DOI: 10.1111/pde.

13382

Pediatric
ORIGINAL ARTICLE Dermatology

Pediatric psoriasis: Evolving perspectives

Lawrence F. Eichenfield MD1,2 | Amy S. Paller MD3,4 | Wynnis L. Tom MD1,2 |

Jeffrey Sugarman MD, PhD5 | Adelaide A. Hebert MD6 | Sheila Fallon Friedlander
MD1,2 | Elaine Siegfried MD7,8 | Nanette Silverberg MD9,10 | Kelly M. Cordoro MD5,11

1
Department of Dermatology, University of
California, San Diego School of Medicine Abstract
and Rady Children’s Hospital, San Diego, Background/Objectives: Childhood-onset psoriasis is a common skin disorder that
CA, USA
2 has recently received increasing attention, particularly because of its significant
Department of Pediatrics, University of
California, San Diego School of Medicine medical, social, financial, and psychological burdens and its associated comorbidities.
and Rady Children’s Hospital, San Diego,
With limited data available and lack of standardized management guidelines for
CA, USA
3
Department of Dermatology, Feinberg pediatric psoriasis, an expert panel desired to provide an updated critical overview
School of Medicine, Northwestern and practical guidance for management of the affected population.
University, Chicago, IL, USA
4
Methods: A panel of pediatric dermatologists with extensive experience in pediatric
Department of Pediatrics, Feinberg School
of Medicine, Northwestern University, psoriasis defined and prioritized a core set of topics, performed an English-language
Chicago, IL, USA
literature review, prepared critical evaluations and presentations of topic areas, and
5
Department of Dermatology, University of
California, San Francisco School of
carried out a consensus meeting and follow-up consensus manuscript.
Medicine, San Francisco, CA, USA Results: The summation of evolving perspectives in pediatric psoriasis includes epi-
6
Pediatric Dermatology, McGovern School demiology and natural history of the disease, precipitating factors and comorbidities,
of Medicine and Children’s Memorial
Hermann Hospital, Houston, TX, USA quality of life and burden of disease, clinical features and disease presentation,
7
Department of Pediatrics, Saint Louis differential diagnosis, pathogenesis and treatment, including topical, photo, and
University School of Medicine, Cardinal
systemic therapies.
Glennon Children’s Hospital, St. Louis, MO,
USA Conclusion: Pediatric psoriasis is an important immune-mediated inflammatory skin
8
Department of Dermatology, Saint Louis disease with potential for significant impact on affected individuals and their care-
University School of Medicine, Cardinal
Glennon Children’s Hospital, St. Louis, MO, givers. Current state-of-the-art care is based primarily on experience and expert
USA consensus, but pediatric data are accumulating and therapeutic options are rapidly
9
Department of Dermatology, Icahn School
evolving.
of Medicine at Mt Sinai, New York, NY,
USA
10 KEYWORDS
Department of Pediatrics, Icahn School of
Medicine at Mt Sinai, New York, NY, USA clinical, disease burden, epidemiology, pediatrics, psoriasis, treatment
11
Department of Pediatrics, University of
California, San Francisco School of
Medicine, San Francisco, CA, USA

Correspondence
Lawrence F. Eichenfield, MD, Professor of
Dermatology and Pediatrics; Chief, Pediatric
and Adolescent Dermatology; Vice Chair,
Department of Dermatology; University of
California, San Diego and Rady Children’s
Hospital, San Diego, CA, USA.
Email: leichenfield.@rchsd.org

Pediatric Dermatology. 2018;1–12. wileyonlinelibrary.com/journal/pde © 2018 Wiley Periodicals, Inc. | 1

