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  • Presentation

Pediatric DRESS and Paradoxical Psoriasis: Diagnosis, Management, and Key Differences from Adults

Description

The talk reviewed two pediatric adverse drug reaction case scenarios and emphasized that children are not just small adults. For pediatric DRESS, a 16-year-old girl developed fever, facial edema, and a morbilliform eruption after minocycline for acne. Key differences from adults included more frequent lymphadenopathy, more gastrointestinal symptoms such as pharyngitis, diarrhea, and abdominal discomfort, more splenic involvement, and a higher likelihood of antibiotic triggers, shorter latency, and later autoimmune sequelae. DRESS in children often showed fever and lymphadenopathy, pruritus and erythroderma were less common, and liver involvement and HHV reactivation were notable. Relapsing or recrudescent DRESS was highlighted as important because severe initial disease may predict recurrence. Corticosteroids remain common therapy, but a small pediatric series suggested cyclosporine may shorten hospitalization, speed ALT normalization, and reduce treatment duration. Long-term follow-up should include monitoring for autoimmune complications such as thyroid disease, type 1 diabetes, and alopecia. The second case focused on pediatric paradoxical psoriasis, usually triggered by anti-TNF therapy, especially infliximab, in children with inflammatory bowel disease. It typically appears late, often after many months to years, and commonly affects the scalp and ears, may be eczematous or weepy, and can include psoriatic alopecia and staph superinfection. Predictors include female sex, younger age, smoking history, and Crohn’s disease, while concomitant immunosuppression may be protective. Management depends on severity and the importance of the biologic for the underlying disease; options include continuing anti-TNF with topical or systemic psoriasis treatment, switching biologics, or stopping the offending drug if feasible. Although hair loss can look dramatic, pediatric psoriatic alopecia is usually non-scarring and resolves over time after drug cessation.

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Conclusions

  • Pediatric DRESS syndrome often differs from adult DRESS by having more antibiotic triggers, shorter latency, more gastrointestinal prodromal symptoms, and a higher risk of later autoimmune sequelae.
  • Fever and lymphadenopathy are especially common in pediatric DRESS, while pruritus and classic erythroderma are less reliable clues than in adults.
  • Children with DRESS still frequently show liver involvement and eosinophilia, but splenic involvement and relapsing/recrudescent disease appear more notable than in adults.
  • Rapid-onset DRESS can occur in children, especially after antibiotic re-exposure, and a short latency should not exclude the diagnosis.
  • Severity at initial presentation may predict later recrudescence, suggesting that earlier aggressive treatment could matter in high-risk pediatric cases.
  • Corticosteroids remain the usual default treatment for pediatric DRESS, but limited data suggest cyclosporine may shorten hospitalization and treatment duration with faster liver enzyme recovery.
  • Autoimmune follow-up after pediatric DRESS is important, especially thyroid disease screening weeks to months after recovery and consideration of diabetes surveillance.
  • Paradoxical psoriasis in children is usually an anti-TNF complication associated most often with infliximab, but adalimumab may be linked to more severe disease.
  • Pediatric paradoxical psoriasis commonly affects the scalp and ears, may look eczematous or weepy, and can be complicated by staph superinfection.
  • Most pediatric paradoxical psoriasis cases improve with either continuing the TNF inhibitor plus topical/systemic therapy or stopping/switching the offending biologic when feasible.
  • Psoriatic alopecia in paradoxical psoriasis is usually non-scarring and tends to regrow after the trigger is removed, although improvement can take months.
  • Management decisions for paradoxical psoriasis must balance skin severity against the necessity of the underlying biologic for the child’s other disease, requiring close specialist coordination.
  • Metterle L, et al. Pediatr Dermatol. 2020;37(1):124-129.
  • Manieri E, et al. Drug rash with eosinophilia and systemic symptoms (DRESS) syndrome in childhood: a narrative review. Front Med (Lausanne). 2023;10:1108345.#10.3389/fmed.2023.1108345
  • Afioni et al., Pediatric drug reaction with eosinophilia and systemic symptoms, Pediatric Dermatology, 2021.#10.1111/pde.12931
  • Zabihi H, et al. Clin Exp Dermatol. 2025;50(6):1183-1187.
  • Salman A. et al., Pediatric Dermatology, 2019, 36:514-516.
  • Croitoru DO, et al. Predictors of severity in paradoxical psoriasis from biologic therapies: a systematic review. J Am Acad Dermatol 2023;88:471e3.#10.1016/j.jaad.2022.06.019
  • Cyrenne BM et al. Pediatr Dermatol. 2021;38(5):1086-1093.