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Management of Psoriasis in Adolescents

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.

Scalp psoriasisWhen 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.

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