Pediatric Psoriasis in Patient with Obesity

Elin Herlina

, Eunice Gunawan

, Retno Indar Widayati

, Widyawati

, Indra Wijaya

Departement of Dermatovenereology,

Departement of Anatomic Pathology Faculty of MedicineDiponegoro University /

Dr. Karyadi General Hospital Semarang

*Corresponding author

Keywords: Childhood psoriasis, psoriasis vulgaris, pediatric psoriasis.

Abstract: Psoriasis is an immunologically mediated chronic inflammatory skin disease, characterized by well-defined

salmon-pink plaques bearing large adherent silvery centrally attached scales. The prevalence in children

aged 10-19 years is about 1.37%. Pediatric psoriasis has been associated with specific comorbidities, such

as obesity, hypertension, hyperlipidemia, diabetes mellitus, and rheumatoid arthritis, making early diagnosis

and management essential.A 12-year-old boywhose have body weight was 120 kilograms presented with

erythematous patches and plaques covered by thick silvery scales on his face, trunk, belly, elbows, lower

limbs, and knees. Patient felt itchy onthose lesions. The diagnosis was made based on clinical history,

clinical examination, and histopathology examination. Histopathological examination showed tissue

covered by keratinized stratified squamous epithelium, hyperkeratotic, parakeratotic, acanthosis, regular rete

ridges, the dermis consisted of skin adnexa and fibro collagenous stroma connective tissue with perivascular

lymphocytes. The patient was treated with Methotrexate 5mg per 12 hours given on the first and second day

of every week, folic acid 1 mg per day is given on the third to seventh day every week, 0.25%

desoximetasone cream and 10% urea cream twice daily. Information, education, communication, and

psychological support were provided to the patient and his parents.A good response was observed after two

months of treatment.

1 INTRODUCTION

Psoriasis is a chronic inﬂammatory

hyperproliferative disease of the skin, scalp, nails,

and joints. Psoriasis is an inherited papulosquamous

skin disorder with a variety of clinical presentations,

most of which eventuate into well-deﬁned

erythematous lesions with typical silvery scales

(Bronkers et al, 2015). The prevalence of psoriasis

in childhood is about 0.55 % in children aged 0–9

years and 1.37 % in children aged 10–19 years

(Bronkers et al, 2015).

Psoriasis in children can have a significant

impact on the quality of life by interfering with self-

esteem, family and social relationship and school.

Children suffering from psoriasis also have a higher

prevalence of comorbidities, including obesity,

diabetes mellitus, hypertension, rheumatoid arthritis,

Crohn’s disease, and psychiatric disorder (Bronkers

et al, 2015)..

Psoriasis flares can be provoked by non-specific

triggers. A higher frequency of stress (associated

with the start of the school year, the birth of

brother/sister, etc.), mild trauma (Koebner

phenomenon), and infection (streptococcal, viral)

were reported. Systemic drugs (beta-blockers,

lithium, antimalarial, etc.) or HIV infection, are less

frequently implicated in children than in an adult

(Mahe, 2016).

Plaque psoriasis is the most common form of

pediatric psoriasis. The presentation in children

resembles psoriasis in adults. However, initial

lesions are less prominent, with mild scaling and

induration. In later stages, the clinical presentation is

dominated by scaly plaques accompanied by itching.

Psoriasis frequently affects elbows, knees, scalp,

umbilicus,and face (Mahe, 2016; Madiraca er al,

2016).

Treatment of psoriasis in the pediatric patient is

challenging because lack of clinical trial and

guidelines. There are currently no international

standardized guidelines for medical treatment of

pediatric psoriasis.Treatment options include topical

agents, systemic agents, biologic agents, and

phototherapy. Treatment success depended mainly

380

Herlina, E., Gunawan, E., Widayati, R., Widyawati, . and Wijaya, I.

Pediatric Psoriasis in Patient with Obesity.

DOI: 10.5220/0009989503800383

In Proceedings of the 2nd International Conference on Tropical Medicine and Infectious Disease (ICTROMI 2019), pages 380-383

ISBN: 978-989-758-469-5

on parental involvement and education.

Psychosocial support is another critical component

of therapy for children with psoriasis (Bronkers et al,

2015; Madiraca et al, 2016).

2 CASE

A 12-year-old boy, Javanese, Indonesian, cameto

Dermatovenereology Department Kariadi General

Hospital Semarang on23 August 2018 with itchy

erythematous plaquesand thick silvery scaling all

over his body for several years. The plaque first

appeared on the face, trunk, belly, elbows, and

knees.

The mother said since he was 5-year-old,

erythematous spots and scales had started to appear

on her son's body and get worse, the patient had

never been treated.

