Treating the Whole Little Person
Nadia Ciuha, ND
Psoriasis is fairly common in today’s pediatric population, with the number of new cases diagnosed every year steadily increasing. This increase is thought be related to various environmental and epigenetic influences, such as stress, environmental allergies and food intolerances, disturbed immunity, and deficiency of vitamin D.
At least 7 different types of psoriasis have been described so far, but only 3 of them are found in the pediatric population with reasonable frequency: plaque psoriasis, guttate psoriasis, and pustular psoriasis. These types of psoriasis share the same histologic features but have different presentations and different pathophysiology.
Psoriasis is a long-known autoimmune disorder, well described in the literature, with some cases arguably mentioned in ancient Hebrew, Greek, and Roman texts.1,2 Despite its “fame,” in conventional settings psoriasis remains a mysterious disorder of unknown origin. Occasionally, hereditary influences are cited as causes of psoriasis.
From this standpoint, it leaves a physician with a challenging task, because it is almost impossible to cure something of an unknown origin, especially when genetics are involved. For a naturopathic physician, however, merely diagnosing “what” is going on is not sufficient; the more important task is to find an answer to “why” a patient is in a state of dis-ease. The search for a cause is particularly important in cases of pediatric psoriasis, because children are extremely resilient, and finding and then removing obstacles to cure almost always ensure full recovery.
The following case studies describe this author’s clinical experience with diagnosing and treating psoriasis in pediatric patients.
Case Study 1
Guttate Psoriasis Coexistent With Other Autoimmune Disorders
Luke, an 8-year-old male, was initially brought in by his parents 1 year ago. Prior to our visit, he was diagnosed with ADD and had been prescribed methylphenidate. His parents were concerned with the personality changes and apathy that became apparent after 2 months of the drug therapy. This prompted them to seek alternative care for his condition.
On his first visit, Luke appeared moderately overweight, detached, and withdrawn. Parents shared that he started gaining weight a year ago, after always being a rather slim child. It was also around that time that he started complaining of poor energy, cold intolerance, and difficulty concentrating. Because of his poor concentration in school, Luke’s parents sought evaluation for ADD, which led to the subsequent treatment with methylphenidate.
Luke had a history of chronic anemia. His parents also reported frequent gas and bloating, constipation, and headaches, which became even more frequent after he started taking the medication. He reported that his skin was very dry, and recently he started having itchy red spots that looked like “bug bites” on his chest, neck and arms.
Physical Exam: Luke’s BP was 118/82 mm Hg; HR 98; Temp 96.9 °F. His BMI was 21. His thyroid was boggy and enlarged and tender to palpation. Thyroid bruits were auscultable. Lungs were mostly clear except for occasional inspiratory wheezes. A Still’s murmur was apparent on heart auscultation. Abdominal examination was positive for periumbilical tenderness and non-tender splenomegaly. His DTRs were diminished bilaterally.
His skin was very dry. Multiple, salmon-colored, erythematous lesions were found on Luke’s torso and neck. There were various degrees of scaling. Upon further examination, similar lesions were found on his elbows and in the gluteal crease. Luke then remarked that he often experiences intense itching in that area.
Assessment: I explained to the patient and his parents that Luke presents with symptoms of several disorders, the most important being possible hypothyroidism and/or thyroiditis, and guttate psoriasis. I suggested that his symptoms of ADD, such as fatigue, sleepiness, and difficulty concentrating, might be related to his underactive thyroid.
Labs: We ordered a series of tests, which revealed the following abnormal results:
- CBC: Eosinophilia; MCV: 76 fL (N: 80-97)
- TSH: 6.8 mIU/mL (N: 0.5-4.5); Thyroid antibodies: anti-TPO: 234 IU/mL (N: 0-33), suggestive of Hashimoto’s thyroiditis
- Vitamin D (25-OH): 5 ng/mL(!) (N: 34-100)
- Gluten sensitivity panel: Anti-gliadin antibodies, native IgG: 68 U/mL (N: 0-19)
Plan: Luke and his parents were instructed to immediately start him on a gluten-free diet. I also advised that he start taking vitamin D, 5000 IU before bed. He started on 17 mg of iron glycinate every morning, to treat his microcytic anemia. To address his hypothyroidism, he was started on 45 mg of dessicated thyroid per day. Inflammation of the thyroid (thyroiditis) was addressed with 750 mg of quercetin per day. His skin lesions were treated with a topical application of a bio-herbal lotion containing extracts of rhubarb.
