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Pediatric Psoriasis Comorbidities: Screening Recommendations for the Primary Care Provider

      Abstract

      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 (
      • Burden-Teh E.
      • Thomas K.S.
      • Ratib S.
      • Grindlay D.
      • Adaji E.
      • Murphy R.
      The epidemiology of childhood psoriasis: A scoping review.
      ). 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 (
      • Elmets C.A.
      • Leonardi C.L.
      • Davis D.M.R.
      • Gelfand J.M.
      • Lichten J.
      • Mehta N.N.
      • Menter A.
      Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with awareness and attention to comorbidities.
      ;
      • Kimball A.B.
      • Gladman D.
      • Gelfand J.M.
      • Gordon K.
      • Horn E.J.
      • Korman N.J.
      National Psoriasis Foundation
      National Psoriasis Foundation clinical consensus on psoriasis comorbidities and recommendations for screening.
      ;
      • Menter A.
      • Cordoro K.M.
      • Davis D.M.R.
      • Kroshinsky D.
      • Paller A.S.
      • Armstrong A.W.
      • Elmets C.A.
      Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
      ;
      • Osier E.
      • Wang A.S.
      • Tollefson M.M.
      • Cordoro K.M.
      • Daniels S.R.
      • Eichenfield A.
      • Eichenfield L.F.
      Pediatric psoriasis comorbidity screening guidelines.
      ). 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
      RecommendationSource(s)
      PSA and uveitis
       Educate all patients about the risk of PSA, including its signs and symptoms
      • Elmets C.A.
      • Leonardi C.L.
      • Davis D.M.R.
      • Gelfand J.M.
      • Lichten J.
      • Mehta N.N.
      • Menter A.
      Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with awareness and attention to comorbidities.
      ;
      • Menter A.
      • Cordoro K.M.
      • Davis D.M.R.
      • Kroshinsky D.
      • Paller A.S.
      • Armstrong A.W.
      • Elmets C.A.
      Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
      ;
      • Osier E.
      • Wang A.S.
      • Tollefson M.M.
      • Cordoro K.M.
      • Daniels S.R.
      • Eichenfield A.
      • Eichenfield L.F.
      Pediatric psoriasis comorbidity screening guidelines.
       Patients with psoriasis should be screened for PSA at each visit with a thorough review of systems and PE (Figure 1)
      • Elmets C.A.
      • Leonardi C.L.
      • Davis D.M.R.
      • Gelfand J.M.
      • Lichten J.
      • Mehta N.N.
      • Menter A.
      Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with awareness and attention to comorbidities.
      ;
      • Kimball A.B.
      • Gladman D.
      • Gelfand J.M.
      • Gordon K.
      • Horn E.J.
      • Korman N.J.
      National Psoriasis Foundation
      National Psoriasis Foundation clinical consensus on psoriasis comorbidities and recommendations for screening.
      ;
      • Menter A.
      • Cordoro K.M.
      • Davis D.M.R.
      • Kroshinsky D.
      • Paller A.S.
      • Armstrong A.W.
      • Elmets C.A.
      Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
      ;
      • Osier E.
      • Wang A.S.
      • Tollefson M.M.
      • Cordoro K.M.
      • Daniels S.R.
      • Eichenfield A.
      • Eichenfield L.F.
      Pediatric psoriasis comorbidity screening guidelines.
       Patients with PSA should be screened routinely for uveitis by review of systems and PE (Figure 2), including routine ophthalmology examination
      • Elmets C.A.
      • Leonardi C.L.
      • Davis D.M.R.
      • Gelfand J.M.
      • Lichten J.
      • Mehta N.N.
      • Menter A.
      Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with awareness and attention to comorbidities.
      ;
      • Menter A.
      • Cordoro K.M.
      • Davis D.M.R.
      • Kroshinsky D.
      • Paller A.S.
      • Armstrong A.W.
      • Elmets C.A.
      Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
      ;
      • Osier E.
      • Wang A.S.
      • Tollefson M.M.
      • Cordoro K.M.
      • Daniels S.R.
      • Eichenfield A.
      • Eichenfield L.F.
      Pediatric psoriasis comorbidity screening guidelines.
      Overweight and obesity
       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)
      • Elmets C.A.
      • Leonardi C.L.
      • Davis D.M.R.
      • Gelfand J.M.
      • Lichten J.
      • Mehta N.N.
      • Menter A.
      Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with awareness and attention to comorbidities.
      ;
      • Menter A.
      • Cordoro K.M.
      • Davis D.M.R.
      • Kroshinsky D.
      • Paller A.S.
      • Armstrong A.W.
      • Elmets C.A.
      Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
      ;
      • Osier E.
      • Wang A.S.
      • Tollefson M.M.
      • Cordoro K.M.
      • Daniels S.R.
      • Eichenfield A.
      • Eichenfield L.F.
      Pediatric psoriasis comorbidity screening guidelines.
       Overweight or obese children should be assessed for comorbidities of obesity (i.e., obstructive sleep apnea, gastroesophageal reflux disease, etc.)
      • Menter A.
      • Cordoro K.M.
      • Davis D.M.R.
      • Kroshinsky D.
      • Paller A.S.
      • Armstrong A.W.
      • Elmets C.A.
      Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
      T2DM
       Educate all patients with psoriasis about the association between psoriasis and T2DM.
      • Menter A.
      • Cordoro K.M.
      • Davis D.M.R.
      • Kroshinsky D.
      • Paller A.S.
      • Armstrong A.W.
      • Elmets C.A.
      Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
       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)
      • Osier E.
      • Wang A.S.
      • Tollefson M.M.
      • Cordoro K.M.
      • Daniels S.R.
      • Eichenfield A.
      • Eichenfield L.F.
      Pediatric psoriasis comorbidity screening guidelines.
      Dyslipidemia
       Educate all patients about the association between psoriasis and dyslipidemia
      • Menter A.
      • Cordoro K.M.
      • Davis D.M.R.
      • Kroshinsky D.
      • Paller A.S.
      • Armstrong A.W.
      • Elmets C.A.
      Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
       Screen with a fasting lipid panel twice (2 weeks to 3 months apart) between ages 9–11 years, and once between ages 17–21 years
      • Menter A.
      • Cordoro K.M.
      • Davis D.M.R.
      • Kroshinsky D.
      • Paller A.S.
      • Armstrong A.W.
      • Elmets C.A.
      Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
      ;
      • Osier E.
      • Wang A.S.
      • Tollefson M.M.
      • Cordoro K.M.
      • Daniels S.R.
      • Eichenfield A.
      • Eichenfield L.F.
      Pediatric psoriasis comorbidity screening guidelines.
       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
      • Menter A.
      • Cordoro K.M.
      • Davis D.M.R.
      • Kroshinsky D.
      • Paller A.S.
      • Armstrong A.W.
      • Elmets C.A.
      Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
      ;
      • Osier E.
      • Wang A.S.
      • Tollefson M.M.
      • Cordoro K.M.
      • Daniels S.R.
      • Eichenfield A.
      • Eichenfield L.F.
      Pediatric psoriasis comorbidity screening guidelines.
      Hypertension
       Measure blood pressure annually, starting at age 3 years, and interpret on the basis of age, sex, and height
      • Menter A.
      • Cordoro K.M.
      • Davis D.M.R.
      • Kroshinsky D.
      • Paller A.S.
      • Armstrong A.W.
      • Elmets C.A.
      Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
      ;
      • Osier E.
      • Wang A.S.
      • Tollefson M.M.
      • Cordoro K.M.
      • Daniels S.R.
      • Eichenfield A.
      • Eichenfield L.F.
      Pediatric psoriasis comorbidity screening guidelines.
      Cardiovascular diseases
       Educate all patients with psoriasis about the increased risk of cardiovascular disease
      • Menter A.
      • Cordoro K.M.
      • Davis D.M.R.
      • Kroshinsky D.
      • Paller A.S.
      • Armstrong A.W.
      • Elmets C.A.
      Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
       Screen patients for cardiovascular risk factors if history and PE are concerning for increased risk
      • Menter A.
      • Cordoro K.M.
      • Davis D.M.R.
      • Kroshinsky D.
      • Paller A.S.
      • Armstrong A.W.
      • Elmets C.A.
      Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
      NAFLD
       Screen for NAFLD with ALT in all children starting at ages 9–11 years who are overweight or obese
      • Menter A.
      • Cordoro K.M.
      • Davis D.M.R.
      • Kroshinsky D.
      • Paller A.S.
      • Armstrong A.W.
      • Elmets C.A.
      Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
      ;
      • Osier E.
      • Wang A.S.
      • Tollefson M.M.
      • Cordoro K.M.
      • Daniels S.R.
      • Eichenfield A.
      • Eichenfield L.F.
      Pediatric psoriasis comorbidity screening guidelines.
       Consider repeat testing every 2–3 years if ALT is normal (< 22 U/L in girls and < 25 U/L in boys)
      • Menter A.
      • Cordoro K.M.
      • Davis D.M.R.
      • Kroshinsky D.
      • Paller A.S.
      • Armstrong A.W.
      • Elmets C.A.
      Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
      ;
      • Osier E.
      • Wang A.S.
      • Tollefson M.M.
      • Cordoro K.M.
      • Daniels S.R.
      • Eichenfield A.
      • Eichenfield L.F.
      Pediatric psoriasis comorbidity screening guidelines.
       Consider earlier screening in patients with severe obesity, family history of NAFLD, or hypopituitarism
      • Osier E.
      • Wang A.S.
      • Tollefson M.M.
      • Cordoro K.M.
      • Daniels S.R.
      • Eichenfield A.
      • Eichenfield L.F.
      Pediatric psoriasis comorbidity screening guidelines.
      IBD
       Screen for IBD with history and PE (i.e., gastrointestinal symptoms, poor growth, unintended weight loss, or other signs/symptoms of IBD)
      • Elmets C.A.
      • Leonardi C.L.
      • Davis D.M.R.
      • Gelfand J.M.
      • Lichten J.
      • Mehta N.N.
      • Menter A.
      Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with awareness and attention to comorbidities.
      ;
      • Menter A.
      • Cordoro K.M.
      • Davis D.M.R.
      • Kroshinsky D.
      • Paller A.S.
      • Armstrong A.W.
      • Elmets C.A.
      Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
      ;
      • Osier E.
      • Wang A.S.
      • Tollefson M.M.
      • Cordoro K.M.
      • Daniels S.R.
      • Eichenfield A.
      • Eichenfield L.F.
      Pediatric psoriasis comorbidity screening guidelines.
      Psychiatric comorbidities
       Educate all patients about the association of psoriasis with depression and anxiety
      • Elmets C.A.
      • Leonardi C.L.
      • Davis D.M.R.
      • Gelfand J.M.
      • Lichten J.
      • Mehta N.N.
      • Menter A.
      Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with awareness and attention to comorbidities.
       Screen annually for depression and anxiety in patients of all ages
      • Menter A.
      • Cordoro K.M.
      • Davis D.M.R.
      • Kroshinsky D.
      • Paller A.S.
      • Armstrong A.W.
      • Elmets C.A.
      Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
      ;
      • Osier E.
      • Wang A.S.
      • Tollefson M.M.
      • Cordoro K.M.
      • Daniels S.R.
      • Eichenfield A.
      • Eichenfield L.F.
      Pediatric psoriasis comorbidity screening guidelines.
       Screen annually for substance use starting at 11 years old
      • Osier E.
      • Wang A.S.
      • Tollefson M.M.
      • Cordoro K.M.
      • Daniels S.R.
      • Eichenfield A.
      • Eichenfield L.F.
      Pediatric psoriasis comorbidity screening guidelines.
      QOL
       Consider using a formal QOL assessment tool, both during evaluation and as part of management.
      • Menter A.
      • Cordoro K.M.
      • Davis D.M.R.
      • Kroshinsky D.
      • Paller A.S.
      • Armstrong A.W.
      • Elmets C.A.
      Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
      ;
      • Osier E.
      • Wang A.S.
      • Tollefson M.M.
      • Cordoro K.M.
      • Daniels S.R.
      • Eichenfield A.
      • Eichenfield L.F.
      Pediatric psoriasis comorbidity screening guidelines.
       Common tools are available through the Cardiff University School of Medicine:

