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Original Investigation |

Antibiotic Exposure, Infection, and the Development of Pediatric Psoriasis A Nested Case-Control Study

Daniel B. Horton, MD, MSCE1,2,3; Frank I. Scott, MD, MSCE1,4; Kevin Haynes, PharmD, MSCE1,5; Mary E. Putt, PhD, ScD1; Carlos D. Rose, MD, CIP2; James D. Lewis, MD, MSCE1,4; Brian L. Strom, MD, MPH1,3
[+] Author Affiliations
1Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
2Division of Rheumatology, Nemours A.I. duPont Hospital for Children, Thomas Jefferson University, Wilmington, Delaware
3Rutgers Biomedical and Health Sciences, Child Health Institute of New Jersey, New Brunswick
4Division of Gastroenterology, Hospital of the University of Pennsylvania, Philadelphia
5Clinical Epidemiology, HealthCore, Wilmington, Delaware
JAMA Dermatol. 2016;152(2):191-199. doi:10.1001/jamadermatol.2015.3650.
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Importance  Antibiotics disrupt human microbiota and have been associated with several pediatric autoimmune diseases. Psoriasis activity has been linked to group A streptococcal and viral infections.

Objective  To determine whether antibiotic exposure and infections are independently associated with incident psoriasis in children.

Design, Setting, and Participants  This nested case-control study used data from the Health Improvement Network database, a population-representative electronic health records database from the United Kingdom, from June 27, 1994, through January 15, 2013. Data were analyzed from September 17, 2014, through August 12, 2015. Children aged 1 to 15 years with newly diagnosed psoriasis (n = 845) were compared with age- and sex-matched controls (n = 8450) randomly chosen at the time of psoriasis diagnosis from general practices with at least one case, excluding children with immunodeficiency, inflammatory bowel disease, and juvenile arthritis.

Exposures  Systemic antibacterial prescriptions and infections of the skin and other sites within 2 years before psoriasis diagnosis.

Main Outcomes and Measures  Incident psoriasis as determined by validated diagnostic codes. The association of antibiotic exposure and infections with incident psoriasis was determined by conditional logistic regression, adjusting for confounders.

Results  After adjusting for matching, country, socioeconomic deprivation, outpatient visits, and infections within the past 2 years, antibiotic exposure in the last 2 years was weakly associated with incident psoriasis (adjusted odds ratio [aOR], 1.2; 95% CI, 1.0-1.5). The associations for infections of skin (aOR, 1.5; 95% CI, 1.2-1.7) and other sites (aOR, 1.3; 95% CI, 1.1-1.6) were similar. Untreated nonskin infections (aOR, 1.5; 95% CI, 1.3-1.8) but not antibiotic-treated nonskin infections (aOR, 1.1; 95% CI, 0.9-1.4) were associated with psoriasis. Results were similar when using a lifetime exposure window. Different classes of antibiotics and age of first antibiotic exposure were also not associated with psoriasis. The findings did not substantively change when excluding periods of varying length before diagnosis.

Conclusions and Relevance  Infections are associated with the development of pediatric psoriasis, but antibiotics do not appear to contribute substantially to that risk.

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Incidence of Psoriasis by Age and Sex in the Source Population

The incidence of pediatric psoriasis in the study’s source population in The Health Improvement Network (THIN) is presented across 4 age groups stratified by sex. Error bars indicate 95% CIs.

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