Exploring the Role of Infection in Pediatric Psoriasis

Source: Ravi M, Cordoro KM, Holland KE, et al. The association of psoriasis and bacterial infections in pediatric patients: a retrospective review. Pediatr Dermatol. 2025;42(4):735-741; doi: 10.1111/pde.16007.Investigators from multiple institutions conducted a retrospective study to describe the association between psoriasis and pharyngeal and/or anogenital bacterial infections in children. For the study, patients ≤18 years old seen at tertiary referral centers in the US and Canada from 2011 to 2021 with a diagnosis of psoriasis were identified by review of ICD-9 and ICD-10 codes. Only those in whom a pharyngeal or anogenital bacterial culture was obtained were included in the analysis. The medical records of study participants were reviewed and demographic and clinical information collected. Study patients were considered to have a bacterial infection if pharyngeal or anogenital cultures were positive for pathogenic bacteria. Main study outcomes included the association of pharyngeal and anogenital infections with different types of psoriasis, the microbiology of pharyngeal and anogenital infections, and whether psoriasis improved or resolved with treatment of the bacterial infection. These outcomes were assessed with a variety of statistical tests.Data were analyzed on 166 children with a mean age of 9.2 ±4.3 years. Among these patients, 82 (49%) had plaque, 60 (36%) guttate, 26 (16%) inverse, 7 (4%) pustular, 6 (4%) nail, and 3 (2%) erythrodermic psoriasis. Bacterial cultures were positive in 94 (57%) study children; 35 had only a positive pharyngeal culture, 53 had only a positive anogenital culture, and 6 had both. Children with a positive anogenital culture were significantly younger than those with a positive pharyngeal culture only (7.8 ±4.0 and 11.2 ±3.5 years, respectively; P = 0.001). Of the 35 patients with a positive pharyngeal culture, 24 (69%) had guttate psoriasis. Conversely, the most common type of psoriasis in the 53 children with a positive anogenital culture only was plaque, occurring in 26 (49%). The most common signs and symptoms in patients with anogenital infections were erythema (78%), pruritus (25%), and pain (8%). Only 24% of children with a pharyngeal infection were symptomatic. Staphylococcus aureus was isolated in 31 (59%) patients with anogenital infections, and 24 (41%) grew a Streptococcus species. Treatments for anogenital infections included systemic antibiotics (77%), topical antibiotics (40%), and dilute bleach baths (16%); 89% of those with pharyngeal infections were treated with systemic antibiotics. Psoriasis improved or resolved in 49% of study children within 30–90 days. There was no association between treatment of anogenital or pharyngeal infections and change in psoriasis severity.The authors conclude that pharyngeal and anogenital infections should be considered in pediatric patients with new-onset or worsening psoriasis.Dr Goyal has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.Psoriasis often arises in childhood, with an estimated incidence of 40.8 new cases per 100,000 per U.S children.1,2 For children with this chronic skin condition, recent guidelines emphasize the threats to psychological well-being, including risk of stigmatization, social isolation, and mood disorders.3 Evaluation for significant comorbidities is now also recommended, including screening for dyslipidemia and liver disease.4 One of the many environmental triggers considered to be associated with pediatric psoriasis is bacterial infection, particularly streptococcal pharyngitis.3,5 Given the plausible connection between bacteria and the immune response in psoriasis, further research is needed to understand the clinical course and treatment out-comes of children with psoriasis who have a positive anogenital or pharyngeal bacterial culture.The current multisite study of 166 children with psoriasis or psoriasiform dermatitis revealed that more than half of the patients had at least 1 positive culture (anogenital or pharyngeal); most were treated with systemic antibiotics. The authors found no association of psoriasis treatment outcomes with either culture results or with antibiotic use. Interpretation of this descriptive study is limited by the lack of clarity between true infection and chronic colonization in some patients and the absence of a comparison group without suspected infection. Future prospective studies likely would provide further insight into the utility of screening and treatment for bacterial infection in pediatric psoriasis patients.Children with psoriasis frequently test positive for bacteria on pharyngeal and anogenital culture. However antibiotic treatment does not appear to improve psoriasis treatment outcomes.We would suggest that future investigations of antibiotic therapy of pediatric psoriasis include pre- and, importantly, post-treatment cultures correlated with psoriasis duration and clinical response.

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