Pediatric Psoriasis

Welcome to season two at Derms on Drugs, a video podcast brought to you by scholars and medicine, the best educational platform in dermatology and provided no cost to medical providers. Derms on Drugs is where cutting edge dirt meets Cidermis comedy. A Matt Cyrus from Docs Dermatology in each week. I'm joined by my residency buddies, Dr. Laura Ferris from the University of North Carolina and Dr. Tim Patton from the University of Pittsburgh. And we use our 60 years of combined-derm experience to discuss, debate and dissect the hottest topics in dermatology. It is everything you need to know to be on the cutting edge of Derm and you'll actually have some fun listening. New episodes drop every Friday on scholars and medicine, Apple Podcasts, Spotify and other major podcast platforms. And the video component to remind everybody has some of the key figures and tables from the article we talk about. And this week's episode is sponsored by Johnson and Johnson. Well, let's go ahead and get into it. We have a very special guest this week, Dr. Doug Cress, also from the University of Pittsburgh, who happened to be deeply involved in training Drs Patton Ferris and I. And we are going to be talking about pediatric psoriasis, which should be a very interesting discussion with Dr. Cress. So before I get into the first slide here, Patton Ferris, do you guys have anything good happen over the weekend? All right, Travelling Home from Las Vegas from a media. Fall clinical for Ferris. Fall clinical, just happy I made it. What was the best? What was the most interesting thing at Fall clinical? Any new data come out that was particularly? Woo. You know, I didn't get to see it, but a castle biosciences has a new test for predicting responses to the atopic dermatitis therapy that was the launch. I didn't get to get all the details from excited to learn about that. I heard that the new Novartis drug had a big presence. The rap, rap, rap, rap, rap, rap, rap, rap, rap, cito. It's not rap, cito. I know you said it correctly, but they want to be very clear. Everybody knows it's not rap, cito. It's rap, cito. It's rap, cito. They actually, the sphere in Las Vegas, they actually had an ad on the sphere. You know, you're big when you make it on the sphere. You too, you're the rap, rap, rap, rap. I don't know how much of that. More than an academic share salary. It's half a million dollars. Okay. Half a million dollars. Wow. That's a lot of money. Wow. All right. Well, let's get into it here. So I'm going to get us started because you know what? For me personally, even I don't even really know what the current pediatric psoriasis drugs approved are. I have always kind of hated seeing kids. It's not that I mind the kids. I just don't like the parents. So I don't have a whole lot of experience with this. So I went into the literature and there was a recent review in JAD reviews March 2025. Pediatric psoriasis, biologics and oral small molecule inhibitors in modern therapy. They didn't go into sort of comparative efficacy, but fortunately, we've got another article about that that Dr. Patton is going to talk about. But just to give everybody the reminder of what's approved into what ages. So first, we've got a tanner set, which was approved by the FDA roughly in 2016. That is given weekly and the kids go through that. Right. At a limb, a map, not approved for pediatric psoriasis in the US. It is approved in Europe, though, that we've got Ustakina Mab. That's a pro so a tanner sentence approved down to age four. Ustakina Mab and the rest of the drugs I'm going to mention are approved down to age six. Ustakina Mab or still are as we have. I think it's Ustakina Mab. Ustakina Mab. I think we should take a look. Ustakina Mab. Who says Ustakina Mab? Me. How about who says Ustakina Mab? I probably switch it up. You do? You switch it up. Okay. I probably don't know how to produce it for years. He called it proof. Right. It's right. It's still working on that. Pure right. All right. So then we so we got still are we'll just say that that's easier. That's approved down to age six. And it's given it week zero week four and then every 12 weeks. So nice spacing out and it's compared to the weekly of a tanner set. Then we've got exochysmab aka a total. So approved down to age six. It is week zero week four and then every four weeks going forward. It is based weight based dosing as this stilara. Second kin Mab also approved down to age six. It is weekly for the first month. And then it goes to every four weeks also weight based dosing. And then a premel astro Tesla also approved down to age six. And that's 20 milligrams twice a day. And then if they get their above 50 kilos, it goes to the normal adult dosing of 30 milligrams twice a day. So just the level set, those are the agents that were approved as of the time of this review. However, we got a new agent approved that we are going to be talking about today. Guselcomab or trim fire. But before we get to that data, let's go on to Dr. Patton and Dr. Patton, what do you got? Yeah. So my deep dive paper was biologics for the treatment of pediatric plaques or isis, a systematic review network metanalysis by Ali Afon et al. And it was October 2025 J E A D D. And M a looked at over a thousand patients, seven randomized controlled trials, different efficacy safety measures. They did all the things a good anime