Most pediatric cases of psoriasis are mild and can be managed adequately with combinations of topical medicines, but some cannot, according to Dr. Kelly M. Cordoro.
“The true challenge exists in treating the subset of children who present with severe, rapidly evolving, and debilitating generalized plaque or pustular psoriasis and/or psoriatic arthropathy,” said Dr. Cordoro of the department of dermatology at the University of California, San Francisco.
The management of this subset of patients “requires immediate response with the utilization of systemic medications that are neither well studied nor [Food and Drug Administration] approved for this indication in children,” said Dr. Cordoro, who discussed such medications in a presentation at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation in Maui.
Targeted therapies that are aimed at specific components of the inflammatory cascade, such as anti-tumor necrosis factor agents, are widely used in adults with psoriasis and psoriatic arthritis.
Although none of the three TNF antagonists that have received FDA approval for adult psoriasis—etanercept, infliximab, and adalimumab—have been approved for pediatric psoriasis, off-label use of these agents has demonstrated some promise in children with severe disease, Dr. Cordoro said in an interview.
“Etanercept has the most significant published literature, and the fact that the drug has received FDA approval for use in children for other indications [ankylosing spondylitis and psoriatic arthropathy for children aged 2 years and older, and juvenile rheumatoid arthritis in children aged 4 years and older] substantiates recommendations for its use in the pediatric psoriasis population,” she said.
A recent, randomized controlled trial showed that etanercept can safely and effectively reduce disease severity in children and adolescents aged 4–17 years who have moderate to severe plaque psoriasis (N. Engl. J. Med. 2008;358:241–51).
Biologic agents have also been used in the treatment of children with generalized pustular psoriasis, a serious and rare form of the disease that can be fatal.
With respect to drug safety, “critical evaluation of the potential risk of the anti-TNF agents in children with psoriasis is difficult because of the small number of children treated and the short follow-up period,” Dr. Cordoro said.
Even so, “because the known side effect profiles of traditional systemic agents used for severe psoriasis in children [including methotrexate, cyclosporine, and acitretin] are unacceptable, the documented benefits of the TNF inhibitors in children affected by severe, debilitating psoriasis create a therapeutic niche for these agents,” she said.
Dr. Cordoro reported having no conflicts of interest with respect to her presentation.
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Off-label use of the three TNF antagonists has demonstrated some promise in children with severe disease. DR. CORDORO