Treatment Options for Youth

Topical treatments can be applied to the skin or scalp and are used to help moisturize the skin, relieve itch and pain, reduce inflammation, and/or slow the high rate of cell growth that occurs in psoriasis. Topicals are available either over-the-counter or by prescription and come in many forms such as lotions, creams, ointments, sprays, foams, or shampoos. Not all topicals can be placed in every location such as areas with thinner skin (i.e. the face or genitals). Some topicals may also be used in combination with other treatments. Some examples of topicals for use in children or teens include:

• Vitamin D analogs: Calcipotriene, calcipotriol, and calcitriol are frequently used in combination with topical corticosteroids and use is avoided on the face, genital area, and in the skin folds.
• Topical calcineurin inhibitors: Tacrolimus 0.1%, pimecrolimus, and cyclosporine are often used off-label in areas such as the face, genital areas, and skin folds.
• Corticosteroids: Come in a variety of potency levels and forms and their use is dependent on a number of factors such as type and thickness of psoriasis, location, and age of the child or teen.
• Phosphodiesterase-4 (PDE4) inhibitor: Roflumilast is a steroid-free, once-daily cream approved for ages 6 and older that can be used for plaque psoriasis including on sensitive areas.
• Coal tar: Available in over-the-counter and prescription strength forms, and is often used in combination with other treatments.
• Combination topicals: Calcipotriol and betamethasone dipropionate (approved for ages 12 and up). 

Tips: Teens typically prefer treatments that are less greasy. For younger children, offer praise and small rewards like stickers or a small treat when they apply creams and can see their skin improve. For more information about topicals and tips for helping children use topicals contact the Patient Navigation Center to receive the free Parent Guide or topicals treatment booklet.

Also called light therapy, the most common type used in children is narrow-band Ultraviolet B or UVB. Light therapy uses ultraviolet (UV) light to penetrate the skin and slow the growth of areas affected by plaque and/or guttate psoriasis. Used under the supervision of a health care provider, phototherapy is given in the provider’s office or at home with instructions from a health care provider. UVB can be used to treat the whole body or smaller more targeted areas like the hands or feet. Expect light therapy treatments to occur two or three times a week. Once the skin clears, less frequent maintenance treatments will be needed. Phototherapy can be used in combination with other treatments.

Tips: Younger children may have some difficulties using phototherapy. Ask your health care provider if they have experience working with children using phototherapy and if you can introduce your child to the photo booth in advance of treatment to help prepare them for what to expect and that it is safe to use.

Note: Phototherapy light is different from using a tanning booth light which should not be used to treat psoriasis. Natural sun exposure with direction from a health care provider can be used to help treat psoriasis. However, be sure to follow instructions from your health care provider and use sunscreen or clothes to help cover unaffected areas.

Oral treatments are medications in pill form taken by mouth. Some medications act more broadly throughout the body while others target specific cells or parts of a cell involved in the development of psoriasis and psoriatic arthritis. Oral systemic treatments are prescribed for children and teens when psoriasis is more severe and response to topical treatment or phototherapy hasn’t worked. They are also prescribed when joint involvement (psoriatic arthritis) is present. The goal of oral treatments is to control and attain clearance or minimal disease activity and then the dose is usually reduced to a maintenance level. The main options that are used off-label with different dosing schedules include methotrexate, cyclosporine, and acitretin.

• Methotrexate: The most commonly prescribed systemic treatment which is taken once a week either orally or by injection. Dosing is weight-based. While it has a slower onset of action it has been proven to be effective for each type of psoriasis. Methotrexate can be used either alone or in combination with a biologic for psoriasis and psoriatic arthritis. Folic acid supplementation is recommended to help decrease the side effects of folate deficiency associated with the use of methotrexate. [1]
• Cyclosporine: Taken either as a liquid or a capsule daily in two divided doses and is effective for crisis management of severe plaque, pustular, or erythrodermic psoriasis. Once the psoriasis is controlled then the dose is reduced and a change is made to another treatment since use is limited due to potential toxicity over long-term use.
• Acitretin: A retinoid that does not suppress the immune system. Acitretin is taken orally once a day and is most effective in treating plaque, guttate, and pustular psoriasis with results being seen in 4 to 12 weeks. Acitretin can be used in combination with topicals and phototherapy which when combined can lower the dosage needed to achieve skin clearance. It is not effective for use in psoriatic arthritis.

