Topical treatments, except for topical corticosteroids, are not indicated in the drug fact sheet for pediatric psoriasis. However, they are widely used in the routine clinical practice for both mild and severe psoriasis as coadjuvant therapy (Table 5). Although specific RCTs are lacking, their safety and efficacy profile and have been analyzed in multiple observational studies, both in the short- and long-term.35–48

Although there are no head-to-head comparative studies, indirect data suggest that corticosteroids, vitamin D analogs, and the combination of calcipotriol/betamethasone dipropionate11 seem to be more effective than other topical treatments for pediatric plaque psoriasis (both mild and severe forms).

Phototherapy is indicated for children≥8 years with moderate-to-severe psoriasis (refer to Table 12 for guidelines). However, access to phototherapy can be limited due to logistical constraints in certain hospitals.

A 2021 a SLR and meta-analysis focused on narrow-band ultraviolet B (UVB) phototherapy, including 10 prospective and retrospective observational studies with nearly 300 pediatric psoriatic patients treated with a mean 17–57 sessions90. An overall efficacy rate of 80% was estimated, defined as excellent or good response if lesion clearance was ≥75%. However, no association was ever found between efficacy and cumulative or maximum mean doses in the review90. Erythema was the most common adverse event.

For the management of mild pediatric psoriasis, first-line therapies include topical therapy or phototherapy/heliotherapy, barring contraindications.

It is important to remember that, except for corticosteroids, topical treatments do not have an approved indication in their product labels.

The selection of a treatment should follow the previously discussed criteria. At this point, experts also emphasize the importance of collaborating with and considering the opinion of the patient's parents or guardians/caregivers.

Many authors consider corticosteroids as the topical treatment of choice.13 If a topical corticosteroid is prescribed, its potency should be adapted to the extent and site of application. Medium- and high-potency corticosteroids are generally preferred, except on the face, folds (including the genital area), and diaper area, where low-potency corticosteroids are recommended. Due to the risk of adverse events, topical corticosteroids should be used at the lowest effective dose and never for long periods of time, especially high-potency corticosteroids. Patients requiring long-term treatment should transition to other types of drugs. For example, topical corticosteroids are recommended once daily for 1–2 weeks, followed by gradual tapering over 2–6 weeks until discontinuation.13–15

For scalp psoriasis, the combination of calcipotriol/betamethasone dipropionate in a single formulation may also be considered.35,48 The recommended quantities of calcipotriol must not be exceeded, taking into account the body surface area to be treated; therefore, it is not a suitable option for extensive psoriasis.91 Calcineurin inhibitors are useful for facial and flexural psoriasis.41 Anthralin and tar preparations can be considered for patients with limited thick plaques.91

Phototherapy/heliotherapy may be considered for patients with more extensive lesions and palmoplantar psoriasis.90

These therapies should be administered until the therapeutic goal has been achieved.

For patients with moderate-to-severe pediatric psoriasis:

• •

  For mild psoriatic patients who do not achieve therapeutic goals with topical treatments or phototherapy/heliotherapy, adherence and treatment compliance should first be evaluated before confirming therapeutic failure.

• •

  If no contraindications exist, classic systemic therapies and biologic therapy as monotherapy are the treatments of choice.

• •

  Biologic therapies, which have demonstrated safe and effective in clinical trials and have been specifically approved for moderate-to-severe pediatric psoriasis, should be considered the first choice.

• •

  Topical therapies should always be considered as coadjuvant therapy for both classic systemic treatments and biologics, at least, at the initiation of systemic therapy while waiting for its effects. They can also be used for residual lesions.

• •

  Phototherapy may be considered (e.g., for patients with extensive lesions) as monotherapy or coadjuvant therapy to systemic treatment.

• •

  Combination therapy with a classic systemic drug and a biologic can be considered in very selected cases (e.g., to reduce or minimize the risk and impact of immunogenicity).

