Generalized pustular psoriasis in a child: observation of long-term combination therapy with etretinate and calcipotriol for 16 years

Pharmacological Management of Pediatric Pustular Psoriasis

Therapeutic management of pustular psoriasis remains a challenge despite the rapid advance in psoriasis research and the development of drugs, especially biologics. Treatment guidelines have been established for pustular psoriasis, but no controlled studies are present for juvenile pustular psoriasis (JPP). Search of the literature reveals that current evidence of JPP treatment is limited to case reports and case series. Among the conventional drugs for JPP, oral retinoid is the most commonly used, yet concerns for growth disturbance exist. Cyclosporine and methotrexate have also been administered as first-line treatment. Etanercept is the first biological agent approved for juvenile plaque psoriasis, followed by adalimumab. However, infliximab is usually recommended for JPP because of the rapidity of onset, despite not being approved for use in pediatric psoriasis patients. More recently, secukinumab, ixekizumab, brodalumab, guselkumab, and risankizumab have been approved for adult pustular psoriasis in selected countries. Controlled studies are needed to prove the efficacy and long-term safety of the therapeutic treatments currently used for JPP.

Systemic Treatment of Pediatric Psoriasis: A Review

Psoriasis is a chronic, immune-mediated, inflammatory skin disease, affecting 1-3% of the white population. Although the existence of two psoriasis incidence peaks has been suggested (one in adolescence before 20 years of age and another in adulthood), its onset may occur at any age, including childhood and adolescence, in which the incidence is now estimated at 40.8 per 100,000. As for adult psoriasis, pediatric psoriasis has recently been associated with obesity, metabolic syndrome, increased waist circumference percentiles and metabolic laboratory abnormalities, warranting early monitoring and lifestyle modifications. In addition, due to psoriasis' chronic nature and frequently occurring relapses, psoriatic patients tend to have an impaired quality of life, often requiring long-term treatment. Therefore, education of both pediatric patients and their parents is essential to successful and safe disease management. Given the lack of officially approved therapies, the very limited evidence-based data from randomized controlled trials, and the absence of standardized guidelines, to date, pediatric psoriasis treatment is primarily based on published case reports, case series, guidelines for adult psoriasis, expert opinions and experience with these drugs in other pediatric disorders coming from the disciplines of rheumatology, gastroenterology and oncology. This review focuses on the use of systemic treatments in pediatric psoriasis and their specific features, analyzing the few literature evidences available, expanding the treatment repertoire and guiding dermatologists in better managing of recalcitrant pediatric psoriasis.