Pediatric psoriasis guideline

Guideline highlights

1. Psoriasis is a chronic, multisystem, inflammatory disease that affects approximately one percent of children, with onset most common during adolescence. One-third of psoriasis cases begin in the pediatric years.

2. Psoriasis may be triggered or exacerbated by infections, physiological, emotional and environmental stressors, as well as cutaneous trauma. Pediatric psoriasis in particular can be associated with emotional stress, increased body mass index, second-hand cigarette smoke, pharyngeal and perianal Group A beta-hemolytic strep infection, Kawasaki disease, withdrawal of systemic corticosteroids.

3. This guideline addresses the assessment and management of major comorbid conditions associated with psoriasis, including psoriatic arthritis, metabolic syndrome, cardiovascular disease, dyslipidemia, hypertension, insulin resistance, mental health and Inflammatory bowel disease.

4. Identification of comorbidities requires the attention of the patient’s primary care provider and may have an important impact on management decisions for psoriasis as a cutaneous disease.

5. Topical corticosteroids with Vitamin D are commonly used as an off label treatment for pediatric psoriasis. However, caution should be used regarding ultra-high and high potency corticosteroids. Topical tazarotene is used in combination with topical corticosteroids for skin or nail psoriasis. Psoriasis treatment of the face and genitalia is effective with off-label topical calcineurin inhibitors either as monotherapy or in combination with topical corticosteroids.

6. Side effects of Anthralin may limit its use and should not be used for face or genitalia. However, it is effective as a long-term treatment of mild to moderate disease.

7. Phototherapy is effective for moderate to severe plaque as well as guttate psoriasis and is often used in conjunction with anthralin or coal tar as adjuvants.

8. Among non-biologic systemic drugs, methotrexate is most commonly used for moderate to severe psoriasis with good efficacy and should be supplemented with folic acid. Cyclosporine is effective for moderate to severe pediatric psoriasis particularly for patients with pustular or erythrodermic psoriasis. While systemic retinoids are effective for guttate psoriasis, pustular and palmar planter psoriasis, it does not cause immunosuppression and can be helpful for transplant patients.

9. Etanercept and Ustekinumab are FDA approved for four years and older and twelve years and older respectively. Other biologic drugs are used off-label. Biologics can be used in combination with systemic and topical therapies.

Read the full pediatric guideline in JAAD.

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