      Cardiff University School of Medicine. (n.d.). Quality of life questionnaires. Retrieved from https://www.cardiff.ac.uk/medicine/resources/quality-of-life-questionnaires

      ;
      • Chernyshov P.V.
      • Boffa M.J.
      • Corso R.
      • Pustišek N.
      • Marinovic B.
      • Manolache L.
      • Marron S.E.
      Creation and pilot test results of the dermatology-specific proxy instrument: the Infants and Toddlers Dermatology Quality of Life.
      ;
      • Lewis-Jones M.S.
      • Finlay A.Y.
      The Children's Dermatology Life Quality Index (CDLQI): initial validation and practical use.
      ;
      • Lewis V.J.
      • Finlay A.Y.
      Two decades experience of the Psoriasis Disability Index.
        Ages 0–4 years: Infants’ and Toddlers’ Dermatology Quality of Life
        Ages 5–16 years: CDLQI
        Ages > 16 years: Psoriasis Disability Index
      Note. ALT, alanine aminotransferase; BMI, body mass index; CDLQI, Children's Dermatology Life Quality Index; IBD, inflammatory bowel disease; NAFLD, nonalcoholic fatty liver disease; PE, physical examination; PSA, psoriatic arthritis; QOL, quality of life; T2DM, type 2 diabetes mellitus.
      TABLE 2Summary of recommended indications for referral for children with psoriasis
      RecommendationSource(s)
      PSA and uveitis
       Referral to a rheumatologist with pediatric expertise for signs and symptoms of PSA
      • Menter A.
      • Cordoro K.M.
      • Davis D.M.R.
      • Kroshinsky D.
      • Paller A.S.
      • Armstrong A.W.
      • Elmets C.A.
      Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
       Referral to an ophthalmologist for signs and symptoms of uveitis
      • Elmets C.A.
      • Leonardi C.L.
      • Davis D.M.R.
      • Gelfand J.M.
      • Lichten J.
      • Mehta N.N.
      • Menter A.
      Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with awareness and attention to comorbidities.
      ;
      • Menter A.
      • Cordoro K.M.
      • Davis D.M.R.
      • Kroshinsky D.
      • Paller A.S.
      • Armstrong A.W.
      • Elmets C.A.
      Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
      Overweight and obesity
       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
      • Menter A.
      • Cordoro K.M.
      • Davis D.M.R.
      • Kroshinsky D.
      • Paller A.S.
      • Armstrong A.W.
      • Elmets C.A.
      Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
      ;
      • Osier E.
      • Wang A.S.
      • Tollefson M.M.
      • Cordoro K.M.
      • Daniels S.R.
      • Eichenfield A.
      • Eichenfield L.F.
      Pediatric psoriasis comorbidity screening guidelines.
      T2DM
       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)
      • Menter A.
      • Cordoro K.M.
      • Davis D.M.R.
      • Kroshinsky D.
      • Paller A.S.
      • Armstrong A.W.
      • Elmets C.A.
      Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
      ;
      • Osier E.
      • Wang A.S.
      • Tollefson M.M.
      • Cordoro K.M.
      • Daniels S.R.
      • Eichenfield A.
      • Eichenfield L.F.
      Pediatric psoriasis comorbidity screening guidelines.
      Dyslipidemia
       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
      • Menter A.
      • Cordoro K.M.
      • Davis D.M.R.
      • Kroshinsky D.
      • Paller A.S.
      • Armstrong A.W.
      • Elmets C.A.
      Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
      ;
      • Osier E.
      • Wang A.S.
      • Tollefson M.M.
      • Cordoro K.M.
      • Daniels S.R.
      • Eichenfield A.
      • Eichenfield L.F.
      Pediatric psoriasis comorbidity screening guidelines.
       Children with LDL of ≥ 250 mg/dl or TG of ≥ 500 mg/dl should be referred directly to a lipid specialist for medical therapy
      • Osier E.
      • Wang A.S.
      • Tollefson M.M.
      • Cordoro K.M.
      • Daniels S.R.
      • Eichenfield A.
      • Eichenfield L.F.
      Pediatric psoriasis comorbidity screening guidelines.
      HTN
       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
      • Menter A.
      • Cordoro K.M.
      • Davis D.M.R.
      • Kroshinsky D.
      • Paller A.S.
      • Armstrong A.W.
      • Elmets C.A.
      Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
      ;
      • Osier E.
      • Wang A.S.
      • Tollefson M.M.
      • Cordoro K.M.
      • Daniels S.R.
      • Eichenfield A.
      • Eichenfield L.F.
      Pediatric psoriasis comorbidity screening guidelines.
      Cardiovascular diseases
       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)
      • Elmets C.A.
      • Leonardi C.L.
      • Davis D.M.R.
      • Gelfand J.M.
      • Lichten J.
      • Mehta N.N.
      • Menter A.
      Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with awareness and attention to comorbidities.
      ;
      • Menter A.
      • Cordoro K.M.
      • Davis D.M.R.
      • Kroshinsky D.
      • Paller A.S.
      • Armstrong A.W.
      • Elmets C.A.
      Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
      ;
      • Osier E.
      • Wang A.S.
      • Tollefson M.M.
      • Cordoro K.M.
      • Daniels S.R.
      • Eichenfield A.
      • Eichenfield L.F.
      Pediatric psoriasis comorbidity screening guidelines.
      Nonalcoholic fatty liver disease
       Pediatric hepatology referral should be made without delay for patients with ALT two times the normal level
      • Osier E.
      • Wang A.S.
      • Tollefson M.M.
      • Cordoro K.M.
      • Daniels S.R.
      • Eichenfield A.
      • Eichenfield L.F.
      Pediatric psoriasis comorbidity screening guidelines.
      IBD
       Pediatric gastroenterology referral should be made without delay for patients in whom IBD is strongly suspected
      • Elmets C.A.
      • Leonardi C.L.
      • Davis D.M.R.
      • Gelfand J.M.
      • Lichten J.
      • Mehta N.N.
      • Menter A.
      Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with awareness and attention to comorbidities.
      ;
      • Menter A.
      • Cordoro K.M.
      • Davis D.M.R.
      • Kroshinsky D.
      • Paller A.S.
      • Armstrong A.W.
      • Elmets C.A.
      Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
      ;
      • Osier E.
      • Wang A.S.
      • Tollefson M.M.
      • Cordoro K.M.
      • Daniels S.R.
      • Eichenfield A.
      • Eichenfield L.F.
      Pediatric psoriasis comorbidity screening guidelines.
      Psychiatric comorbidities
       A positive screening and/or clinician concern for psychiatric comorbidity should instigate more formal evaluation and/or referral to a mental health professional
      • Elmets C.A.
      • Leonardi C.L.
      • Davis D.M.R.
      • Gelfand J.M.
      • Lichten J.
      • Mehta N.N.
      • Menter A.
      Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with awareness and attention to comorbidities.
      ;
      • Menter A.
      • Cordoro K.M.
      • Davis D.M.R.
      • Kroshinsky D.
      • Paller A.S.
      • Armstrong A.W.
      • Elmets C.A.
      Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
      ;
      • Osier E.
      • Wang A.S.
      • Tollefson M.M.
      • Cordoro K.M.
      • Daniels S.R.
      • Eichenfield A.
      • Eichenfield L.F.
      Pediatric psoriasis comorbidity screening guidelines.
      Note. ALT, alanine aminotransferase; BMI, body mass index; IBD, inflammatory bowel disease; LDL, low-density lipoprotein; HTN, hypertension; PSA, psoriatic arthritis; T2DM, type 2 diabetes mellitus; TG, triglycerides.

