The epidemiology of childhood psoriasis: a scoping review

Generating detailed intercellular communication patterns in psoriasis at the single-cell level using social networking, pattern recognition, and manifold learning methods to optimize treatment strategies

Psoriasis, a complex and recurrent chronic inflammatory skin disease involving various inflammatory cell types, requires effective cell communication to maintain the homeostatic balance of inflammation. However, patterns of communication at the single-cell level have not been systematically investigated. In this study, we employed social network analysis tools, pattern recognition, and manifold learning to compare molecular communication features between psoriasis cells and normal skin cells. Utilizing a process that facilitates the discovery of cell type-specific regulons, we analyzed internal regulatory networks among different cells in psoriasis. Advanced techniques for the quantitative detection of non-targeted proteins in pathological tissue sections were employed to demonstrate protein expression. Our findings revealed a synergistic interplay among the communication signals of immune cells in psoriasis. B-cells were activated, while Langerhans cells shifted into the primary signaling output mode to fulfill antigen presentation, mediating T-cell immunity. In contrast to normal skin cells, psoriasis cells shut down numerous signaling pathways, influencing the balance of skin cell renewal and differentiation. Additionally, we identified a significant number of active cell type-specific regulons of resident immune cells around the hair follicle. This study unveiled the molecular communication features of the hair follicle cell-psoriasis axis, showcasing its potential for therapeutic targeting at the single-cell level. By elucidating the pattern of immune cell communication in psoriasis and identifying new molecular features of the hair follicle cell-psoriasis axis, our findings present innovative strategies for drug targeting to enhance psoriasis treatment.

The epidemiology of pediatric psoriasis: A nationwide cohort study in Taiwan

Psoriasis can affect individuals of all age groups. While the epidemiology of psoriasis in adults has been extensively studied, there is limited research specifically investigating pediatric cases. This study aimed to investigate the prevalence and incidence of skin psoriasis (PsO) and psoriatic arthritis (PsA) among pediatric patients in Taiwan. A nationwide cohort of 17 535 patients with psoriatic diseases under the age of 18 was enrolled from the National Health Insurance Research Database for the period 2000-2013, including 16 129 PsO patients and 2022 PsA patients. The age- and sex-standardized prevalence and incidence of pediatric PsO and PsA were calculated. The 2007 yearly reports of age- and sex-specific distribution of the general population was adopted as a standard. The results showed that between 2000 and 2013, the prevalence for pediatric PsO increased from 0.03% to 0.07%, and from 0.003% to 0.014% for pediatric PsA. During the same period, the incidence slightly decreased from 19.81 to 17.55 per 100 000 for pediatric PsO but increased from 1.02 to 5.06 per 100 000 for pediatric PsA. Adolescents (12 to <18 years) had higher prevalence and incidence rates of PsO and PsA than children (aged ≤ 12 years), with no sex difference observed in either age group. PsA preceding PsO was more common among children than adolescents (27.07% vs. 13.46%). This study provides important insights into the prevalence and incidence of psoriatic diseases in the pediatric population. Further research is needed to identify risk factors for pediatric psoriasis and to investigate its long-term health outcomes.

Real-world data on the use of secukinumab and acitretin in pediatric generalized pustular psoriasis

To evaluate the outcomes of secukinumab and acitretin use in children with generalized pustular psoriasis (GPP), we compared the efficacy and adverse events of secukinumab in 20 children and acitretin in 16 children with GPP from January 1, 2019, to January 30, 2022. Among the 20 patients treated with secukinumab, the average time for pustules to fade, temperature to normalize, and C-reactive protein (CRP) to normalize was 3.83, 2.46, and 3.91 days, respectively. All patients recovered (Japanese Dermatological Association severity index score: 0/1) in 3 weeks. The adverse events were abnormal liver enzyme (10%), atopic dermatitis-like lesions (10%), herpes simplex (5%), and neutropenia (10%). For the patients treated with acitretin, the average time for pustules to fade, temperature to normalize, and CRP to normalize was 6, 6.14, and 8.73 days, respectively. The adverse events included mucocutaneous dryness (75%), dyslipidemia (37.5%), and abnormal liver enzyme (25%). These findings demonstrate that secukinumab has more favorable outcomes than acitretin, and secukinumab was well tolerated by the pediatric patients with GPP.

Psoriasis and Cardiovascular Risk in Children: The Usefulness of Carotid Intima-Media Thickness

Psoriasis is a skin disorder which mostly affects adults, beginning in childhood in almost one-third of patients. In adults it is associated with increased risk for cardiovascular diseases (CVD), while this association is still debated at younger age. Our aim was to evaluate the association between psoriasis and metabolic markers and cardiovascular findings in this age group. Twenty consecutive patients previously diagnosed with psoriasis (group A) were enrolled and compared with healthy non- psoriatic age- and sex-matched subjects (group B). The severity of the disease, CV risk factors, including anthropometric data with adiposity and its distribution, blood pressure (BP), laboratory metabolic tests, echocardiography and vascular ultrasound (transcranial echo-Doppler and carotid artery echo-Doppler with carotid intima-media thickness, cIMT) were performed for each subject. Personal history for CV risk, BP, anthropometric data were similar between the two groups, while familiar history for psoriasis was more frequent in group A (p < 0.02). C-IMT was significantly higher in group A compared to B (right, p = 0.001; left, p = 0.002). In addition, c-IMT was positively correlated with disease duration, triglycerides and triglycerides/glucose. Cerebral flow velocities, cardiac measurements, systo-diastolic function, ventricle geometry and mass were normal and comparable between the two groups, and did not correlate with CV risk factors. In childhood psoriasis c-IMT could represent a marker of pre-clinical cardiovascular involvement and contribute to start a personalized management, while cardiac findings seem to be normal in the early stage of disease. Longitudinal studies can clarify the progression of CV involvement in paediatric-onset psoriasis.

Biologics for pediatric moderate-to-severe plaque psoriasis: a systematic review and network meta-analysis

BACKGROUND AND OBJECTIVES

To compare the efficacy and safety of biologic treatments for moderate-to-severe pediatric psoriasis approved by the US Food and Drug Administration and European Medicines Agency.

PATIENTS AND METHODS

MEDLINE, Embase, and Cochrane Central Register of Controlled Trials for relevant randomized controlled trials (RCTs) were searched for the identification of eligible RCTs until May 7, 2021. Fixed-effect frequentist network meta-analysis (NMA) was performed with the surface under the cumulative ranking curve (SUCRA) calculated for ranking. Our primary outcomes included ≥ 90 % improvement of Psoriasis Area and Severity Index score (PASI 90) at 12-16 weeks and discontinuation owing to adverse events (DAE) through the first 12-16 weeks.

