What is the best treatment approach for a 76-year-old patient with non-healing infected psoriasis and a history of alcoholism?

Treatment Approach for Non-Healing Infected Psoriasis in a 76-Year-Old with Alcoholism

For a 76-year-old patient with non-healing infected psoriasis and alcoholism, the optimal treatment approach should include addressing the infection, managing psoriasis, and addressing the alcohol dependency through referral to appropriate specialists. 1

Initial Assessment and Management of Infection

1. Treat the infection first:

   • Obtain cultures from infected psoriatic lesions to identify causative organisms
   • Initiate appropriate systemic antibiotics based on culture results
   • Consider topical antimicrobials for localized infection

2. Address alcohol dependency:

   • Refer to addiction specialists for alcohol dependency management 1
   • Screen for liver function abnormalities before initiating psoriasis treatments
   • Consider laboratory markers to assess alcohol consumption impact 2

Psoriasis Treatment Selection

First-Line Approach

1. Narrowband UVB phototherapy:

   • Well-tolerated in elderly patients with alcohol use issues
   • Cost-effective with minimal drug interactions
   • Safer option given alcohol-related liver concerns 1
   • Typically requires 2-3 sessions weekly for 20-30 treatments

2. Topical therapy (to be used concurrently):

   • Topical corticosteroids: Class 1 (ultrahigh-potency) for thick plaques, class 2-5 (high to moderate potency) for most body areas 3
   • Vitamin D analogues: Calcipotriene or calcitriol, can be combined with corticosteroids 3
   • Coal tar preparations: Start with low concentrations (0.5-1.0%) and gradually increase to maximum 10% as tolerated 3

Treatment Considerations and Contraindications

1. Avoid methotrexate:

   • Contraindicated due to alcoholism and potential for severe hepatotoxicity 1
   • Increased risk of liver damage in elderly patients with alcohol use 4

2. Use caution with systemic agents:

   • Alcohol intake limits treatment options and may decrease efficacy 1, 5
   • Excessive alcohol intake increases risk of liver disease and treatment toxicity 1
   • Alcohol can trigger persistent systemic inflammation, worsening psoriasis 5

3. Consider acitretin with caution:

   • May be an option for postmenopausal patients
   • Can be used in combination with NB-UVB for enhanced efficacy
   • Requires close monitoring of liver function tests due to alcohol history 1
   • Lower doses recommended to minimize mucocutaneous side effects

Monitoring and Follow-up

1. Regular clinical assessment:

   • Monitor for treatment response and adverse effects
   • Assess liver function tests regularly, especially if systemic agents are used
   • Evaluate for signs of alcohol-related complications

2. Quality of life considerations:

   • Address psychosocial impact of psoriasis
   • Consider the relationship between psoriasis, alcohol use, and psychological distress 6, 7

Treatment Algorithm

1. If infection is present:

   • Treat infection with appropriate antibiotics based on culture results

2. For psoriasis management:

   • Begin NB-UVB phototherapy (2-3 times weekly)
   • Add appropriate topical agents based on lesion location and severity

3. If inadequate response after 20-30 NB-UVB treatments:

   • Consider PUVA photochemotherapy
   • Consider cautious trial of acitretin (with close liver monitoring)

4. Throughout treatment:

   • Maintain referral to addiction specialists for alcohol management
   • Monitor liver function and treatment efficacy regularly
   • Adjust treatment based on clinical response and tolerability

Pitfalls and Caveats

• Avoid abrupt discontinuation of topical corticosteroids to prevent rebound phenomenon 3
• Be vigilant for infections as both psoriasis and alcohol use can affect immune function
• Recognize that alcohol may reduce treatment efficacy and increase toxicity of many psoriasis treatments 5
• Poor therapeutic compliance is common in patients with alcohol dependency and psoriasis 5
• Alcohol consumption is associated with increased psoriasis severity and risk of comorbidities 1, 7

The combination of advanced age, alcoholism, and infected psoriasis presents significant treatment challenges, requiring careful consideration of treatment options and close monitoring throughout the therapeutic course.