Poor adherence or improper use of topical therapies is common in pediatric psoriasis.92 Various causes have been described, such as corticophobia, fear of adverse events, low cosmetic acceptance, lack of understanding/knowledge about the mode of application, forgetfulness, etc. Therefore, adherence and compliance should be evaluated before confirming therapeutic failure, and possible errors should be corrected if found. In such cases, the doctor-patient relationship, including interaction with parents or guardians, is fundamental. Effective verbal and non-verbal communication, active listening, and collaboration contribute to an optimal relationship and improve adherence to treatments.92 It is also essential to inform, explain, and educate both patients and their parents or guardians about medication use to improve outcomes.92

For moderate-to-severe pediatric psoriasis, systemic therapy selection should follow previously defined criteria. It is important to adhere to the product label indications (which vary by drug, age, or weight of the patient) and consider the quality of the available evidence.38,66,70,75–80,82,83,93–95 In this regard, biologic therapies, along with acitretin, are the only treatments approved for moderate-to-severe pediatric psoriasis. In terms of evidence, biologic therapies have shown high skin clearance rates in high-quality studies, which are sustained over time. Therefore, and in line with the most recent international consensus documents,13 biologics are considered first-line therapy.

As in adults, in pediatric psoriatic patients, topical treatments can be used as coadjuvant therapy. Their use is recommended at the initiation of systemic therapy due to their rapid action, while awaiting the effect of the main treatment, and later for residual lesions.

Lastly, phototherapy90 and the combination of a classic systemic drug, such as MTX, with a biologic therapy may also be considered in very selected cases.

• •

  Corticosteroids are often considered the topical treatment of choice. Potency should be tailored based on the area and extent of the application. Medium-to-high potency corticosteroids are generally preferred, except on the face, folds (including genital areas), and diaper area, where low-potency corticosteroids are recommended.

• •

  Corticosteroids should be prescribed at the minimal effective dose, avoiding prolonged use, especially with higher-potency formulations. After an initial period (1–2 weeks), tapering is advised over 2–6 weeks before discontinuation.

• •

  For scalp psoriasis, the combination of calcipotriol/betamethasone dipropionate in a single formulation can be considered. Usage should adhere to recommended limits, taking into account the treatment area, and is not suitable for extensive psoriasis.

• •

  Calcineurin inhibitors are useful for facial and fold psoriasis. Anthralin and tar preparations can be considered for thick and limited plaques.

• •

  Phototherapy/heliotherapy may be appropriate for more extensive lesions and palmoplantar psoriasis.

These treatments should continue until therapeutic goals are achieved.

For moderate-to-severe pediatric psoriasis:

• •

  Step-up Treatment: In patients with mild psoriasis who do not respond to topical or phototherapy/heliotherapy, adherence and proper application should be reviewed before concluding treatment failure.

• •

  Systemic and Biologic Monotherapy: Systemic therapies or biologics are first-line options if there are no contraindications. Biologic therapies are prioritized as they have demonstrated efficacy and safety in clinical trials and are approved specifically for moderate-to-severe pediatric psoriasis.

• •

  Adjunctive Topical Therapy: Topical treatments should be considered as adjuncts to systemic or biologic therapy, particularly at treatment initiation or for residual lesions.

• •

  Phototherapy: May be an option for patients with extensive lesions, either as monotherapy or in combination with systemic treatment.

• •

  Combination Therapy: A systemic drug like MTX and a biologic can be considered in select cases to mitigate risks and enhance efficacy.

For example, PASI and BSA thresholds have not been formally validated or adapted for children. These indices may have limitations due to differences in body composition between children and adults.

To address this, the “rule of nines” has been proposed to standardize BSA measurements in children by adjusting regional body proportions and age.29 The CDLQI, on the other hand, is a validated 10-question survey to evaluate quality of life in patients aged 4–16 years, derived from the adult Dermatology Life Quality Index (DLQI).30 It considers variables such as itching, sleep, hygiene, social impact, activities, and treatment efficacy and is available in both text and illustrated formats.30,31 Although it measures quality of life, it can also serve as a surrogate marker for disease severity. From age 16, the DLQI can be used as in adults.

The Simplified Psoriasis Index (PSI) is another validated index for children that evaluates lesion severity, psychosocial impairment, and prior treatments.32 However, its use remains limited.

For children under four years old, these indices are often impractical. In such cases, the PGA may serve as a valid alternative for assessing disease severity. In complex cases, an individual approach using tools such as a visual analog scale (VAS) may also prove helpful.

Despite these limitations, based on expert experience, these indices are considered broadly applicable to pediatric patients using the same thresholds as in adults.

