Biologics in pediatric psoriasis - efficacy and safety

Efficacy of medical treatments for pediatric hidradenitis suppurativa: A systematic review

Hidradenitis suppurativa (HS) is a chronic, inflammatory skin condition that has been insufficiently studied in the pediatric population. Timely and effective medical treatments may improve quality of life, mitigate disease burden, and prevent the need for invasive procedural interventions such as surgical excisions. However, there is a paucity of research on the efficacy of medical management strategies for HS in children and adolescents. The aim of this study was to perform a systematic review of the literature on the efficacy and safety of medical treatments for HS in patients <18 years of age. In April 2022, MEDLINE and EMBASE databases were searched for articles on the efficacy of medical treatments for HS in the pediatric population. Between 1984 and 2022, 35 articles (101 patients) met the inclusion criteria. Most patients had Hurley Stage II disease (46.7%, 35/75) followed by Stage I (36%, 27/75), and Stage III (17.3%, 13/75). 100% (23/23) of patients responded to antibiotics, 100% (8/8) to finasteride, 93.9% (31/33) to biologics, 80% (4/5) to oral retinoids, and 50% (6/12) to metformin. Overall, this study demonstrates that medical treatment regimens can improve HS symptoms in pediatric patients, but the extent of improvement is unclear, and the results were largely based on case reports or case series. Prospective studies are warranted to better understand the efficacy and safety of medical treatments for pediatric HS. Clinical trials of HS therapies need to be inclusive of pediatric patients to help define the optimal timing of treatment initiation and guide patient selection.

The PI3K-Akt-mTOR and Associated Signaling Pathways as Molecular Drivers of Immune-Mediated Inflammatory Skin Diseases: Update on Therapeutic Strategy Using Natural and Synthetic Compounds

The dysregulated phosphatidylinositol-3-kinase (PI3K)-Akt-mammalian target of rapamycin (mTOR) signaling pathway has been implicated in various immune-mediated inflammatory and hyperproliferative dermatoses such as acne, atopic dermatitis, alopecia, psoriasis, wounds, and vitiligo, and is associated with poor treatment outcomes. Improved comprehension of the consequences of the dysregulated PI3K/Akt/mTOR pathway in patients with inflammatory dermatoses has resulted in the development of novel therapeutic approaches. Nonetheless, more studies are necessary to validate the regulatory role of this pathway and to create more effective preventive and treatment methods for a wide range of inflammatory skin diseases. Several studies have revealed that certain natural products and synthetic compounds can obstruct the expression/activity of PI3K/Akt/mTOR, underscoring their potential in managing common and persistent skin inflammatory disorders. This review summarizes recent advances in understanding the role of the activated PI3K/Akt/mTOR pathway and associated components in immune-mediated inflammatory dermatoses and discusses the potential of bioactive natural products, synthetic scaffolds, and biologic agents in their prevention and treatment. However, further research is necessary to validate the regulatory role of this pathway and develop more effective therapies for inflammatory skin disorders.

Efficacy and safety of biologics and small molecules for psoriasis in pediatric and geriatric populations. Part I: focus on pediatric patients

INTRODUCTION

Psoriasis management is challenging, especially in pediatric age for different factors. The introduction of biologic drugs and oral small molecules (OSM) revolutionized the armamentarium of available weapons in psoriasis treatment. Despite the use of these drugs in adult patients has been widely investigated, pediatric patients have often been unconsidered in clinical trials and real-life studies. However, the high efficacy and speed of action, the safety profile and the ease-to-use administration make these innovative drugs an invaluable therapeutic opportunity.

AREAS COVERED

The aim of this manuscript is to perform a review of the current literature examining data on the effectiveness and safety of biologic drugs and OSM for the management of psoriasis in pediatric patients in order to put the basis for universally shared treatment algorithm following available evidence. PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines were used for the literature research.

EXPERT OPINION/COMMENTARY

Our review based on currently available evidence suggests biologics and OSM as an ideal treatment option for pediatric patients, with an excellent profile in terms of efficacy and safety as compared to traditional systemic drugs.

Biologics for psoriasis patients under 18 years of age: Real-world evidence from the Chinese psoriasis real world evidence research group

Background

Treatment for pediatric psoriasis is challenging because of the lack of real-world evidence, especially for biological therapies.

