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CORRESPONDENCE
Year : 2022  |  Volume : 67  |  Issue : 5  |  Page : 601-603
Juvenile pityriasis rubra pilaris in a 4-year-old child treated successfully with secukinumab


Paediatric Dermatology Unit, Department of Paediatrics, Women and Children Hospital, Kuala Lumpur, Malaysia

Date of Web Publication29-Dec-2022

Correspondence Address:
Henrietta Albela
Paediatric Dermatology Unit, Department of Paediatrics, Women and Children Hospital, Kuala Lumpur
Malaysia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijd.ijd_1079_21

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How to cite this article:
Albela H, Lee WQ, Nordin SN, Gopinathan LP, A. Ramli MN, Leong KF. Juvenile pityriasis rubra pilaris in a 4-year-old child treated successfully with secukinumab. Indian J Dermatol 2022;67:601-3

How to cite this URL:
Albela H, Lee WQ, Nordin SN, Gopinathan LP, A. Ramli MN, Leong KF. Juvenile pityriasis rubra pilaris in a 4-year-old child treated successfully with secukinumab. Indian J Dermatol [serial online] 2022 [cited 2023 Jan 30];67:601-3. Available from: https://www.e-ijd.org/text.asp?2022/67/5/601/366097




Sir,

A 4-year-old girl, of Chinese descent, presented to us with a history of progressive skin lesions since 1 year of age, appearing as erythematous, scaly, slightly pruritic skin rash over limbs and trunk, with palmoplantar thickening.

On examination, she had red-orange plaques over her back, face, knees and arms [Figure 1] with palmoplantar hyperkeratosis, scaliness and fissuring [Figure 2] and [Figure 3]. Based on her clinical features, she was classified as type IV pityriasis rubra pilaris (PRP) (circumscribed juvenile). The skin biopsy done was consistent with PRP. She was started on oral acitretin, up to 1mg/kg, with only mild improvement in reducing skin thickness and no effect on pruritus. There was parental concern on long-term retinoid usage; hence, oral acitretin was stopped after 1 year.
Figure 1: Thick red-orange circumscribed plaques present on the patient's arm, before treatment with secukinumab

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Figure 2: Hyperkeratosis with scaliness and painful fissuring

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Figure 3: Plantar hyperkeratosis

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Secukinumab injection was offered as an off-label treatment and parental consent was obtained. 150 mg of secukinumab was administered subcutaneously, with the first two doses at 2 weeks apart and subsequent two doses at longer intervals of 2 months apart, due to limited resources in our setting.

Within a week of the first injection, there was a significant reduction in pruritus, skin thickness, erythema and scaliness. After the second dose of treatment, there was 90% improvement with the resolution of the plaques on her face, trunk and limbs [Figure 4]. Palmoplantar hyperkeratosis has significantly reduced in thickness, without painful fissuring as before [Figure 5] and [Figure 6]. No side effects of secukinumab were reported to date.
Figure 4: Resolution of thick plaques on her arms to postinflammatory hypopigmented patches, after treatment with secukinumab (after two doses)

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Figure 5: Significant reduction in palmar thickness and scaliness, with residual mild erythema

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Figure 6: Reduction in plantar thickness and scaliness

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   Discussion Top


PRP is a papulosquamous inflammatory dermatosis of unknown cause.[1] The classical clinical features are red-orange plaques, hyperkeratotic follicular papules and palmoplantar keratoderma.[1] Type IV is the predominant type in paediatric patients with the cardinal feature of palmoplantar hyperkeratosis, and more prolonged disease duration.[2] PRP is usually self-limiting, but for those with a more protracted course, treatment can be challenging as there is no consensus on treatment guidelines with a lack of high-quality evidence.

Topical therapy can be used for mild disease while oral retinoids are considered to be the first-line systemic treatment for PRP. However, usage of acitretin in the paediatric population, particularly in higher doses for longer periods of time, has a higher risk of systemic side effects.[3]

Given the similarities between psoriasis and PRP, and considering the increasing use of novel biologics in the treatment of psoriasis, it is becoming evident that biologics can be a feasible option for patients with PRP as well. Tumour necrosis factor (TNF) alpha inhibitors, ustekinumab and secukinumab have been used recently for treatment-resistant PRP.[1]

Although the pathogenesis of PRP remains to be completely understood, upregulation of proinflammatory innate cytokines, especially T-helper 17 (TH17) cytokines interleukin (IL)-17A, IL-17F and IL-22, was demonstrated in lesional PRP skin samples.[4] Secukinumab acts by targeting IL-17A with wide effects on the proliferation and maturation of keratinocytes. A recent review of secukinumab for PRP demonstrated excellent outcomes with a response rate of 91.7%, with most patients achieving complete or almost complete skin clearance.[5] The same study reported the first paediatric case of a 7-year-old boy with severe type V PRP, who was treated successfully with secukinumab with marked improvement seen within 5 weeks, without adverse effects.[4] Similarly, our patient, who is younger in age, demonstrated rapid remission and marked improvement while on secukinumab without any side effects. Similar to the use of secukinumab in adults, there are no specific monitoring parameters needed for paediatric patients while on this targeted therapy. As such, secukinumab can be an alternative option for paediatric patients with juvenile PRP.

Acknowledgements

The authors would like to thank the Director General of Health Malaysia for his permission to publish this article.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Wang D, Chong VC, Chong WS, Oon HH. A review on pityriasis rubra pilaris. Am J Clin Dermatol 2018;19:377-90.  Back to cited text no. 1
    
2.
Yang CC, Shih IH, Lin WL, Yu YS, Chiu HC, Huang PH, et al. Juvenile pityriasis rubra pilaris: Report of 28 cases in Taiwan. J Am Acad Dermatol 2008;59:943-8.  Back to cited text no. 2
    
3.
Brecher AR, Orlow SJ. Oral retinoid therapy for dermatologic conditions in children and adolescents. J Am Acad Dermatol 2003;49:171-82.  Back to cited text no. 3
    
4.
Feldmeyer L, Mylonas A, Demaria O, Mennella A, Yawalkar N, Laffitte E, et al. Interleukin 23-helper T cell 17 axis as a treatment target for pityriasis rubra pilaris. JAMA Dermatol 2017;153:304-8.  Back to cited text no. 4
    
5.
Liang JY, Ye RX, Tian X, Zhang SQ, Zhang XB. Secukinumab monotherapy successfully treated severe refractory type V (atypical juvenile) pityriasis rubra pilaris: A case report and literature review. Dermatol Ther 2020;33:e14097. doi: 10.1111/dth. 14097.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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