Management of Psoriasis in Adolescents

Psoriasis can affect patients at all walks of life, from children to the elderly. Adolescents, however, require special considerations, from psychosocial conditions to therapy options, for the short- and long-term management of psoriasis.

When we think of the young adult or adolescent patient, we need to remember that this age group may have concerns about their appearance. When these patients look at themselves in the mirror, they can see a plethora of changes—growth spurts with stretch marks, acne, facial hair—changes that can affect psychosocial development even for the healthy patient.

For the adolescent, psoriasis can compound negative feelings about appearance and self-worth. The psychosocial impact of psoriasis can be detrimental. In a descriptive cross-sectional study of 101 patients with psoriasis, Remröd et al¹ found that patients with early-onset psoriasis (<20 years of age) were significantly more anxious and depressed than those with late-onset psoriasis. Similarly, Paller et al² found that pediatric patients (mean age 12.9 years) with psoriasis (n=7686) had a higher incidence rate of any psychiatric comorbidity, including depression, bipolar disorder, anxiety, suicidal ideation, and substance abuse, than age- and gender-matched control patients without psoriasis. With the exception of anxiety, the incidence rates of psychiatric comorbidities, did not differ when disease severity (moderate to severe vs mild psoriasis) was compared.²

In addition, psoriasis can impact quality of life, only further augmenting mental health. Dermatologists should note how psoriasis can negatively impact comorbid psychosocial concerns and potential comorbid conditions and spend some time discussing the patient’s feelings and concerns. Screening for depression and substance abuse of all patients with psoriasis older than 11 years of age is recommended.³

Effective care for adolescent patient should include evaluation of both the physical manifestations of psoriasis as well as the psychosocial ones. Like with any other patient group, clinicians should ask questions about location (eg, all over the body vs localized to the scalp), characteristics (eg, plaque vs guttate), and other symptoms (eg, itch, swollen joints, heel pain, morning stiffness, so as to note the presence of arthritis). Having every possible detail when the patient presents can change the course of therapy and greatly impact future quality of life. Understanding the whole patient, including psychosocial and physical factors, could help determine what treatment options are appropriate for their disease and lifestyle.

Therapy Options
It is possible that the young adult patient presenting with moderate to severe psoriasis is receiving their first systemic treatment. Because of their age and development, therapeutic options should be carefully considered with future growth and maturity kept in mind. Systemic medications can be a lifetime commitment; starting this commitment early in life could contribute to mental burden and psychosocial conditions.

Phototherapy. One therapy to consider is narrowband UV-B (NB-UVB) phototherapy. For the adolescent with psoriasis, NB-UVB fits very well if their psoriasis is extensive on the body, not too thick, and not in places such as the scalp, palms, or soles.

Furthermore, excimer laser and UV-A light with certain types of psoralen hold further possibilities as efficacious options for treatment, but more studies are needed to elucidate the benefits.⁴ Note that there is insufficient data to support a recommended type, safety, and efficacy of phototherapy for adolescent pustular psoriasis.⁴ It is also important to remember that consistency is key to positive treatment outcomes with phototherapy. If a patient cannot commit to a therapy timeframe, such as those who do not have a home unit, clinicians should explore other options.

Methotrexate. Another therapy to consider, with a long and broad history of use, is methotrexate. This folic acid analog inhibits dihydrofolate reductase, the enzyme necessary for DNA synthesis, repair, and cellular replication.⁵ Generally, methotrexate is FDA approved to treat adults with severe psoriasis unresponsive to topicals or phototherapy,⁶ but it continues to show reasonable effectiveness and safety for younger patient groups. 

Researchers found 69.2% of 390 pediatric patients received methotrexate to treat their moderate to severe psoriasis: 207 received methotrexate orally, 28 received it subcutaneously, and 35 received it both orally and subcutaneously or intramuscularly at different times.⁷ Of all patients who received methotrexate, 48.1% experienced one or more treatment-related adverse event; gastrointestinal upset (nausea, dyspepsia) were most commonly reported. Notably, administration of folic acid six or seven times per week was associated with a lower probability of developing a gastrointestinal adverse event.⁷ Subcutaneous injection can also reduce these adverse events.⁴ 

According to the joint American Academy of Dermatology and National Psoriasis Foundation guidelines for pediatric psoriasis, adolescents (13 years of age and older) of average weight can be dosed similarly to adults.⁴ When methotrexate is used, additional monitoring of complete blood count, hepatic transaminases, and creatine should be undertaken to observe liver and kidney function.

