Pediatric Plaque Psoriasis

Psoriasis (PsO) is a chronic, multisystem disorder that occurs in approximately 1% of chil­dren. Most frequently, PsO initially presents during adolescence; however, about one-third of patients develop the disease during childhood. PsO is associated with numerous comorbidities, including psoriatic arthritis (PsA).¹ The increased frequency of obesity among the pediatric population may account for the growing incidence and prevalence of childhood PsO.

Treatment Options

Markedly fewer therapies for PsO are available for children than for adults. A total of 7 medications (topicals and biologics) are FDA approved for use in pediatric PsO. Topical roflumilast cream, 0.3%, was recently approved for use in children at least 6 years of age, which is an important development in managing this condition. Other FDA-approved topical treatments include:

• Calcipotriene foam, 0.005%, for scalp and body psoriasis in children 4 years and older;
• A foam containing calcipotriene, 0.005%, and betametha­sone, 0.064%, for mild to severe plaque psoriasis in those at least 12 years old;
• A suspension containing calcipotriene, 0.005%, and betamethasone, 0.064%, for scalp and body psoriasis in children 12 years and older.

Approved biologics include etanercept, ustekinumab, ixekizumab, and secukinumab. Most of these agents are approved for use in children 6 years or older, however, etanercept is approved for treatment of those at least 4 years old. Notably, ustekinumab was recently approved for pediatric PsA.

Several therapies are used off label in children with PsO. These include topical corticosteroids, phototherapy/laser therapy, methotrexate,¹ cyclosporine, retinoids, vitamin D analogues, and other biologics.

Disease Correlates and Safety of Therapies in the Pediatric Population

Health care professionals must be cognizant of some signs and symptoms of PsO and PsA that are not obvious. Nail disease reportedly correlates with the severity of PsO in children. Chil­dren who have PsA may also have uveitis.

There are safety concerns associated with agents used to treat PsO. For example, cases of lymphoma associated with adalimumab therapy have been reported, but most occurred in patients with juvenile idiopathic arthritis or inflammatory bowel disease (IBD). Of note, adalimumab is not approved in the United States for the treatment of PsO in children despite being approved for use in this patient population in other countries. It is also approved for the treatment of uveitis in patients as young as 2 years of age; therefore, children with PsO should be evaluated for uveitis.

Development of IBD is also a concern with use of some biolog­ics, although the risk in pediatric patients is not fully understood. These agents, especially interleukin-17 inhibitors, should be used with caution.

Psychological Impact of PsO in Pediatric Patients

The psychological and social impacts of PsO in children are tremendous. Children with PsO, and especially those who have visible lesions, report being the victims of bullying. Providing safe treatments with a goal of clearing skin lesions is critical in this population. Measures related to quality of life (QOL) are important, but seeing the joy or happiness in children who have improved skin and are no longer bullied is priceless.²

The AAD and NPF guidelines recommend consideration of not only body-surface area when determining severity but also the location of lesions on the body and the impact of PsO on the patient’s QOL and activities of daily living.² The Children’s Dermatology Life Quality Index is a survey comprised on 10 questions that assesses QOL influences (eg, itch, impact on relationships, and treatment efficacy) in patients with PsO aged 4 to 16 years. This survey is available in written form or with cartoon images.²

In treating PsO, measures of QOL extend beyond the use of an effective medication that clears skin lesions. For example, patient overall happiness with the treatment and results should be considered. Also, the burden of injections is an important consideration when treating children. Some therapies require more injections than do others. Patient preference is important when selecting a treatment.

Psoriatic Arthritis in Children

According to the AAD and NPF guidelines, children with PsO should receive regular screenings for PsA, including a review of their medical history and a physical examination.² Patients who demonstrate signs and symptoms of inflammatory arthritis should be referred to a rheumatologist who preferably has expertise in treating children. Children with PsA should be regularly assessed for uveitis; those with signs or symptoms of uveitis should be referred to an ophthalmologist.

Value of Early or Aggressive Management in Pediatric PsO

Any visible lesion on a child can make them a target for bullying. The psychological and social effects of even localized disease in children should not be underestimated. Aggressive therapy is sometimes necessary to improve visible lesions and to enhance QOL of children with PsO.

Faculty presenter: Adelaide A. Hebert, MD. This article was reviewed, edited, and approved by Dr Hebert and Dr Stein Gold.

References

1. Siegfried EC, Arkin LM, Chiu YE, et al. Methotrexate for inflammatory skin disease in pediatric patients: consensus treatment guidelines. Pediatr Dermatol. 2023;40(5):789-808. doi:10.1111/pde.15327
2. Menter A, Cordoro KM, Davis DMR, et al. Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients. J Am Acad Dermatol. 2020;82(1):161-201. doi:10.1016/j.jaad.2019.08.049