What is the treatment for Pitryasis Lichenoides et Varioliformis Acuta (PLEVA) in an 8-year-old boy?

Treatment of Pityriasis Lichenoides et Varioliformis Acuta (PLEVA) in an 8-Year-Old Boy

Topical corticosteroids should be used as first-line therapy for PLEVA in an 8-year-old boy, with narrowband UVB phototherapy or oral antibiotics as second-line options if the condition is resistant to topical treatment.

First-Line Treatment

Topical Corticosteroids

• Start with medium to high-potency topical corticosteroids for the acute phase of PLEVA
• Apply once daily to affected areas for 2-4 weeks 1
• Recommended regimen:
  • Initial application: Once daily for 4 weeks
  • Then: Alternate days for 4 weeks
  • Finally: Twice weekly for 4 weeks before reassessment 2
• Monitor for side effects including skin atrophy, particularly in thin-skinned areas

Emollients

• Apply alcohol-free moisturizers after topical corticosteroid application to promote skin healing 1
• Use fragrance-free formulations, applied liberally 3-8 times daily 1

Second-Line Treatments (for resistant cases)

Narrowband UVB Phototherapy

• Consider for children old enough to cooperate with therapy (typically feasible for an 8-year-old) 2
• Treatment protocol:
  • Starting at 70% of minimal erythema dose (MED)
  • 20% increments as tolerated
  • 3 times weekly for at least 5 weeks 2
• Monitor for side effects including erythema and pruritus, which occur in approximately 54% and 15% of cases respectively 2

Oral Antibiotics

• Oral tetracyclines are effective for inflammatory skin conditions but are contraindicated in children under 8 years of age 2
• For an 8-year-old who has just reached the minimum age threshold:
  • Doxycycline 100 mg twice daily for 7-14 days 1
  • Monitor for gastrointestinal side effects and photosensitivity

Third-Line Treatments (for severe or recalcitrant cases)

Methotrexate

• Consider for resistant cases that fail to respond to first and second-line therapies
• Dosing: 10 mg/m² weekly 3
• Requires baseline and regular monitoring of:
  • Complete blood count
  • Liver function tests
  • Renal function tests

Oral Corticosteroids (short course)

• For severe or rapidly progressive cases:
  • Prednisolone 1 mg/kg/day with tapering over at least 4 weeks 1, 3
  • Not recommended for long-term maintenance due to side effects

Supportive Care

Infection Prevention

• Keep any crusted or eroded lesions clean and covered with dry bandages 2
• Consider antiseptic washes with aqueous chlorhexidine 0.05% for erosive lesions 1
• Maintain good personal hygiene with regular bathing 2

Environmental Measures

• Avoid hot water and alcohol-based products which can exacerbate skin irritation 1
• Focus cleaning on high-touch surfaces to prevent secondary infection 2

Monitoring and Follow-up

• Reassess after 4 weeks of initial therapy
• If lesions are improving but not resolved, continue current therapy
• If no improvement or worsening, escalate to next line of treatment
• Monitor for development of new lesions, which may indicate disease progression

Special Considerations

• PLEVA can rarely progress to febrile ulceronecrotic Mucha-Habermann disease (FUMHD), a potentially life-threatening condition characterized by ulcerating lesions, high fever, and elevated TNF-alpha 3
• Warning signs requiring immediate attention include:
  • Development of ulcerative lesions
  • Fever
  • Systemic symptoms
  • Lesions covering >90% of body surface

PLEVA is typically self-limited but may persist for months to years. The treatment approach should be stepped up if the condition is resistant to initial therapy, with careful monitoring for disease progression or complications.