Early treatment in children and adolescents with psoriasis is an important supply target. The updated s2k guideline provides evidence-based decision support for the selection of appropriate therapy. In the new edition published at in early 2022, there is an update on the proven measures as well as some interesting updates on new strategies for the management of this distressing skin disease.
In childhood and adolescence, psoriasis occurs less frequently than in adulthood, but with a prevalence of 0.7%, it is not a rare disease [1]. Psoriasis-affected children and adolescents often have a very high level of suffering. Psychosocial factors such as stigmatization and social exclusion also contribute to this. While the clinical picture with the characteristic erythematosquamous plaques is basically similar to that of adults, guttate psoriasis with small-spotted, oval skin lesions and the characteristic association with infections is a form of psoriasis typical for childhood with a possibly independent etiopathogenesis. Manifestations on the face, soles of the hands and feet, and genital area are also more common in adolescent patients than in adults [2].
Record severity of psoriasis and quality of life
To measure disease activity in childhood and adolescence, established scores such as “Psoriasis Area and Severity Index” (PASI), “Body Surface Area” (BSA) are recommended [3,4]. Alternatively, the Physician Global Assessment (PGA), can be used. As in adults, the recording of health-related quality of life is also of great importance in children and adolescents. For this purpose, the Children’s Dermatology Life Quality Index (CDLQI) can be used for 4-16-year-old patients. This questionnaire is used in clinical trials as well as in routine care and is validated for this age group [5]. For patients 16 years and older, the Dermatologic Quality of Life Questionnaire (DLQI) can be used as it is for adult patients. The classification of psoriasis severity was defined as follows: mild = BSA ≤10 and PASI ≤10 and DLQI ≤10; moderate to severe = BSA >10 or PASI >10 and DLQI >10. Histologic confirmation is recommended only when the clinical picture is not clear.
Define therapy goals and assess course: are comorbidities present?
The overall therapeutic goal in the treatment of psoriasis is an improvement in the severity of the skin changes and an improvement in the quality of life. While complete freedom from the appearance of skin lesions and an unrestricted quality of life are desirable, this often proves to be a difficult goal to achieve. Therefore, it is useful to define a minimum response of a therapy after a certain period of time. Analogous to adults, the lead line suggests the following in this regard: after the induction phase of psoriasis therapy, a reduction of the PASI by at least 75% or by 50-75% while maintaining a good quality of life (DLQI ≤5) [6]. In the 4-16 age group, the scores in the CDLQI apply instead of the DLQI. Repeated questioning regarding joint symptoms is recommended [3]. If joint involvement is suspected, a pediatric rheumatologist should be consulted, especially since this has immediate consequences for the choice of therapy [3]. The presence of arthritis is clinically assessed by swelling, pain on pressure or movement, hyperthermia, and limitation of movement. Regular screening for obesity, arterial hypertension, hyperuricemia, hyperlipidemia, and diabetes mellitus should be performed for early detection of other comorbidities, especially with regard to metabolic syndrome [3]. Psoriasis-affected children are about three times more likely to be affected by obesity than those without psoriasis. Moreover, psoriasis in childhood is often associated with higher levels of insulin resistance and apolipoprotein B and lower levels of high-density lipoprotein (HDL) compared to healthy individuals. Furthermore, there is an association with other inflammatory diseases such as non-bacterial osteomyelitis, SAPHO syndrome, Crohn’s disease or ulcerative colitis. The guideline also advises regular screening with regard to possible accompanying psychological symptoms. The risk of developing an anxiety disorder is about 9-fold higher in children with psoriasis aged eight to 12 years, and the risk of developing depression is about 6.5-fold higher than in skin-healthy controls [3,8]. The guideline also recommends a smear test or a visit to an ENT specialist, as infections in the ear, nose and throat area, such as streptococcal tonsillitis, are frequent triggers of psoriasis or psoriasis flares in children. Treatment with an antibiotic can in some cases lead to healing of the skin at the same time.
Topical therapy as a proven treatment pillar
Another important component in the management of psoriasis is the basic care of the skin with skin care creams and, if necessary, the use of symptom-relieving topical preparations (Fig. 1) . The guideline makes the following recommendations [1,4]: Topical corticosteroids are recommended as first-line therapy alone or in combination with topical vitamin D derivatives (calcipotriol and tacalcitol) for the treatment of psoriasis. Class III corticosteroids can be used in the short term, and class II corticosteroids in sensitive areas (e.g., face, perianal). If vitamin D derivatives and topical corticosteroids have not shown sufficient therapeutic success, a treatment attempt with vitamin A derivatives may be worthwhile. Therapy of psoriasis with topical calcineurin inhibitors (off-label) can be recommended especially for localizations like face and intertrigines. The use of dithranol is advocated in children 1 year of age and older in the inpatient or day-care setting. In the outpatient setting, according to the guideline, therapy of psoriasis with dithranol can be considered in children over 1 year of age under close medical supervision. The use of coal tar in psoriasis may be considered in individual cases.
If these topical treatment measures do not achieve their goal or if the frequent application of ointments and creams is perceived as a nuisance, this can lead to frustration and subsequently to a lack of adherence to therapy. In such cases it makes sense to consider systemic treatment together with the relatives [1,4].
What are the guideline recommendations for systemic therapy?
