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Table of Contents
BRIEF REPORT
Year : 2019  |  Volume : 37  |  Issue : 1  |  Page : 46-49

Childhood and adolescent psoriasis in Taiwan: A retrospective analysis from a single medical center


1 Department of Dermatology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan; Department of Dermatology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
2 Department of Dermatology, National Cheng Kung University Hospital; Department of Biochemistry and Molecular Biology, College of Medicine, National Cheng Kung University, Tainan, Taiwan
3 Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
4 Department of Dermatology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
5 Department of Dermatology; Department of Biochemistry and Molecular Biology, College of Medicine; Center of Applied Nanomedicine, National Cheng Kung University, Tainan, Taiwan

Date of Submission18-Aug-2018
Date of Acceptance17-Oct-2018
Date of Web Publication28-Mar-2019

Correspondence Address:
Tak-Wah Wong
No.138 Sheng-Li Road, Tainan 704
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ds.ds_26_18

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  Abstract 


There are limited studies regarding childhood and adolescent psoriasis in Taiwan. A total of 86 pathologically confirmed cases diagnosed from 1989 to 2017 were retrospectively reviewed. Mean disease onset age was 10.51 years, and plaque psoriasis was the most common type. Compared to studies on Caucasian and other Asian populations, we found a lower estimated prevalence, higher rate of psoriasis limited to the nail at presentation, and higher prevalence of psoriatic arthritis. The most common comorbidities were related to atopy and metabolic syndrome. Positive family history of psoriasis and psoriasis preceded by infection were significantly associated with moderate-to-severe disease.

Keywords: Adolescent psoriasis, Asian, childhood psoriasis


How to cite this article:
Yen H, Su HJ, Tran TTV, Kuo PL, Lee JY, Wong TW. Childhood and adolescent psoriasis in Taiwan: A retrospective analysis from a single medical center. Dermatol Sin 2019;37:46-9

How to cite this URL:
Yen H, Su HJ, Tran TTV, Kuo PL, Lee JY, Wong TW. Childhood and adolescent psoriasis in Taiwan: A retrospective analysis from a single medical center. Dermatol Sin [serial online] 2019 [cited 2019 Jun 20];37:46-9. Available from: http://www.dermsinica.org/text.asp?2019/37/1/46/255031




  Introduction Top


Psoriasis is a multi-systemic inflammatory disease that generally presents on the skin as erythematous plaques with silvery white scales. Although it can affect people of all ages, one-third of patients have disease-onset in the first two decades of life.[1] Childhood psoriasis affects the quality of life,[2] and has been associated with increased rates of comorbidities, including hyperlipidemia, obesity, hypertension, diabetes mellitus, rheumatoid arthritis, and Crohn's disease.[3] There are limited epidemiological studies on Asian childhood psoriasis, including Taiwan. Two community-based surveys reported no psoriasis cases among 7340 Taiwanese school children.[4],[5] This has led to other literature, including the World Health Organization's 2016 Global Report on Psoriasis, to report a 0% prevalence in Taiwan.[6],[7],[8] However, data from Taiwan's National Health Insurance database from 2000 to 2006 found that psoriasis patients younger than 20 years accounted for a mean 1 year prevalence rate of <0.1%,[9] with these patients accounting for 7.2% of all psoriasis cases in 2006.[10] In the present study, we review the demographics, clinical presentation, therapeutic characteristics, and associated comorbidities of childhood and adolescent psoriasis cases from a tertiary medical center in southern Taiwan.


  Methods Top


We conducted a retrospective review of all childhood and adolescent psoriasis cases from a tertiary medical center in southern Taiwan. Cases were identified from a systematic search of the electronic patient database of the Department of Dermatology using the clinical keyword “psoriasis” from January 1989 to February 2017. Only pathologically confirmed cases with disease-onset before 18 years of age were included. For each case, the following data were obtained from the electronic medical record and clinical images: age of onset, sex, family history (yes or no), initial site affected (scalp, face, ear, trunk, elbow, arm, palm or sole, leg, knee, oral, nail, or intertriginous areas), all sites affected during the clinical course, type of psoriasis (plaque psoriasis, guttate psoriasis, inverse psoriasis, erythrodermic psoriasis, pustular psoriasis, acrodermatitis continua, or other), psoriatic arthritis during the course of disease (yes or no), presence of precipitating triggers (infection, emotional stress, trauma, other, or none reported), type of treatment (systemic methotrexate, systemic retinoid, systemic calcineurin inhibitor, topical corticosteroid, topical vitamin D analog, topical tar, topical calcineurin inhibitor, broadband ultraviolet B [UVB], narrow-band UVB, psoralen plus ultraviolet A (PUVA), systemic biologic agent, or other], and documented comorbidities. Body mass index ≥25 kg/m2 was defined as overweight or obese. Medical chart review was conducted for cases with missing data. Cases were excluded if there was significant missing information even after medical chart review. Results were presented as mean with standard deviation or a number of cases as a percentage (%).

