from eczema and other chronic inflammatory skin disorders in children; defines mild, moderate, and severe disease; highlights the challenges pediatricians face in the diagnosis and management of pediatric PsO; and discusses standard first-line treatment for mild to moderate pediatric PsO and emerging treatment options for moderate to severe disease.
Clinical Characteristics of Pediatric PsO
Evolving understanding of the complex characteristics of both pediatric PsO and eczema has allowed recognition of multiple subsets of both diseases, supporting the concept of these conditions as phenotypes rather than single diseases. The clinical hallmarks of pediatric PsO are sharply circumscribed, scaly plaques occurring in characteristic sites of predilection that define subtypes (Table 1 and Figure 1).3,7,11-18 Large plaque PsO is the most common and well-recognized subset of PsO, reported in 69% to 75% of pediatric cases. These lesions typically involve the scalp, elbows, and knees.7,11,12 Posterior auricular scale and nail pits are subtle findings that support the diagnosis.19 Guttate (small plaque) PsO is the second most common subset, reported in 14% to 29% of pediatric cases.20 An initial guttate presentation has been associated with greater PsO severity.20 Streptococcal infection is a well-recognized trigger of guttate PsO,21 which may clear after treating the infection with antibiotics. Tonsillectomy has been demonstrated to induce remission in a minority of children with guttate PsO.22 Other sites of predilection include palms and soles (palmoplantar PsO), skinfolds (inverse PsO), and ear canals (psoriatic otitis externa), which can be isolated or seen in children with large or small plaque disease.
In pediatric patients with PsO, nail involvement occurs in 17% to 39% of cases, and scalp involvement occurs in 18% to 79% of cases.20,23-26 Nail involvement occurs more frequently in boys, while scalp involvement is reported significantly more often in girls.20 Nail involvement may be a sign of a more prolonged course; however, unlike adult PsO, nail involvement has not been directly linked to psoriatic arthritis (PsA).27
Less common PsO subtypes may be more difficult to recognize16 and include PsO-eczema overlap, pustular, isolated palmoplantar, inverse, annular, petaloid, erythrodermic, and tinea amiantacea. Inverse PsO presents with well-demarcated, pink-to-red, often macerated plaques in the axillary, inguinal, and gluteal creases and the umbilicus14,15 and can be confused with infectious or eczematous intertrigo.14 Itching, irritation from sweating, and tenderness are common.
Infants with PsO often present with involvement of the face and diaper area; 26% of children with PsO have a history of diaper rash.28,29 Plaques in this area are characteristically well demarcated and often feature marked erythema with minimal scale. Koebnerization, a diagnostic and therapeutic feature of PsO, is the tendency to develop skin lesions at sites of friction or minor skin trauma.30 Thumb involvement, representing Koebnerization from thumb sucking, is also a common feature of PsO in infants.31
PsO Triggers
Factors such as infections, high body mass index, and
