Treatment of Facial Psoriasis in a 9-Year-Old Child
Tacrolimus 0.1% ointment is the recommended first-line treatment for facial psoriasis in this 9-year-old patient. 1
Rationale for Tacrolimus as First-Line Therapy
The face is a sensitive area where topical corticosteroids carry significant risks of adverse effects, particularly skin atrophy, telangiectasia, and perioral dermatitis. 1 The American Academy of Dermatology-National Psoriasis Foundation guidelines specifically recommend topical calcineurin inhibitors as the preferred first-line therapy for psoriasis of the face, genitalia, and body folds in pediatric patients. 1
Evidence Supporting Tacrolimus for Facial Psoriasis
- Rapid efficacy: Complete clearance of facial psoriasis was achieved within 72 hours in a case series that included a pediatric patient. 1
- Sustained response: A retrospective review of 12 children with facial psoriasis using tacrolimus 0.1% reported clearance within 2 weeks. 1
- Good tolerability: In children ages 6-15 years with facial or inverse psoriasis, 88% of patients who continued treatment for at least 30 days achieved clearance or excellent improvement within 30 days. 1
- Manageable flares: While 7 of 8 patients experienced subsequent flares, they responded well to repeat treatment. 1
Application Protocol
- Apply tacrolimus 0.1% ointment to affected facial areas twice daily until clearance is achieved. 1
- The most common adverse effect is burning and stinging at the application site, which typically diminishes with continued use. 1
- Continue treatment for at least 30 days to assess full response. 1
Alternative and Adjunctive Options
If Tacrolimus Fails or Is Not Tolerated
Low-potency topical corticosteroids (Class V/VI such as hydrocortisone 2.5%) may be used on the face, but only for short durations and with close monitoring. 2
- High-potency or ultra-high-potency corticosteroids should be avoided on facial skin in children due to increased risk of skin atrophy and HPA axis suppression. 1, 2
- If corticosteroids are used, prescribe limited quantities with explicit instructions to prevent overuse. 2
Combination Therapy Considerations
For more extensive disease involving the trunk and extremities in addition to the face:
- Use tacrolimus 0.1% for facial lesions. 1
- Consider calcipotriene/betamethasone dipropionate combination for non-facial areas in children ≥12 years (applied once daily for up to 4 weeks). 2
- For children under 12 years with body involvement, rotational therapy alternating between topical vitamin D analogs (weekdays) and low-to-moderate potency corticosteroids (weekends) can serve as a steroid-sparing approach. 1, 2
Critical Safety Considerations for This Age Group
- Children ages 0-6 years are particularly vulnerable to HPA axis suppression, but at age 9, this risk is lower though still present with high-potency steroids. 1, 2
- Avoid abrupt discontinuation of corticosteroids if they are used, as this can cause rebound flares; transition to tacrolimus or another maintenance therapy. 1, 2
- Regular follow-up with a dermatologist is essential to monitor treatment response and prevent adverse effects. 1
Common Pitfalls to Avoid
- Do not use high-potency corticosteroids on the face in pediatric patients, even for short durations, as the risk of skin atrophy and other adverse effects is significantly elevated on facial skin. 1, 2, 3
- Do not prescribe unlimited quantities of any topical medication; provide clear instructions on amount and frequency to prevent overuse. 1, 2
- Do not ignore the psychological impact of facial psoriasis in children, as visible lesions can significantly affect quality of life and may warrant more aggressive treatment. 4
Maintenance Strategy
Once clearance is achieved: