A slightly overweight 9-year-old child was diagnosed with plaque psoriasis. He was previously given a topical ointment for treatment, which did not yield positive results. He currently complains of severe itching and burning on the backs of his legs, arms, face, and scalp, which has worsened. On examination, there are raised, red, and slightly bleeding plaques observed on his legs, arms, scalp, back, and face. Which treatment options would you opt to try next in this young patient? Also, what biologics can be used in children with moderate to severe plaque psoriasis?
HEALTHCASTS COMMUNITY RESPONSE
This patient case was posted to the Healthcasts peer-to-peer community, and 180 unique opinions were contributed. The case was reviewed and assessed in March 2020. The following is a synopsis of their treatment plan recommendation.
A summary of physician responses follows.
MOST POPULAR TREATMENT OPTIONS
“Conservatively, we could try phototherapy, as the risk for side effects would be low.”
Of the nearly 180 responses, 74 percent of respondents recommended etanercept/Enbrel and 37 percent of respondents recommended phototherapy/UV light therapy, the most commonly recommended treatment options. Many physicians suggested Enbrel due to its FDA approval for use in treating pediatric patients age 2 and older, while phototherapy was suggested due to its ability to produce fewer side effects than biologics. Respondents made the following statements: “Enbrel can be used, though I would try phototherapy first for safety reasons” and “Conservatively, we could try phototherapy, as the risk for side effects would be low.”
OTHER TREATMENT OPTIONS FOR CONSIDERATION
Topical steroids were suggested by 35 respondents (19 percent) in combination with phototherapy, psoriatic cleansers, and moisturizers. Ustekinumab/Stelara was suggested by 33 respondents (18 percent), though 12 other respondents pointed out that Stelara is approved for use only in children age 12 and older. Other popular medications recommended for the treatment of pediatric plaque psoriasis included methotrexate (17 percent) and cyclosporine (5 percent).
BIOPSY RECOMMENDED TO CONFIRM DIAGNOSIS
“If the biopsy is consistent with psoriasis, Enbrel would be a therapeutic treatment option; however, I would seriously consider phototherapy before recommending a biologic.”
About 28 respondents (15 percent) suggested having the patient undergo another biopsy to confirm plaque psoriasis and to rule out other conditions with similar symptoms such as atopic dermatitis and staph infection. The majority of physicians who recommended biopsy suggested phototherapy, systemic therapy, and biologics with confirmation of plaque psoriasis. One respondent stated, “If the biopsy is consistent with psoriasis, Enbrel would be a therapeutic treatment option; however, I would seriously consider phototherapy before recommending a biologic.”
PATIENT COMPLIANCE AND LIFESTYLE CHANGES
“Topical corticosteroids in the correct strength and potency should have at least provided some symptomatic improvement if used correctly, so compliance may be an issue.”
A handful of respondents suggested working with the patient and parents on weight loss methods and education surrounding healthy lifestyle changes. Some suggestions included learning about healthy nutrition, hygiene, and use of appropriate soaps, detergents, and skin emollients. Treatment compliance surrounding the use of topical ointment initially prescribed for this child’s condition was also mentioned as a concern among respondents. One respondent stated, “Topical corticosteroids in the correct strength and potency should have at least provided some symptomatic improvement if used correctly, so compliance may be an issue.”