Facing Challenges in Pediatric Plaque Psoriasis

"I always find it fascinating when I tell people it’s psoriasis and [parents] don’t think that’s a childhood disease. They just think everything is eczema. For me, talking about that and educating about that is really important because, in my eyes, psoriasis has a more multidisciplinary approach long term,” said Karan Lal, DO, during a custom Dermatology Times DermView video series, “Advancing Care in Pediatric Plaque Psoriasis: Emerging Treatments and Management Strategies.” Lal is the only dual fellowship–trained cosmetic and pediatric dermatologist in the US. He practices at Affiliated Dermatology in Scottsdale, Arizona, and is Dermatology Times’ newest Editorial Advisory Board member.
Lal was joined by Helen Shin, MD, section chief of pediatric dermatology in the Department of Pediatrics at the Joseph M. Sanzari Children’s Hospital at Hackensack University Medical Center in New Jersey.
Psoriasis Longevity and Presentation Lal and Shin started the conversation by discussing pediatric psoriasis and its prevalence. Shin, who practices exclusively with pediatric patients, noted that approximately 30% of children develop psoriasis. Within this population, Shin stated that she often sees higher involvement of the face, scalp, and intertriginous areas, making it a unique circumstance compared with adult patients with psoriasis.

When asked about the longevity of pediatric psoriasis, Shin said she sees patients all across the board. “Some of those babies tend to do better, but many of them also come back,” she said. With patients who do see longer-term symptoms, Shin noted that the affected areas are often changing or may present differently.

Lal added that especially when treating patients with skin of color, it is important to recognize various presentations or affected areas to ensure the correct diagnosis. “It changes the whole discussion and management pattern,” Lal said.

Patient and Family Psychosocial Aspects

When discussing the diagnosis with her patients’ families, Shin says the goal is to control psoriasis and its symptoms as best as they can in order for the patient to look and feel their best. “They may feel embarrassed by it, ashamed; it may affect their participation in school activities and sports,” Shin said.

She noted that the National Psoriasis Foundation, the Society of Pediatric Dermatology, and the American Academy of Dermatology have great resources for both patients and their families, who can face both anxiety and depression surrounding psoriasis.

Lal and Shin agreed on the importance of connecting with a pediatric or adolescent psychiatrist, which they noted can take some time within private practice and hospital settings.

Personalized Treatment Plans

When addressing treatment options, Shin said that her goal is always to control psoriasis as best she can, but also as safely as possible. When selecting a first-line therapy, Shin said she typically reaches for a low-potency topical steroid and a calcineurin inhibitor.

Lal and Shin also discussed the recent FDA approval of roflumilast cream (Zoryve) for patients 6 years and older, and the change it has brought to the pediatric treatment space. Shin said she has seen success in efficacy, onset, and overall use for patients using roflumilast. “Always the biggest challenge is coverage,” Shin said, to which Lal agreed.

After practicing for more than 20 years, Shin reflected on the advancements in systemics approved for pediatric indications in recent years. “It’s changed the game for us,” Shin said. When asked about her preference in biologics, she noted the dosing frequency of ustekinumab (Stelara) is often easier to handle for families.

Difficulty in Treating Comorbidities

Although they are treated similarly, Shin said she finds that cases in which eczema and psoriasis overlap are some of the most challenging. “You treat one way and make the other side flare, treat the other way and make the other side flare,” Shin said.

“It stumps me all the time and I see it so often,” Lal said. He noted that the biggest difficulty he finds with treating this overlap is the inability to give long-term guidance due to the back-and-forth responses that can be seen with treatment. Both agreed that phototherapy can be helpful in these cases, whether it be natural or artificial.

Early Diagnosis and Unmet Needs

Although she noted a lack of data and research on the effects of early diagnosis, Shin said she feels it helps to gain control quickly for the psychosocial aspect of the disease. “It clears up a lot of the problems, the guilt and the fears that people have, or the misconceptions,” Lal said. “Getting that diagnosis for people opens the door. They’re able to look at resources.”

Although there are more options than ever within the pediatric psoriasis landscape, Lal and Shin noted that there are still unmet needs. “We just need more options,” Shin said. “We’ve come a very long way, even in the past 5 years, but I think there’s even more in the pipeline that will help us.”

Oral systemics, liquid formulations, and options that require less monitoring were all on Shin’s wish list for therapeutics, with efficacy and safety always at the top of mind. Lal agreed, noting that because many children cannot swallow pills, a liquid formulation would be a great option.

When reflecting on research they would like to see in the near future, Shin said she would like to see data on early intervention and comorbidity rates over longer periods. Similarly, Lal said he would like to see long-term data on malignancy risk, something he believes patients want more data on as well.