Mia's treatment
- Continue with Mia’s journey to find out what happens next
- Read B.A.D. recommendations for biologic therapies that could impact your clinical practice
- Learn key data to treat with confidence and offer hope to patients like Mia
How has Mia been treated in the past?
Mia has tried many treatments over the six years that she suffered from moderate-to-severe psoriasis, but none so far have had any long-term benefits.
In this animation, Mia, her parents and her doctor thoroughly review her treatment history and discuss what has worked and what has caused unacceptable side effects.
Such discussions are invaluable in the shared decision-making treatment approach. As Mia is approaching adolescence, a critical point in the development of emotional and psychosocial well-being25, her parents and doctor are keen to keep trying new treatment options which could work for Mia.
Find out what treatments could be available for Mia soon
Continue on to find out what paediatric psoriasis clinical guidelines recommend and the latest data for approved treatments.
Are we caring enough for Mia?
Paediatric psoriasis treatment guidelines were previously limited
Societies, associations and institutes develop clinical guidelines for the treatment and management of psoriasis at local, national, and international levels. International guidelines for psoriasis in adults have been shown to be relatively consistent concerning older biologic therapies, but differing when it came to switching biologics, monitoring outcomes and combining therapies1.
Until 2020 there were no international guidelines specifically for treating children with psoriasis, with guidance being limited to small sections within adult guidelines if at all.
Professor Paller describes the benefits of having paediatric-specific guidelines for psoriasis.
The following guidelines for childhood psoriasis are currently available:
JAAD - National Psoriasis Foundation Guidelines
This guideline recognises the important pathogenic distinctions between paediatric- and adult-onset psoriasis and offers tailored recommendations focussing on treatment options, comorbidities and quality of life. The guidelines include a summary of new evidence regarding the safety and efficacy of both biologic and non-biologic systemic treatments and there is a strong focus on the importance of establishing a positive patient-physician relationship2.
In the video below, Professor Matthias Augustin explains some of major differences between treating young children and adolescents with psoriasis.
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A number of treatments are approved or recommended for use in children with moderate-to-severe psoriasis
Psoriasis treatment in adults is largely based on disease severity determined by the % of body surface (BSA) affected2:
- <3% BSA considered mild
- 3–10% BSA considered moderate
- >10% BSA considered severe
Generally mild or localised psoriasis are treated by topical agents with systemic and biologic treatments reserved for moderate-to-severe disease.
The location of disease and impact of quality of life (QoL) are equally important in determining disease severity in paediatric patients2 which opens the opportunity for children with milder disease (in terms of % BSA) to also qualify for systemic and biologic treatment based on a large QoL impact.
Professor Matthias Augustin outlines the relative benefits of targeted treatments approved for paediatric psoriasis.
Topical treatments
So when topical agents are not enough, what comes next?
A retrospective study at 20 centres in North America and Europe assessed patterns of use for moderate-to-severe psoriasis in children over a 25-year period6 (Figure 1).
Figure 1. Percentages of children (n = 390) with moderate-to-severe psoriasis treated with systemic therapies (adapted from Bronckers et al.6 ). * Primarily etanercept
Let’s find out more about these treatments next.
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Current treatments are not always effective in the real world
The efficacy of biologics for childhood psoriasis and effect on quality of life (QoL) is certainly impressive from the clinical trial data but could this data be considered a ‘best-case scenario’ given that patients with more severe disease and/or comorbidities may not have been eligible to be included in the clinical trials? How does this compare with real-world data?
There have been two comprehensive studies that have examined these in paediatric patients32,33.
Professor Matthias Augustin, Director of the Institute for Health Services Research in Dermatology and Nursing, in Hamburg, Germany, compares real world data for approved treatments between adults and children with psoriasis.
Efficacy and drug survival vs methotrexate
Hear Professor Tiago Torres describing a real world efficacy study in this short video clip.
The efficacy data here for biologics is similar to that achieved in the Phase III clinical trials. Drug survival is a factor of the rate and duration of adherence to a specific drug (Figure 6).
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References
- Stiff KM, Glines KR, Porter CL, Cline A, Feldman SR. Current pharmacological treatment guidelines for psoriasis and psoriatic arthritis. Expert Review of Clinical Pharmacology. 2018;11(12):1209–1218.
