Is a prednisone shot suitable for an older adult with severe psoriasis?

Prednisone Shot is Not Recommended for Severe Psoriasis in Older Adults

Prednisone shots are not recommended for the treatment of severe psoriasis in older adults due to poor long-term efficacy and significant safety concerns. 1

Why Prednisone Should Be Avoided

• Systemic corticosteroids like prednisone are not mentioned in any of the current treatment guidelines for psoriasis management, indicating they are not considered standard of care 1
• Corticosteroid withdrawal can trigger severe psoriasis flares or even pustular psoriasis when discontinued 1
• Older adults are particularly vulnerable to adverse effects of systemic corticosteroids, including:
  • Increased risk of infections due to immunosuppression 2, 3
  • Exacerbation of comorbidities common in older adults (hypertension, diabetes, osteoporosis) 3, 4
  • Drug interactions with medications commonly used by older adults 4

Recommended First-Line Treatments for Severe Psoriasis in Older Adults

• High-potency topical corticosteroids (class 1-3) are recommended for initial management of localized psoriasis for up to 4 weeks 1, 5
  • Examples include clobetasol propionate 0.05%, betamethasone dipropionate 0.05%, and fluocinonide 0.05% 1
• Combination therapy with topical vitamin D analogues (calcipotriene) plus corticosteroids provides superior efficacy compared to either agent alone 1, 5

Recommended Systemic Treatments for Severe Psoriasis in Older Adults

• Biologic agents are the preferred systemic treatment for severe psoriasis in older adults who have failed topical therapy 1, 3
• The most effective biologics for achieving PASI 90 (90% improvement) in order of effectiveness are:
  • Anti-IL-17 inhibitors (secukinumab, ixekizumab) 1, 6
  • IL-23 inhibitors (risankizumab, guselkumab) 1, 6
  • IL-12/23 inhibitor (ustekinumab) 1, 6
  • TNF-α inhibitors (adalimumab, etanercept, infliximab) 1

Special Considerations for Older Adults

• Comprehensive evaluation of comorbidities and concomitant medications is essential before initiating any systemic therapy 3, 4
• More frequent monitoring of laboratory parameters is recommended in older adults on systemic therapies 3
• Despite proven safety and efficacy, biologic agents are used approximately half as frequently in older adults compared to younger patients 4
• Age alone should not be a limiting factor in psoriasis management decisions 3

Treatment Algorithm for Severe Psoriasis in Older Adults

1. First step: High-potency topical corticosteroids with or without vitamin D analogues 1, 5
2. If inadequate response: Consider phototherapy (narrowband UVB) as second-line treatment 7, 8
3. For moderate-to-severe disease unresponsive to above:
   • Consider biologics based on comorbidity profile 1, 3
   • TNF-α inhibitors should be avoided in patients with heart failure, demyelinating disease, or recurrent infections 1
   • IL-17 inhibitors should be avoided in patients with inflammatory bowel disease 1
   • IL-12/23 inhibitors (ustekinumab) or IL-23 inhibitors may be preferred in older adults due to less frequent dosing and favorable safety profile 1, 3

Common Pitfalls to Avoid

• Avoid systemic corticosteroids like prednisone shots for psoriasis management in any age group, but especially older adults 2, 3
• Do not undertreat severe psoriasis in older adults due to age-related concerns; effective treatment options exist 3, 4
• Carefully monitor for drug interactions when initiating any systemic therapy in older adults 4
• Ensure appropriate dosing adjustments based on renal function, which commonly declines with age 3