Psoriasis (PsO) in children and adolescents has a prevalence of 0.71%, appearing less common than in adults.1 Given its chronic nature and the significant deterioration in quality of life not only for affected children but also for their parents and relatives, as well as the limitations in treatment options, managing the disease appears challenging.1 Although several biologics have been approved by the EMA and FDA in the paediatric population affected by PsO, with differences in age and treatment line (age limits: ≥4 years for adalimumab; ≥6 years for etanercept, ixekizumab, secukinumab and ustekinumab), numerous limitations persist in psoriatic arthritis (PsA) patients, in the reimbursement among different countries and in treatment line indications.1-3 For these reasons, conventional systemic drugs, acitretin, methotrexate, cyclosporine and to a lesser extent fumaric acid esters, still have a place as a first-line systemic treatment for PsO and PsA, although some of these are considered off-label, such as methotrexate and some national consensus recommends them only as second-lines.1, 2 The study by Miaio et al. presents one of the largest real-world experiences in paediatrics regarding the management of PsO and PsA with conventional systemic drugs, involving mainly European centres and one Canadian centre.2 The primary objective of the study was to compare drug survival (DS) of acitretin, methotrexate and cyclosporine.2 The authors also investigated the factors associated with the choice of the treatment as first line, its effectiveness and associated predictors, tolerability and reasons for discontinuation.2 The study confirms some already known evidence, such as the lower DS of cyclosporine compared to the other two treatments, with a higher primary failure rate for this treatment.4 Curiously, this data isn't accompanied by lower treatment effectiveness at 3 and 6 months, time points at which the treatment appears to be the most effective in achieving PASI 90. This trend could suggest an on/off effect of the treatment and an expectation of a rapid response to cyclosporine in the first weeks, compared to methotrexate and acitretin, which are known to be slower in achieving therapeutic responses. These considerations are limited by the evident geographical isolation in the prescription of cyclosporine, which is more commonly prescribed in Italian centres and in the single Portuguese centre.2 Prescribing heterogeneity appears to be the most relevant data, while confirming already known national specificities, such as the higher prescription of methotrexate in Northern Europe, highlighting the lack of clear European and international guidelines on drug management, in the presence of a relatively homogeneous population.2, 5, 6 The available guidelines on paediatric populations are not updated to the recent approval of IL-17 inhibitors.5, 6 The German guidelines on moderate-to-severe psoriasis indicate methotrexate, adalimumab and acitretin, in pustular forms, as first-line therapy, recommend etanercept and ustekinumab as second-line therapy, and consider cyclosporine and dimethyl fumarate as first-line alternatives.5 The National Psoriasis Foundation guidelines do not rank treatment options but give the highest recommendation (A) to etanercept and ustekinumab, and recommendation B to adalimumab, methotrexate, cyclosporine and acitretin.6 The study by Miaio et al. provides greater insight into the effectiveness and safety of systemic drugs, suggesting a lower feasibility of cyclosporine and observing a lower effectiveness of acitretin as a second-line treatment.2 These observations could provide guidance for future structured recommendations. These recommendations should consider the off-label nature of most conventional systemic treatments and recommend biologics as first-line therapy, as well as ensuring greater prescribing consistency between different countries. Biologics have demonstrated greater safety and efficacy in the adult population compared to placebo and traditional drugs and compared to placebo and methotrexate in the paediatric population.1, 3 Concerns regarding the safety and sustainability of biologics shouldn't lead to therapeutic discrimination against children and adolescents. Luca Mastorino received consulting fees from Almirall, AbbVie; received payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Almirall, AbbVie, Bristol Meyer Squib, Novartis, UCB, Sanofi, LeoPharma, Johnson and Johnson, Eli-Lilly, PierreFabre, Accord; received support for attending meetings and/or travel from AbbVie, Novartis, UCB, Sanofi, LeoPharma, Johnson and Johnson, Eli-Lilly. Data sharing not applicable to this article as no datasets were generated or analysed during the current study.
Luca Mastorino (Tue,) studied this question.