Follow-up, 5 weeks later
Luke appeared to be much more “lively.” The main change reported by the patient and the parents was a drastic change in energy level. Luke was not feeling as sleepy during the day, and could now walk 3 blocks without having to sit down to rest. His weight had decreased slightly, mainly around in the abdominal area. His headaches had lessened in severity and in frequency (once a week vs every day). Skin lesions were “thinner and less itchy.” He also reported that there had been no new lesions.
Physical Exam: BP: 107/74 mm Hg; HR: 68; Temp: 97.8 °F. Thyroid was still enlarged and boggy, but no longer tender to palpation. Thyroid bruits persisted. Lungs were clear; heart still showed Still’s murmur; abdomen was non-tender; distention was resolved; splenomegaly persisted. Edema in lower extremities resolved, as well as the general appearance of “swelling.” Skin appeared more hydrated, with better tone and color. Skin lesions were generally the same in size, but there was a decrease in thickness, notably less erythema, and virtually no scaling.
Labs & Sonogram of thyroid: TSH: 3.8 mIU/mL (N: 0.5-4.5); Anti-TPO: 89 IU/mL (N: 0-33); sonogram showed evidence of chronic lymphocytic thyroiditis
Plan: We decided to continue with the initial treatment plan, allowing more time for the thyroid medication, quercetin, and gluten-free diet to work.
Follow-up, 6 months later
Luke was very happy about his weight loss (by now he had lost 8 lbs). He said that he can play basketball with his friends like he always wanted to, but until now felt too “heavy” and tired. Weight loss seemed to have significantly improved his self-esteem. Another important achievement was his ability to focus on his studies. His teachers reported that he is more engaged during classroom activities, and his grades improved as well. Luke himself said that he noticed that his concentration started getting better a few weeks after he began the gluten-free diet. He also reported that he was no longer experiencing tightness in the throat and congestion. His skin was “not angry” anymore; it did not itch, and many lesions faded in color, to the point that they were not as noticeable as before.
Physical Exam: BP: 100/70 mm Hg; HR: 70; Temp: 97.6 °F. Thyroid was normal in size and consistency. Lungs were clear; heart showed Still’s murmur; no peripheral edema or cyanosis were noted. Abdomen showed no distention, no striae, no tenderness to palpation, no masses, and no organomegaly. DTR: +2 bilaterally. Skin was warm and well-hydrated, and showed normal turgor. Lesions on the chest and neck were diminished in numbers. There was clearance of the larger lesions, with new healthy tissue showing through. No excoriations were present.
Labs: CBC: MCV: 89 fL (N: 77-95); Eosinophils: 1; TSH: 1.8 mIU/mL (N: 0.5-4.5); Anti-TPO: 14 IU/mL (N: 0-33); 25-OH-Vitamin D: 44 ng/mL (N: 30-74)
Plan: At this point, we decided to discontinue both iron and vitamin D supplementation, and the patient was advised to spend 20 minutes in the sun each day. He was to continue on the same dosage of dessicated thyroid, and stay on the gluten-free diet. For his skin lesions, he was advised to continue using bio-herbal lotion once a day after showering. He was scheduled to be seen in 9 months for a follow-up.
Discussion
Psoriasis in Luke’s case was part of the systemic autoimmunity. Although, we decided not to do genetic testing at this point, I suspect that Hashimoto’s thyroiditis, psoriasis, and gluten sensitivity were all related to a specific mutation in the HLA class II genes. Such genes code for an over-reactive immune system, which can later express itself as an autoimmune process, or several autoimmune processes.2-4 Gluten is frequently a perpetuating factor in these processes3 and, in Luke’s case, appeared to also be responsible for the ADD symptoms.
Case Study 2
Guttate Psoriasis Related to Chronic Streptococcal Infection
Masha, a 3-year-old female, was brought by her parents for treatment of psoriasis. Masha is of Eastern European origin, and her parents were looking for a holistic approach to her skin condition.
Masha’s psoriasis was of recent onset. Initial lesions appeared on her scalp, followed by inflamed and very itchy spots between her fingers and along the hairline. There was no family history of psoriasis or eczema.
