Adolescence, an already-difficult time in one's life, can be further complicated by psoriasis. Lawrence Green, MD, section editor of the Psoriasis Centers of Excellence, clinical professor of dermatology at George Washington University School of Medicine in Washington, DC, and on the National Psoriasis Foundation Medical Board, discusses his treatment strategies for managing psoriasis in teenagers.
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Hi, everybody. This is Larry Green. I’m a clinical professor of dermatology at George Washington University School of Medicine here in Washington, DC. I’m also online section editor for psoriasis for The Dermatologist. We are here on this podcast to talk about something that I think is an important issue.
How do we treat adolescents who have psoriasis? Is the treatment any different? What kind of concerns do we have? What treatments options are there? How can we best make these young adults happy?
Comorbid psychosocial concerns are one of the foremost things you want to consider in a young adult or adolescent population who has psoriasis.
First of all, you know when we think of young adults or children who have psoriasis, even from the ages of 8 and up (We do not see that many children, usually, people or adolescents are 12 and up when they get psoriasis. There are exceptions to the rule, of course.) These are kids are just starting and growing and maturing, and their hormones are kicking in, and they have a lot of concerns about their appearance.
Psychosocial concerns are foremost, along with potential comorbid conditions, for this age group because they are looking at themselves in the mirror and they see all these changes in their body. To have psoriasis on their skin, while they have all these other changes going on, which could can be acne or just growing up sometimes the facial features don’t fit when they’re adolescents until they become adults. All these things, and they’re starting to realize their self‑worth too, all these things come into play, and having psoriasis can really interfere with that. That’s certainly something to talk about and spend some time looking at the patient and feeling about where they are.
The other things we think about is what kind of impact does psoriasis have on their quality of life. That goes with a psychosocial concern because now they see themselves like this, with psoriasis on their skin, which doesn’t belong there, and all these other changes that are happening to them. How is that impacting their life? Is something happening with school? Is something happening in their social life that’s changing? Is something happening with their parents, their family? All those things can certainly, when someone has psoriasis, can impact a young person’s quality of life.
Then, of course, we want to look at the psoriasis itself as another important clinical consideration. Where is it located on the skin? Is it primarily on the scalp? That can be pretty debilitating and more difficult to treat.
Is it all over the body? Is it guttate, not thick? Do they have arthritis? Psoriatic arthritis can certainly start in adolescents. That’s something that we always want to ask young people when they come in with a new complaint of psoriasis. Is there the presence of arthritis? Do they have morning stiffness or stiffness after periods of inactivity? Do they have asymmetric joint swelling and swollen joints? Do they have heel pain?
Those type of questions we want to ask because that can change the treatment options and what we’re going to do for those patients. That’s another clinical consideration.
To summarize, you certainly want to look at the psychosocial concerns, how their appearance, what they think of themselves, the impact on the quality of life they have, the presence of arthritis. Where is the psoriasis located on their skin? Is it thin? Is it thick? How extensive and in what locations?
So I think, and people listening to this can look at what they do for adolescents and young adults and think about what they’re doing, but I do treat this age group differently because this is most likely the first time they’re going to need a systemic treatment if they have moderate to severe psoriasis, and they’re still growing and maturing.
The first thing I like to do, and maybe I]m old‑fashioned in this respect, if it fits at all, I prefer to use narrow-band (NB) UVB therapy in this patient population, because systemic medications are more a lifetime commitment, and it]d be nice not to have a lifetime commitment when you’re between 12 and 18 or 10 and 18. That’s the way I look at it.
NB UVB is an age‑old treatment for people with psoriasis that we used to use much more frequently, a long time ago. In the adolescent population, it fits very well if their psoriasis is extensive on the body and not too thick, and it’s not in places like on the scalp or palms or soles, which would make NB UVB therapy more difficult to work.
If they have guttate psoriasis or widespread thinner plaque psoriasis on areas of the skin that are amenable to light therapy, that’s something that is my first choice. It’s nice, in a way, and I make a joke about it, but I get the children out of school twice a week, because you have to do NB UVB therapy twice a week, so we’ll be on your good side because they like to get out of school.
It’s something, though, that I know is very safe, and something that is an intermittent, short‑term treatment that doesn’t have long‑term ramifications like a biologic therapy.
Another therapy that’s been used for years, I don’t use it that often, in fact, very infrequently do I personally use it, but especially in Europe this has been used for years, is methotrexate therapy. Methotrexate therapy, for 30 or 40 years has been used safely and effectively in the adolescent population.
It’s not on‑label to use in the United States. Well, methotrexate is not on‑label to use for psoriasis in general, but I think it’s more done in Europe. There’s nothing wrong with methotrexate. It’s got an excellent safety record. You can also use that as an intermittent therapy like NB UVB.
