Optimal Management of Plaque Psoriasis in Adolescents: Current Perspectives

Figures & data

Figure 1 Plaque psoriasis in a 13-year-old boy.

Figure 2 Scalp psoriasis in a 16-year-old boy. This adolescent was suspected of having tinea capitis.

Box 1 Four-Question Evaluation of Clinical History to Screen for Arthritis in Children with Psoriasis

Do you have swelling and stiffness of the joints?

Do you have difficulty getting up and moving in the morning or after a period of rest?

Do you have any problems performing daily activities or taking part in sport?

Do you find it difficult to hold a pen, or have you developed a swollen ‘sausage’ finger/toe?

Notes: Data from Burden-Teh et al²⁹ and Coates et al.³⁰

Figure 3 Clobetasol propionate shampoo-induced acne in a 14-year-old girl with scalp psoriasis.

Figure 4 Severe striae distensae in a 16-year-old girl with psoriasis. The patient received treatment with topical steroids for a long time.

Table 2 Efficacy of Biologics Licensed for Use in Adolescents with Psoriasis: Data from Randomized Studies^{a, b}

	Dosage in Clinical Practice	Evaluation at Week 12
		PASI75	PASI90
Etanercept^Citation63	0.8 mg/kg/week	56% ^c	25% ^c
Adalimumab^Citation64	20 mg (15 – <30 kg) or 40 mg (≥30 kg) on D1, every other week starting at W1	57.9% ^d	29% ^d
Ustekinumab^Citation65	0.75 mg/kg on D1 and every 12 weeks starting at W4	80.6%	61.1%
Ixekizumab^Citation66	40 mg (≥25 – ≤50 kg), 80 mg (>50 kg), two doses, and then every 4 weeks	90%	83%
Secukinumab^Citation67	75 mg (<50 kg), 150 mg (≥ 50 kg) every week for 5 weeks, then every 4 weeks	77–93%	67–76%

Notes: ^aMeaningful between-study comparisons cannot be made because of differences in inclusion criteria, populations, and study design. ^bThe dosage used in clinical practice is not always identical to the dosage used in the clinical studies. ^cIn the adolescent group. ^dEvaluation at week 16. Dosage: 0.8 mg/kg.

Abbreviations: D, day; W, week.

Table 3 Proactive Management Options That Can Be Proposed After Flare-Ups are Under Control, or Used Together with Active Flare-Up Treatments

Education	Explain the pathophysiology and course of psoriasis Choose treatments (pharmaceutical forms) together with the adolescent No restrictions to diet, vaccinations or sports are needed
Avoid factors that aggravate/trigger flare-ups	Avoid injury: onychophagia, scratching, poorly fitting shoes, etc. Keep vaccinations up-to-date (adapt the schedule in case of vaccine-related flare-ups) Tonsillectomy, antibiotic prophylaxis if psoriasis flares are linked to infections Psychological support Management of obesity Mediterranean-style diet
Topical therapy	Emollients Reduce topical corticosteroid use very gradually Weekend therapy (topical corticosteroids: calcipotriol or tacrolimus) Early treatment of flare-ups (topical corticosteroids: calcipotriol)
Systemic therapy	Subcutaneous treatments: local anesthesia Acitretin: mucous, semi-mucous and dermal hydration Methotrexate: folic acid Effective minimum dose (acitretin, cyclosporine, and methotrexate) Dosing intervals (adalimumab and ustekinumab) Weekend therapy (cyclosporine) Intermittent treatment (cyclosporine and etanercept)

Note: Reproduced with permission from Lavaud J, Mahé E. Proactive treatment in childhood psoriasis. Ann Dermatol Venereol. 2020;147(1):29–35.⁴⁸

Table 1 Management of Adolescents with Psoriasis Using Methotrexate, Acitretin, or Cyclosporine

