What are the treatment options for an elderly patient with facial and scalp psoriasis who has failed to respond to Otezla (apremilast)?

Treatment Options for Facial and Scalp Psoriasis After Otezla Failure in Elderly Patients

Switch to a biologic agent, specifically an IL-17 inhibitor (such as secukinumab or ixekizumab) or TNF inhibitor (such as etanercept or adalimumab), as these represent the most effective and safest systemic options for elderly patients with facial and scalp psoriasis who have failed apremilast. 1

Topical Therapy Optimization First

Before escalating to systemic therapy, ensure maximal topical management has been attempted:

For Scalp Psoriasis:

• Escalate to ultra-high potency topical corticosteroids such as clobetasol propionate 0.05% solution applied twice daily to affected scalp areas for 2-4 weeks maximum (not exceeding 50 mL/week). 2, 3
• Add calcipotriene (vitamin D analog) to create a steroid-sparing regimen if partial response occurs, as the combination of calcipotriene and betamethasone dipropionate once daily for 4-8 weeks represents the most effective first-line topical therapy. 2
• Apply solutions or foams directly to scalp skin (not just hair) to ensure adequate penetration. 4, 5

For Facial Psoriasis:

• Use moderate-potency corticosteroids (such as betamethasone valerate or fluocinolone) with caution on facial skin, limiting use to shorter periods with treatment-free intervals to minimize atrophy and telangiectasia. 2, 4
• Consider coal tar preparations (0.5-1.0% crude coal tar in petroleum jelly, increasing to maximum 10%) as an extremely safe and cost-effective alternative, though messier and less cosmetically acceptable for facial use. 1, 2

Systemic Therapy: Biologic Agents (Preferred)

When topical therapy fails or disease affects ≥5% body surface area, biologics are the preferred systemic option for elderly patients:

IL-17 Inhibitors (First Choice for Severe Skin Disease):

• Preferred for facial and scalp involvement due to superior efficacy in skin manifestations compared to other biologic classes. 1
• Well-tolerated in elderly patients with no increased risk of adverse events compared to younger populations. 6, 7
• Caution: May consider alternative if patient has history of recurrent candida infections (in which case tofacitinib may be preferred). 1

TNF Inhibitors (Alternative First-Line):

• Etanercept has been specifically studied in elderly patients (480 RA patients ≥65 years, 138 psoriasis patients ≥65 years) with no overall differences in safety or effectiveness compared to younger patients. 8
• Exercise caution due to higher baseline infection risk in elderly populations. 8
• Contraindicated in patients with congestive heart failure, previous serious infections, recurrent infections, or demyelinating disease. 1

IL-12/23 Inhibitors (Alternative):

• Consider if patient prefers less frequent drug administration (ustekinumab given every 12 weeks after loading). 1
• Conditional recommendation over other oral small molecules based on low-quality evidence. 1
• May be preferred if patient has concomitant inflammatory bowel disease. 1

Systemic Therapy: Small Molecule Alternatives

If biologics are not feasible due to patient preference for oral therapy, cost constraints, or contraindications:

Tofacitinib (JAK Inhibitor):

• May be considered if patient prefers oral therapy over injectable biologics. 1
• Exercise significant caution in elderly patients due to adverse events including increased infection risk and potential cardiovascular concerns. 9

Methotrexate (Most Cost-Effective Systemic):

• Especially useful for extensive chronic plaque psoriasis in elderly or infirm patients. 1, 2
• Dose must not exceed 0.2 mg/kg body weight, with special exceptions for patients over 70 years. 1
• Requires weekly monitoring initially (full blood count, liver function tests, serum creatinine), extending to every 1-2 months once stable. 1
• Avoid drugs that interact: alcohol, salicylates, NSAIDs, co-trimoxazole, trimethoprim, probenecid, phenytoin. 1

Retinoids (Acitretin):

• Response time of 6 weeks; requires contraception and monitoring of liver function tests and fasting serum lipids. 1
• Less commonly used due to side effect profile in elderly.

Critical Monitoring and Safety Considerations

For All Elderly Patients:

• Clinical review every 4 weeks during active treatment to assess response and monitor for adverse effects. 1, 2
• No unsupervised repeat prescriptions of high-potency corticosteroids. 1, 2
• Screen for and address comorbidities, polypharmacy, and drug interactions before initiating systemic therapy. 6, 10, 11, 7

Common Pitfalls to Avoid:

• Never use ultra-high potency corticosteroids beyond 4 weeks continuously due to skin atrophy and systemic absorption risk. 2
• Avoid systemic corticosteroids entirely as they can precipitate severe erythrodermic or pustular psoriasis flares upon discontinuation. 1, 2
• Do not combine salicylic acid with calcipotriene as it inactivates the vitamin D analog. 2
• Avoid medications that worsen psoriasis: lithium, chloroquine, beta-blockers, NSAIDs. 1, 2

Practical Treatment Algorithm

1. Optimize topical therapy: Clobetasol 0.05% solution twice daily × 2-4 weeks for scalp + moderate-potency corticosteroid for face 2, 3
2. Add calcipotriene if partial response 2
3. If inadequate response after 4-6 weeks or disease affects ≥5% BSA: Switch to biologic therapy 2
4. First-line biologic: IL-17 inhibitor (preferred for skin disease) or TNF inhibitor (etanercept well-studied in elderly) 1, 8, 6, 7
5. Alternative biologic: IL-12/23 inhibitor if less frequent dosing preferred 1
6. If biologics not feasible: Consider methotrexate (most cost-effective) with appropriate monitoring 1, 2