RESULTS

Five RCTs involving 798 pediatric psoriasis patients were included. Compared to placebo, all biologic regimens exhibited a significantly higher PASI 90 response but did not differ in the risk for DAE. Based on the SUCRA, secukinumab-low dose (SEC-L) ranked first in the achieved PASI 90 response (84.7 %), followed by ixekizumab (70.8 %).

CONCLUSIONS

Among all biologic treatments, SEC-L showed the best PASI 90 response without increasing the risk for DAE. More long-term studies are warranted.

Diagnosis of Generalized Pustular Psoriasis

Generalized pustular psoriasis (GPP) is a severe rare skin disease characterized by widespread eruption of sterile superficial macroscopic pustules with or without systemic inflammation. Generalized pustular psoriasis flares may lead to life-threatening multiorgan complications, which highlights the need for rapid and accurate diagnosis. However, the rarity of the disease and its heterogeneous cutaneous and extracutaneous symptoms, and the resemblance of symptoms to other skin conditions, pose considerable challenges to the timely diagnosis and treatment of patients with GPP. Current laboratory tests used for GPP diagnosis are generally not GPP specific, and are mainly focused on the assessment of inflammatory markers and clinical and histopathologic features of GPP, and emerging genetic screening approaches. A differential diagnosis to distinguish GPP from other similar conditions requires careful assessment of the patient’s skin symptoms, potential disease triggers, medical history, histopathologic features, laboratory tests, and clinical disease course. The comprehensive interpretation of these assessments can be challenging owing to the lack of standardized global guidelines. While there is currently a lack of standardized international guidelines for the diagnosis of GPP, recent advances in our understanding of the genetics and pathogenesis of the disease have provided new opportunities to enhance diagnosis. In the future, defining specific GPP subtypes using genetic and histopathologic strategies will guide therapeutic decisions, allowing patients to achieve their treatment goals without delay. In this article, we provide an overview of the current diagnostic methods, differential diagnostic strategies, and future advances in the diagnosis of GPP, as well as features of GPP variants.

Efficacy of Secukinumab Across Subgroups and Overall Safety in Pediatric Patients with Moderate to Severe Plaque Psoriasis: Week 52 Results from a Phase III Randomized Study

BACKGROUND

The efficacy and safety of biologic treatments for children and adolescents with moderate to severe psoriasis should be examined over a considerable time period and in different subgroups.

OBJECTIVE

We report the efficacy and safety of secukinumab low dose (LD) and high dose (HD) regimens in pediatric patients with moderate to severe psoriasis for up to Week 52.

METHODS

This was a randomized, open-label, parallel-group, multicenter study in patients aged  6 to < 18 years. Patients were randomized in a 1:1 ratio to receive LD (75/75/150 mg; N = 42) or HD (75/150/300 mg; N = 42) subcutaneous secukinumab. At randomization, patients were stratified by weight (< 25, 25 to < 50, ≥ 50 kg) and disease severity (moderate/severe). The study is ongoing; the present analysis included data up to Week 52 collected from August 29, 2018 (first patient first visit) to May 28, 2020 (last patient last visit for Week 52). Efficacy was measured using Investigator's Global Assessment modified 2011 0/1 (IGA 0/1) and Psoriasis Area Severity Index (PASI) 75/90/100 response. Safety outcomes included assessment of adverse events.

RESULTS

Of the 84 enrolled patients, 78 (92.9%) completed 52 weeks of treatment. Overall, response rates for PASI 75 and IGA 0/1 were similar between the LD (92.8/88.9%) and HD (93.3/84.7%) groups at Week 52. In the LD and HD groups, PASI 90/100 responses at Week 52 were 78.7/53.5% and 84.7/70.0%, respectively. The proportions of IGA 0/1 and PASI 75/90 responders were comparable for the age, body weight, and disease severity subgroups in the secukinumab LD and HD groups. Mean absolute PASI change from baseline at week 52 was - 17.3 ± standard deviation 5.0 and - 18.2 ± 7.0, a percentage change of - 94.3 and - 94.5% for the LD and HD groups, respectively. More than 70% of evaluable patients achieved Children's Dermatology Life Quality Index 0/1 at Week 52 (LD 70.7%; HD 70.3%). The safety profile was consistent with that in adults, with no new safety signals for either secukinumab dosing regimen.

CONCLUSION

A high proportion of pediatric patients with psoriasis responded to both dosing regimens of secukinumab and maintained clinical responses through 52 weeks of treatment. No clinical difference was observed in the efficacy of secukinumab across the pediatric subgroups. Safety events were consistent with the established safety profile of secukinumab.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03668613.

A phase 3 open-label, randomized multicenter study to evaluate efficacy and safety of secukinumab in pediatric patients with moderate to severe plaque psoriasis: 24-week results

BACKGROUND

Psoriasis affects 0.13%-2.1% of children and adolescents. Despite a high unmet need, the current treatment options approved for pediatric psoriasis are limited.

OBJECTIVE

To evaluate the efficacy and safety of 2 secukinumab dosage regimens (low dose: 75/75/150 mg; high dose: 75/150/300 mg) stratified and randomized by weight (<25 kg, 25 to <50 kg, ≥50 kg) and disease severity (moderate, severe) in pediatric patients aged 6-<18 years with moderate to severe plaque psoriasis.

METHODS

This is a phase 3, open-label, randomized, multicenter study (NCT03668613).

RESULTS

Both secukinumab doses were superior to historical placebo with respect to psoriasis area and severity index (PASI)-75/90 and investigator global assessment 0/1 responses at week 12. The estimated probability of a positive treatment effect (ie, log odds ratio > 0) for low- or high-dose secukinumab compared to historical placebo is 1 (ie, 100%). For the low and high doses at week 12, the investigator global assessment 0/1 response rates were 78.6% and 83.3%, respectively, and the PASI-90 response rates were 69% and 76.2%, respectively. The PASI-75 response rate was 92.9% for both the doses.

LIMITATIONS

This is an open-label study design without a control arm.

CONCLUSION

Secukinumab dosing regimens were efficacious and well tolerated in pediatric patients with moderate to severe plaque psoriasis.

Identifying the best predictive diagnostic criteria for psoriasis in children (< 18 years): a UK multicentre case-control diagnostic accuracy study (DIPSOC study)

BACKGROUND

In children, psoriasis can be challenging to diagnose. Difficulties arise from differences in the clinical presentation compared with adults.

