Dr. Chamlin: How common is childhood psoriasis?

Dr. Cordoro: Psoriasis affects approximately 1% of US children. It is not the most common inflammatory disease. For example, atopic dermatitis (i.e. eczema) is much more common, but it is not extremely rare, either.

Dr. Chamlin: What comorbid conditions are more prevalent in this population?

Dr. Cordoro: there are several:

Obesity – The relationship between psoriasis and obesity is complex and goes in both directions. More children with moderate and severe psoriasis are likely to be obese, while obese children are more likely to have or to develop psoriasis. Both psoriasis and obesity are chronic inflammatory disorders, so it is thought that the two conditions are risk factors for one another and also make each other more severe. An amplification cycle exists between obesity and psoriasis. Each drives the other in a dose response relationship (i.e. the more severe one is, the more it is likely to impact the development or severity of the other). Further, both severe psoriasis and obesity each carry an independent set of risks and comorbidities that likely potentiate each other.

Metabolic syndrome – Children with psoriasis may be at greater risk of having or developing metabolic syndrome, as well as its individual components – high blood pressure, obesity, dyslipidemia, and insulin resistance/diabetes – than children without psoriasis. Overweight and obese patients and those with severe psoriasis are at greatest risk for metabolic abnormalities as defined within this syndrome.

Psoriatic arthritis – Children with psoriasis have a risk of developing psoriatic arthritis. The exact prevalence is unknown, but falls within the range of about 10 to 20% of children. Data collection to clarify the prevalence of psoriatic arthritis in children is hampered by the lack of universally accepted diagnostic and classification criteria. Nail changes, joint swelling, and prolonged morning stiffness are clinical signs suggestive of psoriatic arthritis.

Crohn’s disease – There is an association between psoriasis, Crohn’s disease, and ulcerative colitis due to overlapping genetic pathways and shared immunologic dysregulation in these diseases.

Cardiovascular disease – Cardiovascular disease is known develop at a higher rate in adults with psoriasis, especially in young adults with severe psoriasis. We know that CV risk factors in psoriasis patients accumulate with age; most appreciably after the age of 40.¹ Endothelial function, as a surrogate of CV risk in adolescents, has been recently shown by Jensen to be similar to that of healthy children.² Therefore, although children with psoriasis do not show signs of having heart disease or blood vessel damage now, persistent severe psoriasis may create enough long-term inflammation to damage blood vessels in the long run and lead to premature cardiovascular disease, heart attacks, and strokes when they are adults.

Dr. Chamlin: What were the findings of your study regarding pediatric psoriasis severity and central adiposity in children?

Dr. Cordoro: This was an international, multi-institution study that assessed 409 patients in 9 countries aged 5-17 years old.³ The results showed that globally, the odds of obesity and increased waist circumference (as a surrogate for central adiposity) are higher in all psoriasis patients, regardless of severity. Furthermore, there is a dose-response relationship between severity and obesity – the more severe the psoriasis, the more obese the patients, including central obesity. This study was very important because it assessed obesity using waist circumference (WC) and waist to height ratio (WHR), which are surrogates for central/visceral adiposity and are more sensitive indicators of metabolic disease and cardiovascular disease in kids than is body mass index (BMI). This means that obese children, in particular, those with central adiposity and severe psoriasis, are at much greater risk for metabolic and cardiovascular disease than psoriatic children of normal weight.

Dr. Chamlin: What is a practical approach for screening these patients for associated medical comorbidities? Do you screen all patients with psoriasis for metabolic syndrome or just those with an abnormal BMI?

Dr. Cordoro: I think it is our responsibility as physicians to do 3 things for our psoriasis patients:

1. Assess adiposity routinely using measures such as BMI, WC, and WHR.
2. Identify metabolic syndrome early by checking blood pressure, fasting blood lipids and glucose for those at risk (i.e. overweight or obese or showing other evidence of risk such as acanthosis nigricans, etc.)
3. Establish a multidisciplinary provider network consisting of endocrinologists, pediatric nutritionists, cardiologists, pediatricians and others whose expertise may be needed depending on the patient. We can’t do it all, so we must have a network of providers to refer to.

Though there is risk, we must maintain a balanced approach. Not all kids with psoriasis are at risk of metabolic or cardiovascular disease. We want to properly educate but not alarm patients and parents, and to be vigilant in monitoring and treating them, but we also must use sound clinical judgment until we know more. Inadequate evidence exists to justify continuous aggressive therapy in kids with psoriasis so we must always remember to balance benefits and risks of tests, procedures and treatments when managing these patients.

Dr. Chamlin: What is the psychiatric burden of pediatric psoriasis?

