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Abstract
Background: Psoriasis begins in childhood in around one-third of the cases. There has been conflicting evidence regarding the association of paediatric psoriasis with comorbidities. Aims and Objectives: The objective of this study was to find out various comorbidities (abnormal body mass index, metabolic syndrome, lipid abnormalities, diabetes mellitus, and raised blood glucose) associated with paediatric psoriasis. Materials and Methods: All patients of psoriasis (age <18 years) who visited the Paediatric Psoriasis clinic from January 2017 to September 2021 were recruited in this record-based study. Results: Records of 100 patients were analysed, with female to male ratio of 1:1. The age group ranged from 11 months to 18 years. The average body surface area involved was 5.43%. The average psoriasis area and severity index was 2.47. Joint involvement was seen in 7% of patients in our study. A total of 52 (52%) patients had abnormal body mass index, out of which 21 patients were overweight and 31 were obese. At least one lipid abnormality was found in 66 (66%) patients. The most common lipid abnormality was decreased high-density lipoprotein, followed by raised total cholesterol, raised total triglycerides and raised low-density lipoprotein. 8 (8%) patients were found to have raised blood glucose levels. Out of which, six had impaired fasting glucose and two were diagnosed with diabetes mellitus. 5 (5%) patients were diagnosed with metabolic syndrome. Conclusion: Paediatric psoriasis is a chronic disfiguring disease and may have profound emotional and psychological effects. There is a lack of studies from India on the prevalence of these comorbidities in paediatric psoriasis. More studies are required from different parts of the world for a better understanding of paediatric psoriasis.
Keywords: Diabetes, lipid profile, metabolic syndrome, obesity, paediatric psoriasis
Introduction 
Psoriasis is a chronic inflammatory, immune-mediated disease characterised by well-defined, erythematous plaques with silvery-white scales. Psoriasis begins in childhood in around one-third of the cases and prevalence ranges from 0% to 1.37% in children.[1] In recent years, psoriasis is regarded as a systemic inflammatory disease rather than just a cutaneous one.[2]
In the literature, there has been conflicting evidence regarding the association of paediatric psoriasis with comorbidities. A recent systemic review has linked paediatric psoriasis with systemic comorbidities particularly, metabolic comorbidities as is the case with adults.[3] However, except for overweight and obesity, paediatric psoriasis was not associated with metabolic or cardiovascular comorbidities in a systematic review by Badaoui et al.[4] In the long term these systemic comorbidities may have an impact on the patient's health, so appropriate management at early age is warranted.
There are only a few studies on comorbidities in paediatric psoriasis. Considering the disease burden and the scanty published information about associated comorbidities in paediatric psoriasis, we analysed records of paediatric psoriasis, to learn more about various comorbidities associated with paediatric psoriasis. This study will cover various aspects of childhood patterns of psoriasis with emphasis on various comorbidities like obesity, hyperlipidaemia, and metabolic syndrome and throw some light on this less studied aspect of paediatric psoriasis.
Materials and Methods This retrospective analysis included all patients less than 18 years of age with a clinical diagnosis of psoriasis who visited the Paediatric Psoriasis clinic in the Dermatology Department at Kalawati Saran Children's Hospital from January 2017 to September 2021. The diagnosis of psoriasis was made clinically by an experienced dermatologist. As per the predesigned clinical proforma, a detailed evaluation was done which included clinical history, clinical characteristics of psoriasis (types, severity etc.), history of autoimmune disease, history of psoriatic arthritis, body mass index (BMI) calculation, waist circumference (WC) and blood pressure (BP) measurement and results of the various investigations (Haemoglobin, fasting blood glucose, fasting lipid profile). Metabolic syndrome (MS) was diagnosed according to the International Diabetes Foundation (IDF) consensus statement.[5] These recommendations stratify children by age (6 to <10 years; 10 to <16 years; 16+ years). A diagnosis of MS is made in the presence of central obesity as defined by WC ≥90 percentile for age in addition to two of the following four criteria: elevated triglycerides (≥150 mg/dl), low HDL (<40 mg/dl for children <10 years of age or boys, <50 mg/dl in girls aged ≥16 years), hypertension (Systolic Blood pressure >130 mmHg or diastolic blood pressure ≥85 mmHg or on specific treatment for previously diagnosed hypertension) and hyperglycaemia (fasting blood glucose ≥100 mg/dl or known diagnosis of type 2 diabetes mellitus).
The data was collected and analysed statistically using SPSS software. Continuous variables were expressed as mean +/– standard deviation and were analysed using a t-test. Categorical variables were expressed as frequencies and percentages and were analysed using the Chi-square test. Institutional Ethical Committee approval was taken before starting the study.