Objectives

This study evaluated the efficacy and safety of biologics in children with psoriasis based on real-world evidence.

Methods

Pediatric psoriasis patients aged &lt;18 years who were treated with biologics in our hospital (2020–2022) were prospectively analyzed. Patients treated with adalimumab, secukinumab, or ixekizumab were followed up for at least 16 weeks, and 22 of 38 patients completed the 52-week observation period. Dermatologist raters were blinded to ensure the reliability of the PASI, BSA, and PGA score assessments. PASI 75 or PGA 0/1 at week 12 represented an efficient indicator.

Results

Thirty-eight patients (20 males and 18 females; median age, 12.6 ± 4.1 years) were enrolled, and none were lost to follow-up. All participants were diagnosed with psoriasis, including plaque psoriasis (n = 36), nail psoriasis (n = 1), and pustular psoriasis (n = 1). Within 12 weeks, all patients achieved scores above PASI 75 and PGA 0/1. The average time to reach PASI 75 was 4.3 ± 2.0, 3.2 ± 1.8, and 2.4 ± 0.4 weeks in patients using adalimumab, secukinumab, and ixekizumab, respectively, and, 27.2% (3/11), 86.4% (19/22), and 75.0% (3/4) of these patients achieved PASI 100 at week 12, respectively. Moreover, 18 of 20 patients with plaque psoriasis maintained ≥PASI 75 after 52 weeks. The most commonly reported adverse effect was upper respiratory tract infection, and no severe adverse effects were reported.

Conclusions

Our real-world data demonstrated the safety and effectiveness of adalimumab, secukinumab, and ixekizumab in children with psoriasis.

Physician-reported Clinical Unmet Needs, Burden and Treatment Patterns of Paediatric Psoriasis Patients: a US and EU Real-world Evidence Study

This study is a retrospective analysis using data collected from the Adelphi Paediatric Psoriasis Disease-Specific Programme cross-sectional survey. Despite being treated for their psoriasis, a substantial proportion of paediatric patients presented with moderate (18.3%) or severe (1.3%) disease at sampling; 42.9% and 92.0% had a body surface area (BSA) of >10%, and 38.8% and 100.0% had a Psoriasis Area Severity Index (PASI) score >10, respectively. Overall, 69.9% of patients had only ever been treated with a topical therapy for their psoriasis. For patients with moderate or severe disease at sampling, 16.3% and 14.4% were currently receiving conventional systemics or biologic therapy, respectively. There is a clinical unmet need in this paediatric population; a considerable percentage of patients still experienced moderate or severe disease and persistent psoriasis symptoms, with numerous body areas affected. A significant proportion of patients were undertreated, which may explain the high burden of disease observed.

Recommendations for Management of Childhood Psoriasis

Childhood psoriasis is recognized as a potential multisystem disorder and hence it is imperative to optimize disease management to arrest progression, minimize psychological burden and evolution of metabolic syndrome. Clinical practice recommendations are necessary to assist practitioners in appropriate decision making based on available evidence. Owing to the lack of Indian recommendations on childhood psoriasis, the SIG Pediatric Dermatology under IADVL Academy undertook an evidence-based approach based on published literature on the topic, between January 2000 and July 2020 to frame the recommendations.

Biologic Use in Pediatric Patients With Hidradenitis Suppurativa: A Systematic Review

BACKGROUND

There is currently at least 1 biologic (adalimumab) approved in North America for treatment of Hidradenitis Suppurativa in the pediatric population. However, no reviews or clinical trials have specifically analyzed the effectiveness and safety data of biologic use in this population. The objective of this systematic review is to identify and summarize the outcomes of biologic therapy in pediatric patients with HS.

METHODS

MEDLINE and EMBASE databases were used to conduct the search on Sept 18, 2020.

