UVB
Ciclosporin
Azathioprine
Methotrexate
After long-term skin cancer induction
Kidney dysfunction, hypertension
Blood dyscrasia
Liver dysfunction
Numbering indicates the steps of initial treatment options.
Topical Treatment
Local treatment with mild corticosteroids, coal tar preparations and dithranol are often recommended.
Topical Corticosteroids
Topical corticosteroids for psoriasis have not been well studied in children. Corticosteroids have anti-inflammatory, antiproliferative, immunosuppressant, vasoconstrictor and antipruriginous actions. They are a widely used topical therapy in cases of childhood psoriasis in most countries. However, in some geographical regions there has been some restriction in their use, as described, for example, in the German literature. Although some patients require occasional potent corticosteroids, mild and moderate corticosteroids are preferred in children. On the face, only mildly potent corticosteroids should be applied. Delivering the steroid to the involved skin in a convenient, tolerable, safe and efficacious manner requires selection of a vehicle that is well suited to site-specific qualities such as hair (scalp), moisture (intertriginous zones) and occlusion (axillae, nappy/diaper area, gluteal cleft). Thin and intertriginous skin responds to lower potencies, whereas thicker hyperkeratotic areas such as the palms and soles require higher potency agents.
Topical corticosteroids (TCSs) also are likely to be absorbed through the skin, particularly when the more potent preparations are used and when they are applied to areas where the skin is thinnest, such as the eyelids, face, genitalia and intertriginous areas. The degree of systemic absorption of any one TCS, and of different TCSs, during topical application of these therapies, is highly variable.
Patient-related and drug-related factors can affect systemic absorption. The drug-related characteristics encompass the dosing regimen. Also, the vehicle has an important role in the absorption of topical agents. Ointments are more occlusive than creams or lotions and can increase systemic absorption compared with other vehicles. Additionally, the characteristics of the individual steroid, such as the potential to metabolize in skin or other tissues, and potency, affect absorption.
Infants have a large body surface area relative to their volume, which increases the chances of systemic absorption and adverse events, such as adrenal suppression. In general, very high potency agents should be avoided in children. Recently it was reported that a 4-year-old girl with psoriasis, who had been receiving 5–10 g/day of the strongest class of topical corticosteroids for approximately 4 months, had the drug discontinued 2 days before admission, thereby inducing a steroid withdrawal syndrome. This is an objective syndrome resembling true adrenal insufficiency and characterized by fever, anorexia, nausea, malaise, arthralgias and desquamation of the skin, with highly variable grading, in patients undergoing steroid withdrawal. It is essential to pay due attention to the potency and duration of topical corticosteroids when they are used for children [4].
The authors prefer to use a system of applying topical corticosteroids daily for 4 days, followed by 3 days without treatment, or of applying these medications on alternate days.
By tapering the use of TCSs, the risk of developing side-effects or tachyphylaxis is diminished [5].
Coal Tar
Crude coal tar has antipsoriatic, antipruritic and keratolytic effects. Liquor carbonis detergens (LCD) is a modified, less clinically active coal tar with better cosmetic acceptability.
Tar is a safe treatment for childhood psoriasis. It should not be used on acutely inflamed skin, or on pustular erythrodermic psoriasis. Because of the odour, colour and phototoxicity, coal tar (5–30% in zinc ointment) is used almost exclusively in children who are hospitalized. Purified coal tar solution (10–20%) with or without 2% allantoin in an ointment is effective in intertriginous areas and for more superficial lesions.
Dithranol
Dithranol (anthralin) is an anti-inflammatory and antiproliferative agent. Dithranol is thought to affect psoriasis by causing a reduction in cell turnover. Its use has been limited due to staining and irritation, but ‘short-contact’ therapy with dithranol, with application of a cream applied for 30–60 min in the evening, is generally safe and often effective. ‘Short-contact’ treatment also avoids the staining of clothing [6]. The efficacy of short-contact therapy using a dithranol cream preparation was retrospectively evaluated in 58 children with psoriasis. Dithranol cream (0.1–2%) was applied daily for 30 min to affected skin areas. Patients were evaluated at 1–4-week intervals. The median duration of therapy before the onset of remission was 2 months. Remission was achieved in 81% of the children. The median duration of remission was 4 months. Mild adverse skin reactions occurred in 20% of patients, but only one patient had to discontinue therapy. The authors concluded that short-contact therapy with dithranol cream preparation was an effective and well-tolerated treatment for childhood psoriasis [7].
