Abstract Background: Psoriasis is a chronic inflammatory skin disease affecting both adult and children. Clinico-epidemiological data of childhood psoriasis from Bangladesh is rare. Methods: In this cross-sectional study epidemiological and clinical data was collected from 276 children with psoriasis. Psoriasis was diagnosed clinically and histopathologically (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. Result: Mean age was 7.64 years with a range 1 day to 15 years, male: female was 1.06:1 and affected first degree relatives were found in 14 (5.0%) cases. In 198 (71.7%) case there was no complain of any discomfort, itching was present in 67(24.3%) and burning in 11 (4.0%). Plaque psoriasis was the most common type (68.9%) followed by guttate (18.9%). Erythrodermic and pustular psoriasis was found in 2.2% and 1.5% cases. Scalp was the most frequently affected site (75.4%) 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 8.0%, joint was affected in 3.6% and only 2.2% children with psoriasis were Erythrodermic. Conclusion: In Bangladeshi children with psoriasis plaque is the most common type and scalp is the mostly affect site. Male and female are mostly equally affected. Nail and joint involvement is less common. Pustular and erythrodermic psoriasis is rare. Key words: childhood psoriasis, pediatric psoriasis, congenital psoriasis, Bangladesh.

2. Dr. Mohammed Saiful Islam Bhuiyan, MDDr. Mohammed Saiful Islam Bhuiyan, MD
Associate Professor, Department of Dermatology,Associate Professor, Department of Dermatology,
Bangabandhu Sheikh Mujib Medical University (BSMMU). Dhaka, BangladeshBangabandhu Sheikh Mujib Medical University (BSMMU). Dhaka, Bangladesh

4. Pattern ofPattern of
Childhood PsoriasisChildhood Psoriasis
inin
BangladeshBangladesh

6. PsoriasisPsoriasis
AA commoncommon,, life-longlife-long,, geneticgenetic,,
autoimmuneautoimmune skin diseaseskin disease
characterized by wellcharacterized by well
circumscribed areas of thick,circumscribed areas of thick,
silvery or red, scaly skinsilvery or red, scaly skin

7. A global health problemA global health problem
>125 million people, or nearly 3%>125 million people, or nearly 3%
of the world's populationof the world's population
0.7% of Bangladeshi population0.7% of Bangladeshi population
(Bhuiyan et al, 2018)(Bhuiyan et al, 2018)

8. Childhood psoriasisChildhood psoriasis
Fairly common.Fairly common.
True prevalnce is not clearTrue prevalnce is not clear
The overall prevalence in theThe overall prevalence in the
pediatric population is about 1%pediatric population is about 1%

9. Prevalence ratesPrevalence rates
increase linearly fromincrease linearly from
0.2% at the age of 1 year0.2% at the age of 1 year
to 1.2% at the age of 18to 1.2% at the age of 18
yearsyears

10. At least one-third before theAt least one-third before the
age of 16 yearsage of 16 years
In 10% of the patients the onsetIn 10% of the patients the onset
of the disease is before the ageof the disease is before the age
of 10 years and in 2% before 2of 10 years and in 2% before 2
yearsyears

11. Psoriasis in childrenPsoriasis in children
An underrecognized andAn underrecognized and
undertreated disease.undertreated disease.
Can limit physical activity,Can limit physical activity,
Impairs social interactionImpairs social interaction
A significant psychological burdenA significant psychological burden

12. Early recognition andEarly recognition and
management of pediatricmanagement of pediatric
psoriasis is fundamental inpsoriasis is fundamental in
order to prevent psychosocialorder to prevent psychosocial
and physical sequelae that canand physical sequelae that can
result from the diseaseresult from the disease

13. Challenge in diagnosisChallenge in diagnosis
One third of patients who developOne third of patients who develop
psoriasis during childhood are notpsoriasis during childhood are not
diagnosed until adulthooddiagnosed until adulthood

14. Diagnosis is more difficult inDiagnosis is more difficult in
children due to atypicalchildren due to atypical
characteristics and limitedcharacteristics and limited
involvement of skininvolvement of skin
Variable presentationVariable presentation
Changes over timeChanges over time

15. Atypical morphologyAtypical morphology
Atypical sitesAtypical sites
The lesions are relativelyThe lesions are relatively
thinnerthinner
Softer and less scalySofter and less scaly

17. Title:Title:
Pattern of Childhood PsoriasisPattern of Childhood Psoriasis
in Bangladeshin Bangladesh

18. MethodologyMethodology
Multi-center cross-sectionalMulti-center cross-sectional
observational type studyobservational type study
Bangabandhu Sheikh Mujib MedicalBangabandhu Sheikh Mujib Medical
University and Dhaka Medical collegeUniversity and Dhaka Medical college
hospitalhospital
Study period: July 2011 to June 2015Study period: July 2011 to June 2015