As highlighted in other GPS documents, beyond severity, other factors to consider in therapeutic decisions include associated symptoms, quality-of-life impact, psychosocial and educational development, and the perspectives of parents or caregivers.16,17

When setting therapeutic goals (Table 4), as in adults,33 the aim should always be excellence (complete skin clearance and absence of symptoms or disease impact). This goal is particularly critical in children, given their developmental stage and the likelihood of living with psoriasis for many years. Achieving tight control of the disease from diagnosis is therefore essential. However, some pediatric patients may not achieve this goal despite treatment.33 In such cases, less stringent targets may be acceptable on an individual basis (e.g., in refractory patients or those with toxicity concerns).

As previously noted, all decisions must be tailored to the pediatric patient's context. Collaboration with parents or guardians is critical. In pediatric care, it is especially important to thoroughly explain the disease's characteristics and progression, therapeutic options and expectations, and the need for informed consent for specific medications.

Once the severity of psoriasis has been determined, the selection and prioritization of treatments should consider several factors related to:

• 1.

  The type of psoriasis.

• 2.

  The patient (age and comorbidities).

• 3.

  The medication (available evidence, administration route, onset of effect, convenience, etc.).

• 4.

  Patient and family preferences.

• 5.

  The health care system and its organization.16,17

Additionally, the child's idiosyncrasies and environment must be taken into account. It is essential to analyze whether a particular treatment is the most appropriate for each specific case or whether it might negatively impact various aspects of the child's daily life.34 When evaluating potential negative impacts on quality of life, factors to consider include whether the treatment causes school absences due to therapy or lab tests, the presence of stigma, whether topical treatments are cosmetically acceptable, or whether the child has developed needle phobia or experiences stress and anxiety from injections.

Regulatory characteristics as described in the drug data sheets should also be considered (see Tables 5 and 6).

The criteria for defining therapeutic failure are the same as those for adults16,17 but adapted to the pediatric population's specificities. Therapeutic failure is defined as follows:

• •

  Primary therapeutic failure: Failure to achieve the proposed therapeutic goal.

• •

  Secondary therapeutic failure: Loss of the therapeutic goal after it has been achieved.

• •

  Safety failure: The therapeutic goal is reached, but significant toxicity necessitates discontinuation of treatment.

• •

  Negative impact on quality of life: The treatment adversely affects the patient's quality of life.

The timeframes for establishing therapeutic failure depend on the type of treatment used. It is also important to emphasize the need to assess patient adherence to treatment before concluding definitive therapeutic failure.

• 1.

  Evidence and use of available treatments in pediatric psoriasis

• 2.

  Topical treatment

With the exception of topical corticosteroids, topical treatments are not officially indicated for pediatric psoriasis. Nonetheless, they are widely used in clinical practice for both mild psoriasis and more severe cases as adjunctive therapy (Table 5). While they lack high-quality randomized controlled trials (RCTs), their efficacy and safety have been demonstrated in numerous observational studies, both short- and long-term.35–48

Although no head-to-head comparative studies exist, indirect data suggest that corticosteroids, vitamin D analogs, and the combination of calcipotriol/betamethasone dipropionate in a single product11 appear more effective than other topical treatments for pediatric plaque psoriasis (both mild and severe forms).

Evidence for the efficacy and safety of topical corticosteroids comes from observational studies of moderate to low quality (Table 5). Their use over 8–12 weeks has been associated with a 72.7% improvement or resolution of plaques, with greater efficacy linked to higher potency corticosteroids.35–37

The safety profile is acceptable and similar to that in adults, with irritation and pruritus at the application site being the most common adverse events.36 Systemic adverse events are very rare.

High- or very-high-potency topical corticosteroids should be used cautiously and for the shortest duration possible. Patients should be closely monitored by a dermatologist, with follow-up tailored to the child's characteristics.

Experts recommend providing detailed information to parents, guardians, and older children about the proper quantity and method of application, as well as the risk of rebound effects if potent corticosteroids are abruptly discontinued.49,50Tables 5 and 7 present various recommendations, and Table 8 provides a usage guide based on the location and age of the patient.

