recommended on very young children because of potential side effects. We are not keen on heavy use of synthetic corticosteroids in adults and children because they inhibit natural body mechanisms against infection. A dermatologist's advice on this is recommended. Coal tar formulations are considered safe by the FDA, and are often effective either alone or when compounded with other components. However, 5% or greater coal tar is classified as a cancer-causing agent (carcinogen) by the World Health Organization's International Agency for Research on Cancer. Coal tar is in the same group as solar radiation and methoxsalen (used in PUVA therapy)—two other psoriasis treatments.
Calcipotriene or Calcipotriol (Dovonex™, Daivonex™ outside North America and Psorcutan™ in Germany) is a topically-applied vitamin D3 analog that is a commonly prescribed, nonsteroid alternative for adult psoriasis, sometimes used in rotation with steroid-based formulations. Tacalcitol (Curatoderm™) is another vitamin D3 analog. Tacalcitol is applied once a day and people with psoriasis often experience side effects. Topically-applied vitamin D3 analog has been used with psoriasis in children. Potential adverse effects of calcipotriene are related to dose per unit of body weight, and impact calcium metabolism in adults; this is a consideration for use in children.
Phototherapeutic Options for Psoriasis Treatment
Phototherapy is safe and effective option for carefully selected patients, used on its own or in combination with other therapeutic modalities. It can be used treat several different forms of psoriasis in children, including refractory plaque, guttate and pustular disease, where there is diffuse involvement (less than one-fifth the body's surface area), or focal debilitating palmoplantar psoriasis. It is, however, inappropriate for forms that are pustular or erythrodermic.
Phototherapy works through its underlying anti-proliferative, anti-inflammatory, and immunosuppresant mechanism of action. UVB and PUVA radiation are two options shown to be effective, but which must be used under the careful guidance of a professional, preferably with oversight by a dermatologist who is experienced in pediatric cases, as there are a number of contraindications and potential side effects if improperly administered. Ultraviolet light causes genetic damage, collagen damage, as well as destruction of vitamin A and vitamin C in the skin and free radical generation.
Systemic Treatments for Psoriasis
Systemic (ingested) treatments that have shown significant effect in adults have been used in children, but are typically reserved for severe cases. The three common systemic treatments approved for adults by the FDA—acitretin (Soriatane™), methotrexate (Trexall™, Rheumatrex™), and cyclosporine (Sandimmune™)—are not approved for use in children. The data collected showing relative safety on long-term use of these compounds for psoriasis in children has accumulated through the use of these treatments for other ailments. Systemic treatments are only used for individuals with moderate to severe psoriasis and psoriatic arthritis who are not responsive to other treatments.
Acitretin is a retinoid analog that acts on retinoid receptors in the nuclei of keratinocytes to correct abnormal cell differentiation. It is used in children and adolescents for intermittent rescue therapy, and is not recommended for females of child-bearing age because of potential effects on bone. Methotrexate is widely prescribed for severe psoriasis, but carries significant risks for long-term side effects in children and adults. Cyclosporine is an FDA-approved immunosuppressant, indicated for severe psoriasis in non-immunosuppressed adults and for the prevention of transplant rejection in young children. Cyclosporine, however, carries significant risk of serious side effects when used in children, including skin cancer.
The biologic systemics (Humira® and Enbrel®) have given good results with some patients with moderate to severe psoriasis but likewise carry heavy risks. A number of these target-specific compounds act directly upon immune factors involved in the inflammation response throughout the body, and run the risk of serious infection, disease, and even death. They are used with close clinical and laboratory monitoring, and require strict pre-approval testing protocols for adults.
In a clinical trial evaluating a systemic biologic treatment in children and adolescents with moderate to severe plaque psoriasis, many study participants showed marked improvement. However, the safety concerns that proscribe the strict safety warnings in the use of these treatments were manifest in some of the participants who suffered infections or a serious adverse event. To those adults with severe psoriasis that have found relief with systemic biologics these treatments have been a godsend. But the risk of their use must be carefully weighed against the potential benefits for the individual. Their use in children currently might only be in a clinical trial setting.
An Integrative Approach to Treating Psoriasis in Children and Adolescents
Psoriasis in both adults and children is a complicated disease, the more so with the severity of outbreaks. An integrative approach to treating psoriasis in children may draw on conventional treatments to provide relief but convey benefits as well from modifications to the child's diet and environment. A good place to start with psoriasis is with a healthy diet, paying close attention to potential triggers. Close attention to environmental factors that trigger outbreaks is also advised. Conventional medical treatments in the form of topicals and light therapy, in conjunction with changes in diet, targeted nutritional supplements, and to the extent possible, a reduction of stress are all ways to help the young person and their caregivers manage this disease.
Because implementing a healthy diet to help promote natural healing of psoriatic symptoms in children is often a special challenge for parents, Deirdre Earls, MBA, RD, LD, herself a sufferer of chronic psoriasis, offers 5 diet tips for children with psoriasis.