Managing psoriasis in pediatric cases

Miami - Psoriasis is a multifaceted dermatologic disease that is relatively easy to diagnose, is not always so easy to treat and may have widespread systemic implications.

Older therapies are still effective and newer ones show great promise in battling this age-old skin affliction. Robert Kirsner M.D., Ph.D., associate professor of the department of dermatology and cutaneous surgery at the University of Miami School of Medicine, shared his views and experiences in the various aspects of, and how to treat, this sometimes hard-to-handle patient at the Masters of Pediatrics Conference here in January.

Statistics show that 2.6 percent of the population, or 6.4 million individuals, are affected with psoriasis in the United States today, and that one-third of these patients have a relative with the disease. The physical and mental impact of psoriasis is substantial and comparable to the impact of other severe diseases such as diabetes, myocardial infarction, arthritis, hypertension and congestive heart failure. Dr. Kirsner affirms that psoriasis patients must be considered as a group at risk for cardiovascular disease and that this risk seems to be higher with severe psoriasis.

Dr. Kirsner cited a Swedish study in which 8,991 patients hospitalized for psoriasis were evaluated. Here, the mortality from cardiovascular diseases was compared with the general population. Overall, risk among inpatients increased by 50 percent, and the excess risk increased with increasing number of hospital admissions. The study also demonstrated that cardiovascular mortality was higher among those admitted at younger ages.

Another study compared smoking habits, body mass index (BMI), and stressful life events and patients affected with psoriasis. It demonstrated that patients who smoke, have a raised BMI and lead a stressful life show an increase in their guttate, pustular and plaque psoriasis.

A look at treatment modalities

Dr. Kirsner reviews work from his group in Miami, published in the Journal of the American Academy of Dermatology, that found treatment (e.g., with methotrexate) of systemic inflammatory diseases such as psoriasis and rheumatoid arthritis reduced the incidence of vascular diseases, presumably through its anti-inflammatory effect.

However, methotrexate also increases homocysteine levels, which are already elevated in patients with psoriasis. By reviewing patients also treated with folic acid in addition to methotrexate, one reduces two factors associated with the development of vascular disease: chronic inflammation and hyperhomocysteinemia, resulting in an even larger decrease in vascular disease.

Newer topical treatments may have a role as well in the treatment of inverse psoriasis in children and include Elidel cream (Novartis) and Protopic (Astellas), the latter being especially effective.

Even so, corticosteroids remain a mainstay in the treatment for psoriasis. Improvement can usually be achieved within weeks. Dr. Kirsner says that long-term remissions may be maintained by applications on alternate days. As tachyphylaxis can occur fairly rapidly, i.e., within a few days to weeks, he recommends intermittent treatment schedules (once every two or three days or on weekends) for more prolonged treatment courses.

Side effects of corticosteroids are also well-known. They include epidermal atrophy (usually reversible), dermal atrophy with the development of striae (especially in intertriginous zones), perioral dermatitis/steroid rosacea, allergic contact dermatitis and suppression of the pituitary-adrenal axis, especially with class I corticosteroids.

Research ramifications

Research has given birth to other effective treatments, including retinoids, calcipotriol, and tacrolimus (Protopic) and pimecrolimus (Elidel), all of which complement topical steroids and are not steroid-based. Another effective treatment is phototherapy (311 nm narrow band UVB).