The patient is the second child, the father works

as a trader in the market, and the mother is

unemployed.Medical expenses are covered by the

Social Insurance Administration

Organization/Badan Penyelenggara Jaminan

Sosial(BPJS). The socioeconomic impression is

sufficient.

The patient whose body weight was 120

kilogramswith BMI 43belonged to the obese

category, and the health conditions, in general, were

perfect.Physical examination on the face, trunk,

belly, elbows, lower limbs and knees found several

lesions presented as well-defined erythematous

plaques that were partially covered by thick silvery

scales. Auspitz test was positive (+). Laboratory

examination found hemoglobin level of 15.7 g/dL,

SGOT 22 U/L, SGPT 60 U/L, Urea 22 mg/dL,

Creatinine 0.79 mg/dL, blood sugar 81 mg/dL,

which were all within the normal limit.

Histopathology examination showed tissue

covered by keratinized stratified squamous

epithelium, hyperkeratotic, parakeratotic, acanthosis,

regular rete ridges, the dermis consisted of skin

adnexa and fibro collagenous stroma connective

tissue with perivascular lymphocytes. No signs of

malignancy. The 10%Potassium hydroxidetestdid

not find any hypha or spores.

The diagnosis of this patient was psoriasis

Vulgaris with a PASI score of 19.9. The patient was

treated with Methotrexate 5mg per 12 hours given

on the first and second day of every week, folic acid

1 mg per day is given on the third to seventh day

every week,0.25%desoximetasone creamapplied to

the lesion twice a dayand 10% urea cream was

applied twice a day as a moisturizer. Therapy was

done for two months, a significant improvement was

found.

Figure 1. (A)First observation there were erythematous

plaques and silvery scales(B)Second observation after two

months therapy

Figure 2. Histopathologic Findings

3 DISCUSSION

A 12-year-old boy withwell-defined erythematous

plaques, partially covered by thick silvery scales on

the face, trunk, belly, elbows, lower limbs and

knees. According to the references, the disorder may

present in1.37 % children aged 10–19 yearswith

solitary lesions or countless plaques in a generalized

distribution. (Bronkers et al, 2015;De Waard-van der

Spek FB et al,2011).

There was no history of psoriasis in his family. A

child with one affected parent has a 14% chance of

developing psoriasis disease, and this rises to 41% if

both parents are affected.(Fortina et al,2017)

The

prevalence of psoriasis patients with an affected

family member is observed to be higher in early-

onset psoriasis (before age 16) than in adult-onset

psoriasis (after age 16). (Bronkers et al, 2015).

Pediatric Psoriasis in Patient with Obesity

381

The patient whose body weight was 120

kilograms with BMI 43 belonged to the obese

category, but this patient had an excellent metabolic

condition. In the literature, obesity as a comorbidity

of psoriasis has been the focus of much

investigation, and the large international cross-

sectional study has demonstrated the increased risk

of being overweight or obese in pediatric psoriasis in

5- to 17-year-old children with psoriasis. (Bronkers

et al, 2015).

Dermatological examination showed erythematous

plaques, partially covered by thick silvery scaleson

face, trunk, belly, elbows, lower limbs, and knees.

Positive auspitz sign.According to the references

psoriasis in children if often similar to that seen in

adult patients. The lesions are well-defined,

erythematous, and papulosquamous, with silvery

scales. The successive removal of psoriatic scales

produces small bleeding points where the thin

suprapapillary epitheliums are torn off (Auspitz

Sign). (De Waard-van der Spek FB et al,2011).

Although the diagnosis of psoriasis is primarily

based on clinical features, a biopsy can help to

confirm the diagnosis in children. Analysis of a skin

biopsy specimen from the patient showed tissue

covered by keratinized stratified squamous

epithelium, hyperkeratotic, parakeratotic, acanthosis,

regular rete ridges, the dermis consisted of skin

adnexa and fibro collagenous stroma connective

tissue with perivascular lymphocytes.Histological

features of psoriasis include parakeratosis, loss of

granular cell layer, elongation of the rete ridges,

neutrophilic aggregates within the epidermis

(microabscesses of Munro) especially common in

early lesions, dilated blood vessel in the dermis, and

perivascular lymphocytic infiltrates. These

characteristics may vary depending on site of

biopsy, psoriasis subtype, and whether children have

been treated with topical and or systemic treatment.

(De Waard-van der Spek FB et al, 2011;

Rapini,2005).

The differential diagnosis oftinea corporis could

be excluded because the lesion in tinea corporis

showed enlarging raised red rings with a central area

of clearing, mycological examination (+).(Fortina et

al,2017)

Patient’s 10% potassium hydroxide test

result did not find any hypha or spores.

