Guttate Psoriasis in a Teenage Girl

Case:

This teenager had been taking penicillin for a sore throat about 2 weeks before this rash developed. Her pediatrician thought that the rash was a drug reaction and had her discontinue the medication. Nevertheless, the rash persisted for more than a month after therapy was stopped.

The patient is devastated by the rash. Her parents have tried to calm her by telling her that it is "just a skin problem" and that it is "really quite minor, all things considered."

Does this look like an allergic reaction to you-or is something else going on?

Dermclinic-Answer

Psoriasis

Teenagers fear psoriasis more than people of any other age. When psoriasis strikes in adolescents, it is commonly in the guttate form-as in the patient in Figure A. Guttate psoriasis has an explosive onset and covers the body in 3- to 5-mm psoriatic papules that do not respect clothing cover. Fortunately, once we gain control of the initial outbreak, many affected youngsters will once again have clear skin-at least until their next bout of "strep throat," which typically precedes the skin outbreak.

Figure

Figure

Figure

Guttate psoriasis is only one of the ways in which the disorder affects children. Psoriasis affects 2% to 3% of the population; in one-third of those affected, the rash develops before their 16th birthday. Patients who have a childhood onset may have different genetics than those with adult-onset psoriasis for several reasons¹:

• Girls are more often affected than boys (56% vs 41%).

• First-degree relatives are more likely to be affected (49% vs 37%).

• Spontaneous remission is more likely to occur (35% vs 24%).

• There is greater relative involvement of the face and scalp (57% vs 46%). 

A growing body of research suggests that young adults with early-onset psoriasis may have a significant increase in atherosclerotic heart disease that will manifest early in their lives.

The most common presentation in childhood is plaque psoriasis (Figure B). However, if one looks only at children younger than 2 years, then the most common type is "napkin psoriasis" (Figure C) with a subsequent generalized psoriasis.

Napkin psoriasis may present in 2 ways. The first is a localized variant in which the psoriatic plaques are well-demarcated and bright red; they cover most of the diaper area. The second form starts as the localized variant but rapidly spreads to involve the trunk and extremities symmetrically. These diaper rashes are generally more difficult to control than the irritant dermatitis that is most common. I maintain these basic principles when I treat affected children:

• Avoid irritants.

• Provide protection.

• Repair the barrier.

• Remove the inflammation.

I can usually accomplish these goals with the consistent use of pastes (removed by mineral oil) and judicious use of 1% hydrocortisone. On occasion, I prescribe a topical anti-yeast agent.

Children are particularly disadvantaged by therapy. Most practitioners are reluctant to match their treatment efforts to the severity of the psoriasis because there are few therapeutic guideposts. Topical corticosteroids are the mainstay of therapy for mild psoriasis, but these are often inadequate, even for moderate disease. Therefore, most children are undertreated. This is unfortunate because the effect of psoriasis on their quality of life and that of their family is often dramatic.

It is in the best interest of the child with moderate to severe psoriasis to be referred to a pediatric dermatologist. We are gaining significant experience with the use of "biologics" in the treatment of children with inflammatory diseases, such as psoriasis, arthritis, and Crohn disease, and we are having a tremendous impact on their quality of life with minimal adverse effects.

References:

• Raychaudhuri SP, Gross J. A comparative study of pediatric onset psoriasis with adult onset psoriasis. Pediatr Dermatol. 2000;17:174-178.