      EPIDEMIOLOGY

      In approximately one-third of cases, psoriasis begins during childhood (< 18 years of age) and more commonly after puberty (
      • Burden-Teh E.
      • Thomas K.S.
      • Ratib S.
      • Grindlay D.
      • Adaji E.
      • Murphy R.
      The epidemiology of childhood psoriasis: A scoping review.
      ;
      • Relvas M.
      • Torres T.
      Pediatric psoriasis.
      ). Estimates of prevalence and incidence of pediatric psoriasis vary—reports of prevalence range from 0% to 2% (
      • Burden-Teh E.
      • Thomas K.S.
      • Ratib S.
      • Grindlay D.
      • Adaji E.
      • Murphy R.
      The epidemiology of childhood psoriasis: A scoping review.
      ). Current research suggests that pediatric psoriasis is most common in European countries (
      • Burden-Teh E.
      • Thomas K.S.
      • Ratib S.
      • Grindlay D.
      • Adaji E.
      • Murphy R.
      The epidemiology of childhood psoriasis: A scoping review.
      ). In the United States, the incidence has increased from 3 to 63 per 100,000 patient-years between 1970 and 1999 (
      • Tollefson M.M.
      • Crowson C.S.
      • McEvoy M.T.
      • Maradit Kremers H.
      Incidence of psoriasis in children: A population-based study.
      ). Although adult-onset psoriasis is more prevalent in males, pediatric psoriasis has a slight female predominance (
      • Burden-Teh E.
      • Thomas K.S.
      • Ratib S.
      • Grindlay D.
      • Adaji E.
      • Murphy R.
      The epidemiology of childhood psoriasis: A scoping review.
      ). A family history of psoriasis in a first-degree relative has been reported in up to 49% of cases (
      • Burden-Teh E.
      • Thomas K.S.
      • Ratib S.
      • Grindlay D.
      • Adaji E.
      • Murphy R.
      The epidemiology of childhood psoriasis: A scoping review.
      ).
      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 (
      • Burden-Teh E.
      • Thomas K.S.
      • Ratib S.
      • Grindlay D.
      • Adaji E.
      • Murphy R.
      The epidemiology of childhood psoriasis: A scoping review.
      ). It is plausible that psoriasis is more readily diagnosed in more developed countries because of greater access to health care (
      World Health Organization
      Monitoring report executive summary.
      ). Moreover, psoriasis and its variants may go underdiagnosed or misdiagnosed (
      • Kurd S.K.
      • Gelfand J.M.
      The prevalence of previously diagnosed and undiagnosed psoriasis in US adults: Results from NHANES 2003-2004.
      ).

      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 (
      • Bronckers I.M.G.J.
      • Paller A.S.
      • van Geel M.J.
      • van de Kerkhof P.C.M.
      • Seyger M.M.B
      Psoriasis in children and adolescents: Diagnosis, management and comorbidities.
      ;
      • Pinson R.
      • Sotoodian B.
      • Fiorillo L.
      Psoriasis in children.
      ). 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 (
      • Tüzün Y.
      • Wolf R.
      • Bağlam S.
      • Engin B.
      Diaper (napkin) dermatitis: A fold (intertriginous) dermatosis.
      ). TCS may alleviate and improve cutaneous psoriasis without a conclusive diagnosis. Thus, psoriasis should be considered in the differential diagnosis of recalcitrant diaper dermatitis (
      • Bronckers I.M.G.J.
      • Paller A.S.
      • van Geel M.J.
      • van de Kerkhof P.C.M.
      • Seyger M.M.B
      Psoriasis in children and adolescents: Diagnosis, management and comorbidities.
      ).

      CLINICAL PRESENTATION: PLAQUE PSORIASIS

      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 (
      • Burden-Teh E.
      • Thomas K.S.
      • Ratib S.
      • Grindlay D.
      • Adaji E.
      • Murphy R.
      The epidemiology of childhood psoriasis: A scoping review.
      ). This condition is typically characterized by erythematous, well-demarcated, indurated plaques with overlying “micaceous” white or silvery scale (Figure 1;
      • Relvas M.
      • Torres T.
      Pediatric psoriasis.
      ). 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 (
      • Bronckers I.M.G.J.
      • Paller A.S.
      • van Geel M.J.
      • van de Kerkhof P.C.M.
      • Seyger M.M.B
      Psoriasis in children and adolescents: Diagnosis, management and comorbidities.
      ).
      FIGURE 1
      FIGURE 1Chronic plaque psoriasis. Moderately erythematous, indurated, scaly plaques on the arm in this adolescent Hispanic male with plaque psoriasis.
      (This figure appears in color online at www.jpedhc.org)
      FIGURE 2
      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.
      (This figure appears in color online at www.jpedhc.org)

      CLINICAL PRESENTATION: GUTTATE 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;
      • Bronckers I.M.G.J.
      • Paller A.S.
      • van Geel M.J.
      • van de Kerkhof P.C.M.
      • Seyger M.M.B
      Psoriasis in children and adolescents: Diagnosis, management and comorbidities.
      ;
      • Relvas M.
      • Torres T.
      Pediatric psoriasis.
      ). 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 (
      • Bronckers I.M.G.J.
      • Paller A.S.
      • van Geel M.J.
      • van de Kerkhof P.C.M.
      • Seyger M.M.B
      Psoriasis in children and adolescents: Diagnosis, management and comorbidities.
      ). 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 3
      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.
      (This figure appears in color online at www.jpedhc.org)

      CLINICAL PRESENTATION: NAIL AND JOINT INVOLVEMENT

      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 (
      • Mercy K.
      • Kwasny M.
      • Cordoro K.M.
      • Menter A.
      • Tom W.L.
      • Korman N.
      • Paller A.S.
      Clinical manifestations of pediatric psoriasis: Results of a multicenter study in the United States.
      ). The prevalence of psoriatic arthritis (PSA) has been estimated to range from 1% to 11% within the pediatric psoriasis population (
      • Burden-Teh E.
      • Thomas K.S.
      • Ratib S.
      • Grindlay D.
      • Adaji E.
      • Murphy R.
      The epidemiology of childhood psoriasis: A scoping review.
      ). 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 (
      • Al-Mutairi N.
      Childhood psoriasis.
      ;
      • Burden-Teh E.
      • Thomas K.S.
      • Ratib S.
      • Grindlay D.
      • Adaji E.
      • Murphy R.
      The epidemiology of childhood psoriasis: A scoping review.
      ). Both may present with superficial, sterile pustules on an erythematous base in the setting of systemic symptoms such as fever, malaise, and arthralgias (
      • Al-Mutairi N.
      Childhood psoriasis.
      ;
      • Bronckers I.M.G.J.
      • Paller A.S.
      • van Geel M.J.
      • van de Kerkhof P.C.M.
      • Seyger M.M.B
      Psoriasis in children and adolescents: Diagnosis, management and comorbidities.
      ). Generalized pustular psoriasis more commonly arises in infants, whereas annular pustular psoriasis is more often seen in older children (
      • Al-Mutairi N.
      Childhood psoriasis.
      ). Palmoplantar pustular psoriasis presents as plaque psoriasis on the palms and soles with sterile pustules (
      • Bissonnette R.
      • Suárez-Fariñas M.
      • Li X.
      • Bonifacio K.M.
      • Brodmerkel C.
      • Fuentes-Duculan J.
      • Krueger J.G.
      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 (
      • Bissonnette R.
      • Suárez-Fariñas M.
      • Li X.
      • Bonifacio K.M.
      • Brodmerkel C.
      • Fuentes-Duculan J.
      • Krueger J.G.
      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.
      ). Erythrodermic psoriasis is rare and characterized by generalized erythema with > 90% body surface involvement (
      • Burden-Teh E.
      • Thomas K.S.
      • Ratib S.
      • Grindlay D.
      • Adaji E.
      • Murphy R.
      The epidemiology of childhood psoriasis: A scoping review.
      ). This condition may be life-threatening because of the loss of barrier protection, electrolyte instability, and dehydration (
      • Bronckers I.M.G.J.
      • Paller A.S.
      • van Geel M.J.
      • van de Kerkhof P.C.M.
      • Seyger M.M.B
      Psoriasis in children and adolescents: Diagnosis, management and comorbidities.
      ). Inverse psoriasis presents as erythematous plaques with minimal scale affecting the flexural areas, including the axillae, groin, and face (Figure 4;
      • Tollefson M.M.
      Diagnosis and management of psoriasis in children.
      ). This condition may be mistaken for intertrigo, erythrasma, or dermatophyte infection.
      FIGURE 4
      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 (
      • Balak D.M.
      • Hajdarbegovic E.
      Drug-induced psoriasis: Clinical perspectives.
      ). 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 (
      • Balak D.M.
      • Hajdarbegovic E.
      Drug-induced psoriasis: Clinical perspectives.
      ). 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
      TreatmentExamples (not comprehensive)Notes
      All topical therapiesVarious vehicles are often available: ointments, creams, lotions, gels, foamsIn 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 corticosteroidsRange 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 inhibitorsTacrolimus, 0.1% ointment; pimecrolimus, 1% creamRecommended as off-label monotherapy for pediatric psoriasis in the face and genital areas (pimecrolimus for patients aged 2 years and older)
      Topical vitamin D analoguesCalcipotriene, also known as calcipotriol, 0.005% foam, cream, ointment, or solutionBecause 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
      Topical combination therapyCalcipotriene, 0.005% ointment; betamethasone dipropionate, 0.064% ointmentCombination therapies are convenient and may help to improve compliance
      Topical tazaroteneTazarotene, 0.05% creamRecommended off-label for localized skin or nail psoriasis
      AnthralinAnthralin, 1% creamRecommended for long-term use for 12 weeks or longer for mild to moderate disease
      Topical coal tarCoal tar, 2.5% gelMay be used in conjunction with other topical therapies or phototherapy; however, the latter has a theoretical risk of cutaneous carcinogenesis
      PhototherapyNB-UVB, excimer laser, lightboxUV 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
      PhotochemotherapyPUVALimited evidence and theoretical risk of cutaneous carcinogenesis