Masha had a personal history of repeat throat infections, which were treated with antibiotics. After the last treatment with amoxicillin, which was 4 months prior to our visit, she started complaining of a “tummy ache” that would wake her up at night. Her pediatrician diagnosed acid reflux and prescribed esomeprazole. At that point, parents were reluctant to treat her with any medications, and started searching for some less-invasive options.
Physical Exam: Masha appeared to be a well-nourished, very alert, and talkative child.
Her pharynx was erythematous, with no tonsillopathy and no exudate. There was tender, shotty cervical lymphadenopathy. Lungs were clear to auscultation; heart auscultation revealed a systolic flow murmur. (Parents said that this finding had never been reported to them before). Abdominal examination was positive for epigastric tenderness and mild, non-tender splenomegaly. There were no masses.
Masha’s skin was prominent for discrete, round, salmon-colored and scaling lesions on almost all body parts, including her face. There were multiple excoriations, and lesions were in different stages of healing. Her scalp was similarly affected: lesions here were discrete, erythematous, and scaling. There appeared to be exudate on many of the scalp lesions.
Asssessment: I discussed with Masha’s parents her probable diagnosis: guttate psoriasis. I explained that this type of psoriasis is frequently related to persisting or chronic Strep infections. Similarly, Strep infections can eventually cause damage to the mitral valve, as a result of cross-reaction between the antibodies against Strep and the lining of the valve. Masha’s systolic flow murmur could indicate the beginning of mitral valve insufficiency, thus I referred her for an echocardiogram.
Labs & Echocardiogram: CBC: Mild lymphocytosis and mild neutropenia; Anti-streptolysin (ASO) titer: 456 IU (N: 0-200); Echocardiogram: Mild mitral valve insufficiency, mild tricuspid insufficiency
Plan: Positive ASO titers indicated persistent reaction to Streptococcus. We decided not to use antibiotics this time, but instead use a Berberis liquid extract, 20 drops BID for 21 days. Berberis has specific affinity for Strep species and can be used as an alternative to conventional antibiotics. It is safe to use in children older than 24 months. It can, however, similar to antibiotics, cause digestive upset. To prevent this possibility, parents were instructed to give the extract in small amounts of water and only with food. They were also instructed to report if any bloating or abdominal pain developed.
The patient was also recommended to take calcium citrate in chewable form, 400 mg before bedtime, for prevention of acid reflux.
Topically, Masha was recommended Calendula salve, to help with healing of the lesions.
She was also referred to a pediatric cardiologist for consultation.
Follow up, 4 weeks later
Parents reported that Masha tolerated the Berberis tincture well, without any obvious digestive upsets. They were very pleased that since she started on calcium, her acid reflux had resolved, so she started sleeping better through the night. They reported that the Calendula salve improved healing of some very “dry” lesions, but was not very helpful with the itching. They arranged her cardiology appointment for the next month.
Physical Exam: Cervical lymphadenopathy persisted. It was non-tender to palpation, although the patient said it was “ticklish,” which could also be her way of expressing pain. Pharynx was clear. Lungs were clear. Heart showed a systolic flow murmur; there was no apparent edema or cyanosis. Abdominal examination was normal, and splenomegaly had resolved, but mild, epigastric tenderness persisted.
Skin was warm and dry, and Masha’s lesions were clearly less erythematous compared with the previous examination. There was less excoriation. Lesions between Masha’s fingers seemed to have improved the most.
Assessment & Plan: I discussed with the parents that Masha’s response to treatment was positive, thus it was appropriate to pause the Berberis treatment. We also discussed the necessity for gastric and intestinal repair, as well as replenishment of the intestinal flora. I recommended probiotics, 2 billion cfu/day; quercetin powder, 250 mg BID; and, as a mucilaginous agent, flax seed tea, 1 cup BID.
Follow-up, 5 months later
Masha’s mother called me 5 months later to inform me that Masha’s psoriasis had cleared completely. She only had several hyperpigmented marks on her chest, but otherwise, her skin was now healthy. Her digestion seemed to have improved dramatically as she started on flax tea and continued on calcium citrate. Not only did her “acid reflux” resolve, but her gas and bloating, which used to occur almost daily, disappeared.
