Psoriasis Advance
Treating children with psoriasis

From November/December 2006 Psoriasis Advance

Reprinted from Psoriasis Advance, our Member magazine Join the Foundation today to access more in-depth news on treatments and research

Psoriasis can be a difficult disease to treat — especially when the patient is a child. Many psoriasis treatments have not been tested in children, so options may be more limited. Treatment schedules and doctor appointments can interfere with school and other activities. And then there's the matter of finding a doctor who has experience treating children with psoriasis.

Jennifer Smalley of Brick, N.J., finally found the right dermatologist for her 6-year-old son, Joey, who has severe psoriasis. However, the search required persistence — Joey was diagnosed with psoriasis when he was only 18 months old, and she interviewed a lot of doctors before finding the best match.

She eventually found her dermatologist through the Internet. She was relieved when the search was over. "I'll never forget what the doctor said to me. 'We'll take care of him. We'll help him,' " she recalls.

For Joey, what worked was a combination of the biologic drug Enbrel and regular phototherapy treatments. For others, it's something else. Just as with adults, psoriasis treatments work differently for each child. And while safety is a factor when choosing treatment, there are other considerations as well.

Most dermatologists who treat children feel a responsibility to weigh a drug's side effects and long-term risks against the potential psychological damage to a young patient whose psoriasis is left untreated.

Jerry Bagel, M.D.

"At every talk I give, I show a picture from 25 years ago of the elbows and knees of a 7-year-old girl with psoriasis," says Jerry Bagel, M.D., clinical assistant professor of dermatology at the Columbia University College of Physicians and Surgeons, and director of the Psoriasis Treatment Center of Central New Jersey.

"I ask people, what type of life do you think she had? Her interpersonal skills were probably impaired because she was ostracized; her personal development with the opposite sex was likely impaired because she was probably embarrassed by her body appearance."

Early childhood and adolescence are times when self-esteem is developing, he added. "I try to be as aggressive as I can therapeutically to get kids with psoriasis as clear as possible, because once you get it cleared up, the psychological problems diminish significantly."

Dr. Bagel says his treatment approach for children is similar to what he uses for adults. "Ideally, I like to use milder topical steroids for children. If topicals don't work, then I go into phototherapy. If phototherapy doesn't work, I do feel comfortable using Enbrel for children who have psoriasis."

Children and psoriasis

Physical considerations Psoriasis can develop on sites where there has been injury to the skin (known as the Koebner phenomenon). Remind your child to keep nails short, and to avoid picking at or scratching the skin or scalp. Children who engage in athletic activities should wear protective guards, when appropriate, to avoid injury to the skin. Children can get exposed to many germs in the school environment. Be aware that the bacteria streptococcus which causes "strep throat" can trigger the onset of psoriasis or a flare. At the first sign of strep throat, make sure it is treated quickly. Certain drugs can make psoriasis worse. Talk to your doctor about drugs that may trigger psoriasis in your child. Exposure to sunlight is good for psoriasis, but too much sun can result in sunburn, which can trigger a flare. Make sure your child uses sunscreen, and talk to your doctor about how much sun exposure is appropriate for your child.

Emotional considerations Encourage your child to talk about his or her feelings about having psoriasis. Educate your child's principal, school nurse and teacher about his or her psoriasis at the start of each new year. Initiate a classroom discussion about the disease. It's important for other children to know psoriasis is not contagious. Help your child develop a network of friends who will be supportive and appreciate him or her for qualities that are unrelated to the disease. Suggest that your son or daughter visit the National Psoriasis Foundation Web site, www.psoriasis.org, for tips, information, and to connect with other youth on the message board.

Amy Paller, M.D., professor and chair of the Department of Dermatology and professor of pediatrics at Northwestern University's Feinberg School of Medicine in Chicago, Ill., also believes that treatment for kids with psoriasis should be similar to that used for adults. "I generally treat with milder agents and get more aggressive as I need to," says Dr. Paller. She does prescribe phototherapy, but when phototherapy isn't feasible (which is often the case with pediatric patients) or doesn't bring the desired results, she chooses systemic therapy, such as methotrexate and cyclosporine.

Amy Paller, M.D.

Biologic drugs are another valid option for patients who need more than topical therapy to control their psoriasis or for patients for whom phototherapy isn't an option. Currently, the biologics are not approved by the U.S. Food and Drug Administration for children with psoriasis or psoriatic arthritis, but doctors do prescribe them "off-label" for children with these diseases. (Enbrel is currently in clinical trials for pediatric psoriasis.)

Both Dr. Paller and Dr. Bagel are excited about the future of biologic drugs in psoriasis treatment. "They're very new. And I will tell you from my personal experience, very effective," says Dr. Paller. "I think over time we're going to see more comfort with using these."

Regardless of what treatment is selected, Dr. Paller believes children will feel less victimized by their disease if they are involved in treatment decisions and encouraged to participate in their own care.

They should be able to answer questions about psoriasis, be able to apply moisturizers to their skin, and by about the age of 6, be able to apply medications as well. "It's very important for kids to take ownership, to feel that they have some control over this," says Dr. Paller. "They need to know that they can do something that is going to make a difference."

For more information on children and psoriasis, visit www.psoriasis.org/about/youth.

Finding a doctor Finding the right doctor to treat your child's psoriasis may require some shopping around. Pediatric dermatologists specialize in treating children, but you might not have access to one in your area. Consider interviewing several dermatologists to find the right fit for your child. Ask specific questions about the treatments they use, their ability to be flexible to meet the needs of your child's school and activity schedule, and if the doctor treats other children with psoriasis. These resources may help: Go to www.psoriasis.org/treatment/directory to access the National Psoriasis Foundation Physician Directory. Search for a dermatologist on the American Academy of Dermatology Web site, www.aad.org/public/searchderm. Search for a pediatric dermatologist by name or location at the Society for Pediatric Dermatology's Web site, www.pedsderm.net/members.htm.