19. Number of children: 138Number of children: 138
Age: 1 day to 18 yearsAge: 1 day to 18 years

20. We consideredWe considered
HistoryHistory
Clinical presentationClinical presentation
No management orNo management or
treatment issuetreatment issue

21. DiagnosisDiagnosis
Clinical presentationClinical presentation
Histopathology (when inHistopathology (when in
doubt)doubt)

22. ResultResult

23. Age of onsetAge of onset
The peak age of onset inThe peak age of onset in
childhood varied in differentchildhood varied in different
studiesstudies
Mean age of onset of psoriasisMean age of onset of psoriasis
were 7.5±2.7 yearswere 7.5±2.7 years
Peak age of onset was 6-9 yearsPeak age of onset was 6-9 years

24. In surveys from India andIn surveys from India and
Denmark, most patientsDenmark, most patients
developed first symptoms at thedeveloped first symptoms at the
ages of 6 to 10 yearsages of 6 to 10 years
Whereas other authors from theWhereas other authors from the
Middle East and AustraliaMiddle East and Australia
reported a peak of onset at thereported a peak of onset at the
ages of 0 to 4 years.ages of 0 to 4 years.

25. 0
2
4
6
8
10
12
14
Number
of
children
with
psoriasis
2 4 6 8 10 12 14 16 18
age (years)

26. in China the average age ofin China the average age of
pediatric psoriasis patients waspediatric psoriasis patients was
noted to be 11 years, and mediannoted to be 11 years, and median
age of onset 10 yearsage of onset 10 years
May beMay be Asian children develop
the disease later

27. GenderGender
There is no agreement aboutThere is no agreement about
whether the prevalence ofwhether the prevalence of
psoriasis differed between menpsoriasis differed between men
and womenand women
Girl: 51.45%Girl: 51.45%
Boy: 48.55%Boy: 48.55%

28. GenderGender
Equal gender distribution wasEqual gender distribution was
found in Australia and Indiafound in Australia and India
But some previous studies foundBut some previous studies found
female preponderance of aboutfemale preponderance of about
2:12:1

29. Family historyFamily history

30. The lifetime risk of getting psoriasisThe lifetime risk of getting psoriasis
if no parent: 1-3%if no parent: 1-3%
one parent: 25%one parent: 25%
both parents have involved : 65%both parents have involved : 65%

31. InheritanceInheritance
If you have psoriasis, the risk to:If you have psoriasis, the risk to:
 Your unrelated neighbour: 1-3%Your unrelated neighbour: 1-3%
 Your sibling: 15-20%Your sibling: 15-20%
 Your identical twin: 65-70%Your identical twin: 65-70%
 Your child: 25%Your child: 25%

32. Family association isFamily association is greater ingreater in
childhood than adultchildhood than adult
In previous studies positive familyIn previous studies positive family
history in 9.8% to 73%history in 9.8% to 73%

33. Family historyFamily history
Positive family history asPositive family history as
affected first degree relativesaffected first degree relatives
was found in 12%was found in 12%

34. PruritusPruritus
Pruritus was present in 81%Pruritus was present in 81%
In previous different studiesIn previous different studies
pruritus was observed in about 70pruritus was observed in about 70
to 90% of patients with psoriasisto 90% of patients with psoriasis

35. Triggering agentsTriggering agents
Only 16 (12%) can recall aboutOnly 16 (12%) can recall about
any triggering agentany triggering agent
11 gave history of sore throat11 gave history of sore throat
5 initiated by trauma5 initiated by trauma

37. Plaque
69%
Guttate
19%
Erythrodermic
4%
others
8%

38. Other typesOther types
Sebo-psoriasisSebo-psoriasis
PsoriaticPsoriatic
arthritisarthritis
PustularPustular
LinearLinear
InverseInverse

39. Plaque type PsoriasisPlaque type Psoriasis

40. Plaque type PsoriasisPlaque type Psoriasis
Plaque psoriasis with its
variants is the most frequent
type, also in infancy and
childhood.

41. In a large series of over 1200
Australian patients, 34% of the
children presented with Plaque
type and in other smaller studies
plaque type was found in 61%,
69% and 84%.

