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Comprehensive Management of Psoriasis and Psoriatic Arthritis in Adults and Children

Evaluating Treatment Options for a Teenage Patient with Psoriasis

Supported by independent educational grants from Janssen Biotech, Inc and UCB

A 16-year-old female and her father present to your clinic for the first time for evaluation of psoriasis. She reports that she has had symptoms of psoriasis since she was 12 years old and currently has lesions affecting the scalp, elbows, knees, and the back of her hands. She also reports feeling stiffness and pain in her hands and wrists in the mornings that go away after an hour or so. She is very embarrassed because of the appearance of her skin and always wears long sleeves and pants or long skirts to hide her psoriasis. She is currently using topical steroids inconsistently and has used calcipotriene in the past. She and her father would like to consider any treatments that would help her skin heal as quickly as possible. When you talk to her alone, she admits that she has been bullied in the past because of her skin and has felt depressed because of this. She does not drink any alcohol but does regularly use marijuana, which she says help her feel less anxious about the appearance of her skin. On exam, she has erythematous scaly plaques on the scalp, back, abdomen, elbows, forearms, dorsal hands, knees, and lower legs, with a TBSA of ~40%. She also has swelling and tenderness to palpation of the bilateral wrists and left 3rd and 4th digits. What is a good treatment plan for her?

Photo credits: Jennifer Ornelas, MD

As the patient is currently using topical steroids only inconsistently, she should be encouraged to regularly use fluocinonide 0.05% ointment twice daily for 3-4 weeks consistently. She should also be referred to a psychiatrist for further evaluation of possible depression associated with her psoriasis.

As the patient is very bothered by the appearance of her skin she should be given the option to start phototherapy with Nb-UVB 3x/weekly for a 3 month trial. She should also be encouraged to regularly use triamcinolone 0.1% ointment twice daily taking a break on the weekends. She should be referred to a psychiatrist for further evaluation of possible depression associated with her psoriasis.

As the patient has joint symptoms that are concerning for underlying psoriatic arthritis, she should be referred to a rheumatologist for further evaluation. She should also be given the option to start anIL-17 inhibitor, including ixekizumab or secukinumab based on your high suspicion of underlying psoriatic arthritis and severe social distress caused by the appearance of her skin. She should also be referred to a psychiatrist for further evaluation of possible depression associated with her psoriasis.

As the patient is very bothered by the appearance of her skin she should be given the option of starting treatment excimer laser 3x/weekly for 3 months. She should also be encouraged to regularly use mometasone 0.05% ointment twice daily for 1 month.