	Methotrexate	Acitretin	Cyclosporine
Efficacy ^a	30-80% Effective in 1–3 months	60-75% Slowly effective (3 months)	64% Rapidly effective (1 month)
Main contraindications	Renal insufficiency, pregnancy, desire for pregnancy (male and female patients), hepatopathy	Female patients without contraception, pregnancy, severe dyslipidemia, obesity, diabetes, metabolic syndrome, atopic dermatitis, depression	Renal insufficiency, hypertension, caner history
Treatment associations	Topical therapies Acitretin Biologic systemic therapies	Topical therapies Phototherapy Methotrexate Biologic systemic therapies	Topical therapies
Main toxicity	Hepatotoxicity, cytopenia, chest toxicity, abdominal pain, nausea, loss of appetite, alopecia, asthenia, immunosuppression	Dryness (skin and mucous membranes), teratogenicity, headache, myalgia, photosensitivity	Nephrotoxicity, hypertension, hypertrichosis, gingival hypertrophy, cancer (skin, lymphoma), immunosuppression
Particularities	Effective for most of types of psoriasis The only treatment also effective against psoriatic arthritis	No cumulative toxicity Very effective against pustular psoriasis	Duration of prescription restricted to 1–2 years because of cumulative toxicity
Dosage	10–15 mg/m^2/week or 0.2–0.4 mg/kg/week	0.25–1 mg/kg/day	2.5–5 mg/kg/day
Evaluations required before initiation	Blood counts, liver function tests, albumin levels, chest radiography	Liver function tests, serum lipid levels, beta-HCG levels	Two blood pressure measurements Serum creatinine levels (twice), tests for proteinuria and creatinine clearance, serum lipid levels Blood counts, urine analysis, electrolyte levels, liver function tests, magnesium and uric acid levels
Follow-up	Every 2 weeks during 2 months, then every month during 6 months, followed by every 2 months and then once a month: Blood counts, liver function tests Chest radiography if pulmonary symptoms	Liver function tests and serum lipid levels: 1 month after initiation or a dosage increment, Then every 3 months Beta-HCG levels every month No radiological monitoring recommended	Every 2 weeks during 4 weeks and then once a month: Blood pressure measurements Serum creatinine levels After 2 months: Blood counts, urine analyses, electrolyte levels, liver function tests, magnesium and uric acid levels Once a year Creatinine clearance

Notes: ^aExcept for methotrexate, not evaluated in prospective studies. Reproduced with permission from Mahé E, Maccari F, Ruer-Mulard M, et al. Psoriasis de l’enfant vu en milieu libéral: les aspects cliniques et épidémiologiques diffèrent des données habituellement publiées. Ann Dermatol Venereol. 2019;146(5):354–362.²⁴

Burden-Teh E, Thomas KS, Rangaraj S, Cranwell J, Murphy R. Early recognition and detection of juvenile psoriatic arthritis: a call for a standardized approach to screening. Clin Exp Dermatol. 2017;42(2):153–160. doi:10.1111/ced.1301028044348

 PubMed Web of Science ®Google Scholar

Coates LC, Aslam T, Al Balushi F, et al. Comparison of three screening tools to detect psoriatic arthritis in patients with psoriasis (CONTEST study). Br J Dermatol. 2013;168(4):802–807. doi:10.1111/bjd.1219023311587

 PubMed Web of Science ®Google Scholar

Paller AS, Siegfried EC, Langley RG, et al. Etanercept treatment for children and adolescents with plaque psoriasis. N Engl J Med. 2008;358(3):241–251. doi:10.1056/NEJMoa06688618199863

 PubMed Web of Science ®Google Scholar

Papp K, Thaçi D, Marcoux D, et al. Efficacy and safety of adalimumab every other week versus methotrexate once weekly in children and adolescents with severe chronic plaque psoriasis: a randomised, double-blind, Phase 3 trial. Lancet. 2017;390(10089):40–49. doi:10.1016/S0140-6736(17)31189-328478975

 PubMed Web of Science ®Google Scholar

Landells I, Marano C, Hsu MC, et al. Ustekinumab in adolescent patients age 12 to 17 years with moderate-to-severe plaque psoriasis: results of the randomized phase 3 CADMUS study. J Am Acad Dermatol. 2015;73(4):594–603. doi:10.1016/j.jaad.2015.07.00226259989

 PubMed Web of Science ®Google Scholar

Paller AS, Seyger MMB, Alejandro Magariños G, et al. Efficacy and safety of ixekizumab in a Phase III, randomized, double-blind, placebo-controlled study in paediatric patients with moderate-to-severe plaque psoriasis (IXORA-PEDS). Br J Dermatol. 2020;183(2):231–241. doi:10.1111/bjd.1914732316070

 PubMed Web of Science ®Google Scholar

Summary of product characteristics. Available from: https://www.ema.europa.eu/en/documents/product-information/cosentyx-epar-product-information_en.pdf.

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Lavaud J, Mahé E. Proactive treatment in childhood psoriasis. Ann Dermatol Venereol. 2020;147(1):29–35. doi:10.1016/j.annder.2019.07.00531606260

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Mahé E, Maccari F, Ruer-Mulard M, et al. Psoriasis de l’enfant vu en milieu libéral: les aspects cliniques et épidémiologiques diffèrent des données habituellement publiées. Ann Dermatol Venereol. 2019;146(5):354–362. doi:10.1016/j.annder.2019.01.02430954294

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