Pediatric psoriasis, an Italian consensus document updates

Treatment of moderate / severe pediatric psoriasis changes with the constant development of new targeted systemic therapies, while topical corticosteroids remain the first choice for mild forms. Research focused on children is needed to further improve disease treatment in this population, concluded an Italian consensus on disease treatment published in the journal Dermatology and Therapy.

Treatment of moderate / severe pediatric psoriasis changes with the constant development of new targeted systemic therapies, while topical corticosteroids remain the first choice for mild forms. Child-focused research is needed to further improve disease management in this population, concluded an Italian consensus on disease management published in the journal Dermatology and therapy.

The prevalence of pediatric psoriasis is uncertain as epidemiological studies are lacking in this population. The reported rates in Europe vary between 0.17 and 1.5%. In particular, the prevalence appears to increase almost linearly from 1 year of age to 18 years of age. Pediatric psoriasis manifests clinically with erythematous scaly plaques that are generally smaller, less infiltrating, and less peeling than those seen in adults. In infants (<1 year), the disease usually affects diaper-covered areas and groin folds (psoriatic diaper rash). In older children, plaque psoriasis is the most common type and most often affects the scalp, face, elbows and knees.

As in adults, pediatric psoriasis may be associated with comorbidities such as obesity, hyperlipidemia, hypertension, diabetes, Crohn’s disease and psoriatic arthritis, and psychiatric comorbidities including depression and anxiety have been reported in some children and adolescents. A recent retrospective analysis involving 4,754 pediatric patients with psoriasis identified anxiety as the most prevalent comorbidity (6.6%), followed by depression (4.1%) and obesity (3.9%).

The burden of disease in children with psoriasis and their families is significant. Young patients may be ashamed of visible skin lesions, have a very negative body image and face stigma, loss of confidence, anxiety and social isolation. In addition, symptoms associated with psoriasis such as itching can be extremely bothersome for children. The available evidence shows that these young patients have significantly greater impairment in physical, emotional, social and academic functioning than their healthy peers, a impairment similar to that seen in patients with other severe chronic conditions such as arthritis, psychiatric disorders, asthma and diabetes. Parents of psoriatic children also experience a significant decrease in quality of life.

The treatment of pediatric psoriasis it is also challenging due to the lack of specific updated guidelines. With the recent approval of several biological drugs for pediatric psoriasis and the ongoing Covid-19 pandemic, the management of young psoriasis patients is facing major changes. A review of the therapeutic recommendations is therefore necessary, the authors said.

An Italian consensus document
In September 2021, a board of six Italian dermatologists met to update the treatment recommendations and issued evidence-based statements covering relevant areas of pediatric psoriasis, namely assessment of the severity of the disease, management of younger patients and treatment options. To reach consensus, the opinions were presented to a panel of 24 experts in a Delphi video conferencing process, who established a processing algorithm.

There was full agreement that the severity of psoriasis is determined by the extent / severity of the skin lesions, the location of the lesions and the impact on the patient’s quality of life. Agreement was reached on the need for a multidisciplinary approach to pediatric psoriasis and on the importance of patient / parent education.

The relevance of vaccinations for children with psoriasis, including Covid, was recognized by all participants. Management issues that initially did not reach consensus included screening for comorbidities and early treatment with biological drugs to prevent them, as well as the use of telemedicine to facilitate patient follow-up.

Treatment recommendations
Experts agreed that topical corticosteroids are the preferred treatment in mild forms, while phototherapy and systemic therapy are used for children with moderate to severe psoriasis. According to the proposed treatment algorithm, biological drugs represent the first line of systemic therapy.

THAT topical corticosteroids they can be combined with other topical therapies, with phototherapy and with systemic therapies, including biologics. A convenient and effective solid combination of the corticosteroid betamethasone dipropionate with the vitamin D analogue calcipotriol is available if the efficacy and safety profile for the treatment of pediatric psoriasis is supported by evidence from small studies and clinical practice.

That Vitamin D analogues they can be used for children of all ages, with a relatively favorable profile of efficiency, safety and tolerability. They can cause local skin irritation to be dealt with by concomitant application of emollients.

That topical calcineurin inhibitors they can be used as corticosteroid-saving agents. They can be particularly useful in treating injuries that affect sensitive areas of the body surface. Burning is the most commonly reported side effect. Like vitamin D analogues, they are not approved by the EMA for the treatment of psoriasis in children.

There narrowband UVB light treatment (wavelength 311-313 nm) is useful and effective in children and represents a valid option for the treatment of moderate / severe forms of plaque and guttate psoriasis (a form characterized by erythematous and tremorous lesions of small size, prevalent especially on the trunk ).

There systemic therapy is indicated for moderate to severe psoriasis, but in children the decision to start it, as well as the choice of drug, requires an accurate assessment of the severity of the disease, its impact on physical and psychological function and quality of life, patient characteristics, comorbidity profile and response to previous treatments.

According to current guidelines, systemic treatment options include conventional oral medications (methotrexate, cyclosporine, retinoids) and biologic drugs that target the inflammatory pathways involved in the pathogenesis of the disease (tumor necrosis factor (TNF) -α, interleukin (IL) – 12/23 and IL-17A). Conventional systemic therapies are widely used in adults but are not approved for children, while several biologics have been approved by the EMA for the treatment of moderate to severe pediatric psoriasis and include etanercept, adalimumab, ustekinumab, secukinumab and ixekizumab.

“Targeted systemic therapies alter the treatment of moderate to severe pediatric psoriasis, while topical corticosteroids remain the first choice for mild disease,” the authors concluded. “Child-focused research is needed to further improve the treatment of pediatric psoriasis.”

Bibliography

Peris K et al. Update on pediatric psoriasis treatment: an Italian consensus. Dermatol Ther (Heidelb). July 1, 2022; 1-23.

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