Managing children with IMIDs in 2025

Managing paediatric patients with immune-mediated inflammatory diseases (IMIDs) is challenging. Physicians must consider both the child and their family, carefully plan vaccination schedules around systemic treatments, and account for the specific side effect profiles of advanced therapies in paediatric patients. Dr Jan Gutermuth (University Hospital Brussels, Belgium) shared his insights on managing children with IMIDs [1].

“IMIDs are chronic inflammatory diseases caused by immune system imbalances,” explained Dr Gutermuth. “Importantly, paediatric patients with IMIDs tend to have more aggressive disease phenotypes than those with adult-onset IMIDs, and they also have an elevated risk of developing other IMIDs [2].” Common IMIDs in paediatrics include atopic dermatitis, juvenile idiopathic arthritis, inflammatory bowel disease, psoriasis, and juvenile systemic lupus erythematosus.

Dr Gutermuth noted that physicians generally follow a step-up strategy for paediatric IMID patients. First-line options include topical treatments, dietary adjustments, physiotherapy, NSAIDs, and patient/family education. Second-line options involve systemic steroids and classical systemic immunosuppressants like methotrexate and ciclosporin. Third-line therapies comprise biologic therapies and kinase inhibitors. “Doctors with unlimited resources would probably use biologics over classical systemic therapies, because these modern drugs are often more effective and may have fewer side effects than classical drugs, especially systemic corticosteroids,” said Dr Gutermuth. “However, biologics are more expensive, which significantly impacts reimbursement systems.” The latest European guideline for paediatric atopic dermatitis places biologics, JAK inhibitors, and conventional systemic drugs at the same step of the stepped-care plan [3]. “I prefer this horizontal approach over the traditional 3-step model,” said Dr Gutermuth.

It is essential to recognise that children have different physiological characteristics compared with adults. For example, many children have difficulty swallowing large tablets. Additionally, paediatric dosing requires precise calculations based on body weight or surface area, and drug safety profiles may vary.

Focusing on safety, high-dose glucocorticoids are linked to an increased risk of serious infections, whereas this risk is lower with methotrexate and intermediate with biologics and JAK inhibitors [4]. Systemic corticosteroids are also associated with growth and developmental impairments [5]. “That’s why I prefer steroid-sparing therapies when possible, or otherwise perform regular growth assessments and bone health monitoring,” added Dr Gutermuth. In general, immunosuppressive therapies offer benefits like reduced risks of intestinal lesions, malnutrition, certain cancers, and cardiovascular events. However, they also increase the risk for opportunistic infections, lymphomas and skin cancers. Drug-class-specific risks include bone marrow suppression (thiopurines) and interstitial pneumonitis (methotrexate) [6]. “Specific concerns in children include an increased lifetime cumulative malignancy risk, heightened skin-related immune responses, and the diagnostic overlap between drug reactions and common paediatric conditions such as eczema,” Dr Gutermuth explained.

Dr Gutermuth also addressed vaccination in paediatric IMID patients. Inactivated vaccines are safe but may be less effective if the patient is already on immunosuppressants. Ideally, vaccination should begin at least 2 weeks prior to treatment initiation. Additionally, vaccinating household contacts and providing vaccines for HPV and pneumococcal disease should be considered. “Live attenuated vaccines carry a risk of vaccine-induced infections,” said Dr Gutermuth. “They should be administered at least 4 weeks before starting immunosuppressive therapy. If needed during ongoing treatment, immunosuppressants should be paused, respecting the washout period, and restarted 2–4 weeks after vaccination.”

Dr Gutermuth gave practical advice on administering injections to children: “Create a calm environment, use a gentle voice, and engage the child with genuine interest. Have them sit on their caregiver’s lap and use comforting language”. Additional support includes local anaesthesia and distractions like tablets or VR devices. For oral medications, ideal formulations include chewable or dissolvable tablets, crushed capsules, or liquid preparations.

Another key topic was the psychosocial impact of IMIDs. “IMIDs can exert cumulative life-course impairment, beginning with early comorbidities extending to stigmatisation, social exclusion, and psychological distress [7,8],” Dr Gutermuth noted. Strong social support and effective coping mechanisms are critical [9].

“Treating early can limit this cumulative burden,” he emphasised. “The concept of hitting hard and early, long discussed in rheumatology, may now be relevant in dermatology.” For instance, in one study, adolescents with atopic dermatitis treated with dupilumab for 18 weeks showed 43.3% clear/almost clear skin at 5 years without retreatment; 60.3% of children aged 6-11 achieved the same outcome [10,11]. “This suggests potential disease modification through early, intensive therapy,” said Dr Gutermuth. A retrospective study of 4,384 children showed that those on dupilumab had a 40% lower risk of asthma and a 31% lower risk of allergic rhinitis than those on conventional systemic therapies [12]. “The younger the patient, the greater the benefit,” he added.

Finally, Dr Gutermuth highlighted that treatment adherence depends heavily on family engagement [13]. “Peer support and multidisciplinary, integrated care, involving dermatologists, paediatricians, rheumatologists, nurses, and psychologists, are essential to achieving the best outcomes,” he concluded.

1. Gutermuth J. Managing children with IMIDs. SPIN Dermatology Congress, Paris, France, 2-4 July 2025
2. Malham M, et al. Aliment Pharmacol Ther. 2024;59:1551-1558
3. Wollenberg A, et al. JEADV. 2025;00:1-30.
4. Riley T, et al. RMD Open. 2021;7(1):e001235
5. De Vleeschhauwer F, et al. Children. 2024;11:951
6. Beaugerie L, et al. Clin Gastr Hepat. 2019;17:370-379
7. Kimball AB, et al. JEADV. 2010;24(9):989-1004
8. Bieber T, et al. Nat Rev Drug Disc. 2023;22(8):662-680
9. Foulkes AC, Warren RB. Curr Probl Dermatol. 2013;44:145-57.
10. Cork M, et al. Dermatol Ther. 2023;13:2697-2719
11. Siegfried I. Oral presentation, 2024 ESPD Congress, 2-4 May, Kosice, Slovakia.
12. Lin T-L, et al. JAAD. 2024;91(3):466-473
13. Ferraro K, et al. Front Ped. 2024;12:1428758

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Posted on 21 August 2025