Biologics Compared in Systematic Review for Moderate-to-Severe Pediatric Psoriasis

All biologic drugs are significantly more efficacious among children with moderate-to-severe psoriasis versus placebo, recent findings suggest, though ixekizumab ranked highest for complete skin clearance.1

The systematic review and meta-analysis yielding such findings had been conducted to compare biologic treatments for pediatric patients with moderate-to-severe plaque psoriasis. Abdulmajeed Sulaiman Alharbi, from Imam Abdulrahman bin Faisal University’s College of Medicine in Saudi Arabia, led a team of investigators in authoring the analysis.

Alharbi et al noted that while there had previously been a network meta-analysis conducted to establish the optimal biologic agent for psoriasis, only a limited number of trials had been used in this study and had implemented interim data exclusively.2

“We believe it is necessary to overcome the limitations to provide more robust findings; hence, we aim to conduct a network meta-analysis utilizing newly published definitive findings from older trials and findings from newer trials exploring a broader range of interventions,” Alharbi and coauthors wrote.1

Review and Meta-Analysis Design and Findings

The investigative team implemented Embase, PubMed, and the Cochrane CENTRAL databases for their comprehensive search of all records available up to May 2024, without imposing language restrictions. The team's meta-analysis included data if research met the following criteria for evaluation: (1) randomized controlled trials (RCTs); (2) exclusive enrollment of pediatric subjects <18 years old; (3) investigated moderate-to-severe plaque psoriasis; (4) assessed biologic treatments; and (5) reported at least a single example of the investigators' pre-specified primary outcomes.

RCTs that met Alharbi and colleagues' criteria were identified from the aforementioned databases. Then, the investigators would perform a fixed-effects frequentist network meta-analysis (NMA). They would then calculate the surface under the cumulative ranking curve (SUCRA) as well as mean treatment rankings.

The primary endpoints used in this review were the proportions of individuals attaining ≥75%, ≥90%, and 100% improvement in their Psoriasis Area and Severity Index scores (PASI75, PASI90, PASI100), as well as a Children’s Dermatology Life Quality Index (CDLQI) score of 0 or 1 (CDLQI 0/1) at the 12–16-week marks. The team also looked at safety outcomes for the 12–20-week period. They would then calculate absolute risk differences per 1000 patients compared to placebo, with 95% confidence intervals (CIs) to present point estimates of response to biologics.

Ultimately, Alharbi et al included 7 RCTs encompassing 1016 pediatric patients with psoriasis in this review. They concluded that all biologics showed significantly higher PASI75 and PASI90 response rates compared to those of placebo. According to participants' SUCRA rankings, ixekizumab was shown to have the highest likelihood of patient attainment of PASI100 (SUCRA: 0.9; Mean Rank: 1.8).

They also found high-dose secukinumab ranked best for PASI90 responses among participants (SUCRA: 0.8; Mean Rank: 3.0). For both PASI75 (SUCRA: 0.9; Mean Rank: 2.2) and CDLQI 0/1 (SUCRA: 0.8; Mean Rank: 2.2) outcomes, the most favorable performance was standard-dose ustekinumab. All available biologics were consequently shown to be significantly more effective than placebo.

Despite this conclusion, the investigators did not identify statistically significant differences among the biologics themselves in treating moderate-to-severe pediatric plaque psoriasis. They did highlight that the review's results underscore the necessity for larger, adequately powered clinical research to further clarify the optimal biologic therapy for this patient population.

“Our research explored an understudied area and provided new insights, but regardless, it was subject to certain limitations,” the investigative team wrote.1 “There was a scarcity of studies, with even fewer direct comparisons of the pertinent interventions. This limited our ability to perform a more exhaustive analysis and impacted the robustness of our results.”

References

1. Aljalfan AA, Alharbi AS, Alamrie R, et al. Biologics for treatment of paediatric plaque psoriasis: A systematic review and network meta-analysis. J Eur Acad Dermatol Venereol. 2025; 00: 1–13. https://doi.org/10.1111/jdv.70084.

2. Huang IH, Yu CL, Chi CC, et al. Biologics for pediatric moderate-to-severe plaque psoriasis: a systematic review and network meta-analysis. J Dtsch Dermatol Ges J Ger Soc Dermatol. 2022; 20(9): 1201–1209.