Recognizing the Hidden Burdens of Pediatric Psoriasis

Although less prevalent than commonly seen atopic dermatitis, pediatric psoriasis presents a distinct and persistent treatment challenge for clinicians. Psoriasis develops in childhood or adolescence in approximately 40% of adults with psoriasis.¹ Why is this important? It is well known that psoriasis is a multisystem disease that can have longstanding impact and systemic comorbidities. The most concerning comorbidities in pediatric patients are uveitis, arthritis, obesity, type 2 diabetes (T2D), and metabolic syndrome. In adult patients, T2D is associated with psoriasis, and earlier age of onset may be a risk factor.² Although this has not been clearly delineated in pediatric patients, there is a link to pediatric obesity, psoriasis, and diabetes. It has been shown that obesity presents before a diagnosis of psoriasis by at least 2 years in the majority of children, and higher BMI is associated with potentially greater body surface area involvement of psoriasis.^3,4 Obesity then poses as a risk factor for the development of other serious comorbidities, including hypertension and hyperlipidemia. Believe it or not, atherosclerotic plaques can develop as young as 11 years.

Early Intervention

While we are currently in the era of medical weight loss in adults, especially for those with chronic inflammatory diseases, we have to remember that early intervention in children is far more important because of its long-term preventive impact. It is for this reason that we have pediatric psoriasis comorbidity screening guidelines. I do not screen all my patients, but I discuss the risk factors with pediatricians so they can adequately screen my affected patients. The presence of comorbidities gives me more reason to consider systemic therapy for patients who may not have as severe disease in efforts to control the “invisible” aspects of inflammation.

Arthritis is very diffcult to assess in pediatric patients. For example, 80% of pediatric patients develop arthritis prior to the onset of skin plaques, and their presentation may be more heterogeneous than in adults.^5,6 Younger patients tend to have a juvenile idiopathic arthritis–like picture, whereas older patients typically tend to have a spondyloarthritis picture. It may be very hard to elicit the classic criteria for arthritis in adults and children. Asking about a limp, difficulty walking, or delayed walking in the morning is important in young, pediatric patients.⁷

In older teenagers, back pain may be misdiagnosed as “growing pains,” and that’s why it’s important to assess range of motion and response to nonsteroidal anti-inflammatory drugs. It has been reported that there is a mean delay of 1 year to diagnosis of psoriatic arthritis in kids.⁸ Another aspect we don’t usually think of in adults is severe uveitis. Uveitis is more common in pediatric patients with arthritis than in those without.⁷ Younger onset with psoriatic arthritis is associated with more severe uveitis, and referral to ophthalmology is sometimes recommended for baseline evaluation.

Available Therapeutics

Prior to April 2024, we had only injectable biologic therapies for treatment of pediatric psoriasis. While injectable biologics have vastly evolved from twice weekly dosing with etanercept (Enbrel; Amgen and Pfizer) to monthly dosing with ixekizumab (Taltz; Eli Lilly and Company), injectables are still associated with medication anxiety, potential trauma, and injection site reactions. Although methotrexate is an excellent and safe treatment option for pediatric patients, it requires blood monitoring, and explaining this medication to parents can sometimes be difficult. Apremilast (Otezla; Amgen) was approved for moderate to severe plaque psoriasis and pediatric patients 6 years and older.

Based on the 16-week, phase 3 SPROUT study (NCT03701763), significantly more patients achieved a Static Physician’s Global Assessment response and reduction of 75% or more in Psoriasis Area and Severity Index (PASI) with apremilast than placebo, regardless of baseline age, weight, or disease severity. PASI 75 and PASI 90 response rates were significantly greater with apremilast (45.4% and 25.2%, respectively) vs placebo (16.1% and 4.9%, respectively; both P ≤ .0001).⁹

Pediatric Obstacles

Although this medication performs well, in my practice, I have had 2 major issues:

• pill swallowing and

• gastrointestinal (GI) disturbances.

Most children should be able to swallow a small pill by age 5 to 6 years. I have realized that this is not universally the case. Most of my patients are not able to swallow pills until they’re 8 to 10 years of age. Because of the nature of this medication, it cannot be crushed.

Second, some of my patients have had debilitating nausea, which has been a limiting factor. Treatment-emergent adverse events were observed in 65.0% of patients in the apremilast group in the study, most of which were GI disturbances. I have used this opportunity to help patients learn how to swallow pills, and sometimes it’s successful because the pills are small.

I am also excited about topicals in the psoriatic space. We now have a roflumilast 0.3% foam (Zoryve; Arcutis Biotherapeutics) approved for patients 12 years and older for the body and seborrheic dermatitis (I use it off-label) in children 9 years and older. This has been a game changer for my Black patients who have coarser hair and can now use a product that won’t irritate their scalp or change their hair care practices.

