Clinico-epidemiological study of childhood psoriasis

The clinico-epidemiological data of 276 childhood psoriasis were studied. The mean age was 7.64 years (range 1 day to 15 years). There was no complain of any discomfort in 198 cases. Itching was present in 67 cases and burning in 11 cases. Plaque psoriasis was the most common type (68.8%) followed by guttate (18.8%). Erythrodermic and pustular psoriasis were found in 2.2% and 1.5% cases. Scalp was the most frequently affected site (75.36%) followed by extensors of extremities (41.3%), trunk (37.7%), palm and/or sole (13.0%) and diaper area (11.6%). Nail involvement was found only in 8%, joint was affected in 3.6% and only 2.2% children with psoriasis were erythrodermic. In Bangladeshi children with psoriasis, plaque is the most common type and scalp is the mostly affect site. Nail and joint involvement is less common. Pustular and erythrodermic psoriasis is rare.


Introduction
Psoriasis, a chronic inflammatory skin disease causing significant discomfort, disability and disfigurement deserves special attention if it affects children.Childhood psoriasis severely lowers quality of life and interfere its physical and psychological development.4] Although diagnosis of psoriasis is mostly straight cut and clinical but sometimes it is much difficult in children due to its atypical distribution and morphology which changes over time.This cross sectional observational type study was conducted to see the pattern of clinical presentation of childhood psoriasis in Bangladesh.

Materials and Methods
This cross sectional observational type study was conducted in the Department of Dermatology and Venereology, Bangabandhu Sheikh Mujib medical university and Dhaka Medical College, Dhaka, Bangladesh from January 2011 to June 2016.Psoriasis in children was diagnosed mostly clinically and histopathology of skin was done in doubtful cases.Different demographical and clinical variables including age, sex, age of onset, residence, complains, presence of itch, seasonal variation, affected family member, type of psoriasis, site and severity were recorded directly from all children with psoriasis.Severity of psoriasis was assessed as mild, moderate and severe.Patient's palm represented 1% of total body surface area (BSA); <5% was labeled as mild; 5-10% moderate and >10% was severe. 5

Results
A total 276 children with psoriasis was enrolled in the study mean age of 7.64 years with a range 1 day to 15 years.One case of rare congenital psoriasis was found.Among them 142 (51.5%) was male and 134 (48.6%) were female with male: female 1.06:1.History of affected first degree relatives was found in 14 (5.1%) cases.No complain of any discomfort was given by 198 (71.7%), itching and burning sensation were complained by 67 (24.3%) and 11 (4.0%) respectively.Seasonal variation was noticed by 82 (29.7%) cases, 58 (21.0%) had winter exacerbation and 24 (8.7%) had exacerbation in summer or rainy season [Table I].

Abstract
The clinico-epidemiological data of 276 childhood psoriasis were studied.The mean age was 7.64 years (range 1 day to 15 years).There was no complain of any discomfort in 198 cases.Itching was present in 67 cases and burning in 11 cases.Plaque psoriasis was the most common type (68.8%) followed by guttate (18.8%).Erythrodermic and pustular psoriasis were found in 2.2% and 1.5% cases.Scalp was the most frequently affected site (75.36%)followed by extensors of extremities (41.3%), trunk (37.7%), palm and/or sole (13.0%) and diaper area (11.6%).Nail involvement was found only in 8%, joint was affected in 3.6% and only 2.2% children with psoriasis were erythrodermic.In Bangladeshi children with psoriasis, plaque is the most common type and scalp is the mostly affect site.Nail and joint involvement is less common.Pustular and erythrodermic psoriasis is rare.

