INTRODUCTION
A previously healthy 3-year-old boy presented to our Pediatric Dermatology clinic with a 3-month history of marked nail dystrophy involving several fingers and toes. The differential diagnosis included onychomycosis and nail psoriasis. An initial trial of empiric terbinafine was recommended, pending fungal culture of nail clippings. This resulted negative 1 month later.
The patient was subsequently lost to follow-up for 5 years, returning for pruritic, psoriasiform skin lesions that had slowly spread over several years to involve his knees, arms, genitals, and scalp, with an estimated 10% body surface area (BSA). These findings, as well as geographic tongue and worsening nail dystrophy with associated paronychia, were characteristic of plaque psoriasis (see Figure 1).
Initial treatment with topical therapy was prescribed, as allowed by his insurance formulary, with alternating betamethasone and calcipotriene ointments, and ketoconazole shampoo as scalp and body wash. A 2-week trial of this regimen yielded minimal improvement.
The severity and extent of his psoriasis, including areas that were difficult-to-treat topically, met inclusion criteria for participation in a clinical trial of ixekizumab (Taltz®, Lilly), a biologic medication targeting IL-17, which was previously Food and Drug Administration (FDA)-approved for psoriasis in adults. His scalp completely cleared within 1 week of the first injection. His nails and palms continued to improve with subsequent monthly injections, achieving 1% BSA (groin-only) involvement within 6 months. Complete clearing was achieved within 16
The patient was subsequently lost to follow-up for 5 years, returning for pruritic, psoriasiform skin lesions that had slowly spread over several years to involve his knees, arms, genitals, and scalp, with an estimated 10% body surface area (BSA). These findings, as well as geographic tongue and worsening nail dystrophy with associated paronychia, were characteristic of plaque psoriasis (see Figure 1).
Initial treatment with topical therapy was prescribed, as allowed by his insurance formulary, with alternating betamethasone and calcipotriene ointments, and ketoconazole shampoo as scalp and body wash. A 2-week trial of this regimen yielded minimal improvement.
The severity and extent of his psoriasis, including areas that were difficult-to-treat topically, met inclusion criteria for participation in a clinical trial of ixekizumab (Taltz®, Lilly), a biologic medication targeting IL-17, which was previously Food and Drug Administration (FDA)-approved for psoriasis in adults. His scalp completely cleared within 1 week of the first injection. His nails and palms continued to improve with subsequent monthly injections, achieving 1% BSA (groin-only) involvement within 6 months. Complete clearing was achieved within 16
