Paeds · paediatric-dermatology
Psoriasis in children
Also known as Childhood psoriasis · Plaque psoriasis · Guttate psoriasis · Scalp psoriasis · Napkin psoriasis · Juvenile psoriatic arthritis
Fellowship topic on psoriasis in children: the plaque, guttate, scalp, nail, facial and napkin forms and their paediatric-specific presentations; the IL-23 and Th17 and IL-17 immune pathophysiology with HLA-Cw6 genetics, streptococcal and Koebner triggers; the differential from atopic and seborrhoeic dermatitis, tinea and pityriasis rosea; a clinical diagnosis with severity measured by body surface area, PASI and the Children's Dermatology Life Quality Index; stepwise treatment from emollients and potency-matched topical corticosteroid plus calcipotriol through narrowband UVB phototherapy to systemic methotrexate, cyclosporin and acitretin and the biologic agents etanercept, ustekinumab and the IL-17 and IL-23 inhibitors, grounded in the landmark paediatric etanercept trial and the recent biologics network meta-analysis; the obesity, metabolic, juvenile psoriatic arthritis and psychosocial comorbidities; and the ANZ, UK and North American guidance including the joint AAD-NPF paediatric psoriasis guideline.
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Target exams
Red flags
- A child with widespread erythema and superficial desquamation covering most of the body, with shivering, tachycardia or systemic upset — erythrodermic psoriasis; admit for temperature, fluid and electrolyte support and urgent dermatology review
- An unwell child with widespread sterile pustules on fiery erythema, fever and skin pain — generalized pustular psoriasis; a medical emergency needing admission, supportive care and specialist therapy
- Joint pain, early-morning stiffness, dactylitis or a swollen toe or finger in a child with psoriasis — juvenile psoriatic arthritis; refer early to paediatric rheumatology to prevent joint damage and uveitis
- Severe psychological distress, school refusal, bullying or thoughts of self-harm driven by visible disease — the psychosocial burden of psoriasis in children can be as disabling as the skin itself
- An adolescent girl of childbearing potential on acitretin, or being considered for it — acitretin is strongly teratogenic and requires robust contraception and pregnancy avoidance
Life stages
Care settings
Clinical exam formats
Board mappings
- General Paediatrics and Dermatology: recognition of plaque, guttate, scalp and napkin psoriasis; topical and stepwise treatment; comorbidity and psychosocial screening
- Musculoskeletal: juvenile psoriatic arthritis recognition and early referral
- Renewed curriculum — Dermatology: IL-23 and Th17 and IL-17 pathophysiology, phototherapy and systemic and biologic therapy in children
- Population child health: obesity and metabolic comorbidity of paediatric psoriasis and equity of access to specialist therapy
- General Paediatrics: diagnosis and stepwise topical, phototherapy and systemic management of childhood psoriasis and recognition of erythrodermic and pustular emergencies
- Psychosocial: the quality-of-life burden of visible chronic skin disease in a child
- Long Case / Structured discussion: a child with chronic plaque psoriasis — forms, triggers, severity, stepwise treatment, comorbidities and psychosocial impact
- Communication station: explaining chronic disease, topical steroid safety and the biologic decision to a family
- Level 2 / 3 — Dermatology: paediatric psoriasis forms, severity assessment and stepwise treatment
- Mental health and health promotion: the psychosocial and quality-of-life burden and comorbidity screening
- Foundation of Practice (FOP): clinical forms of childhood psoriasis, the guttate post-streptococcal pattern and the differential from eczema and tinea
- Applied Knowledge in Practice (AKP): topical corticosteroid safety, phototherapy and systemic and biologic therapy selection
- History-taking and management: the child with chronic plaque or guttate psoriasis, including severity, comorbidity and quality of life
- Communication: explaining chronic disease, treatment safety and the role of biologics to a family
- General Pediatrics Content Outline — psoriasis: clinical forms, diagnosis, stepwise treatment and comorbidities
- Dermatology: topical, phototherapy, systemic and biologic therapy in children
- Rheumatology: juvenile psoriatic arthritis recognition and referral
- Patient Care: diagnosis and severity-matched, guideline-based management of paediatric psoriasis across severity
- Systems-Based Practice and Population Health: comorbidity screening, equity of access to biologics and psychosocial support
- Medical Knowledge: IL-23 and Th17 and IL-17 pathophysiology, topical steroid safety and systemic and biologic therapy