The patient was treated with Methotrexate 5mg

per 12 hours three times per week and folic acid

1mg per day given except on the day of

methotrexate therapy. From the results of this

patient's laboratory, there were no contraindications

for methotrexate therapy. Methotrexate is considered

the systemic treatment of choice for children with

moderate-to-severe plaque psoriasis. However, its

use in childhood is also appropriate for PsA,

extensive, recalcitrant, severe or disabling psoriasis,

and erythrodermic or generalized pustular disease

resistant to topical and phototherapy. In children,

methotrexate advantages include the efficacy and

weekly oral dose (0.2–0.7 mg/kg/week). Dose

escalations of 1.25–5 mg/week until the achievement

of clinical benefits, followed by a slow taper to a

maintenance dosage, are advised. Based on a study,

acitretin, MTX and CsA may be considered as first-

line therapy for childhood psoriasis with acceptable

efficacy and few adverse effects, with acitretin

seeming efficient on a plaque, pustular and

palmoplantar psoriasis, methotrexate on plaque and

guttate psoriasis, and CsA on erythrodermic and

palmoplantar psoriasis. Folic acid is routinely

administered to improve tolerability and decrease

the appearance of nausea, macrocytic anemia,

pancytopenia, and hypertransaminasemia. Some

authors prescribe folic acid two days after every

methotrexate dose, while others recommend daily

except on the day of methotrexate therapy

(Napolitano et al,2016).

Topical 0.25% Desoxymethason cream was

given twice aday. Topical corticosteroids have a

vital role in treatment due to antiproliferative, anti-

inflammatory, immunosuppressive, and

vasoconstrictive properties. Desoxymethason is a

potent corticosteroid that can be used on thick

psoriatic plaques (Madiraca et al,2016). Emollients

are used as adjunctive agents to decrease the

associated scaling and dryness but should not

replace medications when inflammation is

present.(Paller et al,2011)

4 CONCLUSION

A 12-year-old patient with psoriasis vulgaris and

obesity. The diagnosis was based on the anamnesis

and the clinical features, as well as on

histopathological examinations of our patient's tissue

specimens.The combination treatment

ofMethotrexate and topical corticosteroid

successfullyreduced the PASI Score to 9.9. The

prognosis was quo ad vitam ad bonam, ad sanam

dubia ad bonam, ad cosmeticam ad bonam.

ICTROMI 2019 - The 2nd International Conference on Tropical Medicine and Infectious Disease

382

REFERENCES

Bronkers IMGJ, Paller AS, Van Geel MJ, Van De Kerkhof

PCM, Seyger MMB. 2015. Psoriasis in Children and

Adolescents: Diagnosis, Management and

Comorbidities. June; 17: p. 373-384.

Callen J. P. 2008. Immunosuppressive and

Immunomodulatory Drugs. In: Goldsmith L. A, Katz

S.I, Gilchrest B.A, Paller A. S, Leffell D. J, Wolff K,

editor. Fitzpatrick’s Dermatology in General

Medicine, 8

edition. New York: McGraw Hill. p.

2807-2814

De Waard-van der Spek FB, Oranje AP. 2011. Psoriasis.

In: Irvine A, Hoeger P and, Yan A, editor. Harper’s

Textbook of Pediatric Dermatology, 3

edition. West

Sussex: Blackwell Publishing Ltd. p. 80.1-80.7

Dogra S, Bishnoi A. 2018. Childhood psoriasis: what is

new and what is news. Volume 19. October-Desember

: p. 308-314

Fortina A.B, Bardazzi F, Berti S, Carnevale C, Lernia VD

et al. 2017. Treatment of Severe Psoriasis in Children:

Recommendations of an Italian Expert Group. August

MadiracaD, Situm M, Prkacin I, Bulic SO. 2016.

Treatment Options for Pediatric Psoriasis. February;

24(3): p. 175-180

Mahe E. 2016. Childhood Psoriasis. November. 26(6): p.

537-48

Napolitano, Megna M, Balato A. 2016. Systemic

Treatment of Pediatric Psoriasis: A Review. April; 6:

p. 125-142

Paller A.S, Mancini A.J. 2011. Hurwitz Clinical Pediatric

Dermatology. 4

edition. New York: Elsevier

Saunders. p. 71-91.

Rapini R.P. 2005. Practical Dermatopathology. Elsevier

Mosby. p.51-52

Weller R.B, Hunter H.J.A, Mann M.W. 2015. Psoriasis.

In. Clinical Dermatology,5

edition. West Sussex:

John Wiley & Sons Ltd. p. 52-67

Pediatric Psoriasis in Patient with Obesity

383