- Menter A, Cordoro KM, Davis DMR, Kroshinsky D, Paller AS, Armstrong AW, et al. Joint American Academy of Dermatology–National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients. J Am Acad Dermatol. 2020;82(1):161–201.
- Eisert L, Augustin M, Bach S, Dittmann M, Eiler R, Fölster-Holst R, et al. S2k guidelines for the treatment of psoriasis in children and adolescents – Short version part 2. JDDG - J Ger Soc Dermatology. 2019;17(9):959–973.
- National Institute for Health and Care Excellence (NICE). Recommendations. Adalimumab, etanercept and ustekinumab for treating plaque psoriasis in children and young people. Available at: https://www.nice.org.uk/guidance/ta455/chapter/1-Recommendations. Accessed 15 May 2020.
- Lansang P, Bergman JN, Fiorillo L, Joseph M, Lara-Corrales I, Marcoux D, et al. Management of pediatric plaque psoriasis using biologics. Journal of the American Academy of Dermatology. 2020;82(1):213–221.
- Bronckers IMGJ, Paller AS, van Geel MJ, van de Kerkhof PCM, Seyger MMB. Psoriasis in children and adolescents: Diagnosis, management and comorbidities. Pediatric Drugs. 2015;17(5):373–384.
- van Geel MJ, Mul K, de Jager MEA, van de Kerkhof PCM, de Jong EMGJ, Seyger MMB. Systemic treatments in paediatric psoriasis: a systematic evidence-based update. J Eur Acad Dermatology Venereol. 2015;29(3):425–437.
- Skilarence 30 mg Gastro-resistant Tablets - Summary of Product Characteristics (SmPC). Available at: https://www.medicines.org.uk/emc/product/752/smpc. Accessed 22 May 2020.
- Ergun T, Seckin Gencosmanoglu D, Alpsoy E, Bulbul-Baskan E, Saricam MH, Salman A, et al. Efficacy, safety and drug survival of conventional agents in pediatric psoriasis: A multicenter, cohort study. J Dermatol. 2017;44(6):630–634.
- Balak DMW, Oostveen AM, Bousema MT, Venema AW, Arnold WP, Seyger MMB, et al. Effectiveness and safety of fumaric acid esters in children with psoriasis: A retrospective analysis of 14 patients from the Netherlands. Br J Dermatol. 2013;168(6):1343–1347.
- Bronckers IMGJ, Seyger MMB, West DP, Lara-Corrales I, Tollefson M, Tom WL, et al. Safety of systemic agents for the treatment of pediatric psoriasis. JAMA Dermatology. 2017;153(11):1147–1157.
- Schwartz G, Paller AS. Targeted therapies for pediatric psoriasis. Semin Cutan Med Surg. 2018;37(3):167–172.
- Paller AS, Siegfried EC, Langley RG, Gottlieb AB, Pariser D, Landells I, et al. Etanercept treatment for children and adolescents with plaque psoriasis. N Engl J Med. 2008;358(3):241–251.
- Enbrel 10 mg powder and solvent for solution for injection for paediatric use - Summary of Product Characteristics (SmPC). Available at: https://www.medicines.org.uk/emc/product/4677/smpc. Accessed 14 May 2020.
- Humira 20 mg / 0.2 ml Solution for Injection in Pre-Filled Syringe - Summary of Product Characteristics (SmPC). Available at: https://www.medicines.org.uk/emc/product/9080/smpc. Accessed 14 May 2020.
- Stelara 45 mg solution for injection (vials) - Summary of Product Characteristics (SmPC). Available at: https://www.medicines.org.uk/emc/product/4413/smpc. Accessed 22 June 2020.
- Taltz 80 mg solution for injection in pre-filled syringe - Summary of Product Characteristics (SmPC). Available at: https://www.medicines.org.uk/emc/product/7233/smpc. Accessed 13 January 2021.
- Cosentyx 150 mg solution for injection in pre-filled pen - Summary of Product Characteristics (SmPC) Avai. https://www.medicines.org.uk/emc/product/3669/smpc. Accessed 13 January 2021.
- Landells I, Marano C, Hsu MC, Li S, Zhu Y, Eichenfield LF, et al. Ustekinumab in adolescent patients age 12 to 17 years with moderate-to-severe plaque psoriasis: Results of the randomized phase 3 CADMUS study. J Am Acad Dermatol. 2015;73(4):594–603.
