Severe diaper rash, cradle cap raise suspicion for pediatric psoriasis
NEWPORT BEACH, CALIF. – A history of severe cradle cap and diaper dermatitis helps to differentiate between pediatric psoriasis and atopic dermatitis, so be sure to ask, according to Dr. Alan Menter, chief of the dermatology division at the Baylor University Medical Center in Dallas.
“Both are markers for later onset of psoriasis, and are much more likely to be a marker for psoriasis than atopic eczema,” he said at Skin Disease Education Foundation’s Women’s & Pediatric Dermatology Seminar.
Dr. Alan Menter
The tip to ask about cradle cap and diaper dermatitis is based largely on clinical observation, but is more useful than asking about a family history of psoriasis, because people tend to keep psoriasis to themselves, he noted; family members and even spouses might not know. “It’s a very hidden disease, so family history is of little benefit,” he said.
Recent strep infection also may provide a clue, not only for guttate psoriasis but also probably for plaque psoriasis in children, Dr. Menter said. But the sooner pediatric psoriasis is caught and controlled, the better, no matter how it is detected. Aside from the suffering it causes on its own, psoriasis in children has been linked to diabetes, hypertension, fatty liver disease, obesity, and cardiovascular problems, he noted.
The mechanism of action for these comorbidities remains under investigation. Perhaps mothers with psoriasis gain more weight during pregnancy, and their children are heavier at birth, Dr. Menter said.
Crohn’s disease is far more likely in children with psoriasis, too. Dr. Menter noted that he has had referrals where the diagnosis has been missed, even in the setting of long-standing fatigue and diarrhea. “We have to look for it [Crohn’s] in our psoriasis population,” he said.
Children with psoriasis are often teased, taunted, and bullied, sometimes as young as kindergarten age. The emotional stress, loneliness, and depression can have a major impact on school and social growth, Dr. Menter said.
“Treatment of these kids goes beyond prescribing a topical steroid; they need [both] physical and psychological support,” he emphasized. Talk to parents and teachers about how the child is doing in school and other social settings. Parents might know about grades, but not much about their child’s social interactions. To help catch problems, also “take a quality of life index on all your patients with psoriasis,” he said.
It’s important to intervene early and get children’s skin cleared quickly. “[Although] we’d love to treat [everybody] with topicals and wet compresses,” effective treatment sometimes means systemic therapy, he said.
Cyclosporine is a valid rescue option, particularly for more inflammatory disease. “Rarely, if ever, have I seen any hypertension or serum creatinine issues,” Dr. Menter said. “You just have to warn parents to be careful about gums, because you can get gingival hyperplasia, and girls don’t like the mild hypertrichosis you sometimes get around the temples and forearms,” he said.
Etanercept is another option. It not approved for pediatric psoriasis, but if you try hard enough, you can get insurance companies to cover it, Dr. Menter said. “You have to talk about quality of life and how psoriasis has impacted schooling,” among other topics, he explained.
Clinicians looking for child-oriented resources and support materials can recommend the National Psoriasis Foundation to their patients, he noted. SDEF and this news organization are owned by Frontline Medical Communications.
Dr. Menter disclosed financial relationships with Abbott, AbbVie, and numerous other companies.