Prescribing Differences Seen for Pediatric Psoriasis

Norra MacReady

September 20, 2011

September 20, 2011 — A study of more than 3.8 million physician visits for pediatric psoriasis over the course of 28 years shows important differences in prescribing patterns, depending on physician specialty and the age of the child.

Dermatologists and internists were most likely to prescribe high-potency steroids (usually betamethasone), whereas pediatricians preferred topical tacrolimus. Similarly, children up to 9 years of age were more likely to receive tacrolimus, and older patients were more often prescribed betamethasone. Betamethasone was the single most commonly prescribed drug for all patients.

The findings "suggest that pediatric patients with psoriasis, compared with adults, may be undertreated," lead author Sinae A. Vogel, BS, from the School of Medicine, University of California, San Francisco, and colleagues write in an article published online September 19 in the Archives of Dermatology.

Children make more than 120,000 visits to a clinician each year for treatment of pediatric psoriasis, the authors explain. The prevalence of psoriasis in children from birth to 18 years of age is 1%, with an incidence of 40.8 per 100,000. Nevertheless, good data and standardized, child-specific management guidelines are lacking, making management challenging. The investigators reviewed the patterns of healthcare delivery for children with psoriasis in the United States from 1979 through 2007, in the hopes of bringing more consistency to the management of this condition.

They used data from the National Ambulatory Medical Care Survey, which tracks outpatient visits to non–federally employed physicians in the United States. The data are then analyzed by the National Center for Health Statistics. This study covered visits to dermatologists and nondermatologists, and also included information about medication. No data were collected from 1982 to 1984 or from 1987 to 1988.

More than 3.8 million visits were recorded during the 28 years studied, although the number of visits did not change significantly over time. Boys and girls visited physicians in equal numbers. The vast majority of patients (93%) were white, and of the white patients, 85% were non-Hispanic. The mean age at each visit was 11.3 years. Eighty-two percent of the patients were between the ages of 8 and 18 years.

Dermatologists accounted for 63% of the visits, followed by pediatricians (17%) and internists (14%). The remaining visits were divided among other primary care physicians and specialists. Topical corticosteroids accounted for 7 of the 10 most commonly prescribed medications, with calcipotriene, salicylic acid, and ketoconazole listed as the most commonly prescribed topical noncorticosteroids.

"Over the study period, topical corticosteroids consistently increased in usage, whereas over-the-counter medications sharply declined and then leveled off," report the authors. They also noted an abrupt increase in the use of nonsteroidal topical agents, starting in 1995. Prescriptions for biologic agents in this population were not observed until after 2000.

The study has several limitations, including that it was based on the uncompensated completion of surveys by busy clinicians, and that the authors could not comment on the appropriateness of the treatments used because they did not have specific details for each case, such as clinical characteristics of the psoriasis or the sites of involvement. Also, the data included only outpatient visits to non–federally employed physicians, which may have resulted in ascertainment bias. Nevertheless, the authors write, "to our knowledge this study remains the largest survey of health care delivery to the pediatric psoriasis population to date."

In addition to treatment guidelines, the authors recommend more education of dermatologists and nondermatologists alike on the management of pediatric psoriasis.

The authors have disclosed no relevant financial relationships.

Arch Dermatol. Published online September 19, 2011. Full text

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