Why carry out this study?
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Pediatric psoriasis poses a considerable burden on patients and their families |
The management and treatment of pediatric psoriasis are complex. The availability of new treatment options, as well as the ongoing COVID-19 pandemic, are changing the management of children with psoriasis |
Updated specific guidelines for the management of pediatric psoriasis are needed |
What was learned from this study?
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A panel of Italian dermatologists produced a set of statements covering relevant areas of pediatric psoriasis management based on the literature, their clinical experience, and consensus |
The consensus statements are presented in this article, along with a treatment algorithm. They update current recommendations for the management of children with psoriasis and offer comprehensive practical guidance to dermatologists and pediatricians |
As the field of psoriasis management is rapidly evolving, treatment recommendations and the algorithm will need regular revision |
Introduction
Methods
Study Design
Development of Consensus Statements
Results
Assessment of Disease Severity
Assessment of disease severity | ||
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Statement # | Statement | Level of agreement (%) |
S1 | The Psoriasis Area and Severity Index (PASI) and Body Surface Area (BSA) measurement of involved skin area are the currently available tools for the assessment of pediatric psoriasis severity | 92.6 |
S2 | Disease involvement of sensitive and visible skin areas affects pediatric psoriasis severity, daily activities, and the quality of life | 100 |
S3 | The Children’s Dermatology Life Quality Index (CDLQI) is a validated tool for measuring the impact of psoriasis in children and adolescents up to 16 years | 85.2 |
Management
Management | ||
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Statement # | Statement | Level of agreement (%) |
S4 | Pediatric patients with psoriasis should be screened for psoriatic arthritis through personal and family history, physical signs, and referred symptoms | 92.6 |
S5 | Pediatric patients with psoriasis and their parents should be educated about the possible different clinical manifestations, the disease course, the risk of psoriatic arthritis and other comorbidities | 93.3 |
S6 | Pediatric patients with psoriasis and their parents should be educated about topical and systemic therapies, the risk of adverse events, and vaccination plans | 100 |
S7 | Educational tools (video, leaflets, education programs, etc.) dedicated to children with psoriasis may improve the adherence to topical and systemic treatments, including injectable therapies | 92.6 |
S8 | Early treatment with biologics in pediatric patients with moderate to severe psoriasis might positively modify the disease course | 100 |
S9 | A multidisciplinary approach, if needed, can provide a more appropriate management of pediatric psoriasis and reduce healthcare costs | 92.6 |
S10 | Psychologic support to patients and their parents can reduce the impact of a chronic disease that occurs during childhood | 81.5 |
S11 | In light of the available literature on SARS-CoV-2 infection and vaccination and its administration to the pediatric population, it is essential to clarify how to manage possible discontinuation of immunomodulatory therapy in young psoriasis patients | 88.9 |
S12 | Clinicians could use telemedicine as a useful option for the follow-up of pediatric patients with psoriasis, allowing continuity of care and providing appropriate medical support to patients and families in case of difficulties in reaching referral centers | 100 |
Screening of Comorbidities and Early Treatment
Education of Pediatric Patients and Their Parents
Multidisciplinary Management
Vaccinations
Telemedicine
Treatment
Topical Treatment
Treatment | ||
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Statement # | Statement | Level of agreement (%) |
S13 | Corticosteroids are the first-line topical therapy in pediatric patients with psoriasis | 81.5 |
S14 | Although off-label, the combination calcipotriol-betamethasone dipropionate as ointment, foam, or gel applied once daily for up to 4 weeks is a safe and effective treatment for children with mild to moderate plaque psoriasis, aged ≥ 12 years | 88.9 |
S15 | Skin care including the use of appropriate moisturizers/emollients, detergents and shampoos should be considered in pediatric patients with psoriasis along with pharmacologic topical therapy | 100 |
