Psoriasis in children

A chronic papulosquamous inflammatory skin disease such as psoriasis develops at any age, and psoriasis can begin in children.

It is believed that this genetically determined dermatological pathology has an autoimmune or immune-mediated nature. That is, it is not an infection, but a kind of dermatosis, and it is impossible to become infected with psoriasis. According to ICD-10, psoriasis is classified as class XII (diseases of the skin and subcutaneous tissue) and has the code L40.0- L40.9.

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Epidemiology

Psoriasis in children is much less common than in adults. In various international studies, estimates of the prevalence of this skin pathology in children vary from 0 to 2.1% or within 1% (in adults - from 0.9 to 8.5%).

According to the National Psoriasis Foundation (NPF), about 10-15% of patients develop psoriasis before the age of 10. Typically, the disease begins between the ages of 15 and 40 (equally in both sexes).

As for geographic epidemiology, the number of patients increases as one moves north from the equator.

In addition, as noted by experts from the Association of Pediatric Psoriasis (USA), worldwide almost 48% of children with psoriasis are overweight, which may indicate a certain role of general metabolic disorders in the etiological factors of this disease.

Another study showed that vulgar plaque psoriasis accounts for more than 62% of cases, guttate psoriasis - 26%, pustular psoriasis - 10%, erythrodermic psoriasis - no more than 5%. At the same time, rashes on the scalp are found in 57-65% of patients, and damage to the nail plates - every third.

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Causes of psoriasis in a child

To date, researchers have not identified the exact causes of psoriasis in children and adults, but the etiology of this disease is associated with a combination of immune, genetic, psychogenic and environmental factors.

There are certain hereditary risk factors for the development of psoriasis in a child. According to the International Federation of Psoriasis Associations (IFPA), about 2-4% of the world's population has some form of psoriasis, but this disease is rarely diagnosed in infants and young children. According to some estimates, in a third of adult patients, the manifestation of the pathology began at about 16-20 years. And dermatologists say that if one of the parents has psoriasis, there is a 10-15% chance that the child will also develop this disease. And when psoriasis is in both parents, this risk increases to 50-70%. It is noted that if psoriasis develops in children with healthy parents, then there is a 20% chance that a brother or sister can also develop psoriasis (the principle of alternation of generations with a family tendency to diseases is at work).

In both adults and children, factors such as psychological stress, depression, physical overexertion, the use of certain medications, and sudden changes in climatic conditions (especially cold, dry weather) can be triggers for this chronic disease.

Often psoriasis can manifest itself after a streptococcal infection (pharyngitis, tonsillitis, otitis), and this type is known as guttate psoriasis in children.

In addition, the peculiarities of psoriasis in children are that psoriatic spots (plaques) appear on the injured skin area (at the site of cuts, scratches, abrasions, irritation, etc.). In dermatology, this phenomenon is called an isomorphic provoking reaction or the Koebner phenomenon.

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Pathogenesis

The pathogenesis of psoriasis lies in the accelerated proliferation of keratinocytes - the formation of new cells in the basal and suprabasal layers of the epidermis. Constant natural renewal of keratinocytes and their migration to the stratum corneum are necessary for the regeneration of the skin, but when the speed of this process increases by 6-8 times, there is an "overproduction" of new skin cells, and then they accumulate in the stratum corneum, which is manifested by characteristic thickened spots on the skin and their increased desquamation (flaking).

Now, few people doubt that all this is an autoimmune reaction caused by an inflammatory cascade in the dermis involving dendritic cells, mononuclear phagocytes, intraepidermal macrophages and T-lymphocytes. Immune cells that have perceived skin cells as an antigen move from the dermis to the epidermis and secrete inflammatory cytokines - interleukins and tumor necrosis factor-alpha. In response, abnormal proliferation of keratinocytes and additional synthesis of keratin begin - to replace damaged cells and isolate them from surrounding tissues.

In the pathogenesis of psoriasis, specialists also trace a clear disruption of the tissue structure and synthesis of keratohyalin, a protein of the granular layer of the epidermis that ensures the normal keratinization process.

It also links the causes of psoriasis in children and adults with genetic aberrations of almost 20 loci (PSORS) on different chromosomes responsible for the differentiation of leukocyte T cells, interleukins and their receptors.

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Symptoms of psoriasis in a child

The main symptoms of psoriasis in children are no different from the signs of this pathology in adults and depend on its type.

Types or clinical variants of psoriasis that can be diagnosed in childhood: guttate, plaque, inverse (reverse), pustular, psoriatic erythroderma (or erythrodermic psoriasis), psoriatic arthritis.

