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Correspondence: Bianca Y. Kang, BS, Creighton University School of Medicine, Creighton University, Phoenix Regional Campus, 350 W. Thomas Rd., Phoenix, AZ 85013;
Psoriasis, which affects up to 2% of children may be associated with significant comorbidity, including obesity, diabetes, cardiovascular disease, depression, and reduced quality of life. Screening and decision-making require a multidisciplinary approach with the management of potential comorbidities championed by primary care providers and supported by respective specialists and subspecialists. Research into the comorbidities and systemic manifestations has generated significant data culminating in several proposals for a consensus guideline for both pediatric and nonpediatric populations. Our aim is to provide a summary targeted to the pediatric primary care provider from the best available evidence when caring for children with psoriasis.
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OBJECTIVES
1.
Discuss the epidemiology of pediatric psoriasis.
2.
Describe the clinical presentation of pediatric psoriasis and commonly encountered subtypes.
3.
Describe the common comorbidities in children with psoriasis.
4.
Summarize current screening recommendations for pediatric psoriasis patients, with a focus on the primary care setting.
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INTRODUCTION
Psoriasis is a chronic, systemic, inflammatory disease affecting up to 2% of children in the United States (
). Early diagnosis of psoriasis is crucial for pediatric primary care providers (PCPs) to address, identify, and manage the growing list of established extracutaneous manifestations and comorbidities. Research into the systemic manifestations, comorbidities, and impact on the quality of life (QOL) associated with psoriasis has generated significant data culminating in several consensus guideline proposals for pediatric and nonpediatric populations (
Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
Journal of the American Academy of Dermatology.2020; 82: 161-201
). The purpose of this paper is to present a summary of these guidelines, with a particular focus on screening for and educating families about comorbidities in children with psoriasis. In addition, we discuss clinical presentation and treatment options. A summary of recommended screening and education guidelines is provided in Table 1, and a summary of recommended indications for a referral is detailed in Table 2.
TABLE 1Summary of recommended screening and education guidelines for children with psoriasis
Recommendation
Source(s)
PSA and uveitis
Educate all patients about the risk of PSA, including its signs and symptoms
Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
Journal of the American Academy of Dermatology.2020; 82: 161-201
Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
Journal of the American Academy of Dermatology.2020; 82: 161-201
Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
Journal of the American Academy of Dermatology.2020; 82: 161-201
A screen at each well-child check (at least annually) with BMI percentile for overweight and obesity, starting at age 2 years (the youngest age for which BMI normative values are available)
Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
Journal of the American Academy of Dermatology.2020; 82: 161-201
Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
Journal of the American Academy of Dermatology.2020; 82: 161-201
Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
Journal of the American Academy of Dermatology.2020; 82: 161-201
Screen with fasting plasma glucose every 3 years starting at age 10 years or at the onset of puberty in individuals who are overweight or obese and have at least one additional risk factor (Figure 1)
Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
Journal of the American Academy of Dermatology.2020; 82: 161-201
Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
Journal of the American Academy of Dermatology.2020; 82: 161-201
If additional cardiovascular risk factors (Figure 2, as defined by the National Heart Lung and Blood Institute and American Academy of Pediatrics) are identified, screening should be performed outside of these age ranges and more frequently
Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
Journal of the American Academy of Dermatology.2020; 82: 161-201
Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
Journal of the American Academy of Dermatology.2020; 82: 161-201
Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
Journal of the American Academy of Dermatology.2020; 82: 161-201
Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
Journal of the American Academy of Dermatology.2020; 82: 161-201
Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
Journal of the American Academy of Dermatology.2020; 82: 161-201
Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
Journal of the American Academy of Dermatology.2020; 82: 161-201
Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
Journal of the American Academy of Dermatology.2020; 82: 161-201
Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
Journal of the American Academy of Dermatology.2020; 82: 161-201
Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
Journal of the American Academy of Dermatology.2020; 82: 161-201
Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
Journal of the American Academy of Dermatology.2020; 82: 161-201
Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
Journal of the American Academy of Dermatology.2020; 82: 161-201
Refer to the appropriate specialist(s) as needed (i.e., a tertiary, multidisciplinary child weight management center, dietitian, etc.), particularly children with a BMI > 95th percentile
Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
Journal of the American Academy of Dermatology.2020; 82: 161-201
Refer to an endocrinologist, particularly if there is uncertainty about the ability to successfully treat T2DM in a child (for instance, because of complicating comorbid conditions)
Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
Journal of the American Academy of Dermatology.2020; 82: 161-201
Refer to the appropriate specialist(s) as needed (i.e., dietitian, cardiologist, etc.), particularly children with elevated LDL (≥ 130 mg/dl) or TG (≥ 100 mg/dl in ages < 10 years, and ≥ 130 mg/dl in ages 10–19 years) should be referred to a registered dietician for family medical nutrition therapy
Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
Journal of the American Academy of Dermatology.2020; 82: 161-201
Refer to a pediatric HTN expert as needed. In particular, children with Stage 2 HTN (≥ 99th percentile + 5 mm Hg) should be referred within 1 week or should begin treatment and basic hypertension evaluation
Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
Journal of the American Academy of Dermatology.2020; 82: 161-201
Providers should refer to appropriate specialists, if necessary, for the management of cardiovascular disease and/or its risk factors (i.e., obesity, dyslipidemia, T2DM, HTN, or metabolic syndrome)
Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
Journal of the American Academy of Dermatology.2020; 82: 161-201
Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
Journal of the American Academy of Dermatology.2020; 82: 161-201
A positive screening and/or clinician concern for psychiatric comorbidity should instigate more formal evaluation and/or referral to a mental health professional
Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
Journal of the American Academy of Dermatology.2020; 82: 161-201
Our understanding of pediatric psoriasis epidemiology is limited as there is an inconsistency between studies. Most of the studies are from Europe, Asia, and the United States, and over 80% of countries lack epidemiological data (
CLINICAL PRESENTATION: BACKGROUND AND MISDIAGNOSIS AS DIAPER DERMATITIS
The morphology and distribution of psoriasis may vary by age. In patients aged < 2 years, psoriasis may be misdiagnosed as diaper dermatitis, presenting with well-demarcated, nonscaling, erythematous papules and plaques, and may be refractory to standard irritant diaper dermatitis therapy (
). Compared with most types of psoriasis, the lack of scale seen in psoriasis in the diaper area is secondary to the presence of moisture and humidity in covered areas, similar to inverse psoriasis, and can present a diagnostic dilemma. In addition to complicating accurate diagnosis, irritant diaper dermatitis is multifactorial by nature, and treatment may include low potency topical corticosteroids (TCS) in its management (
). TCS may alleviate and improve cutaneous psoriasis without a conclusive diagnosis. Thus, psoriasis should be considered in the differential diagnosis of recalcitrant diaper dermatitis (
In older children and adults, plaque and guttate psoriasis account for most of the disease. Chronic plaque psoriasis represents 9% to 92% of disease in children (
). This condition is typically characterized by erythematous, well-demarcated, indurated plaques with overlying “micaceous” white or silvery scale (Figure 1;
). The degree of scaling varies and may be more prominent in areas of recurrent friction such as the shins, elbows, knees, and the lower back. It may be more subtle on the trunk, distal extremities, or scalp (Figure 2). Koebnerization, or the onset of psoriatic lesions secondary to repetitive friction or trauma to the skin, is common and may aid diagnosis. Compared with adults, plaques are often less indurated with thinner overlying scales and are more commonly located on the face and flexural surfaces; however, extensor surfaces remain the most common location (
FIGURE 2Chronic plaque psoriasis of the scalp. Plaque psoriasis may be more subtle in areas such as the scalp. Note the presence of individual, isolated, erythematous, nonscaly, indurated papules, and plaques in this adolescent Hispanic male with chronic plaque psoriasis.
Guttate psoriasis accounts for 2% to 48% of childhood-onset psoriasis and is more common in this population than adults. This condition is classically an acute-onset (within 2 weeks) eruption of numerous, small (usually < 1 cm in diameter), red- or salmon-colored papules and plaques, commonly on the trunk (Figure 3;
). The scale may not appear as prominent as in plaque psoriasis. There is a frequent association with recent infection, especially beta-hemolytic streptococcal pharyngitis and perianal infection (
). Similar infections may also precede or exacerbate pustular psoriasis and its variants in children. The onset of either guttate or pustular psoriasis warrants evaluation for such infections.
