Psoriasis has been estimated to affect up to 3% of the population. For the majority of patients, onset occurs before the age of 40, and up to one-third of cases begin in childhood. Related to these data about the epidemiology of psoriasis are unique questions about its treatment and other issues in the pediatric population.
According to Amy S. Paller, M.D., a need for more research aptly describes the current state of knowledge about multiple aspects of psoriasis in the pediatric population. However, there have been some recent positive developments, she says.
Dermatologists can look forward to the upcoming release of Joint American Academy of Dermatology-National Psoriasis Foundation (AAD-NPF) guidelines of care for the management of psoriasis in pediatric patients, which are expected to be published later in 2019.
“It is exciting that we will be having a new set of management guidelines coming out in psoriasis and doubly exciting that for the first time we will have guidelines dedicated to the pediatric population,” says Dr. Paller, Walter J. Hamlin Professor and chair of dermatology, Northwestern University Feinberg School of Medicine, Chicago. “There are unique physiological and social considerations for pediatric patients with psoriasis relative to the adult population, and so it is important to have a separate set of guidelines for psoriasis management in children.”
Expert opinion based on the experience of the guideline working group members was important for developing the guideline’s treatment recommendations considering the limited evidence on treatment of pediatric plaque psoriasis.
“There is some mid-level evidence on the use of biologic agents for treating psoriasis in children, but high-quality trials providing information about the safety and efficacy of other treatments are more limited,” Dr. Paller says.
Only a few treatments have an FDA-approved indication for treatment of psoriasis in children. They include a topical combination corticosteroid-vitamin D3 analog (calcipotriene and betamethasone dipropionate 0.005%/0.064%, Taclonex, LEO Pharma), ustekinumab (Stelara, Janssen), and etanercept (Enbrel, Amgen), but the topical product and ustekinumab are only approved in adolescents aged 12 years and older.
The situation is changing slowly.
A recent phase 3 study compared methotrexate and adalimumab in pediatric patients and the results favored the biologic.1 It should be noted, however, that methotrexate was administered at a relatively dose (mean of ~0.15 mg/kg once weekly), Dr. Paller says.
Dr. Paller serves as consultants to and receive honoraria as speakers for companies that market products used for the treatment of psoriasis.
1. Papp K, Thaçi D, Marcoux D, et al. Efficacy and safety of adalimumab every other week versus methotrexate once weekly in children and adolescents with severe chronic plaque psoriasis: a randomised, double-blind, phase 3 trial. Lancet. 2017;390(10089):40-49.
2. Cordoro KM, Hitraya-Low M, Taravati K, et al. Skin-infiltrating, interleukin-22-producing T cells differentiate pediatric psoriasis from adult psoriasis. J Am Acad Dermatol. 2017;77(3):417-424.
3. Becker L, Tom WL, Eshagh K, Benjamin LT, Paller AS. Excess adiposity preceding pediatric psoriasis. JAMA Dermatol. 2014;150(5):573-574.