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    Pediatric psoriasis, eczema: Triggers and therapies


    3 things to consider before using systemic therapy

    I have three unwavering principles that I consider when I am thinking about systemic therapy for atopic dermatitis or psoriasis, and these are in no particular order:

    First, part of the rationale for systemic therapy is to diminish disabling symptoms such as pruritus, pain, arthralgia resulting in missed school days, lack of mobility, etc. One or more should be present and uncontrolled in candidates for systemic therapy.


    Second, and equally important, is improving the patient’s quality of life. Especially with psoriasis patients, I want to prevent that potential for social stigma, bullying, social isolation and withdrawal. These patients are at higher risk of depression and other mood disorders. When present, in my opinion, that’s a rationale for systemic therapy in an effort to rapidly bring the disease under control.

    Check part one of this three part series: Clinical pearls in pediatric dermatology

    The third thing, which is obvious to all of us, is preventing the complications and morbidity of the disease. For example, a patient who has generalized pustular psoriasis of Von Zumbusch is not going to get topical therapies. They can have serious consequences such as sepsis and even death. So those patients will get treated with a systemic therapy. Psoriatic arthropathy can lead to mutilating arthritis, so most of those patients will get a systemic.

    I’ve been thinking a lot recently about this concept of the psoriatic march. We are all aware of the atopic march and how one aspect of the atopic triad may lead to the next. Is this true for psoriasis?  Will untreated inflammation of psoriasis lead to metabolic syndrome, insulin resistance and cardiovascular disease, which may put our pediatric patients at higher risk for myocardial infarction and stroke as young adults?

    We need longitudinal data. I certainly don’t use the concept of the psoriatic march to provide a definitive rationale to put a pediatric psoriatic patient on long-term systemic therapy, but I certainly consider it and talk to the patients’ families about it.

    There are data on risk of lymphoma in uncontrolled rheumatoid arthritis, patients, for example. We know that patients with psoriasis, particularly more severe disease and younger onset, have a risk for early heart attacks. This is really compelling information for us to wrestle with as pediatric dermatologists, and we should take this into account when managing our patients.

    NEXT: Choosing systemic treatments


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