OBJECTIVES

To test the diagnostic accuracy of previously agreed consensus criteria and to develop a shortlist of the best predictive diagnostic criteria for childhood psoriasis.

METHODS

A case-control diagnostic accuracy study in 12 UK dermatology departments (2017-2019) assessed 18 clinical criteria using blinded trained investigators. Children (< 18 years) with dermatologist-diagnosed psoriasis (cases, N = 170) or a different scaly inflammatory rash (controls, N = 160) were recruited. The best predictive criteria were identified using backward logistic regression, and internal validation was conducted using bootstrapping.

RESULTS

The sensitivity of the consensus-agreed criteria and consensus scoring algorithm was 84·6%, the specificity was 65·1% and the area under the curve (AUC) was 0·75. The seven diagnostic criteria that performed best were: (i) scale and erythema in the scalp involving the hairline, (ii) scaly erythema inside the external auditory meatus, (iii) persistent well-demarcated erythematous rash anywhere on the body, (iv) persistent erythema in the umbilicus, (v) scaly erythematous plaques on the extensor surfaces of the elbows and/or knees, (vi) well-demarcated erythematous rash in the napkin area involving the crural fold and (vii) family history of psoriasis. The sensitivity of the best predictive model was 76·8%, with specificity 72·7% and AUC 0·84. The c-statistic optimism-adjusted shrinkage factor was 0·012.

CONCLUSIONS

This study provides examination- and history-based data on the clinical features of psoriasis in children and proposes seven diagnostic criteria with good discriminatory ability in secondary-care patients. External validation is now needed.

Assessing the compliance of systematic review articles published in leading dermatology journals with the PRISMA statement guidelines: A systematic review

Background

Reporting quality of systematic reviews and meta-analyses is of critical importance in dermatology because of their key role in informing health care decisions.

Objective

To assess the compliance of systematic reviews and meta-analyses in leading dermatology journals with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement guidelines.

Methods

This review was carried out in accordance with PRISMA guidelines. Included studies were reviews published across 6 years in the top 4 highest-impact-factor dermatology journals of 2017. Records and full texts were screened independently. Data analysis was conducted with univariate multivariable linear regression. The primary outcome was to assess the compliance of systematic reviews and meta-analyses in leading dermatology journals with the PRISMA statement.

Results

A total of 166 studies were included and mean PRISMA compliance across all articles was 73%. Compliance significantly improved over time (β = .016; P = <.001). The worst reported checklist item was item 5 (reporting on protocol existence), with a compliance of 15% of articles.

Conclusion

PRISMA compliance within leading dermatology journals could be improved; however, it is steadily improving.

Association of Metabolic Comorbidities with Pediatric Psoriasis: A Systematic Review and Meta-Analysis

Background

An evident relationship has been shown between psoriasis and metabolic comorbidities. However, the results in pediatric psoriasis vary from study to study, and no meta-analysis exists on the association of metabolic comorbidities with pediatric psoriasis.

Objective

To evaluate the association between psoriasis and metabolic comorbidities in pediatric patients.

Methods

We searched articles published in PubMed, EMBASE, and Cochrane Library databases from inception to April 30, 2019. All observational studies reporting the prevalence of obesity or metabolic comorbidities in pediatric patients with psoriasis were included.

Results

The meta-analysis included 16 unique studies meeting the inclusion criteria. The pooled odds ratios in pediatric patients with psoriasis was 2.40 (95% confidence interval [CI], 1.60~3.59) for obesity (13 studies), 2.73 (95% CI, 1.79~4.17) for hypertension (8 studies), 2.01 (95% CI, 1.09~3.73) for diabetes mellitus (8 studies), 1.67 (95% CI, 1.42~1.97) for dyslipidemia (7 studies), and 7.49 (95% CI, 1.86~30.07) for metabolic syndrome (4 studies).

Conclusion

Pediatric patients with psoriasis showed a significantly higher prevalence of obesity, hypertension, diabetes, dyslipidemia, and metabolic syndrome. Adequate monitoring and timely management of metabolic comorbidities should be considered in these patients.

Pediatric Psoriasis Comorbidities: Screening Recommendations for the Primary Care Provider

Psoriasis, which affects up to 2% of children may be associated with significant comorbidity, including obesity, diabetes, cardiovascular disease, depression, and reduced quality of life. Screening and decision-making require a multidisciplinary approach with the management of potential comorbidities championed by primary care providers and supported by respective specialists and subspecialists. Research into the comorbidities and systemic manifestations has generated significant data culminating in several proposals for a consensus guideline for both pediatric and nonpediatric populations. Our aim is to provide a summary targeted to the pediatric primary care provider from the best available evidence when caring for children with psoriasis.

Perspectives on the pharmacological management of psoriasis in pediatric and adolescent patients

INTRODUCTION

Psoriasis affects about 0.5% of children and adolescents, it has a high impact of social life. Management can be difficult. The beginning of the 21st century has been an interesting period for the management of pediatric psoriasis, with access to new topical and systemic treatments including several biotherapies.

AREAS COVERED

Herein, we analyze the current therapeutic strategies for managing psoriasis in young patients, ranging from infants to adolescents, in a holistic approach. Usual treatment but also new galenics, new topical associations, and biological (anti-TNF-alpha, anti-interleukin 12/23, anti-interleukin 17) recently developed are presented. Results from clinical trials are detailed, but also real-world evaluations, and recent guidelines. Practical tips for day-to-day management are finally proposed.

EXPERT OPINION

Currently, we have a wide range of treatments, which we can adapt to all types of psoriasis, depending on the demands of the child and his parents. The near future also looks promising with new topical combinations, new oral therapies (apremilast) and biologics (anti-interleukin 23), as well as genetically targeted therapies for pustular psoriasis.

Successful treatment of paediatric generalized pustular psoriasis with secukinumab: a case series

Generalized Pustular Psoriasis (GPP) is a rare, severe, life-threatening form of psoriasis and accounts for up to 13.1% of all childhood psoriasis. Common first-line systemic treatment for pediatric patients with GPP include oral acitretin, cyclosporin and methotrexate which have varying efficacy and side effects but multiple interventions are often needed to induce remission and maintain long term control. Recently, the anti IL 17 A monoclonal antibody secukinumab have been shown to be effective in adult patients with GPP; however, there is lack of evidence of its usage in the pediatric population. We describe a case series of 4 pediatric patients with GPP who were treated with off-label use of secukinumab. All four patients had marked clearance and reduction in Generalized Pustular Psoriasis Area & Severity Score (GPPASI) within first 48 h of first injection with subsequent almost complete to complete clearance of skin lesions by 1 month follow up. In conclusion, secukinumab was found to be successful in inducing remission, with rapid clearance and maintaining remission, with or without combination with other systemic agents for pediatric GPP.