42. Plaque psoriasisPlaque psoriasis
In the current series 69% wasIn the current series 69% was
plaque typeplaque type

47. Guttate psoriasisGuttate psoriasis
Reported percentage of children
who initially have guttate psoriasis
varies from 6.4% to 44%
In this study Guttate was 19%Guttate was 19%

49. Guttate psoriasisGuttate psoriasis

54. SiteSite
75.36
37.68
41.3
15.21
11.59 13.04
7.97
20.29
2.9
0
10
20
30
40
50
60
70
80
Scalp Trunk Extensors face Diaper
area
Palm/Sole post-
auricular
Nail Joint

56. Scalp involvementScalp involvement
–In this study 75.4% gaveIn this study 75.4% gave
history of scalphistory of scalp
involvement at some pointinvolvement at some point
of their illnessof their illness

58. Palm and/or solePalm and/or sole

60. Knee or elbowKnee or elbow

63. TrunkTrunk

65. Facial psoriasisFacial psoriasis
Face involvement occurs inFace involvement occurs in
children more frequently thanchildren more frequently than
adultsadults
Common in adolescents and
studies show that up to 46
percent of pediatric patients may
have manifestation of the disease
on the face.

66. In our study 15.2% of childrenIn our study 15.2% of children
with psoriasis had facialwith psoriasis had facial
involvementinvolvement

69. Ear involvementEar involvement

70. Post auricularPost auricular

71. Eye browsEye brows

72. Inverse psoriasisInverse psoriasis

73. Nail and jointsNail and joints
NailNail 2828 20.320.3
JointJoint 44 2.902.90

74. Nail changesNail changes
PittingPitting 2222 15.9%15.9%
DiscolorationDiscoloration 1212 8.8%8.8%
Thickening ofThickening of
nail platenail plate
88 5.8%5.8%
Oil spotOil spot 77 5.1%5.1%

75. Nail changesNail changes
RidgingRidging 77 5.07%5.07%
SubungualSubungual
hyperkeratosishyperkeratosis
44 2.9%2.9%
Beau’s linesBeau’s lines 44 2.9%2.9%
OnycholysisOnycholysis 22 1.5%1.5%

76. Diaper psoriasisDiaper psoriasis
A special clinical variant in young
children is psoriatic diaper rash,
which usually occurs until the age of 2
years
In contrast to irritant diaper dermatitis,
it is sharply demarcated, brightly red,
and involves the inguinal folds.

77. Psoriasis in infants often
presents in the napkin areas
but a confident diagnosis at
this stage may be difficult

79. Psoriatic arthritisPsoriatic arthritis
Arthropathic psoriasis is anArthropathic psoriasis is an
uncommon seronegativeuncommon seronegative
inflammatory arthritis in children,inflammatory arthritis in children,
which affects 1% of children withwhich affects 1% of children with
cutaneous psoriasiscutaneous psoriasis

81. Psoriatic arthritisPsoriatic arthritis

82. Psoriatic arthritisPsoriatic arthritis
The onset of psoriatic arthritis inThe onset of psoriatic arthritis in
children often occurs between thechildren often occurs between the
ages of seven and 13 and canages of seven and 13 and can
produce irreversible jointproduce irreversible joint
destruction.destruction.

83. SeveritySeverity
Mild (<5% BSA)Mild (<5% BSA) 8686 62%62%
Moderate (5-Moderate (5-
10% BSA)10% BSA)
4141 29%29%
Severe (>10%)Severe (>10%) 1111 8%8%

84. PustularPustular
Pustular psoriasis is rare in
children
Reported in previous study 5%
Only Three case of PustularOnly Three case of Pustular
psoriasis in the current seriespsoriasis in the current series
All were boysAll were boys

85. PustularPustular

88. Erythrodermic psoriasisErythrodermic psoriasis

89. Erythrodermic psoriasisErythrodermic psoriasis

90. Neonatal PsoriasisNeonatal Psoriasis

91. Congenital psoriasisCongenital psoriasis
Baby of an affected motherBaby of an affected mother
born with psoriatic lesionsborn with psoriatic lesions
Histopathology positive.Histopathology positive.

93. Comorbid diseasesComorbid diseases
New research has found that
pediatric psoriasis is associated
with numerous other serious,
chronic and/or life-threatening
comorbid conditions.

94. ConclusionConclusion
Psoriasis in childhood demandsPsoriasis in childhood demands
special attentionspecial attention

95. Dermatologists should beDermatologists should be
careful not to miss even ill-careful not to miss even ill-
defined lesions of Psoriasisdefined lesions of Psoriasis
to ensure early diagnosisto ensure early diagnosis
and treatment of this chronicand treatment of this chronic
disease of no cure causingdisease of no cure causing
significant discomfort,significant discomfort,
disfigurement and poordisfigurement and poor
quality of life.quality of life.

98. Thank youThank you