Discussion
Sudden onset of guttate psoriasis in Masha’s case was apparently related to a chronic reaction to Strep species. There are several known mechanisms that are responsible for skin changes in such patients, the main one being an immune reaction that fails to cease.1,3,4 It has also been proposed that Strep, especially Streptococcus pyogenes, can infiltrate the connective tissue and dermis, inciting the “attack” of T-cells.5.6 It is not clear, however, why antibiotics that are effective against Strep species in other areas, such as the pharynx, often fail to eradicate this pathogen in the skin. I would think that it could be related to poor peripheral penetration of penicillin-class antibiotics, such as amoxicillin, into the deeper layers of dermis. It is also possible that due to repeat infections and repeat treatments, antibiotic-resistant species of Strep develop in affected individuals.
I have used both – various classes of antibiotics and Berberis – in cases of Strep-related psoriasis, and noticed that while they typically have comparable effectiveness, Berberis is generally better tolerated by children. In addition, we don’t have an issue of microbial resistance with Berberis; therefore, it has become my treatment of choice in eradicating such “skin-deep” infections.
Case Study 3
Pustular Psoriasis Presenting as Fungal Infection
Sam, a 16-year-old Caucasian male, presented with toenail fungus that had been diagnosed 4 years prior to our visit. He had seen various specialists and tried different treatments, both topical and systemic. He reported that initially his condition was improving while on the antifungal medication, but would return shortly after the treatment was discontinued. Then, after 2 long rounds of antifungal medication, Sam stopped responding to this treatment altogether. For the past year, he had not been treating the fungus, choosing instead to simply” leave it alone.” Other than fungus on his toenails, he also had persistent peeling lesions on the bottom of his feet, which were previously diagnosed as fungal as well. He had chronic dandruff, which he treated with weekly applications of ketoconazole shampoo.
All of these conditions started approximately at the same time, when he was 10 years old, after he had an attack of appendicitis and subsequent appendectomy.
Sam reported good sleep, good appetite, no digestive upsets, and no other skin issues. He had mild seasonal allergies, for which he was prescribed antihistamines. He reported frequent pain in both knees, particularly in the morning. Sam indicated that his peeling feet and “infected toenails” were a source of embarrassment for him. His parents were curious about the cause of this stubborn infection that was resistant to treatment.
Physical Exam: BP: 112/70 mm Hg; HR: 78; Temp: 98.2 °F. He had tender cervical lymphadenopathy, with several nodes measuring 1×1.5 cm. Thyroid was normal; lungs were clear; the heart showed an irregularly irregular rhythm, and no murmur. (Patient recalled here that he occasionally felt “dizzy,” especially during physical activity). Abdominal examination was positive for non-tender hepatomegaly and non-tender splenomegaly, and no distension. DTR: +2 bilaterally.
Skin was warm and dry. There were scaling, erythematous, dry patches on the soles of both feet. Some lesions were vesicular, some had a bullous appearance, but there was a characteristic “psoriatic” thickness to them. Toenails on the left foot were pitted and deformed. There was periungual inflammation, with small scaling lesions.
Similar scaling, erythematous lesions were found on the scalp, which were in different stages of healing.
Sam’s skin lesions resembled a rare type of psoriasis – pustular psoriasis – which tends to affect feet and hands and is frequently mistaken for fungal infection. To rule out fungal infection, I took a scrape of tissue from all of the affected areas: nails, feet, and scalp, and sent it to the lab.
Labs: We ordered a CBC, a vitamin D test, and serum quantitative IgA, to rule out IgA deficiency (as a possible contributor to persistent skin infections). The following abnormal were found:
- Eosinophilia: 17% (N: 0-7)
- Vitamin D (25-OH): 12 ng/mL (N: 30-100)
- IgA: <5 mg/dL (N: 5-370)
All skin sample cultures were negative for fungus, with only normal, mixed skin flora present.
Assessment & Plan: We diagnosed pustular psoriasis of feet, toenails, and scalp. In Sam’s case, pustular psoriasis was most likely related to selective IgA deficiency, which causes disturbances in peripheral immunity. Vitamin D deficiency was another probable contributing factor; therefore, we started him on 10 000 iu of vitamin D3 before bed. For his skin lesions, I prescribed topical calcipotriene ointment (0.005%) BID to the affected areas. We also discussed the possibility of food allergies/sensitivities, as these often accompany selective IgA deficiency.7,8 The patient was instructed to keep a diet diary for 2 weeks, in order to better identify any potential allergies.