I prefer NB UVB because I think it’s a lot safer than methotrexate. It doesn’t require lab monitoring, and you don’t have worry about long‑term morbidity with the liver or kidneys like you do with methotrexate, but you can use methotrexate as intermittent therapy like UVB. That’s a common treatment used for years, like I said, especially in Europe.
Enbrel is a biologic that has been FDA‑approved for 4‑years‑old and up to treat psoriasis. That’s something we know has a long‑term track record in the pediatric and adolescent population, and that can be used for young ones with moderate to severe psoriasis. Enbrel is etanercept.
Stelara, or ustekinumab, is also FDA‑approved for 12 years of age and up to treat psoriasis. It fits in our adolescent population and it also has a good, long‑term safety track record and has FDA approval.
There are no other medications currently, biologics, that are approved for psoriasis for the adolescent population.
Humira, or adalimumab, has a pediatric indication for Crohn disease, 6 years old and up, and hidradenitis for 12 years old and up, but not for psoriasis. There is safety data for Humira in the pediatric population, just not with psoriasis. However, there is a study, I think published in The Lancet a few years ago, that showed the use of Humira in the adolescent population. I think it went a few years younger than that as well to treat psoriasis. There is a cohort of patients that were followed, I think for 16 weeks, and was safe for 16 weeks in adolescent cohort, but it’s not FDA‑approved.
We do have experience with systemic treatments like biologics in this patient population, but for me, to summarize, I like to keep it simple and safe for this group, and hoping I’m not going to give them a therapy that potentially has a lifetime commitment. When we start a biologic, we’re thinking a lifetime commitment.
I start with NB UVB, if possible, if the situation fits, and their psoriasis is amenable to that type of therapy.
Just like when we see adult patients with psoriasis, we want to have a shared decision on what medication is best for that person. The same thing goes with adolescents, except the parents are involved as well.
I also want to make sure I look at the child and include them in the conversation, and of course, include the parent in the conversation. We want to talk about all these concerns. How is it affecting them? Not extensively and is not something that takes a long time to assess.
When you talk to the parent and the child just for a minute or 2, you have a sense of how psoriasis is affecting this young person’s life. We can do this in the first few minutes when the patient comes in. We want to see how they feel together with that young person’s psoriasis, what medication will work best for them? What therapy makes them the most comfortable?
That’s the most important thing, talking out. I mentioned I prefer NB UVB if possible, but for some of my adolescents that won’t work because they have severe scalp psoriasis or palm and sole psoriasis, so NB UVB is not a great choice. We look at other choices. What would be better?
Would we have palm‑sole UVB if they’ve palm and soles? Can we find a way to get a topical medicine into their scalp, or would the patient do best on biologic therapy? All those things come into consideration.
Of course, by the way, the presence of arthritis can make a difference as well, because that would lead me away from NB UVB and bring me more towards methotrexate or a biologic.
In the United States, we’re so biologic‑focused, I don’t think methotrexate is used much anymore, except as adjunctive therapy in adults, and short‑term with the biologic. But still, before us thinking about long‑term biologics, it’s wiser, like I mentioned, it’s mostly done in Europe. It’s wise to approach methotrexate as a treatment option in this patient population, but to certainly discuss what methotrexate means in terms of lab monitoring, potential risks for liver and kidneys with long‑term use, but also approach it with the parent that this would be a short‑term therapy, like UVB. It’s an intermittent crisis management therapy, not a long‑term therapy like the biologic.
What I’ve done with adolescents in the past, especially if this is their first psoriasis flare, is I prefer NB UVB if it works in your schedule, and with the type of psoriasis they have, because we don’t know if their psoriasis is going to be a long‑term problem or if we can do crisis management.
If we can do 3 months of UVB, and again the patient doesn’t have psoriatic arthritis as well in this case, and clear the patient for a year or 2, then there’s no reason to go anywhere else. It’s something we talk about together and work with the parent and the child. You’re looking at 2 people, and that’s the main difference, when you work out the shared decision‑making with just 1 person who's an adult, in terms of treatment.
We look at everything, we try and fit what’s best for the patient, but I do try and focus on what’s simplest and safe, if at all possible.
I would summarize and say with this patient population we have to be extra careful, because they’re very sensitive. They are maturing in different ways and seeing themselves in a new way. We want to talk with them, we want to talk with the parents, we want to play it safe, we want to make them happy.
We want to take everything into consideration to make them happy, find the safest way to treat their psoriasis so they can grow up to be healthy adults and psoriasis‑free.
Thank you for listening to this short podcast on psoriasis treatment in the adolescent population. We welcome your comments. I hope you found it informative. Please email us if you have any questions or comments. Thanks a lot for listening.