      UV structures may be anxiety-inducing for younger children
      Nonbiological systemic treatmentMethotrexate, acitretin and other systemic retinoids, cyclosporine, systemic fumaric acid estersEach 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 treatmentsEtanercept, 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
      • Menter A.
      • Cordoro K.M.
      • Davis D.M.R.
      • Kroshinsky D.
      • Paller A.S.
      • Armstrong A.W.
      • Elmets C.A.
      Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
      , as the list of possible treatments and treatment combinations is long, this table is not comprehensive and is rather meant as a brief overview.
      • Menter A.
      • Cordoro K.M.
      • Davis D.M.R.
      • Kroshinsky D.
      • Paller A.S.
      • Armstrong A.W.
      • Elmets C.A.
      Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
      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 (
      • Bhutani T.
      • Kamangar F.
      • Cordoro K.M.
      Management of pediatric psoriasis.
      ). 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 (
      • Menter A.
      • Cordoro K.M.
      • Davis D.M.R.
      • Kroshinsky D.
      • Paller A.S.
      • Armstrong A.W.
      • Elmets C.A.
      Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
      ). Phototherapy is an efficacious therapy to treat poorly controlled psoriasis; however, long-term studies are lacking as to potential side effects (
      • Menter A.
      • Cordoro K.M.
      • Davis D.M.R.
      • Kroshinsky D.
      • Paller A.S.
      • Armstrong A.W.
      • Elmets C.A.
      Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
      ).
      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 (
      • Bronckers I.M.G.J.
      • Paller A.S.
      • van Geel M.J.
      • van de Kerkhof P.C.M.
      • Seyger M.M.B
      Psoriasis in children and adolescents: Diagnosis, management and comorbidities.
      ;
      • Menter A.
      • Cordoro K.M.
      • Davis D.M.R.
      • Kroshinsky D.
      • Paller A.S.
      • Armstrong A.W.
      • Elmets C.A.
      Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
      ).

      COMMON COMORBIDITIES

      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 (
      • Ko S.H.
      • Chi C.C.
      • Yeh M.L.
      • Wang S.H.
      • Tsai Y.S.
      • Hsu M.Y.
      Lifestyle changes for treating psoriasis.
      ).
      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 (
      • Elmets C.A.
      • Leonardi C.L.
      • Davis D.M.R.
      • Gelfand J.M.
      • Lichten J.
      • Mehta N.N.
      • Menter A.
      Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with awareness and attention to comorbidities.
      ;
      • Menter A.
      • Cordoro K.M.
      • Davis D.M.R.
      • Kroshinsky D.
      • Paller A.S.
      • Armstrong A.W.
      • Elmets C.A.
      Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
      ;
      • Osier E.
      • Wang A.S.
      • Tollefson M.M.
      • Cordoro K.M.
      • Daniels S.R.
      • Eichenfield A.
      • Eichenfield L.F.
      Pediatric psoriasis comorbidity screening guidelines.
      ). In 2008, the National Psoriasis Foundation (NPF) published a consensus statement on comorbidity screening in adults (
      • Kimball A.B.
      • Gladman D.
      • Gelfand J.M.
      • Gordon K.
      • Horn E.J.
      • Korman N.J.
      National Psoriasis Foundation
      National Psoriasis Foundation clinical consensus on psoriasis comorbidities and recommendations for screening.
      ). In 2017, the Joint NPF-Pediatric Dermatology Research Alliance–Pediatric Psoriasis Comorbidity Screening Initiative published a consensus statement on comorbidity screening guidelines in children (
      • Osier E.
      • Wang A.S.
      • Tollefson M.M.
      • Cordoro K.M.
      • Daniels S.R.
      • Eichenfield A.
      • Eichenfield L.F.
      Pediatric psoriasis comorbidity screening guidelines.
      ). 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 (
      • Menter A.
      • Cordoro K.M.
      • Davis D.M.R.
      • Kroshinsky D.
      • Paller A.S.
      • Armstrong A.W.
      • Elmets C.A.
      Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
      ) and guidelines for the management of adults, with particular attention to comorbidities (
      • Elmets C.A.
      • Leonardi C.L.
      • Davis D.M.R.
      • Gelfand J.M.
      • Lichten J.
      • Mehta N.N.
      • Menter A.
      Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with awareness and attention to comorbidities.
      ). 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%) (
      • Mercy K.
      • Kwasny M.
      • Cordoro K.M.
      • Menter A.
      • Tom W.L.
      • Korman N.
      • Paller A.S.
      Clinical manifestations of pediatric psoriasis: Results of a multicenter study in the United States.
      ;
      • Ogdie A.
      • Weiss P.
      The epidemiology of psoriatic arthritis.
      ). PSA, on average, develops 10 years after skin disease but precedes skin disease in about 15% of children (
      • Tollefson M.M.
      Diagnosis and management of psoriasis in children.
      ). All patients should be educated about the risk of PSA and its signs and symptoms (
      • Elmets C.A.
      • Leonardi C.L.
      • Davis D.M.R.
      • Gelfand J.M.
      • Lichten J.
      • Mehta N.N.
      • Menter A.
      Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with awareness and attention to comorbidities.
      ;
      • Menter A.
      • Cordoro K.M.
      • Davis D.M.R.
      • Kroshinsky D.
      • Paller A.S.
      • Armstrong A.W.
      • Elmets C.A.
      Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
      ). All children should be screened for PSA at each visit with a thorough review of systems and physical examination (PE; Box 1;
      • Elmets C.A.
      • Leonardi C.L.
      • Davis D.M.R.
      • Gelfand J.M.
      • Lichten J.
      • Mehta N.N.
      • Menter A.
      Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with awareness and attention to comorbidities.
      ;
      • Kimball A.B.
      • Gladman D.
      • Gelfand J.M.
      • Gordon K.
      • Horn E.J.
      • Korman N.J.
      National Psoriasis Foundation
      National Psoriasis Foundation clinical consensus on psoriasis comorbidities and recommendations for screening.
      ;
      • Menter A.
      • Cordoro K.M.
      • Davis D.M.R.
      • Kroshinsky D.
      • Paller A.S.
      • Armstrong A.W.
      • Elmets C.A.
      Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
      ;
      • Osier E.
      • Wang A.S.
      • Tollefson M.M.
      • Cordoro K.M.
      • Daniels S.R.
      • Eichenfield A.
      • Eichenfield L.F.
      Pediatric psoriasis comorbidity screening guidelines.
      ). Patients with signs and symptoms of PSA should be referred to a pediatric rheumatologist (
      • Elmets C.A.
      • Leonardi C.L.
      • Davis D.M.R.
      • Gelfand J.M.
      • Lichten J.
      • Mehta N.N.
      • Menter A.
      Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with awareness and attention to comorbidities.
      ;
      • Menter A.
      • Cordoro K.M.
      • Davis D.M.R.
      • Kroshinsky D.
      • Paller A.S.
      • Armstrong A.W.
      • Elmets C.A.
      Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
      ). Pediatric rheumatologists guide the assessment of PSA severity and PSA-specific treatment, which may involve medications such as methotrexate or biologics (
      • Singh J.A.
      • Guyatt G.
      • Ogdie A.
      • Gladman D.D.
      • Deal C.
      • Deodhar A.
      • Reston J.
      Special Article: 2018 American College of Rheumatology/National Psoriasis Foundation guideline for the treatment of psoriatic arthritis.
      ). Children with PSA have an increased risk of and should be screened routinely for uveitis by review of systems and PE (Box 2;
      • Menter A.
      • Cordoro K.M.
      • Davis D.M.R.
      • Kroshinsky D.
      • Paller A.S.
      • Armstrong A.W.
      • Elmets C.A.
      Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
      ;
      • Osier E.
      • Wang A.S.
      • Tollefson M.M.
      • Cordoro K.M.
      • Daniels S.R.
      • Eichenfield A.
      • Eichenfield L.F.
      Pediatric psoriasis comorbidity screening guidelines.
      ). Those with signs and symptoms of uveitis should be referred to ophthalmology (
      • Elmets C.A.
      • Leonardi C.L.
      • Davis D.M.R.
      • Gelfand J.M.
      • Lichten J.
      • Mehta N.N.
      • Menter A.
      Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with awareness and attention to comorbidities.
      ;
      • Menter A.
      • Cordoro K.M.
      • Davis D.M.R.
      • Kroshinsky D.
      • Paller A.S.
      • Armstrong A.W.
      • Elmets C.A.
      Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
      ).
      Signs and symptoms of psoriatic arthritis (PSA)
      Signs and symptoms of PSA
      Involvement of 1+ joints
      Joint pain, tenderness, and/or swelling
      Joint stiffness, which is often worse with rest and improved with movement
      Abnormal gait (i.e., limping)
      Dactylitis (swelling of an entire digit, with or without pain and/or tenderness)
      Enthesitis (swelling, pain, and/or redness at the site of insertion of ligaments, tendons, joint capsules, or fascia to bone)
      Uveitis
      Note. All patients should be screened for PSA at each visit and referred to rheumatology if there is a concern for PSA. Adapted from
      • Elmets C.A.
      • Leonardi C.L.
      • Davis D.M.R.
      • Gelfand J.M.
      • Lichten J.
      • Mehta N.N.
      • Menter A.
      Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with awareness and attention to comorbidities.
      ,
      • Menter A.
      • Cordoro K.M.
      • Davis D.M.R.
      • Kroshinsky D.
      • Paller A.S.
      • Armstrong A.W.
      • Elmets C.A.
      Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
      ,
      • Osier E.
      • Wang A.S.
      • Tollefson M.M.
      • Cordoro K.M.
      • Daniels S.R.
      • Eichenfield A.
      • Eichenfield L.F.
      Pediatric psoriasis comorbidity screening guidelines.
      , and
      • Stoll M.L.
      • Nigrovic P.A.
      Subpopulations within juvenile psoriatic arthritis: a review of the literature.
      .