2 | Pediatric
Dermatology
1 | INTRODUCTION
The initiative began with identification of a panel of pediatric derma-
tologists with extensive experience in pediatric psoriasis. A core set
of topic areas was proposed, and the panel prioritized areas for
review, evaluation, and discussion, including epidemiology, clinical
features, triggers, pathogenesis, comorbidities, and disease burden
and management. English-language literature review was performed
using Medline, EMBASE, and the Web of Science, and relevant arti-
cles were made available to all panelists. Three experts were
assigned to each topic area, summary presentations were created
and edited, and topic areas were reviewed and discussed when the
panel was convened for a meeting in July 2016. All panelists evalu-
ated post-meeting summaries to achieve consensus, and additional
articles were identified and reviewed. Prioritization for topic areas
included in this manuscript was based upon the desire to provide an
updated overview and practical guidance for managing this impor-
tant population for which there is a tremendous clinical need and
yet a paucity of published data. This article is a summation of expert
presentations, key literature, and consensus review. It is not
intended to be a comprehensive review of all published literature or
a formal management guideline.
2 | EPIDEMIOLOGY AND NATURAL
HISTORY OF DISEASE
Psoriasis is a chronic, immune-mediated, inflammatory skin disease
with a recognized genetic predisposition. Disease prevalence in chil-
dren according to the medical literature varies depending on study
population and age, with 1% as a commonly quoted figure and an
1 sity. Central obesity (high waist circumference percentile and waist
incidence of 40.8 per 100 000 in one study. One-third of psoriasis
2 to height ratio) was associated only with moderate to severe dis-
begins in childhood, and psoriasis represents 4.1% of all dermatoses
seen in children younger than 16 years old in Europe and North
America.3 These data are likely to be an underestimate, because
some patients with mild disease may not seek care or may be misdi-
agnosed, and there may be racial disparities in prevalence and access
to care. Up-to-date epidemiologic data are sparse,4 but the reported
incidence of psoriasis more than doubled between 1970 to 1974
1,5
and 1995 to 1999. The rise in recorded diagnoses of pediatric
psoriasis may result from increases in trigger factors such as stress,
5,6
infection, trauma, and obesity. Increased physician and public
awareness may also contribute.
Although psoriasis may arise at any age, including infancy, the
reported median age of onset of childhood-onset psoriasis is
between 7 and 10 years. 2,7-11
Age of onset varies with psoriasis sub-
type; for example, early disease onset has been reported for pustular
psoriasis.12,13
Approximately 30% of children with psoriasis have an affected
14
first-degree relative, and a positive family history can predict early
disease onset.15 Psoriasis appears earlier in girls,16,17 and some stud-
ies also report a slight female bias in overall incidence.5,10,18,19 This
EICHENFIELD ET AL.
reported pediatric female predominance is the opposite of that com-
monly observed in adults.20 Because high-quality, long-duration pop-
ulation studies are lacking, the true epidemiology and natural history
of childhood-onset psoriasis is unclear.
3 | PRECIPITATING FACTORS AND
COMORBIDITIES
Precipitating factors are more commonly identified in childhood pso-
riasis than in adult-onset disease,21 with infection identified fre-
quently.22 This includes bacterial infection (particularly perianal
streptococci and streptococcal pharyngitis) and viral illnesses. Certain
medications (e.g., systemic corticosteroid withdrawal, lithium, beta
blockers, antimalarials),22 and stress23 have also been implicated in
initiation and exacerbation of early-onset disease.7,24 Psoriasis onset
or flare of existing disease in the context of anti-tumor necrosis fac-
tor (TNF)-a therapy for psoriasis and other inflammatory and autoim-
mune conditions has also been reported in children.25,26 Skin trauma
is a factor via the Koebner phenomenon. Mechanical irritation, as
well as secondary candidal or streptococcal colonization or infection,
may cause psoriasis in the diaper area and skin folds.
According to recent studies, the occurrence of comorbidities in
individuals younger than 20 with psoriasis (14.4%) is double that of
peers without psoriasis (7.2%).27 Obesity as a comorbidity has been
the focus of much investigation.28,29 Forty-eight percent of over-
weight and obese children have a parent who is obese.30 Children
with psoriasis have been identified as having greater adiposity and
central adiposity. There is a dose-response effect between weight
and psoriasis, with mild to moderate psoriasis associated with being
overweight and moderate to severe psoriasis associated with obe-
ease.22 The development of obesity could account for the increases
in severity and incidence beginning after 7 to 8 years of age, the
age at which weight gain usually begins. It is likely that the associa-
tion between obesity and psoriasis is bidirectional. In one pilot study,
more than 90% of overweight or obese children with psoriasis devel-
oped psoriasis at least 2 years after the onset of the increase in adi-
posity and remained obese for at least 2 years after the onset of
psoriasis despite systemic intervention,30 although a decrease in
physical activity or psychosocial effects once psoriasis develops
could also lead to weight gain. Nevertheless, the associated increase
in metabolic risks warrants early monitoring and lifestyle modifica-
tion.28 The first comorbidity screening guidelines for children with
psoriasis were recently published.31 It is unclear whether weight loss
reduces psoriasis severity;30,32,33 but recent data in adults are
encouraging.9
Children with psoriasis have been reported to have two to four
times the risk of hyperlipidemia, hypertension, diabetes mellitus,
rheumatoid arthritis, and Crohn’s disease8 and have a higher preva-
lence of metabolic syndrome (30%) than age-matched controls
EICHENFIELD ET AL.
(7.4%).34,35 It is likely that the relationship between psoriasis and
cardio-metabolic comorbidities is linked to the underlying chronic
systemic inflammation in psoriasis.36 Children with psoriasis have
also been found to have a more atherogenic-cardiometabolic risk
profile, with evidence of insulin resistance and lipoprotein dysfunc-
tion, which may also provide a basis for the observed link between
psoriasis and cardiovascular disease in adulthood.37
Psoriatic arthritis, with a reported prevalence ranging from 6%-
41% in individuals with psoriasis,8,33 is a well-documented comorbid-
ity in children, although a prevalence of 5%-10% is commensurate
with observations from our pediatric practices. International studies
suggest that the prevalence of arthritis is higher in the United States
than in Europe,22 perhaps reflecting a greater prevalence of risk fac-
tors. This includes obesity, which when present in early adulthood
38
may increase the risk of developing psoriatic arthritis later in life.
Psoriatic arthritis may occur in the absence of skin lesions. Age of
onset of psoriatic arthritis in children with skin involvement is usually
between 9 and 12 years. The most common type of juvenile psori-
atic arthritis (JPA) is oligoarticular, affecting approximately two-thirds
