Severe Psoriasis in an Adolescent Boy

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Figure

>Case:

The severe "rash" on this adolescent boy has progressively involved more of his body surface over the past 5 years. He is becoming quite depressed about it and is failing at school.

What treatment might significantly improve this skin condition?

Therapy with biologic agents

This patient has severe psoriasis. There is increasing evidence that the inflammatory nature of psoriasis is associated with an increase in comorbid conditions, such as obesity and cardiovascular disease, and that people with psoriasis have a shortened life expectancy. Cardiovascular disease is the comorbidity that appears to be most closely linked to psoriasis. A recently published review of a large general practice database in the United Kingdom showed that psoriasis is an independent risk factor for myocardial infarction (MI).¹ This risk was increased in young adults with severe disease: 30-year-old patients who had severe psoriasis had a relative risk for MI of 3.1 compared with controls.

The inflammatory reactions seen in psoriasis are immunologically similar to those seen in rheumatoid arthritis and Crohn disease, and the treatment of all 3 conditions with biologic agents (such as adalimumab, alefacept, efalizumab, etanercept, and infliximab) has been a great advance in their management in adults. It is hoped that more aggressive treatment of patients with severe psoriasis can reduce the impact of the comorbidities associated with this disease. In particular, it is hoped that aggressive treatment of psoriasis in young patients with severe disease (body surface area greater than 10%) will reduce the risk of cardiovascular disease. Recent work in adult patients with rheumatoid arthritis suggests that this might be possible.

Biologic agents offer effective and safe systemic therapy for severe psoriasis. Results of the first trial of a biologic agent in children and adolescents with psoriasis were recently published. In this double-blind placebo-controlled trial, Paller and colleagues² evaluated management with etanercept in 211 children and adolescents aged 4 to 17 years who had severe psoriasis (median body surface area of 21%). Etanercept is administered weekly by subcutaneous injection. After 12 weeks of treatment, 57% of the patients who received etanercept experienced a 75% improvement in their psoriasis; after 36 weeks of treatment with etanercept, improvement of 75% or greater was seen in 68%.

These results provide strong support for the use of etanercept in children and adolescents with severe psoriasis. There is reason to hope that other biologic agents may prove similarly effective when trialed in children. Children and adolescents whose psoriasis is severe can now anticipate a significant improvement in their quality of life in both the short and long term.

References:

• Gelfand JM, Neimann AL, Shin DB, et al. Risk of myocardial infarction in patients with psoriasis. JAMA. 2006;296:1735-1741.

• Paller AS, Siegfried EC, Langley RG, et al; Etanercept Pediatric Psoriasis Study Group. Etanercept treatment for children and adolescents with plaque psoriasis. N Engl J Med. 2008;358:241-251.