Psoriasis- Signs, Symptoms and types in Children

Abstract: 

Psoriasis is a chronic, relapsing inflammatory skin disorder that can significantly affect children both physically and emotionally¹. Characterized by erythematous, scaly plaques, pediatric psoriasis often presents with different patterns than in adults, involving areas such as the scalp, face, and flexures. Genetic predisposition, immune dysregulation, and environmental factors contribute to its onset and progression. Conventional treatments include topical therapies, phototherapy, and systemic agents, but these may be associated with side effects, especially in long-term use. Homeopathy, a holistic system of medicine, offers a complementary approach that aims to stimulate the body’s natural healing mechanisms. Individualized homeopathic treatment considers the child’s physical, emotional, and psychological state, with remedies selected based on a detailed case history. Although evidence from large-scale clinical trials is limited, several case studies and observational reports suggest potential benefits of homeopathy in managing pediatric psoriasis, including symptom relief and reduction in recurrence.

Key words: Homoeopathy , paediatric psoriasis , 

Introduction 

Psoriasis is a common, chronic inflammatory disorder that affects the skin, nails, and joints of  2.0%–3.5% of the general population. Psoriasis begins in childhood in approximately one-third of the cases¹. When psoriasis starts in childhood, it has more adverse implications. Psoriatic skin lesions are characterized by well defined erythematous scaly plaques, and tend to have a chronic relapsing and remitting course. Severity ranges from a few scattered plaques to involvement of almost the entire body surface. Children suffering from psoriasis have a higher prevalence of obesity, diabetes mellitus, hypertension, juvenile arthritis, Crohn’s disease (CD), and psychiatric disorders^1,2.

Epidemiology

Although pediatric psoriasis is not uncommon, there are limited epidemiological data available to date. One-third of patients develop psoriasis in childhood, and the incidence of childhood psoriasis increases with age.About 30 % of individuals with psoriasis (children and adults) have an affected first-degree family member. Psoriasis comprised 1.4% of all pediatric dermatoses seen in patients less than 14 years of age at a referral hospital in South India. In an epidemiological study of various dermatoses in school children aged 6-14 years from North India, the point prevalence of psoriasis was found to be 0.02%.³

The relatively low familial incidence of psoriasis of about 4.5 – 9.8% among Indian patients could be explained by the ignorance of family members about the existence of the disease, an attempt to hide information because of social reasons or the actual absence of the disease at the time of enquiry.^1,2,12,13

Quality of life and psychological aspects:

Psoriasis does not affect survival but it has negative effect on patient quality

of life like many other chronic diseases. In recent studies, it is stated that nearly one third of the patient of psoriasis have pathological worry and anxiety. There is a feeling of disgrace by their skin condition leading to avoidance behavior and the belief that they are being evaluated on the basis of their skin disease. Therefore, depression and suicidal tendencies are being found in more than 5% of the patients. The severity of psoriasis depends upon the physical and psychological factors. In 60% of patients, stress is a key exacerbator of the disease and it is found that psychological stress has the potential to regulate the immune response in which there is an abnormal hypothalamic-adrenal axis response to acute stress, and there are lot of evidences that shows abnormal neuro-endocrine responses to stress which may contribute to the pathogenesis of chronic autoimmune diseases.^1,11

Aetiology: 

Psoriasis is genetically complex and a large number of genes are thought to be important in its pathogenesis. Empirical studies suggest that if one parent has psoriasis, then the chance of child being affected is 15-20%, and if both parents are affected, then this chance increases to 50%.^1-4,10-15

Common trigger factors for psoriasis

• Infections (e.g. streptococcal, viral)
• Skin trauma (Koebner phenomenon)
• Psychological stress
• Drugs (e.g. lithium, beta blockers)
• Sunburn
• Metabolic factors (e.g. calcium deficiency)
• Hormonal factors (e.g. pregnancy)

Pathophysiology : 

