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Psoriasis
psoriasis. Subsequently, retinoids have been found to be most effective
involvement of all fingernails. The subject had an extremely strong family
in pustular psoriasis (see Figures 3 and 4).
18
Side effects include cheilitis,
history of psoriasis and psoriatic arthritis in first-degree relatives. He was
xerosis and hair loss. In children, retinoids can influence bone
treated with etanercept subcutaneously for five months, with excellent
development and lead to premature epiphyseal closure, which must be
clinical response that resulted in complete remission of skin lesions and
monitored during long-term treatment.
19
Also, retinoids are highly
nail dystrophy. Side effects of etanercept include injection reactions that
teratogenic, which limits their use in fertile females. However, retinoid
are usually transient. Adverse events noted during the study were three
treatment does not entail general immunosuppression and they are in
cases of infections in roughly 200 patients who received etanercept
fact protective against skin cancer development in at-risk individuals,
during the study. After withdrawing the drug at week 36, 42% of patients
which is an advantage for the proportion of psoriasis patients heavily
had lost the response by week 48. Undoubtedly, the approval of
exposed to UV therapy. Retinoids can be combined with UV therapy,
etanercept for childhood psoriasis will be followed by other biologic
thereby reducing the dose of retinoids as well as of UV light.
20
drugs, and there are already case reports documenting efficacy using the
monoclonal anti-TNF antibodies infliximab and adalimumab.
28
The
Ciclosporin
deepening understanding of psoriasis pathogenesis will lead to the
Ciclosporin inhibits activation of T cells via inhibition of calcineurin. It has
development of new drugs, such as the anti-p40 antibody targeting the
proven efficacy and it is preferentially used to control severe pustular
subunit shared between the interleukin (IL)-23 and IL-12 receptor, which
and/or erythrodermic psoriasis. There are no controlled trials in children
is already showing impressive efficacy in adult psoriasis.
with psoriasis, but there are reports showing its efficacy.
21
The initial dose
of ciclosporin is 3–5mg/kg/day, which should be gradually tapered to the Concluding Remarks
lowest possible dose. With long-term use there are substantial side The increasing awareness of psoriasis as a systemic disease with the
effects such as renal dysfunction and hypertension, and in patients risk of co-morbidities associated with high disease activity will likely lead
exposed to UV treatment there is a significant risk of skin cancer to more active treatment in children. Widespread psoriasis may have a
development.
22
Given the increasing options for systemic treatments, it major psychosocial impact, leading to stigmatisation and a profound
is our view that ciclosporin should be reserved for use during limited impairment of quality of life. Safety issues remain vital in the paediatric
periods as a rescue drug to suppress severe flares of psoriasis. population, and post-marketing surveillance of long-term efficacy and
side effects of novel drugs will be critical. Even though there is as yet no
Methotrexate cure for psoriasis, the rapid development of new and effective
In many countries, methotrexate is the first-line systemic treatment for treatments for psoriasis is highly encouraging. ■
moderate to severe psoriasis in the adult. Side effects and major
concerns include hepatotoxicity and bone marrow depression, as well
Mona Ståhle is a Professor of Dermatology and Head
as teratogenicity. Thus, regular monitoring is needed to identify signs of
of the Dermatology and Venereology Unit in the
organ toxicity. Obviously, as with other systemic drugs, controlled trials Department of Medicine at the Karolinska Institute, a
in children are lacking, even though the drug is used and reports
position she has held since 1999. In recent years, her
research has increasingly focused on the common
describing efficacy are available.
23,24
Recommended doses in children
disease of psoriasis using a combination of genetic,
are 0.2–0.4mg/kg once weekly. Nausea can be a limiting factor, and for epidemiological and immunological methods. She
these patients injectable methotraxate is now available. Folate
works closely with the Swedish psoriasis patient
association, for which she is Medical Adviser. In
supplementation to reduce potential side effects is recommended
addition, Professor Ståhle has developed a line of research into a human cathelicidin
according to guidelines in adults.
25,26
The regimen for folic acid varies, protein and its significance in wound healing, inflammation and tumour development.
but 5mg per day every day except the day on which methotrexate is
given is widely used in dermatological practice.
Josefin Lysell is a Resident in Dermatology and
Venereology in the Unit of Dermatology in the
Department of Medicine at the Karolinska Institute.
Biologics
She has a special interest in childhood psoriasis and
Etanercept is a soluble tumour necrosis factor (TNF) receptor, and is the
is currently collecting material for future studies in
this field.
first biologic drug approved for use in paediatric psoriasis;
27
it had already
been approved for treating children with juvenile rheumatoid arthritis.
Figures 5 and 6 show a 10-year-old boy with plaque psoriasis and
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10 EUROPEAN DERMATOLOGY
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