Biologics. Biologics are becoming more common for the management of psoriasis in adolescents. It is important to mention first that many biologics still require future clinical studies to better understand efficacy in adolescents, but success with off-label use has been described. However, at the time of this article’s publication, several biologics hold approvals for this special patient group.

Etanercept (Enbrel) has been approved by the FDA for patients older than 4 years of age in late 2016. In their study of 211 patients (4-17 years of age) with psoriasis, Paller et al⁸ demonstrated etanercept significantly reduced the severity of moderate to severe plaque psoriasis. At the end of 12 weeks of treatment, 57% of patients who were randomized to receive once-weekly subcutaneous injection of 0.8 mg of etanercept per kg of body weight achieved 75% or greater improvement in Psoriasis Area and Severity Index (PASI; P<.001). 

Ustekinumab (Stelara) received FDA approval in 2017 for the treatment of adolescent psoriasis. A phase 3, multicenter, randomized, double-blind, placebo-controlled trial evaluated ustekinumab in 110 adolescents aged 12 to 17 years with moderate to severe plaque psoriasis.⁹ After 12 weeks of treatment, 69.4% of patients who received standard and 67.6% who received half-standard dosing achieved a Physician’s Global Assessment of clear/minimal vs only 5.4% of those who received placebo. Additionally, significantly greater numbers of patients achieved PASI75 and PASI90 at week 12 vs placebo.

No other biologics are currently approved for the management of psoriasis in adolescents. Adalimumab (Humira), though, has been recently investigated in children and adolescents with severe chronic plaque psoriasis and found to be safe vs methotrexate.¹⁰ Interestingly, adalimumab is approved for use in adolescents in Europe.⁴ 

Topicals. Topical corticosteroids are the most commonly used treatment option for adolescent psoriasis.^4,11 Because of their anti-inflammatory, antiproliferative, and fast-acting properties, corticosteroids are popular among patients. To chose the appropriate potency, frequency of use, and delivery vehicle, dermatologists should weigh a number of factors, including sites and surface area of involvement, type of psoriasis, and disease acuity, among others.⁴ It is recommended clinicians avoid use of high-class potency corticosteroids in delicate anatomical areas, eg, the face and genitalia, and explain to patients that “rebound” flare-ups are possible with abrupt discontinuation without a prescribed alternative therapy.­^4,11 

A popular adjunct therapy with corticosteriods, vitamin D₃ analogs stimulate keratinocyte differentiation while inhibiting their proliferation and DNA synthesis.^4,11 In fact, a retrospective, cross-sectional study of National Ambulatory Medical Care survey data from 1979 to 2007 found that calcipotriene was the most commonly prescribed topical noncorticosteroid.¹² Research has shown calcipotriene and calcitriol as effective and well-tolerated treatment options for childhood plaque psoriasis (levels of evidence A and B, respectively).­¹³ Similarly to corticosteroids, use of topical vitamin D analogs should be avoided in the face and genitalia.¹¹

For the previously mentioned delicate areas with a high risk of skin atrophy, topical calcineurin inhibitors are the preferred option.¹³ In two studies from 2005 and 2007, 12 of 13 patients and 11 of 11 patients achieved clear skin within 2 weeks and 30 days, respectively, with topical tacrolimus 0.1%.^14,15 Vogel et al¹² found that tacrolimus was most commonly prescribed for patients 0 to 9 years of age; this could be due to the more delicate nature of pediatric skin.

A less common topical is anthralin (dithranol). In a retrospective chart review of 60 patients (mean age, 11.1 years) who received dithranol to manage their psoriasis, only 3.7% found their treatment results excellent; 69.5% found their results to be good, 8.5% moderate, 13.4% reasonable, and 4.9% disappointing.¹⁶ It should be noted that patients did have an average 5.5 months of remission at 12-month followup.¹⁶ Due to adverse effects such as local irritation and skin staining, care should be taken to avoid use on the face and in intertriginous areas.⁴ 

Lastly, coal tar can be used for its antiproliferative and anti-inflammatory properties, particularly as part of a combination therapy with phototherapy or corticosteroids.^4,11 A number of formulations are available, and coal tar tends to be a relatively inexpensive option.¹⁷ However, there are some reports of increased risk of carcinogenity, so it is recommended that coal tar use is alternated with other modalities.¹¹

Conclusion
"The adolescent patient population is a special group that dermatologists should be extra careful to monitor while managing psoriasis. Extra considerations should be made with psychosocial conditions, and clinicians should carefully weigh all therapy options and give thought to treatment longevity. Dermatologists should take everything into consideration to make adolescents with psoriasis happy so that they can grow up to be healthy, psoriasis-free adults.

