Treatment persistence in paediatric and adolescent patients with psoriasis followed into young adulthood. From topical to systemic treatment: a prospective, longitudinal, observational cohort study of 448 patients.

BACKGROUND: Although solely topical treatment often suffices, patients with psoriasis may require more intensive treatment (phototherapy and/or systemic treatments) to control their disease. However, in paediatric, adolescent and young adult patients, little is known about persistence of topical treatment and time until switch to systemic treatment. OBJECTIVES: To determine the median time from psoriasis onset until (i) discontinuation of solely topical agents and (ii) switch to systemic treatment, and to identify patient characteristics associated with switching to systemic treatments. METHODS: Data were extracted from the Child-CAPTURE registry, a prospective, observational cohort of patients with paediatric-onset psoriasis followed into young adulthood from 2008 to 2018. Data prior to inclusion in the registry were collected retrospectively. Median times were determined through Kaplan-Meier survival analyses. Cox regression analysis was used to identify patient characteristics associated with switch to systemic treatment. RESULTS: Of 448 patients, 62·3% stayed on solely topical treatment until data lock; 14·3% switched from topicals to phototherapy, but not to systemic treatment; and 23·4% switched to systemic treatment. The median time from psoriasis onset until discontinuation of solely topical treatment was 7·3 years, and until switch to systemics was 10·8 years. Higher Psoriasis Area and Severity Index and (Children's) Dermatology Life Quality Index > 5 were independently associated with switching to systemic treatment. CONCLUSIONS: In a population of paediatric and adolescent patients with mild-to-severe psoriasis, one-third needed more intensive treatment than solely topical therapy to control their disease. We consider the median time until switching to systemics to be long.

Fumaric acid esters in recalcitrant pediatric psoriasis: A prospective, daily clinical practice case series.

BACKGROUND: Evidence on fumaric acid esters (FAE) in the treatment of pediatric psoriasis is scarce. OBJECTIVE: Describe the effectiveness, influence on the quality of life (QoL) and safety of FAE in children with recalcitrant psoriasis in daily clinical practice. METHODS: A prospective case series. RESULTS: Fourteen patients with recalcitrant plaque-type psoriasis were described (mean age 13.7, range 8-17 years). Mean treatment duration was 48.6 weeks (range 12-124). Maximum daily dose varied between 180 and 1200 mg with a mean of 564 mg per day. Mean Psoriasis Area and Severity Index (PASI) (±SEM) at baseline was 10.5 (1.0) compared to 8.6 (1.1), 6.2 (1.6) and 4.9 (1.5) at week 12, 24 and 36, respectively. An improvement in PASI was observed in nine patients (64.3%). Mean CDLQI (±SEM) at week 0, 12, 24 and 36 was 8.9 (1.4), 6.8 (1.2), 3.7 (1.4) and 3.1 (2.0), respectively. Most common adverse events (AEs) were gastrointestinal complaints (n = 13, 92.9%) and flushes (n = 10, 71.4%). Lymphocytopenia (n = 5, 45.5%) and eosinophilia (n = 4, 36.4%) were frequently observed laboratory abnormalities. AEs were usually mild and transient. One serious adverse event, unrelated to FAE, was reported. CONCLUSIONS: 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.

An increased risk of non-melanoma skin cancer during TNF-inhibitor treatment in psoriasis patients compared to rheumatoid arthritis patients probably relates to disease-related factors.

BACKGROUND: Concerns exist about a risk of non-melanoma skin cancer (NMSC) in psoriasis patients and rheumatoid arthritis (RA) patients treated with TNF-inhibitors. However, current data also show that in some psoriasis patients, NMSC is diagnosed relatively short after the start of TNF-inhibitors, which suggests that these NMSC can be explained by previous therapies instead of by TNF-inhibitor therapy. OBJECTIVE: To investigate whether there was a difference in time until first NMSC and the rate of NMSC between psoriasis and RA patients on TNF-inhibitors. METHODS: Time until first NMSC and the rate of NMSC were compared between psoriasis and RA patients from the same region treated with TNF-inhibitors and followed up for at least one year in prospective cohort studies, by using Cox regression and Poisson regression. Both analyses were corrected for confounders (age, gender, disease duration, prior NMSC, duration of anti-TNF and other systemic therapies). RESULTS: The NMSC risk was significantly higher in the psoriasis group [fully adjusted HR 6.0 (1.6-22.4 95%CI)] with a shorter time until first NMSC in psoriasis compared to RA. By Poisson regression, psoriasis patients had a 5.5 (2.2-13.4 95%CI) higher rate of NMSC. CONCLUSION: The time until first NMSC was significantly shorter and the rate of NMSC was significantly higher in psoriasis compared with RA. This indicates that disease-related factors like phototherapy may be important contributing factors to NMSC diagnosed in psoriasis patients treated with TNF-inhibitors.

