'The genetics are complex': Psoriasis is not just a skin disease

The chronic inflammatory skin disorder can expose a child to schoolyard name-calling and make them self-conscious. But systemic medications and biologic treatments have helped to revolutionise the treatment of severe cases 

Amelia Green pictured with her mother Deirdre from Freemount Co Cork. Picture: Howard Crowdy

WHEN Amelia Withers woke up one morning with lots of spots on her skin, her mum, Deirdre Green, thought the then four-year-old had chicken pox.

“It wasn’t a big rash. It was loads of spots all over her body. It started small and got bigger. They were on her stomach, back, thighs and neck,” recalls the mum of two, who lives in Freemount, Co Cork.

Amelia, now 10, didn’t have chicken pox on that February morning. She had guttate psoriasis, a form of psoriasis that comes on suddenly with the widespread appearance of small, red teardrop-shaped patches — a streptococcal throat infection often precedes onset.

“We tried treating her with creams first. It was extremely hard to get an appointment with a dermatologist privately. Eventually, I did — there had to be tears on the phone,” says Green.

Prescribed phototherapy —a form of ultraviolet light therapy — three times a week, this worked well for Amelia. “It cleared her body. Her scalp was one of the worst-affected parts and when she started school that September she still had some there, but that cleared too.”

But the following year — again in the spring — Amelia’s psoriasis returned. With her seven-year-old son, Ronan, plagued with eczema, Green eventually got both children seen by a dermatologist in the public health system who put them on a tablet treatment that blocks inflammation-causing cells and enzymes.

“They had their bloods checked every few months. Then the tablets changed to a pen injection weekly, which I was able to do. It worked very well at the start. Then the dose had to be increased and they had to take folic acid supplements.”

Amelia’s condition again cleared up — only to return when she was around eight. “It had gone — not a mark — and then it came back, on her scalp first. Her scalp was coated white and I’d have to scrape it off.”

Now on a biologic treatment, taken by injection, Amelia again “hasn’t a mark on her skin and is doing really well”, says her mum. Aside from their skin problems, both children are never sick. “They’ve very strong immunity — Amelia has never been on antibiotics.”

She is among the 1% of children with psoriasis, a chronic, systemic inflammatory skin disorder and an autoimmune disease affecting at least 73,000 people in Ireland.

Dr Cathal O’Connor, clinical research fellow in paediatric dermatology at Cork’s South Infirmary Victoria University Hospital

Knock-on effects

According to the Irish Skin Foundation, skin cells normally reproduce and mature as they move from the deeper layers of the epidermis to the surface, a process that typically takes about 28 days. With psoriasis, this process accelerates, taking only about four days. This causes a build-up of dead skin cells and — at the same time — blood flow to the skin increases and the epidermis thickens, leading to the development of red, raised plaques.

“You get these scaly, silvery, thick plaques, often on elbows, knees and scalp,” says Dr Cathal O’Connor, clinical research fellow in paediatric dermatology at Cork’s South Infirmary Victoria University Hospital. “Other hints can be in the belly button and in the lower back, though it can be on the whole body. With some types of psoriasis, you get it in the armpit and groin. Nail problems can also occur.”

O’Connor explains that, because of the very extensive blood supply to the affected parts, the skin bleeds easily. “Psoriasis isn’t usually very itchy, though it can be and this itch can be uncomfortable.”

But psoriasis is not just a skin disease. People who have it are at risk of developing psoriatic arthritis, which commonly affects the joints of fingers, toes and spine, and the condition is associated with a slightly higher risk of diabetes, high blood pressure, high cholesterol, cardiovascular disease, and obesity. O’Connor says psoriasis varies greatly in severity with about 60% of patients presenting with a mild form, 30% with moderate, and 10% with severe.

“Having it in childhood might suggest worse psoriasis. It’s a strongly genetic condition, especially when it presents in children — and the genetics are complex. Grandparents, aunts, uncles, and cousins might have it and not just first-degree relatives.”

Because of the genetic element, when parents spot signs of psoriasis on their children, they’ll often identify it immediately. “Parental concern is usually around the cosmetic impact — or that children might be bullied, get called names like ‘Scaly’ at school,” says O’Connor.

The practical fallout of the condition also has an impact. “People get upset about the scaling. There could be scales all over the bed, where you’d need to hoover it. And there can be bleeding on bedclothes and in the person’s clothing.”

O’Connor says children can feel self-conscious about having psoriasis. “Other children might be asking, ‘What’s wrong with your skin? Is it contagious?’ So we teach children to say, ‘Oh, it’s psoriasis — you won’t catch it off me’.”

Psoriasis is not curable, but there are treatments, which vary depending on severity and location of the disease. They include topical treatments, applied directly to the skin. “Mild cases can be treated with anti-inflammatory creams, ointments, moisturisers, which help skin not to be as scaly,” says O’Connor.

For more severe psoriasis in older children, ultraviolet light therapy, also called phototherapy, can be offered — this is delivered in hospital dermatology departments. “It involves coming to the hospital two to three times a week for three months. A very specific type of ultraviolet light is shone onto the affected skin in a highly specialised booth in which the child stands,” says O’Connor, adding that the first exposure might be just 30 seconds in duration and this gradually increases, with the longest exposure being two to three minutes. “You start to see the benefits after about three weeks.”

Systemic medications and biologic treatments are very targeted in approach and have revolutionised the treatment of severe psoriasis, according to O’Connor. “There are excellent treatments now. They don’t cure psoriasis but they’re extremely effective. Some children might need to take only a couple of injections a year — often, severe cases can be 100% clear on treatment.”

But even if the condition clears, you need to keep using the treatments. “Sometimes psoriasis does go into remission itself, but it’s uncommon to have permanent remission, though you might get a good long break from it.”

Practical advice

The Irish Skin Foundation has the following skincare tips to teach your child:

• Be gentle. Don’t scrub skin, or take a bath or shower in hot water — use warm water only.
• Pat skin dry after cleansing rather than rubbing and irritating it.
• Keep your skin well moisturised — dry skin itches, tempting you to scratch. Applying a moisturiser immediately after shower/bath helps lock in moisture. Emollients and soap substitutes are an important part of treatment.
• Keep nails trimmed — you’re less likely to scratch yourself.
• Wear cotton next to your skin — it is much less likely to irritate skin compared with fabrics like wool.
• Wear sun protection. Psoriasis can benefit from sunlight — but sunburn can cause psoriasis flare-ups.

In Freemount, Amelia is an active girl who plays sport and loves swimming. Green recalls her daughter saying that others would ask about the marks on her face and scalp.

“She has a great bunch of friends. But as children get older, they become more conscious of their appearance, especially girls. Medication is what changed her life and she has no side-effects from it. I feel if I hadn’t put her on it, psoriasis would have affected her emotionally.”

Irish Skin Foundation’s Ask-a-Nurse Helpline ( irishskin.ie/ask-our-dermatology-nurse) operates on an appointment model — people seeking support can be matched with nurse best suited to help with the skin condition/issue they’re experiencing.

• More information on psoriasis: irishskin.ie/psoriasis