studies do. My favorite line on this anime was the inconsistency was assessed via the inconsistency model. That was a good idea. Yeah. That's the best way to do it. They can so they consistently assessed the inconsistencies. I think so. Yeah. The drug studied were etanersept you stack or who stacked in your map. Seki kinemab exochysymab at alimimab because this was in the E A D D. And they also included methotrexate and fumeric acid exters, which really aren't biologics, but I guess they just wanted to make it a complete anime. As Matt said, at alimimab not at the approved treat pediatric plaques or isis, but it is approved by the EMA. So if you spell pediatric with two A's like a weirdo, you're allowed to treat kids with that alimimab. Also, he is self-emab was not included in the analysis, not yet approved in the EMA for kids. And it just got approved like last month, like about a month ago. It's a fresh, fresh approval. You can just still smell it. So results, lots of tables and graphs. And if you were after some sort of ranking, you could go to table two. One of the columns was probability of being the best, which I think Aaron Drucker, like our DOD, NMA expert, would say is a little bit simplistic, but I am a simple man with simple taste and a simple mind. So that was a table that worked for me. What did that table say? This is again, probability of being the best. I love that metric. That might be my new favorite metric. It just makes it so easy. I think we should rank residents like that too. Should do an NMA. Probability of being the best resident. I'm going to think about that. Can we do probability of being the worst resident as well? Yeah. That one's often easier. Yeah. We won't ask Dr. Kemp, which one of us was the best resident, but you know, who you think? You guys are all super strong. That was super very fluidical way of saying it. All right. So Pazzy 90, Sekikina Mab, the high dose. There were two, there was like a low dose and a high dose trial. Basically, the high dose was like 1,5300 as the weight doses. The other one was like 75, 1,5300 or something along those lines. Best Pazzy 100, what it's exochysymab, best Pazzy 75, Eustachiniumab and the children's dermatology life quality index of 0 to 1, the best or most likely to be the best was Eustachiniumab. So if you look at the forest plots for like Pazzy 90, they have forest plots for a lot of these measures. You would say that for the biologic medications, none is really statistically significantly better than any other based on the forest plots that this NMA generated. But like that doesn't make sense to me. You know, like how could XEB the best at getting pediatric patients to Pazzy 100, but not the best at getting them to 90? And in adults, the Xora S trial from like 2019, it compared Eustachin Mab head to head and the percentages of patients that reach Pazzy 75 at week 12 were 88 for XE and 68.7 for Eustachiniumab. Like, do we think that those results would be that different in pediatric patients? I just went to AI and I'm like Pazzy 90 for the trials for pediatric psoriasis. I think I said like week 12 or 16 and they just basically spit back like XE had the best followed by Cecucinamab, which was pretty close. Then Eustachiniumab, they're not Alimimab than any TAN or Cept. And that was just taking like Pazzy 90 scores from the clinical trials. So, you know, NMAs continue to confuse me. It's supposed to be the most powerful tool that you use to analyze data and tell us, you know, how can we think about these drugs? And I just want to say in this case, the NMA, like it just wasn't right, but what did you guys think? So I can't wait to hear it. Yeah, like pediatric strives that they got tough because there's the end is so small, right? So it's hard to get the power to see, you know, robust differences. That's that's my taste on it. I can't wait to hear what Dr. Cress has to say as somebody who has probably treated 157,000 patients with each of these drugs. So yeah, I did look over the articles you sent me and I agree with Tim. It's hard to figure out how, you know, just the kinnamab can get more to pass the 75, but then, you know, it's he can get more to, you know, pass the 100. I think what happens is, you know, the aisle 12 aisle 23 agent gets a lot of patients pretty much better. It's almost like the dupe of psoriasis, right? It gets a lot of patients to 75, but it kind of stalls there. Whereas if it's a, you know, say, kinnamab, it may get fewer people to 75, but if it gets them to 75, they can get them to 900. Okay. Right. Okay. Now I think in clinical practice, I have not seen a huge difference to be honest. What I use them all, you know, it's the say, a kinnamab. And there's the kinnamab or all FDA. And you can, you can use brand names on here. We're not seeing. I wasn't sure. Okay. So, you know, still there, I can't say I'd take some tults. Yeah, it kind of depends on what you get. When was the right? So, yeah. Well, wait, let's, let's go. Ferris, tell us about the new data. Tell us about the Guselcomab study. And then we'll get into more of a general discussion about all of this. Okay. Guselcomab for the treatment of moderate to severe plexerisis and pediatric also spelled with an A patients results of a phase three randomized placebo controlled pro proto star study. And this is proje potty at all in BJD also across the pond. Okay. This is a phase