Secukinumab demonstrates high efficacy and a favourable safety profile in paediatric patients with severe chronic plaque psoriasis: 52-week results from a Phase 3 double-blind randomized, controlled trial

Background

Secukinumab has demonstrated sustained long‐term efficacy with a favourable safety profile in various psoriatic disease manifestations in adults.

Objectives

Here, the efficacy and safety of two secukinumab dosing regimens [low dose (LD) and high dose (HD)] in paediatric patients with severe chronic plaque psoriasis over one year are reported.

Methods

In this multicentre, double‐blind study (NCT02471144), patients aged 6 to <18 years with severe chronic plaque psoriasis were stratified and randomized by weight (<25 kg, 25 to <50 kg, ≥50 kg) and age (6 to <12 years, 12 to <18 years) to receive low‐dose (LD: 75/75/150 mg) or high‐dose (HD: 75/150/300 mg) subcutaneous secukinumab or placebo or etanercept 0.8 mg/kg (up to a max of 50 mg).

Results

Overall, 162 patients were randomized to receive secukinumab LD (n = 40) or HD (n = 40), etanercept (n = 41) or placebo (n = 41). The co‐primary objectives of the study were met with both secukinumab doses (LD and HD) showing superior efficacy compared to placebo (P < 0.0001) with respect to PASI 75 response (80.0%, 77.5% vs. 14.6%) and IGA mod 2011, 0 or 1 response (70%, 60% vs. 4.9%) at Week 12. Both secukinumab doses were superior to placebo (P < 0.0001) with respect to PASI 90 response at Week 12 (72.5%, 67.5% vs. 2.4%). The efficacy of both doses was sustained to Week 52 with secukinumab achieving higher responses vs. etanercept (PASI 75/90/100: LD, 87.5%/75.0%/40.0% and HD, 87.5%/80.0%/47.5.% vs. etanercept, 68.3%/51.2%/22.0% and IGA 0 or 1: LD, 72.5% and HD, 75.0% vs. etanercept, 56.1%). The safety profile of secukinumab was consistent with the adult Phase 3 studies, with no new safety signals identified.

Conclusions

Both doses of secukinumab demonstrated high and sustained efficacy up to Week 52 with a favourable safety profile in paediatric patients with severe chronic plaque psoriasis.

Optimal Management of Plaque Psoriasis in Adolescents: Current Perspectives

The skin is at the interface between the body and its environment and is therefore at the center of adolescent concerns during this period of identity formation and increased awareness of body image issues, and stigmatization. Managing an adolescent with psoriasis involves managing the illness and the individual during their transition from being an older child to a young adult. In addition to ensuring that the patient adheres to treatments and is engaged with the therapeutic strategy, dermatologists may also need to manage issues linked to unspoken suffering or conflicts between the adolescent and their parents, who are often present during consultations. The impact of psoriasis on the social interactions, school life and sexuality of the patients, together with the influence of the internet and social networks, also have to be taken into account. In this review, we summarize the epidemiologic, clinical, and therapeutic data available on psoriasis in adolescents, and propose specific management strategies, adapted to the 21st century, for patients in this age group.

Psoriasis Among Adolescents in Kuwait and the Role of Siblings, Breastfeeding, and Household Cat and Secondhand Smoke Exposure: A Cross-Sectional Study

INTRODUCTION

Globally, the epidemiology of psoriasis is poorly understood, and most countries lack essential epidemiologic data regarding disease burden and its determinants. This study sought to estimate the prevalence of psoriasis among adolescents in Kuwait and assess its association with different risk factors, including obesity, sibship size, breastfeeding, and exposure to household secondhand smoke (SHS) and pets.

METHODS

Schoolchildren aged 11-14 years (n = 3864) were enrolled in a cross-sectional study. Lifetime and current (past 12 months) prevalence of psoriasis were ascertained according to ever having a history of doctor-diagnosis plus current active lesion(s) and/or current use of treatment of psoriasis. Associations were assessed using Poisson regression with robust variance estimation, and adjusted prevalence ratios (aPR) and 95% confidence intervals (CI) were estimated.

RESULTS

The lifetime and current prevalence of psoriasis were estimated to be 3.6% (136/3806) and 1.1% (42/3806), respectively. Commonly reported anatomical sites affected by psoriasis included scalp (47.6%) and the extensor surface of the knees (50%) and elbows (38.1%). Household SHS exposure was associated with increased lifetime psoriasis (aPR = 1.41, 95% CI 1.07-1.98), and showed a trend for association with current psoriasis (1.77, 0.89-3.53). Similarly, cat-keeping during infancy was associated with lifetime psoriasis (1.96, 1.14-3.37), and demonstrated a trend for association with current psoriasis (1.49, 0.52-1.98). In contrast, breastfeeding was associated with a decreased lifetime psoriasis (0.62, 0.44-0.89), but was not associated with current psoriasis. Trend analyses showed that the prevalence of lifetime and current psoriasis increased with increasing numbers of total, older, and younger siblings.

CONCLUSIONS

Psoriasis affects a considerable proportion of schoolchildren in Kuwait. Interestingly, psoriasis prevalence was related to risk factors also found in allergic diseases, such as exposure to SHS, cat-keeping in infancy, breastfeeding, and sibship size, possibly suggesting a role of immune dysregulation.

Management of Paediatric Psoriasis by Paediatricians: A Questionnaire-Based Survey

INTRODUCTION

Paediatric plaque psoriasis (PedPso) in children and adolescents is often diagnosed and treated for the first time by paediatricians. An early onset of psoriasis is associated with a genetic family burden, higher severity of disease and increased risk of comorbidities, sometimes starting in childhood. However, little information is available on prevalence data and the clinical management of PedPso by paediatricians.

METHODS

A total of 191 questionnaires were sent out to paediatricians regarding their management of PedPso, with a focus on prevalence, diagnosis, initiation of therapies, screening for comorbidities and collaboration with dermatologists. Of these, 95 (49.7%) were returned and evaluated anonymously.

RESULTS

Only about one-half of the responding paediatricians reported being certain in their diagnosis of PedPso, even though they regularly see moderate-to-severely affected patients. The questionnaire revealed that there are clear differences in the general management of PedPso if the paediatrician is not certain of the diagnosis of psoriasis. Compared to paediatricians certain of their diagnosis, those who are uncertain less frequently perform whole-body inspection, screen for relevant comorbidities, such as psoriasis arthritis, metabolic syndrome or mental disorders, and prescribe the use of topical or systemic therapies. No responding paediatrician reported the use of modern systemic therapies, such as biologicals, even in severely affected children. The majority of respondents rated their cooperation with dermatologists as good.

