AT WCPD 2017

CHICAGO (FRONTLINE MEDICAL NEWS) – Children with psoriasis face a multitude of potential problems and comorbidities, ranging from anxiety and depression to obesity and metabolic disease, so early and proactive identification is key.

“These children are more likely to engage in high-risk behavior such as use of alcohol, tobacco, and drugs – a trend that continues into adult ages,” Kelly M. Cordoro, MD , said at the World Congress for Pediatric Dermatology. “They also have a higher association with inflammatory bowel disease, among other conditions. Those of us who care for pediatric psoriasis patients are on the front lines of recognition of these potential comorbidities, which allow for, ideally, prevention and certainly, early intervention.”

Arthritis is one of the first understood comorbidities of psoriasis in adults and children, said Dr. Cordoro, a pediatric dermatologist at the University of California, San Francisco Medical Center. In children with the condition, arthritis commonly affects the hands and feet, but it can also impact larger joints such as the hips, the knees, and the back. “The prevalence range is very broad, probably between 10% and 40%,” she said. “Severe nail and distal digital psoriasis is predictive of arthritis, so we need to be thinking of that and not forgetting that children can get arthritis.”

Obesity ranks as the most well understood comorbidity of psoriasis in children. Study after study has demonstrated this association. In addition, obese children with psoriasis may also harbor components of the metabolic syndrome – hypertension, dyslipidemia, and diabetes. “They’re not as much at risk for metabolic syndrome in the absence of obesity, but there’s still a small signal,” Dr. Cordoro said. “We ask ourselves this question as clinicians: Are these pediatric patients at risk for cardiovascular and cerebrovascular disease as they get older? In other words, what is the health of a 6-year-old, obese child with severe psoriasis, who may also have other components of the metabolic syndrome, going to be like when he is 35 or 40? Are these the children who go on to have cardiovascular events as documented in adult studies of psoriasis?”

To date, several studies have identified a clear link between psoriasis and obesity, and between psoriasis and hypertension, diabetes, and dyslipidemia in certain populations. “There is a dose-response effect,” Dr. Cordoro said. “The more severe the psoriasis, the more likely the patient is to be obese, and vice versa.” In one study, researchers analyzed 409 psoriasis patients up to age 17 years in nine countries ( JAMA Dermatol. 2013;149:166-76 ). They concluded that globally, children with psoriasis have excess adiposity and increased central adiposity regardless of psoriasis severity. The researchers used multiple measures of adiposity, not just body mass index, but also waist circumference and waist-to-height ratio. “Waist circumference and waist-to-height ratio are surrogates for central and visceral adiposity,” said Dr. Cordoro, who was involved with the study. “And central adiposity may be a more sensitive indicator of metabolic disease and cardiovascular risk than BMI [body mass index] alone.”

Another study demonstrated that high adiposity preceded psoriasis by up to 2 years in 93% of overweight or obese psoriatic children ( JAMA Dermatol. 2014;150:573-4 ).

In a more recent analysis, researchers evaluated lipid function in 44 psoriatic children ( J Invest Dermatol. 2016;136[1]:67-73 ). Compared with age-matched controls, children with psoriasis were found to have higher waist-to-hip ratio, higher insulin resistance, and 27% were obese. “There was no difference in fasting lipid levels but the blood profiles had atherogenic markers that are worrisome for ongoing risk for atherosclerosis, cardiovascular disease, and cerebrovascular disease,” Dr. Cordoro said.

Research among adults has demonstrated that psoriasis confers an independent risk of atherosclerosis, MI, stroke, and early cardiovascular-related mortality, the so-called “psoriatic march.” Theoretically, Dr. Cordoro said, severe psoriasis sets up a state of chronic systemic inflammation, which leads to insulin resistance, which predisposes affected individuals to endothelial dysfunction, and eventually can lead to atherosclerosis. “When atherosclerosis becomes unstable, now you’ve gone from having severe psoriasis into a situation where the chronic inflammation may have predisposed you to having a thrombotic event such as a heart attack or stroke,” she said. “Obesity replicates that same pattern. What does this all mean? Is this real or is this just a theory? We don’t know, but it’s certainly biologically plausible. It’s not been proven with long-term prospective studies, which we need.”

Dr. Cordoro went on to discuss the importance of assessing young psoriasis patients for psychiatric and emotional comorbidities, including anxiety, depression, and eating disorders. “These kids can become socially isolated, which can lead to more downstream effects: more anxiety, more depression, sometimes overeating and obesity,” she said. “It’s not only that the patient has situational anxiety or depression, the notion that ‘My skin looks terrible. I’m really depressed about it;’ it’s more than that. It turns out that the same inflammatory milieu in psoriasis lesions can be replicated in the brain inflammatory milieu in patients with depression and other psychiatric disorders. That’s fascinating to recognize that these comorbidities can be intrinsic. There’s a biological basis and not just a downstream effect.”

She advises clinicians who care for children with psoriasis to keep potential comorbidities in mind, and to make sure families understand that there can be psychiatric, emotional, and physical consequences to undertreated disease. “We do not yet know how to risk stratify these patients. At the very least, you want to identify overweight or obese children with moderate to severe disease for early intervention,” Dr. Cordoro said. “Weight loss and lifestyle interventions are the hardest goals to accomplish but are really critical. Prevention is the best strategy. We can help ourselves and help our patients by referring to obesity and nutrition experts who can not only help the child but get the entire family involved.”

In a consensus statement published online in JAMA Dermatology, a multidisciplinary panel of experts including Dr. Cordoro offer an evidence- and consensus-based approach to screening children with psoriasis, based on a review of 153 manuscripts in the medical literature. The panel recommends that all psoriasis patients 2-21 years of age should undergo annual measurements of blood pressure and BMI, and screenings for arthritis and mood disorders. “These don’t have to be formal mood disorder screens,” Dr. Cordoro said. “They can be informal questioning about anxiety and depression, like ‘How is your psoriasis impacting you? How do you feel about your psoriasis? What do you say when people ask you about your psoriasis?’ It’s also important to ask overweight patients what they’re doing to keep their weight in check. Oftentimes when you ask a question about mood or impact of disease or stigma or bullying, the child will be completely silent and either stay silent or start crying or start telling you their stories. It’s really important to ask, because it validates that their concerns are more than just about vanity but about their overall health, and that is a critical difference.”

Dr. Cordoro disclosed that she is a consultant for Pfizer and Valeant.