An 8-week RCT in pediatric patients with moderate-to-severe plaque psoriasis found that twice-daily topical calcipotriol significantly outperformed placebo in reducing redness and scaling and achieved a higher proportion of patients with a Physician's Global Assessment (PGA) of 0/1 according to the physician's assessment.38 However, no significant differences were observed in PASI score changes (baseline vs end of treatment), lesion thickness or extent, or the proportion of patients with a patient-reported PGA of 0/1.38 Adverse events were generally mild, with skin irritation being the most frequent.38

Observational studies report improvement or resolution rates of 57.2–100% with topical calcipotriol, along with good cosmetic acceptability and a favorable safety profile.11,35–37,42,52

Topical calcipotriol may also act as a corticosteroid-sparing agent and can be applied to sensitive skin areas to minimize local side effects of topical corticosteroids.

Adherence challenges: Poor adherence to topical treatments is common in pediatric psoriasis due to factors such as corticophobia, fear of adverse effects, cosmetic issues, misunderstandings about usage, and forgetfulness. Before declaring treatment failure, adherence should be reassessed, and errors corrected. A strong physician-patient relationship, effective communication, active listening, and collaboration with parents or caregivers are crucial to improving adherence and treatment outcomes.

Management strategies for psoriasis in specific sites or severe forms of the disease should follow similar principles, prioritizing approved therapies and considering tailored combinations of systemic and topical treatments.

Although limited, we describe below the available evidence on the efficacy of pharmacological therapies and phototherapy in special locations (Table 4 of the annex of the supplementary data) and severe forms of pediatric psoriasis. Psoriasis in special locations is considered moderate-to-severe psoriasis. Of note, the severity of pediatric psoriasis is also influenced by its functional or psychological impact (e.g., school absenteeism, stigma, etc.) or its impact on the patient's quality of life.

It is estimated that between 10% up to 48% of pediatric psoriatic patients experience scalp involvement, either in isolation or associated with other lesions.91–96

Regarding treatment evidence, data from the IXORA-PEDS study conducted on 171 children demonstrated that IXE achieved PASI100 response in 47% of patients at 12 weeks, 76% at 48 weeks, 73.4% at 60 weeks, and 90% at 108 weeks.80,83 Similarly, data from the Child-Capture registry and other observational studies showed that the combination of calcipotriol and betamethasone improved outcomes in pediatric patients with scalp psoriasis.45,89,97 Published studies reported an improvement in the PSI of 19.2% at 6 weeks, increasing up to 29.5% at 12 weeks, with sustained efficacy at week 48.45 The percentages of IGA 0/1 achieved with the combination ranged from 55% up to 85% at 8 weeks.89,97 Further evidence is required for other therapies.

Facial lesions are more common in children than in adults, affecting up to 50% of cases and being the only clinical sign in, approximately, 4% of patients.91,96

Topical therapies, particularly tacrolimus, calcitriol, and corticosteroids, have shown efficacy in generally low-quality studies, at least, in the short-to-mid term.36,37,41 The application of tacrolimus 0.1% ointment twice daily for 6 months resulted in significant clinical improvement, though relapses were frequent shortly after treatment discontinuation41. Further evidence is needed for other therapies.

Up to 10% of pediatric psoriatic patients may experience flexural psoriasis.91,96

Several SLRs and observational studies have shown that some topical treatments may be effective in the short-to-mid term with an acceptable safety profile, although the evidence level is generally low.35,80 The application of tacrolimus 0.1% ointment twice daily for 6 months produced significant lesion improvement in flexural psoriasis. After 30 days of treatment, 88% of patients experienced excellent improvement from baseline, and 12% achieved complete remission of symptoms. However, relapses were frequent after discontinuation.41 Topical corticosteroids and calcitriol have also demonstrated efficacy.35,37 Isolated cases have reported effectiveness with tar-based treatments.35 However, current evidence does not support the efficacy of salicylic acid for pediatric genital psoriasis.35 In a high-quality RCT with 171 children, IXE achieved 85% genital psoriasis clearance at 12 weeks vs 36% with placebo (p<0.001). Moreover, in the IXE arm, genital psoriasis clearance rates were 90% and 88.9% at 48 and 60 weeks, respectively.80,83 Further evidence is needed for other therapies.

Palmoplantar psoriasis is relatively uncommon in pediatric patients.

Evidence on pharmacological treatments for pediatric palmoplantar psoriasis is limited.