Tips: Written plans may help, especially when a combination of treatments is used. For a younger child, write out the plan provided by your child’s health care provider in colors. For a teen, post the plan in a spot where they’ll see it every day. Find more information about oral systemic treatments.

Biologics and biosimilars are medications made from living cells that are given as an injection or intravenous (IV) infusion. A biosimilar is a U.S. Food and Drug Administration (FDA) approved biologic product that is very similar to an already FDA-approved biologic. This already approved biologic is known as the reference product. Biologics and biosimilars target specific parts of the immune system that play a role in psoriatic disease. The FDA has approved a few biologic and biosimilar treatments to treat psoriasis and psoriatic arthritis in children and teens which include:

• Cosentyx (secukinumab): Blocks IL-17A and is used to treat plaque psoriasis (6 years and older) and active psoriatic arthritis (2 years and older).
• Enbrel (etanercept): A TNF-alpha inhibitor used to treat plaque psoriasis (4 years and older) and active psoriatic arthritis (2 years and older).
• Simponi Aria (golimumab): A TNF-alpha inhibitor used to treat active psoriatic arthritis (2 years and older).
• Stelara (ustekinumab): Blocks IL-12/23 to treat plaque psoriasis (6 years and older) and active psoriatic arthritis (6 years and older).
  ➢ Wezlana (ustekinumab-auub) – biosimilar for Stelara: Blocks IL-12/23 to treat plaque psoriasis (6 years and older) and active psoriatic arthritis (6 years and older).
• Spevigo (spesolimab-sbzo): Blocks IL-36 which is known to play a role in the development of generalized pustular psoriasis (12 years and older).
• Taltz (ixekizumab): Blocks IL-17A to treat plaque psoriasis (6 years and older).

Biologics and biosimilars have been proven to be very effective treatments. Additional biologics approved for use in adults are currently in clinical trials for children and teens. This offers the potential for additional treatment choices in the future. Learn more about clinical trials.

Tips: You may need to explain to your child that sometimes medications take time to work and not to get frustrated. Offer praise when you can see a difference to help reinforce that the lesions are getting better.

Find more information about biologics and biosimilars, or request the “Treatments for Children and Teens” fact sheet from the Patient Navigation Center.

Factors to consider when your child is using a biologic or biosimilar: 

• Injections: Talk with your child’s health care provider about the dosage, frequency of injections, what to do about injection site reactions, and any lab monitoring that may be required. The frequency of injections may be a consideration, especially in young children who may find it difficult to follow a treatment plan with more frequent biologic or biosimilar injections.
  Tips: Speak with your child’s health care provider about the possible use of an autoinjector, where the needle is hidden, instead of prefilled syringes. Also, talk with your child about their preference for how to receive an injection.
• Infusions: Talk with your child’s health care provider if you prefer a medication that is given by infusion. Discussion could include the amount of time it takes to do an infusion and the frequency. Ask about preparation needs and potential side effects that could result from the infusion process.
  Tip: Check with your insurance company regarding coverage to see if the infusion is required to occur in a clinic or an infusion center.
• Storage: Most biologics and biosimilars require refrigeration to store the medication to help avoid changes to the medication and its effectiveness. Once out of the refrigerator, you can warm the medication up by leaving it out for an hour prior to giving your child an injection. This will help reduce some of the injection discomfort. If you plan to travel and access to refrigeration is limited, check with the manufacturer to see how long you can leave the medication out and what the temperature limits are.
  Tip: Call the biologic or biosimilar manufacturer to see if they offer a travel kit, which could include ice packs in a bag to travel with.
• Check expiration dates: Expiration dates on the packaging represent how long the biologic or biosimilar will remain active regarding the strength, quality, and purity when stored as required.
  Tip: Talk with your pharmacist regarding how long the biologic or biosimilar will remain effective.

1. Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients. J Am Acad Dermatol. Jan. 2020;82(1):161-201. doi: 10.1016/j.jaad.2019.08.049