Dr. Cordoro: It can be enormous, especially in obese children with psoriasis. Psoriatic children have increased risk of psychiatric disorders, especially anxiety and depression.⁴ There is a complex interplay between psoriasis, psychosocial stigma, and obesity. Psoriasis alone is very socially stigmatizing. This becomes even more so when the same patient is obese – the psychosocial stigma of psoriasis leads to embarrassment and loss of self-esteem, which can lead to social isolation, overeating and inactivity, and chronic rises in stress levels; this predisposes to obesity. The reverse also happens- obesity leads to sadness and anxiety, social isolation and withdrawal, overeating, inactivity and ongoing obesity, which can worsen psoriasis. Obesity and psoriasis each represent an insult to self-esteem and overall well-being, and as a result, children with psoriasis ultimately suffer from high stress levels and poor quality of life in a vicious cycle.

Dr. Chamlin: How do you help counsel affected children and their parents for the teasing, bullying and low self-esteem that may occur with childhood psoriasis?

Dr. Cordoro: I try to offer understanding, support, and resources that are age appropriate. Cutaneous body image is defined as an individual’s mental representation of his/her skin, hair and nails. Body image development in adolescence is deeply affected by peer reactions, which are significantly influenced by skin appearance. Even minimal flaws can have profound effects on the cutaneous body image of adolescents. Imagine being a teen with psoriasis all over your face and body. I think about it using a baseball analogy: strike one is being an adolescent and trying to navigate those waters; strike 2 is having a chronic disease like psoriasis that is physically and emotionally distracting and upsetting, and the third and final strike is being disfigured by your skin condition. 3 strikes and these kids are out in the cold trying to sort out adolescence, develop a healthy body image and confidence. If this does not go correctly, the effects can be long-lasting, as children with chronic diseases may not socialize properly and this can have lasting impact on educational performance and ultimately, ability to live and work productively in society.

Dr. Chamlin: What resources do you suggest to help families cope with the burden of this disease?

Dr. Cordoro: I try to assess a patient’s psychosocial vulnerability by asking about mood, high risk behaviors, shame, social impairment, and bullying. I try to quickly assess cutaneous body image by asking the simple question as recommended in the article: Gupta MA and Gupta AK, Clinics in Dermatology (2013) 31, 72–79, “How satisfied are you with appearance of your skin/hair/nails, on a scale from 1-10?” This approach is therapeutic in that it validates patients concerns as medically relevant and not just a sign of vanity. Further, if we want to help these kids, we should be open to a bio-psycho-social approach using both pharmacological and non-pharmacological interventions such as relaxation therapies, stress management programs, and optimizing social support systems. It is important to offer resources – including websites, educational and support groups, therapists, etc. I have compiled a list of internet-based and age-appropriate resources that I hand to families. (see Appendix)

Dr. Chamlin: Do you have useful resources or counseling pearls to help with the obesity aspect of this disease?

Dr. Cordoro: There are resources on the handout that I offer to families, but I never just hand this without asking the tough questions. Obesity is the elephant in the room sometimes about which it makes everyone uncomfortable to ask. We owe it to our patients to address it head-on. I will often discuss the impact of obesity on the course of psoriasis, response to therapy, and the Catch-22 of obesity and psoriasis. Then I will directly address the weight issue by asking the patient (if old enough) or the parent, “So what are we doing about your/his weight?” This opens the conversation and lets me discuss the impact of weight in individual terms and offer options and resources. I will refer to endocrinology if I think there is metabolic disease or a nutritionist, weight watchers or the like if it is early and weight is an isolated issue. The important thing is to ask the questions and keep asking the questions, because we owe it to our patients to get them on board with that aspect of their health as it relates to their psoriasis and their overall well being. I have learned over time that being specific is much better than making vague or general comments about weight and this engages the patient and family in a specific management plan.

Final Comments:

In closing, I would like to point out that the causal relationships of psoriasis, obesity and other comorbidities in children with psoriasis remains to be determined.

CV risk factors increase with age; therefore we should identify them early and intervene as appropriate to limit their progression.

Adopt a holistic approach. Optimal physical and mental health can combat many of the comorbidities of psoriasis (especially obesity) and may impact the severity of the disease.

