Melodie Young, MSN, ANP-c: Key Psoriasis Treatment Advances for Pediatric Patients

Although it would make treatment a lot easier, children and adolescents are not just “tiny adults,” and instead present unique challenges and considerations for dermatology providers. Children and adolescents with psoriasis, historically, have had few options for treatment and most medications that were in the toolbox were used off-label.

In her talk at Maui Derm NP+PA Fall 2024, Melodie Young, MSN, ANP-c, of Mindful Dermatology in Dallas, Texas, shared treatment updates for this group, detailed the difference in disease manifestation between adults and children, and urged her colleagues to avoid topical corticosteroids at all costs.

This transcript has been edited for clarity.

Dermatology Times: Tell us about your session on children with psoriasis presented at Maui Derm NP+PA Fall, and why it’s important to provide this education to an audience of advanced practice providers?

Melodie Young, MSN, ANP-c: I have been presenting on psoriasis with the Maui Derm meetings for a couple of decades, and this is the first time that I've been asked to focus on children with psoriasis, so it was good for me. I went back and sort of updated my knowledge on the guidelines of care that were jointly published by the AAD and the NPF, and then I also did a review of all the medications that are currently approved for use in the pediatric population for psoriasis. The reason it's really important is because a lot of medications, in fact, most of the medicines that we've been using in the adult population, if you're using them in children, you're probably doing it off-label.

Now we have 2 new psoriasis medications that are FDA approved to use in the pediatric population. One of them is a topical, which is roflumilast, and the other is apremilast, [which] just got approved and is just making its way onto the shelf. So I thought it was important that we kind of review what we're doing so that we can just reset our decision-making when it comes to kids.

Some of the information on how psoriasis presents in children, the quality of life impact on kids and the family—it is not an isolated disease. It has a lot of comorbidities and it's kind of a cluster of other diseases. When you see psoriasis, you can expect to see obesity. You can expect to see insulin resistance developing pretty quickly. We're very well aware of the comorbidities associated with psoriasis in the adult population, but in the pediatric population, there are some very concerning things. For example, there's a 47% increase in the use of psychotropic drugs for children with psoriasis versus age-match controls that come into the dermatology clinic for other things like acne and warts and eczema and those sorts of things. I think we really need to be aware of how important it is that we get the disease under control early and let them live a psoriasis-free life, and we have the medications to do that now.

DT: What are some of the differences in disease manifestation for children with psoriasis versus adults?

MY: One of the things that really struck me [when] I did a review of pediatric psoriatic disease is 80% of the time psoriatic arthritis will be the original manifestation of the disease, as opposed to skin. In the adult population…like 90% of the time, the skin disease manifests first and about 10 years later, you'll start to see signs and symptoms of psoriatic arthritis in about a third of the adult psoriatic population.

In the pediatric population, it is completely opposite [where] 80% will present with some type of arthropathy, and it's also differentiated based on age groups. The early toddler and then that preteen group is when that is most likely to happen, and it appears differently in female population versus the male population, which, for example, tends to have more axial disease. So again, very important that we understand that this is not a skin disease in the pediatric population, and if a person with psoriasis—a child, an infant, an adolescent—presents to your clinic, to me, it's almost a dermatologic urgent matter. You need to intervene aggressively and get the disease under control.

DT: What current therapeutics exist for this population and what does the pipeline look like?

MY: The pediatric population, especially for milder disease, has been treated historically with topical corticosteroids and a few of the topical immunomodulators, and that's all been done off-label. So to have topical medications that are actually gone through the FDA process and are proved to be used in children is a big deal. Roflumilast, for example, and hopefully soon we'll have tapinarof as well that will be used in the pediatric population.

Topical corticosteroids in kids can be absorbed quickly. [Hypothalamic-pituitary-adrenal] suppression is a real thing. It is systemically noted, even sometimes as little as 1 week of use, particularly if it's a stronger drug. I feel like all the NPs and PAs and perhaps even physicians that are treating patients with topical corticosteroids in the pediatric group, whether it's toddlers, preteens, or adolescents, will really rethink those sort of algorithms of care or what they tend to prescribe and use more evidence-based medicine.

DT: Your talk focuses heavily on NOT using topical or systemic steroids for the pediatric population. Can you talk about why you avoid those treatments?

MY: My goal, I say, I'm in my last 10 years of my career as a dermatology NP, [and] my goal is to get my colleagues to stop using topical corticosteroids for chronic diseases and move into medications that are more disease-specific and that have a much better safety profile and better tolerability and even efficacy. I think that's what the new topical therapies have brought to this market and this population.

Reference:

Hawkes J, Shaw K, Young M. Psoriasis and psoriatic arthritis update 2024 – new interactive format. Presented at: Maui Derm NP+PA Fall; September 15-18, 2024; Nashville, Tennessee.