What are the treatment options for psoriatic skin lesions in the elderly?

Treatment of Psoriatic Skin Lesions in the Elderly

For elderly patients with mild-to-moderate psoriatic skin lesions, initiate topical corticosteroids (moderately potent, BNF grade III) combined with emollients as first-line therapy, with careful monitoring for steroid-induced adverse events that occur more frequently in this age group. 1, 2

Initial Topical Management Strategy

First-Line Topical Therapy

• Start with moderately potent topical corticosteroids (BNF grade III) applied to affected areas, limiting use to no more than 100g per month with mandatory regular clinical review every 4 weeks 1
• Apply emollients 1-3 times daily as essential adjunctive therapy to reduce scaling and maintain skin barrier function 3, 4
• Never provide unsupervised repeat prescriptions of corticosteroids in elderly patients due to increased risk of atrophy, purpura, telangiectasia, and secondary infections 1, 2
• Plan mandatory periods each year using alternative non-corticosteroid treatments to prevent tachyphylaxis and minimize cumulative steroid exposure 1, 3

Alternative Topical Agents When Corticosteroids Fail or as Steroid-Sparing Options

• Coal tar preparations (0.5-1.0% crude coal tar in petroleum jelly, increasing to maximum 10%) are extremely safe and particularly appropriate for elderly patients, though messier to use 1
• Vitamin D analogs (calcipotriol) can be used alone or combined with corticosteroids for synergistic effect, particularly effective for stable plaques over limbs 5, 4
• Dithranol (anthralin) starting at 0.1-0.25% concentration with doubling increases as tolerated, though requires careful patient education about irritancy and staining 1

Critical Monitoring in Elderly Patients

• Elderly patients are at significantly higher risk for steroid-induced adverse events including skin atrophy, purpura, telangiectasia, secondary infections, rebound phenomenon, and tachyphylaxis compared to younger populations 2
• Avoid very potent (BNF grade I) or potent (BNF grade II) corticosteroid preparations unless under direct dermatological supervision 1

When to Escalate to Systemic Therapy

Specific Indications for Systemic Treatment in Elderly

• Extensive chronic plaque psoriasis in elderly or infirm patients is a specific indication for systemic therapy even when topical treatments have not been exhausted 1
• Failure of adequate trial of topical treatment after appropriate duration and potency 1
• Generalized pustular or erythrodermic psoriasis requires immediate systemic intervention 1

Systemic Treatment Options for Elderly Patients

For systemically ill elderly patients with erythrodermic psoriasis, cyclosporine 3-5 mg/kg/day divided twice daily is the preferred first-line systemic agent due to rapid and predictable onset with dramatic improvement within 2-3 weeks 6, 5

Cyclosporine Protocol

• Use as short-term "interventional" course for 3-4 months only, not long-term maintenance 6
• Exercise extreme caution in elderly patients with careful monitoring for renal disease, hypertension, or medications affecting cyclosporine levels 6
• After acute control, taper cyclosporine while transitioning to longer-term maintenance therapy 6

Methotrexate Considerations

• Methotrexate is especially useful for extensive chronic plaque psoriasis in elderly or infirm patients with response time of 2 weeks 1
• Maximum dose should not exceed 0.2 mg/kg body weight in patients over 70 years 1
• Requires weekly monitoring initially (full blood count, liver function, renal function) then every 1-2 months once stable 1

PUVA Photochemotherapy

• PUVA is probably the least toxic systemic agent and generally considered systemic treatment of first choice when appropriate 1
• Response time is 4 weeks with careful dose escalation based on minimal phototoxic dose 1

Biologic Therapies

• Biologics (TNF-α, IL-12/23, IL-17, IL-23 inhibitors) are safe long-term options for elderly patients, not associated with higher risk of adverse events in this population 7
• Adalimumab (HUMIRA) is FDA-approved for moderate to severe chronic plaque psoriasis in adults who are candidates for systemic therapy, dosed at 80mg initial dose followed by 40mg every other week 8

Apremilast

• Apremilast has a satisfactory safety profile with low risk of drug interactions, making it an appropriate treatment option for elderly patients with polypharmacy 7

Critical Medications to Avoid

Immediately discontinue or avoid the following medications that precipitate or worsen psoriasis:

• Lithium, chloroquine, and mepacrine may cause severe, even life-threatening deterioration 1, 5
• Beta-blockers and NSAIDs in some patients 1, 5
• Avoid combining methotrexate with antibiotics when treating suspected secondary infection 6

Common Pitfalls in Elderly Patients

• Do not delay systemic therapy in extensive disease - topical treatments alone are insufficient for most patients with extensive chronic plaque psoriasis in elderly or infirm individuals 6
• Never use acitretin as first-line in systemically ill elderly patients due to slow onset of action (6 weeks response time) 1, 6
• Avoid abrupt corticosteroid withdrawal - taper frequency gradually after clinical improvement to prevent rebound flare 3
• Do not use systemic corticosteroids as they can precipitate severe psoriasis flares upon discontinuation 3

Special Considerations for Elderly Population

• Conventional systemic therapies require careful dosing taking into account metabolism changes, organ impairment, comorbidities, and concomitant medications 7
• Topical therapy remains first-line for mild-to-moderate disease in elderly patients as standalone or combination therapy, despite challenges with adherence and reduced physical functioning 2
• All systemic agents are absolutely contraindicated in pregnancy, though this is less relevant in elderly populations 1