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Treatment of severe psoriasis in children: recommendations of an Italian expert group

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Abstract

This article provides comprehensive recommendations for the systemic treatment of severe pediatric psoriasis based on evidence obtained from a systematic review of the literature and the consensus opinion of expert dermatologists and pediatricians. For each systemic treatment, the grade of recommendation (A, B, C) based on the treatment’s approval by the European Medicines Agency for childhood psoriasis and the experts’ opinions is discussed. The grade of recommendation for narrow-band-ultraviolet B phototherapy, cyclosporine, and retinoids is C, while that for methotrexate is C/B. The use of adalimumab, etanercept, and ustekinumab has a grade A recommendation. No conventional systemic treatments are approved for pediatric psoriasis. Adalimumab is approved by the European Medicines Agency as a first-line treatment for severe chronic plaque psoriasis in children (≥ 4 years old) and adolescents. Etanercept and ustekinumab are approved as second-line therapy in children ≥ 6 and ≥ 12 years, respectively.

Conclusion: A treatment algorithm as well as practical tools (i.e., tabular summaries of differential diagnoses, treatment mechanism of actions, dosing regimens, control parameters) are provided to assist in therapeutic reasoning and decision-making for individual patients. These treatment recommendations are endorsed by major Italian Pediatric and Dermatology Societies.

What is Known:

• Guidelines for the treatment of severe pediatric psoriasis are lacking and most traditional systemic treatments are not approved for use in young patients. Although there has been decades of experience with some of the traditional agents such as phototherapy, acitretin, and cyclosporine in children, there are no RCTs on their pediatric use while RCTs investigating new biologic agents have been performed.

What is New:

• In this manuscript, an Italian multidisciplinary team of experts focused on treatment recommendations for severe forms of psoriasis in children based on an up-to-date review of the literature and experts’ opinions.

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Abbreviations

CDLQI:

Children’s Dermatology Life Quality Index

CyA:

Cyclosporine

EMA:

European Medicines Agency

EOW:

Every other week

NB-UVB:

Narrow-band UVB

NRI:

Non-responder imputation

PASI:

Psoriasis Area and Severity Index

PASI 50/75/100:

50/75/100% improvement from baseline PASI

RCT:

Randomized controlled trial

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Author information

Author notes

  1. Authors contributed equally to the paper and are listed in alphabetical order.

Authors and Affiliations

  1. Pediatric Dermatology Unit, Department of Medicine, University of Padua, Via Gallucci, 4, 35128, Padova, Italy

    Anna Belloni Fortina

  2. Dermatology Unit, Department of Specialistic, Diagnostic and Experimental Medicine, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy

    Federico Bardazzi, Iria Neri & Annalisa Patrizi

  3. Dermatology Unit, Department of Surgery and Translational Medicine, University of Florence, Florence, Italy

    Samantha Berti

  4. Dermatology Unit, Bambino Gesù Children’s Hospital-IRCCS, Rome, Italy

    Claudia Carnevale & Maya El Hachem

  5. Dermatology Unit, Arcispedale S. Maria Nuova IRCCS, Reggio Emilia, Italy

    Vito Di Lernia

  6. Pediatric Dermatology Unit, Fondazione IRCCS Ca’ Granda “Ospedale Maggiore Policlinico”, Milan Department of Pathophysiology and Transplantation, University of Milan, Milano, Italy

    Carlo Mario Gelmetti

  7. Center for the Study and Treatment of Psoriasis, San Gallicano Dermatologic Institute, IRCCS, Rome, Italy

    Viviana Lora

  8. Dermatology Unit, “Campo di Marte” Hospital, Azienda USL 2, Lucca, Italy

    Carlo Mazzatenta

  9. Dermatology Unit, Ospedale Civico di Cristina Benfratelli, Palermo, Italy

    Mirella Milioto

  10. Department of Dermatology, Catholic University of the Sacred Heart, Rome, Italy

    Gaia Moretta & Ketty Peris

  11. General Pediatrics and Infectious Disease, Bambino Gesù Children’s Hospital-IRCCS, Rome, Italy

    Alberto Villani

Authors
  1. Anna Belloni Fortina
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  2. Federico Bardazzi
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  3. Samantha Berti
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  7. Iria Neri
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  8. Carlo Mario Gelmetti
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  9. Viviana Lora
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  13. Annalisa Patrizi
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  14. Ketty Peris
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Contributions

Anna Belloni Fortina, Federico Bardazzi, Samantha Berti, Claudia Carnevale, Vito Di Lernia, Maya El Hachem, Iria Neri, Carlo Mario Gelmetti, Viviana Lora, Carlo Mazzatenta, Mirella Milioto, Gaia Moretta, Annalisa Patrizi, Ketty Peris, and Alberto Villani have reviewed the literature, written the chapters of the article, and approved the final version.

Corresponding author

Correspondence to Anna Belloni Fortina.

Ethics declarations

This article does not contain any studies with human participants or animals performed by any of the authors.

Conflict of interest

Anna Belloni Fortina, Federico Bardazzi, Samantha Berti, Claudia Carnevale, Maya El Hachem, Carlo Mario Gelmetti, Viviana Lora, Carlo Mazzatenta, Mirella Milioto, Gaia Moretta, Annalisa Patrizi, and Alberto Villani declare that they have no conflict of interest. Vito Di Lernia has been principal investigator in clinical trials sponsored by Sanofi and Regeneron Pharmaceuticals and in observational studies sponsored by AbbVie, Advisory Board Member for AbbVie, and has received a speaker honorarium from Rottapharm. Iria Neri served as Advisory Board Member for AbbVie, consultant for Bayer, Mustela, speaker for Galderma. Ketty Peris has received a speaker honorarium from LEO, MEDA, and Roche.

Additional information

Communicated by Mario Bianchetti

These treatment recommendations are endorsed by SIDerP (Società Italiana di Dermatologia Pediatrica), SIDeMaST (Società Italiana di Dermatologia medica, chirurgica, estetica e di malattie sessualmente trasmesse), ADOI (Associazione Dermatologi Ospedalieri Italiani), and SIP (Società Italiana di Pediatria).

Appendix 1 Calculation of PASI and Physician Global Assessment

Appendix 1 Calculation of PASI and Physician Global Assessment

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Fortina, A.B., Bardazzi, F., Berti, S. et al. Treatment of severe psoriasis in children: recommendations of an Italian expert group. Eur J Pediatr 176, 1339–1354 (2017). https://doi.org/10.1007/s00431-017-2985-x

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