Magan Medical Clinic, Dermatology
We provide quality dermatology care with compassion. Our specialty is medical dermatology, including:
Note: Cosmetic treatments are not performed in Dermatology but instead by Magan's Medical Aesthetics Laser Center.
If you have psoriasis or hair questions, Dr. Chiang possesses special expertise. He completed fellowships in both fields at University of California, San Francisco where he saw a wide spectrum of patients (including the most severe), performed clinical trials, and published research.
We take pleasure in serving our community including Covina, West Covina, San Dimas, Rancho Cucamonga, Baldwin Park, Azusa, Glendora, Upland, El Monte, Duarte, Monrovia, Arcadia, La Puente, and Diamond Bar.
Same day appointments often available. No referral is necessary if you have PPO insurance. We accept a wide range of insurance plans (unfortunately, we do not accept Medi-Cal as primary insurance, only as secondary insurance).
For appointments, please call (626) 251-1500. We look forward to serving you!
"What's New in..."
A monthly column by Dr. Chiang
What's New in Pediatric psoriasis
While psoriasis is a disease that most often affects, I do see pediatric (Ie, patients younger than 18) patients who develop it. It usually shows itself as thick scaly rashes especially on the scalp, elbows, and knees. However, it can appear anywhere on the body.
Mild to moderate patients are treated the same as adults, most often with steroid ointments, creams, and/or solutions. Patients with severe scalp psoriasis sometimes receive steroid injections directly into the scalp. However, there is not a clear agreement on how to treat severe cases (usually defined as affecting at least 10% of the body surface area). This is because systemic treatments (phototherapy, pills, biologic injections) are to be considered at this point since even the strongest ointments we have usually cannot completely treat large amounts of psoriasis. This is both the way they work in addition to the difficult of applying the ointments to every inch of psoriasis (while being careful not to treat "normal" skin) twice daily for weeks to months. Many patients and parents view this as impractical.
Most agree that the "safest" systemic treatment for severe psoriasis is phototherapy. However, patients and parents again usually view this as impractical to come usually twice weekly for many months to achieve benefit. Then, usually once weekly treatment for months is needed to maintain benefits. Then, it often recurs at some point after treatment is stopped.
Thus, there are two biologic injections I am aware of that are FDA approved for moderate to severe pediatric plaque psoriasis. In 2016, etanercept (Enbrel) was approved for patients as young as age 4. In 2017, Ustekinumab (Stelara) was approved patients as young as age 12. However, FDA approval does not change the fact that, just as with adults treated with the medications, there are risks associated with the immunosuppression including an increased risk of cancer and infections. Most parents I see would not wish to take any increased risk of cancer, which is a very reasonable approach. That being said, etanercept, a TNF inhibitor, likely has the most data in children and the one I would likely choose of the two biologics. Dr. Cordoro, a UCSF pediatric dermatologist well respected for her psoriasis expertise states "these drugs have reassuring safety profiles; low rates of infection and adverse reactions." The 5 year open label extension study published in 2016 followed 181 pediatric psoriasis patients treated with etanercept, of whom 69 completed 264 weeks (~5 years) of treatment. Efficacy-wise, most (60-70%) patients achieved at least 75% improvement in their psoriasis. Common side effects included upper respiratory infections, nasopharyngitis, and headaches. There were 8 serious adverse events. Only one (cellulitis = deep skin infection) was thought to be treatment related. The other seven (an induced abortion, anxiety, infectious mononucleosis, two events of osteonecrosis in a patient with a history of congenital acetabular dyplasia and avascular necrosis of both hips, postoperative intestinal obstruction in a patient with a "history of congenital bladder exstrophy underwent successful Mitrofanoff procedure and reported intestinal obstruction approximately 5 wk after surgery", a thyroid cyst) were thought to be unrelated to etanercept usage. There were no cases of cancer reported. The other issue with all biologics including etanercept is insurance coverage as these medications retail for about $60,000 yearly per goodrx.com (about $75,000 yearly for adult dosing).
There are other options that are not FDA approved. In my experience, the parents in my area would likely not choose these, other than possible phototherapy due to its favorable safety profile. That being said, Dr. Cordoro does mention "tried and true systemic therapies include methotrexate, cyclosporine, acitretin, and phototherapy, but none is approved by the Food and Drug Administration for use in children."
If you have psoriasis or another skin condition, consider making an appointment for dermatology consultation at (626) 251-1500 to discuss your options.
Charles Chiang, MD, FAAD
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