      OVERWEIGHT AND OBESITY

      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 (
      • Koebnick C.
      • Black M.H.
      • Smith N.
      • Der-Sarkissian J.K.
      • Porter A.H.
      • Jacobsen S.J.
      • Wu J.J.
      The association of psoriasis and elevated blood lipids in overweight and obese children.
      ;
      • Paller A.S.
      • Mercy K.
      • Kwasny M.J.
      • Choon S.E.
      • Cordoro K.M.
      • Girolomoni G.
      • Seyger M.M.B.
      Association of pediatric psoriasis severity with excess and central adiposity: An international cross-sectional study.
      ;
      • Paller A.S.
      • Schenfeld J.
      • Accortt N.A.
      • Kricorian G.
      Aretrospective cohort study to evaluate the development of comorbidities, including psychiatric comorbidities, among a pediatric psoriasis population.
      ).
      • Paller A.S.
      • Mercy K.
      • Kwasny M.J.
      • Choon S.E.
      • Cordoro K.M.
      • Girolomoni G.
      • Seyger M.M.B.
      Association of pediatric psoriasis severity with excess and central adiposity: An international cross-sectional study.
      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 (
      • Paller A.S.
      • Mercy K.
      • Kwasny M.J.
      • Choon S.E.
      • Cordoro K.M.
      • Girolomoni G.
      • Seyger M.M.B.
      Association of pediatric psoriasis severity with excess and central adiposity: An international cross-sectional study.
      ).
      Signs and symptoms of uveitis
      Signs and symptoms of uveitis
      Involvement of one or both eyes
      Often insidious in onset without symptoms (especially in children), or with episodic symptoms
      Eye pain
      Eye redness, especially at the limbus
      Photophobia
      Vision change(s) (i.e., floaters, decreased visual acuity)
      Unequal pupils
      Headache or brow ache
      Note. Patients with psoriatic arthritis should be screened routinely for uveitis, and those with uveitis should be referred to ophthalmology. Adapted from
      • Cassidy J.
      • Kivlin J.
      • Lindsley C.
      • Nocton J.
      Section on Rheumatology, & Section on Ophthalmology. Ophthalmologic examinations in children with juvenile rheumatoid arthritis.
      ,
      • Harman L.E.
      • Margo C.E.
      • Roetzheim R.G.
      Uveitis: the collaborative diagnostic evaluation.
      , and
      • Marino A.
      • Weiss P.F.
      • Davidson S.L.
      • Lerman M.A.
      Symptoms in noninfectious uveitis in a pediatric cohort: Initial presentation versus recurrences.
      .
      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 (
      • Swary J.H.
      • Stratman E.J.
      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 (
      • Ko S.H.
      • Chi C.C.
      • Yeh M.L.
      • Wang S.H.
      • Tsai Y.S.
      • Hsu M.Y.
      Lifestyle changes for treating psoriasis.
      ). Moreover, response to medical management in obese patients may be diminished compared with nonobese patients on the same medications (
      • Alotaibi H.A.
      Effects of weight loss on psoriasis: A review of clinical trials.
      ;
      • Jensen P.
      • Skov L.
      Psoriasis and obesity.
      ).
      At least annually, starting at age 2, BMI percentile should be measured by the PCP or dermatologist (
      • Elmets C.A.
      • Leonardi C.L.
      • Davis D.M.R.
      • Gelfand J.M.
      • Lichten J.
      • Mehta N.N.
      • Menter A.
      Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with awareness and attention to comorbidities.
      ;
      • Menter A.
      • Cordoro K.M.
      • Davis D.M.R.
      • Kroshinsky D.
      • Paller A.S.
      • Armstrong A.W.
      • Elmets C.A.
      Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
      ;
      • Osier E.
      • Wang A.S.
      • Tollefson M.M.
      • Cordoro K.M.
      • Daniels S.R.
      • Eichenfield A.
      • Eichenfield L.F.
      Pediatric psoriasis comorbidity screening guidelines.
      ). Overweight or obese children should be assessed for obesity comorbidities, such as obstructive sleep apnea and gastroesophageal reflux disease, by their PCP (
      • Menter A.
      • Cordoro K.M.
      • Davis D.M.R.
      • Kroshinsky D.
      • Paller A.S.
      • Armstrong A.W.
      • Elmets C.A.
      Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
      ). 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 (
      • Menter A.
      • Cordoro K.M.
      • Davis D.M.R.
      • Kroshinsky D.
      • Paller A.S.
      • Armstrong A.W.
      • Elmets C.A.
      Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
      ;
      • Osier E.
      • Wang A.S.
      • Tollefson M.M.
      • Cordoro K.M.
      • Daniels S.R.
      • Eichenfield A.
      • Eichenfield L.F.
      Pediatric psoriasis comorbidity screening guidelines.
      ).