FIGURE 3Guttate psoriasis. A patient presents with guttate psoriasis with numerous, small, erythematous papules, as noted on the trunk in this adolescent Hispanic female. Induration and scale may vary.
Psoriasis may also affect the nails and joints. Nail involvement, including pitting and onycholysis, may be present before, during, or after the onset of cutaneous disease (
). The patient may complain of joint stiffness, which is often worse with rest (e.g., on awakening) and improved with movement. On examination, PSA may present with pain, tenderness, and swelling of a joint, digit, or enthesitis.
CLINICAL PRESENTATION: LESS COMMON PHENOTYPES
Less common phenotypes include pustular, palmoplantar pustular, erythrodermic, inverse, and drug-induced psoriasis. Pustular psoriasis represents 0% to 13% of childhood psoriasis and is divided into several subtypes, the most common of which in children are generalized (or von-Zumbusch) pustular psoriasis and annular pustular psoriasis (
in: Oranje A.P. Al-Mutairi N. Shwayder T. Practical pediatric dermatology: Controversies in diagnosis and treatment. Springer International Publishing,
Cham, Switzerland2016: 37-49
). Both may present with superficial, sterile pustules on an erythematous base in the setting of systemic symptoms such as fever, malaise, and arthralgias (
in: Oranje A.P. Al-Mutairi N. Shwayder T. Practical pediatric dermatology: Controversies in diagnosis and treatment. Springer International Publishing,
Cham, Switzerland2016: 37-49
in: Oranje A.P. Al-Mutairi N. Shwayder T. Practical pediatric dermatology: Controversies in diagnosis and treatment. Springer International Publishing,
Cham, Switzerland2016: 37-49
Based on molecular profiling of gene expression, palmoplantar pustulosis and palmoplantar pustular psoriasis are highly related diseases that appear to be distinct from psoriasis vulgaris.
). Although often associated with psoriatic nail disease and psoriasis elsewhere on the body, palmoplantar pustular psoriasis may represent a disease separate from psoriasis entirely (
Based on molecular profiling of gene expression, palmoplantar pustulosis and palmoplantar pustular psoriasis are highly related diseases that appear to be distinct from psoriasis vulgaris.
). Inverse psoriasis presents as erythematous plaques with minimal scale affecting the flexural areas, including the axillae, groin, and face (Figure 4;
). This condition may be mistaken for intertrigo, erythrasma, or dermatophyte infection.
FIGURE 4Inverse psoriasis. Inverse psoriasis often presents as indurated erythematous papules and plaques in the flexural areas, as demonstrated in the axilla of this African American child. Scaling is less prominent or absent in inverse psoriasis.
(This figure appears in color online at www.jpedhc.org.)
Drug-induced psoriasis is rare in pediatric patients. It should be considered if there is psoriasiform dermatitis associated with the initiation of certain medications, the most common of which include β-blockers, lithium, chloroquine, hydroxychloroquine, nonsteroidal anti-inflammatory drugs, tetracyclines, terbinafine, and interferons (
). There is a paradoxical eruption of psoriasis-like lesions in patients undergoing therapy with tumor necrosis factor-alpha (TNF-α) inhibitors (e.g., etanercept, adalimumab, or infliximab) for psoriasis or other indications such as inflammatory bowel disease or juvenile idiopathic arthritis (
). This eruption is typically short-lived and improves over time but should be considered in patients undergoing TNF-α inhibitor therapy with temporally associated worsening of underlining psoriasis or new-onset psoriasis. Drug-induced pustular psoriasis, both generalized and annular variants, can also be seen following the initiation of high-dose systemic steroid followed by rapid or truncated tapers over short periods in patients with preexisting psoriasis.
TREATMENT
There are many treatment options for pediatric psoriasis, including topical and systemic therapies, overviewed briefly in Table 3. The therapeutic approach is individualized on the basis of multiple considerations in the pediatric patient. Variables such as the type of psoriasis, the patient's age, area of involvement, comorbidities, cost, and availability of treatment modalities affect both recommendations and adherence.