- Medical Expert: paediatric psoriasis diagnosis, forms, severity and stepwise management
- Health Advocate and Collaborator: comorbidity and psychosocial screening and coordinated dermatology-rheumatology care
- Communicator: explaining chronic disease and treatment safety to children and families
Two paediatric patterns
Chronic plaque psoriasis
Acute guttate psoriasis
The psoriasis engine is IL-23 driving Th17 cells to release IL-17 and IL-22, which makes keratinocytes proliferate too fast and stick around as scale. Every modern biologic sits on this pathway: ustekinumab blocks IL-12/23 (the p40 subunit), guselkumab and risankizumab block IL-23 itself (p19), and secukinumab and ixekizumab block IL-17A. The landmark paediatric trial — etanercept, a TNF-alpha fusion protein — opened the door in 2008. Remember the three plaque clues that this engine produces: erythema (inflammation), scale (hyperproliferation) and thickness (acanthosis). [2] [9]
Overview & Definition
Picture an eight-year-old brought in with thick, scaly patches on the elbows and scalp that have come and gone for a year, itchy and embarrassing at school. Or a twelve-year-old who, two weeks after a sore throat, breaks out in hundreds of small, teardrop spots over the trunk. Both are psoriasis — the most common immune-mediated skin disease of childhood after atopic dermatitis, and a condition whose visible burden can quietly shape a child's schooling, friendships and self-image. [2] [3]
Psoriasis is a chronic, relapsing, immune-mediated inflammatory skin disease in which a dysregulated IL-23 and Th17 and IL-17 immune response drives keratinocytes to proliferate excessively, producing the well-demarcated, scaly erythematous plaques that are its hallmark. It runs in families, reflects a strong polygenic susceptibility led by the HLA-Cw6 allele, and is triggered by streptococcal infection, skin trauma (the Koebner phenomenon), stress, obesity and certain drugs. In children it has its own patterns — more facial and scalp involvement, the distinctive guttate form after strep, and napkin-area disease in infants. [1] [2]
The clinician's task has three layers. The first is recognition — distinguishing psoriasis from atopic and seborrhoeic dermatitis, tinea and pityriasis rosea, and the rare but dangerous erythrodermic and pustular forms from severe eczema. The second is severity-matched treatment, climbing from emollients and topical therapy through phototherapy to systemic and biologic agents, while protecting the child from the harms of strong steroids, cumulative ultraviolet light and immunosuppression. The third is the whole-child layer — screening for obesity, metabolic risk, juvenile psoriatic arthritis and the psychosocial burden, because psoriasis in a child is a skin disease whose consequences reach far beyond the skin. [1] [11]
References11ShowHide
- [1]Menter A; Cordoro KM; Davis DMR; Feldman SR; et al Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients. J Am Acad Dermatol, 2020.PMID 31703821
- [2]Eichenfield LF; Paller AS; Tom WL; Lara-Corrales I; et al Pediatric psoriasis: Evolving perspectives. Pediatr Dermatol, 2018.PMID 29314219
- [3]Mahé E Childhood psoriasis. Eur J Dermatol, 2016.PMID 27900946
- [4]Augustin M; Glaeske G; Radtke MA; Christophers E; et al Epidemiology and comorbidity of psoriasis in children. Br J Dermatol, 2010.PMID 19922529
- [5]Paller AS; Singh R; Cloutier M; Gauthier-Loiselle M; et al Prevalence of psoriasis in children and adolescents in the United States: A claims-based analysis. J Drugs Dermatol, 2018.PMID 29462227
- [6]Mehrmal S, Uppal P, Nedley N, et al. The global, regional, and national burden of psoriasis in 195 countries and territories, 1990 to 2017: A systematic analysis from the Global Burden of Disease Study 2017. J Am Acad Dermatol, 2021.PMID 32376432
- [7]Maruani A; Samimi M; Stembridge N; McBride S; et al Non-antistreptococcal interventions for acute guttate psoriasis or an acute guttate flare of chronic psoriasis. Cochrane Database Syst Rev, 2019.PMID 30958563
- [8]Wu W; Debbaneh M; Moslehi H; Koo J; Liao W Tonsillectomy as a treatment for psoriasis: a review. J Dermatolog Treat, 2014.PMID 24283892
- [9]Paller AS; Siegfried EC; Langley RG; Gottlieb AB; et al Etanercept treatment for children and adolescents with plaque psoriasis. N Engl J Med, 2008.PMID 18199863
- [10]Aljalfan AA; Maniya MT; Sachedina D; Alavi A; et al Biologics for treatment of paediatric plaque psoriasis: A systematic review and network meta-analysis. J Eur Acad Dermatol Venereol, 2026.PMID 41090545
- [11]Phan K; Lee G; Fischer G Pediatric psoriasis and association with cardiovascular and metabolic comorbidities: Systematic review and meta-analysis. Pediatr Dermatol, 2020.PMID 32436322