CASE REPORT Year : 2022  |  Volume : 23  |  Issue : 2  |  Page : 139-141

Pediatric scalp psoriasis: Therapeutic response to oral apremilast: A report of two cases

Anil Kumar Panda, Farheen Begum, Maitreyee Panda, Chinmoy Raj
Department of DVL, Institute of Medical Sciences and SUM Hospital, S ‘O’A University, Bhubaneswar, Odisha, India

Date of Submission13-Apr-2021Date of Decision24-Oct-2021Date of Acceptance23-Nov-2021Date of Web Publication30-Mar-2022

Correspondence Address:
Dr. Anil Kumar Panda
Department of DVL, Institute of Medical Sciences and SUM Hospital, S ‘O’A University, Bhubaneswar, Odisha
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/ijpd.ijpd_56_21

Localized childhood scalp psoriasis is usually controlled with topical therapy. Therapies resistant to topical treatment require a switch to oral therapy. Standardized guidelines for treating childhood psoriasis are lacking, and there are only limited evidence-based data and approved treatments. However, in this current pandemic situation, oral immunosuppressants should be avoided, and a safer molecule-like apremilast can be a better option. We present two cases of childhood scalp psoriasis not responding to topical therapy and showing excellent results with apremilast with better safety profile.

Keywords: Apremilast in pediatric age group, apremilast in scalp psoriasis, pediatric scalp psoriasis

How to cite this article:
Panda AK, Begum F, Panda M, Raj C. Pediatric scalp psoriasis: Therapeutic response to oral apremilast: A report of two cases. Indian J Paediatr Dermatol 2022;23:139-41
How to cite this URL:
Panda AK, Begum F, Panda M, Raj C. Pediatric scalp psoriasis: Therapeutic response to oral apremilast: A report of two cases. Indian J Paediatr Dermatol [serial online] 2022 [cited 2022 Mar 30];23:139-41. Available from: https://www.ijpd.in/text.asp?2022/23/2/139/341474   Introduction 

Psoriasis is a chronic inflammatory disorder with a strong genetic basis, characterized by complex alteration in epidermal proliferation and differentiation. Childhood psoriasis could have a potentially profound impact on physical, emotional, and social functioning and overall quality of life in children. Chronic plaque psoriasis is generally the most common type of childhood psoriasis (74%), followed by guttate psoriasis (9.7%–28.9%). Pediatric scalp psoriasis accounts for 20.7% of cases.[1] Standardized guidelines for treating childhood psoriasis are lacking, and there are only limited evidence-based data and approved treatments. Management of scalp psoriasis includes keratolytics, tar, anthralin, corticosteroids, Vitamin D analog, and calcineurin inhibitors. The various systemic therapies available are immunosuppressants (methotrexate, cyclosporine, and retinoid) and biologics. Apremilast is a small molecule and oral phosphodiesterase-4 inhibitor that works intracellularly to regulate the production of pro- and anti-inflammatory mediators. It is approved for the treatment of adult psoriasis of moderate-to-severe variety. However, its safety and effectiveness have not been established in pediatric patients. We report two cases of scalp psoriasis in childhood treated with oral apremilast showing encouraging outcomes with mild side effects.

  Case Report 

Both of our patients were clinically diagnosed as having scalp psoriasis. The patient's demography is given in [Table 1]. They were initially kept on the topical steroid-salicylic acid combination in lotion form, topical Vitamin D analog, and oral antihistamines for 4 weeks. Subsequently, topical steroid-salicylic acid combination was given as weekend therapy. Because of the poor control of disease, there was a need to switch over to oral therapy. Since they were of the pediatric age group and keeping in mind the current COVID scenario, we opted for oral apremilast as a safe option to be used in both patients.

Both the patients were started on oral apremilast at a dose of 30 mg once daily initially and gradually increased to 30 mg twice daily as it was well tolerated by the patients. Topical therapy included the same steroid-salicylic acid combination lotion as weekend therapy and topical calcipotriol lotion daily. After 8 weeks of therapy, there was notable improvement seen with complete clearance of erythema, induration, pruritus, and scaling with significant improvement in the quality of life. In one patient, Psoriasis area and severity index (PASI) 90 was achieved after 6 weeks of therapy [Figure 1] and [Figure 2].

  Discussion 

Psoriasis is a chronic inflammatory cutaneous disorder affecting up to 2%–5% of the world population. Owing to the chronic course displayed in this condition, long-term treatment is necessitated. Traditionally, drugs employed in this setting, such as methotrexate and cyclosporine, are associated with serious adverse effects and warrant proper monitoring throughout treatment.[2]

Apremilast is an oral PDE4 inhibitor and causes accumulation of cyclic adenosine monophosphate in leukocytes and exerts anti-inflammatory effects by reducing cytokine transcription and inhibiting other inflammatory responses such as neutrophil degranulation, chemotaxis, and adhesion to endothelial cells.

It is approved for the treatment of adult patients with active psoriatic arthritis and for moderate-to-severe plaque psoriasis in patients who are candidates for phototherapy or systemic therapy. However, its safety and effectiveness have not been established in pediatric patients. A search of the published literature found very few publications describing the use of apremilast in children or adolescents.

In a Phase II clinical study by Papp et al. of 260 psoriasis patients, a PASI-75 response was achieved with 20 mg of apremilast given twice daily in 24.4% of patients after 84 days of treatment, compared to 10.3% in the placebo group.[3]

Smith et al. described that treatment with apremilast led to noticeable improvements in the patient's psoriasis and quality of life, in contrast to topical therapies, which had been ineffective. Therefore, apremilast may be an effective and well-tolerated treatment option for adolescent patients with psoriasis.[4]

In both our patients, we observed that there was a noticeable improvement in psoriasis and their quality of life with mild gastrointestinal symptoms despite receiving the adult dose of apremilast.

In the current pandemic situation, it is best to avoid systemic immunosuppressants in view of the novel virus, and oral immunosuppressants should only be given after determining the risk-to-benefit ratio. Therefore, oral apremilast seems to be the ideal choice in this situation and may be an effective, well-tolerated, safer treatment option for pediatric patients with scalp psoriasis; however, further clinical trials with a larger sample size are required to establish apremilast as an effective treatment modality.

Declaration of consent

The authors certify that they have obtained all appropriate consent forms, duly signed by the parent(s) of the patient. In the form the parent(s) has/have given his/her/their consent for the images and other clinical information of their child to be reported in the journal. The parents understand that the names and initials of their child will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 

  References 
1.Kumar B, Jain R, Sandhu K, Kaur I, Handa S. Epidemiology of childhood psoriasis: A study of 419 patients from northern India. Int J Dermatol 2004;43:654-8.  
    2.Menter A, Korman NJ, Elmets CA, Feldman SR, Gelfand JM, Gordon KB, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis: Section 4. Guidelines of care for the management and treatment of psoriasis with traditional systemic agents. J Am Acad Dermatol 2009;61:451-85.  
    3.Papp K, Cather JC, Rosoph L, Sofen H, Langley RG, Matheson RT, et al. Efficacy of apremilast in the treatment of moderate to severe psoriasis: A randomised controlled trial. Lancet 2012;380:738-46.  
    4.Smith RL. Pediatric psoriasis treated with apremilast. JAAD Case Rep 2016;2:89-91.  
    
  [Figure 1], [Figure 2]
 
 
  [Table 1]