Management and Treatment of Psoriasis in Pediatric Patients
Publication Date: November 1, 2019
Last Updated: March 14, 2022
Recommendations
Pediatric psoriasis and disease severity measures
Body surface area measurement of involved skin is recommended as a useful measure of psoriasis severity in children. (C)
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Disease location on the body and impact on physical, social, and psychological quality of life and/or activities of daily living are recommended as measures of psoriasis severity and should be taken into consideration when determining psoriasis severity in children. (C)
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Pediatric psoriasis and psoriatic arthritis
Pediatric patients with psoriasis should be educated about the risk of PSA and its clinical manifestations. (C)
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Pediatric patients with psoriasis should be routinely screened for PSA via a thorough history and physical examination. (C)
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Pediatric patients with psoriasis who show signs and symptoms of inflammatory arthritis should be referred to a rheumatologist with pediatric expertise, if available, for further evaluation and management. (C)
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Pediatric psoriasis patients with PSA should be routinely screened for uveitis by history and physical examination. (C)
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Pediatric patients with psoriasis who show signs and symptoms of uveitis should be referred to an ophthalmology specialist for further evaluation and management. (C)
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Pediatric psoriasis and obesity
Pediatric patients with psoriasis should be routinely assessed for obesity status either by their primary care provider or dermatologist. (B)
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Pediatric psoriasis patients with obesity should be routinely assessed for the comorbidities of obesity (independent of psoriasis) by their primary care provider or dermatologist. (B)
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Pediatric psoriasis and cardiovascular disease
Pediatric patients with psoriasis and their families should be educated about the increased risk of cardiovascular disease. (C)
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Pediatric patients with psoriasis should be screened for cardiovascular risk factors when history and physical examination findings show a potential risk. (B)
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Pediatric patients with psoriasis who have been identified as having cardiovascular risk factors such as obesity, dyslipidemia, diabetes, hypertension, or metabolic syndrome should be referred to appropriate specialists for further evaluation and management. (C)
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Pediatric psoriasis and dyslipidemia
Pediatric patients with psoriasis should be educated about their increased risk of dyslipidemia. (C)
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Pediatric patients with psoriasis should be screened for dyslipidemia between ages 9 and 11 years and 17 and 21 years, as recommended by the AAP for all children. (B)
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Pediatric psoriasis patients with increased risk for dyslipidemia may be screened more frequently at the provider’s discretion. (C)
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Pediatric psoriasis patients with dyslipidemia should be referred to their primary care provider or an endocrinologist for further assessment and management. (C)
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Pediatric psoriasis and hypertension
In accordance with the AAP screening guidelines, pediatric patients with psoriasis ages 3 years and older should be screened annually for hypertension by their primary care provider. (B)
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Pediatric psoriasis and insulin resistance
Pediatric patients with psoriasis should be educated about the potential association between psoriasis, insulin resistance, and diabetes mellitus. (C)
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Pediatric patients with psoriasis who are obese should be screened for insulin resistance and diabetes by their dermatologist or primary care provider every 3 years at the onset of puberty or age 10 years, whichever is sooner. (C)
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Pediatric patients with psoriasis who are overweight and have increased risk for insulin resistance may be screened similarly to obese patients at the provider’s discretion. (C)
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Pediatric psoriasis patients with insulin resistance or diabetes mellitus should be referred to their primary care provider or an endocrinologist for further assessment and management. (C)
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Psoriasis and mental health
Pediatric patients with psoriasis should be screened routinely for mental health diseases including depression and anxiety, regardless of age. This may be achieved through careful assessment of interactions during the visit in the presence of parents, as well as via a private conversation with the patient. Although a specific mental health inventory screening may be used, it is not required for routine mental health assessment in the context of a dermatology office visit. (C)
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Pediatric patients with psoriasis should be asked about substance abuse. (C)
