Therapies for the Management of Childhood Psoriasis

Therapies for the Management of Childhood Psoriasis

Authors and Disclosures:
K. M. Cordoro, MD, Department of Dermatology,
University of California, San Francisco, CA, USA

Phototherapy is an excellent, safe, and appropriate treatment for carefully selected patients with refractory plaque, guttate and pustular disease, diffuse (>15%-20% body surface area) involvement, or focal debilitating palmoplantar psoriasis. To avoid burns and other light-associated complications, it is essential to utilize a phototherapy unit with experienced and well-trained personnel who are comfortable working with children. Three main types of therapeutic light options exist: broadband UVB (BB-UVB, 280-320nm), NB-UVB (311-313nm) and UVA (320-400nm).

BB-UVB encompasses the most biologically active radiation in sunlight and guttate psoriasis responds best, but plaque psoriasis in children tends to be thinner and will respond to higher doses and a longer duration of treatment. One of the greatest advances in phototherapy for psoriasis is the use of NB-UVB, which, at therapeutic doses, is lesserythemogenic than other wavelengths in the UVB range.[16]

Centered on 311-313nm, NB-UVB is safe and effective for a number of photoresponsive dermatoses in children, including psoriasis.[17-19] Short-term side-effects of UVBphototherapy are usually mild and consist of xerosis, erythema, pruritus, and photoactivation of herpesvirus. Potential long-term effects include premature photoagingand cutaneous carcinogenesis.[20]

Photochemotherapy (psoralen plus ultraviolet A, [PUVA]) is based on the interaction between UVA radiation and psoralen, a photosensitizing chemical. In children less than12 years, oral PUVA is rarely used and if so, is done with extreme caution and should be restricted to psoriasis and phototherapy centers staffed by well trained, experiencedphysicians and nurses.

Many authors consider oral psoralen relatively contraindicated in children less than age 12 and prefer topical PUVA because of the many short- and longterm toxicities associated with psoralen ingestion (e.g., nausea, vomiting, headache, hepatotoxicity, generalizedphotosensitization requiring 24 hours of photoprotection, ocular toxicity, acute risk of burning, and long-term risk of skin cancer).[21] In children, NB-UVB is more convenient and may be less carcinogenic. Given the downsides of using psoralens in children and adults, NB-UVB is now considered first-line phototherapy.[22]

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