three study kids six to 17 years old. They were randomized to Guselcomab or placebo. But then they could also go on to, there was an arm that was open label etanersept as a comparator. I never quite, I mean, I kind of get it. But basically, what does that mean? You cannot draw statistical conclusions between the etanersept arm and the Guselcomab arm, but you're like, it's like a sniff test. Like does that look good? Yeah. Okay. That seems like what I would expect. So inclusion. I'm worried that the, what's that? They worried the etanersept was going to beat them. Like what the heck? You might know. Yeah. I don't know. I think powering it to be able to compare three different groups would have been hard, but do they wanted to have sort of like, I guess, the most commonly used biologic in there? So, you know, I think when you have these smaller studies, you got to do kind of creative things versus a face-through-adult study. Okay. Inclusion criteria. It's what we think. BSA 10% PASI 12, IGA 3 plus. But because they're kids, they had to do something different. So they also had to one or more of the following. Very thick lesions, clinically relevant facial genital or hand foot involvement. A PASI greater than or equal to 20, greater than 20% BSA or an IGA of 4. So basically what they were saying is moderate, like they really wanted them to have a criteria that really kind of pushed you more toward the severe end of moderate to severe. Okay. Double blinded, as I mentioned, weight-based. So less than 70 kilograms, 1.3 migs per kg, greater than or equal to 70 kg, the adult dosing 100 milligrams. On label, E. Tannersept was given. No comparison's made PASI of the group was around 18 baseline. Very few of them had PSA, their kids, I guess. Most had previous systemic therapy or photo therapy. And they all had to be, you know, candidates for photo or systemic therapy. And it was down to age six. Yep, down to age six. Okay. So primary endpoint was the 16 week data. So they were, they were, you know, smaller arms, basically they were either in, they're randomized either Giselle Cumab or 41 patients got Giselle Cumab 40. I'm sorry, 25 got placebo. And then 26 got randomized to that open label reference arm of E. Tannersept. And, you know, now that I think about it, maybe it all said sling to do with like, not being able to get blinded E. Tannersept, I don't know. I'm making that up. I don't know. It's, I think it's the, that it way powered it just to compare two groups. Okay. So what happened was after 16, after week 16, everybody got sort of in, they got moved over. There was a decision point. So if they had a Pazzy 90, then they were, you know, then the Giselle Cumab arm, then they would, they were withdrawal, they were taken off. And then it was like a withdrawal retreat arm. Once they lost 50% of response, then they went back on Giselle Cumab. If you weren't at Pazzy 90, you stayed on Giselle Cumab. placebo. If you did not respond, if you didn't have a Pazzy 90, then you got on Giselle Cumab. If you did have a Pazzy 90, then you got on Giselle Cumab until you lost at least 50% of your initial response, which is a kind of a weird way to look at it. And then E. Tannersept patients could either decide to roll over and go on Giselle Cumab or stop the study. There was also then a part two open label extension 28 patients that just went on to open label the Selkumab. Okay. So what did they see at week 16 patients on Giselle Cumab did better than patients on placebo. So IGA 01 66% 16% placebo. Pazzy 75 rate 76%. Pazzy 90 rate was 56%. Pazzy 100 was 34%. So you can kind of put that into context of your other NMAs, right? So I'm so so interesting that the IGA zero and the Pazzy 100 are almost never the same number. Yeah. Seems like they should be. Yeah. I know. I would like to meet the person who's like, that is an IGA zero, but a Pazzy 99 or you know, I don't know who does that. But me, they're the same. Okay, patients who got open label, E Tanner, except actually had pretty high response rates. Their IGA 01 was 69%. I mean, it's sort of like the same as the as the Trump fire group has the 75 was 69%. A little bit lower. Pazzy 90 was 54% pretty equivalent. They were actually better in adolescence than in children, probably a little bit of the weight things. But so that they did note that's like higher than what they've seen in previous studies. So take that for what it's worth. Sometimes that happens. You're like, if you want your drug to look good, have another company do the trial with your drug. You know, so that was so 85% of patients, randomized to open label E Tanner set when given that choice of go off study or crossover. They did crossover and go and Giselle Kimab. And then when we look by week 20, they did have like slightly higher rates. So IGA 01 was then six. No, it's not the same. 64% Pazzy 75 was 55% in Pazzy 90 was 36%. So it actually went down to state the same. Perfect. No, I said that wrong. Of that was the kid crossed over. Though he did crossover, they did get better. They went up to like Pazzy 90 of 91% Pazzy 75 96%. So Ferris, I don't know the data at all for adult psoriasis drugs. Is this similar to the, you know, Giselle Kimab and adults? Is it not as good? Is it better? Like do you know what's up your head? This is I'd have to, um, this is actually slight. Well, no, this is about what I would expect. So Pazzy one, it's