The guideline update highlights a development in recent years that includes simplification and improvement of systemic therapy as a central point [1]. In adult psoriasis patients, internal systemic therapies are now standard of care for moderate to severe psoriasis. In children and adolescents, the focus is not only on efficacy but also on safety and tolerability aspects. In this regard, new findings in recent years have led the guideline to recommend, among other things, several biologics as a therapeutic option [1,4]. There are now several monoclonal antibodies approved for use in children and adolescents that are targeted and have a high overall level of safety and tolerability. Of particular note are adalimumab, secukinumab, and ixekizumab (Fig. 1) [1,3]. Monoclonal antibodies are used for the targeted inactivation of specific molecules. Target structures are in particular proinflammatory cytokines such as tumor necrosis factor or interleukins together with the corresponding receptors. Adalimumab, secukinumab and ixekizumab are applied subcutaneously, the dosing regimen in children and adolescents is adjusted to body weight.
Adalimumab: This anti-TNF-α monoclonal antibody has been in use the longest in the pediatric setting. In Germany, adalimumab is approved for the treatment of severe chronic plaque psoriasis from the age of 4 years in children and adolescents who have responded inadequately to topical therapy and phototherapies or for whom these therapies are not appropriate. For body weight up to 30 kg, 20 mg is administered subcutaneously every 2 weeks. From a body weight of 30 kg, doses of 40 mg adalimumab are given. The first two doses are given weekly, then every 2 weeks. Continuation of therapy longer than 16 weeks should be carefully considered in patients who do not respond within this time period.
Ixekizumab: This monoclonal antibody inhibits interaction with the IL-17 receptor via binding to the proinflammatory cytokine interleukin 17A, thereby preventing keratinocyte activation and proliferation in psoriasis. In 2020, ixekizumab was the first interleukin-17A antibody approved in Germany for the treatment of moderate-to-severe plaque psoriasis in children and adolescents aged 6 years and older with a body weight of at least 25 kg. For patients six years of age and older with a body weight of 25 to 50 kg, a starting dose of 80 mg ixekizumab is recommended, followed by a maintenance dose of 40 mg every 4 weeks. From a body weight of more than 50 kg, the dosage recommendation for the starting dose is 160 mg and for the maintenance dose will be 80 mg every four weeks.
Secukinumab: This is a monoclonal antibody that inhibits interaction with the IL-17 receptor via binding to the proinflammatory cytokine interleukin 17A, thereby preventing keratinocyte activation and proliferation in psoriasis. Secukinumab was approved in Germany as the second interleukin-17A antibody for the treatment of moderate to severe plaque psoriasis in children and adolescents aged 6 years and older. The recommended dose is based on body weight and is administered as a subcutaneous injection with starting doses at weeks 0, 1, 2, 3, and 4, followed by monthly maintenance doses. Children and adolescents under 50 kg receive 75 mg each as a starting and maintenance dose. Starting at a body weight of 50 kg, starting and maintenance doses of 150 mg are recommended. In case of insufficient response, doses may be increased to 300 mg from a body weight of 50 kg.
Therapy monitoring during treatment with biologics
Detailed information on the recommended laboratory controls during treatment with adalimumab, ixekizumab or secukinumab can be found in the guideline [3,4]. It is recommended that children with psoriasis receive all immunizations according to the current official immunization recommendations of public health authorities. During immunosuppressive system therapy, inactivated vaccines can be administered without any problems. Live vaccines should be avoided during biologics treatment. After vaccination with a live vaccine, it is recommended to wait four weeks before starting biologic therapy. Measles-naive children with psoriasis on immunosuppressive therapy should be passively immunized as soon as possible within 2-3 days after measles contact [3,4].
Adalimumab, ixekizumab, secukinumab: approval status in Switzerland
All three of these biologics have Swissmedic approvals for the treatment of plaque psoriasis in children and/or adolescents [7]. The recommended dose of these subcutaneously applied monoclonal antibodies is based on body weight. If patients do not respond after a treatment period of 16 weeks, continuation of therapy should be carefully considered. Biologics are currently not approved for psoriasis patients under 6 years of age in Switzerland.
Congress: Inflammation Update
Literature:
- “Pathogenetics: psoriasis vs atopic dermatitis,” “Psoriasis therapy in children and adolescents gets an upgrade with the new S2k guideline,” Psoriasis Practice Network Southwest, 4/21/2022.
- Swanbeck G, et al: Age at onset and different types of psoriasis. The British journal of dermatology 1995; 133: 768-773.
- S2k guideline: therapy of psoriasis in children and adolescents, 013-094, update 2021, www.awmf.org/leitlinien/detail/ll/013-094.html (last accessed 07.09.22).
- DDG/BVDD: Guideline Implementation Guide, S2k Guideline “Therapy of Psoriasis in Children and Adolescents” (AWMF Register No. 013-094)
- Lewis-Jones MS, Finlay AY: The Children’s Dermatology Life Quality Index (CDLQI): initial validation and practical use. The British journal of dermatology 1995; 132: 942-949.
- Mrowietz U, et al: Definition of treatment goals for moderate to severe psoriasis: a European consensus. Archives of dermatological research 2011; 303: 1-10.
- Swissmedic: Medicinal Product Information, www.swissmedicinfo.ch, (last accessed 07.09.22).
- Kara T, et al: Pediatric patients with psoriasis and psychiatric disorders: premorbidity and comorbidity in a case-control study. SO-J Dermatolog Treat 2018: 1-6.
DERMATOLOGIE PRAXIS 2022; 32(5): 39-42 (published 10/25-22, ahead of print).
