What is the recommended treatment for a 16-year-old female with eczema and psoriasis?

Treatment of Eczema and Psoriasis in a 16-Year-Old Female

For a 16-year-old female with both eczema and psoriasis, the recommended first-line treatment is a combination of topical corticosteroids with vitamin D analogues, followed by consideration of biologic therapy such as adalimumab if the condition is moderate to severe and unresponsive to topical treatments.

Initial Assessment and Topical Therapy

• Begin with moderately potent (class III) topical corticosteroids for both conditions, as they effectively reduce inflammation while minimizing side effects 1
• Add emollients 1-3 times daily to improve hydration, reduce itching, and maintain skin barrier function 1, 2
• Consider calcipotriene (vitamin D analogue) for psoriatic lesions, which can be used alone or in combination with corticosteroids for better efficacy 1, 3
• For eczematous areas, topical calcineurin inhibitors (tacrolimus 0.03% or 0.1%) can be used as steroid-sparing agents, particularly in sensitive areas 2
• Implement a proactive therapy approach with intermittent low-dose anti-inflammatory treatment to previously affected skin areas to prevent flares 4

Phototherapy Options

• If topical treatments provide inadequate response, narrowband UVB (NB-UVB) phototherapy is recommended as a second-line treatment for both conditions 5
• For patients old enough to cooperate with therapy (applicable to a 16-year-old), phototherapy can be administered 2-3 times weekly 5
• Baseline monitoring should include skin cancer screening and eye examination before starting phototherapy 5
• Regular skin examinations should be conducted during treatment to monitor for adverse effects 5

Systemic Therapy Considerations

• For moderate to severe psoriasis unresponsive to topical therapy and phototherapy, consider biologic therapy 5
• Adalimumab is recommended for adolescents with moderate to severe psoriasis at a dose of 0.8 mg/kg (maximum 40 mg) at weeks 0 and 1, then every other week 5
• Etanercept is an alternative option for patients 6 years and older at a dose of 0.8 mg/kg (maximum 50 mg) once weekly 5
• Ustekinumab is recommended for adolescents 12 years and older with moderate to severe plaque psoriasis, administered at weeks 0,4,16, and then every 12 weeks with weight-based dosing 5

Special Considerations for Female Adolescents

• Avoid acitretin in female adolescents approaching childbearing potential due to its teratogenic effects that can persist for up to 3 years 5
• If systemic therapy is needed, methotrexate should be used with extreme caution and only with reliable contraception due to its teratogenic potential 5
• Counsel regarding contraception if considering any systemic therapy, as most are contraindicated in pregnancy 5, 6
• Monitor for psychological impact of visible skin disease, which can be particularly significant in adolescents 7

Monitoring and Follow-up

• Regular clinical reviews are essential when using topical corticosteroids to monitor for adverse effects 1
• For patients on biologics, monitor for injection site reactions and increased risk of infection 5
• If using methotrexate, perform baseline and periodic monitoring of full blood count, liver function tests, and serum creatinine 5, 6
• Consider allergic contact dermatitis as a potential complicating factor if there is poor response to treatment, as it can coexist with psoriasis 7

Treatment Algorithm

1. Mild disease:

   • Start with topical therapy: moderately potent corticosteroids + emollients 1, 2
   • Add calcipotriene for psoriatic lesions 1, 3
   • Use for 2-4 weeks, then reassess 1

2. Moderate disease or inadequate response to topicals:

   • Add NB-UVB phototherapy 2-3 times weekly 5
   • Consider combination with topical treatments 5

3. Severe disease or inadequate response to above:

   • Consider biologic therapy with adalimumab, etanercept, or ustekinumab based on age and weight 5
   • Biologics may be safely combined with topical treatments to enhance effectiveness 5

4. For flare management:

   • Implement proactive therapy with intermittent application of anti-inflammatory agents to prevent recurrence 4
   • Adjust treatment intensity based on disease severity 5

Important Pitfalls to Avoid

• Avoid high-potency (class I or II) corticosteroids for long-term use due to increased risk of skin atrophy 1
• Do not use systemic corticosteroids as they can precipitate erythrodermic psoriasis or generalized pustular psoriasis upon discontinuation 6
• Recognize that psoriasis and eczema can coexist, contrary to some beliefs that they are mutually exclusive 8
• Be aware that some cases may represent "eczematized psoriasis" rather than two distinct conditions, which may influence treatment approach 7