Psoriasis is a common chronic immune-mediated inflammatory skin disorder and begins in childhood in almost one-third of the cases. Although children present with the same clinical subtypes of psoriasis seen in adults, lesions may differ in distribution and morphology, and their clinical symptoms at presentation may vary from those reported by adult patients. Nevertheless, diagnosis of psoriasis is primarily based on clinical features. Pediatric psoriasis can have a profound long-term impact on the psychological health of affected children. Additionally, pediatric psoriasis has been associated with certain comorbidities, such as obesity, hypertension, hyperlipidemia, diabetes mellitus and rheumatoid arthritis, making early diagnosis and management essential. As guidelines are lacking and most (systemic) treatments are not approved for use in children, treatment of pediatric psoriasis remains a challenge. A prospective, multicenter, international registry is needed to evaluate these treatments in a standardized manner and ultimately to develop international guidelines on pediatric psoriasis. This article reviews current concepts in pediatric psoriasis including epidemiology, clinical features, diagnosis, the role of topical and systemic agents and the association with other morbidities in childhood.

In 2008, a systematic review revealed that evidence-based data on efficacy and safety of treatments in paediatric psoriasis are scarce and with low level of evidence. In recent years, publications on this topic have increased exponentially. To present a systematic, evidence-based update on the efficacy and safety of systemic treatments in paediatric psoriasis and to provide treatment recommendations, an update of the previous review was performed. PubMed, EMBASE and the Cochrane Controlled Clinical Trial Register were searched between January 2007 and March 2014 for all available literature on efficacy and safety of all systemic treatments in paediatric psoriasis. The levels of evidence were determined on the Oxford Centre for Evidence-based Medicine Levels of Evidence. The newly retrieved evidence was combined with the evidence available in the former review. Fifty-two studies were included: 36 from the former review, plus 16 new articles. New evidence on induction therapy was mainly available on fumaric acid esters (FAEs), which are shown to be effective in a subgroup of patients. Long-term (96 weeks) safety and efficacy data on etanercept were found. Prospective studies are scarce. Most conclusions are formulated on studies with low level of evidence. Of the conventional systemic treatments, methotrexate still has the most evidence albeit in a low number of patients and with a low level of evidence. FAEs seem to be effective in a subgroup of patients, with gastro-intestinal complaints, flushes and temporary shifts in leucocyte counts and liver enzymes being the main side-effects. Etanercept has still accumulated most evidence of the available systematic treatments, with a large efficacy and reassuring safety profile in a 96-week follow-up.

MTX shows a positive effect on PASI scores, improves Qol and has a reasonable safety profile.

BackgroundLimited data are available on the frequency of IgE mediated food sensitization and food allergy (FA) in adults with atopic dermatitis (AD).ObjectiveWe investigated the pattern of food sensitization in adults with AD in relation to AD severity using multiplexed allergen microarray.Methods211 adult patients referred between January 2010-July 2011 for evaluation of AD were unselectively included. Severity of AD was determined by therapy intensity, SASSAD-skin-score and sTARC levels. Allergen specific sIgE levels were measured by ImmunoCAP ISAC® microarray. FA was defined as convincing history taken by physician and sensitization to the corresponding allergen.ResultsSensitization to food was found in 74.4% of the AD patients, 54% had a positive history of FA and 20.4% asymptomatic sensitization. There was no association between severity of AD and frequency of food sensitization or history of FA.Sensitization to PR-10 related food allergens occurred most frequently (63.5%) and was independent from AD severity. Correspondingly, pollen-food syndrome accounted for most of the FA, being also independent from AD severity. Of all plant food allergens only sensitization to nAra h 1 was significantly more frequent in patients with severe AD. In the total group 75 (35.5%) patients with AD showed sensitization to any animal food allergen. The percentage was significantly higher in patients with severe AD (51.4%) compared to patients with mild/moderate AD (27.7%). Sensitization to cow’s milk allergens, in particular to nBos d lactoferrin, was more frequent in severe AD patients.ConclusionAD was frequently associated with food sensitization. The percentage of sensitization to animal food allergens was significantly higher in severe AD patients.

In the young adult psoriasis population, substantial QoL impairments were found. Female patients, patients with high BMI, or long disease duration in particular tended to experience more difficulties. These exploratory findings indicate the need for further studies in young adults to detect potential clinical predictors for severe HRQoL impairments.

In patients with psoriasis aged 16-17 years, DLQI and CDLQI scores closely correlate, but the mean DLQI score was lower than the mean CDLQI score. This was caused primarily by differences in the answers to questions regarding sexual difficulties and sleep. As the QoL impacts experienced by people aged 16-17 may differ from those experienced by children or adults, QoL measures designed for use in this age range may have advantages over both child- and adult-specific measures.

In this daily clinical practice study in paediatric psoriasis, calcipotriol/betamethasone dipropionate ointment initially improved mild-to-moderate psoriasis and then maintained its effect. In addition, it improved QoL, with few adverse events.

FAE showed improvement of disease severity and QoL in the majority of children. Side-effects occurred frequently, but were usually mild and transient. FAE may be an alternative systemic treatment option for pediatric psoriasis, provided that also the long-term safety data are closely monitored, in particular lymphocytopenia.