Psoriasis in the elderly: From the Medical Board of theNational Psoriasis Foundation

Ivan S. Grozdev, MD, PhD,a Abby S. Van Voorhees, MD,b Alice B. Gottlieb, MD, PhD,c Sylvia Hsu, MD,d

Mark G. Lebwohl, MD,e Bruce F. Bebo, Jr, PhD,f and Neil J. Korman, MD, PhD,a for the National Psoriasis Foundation

Cleveland, Ohio; Philadelphia, Pennsylvania; Boston, Massachusetts; Houston, Texas;

New York, New York; and Portland, Oregon

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Background: The continuous increase in the US population older than 65 years and the chronic course ofpsoriasis make management of psoriasis in the elderly an important health care problem.

Objective: We sought to develop a treatment algorithm for patients with psoriasis who are older than 65 years.

Methods: A systematic literature search for studies on elderly patients with psoriasis was performed usingMEDLINE.

Results: We summarize the available published data on therapeutic modalities used in the elderly. Wesuggest a treatment algorithm including topical medications as first-line treatment for limited disease, withphototherapy, systemic retinoids, methotrexate, and biologics as the first-line systemic treatments forpatients with more extensive disease. Cyclosporine should only rarely be used as a second-line systemictreatment for extensive disease in elderly patients with psoriasis.

Limitations: Limited data are available regarding treatment modalities specifically for elderly patients withpsoriasis.

Conclusion: Appropriate treatment for elderly patients with limited psoriasis includes topical corticosteroids,topical vitamin D analogues, and topical tazarotene. For appropriately monitored elderly patients who havepsoriasis with extensive disease, phototherapy, acitretin, methotrexate, alefacept, etanercept, adalimumab,infliximab, and ustekinumab are first-line therapies that can generally be safely used. There remains a need forfurther research on the management of psoriasis in elderly patients with psoriasis. ( J Am Acad Dermatol2011;65:537-45.)

Key words: algorithm; elderly; evidence; geriatric; management; psoriasis; therapy.

the Department of Dermatology and Murdough Family

enter for Psoriasis, University Hospitals Case Medical Center,

levelanda; Department of Dermatology, University of Penn-

lvaniab; Department of Dermatology, Tufts Medical Center,

stonc; Department of Dermatology, Baylor College of Med-

ine, Houstond; Department of Dermatology, Mount Sinai

hool of Medicine, New Yorke; and National Psoriasis

undation, Portland.f

ing sources: Ivan S. Grozdev, MD, PhD, was supported by the

urdough Family Center for Psoriasis Research Fellowship.

osure: Dr Van Voorhees has been a consultant, investigator,

speaker for Abbott, Amgen, Astellas, Centocor, Genentech,

cyte, Connetics, Warner Chilcott, Photomedix, Roche, and

nta. She has a significant conflict of interest with Merck.

lmost all of Dr Gottlieb’s consulting and speaking fees are

id to Tufts Medical Center. She has current consulting/advi-

ry board agreements with Amgen, Centocor, Wyeth Pharma-

uticals, Celgene, Bristol Myers Squibb, Beiersdorf, Abbott,

VA, Actelion, UCB, Novo Nordisk, Almirall, Immune Control,

ermipsor, Can-Fite, Incyte, Magen Biosciences, Alnylam, Ono,

ytokine Pharmaciences, and Puretech. Tufts Medical Center

s received research/educational grants from Centocor, Am-

n, Wyeth Pharmaceuticals, Immune Control, Celgene, Pfizer,

cyte, and Abbott. Dr Hsu has been a consultant for Abbott,

Amgen, Biogen Idec, Centocor, and Genentech. She has been a

clinical investigator for Amgen and Centocor. Dr Lebwohl has

been a consultant for Abbott, Amgen, Astellas, Centocor,

Genentech, UCB Pharma, Stiefel, Triax, Pharmaderm, Medicis,

Novartis, and Warner Chilcott. He has been a speaker for

Abbott, Amgen, Astellas, Centocor, and Genentech. Dr Bebo is

employed by the National Psoriasis Foundation. The founda-

tion receives unrestricted financial support from Abbott,

Centocor, Amgen, Wyeth, Genentech, Astellas, Stiefel, Gal-

derma, Warner Chilcott, and Photomedix. Dr Korman has

been a consultant, investigator, or speaker for Abbott, Amgen,

Astellas, Celgene, Centocor, Genentech, Novartis, Pfizer, and

Warner Chilcott. He has also received fellowship support from

Centocor. Dr Grozdev has no conflicts of interest to declare.