According to dermatologists, spotted or guttate psoriasis is more common in children than other types. And its first signs appear on the skin of the extremities, head and body suddenly - in the form of small red nodules that begin to peel and can cause itching.

The second most common in childhood or adolescence is plaque (common) psoriasis. In these cases, the initial stage of psoriasis in children is manifested by the formation of dry, slightly protruding reddish spots (plaques) on the elbows and knees, quickly covered with a layer of whitish-silver scales. See - Symptoms of psoriasis

The plaques enlarge, the scaly layer (made up of dead skin cells) becomes thicker; new spots, often symmetrically located, appear all over the body and on the scalp. They may itch, the scaly "crust" on them may crack and cause slight pain; the skin underneath becomes covered with protruding microscopic droplets of blood. The nail plates become dull and crumble, and partial detachment of the nail plates (onycholysis) may occur.

Some classifications distinguish between the seborrheic form of the disease and nail psoriasis, although psoriasis on the head of a child, as well as nail psoriasis in children, are only local symptoms of the plaque variety of the disease.

There is inverse psoriasis, in which plaques appear not on the extensor part of the elbow and knee joints, but on smooth areas and in the folds of the skin. This type manifests itself as psoriasis in children under one year old, it can also be defined as diaper psoriasis. This form is very often confused with common or exfoliative dermatitis, pemphigus of newborns or diaper rash, since psoriasis is an extremely rare disease among infants, especially if it is not in the family history. The rash in the diaper area has the appearance of red shiny spots, clearly demarcated from healthy skin.

The clinical forms that appear extremely rarely in childhood include:

• erythrodermic psoriasis (psoriatic erythroderma) - a severe burn-like redness that covers most or all of the body; generalized hyperemia may be accompanied by intense itching, tactile soreness of the skin, and fever;
• pustular psoriasis - rashes in the form of blisters with purulent exudate, exudative rash, which quickly increases and merges into solid spots (in this case, blisters often appear on the soles and palms). With this form, symptoms of psoriasis in children may include subfebrile temperature, loss of appetite, muscle weakness;
• arthropathic psoriasis or psoriatic arthritis - swelling of the joints, their stiffness, pain (usually against the background of plaque rashes, but also possible before the appearance of skin symptoms).

Stages

The following stages of the immune-inflammatory process in psoriasis are distinguished: progressive, stationary and regressive. All of them successively replace each other.

The acute progressive stage is characterized by the appearance of new rashes, and those that are already there increase in size and become flaky. Moreover, the plaques have clear boundaries in the form of a red border, and in the middle of them is the epicenter of desquamation.

The cessation of the formation of new plaques, as well as the increase in the size of old ones, are the symptoms by which the stationary stage is determined. In addition, the plaques become slightly bluish, and their entire surface is already intensively peeling.

At the regressive stage, the plaque becomes flat, the scales gradually disappear, the spots fade, and in their place there remain whitish traces of the leukoderma type.

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Complications and consequences

The consequences and complications of psoriasis are related to the fact that this disease is chronic, with periods of exacerbation and remission. Therefore, parents should be aware that there is a risk of children developing severe forms, in particular, psoriatic arthritis.

In addition, experts warn of a fairly high probability of developing other metabolic diseases of an autoimmune nature, in particular, gluten enteropathy or celiac disease (gluten intolerance) and granulomatous enteritis (Crohn's disease).

Psoriasis can also lead to the development of metabolic syndrome, which includes increased blood pressure, insulin levels (type II diabetes) and cholesterol.

Complications of psoriatic arthritis, which affects any joint and surrounding connective tissue, can cause swelling of the fingers and toes, known as dactylitis. Joints of the hip, knee, spine (spondylitis) and sacroiliac joints (sacroiliitis) may become inflamed.

Psoriasis in children and adults often negatively affects the quality of life, causing the formation of low self-esteem, frequent depression and the desire to avoid the company of other people.

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Diagnostics of psoriasis in a child

Dermatologists claim that diagnosing psoriasis in children is not difficult: it is enough to conduct a physical examination of the child's skin, scalp and nails. Clinical signs are the basis for determining this disease.

The doctor should also ask the parents what the child was sick with; they themselves are all close relatives.

Instrumental diagnostics are carried out using a dermatoscope, which magnifies fragments of the rash and records it on the monitor screen and in the form of a scanned image.

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Differential diagnosis

If necessary, a skin sample (biopsy) can be taken to examine it under a microscope. This allows the dermatologist to clarify the situation, since only differential diagnostics makes it possible to distinguish psoriasis from other dermatological pathologies with partially similar symptoms: ichthyosis, xerosis of the skin, red flat, pink or ringworm, seborrheic dermatitis or keratosis, contact or atopic dermatitis, etc.