• Stress, genetic , autoimmune reaction and medication cause
• Hyperactive of t-cells
• Epidermis infiltration and keratinocyte proliferation
• Deregulated inflammatory process 
• Large production of various
• Cytokines (inteferon, interleukin-12)
• Superficial blood vessel dilated and vascular engorgement
• Epidermal hyperplasia and improper cell maturation
• Fails to release adequate lipids which lead to flaking, scaling presentation of psoriasis lesion
• Silver scaling of skin .^2,15,16

Signs and symptoms: 

• Red patches of skin covered with thick, silvery scales
• Small scaling spots (commonly seen in children)
• Dry, cracked skin that may bleed 
• Itching, burning and soreness 
• Thickened , pitted or ridged nail .
• Swollen and stiff joints.^10-14

Clinical Types

• Plaque psoriasis : Plaque psoriasis is the most common type which affects in children¹. The typical plaque is a sharply demarcated, red plaque, covered by silvery white scales. In younger children, the lesion can be atypical, smaller, pinker, less demarcated, and less scaly. It affects typical locations of psoriasis such as the elbows, knees, scalp, and umbilicus, but can be generalized and the distribution is often symmetric. The most common sites affected are elbows, knees, scalp, and lower back.^1-4,11-15 

Guttate psoriasis : Guttate psoriasis was derived from the Latin “gutta” (a drop), meaning “drop-like” appearance of cutaneous lesions². It is acute in onset, often a week after a streptococcal pharyngitis and less often with an association with perianal streptococcal dermatitis. Characterized by round and slightly oval papules and plaques; varying from 2 to 3 mm to 1 cm in diameter. The small papular lesions have characteristic overlying silvery-white scales and are scattered more or less symmetrically mainly on the trunk, abdomen, and back. The lesions occur less frequently on the face, ears, and scalp, and are unusual on the palms and soles. It usually persists for 3–4 months and resolves spontaneously and may continue for more than a year. Most patients may experience a recurrence within the next 3–5 years after an attack of guttate psoriasis.^{1-2 ,15-16}

• Pustular psoriasis : Pustular psoriasis is characterized by localized or generalized superficial sterile pustules over an erythematous base. This variant of psoriasis is rare in this age group. Four clinical patterns of pustular psoriasis have been described in children: generalized pustular psoriasis (Von Zumbusch)¹⁵, annular pustular psoriasis, exanthematic pustular psoriasis, and localized pustular psoriasis. The generalized pustular psoriasis pattern is characterized by waves of widespread eruption of sterile pustules, associated with constitutional symptoms such as high fever, malaise, anorexia, and pain. Most patients with this pattern tend to develop psoriasis vulgaris.The annular pattern is a more frequent, subacute eruption and is characterized by erythema and pustules in a circinate pattern. This form can follow or precede the generalized form of pustular psoriasis. Juvenile generalized pustular psoriasis can occur at any age, but the onset of the disease is often during the 1st year of life¹³.

• Scalp psoriasis: It is a type of psoriasis which is very common in children. The scalp is the first site to be involved in many children . The hairline and occipital area of the scalp are often the first sites with typical plaque form. In mild forms, it appears as seborrheic dermatitis, but in severe forms, it can present with pityriasis amiantacea, i.e., thick fixed, silver scales^2,.

• Nail psoriasis: Nearly 25-50% of children with psoriasis have associated nail involvement. The most common feature is pitting; other features include discoloration, onycholysis, subungual hyperkeratosis, “oil drop” sign or salmon patch, and transverse lines and ridges².

• Inverse psoriasis: This type of psoriasis develops in flexural and intertriginous areas, such as retroauricular, axillae, groin, genital, or perianal areas. Because of moisture, the typical scale is absent in these sites and presents as a glazed erythema leading to absence of Auspitz’s sign.^1-4,15

• Napkin psoriasis : Napkin psoriasis presents as erythematous, bright, and well-demarcated plaques on the skin covered by the diaper. Most of the times, scales may not be visible due to high moisture content in the diaper area. It may be the initial manifestation of psoriasis in young children, with or without psoriasis present elsewhere on the body². 