Accepted for publication May 10, 2010.

Reprint requests: Neil J. Korman, MD, PhD, Department of

Dermatology, Murdough Family Center for Psoriasis,

University Hospitals Case Medical Center, 11100 Euclid Ave,

Cleveland, OH 44106. E-mail: njk2@case.edu.

Published online April 18, 2011.

0190-9622/$36.00

ª 2010 by the American Academy of Dermatology, Inc.

doi:10.1016/j.jaad.2010.05.014

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Although the exact prevalence and incidence of

psoriasis in the elderly is unknown, psoriasis iscommon in this age group. In a US population-based study, the highest rate of occurrence of pso-riasis was in the 60- to 69-year-old age group(113/100,000 population).1 The prevalence of psori-asis was 3.9% in a study of 16,924 geriatric outpatients

CAPSULE SUMMARY

d Appropriate first-line treatment forelderly patients with limited psoriasisinvolves application of topicalmedications.

d Phototherapy, oral retinoids,methotrexate, and biologics arerecommended as first-line systemictreatments for patients with moreextensive disease.

d Cyclosporine should only rarely be usedas a second-line systemic treatment forextensive disease in elderly patients withpsoriasis.

at a tertiary referral center inTaiwan.2 The importance ofpsoriasis in the elderly is un-derscored by the continuingincrease in the populationaged 65 years and older, andthe chronic course of thisdisease.3 According to de-mographers, the elderly willconstitute up to 25% of the USpopulation by 20254 and upto 34% of the European pop-ulation by 2050.5

Psoriasis is a chronic in-flammatory disease that maypredispose patients to signifi-cant comorbidities.6 These in-clude psoriatic arthritis (PsA),cardiovascular disease, meta-

bolic syndrome, and malignancy. PsA occurs in asubset of patients with psoriasis (between 6% and42% of patients depending on the study).7 The ageof onset of PsA ranges between 32 and 60 years, andtherefore there is an increased rate of this conditionin the elderly.8 In a US population-based study, PsAoccurred in 11% in patients with psoriasis, and 20%of patients with PsA were older than 65 years.9

Metabolic syndrome (defined as the presence of$ 3 of the following components: abdominal obe-sity, increased insulin resistance/elevated fastingblood glucose level, decreased high-density lipo-protein cholesterol, hypertriglyceridemia, and hy-pertension6,10) occurs with increased frequency inpatients with psoriasis.11 Psoriasis is more likely tobe associated with metabolic syndrome in theelderly, and those patients tend to have had alonger disease duration than those without meta-bolic syndrome.12 Young patients with severe pso-riasis may be at increased risk for the developmentof multiple cardiovascular risk factors.13

Psoriasis has been associated with hematopoieticcancers and pancreatic cancer.14 Bullous pemphi-goid, an autoimmune blistering disease of the el-derly, has been associated with psoriasis15 althoughthe pathogenic relationship between these two con-ditions is unclear. As elderly patients with psoriasisoften take multiple medications, these medicationsmay precipitate or aggravate psoriasis.16

Although little is known about the associationbetween psoriasis and osteoporosis, two recentstudies give conflicting results. A large case-controlstudy of almost 23,000 patients (about 8000 withpsoriasis and 15,000 control subjects) showed thatpsoriasis was associated with osteoporosis in malepatients only,17 whereas a small open study of

35 postmenopausal womenwith psoriasis previously ex-posed to ultraviolet (UV)Bshowed significantly higherbone mineral density thanalmost 2500 age- and sex-matched control subjects.18

