Guidelines on Psoriasis Comorbidity Screening in Kids Issued

Veronica Hackethal, MD

May 23, 2017

The first guidelines on comorbidity screening in children with psoriasis were jointly released by the Pediatric Dermatology Research Alliance and National Psoriasis Foundation.

"These mainly consensus-based recommendations provide a starting point for screening that will be refined as more is learned. As studies further detail the comorbidity risks in children, there may be a need to further stratify screening (eg, by age group, disease subtype, severity)," the authors write. "It will also be important to assess the effectiveness of early detection and proactive intervention in preventing future complications."

Emily Osier, MD, from the Department of Dermatology, Eastern Virginia Medical School, Norfolk, and colleagues, published the consensus statement online May 17 in JAMA Dermatology.

Psoriasis develops during childhood in almost one third of patients, and the guidelines are geared toward providers who care for such patients: primary care physicians, dermatologists, and other pediatric specialists. The recommendations emphasize routine screening and early intervention for comorbidities associated with pediatric psoriasis.

"Pediatricians may not be aware of the very strong literature of psoriasis being associated with comorbidities. It's very clear in adults that there are significant health issues that are associated with psoriasis, including increased incidence of myocardial infarction, diabetes, hypertension, hyperlipidemia, arthritis, obesity, metabolic syndrome, and liver disease," lead author Lawrence Eichenfield, MD, told Medscape Medical News. Dr Eichenfield is professor of dermatology and pediatrics at the University of San Diego School of Medicine, California.

"When we see children and adolescents with psoriasis, it makes sense to assess if they have any risk factors that would put them at greater risk as adults. By identifying them, we may be able to minimize the impact on their health over time," he added.

He advised primary care physicians, dermatologists, and other providers who care for children with psoriasis to "recognize psoriasis as a significant cutaneous disease in its own right, but understand that there's also a systemic aspect. Providers should make sure patients have simple screening for comorbidities and explain to patients that psoriasis may be an added risk for health problems in the future."

Although many gaps remain in the pediatric literature, the guidelines were published now as a result of a recognized need to provide a pediatric approach focused on preventing adult disease by identifying risk factors and intervening at younger ages.

Another recent development is that in November 2016, etanercept (Enbrel, Amgen, Inc) became the first biologic specifically approved for the treatment of pediatric psoriasis. Dr Eichenfield said he expects more biologics to be approved for pediatric psoriasis in the coming years.

"The tools to intervene in psoriasis in children are greater now, and will be even greater in the future," he said. "While all the questions aren't answered in terms of management, it made sense to get specialists together to come up with what they thought would be the best recommendations."

The guidelines development process included experts from a broad range of fields, including pediatric dermatology, pediatric endocrinology, pediatric liver disease, pediatric rheumatology, pediatric gastroenterology, and adult and pediatric cardiology (including preventive cardiology). The group conducted a PubMed review for studies published in English from January 1999 through December 2015. The search yielded 153 relevant studies, of which 26 were about pediatric patients.

As a result of the limited number of pediatric studies, the panel gave the consensus recommendations a C grading, meaning they are based on consensus, usual practice, opinion, disease-oriented evidence, or case series. Most studies in children were quality level 3 (other evidence: usual practice, opinion, disease-oriented evidence).

Overall, the recommendations are not so different from the American Academy of Pediatrics' recommendations for children and adolescents without psoriasis. The group concludes that current evidence is insufficient to support more intensive screening for patients with pediatric psoriasis.

However, Dr Eichenfield emphasized that providers should be aware that having psoriasis means some children may be at increased risk for such comorbidities.

For example, both the adult and pediatric literature have shown that individuals with obesity are more likely to have psoriasis than normal weight individuals. Whether or not obesity, as a pro-inflammatory state, increases the risk for psoriasis has yet to be established. However, obesity can add to health risks in patients with psoriasis, further increasing the risk for heart disease, liver disease, metabolic syndrome, hyperlipidemia, and other health problems.

The guidelines also highlight other serious comorbidities. Adults with severe psoriasis have an increased risk for early myocardial infarction, and providers should consider this risk as pediatric patients transition to adulthood. Providers should also be aware of increased risk for psoriatic arthritis to intervene early and minimize disability. The guidelines also draw attention to depression, anxiety, and decreased quality of life. They emphasize that children with psoriasis may have impaired emotional, school, and social functioning and experience school bullying.

The recommendations include:

  • Overweight or obesity:

    • Screen for overweight and obesity using body mass index criteria starting at age 2 years (overweight: ≥85th percentile to <95th percentile; obese: ≥95th percentile).

  • Type 2 diabetes:

    • Screen every 3 years starting at age 10 years or the onset of puberty in overweight patients who have two risk factors for type 2 diabetes (a table is provided that lists five relevant risk factors for type 2 diabetes).

    • Screen obese patients every 3 years starting at age 10 years or puberty onset, regardless of risk factors.

    • Screen using fasting serum glucose.

    • Screening is not recommended in prepubertal children, as there is a very small risk for type 2 diabetes in this group.

  • Dyslipidemia:

    • Perform universal lipid screening for children aged 9 to 11 years and again between ages 17 and 21 years.

    • Outside these age ranges, screen children who have cardiovascular risk factors (a table is provided that lists 12 relevant risk factors for dyslipidemia).

    • A fasting lipid panel is recommended.

  • Hypertension:

    • Screen yearly starting at age 3 years, using age, sex, and height reference charts.

  • Nonalcoholic fatty liver disease (NAFLD):

    • Screen with alanine aminotransferase starting at age 9 to 11 years in all children with obesity or overweight with risk factors including central adiposity, insulin resistance and associated conditions, prediabetes or diabetes, dyslipidemia, obstructive sleep apnea, or family history of NAFLD/NASH (nonalcoholic steatohepatitis).

    • Consider earlier screening in younger patients with risk factors such as severe obesity, family history of NAFLD or NASH, or hypopituitarism.

    • After initial normal screen, consider repeat aminotransferase screening every 2 to 3 years if risk factors stay the same, or sooner if they increase in number or severity.

  • Polycystic ovary syndrome:

    • Providers should be aware of the possible coexistence of polycystic ovary syndrome; consider testing in patients with symptoms (oligomenorrhea, hirsutism).

  • Gastrointestinal disease:

    • Children with psoriasis have an increased risk for inflammatory bowel disease; consider gastrointestinal evaluation in patients with decreased growth rate, unexplained weight loss, or symptoms of inflammatory bowel disease.

  • Arthritis:

    • Screen with review of systems and physical exam (provides list of typical features of pediatric psoriatic arthritis).

    • Screen for arthritis at time of psoriasis diagnosis and periodically thereafter.

  • Uveitis:

    • Screening with routine ophthalmology exams is only warranted in patients with psoriatic arthritis.

  • Mood disorders and substance abuse:

    • Conduct annual screening for depression and anxiety regardless of age.

    • Conduct annual screening for substance abuse starting at age 11 years.

  • Quality of life (QOL):

    • Screen for QOL issues; consider using a formalized QOL instrument like the Children's Dermatology Life Quality Index.

  • Systemic therapy:

    • Before starting systemic therapy consider comorbidities, which can affect medication choice, tolerability, and adverse effects; perform baseline and monitoring tests (eg, lipids or liver enzyme tests) as needed.

The authors note that these guidelines will need updating as more research accumulates.

Development of the guidelines was supported by the National Psoriasis Foundation and the Rady Children's Hospital/University of California, San Diego-Eczema and Inflammatory Skin Disease Center The authors have disclosed no relevant financial relationships.

JAMA Dermatol. Published online May 17, 2017. Full text

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