not quite where it depends what you look at. They're a little bit all over the board. So Pazzy 100 rates for Giselle Kimab for Trump via are a little better than 34% for the oral. I'll 23 in a bit. Or it's about 40 Pazzy 100 about 60 Pazzy 90 and about 80 Pazzy 75. So these are kind of similar ish to maybe a little bit lower, but also realize the responses to Trump via are slightly higher than what you saw. I, you know, on the average, Trump via patient, then with the oral peptide. So they're, they're all in the same given the number, given the end, I would call it kind of similar. Okay. Is that a confusing enough answer? Yes. Open label. That's very good. Cheers. Peaky. Yes. Exactly. Exactly. The end brawl, the end brawl data in that trial is very generous. Those are the highest numbers I've ever seen for. Yeah. Like I remember when we were training with you, Dr. Chris, you were like a big NBRL user, but like you've got lots of experience with it. That's all we had. Yeah. I mean, prior to the study, Laura just gave the best number I ever saw. Pazzy 75 for NBRL was 59% at 16 weeks. This is a full 10 points better. So now whether they do trials a little bit differently in Europe and you know, you would already come in and you know, why is IGA zero, not all pass you 100. But yeah, I think that date is a little generous for. Yeah. So. So that now, you know, I don't use a tender step to any more kids unless I have to. Right. So yeah. And then if you look at the open label extension of the 28 kids who went on at week 52, IGA 01 was 86% Pazzy 90 of 82%. So that's kind of up there. That's like around where I would see adult numbers too. So, you know, so fit, you know, good safety data, nothing to like talk about basically nasopharyngeitis, URIs headaches like every other study. And they did look for anti drug antibodies and 18% were positive for them, but there were low titers, of course, spelled a very British way. And no anti drug antibody positive patients had neutralizing antibodies and they didn't like correlate with the pharmacokinetics or clinical response or injection site reactions or anything. So not like a no like kind of immunology signal or immun, you know, that would make you worry. So yes, trim via now approved in adults and children, six years old and older who also weigh at least 40 kilograms. And it is approved for psoriasis and psoriatic arthritis. I did think I've got to say from the, which I'm a call it the safety data. It was fat. So there were fewer people. There were fewer nasopharyngeitis cases in the gazellcomap group compared to the placebo group. Yeah, it's crazy. The drugs always cause nasopharyngeitis. You had kids kids are stunned. They get stuff all the time like that is when I see those numbers of pediatric trials of like, okay, they had colds. Right. Yes, it wasn't it's shocking. There wasn't a hundred. 100% got maybe that was really how many. Very hard. Yes. Right. So we've been we've been through the data now. So for any for those of you who do not know Dr. Doug Cress, he is. When Pat and Ferris and I were residents, he was the primary dermatologist at the University of Pittsburgh. So take care of all the kids, all the adults and all the inpatient consults. So I'm primarily a pediatric dermatologist and has been take care of pretty much nothing but kids for the last 20 years. Extremely busy. So sees an insane number of patients, you know, works closely with. APPs in order to get that done takes amazing care, but his breadth of clinical experience would be hard to hard to match. And you know, he was at ground zero whenever and braille came out as the first biologic. So that's kind of the intro for Dr. Cress. But I'm going to go in there now that I'm like a chair, I appreciate this. He was also program director of our residency program. Like you were like the guy seeing every consult every patient, you were also the program director. I mean, yeah, now that I get like how much time that takes kudos to you. I can't believe he didn't kill us all. So thank you. I did, but I did get divorced one of those years. I appreciate that backhanded way of telling everybody how old I am. I was around and braille was launched in 1999, which is hard to believe. That's been out 26 years. Wow. Let's let's start. So, you know, I'm sure that all of our listeners are very, you know, treat a lot of adult psoriasis. I'm sure a lot of them treat some pediatric psoriasis because it's, you know, it's not always easy to access a pediatric dermatologist. But so in your, you know, thumbnail sketch. What's the difference in, you know, kid and an adult walk in. You know, you go from roommate to room B. They've got similar psoriasis, you know, 15% PSA, whatever. How do you think about kids differently? Are you, are you less likely to go to a systemic and a kid? Are you more likely like what do you, how's it work? So a couple differences. So first, you know, for those who don't know me on the podcast, I'm pretty aggressive as pediatric dermatologist goes. So I'm not less likely to go to a biology if the kid needs. I think just like our adult patients, you know, we want to maximize topical therapy that's reasonable. And we have some new options and beads that I'll touch on. But you know, I think once you have more than 10, 15% body service area, you have to consider systemic there. Couple differences between kids and adults. One, we