Pediatricians caring for children with psoriasis should screen these patients for risk factors for what can be serious psoriasis-associated comorbidities, according to the Pediatric Psoriasis Comorbidity Screening Guidelines released in JAMA Dermatology, July 2017.1
“Pediatricians may not be aware of the incredibly strong knowledge that adults with psoriasis have significant medical comorbidities, including much higher rates of cardiovascular disease and other comorbidities, even as early as in young adulthood,” says guidelines’ author Lawrence F. Eichenfield, MD, professor of Dermatology and Pediatrics, University of California, San Diego School of Medicine, La Jolla, and chief of Pediatric and Adolescent Dermatology, Rady Children's Hospital-San Diego, California. “About a third of psoriasis starts in childhood. So, there’s a recognition highlighted in the guidelines that children with psoriasis may have higher rates of associated medical comorbidities, and they should be screened for this.”
A growing body of evidence suggests that adults with psoriasis are at risk for a litany of systemic and behavioral comorbidities. Among them: obesity, hypertension, dyslipidemia, type 2 diabetes mellitus, psoriatic arthritis, nonalcoholic fatty liver disease, depression, anxiety, suicidality and impaired quality of life.1
“We’re beginning to see similar changes in adolescent patients with psoriasis,” says Douglas W. Kress, MD, clinical associate professor of Dermatology, University of Pittsburgh School of Medicine, Pennsylvania.
One example is that whereas providers generally know arthritis is an adult psoriasis comorbidity, pediatricians might not suspect it in their adolescent psoriasis patients, and kids shouldn’t have joint pain, according to Kress. “Any child with psoriasis and unexplained joint pain should be evaluated by a subspecialist for the possibility of psoriatic arthritis, which would warrant more aggressive therapy,” he says.
By identifying comorbidity risk factors early, pediatricians and other providers can intervene to minimize health effects in the patient’s lifetime and lessen the impact of psoriasis.1
Until last year, pediatricians and other providers treating children with the disease lacked comorbidity screening guidelines looking specifically at pediatric psoriasis. That changed in July last year, when a multispecialty panel of psoriasis experts released the first such consensus statement. It offers recommendations that are relevant for all healthcare providers who care for pediatric psoriasis patients, including pediatricians and dermatologists.1
Pediatricians have long known that having psoriasis is a major psychosocial issue for kids, says Bernard A. Cohen, MD, professor of Pediatrics and Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland.
“We’re aware that especially adolescents with things like psoriasis, bad eczema, and moderate-to-severe acne actually score worse on quality of life studies than kids with things like liver disease, renal failure, heart disease,” Cohen says.2
With today’s knowledge that psoriasis is associated with so many other medical comorbidities, pediatricians and others are realizing psoriasis is a systemic disease—not just a skin thing, Cohen says.
“If you have uncontrolled psoriasis or psoriasis that has been active for long periods of time, it puts kids at risk for atherosclerotic disease, obesity, and complications that come with that. It puts kids at increased risk for being hypertensive, having elevated lipids. It also affects quality of life because those kids are afraid to go to school and show off their skin,” Cohen says. “[The recent guidelines] give us data to support the things that we have thought for the last number of years, but now we have something official for pediatricians—not just for dermatologists.”
The Pediatric Dermatology Research Alliance (PeDRA), a consortium of pediatric dermatology researchers, and the National Psoriasis Foundation evaluated and graded evidence quality after doing a literature review from 1999 to 2015. Of the 153 manuscripts they analyzed, 26 studies involved children and teens.1
Many of the screening recommendations are consistent with what the American Academy of Pediatrics (AAP) endorses for the general pediatric patient, with a few exceptions. The researchers note that because there were so few pediatric studies on psoriasis, the document offers level C recommendations based on consensus, usual practice, opinion, disease-oriented evidence, or case series.1
The panel recommends screening for overweight and obesity annually using body mass index (BMI) percentile, starting at age 2 years. Pediatricians identifying patients as overweight or obese should counsel patients and families about the importance of making lifestyle changes. Pediatricians should consider referral to a pediatric tertiary weight management center for children whose BMIs are greater than 120% of the 95th percentile.1
Studies show pediatric psoriasis patients are more likely to be obese or overweight than pediatric patients without psoriasis. The theory is that excess adipose tissue is linked with a proinflammatory state, including increased cytokine expression, which could predispose some people to develop psoriasis.1
Type 2 diabetes mellitus
Recommendations include: In pediatric psoriasis patients who are overweight and have two risk factors for diabetes, screen every 3 years for diabetes, beginning at age 10 years or the onset of puberty. In patients who are obese, screen every 3 years regardless of whether they have risk factors for diabetes. Pediatricians should use fasting serum glucose to screen patients.