RESULTS

The 15 included studies consisted of 26 patients, with the mean age of 15 ± 2.3 years. Females accounted for 53.8% (n = 14/26) of cases. The mean duration of HS prior to biologic initiation was 3.5 ± 2.9 years, with the majority having Hurley Stage II. The 26 patients received 34 biologics in total: 85.3% treated with TNF alpha inhibitors (adalimumab n = 17, infliximab n = 10, etanercept n = 1, unspecified n = 1), 5.9% with IL-12/23 inhibitors (ustekinumab n = 2), 5.9% with IL-1 inhibitors (i.e., anakinra n = 2) and 2.9% received IL-23 inhibitors (i.e., guselkumab n = 1) biologics. Of the 26 patients, 23.1% (n = 6/26) experienced complete resolution (CR), 73.1% (n = 19/26) experienced partial resolution (PR), and 3.8% (n = 1/26) had no resolution outcomes reported. The time to resolution of HS lesions after biologic initiation ranged from 10 days to 11.5 months (mean: 5.1 months). No adverse events were reported in the studies.

CONCLUSION

Although anti-TNF alpha were the most common biologics used for HS in pediatric cases, large-scale trials specific to pediatric patients with HS are needed to confirm these findings.

Biologicals for moderate-to-severe plaque type psoriasis in pediatric patients

INTRODUCTION

Psoriasis affects around 2% of children in Europe. The majority of cases is readily managed with topical treatments using corticosteroids without or with calcipotriol. More resistant and extensive moderate-to-severe cases require UVA or UVB phototherapies or conventional systemic treatment including ciclosporin, acitretin and methotrexate. However, these therapies are associated with a low tolerability and potential cumulative long-term adverse effects and toxicities.

AREAS COVERED

About 15 years ago, the first biological appeared for the treatment of moderate-to-severe plaque type psoriasis in adult patients. Several years later, the first biologic treatment to be approved in children was etanercept, a soluble receptor that binds both tumor necrosis factor (TNF)-α and β followed by adalimumab, a monoclonal antibody against TNF-α, and currently by ustekinumab, a monoclonal IL12/23 p40 antagonist and, very recently, secukinumab and ixekizumab, both IL17 antagonists. All these biologic treatments brought significantly improved treatment results compared to light-based therapies and conventional treatments and present very good tolerance and safety profiles.

EXPERT OPINION

Due to their excellent efficacy and safety profiles ustekinumab, secukinumab and ixekizumab could currently be considered as a first-line treatment options for moderate-to-severe childhood and adolescent psoriasis requiring a systemic treatment.

An Association of Pediatric Psoriasis with Metabolic Syndrome in Thai Children: 20 Years Retrospective Study

Purpose

To explore epidemiological data of pediatric psoriasis age under 18 years old regarding, types of psoriasis, the correlation with metabolic syndrome (MetS), treatments, and treatment outcomes of at least one year follow-up.

Patients and Methods

This was a 20-year-retrospective study of pediatric psoriasis patients in a single tertiary pediatric referral center, Faculty of Medicine, Khon Kaen University, Thailand, between January 2001 and December 2020. The diagnosis of psoriasis was based on recorded diagnosis from ICD-10, and medical record was evaluated by certified pediatricians.

Results

There were 177 pediatric psoriasis in the study population. The mean age was 10.50, SD 4.80. The mean body mass index (BMI) was 19.10 (SD 5.44). There were 52 cases (29.37%) with MetS. Pediatric psoriasis patients over the age of 12 years old developed MetS 27 out of 70 cases (0.38) compared to the patients younger than 12 years old (25 out of 107 cases, 0.23), absolute risk reduction = 0.15, 95% CI 0.01–0.29, P = 0.029. The overall outcomes of pediatric psoriasis were good even though traditional topical and systemic treatments were provided in the study population.

Conclusion

The present study revealed that there was 15% increased MetS in the pediatric psoriasis patients over the age of 12 years old as compared to the patients of prepubertal age (≤12 years old). Increased attention to the early detection of MetS in pediatric psoriasis is recommended. Biologic therapy would be an alternative option in severe recalcitrant pediatric psoriasis cases in the future.

Paediatric Medicines - Regulatory Drivers, Restraints, Opportunities and Challenges

The investment in the pharmaceutical development of medicines for paediatric use represents a minority when compared to that one made for adult population. Which reasons lie behind this status quo? Which policies have been implemented to reverse such asymmetry? Is there room to new regulatory initiatives? The creation of regulations establishing the obligation to conduct paediatric trials was deemed necessary as a means of producing products of proven quality, safety and efficacy and, in addition, to set forth financial incentives for the pharmaceutical industry reduce this delay. The first regulatory initiatives were carried out by the Food and Drug Administration (FDA) at the end of the 20^th century. Later on, the European Medicines Agency (EMA) issued the Paediatric Regulation, which has boosted a closer collaboration between both regulatory agencies. Along with the implemented legislation, pharmaceutical dosage forms, more adapted to the paediatric population have emerged, increasing the availability of age-appropriate formulations. However, a case-by-case analysis is required to ensure the best therapeutic option for the specific child. This review aims at discussing the development of medicines for paediatric use from a regulatory perspective, comparing the policies adopted by the EMA and FDA, following an overview of the drivers, restraints, opportunities and challenges.