The severity of psoriasis was dichotomized into mild disease versus moderate-to-severe disease. The moderate-to-severe disease was defined as requiring systemic methotrexate, cyclosporine, retinoid, corticosteroid, or biologic agent treatment. Comparison of mild with moderate-to-severe psoriasis was evaluated by obtaining P values using t-tests for means and Chi-squared tests for proportions. All statistical analyses were conducted using STATA software (version 13; StataCorp, College Station, TX, USA). Statistical tests were two-sided, with P < 0.05 considered statistically significant.


  Results Top


A total of 86 childhood and adolescent psoriasis cases were included for final analysis, representing 0.09% of the total 97,330 unique patients who visited our outpatient clinic during this time frame, providing an estimate of its prevalence. [Table 1] describes the main characteristics of these cases. The mean age of disease onset was 10.51 years, and the female-to-male ratio was 1:1. Of those with documentation of family history, 27.3% had a positive family history of psoriasis. Plaque psoriasis was the most prevalent type at presentation (87.2%), whereas pustular psoriasis (8.1%) and guttate psoriasis (4.7%) were less common. The initial presentation was limited to the scalp in 26.7% of cases, and 11.6% solely to the nails. During the disease course, the most frequently affected sites were scalp, trunk, and extremities (62.8%, 58.1%, and 54.7%, respectively). Psoriatic arthritis was observed in 14% of patients. With regard to precipitating triggers, psoriasis was preceded by an infection in 16.3% of cases.
Table 1: Main demographic, clinical, and therapeutic characteristics of 86 childhood and adolescent psoriasis cases

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Almost all patients (98.8%) received topical corticosteroid treatment. More than half received topical vitamin D analog (54.7%) and topical tar (53.5%). Narrow-band UVB was offered to 26.7% of patients, while excimer laser and PUVA were used infrequently. Fifteen patients (17.4%) received systemic treatments for moderate-to-severe disease. Pruritus requiring antihistamine treatment was documented in 41.9% of the patients, whereas 8.1% required prescription for pain relief. For cases requiring pain relief, the majority (71%) were for psoriatic arthritis-related pain. The most common comorbidities were atopy-associated (12.8%) followed by metabolic syndrome-associated (8.1%), with allergic rhinitis and overweight/obesity being the most prevalent diagnoses. [Table 2] compares moderate-to-severe with mild cases. We found that cases with a positive family history of psoriasis and psoriasis preceded by infection were significantly associated with the moderate-to-severe disease. No association for psoriasis severity was found for sex, age of onset, or the presence of psoriatic arthritis.
Table 2: Results of comparison between moderate-to-severe and mild psoriasis cases

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  Discussion Top


This single-center retrospective review of 86 Taiwanese childhood and adolescent psoriasis cases highlights the importance of recognizing the similarities and differences of this disease in Taiwanese children versus other populations.

In a systematic review of 131 published studies, Burden-Teh et al. reported that the prevalence rate of childhood psoriasis based on population-based studies ranged from 0% (Taiwan) to 2.1% (Italy).[7] Similar to that systematic review, the present series also shows plaque psoriasis as the most common type, a comparable percentage of cases with positive family history, and a mean age of onset of 10.51 years, which was at the higher end of the reported range of 2.1 months to 10.6 years.[7] Our study found a childhood and adolescent psoriasis estimated prevalence of 0.09%, lower than the reported prevalence of 0.7%–6.2% at other pediatric dermatology clinics.[7] The estimated prevalence from our study is comparable to the results using Taiwan's National Health Insurance database,[9] suggesting that the prevalence of childhood and adolescent psoriasis is relatively lower in Taiwan compared to other populations. Additional differences in our series include no gender preference instead of a female predominance,[7] a higher rate with psoriasis limited to nail at presentation (11.6% vs. 2.3% from another retrospective study),[11] and a higher rate of psoriatic arthritis (14%) compared to the reported range of 0.7%–10.5%.[7]

The most prevalent comorbid conditions in our study were atopy-associated, a finding similar to the study by Wu et al. on Asian childhood psoriasis patients in which allergic contact dermatitis and eczema were the most commonly documented comorbidities.[12] The second-most prevalent comorbid conditions in our series were metabolic syndrome-associated comorbidities, which were not observed in the study by Wu et al.,[12] but was found to have a significant association in a large study on juvenile psoriasis in Germany.[3] The limitations of the present study include: a retrospective design, small case number, possible underestimation of the prevalence rate, and selection bias since only pathology-confirmed cases were included.


