What is the appropriate management for a 2‑year‑old child with itchy plaque psoriasis (psoriasis vulgaris)?

Management of Plaque Psoriasis in a 2-Year-Old Child

For a 2-year-old with itchy plaque psoriasis, start with a combination of emollients plus low-potency topical corticosteroid (hydrocortisone 1-2.5%) applied twice daily to the trunk and extremities, while using tacrolimus 0.1% ointment for any facial or genital involvement. 1, 2

Initial Treatment Approach

Body (Trunk and Extremities)

• Apply hydrocortisone 1-2.5% cream twice daily to affected plaques on the trunk and extremities for up to 2-4 weeks until significant improvement occurs 2
• At age 2 years, the child is in the highest-risk category (0-6 years) for HPA axis suppression due to high body surface area-to-volume ratio, making low-potency steroids essential 1, 2
• Prescribe limited quantities (no more than small tubes) with explicit instructions on amount and application sites to prevent overuse 1, 2
• Never use medium-potency or higher steroids at this age due to unacceptable risk of systemic absorption and HPA suppression 1, 2

Face and Genital Areas

• Use tacrolimus 0.1% ointment twice daily instead of any corticosteroid for facial or genital psoriasis 1, 3
• Tacrolimus achieves clearance within 72 hours to 2 weeks in pediatric facial psoriasis and avoids steroid-related atrophy risks 1, 3
• This is the preferred first-line therapy for sensitive areas per American Academy of Dermatology guidelines 3

Essential Adjunctive Therapy

• Apply thick emollients (ointment-based) liberally and frequently throughout the day, ideally after a 10-15 minute lukewarm bath 2
• Emollients provide steroid-sparing effects and reduce irritation from active treatments 1
• This is not optional—emollients are a cornerstone of pediatric psoriasis management 2

Transition to Maintenance Phase

Once plaques show significant improvement (typically 2-4 weeks):

• Transition to twice-weekly application of the low-potency corticosteroid on previously affected trunk/extremity sites to prevent relapse 2
• Continue tacrolimus twice weekly on facial areas if those were involved 3
• Maintain daily emollient use indefinitely 2
• This proactive maintenance approach reduces relapse rates without continuous steroid exposure 2

Alternative First-Line Options if Initial Therapy Inadequate

If there is no improvement after 2 weeks of the above regimen:

Consider Adding Topical Vitamin D Analog

• Calcipotriene/calcipotriol 0.005% ointment can be added to non-facial areas, applied once daily 1
• Use emollients with calcipotriene to reduce stinging and burning 1
• Maximum dose: 50 g/week/m² to prevent hypercalcemia 2
• Monitor for irritation, which is common in young children 1

Rotational Therapy Strategy

• Alternate between different topical agents (low-potency steroid on weekends, calcipotriene on weekdays) to minimize steroid exposure 1
• This steroid-sparing approach is specifically recommended by American Academy of Dermatology guidelines for children 1

Second-Line Option: Short-Contact Anthralin

If topical steroids, tacrolimus, and vitamin D analogs fail after 4-6 weeks:

• Short-contact anthralin 0.1-0.25% applied for 15-30 minutes daily, then washed off 1
• Increase concentration gradually (doubling) as tolerated, up to 1-2% 1
• 69.5% of pediatric patients achieve good response with average remission of 5.5 months 1
• Critical warning: Causes severe irritation in 63% of patients and stains skin/clothing brown-purple 1
• Should be considered before phototherapy or systemic agents per American Academy of Dermatology 1

Critical Safety Considerations for This Age Group

HPA Axis Suppression Risk

• Infants and toddlers (0-6 years) are uniquely vulnerable to systemic corticosteroid absorption even with low-potency agents 1, 2
• Avoid application to large body surface areas (>20%) even with hydrocortisone 2
• Never use occlusive dressings at this age 2

Rebound Flare Prevention

• Never abruptly stop corticosteroids after more than 2 weeks of use 1, 2
• Taper by reducing frequency (daily → every other day → twice weekly) over 1-2 weeks 2
• Transition to maintenance therapy rather than complete cessation 2

Monitoring Requirements

• Follow-up at 2 weeks to assess response and check for adverse effects 2
• If using calcipotriene on large areas, consider monitoring serum calcium and vitamin D metabolites 1
• Regular dermatology follow-up is essential to prevent overuse and ensure proper technique 1, 2

Common Pitfalls to Avoid

• Using medium-potency steroids (fluticasone, mometasone) at age 2: These are only appropriate for children ≥11 years on trunk/extremities 2
• Applying any corticosteroid to the face: Always use tacrolimus instead to avoid irreversible atrophy 1, 3
• Neglecting emollients: This single error increases steroid requirements and prolongs disease 2
• Prescribing large quantities without clear instructions: Leads to overuse and systemic toxicity in this vulnerable age group 1, 2
• Using salicylic acid with calcipotriene simultaneously: The acidic pH inactivates calcipotriene; if using both, apply salicylic acid 1 week before starting calcipotriene 1

When to Refer to Pediatric Dermatology

• Failure to respond to appropriate topical therapy after 6-8 weeks 1
• Extensive body surface area involvement (>20%) 1
• Severe pruritus interfering with sleep or development 4
• Need for consideration of phototherapy (narrowband UVB) or systemic agents 4, 5