 

APPENDIX : Resources for Children and Families Coping with Psoriasis

National Psoriasis Foundation “PsoMe” and “PsoSmart” Pediatric Psoriasis Website:

• Information, education, handouts for parents, teachers, coaches, families
• Child-appropriate educational material, pediatric psoriasis art contests, penpals, etc.
• Links to other websites to cope with the impact of skin disease, bullying, etc.
• www.psoriasis.org/kids
• www.psoriasis.org/parents

National Psoriasis Foundation:

• Education and detailed information for healthcare providers and families
• Letter templates for insurance authorization for home light boxes, etc.
• www.psoriasis.org

Kids Health

• For parents, kids and teenagers- education and information
• Links to coping with bullying, etc:
• www.kidshealth.org

Changing Faces

• Organization dedicated to helping patients/families cope with the impact of disfigurement. – Provides parent and age-appropriate resources and guides.
• www.changingfaces.org.uk
• www.changingfaces.org.uk/Resources-and-Guides/Guides-for-children-and-young-people

Psoriasis Cure Now

• Advocacy organization for psoriasis; has pediatric psoriasis content including back to school letters for teachers, coaches, etc. Information for parents; social pages, etc.
• www.psoriasis-cure-now.org
• www.psoriasis-cure-now.org/school-psoriasis-fact-sheet.php 

Resources for Pediatric Obesity, Healthy Weight and Lifestyle

 Centers for Disease Control and Prevention- Childhood Obesity Website

• Comprehensive information on obesity including facts and figures, publications, evaluation, intervention and prevention strategies, nutrition and physical activity.
• Resources for physicians, children, parents, schools, communities, etc.
• www.cdc.gov (type in “childhood obesity” in search bar)
• www.cdc.gov/healthyyouth/obesity/facts.htm

Let’s Move!

• Comprehensive initiative launched by Michelle Obama to help solve the challenge of childhood obesity. Combines comprehensive strategies with common sense.
• Provides parents helpful information that supports healthy choices and strategies to help kids become more physically active.
• http://www.letsmove.gov

 Key Articles

Metabolic and Other Medical Comorbidity:

Wootton CI, Murphy R. Psoriasis in children: should we be worried about comorbidities? Br J Dermatol. 2013 Mar;168(3):661-3.

Paller AS, Mercy K, Kwasny MJ, Choon SE, Cordoro KM, Girolomoni G, Menter A, Tom WL, Mahoney AM, Oostveen AM, Seyger MM. Association of pediatric psoriasis severity with excess and central adiposity: an international cross-sectional study. JAMA Dermatol. 2013 Feb;149(2):166-76.

Mercy K, Kwasny M, Cordoro KM, Menter A, Tom WL, Korman N, Belazarian L, Armstrong AW, Levy ML, Paller AS. Clinical Manifestations of Pediatric Psoriasis: Results of a Multicenter Study in the United States. Pediatr Dermatol. 2013 Jan 30.

Azfar RS, Seminara NM, Shin DB, Troxel AB, Margolis DJ, Gelfand JM. Increased risk of diabetes mellitus and likelihood of receiving diabetes mellitus treatment in patients with psoriasis. Arch Dermatol. 2012 Sep;148(9):995-1000.

Au SC, Goldminz AM, Loo DS, Dumont N, Levine D, Volf E, Michelon M, Wang A, Kim N, Yaniv S, Lizzul PF, Kerensky T, Lopez-Benitez JM, Natter M, Miller L,Pelajo CF, Davis T, Gottlieb AB. Association between pediatric psoriasis and the metabolic syndrome. J Am Acad Dermatol. 2012 Jun;66(6):1012-3.

Zhu KJ, He SM, Zhang C, Yang S, Zhang XJ. Relationship of the body mass index and childhood psoriasis in a Chinese Han population: a hospital-based study. JDermatol. 2012 Feb;39(2):181-3.

Ryan C, Leonardi CL, Krueger JG, Kimball AB, Strober BE, Gordon KB, Langley RG, de Lemos JA, Daoud Y, Blankenship D, Kazi S, Kaplan DH, Friedewald VE, Menter A. Association between biologic therapies for chronic plaque psoriasis and cardiovascular events: a meta-analysis of randomized controlled trials. JAMA. 2011 Aug 24;306(8):864-71.

Volf EM, Levine DE, Michelon MA, Au SC, Patvardhan E, Dumont N, Loo DS, Kuvin J, Gottlieb AB. Assessor-blinded study of the metabolic syndrome and surrogate markers of increased cardiovascular risk in children with moderate-to-severe psoriasis compared with age-matched population of children with warts. J Drugs Dermatol. 2011 Aug;10(8):900-1.

Rosa DJ, Machado RF, Matias FA, Cedrim SD, Noronha FL, Gaburri D, Gamonal A. Influence of severity of the cutaneous manifestations and age on the prevalence of several cardiovascular risk factors in patients with psoriasis. J Eur Acad Dermatol Venereol. 2012 Mar;26(3):348-53.

Koebnick C, Black MH, Smith N, Der-Sarkissian JK, Porter AH, Jacobsen SJ, Wu JJ. The association of psoriasis and elevated blood lipids in overweight and obese children. J Pediatr. 2011 Oct;159(4):577-83.

