Adelaide A. Hebert, MD

multisystem disorder that occurs in approximately 1% of chil­dren. Most frequently, PsO initially presents during adolescence; however, about one-third of patients develop the disease during childhood. PsO is associated with numerous comorbidities, including psoriatic arthritis (PsA).

 The increased frequency of obesity among the pediatric population may account for the growing incidence and prevalence of childhood PsO.

Markedly fewer therapies for PsO are available for children than for adults. A total of 7 medications (topicals and biologics) are FDA approved for use in pediatric PsO. Topical roflumilast cream, 0.3%, was recently approved for use in children at least 6 years of age, which is an important development in managing this condition. Other FDA-approved topical treatments include:

Calcipotriene foam, 0.005%, for scalp and body psoriasis in children 4 years and older;

A foam containing calcipotriene, 0.005%, and betametha­sone, 0.064%, for mild to severe plaque psoriasis in those at least 12 years old;

A suspension containing calcipotriene, 0.005%, and betamethasone, 0.064%, for scalp and body psoriasis in children 12 years and older.

Approved biologics include etanercept, ustekinumab, ixekizumab, and secukinumab. Most of these agents are approved for use in children 6 years or older, however, etanercept is approved for treatment of those at least 4 years old. Notably, ustekinumab was recently approved for pediatric PsA.

Several therapies are used off label in children with PsO. These include topical corticosteroids, phototherapy/laser therapy, methotrexate,

 cyclosporine, retinoids, vitamin D analogues, and other biologics.

Disease Correlates and Safety of Therapies in the Pediatric Population

Health care professionals must be cognizant of some signs and symptoms of PsO and PsA that are not obvious. Nail disease reportedly correlates with the severity of PsO in children. Chil­dren who have PsA may also have uveitis.

There are safety concerns associated with agents used to treat PsO. For example, cases of lymphoma associated with adalimumab therapy have been reported, but most occurred in patients with juvenile idiopathic arthritis or inflammatory bowel disease (IBD). Of note, adalimumab is not approved in the United States for the treatment of PsO in children despite being approved for use in this patient population in other countries. It is also approved for the treatment of uveitis in patients as young as 2 years of age; therefore, children with PsO should be evaluated for uveitis.

Development of IBD is also a concern with use of some biolog­ics, although the risk in pediatric patients is not fully understood. These agents, especially interleukin-17 inhibitors, should be used with caution.

Psychological Impact of PsO in Pediatric Patients

The psychological and social impacts of PsO in children are tremendous. Children with PsO, and especially those who have visible lesions, report being the victims of bullying. Providing safe treatments with a goal of clearing skin lesions is critical in this population. Measures related to quality of life (QOL) are important, but seeing the joy or happiness in children who have improved skin and are no longer bullied is priceless.

The AAD and NPF guidelines recommend consideration of not only body-surface area when determining severity but also the location of lesions on the body and the impact of PsO on the patient’s QOL and activities of daily living.

 The Children’s Dermatology Life Quality Index is a survey comprised on 10 questions that assesses QOL influences (eg, itch, impact on relationships, and treatment efficacy) in patients with PsO aged 4 to 16 years. This survey is available in written form or with cartoon images.

In treating PsO, measures of QOL extend beyond the use of an effective medication that clears skin lesions. For example, patient overall happiness with the treatment and results should be considered. Also, the burden of injections is an important consideration when treating children. Some therapies require more injections than do others. Patient preference is important when selecting a treatment.

According to the AAD and NPF guidelines, children with PsO should receive regular screenings for PsA, including a review of their medical history and a physical examination.

 Patients who demonstrate signs and symptoms of inflammatory arthritis should be referred to a rheumatologist who preferably has expertise in treating children. Children with PsA should be regularly assessed for uveitis; those with signs or symptoms of uveitis should be referred to an ophthalmologist.

Value of Early or Aggressive Management in Pediatric PsO

Any visible lesion on a child can make them a target for bullying. The psychological and social effects of even localized disease in children should not be underestimated. Aggressive therapy is sometimes necessary to improve visible lesions and to enhance QOL of children with PsO.

Faculty presenter: Adelaide A. Hebert, MD. 

This article was reviewed, edited, and approved by Dr Hebert and Dr Stein Gold.

Siegfried EC, Arkin LM, Chiu YE, et al. Methotrexate for inflammatory skin disease in pediatric patients: consensus treatment guidelines. 