• Facial involvement: Sometimes, it can be the sole manifestation of psoriasis in 4%–5% of children. It presents as erythematous, scaly patches or plaques on the eyebrows, nasolabial folds, perioral skin, or other facial areas.
• Psoriatic arthritis : Juvenile psoriatic arthritis is a rare condition in children and affects 0.7%–10% of children with psoriasis.The peak age of onset for arthritis is around puberty. Psa may precede or follow the onset of cutaneous manifestations of psoriasis. Joint involvement is often asymmetric and may be monoarticular or polyarticular. Younger children tend to have dactylitis and small joint involvement, while older children more often have enthesitis and axial joint disease.
• Oral psoriasis: Tongue involvement affects 5%–10% of children. In adults, fissured tongue is more frequently seen, but in children, migratory glossitis is mostly observed.
• Erythrodermic psoriasis : Erythrodermic psoriasis is very rare in children. It is characterized by widespread cutaneous erythema and associated scale and exfoliation.

• Rarer Presentations In Children : Linear, annular, and palmoplantar psoriasis are rare types of psoriasis in children. Some cases of congenital psoriasis have also been reported^1-4.

Diagnostic tool : 

Psoriasis is usually diagnosed clinically and occasionally a skin biopsy may be necessary. Histological features of psoriasis are epidermal acanthosis with parakeratosis, indicative of chronicity of the disease, loss of the granular cell layer, elongation of the rete ridges, and neutrophilic aggregates within the parakeratosis (microabscesses of Munro). The neutrophils and parakeratosis alternate in stratum corneum forming the so-called sandwich sign. The neutrophils are also grouped within the epidermis forming spongiform pustules of Kogoj. Tortuous and dilated blood vessels are present in the dermis, and there is a perivascular lymphocytic infiltrate. ‘ Dermoscopy is a new diagnostic tool that features psoriatic plaques as having dotted vessels regularly distributed over a light red background and diffuse superficial white scales. Further research is warranted to determine the added value of dermoscopy in diagnosing psoriasis. If a patient complains of joint pain and swelling, X-ray or magnetic resonance imaging of involved joint may help differentiate features of psoriatic arthritis from other forms of arthritis⁴.

Differential Diagnosis

S.No	TYPE OF PSORIASIS	DIFFERENTIAL DIAGNOSIS
1.	Plaque psoriasis	Nummular dermatitisAtopic dermatitisPityriasis rubra pilarisSeborrheic dermatitisTinea corporis
2.	Guttate psoriasis	Lichen planusPityriasis lichenoides chronicaPityriasis roseaPityriasis rubra pilarisSecondary syphilisDrug eruptionsViral infections
3.	Pustular psoriasis	Acute generalized exanthematous pustulosisStaphylococcal scalded skin syndromeSubcorneal pustular dermatosisInfected contact dermatitisInfected dyshidrotic dermatitisSweet syndromeTinea corporis, manuum, and pedis
4.	Scalp psoriasis	seborrheic dermatitis Tinea capitis
5.	Nail psoriasis	OnychomycosisChronic nail trauma
6.	Inverse psoriasis	IntertrigoCandidiasisDarier’s/Hailey-Hailey diseaseContact dermatitis
7.	genital psoriasis	Contact dermatitisLichen planusLichen sclerosusLichen simplex
8.	Erythrodermic psoriasis	Atopic dermatitisLichen planusPityriasis rubra pilarisSebortheic dermatitisLangerhans cell histiocytosisStaphylococcal scalded skin syndrome1-4,19

Comorbidities

The comorbidities are divided into metabolic and nonmetabolic comorbidities. 

