Psoriasis, a common dermatologic disorder affecting individuals of all ages, can begin in childhood in almost one-third of patients. This disease is commonly associated with a mosaic of serious comorbidities in adults including obesity, hypertension, dyslipidemia, type 2 diabetes mellitus, psoriatic arthritis, nonalcoholic fatty liver disease, depression, anxiety, and decreased quality of life (QOL). Challenges to diagnosis underscore the urgency of early identification of comorbidities as well as the risk of developing these conditions in the long term.
Almost a decade ago, the National Psoriasis Foundation (NPF) put forth comorbidity screening guidelines for adults with psoriasis. However, there were no equivalent screening guidelines for pediatric psoriasis patients. More recently, a group of researchers conducted a comprehensive literature review for psoriasis and comorbidities with the intent of establishing the first set of comorbidity screening guidelines for the pediatric psoriasis population.1 In the PubMed review from 1999 to 2015, a panel of experts in psoriasis, pediatric dermatology, pediatric rheumatology, pediatric gastroenterology, pediatric endocrinology, and adult and pediatric cardiology used the patient-centered Strength of Recommendation Taxonomy (SORT) method to evaluate and grade the quality of evidence.
Grading the guidelines
The researchers identified 153 relevant manuscripts in English, 26 of which involved pediatric patients. The strength of the panel’s recommendations was classified as SORT level C expert consensus recommendations, because of the limited number of pediatric studies published on these topics. The C grading means the recommendations are based on consensus, usual practice, opinion, disease-oriented evidence, or case series. Most of the studies in children were quality level 3 (other evidence: usual practice, opinion, disease-oriented evidence).
“These mainly consensus-based recommendations provide a starting point for screening that will be refined as more is learned,” the researchers write. “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). It will also be important to assess the effectiveness of early detection and proactive intervention in preventing future complications.”
Interestingly, the majority of recommendations were found to coincide with those endorsed by the American Academy of Pediatrics (AAP) for the general pediatric patient, including pediatric screening for overweight or obesity, diabetes, dyslipidemia, and hypertension, with added attention to the signs and symptoms of psoriatic arthritis, depression, anxiety, substance abuse, and decreased quality of life.
Why look for comorbidities?
The new guidelines emphasize that children with psoriasis may have impaired emotional, school, and social functioning, and experience school bullying. The researchers also recommended comorbidity background awareness for polycystic ovary syndrome, gastrointestinal diseases, and uveitis. In addition, it was suggested that healthcare providers should consider the existence of comorbidities before embarking on systemic therapies in their patients with psoriasis.
The goal of the new guidelines is to assist healthcare providers to better assess and identify potential risk factors in children with psoriasis who could carry these increased risks into adulthood. A concerted effort in communication and cooperation among all healthcare providers caring for the pediatric psoriasis patient, such as primary care physicians, dermatologists, and pediatric specialists, could help optimize therapeutic choices and patient management outcomes. Overall health management also includes educating patients and their families about associated conditions, improving their lifestyle choices early, and offering a supporting environment.
Future research should be aimed at addressing the impact of early detection as well as proactive intervention strategies on preventing future complications and morbidity in this patient population, the study said.
1. Osier E, Wang AS, Tollefson MM, et al. Pediatric psoriasis comorbidity screening guidelines. JAMA Dermatol. 2017;153(7):698-704.