Dermatology Online Journal

Successful use of infliximab following a failed course of etanercept in a pediatric patient
Neil N Farnsworth MD, Saira J George MD Sylvia Hsu MD
Dermatology Online Journal 11 (3): 11

Most cases of pediatric psoriasis can be controlled with topical modalities. Resistant cases, however, often lead to significant physical and psychological morbidity and pose difficult clinical decisions regarding the long-term term use of systemic immunosuppressive therapy. Recent biologic agents, which antagonize tumor necrosis factor-α (TNF-α), a major inflammatory cytokine that appears to mediate the disease, offer the prospect of more targeted and safer systemic therapy [1]. Although data supporting the safety and efficacy of biologics in the treatment of recalcitrant adult psoriasis continues to grow, very little has been reported regarding their use in pediatric psoriasis.

Etanercept is FDA-approved for the treatment of juvenile rheumatoid arthritis, and infliximab has been reported to be beneficial and well tolerated in the treatment of pediatric inflammatory bowel disease and juvenile rheumatoid arthritis [2, 3]. To the best of our knowledge, there are no reports of etanercept in the treatment of pediatric psoriasis, and only one report, by Menter et al., chronicling the use of infliximab in the successful treatment of a 13-year-old girl with psoriasis treated with 3.3 mg/kg infused at 0, 2, 6, and then every 8 weeks [4, 5].

Figure 1A	Figure 1B

We report the case of an adolescent boy who initially presented at age 14 with erythematous, confluent, scaling plaques over his scalp, trunk, and extremities. Past treatment included systemic steroid therapy complicated by the development of steroid induced obesity, hypertension, and severe acne. He failed treatment with a variety of topical agents including tazorotene, triamcinolone, pimecrolimus, and tacrolimus, and was started on biweekly injections of 25 mg etanercept, which he tolerated without side effects but also without improvement following 8 months of therapy (Fig. 1A). At age 15 he was then switched to infliximab at a dose of 5 mg/kg at 0, 2, 6 weeks and then every 8 weeks. After three infusions, he showed marked clearing of his psoriasis (Fig. 1B), with only residual plaques remainining on his shins. He continues to receive infliximab infusions every 8 weeks without complications.

The success of biologic agents in the treatment of pediatric inflammatory bowel disease and juvenile rheumatoid arthritis as well as adult psoriasis suggests that they may be equally promising in the treatment of recalcitrant pediatric psoriasis. Our report emphasizes the need for large-scale randomized control trials to demonstrate that these agents are both beneficial and safe for use in children suffering from psoriasis.

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