Clinical Decisions in Pediatric Psoriasis: A Practical Approach to Systemic Therapy.

Deciding when to start and selecting a specific systemic treatment for pediatric psoriasis patients can be a complex process involving many factors. Considerations include type of psoriasis, severity, potential genetic etiologies, comorbidities, triggering events and characteristics unique to each patient. The constellation of clinical features and drug related factors may prompt selection of a specific agent. Systemic treatments may be considered on the basis of those that are "tried and true" (acitretin, methotrexate, cyclosporine, phototherapy) and "new and novel" (the biologic agents). Conventional systemic agents have decades of use to support their safety and efficacy and may be used in very flexible ways with titration of dose when maintenance is achieved or when flares occur. Targeted biologic therapies have overall reassuring safety profiles, can be very efficacious, and require little to no lab monitoring as compared to conventional systemics. However, they can be cost prohibitive and most are administered via injection. Here, we provide data and principles guiding the approach to therapy of moderate to severe psoriasis in children and use case examples to highlight several different clinical scenarios.