another feature that distinguishes pediatric PsO from eczema, with PsO most often causing hypopigmentation and eczema most often causing hyperpigmentation.49 This feature is most apparent and upsetting for patients with darker skin tones. PsO-eczema overlap features skin signs of both eczema and PsO but may be less responsive to topical corticosteroids. Recognizing overlap is especially important when considering options for systemic treatment.48
Comorbidities
Extracutaneous comorbidities associated with pediatric PsO can contribute to the physical and psychosocial burden of disease and can negatively impact quality of life. Patients with pediatric PsO are at increased risk for arthritis, IBD, Crohn's disease, hypertension, bronchial asthma, hyperlipidemia, nail disorders, and arterial hypertension than those without pediatric PsO.6,50,51 Obesity, diabetes, and metabolic syndrome have also been more frequently observed in pediatric patients with PsO than patients without PsO, suggesting that PsO is an independent risk factor for developing metabolic comorbidities.51,52 PsO can also coexist with vitiligo, alopecia areata, and lichen planus, further complicating optimal treatment.53 Hypermetabolic syndrome, in which elevated resting energy expenditure leads to insulin resistance and excessive breakdown of proteins and triglycerides, has also been associated with PsO.54
In light of these findings, the NPF and the Pediatric Dermatology Research Alliance (PeDRA) established the NPF-PeDRA–Pediatric PsO Comorbidity Screening Initiative, which recommends regular screenings for obesity, type 2 diabetes, dyslipidemia, hypertension, IBD, arthritis, mood disorders, and substance use disorder for pediatric patients with PsO.55 These evidence-based guidelines are targeted toward all healthcare providers treating pediatric patients with PsO to help minimize the long-term health effects of PsO.
PsO-associated symptoms negatively impact psychosocial quality of life in children, resulting in a greater risk of mood disorders than are associated with healthy patients or those with other pediatric chronic diseases such as arthritis, asthma, and diabetes.56-58 Pediatric patients with PsO reported a higher incidence of anxiety, depression, and suicidal ideation than pediatric patients without PsO.50,59 Children aged 5 to 16 years with PsO or AD reported the greatest impairments in HRQOL compared with other common skin conditions such as localized eczema, acne, and urticaria.60 These patients also reported greater impairments in HRQOL than children with epilepsy, enuresis, or diabetes.60 Pediatric patients with PsO often experience teasing or bullying due to their appearance, which can negatively impact self-esteem and lead to feelings of social exclusion.61 Of pediatric patients with PsO, 65% reported feeling stigmatization62 due to bullying or teasing,63 which negatively impacted family and social relationships.
Juvenile PsA is a chronic inflammatory disease affecting the joints that occurs in some patients with pediatric PsO and can complicate disease treatment and management strategies.64 In an analysis using pooled US claims data, the estimated prevalence of PsA in pediatric patients with PsO was approximately 2%,65 which is lower than the approximately 30% reported prevalence in adults.66,67 However, since patients may present with signs of arthritis before or after development of pediatric PsO, the overall prevalence of arthritis in pediatric patients remains uncertain. In 80% of pediatric patients with juvenile PsA, joint inflammation develops before onset of skin disease, and the most common age ranges for joint involvement are 2 to 3 years and 10 and 12 years.55 Juvenile PsA has been estimated to account for 6% to 8% of all cases of pediatric inflammatory arthritis.68 Pediatric patients with PsA should be evaluated for uveitis.
Treatment Options for Pediatric PsO
Although an increasing number of treatments have been approved by the FDA for pediatric PsO, most treatments are prescribed off label. The currently available treatment options recommended by AAD-NPF guidelines are topical medications, phototherapy, oral retinoids, immunosuppressants, and biologic agents (Table 3).69,70 A topical corticosteroid is most often used first line for children with mild to moderate PsO. A limited number of low-potency topical corticosteroids are the only choices labeled to treat pediatric PsO in children under the age of 12 years. Although narrowband UV-B phototherapy has been shown to be an effective treatment, second-line use in children is limited by cost and need for in-office visits 2 to 3 days per week. Coal tar can be used in combination with other therapies such as phototherapy. For patients with an inadequate response to topical treatments or with additional comorbidities, oral immunomodulating agents, such as methotrexate or cyclosporin, or systemic retinoids, such as isotretinoin or acitretin, may be used. Children with involvement that is widespread or affecting sites that are difficult to treat topically (such as the scalp, face, groin, palms, soles, and nails), juvenile PsA, or contraindication to oral agents are candidates for treatment with a biologic. Biologics that are labeled for pediatric use include inhibitors of TNF (etanercept in the United States and European Union and adalimumab in the European Union), IL-12/23 (ustekinumab), and IL-17A (ixekizumab and secukinumab). Dosing information and clinical trial results for biologics for the treatment of pediatric PsO were previously reviewed.71 The topical phosphodiesterase-4 (PDE4) inhibitor roflumilast was also recently approved in the United States for the treatment of plaque PsO in patients greater than or equal to 12 years. Other systemic medications currently under investigation for pediatric PsO include biologics such as the TNF inhibitor certolizumab pegol; the IL-17 receptor A inhibitor brodalumab; the IL-23 inhibitors guselkumab, tildrakizumab, and risankizumab; oral PDE4 inhibitors such as apremilast; the tyrosine kinase 2 inhibitor deucravacitinib; and new nonsteroidal topicals such as tapinarof (an aryl receptor inhibitor).