of young people with arthritis. It is often mild. Other types include
polyarthritis and enthesitis-related JPA. Although joint involvement
can occur at any time, children are more likely to experience simulta-
neous onset of psoriasis and psoriatic arthritis than adults.
4 | QUALITY OF LIFE AND BURDEN OF
DISEASE
39-42
Psoriasis greatly influences quality of life (QoL). In QoL studies in
children with different skin diseases, those with psoriasis reported
some of the greatest impairments.43,44 Stress levels were as high as in
children with atopic dermatitis and higher than in children with urti-
45
caria or acne. Stress or lack of social support can also play a major
role in making the course of the disease worse.16 Other authors have
demonstrated that the significant damage to QoL of plaque psoriasis
is generally comparable with the effect of other serious pediatric
chronic diseases such as arthritis, asthma, and diabetes.45 There is a
greater risk of depression, anxiety, and bipolar disorder.23,46,47
The social development domain of the Children’s Dermatology
Life Quality Index (CDLQI) is particularly impaired in children with
psoriasis,44 affecting emotional and school functioning.42 Children
can experience teasing, social exclusion by peers, name calling, intim-
idation, and in some cases physical violence. Moreover, psoriasis
results in a high degree of recreational activity limitations in at least
15%-30% of children.2 Pruritus with sweating, visibility of psoriatic
lesions (e.g., excess representation of facial disease in childhood),
and problems with treatment regimens have the highest effect on
QoL.48 In the long term, the severity of psoriasis, rather than the
age of onset, seems to determine QoL.48 Defining severity, which is
not entirely related to body surface area (BSA), depending also on
disease location and individual differences in perception of disease,
is complex. Common measures of disease severity used in research,
such as the Psoriasis Area and Severity Index (PASI), have not been
Pediatric | 3
Dermatology
validated in children. In the clinical setting, practical assessment of
severity includes a combination of factors such as BSA involved; dis-
tribution; age; social, medical, and emotional effect; response to
therapy; and practicality of certain therapies.
Two aspects rarely discussed in the literature are the degree of
scale that children shed and the odor of affected skin. Both are sig-
nificant problems for many children, adding to their embarrassment
about their bodies. Dissatisfaction with cutaneous body image (an
individual’s mental representation of their skin, hair, and nails) is
important to elicit from patients in relation to the effect of their pso-
riasis. Asking children to rate their satisfaction with the appearance
of their skin on a scale from 1 to 10 is an easy way to assess this
issue objectively and to validate this concern as being medically
important and not just a question of vanity.49
5 | CLINICAL FEATURES AND DISEASE
PRESENTATION
Psoriasis presents with variable manifestations and degrees of sever-
ity. Available data suggest that approximately 80% of patients have
mild to moderate disease, defined as an affected BSA of less than
10%, although specific data on disease severity in children are lacking.
It is likely that the numbers underestimate the percentage of patients
with moderate to severe disease when accounting for factors such as
practice setting, body site affected, effect on physical functioning, and
QoL. Many clinical trials use PASI and Physicians Global Severity
scores, but these are not commonly used in clinical practice.10 Children
have greater involvement of the face and anogenital regions than
adults, with facial psoriasis the sole manifestation in 4%-5% of chil-
dren.22 The most frequent sites of involvement at onset are the scalp,
trunk, and extremities. Anogenital psoriasis is the most common pre-
sentation in children younger than 2 years old. There are notable sex-
related differences in scalp (more often female) and nail (more often
male) involvement, which may be related to environmental trauma.5
Pruritus is common.25 Spontaneous remission is more frequent in chil-
dren than adults and may be a function of severity and triggering fac-
tors. This is especially true when Streptococcus triggers psoriasis onset
or flare in a child with no family history of psoriasis.7
Plaque psoriasis is the most common variant (73.7%),5,50 present-
ing as erythematous plaques with silvery-white scale typically involv-
ing the scalp, postauricular region, elbows, knees, and umbilicus.
Plaque psoriasis in a subset of children may be smaller, thinner, and
less scaly than in adults. Infants with psoriasis often have involve-
ment of the diaper area, which frequently presents as a large area of
confluent erythema or salmon-colored patches or plaques, possibly
related to the Koebner phenomenon. Given the moisture from occlu-
sion of the diaper area, scaling may be obscured, and therefore it
can be difficult to differentiate diaper psoriasis from other common
diaper rashes. Involvement of the umbilical area or dissemination of
typical plaques is often helpful in distinguishing it from other causes
of diaper rash. There are few data on the longitudinal course of
infants who present with diaper psoriasis.51
4 | Pediatric
Dermatology
Guttate psoriasis is more common than in adults (13.7%)5 and
manifests as a few to numerous small, droplike, erythematous, scaly
papules on the trunk and extremities. Infections, especially group A
beta hemolytic streptococcus of the pharynx and occasionally the
perianal area,52 often precede the onset or flare of psoriasis, particu-
larly the guttate form. Recent data suggest that the presence or
absence of strep infections may be prognostic in a subset of
patients. Patients who have guttate disease associated with strepto-
coccus may spontaneously clear, and those without streptococcus as
a trigger may persist because guttate psoriasis may progress to
plaque-type psoriasis, which may ultimately be more severe than in
28,53
those whose psoriasis began as plaque-type at onset.
6 | DIFFERENTIAL DIAGNOSIS
Making the diagnosis of psoriasis is more difficult in children because
of atypical characteristics. Lesions in children may be thinner, softer,
less scaly, and sometimes less well defined than in adults.27 As a
result, pediatric psoriasis can be confused with atopic or nummular
dermatitis, pityriasis rosea, or superficial fungal infections.
Psoriasis of the hands, feet, or scalp and annular lesions on the
trunk may be confused with tinea; a potassium hydroxide prepara-
tion will distinguish between the two. Plaque formation on the scalp
is common and may be difficult to differentiate from, or may overlap
with, seborrheic dermatitis in adolescents. Diaper area psoriasis is
often mistaken for irritant or seborrheic dermatitis or Candida infec-
tion.5 Concomitant psoriasis and atopic dermatitis is occasionally
encountered, and many children with psoriasis have a psoriasiform
dermatitis that is intermediate between psoriasis and dermatitis,
often without the sharply delineated, very scaly lesions that are typi-
cal of psoriasis in adults. This condition is also referred to as overlap,
54
eczematous psoriasis, or psoriasiform eczema.
7 | PATHOGENESIS
The pathogenesis of psoriasis involves a complex interaction
between the immune system and the two main areas that affect the
onset and exacerbation of the disease: environmental factors and