Patientswithpsoriasis havelow health-related quality oflife19,20 and psoriasis disabilityis similar to other major med-icaldiseases, includingcancer,arthritis, hypertension, diabe-tes, and depression.21 Usingboth dermatologic-specific(Skindex-29 and theDermatology Life QualityIndex) and psoriasis-specific(Psoriasis Disability Index

and the Impact of Psoriasis Questionnaire) instru-ments, Sampogna et al22 reported that both quality oflife and psychologic distress were more impaired inolder than younger patients with psoriasis. The finan-cial burden of treatment may be more significant in theelderly, who often are retired, financially dependenton others, or both.23 The psychologic distress of beingconsidered dirty or contagious are other importantconcerns for patients with psoriasis, although somehave suggested that older patients are less concernedby appearance.24

Elderly patients with psoriasis may need specialattention when psoriasis affects certain areas.Flexural psoriasis (involving the axillae, interglutealfold, groin, and inframammary folds) commonlyoccurs in the elderly, especially those who are obeseor bedridden.25 This flexural skin is very thin andtherefore topical corticosteroids should be used withcaution because of the increased risk of side effects.Management of scalp psoriasis in the elderly maycause difficulties because of physical limitations ofelderly patients in applying topical medications. Theskin of the elderly is usually xerotic, making pruritusan even more common symptom in this age group.The pruritus associated with scalp psoriasis leads toscratching, which can cause new lesions to appearthrough the Koebner phenomenon.26 PsA and otherage-related arthritides, particularly osteoarthritis,may further aggravate the management of psoriasis

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Abbreviations used

NPF: National Psoriasis FoundationPASI: Psoriasis Area and Severity IndexPASI 75: PASI seventy five, 75% reduction of PASIPsA: psoriatic arthritisPUVA: psoralen plus ultraviolet ARA: rheumatoid arthritisUV: ultraviolet

in the elderly, making compliance with topical ther-apy lower because their mobility is affected.

METHODOLOGYWe searched for studies on elderly patients with

psoriasis in the literature through MEDLINE. We usedkey words including ‘‘psoriasis,’’ ‘‘elderly,’’ and thename of the therapy. The articles were evaluatedwith levels of evidence, previously reported byShekelle et al.27 IA evidence includes evidencefrom meta-analysis of randomized controlled trials.IB evidence includes randomized controlled studies.Nonrandomized controlled studies are IIA. IIB evi-dence includes evidence from at least one other typeof quasiexperimental study. Nonexperimental stud-ies, comparative studies, correlation studies, andcase-control studies are graded III. Expert committeereports or opinions, and clinical experience fromrespected authorities are graded IV. Limited data areavailable in the literature regarding treatment mo-dalities specifically for the elderly population.Typically, patients aged 65 years and older arereported in the context of the whole study popula-tions and there are very few reports that extract datafor elderly patients and make therapeutic conclu-sions for this specific age group.

RESULTS1. Topical agents are the first-line option for

treating limited plaque psoriasis in the elderly de-spite the lack of study specifically in this population.Topical corticosteroids, however, should be usedwith caution in the elderly because of their knowncutaneous side effects including atrophy, purpura,telangiectasia, secondary skin infections, reboundphenomenon, and tachyphylaxis.

Calcipotriol/betamethasone dipropionateEvidence IA. Parslew R, Trauslen J. Efficacy and

local safety of a calcipotriol/betamethasone dipropi-onate ointment in elderly patients with psoriasisvulgaris. Eur J Dermatol 2005;15:37-9.28

d Descriptive analysis of patients aged 60 years andolder.

d Total of 1534 patients, including 357 aged 60years and older with psoriasis vulgaris.

d Once-daily calcipotriol/betamethasone dipropio-nate combination for 4 weeks in 4 randomized,double-blind studies.

d Mean reduction of Psoriasis Area and SeverityIndex (PASI): 73% in patients aged 60 years andolder compared with 68% in patients youngerthan 60 years.

d ‘‘Controlled disease’’: 58% of patients aged 60years and older compared with 52% of patientsyounger than 60 years.

d Lesional/perilesional adverse drug reactions: 5%in patients aged 60 years and older comparedwith 6% in patients younger than 60 years.

d Effective and well-tolerated combination in thetreatment of psoriasis vulgaris, regardless of theage group.