A Comparison of Psoriasis Severity in Pediatric Patients Treated With Methotrexate vs Biologic Agents

Importance

Few studies have compared the use of methotrexate and biologics, the most commonly used systemic medications for treatment of moderate to severe psoriasis in children.

Objective

To assess the real-world, 6-month reduction in psoriasis severity and long-term drug survival (rate and duration of adherence to a specific drug) of methotrexate vs biologics in plaque psoriasis in children.

Design, Setting, and Participants

A retrospective medical records review was conducted at 20 European and North American centers. Treatment response was based on site-reported Psoriasis Area and Severity Index (PASI) and/or Physician Global Assessment (PGA) scores at baseline and within the first 6 months of treatment. Participants included all 234 consecutively seen children with moderate to severe psoriasis who received at least 3 months of methotrexate or biologics from December 1, 1990, to September 16, 2014, with sufficient data for analysis. Data analysis was performed from December 14, 2015, to September 1, 2016.

Main Outcomes and Measures

PASI, with a range from 0 to 72 (highest score indicating severe psoriasis), and/or PGA, with a scale of 0 (clear), 1 (minimal), 2 (mild), 3 (moderate), 4 (severe), and 5 (very severe).

Results

Of 234 pediatric patients (103 boys [44.0%]; 131 girls [56.0%]) treated with methotrexate and/or biologics, 163 patients (69.7%) exclusively received methotrexate, 47 patients (20.1%) exclusively received biologics, and 24 children (10.2%) received methotrexate and biologics sequentially. Of the latter cohort, 23 children were treated initially with methotrexate. Mean (SD) age at initiation was 11.6 (3.7) years for methotrexate and 13.3 (2.9) years for biologics (73.2% for etanercept) (P = .002). Among patients evaluated by a scoring method at 6-month follow-up, 75% or greater improvement in PASI (PASI75) was achieved in 12 of 30 patients (40.0%) receiving methotrexate and 20 of 28 patients (71.4%) receiving biologics, and PGA was clear/almost clear (PGA 0/1) in 41 of 115 patients (35.6%) receiving methotrexate and 18 of 37 patients (48.6%) receiving biologics. Achieving PASI75 and/or PGA 0/1 between baseline and 6 months was more likely with biologics than methotrexate (PASI75: odds ratio [OR], 4.56; 95% CI, 2.02-10.27; P < .001; and PGA 0/1: OR, 2.00; 95% CI, 0.98-4.00; P = .06). Decreased mean PASI and PGA scores were associated with biologics more than with methotrexate (PASI effect, -3.13; 95% CI, -4.33 to -1.94; P < .001; and PGA effect, -0.31; 95% CI, -0.56 to -0.06; P = .02). After 1, 3, and 5 years of use, overall drug survival rates for methotrexate were 77.5%, 50.3%, and 35.9%, and for biologics, the rates were 83.4%, 64.3%, and 57.1%, respectively. Biologics were associated with a better confounder-corrected drug survival than methotrexate (hazard ratio [HR], 2.23; 95% CI, 1.21-4.10; P = .01). Discontinuation owing to lack of response was comparable (HR, 1.64; 95% CI, 0.80-3.36; P = .18).

Conclusions and Relevance

Methotrexate and biologics appear to be associated with improvement in pediatric psoriasis, although biologics seem to be associated with greater reduction in psoriasis severity scores and higher drug survival rates than methotrexate in the real-world setting. Additional studies directly comparing these medications should be performed for confirmation.