genetic disposition. Pathogenic differences between adult- and
pediatric-onset psoriasis have yet to be defined in large studies, but
this work is under way. Approximately one-third of patients with
psoriasis have a first-degree relative with the condition, emphasizing
the influence of genetics.55,56 Environmental factors are involved in
the expression of the disease. Several factors such as physical
trauma, psychological stress, drugs, diet, and infections may trigger
the disease. The most compelling of these is infection with group A
streptococcus (GAS). Streptococcal throat infections frequently pre-
cede outbreaks of guttate psoriasis, which can then lead to chronic
plaque psoriasis. Psychological or emotional stress may exacerbate
psoriasis, as can physical trauma to the skin such as from sunburn or
scratches. Seasonal variation can also affect plaque psoriasis,
EICHENFIELD ET AL.
worsening in the winter, although the reduction in exposure to ultra-
violet light may play a role in this change.
Psoriasis in general is thought to be driven by type 17 T helper
(Th17)/interleukin (IL)-23 pathway activation with a positive inflamma-
tory feedback loop due to the persistent release of pro-inflammatory
cytokines, particularly TNF-a, IL-23, and IL-17A. Although large-scale
studies have yet to be published about the composition of the inflam-
matory infiltrate in the skin of children with psoriasis, early work in this
area has revealed differences in the inflammatory composition of
psoriatic plaques in children and adults.57
In the last 3 decades, the development of several highly effective
biologic drugs has revolutionized the treatment of moderate to sev-
ere plaque psoriasis, reflecting our increased understanding of its
pathogenesis, including the central importance of IL-23 and IL-17.
Furthering our understanding of the differences between pediatric
and adult psoriasis, and between individual patients, will allow for a
more personalized approach to therapy.
8 | TREATMENT
Several factors should be considered to determine the most appro-
priate therapeutic intervention for an individual: age, psoriasis mor-
phology, whether this is the initial episode or a recurrence or flare
of preexisting disease, site and extent of involvement, speed of pro-
gression, health history, current and prior treatments, triggering fac-
tors, presence of comorbidities, level of disability, effect on QoL,
patient and family preference, and cost of and access to medicines
and other modalities.58 A trial of an oral antibiotic in addition to
skin-directed therapy is indicated for patients with a GAS- or other
bacteria-positive throat or anal culture. An antibiotic directed at the
culture and sensitivities is the preferred treatment given the poten-
tial systemic sequelae of untreated streptococcal infection, although
data are mixed regarding effects on the psoriasis itself.59 Tonsillec-
tomy may be beneficial in a subset of patients with chronic GAS car-
riage, recurrent infections, and refractory psoriasis.60,61
Lately, the pediatric psoriasis treatment paradigm is shifting.
Recognition of extracutaneous comorbidities and the potential for
lifelong chronicity and effect supports a potentially more aggressive
management plan in a subset of children for whom a “less is more”
approach may not be appropriate. Discussion with patients and fami-
lies about the multiple factors involved in making treatment decisions,
the risks and benefits of and alternatives to each treatment, and shar-
ing those decisions with the family will create a therapeutic alliance
that may optimize medical outcomes and patient satisfaction.
9 | TOPICAL THERAPY
The majority of children present with mild, localized psoriasis that
can often be adequately treated with topical antiinflammatory
medications and adjunctive gentle skin care. The Food and Drug
Administration (FDA) has not approved any topical medications for
T A B L E 1 Topical treatment options for pediatric psoriasis27,90
Drug Mechanism
a
Anthralin (dithranol) Antiproliferative and anti-
inflammatory effects on
skin
Calcipotrienea,b Synthetic vitamin D3 analog;
inhibits epidermal
proliferation; promotes
keratinocyte differentiation
Tazarotenea Vitamin A derivative
(retinoid); thought to
regulate epidermal
proliferation
Corticosteroids (e.g., Antiinflammatory and
desonide, triamcinolone antiproliferative effects
acetonide, clobetasol
propionate)b,c
Salicylic acidd Keratolytic; acts as a scale
lifter to soften and remove
psoriasis scales
Coal tara Antiproliferative, anti-
inflammatory through
enzyme and DNA inhibition
Calcineurin inhibitorse Nonsteroidal immune-
modulating agents; inhibit
interleukin-2 production
and T-cell activation
a
Approved to treat adult psoriasis but not pediatric psoriasis.
b
Combination suspension for scalp psoriasis containing calcipotriene 0.005% and betamethasone dipropionate 0.064% available and indicated for patients age 12 years and older.
c
Approved to treat adult and pediatric psoriasis (minimum age for pediatric use depends on the specific agent).
d
Approved to treat adult and pediatric psoriasis; restrict use to children aged >6 years. (Do not use at all in infants and young children).
e
Not approved for adult or pediatric psoriasis.
Dosing regimens
0.1% cream applied daily for 10-
30 min; increase every other day
up to 3%-4% until mildly irritating
Can be used as monotherapy or in
combination with topical
corticosteroids for steroid-sparing
effects
Applied to affected area in short
courses of 10-60 min; can be used
every other day or weekly as part
of sequential or rotational therapy
with corticosteroids
Varying strengths and formulations
available
Applied in concentrations up to 6%
to small, thick, focal plaques on
scalp, palms, and soles (shampoo
and gel formulations available)
Can be applied directly as ointment,
cream, or solution or added to
bath water
Pimecrolimus available as cream;
tacrolimus as ointment
Contraindications
Erythroderma, generalized pustular
psoriasis
Calcium metabolism disorders
Pregnancy (may cause fetal harm)
Local viral, fungal, or bacterial
infection
Avoid in infants and young children
Inflamed, erythrodermic, or pustular
psoriasis; photosensitivity;
folliculitis; acne vulgaris
Food and Drug Administration
warns against use of pimecrolimus
and tacrolimus 0.03% and 0.1% in
children aged <2 years; tacrolimus
0.1% approved for children aged
≥15 years
Side effects
Skin irritation, staining
Irritation, hypercalcemia,
folliculitis
Skin irritation
Skin atrophy or stretching,
acne
Salicylate intoxication
Skin irritation, redness, and
dryness; sensitivity to
sunburn; known carcinogen
at high concentrations
Burning, stinging, pruritus
Comments
Appropriate for use on
EICHENFIELD
scalp, trunk, extremities
ET AL.
Appropriate for use on
extremities, nails, scalp;
calcipotriol may be less
irritating
Can be used on palms,
soles, and nails and on
thick plaques on trunk and
extremities
Use only low-potency
formulations for face and
flexural sites; rotation
with steroid-sparing
agents can minimize risk
of side effects
Use sparingly because of
risk of percutaneous
salicylate intoxication;
limit use to thick localized
plaques on scalp, palms,
soles
Inexpensive but messy,
strong odor, stains; can be
compounded with topical
corticosteroids; can use
on scalp, face, trunk,
extremities, palms, and
soles
Steroid-sparing option for
face, flexures, and
anogenital regions; nails
Pediatric
Dermatology
|5
6 | Pediatric EICHENFIELD ET AL.