CONCLUSION

The certainty of the diagnosis, the use of system therapies and the screening for comorbidity could improve the care of PedPso through targeted training of paediatricians and intensified interdisciplinary cooperation with dermatologist.

Pharmacological Management of Pediatric Pustular Psoriasis

Therapeutic management of pustular psoriasis remains a challenge despite the rapid advance in psoriasis research and the development of drugs, especially biologics. Treatment guidelines have been established for pustular psoriasis, but no controlled studies are present for juvenile pustular psoriasis (JPP). Search of the literature reveals that current evidence of JPP treatment is limited to case reports and case series. Among the conventional drugs for JPP, oral retinoid is the most commonly used, yet concerns for growth disturbance exist. Cyclosporine and methotrexate have also been administered as first-line treatment. Etanercept is the first biological agent approved for juvenile plaque psoriasis, followed by adalimumab. However, infliximab is usually recommended for JPP because of the rapidity of onset, despite not being approved for use in pediatric psoriasis patients. More recently, secukinumab, ixekizumab, brodalumab, guselkumab, and risankizumab have been approved for adult pustular psoriasis in selected countries. Controlled studies are needed to prove the efficacy and long-term safety of the therapeutic treatments currently used for JPP.

Influence of disease phase on embitterment and emotional dysregulation in psoriatic patients

This study aimed to evaluate the psychosocial differences between patients with psoriasis in different phases of the disease. Seventy-one patients in exacerbation and 83 in remission were evaluated regarding sociodemographic, clinical and psychological variables, on the premise that the visibility of lesions (exacerbation phase) may impact the emotional regulation and embitterment. A regression analysis was performed to identify the variables that contribute to explain embitterment: a diagnosis of anxiety and/or depression and psoriasis severity are the identified ones. The results point to higher values of emotional dysregulation and embitterment, as well as more critical clinical variables in patients with active disease, namely, alcohol and coffee consumption, smoking and less satisfaction with current treatment, more diagnoses and more family history of anxiety and depression, more psychology/psychiatry consultations and more use of anxiolytics and antidepressants. However, only the results referring to alcohol consumption and embitterment are significantly higher in subjects in the exacerbation phase of the disease. Particular clinical attention should be provided to patients in exacerbation phase regarding psychotherapeutic approach.

Clinical characteristics including cardiovascular and metabolic risk factors in adolescents with psoriasis

BACKGROUND

Clinical studies on psoriasis in adolescents have mainly been performed in patients with severe psoriasis. Population-based studies of clinical characteristics and risk factors for later cardiovascular and metabolic disease in children and adolescents are lacking.

OBJECTIVES

To examine the clinical characteristics of adolescents with psoriasis nested in a general population cohort. Furthermore, to investigate cardiovascular and metabolic risk factors in the adolescents with psoriasis compared to parentally predisposed and non-predisposed adolescents without psoriasis from the same birth cohort.

METHODS

We identified adolescents with and without psoriasis using a nationwide general population birth cohort in Denmark. A clinical examination included skin inspection and scoring of psoriasis severity, completion of a questionnaire on psoriasis and comorbidities, physical measurements, and blood sampling. Participants also completed self-administered questionnaires on quality of life and mental health.

RESULTS

We included 81 adolescents with psoriasis and 234 controls (110 with genetic predisposition for psoriasis and 124 without predisposition). Median age was 15.6 (13.5-18.5) years, and in those with active psoriasis, median Psoriasis Area and Severity Index score was 1.2 (0.1-11.4). The scalp was the most common site of psoriasis, both at debut and at time of examination. Diaper rash in infancy was more frequent in the psoriasis group. No significant differences regarding quality of life, anxiety and depression were found. More adolescents with psoriasis were obese (8.6% vs. 1.7%, P = 0.008), and physical measures of abdominal obesity were also significantly higher. HbA1c was significantly higher (31.55 vs. 30.81 mmol/mol, P = 0.048), while no differences were found for blood pressure, lipids or high-sensitivity C-reactive protein. In a subgroup analysis, this was evident in the non-predisposed psoriasis-free controls only.

CONCLUSIONS

Overall, adolescents with psoriasis from this general population had mild disease. Still, early markers of cardiovascular and metabolic disease were elevated.

Protocol for a case-control diagnostic accuracy study to develop diagnostic criteria for psoriasis in children (DIPSOC study): a multicentre study recruiting in UK paediatric dermatology clinics

INTRODUCTION

Diagnosing psoriasis in children can be challenging. Early and accurate diagnosis is important to ensure patients receive psoriasis specific treatment and monitoring. It is recognised that the physical, psychological, quality of life, financial and comorbid burden of psoriasis are significant. The aim of this study is to develop clinical examination and history-based diagnostic criteria for psoriasis in children to help differentiate psoriasis from other scaly inflammatory rashes. The criteria tested in this study were developed through a consensus study with a group of international psoriasis experts (International Psoriasis Council).

METHODS AND ANALYSIS

Children and young people (<18 years) with psoriasis (cases) and other scaly inflammatory skin diseases (controls) diagnosed by a dermatologist are eligible for recruitment. All participants complete a single research visit including a diagnostic criteria assessment by a trained investigator blinded to the participant's diagnosis. The reference standard of a dermatologist's diagnosis is extracted from the medical record. Sensitivity and specificity of the consensus derived diagnostic criteria will be calculated and the best predictive criteria developed using multivariate logistic regression.

ETHICS AND DISSEMINATION

Health Regulatory Authority and National Health Service Research Ethics Committee approvals were granted in February 2017 (REC Ref: 17/EM/0035). Dissemination will be guided by stakeholders; patients, children and young people, dermatologists, primary care and paediatric rheumatologists. The aim is to publish the study results in a high-quality peer-reviewed journal, present the findings at international academic meetings and disseminate more widely through social media and working with patient associations.

TRIAL REGISTRATION NUMBER

ISRCTN98851260.

Enthesitis-related arthritis is the most common category of juvenile idiopathic arthritis in Taiwan and presents persistent active disease

BACKGROUND

Juvenile idiopathic arthritis (JIA) has been categorized into seven different categories according to the International League of Associations for Rheumatology (ILAR) criteria. Enthesitis-related arthritis (ERA) was found to represent the largest category in a Taiwanese cohort study. The aim in this study was to compare the clinical characteristics, treatments, and outcomes of ERA in a single tertiary center in Taiwan, as compared to those of other categories of JIA. Furthermore, we determined patients' characteristics and risk factors that can help assess the outcomes in ERA.