2. There are limited data about the role of UVBphototherapy in the elderly; psoralen plus UVA(PUVA) has not been formally studied. It is theopinion of the Medical Board of the NationalPsoriasis Foundation (NPF), however, that UV lightmay be an appropriate treatment for elderly patientswith psoriasis in many clinical scenarios whenfeasible.

Broadband UVBEvidence III. Osmancevic A, Landin-Wilhelmsen

K, LarkoO,MelstromD,WennbergAM,HulthenL, et al.UVB therapy increases 25(OH) vitamin D syntheses inpostmenopausalwomenwithpsoriasis. PhotodermatolPhotoimmunol Photomed 2007;23:172-8.29

d Twenty four women with psoriasis (aged 60-81years) treated with broadband UVB therapy 2 to 3times per week for 8 to 12 weeks to evaluate theeffect of phototherapy on vitamin D synthesis.

d Good efficacy (baseline PASI scores from 6-12before treatment to 1-4 after 8-12 weeks of broad-band UVB) and tolerability along with increasedserum vitamin D levels.

3. Methotrexate can be an often effective treat-ment in the elderly. However, methotrexate must becarefully used given the increased likelihood ofimpaired renal function, and other possible comor-bidity issues. Therefore, the dose of methotrexate inthe elderly may need to be lower than that inyounger patients.30

MethotrexateEvidence IIB. Fairris GM, Dewhurst AG, White

JE, Campbell MJ. Methotrexate dosage in patientsaged over 50 with psoriasis. BMJ 1989;298:801-2.30

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d A total of 23 patients older than 50 years (age 50-93 years) treated with methotrexate.

d A significant correlation between the minimumtherapeutic dose of methotrexate and both pre-dicted creatinine clearance and age.

d Six of 10 patients older than 70 years treated withless than the generally recommended dose ofmethotrexate for patients younger than 70 years.

d Four patients older than 80 years adequatelytreated with 2.5 mg of methotrexate weekly.

Evidence III. Collins P, Rogers S. The efficacy ofmethotrexate in psoriasisea review of 40 cases. ClinExp Dermatol 1992;17:257-60.31

d Forty patients (mean age 53 years and age range23-86 years) treated with methotrexate; unknownnumber of patients aged 65 years and older.

d One 86-year-old patient with toxic epidermal ne-crolysis 4 weeks after starting methotrexate.

d The development of toxic epidermal necrolysisattributed to drug interactions as possibleindomethacin, furosemide, and bendrofluazide-enhanced methotrexate toxicity.

4. Alefacept and etanercept have both been stud-ied in elderly patients with psoriasis. Although thenumber of patients studied is small, there does notappear to be an age-related difference in efficacy ortoxicity. No published information is available re-garding the efficacy or risk of toxicity in the elderly ofthe other tumor necrosis factor inhibitors, includingadalimumab and infliximab. No information isknown about the possible role of ustekinumab inthe treatment of elderly patients with psoriasis and itis not possible to ascertain its safety or efficacy untilfurther studies are performed.

AlefaceptEvidence IA. Gottlieb AB, Boehncke WH, Darif

M. Safety and efficacy of alefacept in elderly andother special populations. J Drugs Dermatol2005;4:718-24.32

d Safety and efficacy of alefacept in patients whoare elderly, obese, and diabetic with moderate tosevere psoriasis, assessed by integrating data fromseveral clinical trials.

d A total of 99 elderly patients with at least onecourse of alefacept.

d Accidental injury, headache, and pharyngitis—themost common adverse events; skin carcinomas—the most common malignancies; no opportunisticinfections; maintained safety over repeated courses.

d Twenty four percent to 33% of the elderly patientswith a PASI seventy five (PASI 75) at any timeduring the first course of alefacept.

d Further enhancement of benefit with subsequentcourses; after 3 courses of alefacept, 41 to 58% ofpatients with PASI 75 at any time.

d Well-tolerated and effective treatment for psoria-sis in elderly patients.

