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    Pediatric psoriasis, eczema: Triggers and therapies


    Choosing systemic treatments

    Dr. Siegfried: How do you decide whether a patient needs systemic treatment and then how do you choose which one?

    Dr. Cordoro: First of all, there are different drugs that we know historically, mechanistically, work better for different types of psoriasis. In those situations, it’s a given. For example, we know that thin guttate psoriasis will respond very well to oral retinoids, phototherapy, or both, while thick diffuse plaques are not going to respond as well to oral retinoids. 

    Also there’s the risk-benefit analysis. In the discussion I have with parents, I talk about these specifically for the different treatments. At the end of the day, there is not an enormous difference in efficacy for atopic dermatitis between the various systemic agents. For psoriasis, I believe there is a difference in efficacy depending on the presenting morphology of the disease. So those are important clinical considerations.

    Morphology often trumps everything else in terms of what you are going to use for psoriasis.  For example, if a patient has pustular psoriasis, they are probably going to need an oral retinoid or cyclosporine if it’s more rapidly moving. If the patient’s disease is really severe and the patient is hospitalized, he or she will likely need a TNF (tumor necrosis factor) inhibitor.

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

    There are few patterns I think we have established, and speed of progression is important. So if you need something that acts really quickly, you are going to reach for cyclosporine, because methotrexate does not work quickly for AD or psoriasis. The patient’s age and gender are considerations. None of us will use a retinoid in a girl of child-bearing potential, but retinoids are a fine consideration in boys of all ages, for example low dose acitretin for psoriasis. Level of disability should be considered, and the risks and benefits of individual drugs in individual patients. So for example, I might avoid methotrexate in a very obese child who may have fatty liver.

    Then I think feasibility: How often is lab testing required, what’s the dosing schedule, does the patient have to visit an infusion center if you are choosing to use a biologic agent, etc. Finally, cost. Sadly, going back to where we started, I think cost oftentimes trumps a lot of these other considerations, particularly by way of biologics.

    I don’t really have a gold nugget for systemic therapies for atopic dermatitis, other than what we just mentioned. In addition to patient and disease-related factors, choice of therapy often is based on your experience with the drugs, your comfort level, where you trained. We all have our favorites. I will say that I think azathioprine is the most potent agent for atopic dermatitis, but it’s probably also the one with the most risk.

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