Systemic Treatment of Recalcitrant Pediatric Psoriasis: A Case Series and Literature Review

August 2015 | Volume 14 | Issue 8 | Original Article | 881 | Copyright © August 2015

Caren Garber BA,a,b Malcolm Creighton-Smith BA,a,b Eric P Sorensen BS,a Nicole Dumont,a
Alice B. Gottlieb MD PhDa,b

aDepartment of Dermatology Research, Tufts Medical Center, Boston, MA bTufts University School of Medicine, Boston, MA

BACKGROUND/PURPOSE: No systemic drugs are approved by the Food and Drug Administration to treat pediatric psoriasis due to a lack of supporting data. The purpose of this study is to present cases demonstrating the use of systemic drugs in pediatric psoriasis.
METHODS: In this case series, data were collected on patients ≤ 18 years old with moderate-to-severe psoriasis treated with systemic medications (traditional systemic drugs or biologics) from 2008 through 2014. Efficacy was measured using the validated simple measure for assessing psoriasis activity (S-MAPA), and the product of the body surface area and Physician Global Assessment.
RESULTS: Twenty-seven patients aged 5 to 18 years were eligible, and 56 treatment courses were analyzed. Methotrexate (MTX) was the most frequently prescribed systemic (70%), followed by etanercept (59%). Clearance rates were highest on biologic medications (67% for etanercept and adalimumab, 33% for ustekinumab). Phototherapy, cyclosporine, and MTX were less effective in clearing psoriasis, although they were successful in improving S-MAPA ≥ 50% from baseline 100%, 67%, and 36% of the time, respectively. The most common adverse events were sunburn for patients on narrowband ultraviolet B phototherapy (14%), gastrointestinal intolerance and minor infections for patients on MTX (16% each), and minor infections for patients on etanercept (25%) and adalimumab (33%). The most common reasons for discontinuation were secondary failure (38% for etanercept, 33% for adalimumab) or lack of response (37% for MTX, 33% for cyclosporine).
CONCLUSION: Although phototherapy, MTX, and cyclosporine are effective for controlling resistant pediatric psoriasis, concerns about long-term safety or inconvenience have led people to consider biologics in their place. However, there is a lack of literature on the use of biologics in pediatric psoriasis. These cases attest to the safety and efficacy of etanercept, adalimumab, and ustekinumab in pediatric psoriasis, expanding the treatment repertoire and guiding dermatologists in better managing recalcitrant pediatric psoriasis.

J Drugs Dermatol. 2015;14(8):881-886.


The exact incidence of pediatric psoriasis is unknown. However, an estimated 31% to 45% of psoriasis patients have disease onset before the age of 16 years.1 As in adults, pediatric psoriasis causes considerable psychosocial stress for patients and their caretakers, including concern over physical appearance and fear of social stigmatization.1,2 This underlines the importance of prompt treatment in pediatric psoriasis.
The majority of children with psoriasis have mild disease that can be managed with topical agents or phototherapy.3 However, many cases of pediatric psoriasis are recalcitrant and require transition to systemic therapy (with traditional systemic agents or biologics). While systemic medications are well studied in adults with psoriasis, none are approved by the Food and Drug Administration (FDA) to treat pediatric psoriasis due to limited data in this population.3
With much of the information on the use of systemic agents in children stemming from case reports, case series, or the use of these medications to treat other FDA-approved pediatric indications, there is an obvious need for more literature on the treatment of pediatric psoriasis.3 The purpose of this study is to examine prescribing patterns and treatment outcomes in cases in which recalcitrant pediatric psoriasis was treated systemically, and to thereby help guide dermatologists in the treatment of similar cases.


In this retrospective case series, the records of all pediatric psoriasis patients seen at the Tufts Medical Center General Dermatology Clinic (a combined pediatric and adult clinic affiliated with a tertiary care center) from 2008 through 2014 were considered. Pediatric psoriasis patients were identified based on the ICD-9-CM 696.1 code for psoriasis and if they were aged ≤18 years at the time of treatment onset. Disease severity was evaluated based on the simple measure for assessing psoriasis activity (S-MAPA), the product of body surface area and Physician Global Assessment. S-MAPA is a validated alternative measure that correlates tightly with