Follow-up, 6 weeks later
Patient reports significant improvement in his skin condition. With application of calcipotriene ointment, his lesions on the feet were not as itchy and seemed to have thinned and stopped peeling. He had difficulties applying the ointment to the scalp lesions because of the hair, but tried to do his best, and his scalp was not as itchy. He kept a diet diary, which upon review, indicated that he might be reacting to peanuts and wheat, with symptoms of bloating and skin irritation.
Physical Exam: Skin was warm and dry. Lesions on the bottom of his feet were less erythematous, and there were significant decreases in thickness and peeling. His nails were pitting as usual, but inflammation around nail beds had subsided, and no peeling was observed. Lungs were clear to auscultation; his heart showed a persisting irregularly irregular rhythm, and there was no edema or cyanosis. Abdomen was non-tender; splenomegaly persisted; and the hepatomegaly had resolved.
Labs: We ordered an allergy panel (IgE, basic foods) to rule out coexisting food allergies. It came back positive for level-3 allergy to soy, level4 allergy to wheat, and level-4 allergy to peanuts.
Plan: The patient was instructed to immediately remove allergens from his diet and to continue on the treatment as previously prescribed.
Follow-up, 3 months later
With elimination of food allergens, Sam’s skin improved dramatically. Peeling lesions had almost disappeared. His energy level was higher than before and he reported better sleep and improved ability to concentrate in school.
Summary
Advancements in modern healthcare and changes in our lifestyle completely altered the spectrum of pediatric dermatological disorders in developed countries. Infectious skin diseases, which were forming the bulk of skin disorders 40-50 years ago, have been almost entirely replaced with inflammatory conditions, such as psoriasis, eczema, allergic rashes, and various types of dermatitis. Therefore, a rigid conventional paradigm, wherein skin disorder is viewed as something very localized and topical, and systemic influences are overlooked, has become obsolete.
The naturopathic approach of finding a cause and removing obstacles to cure is very effective for long-term recovery. Almost always, children with inflammatory skin disorders experience significant discomfort, and therefore require immediate relief. Fortunately, we, as naturopathic physicians, are particularly well-equipped to accomplish both of these tasks: to relieve the suffering and to treat the whole little person. With that in place, our pediatric patients, who are invariably resilient, will complete the rest of the healing.
Nadia Ciuha, ND, is a licensed naturopathic physician in Washington DC. She is a 2006 graduate of Bastyr University, School of Naturopathic Medicine. She has been a practicing physician since early 2007, serving as a primary healthcare provider, as well as a naturopathic specialist. Her focus areas include dermatology and digestive health.
References:
- Bhalerao J, Bowcock AM. The genetics of psoriasis: a complex disorder of the skin and immune system. Hum Mol Genet. 1998;7(10):1537-1545.
- Brajac I, Gruber F. History of Psoriasis In: O’Daly J, ed. Psoriasis – A Systemic Disease. Rijeka, Croatia: InTech Publishing; 2012.
- Fotiadou C, Lazaridou E, Ioannides D. Management of psoriasis in adolescence. Adolesc Health Med Ther. 2014;5:25-34.
- Bhatia BK, Millsop JW, Debbaneh M, et al. Diet and psoriasis, part II: Celiac disease and role of a gluten-free diet.J Am Acad Dermatol. 2014 Apr 26. [Epub ahead of print]
- Krishnamurthy K, Walker A, Gropper CA, Hoffman C. To treat or not to treat? Management of guttate psoriasis and pityriasis rosea in patients with evidence of group A Streptococcal infection. J Drugs Dermatol. 2010;9(3):241-250.
- Villeda-Gabriel G, Santamaría-Cogollos LC, Pérez-Lorenzo R, et al. Recognition of Streptococcus pyogenes and skin autoantigens in guttate psoriasis. Arch Med Res. 1998;29(2):143-148.
- Janzi M, Kull I, Sjöberg R, et al. Selective IgA deficiency in early life: association to infections and allergic diseases during childhood. Clin Immunol. 2009;133(1):78-85.
- Kruszewska M, Kowalczyk D, Stopyrowa J, et al. Clinical manifestation of IgA deficiency. Rocz Akad Med Bialymst. 1995;40(3):630-633.