FDA Approved Biologics: Can Etanercept and Ustekinumab be Considered a First-Line Systemic Therapy for Pediatric/Adolescents in Moderate to Severe Psoriasis? A Systematic Review

Psoriasis is a chronic immune-mediated skin disorder. Due to lack of clarity in its pathogenesis, a cure with existing treatment is a big challenge. Biologics, a revolutionary treatment, are potent immunomodulators that explicitly target the culprit cells of the immune system to achieve the maximum level of Psoriasis Area and Severity Index (PASI) score (75 to 90) and clear or almost clear skin in moderate to severe psoriasis. They have been a successful therapy in adult severe psoriasis for a decade. In recent years, biologics have unprecedently sought the attention of the pediatric psoriatic population by proving an efficacious and safe option. The aim of the study is to provide a systematic review of efficacy, safety, and impact on the quality of life of Food and Drug Administration (FDA)-approved biologics, namely etanercept and ustekinumab, and their use as a "first-line systemic therapy" in the moderate to severe pediatric and adolescent psoriatic population. We explored PubMed, Cochrane Library, Google Scholar, American Academy of Dermatology website, ClinicalTrials.gov, the FDA site, and the National Psoriasis Foundation USA site as major database searches. Psoriasis, pediatric, etanercept, and ustekinumab were keywords used to find the relevant literature. Clinical trials and observational studies were retrieved and analyzed to assess the efficacy and safety of FDA-approved biologics as first-line systemic therapy in pediatric psoriasis. The relevant evidence-based studies and the Joint American Academy of Dermatology-National Psoriasis Foundation (AAD-NPF) guideline have shown that etanercept and ustekinumab biologics are significantly effective and safe systemic therapies in dealing with moderate to severe psoriasis in pediatric and adolescent patients and have unprecedently improved their quality of life. Thus, they can be confidently considered as first-line systemic therapy in moderate to severe pediatric and adolescent psoriatic patients by applying the specific criteria and proper monitoring. However, health practitioners and dermatologists must educate pediatric patients and their caretakers about their adverse effects, success/failure chance, careful monitoring, and follow-up plan to achieve the desired result.

Management of Paediatric Psoriasis by Paediatricians: A Questionnaire-Based Survey

INTRODUCTION

Paediatric plaque psoriasis (PedPso) in children and adolescents is often diagnosed and treated for the first time by paediatricians. An early onset of psoriasis is associated with a genetic family burden, higher severity of disease and increased risk of comorbidities, sometimes starting in childhood. However, little information is available on prevalence data and the clinical management of PedPso by paediatricians.

METHODS

A total of 191 questionnaires were sent out to paediatricians regarding their management of PedPso, with a focus on prevalence, diagnosis, initiation of therapies, screening for comorbidities and collaboration with dermatologists. Of these, 95 (49.7%) were returned and evaluated anonymously.

RESULTS

Only about one-half of the responding paediatricians reported being certain in their diagnosis of PedPso, even though they regularly see moderate-to-severely affected patients. The questionnaire revealed that there are clear differences in the general management of PedPso if the paediatrician is not certain of the diagnosis of psoriasis. Compared to paediatricians certain of their diagnosis, those who are uncertain less frequently perform whole-body inspection, screen for relevant comorbidities, such as psoriasis arthritis, metabolic syndrome or mental disorders, and prescribe the use of topical or systemic therapies. No responding paediatrician reported the use of modern systemic therapies, such as biologicals, even in severely affected children. The majority of respondents rated their cooperation with dermatologists as good.

CONCLUSION

The certainty of the diagnosis, the use of system therapies and the screening for comorbidity could improve the care of PedPso through targeted training of paediatricians and intensified interdisciplinary cooperation with dermatologist.

Adalimumab in children and adolescents with severe plaque psoriasis: a safety evaluation

Introduction: Psoriasis is a chronic inflammatory systemic disease that affects 2% of the population and is associated with an important physical and physiological burden. About 0.5-2% of psoriatic cases onset during the pediatric age range, and often it's not diagnosed until adulthood. Adalimumab is an antitumor necrosis factor monoclonal antibody approved for use in children in 2008 and now it was used in several diseases in rheumatology, gastroenterology, and in dermatology.Areas covered: The purpose of this article was to summarize what has been described in the literature so far, about safety in the use of adalimumab in pediatric psoriasis. The presented data was extrapolated from a literature review from PubMed searches (using words 'pediatric psoriasis,' 'adalimumab children,' 'adalimumab safety,' 'pediatric psoriasis treatment,' 'adalimumab clinical trial'), treatment guidelines, and reports from European and United States regulatory agencies.Expert opinion: Actually there are some biologic agents for the treatment of pediatric psoriasis, but the lack of safety data from controlled trials is evident. The safety data on the use of adalimumab in pediatric psoriasis was taken from long-term studies in the adult population. These studies confirm the data on the safety of the drug as it is also supported by several works on real-life.

