Objective: To investigate the relationship of excess and central adiposity with pediatric psoriasis severity. Design, Setting, and Participants: Multicenter, crosssectional study of 409 psoriatic children. Psoriasis was classified as mild (worst Physician's Global Assessment score≤3 with body surface area≤10%) or severe (worst Physician's Global Assessment score ≥3 with body surface area >10%). Children were enrolled from 9 countries between June 19, 2009, and December 2, 2011. Main Outcome Measures: Excess adiposity (body mass index percentile) and central adiposity (waist circumference percentile and waist to height ratio). Results: Excess adiposity (body mass index≥85th percentile) occurred in 37.9% of psoriatic children (n=155) vs 20.5% of controls (n=42) but did not differ significantly by severity. The odds ratio (95% CI) of obesity (body mass index ≥95th percentile) overall in psoriatic children vs controls was 4.29 (1.96-9.39) and was higher with severe (4.92; 2.20-10.99) than with mild (3.60; 1.56- 8.30) psoriasis, particularly in the United States (7.60; 2.47-23.34, and 4.72; 1.43-15.56, respectively). Waist circumference above the 90th percentile occurred in 9.3% of the control (n=19), 14.0% of the mild psoriasis (n=27), and 21.2% of the of severe psoriasis (n=43) participants internationally; this incidence was highest in the United States (12.0% [n=13], 20.8% , and 31.1% , respectively). Waist to height ratio was significantly higher in psoriatic (0.48) vs control (0.46) children but was unaffected by psoriasis severity. Children with severe psoriasis at its worst, but mild at enrollment, showed no significant difference in excess or central adiposity from children whose psoriasis remained severe. Conclusions: Globally, children with psoriasis have excess adiposity and increased central adiposity regardless of psoriasis severity. The increased metabolic risks associated with excess and central adiposity warrant early monitoring and lifestyle modification.