In this episode of Topical Conversations, pediatric dermatologists Lisa Swanson, MD, and Karan Lal, DO, discuss managing psoriasis in pediatric patients and the advantages of ixekizumab and other biologics, providing insights into optimal treatment choices and addressing challenges unique to treating pediatric psoriasis. 

Psoriasis in pediatric patients is becoming more common, necessitating effective treatment options tailored to the specific needs of young patients. Recognizing psoriasis as more than just a skin condition—as a chronic, systemic inflammatory disease—is essential when considering therapeutic strategies, particularly systemic treatments. 

Pediatric psoriasis: a systemic disease requiring systemic treatments 

Psoriasis in children has significant impacts beyond the skin, affecting overall health and increasing the risk of comorbidities, including arthritis and metabolic conditions. Acknowledging this systemic nature makes systemic treatments, such as biologics, a vital part of comprehensive care for many pediatric patients. Dr. Swanson notes that 5 systemic treatments are approved for pediatric use, including 4 injectable options (etanercept, ixekizumab, secukinumab, and ustekinumab) and one oral option (apremilast). While effective, the usage of apremilast is often limited in younger children due to side effects like nausea and diarrhea and the common difficulty of swallowing pills. 

Ixekizumab: a preferred biologic for pediatric psoriasis 

For Dr. Lal, ixekizumab is often the first choice for treating pediatric psoriasis, and he has observed strong results in adults that translate well to younger patients. Ixekizumab’s once-monthly dosing is particularly beneficial for children and their families due to the simplified dosing regimen, which can help improve adherence and reduce the burden of frequent injections. Moreover, ixekizumab acts rapidly, which is a boon for both patients and their caregivers. 

Addressing psoriatic arthritis in pediatric patients 

Psoriatic arthritis may go undetected in patients with pediatric psoriasis, particularly before treatment begins. Dr. Lal shares that increased activity levels post-treatment sometimes reveal undiagnosed joint inflammation. Dr. Swanson also emphasizes the importance of examining nail health in pediatric patients with psoriasis, as nail psoriasis is associated with an increased risk of psoriatic arthritis. Ixekizumab’s efficacy in managing nail psoriasis offers an added advantage in this context, helping dermatologists improve overall patient outcomes. 

Citrate-free ixekizumab for pediatric patients 

The original formulation of ixekizumab was painful, which often posed a challenge in younger patients. However, a citrate-free formulation now available improves comfort for pediatric patients, making the injections more tolerable. Dr. Lal notes his strategy of using EMLA cream under a bandage prior to injection to ease discomfort for children, who often become accustomed to injections over time. 

Moving beyond topicals: a comprehensive approach to psoriasis 

Many children and families express frustration with topical treatments, particularly the “whack-a-mole” effect, where plaques reappear in new locations despite regular topical application. Ixekizumab helps to address the underlying systemic inflammation, allowing for better control over psoriasis with a simpler regimen. As Dr. Lal highlights, biologics like ixekizumab not only reduce dependence on topicals but also work well alongside other therapies, such as phototherapy, offering a versatile, multimodal approach that reduces the overall burden on patients and caregivers. 

Safety considerations: screening for inflammatory bowel disease 

One concern with IL-17 inhibitors such as ixekizumab is the potential activation of inflammatory bowel disease (IBD) in patients predisposed to it. While IL-17 inhibitors don’t cause IBD directly, they may unmask it in genetically susceptible patients. Dr. Swanson and Dr. Lal emphasize the importance of screening for IBD in pediatric patients with psoriasis before initiating an IL-17 therapy. 

To address this, Dr. Swanson collaborated with pediatric gastroenterologists and developed a set of screening questions and labs. She makes sure to question patients and caregivers on the following key areas: 

1. Family history of IBD 
2. Growth issues, as growth delays can indicate Crohn’s disease 
3. Nocturnal diarrhea or frequent bowel movements at night 
4. Pain during bowel movements, including rectal pain or fissures 

In addition to these questions, she considers 3 laboratory tests: 

1. CBC to check for anemia 
2. CRP, which is usually normal in psoriasis but may be elevated in IBD or psoriatic arthritis 
3. Fecal calprotectin, a noninvasive test with high sensitivity and specificity for intestinal inflammation 

Dr. Lal concurs, noting that the fecal calprotectin test, while sometimes challenging to obtain from pediatric patients, is a critical tool for assessing IBD risk, especially in younger children for whom biologics may be considered. 

Ixekizumab’s role in evolving pediatric psoriasis care 

As pediatric psoriasis rates rise, so does the need for safe, effective treatments that address the full spectrum of the disease’s impact. Ixekizumab’s rapid efficacy, once-monthly dosing, and now pain-free formulation make it a valuable option in pediatric dermatology. By considering both the physical and psychological needs of young patients, and carefully screening for potential complications like IBD, dermatologists can leverage ixekizumab to improve outcomes for children with psoriasis.