Effectiveness and safety of Ustekinumab for Crohn's disease; systematic review and pooled analysis of real-world evidence

BACKGROUND

Ustekinumab [UST] is effective in Crohn's disease (CD) in the UNITI studies. Several real-world experience (RWE) studies with UST have been published to date. Our aim was to summarize the available RWE data for UST effectiveness and safety.

METHODS

A systematic review of the available RWE studies of UST for CD and pooled analysis of the available effectiveness and safety data was performed.

RESULTS

Eight relevant studies of 6 RWE were included for analysis. Data from 578 patients were pooled for analysis. Most patients (97.7%) were anti-TNF experienced. Pooled clinical response rate was 60%, 62%, 49% at 12, 24 and 52 weeks respectively (95% CI (0.42-0.77), (0.48-0.75), (0.37-0.62)). Pooled remission rate was 39% (95% CI (0.18-0.65)) at 24 weeks and pooled endoscopic response rate was 63% (95% CI (0.53-0.72)) after approximately one year of UST; 134 adverse events (AE) were reported in total, pooled proportion 21% (95% CI (0.12-0.35)). Serious AE were reported in 19 patients, pooled proportion 5% (95% CI (0.03-0.08)). Infections were reported in 38, pooled proportion 6% (95% CI (0.04-0.11)).

CONCLUSION

Pooled analysis of the RWE data suggests that the real-world effectiveness and safety are comparable to that reported in the randomized control trials.

Sustained long-term efficacy and safety of adalimumab in paediatric patients with severe chronic plaque psoriasis from a randomized, double-blind, phase III study

BACKGROUND

Adalimumab (ADA) (Humira^® , AbbVie Inc., U.S.A.) is approved by the European Medicines Agency for children aged ≥ 4 years with severe plaque psoriasis.

OBJECTIVES

To evaluate the long-term efficacy and safety of ADA in children with severe plaque psoriasis.

METHODS

Results are presented from the 52-week long-term extension (LTE) of the randomized, double-blind, double-dummy, phase III trial, in children with severe plaque psoriasis (results from prior periods have been published). Patients aged ≥ 4 and < 18 years were randomized 1 : 1 : 1 to ADA 0·8 mg kg^-1 (40 mg maximum) or 0·4 mg kg^-1 (20 mg maximum) every other week or to methotrexate (MTX) 0·1-0·4 mg kg^-1 (25 mg maximum) weekly. The 16-week initial treatment (IT) period was followed by a 36-week withdrawal period and a 16-week retreatment period. Patients could enter the LTE at prespecified time points to receive ADA 0·8 mg kg^-1 (blinded or open label) or ADA 0·4 mg kg^-1 (blinded), or to remain off treatment. Efficacy is reported for patient groups according to doses received in the IT and LTE periods.

RESULTS

Of the 114 patients randomized in the IT period, 108 entered the LTE (n = 36 in each group); 93 received ADA 0·8 mg kg^-1 . Efficacy (≥ 75% improvement from baseline in Psoriasis Area and Severity Index) was maintained or improved from entry to the end of the LTE: MTX(IT)/ADA 0·8(LTE) 31-86% of patients; ADA 0·4(IT)/0·4 or 0·8(LTE) 28-47%; ADA 0·8(IT)/0·8(LTE) 50-72%. No serious infections occurred in the LTE.

CONCLUSIONS

After 52 weeks of long-term ADA treatment in children aged 4-18 years with severe plaque psoriasis, disease severity was reduced and maintained or further improved, as demonstrated by efficacy outcomes. No new safety risks were identified. What's already known about this topic? The results from the first three periods of this phase III trial in children aged 4-18 years with severe plaque psoriasis suggest that adalimumab is a safe and efficacious treatment option in this population. What does this study add? This is the first study to evaluate long-term treatment of adalimumab in children with severe psoriasis, and the first to evaluate switching from methotrexate to adalimumab in this population.