A 5-year-old girl is referred by her pediatrician for evaluation of a spreading rash on her head. The dermatitis was first noted on her scalp approximately 5 months ago and was diagnosed as tinea capitis. Therapy with ketoconazole shampoo did not afford relief and oral griseofulvin was commenced but discontinued after 2 weeks because of gastrointestinal upset. Subsequently, the rash has spread to her forehead, ears, and neck. According to the patient’s parents, the condition has remained asymptomatic. Physical examination reveals extensive erythema and scaling of the affected areas.
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Psoriasis is a chronic papulosquamous disorder that affects approximately 3% of the US population.1 The condition results from uncontrolled keratinocyte proliferation engendered by the overproduction of various cytokines such as tumor necrosis factor (TNF)-α, interleukin (IL)-17, and IL-23.2 The disorder most frequently involves the elbows, knees, and scalp and is characterized by sharply marginated plaques with varying degrees of silvery-white scale.
Approximately one-third of psoriasis cases begin in childhood.3 A review by Augustin et al noted an almost linear increase in prevalence rates between aged 1 and 18 years.4 Young children may first present with a diaper rash, which is initially attributed to either contact dermatitis or irritant dermatitis. The scalp is the most frequently site involved and often the first area of presentation.
The majority of childhood cases can be managed by topical therapies.5 Topical steroids of medium potency are best used on a rotational basis. Additional topical therapies include vitamin D analogs and calcineurin inhibitors. Cases that are unresponsive to topical therapy may require systemic therapy. Although not specifically approved for childhood psoriasis, methotrexate is both safe and effective for use in children.6 Biologic agents are now considered the systemic treatment of choice for pediatric patients because their efficacy exceeds that achieved by methotrexate. Agents that are approved by the US Food and Drug Administration for use in children include etanercept (age ≥4 years), ixekizumab (age ≥6 years), secukinumab (age ≥6 years), and ustekinumab (age ≥6 years).7
Alleigh Dunagan, CRNP, Stephen Schleicher, MD, is director of the DermDox Dermatology Centers, associate professor of medicine at Geisinger Commonwealth Medical College, and clinical instructor of dermatology at Arcadia University and Kings College.
1. Armstrong AW, Mehta MD, Schupp CW, Gondo GC, Bell SJ, Griffiths CEM. Psoriasis prevalence in adults in the United States. JAMA Dermatol. 2021;157(8):940-946. doi:10.1001/jamadermatol.2021.2007
2. Rendon A, Schäkel K. Psoriasis pathogenesis and treatment. Int J Mol Sci. 2019;20(6):1475. doi:10.3390/ijms20061475
3. Bronckers IM, Paller AS, van Geel MJ, van de Kerkhof PC, Seyger MM. Psoriasis in children and adolescents: diagnosis, management and comorbidities. Paediatr Drugs. 2015;17(5):373-384. doi:10.1007/s40272-015-0137-1
4. Augustin M, Glaeske G, Radtke MA, Christophers E, Reich K, Schafer I. Epidemiology and comorbidity of psoriasis in children. Br J Dermat. 2010;162(3):633-636. doi:10.1111/j.1365-2133.2009.09593.x
5. Hamm H, Höger PH8/Monatsschr Kinderheilkd. 2023;171(5):420-429. doi:10.1007/s00112-023-01764-0
6. Bruins FM, Van Acht MR, Bronckers IMGJ, Groenewoud HMM, De Jong EMGJ, Seyger MMB. Real-world methotrexate use in a prospective cohort of paediatric patients with plaque psoriasis: effectiveness, adverse events and folic acid regimen. Acta Derm Venereol. 2022;102:adv00745. doi:10.2340/actadv.v102.1000
7. Hebert AA, Browning J, Kwong PC, Duarte AM, Price HN, Siegfried E. Managing pediatric psoriasis: update on treatments and challenges-a review. J Dermatolog Treat. 2022;33(5):2433-2442. doi:10.1080/09546634.2022.2059051