METHODS

A retrospective chart review of all patients with JIA referred to a pediatric rheumatology clinic in the National Taiwan University Hospital between 1993 and 2018 were identified according to ILAR criteria. Outcomes were assessed based on the Wallace criteria to categorize patients into active and non-active, including inactive, remission on medication, and remission off medication, groups. A subset of samples was further tested by DNA sequencing to identify HLA-B27 subtypes.

RESULTS

One-hundred and eighty-three patients were included in the study, with a mean of 8 years' follow-up. ERA was the single largest category of JIA (39.9%); psoriasis and undifferentiated JIA were both the least common type (0.5%). ERA was male predominant (86%), had a late age of onset (11.0 ± 3.2 years), and the majority of ERA patients was HLA-B27-positive (97%). Of 25 HLA-B27-positive ERA patients checked by HLA-B27 sequencing, 23 were B*27:04 and 2 were B*27:05. ERA patients were significantly less likely to achieve non-active status compared to patients with persistent oligoarthritis (P = 0.036). In terms of treatment response to TNF-α inhibitors in methotrexate-refractory ERA, 26 patients remained active and only 11 patients (30%) achieved a non-active status. Sacroiliitis was a risk factor contributing to poorer treatment response in ERA (P = 0.006).

CONCLUSION

ERA represented the most common category of JIA in Taiwan. Those ERA patients with sacroiliitis were likely to have persistent active disease and may require a more aggressive treatment strategy to improve their outcomes.

Epidemiology and Comorbidities of Psoriasis among Israeli Adolescents: A Large Cross-Sectional Study

BACKGROUND AND AIMS

Although psoriasis can develop at any age, the data regarding its characteristics in adolescents are sparse. This study was designed to determine the psoriasis prevalence and its associations with the body mass index (BMI), lipid profile, and comorbidities in adolescents.

METHODS

This was a nationwide population-based cross-sectional retrospective study of adolescents (16-18 years old) evaluated for military service between January 1999 and January 2014.

RESULTS

Our database included 887,765 adolescents (57.1% males), of whom 3,112 (0.35%) were diagnosed with psoriasis. During the 15-year study period, the psoriasis prevalence increased by 1.4-fold, from 0.3 to 0.42% (1.25-fold for the males and 1.63-fold for the females). Certain comorbidities, such as contact dermatitis, hyperhidrosis, and arthritis, were significantly associated with psoriasis (odds ratios [ORs] of 2.26, 1.51, and 5.3, respectively). The adolescents with psoriasis had significantly elevated BMI and triglyceride values. We found increased ORs of 1.34 (95% confidence interval [CI] = 1.25-1.56) and 1.56 (95% CI = 1.32-1.83) for the overweight and obese adolescents, respectively, while a lower BMI (<20) had an opposite effect with psoriasis (OR = 0.8).

CONCLUSIONS

Based on our results, the psoriasis prevalence in Israeli adolescents is rising. Dermatological comorbidities and an increased BMI were associated with psoriasis in these adolescents. A better understanding of the distinctive epidemiological characteristics of juvenile psoriasis may allow for the early detection of comorbidities and improve its management.

Sustained long-term efficacy and safety of adalimumab in paediatric patients with severe chronic plaque psoriasis from a randomized, double-blind, phase III study

BACKGROUND

Adalimumab (ADA) (Humira^® , AbbVie Inc., U.S.A.) is approved by the European Medicines Agency for children aged ≥ 4 years with severe plaque psoriasis.

OBJECTIVES

To evaluate the long-term efficacy and safety of ADA in children with severe plaque psoriasis.

METHODS

Results are presented from the 52-week long-term extension (LTE) of the randomized, double-blind, double-dummy, phase III trial, in children with severe plaque psoriasis (results from prior periods have been published). Patients aged ≥ 4 and < 18 years were randomized 1 : 1 : 1 to ADA 0·8 mg kg^-1 (40 mg maximum) or 0·4 mg kg^-1 (20 mg maximum) every other week or to methotrexate (MTX) 0·1-0·4 mg kg^-1 (25 mg maximum) weekly. The 16-week initial treatment (IT) period was followed by a 36-week withdrawal period and a 16-week retreatment period. Patients could enter the LTE at prespecified time points to receive ADA 0·8 mg kg^-1 (blinded or open label) or ADA 0·4 mg kg^-1 (blinded), or to remain off treatment. Efficacy is reported for patient groups according to doses received in the IT and LTE periods.

RESULTS

Of the 114 patients randomized in the IT period, 108 entered the LTE (n = 36 in each group); 93 received ADA 0·8 mg kg^-1 . Efficacy (≥ 75% improvement from baseline in Psoriasis Area and Severity Index) was maintained or improved from entry to the end of the LTE: MTX(IT)/ADA 0·8(LTE) 31-86% of patients; ADA 0·4(IT)/0·4 or 0·8(LTE) 28-47%; ADA 0·8(IT)/0·8(LTE) 50-72%. No serious infections occurred in the LTE.

CONCLUSIONS

After 52 weeks of long-term ADA treatment in children aged 4-18 years with severe plaque psoriasis, disease severity was reduced and maintained or further improved, as demonstrated by efficacy outcomes. No new safety risks were identified. What's already known about this topic? The results from the first three periods of this phase III trial in children aged 4-18 years with severe plaque psoriasis suggest that adalimumab is a safe and efficacious treatment option in this population. What does this study add? This is the first study to evaluate long-term treatment of adalimumab in children with severe psoriasis, and the first to evaluate switching from methotrexate to adalimumab in this population.

A retrospective cohort study to evaluate the development of comorbidities, including psychiatric comorbidities, among a pediatric psoriasis population

BACKGROUND/OBJECTIVE

Compared with the adult psoriasis population, knowledge about the incidence of comorbidities in the pediatric psoriasis population is limited. The objective of this study was to assess the prevalence and incidence of comorbidities, including psychiatric comorbidities, in patients with pediatric psoriasis.

METHODS

In this claims-based, retrospective cohort study, patients with pediatric psoriasis were matched 1:3 with a nonpsoriasis cohort based on age, sex, and index date (the earliest of inpatient claims or the latter of two outpatient claims).

RESULTS

Obesity, serious infection, and juvenile idiopathic arthropathy had higher prevalence and incidence rates in the psoriasis cohort than the nonpsoriasis cohort. Psychiatric comorbidities were also more common in the psoriasis cohort than the nonpsoriasis cohort, as were ulcerative colitis and Crohn disease. Stratifying the psoriasis cohort by disease severity-mild and moderate-to-severe-found no differences in incidence rates of comorbidities between the two subsets.

