Diagnosis and Management of Pediatric Psoriasis: An Overview for Pediatricians

August 2023 | Volume 22 | Issue 8 | 742 | Copyright © August 2023


Published online July 25, 2023

doi:10.36849/JDD.7531.

Adelaide A. Hebert MDa, John Browning MDb, Pearl C. Kwong MD PhDc, Ana Duarte MDd, Harper N. Price MDe, Elaine Siegfried MDf

aUT Health McGovern Medical School, Houston, TX 
bUT Health San Antonio, San Antonio, TX 
cWolfson Children’s Hospital, Jacksonville, FL 
dThe Children’s Skin Center, Nicklaus Children’s Hospital, Miami, FL 
ePhoenix Children’s Hospital, Phoenix, AZ 
fSaint Louis University School of Medicine, St Louis, MO

Abstract
Pediatric psoriasis (PsO) and its associated comorbidities carry physical and psychosocial burdens in children and adolescents, which can negatively impact quality of life. However, features distinguishing pediatric PsO from eczema and other common inflammatory skin diseases may not be obvious to primary care providers, which may contribute to underrecognition and misdiagnosis. Accurate diagnosis of pediatric PsO is critical for managing the physical and psychological burdens associated with this disease. This review aims to support pediatricians with enough information to confidently diagnose pediatric PsO, assess associated physical and mental health comorbidities, and recommend first-line treatment options for children with mild to moderate PsO. To accomplish this, we provide information that distinguishes the appearance and symptoms of pediatric PsO from other common pediatric skin conditions. In addition, comorbidities and some of the mental health challenges associated with pediatric PsO are reviewed to help pediatricians provide appropriate care for patients in their clinical practice.

Hebert AA, Browning J, Kwong PC, et al. Diagnosis and management of pediatric psoriasis: an overview for pediatricians. J Drugs Dermatol. 2023;22(8):742-752. doi:10.36849/JDD.7531.

INTRODUCTION

Psoriasis (PsO) is a chronic, inflammatory skin disease characterized by cutaneous features, extracutaneous comorbidities, and an unpredictable course.1,2 PsO is the second most common chronic pediatric skin disorder after atopic dermatitis (AD) and is reported to affect 0.05% to 2.15% of children,3 compared with a 15% to 20% prevalence of eczema.4 PsO is often mistaken for eczema because both are chronic diseases that feature red, scaly skin, suggesting that the true prevalence of pediatric PsO may be higher.5  The mean age of onset of PsO is between 8 and 11 years, and the prevalence increases with age, estimated at 0.13% in those under the age of 2 years and 0.67% in teenagers.6,7 Approximately 30% of adults with PsO experienced symptoms before the age of 20 years.8 

Clinical features of PsO in infants and children are somewhat different from those of adults, which may also make distinguishing pediatric PsO from eczema more difficult. In an anonymous survey, 53.7% of pediatricians (n=95) reported being uncertain or very uncertain about their ability to diagnose pediatric PsO, despite regularly seeing pediatric patients with PsO.1 Pediatricians who are less confident in their diagnostic ability are also less likely to perform total skin examinations, screen for relevant comorbidities, and prescribe disease-specific treatment. None of the pediatricians surveyed prescribed standard-of-care systemic immunomodulating agents (eg, methotrexate and/ or cyclosporine) or US Food and Drug Administration (FDA)-approved therapies labeled for this condition (including targeted biologics or retinoids) for their patients with PsO. A French national survey of clinicians who treat children with PsO found a much lower use of severity scores and systemic treatments among general practitioners and pediatricians compared with dermatologists, thereby limiting treatment options for pediatric patients.9 Dermatologists more frequently prescribed topical corticosteroids and vitamin D analogs for pediatric patients with PsO than general practitioners, suggesting a reluctance to prescribe or lack of awareness of preferred treatments for pediatric PsO.10

Early intervention in pediatric PsO can reduce the impact and burden of the disease and possibly its comorbidities, emphasizing the need for accurate and early diagnosis of pediatric PsO. This review describes the features and triggers that distinguish PsO