A multi-specialty panel of physician experts has released the first comorbidity screening guidelines for pediatric psoriasis. The consensus statement, released last July, comes out amid increasing evidence that — like adults with psoriasis — children with the disease are at elevated risk for systemic and behavioral comorbidities.
“There is increasing evidence that psoriasis is an inflammatory skin condition where other organs are affected. Data has shown higher rates of heart attacks, strokes in adults with psoriasis and evidence of vascular inflammation. Psoriatic arthritis, hepatic disease, obesity, depression and anxiety are also associated with psoriasis,” said Lawrence F. Eichenfield, M.D., chief of pediatric and adolescent dermatology at University of California, San Diego and Rady Children’s Hospital, San Diego. “Recognizing that children and teenagers with psoriasis have higher risk of these comorbidities over a lifetime, we should try to minimize their development and impact.”
Despite statistics that suggest psoriasis starts in childhood in almost one-third of cases, there were no prior guidelines for screening children for comorbidities. However, there are screening recommendations for adults by the National Psoriasis Foundation and other organizations. “By increasing awareness and providing a tool to help address these important health issues, we hope to optimize the comprehensive care of patients with pediatric psoriasis,” the authors write.
The Pediatric Dermatology Research Alliance (PeDRA), a consortium of pediatric dermatology researchers and National Psoriasis Foundation developed the statement.
The panel included experts in pediatric and adult psoriasis, epidemiology and relevant pediatric specialties related to the comorbidities, including cardiology, endocrinology, gastroenterology and rheumatology.
Researchers combed PubMed from January 1999 to December 2015, looking for relevant papers narrowing it down to 26 studies involving children and teens.
Many of the screening recommendations are consistent with what the American Academy of Pediatrics endorses for the general pediatric patient. The authors note that, because of limited pediatric studies on psoriasis, the document offers level C recommendations based on consensus, usual practice, opinion, diseaseoriented evidence or case series, according to the paper.
The consensus includes recommendations for overweight and obesity, type 2 diabetes mellitus, dyslipidemia, hypertension, nonalcoholic fatty liver disease, polycystic overall syndrome, gastrointestinal diseases, arthritis, uveitis, mood disorders and substance abuse and quality of life.
The panel recommends screening for overweight and obesity starting at age two years and counseling or referring some patients and families that fall into those categories.
While it’s not clear whether being overweight increases psoriasis risk or makes the disease worse in children, studies show pediatric psoriasis patients are more likely to be obese or overweight than pediatric patients without psoriasis. The theory is that excess adipose tissue is linked with a proinflammatory state, including increased cytokine expression, which could predispose some people to develop psoriasis, according to the paper.
2. TYPE 2 DIABETES MELLITUS
Among the recommendations is to screen every three years, beginning at 10 years or the onset of puberty for pediatric psoriasis patients with two or more diabetes risk factors, such as body mass index in the 85th percentile or higher or family history. Psoriasis is an independent risk factor for diabetes, according to the adult literature, but the risk for children needs to be delineated, the authors write.
While the recommendations regarding type 2 diabetes reflect those of the American Diabetes Association for all children, the American Academy of Pediatrics has not yet officially endorsed them.
Included in these recommendations is universal lipid screening for all children during age ranges 9 to 11 and 17 to 21 years. Evidence of early metabolic and lipid abnormalities in children exists, and adult studies report an association between psoriasis and dyslipidemia. But the limited literature that is available doesn’t warrant screening beyond general recommendations for all children, unless pediatric psoriasis patients have other cardiovascular risk factors.
High blood pressure screenings should start at three years, according to the panel. Adult studies show an association between psoriasis and hypertension, and one retrospective study supports the association in children.
Pediatric psoriasis patients should be screened for arthritis development by a “directed review of symptoms and physical examination,” according to the authors.
“Notably, 80 percent of children with psoriatic arthritis develop arthritis two to three years prior to skin findings, whereas adult patients tend to develop cutaneous manifestations first…,” the authors write.
6. MOOD DISORDERS, SUBSTANCE ABUSE
Providers should screen annually for depression and anxiety regardless of age, and yearly for substance abuse starting from age 11 years.
Researchers have found that pediatric patients with psoriasis were at about 25 percent to 30 percent higher risk for developing depression and/or anxiety versus children without psoriasis.
While more research is needed to determine if pediatric psoriasis patients are more likely than those without psoriasis to develop alcohol abuse, adult studies suggest a link exists.
7. QUALITY OF LIFE
Children who have psoriasis tend to be more notably impaired emotionally and socially, compared to children without the disease. They’re more likely to have trouble functioning at school and often are bullied and teased. The psychosocial effects of psoriasis can be profound, greatly impacting these children’s quality of life.
Providers should ask patients and families about the effects of psoriasis and consider using a quality of life screening instrument, such as the Children’s Dermatology Life Quality Index, according to the authors.
8. MAKING TREATMENT CHOICES
The authors note that dermatologists and others who start systemic therapies in pediatric psoriasis patients should consider these and other comorbidities because they might impact a particular medication’s tolerability and adverse effects.
9. DERMATOLOGISTS PLAY KEY ROLE
It’s critical that dermatologists, primary care providers and other pediatric specialists communicate and collaborate in the care of this disease in children.
“I like to emphasize that when evaluating a pediatric patient with psoriasis, there is a quick assessment of other medical risks and associations: a screening question for arthritis, assessment of obesity and risk factors for heart disease and diabetes and assessment for depression and anxiety,” Dr. Eichenfield says. “A dermatologist can ask if the pediatrician or other family practice doctor has done screening (e.g. for BMI, blood pressure, lipids) and/or mention to the family that the screening should be performed. The engagement of the patient and family so they are aware of the risks is part of the benefits of screening.”
Paying attention to potential comorbidities in the youngest of psoriasis patients is worth it, Dr. Eichenfield says.
“Dermatologists are busy practitioners, and managing pediatric psoriasis involves education and selection of appropriate therapies,” he says. “It would be easy to ignore secondary issues about possible complications that may not be seen for decades. But it would be really helpful to lay the ideas out to patients and families so they can work with their health care practitioners, specialists and primary care, to optimize care and minimize the impact of psoriasis over the lifetime of the individual.” Â
Osier E, Wang AS, Tollefson MM, et al. “Pediatric Psoriasis Comorbidity Screening Guidelines,” JAMA Dermatology. July 1, 2017. DOI: 10.1001/jamadermatol.2017.0499.