Don't Be Rash: Building the Pediatric Psoriasis Treatment Ladder

Welcome back to Don't Be Rash!

Lisa Swanson, MD, a board-certified pediatric dermatologist in private practice with Ada West Dermatology and affiliated with St. Luke's Children's Hospital in Boise, Idaho, recently joined Don't Be Rash host Andrew C. Krakowski, MD, in a part 2 discussion to review the treatment ladder for pediatric psoriasis, from first-line topicals through newer oral and injectable options. Swanson also addressed insurance barriers, adherence habits for teenage patients, and injection-day pearls.

To hear more from their first conversation on recognizing pediatric psoriasis for Psoriasis Awareness Month, click here.

Generic Topicals Remain the Starting Point

Swanson starts most new diagnoses with clobetasol for the body, a topical calcineurin inhibitor (TCI) such as tacrolimus or pimecrolimus for the face and folds, and fluocinolone oil for the scalp. She dosed clobetasol twice daily until plaques clear, with follow-up at 1 month.

"I feel like the first visit when I'm meeting a kiddo and making the diagnosis of psoriasis, I'm going to start with some generic topicals," Swanson said.

TCIs limit steroid-related thinning and striae on facial psoriasis, a presentation Swanson said she frequently sees on the eyelids. Vitamin D analogs and tar preparations rarely factor into her regimens now, with nonsteroidal options available; she reserves tar mainly for the scalp.

Newer Nonsteroidal Topicals Extend the Ladder

Roflumilast cream 0.3% (Zoryve; Arcutis Biotherapeutics) is approved for plaque psoriasis down to age 2, and roflumilast foam 0.3% (Zoryve; Arcutis Biotherapeutics) is approved for plaque psoriasis down to age 12 and for seborrheic dermatitis down to age 9. Both are once-daily and nonsteroidal, with the foam suited for the scalp or anywhere else on the body.

"These medicines are non-steroidal, so they're safe to apply on any body part," Swanson said.

Swanson tells families to shake the roflumilast foam canister well and tip it fully over before dispensing, since a partial tip releases mostly propellant and traps the medication inside. Topical tapinarof (Vtama; Organon), an aryl hydrocarbon receptor agonist, carries a pediatric indication for atopic dermatitis down to age 2 but stays limited to adults for psoriasis. Swanson moves quickly from a steroid-TCI combination to roflumilast, since families want to avoid ongoing corticosteroid use, and she flags the 8-week trial end point up front.

Biologics and a New Oral IL-23 Blocker Extend the Ladder Further

When topicals fall short, Swanson steps up to systemic treatment: etanercept (Enbrel; Amgen), approved down to age 4, and ustekinumab (Stelara; Janssen), ixekizumab (Taltz; Eli Lilly and Company), and secukinumab (Cosentyx; Novartis), each approved down to age 6. Guselkumab (Tremfya; Johnson & Johnson) and risankizumab (Skyrizi; AbbVie) recently added pediatric indications, with infrequent dosing and a favorable safety profile, Swanson said.

Ustekinumab also carries a pediatric psoriatic arthritis indication down to age 6, and ixekizumab performs well clinically in patients with concurrent psoriatic arthritis, Swanson said.

Icotrokinra (Icotyde; Johnson & Johnson), an oral IL-23 receptor antagonist approved for patients 12 and older weighing at least 40 kg, adds a pill option. Insurance denials were common after its spring launch, Swanson said, though a company bridge program can help. The 18-mm tablet can be dispersed in 4 mL of water and must be taken on an empty stomach at least 30 minutes before breakfast.

"I think icotrokinra is a well-tolerated medicine that conveniently comes in a pill," Swanson said.

For injection visits, Swanson keeps a prize box stocked for patients to choose from afterward. She rates the pain from psoriasis biologic injections around 5 out of 10, lower than many children expect.