. 2023;40(5):789-808. doi:10.1111/pde.15327

Menter A, Cordoro KM, Davis DMR, et al. Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients. 

. 2020;82(1):161-201. doi:10.1016/j.jaad.2019.08.049

Articles

This publication was developed independently by MJH Life Sciences Global Medical Affairs. Support for the thought leaders meeting and the publication was provided by Arcutis Biotherapeutics, Inc; The Bristol Myers Squibb Company; Janssen Global Services, LLC; and UCB, Inc.

Pediatric Plaque Psoriasis

Dermatologists end their discussion on seborrheic dermatitis (SD), highlighting key takeaways for patients and clinicians on managing this condition.

Beyond Skin Deep: Validating and Transforming SD Patient Care

 As we kind of wrap things back around, we’ve all been in practice for a good amount of time. I think we all have kind of a unique perspective on treating patients with seborrheic dermatitis. I’m just wondering, based on the information that you’ve seen, based on your own clinical practice and any clinical trials, if you could think about some kind of a pearl that you would give to our viewers to take home, maybe to make us all a little bit better in our prescribing or our understanding the needs of a seborrheic dermatitis patient. Adelaide, I’m going to start with you, talking about children, is [there] some special way to communicate or [do] you know some special kernel of truth that you’ve learned in treating a seborrheic dermatitis pediatric patient?

 Well, I think one of the first things I do is I reassure them that it is a treatable problem and that we have tools that will be helpful. And we also have on the horizon some medicines which I’m always proud to say that I’ve had a small role in bringing forward hopefully to the market, and they’ll be coming soon, and I’ll update them as we go along. I think addressing it front and center as a medical problem for which we have treatments and hopefully, soon, better treatments is reassuring. The other thing I say is we take this seriously. I’ve had too many patients come in and say [that] the doctor barely looked then they left the room. “I got a prescription, but then what do I do?” They don’t feel that they’re really feeling validated, so [as] I do often with many disease states I say [that] we take this seriously, and they tell me how grateful they are to hear somebody say that.

 Adelaide, I think I’m taking that home. I want to tell my patients from now, “I take this very, very seriously,” because I think I want to be heard as a patient. I want you to hear what I’m saying and understand that this is important to me even if it doesn’t look like it’s so terrible; I want I want my physician to hear me and understand what I’m saying. James, thoughts on anything that you can give us to take home?

 Just to validate the patient’s concerns and the impact that it has on her life. [Telling them,] “Hey, it’s OK for you to feel this way about your condition. It’s not too trivial, and [I] take it very seriously.” I also thinking establishing that this is a condition that we’re going to be able to treat. It’s not a cure, but we’re going to treat this. We have really good treatments now on the horizon that could really help you get to the place you want to be.

 I think it’s important not to make judgments based on how their seborrheic dermatitis may appear. It’s important to ask patients about their symptoms. In particular, I really focus on asking about their itch. I’ve been surprised so many times. And I think seborrheic dermatitis is just one of those diseases where itch can be a significant burden. You should ask them about it. And now we have the emergence of [a] novel therapeutic that can reduce itch so quickly.

 It’s so interesting because I ask all of my atopic dermatitis patients, talk to me about your itch. That’s so easy because it’s so quick, and I can write it down. I don’t have to do a whole EASI [Eczema Area and Severity Index] score. I can ask them about their itch, do an overall IGA, or investigator’s global assessment. I’ve learned that itch is very important for my psoriasis patients. So now I try to ask my patients [about it]; not [that] everybody itches, but a significant number of psoriasis patients do itch. But I haven’t always asked my seborrheic dermatitis patients about their itching. I think that we could all kind of take that back, and maybe that will make us even better in terms of understanding their burden and being able to monitor it a little bit closer.

 I think all of you said it best, but I would take it a step further and just make them unravel it and remind them of the itch, the dryness, the epidermal changes of scale, the redness, and then bring it back to why are we treating with all these different components of cleansing, moisturizing, and the active ingredient. But also make them think about the marathon and not the sprint, not just making [it] go away quickly, but making things stay away and the safety of giving them things that will do that.