Vitamin D Analogues
Calcipotriol (calcipotriene) ointment, a vitamin D3 analogue, is suitable for mild to moderate psoriasis (<30% of the skin involved). Calcipotriol has been well investigated in children, but only for short-period treatment [8]. It should be a first stage in the treatment, but in many countries it is not accepted as an option in children, only permitted for short periods.Calcipotriol induces differentiation of keratinocytes and inhibits their proliferation [8]. In addition, calcipotriol appears to affect immunological markers that play a role in the aetiology of the disease [9]. A prospective, multicentre, double-blind study involving 77 children has been performed. Calcipotriol was safe and effective in treating children with psoriasis involving less than 30% of the body surface. There were no serious side-effects and no effects on calcium and bone metabolism. The maximum recommended dose is 50 g/week/m2 [8]. If large quantities are applied, absorption of the vitamin D analogue can result in hypercalcaemia. It should not be applied on the face, scalp, genital region and areas that are covered (e.g. the napkin area).
There are very few studies on the effect of calcitriol (1,25-dihydroxyvitamin D3) in children with psoriasis. Saggese et al. reported that in a small number of patients topical calcitriol may be an effective and safe alternative therapy for psoriasis in children [10].
Calcipotriol is an effective, well-tolerated treatment option for childhood plaque psoriasis. At present, the authors consider calcipotriol to be the treatment of first choice for plaque-type psoriasis involving less than 30% of the body surface. A combination of topical calcipotriol with topical corticosteroids is a superior alternative treatment (authors’ personal observation).
Topical Immunomodulators
Tacrolimus is a calcineurin inhibitor that acts by preventing the production of cytokines in T-cells and mast cells. Tacrolimus ointment is an effective treatment for psoriasis on the face or intertriginous areas in children [11]. Tacrolimus ointment is currently approved for the treatment of atopic dermatitis in children aged 2 years and above, and shows anti-inflammatory effects. In a prospective study, 11 patients aged between 6 and 15years with facial or inverse psoriasis were evaluated in a 6-month open-label trial. Within the first 30 days of treatment with 0.1% tacrolimus ointment, every patient had cleared or achieved excellent improvement with the use of tacrolimus ointment. Statistically significant improvement was achieved for each sign of the disease and the overall severity score. The only adverse event reported in 6 months of observation was significant pruritus in one patient. In this study tacrolimus ointment was an effective treatment for psoriasis on the face or intertriginous areas in children [11]. The long-term safety has so far not been established.
Phototherapy
Ultraviolet light (UVB alone or in combination with UVA) may be used in the treatment of chronic psoriasis. Tar baths, followed by UVB therapy and application of dithranol, have been used successfully in the plaque form of psoriasis. However, phototherapy has undesired potential side-effects, namely its carcinogenic potential and premature ageing of the skin. Photochemotherapy (phytotoxic psoralens used in combination with UVA) is not indicated in the routine management of childhood psoriasis because long-term use increases the risk of skin cancer. More recently, TLO1 [narrow-band UVB, 311 nm (NB-UVB)] has become the preferred option for phototherapy to treat older children with stable plaque psoriasis (J.I. Harper, personal communication).
In an open-label study NB-UVB treatment was performed in 20 psoriasis patients aged 6–14 years. Eighteen had chronic plaque psoriasis and two had guttate psoriasis. Narrow-band UVB was administered twice a week. All topical therapies other than emollients and scalp therapies were discontinued. At the end of treatment, 80% of patients had responded (60% excellent, 15% good, 5% moderate response). Narrow-band UVB was well tolerated and no serious side-effects were observed, besides mild erythema in two patients. Worsening of psoriasis, necessitating withdrawal, was seen in two patients [12]. The therapeutic efficacy was good, and there was a low profile of acute side-effects, but long-term side-effects are not known yet. More experience is needed to establish firmly the safety of narrow-band UVB phototherapy. Besides, it is important to realize that phototherapy may cause practical problems, because the child will miss school frequently. Moreover, treatment within a small cabin with protection for the eyes may elicit anxiety and phobic reactions in children.
References
1 Leman J, Burden D. Psoriasis in children: a guide to its diagnosis and management. Paediatr Drugs 2001;3:673–80.
2 Burden AD. Management of psoriasis in children. Clin Exp Dermatol 1999;24:341–5.
3 Pariser D. Topical corticosteroids and topical calcineurin inhibitors in the treatment of atopic dermatitis: focus on percutaneous absorption. Am J Ther 2009;16:264–73.
4 Saeki H, Watanabe A, Tada Y et al. Juvenile pustular psoriasis associated with steroid withdrawal syndrome due to topical corticosteroid. J Dermatol 2009;35:601–3.
5 Lebwohl M, Ting PT, Koo JYM. Psoriasis treatment: traditional therapy. Ann Rheum Dis 2005;64(Suppl. II):ii83–ii86.
6 Zvulunov A, Anisfeld A, Metzker A. Efficacy of short-contact therapy with dithranol in childhood psoriasis. Int J Dermatol 1994;33:808–10.
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