Pediatric Psoriasis Comorbidities

Nicole W. Kittler, MD; Kelly M. Cordoro, MD


Skin Therapy Letter. 2020;25(5):1-6. 

In This Article

Case Resolution (Denouement)

A reasonable approach to this patient is to confirm his diagnosis given the severity and disease escalation despite treatment with an aggressive form of phototherapy (Goeckerman), assess for triggers such as infection, and investigate for comorbidities. A skin biopsy revealed psoriasis, and bacterial cultures from the skin erosions, pharynx and anus were negative. A comprehensive review of systems and discussion with the patient and his family revealed depression, social isolation, and social stigma. As his disease improved (he was initially treated with methotrexate while awaiting insurance approval for an anti-TNF agent; once approved, he started adalimumab), his mood remained low and the rage attacks continued. Despite near total skin clearance on biologic therapy, he remained anxious and depressed, spoke very little during office visits, and was referred for psychological evaluation and therapy. Over time, both his skin and his psychological health improved. Now, 4 years after his initial presentation, he remains on adalimumab, has a few localized plaques on the legs, his mood has normalized, and he enjoys and is doing well in school. During check-ups, he engages, smiles, answers questions, makes eye contact, and has hopes and dreams for his future which he shares openly.

This case highlights the importance of a thorough evaluation for comorbid conditions and triggers in patients with psoriasis, as well as the disease impact on social and psychological health and well-being. Consider both extrinsic (i.e., the patient is sad, depressed and withdrawn because he does not like the way he looks and feels) and intrinsic factors (e.g., the inflammation in the skin leading to psoriasis may also be at play in the brain, resulting in altered mood or potentially organic mental health disease; i.e., not just a "cause and effect" phenomenon). Many children with psoriasis are undertreated often due to age, a paucity of short- and long-term safety data for newer targeted therapies, and lack of experience and comfort with systemic therapies for children on the part of dermatologists. As we enter a new era of pediatric patient population involvement in clinical trials and the US FDA approval of biologic therapies for children, hopefully the treatment gap between children and adults with psoriasis will narrow. In addition, as we learn more about the long-term consequences of chronic, undertreated inflammation on the cardiovascular and other organ systems (i.e., the "psoriatic march"), the psychosocial impact of having a disfiguring, severe chronic disease in childhood, and other comorbidities associated with pediatric psoriasis, we will be better positioned to face the demands, challenges and opportunities of comprehensively and optimally managing children with psoriasis.