Derms on Drugs – Pediatric Psoriasis
Podcast: Derms on Drugs by Scholars in Medicine
Episode: Pediatric Psoriasis
Date: November 7, 2025
Hosts: Dr. Matt Zirwas, Dr. Laura Ferris, Dr. Tim Patton
Guest: Dr. Doug Kress
Overview
This episode dives into the complexities of pediatric psoriasis, with a special focus on the latest treatments, comparative data for biologics, clinical practice pearls, and real-world challenges in managing this condition in children. Pediatric dermatology expert Dr. Doug Kress joins the usual panel for a candid, insightful, and at times comedic discussion about what's new, what's effective, and what's actually feasible for kids and their families.
Key Discussion Points & Insights
1. Current FDA-Approved Treatments for Pediatric Psoriasis
[02:27–05:35]
- Quick summary of biologics and small molecule inhibitors currently approved:
- Etanercept (Enbrel): Approved down to age 4; weekly dosing.
- Ustekinumab (Stelara): Approved down to age 6; less frequent dosing (q12 weeks after induction).
- Ixekizumab (Taltz): Approved down to age 6; weight-based, every 4 weeks.
- Secukinumab (Cosentyx): Approved down to age 6.
- Apremilast (Otezla): Approved down to age 6; oral.
- Adalimumab approved in Europe, not the US, for pediatric psoriasis.
- Newly approved: Guselkumab (Tremfya), discussion of data later in episode.
"For me personally...I have always kind of hated seeing kids. It's not that I mind the kids, I just don't like the parents." – Dr. Matt Zirwas [02:27]
2. Latest Network Meta-Analysis (NMA) Data in Pediatric Psoriasis
[05:35–11:15]
- Dr. Patton reviews a pivotal NMA (Aliäfon et al, 2025) of 7 RCTs including over 1,000 children.
- Studied agents: Etanercept, Ustekinumab, Secukinumab, Ixekizumab, Adalimumab (EMA only), plus methotrexate and fumaric acid esters.
- Key findings:
- Secukinumab (high dose): Highest probability of being "best" for PASI 90.
- Ixekizumab: Best for PASI 100.
- Ustekinumab: Best for PASI 75 and for the Children’s Dermatology Life Quality Index (CDLQI).
- No single biologic statistically superior to others in forest plots due to small sample sizes.
- The limitations of NMAs in rare pediatric indications are discussed.
"My favorite line on this NMA was 'the inconsistency was assessed via the inconsistency model.' That was a good idea." – Dr. Tim Patton [05:58]
"For the biologic medications, none is really statistically significantly better than any other...but, like, that doesn't make sense to me...NMAs continue to confuse me." – Dr. Tim Patton [09:52]
"Pediatric psoriasis studies, I think, are tough because the N is so small." – Dr. Laura Ferris [10:01]
3. Expert Clinical Perspective – Dr. Doug Kress
[10:28 onward; expanded at 24:15–41:14]
- On clinical differences in kids vs. adults:
- More facial and inverse psoriasis in kids.
- High prevalence of guttate psoriasis; always check for strep or recent illness.
- Psoriatic arthritis (PsA) does occur in kids at similar rates to adults, but often missed.
"We see a lot of facial psoriasis. Very common in kids...And we see a lot of guttate psoriasis in kids. So you have to make sure they haven’t had a strep throat." – Dr. Doug Kress [24:59]
- On real-world treatment approach:
- Aggressiveness: "I’m not less likely to go to a biologic if the kid needs it."
- Usually tries 2–3 topical regimens before moving to biologic; new topical options noted (e.g., Zoryve).
- Insurance dictates much of the agent selection, with biosimilar switching common.
"I tell them...Enbrel: approved to age four, been out the longest for sure the safest, least effective shot once a week. Then Cosentyx and Taltz...Stelara...after the two loads...four shots a year. So I usually nudge people to do that just because I think it’s the easiest and best for kids." – Dr. Doug Kress [33:37]
4. Deep Dive: Guselkumab (Tremfya) in Pediatric Psoriasis – The PROTOSTAR Study
[11:37–21:15]
- Summary of Prajapati et al (BJD 2025):
- Randomized, double-blind, phase 3 trial in kids ages 6–17.
- Guselkumab vs. placebo, open-label etanercept arm (not powered for statistical comparison).
- Primary endpoint at week 16:
- IGA 0/1: 66% for Tremfya vs. 16% placebo
- PASI 75: 76%
- PASI 90: 56%
- PASI 100: 34%
- Open-label etanercept arms scored surprisingly high (possibly study bias).
- By week 52 (OLE): IGA 0/1 of 86%, PASI 90 of 82%.
- Safety profile reassuring; nasopharyngitis and mild infections only; some anti-drug antibodies, but not clinically meaningful.