Gelfand JM, Mehta NN, Langan SM. Psoriasis and cardiovascular risk: strength  in numbers, part II. J Invest Dermatol. 2011 May;131(5):1007-10.

Kutlu S, Ekmekci TR, Ucak S, Koslu A, Altuntas Y. Prevalence of metabolic syndrome in patients with psoriasis. Indian J Dermatol Venereol Leprol. 2011 Mar-Apr;77(2):193-4.

Bryld LE, Sørensen TI, Andersen KK, Jemec GB, Baker JL. High body mass index  in adolescent girls precedes psoriasis hospitalization. Acta Derm Venereol. 2010  Sep;90(5):488-93.

Augustin M, Reich K, Glaeske G, Schaefer I, Radtke M. Co-morbidity and age-related prevalence of psoriasis: Analysis of health insurance data in Germany. Acta Derm Venereol. 2010 Mar;90(2):147-51.

Augustin M, Glaeske G, Radtke MA, Christophers E, Reich K, Schäfer I. Epidemiology and comorbidity of psoriasis in children. Br J Dermatol. 2010 Mar;162(3):633-6. doi: 10.1111/j.1365-2133.2009.09593.

Wolk K, Mallbris L, Larsson P, Rosenblad A, Vingård E, Ståhle M. Excessive body weight and smoking associates with a high risk of onset of plaque psoriasis. Acta Derm Venereol. 2009;89(5):492-7.

Boccardi D, Menni S, La Vecchia C, Nobile M, Decarli A, Volpi G, Ferraroni M. Overweight and childhood psoriasis. Br J Dermatol. 2009 Aug;161(2):484-6.

Brauchli YB, Jick SS, Meier CR. Psoriasis and the risk of incident diabetes mellitus: a population-based study. Br J Dermatol. 2008 Dec;159(6):1331-7.

Kaye JA, Li L, Jick SS. Incidence of risk factors for myocardial infarction and other vascular diseases in patients with psoriasis. Br J Dermatol. 2008 Sep;159(4):895-902.

Shapiro J, Cohen AD, David M, Hodak E, Chodik G, Viner A, Kremer E, Heymann A. The association between psoriasis, diabetes mellitus, and atherosclerosis in Israel: a case-control study. J Am Acad Dermatol. 2007 Apr;56(4):629-34.

Psychological, Social and Emotional Comorbidity:

Remröd C, Sjöström K, Svensson A. Psychological differences between early and  late onset psoriasis: A study of personality traits, anxiety and depression in psoriasis. Br J Dermatol. 2013 Apr 8. doi: 10.1111/bjd.12371.

Schmieder A, Schaarschmidt ML, Umar N, Terris DD, Goebeler M, Goerdt S, Peitsch WK. Comorbidities significantly impact patients’ preferences for psoriasis treatments. J Am Acad Dermatol. 2012 Sep;67(3):363-72.

Kimball AB, Wu EQ, Guérin A, Yu AP, Tsaneva M, Gupta SR, Bao Y, Mulani PM. Risks of developing psychiatric disorders in pediatric patients with psoriasis. J Am Acad Dermatol. 2012 Oct;67(4):651-7.e1-2.

Kumar S, Kachhawha D, Das Koolwal G, Gehlot S, Awasthi A. Psychiatric morbidity in psoriasis patients: a pilot study. Indian J Dermatol Venereol Leprol. 2011 Sep-Oct;77(5).

Bilgic A, Bilgic Ö, Akış HK, Eskioğlu F, Kılıç EZ. Psychiatric symptoms and health-related quality of life in children and adolescents with psoriasis. Pediatr Dermatol. 2010 Nov-Dec;27(6):614-7.

Kurd SK, Troxel AB, Crits-Christoph P, Gelfand JM. The risk of depression, anxiety, and suicidality in patients with psoriasis: a population-based cohort study. Arch Dermatol. 2010 Aug;146(8):891-5.

Malhotra SK, Mehta V. Role of stressful life events in induction or exacerbation of psoriasis and chronic urticaria. Indian J Dermatol Venereol Leprol. 2008 Nov-Dec;74(6):594-9.

Zalewska A, Miniszewska J, Chodkiewicz J, Narbutt J. Acceptance of chronic illness in psoriasis vulgaris patients. J Eur Acad Dermatol Venereol. 2007 Feb;21(2):235-42.

Picardi A, Mazzotti E, Gaetano P, Cattaruzza MS, Baliva G, Melchi CF, Biondi M, Pasquini P. Stress, social support, emotional regulation, and exacerbation of  diffuse plaque psoriasis. Psychosomatics. 2005 Nov-Dec;46(6):556-64.

 References