Results Records of 100 patients were analysed in our study. There were 50 females (50%) and 50 males (50%), with an F: M ratio of 1:1. The age group ranged from 11 months to 18 years, with the mean age being 10.87 ± 3.96 years. The duration of psoriasis ranged from seven days to 13 years, with the mean duration being 2.85 ± 0.30 years. The most common subtype of psoriasis was plaque psoriasis (61%), followed by palmoplantar (16%), guttate (6%), scalp (6%), flexure (4%), sebopsoriasis (3%), erythroderma (2%) and pustular (2%). Body surface area (BSA) involvement was calculated according to the rule of palm. The average BSA involved was 5.43%. The majority (49%) of patients had involvement of 3%–10% BSA. 39% had involvement of <3% and the rest 12% had involvement of >10% BSA. The average psoriasis area and severity index (PASI) in our study was 2.47. PASI >10 was found in only five patients, the rest 95 had PASI <10. Only 7% of patients had joint involvement in our study. Descriptive characteristics of psoriatic children are mentioned in [Table 1].
Abnormal waist circumference (WC) was defined as >90 percentile for age and sex. A total of 27 patients has abnormal WC. The mean BMI in our study was 21.33 ± 5.79. BMI for age and sex ranging from 5th – 85th percentile was defined as normal. Overweight and obesity were defined as BMI >85 percentile and >95 percentile for age and sex respectively. A total of 52 patients had abnormal BMI, out of which 21 patients were overweight and 31 were obese. Rest 48 patients had normal BMI. All patients had normal blood pressure.
Normal haemoglobin levels were considered as 11–15 gm/dl. Raised fasting blood glucose (FBG) was considered ≥100 mg/dl. Dyslipidaemia was considered as Serum triglycerides (TG) ≥150 mg/dl, high-density lipoprotein (HDL) ≤50 mg/dl, low-density lipoprotein (LDL) ≥100 mg/dl and total cholesterol (TC) ≥200 mg/dl. The mean haemoglobin in our study was 12.24 ± 1.64. The mean FBG was 86.33 ± 13.87. The mean TG was 116.67 ± 29.58, the mean TC was 146.9 ± 27.32, the mean HDL was 49.94 ± 11.68 and the mean LDL was 80.16 ± 15.55. The distribution of abnormal laboratory investigations is presented in [Table 2]. Anaemia, defined as haemoglobin levels <11 gm/dl was present in 21 (21%) patients in our study. At least one lipid abnormality was found in 66 (66%) patients. The most common lipid abnormality was decreased HDL in 53 patients, followed by raised TC in 15 patients, raised TG in 12 patients and raised LDL in six patients. Eight patients were found to have raised fasting blood glucose levels. Out of which, six had impaired fasting glucose and two were diagnosed with type 2 diabetes mellitus. According to IDF, 5 (5%) patients were diagnosed with MS.
Discussion Currently, a changing viewpoint contends that psoriasis is not just a skin-limited condition, but rather a cutaneous expression of systemic inflammation.[6] In adults, the link between psoriasis and cardiometabolic comorbidities is well known, but the evidence is less clear in children. However, paediatric psoriasis has recently been associated with many comorbidities such as obesity, insulin resistance, diabetes, cardiovascular disease and dyslipidaemia.[2]
In our study, BSA involved and PASI were used to categorise the severity of psoriasis. BSA <3% was considered mild, 3%–10% was considered moderate and >10% was considered severe.[7] The majority (49%) of patients had moderate disease, followed by mild (39%) and severe (12%) according to the BSA involved. Al-Fouzan et al.,[8] also observed <10% BSA involvement in the majority of their patients which is similar to our study. According to the literature, paediatric psoriasis has been found to run a benign course with minimal skin involvement.[8],[9],[10]
95 patients had PASI <10, whereas only five patients had PASI >10. As compared to using BSA alone, PASI is a more precise method of determining the extent and severity of psoriasis. PASI is a part of standard clinical assessment in many countries and is also used in clinical trials. In addition to BSA and PASI, other factors that are taken into consideration while determining severity in a clinical setting include sites involved, social and emotional effect, type of psoriasis, presence of psoriatic arthritis and other comorbidities, response to therapy etc., Only 7% of patients had joint involvement in our study. It is believed that psoriatic arthritis develops about one decade after the skin disease onset.[11] The prevalence of psoriatic arthritis ranges from 1%–10%.[12] Our results were also in this range. However, it was much higher as compared to other studies from India.[9],[10] This may be due to the inclusion of patients of <18 years in our study as compared to these studies where patients <14 years were included.
