Treatment of Psoriasis in a 13-Year-Old Girl
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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