Joel M. Gelfand
The new guidelines from the American Academy of Dermatology and the National Psoriasis Foundation are the first of its kind to focus on pediatric psoriasis, according to Joel M. Gelfand, MD, MSCE, professor of dermatology and epidemiology at University of Pennsylvania Perelman School of Medicine.
“These new AAD/NPF pediatric psoriasis guidelines raise the bar for the standard of care treatment approach for children affected by psoriasis,” Gelfand, who worked on the guidelines, told Healio Dermatology.
“They provide guidance on comorbidity screening and review all available treatments for pediatric psoriasis including topicals, phototherapy, oral systemic therapies and the relatively newer biologics,” said Joy Wan, MD, MSCE, pediatric dermatologist and professor of dermatology at University of Pennsylvania Perelman School of Medicine.
Published in Journal of the American Academy of Dermatology, the guidelines cover the relevant screening tools used to measure psoriasis severity, screening or therapeutic interventions, along with efficacy and adverse events from monotherapy or combination treatments.
Determining pediatric guidelines was difficult because many treatments are not approved for use in children, according to co-chair of the committee Alan Menter, MD, chairman of the division of dermatology at Baylor University Medical Center in Dallas.
Approved, recommended therapies
Enbrel (etanercept, Amgen) is approved for children aged at least 4 years, and ustekinumab (Stelara, Janssen) is approved in adolescents aged at least 12 years, but not yet in children, Menter said.
“With topical steroids, we need to be more cautious,” Menter said. “They get absorbed and cause systemic side effects more common in children than in adults. A lot of the discussion points were how comfortable do we feel with methotrexate and cyclosporine for children. I am much more comfortable with cyclosporine with young people than older patients, because in children the risk of renal side effects is significantly lower.”
The committee does not recommend topical steroids in young children due to absorption, according to Menter.
“Talking about moderate to severe psoriasis is rather difficult in the pediatric world. We had to recognize that mild to moderate psoriasis is still 70% of all forms of psoriasis. We all get taken up with biologic drugs because they work so well, but the majority of patients have mild to moderate disease. All of us treat children and adolescents all the time. What patients fear most is side effects. Once we tell them this drug is approved for children, they feel like it’s safer for adults,” Menter said.
“Although psoriasis is less common in children, it can have a devastating impact on the physical and emotional well-being of those affected. There have been tremendous advances in the management of pediatric psoriasis, with several biologic agents receiving FDA approval for this indication,” Gelfand said.
The emotional toll of having psorasis as a child
“Dermatologists should know that children with psoriasis get teased and bullied a lot more than people recognize, and many wish to drop out of school because of it,” Menter said.
Menter told the story of a young female patient who had significant disease and was facing so much bullying at school she came to his office in tears. He prescribed cyclosporine, which achieved clearance in 3 months. Afterward, he prescribed etanercept, which maintained her skin clearance. She graduated at the top of her class and earned a scholarship at a top university.
“We have to recognize that it’s important to get these children clear, safely. A 70-year-old patient is going to be far less uncomfortable with their disease because they’ve had it for so long,” Menter said. “A child with recent onset has to be treated appropriately and cleared in a safe way. Recognize how much psoriasis impacts a younger child’s life and the comorbidities, particularly from an emotional and mental perspective.”
According to the guidelines, knowledge gaps exist in understanding pediatric psoriasis including the mechanisms of disease onset; etiology; development of comorbidities; systemic treatment options, their ideal dosage and adverse effect profiles; the use of combination therapy and transition between treatment options. The experts also stressed the importance of patient education, which is recommended no matter the level of disease.
“These guidelines not only guide current clinical practice but they also highlight the need for more research in psoriasis focused on comorbidities and long-term treatment safety and efficacy particular to the pediatric population,” Wan said. – by Abigail Sutton
Disclosures: Gelfand reports he served as a consultant for AbbVie, Bristol-Myers Squibb, Boehringer Ingelheim, Dermira, Dr. Reddy, GlaxoSmithKline, Janssen Pharmaceuticals, Menlo Therapeutics, Novartis Pharmaceuticals, Pfizer, Regeneron, Sanofi US Services, UB and Valeant Pharmaceuticals North America. Please see the study for his other financial disclosures. Menter reports he served as a consultant for Abbott Labs, AbbVie, Amgen, Eli Lilly and Co., Galderma USA, Janssen Pharmaceuticals, LEO Pharma US, Menlo Therapeutics, Novartis, Sienna Biopharmaceuticals and Wyeth Labs. Please see the study for his other financial disclosures. Wan reports he conducts research in inflammatory skin disease and has received funding from Pfizer and NPF.