Evaluation of Trends in Pediatric Psoriasis Outpatient Health Care Delivery Finds Some Treatment Variability



Most outpatient visits for pediatric psoriasis in the United States are made by white children ages 8 years and older and are made to dermatologists and pediatricians, but the treatment approach may differ by physician specialty and patient age, according to a report published Online First by Archives of Dermatology, one of the JAMA/Archives journals.

According to background information in the article, approximately 2.5 percent of the U.S. population is affected by psoriasis, including 1 percent of children from birth to 18 years. In one-third of patients, the first signs and symptoms appear by the age of 20 years. Clinicians consider disease severity, presentation and distribution of lesions, patient age and the presence of concurrent conditions in determining treatment. For mild, localized cases in the pediatric population, topical medications are generally used, with phototherapy and systemic medication usually utilized for more complex cases. “Management of psoriasis in children can be challenging,” write the authors, “owing to a paucity of data and lack of standardized guidelines specific to the pediatric population.”

Sinae A. Vogel, B.S., from the University of California, San Francisco School of Medicine, and colleagues conducted a retrospective, cross-sectional investigation of data from the National Ambulatory Medical Care Survey. The authors examined outpatient-visit data from dermatologists and nondermatologists from 1979 to 2007 (except the periods 1982–1984 and 1987–1988, when data were not collected) for pediatric visits (children ages 0 to 18 years) with a diagnosis of psoriasis. The researchers tabulated the frequency of medications in the database and assigned them to three categories: topical corticosteroid, topical noncorticosteroid and systemic. Corticosteroids were further assigned a relative potency value from one (super potent) to seven (very weak).

In total, an estimated 3.8 million pediatric psoriasis visits occurred during the 28-year interval, with a median (midpoint) of 123,420 visits per year. Nearly two-thirds of patients visited dermatologists for the condition (63 percent); 17 percent of psoriasis visits were made to pediatricians and 14 percent were made to internists. Equal numbers of visits were made by male and female patients, 93 percent of whom were white. Patients ages 13 to 18 years made 47 percent of the visits, children ages 8 to 12 years made 35 percent of the visits and those ages 0 to 7 years made 18 percent of the visits.

The most commonly prescribed medications were topical corticosteroids, and the potency levels of these medications appeared equal in younger and older children. Overall, and in both younger and older age groups, the most commonly prescribed medication was the topical corticosteroid betamethasone. Dermatologists and internists most commonly prescribed high-potency steroids, and pediatricians most commonly prescribed the topical immunosuppressant tacrolimus. The top 20 most-prescribed medications by dermatologists did not include topical calcineurin inhibitors (medications that prevent inflammation), and the top 20 most-prescribed medications in any age group did not include systemic antipsoriatic agents.

“This study confirms that pediatric psoriasis visits are frequent and represent a substantial burden of disease in the United States, validating the social, economic, and medical impact of this disease,” write the authors. They note the age differences in office visits for the condition as well as the trends in medication usage, and are particularly concerned about the frequency of strong corticosteroid use in patients younger than 8 years. “In our experience, the highest potency topical corticosteroids are not commonly needed for psoriasis in young children,” the researchers state.

Such trends appear to point to a need for treatment guidelines that address the condition in children. “The current state-of-the-art care for pediatric psoriasis is based primarily on experience and expert consensus,” and some clinicians may not be anticipated to change even if standardized treatment guidelines existed, write the authors. “As such, education of our dermatology and nondermatology colleagues about unique clinical and treatment aspects of pediatric psoriasis, rather than guidelines alone, may decrease the treatment gap by creating more comfortable, safe, and effective use of topical and systemic regimens for children with psoriasis.”

(Arch Dermatol. Published online September 19, 2011. doi:10.1001/archdermatol.2011.263.