This article was adapted from a transcript of a recent podcast by Lawrence Green, MD, available at www.the-dermatologist.com/coe/psoriasis.

References
1. Remröd C, Sjöström K, Svensson A. Psychological differences between early- and late-onset psoriasis: a study of personality traits, anxiety and depression in psoriasis. Br J Dermatol. 2013;169(2):344-350. doi:10.1111/bjd.12371

2. Paller AS, Schenfeld J, Accortt NA, Kricorian G. A retrospective cohort study to evaluate the development of comorbidities, including psychiatric comorbidities, among a pediatric psoriasis population. Pediatr Dermatol. 2019;36(3):290-297. doi:10.1111/pde.13772

3. Osier E, Wang AS, Tollefson MM. Pediatric psoriasis comorbidity screening guidelines. JAMA Dermatol. 2017;153(7):698-704. doi:10.1001/jamadermatol.2017.0499

4. Menter A, Cordoro KM, Davis DMR, et al. Joint American Academy of Dermatology–National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients. J Am Acad Dermatol. 2020;82(1):161-201. doi:10.1016/j.jaad.2019.08.049

5. Dadlani C, Orlow SJ. Treatment of children and adolescents with methotrexate, cyclosporine, and etanercept: review of the dermatologic and rheumatologic literature. J Am Acad Dermatol. 2005;52(2):316-340. doi:10.1016/j.jaad.2004.07.043

6. Psoriasis treatment: methotrexate. American Academy of Dermatology. https://www.aad.org/diseases/psoriasis/psoriasis-methotrexate. Accessed January 3, 2020.

7. Bronckers IMGJ, Seyger MMB, West DP, et al; Psoriasis Investigator Group of the Pediatric Dermatology Alliance, European Working Group on Pediatric Psoriasis. Safety of systemic agents for the treatment of pediatric psoriasis. JAMA Dermatol. 2017;153(11):1147-1157. doi:10.1001/jamadermatol.2017.3029

8. Paller AS, Siegfried EC, Langley RG, et al; Etanercept Pediatric Psoriasis Study Group. Etanercept treatment for children and adolescents with plaque psoriasis. New Engl J Med. 2008;358(3):241-251. doi:10.1056/NEJMoa066886

9. Landells I, Marano C, Hsu M-C, 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.2015.07.002

10. 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)31189-3

11. Fotiadou C, Lazaridou E, Ioannides D. Management of psoriasis in adolescence. Adolesc Health Med Ther. 2014;5:25-34. doi:10.2147/AHMT.S36672

12. Vogel SA, Yentzer B, Davis SA, Feldman SR, Cordoro KM. Trends in pediatric psoriasis outpatient health care delivery in the United States. JAMA Dermatol. 2012;148(1):66-71. doi:10.1001/archdermatol.2011.263

13. de Jager MEA, de Jong EMGJ, van de Kerkhof PCM, Seyger MMB. Efficacy and safety of treatments for childhood psoriasis: a systematic literature review. J Am Acad Dermatol. 2010;62(6):1013-1030. doi:10.1016/j.jaad.2009.06.048

14. Steele JA, Choi C, Kwong PC. Topical tacrolimus in the treatment of inverse psoriasis in children. J Am Acad Dermatol. 2005;53(4):713-716. doi:10.1016/j.jaad.2005.05.036

15. Brune A, Miller DW, Lin P, Cotrim-Russi D, Paller AS. Tacrolimus ointment is effective for psoriasis on the face and intertriginous areas in pediatric patients. Pediatr Dermatol. 2007;24(1):76-80. doi:10.1111/j.1525-1470.2007.00341.x

16. de Jager MEA, van de Kerkhof PCM, de Jong EMGJ, Seyger MMB. Dithranol therapy in childhood psoriasis: unjustifiably on the verge of falling into oblivion. Dermatology. 2010;220(4):329-332. doi:10.1159/000278241

17. Psoriasis treatment: coal tar. American Academy of Dermatology. https://www.aad.org/diseases/psoriasis/psoriasis-coal-tar. Accessed January 5, 2020.