S16 | Rotational therapy with topical vitamin D analogues, topical calcineurin inhibitors, and emollients should be considered in pediatric patients with psoriasis as a corticosteroid-sparing strategy that may reduce the potential adverse effects of corticosteroids | 96.3 |
S17 | Although off-label, the use of topical calcineurin inhibitors should be considered as a corticosteroid-sparing therapy for the treatment of sensitive areas such as face and genitals | 92.6 |
S18 | Narrow band-UVB is a treatment option for moderate to severe plaque and guttate psoriasis in children aged > 12 years | 92.6 |
S19 | The decision to treat pediatric psoriasis with systemic therapy is based on patient characteristics including age, disease severity, the presence of comorbidities, the lack of response to topical agents and/or phototherapy, reduced physical or psychologic functioning, and impaired quality of life | 100 |
Phototherapy
Systemic Therapy
Treatment Algorithm
Corticosteroids | Class II and Class III Apply once daily and avoid prolonged or repeated treatment In sensitive areas, 1–2 week-treatment duration Class IV only for certain areas (scalp) and very short periods Discontinue treatment gradually |
Calcipotriol-betamethasone dipropionate (off-label) | Fixed-dose combination of 50 mcg/g calcipotriene and 0.643 mg/g betamethasone dipropionate (foam, gel, ointment) Apply once daily for up to 4 weeks Approved by FDA in patients aged ≥ 12 years |
Vitamin D analogues (off-label) | Calcipotriene, tacalcitol Apply once daily Do not apply to large skin areas (< 30% BSA for calcipotriene; < 15% BSA for tacalcitol) Treatment duration ≥ 2 weeks for full efficacy |
Calcineurin inhibitors (off-label) | Tacrolimus 0.1%, pimecrolimus Use preferentially for sensitive areas (face, body folds, genitals) Recommended twice day for a short term use and intermittent use in long term |
NB-UVB | Minimum age limit is 8 years Initial dose: 0.2–0.6 J/cm2, depending on skin type Increase dose subsequently by ≤ 25% 20–30 sessions usually required per treatment cycle, with a frequency of 3–5 sessions per week |
Adalimumab | Children aged 4–17 years Patient weight ≥ 15 kg and < 30 kg: initial dose of 20 mg SC, followed by 20 mg SC every other week Patient weight ≥ 30 kg: initial dose of 40 mg SC, followed by 40 mg SC every other week In non-responders, treatment beyond 16 weeks should be carefully considered |
Ixekizumab | Children aged ≥ 6 years, with body weight ≥ 25 kg and for adolescents Patient weight 25–50 kg: start with 80 mg SC, followed by 40 mg SC every 4 weeks Patient weight > 50 kg: start with 160 mg SC (two 80 mg-injections), followed by 80 mg SC every 4 weeks |
Secukinumab | Children aged ≥ 6 years Weekly dosing for 5 weeks, followed by monthly dosing for maintenance Body weight < 25 kg: 75 mg SC Body weight ≥ 25 kg and < 50 kg: 75 mg SC Body weight ≥ 50 kg: 150 mg SC (may be increased to 300 mg SC) |
Etanercept | Children aged ≥ 6 years 25 mg twice weekly or 50 mg SC once weekly Alternatively: 50 mg SC twice weekly for up to 12 weeks, followed by 25 mg SC twice weekly, or 50 mg SC once weekly, if needed Treatment should be continued until remission, for up to 24 weeks Discontinue treatment if no response after 12 weeks |
Ustekinumab | Children aged ≥ 6 years Administer at week 0 and 4, and then every 12 weeks Body weight < 60 kg: 0.75 mg/kg SC (table with injection volumes available in EMA label) Body weight ≥ 60 kg SC and ≤ 100 kg: 45 mg SC Body weight > 100 kg: 90 mg SC Discontinue treatment if no response after up to 28 weeks of treatment |
Methotrexate (off-label) | Oral or subcutaneous/intramuscular administration Usual dose: 0.2–0.7 mg/kg once weekly, up to 15 mg per week As soon as disease control is achieved (12–16 weeks), reduce gradually dose to lower maintenance regimen Daily folic acid (1–5 mg) recommended (except on day of methotrexate administration) to reduce side effects |
Cyclosporine A (off-label) | Oral administration Initial dose: 2.5–5.0 mg/kg per day Optimal response expected after 8–16 weeks When disease is stable, slowly reduce to lowest effective dose Intermittent treatment courses are recommended |
Retinoids (off-label) | Oral administration Initial acitretin dose: 0.3–0.5 mg/kg per day Maintenance dose: up to 1 mg/kg per day Improvement of skin lesions usually seen after 2–3 months of treatment Contraception recommended in female adolescents for up to 3 years from treatment discontinuation |