"Often, we think of pediatric dermatology as a medical specialty, but there's a fair amount of procedural pediatric dermatology that goes on as well,” said Lawrence F. Eichenfield, MD, at the start of his presentation at Maui Derm Connect 2021.1 Dr Eichenfield is a professor of dermatology and pediatrics as well as vice chair, dermatology, at University of California, San Diego, and Rady’s Children’s Hospital. As part of the “Pediatric Dermatology 2021” session, he discussed pediatric inflammatory skin diseases and pediatric laser procedures. Among the from the former topic included a number of pearls regarding pediatric psoriasis.
As background, Dr Eichenfield emphasized some of the updates from the recently published joint guidelines of care for pediatric patients with psoriasis by the American Academy of Dermatology and National Psoriasis Foundation.2 It is important for all dermatologists, not just those who specialize in the treatment of pediatric skin, to remember that one-third of psoriasis cases begin in patients younger than 20 years. These pediatric cases are often associated with a variety of comorbid conditions, including psoriatic arthritis.
In his first pearl, Dr Eichenfield noted that most pediatric psoriasis can be appropriately managed with local agents. Among those recommended is rotational therapy, which is used to avoid overreliance on and potential damage from long-term use of topical steroids. Rotational therapy consists of:
- Topical vitamin D analogues
- Topical calcineurin inhibitors
- Emollients
- Tar-based therapies
- Topical corticosteroids
Other local agents recommended by the guidelines include topical tazarotene (though Dr Eichenfield stated this is off-label, it can be used as monotherapy or in combination with topical corticosteroids), anthralin (recommended to be used with short contact protocols), and coal tar (though has a low strength of recommendation).
He also highlighted that due to the publication process, the guidelines2 do not include a number of new and in development local agents, including:
- Halobetasol, which has data in adolescents both as 0.05% foam monotherapy and as combined with tazarotene
- Tapinarof, an aryl hydrocarbon receptor agonist studied in adults so far but with data in patients aged 12 years and older for atopic dermatitis
- Roflumilast, a PDE-4 inhibitor with adult data and the beginning of trials in pediatric patients
Dr Eichenfield then moved on to more systemic agents, focusing more narrowly on biologic therapies. “Until very recently, we has basically two approved biologics—etanercept at age 4 and older and ustekinumab age 12 and older, even though other biologics and even these were approved at much younger ages for other conditions,” he explained. However, the past year has seen a several updates, and the future is bright for patients with moderate to severe pediatric psoriasis. “I think we’re in a new age now with both the expanded indications for both the IL-12/23 and IL-17s,” he emphasized.
The most exciting addition to the pediatric psoriasis toolbox is ixekizumab, approved for patients as young as 6 years. The dosing follows weight:
- Less than 25 kg receives 20-mg dose with a 40-mg loading dose
- 25-50 kg receives 40-mg dose with an 80-mg loading dose
- Greater than 50kg receives a 80-mg dose with a 160-mg loading dose
Ixekizumab showed very positive results at week 12, with 89% of patients achieving at least 75% improvement in Psoriasis Area and Severity Index (PASI). The safety data has largely been consistent with that of in adults with an increased risk of Crohns diagnosis.3
Next in the biologic options is ustekinumab, which lowered its approval age to 6 years. This option showed 84% achieving PASI 75 after 12 weeks.4
As for additional expanded indications, Dr Eichenfield highlighted secukinumab. While it is not approved yet by the FDA for children, it has been approved in Europe down to age 6 years. Studies have shown that a 12-week PASI 90 rate of 69% and a 24-week rate of 88%, so there is hope.
“So, how will our new biologics stand up compared to older systemic therapies?” asked Dr Eichenfield. He noted that the new stuff is the better stuff, citing Bronckers et al.6 Their study compared the biologics to methotrexate, finding that the PASI 75 or Physician Global Assessment status of clear/almost clear greatly favors biologics. The other advantage, he stressed, was the longer duration of biologics.
References
1. Eichenfield LF. Pediatric inflammatory skin disease: mini-update & what’s new(ish) in pediatric laser procedures. Presented at: Maui Derm Connect 2021; January 25-29, 2021; Maui, HI.
2. Menter A, Cordoro KM, Davis DMR, et al. Joint American Academy of Dermatology–National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients. J Am Acad Dermatol. 2020;82(1):161-201. doi:10.1016/j.jaad.2019.08.049
3. Paller AS, Seyger MMB, Magariños GA, et al. Efficacy and safety of ixekizumab in a phase III, randomized, double-blind, placebo-controlled study in paediatric patients with moderate-to-severe plaque psoriasis (IXORA-PEDS). Br J Dermatol. 2020;183(2):231-241. doi:10.1111/bjd.19147
4. Philipp S, Menter A, Nikkels AF, et al. Ustekinumab for the treatment of moderate-to-severe plaque psoriasis in paediatric patients (≥ 6 to < 12 years of age): efficacy, safety, pharmacokinetic and biomarker results from the open-label CADMUS Jr study. Br J Dermatol. 2020;183(4):664-672. doi: 10.1111/bjd.19018
5. Bodemer C, Kaszuba A, Kingo K, et al. Secukinumab demonstrates high efficacy and a favourable safety profile in paediatric patients with severe chronic plaque psoriasis: 52‐week results from a Phase 3 double‐blind randomized, controlled trial. J Eur Acad Dermatol Venereol. Published online October 17, 2020. doi:10.1111/jdv.17002
6. Bronckers IMGJ, Paller AS, West DP, et al. A comparison of psoriasis severity in pediatric patients treated with methotrexate vs biologic agents. JAMA Dermatol. 2020;156(4):384-392. doi:10.1001/jamadermatol.2019.4835
