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Associate Professor of Clinical Pediatrics and Dermatology
Perelman School of Medicine
University of Pennsylvania
Children's Hospital of Philadelphia
Jim Treat, MD, has no relevant conflicts of interest to report.
One of the greatest challenges when caring for pediatric patients with psoriasis occurs when their parents have decided beforehand not to pursue systemic therapy. In some cases, this occurs even if the child is withdrawn, reluctant to wear shorts or short sleeves, and feeling quite uncomfortable because of their psoriasis. I once had a child tell me, “I don’t like to go to school because people tell me I’m ugly”—a statement that just broke my heart.
In these cases, I often try to focus on two helpful—and sometime complementary—discussions with the patient and their family: discussions about the benefits of behavioral health and discussions about the benefits of systemic therapy.
One of the major risks that comes with psoriasis is mental health problems. If a child is withdrawn and at risk for depression and potential suicidality, then I immediately refer them to behavioral health.
Simply treating their skin may not solve all their problems. I tell children, “Anyone may benefit from therapy, because it’s just nice to have someone to talk to who is going to help you work through life problems. It’s great for everyone.”
In addition to discussing behavioral health issues that are prevalent in patients with significant psoriasis, I compassionately counsel parents and children to consider systemic therapy options for managing pediatric psoriasis, even when they have previously decided against this option before their first visit.
Including the Patient
To me, it is vital to include the child in the conversation about their psoriasis and systemic therapy options, both when selecting treatment and while they are on treatment. We must provide them with the opportunity to tell their parents and healthcare provider how much the psoriasis is affecting them and, if they are receiving treatment, whether any side effects bother them.
For example, when speaking with the mother of the child quoted above, I helped her see how much the psoriasis was adversely affecting her child socially, and I suggested that we needed to do something different from their current approach.
I approach educating patients and parents about the potential benefits of systemic therapy by first calling their attention to how, when a child has severe skin disease, they have often reached that point over the course of months or years. During this time, while trying various approaches, the parents may not fully recognize how much the psoriasis is affecting them and how withdrawn the child has become.
I try to walk them forward to 6 months after starting effective therapy. I counsel that after they have gone through the stress of starting the medication, after the child is hopefully tolerating the therapy well, then the child may be able to do all the things that they wanted to do before. I tell the parents that they may feel like they are seeing their child’s personality anew, a personality that had gradually been dampened because of how much the psoriasis was affecting them on a day‑to‑day basis.
When counseling the parents and child, I recognize that it is difficult to start a child on therapy that is not curative. Furthermore, because many systemic therapies “turn down” the immune system, they come with long lists of warnings about potential adverse events.
It is crucial to educate families about the potential risks and adverse events of treatment, but I also emphasize that there is a risk of adverse outcomes with not treating psoriasis. I tell the family that it is my job to present all the different options so they can make the best decision for their child. I tell them other children who have been in similar situations who have been treated successfully.
The Bottom Line
I have had many conversations about the potential benefits and risks of systemic therapy, and I have often found that, even when parents are initially resistant to or concerned about using systemic medications for their child, they experience this “awakening” of their child 3‑6 months after starting therapy. The child is typically much better, and practically bounces into the room because their skin has improved, and they feel like they have a new lease on life. That is the best moment for me as a clinician, and the vast majority of parents who start systemic therapy are very happy with their choice after they see such a difference for their child.