#VisualAbstract: A Comparison of Psoriasis Severity in Pediatric Patients Treated With Methotrexate vs Biologic Agents

1. Treatment with biologics in pediatric patients with moderate to severe psoriasis was significantly associated with greater reduction in psoriasis severity than methotrexate, though methotrexate remains an effective treatment for the condition.

Evidence Rating: 2 (Good)

Psoriasis is a highly debilitating chronic inflammatory skin disorder that affects up to 1.37% of children, with its highly visible nature contributing to significantly impaired quality of life and necessitating therapy. While most cases of psoriasis are responsive to topical therapy, 20% of children have more severe forms of the disease that require systemic therapy. Methotrexate is currently the most commonly prescribed and least expensive disease modifying anti-rheumatic drug. While multiple biologic agents have been approved as alternative treatment options, no investigations have prospectively compared their efficacy against methotrexate, aside from a previous study that found adalimumab to be a potentially superior option. In this retrospective cohort study, clinical data from 234 pediatric patients with moderate to severe psoriasis who had received at least 3 months of biologic or methotrexate treatment were analyzed. Primary outcome measures were the Psoriasis Area and Severity Index (PASI) and Physician Global Assessment (PGA) as operational measures of psoriasis severity and responsiveness to treatment. A PASI75 score indicates 75% or greater improvement and PGA0/1 represents a clear or minimal assessment. Drug survival rates were additionally analyzed. At 6 months follow up, 75% or greater improvement in PASI was achieved in 71.4% of patients receiving biologic agent treatment versus 40% in the methotrexate group. Likewise, achievement of PASI75 or PGA0/1, and decreased mean PASI and PGA scores were more strongly associated with biologic agent usage than methotrexate. Finally, after 1, 3, and 5 years of use, overall drug survival rates for methotrexate were 77.5%, 50.3%, and 35.9% versus 83.4%, 64.3%, and 57.1% for biologic agents, demonstrating a significantly higher survival rate for biologics than methotrexate (HR, 2.23; 95% CI, 1.21-4.10; p = .01). Prior research has found biologics to be additionally associated with fewer treatment related toxic effects and requiring less monitoring during administration. As such, while methotrexate remains a cost-effective strategy in the treatment of moderate to severe psoriasis, study findings suggest that biologic treatment may be a more effective and safe treatment option when compared to methotrexate, with the caveat of being more expensive.

Click to read the study in JAMA Dermatology

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