International Psoriasis Council

Advancing Knowledge. Improving Care.

Advancing Knowledge. Improving Care.

Psoriasis in Older Patients: Epidemiology, Clinical Features, and Treatment Discussion

  • Psoriasis affects individuals of all ages, including children, adults, and older adults, with an onset typically occurring at two peaks: 15-25 years old and 50-60 years old.
  • Psoriasis patients aged 65 and older are often excluded or underrepresented in clinical trials, posing challenges for treatment optimization.
  • Treatment options for older patients often start with topical agents and phototherapy due to concerns about systemic agents’ side effects and drug interactions.
  • While systemic therapies like oral medications and biologics are available for all age groups, their safety and efficacy in older adults remain underexplored, necessitating cautious use.

Psoriasis in Older Adults: Unique Considerations

Psoriasis is a multifaceted disease affecting children, adults, and older adults. Although psoriasis can present at any time, it onsets most commonly at two peaks of life, one occurring at 15-25 years old and another at 50-60 years old.1 There is currently little information in the literature regarding psoriasis in older adults, those ≥65 years old, as they are often excluded or underrepresented in many randomized clinical trials. Considerations for this population include those diagnosed with psoriasis at a younger age who then transition into the older adult population and those newly diagnosed at an older age. Approximately 15% of older psoriasis patients experience moderate to severe disease requiring systemic treatments.2 Despite numerous advancements in psoriasis treatments, data for the use and tolerability of newer systemic agents in older adults continue to be limited, making it difficult for providers to optimize safe, effective care for this population.

Treatment Modalities for Older Adults

In caring for older adults, there are often concerns regarding possible side effects and drug-drug interactions of systemic agents. Due to these concerns, treatment options for older adults often begin with topical agents as the first line and phototherapy as the second line to reduce risks. In the prescribing of topicals to older adults, it is important to consider body surface area involvement, decreased absorption due to natural age-related changes in the skin (reduced skin integrity, decreased hydration, less surface lipids, thinner epidermal layer)3,4 and other biological processes of aging such as reduced vision, hearing, mobility and the potential need for assistance from family members, caregivers, and/or personnel in long-term care facilities.5 Older adults who live alone or have limited support may not be able to successfully apply a topical agent once or twice daily due to these age-related factors, and reduced adherence often results in reduced treatment efficacy. Furthermore, depending on insurance coverage, many older patients are limited to formulary options, as they may live on fixed incomes during retirement. As a result, some patients cannot afford more expensive, newer, non-steroidal topical agents. Long-term use of topical steroids may potentiate further skin atrophy in older patients, and thus, treatment breaks should be employed when possible once remission is achieved.

Challenges and Opportunities with Systemic Therapies in Older Adults

Despite these considerations, topicals are highly prescribed in older psoriasis patients worldwide. In a study of 718 older psoriasis patients living in nursing homes in Germany, 40% received at least one prescription for a topical steroid, followed by 8.8% for vitamin D3 analogues. Similarly, in a cross-sectional study of 799,607 Medicare beneficiaries in the United States, Takeshita et al. demonstrated that 76.6% of older psoriasis patients were given topical therapies. Among the topicals prescribed, the majority were also topical steroids 75% followed by vitamin D analogues 13.9%.6

For those with inadequate clearance from topicals alone, phototherapy is a safe, alternative treatment modality for older psoriasis patients. Phototherapy can be administered in-office or at home and requires treatments two to three times weekly. The logistical challenges of in-office treatments include transportation to and from dermatology offices. For at-home treatments, patients with cognitive impairment without regular caregivers may find it hard to follow instructions or stay consistent with phototherapy. In the United States Medicare population, only 7% of patients received phototherapy, and the rates are declining due to a variety of presumed factors such as poor reimbursement rates, greater out-of-pocket costs, and increased time commitment from patients.6