TABLE 3Treatment options for pediatric psoriasis
Treatment
Examples (not comprehensive)
Notes
All topical therapies
Various vehicles are often available: ointments, creams, lotions, gels, foams
In general, ointments are more potent than creams of the same medication Lotions and foams are often more useful than other vehicles for hairy areas
Topical corticosteroids
Range from least potent (e.g., group 7: hydrocortisone, 0.1% cream) to superhigh potency (e.g., group 1: clobetasol, 0.05% ointment)
Off-label, but frequently and widely used, treatment, especially for localized disease Many delivery vehicles and potencies are available Range in potency from Class VII representing least potent (e.g., hydrocortisone, 1% cream) to Class I representing superpotent (e.g., clobetasol propionate, 0.05% ointment)
Topical calcineurin inhibitors
Tacrolimus, 0.1% ointment; pimecrolimus, 1% cream
Recommended as off-label monotherapy for pediatric psoriasis in the face and genital areas (pimecrolimus for patients aged 2 years and older)
Topical vitamin D analogues
Calcipotriene, also known as calcipotriol, 0.005% foam, cream, ointment, or solution
Because of the possible risk of hypercalcemia, treatment of large surface areas should either be avoided or done so with monitoring of vitamin D metabolites Foam is approved for the treatment of plaque psoriasis on the scalp and body in children aged ≥ 12 years; cream and ointment are approved for scalp and body in children ≥ 2 years of age
Combination therapies are convenient and may help to improve compliance
Topical tazarotene
Tazarotene, 0.05% cream
Recommended off-label for localized skin or nail psoriasis
Anthralin
Anthralin, 1% cream
Recommended for long-term use for 12 weeks or longer for mild to moderate disease
Topical coal tar
Coal tar, 2.5% gel
May be used in conjunction with other topical therapies or phototherapy; however, the latter has a theoretical risk of cutaneous carcinogenesis
Phototherapy
NB-UVB, excimer laser, lightbox
UV structures may be anxiety-inducing for younger children NB-UVB is recommended for moderate to severe plaque and guttate psoriasis An excimer laser may be safe and efficacious but has limited evidence
Photochemotherapy
PUVA
Limited evidence and theoretical risk of cutaneous carcinogenesis UV structures may be anxiety-inducing for younger children
Nonbiological systemic treatment
Methotrexate, acitretin and other systemic retinoids, cyclosporine, systemic fumaric acid esters
Each systemic medication has various potential systemic side effects, and routine monitoring (e.g., with laboratory studies) is recommended for specific treatments Methotrexate is the most commonly recommended systemic treatment of moderate to severe disease and should be used in conjunction with folic acid supplementation and monitoring of blood count, hepatic transaminases, and serum creatinine The use of acitretin is discouraged in females near childbearing age and should be monitored with blood count, serum lipids, and hepatic transaminases Cyclosporine should be monitored with blood pressure measurements, blood count, serum lipids, serum creatinine, blood urea nitrogen, uric acid, potassium, and magnesium
Biological systemic treatments
Etanercept, adalimumab, infliximab, ustekinumab
Immunomodulating medications are used for moderate to severe disease Etanercept and ustekinumab are approved in the United States for the treatment of psoriasis in children aged 4 years and older. Others are used off-label. Risk of injection site reaction and opportunistic infection
Note. PUVA, psoralen, and ultraviolet A; UV, ultraviolet; NB-UVB, narrowband ultraviolet B. Summarized from
Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
Journal of the American Academy of Dermatology.2020; 82: 161-201
Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
Journal of the American Academy of Dermatology.2020; 82: 161-201
reported suggested guidelines for the management of psoriasis in children and adolescents. These experts have recommended that TCS be considered for localized disease. In general, the use of ultrapotent TCS should be avoided in young children and sensitive areas such as the face, folds, creases, and groin because of concern for hypothalamic pituitary adrenal axis suppression. Although off-label, topical calcineurin inhibitors may be an acceptable substitute for young children or sensitive areas. In addition, this committee recommended the cautious use of topical vitamin D analogue therapy in small areas for pediatric patients because of concern for absorption if applied to large areas. No formal guidelines exist for the use of vitamin D analogues in children; however, up to 45 g/m2/week appears to be safe and well-tolerated (
). Dithranol (anthralin) is a topical agent that has been used successfully in pediatrics but is best applied in the office; thus, it is not generally within the practice of the PCP (
Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
Journal of the American Academy of Dermatology.2020; 82: 161-201
Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
Journal of the American Academy of Dermatology.2020; 82: 161-201
Systemic treatments for recalcitrant psoriasis are sometimes employed, but the majority are used off-label. These medications include methotrexate, cyclosporine, retinoids, and biological agents such as those targeting TNF-α and interleukin-12/23. These agents have been used successfully in other pediatric populations; however, they are still under investigation for children with psoriasis (
Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
Journal of the American Academy of Dermatology.2020; 82: 161-201
Our understanding of psoriasis is rapidly evolving. The multitude of comorbidities associated with this systemic inflammatory disease poses a significant burden on patients, their families, and public health. Unaccounted for, these comorbidities can significantly impact and impede QOL and include PSA, overweight and obesity, type 2 diabetes mellitus (T2DM), dyslipidemia, cardiovascular disease (CVD), hypertension (HTN), nonalcoholic fatty liver disease (NAFLD), inflammatory bowel disease (IBD), and psychiatric disease (e.g., mood disorders and substance use). In addition, there may be a correlation between the severity of psoriasis and comorbidities, suggesting that control of cutaneous disease may allow for better control of comorbidities (
There is a relative paucity of literature on psoriasis comorbidities in children compared with adults. As a result, many current recommendations are based on adult studies (
Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
Journal of the American Academy of Dermatology.2020; 82: 161-201
). In 2017, the Joint NPF-Pediatric Dermatology Research Alliance–Pediatric Psoriasis Comorbidity Screening Initiative published a consensus statement on comorbidity screening guidelines in children (
). These guidelines are generally consistent with current American Academy of Pediatrics (AAP) recommendations for all children. In 2019, the Joint American Academy of Dermatology-NPF released guidelines for the management of children with psoriasis (
Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
Journal of the American Academy of Dermatology.2020; 82: 161-201
). Clinicians must maintain a high index of suspicion for extracutaneous involvement in the pediatric population to recognize and manage these comorbidities. Here, we provide a summarized guideline for the pediatric PCP.
PSORIATIC ARTHRITIS
PSA occurs in children (0.7% to 10.5%) but is less prevalent than in adults (6% to 41%) (
Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
Journal of the American Academy of Dermatology.2020; 82: 161-201
Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
Journal of the American Academy of Dermatology.2020; 82: 161-201
Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
Journal of the American Academy of Dermatology.2020; 82: 161-201
). Pediatric rheumatologists guide the assessment of PSA severity and PSA-specific treatment, which may involve medications such as methotrexate or biologics (
Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
Journal of the American Academy of Dermatology.2020; 82: 161-201
Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
Journal of the American Academy of Dermatology.2020; 82: 161-201
Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
Journal of the American Academy of Dermatology.2020; 82: 161-201
Comorbidities that have warranted much discussion regarding their relationship to pediatric psoriasis, psoriasis severity, and impact on psoriasis treatment are overweight (body mass index [BMI] ≥ 85th to < 95th percentile) and obesity (BMI ≥ 95th percentile;
). Multiple studies have demonstrated increased odds of psoriasis in overweight or obese children, although the direction of causation is not fully understood (
demonstrated that these odds are significantly greater than those for adults, suggesting a possible increased correlation with overweight and obesity in childhood-versus adult-onset psoriasis. This same cross-sectional cohort study found higher odds of central adiposity in children with psoriasis than age- and sex-matched controls (
Note. Patients with psoriatic arthritis should be screened routinely for uveitis, and those with uveitis should be referred to ophthalmology. Adapted from
This finding presents a significant practice gap. A chart review found that nearly 67% of children with psoriasis do not receive BMI counseling, either by their dermatologist or pediatrician (
Identifying performance gaps in comorbidity and risk factor screening, prevention, and counseling behaviors of providers caring for children with psoriasis.
