Diagnosis and Management of Pediatric Psoriasis: An Overview for Pediatricians

August 2023 | Volume 22 | Issue 8 | 742 | Copyright © August 2023


Published online July 25, 2023

Adelaide A. Hebert MDa, John Browning MDb, Pearl C. Kwong MD PhDc, Ana Duarte MDd, Harper N. Price MDe, Elaine Siegfried MDf

aUT Health McGovern Medical School, Houston, TX 
bUT Health San Antonio, San Antonio, TX 
cWolfson Children’s Hospital, Jacksonville, FL 
dThe Children’s Skin Center, Nicklaus Children’s Hospital, Miami, FL 
ePhoenix Children’s Hospital, Phoenix, AZ 
fSaint Louis University School of Medicine, St Louis, MO

can help reduce the risk of comorbidities.76 Use of a moisturizer that contains scale softeners, salicylic acid, lactic acid, glycolic acid, urea, or the anti-itch ingredients pramoxine, menthol, or calamine can augment skin care.77 Other alternative management approaches include acupuncture, apple cider vinegar for scalp itch, capsaicin added to topical medications, dilute bleach, Dead Sea or Epsom salt baths, or tea tree oil; however, these approaches lack clinical research on their long-term effectiveness and safety,78 and some can sting or cause skin irritation. The NPF website provides articles, webinars, podcasts, and videos about PsO and PsA, including treatment options and management, news, and stories from patients with PsO.79 Other support resources provided by the NPF include a free patient navigation center to help with questions about PsO and a peer support network that matches patients and caregivers with people who have experienced a similar situation and can provide guidance and reassurance.80 "Our Spot for Youth" is a patient resource center that provides welcome kits for pediatric patients with PsO and their families, tips on communicating with teachers and friends, and downloadable school resources.81 The AAD also provides a PsO resource center with information about the disease, diagnosis, and treatment options as well as skin, hair, and nail care guides for patients with PsO.82 These resources include a youth education campaign, "Good Skin Knowledge," which provides lesson plans and handouts to teach kids about common skin, hair, and nail conditions, such as PsO.83

Children with skin conditions, including PsO, are eligible to attend specialty summer camps. This experience can help improve self-esteem, social skills, body image, and skin care routines.84 The AAD Camp Discovery is a no-cost summer camp designed for pediatric patients with chronic skin conditions.85 The Children's Skin Disease Foundation's Camp Wonder is a week-long summer camp opportunity for children with chronic and life-threatening skin diseases provided free of cost for campers.86 

Current Challenges for Pediatricians in the Treatment of Pediatric PsO
Misdiagnosis can prompt treatment of PsO with an oral or parenteral corticosteroid. This approach is well known to trigger rebound worsening or even pustular flares. Other pediatric-specific challenges can complicate treatment, including tactile aversion to topical medications, needle phobia, and anticipatory nausea or emesis.87 Among the many systemic options FDA approved to treat PsO in adults, only 5 drugs are currently approved by the FDA for moderate to severe pediatric PsO. Insurance coverage is often denied for off-label treatments.88,89 When access is available, out-of-pocket treatment for PsO has been documented to cost an average of $2528 per year, an important factor that limits optimal treatment.90 Due to the difficulty in diagnosing pediatric PsO, patients are often misdiagnosed and prescribed treatments that can worsen their disease (Table 3). As skin lesions often resemble a rash, patients with PsO who are treated at emergency clinics are often prescribed oral, topical, or systemic corticosteroids that can worsen their PsO. Patients with PsO who are misdiagnosed and treated with TNF inhibitors may experience induction or exacerbation of PsO. Pediatricians should be aware that prescribing corticosteroids before an accurate diagnosis is made is not best practice and should consult a dermatologist if there is uncertainty about a diagnosis.88,89   

Pediatricians should also be aware of potential adverse effects when prescribing topical corticosteroids for children. Although these medications are a time-honored and cost-effective approach, long-term safety data are limited. Safety is supported by using the lowest potency product that is effective for the patient.45 Higher potency topical corticosteroids used more than once a day and applied under occlusion (eg, diaper area) and on the face and fold carry the highest risk of skin barrier compromise, percutaneous absorption, and hypothalamic-pituitary-adrenal axis suppression.45 Phototherapy can be time-consuming and require high out-of-pocket costs, and improvement is typically not appreciated for several weeks. Potential long-term adverse effects of phototherapy include photoaging, actinic keratoses, and skin cancer,91 although this risk is lower for narrowband UV-B than combination UV-A plus topical psoralens.92  The need for protective eyewear also poses special risks for children undergoing phototherapy, and isolated, underreported retinal burns have occurred in children unwilling to leave eyewear in place.56 