Dermatology
T A B L E 2 Conventional systemic treatment options for pediatric psoriasis27,74
Drug Mechanism Dosing regimens
Cyclosporinea Inhibits T lymphocytes 1.5-5 mg/kg per day
and production of (maximum
interleukin-2 and dose = 4 mg/kg per
interferon-c day in United States,
5 mg/kg per day
internationally; use
limited to 1-2 years
depending on country)
Methotrexatea Inhibits dihydrofolate In children, 0.1-0.4 mg/
reductase kg per week (maximum
25 mg/wk); consider
test dose up to 5 mg
followed by laboratory
monitoring after
1 week to assess
marrow toxicity; if no
toxicity, increase dose
incrementally to
therapeutic effect
Acitretina Oral retinoid; regulates Initiate treatment at
epidermal cell growth ≤0.5-1 mg/kg per day
and apoptosis to minimize toxicity
Contraindications Side effects Comments
Active, serious Decreased renal Risk of cutaneous
infections; abnormal function, malignancy and
kidney function; hypertension, lymphoma minimal in
uncontrollable hyperkalemia, immunocompetent
hypertension; cancer or hypermagnesemia, patients; many drug-
history of cancer (other gingival hyperplasia, drug reactions with
than certain skin hypertrichosis, cyclosporine;
cancers); phototherapy nausea, emesis, improvement can
diarrhea, arthralgia, occur within 4-
headache, 8 weeks; taper doses
paresthesia after 1 to 3 mos of
stable response
Alcoholism, liver disease, Nausea, vomiting, Folic acid
immunodeficiency headache, diarrhea, supplementation 6 or
syndromes, pregnancy hepatotoxicity, 7 d/wk may reduce
or planning pregnancy, interstitial gastrointestinal
significant kidney or pneumonitis, bone toxicity, tolerance
liver abnormalities, marrow suppression,
serious active photosensitivity,
infections, hematologic infections
disorders
Severe liver or kidney Mucocutaneous Teratogen; avoid in
disease, uncontrolled effects (xerosis, women of child-
hyperlipidemia, cheilitis, bearing potential;
concurrent use of xerophthalmia; response may be seen
tetracycline or vitamin granulation tissue of in as little as 3 weeks,
A derivatives; nails); dyslipidemia, particularly effective
pregnancy high liver enzymes, for pustular psoriasis
rare skeletal
hyperostosis,
calcification of
ligaments