EtanerceptEvidence IA. Militello G, Xia A, Stevens SR,

Van Voorhees AS. Etanercept for the treatment ofpsoriasis in the elderly. J Am Acad Dermatol2006;55:517-9.33

d Post hoc analysis of two phase III randomizedplacebo trials of etanercept.

d One thousand one hundred fifty eight patientsyounger than 65 years and 77 patients aged 65years and older.

d No statistically significant differences between theelderly and young with regard to the percentage ofpatients reaching PASI fifty (PASI 50) or PASI 75.

d Similar changes in Dermatology Life Quality In-dex with therapy in the elderly and young.

d Limitation of the study: the small number ofelderly patients (77 patients aged $ 65 years).

5. No studies have been performed evaluating therole of acitretin in the elderly. Although the risk ofelevated triglycerides must be considered, it is theopinion of the Medical Board of the NPF that the riskmay be acceptable in certain clinical situations aselevated lipid levels can generally be successfullytreated.

6. Cyclosporine, although also not studied inelderly patients, is likely to have elevated risk, giventhe baseline age-related renal impairment in thispopulation.

TREATMENT ALGORITHMPlease see Figure 1.

DISCUSSIONThe choice of treatment regimens for psoriasis is

based on the severity of the disease, age, treatmenthistory, and the level of compliance.34 Physiciansmust be aware of the potential problems that candevelop when treating psoriasis in the elderly. This isespecially important because of the concomitantcomorbidities, potential adverse effects, existingquality of life, drug history, self-care ability, financialneeds, and patients’ expectations.

Topical therapiesTopical agents are commonly prescribed for

elderly patients as first-line therapy because of the

Fig 1. Treatment algorithm.

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potential risk of adverse reactions and drug interac-tions of systemic medications.16 The physicianshould ascertain whether the patient can apply themedication without assistance. Compliance withtreatment in elderly patients can be reduced becauseof the time-consuming nature and difficulty of ap-plying topical agents.28 The only data for elderlypatients with psoriasis are for the calcipotriol/beta-methasone dipropionate combination. This therapywas an effective and well-tolerated topical treatmentof psoriasis, regardless of age.28

There are no reports demonstrating efficacy andsafety of the use of other topicals in elderly patientswith psoriasis. Topical corticosteroids are widely usedfor the treatment of psoriasis because of their efficacyand patient acceptability,35 but they should be usedcarefully in the elderly because of the possible risk ofcutaneous side effects, including atrophy, purpura,telangiectasia, secondary skin infections, reboundphenomenon, and tachyphylaxis.36

PhototherapyUVB phototherapy, PUVA, and home photother-

apy have not been studied in the elderly, with theexception of one study of 24 women, aged 60 to 81years, who were treated with broadband UVB thatshowed it to be efficacious and well tolerated.29

Although the data are limited, it is the opinion of theMedical Board of the NPF that phototherapy may bean appropriate treatment for elderly patients withpsoriasis in many clinical scenarios. Physiciansshould be aware of logistical concerns when treatingelderly patients with phototherapy such as whetherthe patient can stand for prolonged periods of time in

the light box without falling, and transportationissues for a therapy that is usually administered 2 to3 times per week. Studies evaluating the efficacy ofclimatotherapy performed at the Dead Sea in Israeldemonstrate that elderly patients with psoriasis im-prove and that hypertension is not a contraindicationfor this treatment.37,38 These intriguing data suggest apossible role of climatotherapy in ameliorating hy-pertension, a significant comorbidity in psoriasis.