Psoriasis is an independent risk factor for diabetes, according to adult studies.1
There is evidence of early metabolic and lipid abnormalities in children with psoriasis, and adult studies suggest associations between psoriasis and dyslipidemia, as well as abnormal lipid function and composition. However, the literature in this area is limited in children. For now, the panel suggests that pediatric psoriasis patients should have the general age-related universal lipid screenings, unless these patients have other cardiovascular risk factors. The panel recommends using a fasting lipid panel.1
Hypertension screening, using AAP guidelines, should start at age 3 years. Adult studies show an association between psoriasis and hypertension, and 1 retrospective study supports the association in children.1
Nonalcoholic fatty liver disease
Panel members write that they have not seen evidence to recommend screening pediatric psoriasis patients with normal BMI for nonalcoholic fatty liver disease (NAFLD), but they do recommend screening for some psoriasis patients, including obese or overweight children with diabetes or a family history of NAFLD. They suggest using the alanine aminotransferase measurement, starting at ages 9 to 11 years.1
Polycystic ovary syndrome (PCOS)
Adult studies suggest psoriasis might be associated with PCOS, but such studies have not yet been done in children. For now, the panel recommends pediatricians should be aware of a potential association with psoriasis in case patients develop symptoms of hirsutism or oligomenorrhea.1
Because psoriasis patients have higher rates of inflammatory bowel disease, the panel recommends performing a gastrointestinal evaluation in pediatric psoriasis patients with a decreased growth rate, unexplained weight loss, or inflammatory bowel disease symptoms.1
It’s a priority for providers to identify and treat psoriatic arthritis early, and asking patients and families about arthritis symptoms should be a standard part of ongoing psoriasis management. Psoriatic arthritis can be destructive and debilitating and mimics clinical characteristics of juvenile idiopathic arthritis.
“Notably, 80% of children with psoriatic arthritis develop arthritis 2 to 3 years prior to skin findings, whereas adult patients tend to develop cutaneous manifestations first,” the researchers write.
Pediatricians should screen for arthritis development by reviewing symptoms and with a physical examination, looking for features such as joint pain and swelling, dactylitis, joint stiffness after rest, a limp, enthesitis, or uveitis.1
Mood disorders, substance abuse
Providers should screen annually for depression and anxiety regardless of age, and yearly for substance abuse starting from age 11 years.1
Researchers have found that pediatric patients with psoriasis were at about 25% to 30% higher risk for developing depression and/or anxiety versus children without psoriasis.
Although more research is needed to determine if pediatric psoriasis patients are more likely than those without psoriasis to develop alcohol abuse, adult studies suggest a link.1
Quality of life
Children who have psoriasis tend to be more notably impaired emotionally and socially, compared with children without the disease. They’re more likely to have trouble functioning at school and often are bullied and teased. The psychosocial effects of psoriasis can be profound.1
Providers should ask patients and families about the effects of psoriasis and consider using a quality of life screening instrument, such as the Children’s Dermatology Life Quality Index.1
Pediatricians play a key role
Pediatricians play a pivotal role not only in performing screenings early on, but also in referring these patients and in partnering with dermatologists, according to Amy S. Paller, MD, chair of Dermatology at Northwestern University Feinberg School of Medicine, Chicago, Illinois, and PeDRA immediate past co-chair and founding co-chair.
"Pediatricians should become familiar with the clinical features of psoriasis in children for early recognition and referral to a dermatologist for confirmation. This may be particularly important when a parent has a history of psoriasis, since 30% to 35% of affected children have an affected parent,” Paller says. “In providing optimal care, pediatricians and dermatologists should team in monitoring for possible comorbidities, sharing information about patient laboratory and blood pressure values (many of which are routinely performed in pediatric practice). Good communication about our shared patients will increase the opportunity for early detection of a comorbidity.”
Dr Kress is on the speaker’s bureau for Amgen. Drs. Eichenfield, Cohen, and Paller have nothing to disclose.
1. Osier E, Wang AS, Tollefson MM, et al. Pediatric Psoriasis Comorbidity Screening Guidelines. JAMA Dermatol. 2017;153(7):698-704. Available at: https://jamanetwork.com/journals/jamadermatology/article-abstract/2627297. Accessed July 30, 2018.
2. Beattie PE, Lewis-Jones MS. A comparative study of impairment of quality of life in children with skin disease and children with other chronic childhood diseases. Br J Dermatol. 2006;155(1):145-151. Available at: https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1365-2133.2006.07185.x. Accessed July 30, 2018.