All systemic therapies require baseline and routine laboratory monitoring.

a
Approved to treat adult but not pediatric psoriasis.

treatment of psoriasis in children younger than 12 years old.
Despite this, there is vast clinical experience and expert consensus
on the safe and effective use of topical therapies as first-line
agents for mild to moderate psoriasis. Effective interventions have
a positive effect on QoL through reducing itch and sleep distur-
bance, among other parameters.48 Table 1 summarizes topical
therapy options. Topical corticosteroids (TCS) are considered first-
line therapy. Although TCS monotherapy may be effective and
appropriate in some cases, using TCS in combination and rotation
with nonsteroidal topicals such as vitamin D analogs, topical cal-
cineurin inhibitors (TCI), tar, and keratolytics can optimize efficacy
while reducing the risk of side effects. Midstrength to ultrapotent
TCS are often required for thicker plaques that occur on sites
other than the facial, genital, or intertriginous areas because the
psoriasiform hyperplasia limits the efficacy of lower-strength
products. Topical calcineurin inhibitors are often used as steroid-
sparing agents for psoriasis on the facial, genital, and intertriginous
areas.62
Because the only topical medication that the FDA has approved
for pediatric psoriasis is the combination suspension for scalp psoria-
sis containing calcipotriene 0.005% and betamethasone dipropionate
0.064%, indicated for patients aged 12 years and older,63 access to
medications is a significant barrier to proper care because insurers
often deny payment for prescriptions that are “off label.”
There are no data on treatment adherence in children with psoria-
sis. Most studies in adults report low adherence rates (21.6%-75%).
Four studies found a positive association between treatment adher-
ence and clinical improvement in psoriasis symptoms.64-67 Poor adher-
ence to topical therapy is the most common cause of treatment
failure. Major contributing factors are complicated, confusing, and
time-consuming skin care regimens and poor tolerability and accep-
tance of messy topical medications.68 Strategies to improve adherence
include frequent office visits for positive reinforcement, remote app-
based reminders, and monitoring quantities of medications used.
Given the multiple barriers to successful use of topical therapy,
including patient comprehension and adherence to complex
EICHENFIELD ET AL. Pediatric | 7
Dermatology
T A B L E 3 Drug monitoring suggestions for conventional systemic therapies for pediatric psoriasis
Drug Baseline Follow-up Miscellaneous
Cyclosporine Blood pressure 9 2 Blood pressure every visit Whole-blood CSA trough level if
Renal function Renal function, liver function, lipids, CBC, inadequate clinical response or
Urinalysis with micro magnesium, potassium, uric acid every concomitant use of potentially
Fasting lipid profile 2 weeks for 1-2 mos, then monthly interacting medications (see text)
CBC and platelets Individualize for each patient If creatinine increases > 25% above
Liver function baseline, reduce dose by 1 mg/kg per
Magnesium day for 2-4 weeks and recheck. Stop
Potassium CSA if creatinine remains > 25% above
Uric acid baseline; hold lower dose if level is
HIV if at risk within 25% of baseline
Methotrexate CBC and platelets CBC and platelets 5-7 days after test dose, Liver enzymes transiently rise after
Liver function then CBC and liver function test weekly methotrexate dosing; obtain laboratory
Renal function or biweekly for 1 mo then every 2-3 mos results 5-7 days after last dose
Hepatitis A, B, C while on stable doses Liver biopsy: no standard
HIV if at risk Renal function every 6-12 mos recommendations for pediatric patients
Individualize for each patient (avoid methotrexate in patients with
severe liver disease)
Chest radiograph if respiratory symptoms
arise
Retinoids CBC and platelets Liver function and lipid profile at baseline Bone and joint imaging decisions must be
Liver function and after 1 mo of treatment and with individualized based on patient factors,
Renal function dose increases, then every 1 to 3 mos signs, symptoms, and duration of
Fasting lipid profile Monthly pregnancy test therapy
Pregnancy testing Individualize for each patient Ophthalmologic examination if symptoms
according to Food arise
and Drug Administration
prevention program
guidelines

Adapted from Marqueling et al.91

Monitoring must be individualized according to patient, drug, and other factors; these are suggestions only; more or less monitoring may be indicated
based on the clinical scenario.
CBC, complete blood count; CSA, cyclosporin A.

regimens, tactile aversion, access, prohibitive out-of-pocket costs,
potential side effects, and concerns about medication risks, including
corticosteroid phobia, best practice is to discuss these barriers with
the patient and family at the beginning of treatment and decide
together on the most acceptable regimen. Percutaneous absorption
of topical agents may be greater in infants and very young children
who have a greater BSA to volume ratio. The risk is greatest when
topical agents are applied to extensive areas of skin or occluded
sites such as the diaper area. Thus, frequent office visits are impor-
tant to discuss and monitor the real-world use of topical agents at
home and to adjust regimens appropriately as the disease evolves.
for pediatric psoriasis and works particularly well for diffuse guttate
and thin-plaque psoriasis.70-72
Broadband UVB and psoralen plus ultraviolet A (PUVA) are also
viable phototherapy options for selected children but have fallen
out of favor given the safety and utility of NB-UVB.73 Photother-
apy requires two to three office visits per week, a time commit-
ment that is often prohibitive for school-aged children and
caregivers. Home-based units provide a convenient option for some
families. Phototherapy units are not designed to treat infants and
young children, but creativity and close adult supervision in the
booth to ensure adherence to protective eyewear will allow even
young children to be successfully treated.

