Overview
Definition:
Pediatric psoriasis is a chronic, relapsing inflammatory skin condition characterized by well-demarcated erythematous plaques with silvery scales, affecting children and adolescents
Scalp psoriasis typically presents as thick, greasy scales on the scalp
Inverse psoriasis (intertriginous psoriasis) occurs in skin folds, appearing as smooth, erythematous, and often macerated lesions without prominent scaling.
Epidemiology:
Psoriasis affects approximately 0.7% to 3.7% of children, with prevalence increasing with age
Scalp involvement is common, seen in up to 50% of pediatric psoriasis cases
Inverse psoriasis is less common in children than plaque psoriasis but significant due to its location and potential for secondary infection, occurring more frequently in infants (diaper psoriasis) and obese adolescents.
Clinical Significance:
Pediatric psoriasis can significantly impact a child's quality of life, leading to psychological distress, social isolation, and reduced self-esteem
Accurate diagnosis and appropriate management are crucial to control disease activity, prevent complications, and improve long-term outcomes
Understanding management strategies for specific presentations like scalp and inverse disease is vital for DNB and NEET SS preparation.
Clinical Presentation
Scalp Psoriasis Symptoms:
Itchy scalp
Thick, silvery-white scales
Erythematous patches
Hair loss (temporary, due to scratching or treatment)
Lesions may extend beyond the hairline onto the forehead or neck.
Scalp Psoriasis Signs:
Well-demarcated, erythematous plaques covered with thick, adherent, silvery scales
Punctate bleeding points (Auspitz sign) may be present on removal of scales
Onychodystrophy (nail changes) may also be noted.
Inverse Psoriasis Symptoms:
Burning sensation
Discomfort
Mild itching
Lesions in areas of skin-on-skin contact.
Inverse Psoriasis Signs:
Smooth, shiny, well-demarcated erythematous plaques
Often macerated and moist
Lack of typical silvery scale due to moisture and friction
Common sites include axillae, inguinal folds, gluteal cleft, inframammary areas (in girls), and perianal region
Can be mistaken for fungal or bacterial infections.
Diagnostic Approach
History Taking:
Age of onset
Duration and progression of lesions
Family history of psoriasis or autoimmune diseases
Triggers (infections, stress, trauma)
Previous treatments and response
Impact on quality of life
Symptoms of joint pain (psoriatic arthritis).
Physical Examination:
Thorough skin examination, noting distribution, morphology, and character of lesions in all body areas, including scalp, nails, and intertriginous regions
Assess for signs of secondary infection (e.g., pustulation, purulent discharge)
Examine joints for swelling, tenderness, or limited range of motion.
Investigations:
Diagnosis is primarily clinical
Skin biopsy is rarely needed but may show characteristic epidermal hyperplasia, parakeratosis, and Munro's microabscesses
If infection is suspected (e.g., in inverse psoriasis), potassium hydroxide (KOH) preparation to rule out tinea, and bacterial or fungal cultures may be considered
Serological markers (e.g., anti-CCP, rheumatoid factor) are not diagnostic but helpful if psoriatic arthritis is suspected.
Differential Diagnosis:
For scalp psoriasis: seborrheic dermatitis, tinea capitis, lichen simplex chronicus
For inverse psoriasis: intertrigo (bacterial or candidal), seborrheic dermatitis, diaper dermatitis, irritant contact dermatitis, hidradenitis suppurativa.
Management
Scalp Psoriasis Medical Management:
Topical corticosteroids (e.g., clobetasol propionate 0.05% lotion/foam, betamethasone valerate 0.1% lotion) applied to the scalp, often daily for limited periods, followed by less potent agents or intermittent use
Coal tar shampoos or solutions
Salicylic acid preparations to help debride scales
Anthralin (dithranol) for resistant cases, used carefully to avoid irritation
Calcipotriol (a vitamin D analogue) or calcipotriol/betamethasone combination products for longer-term management.
