From the Guidelines
The worsening of psoriasis symptoms in a 1-year-old after using steroid cream is likely due to a rebound effect or incorrect diagnosis, and I recommend switching to a topical vitamin D analogue such as calcipotriol as a safer and more effective alternative. The child may actually have infantile seborrheic dermatitis or atopic dermatitis, which can be misdiagnosed as psoriasis. According to the joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients 1, topical vitamin D analogues are safe, effective, and relatively well tolerated in children of all ages. Some key points to consider when using topical vitamin D analogues in pediatric patients include:
- They inhibit keratinocyte proliferation and DNA synthesis and promote keratinocyte differentiation 1
- They are frequently used in combination with topical corticosteroids, but have a corticosteroid-sparing function 1
- The maximum recommended dosages to prevent hypercalcemia are 50 g/wk/m2 for calcipotriol and 100 g/wk/m2 for calcipotriene 1 In addition to topical vitamin D analogues, maintaining the skin barrier with regular application of fragrance-free emollients like petroleum jelly or ceramide-containing moisturizers several times daily is essential. Gentle bathing with lukewarm water and mild, fragrance-free cleansers will help prevent further irritation. If symptoms persist after 2 weeks of this regimen, the child should be referred to a pediatric dermatologist for further evaluation, as infantile psoriasis is rare and may require specialized care. It's also worth noting that topical calcineurin inhibitors such as tacrolimus ointment (0.03%) or pimecrolimus cream can be used as an alternative treatment, but the evidence for their use in pediatric psoriasis is mostly derived from studies in atopic dermatitis 1.
From the Research
Reason for Worsening Symptoms
- The worsening of symptoms in a 1-year-old with skin psoriasis after using steroid cream medication could be due to various factors, including the potential for tumor necrosis factor (TNF)-α inhibitors, such as those found in some steroid creams, to induce or exacerbate psoriasis in children 2.
- Another possible reason is that the steroid cream may not be suitable for the child's specific condition, or the dosage may be incorrect, leading to adverse effects 3.
Alternative Treatment Options
- Topical vitamin D analogs, such as calcipotriene, may be a suitable alternative or addition to steroid cream for treating psoriasis in children 4.
- Phototherapy, conventional systemic agents, and biologics may also be considered for patients with more severe disease, although these options should be carefully evaluated and monitored by a healthcare professional 4.
- A multidisciplinary approach to treatment, involving dermatologists, pediatricians, and other specialists, may be necessary to effectively manage pediatric psoriasis and address associated comorbidities 5, 6, 3.