see a lot of facial psoriasis. Very commonly kids, you know, we all see the scalp, but in kids, we often see it on the face, eyelids. One of the things I'll do there, it's one of the new options we have is the reef. We have the reef approved now down to age six. So I love that, typically for the face. Remember kids get a lot more inversoriasis. So we see armpits, we see kind of private area, even when they're not in diapers. See less scale. You know, a lot of people think it's intertri-go, but you know, don't be fooled. Again, you know, Zaree was a nice thing there just because it's a sensitive area. And then we see a lot of guttites, psoriasis and kids, right? So you have to make sure they have an extra throat. You want to kind of cover for that. Otherwise, wait, Doug, I have a question for you here. So I remember when I, Dr. Jay, so Pat and Ferris, I don't know if they've even met Dr. Jay. He was the chair. Whatever I was a medical student at the University of Pittsburgh, he passed away before I started residency. But I remember as a medical student, him talking about type one psoriasis and type two psoriasis. And it was like one of them started in childhood and had a positive family history and was much more recalcitrant to therapy. If that, or do you, you know, if you get psoriasis as a kid, is it an indicator of tartar to treat? Now, I think that may have passed with him. I think that was kind of his thing. You know, look, we see, if you think about psoriasis patients, you know, what do you think is the incidence in the adult patient population? Two to three percent in the US? We live with that. Right. So there's some data different than what was in the articles you guys read today. But that suggests about 10% of that two to three percent present before the age of 10. Only two percent of that two to three percent before the age of two. Okay. Well, probably in common under 10. So, you know, as far as, you know, their progression. I mean, I think they do the same. And I heard you mentioned, you know, their kids, they don't have psoriasis arthritis. They do, actually. If you look at the data, they have the same incidents of psoriasis arthritis that adults do, people just don't ask. You know, you all have kids or any of your kids ever told they had growing pains. I felt it. I always felt it. I always felt it. You know, if you see somebody, a kid with psoriasis and growing pains, they probably have early psoriasis arthritis. And again, the rheumatologist we're never going to call it that. I call it psoriasis arthritis. I don't know if you're going to call it psoriasis arthritis, but you know, we should get them on a biology at that point. Yeah. And now we're going to switch over to study. It was a very low percent, but you're right. Like how carefully were they screening them? Right for the kids. Yeah. Right. You know, especially if it's extremely adults, if you see a lot of nail-pitting, you know, you really got to look for psoriasis arthritis. I kind of don't know an x-ray, but I do think you can alter these kids progression if you get them on a biology girl. Go ahead, man. So, how many, by how many topicals will you try in a kid? So, right, there's, there's the kid who's, you know, 20, 30% BSA, who you're sort of going to go to a systemic kind of right away. But the kid who's, you know, 10, 15, 20% who you couldn't treat adult who was 20% topically, but you could a kid. Right. How, how many ages do you try before you? I mean, I'll probably do two or three. I might give them try and sit alone and dovonex, you know, the first time I see them. And if they're not better, you know, I might go to Colbetisol, but you know, I'm not going to keep screwing around at that point. Okay. And then I'll try to go to a biology if I can, you know, until trim fire came out, I did prefer stilair just because it was the fewer shots. Yeah. For kids, even though just like an adult stilair loses some efficacy about 10 weeks. In fact, you know, in our market, which Tim knows well, you know, you guys abandoned us there in Pittsburgh, but, you know, we have such mean managed care. I often don't get to choose what age and I want to get. Yeah, I was going to say there are. So I think you stuck in you, ma'am. It's up to like six, maybe five biosimilars. Do you see that as pretty much driving what they're going to let you do because. In fact, that just happened today. I had a kid in that I've had on stilair for years doing great. And they said we had to switch, but I have to tell you, I have had many fewer issues with stilair biosimilars, although it's newer. I've had terrible issues with ramicated biosimilars and humor biosimilars in my cron psoriasis overlap patient population. I don't know if you guys want to go there, but I have had a lot of issues with humor and ramicated biosimilars, but not gets the layer. Yeah, I. Humira world is tough because there's so many of them, right? Yeah, okay. It's not. And then now we're hearing that, you know, certain insurance is only cover certain biosimilars. Yeah, we've had that happen. It's not a lot. And then the thing you have to use this one and then you'll prescribe it and they're like, that's not available anymore. I'm like, okay, well, I guess your stock because that's what you got to use. And if you don't, we're not going to approve it. Yeah. But I mean, I'm super excited about the triumflying rate that, you know, I don't know if we can get it. But I love the idea of the 23 kids and, you know, the pill get approved to 12. It did, right? 