Management of psoriasis in childhood

It is not unusual for psoriasis to start in childhood although a mild or atypical presentation sometimes makes it difficult to establish a confident diagnosis at this age. All adult forms occur but flexural psoriasis and guttate psoriasis are particularly common. Management involves education of the child and parents concerning the nature of psoriasis and the effects of treatment. Genetic counselling may be provided if needed based on population data. Environmental triggers of psoriasis should be sought particularly infection. Psoriasis can usually be treated effectively in children with topical agents including emollients, coal tar, corticosteroids, dithranol and calcipotriol according to age and the sites affected. In those who do not respond, consideration should be given first to day care or in-patient treatment which may be combined with UVB phototherapy. Systemic therapy should be used only under extreme circumstances such as resistant erythrodermic, pustular or arthropathic psoriasis. There are no controlled trials in this age group but the most experience has been with retinoids which are probably the second-line drug of choice for children. Methotrexate and cyclosporin appear to be effective in children but more efficacy and safety data are required.