). Furthermore, there exists a dynamic relationship between weight control, psoriasis severity, and the impact obesity has on the management of psoriasis. Lifestyle changes may reduce psoriasis severity, improve QOL, and reduce BMI (
Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
Journal of the American Academy of Dermatology.2020; 82: 161-201
). Overweight or obese children should be assessed for obesity comorbidities, such as obstructive sleep apnea and gastroesophageal reflux disease, by their PCP (
Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
Journal of the American Academy of Dermatology.2020; 82: 161-201
). AAP intervention guidelines should be followed for overweight or obese children, and referrals to the appropriate specialist(s) such as a multidisciplinary child weight management center or dietician, should be made as needed, particularly for children with a BMI > 95th percentile (
Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
Journal of the American Academy of Dermatology.2020; 82: 161-201
). Therefore, current screening guidelines are the same in children with and without psoriasis. This association represents another opportunity to address a practice gap, as most children with psoriasis may not undergo diabetes screening (up to 67%) or counseling (up to 93%) (
Identifying performance gaps in comorbidity and risk factor screening, prevention, and counseling behaviors of providers caring for children with psoriasis.
Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
Journal of the American Academy of Dermatology.2020; 82: 161-201
). Every 3 years, routine screening should be performed with a fasting plasma glucose starting at age 10 years or the onset of puberty in overweight or obese children with least one additional risk factor (Box 3;
). For children with T2DM, AAP management guidelines should be followed, including lifestyle modification, pharmacological therapy, and monitoring of blood glucose and glycated hemoglobin (
Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
Journal of the American Academy of Dermatology.2020; 82: 161-201
Maternal history of diabetes or gestational diabetes during the child's gestation
First- or second-degree relative with T2DM
Race/ethnicity (Native American, African American, Latino, Asian American Pacific Islander)
Signs of insulin resistance or associated conditions (acanthosis nigricans, hypertension, dyslipidemia, polycystic ovarian syndrome, small for gestational age birth weight)
Note. Starting at age 10 years (or the onset of puberty), children who are overweight or obese and have at least one additional T2DM risk factor should be screened every 3 years with a fasting plasma glucose. Adapted from Classification and Diagnosis of Diabetes: Standards of Medical Care in
Expert Committee, Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report.
); therefore, when screening pediatric patients at risk for CVD, psoriasis should be considered as an additional risk factor, particularly in the older adolescent transitioning to early adulthood when acute CVD is more likely. This consideration is especially important in patients with PSA, in whom the risk of intimal medial thickness is heightened (
Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
Journal of the American Academy of Dermatology.2020; 82: 161-201
Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
Journal of the American Academy of Dermatology.2020; 82: 161-201
). AAP guidelines should be followed with referral to appropriate specialists, if necessary, for management of CVD and/or its risk factors, such as obesity, dyslipidemia, diabetes mellitus, HTN, or metabolic syndrome (
Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
Journal of the American Academy of Dermatology.2020; 82: 161-201
). The AAP recommends routine age-guided lipid screening for children. Again, many (possibly ≥60% of) children with psoriasis are not screened for or counseled on their increased risk for dyslipidemia (
Identifying performance gaps in comorbidity and risk factor screening, prevention, and counseling behaviors of providers caring for children with psoriasis.
Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
Journal of the American Academy of Dermatology.2020; 82: 161-201
). Screening should be with a fasting lipid panel, which consists of total cholesterol level, low-density lipoprotein (LDL) cholesterol level, high-density lipoprotein cholesterol level, and triglycerides (TG) level twice between ages 9–11 years (at least 2 weeks but < 3 months apart), and once between ages 17–21 years (
Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
Journal of the American Academy of Dermatology.2020; 82: 161-201
Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
Journal of the American Academy of Dermatology.2020; 82: 161-201
). The National Heart Lung and Blood Institute and AAP guidelines should be followed for recommended cutoff levels for lipid and lipoprotein levels, as well as diagnostic considerations and management algorithms (
). Referrals should be made to the appropriate specialist(s) as needed, such as a dietitian or cardiologist. In particular, children with an elevated LDL level ≥ 130 mg/dl or TG level ≥ 100 mg/dl in ages < 10 years or ≥ 130 mg/dl in ages 10–19 years should be referred to a registered dietitian for family medical nutrition therapy (
Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
Journal of the American Academy of Dermatology.2020; 82: 161-201
). Screening for HTN follows the AAP guidelines for children regardless of psoriasis. Counseling on the increased risk of HTN is under-addressed, with fewer than 15% of providers documenting this discussion (
Identifying performance gaps in comorbidity and risk factor screening, prevention, and counseling behaviors of providers caring for children with psoriasis.