10 | PHOTOTHERAPY AND SYSTEMIC

THERAPIES 11 | CONVENTIONAL SYSTEMIC THERAPY

Phototherapy69 and systemic medications are typically reserved for
extensive or refractory disease. The decision to implement more
aggressive treatment may not be easy, and there are often several
barriers to overcome. Phototherapy, particularly narrowband ultravi-
olet B (NB-UVB), is widely used, safe, effective first-line treatment
Although there are many systemic choices available to adults,
access to these agents is more limited for children with severe
disease. Methotrexate, cyclosporine, and acitretin are the most
commonly used conventional systemic agents in adults and chil-
dren for the treatment of moderate to severe plaque psoriasis.
 8

T A B L E 4 Biologic treatment options for pediatric psoriasis80,92

|

Drug Mechanism Dosing regimens Contraindications Side Effects Baseline monitoring Follow-up Comments
a
Etanercept Fusion protein of TNF-a SC injection of 0.8 Active serious Dizziness, sore throat, PPD or CBC, liver function Avoid live and live-
receptor extracellular mg/kg per week infection; history of cough, stomach pain, QuantiFERON-TB every 4-6 mos attenuated vaccines
domain and fragment recurrent infections; injection-site reaction, gold Liver function more (e.g., varicella; measles,
crystallizable portion of history of heart upper respiratory Liver function frequently with mumps, rubella; oral
human IgG failure, multiple infection, headache, CBC with differential infliximab typhoid; yellow fever;
sclerosis, or other rhinitis Hepatitis A, B, C if at PPD annually intranasal influenza,
demyelinating risk Other laboratory herpes zoster; bacille
disease HIV if at risk tests and serologies Calmette-Guerin)
Pediatric

Update vaccinations according to signs Vaccinate household

and symptoms contacts prior to
Dermatology

Adalimumabb Human recombinant IgG SC injections of 24
monoclonal antibody
specific for TNF-a
Infliximabc Chimeric monoclonal IgG IV infusion of 3.3-5 mg/
antibody targeting TNFa
Ustekinumabd Human monoclonal antibody Ongoing trial evaluating
targeting the p40 subunit
of IL-12 and IL-23
treatment initiation
Active serious Upper respiratory tract
mg/m2 (maximum infection, history of infection, abdominal
40 mg) or 0.4-0.8 recurrent infections, pain, headache, rash,
mg/kg (maximum history of heart injection-site reaction,
40 mg) every 2 weeks failure, multiple urinary tract infection
sclerosis or other
demyelinating
disease
Active serious Infusion reaction, upper
kg at weeks 0, 2, and 6, infection; history of respiratory tract
then once every 7- recurrent infections; infection, headache,
8 weeks history of heart rash, cough, stomach
failure, multiple pain
sclerosis, or other
demyelinating
disease
Active infection, Upper respiratory PPD PPD annually Avoid live and live-
0.375 and 0.75 mg/kg history of recurrent infection, headache, Update vaccinations Not specific, attenuated vaccines
at weeks 0 and 4, then infections fatigue, redness at Not specific, probably similar to (eg, varicella; measles,
once every 12 weeks injection site, back pain probably similar to other biologic mumps, rubella; oral
other biologic agents typhoid; yell,ow fever;
agents intranasal influenza,
herpes zoster; bacille
Calmette-Guerin)
Vaccinate household
contacts before
treatment initiation
Ustekinumab has not
been studied in
individuals with HIV

(Continues)
EICHENFIELD
ET AL.
 EICHENFIELD ET AL. Pediatric | 9
Dermatology
The FDA has not approved these agents for use in children
because their efficacy and safety have not been evaluated in ran-
domized controlled trials in children. Comfort with their use for
pediatric psoriasis is based on the combination of anecdotal evi-
Comments

dence of safety and efficacy in psoriasis and their widespread use

for other pediatric indications. Methotrexate is the most pre-
scribed agent for pediatric psoriasis internationally and the least

Monitoring must be individualized according to patient, drug, and other factors; these are suggestions only; more or less monitoring may be indicated based on the clinical scenario.
expensive of the systemic medications. Folic acid supplementation
given six to seven times per week has been shown to reduce the risk
of gastrointestinal side effects from methotrexate. Improvement in
psoriasis may take 3 to 6 months, with dose escalations as neces-
Follow-up

Approved to treat adult psoriasis, but not approved for pediatric psoriasis in United States (approved for psoriasis in European Union for individuals aged ≥12). sary.74 Cyclosporine is faster acting and is therefore a good choice
for rapidly progressing, severe disease, including pustular psoriasis in
IL, interleukin; TNF, tumor necrosis factor; Ig, immunoglobulin; PPD, purified protein derivative SC, subcutaneous; IV, intravenous; PDE, phosphodiesterase.

Approved to treat adult psoriasis, but not for pediatric psoriasis in United States (approved for psoriasis in European Union for individuals aged ≥4 years).

children. Acitretin, although slower to act, has the advantage of being

Baseline monitoring

nonimmunosuppressive, but its teratogenicity and potential effects

on bone growth limit its use to a subset of patients. Combining sys-
temic therapies with topical therapies and phototherapy, if appropri-
Drug monitoring suggestions based on Marqueling et al.91 Data on contraindications and side effects from individual prescribing information.

ate, may optimize efficacy and reduce the risk of cumulative

toxicity.27 For example, combining NB-UVB with acitretin is a syner-
gistic combination that features lower dose and exposure of acitretin
and NB-UVB, thereby reducing risk of adverse effects while optimiz-
ing efficacy.75,76 Baseline and ongoing clinical and laboratory monitor-
ing is required for all patients treated with conventional systemic
agents (Tables 2 and 3).
Side Effects

Approved to treat adult but not pediatric psoriasis (approved for pediatric Crohn’s disease and ulcerative colitis).

