Extensive Psoriasis in a 9-Year-Old Girl

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Case:

This 9-year-old girl has extensive psoriasis and is currently receiving narrowband UVB phototherapy for her body plaques. Her mother has insisted on covering her daughter's face during treatment and on having the girl use sunscreen on her face whenever she is outdoors to prevent premature aging.

Which topical therapy would be best for treating this patient's facial psoriasis?

This patient's plaque-type facial psoriasis was treated with topical tacrolimus

DISCUSSION

Facial psoriasis presents a unique challenge because it has a significant impact on a child's self-esteem and because the available treatments may produce local adverse effects. Facial involvement occurs in up to two-thirds of patients with psoriasis and is often seen in early-onset and severe disease. There are 3 distinct clinical patterns of facial involvement in patients with psoriasis:

• Hairline.

• Sebopsoriasis (central facial).

• Plaque.

The hairline pattern is commonly associated with scalp psoriasis and is treated in conjunction with the scalp. The central facial variant is thought to be related to seborrheic dermatitis; a trial of topical ketoconazole in addition to an anti-inflammatory agent often proves effective against this type of facial psoriasis. Topical corticosteroids are the anti-inflammatory treatment of choice for the plaque variant. The clinical challenge of corticosteroid treatment is to balance effectiveness with the known adverse effects of atrophy and telangectasia. I typically initiate treatment with 1% hydrocortisone applied twice daily and increase to a midstrength corticosteroid if I do not see a response in 2 weeks. Topical calcipotriol has been reported to be effective for all types of facial psoriasis, but its tendency to irritate precludes routine use.

In addition, topical calcineurin inhibitors (pimecrolimus and tacrolimus)- which also are anti-inflammatory agents-can be very useful in the management of facial psoriasis. Pimecrolimus and tacrolimus are applied twice daily and do not have the adverse effects of atrophy and telangectasia commonly seen with topical corticosteroids used long-term. However, the treatment of psoriasis is an off-label use of these agents.