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Pediatric patients with psoriasis found to have mental health or substance abuse concerns should be referred to an appropriate health care professional for further assessment and management. (C)
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Pediatric psoriasis and inflammatory bowel disease
Pediatric patients with psoriasis who show signs and symptoms of inflammatory bowel disease should be considered for consultation with a gastroenterologist with pediatric expertise, if available, for further evaluation and management. (C)
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Pediatric psoriasis and topical steroid therapy
Topical corticosteroids are recommended for the treatment of pediatric psoriasis as an off-label therapy. (B)
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The use of ultra-highpotency topical corticosteroids as monotherapy is effective for short-term treatment of localized psoriasis in pediatric patients. (C)
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Pediatric psoriasis and topical calcineurin inhibitors
Tacrolimus 0.1% ointment is recommended for off-label use as monotherapy for pediatric psoriasis of the face and genital region. (C)
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Pediatric psoriasis and topical vitamin D analogue therapy
Calcipotriene/calcipotriol is recommended as a treatment option for childhood plaque psoriasis. (B)
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Because of the theoretical risk of increased calcium absorption and systemic effects of hypercalcemia, occlusion of calcipotriene/calcipotriol applied to large body surface areas is not recommended. (B)
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Monitoring of vitamin D metabolites may be considered during calcipotriene/ calcipotriol therapy when applied to a large body surface area. (B)
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Pediatric psoriasis and topical combination therapy
The combination of calcipotriol/betamethasone dipropionate ointment applied once daily for up to 4 weeks at a time is recommended as a safe and effective treatment for children ages 12 years and older with mild to moderate plaque psoriasis. (B)
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The combination of calcipotriol/betamethasone dipropionate suspension applied once daily for up to 8 weeks at a time is recommended as a safe and effective treatment for children ages 12 years and older with mild to moderate plaque psoriasis of the scalp. (B)
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The use of emollients (at the same time or different time of day) with topical calcipotriene may be considered to reduce irritation and enhance the efficacy of calcipotriene. (C)
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Rotational therapy with topical vitamin D analogues, topical calcineurin inhibitors, emollients, tar-based therapies, and topical corticosteroids may be considered in children as steroid-sparing regimens that may reduce potential adverse effects from overreliance on topical steroid therapy. (C)
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Pediatric psoriasis and topical tazarotene therapy
The off-label use of topical tazarotene may be recommended as monotherapy or in combination with topical corticosteroids for the treatment of localized pediatric skin or nail psoriasis. (C)
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Pediatric psoriasis and anthralin therapy
Long-term use (12 weeks or longer) of topical anthralin is recommended for the treatment of mild to moderate psoriasis. Shortcontact anthralin protocols are recommended to limit adverse effects. (B)
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Pediatric psoriasis and topical coal tar
Coal tar preparations can be used as a monotherapy or combined with other topical therapies for the treatment of pediatric psoriasis. (C)
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The use of coal tar preparations in conjunction with phototherapy is effective for the treatment of psoriasis in children but may be limited by the theoretical long-term risk of carcinogenesis. (B)
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Pediatric psoriasis and phototherapy/photochemotherapy
NB-UVB is recommended as a treatment option for moderate to severe pediatric plaque and guttate psoriasis. (B)
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The use of excimer laser or PUVA therapy in children with psoriasis may be efficacious and well tolerated but has limited supporting evidence. (C)
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Pediatric psoriasis and methotrexate therapy
Methotrexate is recommended as an effective systemic therapy for moderate to severe plaque psoriasis and other psoriasis subtypes in children. (B)
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Methotrexate is recommended as an effective systemic therapy for pustular psoriasis in children. (B)
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Methotrexate weight-based dosing is recommended in younger children, ranging from 0.2 to 0.7 mg/kg/wk (maximum, 25 mg/wk). (B)
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Folic acid supplementation daily or 6 times weekly during treatment with methotrexate is recommended. (B)
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Routine clinical and laboratory monitoring is recommended before and during treatment with methotrexate. (B)
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Pediatric psoriasis and cyclosporine therapy
Cyclosporine is recommended as an effective systemic therapy for moderate to severe plaque psoriasis in children. (B)
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Cyclosporine is recommended as an effective systemic therapy for moderate to severe pustular psoriasis in children. (B)