12 | BIOLOGIC THERAPY
Contraindications

Approval of targeted therapies for psoriasis has dramatically altered

the treatment landscape for individuals with psoriasis (Table 4).
Because biologics directly target cytokines in the psoriasis inflamma-
tory cascade, they are generally associated with less treatment-
related toxicity than conventional systemic agents. As of November
2016, the anti-TNF agent etanercept is the only biologic medication
that the FDA has approved for use in children aged 4 years and
Not established for

older with moderate to severe plaque psoriasis. The approval, which

children; trials in
Dosing regimens

Approved to treat pediatric psoriasis for children aged ≥4 years.

followed European approval, was based largely on a randomized,

double-blind, placebo-controlled clinical trial and reassuring long-
progress

term safety data with meaningful effect on QoL.46,77-79 Published

results from clinical trials and increasing anecdotal evidence also sup-
Approved to treat adult but not pediatric psoriasis.

port the use of other TNF inhibitors80-83 and the IL-12/23 inhibitor
ustekinumab for treatment of pediatric psoriasis.84-86 A randomized
controlled clinical trial (Study of the Safety and Efficacy of Ustek-
inumab in Adolescent Patients with Psoriasis) documented the safety
Humanized IL-17A

PDE-4 inhibitor

and efficacy of ustekinumab for adolescents aged 12 to 17 with

Mechanism

moderate to severe plaque psoriasis.87 In 2015, ustekinumab was

antagonist
(Continued)

approved in Europe for use in adolescents (aged ≥12) and adali-

mumab for use in children (aged ≥4 years) and adolescents with pso-
riasis who have had an inadequate response to or are inappropriate
(apremilast)

candidates for topical therapy and phototherapies. Little has been

inhibitorse
TABLE 4

Anti-IL-17
agentse

published about the use of anti-IL-17 agents in children, although

PDE-4
Drug

recent findings suggest it may play an important role in therapy for

children.57,88
b

e
a

c
10 | Pediatric
Dermatology
13 | COMMENT
Children with moderate to severe psoriasis are undertreated in the
United States.89 The landscape is shifting, based in large part on the
identification of comorbidities in children and adults and the concern
that undertreating children may facilitate the “psoriatic march” from
severe untreated inflammation in childhood and its associations to
cardiovascular morbidity and mortality in adults. Physicians should
consider each person’s unique presentation, comorbidities, effect on
QoL, and health now and in the future when making treatment deci-
sions, despite the lack of FDA approval for most systemic therapies.
14 | CONCLUDING REMARKS
Psoriasis is an immune-mediated inflammatory skin disease with a
recognized genetic predisposition and environmental triggers. Pedi-
atric psoriasis is becoming increasingly common in children, although
this may be a result of greater awareness and recognition. Its course
is unpredictable but often recurrent or chronic. Comorbidities
include obesity, hypertension, and psychosocial disorders. This
chronic skin condition may affect emotional and school functioning.
Pediatric psoriasis can have distinct presentations that may evolve
over time and vary from those classically seen in adults. Other con-
ditions can mimic, trigger, or complicate psoriasis. Most cases are
mild or moderate and respond to topical therapy. Children with more
severe disease are candidates for phototherapy or systemic therapy.
Current state-of-the-art care for pediatric psoriasis is based primarily
on experience and expert consensus. Given the potential need for
life-long treatment, shared decision making with the family is critical.
In most children with psoriasis, management involves topical therapy
and trigger avoidance, but in many cases, therapy must be escalated
in accordance with the disease’s effect on the patient. Most impor-
tantly, there is no “one size fits all” algorithm; treatment must be tai-
lored to each individual presentation.
ACKNOWLEDGMENTS
The authors acknowledge Brian Bulley, MSc, of Konic Limited for
medical writing support. Valeant Pharmaceuticals North America LLC
funded Konic’s activities pertaining to this manuscript.
CONFLICT OF INTEREST
Dr. Eichenfield has served as a consultant and investigator for Valeant
and Anacor Pharmaceuticals. Dr. Sugarman has served as a consultant
for Valeant and Promius. Dr. Siegfried has served as a consultant or
investigator for Amgen, Lilly, and Janssen. Dr. Cordoro has served as a
consultant for Pfizer. Dr. Paller has served as an investigator for Abb-
vie, Amgen, Celgene, Janssen, and Lilly and as a consultant for Amgen,
Lilly, and Pfizer. Dr. Tom has served as a consultant for Valeant and as
an investigator for Celgene, Janssen, and Promius.
EICHENFIELD ET AL.
ORCID
Lawrence F. Eichenfield http://orcid.org/0000-0002-2760-0474
Elaine Siegfried http://orcid.org/0000-0002-4794-9905
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How to cite this article: Eichenfield LF, Paller AS, Tom WL,
et al. Pediatric psoriasis: Evolving perspectives. Pediatr
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