Does the treatment response for psoriasis differ between twins?

Hello,

Welcome to icliniq.com.

I read your query and understand your concern.

It is understandably concerning and perplexing when your twins are experiencing different responses to the same treatment for psoriasis, despite similar circumstances. Here are possible explanations for their differing responses and guidance on whether they should receive distinct treatments:

1. Psoriasis and its individualized nature:

Psoriasis is a complex autoimmune condition, influenced by:

a. Genetics: While twins share a significant portion of their DNA (deoxyribonucleic acid), their genetic expression (epigenetics) may differ slightly, impacting how their immune systems react to triggers or treatments.

b. Environmental factors: Each child’s response to triggers like infections, sunlight, or stress can vary due to subtle immune system differences.

2. Sunlight's varied effect:

a. Beneficial for one twin: Sunlight often helps psoriasis by reducing inflammation and slowing down the rapid skin cell turnover through UVB (ultraviolet B) rays. It is possible that this twin’s psoriasis is predominantly inflammatory, and UV exposure reduces immune overactivity in the skin.

b. Worsening for the other twin: In rare cases, photosensitivity or photo-aggravated psoriasis occurs, where UV light exacerbates symptoms. This twin might have a more complex interplay between their psoriasis and skin barrier function, or an underlying photosensitive condition (e.g., lupus or polymorphous light eruption) complicating the picture.

3. Tonsillitis as a trigger:

Both children developing psoriasis after tonsillitis strongly suggest a guttate psoriasis pattern, often triggered by streptococcus infections. Differences in how their immune systems cleared the infection or managed post-infectious inflammation may explain the divergent responses. It is worth considering a repeat strep throat culture or ASO (antistreptolysin O) titers to check for lingering infection.

4. Patches in different places:

Psoriasis types or variants: One twin might have plaque psoriasis, while the other could have a mix of guttate or inverse psoriasis, leading to differences in location and severity. Distribution can also be influenced by skin trauma (Koebner phenomenon) or areas prone to friction.

5. Why do they respond differently?

Several factors could explain the disparity:

a. Immune system variability: Twin immune systems can develop unique differences due to environmental exposures, infections, or diet.

b. Microbiome differences: The skin and gut microbiomes, which influence psoriasis, may vary between them, affecting treatment response.

c. Hormonal or epigenetic factors: Even slight variations in hormone levels or gene expression can impact disease behavior.

6. Should they get different treatments?

Yes, tailoring treatments to their responses may be necessary. Here is what you can consider:

a. For the twin worsened by sunlight:

Ⅰ. Avoid direct UV exposure. Use broad-spectrum sunscreen and protective clothing.

Ⅱ. Explore non-UV-based treatments:

Ⅲ. Topical therapies: Steroids, vitamin D analogs (e.g., Calcipotriol), or calcineurin inhibitors (e.g., Tacrolimus for sensitive areas).

Ⅳ. Non-UV light therapy: Narrowband UVB may be an option, under dermatological supervision, as it is controlled and less likely to exacerbate symptoms.

b. For the twin improved by sunlight:

Ⅰ. Encourage safe sun exposure during early mornings or late afternoons.

Ⅱ. Consider UVB phototherapy, which mimics sunlight’s beneficial wavelengths in a controlled way, especially during months with limited sunlight.

c. Both twins:

Ⅰ. Keep up with emollients and moisturizers to reduce skin irritation.

Ⅱ. Maintain a trigger-free environment:

Ⅲ. Avoid infections, manage stress, and minimize exposure to harsh soaps or chemicals.

Ⅳ. Reassess their response to treatments like topical steroids or systemic medications (if needed).

7. Next steps:

a. Consult a Pediatric Dermatologist: A specialist can evaluate the distinct responses and recommend tailored treatments. Tests to rule out photosensitivity conditions for the sun-sensitive twin may be necessary.

b. Investigate triggers: Test for lingering strep infection with throat swabs or blood tests (e.g., ASO titer). Check for potential allergens or irritants in their environment.

c. Consider systemic therapy for severe psoriasis: If their psoriasis does not respond to topical therapies, options like Methotrexate, biologics (e.g., Etanercept or Adalimumab), or other systemic treatments may help.

d. Lifestyle support: Anti-inflammatory diets (e.g., Mediterranean diet) may reduce flares.

Supplements like omega-3 fatty acids or vitamin D (if levels are low) could support skin health.

8. Monitoring and long-term plan:

Keep detailed notes of flare triggers, treatment responses, and environmental factors. Schedule regular follow-ups with a dermatologist to adjust treatments as needed.

Twins sharing a diagnosis but responding so differently highlights the importance of individualized care. With targeted adjustments and monitoring, both children can achieve better control of their psoriasis and improved quality of life.

I hope this helps.

Thank you and take care.

Regards.