Update on the Management of Pediatric Psoriasis: An Italian Consensus

Abstract

Introduction: Psoriasis affects children with a considerable burden in early life. Treating pediatric psoriasis is challenging also because of the lack of updated specific guidelines. With the recent approval of several biologics for pediatric psoriasis and the ongoing COVID-19 pandemic, the management of young psoriatic patients is facing major changes. A revision of treatment recommendations is therefore needed.

Methods: In September 2021, a board of six Italian dermatologists convened to update treatment recommendations. The board issued evidence- and consensus-based statements covering relevant areas of pediatric psoriasis, namely: assessment of psoriasis severity, management of children with psoriasis, and treatment of pediatric psoriasis. To reach consensus, the statements were submitted to a panel of 24 experts in a Delphi process performed entirely via videoconference. A treatment algorithm was produced.

Results: There was full consensus that psoriasis severity is determined by the extension/severity of skin lesions, site of lesions, and impact on patient quality of life. Agreement was reached on the need for a multidisciplinary approach to pediatric psoriasis and the importance of patient/parents education. The relevance of vaccinations, including COVID-19 vaccination, for psoriatic children was acknowledged by all participants. Management issues that initially failed to reach consensus included the screening for psoriasis comorbidities and early treatment with biologics to prevent them and the use of telemedicine to facilitate patient follow-up. There was full consensus that topical corticosteroids are the first choice for the treatment of mild pediatric psoriasis, while phototherapy and systemic therapy are used in children with moderate-severe psoriasis. According to the proposed treatment algorithm, biologics are the first line of systemic therapy.

Conclusions: Targeted systemic therapies are changing the treatment of moderate-severe pediatric psoriasis, while topical corticosteroids continue to be the first choice for mild disease. Children-centered research is needed to further improve the treatment of pediatric psoriasis.

Keywords: Adolescents; Biologics; Children; Corticosteroid-sparing; Health-related quality of life; Pediatric psoriasis; Plaque psoriasis; Systemic therapy; Topical corticosteroids.

Fig. 1

Flowchart of the Delphi study

Fig. 2

Treatment algorithm. BSA body surface area, CDLQI Children’s Dermatology Life Quality Index, NB-UVB narrow-band ultraviolet light B, PASI Psoriasis Area and Severity Index. ^aNot approved by EMA for use in pediatric patients with psoriasis; approved by FDA for patients aged ≥ 12 years. ^bNot approved by EMA for use in pediatric patients with psoriasis. ^cNB-UVB phototherapy is suitable for children aged > 12 years. ^dAdalimumab is approved by EMA for severe chronic psoriasis in children ≥ 4 years old who have had an inadequate response to, or are ineligible for, topical therapies and phototherapy. ^eIxekizumab is approved by EMA for moderate to severe psoriasis in children ≥ 6 years old, of at least 25 kg of weight, who are candidates for systemic therapy. The reimbursement of ixekizumab for use in children is currently under review by the Italian healthcare system. ^fSecukinumab is approved by EMA for moderate to severe psoriasis in children ≥ 6 years old who are candidates for systemic therapy. The reimbursement of secukinumab for use in children is currently under review by the Italian healthcare system. ^gEtanercept is approved by EMA for severe chronic psoriasis in children ≥ 6 years old who are inadequately controlled by, or are intolerant to, other systemic therapies or phototherapy. ^hUstekinumab is approved by EMA for moderate to severe psoriasis in children ≥ 6 years old who are inadequately controlled by, or are intolerant to, other systemic therapies or phototherapy. Ustekinumab is however not reimbursed by the Italian healthcare system for use in children