Table 3.
Summary of on- and off-label systemic agents for pediatric psoriasis.
| Drug | Mode of administration/frequency of maintenance dose | Mechanism of action | Warnings/precautions | Monitoring Parameters |
|---|---|---|---|---|
| Etanercept | Subcutaneous/once weekly | Recombinant DNA-derived protein composed of TNF alpha receptor linked to the Fc portion of human IgG1 that binds to TNF and blocks its interaction with cell surface receptors | Serious infections (TB, HBV reactivation, invasive fungal infections), malignancies (lymphoma)a, injection site reactions, autoimmune disorder, demyelinating disease, heart failure, hematologic toxicity | TB and HBV screening, CBC with differential |
| Adalimumab | Subcutaneous/every other week | Recombinant monoclonal antibody that binds to TNF alpha, thereby interfering with binding to TNF receptor sites and subsequent cytokine-driven inflammatory processes | Serious infections (TB, HBV reactivation, invasive fungal infections), malignancies (lymphoma)a, injection site reactions, autoimmune disorder, demyelinating disease, heart failure, hematologic toxicity | TB and HBV screening, CBC with differential |
| Infliximab | Intravenous/every 8 weeks | Chimeric monoclonal antibody that targets TNF alpha | Serious infections (TB, HBV reactivation, invasive fungal infections), autoimmune disorders, malignancies (lymphoma)a, cardiovascular reactions during and after infusion, hematologic toxicity (pancytopenia) | TB and HBV screening, CBC with differential, LFTs |
| Ustekinumab | Subcutaneous/every 12 weeks | Human monoclonal antibody that targets the p40 subunit of the proinflammatory cytokines, IL-12 and IL-23 | Antibody formation, hypersensitivity reactions, infections (fungal most common), malignancies (multiple aggressive cutaneous SCCs)a, interstitial pneumonia | TB screening, ustekinumab-antibody formation, CBC |
| Guselkumab | Subcutaneous/every 8 weeks | Human IgG1 monoclonal antibody selectively binds with IL-23, thereby reducing serum levels of proinflammatory cytokines IL-17A, IL-17F, and IL-22 | Infections (herpes simplex, tinea, TB), hypersensitivity reactions | TB screening |
| Secukinumab | Subcutaneous/every 4 weeks | Human IgG1 monoclonal antibody that selectively binds to the IL-17A cytokine | Infections (mucocutaneous candidiasis, TB), hypersensitivity reactions, drug-drug interactions | TB screening |
| Ixekizumab | Subcutaneous/every 4 weeks | Humanized IgG4 monoclonal antibody that selectively binds with the IL-17A cytokine | Infections (TB, upper respiratory tract, oral candidiasis, conjunctivitis, tinea), injection site reactions | TB screening |
| Tofacitinib | Oral/twice daily | Nonselective Janus kinases 1 and 3 inhibitor | Serious infections (TB, invasive fungal, viral), malignancies (lymphoma, cutaneous SCCs)a, thrombosis (pulmonary embolism, deep vein thrombosis), hematologic toxicity (pancytopenia) | CBC with differential, lipid profile, LFTs, hepatitis B and C viral screening |
| Apremilast | Oral/twice daily | Inhibits phosphodiesterase 4, which results in increased intracellular cAMP levels and regulation of numerous inflammatory mediators including TNF alpha and IL-23 | Gastrointestinal effects (diarrhea, nausea, vomiting), neuropsychiatric effects (depression, suicidal ideation), weight loss | If patient has renal impairment, monitor renal function |
| Methotrexate | Oral or subcutaneous/weekly | Inhibits dihydrofolate reductase, reducing nucleic acid synthesis | Gastrointestinal distress, hepatotoxicity, bone marrow suppression, pulmonary toxicity | CBC, LFTs, renal function |
| Cyclosporine | Oral/ twice daily | Binds to cyclophilin on lymphocytes and the subsequent cyclosporine-cyclophilin complex inhibits calcineurin and transcription of IL-2 | Renal toxicity, hypertension, immunosuppression, nonmelanoma skin cancers | CBC, serum electrolytes, renal function, lipid profile, regular blood pressure monitoring |
CBC, complete blood count; HBV, hepatitis B virus; IgG, immunoglobulin G; IL, interleukin; LFT, liver function test; SSC, squamous cell carcinoma; TB, tuberculosis; TNF, tumor necrosis factor.
a
No malignancies have been reported in pediatric patients with psoriasis treated with anti-TNF alpha agents.