Assessing the severity of psoriasis can help decide on the most appropriate treatment. The severity of psoriasis is determined by determining the area of the body surface affected by the rash: mild - less than 3% of the body surface; moderate - from 3 to 10%; severe - more than 10%.

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Treatment of psoriasis in a child

It is impossible to cure psoriasis, that is, to get rid of it completely. As in adults, the treatment of psoriasis in children is aimed at reducing the manifestations of the disease. Most children have a mild degree, in which local therapy is sufficient.

Skin moisturizing plays a role in normalizing hyperproliferation and also has an anti-inflammatory effect by saturating epidermal cells with lipids. Therefore, it is recommended for young children to treat the affected areas of skin with mineral oils or petroleum jelly.

Doctors prescribe medications for external use, including corticosteroids - ointments Hydrocortisone, Betasalic (Betamethasone, Betaderm A, Diprosalic), Flucinar (Sinaflan), Lorinden, etc., which are used only during exacerbations and help reduce itching, inflammation and the size of rashes.

For example, Betasalic ointment (betamethasone + salicylic acid) should be applied no more than twice a day, lightly rubbing into the affected area. The duration of use of ointments with corticosteroids is determined by the attending physician, since side effects of drugs in this group include burning, allergic irritation, dryness and atrophy of the skin. Betasalic lotion is used to lubricate the scalp.

Only for plaque psoriasis and only for children over 12 years of age can ointments such as Calcitriol, Daivobet, Forcal, Xamiol be prescribed, containing a synthetic analogue of the active metabolite of vitamin D. However, the manufacturers of Psorkutan ointment (with the same active substance) indicated that it may be prescribed to patients under 18 years of age in case of ineffectiveness of other means and for a short time; and for Daivonex ointment with calcitriol, the age limit was reduced to 6 years of age. Side effects of calcitriol: dermatitis, eczema, angioedema, hypercalcemia, exacerbation of psoriasis, etc.

External agents containing dithranol obtained from bitumen (Cygnoderm, Ditrastik, Anthralin) are contraindicated for use in pediatric dermatology, since this substance has carcinogenic properties.

It is recommended to use absorbable ointments in the stationary and regressive stages of plaque psoriasis: 5% tar, 3% sulfur-tar, naphthalene, 2% salicylic. More information - Non-hormonal ointments for psoriasis

Vitamins A, C, B1, B6, B9, B12, B15, PP, taken in courses of 28-30 days with breaks, are designed to improve the condition of the skin.

Physiotherapeutic treatment can also be used: UV therapy (sunbathing for 30 minutes a day); narrow-band PUVA therapy (for children over 10 years old); in the remission stage – sea bathing, mud therapy (from 3 to 14 years old, every other day, for 10 minutes).

Folk remedies

For rashes on the scalp, folk treatment involves washing the head with a decoction of St. John's wort (two tablespoons of the herb per liter of water). And if psoriasis occurs in children under one year old, the baby should be bathed in a decoction of three-part succession (3 parts), chamomile (1 part) and horsetail (1 part).

It is recommended to lubricate the plaques with the following remedy: dry linden branches, remove the bark (to make 100-150 g), burn the bark from a metal container and lubricate the affected areas with the resulting semi-liquid resinous substance (morning and evening).

After this remedy is finished, take a break for 6-7 days and prepare a homemade ointment according to the following recipe. Rub 150 g of fresh cranberries through a sieve, squeeze out and boil the resulting juice for 10 minutes. Put a tablespoon of homemade lard or melted butter into the thickened juice, drop 5 drops of fish oil, stir until smooth, pour into a jar with a lid (keep the remedy in the refrigerator), lubricate the rashes at the initial stage of psoriasis in children.

A mixture of Vaseline and alcohol extract of the succession (1:1) makes a good ointment for the acute stage of common psoriasis. More information in the article - Treatment of psoriasis at home

Herbal treatment in the form of decoctions for oral administration to children is not recommended, so it is better to do baths. Ingredients: sage herb (1 part), plantain leaves (2 parts), wild pansy herb (1 part), stinging nettle herb (1 part). The decoction is prepared from 1.5 liters of water, filtered and added to the bath. This decoction can also be used to rinse the head after washing, when the child has psoriasis on the head. And it is recommended to add 10 drops of tea tree oil or juniper essential oil to the shampoo for washing the head.

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Prevention

It is obvious that prevention of psoriasis in children, given the etiology of the disease, is hardly possible. But it is possible to regulate the nutrition of a child with such a diagnosis, since a Diet for Psoriasis has been developed

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