Addressing potential long-term care needs of patients with pediatric psoriasis
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Healio spoke with Joy Wan, MD, MSCE, pediatric dermatologist at Johns Hopkins University, about challenges in pediatric psoriasis, collaborative care and available treatment options.
Wan also highlighted gaps in care and important questions for pediatric psoriasis research.
Healio: What differences are there in pediatric psoriasis compared with adult psoriasis — whether in actual presentation or in diagnosis and treatment?
Wan: Psoriasis affects about 1% of the population and many cases begin during childhood. While there’s much overlap between children and adults, there are some differences to note. Some subtypes of psoriasis, notably guttate psoriasis, are more commonly present in children than adults. Facial involvement of psoriasis is also more common in children, and infants who present with psoriasis can often have involvement of the diaper area. Select triggers, or exacerbating factors, can be more common in pediatric psoriasis. For example, strep infections can trigger the initial presentation and recurrent flares of psoriasis, and we tend to see this more often in children and with guttate psoriasis.
Healio: How common is pediatric psoriasis and what advice do you have for pediatricians who may suspect psoriasis?
Wan: Although the prevalence of pediatric psoriasis varies by age, generally increasing from childhood to adolescence, it has been estimated to affect approximately 0.2% to 0.8% of children overall. For pediatricians who suspect psoriasis in a patient, I would recommend referring the patient to a dermatologist for evaluation and treatment. Psoriasis is often a clinical diagnosis which can be made by a dermatologist. There are also many types of treatment available for psoriasis, and a dermatologist would be able to help with appropriate treatment selection and education.
Healio: What does collaboration look like between pediatricians and dermatologists?
Wan: Close communication between pediatricians and dermatologists is paramount to the care of children with psoriasis, which is often a chronic disease that persists lifelong. Psoriasis is associated with comorbidities such as arthritis; obesity; cardiovascular risk factors, such as dyslipidemia and insulin resistance; and depression. Appropriate screening and management of these comorbid conditions relies on collaboration between pediatricians and dermatologists. Additionally, some treatments for psoriasis may increase one’s risk for infections or other adverse effects, and close communication between dermatologists and pediatricians is thus necessary for optimal long-term medication monitoring.
Healio: What treatments are available for children with psoriasis? Are there new treatments in the pipeline?
Wan: Available treatments range from topical therapies to phototherapy to systemic or biologic medications. What has been exciting about the treatment landscape in psoriasis is that many novel and highly effective therapies have emerged in the last 5 years, and more continue to emerge. Select therapies — for example, some of the biologics — are now also approved for pediatric use, and with time, children will hopefully have access to even more of these novel therapies in the pipeline.
Healio: Where are there gaps in the care continuum for pediatric psoriasis? Where does research need to focus?
Wan: Psoriasis often follows a chronic course, so affected individuals, particularly those who are diagnosed during childhood, will need long-term care and monitoring. Some gaps in the care continuum include appropriate screening for comorbidities as well as long-term medication management, particularly as more children initiate systemic or biologic therapies at younger ages. For example, how long should children stay on these treatments? If treatments stop working, what should be the approach to subsequent treatment selection? Does earlier initiation of select treatments mitigate the risk for associated comorbidities? What is the long-term safety (ie, 20 to 30 years or longer) of treatments? In addition to addressing these questions, future research will also need to focus on dissecting the mechanisms of disease onset and comorbidity risk and prevention in children.
Healio: In November 2020, guidelines were released for pediatric psoriasis. What impact have they had in practice? Have there been any updates?
Wan: The 2020 joint AAD-NPF guidelines for pediatric psoriasis were the first set of guidelines focused specifically on the care of children with psoriasis. The guidelines are comprehensive and provide practical guidance for both dermatologists and primary care providers. Although I don’t have any hard data to measure the impact of these guidelines, the guidelines have likely raised awareness about comorbidity screening and treatment considerations among children with psoriasis and established best practices for clinicians to follow. To my knowledge, there has not yet been an update to these guidelines; however, the guidelines will certainly evolve over time as more research on pediatric psoriasis is done.
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