Because elderly patients with psoriasis often takemedications for concomitant diseases, the potentialrisk for drug-induced photosensitivity needs to beconsidered when patients are treated with photo-therapy. See Table I for a list of medications that maylead to phototoxic or photoallergic reactions.39

General approach to treating elderly patientswith systemic agents

Pharmacotherapy in the elderly requires an un-derstanding of age-dependent changes in functionand composition of the body. Because the elderlyoften have more than one disease and take multiplemedications, they are at greater risk of experiencingadverse drug reactions and interactions.40 Aging ischaracterized by a progressive loss of functionalcapacities of most organs, a reduction in response toreceptor stimulation and homeostatic mechanisms,and a loss of water and an increase in fat content ofthe body. The most important pharmacokineticchange in old age is a decrease in the excretorycapacity of the kidney; in this regard, the elderlyshould be considered to be renally insufficient.41

A higher prevalence of multidrug regimens andalterations in drug metabolism and elimination

Table I. Phototoxic and photoallergic drugs and chemicals

Phototoxic agents and chemicals Photoallergic drugs and chemicals

d Psoralensd Porphyrinsd Coal tard Antibiotics: tetracyclines, fluoroquinolones, nalidixic acid,

ceftazidime, griseofulvin, ketoconazole, trimethoprim,sulfonamides

d NSAIDs: benoxaprofen, ibuprofen, ketoprofen,nabumetone, naproxen, tiaprofenic acid, aspirin, diflunisal,meclofenamic acid, phenylbutazone, oxyphenbutazone

d Diuretics: hydrochlorothiazide, bendroflumethiazide,furosemide

d Retinoids: isotretinoin, etretinated Antineoplastic agents: 5-fluorouracil, dacarbazine,

methotrexate, vinblastined Miscellaneous: amiodarone, diltiazem, fibric acid

derivatives, phenothiazines

d Topical antimicrobials: halogenated salicylanilides,sulfonamides

d Fragrances: musk ambrette, 6-methylcoumarind Sunscreen ingredients: PABA derivatives,

benzophenones, dibenzophenones, cinnamates,camphor derivatives, benzocaine

d NSAIDs: piroxicamd Psychiatric medications: phenothiazines, tricyclic

antidepressantsd Miscellaneous: amantadine, chloroquine, dapsone,

diphenhydramine, fibric acid derivatives, flutamide,hydrocortisone, isotretinoin, lomefloxacin, methyldopa,minoxidil, nifedipine, pilocarpine, psoralens,pyrimethamine, quinine, quinidine, sulfonylureas,thiazide diuretics, triamterene

Data from Gould et al.39 Used with permission of the American Academy of Dermatology.

NSAIDs, Nonsteroidal anti-inflammatory drugs; PABA, para-aminobenzoic acid.

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make the elderly more susceptible to adverse drugreactions and interactions.42 Drug response in theelderly shows individual variability. Therefore, thecorrect dosage of systemic medications should bedetermined for every patient individually. Whenprescribing drugs to the elderly, it is important totake a careful drug history, start with a small dose andtitrate up to a defined therapeutic response, reducethe number of drugs administered, and regularlycheck for possible adverse drug reactions orinteractions.

Traditional systemicsTraditional systemic agents, such as methotrexate,

are often effective in the elderly. However, metho-trexate must be carefully used given the risk ofimpaired renal function, and other possible comor-bidity issues, and therefore the dose of methotrexatein the elderly may need to be lower than in youngerpatients.30 The clearance of free and total metho-trexate is inversely proportional to age in patientswith rheumatoid arthritis (RA) and methotrexateclearance decreases with decreasing creatinine clear-ance.43 The dose of methotrexate needed to controlsevere psoriasis in patients older than 50 yearsdecreases with decreasing predicted creatinine clear-ance and increasing age.35 Acute myelosuppression,the cause of most of the rare deaths attributable tomethotrexate for psoriasis, is the major short-termside effect of methotrexate, and myelosuppressionoccurs more commonly in the elderly.44 The othermajor toxicity of methotrexate is hepatic fibrosis,which typically only occurs with long-term therapy.Risk factors for hepatic fibrosis include obesity,