Evidence on pharmacological treatments for pediatric palmoplantar psoriasis is very limited. In the IXORA-PEDS RCT with IXE, 69% of patients achieved a PASI 0 at 12 weeks, 74% at 48 weeks, 81.8% at 60 weeks, and 90% at 108 weeks.80,83 Small observational studies have demonstrated the efficacy of phototherapy in this location.98,99 Cases suggesting that acitretin and phototherapy could be effective have been reported too.90,100 Further evidence is needed to support the efficacy of other therapies.

Guttate psoriasis is the second most common form of pediatric psoriasis.91.96

Many of the results discussed for plaque psoriasis could potentially be extrapolated to guttate psoriasis.36,69 More specifically, phototherapy has shown good outcomes in a small RCT with 20 pediatric patients and other observational studies.90,93 Further evidence is needed to support the efficacy of other therapies.

Although less common than in adults, nail involvement has been documented in 7% up to 40% of pediatric psoriatic patients.91,96

The impact of various therapies on nail involvement has been scarcely studied. A RCT with IXE found no statistically significant differences in the Nail Psoriasis Severity Index (NAPSI) at 12 weeks vs placebo. However, at 48, 60, and 108 weeks, 50%, 65.3%, and 68.1% of patients, respectively, achieved NAPSI0.80,83 Further evidence is needed for other therapies.

This severe form of psoriasis is rare in children and even less common in adults.91–96

Acitretin—monotherapy or in combination with phototherapy—may be effective with an acceptable safety profile in patients with pustular and erythrodermic psoriasis.36,68,69 Nine months of treatment reported PASI75 and PASI90 responses in 21.3% and 26.2% of patients, respectively.64 Small case series have also shown that MTX, CsA, phototherapy, and ETN may be effective.68 Further evidence is needed for other therapies.

Erythrodermic psoriasis is considered a severe form of psoriasis in children.

Although evidence quality is low, acitretin and CsA may be effective in these patients.36,64,68,69,101,102 Further evidence is needed for other therapies.

In relation to the prevention and presence of comorbidities in pediatric psoriatic patients:

• •

  The presence of comorbidities is a common finding and can impact the child and even interfere with the indication, safety or efficacy of treatments. Therefore, comorbidities are a topic of special relevance in the management of patients with pediatric psoriasis.

• •

  It is the responsibility of the dermatologist to screen for comorbidities.

• •

  Comorbidity screening should be performed regularly, considering the patient's medical history and physical examination. When deemed appropriate, additional tests will be requested.

• •

  If a comorbidity is suspected, the patient will be referred to the corresponding health professional depending on local organizational characteristics.

• •

  If necessary, multidisciplinary care will be provided with shared decision-making between the dermatologist and other specialists/health professionals.

• •

  If necessary, inform, explain, and educate patients and parents or guardians/caregivers about the possibility of comorbidities emerging and the need to prevent many of them.

• •

  It is the responsibility of everyone involved in the management of patients with pediatric psoriasis to promote health and prevention.

Psoriasis is a multisystem inflammatory disease. Both adults and children can present comorbidities that may impact their health, quality of life, educational, and psychosocial development or interfere with the safety and efficacy of treatments.18 It has been described that in children with psoriasis, the risk of presenting comorbidities is twice as high vs children without the disease.103 Although evidence is limited, the appearance of comorbidities could be more frequent in children with more severe disease.104 Among the most frequent and/or impactful are obesity, depression, or PsA.105

In line with other international consensus documents,8 regular screening of comorbidities is recommended, at least, for the most frequent ones or those that may have a greater impact on the patient and/or treatments.

On the other hand, experts are aware of the lack of time and logistical resources (e.g., pediatric-specific materials) in some consultations to address comorbidity in the routine clinical practice (both screening and prevention). To simplify and facilitate this work, we present Tables 13 and 14, which illustrate the characteristics and impact of the main comorbidities and show a series of recommendations for their prevention, screening, and other practical considerations.

Overweight is defined as a body mass index (BMI)≥85th percentile but <95th percentile (for age and sex), and obesity as BMI≥95th percentile (for age and sex).

