Psoriasis in a 9 yo Girl

The patient is a 9 year old girl who presents to the office for evaluation of psoriasis of 4 months duration. Initially, this started on the bilateral knees with erythematous scaly plaques that have generalized since onset. She was prescribed topical mometasone by her pediatrician with little improvement. 

Physical exam: On exam, patient has erythematous, scaly plaques varying in size on the chest, back, upper extremities, abdomen and lower extremities. She has also started to develop a few smaller plaques on the face. 

This has been difficult on the patient who has been made to sit out of her swim classes due to the instructors fear of her spreading the rash to other students. Her parents are going through a contentious divorce and her mother feels her skin is causing the patient significant distress. Otherwise, the child is healthy and denies any recent illnesses. There is no family history of psoriasis.

We are presenting her case to seek advice from those who have treated widespread psoriasis in pediatric patients. She is currently using clobetasol ointment, however we wonder if systemic treatment is necessary at this time. 

 

Clinical Images

Note: While this is relatively mild at this time, the short history suggests that it may become more or a problem, and it is impacting on the patient's life at this time. We are reluctant to prescribe MTX for a 9 year old and NB UVB is not an option as she lives far from a unit.

 

 Reference:

1. Das D, Ludvigsson J. Early childhood stress and the risk of developing psoriasis: a cohort study. J Invest Dermatol 2025 Sep 2 PubMed 40907801.
Children experiencing the psychological stress of a "New family structure" during the first 8 years of life have an increased risk of developing psoriasis later. 

2. Yang Y et. Al. The Burden of Pediatric Psoriasis: A Systematic Review Am J Clin Dermatol. 2025 Sep;26(5):695-710.Angela Yang.  PMID 40694272. Psoriasis leads to high burden for pediatric patients and caregivers. Evaluation and management decisions should include and incorporate a thorough assessment of burden. Additional studies using validated tools are necessary to fully assess psychosocial and family burdens of psoriasis.

Linear Forehead Dermatitis

 The patient is an otherwise healthy 30 yo man in good general health.  For two months he has had a slightly pruritic dermatitis on his forehead.

Clinically, we considered En Coup de Sabre (Linear scleroderma)

Dermatoscopic Image: (Courtesy of Makayla Powers PA-C)

Punch biopsy showed:
Lichenoid interface and perifollicular dermatitis with postinflammatory pigment alteration.  No features of localized scleroderma.  These findings are suggestive of discoid L.E. or linear L.P.
Photomics courtesy of David Jones, MD, Berkshire Medical Center, Pittsfield, Massachusetts.

Treatment was initiated with clobetasol ointment.  Will switch to tacrolimus ointment if response is good.

 References
1. Rodriguez E et. Al. Acute Onset Linear Lichen Planus Pigmentosus of the Forehead: A Case Series  J Drugs Ddermatol 2023 Jan 1;22(1):94-97.  Free Full Text

2. Khelifa E.  Linear sclerodermic lupus erythematosus, a distinct variant of linear morphea and chronic cutaneous lupus erythematous. Int J Dermatol 2011 Dec;50(12):1491-5. PMID 22097995

3. Reference suggested by Dr. Sontheimer.  Dao DP, Sahni DR, Sontheimer DR. Linear discoid lupus erythematous simulating en coup de sabre morphea in a female chronic granulomatous disease carrier. Dermal Online J. 2023 Dec 15;29(6). Free Full Text. 

4. Das A et al. Linear lesions in dermatology: a clinicoaetiopathological study. Clin Exp Dermatol 2021 Dec;46(8):1452-1461. PMID: 34022084 

5. Urur YG. Et. Al. Dermoscopic Characteristics of Cutaneous Lupus Erythematosus According to Subtype, Lesion Location, Lesion Duration, and CLASI Score. Dermatol Pract Concep. 2024 Jan 1;14(1):e2024040. Free Full Text.