elevated triglycerides, alcohol consumption, andelevated liver function tests. As elderly patientsmay have compromised liver function in part be-cause of aging, it is important to screen for abnormalliver function study results and hepatitis B and C, andto take a good history of alcohol consumption.Whether the risk of a liver biopsy in an elderlypatient exceeds the benefit is not known and it istherefore difficult to make recommendations aboutthe need for liver biopsies in elderly patients main-tained on long-term methotrexate. Although elderlypatients often take concomitant medications, whichcan affect methotrexate metabolism,44,45 drug inter-actions are not common with methotrexate; eventhe interaction with nonsteroidal anti-inflammatorydrugs is of some debate.46 However, important druginteractions may occur, such as with trimethoprim.Older patients may benefit from treatment withmethotrexate because of its ability to decrease in-flammation and hyperhomocysteinemia, which areindependent risk factors for vascular disease. In aretrospective study of 7615 patients with psoriasisand 6707 patients with RA, patients with psoriasiswho developed vascular disease were significantlyolder than patients with psoriasis without vasculardisease (69% vs 61%; P \ .01).47 Patients givenmethotrexate had a significantly reduced risk ofvascular disease compared with those not givenmethotrexate. After adjusting for age, sex, comor-bidities, and medications, patients with psoriasis orRA who were treated with methotrexate had signif-icantly reduced risk of vascular disease. Reductionin vascular disease only occurred among patientswho took low to moderate cumulative doses of

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methotrexate. In conclusion, methotrexate can beused safely in the elderly as long as the decreasedrenal function is taken into consideration whendosing. A potential advantage of using methotrexatein the treatment of elderly patients with psoriasis is itsbeneficial effect on cardiovascular comorbidity.

No studies have been performed evaluating therole of acitretin in the elderly. Although the risk ofelevated triglycerides must be considered, it is theopinion of the Medical Board of the NPF that therisk may be acceptable in certain clinical situationsas elevated lipid levels can generally be successfullytreated. As the cardiovascular risk of hypertriglyc-eridemia generally takes many years to develop, therisk of acitretin-induced hypertriglyceridemia maybe less important in elderly patients with psoriasis.Dryness associated with retinoids is an importantissue in patients with psoriasis of all ages. Althoughthere are no studies of acitretin for the treatment ofelderly patients with psoriasis, this therapy is gen-erally not associated with any life-threatening tox-icity and therefore it is a reasonable therapeuticoption.

Cyclosporine, although also not studied in elderlypatients, is likely to have elevated risk, given thebaseline renal impairment in this population. Age-related decreased renal clearance of cyclosporinehas been demonstrated in elderly kidney transplantrecipients.48 Hypertension, renal dysfunction, andmultiple drug interactions are the major concernswhen treating a patient with cyclosporine.49

Although cyclosporine trough level monitoring isgenerally not used when monitoring patients withpsoriasis, it may be indicated when cyclosporine isused long term at doses greater than 3 mg/kg daily50

and could also be considered for the elderly. It is theopinion of the Medical Board of the NPF that allelderly patients must have their glomerular filtrationrate measured before initiating cyclosporine and thatthis therapy should not be used in patients withabnormal baseline glomerular filtration rate.Cyclosporine should be used with great caution inelderly patients with psoriasis.

BiologicsThe introduction of biologics has had a major

impact in managing psoriasis. Both alefacept (T-cellblocker) and etanercept (tumor necrosis factor-ablocker) have been studied in elderly patients withpsoriasis.32,33 Although the number of patients stud-ied is small (99 patients given alefacept and 77patients given etanercept), there does not appearto be a difference in efficacy or toxicity in the elderlywith either agent compared with placebo. An anal-ysis of 4322 elderly patients treated with etanercept