      DIABETES MELLITUS

      Psoriasis in adults is correlated with an increased risk of insulin resistance and T2DM (
      • Azfar R.S.
      • Seminara N.M.
      • Shin D.B.
      • Troxel A.B.
      • Margolis D.J.
      • Gelfand J.M.
      Increased risk of diabetes mellitus and likelihood of receiving diabetes mellitus treatment in patients with psoriasis.
      ;
      • Qureshi A.A.
      • Choi H.K.
      • Setty A.R.
      • Curhan G.C.
      Psoriasis and the risk of diabetes and hypertension: A prospective study of us female nurses.
      ). This association is not as clear in children (
      • Augustin M.
      • Glaeske G.
      • Radtke M.A.
      • Christophers E.
      • Reich K.
      • Schäfer I.
      Epidemiology and comorbidity of psoriasis in children.
      ;
      • Augustin M.
      • Radtke M.A.
      • Glaeske G.
      • Reich K.
      • Christophers E.
      • Schaefer I.
      • Jacobi A.
      Epidemiology and comorbidity in children with psoriasis and atopic eczema.
      ;
      • Paller A.S.
      • Schenfeld J.
      • Accortt N.A.
      • Kricorian G.
      Aretrospective cohort study to evaluate the development of comorbidities, including psychiatric comorbidities, among a pediatric psoriasis population.
      ). 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%) (
      • Swary J.H.
      • Stratman E.J.
      Identifying performance gaps in comorbidity and risk factor screening, prevention, and counseling behaviors of providers caring for children with psoriasis.
      ). All patients should be educated about the association between psoriasis and T2DM (
      • Menter A.
      • Cordoro K.M.
      • Davis D.M.R.
      • Kroshinsky D.
      • Paller A.S.
      • Armstrong A.W.
      • Elmets C.A.
      Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
      ). 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;
      • Osier E.
      • Wang A.S.
      • Tollefson M.M.
      • Cordoro K.M.
      • Daniels S.R.
      • Eichenfield A.
      • Eichenfield L.F.
      Pediatric psoriasis comorbidity screening guidelines.
      ). Fasting serum glucose is recommended over hemoglobin A1c for the classification of diabetes in children (
      • Osier E.
      • Wang A.S.
      • Tollefson M.M.
      • Cordoro K.M.
      • Daniels S.R.
      • Eichenfield A.
      • Eichenfield L.F.
      Pediatric psoriasis comorbidity screening guidelines.
      ). For children with T2DM, AAP management guidelines should be followed, including lifestyle modification, pharmacological therapy, and monitoring of blood glucose and glycated hemoglobin (
      • Osier E.
      • Wang A.S.
      • Tollefson M.M.
      • Cordoro K.M.
      • Daniels S.R.
      • Eichenfield A.
      • Eichenfield L.F.
      Pediatric psoriasis comorbidity screening guidelines.
      ). Referral to an endocrinologist may be appropriate, particularly if there is uncertainty about the ability to successfully treat T2DM (
      • Menter A.
      • Cordoro K.M.
      • Davis D.M.R.
      • Kroshinsky D.
      • Paller A.S.
      • Armstrong A.W.
      • Elmets C.A.
      Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
      ;
      • Osier E.
      • Wang A.S.
      • Tollefson M.M.
      • Cordoro K.M.
      • Daniels S.R.
      • Eichenfield A.
      • Eichenfield L.F.
      Pediatric psoriasis comorbidity screening guidelines.
      ).
      Risk factors for type 2 diabetes mellitus (T2DM)
      T2DM risk factors
      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
      American Diabetes Association, 2
      Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes-2019.
      and
      • Barlow S.E.
      Expert Committee, Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report.
      .

      CARDIOVASCULAR DISEASE

      Psoriasis is associated with atherosclerosis and an increased risk for CVD, such as myocardial infarction (
      • Elmets C.A.
      • Leonardi C.L.
      • Davis D.M.R.
      • Gelfand J.M.
      • Lichten J.
      • Mehta N.N.
      • Menter A.
      Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with awareness and attention to comorbidities.
      ); 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 (
      • Kimball A.B.
      • Gladman D.
      • Gelfand J.M.
      • Gordon K.
      • Horn E.J.
      • Korman N.J.
      National Psoriasis Foundation
      National Psoriasis Foundation clinical consensus on psoriasis comorbidities and recommendations for screening.
      ). Dyslipidemia and HTN, risk factors for CVD, are discussed separately below. All patients should be educated about the increased risk of CVD (
      • Menter A.
      • Cordoro K.M.
      • Davis D.M.R.
      • Kroshinsky D.
      • Paller A.S.
      • Armstrong A.W.
      • Elmets C.A.
      Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
      ). Children should be screened for CVD risk factors if history and PE are concerning (
      • Menter A.
      • Cordoro K.M.
      • Davis D.M.R.
      • Kroshinsky D.
      • Paller A.S.
      • Armstrong A.W.
      • Elmets C.A.
      Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
      ). 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 (
      • Elmets C.A.
      • Leonardi C.L.
      • Davis D.M.R.
      • Gelfand J.M.
      • Lichten J.
      • Mehta N.N.
      • Menter A.
      Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with awareness and attention to comorbidities.
      ;
      • Menter A.
      • Cordoro K.M.
      • Davis D.M.R.
      • Kroshinsky D.
      • Paller A.S.
      • Armstrong A.W.
      • Elmets C.A.
      Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
      ;
      • Osier E.
      • Wang A.S.
      • Tollefson M.M.
      • Cordoro K.M.
      • Daniels S.R.
      • Eichenfield A.
      • Eichenfield L.F.
      Pediatric psoriasis comorbidity screening guidelines.
      ).

      DYSLIPIDEMIA

      An association between dyslipidemia and psoriasis has been reported in children (
      • Augustin M.
      • Glaeske G.
      • Radtke M.A.
      • Christophers E.
      • Reich K.
      • Schäfer I.
      Epidemiology and comorbidity of psoriasis in children.
      ;
      • Gutmark-Little I.
      • Shah K.N.
      Obesity and the metabolic syndrome in pediatric psoriasis.
      ;
      • Koebnick C.
      • Black M.H.
      • Smith N.
      • Der-Sarkissian J.K.
      • Porter A.H.
      • Jacobsen S.J.
      • Wu J.J.
      The association of psoriasis and elevated blood lipids in overweight and obese children.
      ;
      • Tom W.L.
      • Playford M.P.
      • Admani S.
      • Natarajan B.
      • Joshi A.A.
      • Eichenfield L.F.
      • Mehta N.N.
      Characterization of lipoprotein composition and function in pediatric psoriasis reveals a more atherogenic profile.
      ). 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 (
      • Swary J.H.
      • Stratman E.J.
      Identifying performance gaps in comorbidity and risk factor screening, prevention, and counseling behaviors of providers caring for children with psoriasis.
      ). The PCP should additionally be aware of psoriasis medications that may exacerbate dyslipidemia, particularly oral retinoids and cyclosporine (
      • Gisondi P.
      • Galvan A.
      • Idolazzi L.
      • Girolomoni G.
      Management of moderate to severe psoriasis in patients with metabolic comorbidities.
      ;
      • Mikhaylov D.
      • Hashim P.W.
      • Nektalova T.
      • Goldenberg G.
      Systemic psoriasis therapies and comorbid disease in patients with psoriasis: A review of potential risks and benefits.
      ).
      All patients should be educated about this association (
      • Menter A.
      • Cordoro K.M.
      • Davis D.M.R.
      • Kroshinsky D.
      • Paller A.S.
      • Armstrong A.W.
      • Elmets C.A.
      Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
      ). 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 (
      • Menter A.
      • Cordoro K.M.
      • Davis D.M.R.
      • Kroshinsky D.
      • Paller A.S.
      • Armstrong A.W.
      • Elmets C.A.
      Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
      ;
      • Osier E.
      • Wang A.S.
      • Tollefson M.M.
      • Cordoro K.M.
      • Daniels S.R.
      • Eichenfield A.
      • Eichenfield L.F.
      Pediatric psoriasis comorbidity screening guidelines.
      ). If additional risk factors (Box 4) are identified, screening should be performed outside of these age ranges and more frequently (
      • Menter A.
      • Cordoro K.M.
      • Davis D.M.R.
      • Kroshinsky D.
      • Paller A.S.
      • Armstrong A.W.
      • Elmets C.A.
      Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
      ;
      • Osier E.
      • Wang A.S.
      • Tollefson M.M.
      • Cordoro K.M.
      • Daniels S.R.
      • Eichenfield A.
      • Eichenfield L.F.
      Pediatric psoriasis comorbidity screening guidelines.
      ). 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 (
      • Osier E.
      • Wang A.S.
      • Tollefson M.M.
      • Cordoro K.M.
      • Daniels S.R.
      • Eichenfield A.
      • Eichenfield L.F.
      Pediatric psoriasis comorbidity screening guidelines.
      ). 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 (
      • Menter A.
      • Cordoro K.M.
      • Davis D.M.R.
      • Kroshinsky D.
      • Paller A.S.
      • Armstrong A.W.
      • Elmets C.A.
      Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
      ;
      • Osier E.
      • Wang A.S.
      • Tollefson M.M.
      • Cordoro K.M.
      • Daniels S.R.
      • Eichenfield A.
      • Eichenfield L.F.
      Pediatric psoriasis comorbidity screening guidelines.
      ). Children with an LDL level of ≥ 250 mg/dl or a TG level of ≥ 500 mg/dl should be referred directly to a lipid specialist for medical management (
      • Osier E.
      • Wang A.S.
      • Tollefson M.M.
      • Cordoro K.M.
      • Daniels S.R.
      • Eichenfield A.
      • Eichenfield L.F.
      Pediatric psoriasis comorbidity screening guidelines.
      ).
      Risk factors for dyslipidemia
      Dyslipidemia risk factors
      Family (parent, grandparent, aunt, or uncle) history of cardiovascular disease (at age < 55 years in men, < 65 years in women)
      Hypertension
      Tobacco use
      Body mass index ≥ 95th percentile
      High-density lipoprotein < 40 mg/dl
      Diabetes mellitus
      Chronic renal disease
      Nephrotic syndrome
      Heart transplant
      Kawasaki's disease with current or prior aneurysm(s)
      Human immunodeficiency virus
      Chronic inflammatory disease
      Note. If risk factors are present, screening for dyslipidemia should occur more frequently.
      Adapted from
      • Daniels S.R.
      • Greer F.R.
      & Committee on Nutrition, Lipid screening and cardiovascular health in childhood.
      .

