A child with psoriasis on thick plaques uses a moderate-potency topical steroid on thick plaques and a high-potency topical steroid on the elbows and knees, but symptoms worsen. Which treatment should be added?

A child with psoriasis on thick plaques uses a moderate-potency topical steroid on thick plaques and a high-potency topical steroid on the elbows and knees, but symptoms worsen. Which treatment should be added?

• A. Anthralin ointment in high strength applied for 10 to 30 minutes daily
• B. Calcipotriol cream applied liberally each day to the entire body
• C. Oral steroids and methotrexate therapy until plaques resolve
• D. Wideband ultraviolet therapy for 15 minutes twice daily

Answer: (A)

When thick psoriatic plaques in a child do not respond adequately to appropriate topical steroids, adding a non-steroidal antiproliferative agent that can be used on plaques is a logical next step. Anthralin ointment, used as short-contact therapy, fits this role well. It helps slow keratinocyte proliferation and reduce local inflammation in stubborn plaques. Because the plaques are thick, applying a higher-strength anthralin for a limited daily period (for example, 10 to 30 minutes) can promote clearer skin while minimizing irritation. Protect surrounding skin, use barrier cream around margins, and wash off thoroughly after the exposure. Start with a brief duration to gauge tolerance and gradually lengthen if well tolerated. This approach is preferable to systemic options or broad, unsupervised topical regimens in a child with localized thick plaques. Wideband UV therapy, while effective for some patients, requires multiple sessions and monitoring and is not always the immediate next step after topical steroids fail. Calcipotriol can be helpful but applying it liberally to the entire body isn’t standard practice and carries risks if used broadly. Systemic steroids and methotrexate are generally reserved for more extensive disease and carry significant side effects, especially in children.

When thick psoriatic plaques in a child do not respond adequately to appropriate topical steroids, adding a non-steroidal antiproliferative agent that can be used on plaques is a logical next step. Anthralin ointment, used as short-contact therapy, fits this role well. It helps slow keratinocyte proliferation and reduce local inflammation in stubborn plaques. Because the plaques are thick, applying a higher-strength anthralin for a limited daily period (for example, 10 to 30 minutes) can promote clearer skin while minimizing irritation. Protect surrounding skin, use barrier cream around margins, and wash off thoroughly after the exposure. Start with a brief duration to gauge tolerance and gradually lengthen if well tolerated.

This approach is preferable to systemic options or broad, unsupervised topical regimens in a child with localized thick plaques. Wideband UV therapy, while effective for some patients, requires multiple sessions and monitoring and is not always the immediate next step after topical steroids fail. Calcipotriol can be helpful but applying it liberally to the entire body isn’t standard practice and carries risks if used broadly. Systemic steroids and methotrexate are generally reserved for more extensive disease and carry significant side effects, especially in children.