for rheumatologic disease (including RA, PsA, andankylosing spondylitis) demonstrated that the inci-dence of serious adverse events, infectious events,and malignancies was not different in elderly pa-tients than in those younger than 65 years.51 No casesof tuberculosis were reported and demyelinatingdiseases occurred only in patients aged younger than65 years. The incidence and types of death in theelderly patients were consistent with the expectedrates for patients of comparable age. The authorsconcluded that etanercept is generally safe and awell-tolerated agent for the treatment of rheumato-logic diseases in the elderly, and the risk of adverseevents was not greater in subjects aged 65 years andolder than in those younger than 65 years.51 It isunknown whether the results of this study ofetanercept in elderly rheumatologic patients areapplicable to elderly patients with psoriasis treatedwith etanercept. There is no published informationavailable regarding the efficacy and safety of adali-mumab, infliximab, and ustekinumab in elderlypatients with psoriasis. However Menter et al52

found that 61% of elderly patients with psoriasis(age $ 64 years; n = 64) treated with adalimumabachieved PASI 75 at week 16 as compared with 70%of patients aged 40 to 64 years (n = 455) and 74% ofpatients younger than 40 years (n = 305). Accordingto the adalimumab package insert, there was nodifference in the efficacy of adalimumab for thetreatment of RA between those older than 65 yearsand younger patients; however, the frequency ofserious infections and malignancies was higher inthe elderly than in the younger patients.53 Accordingto the infliximab package insert, there was no overalldifference in the efficacy of infliximab betweenelderly and younger patients with either psoriasisor RA.54 However, both the infliximab package insertand another study reported in abstract form demon-strate that the incidence of serious adverse events,including cardiovascular events, infusion reactions,and infections in elderly patients, was higher inelderly patients with psoriasis and RA than in youn-ger patients.54,55 Another abstract reported that dis-continuation of tumor necrosis factor-a blockersoccurred in 26 patients aged 65 years and olderand in 98 patients younger than 65 years, andmalignancies were more common in the elderly,whereas allergic reactions were more common in theyounger patients.56 Limitations of these data are thatmost of the elderly data come from patients withRA who have higher infection and lymphoma ratesthan patients with psoriasis and these patients aremore likely to be on combination therapy withmethotrexate, prednisone, and/or nonsteroidalanti-inflammatory drugs, so that the data may not

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be completely applicable to patients with psoriasis.However, these reports suggest that caution be usedwhen treating elderly patients who have psoriasiswith biologics because there is a higher baselineincidence of infections and malignancies in thispopulation.

Because biologics target the immune system, infec-tions are among their most common adverse events.Immunosenescence, aging of the immune system,may lead to increased infection risk, more severeinfections, and decreased responses to vaccines inelderly patients.57 Although there are no guidelines forvaccination of patients taking biologic therapies, theMedical Board of the NPF published a consensusstatement on safety monitoring and vaccinations.58

The conclusions of this publication were that there isno evidence to demonstrate that vaccination of pa-tients treated with biologics reduces the severity ofsubsequent infection and no evidence of decreasedefficacy of vaccinations when given to patients receiv-ing biologics. When possible, vaccinations shouldbe given before initiating biologics. For patients whoarecurrently takingbiologics,physiciansmayconsideradministering killed vaccines but must absolutelyavoid live vaccines.58

ConclusionsManaging psoriasis in the elderly is a challenging

task as there are limited data regarding safe andefficacious treatment options. Only topical calcipo-triol/betamethasone, broadband UVB, alefacept, eta-nercept, and methotrexate have been studied in theelderly. However, it is the opinion of the MedicalBoard of the NPF that under appropriate guidancetopical corticosteroids, topical vitamin D analogues,and topical tazarotene along with narrowband UVB,PUVA, acitretin, methotrexate, alefacept, etanercept,adalimumab, infliximab, and ustekinumab can gener-ally be safely used in the treatment of elderly patientswithpsoriasis. Cyclosporine shouldbeusedwith greatcaution in the elderly when other options have beenexhausted and,whenappropriate, in conjunctionwitha consulting nephrologist or an experienced primarycare physician. The goals of treating psoriasis are toachieve clinical control of the disease, to fulfill thepatient’s expectations, to improvequalityof life, and toprovide safe and tolerable treatment modalities. Thereremains a need for further research on the manage-ment of psoriasis in the elderly.

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