- Thaçi D, Papp K, Marcoux D, Weibel L, Pinter A, Ghislain PD, et al. Sustained long-term efficacy and safety of adalimumab in paediatric patients with severe chronic plaque psoriasis from a randomized, double-blind, phase III study. Br J Dermatol. 2019;181(6):1177–1189.
- FDA. Enbrel (etanercept) injection, for subcutaneous use. Highlights of prescribing information. Available at: www.fda.gov/medwatch. Accessed 2 July 2020.
- FDA. Stelara (ustekinumab) injection, for subcutaneous or intravenous use. Highlights of prescribing information. Available at: www.fda.gov/medwatch. Accessed 2 July 2020.
- FDA. Taltz (ixekizumab) injection, for subcutaneous use. Highlights of prescribing information. Available at: www.fda.gov/medwatch. Accessed 2 July 2020.
- Paller AS, Seyger MMB, Magariños GA, Bagel J, Pinter A, Cather J, et al. Efficacy and safety of ixekizumab in a phase 3, randomized, double‐blind, placebo‐controlled study in paediatric patients with moderate‐to‐severe plaque psoriasis (IXORA‐PEDS). Br J Dermatol. 2020. doi:10.1111/bjd.19147.
- Philipp S, Menter A, Nikkels AF, Barber K, Landells I, Eichenfield LF, et al. Ustekinumab for the treatment of moderate‐to‐severe plaque psoriasis in paediatric patients (≥ 6 to < 12 years of age): efficacy, safety, pharmacokinetic and biomarker results from the open‐label <scp>CADMUS</scp> Jr study. Br J Dermatol. 2020;bjd.19018.
- Bodemer C, Kaszuba A, Kingo K, Tsianakas A, Morita A, Rivas E, et al. Secukinumab demonstrates high efficacy and a favourable safety profile in paediatric patients with severe chronic plaque psoriasis: 52‐week results from a Phase 3 double‐blind randomised, controlled trial. J Eur Acad Dermatology Venereol. 2020;jdv.17002.
- Reich A, Magnolo N, Kingo K, Laquer V, Browning J, Keefe D, et al. Secukinumab is highly efficacious and has a favorable safety profile in pediatric patients with moderate-to-severe plaque psoriasis. Presented at at AAD VMX 2020, 12–14 June 2020. Available at: https://www.aad.org/member/meetings-education/aadvmx/2020-library#late-breaking.
- Magnolo N, Kingo K, Laquer V, Browning J, Reich A, Szepietowski JC, et al. Secukinumab is highly efficacious and has a favorable safety profile in pediatric patients with moderate to severe plaque psoriasis: 24 week results. EADV Congress Oral presentation. 2020.
- Paller AS, Siegfried EC, Eichenfield LF, Pariser D, Langley RG, Creamer K, et al. Long-term etanercept in pediatric patients with plaque psoriasis. J Am Acad Dermatol. 2010;63(5):762–768.
- World Health Organization. Coronavirus disease 2019 (COVID-19) Situation Report – 51. 2020. Available at: https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200311-sitrep-51-covid-19.pdf?sfvrsn=1ba62e57_10. Accessed 22 May 2020.
- Prompetchara E, Ketloy C, Palaga T. Immune responses in COVID-19 and potential vaccines: Lessons learned from SARS and MERS epidemic. Asian Pacific journal of allergy and immunology. 2020;38(1):1–9.
- Bruins FM, Bronckers IMGJ, Groenewoud HMM, Van De Kerkhof PCM, De Jong EMGJ, Seyger MMB. Association between quality of life and improvement in psoriasis severity and extent in pediatric patients. JAMA Dermatology. 2020;156(1):72–78.
- Bronckers IMGJ, Paller AS, West DP, Lara-Corrales I, Tollefson MM, Tom WL, et al. A comparison of psoriasis severity in pediatric patients treated with methotrexate vs biologic agents. JAMA Dermatology. 2020;156(4):384–392.
- Langley RG, Paller AS, Hebert AA, Creamer K, Weng HH, Jahreis A, et al. Patient-reported outcomes in pediatric patients with psoriasis undergoing etanercept treatment: 12-week results from a phase III randomized controlled trial. J Am Acad Dermatol. 2011;64(1):64–70.
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