• The metabolic comorbidities include abdominal obesity, Obese habitus, metabolic syndrome,dyslipidemia, diabetes, and hypertension.
• The nonmetabolic comorbidities include atopic dermatitis,vitiligo, alopecia areata, lichen planus,celiac disease, rheumatoid arthritis, epilepsy, valvular cardiomyopathy,and ischemic heart disease.^4,19

Treatment: 

Conventional treatment

There is a selection of conventional treatments on offer, starting with topical treatments, then phototherapy (light treatment) and then stronger, oral treatments. Topical treatments vary from simple emollients to moisturise the skin and alleviate itching, to salicylic acid based creams, topical steroid cream of varying strength and tar preparations. Treatment with various forms of ultraviolet light is  also used.Sometimes in combination with a medicine called Psoralen. Many patients themselves notice the beneficial effect on their skin of ultraviolet light when their psoriasis improves with exposure to sunlight in the summer season. For severe psoriasis, oral medication can be used, often in addition to topical treatment.^3-4,17-19

Homoeopathic treatments : 

As per the Homoeopathic philosophy skin diseases are the manifestation of the disarrangement of the internal disorders. If the treatment of the skin disorders are being done by the external or topical agents, suppression caused by this practice leads to damage to the more vital internal organs .Psoriasis is one of the diseases which not only affect the skin alone but Involve the other parts of the body bod also, like joints, cardiovascular, kidney. Homoeopathic medicines when used for this type of disease not only improve the conditions of outer skin but also remove any disturbance appeared in the internal body .^7-9

Homoeopathic medicines for psoriasis-

According to some studies most effective drugs in cases of psoriasis are Arsenicum album,Calcarea carbonicum, Hydrocotyle asiatica,Ignatia amara, Kalium arsenicosum, Lycopodium clavatum, Natrum muriaticum, Nux vomica, Opium, Petroleum, Psorinum, Sepia officinalis, Sulphur, Thyroidinum, Tuberculinum.

Arsenicum iodatum– it is preferred in persistently irritating, corrosive discharges with debilitating night sweats.Lesions are dry, scaly, itching with marked exfoliation of skin in large scales, leaving a raw exuding surface beneath.^5-9

Chrysarobinum-itis used successfully in skin diseases especially in ringworm, psoriasis, herpes, acne rosacea. Vesicular or squamous lesions, associated with foul smelling discharge and crust formation, tending to become confluent and to give the appearance of a single crust covering the entire area. There is violent itching on thighs, legs and ears. Presence of dry, scaly eruption, especially around eyes and ears, scabs with pus underneath.

Graphites– Skin is rough, hard, persistent dryness unaffected by eczema. Eruptions which ooze out a sticky exudation with rawness in bend of limbs, groins, neck, behind ears. Ulcers discharging a glutinous fluid which is thin and sticky. Skin is unhealthy and every little injury suppurated 

Sulphur– Intensely burning, itching, inflamed eruptions that are worse from warmth and bathing suggest a need for this remedy.Affected areas often look bright red and irritated, with scaling skin that gets inflamed from scratching. This remedy is sometimes helpful to people who have repeatedly used medications to suppress psoriasis (without success).

Kalium bromatum– Itching in lesions which are worse on chest, shoulders,and face. There is anaesthesia of skin along with profound melancholic delusion, religious depression and night terrors.

Petroleum– Itching at night. Skin is dry, constricted, very sensitive,rough and cracked, leathery, thick,greenish crusts, with burning,itching and cracks that bleed easily.

Kalium arsenicosum– Intolerable itching, worse while undressing.Dry, scaly, wilted. Acne; pustules worse during menses. Chronic eczema; itching worse from warmth,walking, undressing. Psoriasis,lichen. Phagedenic ulcers. Fissures in bends of arms and knees. Worse on change of weather.

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NAME : DR JAGGESH 

PG SCHOLAR ( MD PART -I) 

DEPARTMENT OF PAEDIATRICS 

FMHMC MANGLORE