23. It's not approved yet. It didn't try as in pediatric trials. Yeah. So that'll be me. That'll be even. So I'm curious, your question. So every time I talk to, or your answer, I talk to industry, they're like, what do you think? What are you going to do when you've got a pill? And you've got a shot that's both, you know, inhibit the aisle 23 pathway. And I'm like, I don't know. Like people can choose. And I was, I mean, you know, I'm like, some people would be like, I would way rather take a shot every three months than take a pill every day. You know, some kids aren't good at swap. Like what do you think parents and kids want? Do you think they want to pill more than that? Well, look, the counter to that theory is a Tesla. Yeah. I mean, Tesla's not the best drug we have for psoriasis. And it does $3 billion a year. Yeah, but that's because it's so safe. It's, it's poorly tolerated. But it's so you don't have to talk to people about immunosuppression or anything else. How safe is the oral aisle 23 going to be? I think it's going to be awfully safe. I mean, the data look very good. And yeah, I mean, if I could get a safe oral, I would so much rather, you know, you guys haven't been in my office in a long time. The most common sand you hear in my office is screaming of kids who are getting a shot. This could just be worse. So now it's the kill. Okay. But families aren't comfortable to do it, right? Even if it's a couple times a year. You know, poor Dr. Pat and shares an office with another pediatric dermatologist that every now and then one of her patients comes in to get a shot and poor Dr. Pat has to hear the screaming. Yeah. Okay. So it really, it is real. And with kid, that is going to be a big deal to be able to have a pill. And especially if we get a pill with no labs, which is, I think, one of the most appealing things about Tesla. I mean, I had two kids in today, clear on Dupy and the parents are like, we need to stop because they just don't want to do a shot anymore. The anxiety, it's so stressful. The kids were bawling when they came into my office today thinking they were going to get a shot even though they didn't because we stopped. Wow. Yeah. Wow. So for kids, I think a pill is always going to be better. If you don't have to do labs. Right. So it's a difference. You've been doing this long enough now that you'm sure you've got plenty of kids who started, you know, especially with the psoriasis drugs, you know, that's been five, 10 years they've been on shots now. Do you think it scars any of them long term where they're like medical, you know, medical anxiety for the rest of their life because of the, you know, terror of the shots? I don't. The ones that have true needle phobia and true needle phobia, that's a thing. I mean, that is a real serious thing and some adults have it too, right? Yeah. So, you know, the kids that truly have needle phobia can't stay on the biologics. We try and they just can't and then we have to do topicals and look now we have a lot of new topical choices, right? More for AD than psoriasis, but it's, you know, unbelievable what we can offer these kids now. So in recent years, since Tulsa and Cocentic's got approved for psoriasis, if we take insurance out of the picture and just say you could pick, you know, Tulsa, Cocentic, Stilara, just, and, you know, it is going to, you're going to offer all of them to the patients and blah, blah, blah, blah. What, you know, how did you, or how do you kind of present them to patients? How do you differentiate it? That's easy. So, I tell them they're four, right? And then, Braille approved to age four, been out the longest for sure the safest, least effective shot once a week. And then Cocentic's and Tulsa, which I think are similar. I like Tulsa a little bit better because I think the dosing is a little bit easier now that they have the pediatric formulation. And I think it's a little quicker, just my personal experience, but I think they're similar. And then, it's the way, which I think has good data. And, you know, basically after the two loads, you know, it's four shots a year. So I usually nudge people to do that just because I think it's the easiest and best for kids. And I do think the data is a little bit better than what you guys presented. I've seen some other data that I thought was a little better. But, you know, that I try to get what the parents and I decide on, but that's not always what we get. Yeah. I don't know if this happened to you guys. I routinely have had patients on Tulsa Cocentic's and a year in, the insurance tells me I have to switch to the other one. Yes. Okay. Which I do. I don't know if it's a big deal. Yeah. But, you know, I think Trump, I probably would all go to. I just have no idea if I'll be able to get it first line. Yeah. I like the IL-23 pathway safety now, safety. Yeah. So, and continue. How much worried are you about the IBD signal? Did they still, they have that signal with these 17s? Do you see parents saying, what about this IBD? How come these, this group has that and the other ones don't? Yeah. I thought that was interesting and I thought that percentage they quoted was higher than made me super happy actually. And it was one of the three articles. Look, I think that's