CONCLUSION

The incidence rates of many comorbid conditions were higher for patients with pediatric psoriasis compared with patients without pediatric psoriasis, and similar between patients with moderate-to-severe and mild pediatric psoriasis.

Guidance for assessment of erythroderma in neonates and infants for the pediatric immunologist

Neonatal and infantile erythroderma (NIE) represents the common clinical phenotype of heterogeneous diseases ranging from benign and transient skin conditions to fatal multiorgan disorders. NIE regularly demands a comprehensive diagnostic workup in a multiprofessional setting, especially if newborns and young infants with the disease develop a failure to thrive and concomitant infectious, neurologic, or metabolic complications. By obtaining a detailed medical history and performing a thorough clinical examination, targeted diagnostic steps can be scheduled for most affected children. If NIE occurs in the early neonatal period, lesional skin biopsy and histology are often indicated. Likewise, if monogenic skin or immunologic diseases are suspected, genetic testing with customized panels of potentially underlying genes is mandatory. Of note, if acute symptoms such as severe infections, metabolic acidosis, or seizures occur, rapid microbiologic and metabolic investigations are warranted to rule out immunodeficiency and inborn errors of metabolism.

Abnormal Serum Copper and Zinc Levels in Patients with Psoriasis: A Meta-Analysis

Background:

Copper and zinc are important trace elements involved in the development of psoriasis. However, reports regarding changes in serum copper and zinc levels in patients with psoriasis have been inconsistent.

Aims:

This meta-analysis was designed to analyze changes in serum copper and zinc levels between patients with psoriasis and a healthy population.

Materials and Methods:

English and Chinese literature from international and national electronic databases from 1988 to May 2016 was analyzed. Studies that performed a comparative analysis of serum copper and zinc levels between patients with psoriasis and healthy controls were included in the meta-analysis. The random-effects model was used to calculate the overall combined estimates of serum copper and zinc levels between patients with psoriasis and healthy individuals. Results: Fifteen references were included in this study, including 1324 patients with psoriasis and 1324 healthy controls. Compared with healthy controls, serum copper levels were significantly increased (Z = 4.02, P < 0.0001; standardized mean difference [SMD], 1.23; 95% confidence interval [CI], 0.63 to 1.82), and serum zinc levels were significantly decreased (Z = 2.95, P < 0.0001; SMD, −1.35; 95% CI, −2.25 to − 0.45) in patients with psoriasis.

Conclusions:

In conclusion, increased serum copper and decreased serum zinc levels were generally observed in patients with psoriasis. Treatments to normalize the serum copper and zinc levels may improve the outcome of psoriasis patients.

Associations between maternal socioeconomic position and psoriasis: a cohort study among the offspring of the Danish National Birth Cohort

BACKGROUND

The socioeconomic determinants of paediatric-onset psoriasis have not been previously investigated.

OBJECTIVE

To identify whether a social gradient exists for paediatric-onset psoriasis, using measures of maternal socioeconomic position.

METHODS

Data on paediatric-onset psoriasis from 36 003 Danish National Birth Cohort offspring were cross-linked with nationwide registry data on maternal age and three measures of maternal socioeconomic position: maternal educational attainment, maternal labour market attachment and equivalized household income. Univariable and multivariable logistic regression analyses were conducted to estimate the odds ratios (ORs) of psoriasis in the offspring, in cohort analyses for data from the year of enrolment and cross-sectional analyses from the year of the 11-year follow-up.

RESULTS

Maternal age at birth, maternal educational attainment and equivalized household income were inversely associated with psoriasis in the offspring. Low maternal educational attainment was associated with offspring psoriasis [adjusted OR 1·62, 95% confidence interval (CI) 1·20-2·18] after adjusting for maternal psoriasis and age in the cohort analysis. The crude OR of psoriasis in offspring of mothers in the highest quartile compared with mothers in the lowest quartile of equivalized household income was 0·57 (95% CI 0·43-0·76), and the adjusted OR was 0·59 (95% CI 0·44-0·80) after adjusting for maternal psoriasis and age. Similar results were observed for data on maternal socioeconomic position at enrolment and at follow-up.

CONCLUSIONS

A steep social gradient in paediatric-onset psoriasis was observed. Maternal socioeconomic position may play a role in early-life exposure to modifiable risk factors for psoriasis. Future studies may help to elucidate which biological factors mediate the social gradient observed in our study.

Topical heat shock protein 70 prevents imiquimod-induced psoriasis-like inflammation in mice

Psoriasis is a chronic inflammatory skin disease with systemic manifestations and potential genetic etiology. The newest treatments utilize antibodies against one of several cytokines known to underlie the inflammatory signaling molecules that produce the skin and systemic symptoms. However, these agents must be regularly injected, and they may compromise the normal responses of the immune system. Furthermore, they do not address the causes of the abnormal immunoregulatory responses of the disease because the etiology is not yet completely understood. In this short-term treatment study, the potential anti-inflammatory activity of an alfalfa-derived Hsp70-containing skin cream (aHsp70) was tested on imiquimod (IMQ)-induced psoriasis-like lesions in wild-type mice. Treatment of the mice with the aHsp70 skin cream simultaneously with the imiquimod application mitigated the induction of psoriatic-like lesions and correlated with altered expression of various skin cytokines.

Assessment of quality of life in Turkish children with psoriasis and their caregivers

BACKGROUND/OBJECTIVES

The effect of pediatric psoriasis on quality of life has been demonstrated, but data regarding its influence on caregiver quality of life are scarce. The objective was to investigate how psoriasis affects quality of life of children and their caregivers.

METHODS

This multicenter study included 129 children with psoriasis and their caregivers, who were family members accompanying patients to the clinic. Patient quality of life was measured using the Child Dermatology Life Quality Index. Caregiver quality of life was assessed using Dermatological Family Impact Scale, a 15-item questionnaire validated for use in the Turkish language.

RESULTS

Mean Child Dermatology Life Quality Index score was 7.6, indicating a moderate effect on patient quality of life. Symptoms and feelings were the most severely impaired domains of patient quality of life, and emotions was the most severely impaired domain of caregiver quality of life. Dermatological Family Impact Scale score was significantly correlated with Child Dermatology Life Quality Index (correlation coefficient [r] = .554, P < .001) and Psoriasis Area and Severity Index (r = .350, P < .001). Caregivers of patients receiving systemic agents or phototherapy had relative impairment of multiple domains of quality of life compared to caregivers of patients receiving topical treatment only.