      HYPERTENSION

      HTN appears to be associated with psoriasis in children (
      • Augustin M.
      • Glaeske G.
      • Radtke M.A.
      • Christophers E.
      • Reich K.
      • Schäfer I.
      Epidemiology and comorbidity of psoriasis in children.
      ;
      • Augustin M.
      • Radtke M.A.
      • Glaeske G.
      • Reich K.
      • Christophers E.
      • Schaefer I.
      • Jacobi A.
      Epidemiology and comorbidity in children with psoriasis and atopic eczema.
      ). 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 (
      • Swary J.H.
      • Stratman E.J.
      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 (
      • Gisondi P.
      • Galvan A.
      • Idolazzi L.
      • Girolomoni G.
      Management of moderate to severe psoriasis in patients with metabolic comorbidities.
      ;
      • Mikhaylov D.
      • Hashim P.W.
      • Nektalova T.
      • Goldenberg G.
      Systemic psoriasis therapies and comorbid disease in patients with psoriasis: A review of potential risks and benefits.
      ).
      In pediatrics, blood pressure should be measured annually, starting at age 3 years, and interpreted on the basis of age, sex, and height (
      • Menter A.
      • Cordoro K.M.
      • Davis D.M.R.
      • Kroshinsky D.
      • Paller A.S.
      • Armstrong A.W.
      • Elmets C.A.
      Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
      ;
      • Osier E.
      • Wang A.S.
      • Tollefson M.M.
      • Cordoro K.M.
      • Daniels S.R.
      • Eichenfield A.
      • Eichenfield L.F.
      Pediatric psoriasis comorbidity screening guidelines.
      ). 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 (
      • Osier E.
      • Wang A.S.
      • Tollefson M.M.
      • Cordoro K.M.
      • Daniels S.R.
      • Eichenfield A.
      • Eichenfield L.F.
      Pediatric psoriasis comorbidity screening guidelines.
      ). 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 (
      • Menter A.
      • Cordoro K.M.
      • Davis D.M.R.
      • Kroshinsky D.
      • Paller A.S.
      • Armstrong A.W.
      • Elmets C.A.
      Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
      ;
      • Osier E.
      • Wang A.S.
      • Tollefson M.M.
      • Cordoro K.M.
      • Daniels S.R.
      • Eichenfield A.
      • Eichenfield L.F.
      Pediatric psoriasis comorbidity screening guidelines.
      ).

      NONALCOHOLIC FATTY LIVER DISEASE

      NAFLD is associated with overweight, obesity, diabetes, and adult psoriasis (
      • Ortolan A.
      • Lorenzin M.
      • Tadiotto G.
      • Russo F.P.
      • Oliviero F.
      • Felicetti M.
      • Ramonda R.
      Metabolic syndrome, non-alcoholic fatty liver disease and liver stiffness in psoriatic arthritis and psoriasis patients.
      ). The association between NAFLD and psoriasis in children has been suggested (
      • Tollefson M.M.
      • Van Houten H.K.
      • Asante D.
      • Yao X.
      • Maradit Kremers H.
      Association of psoriasis with comorbidity development in children with psoriasis.
      ). Providers should be aware that obesity, alcohol consumption, and hepatotoxic medications such as methotrexate are associated with an increased risk of NAFLD (
      • Ogdie A.
      • Grewal S.K.
      • Noe M.H.
      • Shin D.B.
      • Takeshita J.
      • Chiesa Fuxench Z.C.
      • Gelfand J.M.
      Risk of incident liver disease in patients with psoriasis, psoriatic arthritis, and rheumatoid arthritis: A population-based study.
      ). Methotrexate is the most common systemic treatment for moderate to severe psoriasis, and it is often used when topical treatments and phototherapy fail (
      • Elmets C.A.
      • Leonardi C.L.
      • Davis D.M.R.
      • Gelfand J.M.
      • Lichten J.
      • Mehta N.N.
      • Menter A.
      Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with awareness and attention to comorbidities.
      ;
      • Menter A.
      • Cordoro K.M.
      • Davis D.M.R.
      • Kroshinsky D.
      • Paller A.S.
      • Armstrong A.W.
      • Elmets C.A.
      Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
      ).
      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 (
      • Snast I.
      • Atzmony L.
      • Braun M.
      • Hodak E.
      • Pavlovsky L.
      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.
      ). 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 (
      • Kaushik S.B.
      • Lebwohl M.G.
      Psoriasis: Which therapy for which patient: Focus on special populations and chronic infections.
      ).
      To screen for NAFLD, alanine aminotransferase (ALT) should be obtained in all children who are overweight or obese, starting at ages 9–11 years (
      • Menter A.
      • Cordoro K.M.
      • Davis D.M.R.
      • Kroshinsky D.
      • Paller A.S.
      • Armstrong A.W.
      • Elmets C.A.
      Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
      ). Earlier screening should be considered in patients with severe obesity, family history of NAFLD, or hypopituitarism (
      • Osier E.
      • Wang A.S.
      • Tollefson M.M.
      • Cordoro K.M.
      • Daniels S.R.
      • Eichenfield A.
      • Eichenfield L.F.
      Pediatric psoriasis comorbidity screening guidelines.
      ). Repeat testing should be considered every 2–3 years if ALT level is normal (< 22 U/L in girls and < 25 U/L in boys) (
      • Menter A.
      • Cordoro K.M.
      • Davis D.M.R.
      • Kroshinsky D.
      • Paller A.S.
      • Armstrong A.W.
      • Elmets C.A.
      Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
      ;
      • Osier E.
      • Wang A.S.
      • Tollefson M.M.
      • Cordoro K.M.
      • Daniels S.R.
      • Eichenfield A.
      • Eichenfield L.F.
      Pediatric psoriasis comorbidity screening guidelines.
      ). Children with ALT levels two times the normal level should be referred to hepatology (
      • Osier E.
      • Wang A.S.
      • Tollefson M.M.
      • Cordoro K.M.
      • Daniels S.R.
      • Eichenfield A.
      • Eichenfield L.F.
      Pediatric psoriasis comorbidity screening guidelines.
      ).

      INFLAMMATORY BOWEL DISEASE

      The risk of IBD is increased in patients with psoriasis (
      • Augustin M.
      • Radtke M.A.
      • Glaeske G.
      • Reich K.
      • Christophers E.
      • Schaefer I.
      • Jacobi A.
      Epidemiology and comorbidity in children with psoriasis and atopic eczema.
      ). Those affected by both psoriasis and IBD have higher rates of complications such as diabetes and arthritis when compared with psoriasis patients without IBD (
      • Binus A.M.
      • Han J.
      • Qamar A.A.
      • Mody E.A.
      • Holt E.W.
      • Qureshi A.A.
      Associated comorbidities in psoriasis and inflammatory bowel disease.
      ). 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 (
      • Elmets C.A.
      • Leonardi C.L.
      • Davis D.M.R.
      • Gelfand J.M.
      • Lichten J.
      • Mehta N.N.
      • Menter A.
      Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with awareness and attention to comorbidities.
      ;
      • Menter A.
      • Cordoro K.M.
      • Davis D.M.R.
      • Kroshinsky D.
      • Paller A.S.
      • Armstrong A.W.
      • Elmets C.A.
      Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
      ;
      • Osier E.
      • Wang A.S.
      • Tollefson M.M.
      • Cordoro K.M.
      • Daniels S.R.
      • Eichenfield A.
      • Eichenfield L.F.
      Pediatric psoriasis comorbidity screening guidelines.
      ). If IBD is strongly suspected, children should be referred to gastroenterology (
      • Elmets C.A.
      • Leonardi C.L.
      • Davis D.M.R.
      • Gelfand J.M.
      • Lichten J.
      • Mehta N.N.
      • Menter A.
      Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with awareness and attention to comorbidities.
      ;
      • Menter A.
      • Cordoro K.M.
      • Davis D.M.R.
      • Kroshinsky D.
      • Paller A.S.
      • Armstrong A.W.
      • Elmets C.A.
      Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
      ;
      • Osier E.
      • Wang A.S.
      • Tollefson M.M.
      • Cordoro K.M.
      • Daniels S.R.
      • Eichenfield A.
      • Eichenfield L.F.
      Pediatric psoriasis comorbidity screening guidelines.
      ).

