Pediatric Psoriasis Comorbidities

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


Skin Therapy Letter. 2020;25(5):1-6. 

In This Article

Psychiatric Disturbances & Impaired Quality of Life

Understanding and managing the association between psoriasis and mental health is critical to caring for pediatric patients with psoriasis. Children with psoriasis have a significantly increased risk of developing depression (6.65-fold higher) and/or anxiety (9.21-fold higher) compared to their peers;[36,37] this association is stronger in younger children (8–12 years) compared to adolescents.[38] This trend is particularly concerning because depressive episodes earlier in life increase the risk of chronic psychiatric disability.[39] Adults with psoriasis have a significantly higher rate of suicidal ideation, attempts and completed suicides.[40] This increased risk correlates with disease severity[40,41] and is stronger among younger adult patients (20–30 years) compared to older adults (>60 years).[40,42]

There may also be an association between psoriasis and other psychiatric conditions such as bipolar disorder and schizophrenia in pediatric patients with psoriasis,[43] but the nature of that association remains unclear. An increased tendency towards substance use and abuse has been demonstrated among adult patients with psoriasis, and early data suggests a similarly increased risk among pediatric psoriasis patients.[43] Environmental tobacco exposure at home is a risk factor for the development of pediatric psoriasis,[44] although the relationship between pediatric psoriasis and personal history of cigarette smoking has not been explored. The psychosocial stress caused by having psoriasis likely engenders depressive symptoms that lead to increased risk-taking behavior such as substance abuse, which may then worsen psoriasis. Since mental illness, tobacco smoke and substance abuse are independent risk factors for cardiovascular disease, these sequential associations may be another mechanism by which psoriasis can lead to cardiovascular disease.

While it has been suggested that the increased risk of psychiatric disturbance among pediatric psoriasis patients reflects the associated stigmatization of the skin disease, there may also be a shared immunopathogenesis affecting the brain and skin of patients with psoriasis and psychiatric disease.[45] Further research is needed to clarify whether psoriasis and psychiatric disturbance are causally and/or intrinsically related. Nonetheless, these statistics highlight the importance of early screening and intervention to mitigate the effects of psoriasis on mental health. The AAP recommends yearly screening for anxiety and depression in all pediatric patients. Dermatologists caring for children with psoriasis should routinely ask patients and their caretakers about the psychosocial impact of psoriasis, inquire about mood symptoms, and maintain a low threshold for referral to mental health providers. The psoriasis CSI echoes the AAP's recommendation for annual screening for substance abuse beginning at age 11.[3,46] In addition, counseling on the deleterious effects of alcohol, recreational drugs and tobacco smoke should be offered to pediatric psoriasis patients. Currently, few patients receive counseling on smoking as a risk factor for psoriasis.[47]

While stress is a known trigger for psoriasis in adults, it may be even more relevant in pediatric psoriasis. Stressful life events during the year prior to diagnosis correlate with the onset of pediatric psoriasis, and relationship problems are associated with the most significantly increased risk. Half of adults with pediatric-onset psoriasis report developing new psoriatic lesions during times of distress, compared to fewer patients with adult-onset psoriasis.[2] Dermatologists caring for pediatric psoriasis patients should routinely inquire about life stressors and counsel patients and their caregivers on the relationship between stress and psoriasis. Currently, this is not standard practice.[47]

Quality of Life

Psoriasis negatively impacts the quality of life (QOL) of affected children and their caregivers. The effect of psoriasis is estimated to exceed that of diabetes or epilepsy in childhood.[48,49] Younger children (ages 8–12 years vs. 13–18 years) and those with associated arthritis are most severely impacted, although it is possible that our QOL measurement tools are not as sensitive in demonstrating the impact on adolescents.[38,48,50] Pain, pruritus and fatigue associated with psoriasis all contribute to poor QOL even in children with mild disease;[51] in focus groups, however, affected children reported that the "worst part" of their psoriasis is the appearance.[50] Psoriasis affects social, emotional and school functioning, and children with psoriasis may be the victims of stigma and/or bullying.[48,51,52] Parents and caregivers of children with psoriasis also report decreased QOL.[52] Adults with a history of earlier age of onset of psoriasis (as young as 2 years of age) are more likely to report chronic effects on QOL and to attribute their depression to psoriasis than adults with similar severity of disease but later age of onset.[53] Providers should routinely inquire about the psychosocial impacts of psoriasis on the patient and their family so that support and resources can be provided as necessary.