Study Identifies Key Prescribing Differences for Pediatric Psoriasis

Psoriasis remains one of the most common chronic skin conditions seen in children. The prevalence of psoriasis in children from birth to 18 years of age is 1%, with an incidence of 40.8 per 100,000. However, management of psoriasis can be challenging due to limited data and lack of standardized guidelines specific to the pediatric population. A study of approximately 3.8 million physician visits for pediatric psoriasis over >2 decades demonstrated key differences in prescribing patterns, depending on the physician specialty and age of the child [Arch Dermatol. 2012;148(1):66-71]. To help bring more consistency to the management of psoriasis, researchers conducted a retrospective, cross-sectional investigation to characterize patterns of childhood psoriasis healthcare delivery from 1979 to 2007 in children from birth to 18 years of age. The primary outcome measures were demographics, physician specialty, and medication prescribed. The researchers used data from the National Ambulatory Medical Care Survey (NAMCS) to assess visits for psoriasis in children. NAMCS tracks outpatient visits to nonfederally employed physicians in the United States. The data are then analyzed by the National Center for Health Statistics. The study covered dermatologists and nondermatologists over the 28-year interval including the years 1979-2007. The periods 1982-1984 and 1987-1988 were omitted because no data were collected in those years. NAMCS also included information about medication. The results showed that >3.8 million visits were recorded during the 28 years studied, with a median of 123,420 visits per year. The number of pediatric psoriasis visits, however, did not change considerably over time (P=.75). Physician visits were equal between males and females. The vast majority of patients (93%) were white, and of these, 83% were non-Hispanic. Children aged 13 to 18 years accounted for 47% of visits, those aged 8 to 12 years for 35%, and those aged 0 to 7 years for 18%. Dermatologists accounted for 63% of visits, followed by pediatricians (17%) and internists (14%). The remaining 4% of visits were divided among other primary care physicians and specialists. Topical corticosteroids accounted for 7 of the top 10 most prescribed medications. Among all patients, the most prescribed medication was topical betamethasone; among those aged 0 to 8 years, tacrolimus; and among those aged 9 to 18 years, betamethasone. High-potency corticosteroids were equally often prescribed for younger and older children. The most commonly prescribed topical noncorticosteroids included calcipotriene, salicylic acid, and ketoconazole. By physician specialty, the most frequently listed medications for dermatologists and internists were high-potency topical steroids including fluocinonide, betamethasone, and clobetasol. Among pediatricians, tacrolimus and selenium sulfide were the most prescribed topical corticosteroids. “Over the study period, topical corticosteroids consistently increased in usage, whereas over-the-counter medications sharply declined and then leveled off,” said the investigators. They also noted an abrupt increase in the use of nonsteroidal topical agents, starting in 1995. Prescriptions for biologic agents in this patient population were not observed until after 2000. Studied limitations cited by the researchers include that the study was based on uncompensated completion of surveys by busy clinicians and relied on systemic extrapolation of visits. They were also unable to comment on the appropriateness of treatment, such as the clinical characteristics of the psoriasis or the sites of involvement. Also based on the NAMCS methodology, only office visits to nonfederally employed physicians were included, which may have resulted in ascertainment bias. Despite these limitations, the authors said, “To our knowledge this study remains the largest survey of healthcare delivery to the pediatric psoriasis population to date.” Along with treatment guidelines for pediatric psoriasis that may help reduce treatment variability, the researchers recommended more education of dermatologists and nondermatologists about the unique clinical and treatment aspects of this skin condition, which may “decrease the treatment gap by creating more comfortable, safe, and effective use of topical and systemic regimens for children with psoriasis.”