Onset of psoriasis in childhood and adolescence has a significant impact on the patient's physical and psychological health. The disease is associated with decreased quality of life and reduced self confidence, and therefore requires specific management. Patients and their parents must receive detailed information about the disease and its course. While most of these patients present mild forms of psoriasis that can be controlled with topical treatments, systemic therapy is required in some cases. There is scant evidence in the literature on the use in children of the classic systemic therapies (ciclosporin, methotrexate, and acitretin). Moreover, because these drugs are not approved for use in pediatric patients, their use in this setting is deemed off-label despite the considerable experience accumulated by dermatologists. The biologic agents that have demonstrated efficacy and safety in randomized clinical trials and are currently approved for use in children are etanercept (from age 6), adalimumab (from age 4), and ustekinumab (from age 12). The use of other molecules in patients aged under 18 is currently under study, and more drugs will very likely become available in the coming years. Immunological differences between pediatric and adult psoriasis are also being studied and the results of that research may open the way to new therapeutic approaches.1

It is important to understand the management in clinical practice of this disease in Spain since there are few studies in the literature and there are no guidelines for clinical dermatologists. The study reported in this issue analyzed data from 40 patients with psoriasis aged under 18 years who were treated with phototherapy or systemic drugs in 7 hospitals in Galicia over a 12-year period.2 It is interesting to note that 30% of those patients had guttate psoriasis, a high proportion that reflects the greater frequency of this form of the disease in the pediatric population. The treatment most often prescribed was phototherapy, followed by methotrexate, acitretin, ciclosporin, etanercept and adalimumab, in that order. In total, 88% of the patients had a good or partial response at week 12, a percentage that fell to 68% (excluding phototherapy) at week 24. Phototherapy was effective in 80% of the patients treated, demonstrating good safety and effectiveness. It is, therefore, important to highlight the need for measures that will improve accessibility to this resource in Spain. Six patients were treated with biologic drugs: 4 with etanercept (75% with a good response at week 24) and 2 with adalimumab (good response in both patients at week 24). All the treatments were well tolerated. Adverse events were scarce and in no case led to withdrawal of treatment.

The study did not include any patients with psoriatic arthritis and 10% of the patients were obese; these proportions were lower than those reported in the literature for similar groups. One aspect of great importance is the systemic nature of psoriasis and the need for multidisciplinary management starting in childhood, with particular emphasis on psychiatric disorders (anxiety and depression), metabolic syndrome, and joint involvement.3 It is essential that our healthcare system provide these patients and their families maximum social support so that they can, as far as is possible, achieve a return to normality in their daily lives.