Severe Psoriasis Presenting in 3-Year-Old Child With Nail Dystrophy: Response to Biologic Treatment

August 2022 | Volume 21 | Issue 8 | 897 | Copyright © August 2022


Published online August 1, 2022

Danielle Rinck MDa, Elaine Siegfried MDb

aBeth Israel Deaconess Medical Center, Boston, MA
bSaint Louis University School of Medicine, St. Louis, MO

Abstract
Psoriasis, a chronic inflammatory skin condition, affects about 2% of children. A small subset have isolated nail involvement refractory to topical treatment that can be disabling. The development of targeted biologic agents offers safe, effective options for children with moderate-to-severe skin and nail disease. A few are now Food and Drug Administration (FDA)-approved for children.

J Drugs Dermatol. 2022;21(8):897-899. doi:10.36849/JDD.6888

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