  Conclusion Top


The results of this study have important clinical implications. Examining the scalp and nails of suspected childhood psoriasis patients can provide additional diagnostic clues for the physician. Confirming a positive family history of psoriasis or disease preceded by a recent infectious episode may be suggestive of a more severe disease course. In addition, the presence of joint pain should be evaluated in these patients, as psoriatic arthritis requiring pain medication is not uncommon. Finally, atopy or metabolic-associated comorbidities should also be inquired in this population. Larger observational studies are warranted to further characterize childhood and adolescent psoriasis in Taiwan.

Financial support and sponsorship

The study was supported by National Cheng Kung University Hospital (NCKUH10703019), the Ministry of Science and Technology (MOST 1072321B006008), and the Center of Applied Nanomedicine, National Cheng Kung University from the Featured Areas Research Center Program within the framework of the Higher Education Sprout Project by the Ministry of Education in Taiwan.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Farber EM, Nall ML. The natural history of psoriasis in 5,600 patients. Dermatologica 1974;148:1-8.  Back to cited text no. 1
    
2.
Gånemo A, Wahlgren CF, Svensson Š. Quality of life and clinical features in Swedish children with psoriasis. Pediatr Dermatol 2011;28:375-9.  Back to cited text no. 2
    
3.
Augustin M, Glaeske G, Radtke MA, Christophers E, Reich K, Schäfer I, et al. Epidemiology and comorbidity of psoriasis in children. Br J Dermatol 2010;162:633-6.  Back to cited text no. 3
    
4.
Yang YC, Cheng YW, Lai CS, Chen W. Prevalence of childhood acne, ephelides, warts, atopic dermatitis, psoriasis, alopecia areata and keloid in Kaohsiung county, Taiwan: A community-based clinical survey. J Eur Acad Dermatol Venereol 2007;21:643-9.  Back to cited text no. 4
    
5.
Chen GY, Cheng YW, Wang CY, Hsu TJ, Hsu MM, Yang PT, et al. Prevalence of skin diseases among schoolchildren in Magong, Penghu, Taiwan: A community-based clinical survey. J Formos Med Assoc 2008;107:21-9.  Back to cited text no. 5
    
6.
Parisi R, Symmons DP, Griffiths CE, Ashcroft DM; Identification and Management of Psoriasis and Associated ComorbidiTy (IMPACT) project team. Global epidemiology of psoriasis: A systematic review of incidence and prevalence. J Invest Dermatol 2013;133:377-85.  Back to cited text no. 6
    
7.
Burden-Teh E, Thomas KS, Ratib S, Grindlay D, Adaji E, Murphy R, et al. The epidemiology of childhood psoriasis: A scoping review. Br J Dermatol 2016;174:1242-57.  Back to cited text no. 7
    
8.
World Health Organization. Global Report on Psoriasis. Geneva: World Health Organization; 2016.  Back to cited text no. 8
    
9.
Chang YT, Chen TJ, Liu PC, Chen YC, Chen YJ, Huang YL, et al. Epidemiological study of psoriasis in the national health insurance database in Taiwan. Acta Derm Venereol 2009;89:262-6.  Back to cited text no. 9
    
10.
Tsai TF, Wang TS, Hung ST, Tsai PI, Schenkel B, Zhang M, et al. Epidemiology and comorbidities of psoriasis patients in a national database in Taiwan. J Dermatol Sci 2011;63:40-6.  Back to cited text no. 10
    
11.
Kumar B, Jain R, Sandhu K, Kaur I, Handa S. Epidemiology of childhood psoriasis: A study of 419 patients from Northern India. Int J Dermatol 2004;43:654-8.  Back to cited text no. 11
    
12.
Wu Y, Lin Y, Liu HJ, Huang CZ, Feng AP, Li JW, et al. Childhood psoriasis: A study of 137 cases from central China. World J Pediatr 2010;6:260-4.  Back to cited text no. 12
    



 
 
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  [Table 1], [Table 2]



 

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