"At week 16, patients on Guselkumab did better than patients on placebo. So IGA 0/1, 66% versus 16%...PASI 75 of 76%...PASI 90 rate was 56%. PASI 100 was 34%." – Dr. Laura Ferris [14:00]
"The Enbrel data in that trial is very generous...prior to the study, Laura just gave the best number I ever saw PASI 75 for Enbrel was 59 at 16 weeks—this is a full 10 points better." – Dr. Doug Kress [19:15]
5. Practical Pearls & Parent/Kid Considerations
[24:15–41:14]
- Needle phobia and medication choice:
- Shots present a significant barrier; many kids/parents prefer a pill.
- Oral IL-23s would be "game-changer" if/when approved.
- Topical options increasingly important, especially for those who can't tolerate, or refuse, injections.
"The most common sound you hear in my office is screaming of kids who are getting [shots]...for kids, I think a pill is always going to be better if you don’t have to do labs." – Dr. Doug Kress [31:00]
- Vaccine guidance while on biologics:
- General practice: Attempt to catch up vaccines pre-biologic.
- For monthly biologics, strategize vaccine timing by skipping one dose ("skip a shot, vaccinate in the interim, restart two weeks or a month later").
- More complex for longer-interval agents like Stelara.
- For dupilumab, short breaks if necessary, though data suggests it's not required for non-live vaccines.
"First thing you want to do is get everybody caught up on vaccines before you start a biologic...Non-live vaccines, right, not an issue, and live vaccines are only a theoretic issue." – Dr. Doug Kress [35:59]
6. Challenges with Biosimilars and Insurance Mandates
[28:17–29:29]
- Biosimilar switching is an ongoing challenge—particularly Humira and Remicade biosimilars have presented issues in real-world use, though Ustekinumab (Stelara) biosimilars have been better tolerated.
- Insurance dictates which biosimilars can/can’t be used; can abruptly change covered agents.
7. Comparison Between Biologics – Decision-Making Framework
[33:04–34:46]
- Dr. Kress succinctly summarizes biologic choices for parents:
- Enbrel: Oldest, safest, least effective, most frequent (weekly) injections.
- Cosentyx/Taltz: Similar efficacy, monthly shots.
- Stelara: Less frequent dosing, favored for ease, nudge most patients toward it.
- Guselkumab (Tremfya): Potential new favorite, if accessible.
8. Methotrexate and Conventional Therapies – Still a Role?
[39:44–40:27]
- Some insurance plans still require methotrexate failure before biologic approval, but generally less common.
- Methotrexate still used for select kids, especially with comorbidities or insurance barriers.
"It's not that methotrexate doesn't work...and nobody wants a kid on methotrexate. But, yeah, I still have some thor addicts on methotrex." – Dr. Doug Kress [40:22]
Notable Quotes & Memorable Moments
- "You guys know how much that [Sphere ad] costs?...half a million dollars." – Dr. Tim Patton [02:20–02:27]
- "Pediatric psoriasis studies, I think, are tough because the N is so small." – Dr. Laura Ferris [10:01]
- "I think a pill is always going to be better if you don’t have to do labs." – Dr. Doug Kress [32:06]
- "You all have kids. Were any of your kids ever told they had growing pains? ...If you see somebody, a kid with psoriasis and growing pains, they probably have early psoriatic arthritis." – Dr. Doug Kress [26:26]
- "I tell people with dupilumab to not skip any doses because I’ve seen enough kids who you skip one dose and their eczema flares and now they’re at risk for staph infection." – Dr. Matt Zirwas [37:04]
Fun & Trivia Segment
[41:14–46:10]
- Pediatrics-flavored trivia ranging from the historical classification of rash illnesses to the 2008 NEJM propranolol/hemangioma paper.
- Discussion of topical timolol for hemangiomas, pyogenic granulomas, and even hand fissures.
"The most common sound you hear in my office is screaming of kids who are getting [shots]...Even if it’s a couple times a year." – Dr. Doug Kress [31:00]
Timestamps for Major Segments
| Segment | Start | |-----------------------------------------|--------------| | Pediatric drug approvals overview | 02:27 | | Network meta-analysis review | 05:35 | | Dr. Kress joins, clinical perspectives | 10:28, 24:15 | | Guselkumab (Tremfya) study deep dive | 11:37 | | Parent/kid/topical/needle considerations| 24:15 | | Insurance/biosimilar discussion | 28:17 | | Biologic choice explanation | 33:04 | | Vaccine management in kids on biologics | 35:59 | | Methotrexate’s role | 39:44 | | Trivia/final segment | 41:14 |
Conclusion
The episode delivers a rich blend of evidence-based updates, clinical wisdom, and practical insights for the management of pediatric psoriasis—peppered with humor and heartfelt anecdotes about the unique challenges of treating children. Dr. Kress’s experience underscores the nuances of therapy selection, insurance battles, and the real-world factors that matter most to young patients and their families.
For listeners wanting cutting-edge knowledge, candid clinical discussion, and a laugh or two—this is essential medical podcast listening.