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Cyclosporine is recommended for short-term crisis management of severe or unstable plaque, erythrodermic, or pustular psoriasis until the patient can be transitioned to a medication appropriate for long-term use. (C)
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Routine blood pressure clinical and laboratory monitoring is recommended during therapy with cyclosporine. (A)
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Modified cyclosporine (for microemulsion in capsules or solution) is recommended for use and is not interchangeable with unmodified forms of cyclosporine. (C)
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Pediatric psoriasis and systemic retinoid therapy
Acitretin is recommended as an effective, nonimmunosuppressive systemic therapy for children with extensive guttate or moderate to severe (ideally thin plaque) psoriasis vulgaris at a dosage of 0.1 to 1 mg/kg/d. (B)
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Acitretin is recommended as an effective systemic therapy for pustular psoriasis in children. (B)
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Acitretin combined with NB-UVB therapy may be synergistic for plaque and pustular psoriasis in childhood and allows for a reduction in dosing of both agents. (C)
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Acitretin may be combined with other systemic therapies such as methotrexate or cyclosporine, or biologics, depending on the individual clinical situation. (C)
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Routine clinical and laboratory monitoring is recommended during therapy with acitretin. (C)
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Pediatric psoriasis and fumaric acid ester therapy
Fumaric acid esters may be considered as a potentially effective alternative therapy for pediatric patients with moderate to severe psoriasis who are candidates for systemic therapy. (C)
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Clinical and laboratory monitoring is recommended during treatment with fumaric acid esters. (C)
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Pediatric psoriasis and biologic therapy
Etanercept is recommended as an effective therapy for moderate to severe psoriasis in children 6 years of age and older. (A)
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Etanercept dosing is typically once weekly and is dosed subcutaneously at 0.8 mg/kg with a maximum of 50 mg weekly. (A)
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Adalimumab is recommended for off-label use as an effective therapy in children and adolescents with moderate to severe psoriasis. (B)
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The dose of adalimumab is 0.8 mg/kg (maximum, 40 mg) at weeks 0 and 1 and then is given every other week. Adalimumab administered at a dose of 0.8 mg/kg is more efficacious than at a dose of 0.4 mg/kg. (B)
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Infliximab can be recommended as monotherapy or in combination with methotrexate for use in pediatric patients with severe plaque or pustular psoriasis that is unresponsive to other systemic medications, rapidly progressive, unstable, and/or life threatening. (C)
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The starting dose of infliximab is an infusion of 5 mg/kg administered on weeks 0, 2, and 6 and then every 8 weeks. (C)
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Ustekinumab is recommended as an effective therapy for adolescents 12 years and older with moderate to severe plaque psoriasis. (A)
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Ustekinumab can be used as an effective therapy for pediatric patients younger than 12 years old with moderate to severe plaque psoriasis. (C)
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Ustekinumab is given at weeks 0, 4, and 16 and then every 12 weeks with weight-based dosing as follows: 0.75 mg/kg if <60 kg, 45 mg if 60 to ≤100 kg, and 90 mg if >100 kg. (B)
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Biologics may be safely combined with topical corticosteroids, with or without a vitamin D analogue, to augment effectiveness for the treatment of moderate to severe plaque psoriasis. (C)
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The major risk for biologics in children is injection site reaction, but patients should be monitored for their increased risk of infection. (B)
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Recommendation Grading
Overview
Title
Management and Treatment of Psoriasis in Pediatric Patients
Authoring Organizations
American Academy of Dermatology
National Psoriasis Foundation
Publication Month/Year
November 1, 2019
Last Updated Month/Year
January 31, 2024
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Document Objectives
This guideline addresses the management of psoriasis and its extracutaneous manifestations in children and adolescents, with attention to topical and systemic treatment options, phototherapy, and comorbidities, including psychosocial wellness and quality of life (QOL).
Target Patient Population
Children and adolescents with psoriasis
Inclusion Criteria
Female, Male, Adolescent, Child
Health Care Settings
Ambulatory, Outpatient, Radiology services
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Assessment and screening, Management, Treatment
Diseases/Conditions (MeSH)
D015535 - Arthritis, Psoriatic, D011565 - Psoriasis, D001691 - Biological Therapy, D010789 - Phototherapy
Keywords
psoriatic arthritis, psoriasis, biologic therapy
Source Citation
Methodology
Number of Source Documents
153
Literature Search Start Date
January 1, 2011
Literature Search End Date
December 31, 2017