Article Info
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Discussion
The exact prevalence psoriasis in Bangladesh is not known and previous study conducted over Bangladeshi children with psoriasis is not available.7] In this study we analyzed 276 cases of pediatric psoriasis age ranging from one day to fifteen years with a mean 7.6 years and the median age was 9 years.In previous studies the mean age of onset varied from 8 to 11 years.The first onset of psoriasis varies in different population of world; in previous study it was found that the onset of disease in girls is earlier than boys. 11But some studies found equal sex distribution. 12-14Among our children with psoriasis 51.5% were male and 48.5% female.
The risk of getting affected with psoriasis if no sibling, one sibling or both siblings affected are 0.2%, 0.5% and 0.8%, respectively. 15Some studies found higher (up to 89%) family association with childhood psoriasis. 12, 16But here only 5.1% of children with psoriasis have family members with psoriasis which is consistent with previous Indian studies. 17Seasonal variation of disease was noticed by 29.7% cases, among them 21.0% gave history of winter exacerbation and 8.7% exacerbation in summer or rainy season.In a Chinese study seasonal variation was found 41.6% children with psoriasis mostly winter exacerbation. 13 the sixty-seventh world health assembly in 2014 World Health Organization (WHO) recognized that too many people suffer needless with psoriasis due to delayed or incorrect diagnosis, inadequate treatment options and insufficient access to health care. 18This statement is more appropriate for childhood psoriasis considering its atypical presentation, limited area of involvement and various kinds of disease may be presented at different age of a particular person. 19Presence of itching is less common among Asian children comparing with European (14•2% Vs. 80.0%) 20 .In our series children were asymptomatic in 71.74%, itching was present in 24.28% children and 3.99% had complaints of burning.
In the current study 68.8% children had plaque type.The development of plaque psoriasis in children is often preceded by guttate psoriasis and it is second most common psoriasis. 13, 23Mercy et al. suggested that the risk of severe disease is higher if psoriasis started as guttate psoriasis which persisted. 24In our study, 18.8% children had Guttate psoriasis.One Danish study found guttate psoriasis as the most common variant. 25her less common types were psoriasis eczema overlap (5.1%), erythrodermic (2.2%), acropustulosis (2.2%), pustular 1.5%, linear (0.7%) and flexural (0.7%).Erythrodermic and pustular forms of psoriasis, are considered unusual in children.In past studies pustular psoriasis is seen in only 1.0-10.9% of children with psoriasis. 13,26 everal children in different studies showed an overlap with "eczema like" lesions, excoriated, not wellcircumscribed plaques without typical Auspitz's sign or psoriatic scaling that is called "psoriasiseczema overlap". 27In this study 5.1% patients were psoriasis eczema overlap.
In most previous studies among different ethnic groups scalp is the most frequently involved site for childhood psoriasis. 14, 21, 24, 25, 28It is difficult to establish a correct diagnosis when psoriasis appears in a child with a single atypical eruption.In our children with psoriasis 75.4% presented with scalp lesions followed by extensors of extremities (41.3%) and trunk (37.7%).In many previous Asian and   In one Australian study nail was involved in only 0.6% children. 14One south Indian study found nail involvement to be the sole presenting feature in 23% of children. 22Pitting was the most common nail sign on nail like other previous studies. 20, 22, 24, 29Chelitis and mucosal involvement in childhood psoriasis is very rare.We got 4 (1.5%) patients with chelitis with psoriasis.
Here, 10 (3.6%) children with psoriasis also developed arthritis.In a predominantly plaque or guttate psoriasis population, the prevalence of psoriatic arthritis was reported to be between 0.7% and 10.5%. 9-14, 17, 24In a review of previous reports on childhood psoriasis the range of frequencies of erythroderma among children with psoriasis was o.1% to 5.8%. 30In our study, six (2.2%) children with psoriasis were erythrodermic.

Conclusion
In Bangladeshi children like most other Asian studies, plaque is the most common type and scalp is the mostly affect site for childhood psoriasis.Though in many previous studies found girls are more affected then boys here both are mostly equally affected.Nail and joint involvement are less common.Pustular and erythrodermic psoriasis are rare.

Zayedul Haque and Sabbir Muhammad Shawkat
t e t of De atology a d Ve eeology, Fa ulty of Medi i e, Ba gaa dhu Sheikh Muji Medi al U i e sity, Shah ag, Dhaka, Ba gladesh MSIB, ASMZS, AS, SMS ; Depa t e t of Deatology a d Ve e eology, Ta gail Medi al College, Ta gail, Ba gladesh AKMZH Copyright:The opy ight of this a ti le is etai ed y the autho s [Att i utio CC-BY .]Availaleat:.aglajol.ifoAJou al of Ba ga a dhu Sheikh Muji Medi al U i e sity, Dhaka, Ba gladeshClinico-epidemiological study of childhood psoriasisMohammed Saiful Islam Bhuiyan, A. S. M. Zakaria, Abida Sultana, A. K. M.