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JAMA Dermatol. 2020 Feb 5. doi: 10.1001/jamadermatol.2019.4835. [Epub ahead of print]

A Comparison of Psoriasis Severity in Pediatric Patients Treated With Methotrexate vs Biologic Agents.

Author information

Department of Dermatology, Radboud University, Nijmegen, the Netherlands.
Department of Dermatology, Northwestern University, Chicago, Illinois.
Department of Pediatrics, Northwestern University, Chicago, Illinois.
Department of Pediatric Medicine, Dermatology Section, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
Department of Dermatology, Mayo Clinic, Rochester, Minnesota.
Department of Dermatology, Rady Children's Hospital San Diego, University of California, San Diego.
Department of Pediatrics, Rady Children's Hospital San Diego, University of California, San Diego.
Department of Dermatology, Phoenix Children's Hospital, Phoenix, Arizona.
now with the Department of Dermatology, UCLA (University of California, Los Angeles).
Department of Dermatology, University of Massachusetts Medical School, Worcester.
Department of Dermatology and Allergy, Herlev-Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark.
Department of Dermatology, Hôpital Victor Dupouy Argenteuil, Argenteuil, France.
Department of Dermatology, St Louis University School of Medicine, St Louis, Missouri.
Department of Pediatrics, St Louis University School of Medicine, St Louis, Missouri.
Department of Dermatology and Allergy, Charité- Universitätsmedizin, Berlin, Germany.
Department of Dermatology, Heim Pál Children's Hospital, Budapest, Hungary.
Department of Dermatology, Boston Children's Hospital, Boston, Massachusetts.
Department of Dermatology, Medical College of Wisconsin, Milwaukee.
Department of Pediatrics, Medical College of Wisconsin, Milwaukee.
Paediatric Dermatology Department, Nottingham University Hospitals, Nottingham, England.
Department of Dermatology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.
Department of Dermatology, University of California, San Francisco Medical Center, San Francisco.
Department of Pediatrics, University of California, San Francisco Medical Center, San Francisco.
Department of Dermatology, Ghent University Hospital, Ghent, Belgium.
First Department of Pediatrics, Agia Sofia Children's Hospital, University of Athens Medical School, Athens, Greece.
Psoriasis Center at the Department of Dermatology, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany.
Department for Health Evidence, Radboud University, Nijmegen, the Netherlands.



Few studies have compared the use of methotrexate and biologics, the most commonly used systemic medications for treatment of moderate to severe psoriasis in children.


To assess the real-world, 6-month reduction in psoriasis severity and long-term drug survival (rate and duration of adherence to a specific drug) of methotrexate vs biologics in plaque psoriasis in children.

Design, Setting, and Participants:

A retrospective medical records review was conducted at 20 European and North American centers. Treatment response was based on site-reported Psoriasis Area and Severity Index (PASI) and/or Physician Global Assessment (PGA) scores at baseline and within the first 6 months of treatment. Participants included all 234 consecutively seen children with moderate to severe psoriasis who received at least 3 months of methotrexate or biologics from December 1, 1990, to September 16, 2014, with sufficient data for analysis. Data analysis was performed from December 14, 2015, to September 1, 2016.

Main Outcomes and Measures:

PASI, with a range from 0 to 72 (highest score indicating severe psoriasis), and/or PGA, with a scale of 0 (clear), 1 (minimal), 2 (mild), 3 (moderate), 4 (severe), and 5 (very severe).


Of 234 pediatric patients (103 boys [44.0%]; 131 girls [56.0%]) treated with methotrexate and/or biologics, 163 patients (69.7%) exclusively received methotrexate, 47 patients (20.1%) exclusively received biologics, and 24 children (10.2%) received methotrexate and biologics sequentially. Of the latter cohort, 23 children were treated initially with methotrexate. Mean (SD) age at initiation was 11.6 (3.7) years for methotrexate and 13.3 (2.9) years for biologics (73.2% for etanercept) (P = .002). Among patients evaluated by a scoring method at 6-month follow-up, 75% or greater improvement in PASI (PASI75) was achieved in 12 of 30 patients (40.0%) receiving methotrexate and 20 of 28 patients (71.4%) receiving biologics, and PGA was clear/almost clear (PGA 0/1) in 41 of 115 patients (35.6%) receiving methotrexate and 18 of 37 patients (48.6%) receiving biologics. Achieving PASI75 and/or PGA 0/1 between baseline and 6 months was more likely with biologics than methotrexate (PASI75: odds ratio [OR], 4.56; 95% CI, 2.02-10.27; P < .001; and PGA 0/1: OR, 2.00; 95% CI, 0.98-4.00; P = .06). Decreased mean PASI and PGA scores were associated with biologics more than with methotrexate (PASI effect, -3.13; 95% CI, -4.33 to -1.94; P < .001; and PGA effect, -0.31; 95% CI, -0.56 to -0.06; P = .02). After 1, 3, and 5 years of use, overall drug survival rates for methotrexate were 77.5%, 50.3%, and 35.9%, and for biologics, the rates were 83.4%, 64.3%, and 57.1%, respectively. Biologics were associated with a better confounder-corrected drug survival than methotrexate (hazard ratio [HR], 2.23; 95% CI, 1.21-4.10; P = .01). Discontinuation owing to lack of response was comparable (HR, 1.64; 95% CI, 0.80-3.36; P = .18).

Conclusions and Relevance:

Methotrexate and biologics appear to be associated with improvement in pediatric psoriasis, although biologics seem to be associated with greater reduction in psoriasis severity scores and higher drug survival rates than methotrexate in the real-world setting. Additional studies directly comparing these medications should be performed for confirmation.

[Available on 2021-02-05]

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