). Routine surveillance and counseling are important and again represent an opportunity to improve the management of children with psoriasis in the primary care setting. The PCP should also be aware that certain psoriasis medications, especially cyclosporine, may increase the risk of HTN (
Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
Journal of the American Academy of Dermatology.2020; 82: 161-201
). For children with elevated blood pressure, the National Heart Lung and Blood Institute and AAP recommended management strategies should be followed, including diet and pharmacological interventions (
). Referral should be made to a pediatric HTN expert as needed. In particular, children with stage 2 HTN (≥ 99th percentile + 5 mm Hg) should be referred within 1 week or should begin treatment and basic HTN evaluation (
Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
Journal of the American Academy of Dermatology.2020; 82: 161-201
). Providers should be aware that obesity, alcohol consumption, and hepatotoxic medications such as methotrexate are associated with an increased risk of NAFLD (
). Methotrexate is the most common systemic treatment for moderate to severe psoriasis, and it is often used when topical treatments and phototherapy fail (
Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
Journal of the American Academy of Dermatology.2020; 82: 161-201
Several medications used in psoriasis management are associated with a risk of hepatitis B, and possibly hepatitis C, reactivation. In particular, biological therapies such as TNF-α inhibitors, ustekinumab (a monoclonal antibody against interleukin-12/23), and secukinumab (a monoclonal antibody against interleukin-17) pose such a risk (
Risk for hepatitis B and C virus reactivation in patients with psoriasis on biologic therapies: A retrospective cohort study and systematic review of the literature.
Journal of the American Academy of Dermatology.2017; 77 (e5): 88-97
). Psoriasis patients with known chronic hepatitis treated with biological agents should be closely monitored with viral titers and liver function tests in collaboration with a gastroenterologist (
Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
Journal of the American Academy of Dermatology.2020; 82: 161-201
Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
Journal of the American Academy of Dermatology.2020; 82: 161-201
). Those affected by both psoriasis and IBD have higher rates of complications such as diabetes and arthritis when compared with psoriasis patients without IBD (
). History and PE should be used to screen children with gastrointestinal symptoms (e.g., weight loss, abdominal pain, diarrhea, rectal bleeding), poor growth, unintended weight loss, or other signs/symptoms worrisome for IBD (
Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
Journal of the American Academy of Dermatology.2020; 82: 161-201
Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
Journal of the American Academy of Dermatology.2020; 82: 161-201
). A large cohort study of children with psoriasis found that these individuals were more often managed with psychotropic medications, including tricyclic antidepressants and anxiolytic drugs (
). In addition, they were 78% more likely to be treated with anxiolytic medications compared with age-matched patients with acne and similar incidences of psychiatric disorders. In adults, there is an association with substance use disorders (
Considering the widespread accessibility and low cost of screening tools and the potentially devastating consequences of untreated psychiatric disease, it is prudent for providers to routinely assess children for depression, anxiety, and substance use. Practitioners should be vigilant for potential consequences of psychiatric disease and/or substance use, such as bullying and negative effects on self-esteem (
). As these patients transition into adult care, PCPs should keep in mind that substance use becomes more prevalent in the adult psoriatic population (
All patients should be educated about the association of psoriasis with depression and anxiety. This recommendation has only been established in adults (
Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
Journal of the American Academy of Dermatology.2020; 82: 161-201
). A simple tool, such as the Car, Relax, Alone, Forget, Friends, Trouble tool, can be used for screening purposes. Annual substance use screening should start at age 11 (
Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
Journal of the American Academy of Dermatology.2020; 82: 161-201
). Nocturnal pruritus, causing sleep deprivation, may have long-term consequences, including fatigue, mood and behavior disturbances, impaired productivity in work and school, and increased risk of chronic diseases such as T2DM, HTN, and CVD (
Identifying performance gaps in comorbidity and risk factor screening, prevention, and counseling behaviors of providers caring for children with psoriasis.
Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
Journal of the American Academy of Dermatology.2020; 82: 161-201
). The pediatric PCP should facilitate an open conversation with the patient and caregiver(s) regarding QOL, including physical, social, emotional, and academic well-being (
Psoriasis is a systemic inflammatory disease, and, although it may begin in childhood, its ramifications are lifelong. Therefore, the prevention of comorbidities should begin at diagnosis. Commonly reported associations include PSA, uveitis, overweight and obesity, T2DM, dyslipidemia, CVD, HTN, NAFLD, IBD, psychiatric disease, and reduced QOL. The most recent and comprehensive guidelines for children with psoriasis, put forth by the NPF, the Joint NPF-Pediatric Dermatology Research Alliance–Pediatric Psoriasis Comorbidity Screening Initiative, and the American Academy of Dermatology-NPF (
Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
Journal of the American Academy of Dermatology.2020; 82: 161-201
Identifying performance gaps in comorbidity and risk factor screening, prevention, and counseling behaviors of providers caring for children with psoriasis.
). Children with psoriasis do not often receive adequate counseling from their dermatologist or PCP regarding their increased risk of these comorbidities. Furthermore, though BMI and blood pressure screening are routinely performed, most children with psoriasis are not screened for diabetes, dyslipidemia, or psychiatric disease. Increased awareness of these risks is necessary to initiate improvement in diagnosis, prevention, and improved management of comorbid disease in this population.
PCPs should have a heightened awareness of the common comorbidities of pediatric psoriasis. These comorbidities have nonnegligible and potentially life-threatening consequences, including debilitating arthritis, blindness, CVD such as myocardial infarction, and suicide. The severity of psoriasis is correlated to the severity of multiple comorbidities suggesting that outcomes may be improved in patients whose disease is better controlled (
). Considering this and the easily accessible and economical screening tests and tools currently available, children with psoriasis should undergo routine evaluation for associated comorbidities. Strong collaboration between PCPs, dermatologists, and pediatric dermatologists, as well as other pediatric specialists, as indicated, is imperative in providing these patients with the comprehensive, multidisciplinary care needed to mitigate their lifelong increased risk of systemic comorbid disease.
References
Al-Mutairi N.
Childhood psoriasis.
in: Oranje A.P. Al-Mutairi N. Shwayder T. Practical pediatric dermatology: Controversies in diagnosis and treatment. Springer International Publishing,
Cham, Switzerland2016: 37-49
Expert Committee, Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report.
Based on molecular profiling of gene expression, palmoplantar pustulosis and palmoplantar pustular psoriasis are highly related diseases that appear to be distinct from psoriasis vulgaris.
Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
Journal of the American Academy of Dermatology.2020; 82: 161-201
Risk for hepatitis B and C virus reactivation in patients with psoriasis on biologic therapies: A retrospective cohort study and systematic review of the literature.
Journal of the American Academy of Dermatology.2017; 77 (e5): 88-97
Identifying performance gaps in comorbidity and risk factor screening, prevention, and counseling behaviors of providers caring for children with psoriasis.
Bianca Y. Kang, Student, Creighton University School of Medicine, Creighton University, Phoenix Regional Campus, Phoenix, AZ.
Judith O'Haver, Pediatric Nurse Practitioner and Nursing Scientist, Department of Pediatric Dermatology, Phoenix Children's Hospital, Phoenix, AZ.
Israel D. Andrews, Associate Program Director, Department of Pediatric Dermatology, Phoenix Children's Hospital, Phoenix, AZ.
Article info
Footnotes
Conflicts of interest: None to report.
As a review article, the preparation of this manuscript did not need any ethical approvals or informed consent. The preparation of this manuscript did not involve human subjects and/or animals or case reports/case series. The content of this manuscript represents our discussion of screening for comorbid disease in patients with pediatric psoriasis. All publications that influenced the writing of this manuscript are cited. We ensure that we have written an original study. All publications, books, or statements that influenced the writing of this manuscript are cited as such. This manuscript, or parts of it, have not and will not be submitted elsewhere for publication. All individuals who contributed to the preparation of this manuscript are listed as an author.
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