Dr. Siegfried: It is an advantage and a disadvantage that we don’t have a lot of high-tier, evidence-based medicine, and so we have the privilege of customizing treatment for our patients. Patients aren’t templates; they all have unique issues that impact the best treatment choice. What advice would you give to new clinicians about this?
Dr. Cordoro: Well said. I think my advice to very junior clinicians is to start by the textbooks, go by what’s been written by those with more knowledge and experience. In general we tend to be more cautious with monitoring at first and then over time, the approach may evolve.
However, I will say this: I am constantly humbled by these medications—both conventional systemic therapies and biologics. We have to be careful as we are modifying and customizing that we don’t become complacent and say, ‘I’ve been doing this for so many years, we don’t have to check that anymore.’ Because as soon as we let our guard down, we can get burned. So the right answer is somewhere between being cost-effective and not over-monitoring, but not getting too comfortable either.
Dr. Siegfried: Do you check all kids that you are going to put on any kind of immunomodulating therapy for TB risk?
Dr. Cordoro: I do because I live in a high-prevalence area in the San Francisco Bay area. When I practiced in Virginia, I did not. I would routinely do it for TNF inhibitors, I routinely did it for methotrexate; and, right or wrong, I did not do it for some of the other systemic agents. Now of course I am doing it for everybody and maybe everybody should be doing it for every patient with all of these medications.
Dr. Siegfried: Are you doing purified protein derivative (PPD) or QuantiFERON (Cellestis)?
Dr. Cordoro: I am doing PPD (purified protein derivative) for the most part. I think it’s the most cost-effective screen. If we are not guaranteed that they will follow up on their PPD and we can’t reach their pediatrician, then we will do a QuantiFERON. However, data on performance are scant in the pediatric age group. The Centers for Disease Control and Prevention cautions use in patients less than 17, and in particular in kids less than 5 years old.
Check out part two of this three part series: Pediatric psoriasis, eczema:Triggers and therapies
Dr. Siegfried: What biologics have you used?
Dr. Cordoro: Well, as you well know, all biologic treatments for dermatologic use in kids are off-label, as are all systemic medications for psoriasis and atopic dermatitis. So yes, I’m always prescribing off-label and I use the TNF inhibitors the most. I use this for recalcitrant plaque and pustular psoriasis. I tend to prescribe etanercept initially, because it has the most data for kids. There has been a randomized, controlled trial, as you know, spearheaded by [Dr.] Amy Paller.3 However, its efficacy often wanes over time and may require a transition to other TNF agents or a class change.
I would say that I have the most experience with TNF inhibitors. I don’t use them as much as I do systemic therapies. I am still in the “drugs I know and can monitor” phase of my career. I have some concerns about the lack of knowledge about long-term risks of some of these agents. For example, I do not have a vast experience with ustekinumab yet. I have prescribed it only one time to a teenager with severe psoriasis who failed anti-TNF.
For generalized pustular psoriasis, my drug of choice is infliximab if I need to achieve really rapid control. I often accompany that by small doses of methotrexate to block human antichimeric antibodies, which overtime can lead to loss of efficacy and increased infusion reactions. I have not used a biologic agent for the treatment of atopic dermatitis.