Psoriasis is uncommon in children; however, its prevalence increases with age. Pediatric psoriasis is associated with marked clinical heterogeneity, with forms such as inverse, nail, and mucosal psoriasis being more common in children than plaque psoriasis that is more prevalent in adults.

In the absence of dedicated management guidelines and with limited published evidence, specialist expertise is essential for assessing severity, selecting therapies, and tailoring treatment to individual needs, as highlighted at the 2025 Dermatology Days of Paris conference, held from December 2 to 6, 2025, in Paris, France.

Assessing Severity

One of the challenges for clinicians is the assessment of disease severity. In adults, the percentage of body surface area involved is used to classify the disease as mild, moderate, or severe. However, this categorization has not been established in children and remains a matter of debate.

Severity scores validated in adults have limitations in pediatric practice. This is particularly true for the Psoriasis Area and Severity Index because hyperkeratosis, scaling, and infiltration are often underestimated in pediatric patients. The Physician Global Assessment score is easier to use in routine clinical practice.

Quality of life in 5- to 16-year-old children can be measured using the Children’s Dermatology Life Quality Index and that in younger children can be measured using the cartoon Dermatology Life Quality Index. The extent and characteristics of the lesions directly influence psychosocial and functional outcomes.

“A visible dermatosis, teasing, or difficulty holding a pencil because of palmoplantar psoriasis can make psoriasis highly disabling, even if it is not extensive,” said Anne-Claire Bursztejn, MD, PhD, a dermatologist at the Centre Hospitalier Régional Universitaire de Nancy, Nancy, France.

Therefore, patient-reported outcomes can be valuable, although they are complicated by the fact that parents may perceive the severity of the disease differently than the child.

Hidden psoriasis without pruritus or burning may be well tolerated by the child, although parents remain more concerned. In contrast, limited but visible lesions may have a greater social and functional impact, particularly in schoolchildren.

No Guidelines

The scientific literature on pediatric psoriasis management is limited, which explains the absence of dedicated guidelines for its management. Consequently, the practitioner’s expertise plays a significant role.

The first question is whether treatment should be withheld. “We know that some mild forms of psoriasis often resolve spontaneously within a few months. There is no formal position on whether they should be treated systematically,” said Maëlla Severino-Freire, MD, a dermatologist at Hôpital Larrey, Centre Hospitalier Universitaire de Toulouse, Toulouse, France.

Topical corticosteroids are the first-line therapy for initial treatment. They may be combined with vitamin E analogs or salicylic acid, except in very young children, particularly those younger than 2 years. Phototherapy is permitted from the age of 8 years but must be weighed against the carcinogenic risk. Systemic treatments are considered only thereafter.

• Retinoids such as acitretin require careful medical supervision due to a range of side effects, including serious neurologic and growth side effects
• Cyclosporine at the dose of 3-4 mg/kg/d, and sometimes up to 5 mg/kg/d, has the advantage of rapid onset of action
• Methotrexate

In clinical practice, combinations of two or three of these agents are often used.

According to a recent literature review, biological therapies appear to be more effective than conventional systemic treatments. These agents are approved for use at 4 years of age for adalimumab; 6 years for ustekinumab, ixekizumab, secukinumab, and apremilast; and 8 years for etanercept.

“The level of evidence is often lacking, which explains the difficulty in drafting recommendations. However, comparative studies are increasing and should soon allow a consensus to be developed,” said Emmanuel Mahé, MD, a dermatologist and venereologist at the Victor Dupouy Hospital Center in Argenteuil, France. These studies should also explain the role of newer biologics targeting interleukin (IL)-23 inhibitors — guselkumab, risankizumab, tildrakizumab, and deucravacitinib via tyrosine kinase 2 — or IL-17 inhibitors, such as netakimab, which is currently being evaluated in phase 3 trials.

Clinicians must be vigilant regarding pediatric comorbidities and drug-related contraindications when prescribing medications. Precautions are required to prevent treatment-related skin adverse effects. These include acne treated with corticosteroids, cyclosporine, or JAK inhibitors; stretch marks treated with corticosteroids; alopecia treated with acitretin or methotrexate; and hypertrichosis treated with cyclosporine.

Dose adjustment may be required in children who have overweight or obesity. For weight-based treatments, such as cyclosporine, acitretin, methotrexate, ustekinumab, and etanercept, the dosing does not vary with body weight. In contrast, fixed-dose treatments such as adalimumab, secukinumab, and apremilast do not account for body weight. These should be considered when prescribing and assessing the efficacy of treatments.

Specific Clinical Situations

When psoriasis occurs as part of psoriatic arthritis, management follows rheumatology algorithms: nonsteroidal anti-inflammatory drugs alone, followed by a combination with methotrexate as a second-line therapy before considering TNF or IL-17 inhibitors.

“Regarding diaper rash, progression to a chronic form is very rare. Although often perceived as an emergency by parents, it is well tolerated by many children who experience neither pain nor itching. Parents should be reassured and advised to follow gentle care, including cleansing with water and soap, pat drying, and very frequent diaper changes. Because the lesions are dry, the application of liniments or zinc paste is unnecessary. However, ciclopirox olamine can also be used for this purpose. If topical corticosteroids are required, a potent agent should be chosen and applied for a brief period of 3-4 days, which is usually sufficient,” Mahé said.

This story was translated from Univadis France, part of the Medscape Professional Network.