1.1. Paediatric psoriasis

The psychological suffering brought about by psoriasis in a child, and hence the severity of the psoriasis, is much more difficult to assess than in the adult. It is also difficult to distinguish from the anguish experienced by the parents. The questioning, explanations and negotiations must therefore be done not only with the child but with the parents too. Children are much better at tolerating systemic treatments than adults, but the cumulative toxic effects of treatment are most feared in children, of course, because the future is not something to be signed away.

  • The first line of treatment is moisturizing of the skin.
  • The second line of treatment is vitamin D derivatives.
  • The third line of treatment is UVB phototherapy, to cope with a crisis situation.
  • The fourth line of treatment is retinoids. In general, these are remarkably effective and very well tolerated at a dose that must never exceed 1/2 mg/kg/j (photos 93 and 94). Two side effects are more frequent in children: these are cephalalgia and irritability. These two side effects are the consequence of mild cerebral oedema. These must prompt a reduction in dosage and, if they fail to disappear, the treatment must be stopped.

Photo 93. Photo 93. Before systemic retinoids (photo: C. Beylot).

Photo 94.

hoto 94. After systemic retinoids (photo: C. Beylot).

Retinoid treatment in infants must be monitored in collaboration with the paediatrician and the GP in order to make sure that there is no negative repercussion on the growth curve. It should be recalled that extensive psoriasis, like any other chronic inflammatory disease, might curb child’s growth.
Treatment with retinoids poses a very difficult problem in young girls during puberty. In medico-legal terms, as soon as the period has occurred for the first time, contraception is necessary. This is not always immediately workable in a reasonable fashion, but the question must always be raised, the dialogue engaged and the contraception arranged as soon as it can be taken on. As a matter of fact, retinoids are rarely prescribed to young girls embarking on adolescence.

  • Methotrexate and cyclosporine, in those exceptional cases indicated, are certainly better tolerated in children than in adults.
  • Anti-TNF began to be used in children suffering from arthritis and etanercept began to be used in children suffering from severe psoriasis.

[|Anthralin works very well and
rapid in children, as the psoriasis in children often is very superficial. The
discoloration of the skin may be disturbing, but the effect is excellent.|auteur195]

1.2. The fertile woman

Two teratogenic drugs, retinoids and methotrexate, require strict precautions when used in fertile women.
Current retinoids require contraception throughout the duration of the treatment and for two years following discontinuation of treatment. This means that, in practice, they are of no use in the fertile woman. We await impatiently the advent of other retinoids that will only require contraception for the duration of the treatment and the month following discontinuation of treatment. In the event of pregnancy occurring in the weeks following the withdrawal of acitretine, the teratogenic risk is minimal. Before discussing pregnancy termination, retinoid levels in the blood must be determined. This analysis can be done with the aid of the Roche Laboratories. Most often, the analysis will be negative and the pregnancy can be allowed to continue with no worries.
Methotrexate requires contraception during treatment and for the three months following its discontinuation. Methotrexate is not mutagenic but is powerfully teratogenic. It is wise to recommend contraception in the woman as well as the man, due to the disruption in spermatogenesis caused by methotrexate.
Biological treatments need contraception because we do not have today data proving their safety during pregnancy.

[|I would mention in this paragraph the fact that the biologic agents are certainly of more value than methotrexate, ciclosporin, and retinoids, ie the traditional agents, in family planning situations. |auteur215]

1.3. The pregnant woman

One of the rules with pregnant women is to use as few drugs as possible.
In topical terms, moisturizing of the skin is always important; topical corticotherapy may be used, but only stintingly, particularly given the significant risk of promoting the appearance of stretch marks.
UVB phototherapy may be done in pregnant women without any problem.
In the severe forms, the only systemic treatment authorized is cyclosporine after agreement of the gynaecologist or obstetrician.

1.4. The elderly

In the elderly, topical treatment is only worth prescribing if applied by a nurse.
Phototherapy and PUVA therapy may be widely used without any misgivings about the several-year period between genotoxic aggression and the appearance of skin cancer. However, elderly people with ample solar keratosis or a history of skin cancer will not derive reasonable benefit from phototherapy. Retinoids may only be used at a weak dose to avoid weakening the skin too much. The risk of senile pruritus or prurigo triggered by retinoids is more significant in the elderly.
The medicine of medicines for major psoriasis in elderly individuals is methotrexate. It is important always to start off at 5 mg a week, and extreme caution must be exercised when increasing dosage. It is rare to have to exceed 10 or 15 mg a week in elderly subjects.
Cyclosporine is not indicated in the elderly, as side-effects appear quite more quickly with advancing age.
Age is not a contraindication by itself to the use of biological treatments.

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