The prevalence of overweight and obesity varies greatly depending on the study, but in general, it is very high in pediatric psoriasis. It has been reported that up to 17.6% of patients with pediatric psoriasis are overweight and 4% up to 20.2% are obese.105,106 The risk of a child with psoriasis having obesity is 4.29 times higher than a child without the disease, and this risk increases with the severity of psoriasis.106 Obesity in pediatric psoriatic patients tends to be central and generally develops around 8 years of age.11 The impact on the child's health—it is a cardiovascular risk factor—and quality of life is significant and can negatively affect health outcomes in adulthood. Moreover, it has been found that the efficacy of ETN is lower in overweight/obese patients vs children with a normal weight.79

Obesity is considered particularly relevant among the comorbidities of children with psoriasis, and therefore, regular screening should be conducted. Additionally, information about the impact of this comorbidity should be provided, along with general recommendations for a healthy lifestyle to prevent it.

The prevalence of hypertension (HTN) is poorly studied in pediatric psoriasis, but some studies have found a specific association.107,108 Like obesity, HTN can impact the child's health and future health as an adult.

It is recommended to follow the approved guidelines for HTN screening in children and adolescents109 and provide information on the impact of this comorbidity along with general recommendations for a healthy lifestyle to prevent it.

Although the prevalence of diabetes mellitus (DM) is poorly analyzed in pediatric psoriasis, studies have found an association between pediatric psoriasis and insulin resistance and T2DM, especially in obese patients.108,110 This disease and its treatments can have a very negative impact on the health and quality of life of pediatric patients.

It is recommended to follow the approved guidelines for DM screening in children and adolescents,111 and provide information on the impact of this comorbidity along with general recommendations for a healthy lifestyle to prevent it.

Metabolic syndrome includes a group of cardiovascular risk factors, with various definitions, most of which apply to children from 10 years of age. One of the most widely used definitions is shown in Table 15.112

Although prevalence data is scarce, different studies suggest an increased risk of metabolic syndrome in pediatric patients with psoriasis vs children without this disease.113 Like the previously described comorbidities, it has an important impact on the child's health and can affect their health as an adult.

One of the criteria included in the definition is central obesity. Fat distribution significantly influences the development of the metabolic complications of obesity.114 Abdominal circumference has been recognized as the best clinical indicator of visceral fat accumulation,115 and various studies have shown that it is a more appropriate measure for metabolic syndrome and cardiovascular risk.116

It is recommended to follow the guidelines outlined in the previous comorbidities and provide information on the impact of this comorbidity, along with general recommendations for a healthy lifestyle to prevent it.

The prevalence of PsA is lower in children vs adults with psoriasis, with an estimated prevalence of 0.7% in all children with psoriasis, increasing up to 1.2% by the time they reach 18 years old.117 Although PsA can appear in children of any age, there are 22 peaks of onset: one at 2–3 years and another at 10–12 years.118 Disability and the impact on the child's quality of life can be very significant.104 Moreover, although many of the drugs used for both diseases are the same, their efficacy may differ depending on the type of involvement.

Pediatric patients with PsA exhibit symptoms of inflammatory arthritis, such as pain, swelling, and joint stiffness at rest or upon waking. Younger children with PsA, especially girls, tend to have oligoarticular disease and/or dactylitis. Older children, particularly boys, often present enthesitis and axial involvement.8,118,119

Based on this information, it is essential to conduct regular screening and, if diagnosis is confirmed, to adopt a multidisciplinary approach to the patient.

It is estimated that up to 70% of pediatric psoriatic patients experience some psychological-psychiatric issues, which can appear at any age.120 More specifically, it has been described that pediatric psoriatic patients have a 25% up to 30% increased risk of developing depression and/or anxiety vs children without psoriasis.121

The impact of psoriasis on the mental health of children is equal to or even greater than that of diabetes, epilepsy, or atopic dermatitis.122 A qualitative study showed that 65% of children experienced some form of stigmatization or even bullying due to psoriasis.25 Others have shown that psoriasis in children can lead to mood changes, low self-esteem, social isolation, and risk behaviors.123

In adult patients, a strong correlation between psoriasis and the use of alcohol and tobacco has been found. Although this may also occur in adolescents and young adults with psoriasis, there is currently insufficient data to prove it.

However, given the prevalence of mental health problems and substance use in this population, the recommendations for mental health screening124 should be followed.

Various studies have shown that the risk of inflammatory bowel disease (IBD) in children with psoriasis is 3–4 times higher than in children without psoriasis.1,8,125 Although it can appear at any age, it is uncommon before puberty.126 Like PsA, its impact on the child and treatments can be significant, so it should be regularly ruled out.

