The Little Ones: Perspectives on Pediatric Psoriasis and AD

When it comes to children who have psoriasis or stopic dermatitis (AD), no practitioner can afford to be out of the loop on the latest treatments and care strategies. Practical Dermatology® editors interviewed Andrew C. Krakowski, MD, network chair of dermatology and program director for the residency in dermatology at St. Luke’s University Health Network in Bethlehem, PA, to get his perspective on treating these challenging conditions in children.

Psoriasis

As a residency program director, I try to impress on our trainees just how hard it was for me as a budding pediatric dermatologist to simply get comfortable calling psoriasis “psoriasis” in a child. The rash could look like classic psoriasis. It could be right where you would expect psoriasis to be–on the extensors and, in kids, oftentimes involving the umbilicus and gluteal cleft. It could be associated with the things we classically think of, such as Strep throat or nail pitting and geographic tongue. Still, I had a hard time hard-lining the diagnosis because of some subconscious mental block that prevented me from seeing psoriasis as anything other than an “adult” condition. We teach our residents that the morphology of the rash, regardless of age, should guide them to the correct diagnosis. Call it what it looks like and don’t be afraid to perform a biopsy on a child if it helps you to be more accurate. Do what you can to get the patient moving towards proper management and a better prognosis.

The big thing I stress about is if the child shows any signs of psoriatic arthritis. You do not want to catch that on an X-ray because, by that point, you may have missed the opportunity to have prevented it. Treat psoriatic arthritis aggressively and get pediatric rheumatology involved early in the process. Same thing if the child has risk factors for cardiovascular disease. Let’s get pediatric cardiology, pediatric endocrinology, weight management, nutrition, and behavioral health involved and make sure these children are being managed comprehensively and optimally. With the new medications we are seeing in the pipeline–all going for younger and younger age indications–we now have the expectation of “total clearance” as a clinical goal for psoriatic skin lesions. These same medications–combined with others we may not typically prescribe in dermatology–may help prevent the comorbidities of psoriasis. Consequently, it is critical that we make these interventions and that we make these specialty referrals as early as possible so that quality of life is maximally enhanced for the long run.

Atopic Dermatitis

Recently, the American Academy of Allergy, Asthma and Immunology/American College of Allergy, Asthma and Immunology Joint Task Force (JTF) released its 2023 guidelines around AD (eczema). Overall, pretty comprehensive, and I like that it addresses some of the touchier family discussion points such as “suggesting against” elimination diets compared with an unrestricted diet. I feel better supported on the clinical front having this recommendation in print from this group. It goes a long way with families who want to see every specialist for their kid’s mild eczema. Likewise, recommending use of an over-the-counter (OTC) “bland” moisturizer instead of prescription moisturizers (ie, prescription medical devices) is a welcome relief. Clinically, I never thought the medical device moisturizers worked any better than OTC moisturizers, and now, patients can save some money without feeling guilty about it.

What may (or may not) be a surprise is the JTF’s recommendation to add a recommendation around allergen immunotherapy in patients with moderate-to-severe AD that is refractory and in patients who are intolerant or unable to use mid-potency topical treatment. An association in which its members are all armed with immunotherapy hammers chose to nail this to its guidelines. Ok, I get it. However, in my experience, I do not find immunotherapy to be all that necessary—especially in this era of dupilumab.

Finally, some missed, forgotten, or purposely dodged points I would have loved to have seen addressed by the JTF include the following:

1. What constitutes an ideal moisturizer? What ingredients should be included, and what should specifically be excluded or avoided?

2. What does the group recommend in terms of handling vaccine schedules when using dupilumab and other such systemic medications?

3. How long do you try a patient on one of the systemic treatments before considering it a treatment failure? Vice versa, if a systemic is working, how long do you keep it going before trialing the patient off the medication?