 I think these are all such critical points. What I’m hearing from all of you, who are some of the best clinicians out there, is validating that they have a real medical condition and that they deserve appropriate therapy, that we hear them, we have new options that are available, we can help to simplify the treatment regimen, we can give them something that’s safe, effective, [and] well tolerated, and we can help them in this journey. My goal always is to make them not think about their skin. If they want to think about it in a good way, that’s great, if they’re happy with their skin, that’s great. I want you to live your life and your skin goes with you, but your skin should not be the center of how you live your life, trying to hide the flake, trying to hide the redness, trying to not scratch. I think this is really, really critical. I’ve learned a lot from my colleagues and from talking to each one of you. I think we have some really interesting information. I want to thank each of you for participating today, I’d like to thank the audience for joining us. I hope that you’ve all been able to take home some kernels of truth, and I’d like to thank you all for watching this HCPLive 

Transcript was AI-generated and edited for clarity. 

Videos

Experts discuss the profound impact of seborrheic dermatitis on a patients' well-being, examining the common misconceptions and diagnostic delays.

Silently Struggling: Discussing the Unseen Burdens of SD

 I think what we’re understanding is, this is a condition that is highly prevalent. It is symptomatic, it’s itchy, it can be painful. It’s emotionally devastating because people are judged. And we wonder if our patients are paranoid because they say, I’m not getting the promotion that I want. I was not picked to be the one to present. But the truth is, we’ve seen studies where people are being judged based on their skin conditions. And you mentioned earlier this Harris study. This did involve a lot of seborrheic dermatitis patients. Do these patients know that they have a skin disease, or do they think that they just have a little dandruff and that this is not something that deserves medical treatment?

 Great question, Linda. I think one of the challenges is that there’s very little out there on education for seborrheic dermatitis. So many patients don’t actually realize this is a medical condition that could be potentially treated. They look it up online, to Neal’s point, they’re like, “Is this psoriasis? Is this eczema?” And they realize that seborrheic dermatitis can actually affect areas outside of the scalp. A lot of these patients, they do feel embarrassed, but they also feel like sometimes maybe it’s not serious enough to bring up to a health care provider, even though that Harris poll data showed it has such a profound impact on quality of life. So it’s a tough situation to be in.

 And I think as dermatologists, we don’t necessarily understand the journey that these patients have gone through. They ask dermatologists, well, how long do you think it takes for the diagnosis to be made? And they estimate maybe a year and a half or so. And then, as you mentioned, you ask the patients, and they say it takes between 3 and 4 years to make that diagnosis. In the meantime, these people are walking around without the care that they need. I think we really [owe] it to our patients to ask them a little bit more about their journey and what they’re going through.

 I think part of that equation, too, is the perception. Again, we talked before about [how] they just think it’s dry skin. They think it’s bad hygiene. They blow it off to things that they can correct at home. But I think the other population that deserves that, again, we mentioned before about the neurological patients, the HIV and the AIDS patients, they don’t realize that’s a significant part of their disease. And I don’t think they’re getting the treatment that they probably should be getting because I don’t think it’s identified as serious enough.

 Yes, many patients think that it’s a hygiene problem. I’ve heard parents say about the children, we just can’t get them to wash his hair enough or we can’t get them to use the shampoo that I put there for them. And so there are a lot of misconceptions here. And I think also some patients feel like they should be able to go to their local pharmacy and treat themselves. The failure of recognition of its medical condition or that a dermatologist can be so impactful in getting them better, it’s just not part of the everyday regimen that we see. So our outreach has to be better.

 I agree. I have seen so many teenage patients who come in. When you have seborrheic dermatitis, no matter what you do, I think your hair looks dirty because it’s flaky. You ask patients about hairstyles, and that impacts both men and women. I have one patient who’s actually grown his beard and his hair long and he said, I will kind of shave and trim it up once I don’t have this problem because by wearing the hair really long and keeping the beard, it covers a lot of the redness, the scaling and everything else. It’s embarrassing.

 Well, you wonder too how many physicians outside of dermatology are just also sending that message to them, saying, “Well, that’s just dry skin. It’ll go away. Shower once a day, shower twice a day.” So some of it’s not just on the dermatologist and the patient. I mean, there’s probably some disconnect somewhere where people aren’t getting treated.

