- Thursday, January 12, 2023
- KELLY CORDORO
- Expert Insights, Pediatrics
Kelly Cordoro, MD
Associate Professor of Dermatology and Pediatrics
University of California, San Francisco
San Francisco, California, United States
TERMS TO KNOW
Biologics are drugs designed to treat disease by using living organisms or components of living organisms and may come from natural sources such as animals, humans, or microorganisms. Currently, there are multiple biologics for children with psoriasis, alongside other treatment options. Unfortunately, they are not all equally accessible in different regions of the world.
Comorbidities are when two or more diseases are present in a patient at the same time. More research is needed to understand how comorbidities arise in children with psoriasis and how early intervention methods can benefit them.
THE 101
While most cases of psoriasis have their first peak between ages 20 and 30 years old, psoriasis does impact children. In fact:
- 33% of psoriasis cases occur in children.
- 2% of children worldwide are diagnosed with psoriasis.
- Children diagnosed with psoriasis have almost twice a higher rate of comorbidities than children without psoriasis.
TIMELINE
2017: The Pediatric Psoriasis Comorbidity Screening Initiative (CSI) publishes its screening recommendations for children with psoriasis.
2022: To review existing literature and better understand the impact of psoriasis in children, the IPC convenes a small group of IPC Councilors and colleagues on the Global Burden of Pediatric Psoriasis project.
RECENT RESEARCH
Challenges in Noninvasive Skin Biomarker measurements in Daily Practice: A Longitudinal study on skin Surface Protein Detection by the Transdermal Analysis Patch in Pediatric Psoriasis. Schaap MJ, Bruins FM, van den Brink NJM, et al. Skin Pharmacol Physiol. 2022 Oct 6. doi: 10.1159/000527258. Epub ahead of print. PMID: 36202075.
Treatment Goals and Preferences of Pediatric Psoriasis Patients, Young Adults, and Parents. Schaap MJ, Broekhuis SCE, Spillekom-van Koulil S, Groenewoud HMM, de Jong EMGJ, Seyger MMB. J Dermatolog Treat. 2022 Aug;33(5):2527-2533. doi: 10.1080/09546634.2021.1985058. Epub 2021 Oct 8. PMID: 34620033.
Clinical Decisions in Pediatric Psoriasis: A Practical Approach to Systemic Therapy. Ornelas J, Cordoro KM. Dermatol Clin. 2022 Apr;40(2):145-166. doi: 10.1016/j.det.2021.12.003. PMID: 35366969.
Pediatric Psoriasis: From New Insights into Pathogenesis to Updates on Treatment. Kim HO, Kang SY, Kim JC, Park CW, Chung BY. Biomedicines. 2021 Aug 2;9(8):940. doi: 10.3390/biomedicines9080940. PMID: 34440145; PMCID: PMC8393839.
Pediatric Psoriasis Comorbidities. Kittler NW, Cordoro KM. Skin Therapy Lett. 2020 Nov;25(5):1-6. PMID: 33196156.
Research on pediatric psoriasis has increased exponentially in recent years as experts focus on this under-studied population.
As a Professor of Dermatology and Pediatrics and the Division Chief of Pediatric Dermatology at the University of California, IPC Councilor Kelly Cordoro, MD, is working to change how dermatologists view pediatric psoriasis.
Dr. Cordoro’s research interests and professional experience have centered on better understanding, treating, and supporting children diagnosed with psoriasis. As a working group member for the Global Burden of Pediatric Psoriasis, Dr. Cordoro is a part of the team’s systematic review of existing literature while also conducting and publishing her research on pediatric psoriasis.
Here we dive into Dr. Cordoro’s recent publications and discuss how these findings can be translated into accessible recommendations for parents and guardians of children with psoriasis.
Making Decisions About Treatment
No two patients are the same, and no two cases of psoriasis are the same. While the phrase “pediatric psoriasis” can create the impression of one way that psoriasis presents in children, each case is unique. Different treatment options should be considered for each patient based on a constellation of factors.
“We have to hold on to dogma loosely,” says Dr. Cordoro when making treatment decisions. “There’s not always one right way to do things. It’s okay. We have to be independent thinkers when we’re treating psoriasis.”