probably one of the reasons that I pursue this still air if I can get it. Okay. You know, I work pretty closely with the PGI group because you can't imagine there's a tremendous amount of overlap between, you know, psoriasis and Crohn's and HS. You know, they don't seem hugely worried. You know, they don't tell me I can't put these kids in IL-17 agents if I need. And knock wood, I mean, I haven't seen a case that I can think that happened to me. And like Matt said, I see a lot of these patients. But, you know, it's in the back of my mind. Doug, I'm going to ask you a question that always comes up when I talk about biologics. And this is more relevant to kids. What do you do about vaccines? Give your, everyone's going to want to know. Because kids need them. Right. So, that is the one downside is still air, right? Because it's in for a long time. So, first thing you want to do is get everybody caught up on vaccines before you start a biologic if you can. Right? And often you can do that. Like, you know you're going to get ready to start a biologic. Non-life vaccines, right? Not an issue. And live vaccines are only a theoretical issue, right? So what I do, like let's say you're going to give for Tulsa Cocentix, right? You're giving it monthly. So they take their shot. Now they're due to their next shot. You don't give it. Right? And if you think about immunoglobin class switching from, you know, IgM to IgG, it generally takes about two weeks. So theoretically you could start back up two weeks later. You know, if not you could start back up a month later. But for monthly drugs, I just skip one shot and get them vaccinated on that time the shot would be due. All right. So tell what do you, so what I tell people with, you know, with Dupy. So let's go to a different drug here. This is a different conversation, right? So I tell people with Dupy to not skip any doses because I've seen enough kids who you skip one dose and they're exome flares. And now they're risked for a staff infection. But, you know, just because AD is so much faster of a disease, is that what do you skip Dupy doses or do you? No, for Dupy I do it a little bit different. So again, if it's a non-life vaccine, if it doesn't matter, among friends, if it's a live vaccine, we have data that shows her Dupy, it doesn't matter anyway, right? But medical legally, the rest of us have to tell people they need to stop her shot. I know you don't, but medical legally they're, they're sick. But so for Dupy, if they're cute two week Dupy, right? I skip one shot, right? Then a month in, given the vaccine. So again, it's a month later and then two weeks later, stop. So they're really only off, you know, about four to six weeks and I would manage with topicals in the midst. Because the pediatricians that I work with, you know, they read package inserts. They're just not going to give the vaccines if the kids on Dupy, even if I talk to them. So I do take very short breaks from Dupy if they're, you know, the younger kids who get most vaccines, obviously, and Dupy six and under is monthly anyway. So they just take their shot, a month later, get their vaccine, a month later, start back up. If you call the company, they tell you to stop Dupy for three months, get the vaccine and then take a shot three months later, which is absurd scientifically, but that's what the lawyers want. So, but again, there was a huge study in Brazil, live vaccine, Dupy, everybody did fine. Yeah. You know, everybody did. Yeah, lof, even. Very exciting. You know, even if we talk about, you know, from five and six year olds, what immunologically does Trump fight? It's going to keep you from mounting inappropriate antibody response to vaccine. Yeah. Nothing. It's just class labeling. So yeah, it's frustrating that in just the absence of data, the assumption is risk. When there is risk to stopping these drugs, right? There's not a ton. I know he's slipping a shot. I haven't found any trouble really. Either with Dupy or the biologist. Yeah. Stilera is trickier. That's tougher. You give people off with stilera if you do it. You know, if you think about two, three months, you'd ask to have them take a shot and then wait three months, get a vaccine and then take the next shot a month later. Yeah. Yeah. Yeah. All right, Pat and Ferris, you got anything else you want to ask Doug while we've got him on here? Oh, conventional therapies, methotrexate. I mean, do you have to use those at all anymore? Is it easier and case even then? There are still some insurance companies that require a three month failure of methotrexate. If we have a few, I hope other areas of the country do. but we still have a few. And look, it's not that metatrixate doesn't work. Yeah, you know, like I have kids that I have to put on metatrixate for alopecia areata before I can get them on the fullo. Yeah, it works, you know, not well. And nobody wants to kid on metatrixate, right? Right. But yeah, I still have kids on metatrixate for both alopecia and psoriasis. I almost never have to do it anymore for eggs alone. I mean, there's so many options of 12. Yeah, but I still have some psoriatic somnatatrixate. Especially if they're kids like Pat who start drinking at age nine, you really gotta worry about that liver toxicity at that age. Nine in the morning is what you're talking about. So it's been about each other a long time. I seem to remember I was somewhere