 And I think education is so important, because unfortunately, if you shower 2 or 3 times a day, you’re going to end up having a worse problem. You’re not going to make the seborrheic dermatitis any better. It’s going to be really, really a significant problem. So I think what we’ve identified here is the fact that this is a major problem. I tell people, I could walk out into the waiting room today and find people with seborrheic dermatitis. You are not alone. It’s so common. And, unfortunately, I think this is something that our patients cannot necessarily handle on their own. For those with the most mild [cases], I think it’s appropriate, certainly, to try an over-the-counter product, try a medicated shampoo, see how it does. But I think what we’ve learned from the polls and our patients and actually doing these trials is that this is very prevalent. We’re not diagnosing it when it’s there in front of us, necessarily, if we’re not looking for it and the patient’s not complaining about it. And the patient doesn’t necessarily think about telling us about it. So there’s a lot going on. I’m glad we have a new option. It sounds like we don’t have a whole lot more on the horizon at this point, but fortunately we do have something that is safe and effective.

Transcript was AI-generated and edited for clarity.

Experts discuss the profound impact of seborrheic dermatitis on a patients' well-being, examining the common misconceptions, diagnostic delays, and societal judgments that hinder effective management and necessitate enhanced clinical outreach and patient education.

Dermatologists discuss the realm of emerging therapies for seborrheic dermatitis (SD), emphasizing the importance of breakthrough and failed trials.

Emerging Therapies in Seborrheic Dermatitis

 James, maybe you can talk to us a little bit. We talked about what’s new, and it’s exciting, but is this now the front door to a whole lot of other potential therapeutic options that are being investigated for seborrheic dermatitis?

 Yeah, it’s always really fun when we see just how much or how little we know about a disease or the pathogenesis, and then how they respond to a certain medication, [it] does give us some insights as to what’s actually causing it, right? So, it’s translational research, I guess you could call it. I think the fact that roflumilast foam works so well for seborrheic dermatitis tells you that PDE4 is absolutely a validated target as well as [able to improve] the skin barrier. We do have another PDE4, it’s a novel PDE4 topical that’s being studied, as well as a topical JAK [Janus kinase] inhibitor; this is more of an investigator-initiated trial. But what’s also interesting is that PDT, a photodynamic therapy study that’s being done for seborrheic dermatitis, and that comes off the heels of some positive data we saw with narrowband UVB and red light. I also think it’s worth mentioning negative studies, studies that didn’t pan out. There is an antimicrobial peptide that was used because we did see higher levels of [

] in some patients with seborrheic dermatitis, so it makes sense; let’s use an antimicrobial peptide that has antibacterial, antifungal effect. When they did a proof-of-concept study against ketoconazole and placebo, it just didn’t look all that much better than the placebo, so I think for now we can say that’s probably not the right approach.

 You bring up a really, really interesting point. We all run clinical trials, and I think that the dermatology community kind of takes it as a given, here’s a clinical trial, we run different studies, they meet their end point, we see a lovely delta of the active versus the vehicle, it’s highly statistically significant, yet as you mentioned, these trials don’t always pan out. You can have the best idea, as in this case, this last treatment, the best idea, it makes sense, it’s scientifically rigorous, it, we’re studying the right population, yet it might do well initially, and then when we bring it to those phase 3 clinical trials, it doesn’t work. And so, you have to realize this matters.

 And what it does is it helps us also understand what is driving pathogenesis. If you’re using a microbial modulating agent, and it’s not working, and then we know when you target the inflammation of these cytokines, it works, it kind of tells us what’s primary. So in seborrheic dermatitis, it’s not the microbial alterations, it’s the inflammation that’s primary.

 But you know, we could try to match the mechanisms of the drug to the disease, but if it’s not in the right vehicle, or if the trial end points are flawed, or if the study population don’t meet the criteria, but all of these other variables go back to the entire design of what made the trial not pass.

 And that’s so important, because when we talk about a topical, was the drug absorbed appropriately into the vehicle, does the drug penetrate into the skin in the vehicle where it’s supplied? There are so many different factors that go into it. And then again, tolerability. One should say it’s dissolving great and it gets into the skin, but can I tolerate it? Is it causing a contact dermatitis? Is it causing a problem? Is it causing my skin to dry out? Is it causing my hair to break? These are all those little pieces of the puzzle that kind of go together.

Dermatologists discuss the realm of emerging therapies for seborrheic dermatitis (SD), emphasizing the importance of both breakthrough and failed trials, while highlighting the need for scientific rigor and patient-reported outcomes.