Methotrexate in pediatric plaque-type psoriasis: Long-term daily clinical practice results from the Child-CAPTURE registry.

BACKGROUND: Evidence on effectiveness and safety of methotrexate (MTX) in pediatric psoriasis is scarce. OBJECTIVES: To study the effectiveness and safety of MTX in pediatric plaque-type psoriasis and its influence on quality of life (Qol) in daily clinical practice. METHODS: Subset analysis of prospectively collected data extracted from the Child-CAPTURE registry, a single center, longitudinal, long-term, observational daily practice cohort of pediatric psoriasis patients. A maximum dose between 0.14 and 0.63 mg/kg once weekly was prescribed in 25 children. Primary endpoints were percentages of patients with ≥ 75% improvement in the Psoriasis Area and Severity Index (PASI) at week 12 and 24. RESULTS: PASI75 was achieved in 4.3% and 33.3% of patients at week 12 and 24, whereas 40% and 28.6% reached PASI 75 at week 36 and 48. Median PASI and body surface area decreased from 10.0 (range 3.8-42.4) and 11.0 (range 3.5-72.0) at baseline to 4.3 (range 0-19.8) and 2.6 (range 0.0-39.6) at week 24, respectively. Physician Global Assessment improved significantly from 3.0 to 1.2 at week 24. A significant decrease in Children's Dermatology Life Quality Index from 9.0 to 3.8 at week 24 was found. Most reported adverse events were severe nausea (n = 5), infections requiring antibiotics (n = 5) and tiredness (n = 4). CONCLUSIONS: MTX shows a positive effect on PASI scores, improves Qol and has a reasonable safety profile.

Period of remission after treatment with UVA-1 in sclerodermic skin diseases.

BACKGROUND: Sclerodermic skin diseases can cause severe morbidity and disability. UVA-1 has shown to be an effective therapy for sclerodermic skin diseases. However, the period of remission in these patients is not clear. In this study, the effect and remission period of UVA-1 phototherapy in various sclerotic skin diseases is described using a semiquantitative clinical score combined with the durometer score as an objective apparatus to measure the hardness of the skin. OBJECTIVE: Our purpose was to determine the effectiveness of UVA-1 phototherapy and the duration of remission in sclerodermic skin diseases. METHODS: In this prospective study, 10 patients with various sclerodermic skin diseases were treated with UVA-1 phototherapy. The durometer was used to observe the hardness of the skin. Hardness of the skin was measured by one investigator at 10 locations, distributed evenly on the representative sclerotic skin. Each spot was measured three times, and the average of each of these measurements was summed to give the total durometer score. Durometer scores were recorded weekly until the final treatment date and 4 weeks after treatment. Clinical scores were carried out at the end date of the treatment using a 6-point scale semiquantitative score. Long-term effects were evaluated up to 29-46 months. RESULTS: The patients were treated with UVA-1 in a cumulative dose of 1286 +/- 58.8 (SEM) J/cm(2) (range, 846-1470 J/cm(2)) divided over five times a week for 4 weeks. In all patients studied, the sclerotic skin lesions were markedly softer after UVA-1 treatment. All durometer scores improved highly significant during the first 3 weeks of treatment and borderline significant during the last week of treatment. There was no significant improvement between the end of UVA-1 phototherapy and 1 month after ending the therapy (P > 0.05). All patients noted improvement of the semiquantitative clinical score during treatment. Clinical improvement was associated with improvement of the durometer score (95% confidence interval). With a follow-up until 46 months, the remission period was stable up to 26 months in six patients. The duration of sclerodermic skin diseases before start of treatment did not influence improvement in the clinical or durometer score. One patient had an acute side effect of minimal erythema. No other side effects, except tanning and fatigue, were noted. LIMITATIONS: This is an open-label uncontrolled study. CONCLUSION: UVA-1 is an effective treatment for sclerodermic skin diseases with a long period of remission and clinical improvement even in patients with a long history of a sclerotic skin disease. UVA-1 should be considered among the first approaches in the management of sclerotic skin diseases.