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Systemic treatment is reserved for severe, recalcitrant psoriasis in children. All systemic treatments have potential adverse effects that require baseline and follow-up clinical and/or laboratory monitoring.
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Narrow-band ultraviolet B (NB-UVB) as monotherapy works best for guttate and thin-plaque psoriasis, but its use may be limited by the practicality of attending multiple weekly treatments. NB-UVB used in combination with acitretin is synergistic.
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Acitretin is a nonimmunosuppressive treatment
Systemic Treatments for Severe Pediatric Psoriasis: A Practical Approach
Section snippets
Key points
Phototherapy
Ultraviolet (UV) light has been used as a treatment for psoriasis even before Goeckerman popularized UVB phototherapy in 1925.5 Indications for phototherapy in children include diffuse involvement, disease refractory to combination topical therapy, contraindications to systemic therapy, and debilitating palmoplantar psoriasis. Three types of UV light are used for phototherapy: narrow-band UVB (NB-UVB, 311–313 nm), broadband UVB (BB-UVB, 290–320 nm) and UVA (320–400 nm). Although
Acitretin (Soriatane)
Retinoids are nonimmunosuppressive vitamin A analogues that bind to nuclear receptors and affect cellular metabolism, epidermal differentiation, and apoptosis.34 Acitretin, a metabolite of etretinate, replaced etretinate in 1998. Long-term experience treating children with disorders of cornification with oral retinoids supports their safety in children, although laboratory monitoring is necessary (Table 1).35 Acitretin works best for guttate and pustular psoriasis and has been used in children
Methotrexate (Rheumatrex, Trexall)
Methotrexate (MTX) has been used to treat psoriasis since the 1950s and remains the most widely prescribed drug for severe psoriasis worldwide.46 It is a folic acid analogue that reversibly inhibits dihydrofolate reductase, resulting in interference with DNA synthesis and effects on T cells.46, 47 De Jager and colleagues48 recently deemed MTX the systemic treatment of choice for children with moderate to severe psoriasis based on a systematic literature review of published data from 1980 to
Cyclosporine (Gengraf, Neoral)
CSA is an immunosuppressive agent that is used for the prevention and treatment of transplant rejection in children older than 6 months. There is substantial clinical experience with off-label use for refractory pediatric atopic dermatitis and psoriasis.68, 69, 70, 71, 72, 73 CSA is a good choice for rapidly evolving or recalcitrant plaque or pustular psoriasis (Case 3). Its use has been deemed effective and well tolerated in children as young as 11 months old at doses ranging from 1.5 to 5
Biologics
Biological medications target and interrupt specific components of the inflammatory cascade involved in psoriasis pathogenesis. The details of mechanism of action, adverse effects, and contraindications of each agent have recently been reviewed.81 Biological therapies are an attractive choice for treating psoriasis in children, but their proper role in the management of this disease remains to be defined. Biologics offer the convenience of less frequent dosing and far less laboratory monitoring
Case 1
A 3-year-old boy presents with a severe, explosive-onset psoriatic eruption on the trunk (Fig. 1A, B). It progresses rapidly over 4 days and then stabilizes. It is intensely pruritic. He presents to the office with a low-grade fever, mild cough, and nasal congestion. Assessment is severe plaque psoriasis and concomitant viral upper respiratory infection versus streptococcal pharyngitis. There is no evidence of arthritis. A throat culture is obtained. Treatment choices include the conventional
Summary
Treating severe psoriasis in children is not an exact science. As we accumulate data and gain familiarity with new and emerging targeted therapies, we continue to build on the collective experience using conventional therapies. Children have a potential lifetime of treatment ahead of them. As such, we should consider not only today’s known and unknown effects of various treatments but also tomorrow’s. Although psoriasis is one of the most common diseases of childhood, several key issues remain
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Cited by (49)
Evolving Landscape of Biologic Therapy for Pediatric Psoriasis
2024, Dermatologic ClinicsDermatologic Drug Therapy in Children
2020, Comprehensive Dermatologic Drug Therapy, Fourth EditionJoint American Academy of Dermatology–National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients
2020, Journal of the American Academy of DermatologyCitation Excerpt :These agents may be selected based on individual clinical factors in selected cases but will not be discussed here. Monitoring suggestions for nonbiologic systemic medications for pediatric psoriasis are summarized in Table XXXVI.101,133,134 Biologic medications are immunomodulators that regulate inflammation via specifically targeted pathways involving cell signaling, immune cell development, recruitment, and apoptosis.
Management of pediatric plaque psoriasis using biologics
2020, Journal of the American Academy of DermatologyCitation Excerpt :Narrow-band ultraviolet B phototherapy is acceptable as a first-line treatment after topical therapy has failed. Conventional systemic nonbiologic therapies, such as methotrexate (MTX), cyclosporine, and acitretin, are off-label for the indication of pediatric psoriasis but are often used after failure, intolerance, or unavailability of narrow-band ultraviolet B.13,24,25 These treatment modalities can offer effective control, but use may be limited by adverse events (AEs) and toxicities. Among the conventional systemic nonbiologic therapies, MTX is most commonly used, reflecting its extensive experience from other pediatric inflammatory diseases.
Phototherapy in the Pediatric Population
2020, Dermatologic ClinicsCitation Excerpt :One study found that pediatric patients with psoriasis responded better to phototherapy than children with AD and required fewer treatments.37 As in AD, combination therapy for NBUVB with topical agents may increase the efficacy of phototherapy in childhood psoriasis while decreasing overall exposure to UV light.54 BBUVB and Goeckerman treatment have also been reported to be safe and effective in childhood psoriasis (see Table 4).21,46,50,52,55
Psoriasis: Which therapy for which patient: Focus on special populations and chronic infections
2019, Journal of the American Academy of DermatologyCitation Excerpt :A phase III trial compared adalimumab and methotrexate in 114 pediatric patients (4-17 years of age) with severe psoriasis. At week 16, a 75% improvement in the Psoriasis Area and Severity Index score in the adalimumab group was 58%, which was significantly higher than 32% in the methotrexate group.64,65 Infliximab is approved for the treatment of Crohn's disease in children ≥6 years of age.66