Psoriasis can be a challenging diagnosis to manage and even more challenging to treat in the pediatric/adolescent patient. Among the 100 million individuals affected worldwide, one-third of these patients develop their skin disease during childhood.1 The mean age of a pediatric patient with psoriasis is 7 to 11 years old. Psoriasis not only affects the skin but is documented to impact adolescents’ quality of life and increase the risk of depression.2 Recently, treatment options for our pediatric/adolescent patient with psoriasis expanded to include etanercept (Enbrel) and ustekinumab (Stelara). However, the obstacle of needle phobia still exists among the younger population. This case report discusses the use of another systemic alternative—apremilast (Otzela) for the treatment of psoriasis. To our knowledge only one other case study of an adolescent being treated for plaque psoriasis with apremilast is documented in literature.3 The positive outcome with our patient may be encouraging for future research and utilization.
A 13-year-old girl with a 6-year history of plaque psoriasis presented to the office in the summer of 2015 for further management and evaluation of her psoriasis. She also had history of anxiety and depression treated with citalopram and mirtazapine. The patient was only using clobetasol foam, ointment, and solution for management of her psoriasis. In the past she had tried and failed triamcinolone spray, betamethasone/calcipotriene ointment, betamethasone foam, and tar shampoo.
She had 20% affected body surface area (BSA) involving her back, chest, arms, legs, and scalp (Figure 1). She had used etanercept for 6 weeks but stopped the medication due to injection site pain and needle phobia. On our initial visit, it was decided to start narrowband UV-B treatments twice a week. She continued narrowband UV-B light box treatments for 6 weeks with mild improvement. A home light box unit was ordered for the patient. She was followed and monitored every 3 to 4 months in our office. She responded fairly well to the treatment of narrowband UV-B and topical steroids with a thinning of her plaques and decreased pruritus at her 12-month follow-up visit.
Unfortunately, at her 18-month follow-up visit, she had expressed a decrease in the improvement of the psoriasis with the narrowband UV-B and topical corticosteroids. The patient and parent were very frustrated with her condition. She continued to wear long sleeves and pants to school (despite living in Florida with 90-degree weather) secondary to embarrassment.
All treatment options were discussed including etanercept, methotrexate, and apremilast. At the time of this visit, etanercept and apremilast would be used off -label, since neither were FDA approved for use in the pediatric psoriasis population. The patient was against any injectable medication secondary to her needle phobia. The patient and parent agreed to start apremilast as an off-label use, due to the medication’s low side effect profile, while also continuing light treatments. She was started on 10 mg daily and titrated to 30 mg daily over 4 weeks.
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At her 4-week follow-up visit, her BSA was decreased to 9% and she had denied any diarrhea or worsening of her depression. Of note, she was wearing a tank top in the office with jeans rather than a long sleeve shirt. She also admitted to stopping her light box treatments at home. Her dose of apremilast was increased to 60 mg daily (divided 30 mg twice a day). She developed nausea with the increased dose of 60 mg within 1 week and was then decreased back to 30 mg daily. At her 12-week follow-up visit, her symptoms continued to improve with a decrease in plaques and having a 5% BSA (Figure 2). Her depression remained stable with no enhancement of symptoms. Her citalopram was discontinued after being on apremilast for 12 weeks. Throughout her treatment she was also followed closely by a psychiatrist. Overall, our patient was very happy with the improvement of her psoriasis on apremilast; therefore, we have maintained her at 30 mg daily.
In this case, apremilast was able to achieve positive improvement of psoriasis in an adolescent patient as a monotherapy treatment. Our patient had failed multiple treatments including topicals of all strengths, potencies, and various vehicle options. She also failed light treatments. Biologics were not an option for our patient since she tried them for a short period and developed significant needle phobia.
Apremilast is a phosphodiesterase-4 inhibitor FDA approved for plaque psoriasis and psoriatic arthritis. FDA-approved psoriasis treatments for the pediatric population is limited. Etanercept was approved for the pediatric psoriatic population in 2016 and ustekinumab in 2018. Limiting factors with these medications include mode of delivery, and many pediatric patients have significant needle phobias causing difficulty in administrating the medication. Of note, our patient did suffer from depression and anxiety and did not have an increase in her symptoms, comparable with results shown in the long-term safety trials of apremilast. Because of its efficacy and tolerability, this systemic treatment could be an option for the pediatric/adolescent patient. Studies would need to be conducted on this medication in the pediatric patient for further investigation and safety.
Ms Mangin is a physician assistant with Sand Lake Dermatology Center in Orlando, FL.
Dr Crotty is a board-certified dermatologist in private practice at Sand Lake Dermatology Center in Orlando, FL.
Disclosures: Ms Mangin has received speaking honoraria from Galderma and for Promius Pharma.
Dr Crotty reports no relevant financial relationships.
1. Tollefson MM, Crowson CS, McEvoy MT, Maradit KH. Incidence of psoriasis in children: a population-based study. J Am Acad Dermatol. 2010;62(6):979-987.
2. Bilgic A, Bilgic O, Akis HK, Eskioglu F, Kilic EZ. Psychiatric symptoms and health-related quality of life in children and adolescents with psoriasis. Pediatr Dermatol. 2010;27(6):614-617.
3. Smith RL. Pediatric psoriasis treated with apremilast. JADD Case Rep. 2016;2(1):89-91.
4. Crowley J, Thaci D, Joly P, et al. Long-term safety and tolerability of apremilast in patients with psoriasis: pooled safety analysis for > 156 weeks from 2 phase 3, randomized, controlled trials. J Am Acad Dermatol. 2017;77(2):310-217.