The autoimmune disease was found in 5% of patients, out of which vitiligo and hypothyroidism were present in two patients each and one patient had morphoea. Paediatric psoriasis has been linked to various autoimmune diseases and vice-versa.[13] Similar to our study, a study from Kuwait also reported vitiligo in 2% patients of with childhood psoriasis.[8] Rheumatoid arthritis and Crohn's disease are two to four times more prevalent in children with psoriasis according to a study by Augustin et al.[14]
Overweight and obese were defined as BMI >85 percentile and >95 percentile respectively for age and sex. A total of 52 (52%) patients had abnormal BMI, out of which 21 (21%) patients were overweight and 31 (31%) were obese. In a study by Boccardi et al.,[15] 43.75% patients of with childhood psoriasis were found to be overweight. In an international cross-sectional study on childhood psoriasis, 37.8% of patients were found to be overweight as compared to controls (20.5%) and 20.2% of patients were obese as compared to controls (7.3%).[16] Guidelines recommend screening in paediatric psoriasis for overweight and obesity yearly using BMI percentile, starting at two years of age.[17] The relation between obesity and psoriasis emerged through the recent concept of “psoriatic march” in which psoriasis and obesity lead to smouldering systemic inflammation leads to insulin resistance which in turn triggers endothelial dysfunction which finally leads to atherosclerosis and cardiovascular events.[18] Since psoriasis is itself an independent risk factor for cardiovascular disease in adults, lifestyle changes should be advised to children and parents to minimise any additional risk factors from overweight and obesity.
In our study, abnormal laboratory investigations were reported in many patients. Anaemia, defined as haemoglobin levels <11 gm/dl was present in 21 patients. Hyperlipidaemia was the most common abnormal laboratory parameter. At least one lipid abnormality was found in 66% of patients. The most common lipid abnormality was decreased HDL followed by raised TC, raised TG and raised LDL. In a study from Iraq, an abnormal lipid profile was reported in 62% of the paediatric psoriasis patients which is similar to our study.[19] In a study by Aalemi et al.,[20] the frequency of lipid abnormality was higher among children with psoriasis as compared to controls, 19% of paediatric psoriasis had high levels of TG as compared to 7.6% of the controls. Similarly, lower HDL was more common among children with psoriasis (16.2%) than controls (6.7%). In a study by Augustin et al.,[14] hyperlipidaemia was found to be twice as often in children with psoriasis as compared to controls. A multicentre study in France of 2201 patients with psoriasis found that childhood psoriasis did not correlate to the severity of dyslipidaemia in adulthood.[21] The data available to date did not suggest a need to alter the screening recommendations for dyslipidaemia in patients with paediatric psoriasis relative to other children. Universal lipid screening should be performed at two age ranges: 9 to 11 years and 17–21 years of age.[17]
Six (6%) patients were diagnosed with impaired fasting glucose and two were diagnosed with diabetes mellitus. Similar to our study, Dhaher et al.[19] also found raised fasting glucose in 8% of paediatric psoriasis patients. Psoriasis in adults is correlated with an increased risk of insulin resistance and type 2 diabetes mellitus.[22],[23] However, this association is not as clear in children.[14],[24],[25]
A consensus definition and criteria for the diagnosis of MS in adults have been established.[26] However, in children, there is no clear agreement on diagnostic criteria, although a consensus statement has been published by IDF.[5] According to IDF criteria, 5 (5%) patients were diagnosed with MS. Aalemi et al.,[20] and Au et al.,[27] reported MS in 13.3% and 30% of paediatric psoriasis patients respectively, which is much higher than our study. There is only one study from India on the prevalence of MS in paediatric psoriasis, in which MS was found in 3.6% patients of with childhood psoriasis.[28] Early lifestyle intervention and education may help in the prevention of these comorbidities in patients with paediatric psoriasis at a later age. The association between MS and paediatric psoriasis requires further exploration by conducting prospective case-controlled studies with a larger sample size.
Limitations of this study include small sample size, record-based study design and conducted at a single centre thus limiting generalisability.
Conclusion Paediatric psoriasis is a chronic disfiguring disease and may have profound emotional and psychological effects. Our study revealed that plaque psoriasis is the most common subtype. Associated comorbidities like psoriatic arthritis, obesity, hyperlipidaemia, diabetes mellitus and metabolic syndrome were found in a significant number of patients. There is a lack of studies from India on the prevalence of these comorbidities in paediatric psoriasis. More studies are required from different parts of the world for a better understanding of paediatric psoriasis.
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Conflicts of interest
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References 
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