where one of Matt's children was young enough that he was holding him like this and having him taste the beer. So I'd be careful. I got a long memory. [LAUGHTER] Yeah. How old that kid is now? Probably a college. No, yeah. Margaret is now a senior at the University of Virginia. Yeah. That's what I figured. We have president of a sorority applying for full-bright scholarship. She's just like that. Oh my god. Yeah. Yeah. They're just start 'em early. That's the lesson there. Yeah. All right. So let's move on to our everybody's favorite segment, our trivia segment. So Doug, here's how it works. OK. Pat and is going to read a question. You have to let 'em finish reading it. But then as soon as he finishes reading it, you shout out, you know, whatever your best guess is. Whoever sounds out the answer first gets it. We'll typically do three questions. OK. All right, Pat. And it's all pediatric stuff, keeping with the theme. OK. And 1948, Sophie Spitz described 13 cases of juvenile melanoma in patients that ranged in age from 18 months to 12 years. How many of these 13 patients died from their melanoma? One. 70%. Somebody said one. It was one. It was one. Yeah. One of the patients died, 12-year-old girl. She still brought up the fact that this was a very low percentage. It was like 7%. She compared it to a group of patients from like 13 to 18. It was like it was 70%. And so it's kind of like there's something about these things that we call melanomas in very, very young kids where they're just not the same thing. But it was like a seminal landmark. I was back in the day if you lost one out of 12 kids, you're like, that's fine. Yeah. Yeah. Yeah. For the farm. Yeah. 1948, right? What's that? I was asking, Doug, what do you do with Spitz-Neevi these days? If people complete oxygen, you're in alone. I mean, if they're not doing anything, we just watch them. We monitor photographically. If we cut them out and they're all atypical, we re-excise. But we'd see a lot of Spitz-Neevi that are stable. Yep. That would drive me crazy. All right. All right. Number two, erythema infectosum is also known as fifth disease. It was so named because it was listed as the fifth disease in a list of rash-causing illnesses. What was first disease? Measles. Measles. Rosiola. It was measles. Rosiola was-- That fourth? Third? No, you know what? Fourth was dukes, which they're like that. That was probably just the best classification. I think Rosiola is six. There's six. Is that six? Rubyola was third. Second was Scarlet fever. I usually have residents with you to answer these questions. Yeah. Well, we're on the front line now. We got to talk about your own. Last one, it's a little bit wordy. All right. So we talked about biologic psoriasis. I think they've revolutionized the treatment for both pediatric and adult patients. But another revolutionary pediatric germ therapy, at least in our time, was using proprandal all for the treatment of congenital hemangiomas. The widespread adoption of this treatment followed a case series published in the New England Journal of Medicine in what year? All right. 2006. I'm going to go with 2003. No, 2005 was 2008. Wow. Yeah, it was like a letter to the editor of, hey, we treated these 11 kids. I think this is like the new treatment. And it was that of the Nick, you and Paris. Yeah, right. I can remember starting to do that as a resident. Yeah, during right when we started. That worked in our residency. OK. Did you use my topical Timalol at this point? I do. I love topical Timalol, if you catch them early, especially on the face or under the diaper. Do you use it for piegenic granulomas? I do. How else it worked for those? I think it doesn't work as well. But it can save-- I see a lot of autistic kids who facial surgery is going to be really difficult. I try the Timalol. I think it works more often than it does. OK. We've talked about the other day about Timalol for hand fissures and for fissured skin and hand dermatitis, right? Yep. Yeah. From like 2021, it was a single case report. Somebody's doing an actual study on it now. Doesn't work for like the hand x-men in general. But for the fissures, like you get on your fingertip or something, it actually can help accelerate the healing. They came up with this idea because there's some data showing that Timalol helps with poorly healing wounds. So lower extremity wounds, they'll use Timalol or the edges. And it does seem to help. And just for our listeners next week's episode, I'll be covering this. But there was also just an article about using Timalol for spider angiomas and kids. So that? Yeah. So it was not terribly effective, but it's something. That one I haven't tried. Most of my patients don't seem terribly bothered by those. Yeah. They're not surprised. It works for some. Yeah. Made some sense. It was really wide. What's that? Yeah. Don't know why. Yes. No idea why. I mean, I think it's correct again, imbalancing the humors. You guys know the humors. Yeah. That would do. Well, Doug, thanks for coming on. It was great having you on and great having this conversation about pediatric psoriasis for all of our services. Thanks for joining us this week. I hope you learned a few things. Hope you laughed once or twice. And mostly we're hoping you're planning to join us next week. And until then, I'm Matt Zyrus. I'm Tim Patton. And I'm Laura Ferris, and we are Derms on Drugs.