PsO that requires long-term use of systemic medication carries risks of drug-specific, treatment-emergent  adverse  effects (Table 3). Injection site reactions are the most common adverse effect of biologic agents.93 Long-term safety concerns with TNF inhibitors include increased risk of serious infections (eg, tuberculosis), development of autoimmune phenomena (ie, IBD, diabetes, and paradoxical PsO),93 and lymphomas and other malignancies,94 although there were no reported malignancies in a long-term safety study of etanercept treatment in pediatric patients with PsO.95 Pediatric patients receiving secukinumab or ixekizumab should be monitored for new or worsening IBD, which has occurred in adult patients with PsO receiving these biologics.96,97 However, no confirmed cases of treatment-emergent IBD in pediatric patients receiving secukinumab have been observed in clinical trials to date. Hypersensitivity reactions and serious infections have been reported for every biologic approved for use in children. There are no data on the impact of biologic agents on vaccine response; therefore, up-to-date immunization status is recommended prior to starting any of these medications. Avoiding live virus vaccines is recommended in all children receiving immunosuppressant or biologic medication. 

CONCLUSION

Pediatrician familiarity with the clinical presentation, diagnosis, and treatment of pediatric PsO will allow earlier and more effective management, alleviation of the physical and psychosocial burdens, and referral for long-term treatment when indicated. 

DISCLOSURES

Dr Hebert received research grants paid to the UT Health McGovern Medical School, Houston, from Pfizer, GSK, Mayne Pharma, LEO Pharma, Sienna, Ortho Dermatologics, Amgen, Promius, and Arcutis; received honoraria from Incyte, GSK, Ortho Dermatologics, Mayne Pharma, Amgen, LEO Pharma, Pfizer, Dermira, Verrica, Novan, UCB, Almirall, Novartis, Pierre Fabre, Aslan, and Janssen; and has served on the data safety monitoring boards for GSK, Ortho Dermatologics, and Sanofi-Regeneron. Dr Browning is an investigator for Amryt, Arcutis, Brickell Biotech, Celgene, ChemoCentryx, Dermavant, Eli Lilly, Incyte, Lenus Pharma, LEO Pharma, Mayne Pharma, Novartis, Pfizer, Regeneron, and Valeant; a consultant for Dermavant and LEO Pharma; and a speaker for Dermira, Regeneron, and Pfizer. Dr Kwong is an investigator, a speaker, and/or a consultant for Regeneron/Sanofi Genzyme, Eli Lilly, Verrica, Aclaris, Amgen, Novan, Almirall, Galderma, Pfizer, Novartis, Biofrontera, Mayne Pharma, Dermira, and Ortho Dermatologics. Dr Duarte has received speaker fees from Sanofi Regeneron, Pfizer, and Pierre Fabre and is an investigator for Pfizer, Novartis, and UCB. Dr Price is a principal investigator for Venthera, Sanofi, Amryt, AFT Pharmaceuticals, and Amgen and is a consultant for Amryt and Krystal Bio, with all funds paid to Phoenix Children's Hospital. Dr Siegfried is a consultant for Regeneron, Sanofi Genzyme, UCB, AbbVie, Verrica, LEO Pharma, Novan, Pfizer, and Pierre Fabre; is an investigator for Janssen and Eli Lilly; and is on the data safety monitoring committees for LEO Pharma and Novan. This commentary does contain a discussion of an unapproved/investigative use of a commercial product/device.

Funding sources: This work was supported by Novartis Pharmaceuticals Corporation, East Hanover, New Jersey, in accordance with Good Publication Practice (GPP 2022) guidelines (http://www.ismpp.org/gpp-2022).

ACKNOWLEDGMENT

Medical writing support was provided by Ken Gresham, PhD, of Health Interactions, Inc., and was funded by Novartis Pharmaceuticals Corporation. This manuscript was developed in accordance with Good Publication Practice (GPP 2022) guidelines. Authors had full control of the content and made the final decision on all aspects of this publication.

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AUTHOR CORRESPONDENCE

Adelaide A. Hebert MD Adelaide.A.Hebert@uth.tmc.edu
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