Treating severe plaque psoriasis in a paediatric patient with etanercept

We describe the case of a 14-year-old boy diagnosed with severe plaque psoriasis since age 3. He has a family history of psoriasis on both sides. He achieved only minor control with topical steroid treatments up until age 11. His PASI score then was 66. Treatment options were discussed with his parents and in 2013 methotrexate was commenced. His psoriasis improved significantly, however after five months the treatment was ceased due to intolerable nausea and persistently elevated liver enzymes. Acitretin 20 mg daily was then trialled for four months with little improvement and his PASI score remained at 34. The dose was increased to 30 mg with some improvement to his psoriasis, however the side effects became intolerable. The dose was reduced but his psoriasis worsened. Narrowband UVB treatment was added but his PASI score remained above 30. In October 2014, he commenced treatment with etanercept, a tumour necrosis factor inhibitor recently approved for subsidy in Australia for children with severe plaque psoriasis. His psoriasis initially improved but treatment had to be ceased for several months after the patient developed cholangitis not believed to be related to the etanercept. Etanercept was recommenced in December 2015 with excellent results. The patient’s PASI score improved to 3 within six months of treatment and he has tolerated the medication well with no side effects. Whilst the use of biologic agents to treat severe plaque psoriasis is well described in the adult population, their use in the paediatric population is far less common.

Dr. Paul Stevenson