What is the best treatment approach for an elderly patient with severe psoriasis, considering their potential comorbidities and current medications, including biologic agents such as etanercept (Enbrel) or adalimumab (Humira)?

Severe Psoriasis Management in Elderly Patients

For elderly patients with severe psoriasis, TNF inhibitor biologics—specifically adalimumab (Humira) or infliximab—are recommended as first-line systemic therapy, with adalimumab preferred due to its established efficacy, favorable cardiovascular outcomes, and manageable safety profile in this population. 1

Initial Assessment and Screening

Before initiating biologic therapy in elderly patients, comprehensive screening is essential:

• Screen for latent tuberculosis with PPD testing (consider ≥5mm induration as positive, even in BCG-vaccinated patients) 2
• Obtain baseline laboratory monitoring including complete blood count, liver function tests, and hepatitis B screening 3
• Evaluate cardiovascular comorbidities, as severe psoriasis increases MI risk (incidence rate 5.13 per 1000 person-years vs 3.58 in controls) 1
• Assess for psoriatic arthritis in all patients, as this affects treatment selection and PsA occurs commonly with cutaneous disease 1

Biologic Selection Algorithm

First-Line: TNF Inhibitors

Adalimumab (Humira) is the preferred initial biologic for elderly patients with severe psoriasis:

• Dosing: 80 mg initial dose (two 40 mg injections), followed by 40 mg one week later, then 40 mg every 2 weeks 1
• Efficacy: Achieves PASI 75 in 71% of patients at week 16 (vs 7% placebo) 1
• Cardiovascular benefit: TNF inhibitors reduce major cardiovascular event risk by 50% compared to topical therapy alone (HR 0.50,95% CI 0.32-0.79, P=0.003) 1
• Work productivity: Significantly improves functional outcomes (15.5% improvement vs 11.1% placebo, P<0.001) 1

Alternative TNF inhibitor considerations:

• Infliximab may be used for more rapid response in severe cases, though requires IV infusion 1
• Etanercept should be avoided if the patient has concomitant inflammatory bowel disease, as monoclonal antibody TNF inhibitors are superior for IBD (moderate-quality evidence) 1

Special Contraindications in Elderly Patients

Do not initiate TNF inhibitors if the patient has 2:

• Active infection (including localized infections)
• Congestive heart failure (consider IL-12/23 or IL-17 inhibitors instead) 1
• History of demyelinating disease 1
• Recent serious or recurrent infections 1

Exercise particular caution in patients ≥65 years with comorbidities or taking concomitant immunosuppressants (corticosteroids, methotrexate), as infection risk is elevated 2

Alternative Biologic Options

If TNF inhibitors are contraindicated or ineffective:

• IL-12/23 inhibitors (ustekinumab) are conditionally recommended, particularly if the patient prefers less frequent dosing or has contraindications to TNF inhibitors 1
• IL-17 inhibitors may be considered, though avoid in patients with inflammatory bowel disease 1

Combination Therapy to Enhance Efficacy

Adding topical corticosteroids to biologics accelerates clearance:

• High-potency (class 1) topical corticosteroids with etanercept for 12 weeks is recommended (strength A) 1
• Calcipotriene/betamethasone with adalimumab for 16 weeks accelerates plaque clearance (strength B) 1

Monitoring During Treatment

Continuous surveillance is critical in elderly patients 2:

• Monitor closely for signs of infection during and after treatment
• Tuberculosis can develop even in patients who tested negative at baseline
• Discontinue immediately if serious infection or sepsis develops
• Consider invasive fungal infections in patients who develop systemic illness, especially if residing in endemic areas
• Empiric antifungal therapy may be warranted while diagnostic workup proceeds 2

Critical Safety Considerations

Elderly-specific risks that require heightened vigilance 4, 5:

• Progressive immunosenescence increases infection susceptibility
• Polypharmacy increases drug interaction risks
• Organ function decline affects drug metabolism
• Higher baseline cardiovascular disease burden

However, biologics demonstrate superior safety compared to conventional systemics (methotrexate, cyclosporine, acitretin) in elderly patients, with no increased adverse event rates in this population 4

Avoid Conventional Systemics as First-Line

Methotrexate, cyclosporine, and acitretin should be reserved only for cases where biologics are absolutely contraindicated 6, 5:

• These agents have lower therapeutic indices in elderly patients
• Organ impairment and comorbidities increase toxicity risk
• TNF inhibitors provide better cardiovascular outcomes (cumulative TNF inhibitor exposure reduces cardiovascular events by 11% over 24 months, P=0.02) 1

Common Pitfalls to Avoid

• Do not delay biologic therapy due to age alone—biologics are safe and effective in elderly populations 4
• Do not administer live vaccines while on biologic therapy 3
• Do not ignore quality of life assessment—severe psoriasis significantly impairs work productivity and sexual function regardless of age 1
• Do not use etanercept if IBD is present or suspected—switch to monoclonal antibody TNF inhibitors (adalimumab, infliximab) which are effective for both conditions 1