Paediatric patients need early and aggressive treatments too, say experts.
The Australasian College of Dermatologists has launched new guidelines and targeted treatment options for children and adults with moderate to severe psoriasis.
And while the college president Dr Adriene Lee says they “have the potential to change the narrative in psoriasis patient care” in Australia, “the consensus process highlighted that these outcomes can only be achieved if challenges to timely and equitable access are to be addressed”.
“For our patients with psoriasis this means improving access to therapies under the Pharmaceutical Benefits Scheme (PBS) and jurisdictional investment in specialist dermatologist services and training to address the workforce shortage,” said Dr Lee.
The ACD launched the new guidance on 23 May. The consensus adaptation, Treatment goals for moderate-to-severe psoriasis in paediatric and adult Australian patients, provides an overview of the recommendations from the college’s two recent consensus guidelines published in the Australasian Journal of Dermatology (AJD).
The new guidance provides health professionals with practical advice on the treatment and management of patients in light of the new and more effective therapeutic options available.
The revised framework for adults aligns with current international recommendations and, importantly, makes modifications for the paediatric setting. The new guidance expands the definition of severity and broadens the scope of high-impact sites, with focus on patient-centred treatment outcomes such as quality-of-life measures.
“Therapeutic guidance is limited in the paediatric setting, especially when it comes to quality-of-life measures,” said Dr Lee.
“These recommendations will help dermatologists better understand the burden of disease on the patient and their family when considering treatment options, including the transitional period from childhood to adolescence.”
Over the last decade, the treatment landscape for moderate-to-severe psoriasis has evolved rapidly with new therapies providing alternate treatment options for many patients. These include anti-TNFs, JAK inhibitors, interleukin inhibitors, PDE4 inhibitors and TYK2 inhibitors.
The development of the guidance was led by ACD Fellows, Associate Professor Peter Foley and Associate Professor Christopher Baker.
Prior Australian guidance, published a decade ago, identified requirements for assessments and established treatment goals to facilitate decision-making, enhance the appropriate use of available medications, and increase patient satisfaction with care.
“The therapeutic landscape has since changed, warranting the need for updated guidance and practical advice on the management of adults with moderate to severe psoriasis,” wrote the authors on one of the two AJD papers.
The updated guidance has focused on three key areas, including:
- widening the scope of the classification and definition of psoriasis to include the use of a wider range of metrics and encourage consideration of how best to evaluate disease at high impact sites;
- revising overall treatment goals, now that more efficacious products are available, and consideration of strategies to help reduce treatment delays; and
- expanding on the treatment goals to provide considerations for the management of paediatric patients.
In the most recent AJD paper, published in April, researchers sought to specifically determine if and how these adult treatment goals could be modified to accommodate the needs of paediatric and adolescent patients.
Plaque psoriasis is the most common subtype of psoriasis in children, affecting around 75% of children, with scalp, genital and facial involvement also frequently observed. However, at initial presentation, the distribution, morphology and clinical symptoms of psoriasis differ depending on age and can evolve over time, the authors wrote.
Infants typically present with “diaper rash”, characterised by sharply demarcated, minimally elevated erythematous plaques involving the inguinal folds. In younger children, erythematous plaques with overlying white scale are frequently observed to be thinner and smaller than in adults, and tend to develop more often on the scalp, face and flexural areas.
In school-aged children, disease involvement in the ear canal, upper eyelids and nails is common, while in adolescents, chronic plaque psoriasis resembles that in adults with well-defined erythematosquamous papules or plaques with overlying silvery-white scale.
“While the assessment, classification and management of moderate-to-severe psoriasis in paediatric patients aligns with metrics established for adults, it is vital that nuances in the transition from childhood to adolescence be taken into account,” the authors concluded.
Lead author, Professor Foley, said one of the most important findings from this research was the impact of paediatric psoriasis on patients but also their families. He said they found paediatric patients with psoriasis were at increased risk of comorbidities including psoriatic arthritis, metabolic syndrome such as obesity, diabetes, hypertension, and dyslipidaemia, and mental health issues such as anxiety and depression.
“When we went through the process of developing these recommendations, we chose to separate adults and children, acknowledging that children are not just mini adults,” he told Rheumatology Republic.
“There were far greater impacts with childhood, or paediatric psoriasis on the family, it wasn’t just the individual, it was the whole family.
“It’s affecting people at a really vulnerable time in their life when they’re developing social networks when they’re developing their personalities. And when you’ve got a condition that is so visible, so any type of dermatological condition, every time it’s summer, or the child is involved in sport, their skin’s being exposed, other people see it, there’s a lot of stigmatisation, there’s a lot of ostracisation.
“Kids can be cruel. I’m not dismissing asthma or diabetes, but no one else needs to know about those conditions, whereas a skin condition, it’s always there to see.”
Professor Foley said the medical profession tended to treat skin disease in paediatrics “a little bit conservatively, we’re not as aggressive”, and this was something that needed to be reconsidered.
“So this is really trying to emphasise that we need to act early and to treat aggressively to try and lessen those mental health impacts the impact on the quality of life for the child and the family,” he said.
“There is also this growing awareness of so-called cumulative life-course impairment. When someone has a significant illness, and we tend to focus on skin disease, it means that the individual doesn’t achieve their full potential because they’re being held back.
“And then there’s the comorbidities. There’s growing evidence that any systemic inflammatory conditions such as psoriasis, rheumatoid arthritis, inflammatory bowel disease, if you don’t treat, there are higher rates of cardiovascular disease. If we can treat early, we may be able to lessen that impact.”
Professor Foley said studies showed early aggressive treatments of psoriasis may could have big impacts on long-term outcomes.
“Not waiting is probably the key message, and aiming higher, trying to achieve better outcomes from an objective point of view,” he said.
“And then we’re really also trying to emphasise that it’s not just about how extensive the disease is but there are particular sites that push people into the moderate to severe category that’s often underplayed.
“So if there is significant involvement in the scalp, or destruction of nails, or visible signs, such as the face or pecs or hand, that really tends to push both children and adults into that high disease severity category.”
Australasian Journal of Dermatology 2024, online 28 April
Australasian Journal of Dermatology 2023, online 28 July