Beyond topicals and light therapy, oral and biologics are available for patients of all ages, yet they are rarely studied in patients over 65. A benefit to taking oral agents in older patients is that many are accustomed to taking pills regularly. Similarly, administering biologics may reduce the burden on this patient population as they can be given less frequently at home or in the office. Despite its benefits, systemic therapies must be given with caution in older patients with psoriasis as they often have important considerations such as polypharmacy, medical comorbidities, logistical issues, higher risk of infections, frailty, and concern for current and future malignancies. Conventional systemic therapies such as methotrexate, acitretin, and cyclosporine may be contraindicated due to their side effects and drug interactions for patients with polypharmacy. In limited real-world studies, small molecules and biologics, including tumor necrosis factor, interleukin IL-12/23, interleukin IL-23, and interleukin IL-17, show safety and efficacy in older patients similar to those in adults.2 Access to these newer targeted therapies remains the major challenge for many patients due to limited insurance coverage, prohibitive out-of-pocket costs, and concerns regarding potential side effects. In the Medicare study, 14.3% of older patients received systemic oral therapy, with the majority receiving methotrexate (85.7%). In addition, 10% of the older patients received biologics, with the majority receiving etanercept (44.4%), followed by adalimumab (34.2%), infliximab (22.7%), and ustekinumab (7.9%).6 For those who received biologics, 31% used a physician-administered medication versus 78.6% performed self-administration.

Establishing Treatment Goals and Enhancing Quality of Life

Regardless of which treatment modality is employed, it is essential to establish common treatment goals with patients at any age before treatment initiation, especially older patients. Patients with newly diagnosed psoriasis at an older age may also benefit from up-to-date cancer screenings with their primary care providers, as treatment decisions may be affected by additional comorbidities. Many older adults already have a reduced quality of life from medical, social, and economic factors, and further quality of life reduction from psoriasis-related symptoms such as pruritus or pain may negatively impact patients. Studies show that older psoriasis patients’ expectations mirror those of their younger counterparts, including long-term psoriasis remission and improved quality of life.2 In this rapidly aging world population, it is predicted that the number of older patients diagnosed with psoriasis will continue to grow. Thus, it is crucial to include representation of the older adult population in clinical trials and create clinical guidelines to guide treatment for older patients with psoriasis.

Reference

  1. Psoriasis of Early and Late Onset: Characterization of Two Types of Psoriasis Vulgaris. Henseler T, Christophers E. J Am Acad Dermatol. 1985 Sep;13(3):450-6.
  2. Treating Psoriasis in the Elderly: Biologics and Small Molecules. Megna M, Potestio L, Fabbrocini G, Camela E. Expert Opin Biol Ther. 2022 Dec;22(12):1503-1520.
  3. Characteristics of the Aging Skin. Farage MA, Miller KW, Elsner P, Maibach HI. Adv Wound Care (New Rochelle). 2013 Feb;2(1):5-10.
  4. Pharmacotherapies in Geriatric Chronic Pain Management. Marcum ZA, Duncan NA, Makris UE. Clin Geriatr Med. 2016 Nov;32(4):705-724.
  5. Medicinal Treatment of Elderly Psoriasis Patients Before and After Entering a Nursing Home. Petersen J, Garbe C, Wolf S, Stephan B, Augustin M, Hagenström K. Healthcare (Basel). 2022 Sep 8;10(9):1730.
  6. Psoriasis in the US Medicare Population: Prevalence, Treatment, and Factors Associated with Biologic Use. Takeshita J, Gelfand JM, Li P, et al. J Invest Dermatol. 2015 Dec;135(12):2955-2963.
  7. Psoriasis in the Elderly: Epidemiological and Clinical Aspects, and Evaluation of Patients with Very Late Onset Psoriasis. Phan C, Sigal ML, Estéve E, et al. J Eur Acad Dermatol Venereol, 30: 78-82.

Leave a Reply

Your email address will not be published. Required fields are marked *

This site uses Akismet to reduce spam. Learn how your comment data is processed.

Categories

Recent Posts

Elevate Your Psoriasis Care and Boost Your Expertise: Join the IPC Psoriasis Masterclass for North America in Chicago

Getting to Know IPC’s Board Member André Carvalho: What Inspired Me to Specialize in Psoriasis

Beyond Skin-Deep: Tackling Gaps in Psoriasis Care

Also Read

Subscribe to the IPC Newsletter

Stay up-to-date on the latest research, news, and upcoming events right in your inbox.