Patient Presentation
A 14-year-old male came to clinic with a history of a new scalp lesion that had been present for 2 weeks. He had recently seen his barber who noticed the lesion and thought that it was psoriasis. The patient had not tried any treatment. He denied any new soaps, lotions, shampoos, acne or other skin or makeup products. He denied pain, pruritus or burning. The past medical history showed that he had scalp and facial seborrhea as an infant that lasted until 15 months of age. He occasionally had a dry scalp and needed to use a general dandruff shampoo in the winter. He also has general xerosis that was controlled by emollients. The family history was positive for atopic dermatitis. The review of systems showed he was healthy with no fevers, weight loss, arthralgias or infections.
The pertinent physical exam showed a healthy male with growth parameters in the 75-95%. The left parietal area had a 2.5 cm round lesion with thick yellow, greasy scale. There were no broken hairs or alopecia. There was mild erythema but no edema of the area. He had generalized xerosis, but no changes to his nails or umbilicus. The diagnosis of seborrhea was made. The patient was started on a topical steroid and a general selenium sulfide-containing dandruff shampoo to assist with the scale.
The patient’s clinical course over the next 3 weeks revealed that he had improvement but not complete resolution. There was no erythema and markedly decreased scale. He was changed to a tar-containing shampoo along with continued steroid therapy. Three weeks later, he had continued improvement but again not resolution and was referred to a dermatologist. The dermatologist performed a skin scraping confirming that this lesion was not tinea capitus and agreed that this was seborrhea. He was changed to a lotion-based steroid cream and a salicylic acid-containing shampoo. The lesion resolved over the next 6 weeks.
Discussion
Psoriasis is an inflammatory skin disease that is chronic and relapsing with periods of remission. It occurs in genetically susceptible persons and is felt to be triggered by environmental factors including infection (especially Group A, β-hemolytic streptococcus), emotional and physical stress, and skin irritation including friction, rubbing, pressure and scratching. It is common in patients with certain HLA types including HLA-Cw*0602, HLA-Cw6, IL-15 plus others.
It occurs in about 1% of the general population with two age-onset peaks: 16-22 years and ~60 years, but can occur at any age. Some studies show differences with girls/women more affected (2:1 over boys/men) and other studies do not support gender differences. Pediatric psoriasis patients are more likely to have a family history of psoriasis than adults.
Diagnosis is by clinical features and/or skin biopsy. Treatment is multimodal with education and psychosocial support being important component of this chronic disease. Many treatments in the US are used “off-label” in pediatric patients as they are not approved by the Federal Drug Administration for psoriasis in the pediatric age group. Treatment includes topical, phototherapy, and systemic treatment. Topical treatments include corticosteroids, calcineurin inhibitors, coal tar, keratolytics, retinoids, Vitamin D3 analogs and anthralin. Phototherapy with UVA and UVB can be used in various manners. Systemic treatments include cyclosporine, methotrexate, erythromycin, and various tumor-necrosis factors.
The general differential diagnosis of psoriasis includes:
- Atopic dermatitis
- Contact dermatitis
- Pustular rashes
- Pitarysis
- Seborrhea
- Tinea
In specific locations many other diagnoses may be included such as squamous cell carcinoma, oncomycosis, and blepharitis.
Learning Point
Common subtypes of pediatric psoriasis include:
- Plaque
- Silver-scaled, well-demarcated plaques
- Usually on knees and elbow extensor surfaces but can occur in any skin area
- This is the most common subtype – 34-84%
- Scalp
- If only occurring on scalp, may present with mild greasy and scaly plaques
- Alopecia may be present
- May be the site of initial presentation in 50% of patients
- Face
- Is more commonly involved with pediatric psoriasis than adult psoriasis
- Diaper
- Occurs in infants
- Can occur in disseminated psoriasis
- Guttate
- Multiple, small, scaly papules
- Occurs on extremities, trunk and sometimes face
- Often triggered by Group A, β-hemolytic streptococcus
- Pustular
- Multiple papules occurring on erythematous skin
- Papules may be localized or generalized
- Papules are sterile
- Often occurs with onset of fever and arthralgias
Other physical findings associated with psoriasis include nail pitting or other changes, mucosal ulcerations, geographic tongue and arthritis.
Questions for Further Discussion
1. What are the presentations of psoriatic arthritis?
2. What are the potential side effects of topical steroids?
3. What are the potential side effects of systemic treatment of psoriasis for pediatric patients?
Related Cases
- Disease: Psoriasis
- Symptom/Presentation: Eczematous Dermatitis
- Specialty: Dermatology
- Age: Teenager
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for this topic: Psoriasis.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Bard S, Torchia D, Schachner LA. Managing pediatric patients with psoriasis. Am J Clin Dermatol. 2010;11 Suppl 1:15-7.
Sticherling M, Augustin M, Boehncke WH, Christophers E, Domm S, Gollnick H, Reich K, Mrowietz U. Therapy of psoriasis in childhood and adolescence – a German expert consensus. J Dtsch Dermatol Ges. 2011 Oct;9(10):815-23.
Shah KN. Diagnosis and treatment of pediatric psoriasis: current and future. Am J Clin Dermatol. 2013 Jun;14(3):195-213.
Meffert J. Psoriasis. Medscape. Available from the Internet at http://emedicine.medscape.com/article/1943419-differential (rev. 1/21/14, cited 2/21/14).
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
7. All medical and invasive procedures considered essential for the area of practice are competently performed.
8. Health care services aimed at preventing health problems or maintaining health are provided.
9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital
Pediatric Education 