Psoriatic erythroderma in children – clinical case presentation

Abstract

Erythrodermic psoriasis (EP) in children is a rare and severe form of psoriasis, induced by various triggers or topical irritative treatment. The incidence of EP in children is 0.11%, representing 1.4% of psoriasis cases in children [1]. According to literature data, the mortality rate among patients with EP is 9-15% [2]. Clinically it is manifested by generalized erythema and flap desquamation, affecting 75-90% of the body surface (BSA). Due to extensive skin involvement, EP patients may experience systemic changes such as pruritus, fever, chills, asthenia, dehydration, lymphadenopathy, and arthralgia. Diagnosis includes clinical manifestations, PASI and BSA indices, and histopathological examination. This study aims to present the clinical and behavioral features of PE in children. Case presentation We present the case of a patient, boy, age 11, hospitalized in the Department of Children’s Dermatology, with the complaints: generalized skin lesions on the scalp, face, trunk, upper and lower limbs, accompanied by burning sensation and pain, which were accentuated when touched. The anamnesis dates back to February 2023, regarding the treatment of otitis media and a psychoemotional stress, the first erythematoussquamous eruptions appeared on the palms and plants. The dermatologist indicated vitaminotherapy, hyposensebilizing and antihistamines, as well as antimycotics, topical corticosteroids with moderate effect in dynamics. Subsequently, the cutaneous process advanced, the lesions disseminated to the entire skin, with the intensification of subjective sensations and subfebrility states, which is why the child was hospitalized in the Intensive Care Unit for intrahilar pneumonia on the left, severe evolution, pleurisy associated with psoriatic erythroderma, where he received treatment with Cefotaxim, Ceftriaxone, Clemastin, Dexametazone, Prednisolone, ointment Hydrocortisone. 7 days after finishing treatment with Prednisolone the child presented generalized erythema (rebound effect), which is why he was admitted to the Dermatological Clinic for specialized assistance. Physical examination: diffuse generalized erythema, extensive pastosity of the skin (edema), desquamation in places in flaps (on the face and palmoplantar), on the rest of the skin abundant lamellar desquamation, BSA 90%. Positive psoriatic triad. The skin of the scalp showed erythema and detachable scales. The dermatological status also included nail pitting of the fingers of the hand. Treatment by detoxification with sodium thiosulfate, ascorbic acid solution, topical emollient creams, led to slight clinical improvement. In a short time, the skin process worsened, the decision was made to refer the patient to pediatric rheumatologists, who administered systemic sol. Golimumab subcutaneously, according to the treatment scheme, leading to insignificant clinical impact , PASI was reduced by 25% . Golimumub treatment has been associated with Malassezia-Pityriasis amiantacea. Discussion According to a medical study, biological treatment with Golimumab in an adult patient with EP showed a rapid and significant clinical response, being associated with an excellent safety profile [2]. As per to some authors, EP is often resistant to contemporary biological therapy [3]. Modern treatment of EP includes the use of anti-TNF agents such as infliximab, and etanarcept, which for better efficacy are combined with traditional immunosuppressive agents [4]. Anti-IL 12/23 (Ustekinumab) and anti-IL 17 (Secukinumab, Ixekizumab, Brodalumab) can also be used as monotherapy, due to their superior efficacy, also constituting a first-line option [4]. Conclusions EP is a severe and disabling variant of psoriasis that presents numerous clinical and treatment challenges. The clinical particularity of the present case consists in the manifestation of the skin process through a generalized erythema and not an infiltrative aspect, noted more often in adults. Detoxification, anti-inflammatory and biological treatment with Golimumab did not lead to any obvious results. Considering the high mortality with which EP can be associated, it represents an emergency in dermatological practice.