What is the first-line treatment for a 17-year-old patient with psoriasis?

First-Line Treatment for Psoriasis in a 17-Year-Old

For a 17-year-old with psoriasis, the first-line treatment is dual topical therapy combining a high-potency topical corticosteroid with a vitamin D analog (calcipotriene/calcipotriol), applied either simultaneously or sequentially. 1, 2

Topical Therapy Approach

Standard Regimen for Body/Trunk Psoriasis

• Apply high-potency topical corticosteroid (class 2-5) combined with calcipotriene/calcipotriol for initial control 1, 2
• The most common approach is to mix both medications 1:1 on the finger and apply together twice daily for the first 2 weeks 1
• After initial 2 weeks, transition to weekend-only corticosteroid application with weekday calcipotriol application to maintain remission while minimizing steroid exposure 1
• Maximum duration of continuous high-potency corticosteroid use should not exceed 4 weeks 2

Site-Specific Modifications

For facial and genital psoriasis:

• Use tacrolimus 0.1% ointment as first-line monotherapy (off-label) 1
• This avoids skin atrophy risk from corticosteroids in sensitive areas 1
• Clearance typically occurs within 2 weeks for facial lesions 1

For scalp psoriasis:

• Use calcipotriol/betamethasone dipropionate suspension once daily for up to 8 weeks 1
• This formulation is specifically approved for ages 12 and older 1

Dosing Limits to Prevent Adverse Effects

• Maximum calcipotriol: 50 g/week/m² to prevent hypercalcemia 1
• Maximum for combination scalp formulation: 80 g/week for adolescents 1
• Monitor closely for HPA axis suppression with high-potency corticosteroids, though 17-year-olds have lower risk than younger children 1

When to Escalate Beyond Topical Therapy

Consider systemic therapy if:

• Body surface area involvement >5% 1
• Inadequate response to topical therapy after 4-8 weeks 2
• Significant impact on quality of life despite topical treatment 2

Systemic Options for Adolescents

If topical therapy fails, the treatment algorithm for patients <18 years with >5% BSA involvement includes: 1

First-line systemic options:

• UVB phototherapy (narrowband or broadband) as monotherapy if available 1
• Methotrexate (with or without UVB) 1
• Adalimumab (approved for ages ≥4 years) 1
• Etanercept (ages ≥6 years) - the only biologic with Level 1 evidence in pediatrics 1, 3
• Ustekinumab (ages ≥12 years) 1

Etanercept dosing for ages 4-17: 0.8 mg/kg (maximum 50 mg) once weekly achieved 57% PASI-75 response at 12 weeks in pediatric trials 3

Critical Safety Considerations

Corticosteroid Precautions

• Never abruptly discontinue high-potency corticosteroids - risk of severe rebound flare 1
• Transition to alternative maintenance therapy (vitamin D analog, calcineurin inhibitor, or weekend-only corticosteroid) 1
• Provide limited quantities and clear instructions on amount and application sites 1

Medications to Avoid

• Do not use systemic corticosteroids - can precipitate or worsen psoriasis flares upon discontinuation 2
• Avoid salicylic acid with calcipotriol - acidic pH inactivates calcipotriol and reduces effectiveness 2

Evidence Quality Note

The 2020 Joint AAD-NPF pediatric psoriasis guidelines provide the most current and specific recommendations for this age group 1. The combination calcipotriol/betamethasone formulation has Strength B recommendation with Level I-II evidence for ages 12 and older 1. While systematic reviews suggest vitamin D monotherapy as first-line, expert opinion and clinical practice favor the combination approach for faster initial control 1.