Dr. Cordoro recommends that dermatologists consider the following factors when determining potential treatment options:
- Psoriasis type
- Severity of psoriasis
- The child’s age
- Comorbidities
- Past treatments and their efficacy
- Potential genetic causes
- Events that trigger flare-ups
- Other characteristics that are unique to the individual child
“We hold on to a lot of biases,” Dr. Cordoro says. “We are inundated with commercials. We are told the way we should treat patients. But the truth is that all that can confuse us. We have to remember that the old drugs are still good drugs and newer drugs are also available to us at certain times.”
Communicating with Parents
With so many options for psoriasis care, communicating with a parent or guardian about the best fit for their child is imperative. Dr. Cordoro urges dermatologists to prioritize shared decision-making regarding pediatric psoriasis cases.
“We have to let patients know that in the vacuum of our knowledge and our data, we can’t know everything, but what we do know right now suggests A, B, or C treatment,” says Dr. Cordoro. With pediatric psoriasis patients, the parent or guardian’s input should be a key aspect of determining what treatment might be the best fit for a child at any given time — and that treatment plan will most likely change over time.
Having conversations, asking questions, and coordinating with a child’s other healthcare providers can enable the dermatologist and the family to make a decision that fits each child.
Pediatric Psoriasis and Comorbidities
While research has focused on the connection between psoriasis and various comorbidities for adults, much is still to be understood about pediatric psoriasis and comorbidities. With many psoriasis cases beginning early in life, it raises the important question of risk of additional issues that may arise due to psoriasis.
Dr. Cordoro’s research and shared case studies highlight the unique ways comorbidities can develop in children — sharing an example of psoriatic arthritis (which often presents before the skin condition itself), and mental health issues such as depression (which may accompany psoriasis in children of any age but often manifests in late childhood to early adolescence).
With psoriatic comorbidities manifesting differently in children than adults, dermatologists may need to manage their expectations and assumptions about pediatric psoriasis patients.
Communicating with Parents
Parents and guardians may not be as aware of how comorbidities can manifest with psoriasis, and early intervention may not be top of mind.
Knowing that comorbidities may present earlier with pediatric psoriasis patients, it’s important to discuss screening options and recommendations with a child’s guardian — without over-treating.
“Comorbidities may impact our decision if the comorbidities are present, but we should never use the risk of comorbidities as a fear factor to talk a patient into a treatment,” Dr. Cordoro explains. “We have no prospective data that aggressively treating a child, adolescent, or young adult really reduces risk [of specific comorbidities] in 20 or 30 years. It’s biologically possible that it does, but we do not have that data.”
Dr. Cordoro encourages dermatologists to be cognizant of the line between assessing for or treating present comorbidities and aggressively treating comorbidities that have not yet developed.
The Importance of Case Studies and Future Research
There is still much work to be done to understand pediatric psoriasis and its burden on young people’s lives, but one way dermatologists can push the field forward is by sharing and publishing case studies.
“What’s really hard to put into writing is the art of therapy and the thinking through individual patients,” Dr. Cordoro explains. Across the globe, different treatments are available, approved, and recommended. By sharing real-life case studies — as she did in a recent presentation with IPC fellows — Dr. Cordoro hopes to open the conversation about what is possible and give dermatologists more confidence in approaching these pediatric cases of psoriasis.
“Remember, your case reports are very important when there’s little data for very rare scenarios,” she says. “It’s important to publish your experience because it helps all of us figure out how to treat children.”
In addition to sharing case studies, Dr. Cordoro also sees the field changing due to the changing nature of clinical trials, treatment options, and available research.
“Finally, pediatric patients are enrolled in clinical trials. When I first started practicing, we could never get a pediatric patient to trial. A drug had to be approved for adults, be in use for many years, and then maybe pediatric patients would be included in clinical trials because it was thought to be unethical to put a child in a trial,” Dr. Cordoro shares. “Now, we’re recognizing that it was unethical to eliminate kids from trials and that we need to stop borrowing data from adults and extrapolating it to children because pediatric patients are their own group.”
While not all treatment options are available in different regions of the world, dermatologists have a range of options to treat pediatric psoriasis, including “tried and true” treatments such as acitretin, methotrexate, cyclosporine, and phototherapy; and “new and novel” treatments such as biologic agents.
Through continued research from dermatologists like Dr. Cordoro and the members of the Global Burden of Pediatric Psoriasis team, together, we can better treat and support children with psoriasis.