      PSYCHIATRIC COMORBIDITIES

      Psychiatric comorbidities, particularly depression and anxiety, are associated with psoriasis in both adults and children (
      • Han C.
      • Lofland J.H.
      • Zhao N.
      • Schenkel B.
      Increased prevalence of psychiatric disorders and health care-associated costs among patients with moderate-to-severe psoriasis.
      ;
      • Kimball A.B.
      • Wu E.Q.
      • Guérin A.
      • Yu A.P.
      • Tsaneva M.
      • Gupta S.R.
      • Mulani P.M.
      Risks of developing psychiatric disorders in pediatric patients with psoriasis.
      ;
      • Paller A.S.
      • Schenfeld J.
      • Accortt N.A.
      • Kricorian G.
      Aretrospective cohort study to evaluate the development of comorbidities, including psychiatric comorbidities, among a pediatric psoriasis population.
      ). The risk of suicidal ideation may be higher in psoriasis patients of all ages (
      • Paller A.S.
      • Schenfeld J.
      • Accortt N.A.
      • Kricorian G.
      Aretrospective cohort study to evaluate the development of comorbidities, including psychiatric comorbidities, among a pediatric psoriasis population.
      ). 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 (
      • Kimball A.B.
      • Wu E.Q.
      • Guérin A.
      • Yu A.P.
      • Tsaneva M.
      • Gupta S.R.
      • Mulani P.M.
      Risks of developing psychiatric disorders in pediatric patients with psoriasis.
      ). 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 (
      • Kirby B.
      • Richards H.L.
      • Mason D.L.
      • Fortune D.G.
      • Main C.J.
      • Griffiths C.E.M.
      Alcohol consumption and psychological distress in patients with psoriasis.
      ;
      • Russo P.A.J.
      • Ilchef R.
      • Cooper A.J
      Psychiatric morbidity in psoriasis: A review.
      ); however, in children, the data are limited and have not shown a clear correlation with substance use (
      • Kimball A.B.
      • Wu E.Q.
      • Guérin A.
      • Yu A.P.
      • Tsaneva M.
      • Gupta S.R.
      • Mulani P.M.
      Risks of developing psychiatric disorders in pediatric patients with psoriasis.
      ;
      • Paller A.S.
      • Schenfeld J.
      • Accortt N.A.
      • Kricorian G.
      Aretrospective cohort study to evaluate the development of comorbidities, including psychiatric comorbidities, among a pediatric psoriasis population.
      ).
      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 (
      • Osier E.
      • Wang A.S.
      • Tollefson M.M.
      • Cordoro K.M.
      • Daniels S.R.
      • Eichenfield A.
      • Eichenfield L.F.
      Pediatric psoriasis comorbidity screening guidelines.
      ). As these patients transition into adult care, PCPs should keep in mind that substance use becomes more prevalent in the adult psoriatic population (
      • Kirby B.
      • Richards H.L.
      • Mason D.L.
      • Fortune D.G.
      • Main C.J.
      • Griffiths C.E.M.
      Alcohol consumption and psychological distress in patients with psoriasis.
      ;
      • Russo P.A.J.
      • Ilchef R.
      • Cooper A.J
      Psychiatric morbidity in psoriasis: A review.
      ).
      All patients should be educated about the association of psoriasis with depression and anxiety. This recommendation has only been established in adults (
      • Elmets C.A.
      • Leonardi C.L.
      • Davis D.M.R.
      • Gelfand J.M.
      • Lichten J.
      • Mehta N.N.
      • Menter A.
      Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with awareness and attention to comorbidities.
      ); however, we recommend this for children, as well. Children of all ages should be screened annually for depression and anxiety (
      • Menter A.
      • Cordoro K.M.
      • Davis D.M.R.
      • Kroshinsky D.
      • Paller A.S.
      • Armstrong A.W.
      • Elmets C.A.
      Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
      ;
      • Osier E.
      • Wang A.S.
      • Tollefson M.M.
      • Cordoro K.M.
      • Daniels S.R.
      • Eichenfield A.
      • Eichenfield L.F.
      Pediatric psoriasis comorbidity screening guidelines.
      ). 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 (
      • Osier E.
      • Wang A.S.
      • Tollefson M.M.
      • Cordoro K.M.
      • Daniels S.R.
      • Eichenfield A.
      • Eichenfield L.F.
      Pediatric psoriasis comorbidity screening guidelines.
      ). A more formal evaluation or referral to a mental health professional should occur in children with positive screening or for clinician concern (
      • Elmets C.A.
      • Leonardi C.L.
      • Davis D.M.R.
      • Gelfand J.M.
      • Lichten J.
      • Mehta N.N.
      • Menter A.
      Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with awareness and attention to comorbidities.
      ;
      • Menter A.
      • Cordoro K.M.
      • Davis D.M.R.
      • Kroshinsky D.
      • Paller A.S.
      • Armstrong A.W.
      • Elmets C.A.
      Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
      ;
      • Osier E.
      • Wang A.S.
      • Tollefson M.M.
      • Cordoro K.M.
      • Daniels S.R.
      • Eichenfield A.
      • Eichenfield L.F.
      Pediatric psoriasis comorbidity screening guidelines.
      ).

      QUALITY OF LIFE

      Psoriasis has a profound impact on QOL in patients and their caregivers (
      • Żychowska M.
      • Reich A.
      • Maj J.
      • Jankowska-Konsur A.
      • Szepietowski J.C.
      Impact of childhood psoriasis on caregivers' quality of life, measured with family dermatologylife quality index.
      ). This impact is associated with significant impairment in physical, social, emotional, and academic function (
      • De Jager M.E.A.
      • De Jong E.M.G.J.
      • Evers A.W.M.
      • Van De Kerkhof P.C.M.
      • Seyger M.M.B
      The burden of childhood psoriasis.
      ;
      • Gånemo A.
      • Wahlgren C.F.
      • Svensson Å.
      Quality of life and clinical features in Swedish children with psoriasis.
      ;
      • Varni J.W.
      • Globe D.R.
      • Gandra S.R.
      • Harrison D.J.
      • Hooper M.
      • Baumgartner S.
      Health-related quality of life of pediatric patients with moderate to severe plaque psoriasis: Comparisons to four common chronic diseases.
      ). The degree of QOL impairment in psoriasis is similar to that seen in children with arthritis and asthma (
      • Varni J.W.
      • Globe D.R.
      • Gandra S.R.
      • Harrison D.J.
      • Hooper M.
      • Baumgartner S.
      Health-related quality of life of pediatric patients with moderate to severe plaque psoriasis: Comparisons to four common chronic diseases.
      ). Pruritus, fatigue, and stigmatization may all contribute negatively to QOL (
      • De Jager M.E.A.
      • De Jong E.M.G.J.
      • Evers A.W.M.
      • Van De Kerkhof P.C.M.
      • Seyger M.M.B
      The burden of childhood psoriasis.
      ;
      • Hrehorów E.
      • Salomon J.
      • Matusiak L.
      • Reich A.
      • Szepietowski J.C.
      Patients with psoriasis feel stigmatized.
      ;
      • Reich A.
      • Hrehorów E.
      • Szepietowski J.C.
      Pruritus is an important factor negatively influencing the well-being of psoriatic patients.
      ). 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 (
      • Lavery M.J.
      • Stull C.
      • Kinney M.O.
      • Yosipovitch G.
      Nocturnal pruritus: The battle for a peaceful night's sleep.
      ). Over 80% of the children with psoriasis may not undergo stress counseling by their dermatologist or pediatrician (
      • Swary J.H.
      • Stratman E.J.
      Identifying performance gaps in comorbidity and risk factor screening, prevention, and counseling behaviors of providers caring for children with psoriasis.
      ).
      A formal QOL assessment tool should be considered (
      • Menter A.
      • Cordoro K.M.
      • Davis D.M.R.
      • Kroshinsky D.
      • Paller A.S.
      • Armstrong A.W.
      • Elmets C.A.
      Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
      ;
      • Osier E.
      • Wang A.S.
      • Tollefson M.M.
      • Cordoro K.M.
      • Daniels S.R.
      • Eichenfield A.
      • Eichenfield L.F.
      Pediatric psoriasis comorbidity screening guidelines.
      ). Common tools are available through the Cardiff University School of Medicine and are outlined in Table 1 (

      Cardiff University School of Medicine. (n.d.). Quality of life questionnaires. Retrieved from https://www.cardiff.ac.uk/medicine/resources/quality-of-life-questionnaires

      ). The pediatric PCP should facilitate an open conversation with the patient and caregiver(s) regarding QOL, including physical, social, emotional, and academic well-being (
      • Elmets C.A.
      • Leonardi C.L.
      • Davis D.M.R.
      • Gelfand J.M.
      • Lichten J.
      • Mehta N.N.
      • Menter A.
      Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with awareness and attention to comorbidities.
      ;
      • Osier E.
      • Wang A.S.
      • Tollefson M.M.
      • Cordoro K.M.
      • Daniels S.R.
      • Eichenfield A.
      • Eichenfield L.F.
      Pediatric psoriasis comorbidity screening guidelines.
      ).
      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 (
      • Elmets C.A.
      • Leonardi C.L.
      • Davis D.M.R.
      • Gelfand J.M.
      • Lichten J.
      • Mehta N.N.
      • Menter A.
      Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with awareness and attention to comorbidities.
      ;
      • Menter A.
      • Cordoro K.M.
      • Davis D.M.R.
      • Kroshinsky D.
      • Paller A.S.
      • Armstrong A.W.
      • Elmets C.A.
      Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients.
      ;
      • Osier E.
      • Wang A.S.
      • Tollefson M.M.
      • Cordoro K.M.
      • Daniels S.R.
      • Eichenfield A.
      • Eichenfield L.F.
      Pediatric psoriasis comorbidity screening guidelines.
      ), encourage screening for and educating patients and families about common comorbid conditions.
      These associations present significant practice gaps (
      • Swary J.H.
      • Stratman E.J.
      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 (
      • Elmets C.A.
      • Leonardi C.L.
      • Davis D.M.R.
      • Gelfand J.M.
      • Lichten J.
      • Mehta N.N.
      • Menter A.
      Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with awareness and attention to comorbidities.
      ;
      • Ko S.H.
      • Chi C.C.
      • Yeh M.L.
      • Wang S.H.
      • Tsai Y.S.
      • Hsu M.Y.
      Lifestyle changes for treating psoriasis.
      ;
      • Takeshita J.
      • Grewal S.
      • Langan S.M.
      • Mehta N.N.
      • Ogdie A.
      • Van Voorhees A.S.
      • Gelfand J.M
      Psoriasis and comorbid diseases: Epidemiology.
      ). 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.

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      Biography

      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.