As we evolve in our therapeutic armamentarium, we have to recognize that psoriasis may occur from commonly prescribed therapies for other skin diseases. One such phenomenon that I have seen is psoriasis development after initiating dupilumab (Dupixent; Sanofi and Regeneron) for atopic dermatitis. A retrospective study identified 6 patients on dupilumab for atopic dermatitis who developed new-onset psoriasis.¹⁰ They found that the majority of patients showed clearance or near clearance with the use of medium-strength to potent topical corticosteroid ointments, and 83% continued use of dupilumab.

This new-onset occurrence is likely due to Th1 skewing of the immune response. One case series of 2 patients with de novo psoriasis on dupilumab identified increased lesional mRNA expression of IL-17A in these patients.¹¹ There is also a phenotype of mixed atopic dermatitis and psoriasis called eczematoid psoriasis, which often can show both psoriasiform and spongiotic findings on pathology. This poses a significant therapeutic challenge where optimization of topical therapies is preferred to prevent exacerbation of either condition with targeted biologic therapy.

These patients may also benefit from concomitant narrowband UVB, which should not be forgotten in pediatric patients. I tell young patients that entering the booth is like entering a spaceship. The youngest person I have had in a booth was 4 years old. Localized excimer lamp/laser may also be great for this condition if children are unable to enter a booth. In these patients with atopic psoriasis, tapinarof (Vtama; Organon) cream works very well. This is because it can be used once daily, allowing for emollient use without the risk of excessive layering. It also has a pediatric atopic indication for children 2 years and older and an adult psoriasis indication. It is very well tolerated and can be combined with phototherapy and biologics.

Looking Ahead 

The question I struggle to answer is, “When will this go away?” Unfortunately, it is hard to predict which patients will enter long-term remission vs who will continue to have flares throughout their lives. We used to believe guttate psoriasis had the best prognosis, but that has been demystified. Overall, reducing risk factors for systemic comorbidities and encouraging continued use of nonsteroidal topical therapies with or without systemic therapies is crucial for our pediatric patients with psoriasis.

Karan Lal, DO, MS, FAAD, is the first and only dual fellowship–trained pediatric and cosmetic dermatologist in the US, practicing at Affiliated Dermatology in Scottsdale, Arizona, and a Dermatology Times editorial advisory board member.

References

1. Raychaudhuri SP, Gross J. A comparative study of pediatric onset psoriasis with adult onset psoriasis. Pediatr Dermatol. 2000;17(3):174-178. doi:10.1046/j.1525- 1470.2000.01746.x

2. Li W, Han J, Hu FB, Curhan GC, Qureshi AA. Psoriasis and risk of type 2 diabetes among women and men in the United States: a population-based cohort study. J Invest Dermatol.2012;132(2):291-298. doi:10.1038/ jid.2011.319

3. Bryld LE, Sorensen TI, Andersen KK, Jemec GB, Baker JL. High body mass index in adolescent girls precedes psoriasis hospitalization. Acta Derm Venereol. 2010;90(5):488-493. doi:10.2340/00015555-0931

4. Becker L, Tom WL, Eshagh K, Benjamin LT, Paller AS. Excess adiposity preceding pediatric psoriasis. JAMA Dermatol. 2014;150(5):573- 574. doi:10.1001/jamadermatol.2014.324

5. Stoll ML, Punaro M. Psoriatic juvenile idiopathic arthritis: a tale of two subgroups. Curr Opin Rheumatol. 2011;23(5):437-443. doi:10.1097/BOR.0b013e328348b278

6. Lewkowicz D, Gottlieb AB. Pediatric psoriasis and psoriatic arthritis. Dermatol  er. 2004;17(5):364-375. doi:10.1111/j.1396- 0296.2004.04039.x

7. Kittler NW, Cordoro KM. Pediatric psoriasis comorbidities. Skin  erapy Lett. 2020;25(5):1-6.

8. Zisman D, Gladman DD, Stoll ML, et al.  e juvenile psoriatic arthritis cohort in the CARRA registry: clinical characteristics, classi cation, and outcomes. J Rheumatol. 2017;44(3):342-351. doi:10.3899/jrheum.160717

9. Fiorillo L, Becker E, de Lucas R, et al. Ef-  cacy and safety of apremilast in pediatric patients with moderate-to-severe plaque psoriasis: 16-week results from SPROUT, a randomized controlled trial. J Am Acad Dermatol. 2024;90(6):1232-1239. doi:10.1016/j. jaad.2023.11.068

10. Parker JJ, Sugarman JL, Silverberg NB, et al. Psoriasiform dermatitis during dupilumab treatment for moderate-to-severe atopic dermatitis in children. Pediatr Dermatol. 2021;38(6):1500-1505. doi: 10.1111/pde.14820

11. Ali K, Wu L, Qiu Y, Li M. Case report: clinical and histopathological characteristics of psoriasiform erythema and de novo IL-17A cytokines expression on lesioned skin in atopic dermatitis children treated with dupilumab. Front Med (Lausanne). 2022;9:932766. doi:10.3389/fmed.2022.932766