Non-alcoholic fatty liver disease (NAFLD) is a term that includes both simple steatosis and non-alcoholic steatohepatitis. It is characterized by excessive accumulation of liver fat not due to an autoimmune, metabolic, or infectious process. Its prevalence in pediatric psoriatic patients is not well known. In the general population, the prevalence of NAFLD increases with age, being exceptional in children<3 years old and rare in children<10 years old.127 The symptoms associated with NAFLD are nonspecific, such as fatigue or abdominal pain. This disease is associated with acanthosis nigricans (present in 33% up to 50% of cases), increased abdominal circumference, and hepatomegaly (in up to 50% of cases).

Due to the association of NAFLD with overweight, obesity, and insulin resistance, regular screening for this condition in pediatric patients is recommended.

A phase II RCT analyzed the use of apremilast 20–30mg twice a day (depending on age and weight) in children aged 6–17 years with moderate-to-severe plaque psoriasis.128 On week 16 of treatment, the mean changes in PASI for adolescents with 20mg apremilast were −69.6, and with 30mg apremilast, −66.5. In children on 20mg apremilast, the changes in PASI at week 16 were −79.3. The drug was generally well tolerated. The data being presented from phase III studies with apremilast (NCT03701763, NCT06088199, NCT04175613) are consistent with these results.

Currently, a phase III RCT (NCT03451851) is evaluating the safety and efficacy of subcutaneous guselkumab vs ETN and placebo in pediatric patients aged 6–18 years with moderate-to-severe plaque psoriasis.

A phase III RCT (NCT04435600) is in the pipeline evaluating subcutaneous risankizumab vs UST for pediatric participants aged 6–17 years with moderate-to-severe psoriasis.

A phase III RCT is ongoing with tildrakizumab (NCT03997786), placebo, and active control in children aged 6 to <18 years with moderate-to-severe plaque psoriasis.

An open study is analyzing the safety, tolerability, and pharmacokinetics of brodalumab in children aged 6–17 years with severe plaque psoriasis (NCT03240809).

A study is underway to evaluate the safety, efficacy, and pharmacokinetics of 2 doses of bimekizumab in adolescents with moderate-to-severe plaque psoriasis (NCT04718896).

A recent open study including 47 patients with pediatric psoriasis showed significant improvement in efficacy and quality of life with tofacitinib. At week 12, 55.32% of patients achieved PASI75, and 70.21% reached PASI75 at week 36.129 No severe adverse events were observed.

A phase III RCT is currently underway to evaluate the safety, efficacy, pharmacokinetics, and immunogenicity of netakimab in children (6–18 years) with plaque psoriasis (NCT06640517).

Data on other Janus kinase (JAK) inhibitors, specifically tyrosine kinase 2 (TYK2) inhibitors such as deucravacitinib, are still being tested in children (phase III RCT NCT04772079).

Although it depends on the type of treatment, adverse events from topical treatments are not very common37 and are generally mild (though they vary depending on the drug), especially when following the guidelines provided in the drug prescribing information. Systemic adverse events from these therapies are rare, and monitoring is primarily clinical (Table 16).

Of note, regarding the use of topical corticosteroids, children—especially younger ones—have thinner skin and a proportionally larger skin surface area, making the risk of systemic absorption of these drugs higher than in adults. Therefore, the appropriate corticosteroid (lower potency) should be selected, and application over large areas and for prolonged periods should be avoided.

On the other hand, classic systemic treatments and biological therapies generally present a safety profile similar to that observed in adults,36 so the recommended follow-up is very similar (Table 11). One of the most common adverse events with these therapies is respiratory infections, which are also very common in healthy children. Pediatric infections are caused by different germs than in adults, and the clinical presentations are also particular. Therefore, in case of fever or infection, it is important to conduct a medical evaluation. For mild infections, it is not mandatory to discontinue treatment, but for moderate and severe infections, it is recommended to suspend treatment until clinical improvement.

Children with pediatric psoriasis, especially those on classic systemic treatments and biological therapies, may be at a higher risk of infections. Therefore, updating the child's vaccination schedule, as well as that of their close contacts, is considered essential.

In general, the vaccines recommended according to the current vaccination schedule of each region should be administered, with some specifications in line with recommendations issued for pediatric patients who are immunocompromised due to other diseases and immunosuppressive treatments (Table 11).