Systemic treatments in paediatric psoriasis: a systematic evidence-based update.

In 2008, a systematic review revealed that evidence-based data on efficacy and safety of treatments in paediatric psoriasis are scarce and with low level of evidence. In recent years, publications on this topic have increased exponentially. To present a systematic, evidence-based update on the efficacy and safety of systemic treatments in paediatric psoriasis and to provide treatment recommendations, an update of the previous review was performed. PubMed, EMBASE and the Cochrane Controlled Clinical Trial Register were searched between January 2007 and March 2014 for all available literature on efficacy and safety of all systemic treatments in paediatric psoriasis. The levels of evidence were determined on the Oxford Centre for Evidence-based Medicine Levels of Evidence. The newly retrieved evidence was combined with the evidence available in the former review. Fifty-two studies were included: 36 from the former review, plus 16 new articles. New evidence on induction therapy was mainly available on fumaric acid esters (FAEs), which are shown to be effective in a subgroup of patients. Long-term (96 weeks) safety and efficacy data on etanercept were found. Prospective studies are scarce. Most conclusions are formulated on studies with low level of evidence. Of the conventional systemic treatments, methotrexate still has the most evidence albeit in a low number of patients and with a low level of evidence. FAEs seem to be effective in a subgroup of patients, with gastro-intestinal complaints, flushes and temporary shifts in leucocyte counts and liver enzymes being the main side-effects. Etanercept has still accumulated most evidence of the available systematic treatments, with a large efficacy and reassuring safety profile in a 96-week follow-up.