Pediatric psoriatic arthropathy requires more than combinations of topical medicines, according to Dr. Kelly M. Cordoro.
Among children with psoriasis, those who present with psoriatic arthropathy; severe, rapidly evolving, and debilitating generalized plaque; or pustular psoriasis represent a challenging subset, management of which “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 of the department of dermatology at the University of California, San Francisco, who discussed such medications in a presentation at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation.
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) has 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. “Systemic retinoids, cyclosporine, and methotrexate are considered standard therapy, but the use of TNF agents for this indication in children is based on several isolated cases reporting beneficial use in adults with severe forms of pustular psoriasis,” Dr. Cordoro said. “Infliximab is the most widely reported agent, but etanercept and adalimumab also have been reported as successful in children with this form of psoriasis.”
“Biologic agents represent an excellent choice for well-selected children who have contraindications to the use of phototherapy or other conventional systemic agents for severe psoriasis,” said Dr. Cordoro.
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, and enthusiasm for the efficacy, short-term safety, and ease of use of these agents in children is reasonably tempered by concerns about the risk of infection, lymphoma, demyelinating disorders, and cost,” 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.”
Dr. Cordoro reported having no conflicts of interest with respect to her presentation. SDEF and this news organization are owned by Elsevier.