Pediatric Psoriasis: Comorbidities, Treatment Challenges and Unmet Needs.

Abstract

Pediatric psoriasis is a chronic, immune-mediated inflammatory disease that frequently begins in childhood or adolescence. Beyond cutaneous involvement, it is associated with a wide spectrum of metabolic, psychological, and inflammatory comorbidities, as well as a marked impairment in health-related quality of life in both patients and their caregivers. This narrative review summarizes current evidence on comorbidities, treatment challenges, unmet needs, and future directions in pediatric psoriasis. Available data indicate an increased risk of overweight and obesity, the clustering of cardiometabolic risk factors, and a high prevalence of psychological and psychiatric comorbidities, including depression, anxiety, and suicidal ideation. Inflammatory comorbidities, particularly psoriatic arthritis, require early recognition to prevent irreversible complications. Therapeutic management of pediatric psoriasis has advanced in recent years with the approval of several biologic therapies supported by pediatric-specific clinical trials. Nevertheless, important challenges remain. These include limited access to biologics, age restrictions, off-label use of conventional systemic therapies, vaccination considerations, and scarcity of long-term safety data, particularly regarding growth, pubertal development, and cumulative drug exposure. Moreover, clear and regularly updated therapeutic algorithms for pediatric patients are still lacking. Despite increasing research activity and ongoing clinical trials, substantial unmet needs persist. These include delays in pediatric drug development, limited evidence beyond plaque psoriasis, insufficient evaluation of extracutaneous outcomes, and poor understanding of the long-term trajectory of comorbidities. Emerging data suggesting immunopathogenic differences between pediatric and adult psoriasis, together with ongoing biomarker research, may inform future personalized approaches. Addressing these gaps will be essential to optimize long-term, patient-centered care for children and adolescents with psoriasis.