Inverse Psoriasis Medical Management:
Gentle cleansing with mild soaps
Topical corticosteroids (e.g., hydrocortisone 1% or desonide 0.05%) applied thinly, as potent steroids can cause skin atrophy and striae in intertriginous areas
Topical calcineurin inhibitors (e.g., tacrolimus, pimecrolimus) are often preferred for sensitive areas due to their steroid-sparing effect and lack of skin atrophy
Barrier creams (e.g., zinc oxide) may help protect the skin
Antifungal or antibacterial agents if secondary infection is present.
Systemic Treatment Indications:
Severe or widespread psoriasis
Psoriasis unresponsive to topical therapy
Presence of psoriatic arthritis
Significant impact on quality of life
For recalcitrant cases, systemic agents like methotrexate, cyclosporine, acitretin, or biologics (e.g., etanercept, adalimumab, ustekinumab) may be considered under specialist supervision, based on age, weight, and disease severity, following strict monitoring protocols.
General Measures:
Patient education on disease chronicity and treatment adherence
Emollients to moisturize the skin
Avoiding triggers like scratching or harsh skin products
Weight management for obese individuals
Phototherapy (UVB) can be an option for older children with extensive disease, under dermatological supervision.
Complications
Scalp Psoriasis Complications:
Secondary bacterial infection (e.g., impetiginization) from scratching
Hair loss (alopecia) that is usually reversible
Onychodystrophy
Scarring in severe, chronic cases with repeated inflammation.
Inverse Psoriasis Complications:
Secondary bacterial or fungal infections (e.g., Candida, Staphylococcus aureus)
Skin maceration and fissuring
Erythrasma
Intertrigo leading to pain and difficulty with hygiene
Development of lichen simplex chronicus from chronic scratching.
General Complications:
Psychosocial impact (anxiety, depression, bullying)
Increased risk of comorbidities (obesity, metabolic syndrome, cardiovascular disease in adults, though less established in children)
Psoriatic arthritis.
Prognosis
Factors Affecting Prognosis:
Age of onset (earlier onset may correlate with more severe disease and longer duration)
Family history
Extent and severity of disease
Adherence to treatment
Presence of comorbidities
Response to initial therapies.
Outcomes:
Pediatric psoriasis is often a lifelong condition with periods of remission and exacerbation
Scalp and inverse psoriasis can be managed effectively with appropriate topical and, in severe cases, systemic therapies
With consistent management, symptoms can be controlled, and quality of life can be significantly improved
Early intervention can prevent long-term complications and reduce psychosocial burden.
Follow Up:
Regular follow-up with a dermatologist or pediatrician is essential, typically every 3-6 months, or more frequently during active flares or when initiating new treatments
Monitoring for treatment efficacy, side effects, disease progression, and associated conditions (e.g., psoriatic arthritis, metabolic issues) is crucial
Education on self-management and prompt reporting of worsening symptoms or new lesions is encouraged.
Key Points
Exam Focus:
Distinguishing pediatric psoriasis from seborrheic dermatitis
Management of inverse psoriasis, emphasizing steroid-sparing agents
Indications for systemic therapy in pediatric psoriasis
Recognizing secondary infections in intertriginous areas.
Clinical Pearls:
For scalp psoriasis, using a corticosteroid lotion or foam offers better scalp penetration than creams
In inverse psoriasis, always consider bacterial and fungal causes as co-factors or primary issues
a prompt KOH or culture can be invaluable
Topical calcineurin inhibitors are excellent for sensitive inverse areas
Biologics are used judiciously in severe pediatric cases after failure of conventional systemic therapy.
Common Mistakes:
Over-reliance on potent topical corticosteroids in inverse psoriasis leading to atrophy
Failing to consider and treat secondary infections in inverse psoriasis
Underestimating the psychosocial impact of psoriasis on children
Prescribing systemic therapy without adequate topical control or prior evaluation for comorbidities.