CONCLUSION

Psychosocial effect of pediatric psoriasis was shown to extend beyond the individual, highlighting the importance of addressing patient and caregiver quality of life concerns in an integrated approach.

Bidirectional relationships between psychological health and dermatological conditions in children

Dermatological conditions are common among children. They are a frequent cause of presentation to health care services and a leading contributor to burden of disease. Evidence supports the notion that bidirectional relationships exist between children’s physical and psychological health, whereby the child’s dermatological condition can impact their psychological health and well-being, while, in the reverse direction, psychological factors (eg, stress) can impact the severity and course of the child’s skin disease. The psychological impact of dermatological conditions in childhood needs to be taken into account during the assessment, planning, and treatment phases of management. Likewise, the potential effect of children’s emotional and behavioral difficulties on management, particularly in terms of the impact on parents’ ability to implement their child’s treatment plan, should be considered. This literature review summarizes the current evidence for the relationships between three common chronic dermatological conditions of childhood – atopic dermatitis, psoriasis, and urticaria – and psychological adjustment and quality of life in childhood. Overall, a general paucity of research in the pediatric context – combined with limitations in terms of study design, variability in operationalization of constructs, and heterogeneity in measurement of outcomes – makes it difficult to draw firm conclusions in this area. Based on the available research, implications for successful long-term management of these conditions are discussed in terms of integrating psychological and parenting support with medical management to improve adherence, reduce disease severity, and improve quality of life for children and their families.

Adalimumab, etanercept and ustekinumab for treating plaque psoriasis in children and young people: systematic review and economic evaluation

BACKGROUND

Psoriasis is a chronic inflammatory disease that predominantly affects the skin. Adalimumab (HUMIRA^®, AbbVie, Maidenhead, UK), etanercept (Enbrel^®, Pfizer, New York, NY, USA) and ustekinumab (STELARA^®, Janssen Biotech, Inc., Titusville, NJ, USA) are the three biological treatments currently licensed for psoriasis in children.

OBJECTIVE

To determine the clinical effectiveness and cost-effectiveness of adalimumab, etanercept and ustekinumab within their respective licensed indications for the treatment of plaque psoriasis in children and young people.

DATA SOURCES

Searches of the literature and regulatory sources, contact with European psoriasis registries, company submissions and clinical study reports from manufacturers, and previous National Institute for Health and Care Excellence (NICE) technology appraisal documentation.

REVIEW METHODS

Included studies were summarised and subjected to detailed critical appraisal. A network meta-analysis incorporating adult data was developed to connect the effectiveness data in children and young people and populate a de novo decision-analytic model. The model estimated the cost-effectiveness of adalimumab, etanercept and ustekinumab compared with each other and with either methotrexate or best supportive care (BSC), depending on the position of the intervention in the management pathway.

RESULTS

Of the 2386 non-duplicate records identified, nine studies (one randomised controlled trial for each drug plus six observational studies) were included in the review of clinical effectiveness and safety. Etanercept and ustekinumab resulted in significantly greater improvements in psoriasis symptoms than placebo at 12 weeks' follow-up. The magnitude and persistence of the effects beyond 12 weeks is less certain. Adalimumab resulted in significantly greater improvements in psoriasis symptoms than methotrexate for some but not all measures at 16 weeks. Quality-of-life benefits were inconsistent across different measures. There was limited evidence of excess short-term adverse events; however, the possibility of rare events cannot be excluded. The majority of the incremental cost-effectiveness ratios for the use of biologics in children and young people exceeded NICE's usual threshold for cost-effectiveness and were reduced significantly only when combined assumptions that align with those made in the management of psoriasis in adults were adopted.

LIMITATIONS

The clinical evidence base for short- and long-term outcomes was limited in terms of total participant numbers, length of follow-up and the absence of young children.

CONCLUSIONS

The paucity of clinical and economic evidence to inform the cost-effectiveness of biological treatments in children and young people imposed a number of strong assumptions and uncertainties. Health-related quality-of-life (HRQoL) gains associated with treatment and the number of hospitalisations in children and young people are areas of considerable uncertainty. The findings suggest that biological treatments may not be cost-effective for the management of psoriasis in children and young people at a willingness-to-pay threshold of £30,000 per quality-adjusted life-year, unless a number of strong assumptions about HRQoL and the costs of BSC are combined. Registry data on biological treatments would help determine safety, patterns of treatment switching, impact on comorbidities and long-term withdrawal rates. Further research is also needed into the resource use and costs associated with BSC. Adequately powered randomised controlled trials (including comparisons against placebo) could substantially reduce the uncertainty surrounding the effectiveness of biological treatments in biologic-experienced populations of children and young people, particularly in younger children. Such trials should establish the impact of biological therapies on HRQoL in this population, ideally by collecting direct estimates of EuroQol-5 Dimensions for Youth (EQ-5D-Y) utilities.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42016039494.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Individuals with filaggrin-related eczema and asthma have increased long-term medication and hospital admission costs

BACKGROUND

Eczema and asthma are chronic diseases with onset usually before the age of 5 years. More than 50% of individuals with eczema will develop asthma and/or other allergic diseases. Several loss-of-function mutations in filaggrin (FLG) have been identified in patients with eczema. However, the association of FLG with healthcare use is unknown.

OBJECTIVES

To determine whether FLG mutations are associated with increased prescribing for eczema and asthma and whether increased prescribing is associated with increased healthcare costs.

METHODS

A secondary analysis of BREATHE, a cross-sectional study of gene-environment associations with asthma severity, was undertaken. BREATHE data was collected for 1100 participants with asthma, in Tayside and Fife, Scotland during the period 2003-2005. Through collaboration with the Health Informatics Centre in Dundee, BREATHE was linked to accident and emergency, community prescribing and Scottish morbidity records. The data linkage allowed longitudinal exploration of associations between genetic variation and prescribing.

RESULTS

An association was found between FLG mutations and increased prescribing for mild and moderate eczema, asthma-reliever medicine and asthma exacerbations. A strong association was found between FLG mutations and prescribing of emollients [incidence rate ratio (IRR) 2·19, 95% confidence interval (CI) 1·36-3·52], treatment for severe eczema (IRR 2·18, 95% CI 1·22-3·91) and a combination of a long-acting β₂ -agonist and corticosteroids (IRR 3·29, 95% CI 1·68-6·43).

CONCLUSIONS

The presence of FLG mutations in this cohort is associated with increased prescribing for eczema and asthma. Randomized controlled trials are required to determine if these individuals could benefit from management strategies to reduce morbidity and treatment costs.