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Treating older adult patients with psoriasis can be difficult because of the increased prevalence of comorbidities, polypharmacy issues, potential adverse drug reactions, and progressive functional impairment of the immune system in this population.
First-Line Therapy
Topical agents are frequently prescribed as first-line therapy for older adult patients with psoriasis. These include corticosteroids, vitamin D, and tazarotene. However, these medications may be inadequate, and potential problems associated with corticosteroid use in older adult patients include thinning skin, bruising, purple spots, and infection, according to the American Academy of Dermatology (AAD) Association.1
Phototherapy is regarded as a safe and effective option for older adult patients with moderate or severe psoriasis. Nonbiologic systemic treatments include acitretin, apremilast, methotrexate, dimethyl fumarate, and cyclosporine, although the AAD advises that cyclosporine should be used with caution in patients aged 65 years and older. Biologic treatment options include etanercept, adalimumab, brodalumab, infliximab, secukinumab, and ustekinumab, among others.
Safety and Efficacy Concerns
The limited clinical data regarding the safety and efficacy of current therapies, especially the newer biologic agents, among older adult patients with psoriasis can make treatment selection problematic, according to Afsaneh Alavi, MD, a dermatologist at the Mayo Clinic in Rochester, Minnesota.
“Management of psoriasis in [older adults] can be challenging owing to some patient-related factors and also for the lack of evidence on the response to treatment,” Dr Alavi told us. “Many older patients have been excluded from clinical trials.”
This concern is shared by Daniel C Butler, MD, assistant professor at the Department of Dermatology and co-director of the Geriatric Dermatology Clinic at the University of California, San Francisco.
“The main issue is that many of our medications have not been tested in older adults,” Dr Butler told us. “Thus, providers are often wary of starting something that does not have great, or any, evidence in the population.”
Apremilast, an oral small-molecule inhibitor, is a safe and long-term option with a low risk for adverse events (AEs), according to Dr Alavi. “The newer biologics like anti-interleukin (IL)-17 and anti-IL-23 therapies are associated with a low risk for infection and malignancy and could be a better option in [older] patients,” she said. “Cyclosporine and methotrexate must be given very carefully, with the risk for impaired renal function, drug interaction, and other comorbidities. Retinoid might be associated with extreme dryness, and it is difficult for patients to tolerate.”
Matching Goals With Treatment
There is no single treatment that is better for older patients compared with younger ones, noted Dr Butler. “The key to care of older adults is matching their goals of care with the treatments we have to offer,” he said. “Over the past year, many older adults understandably did not want to be on any immunosuppressing agents. Moreover, their psoriasis was not what bothered them, but rather it was the itching.”
When the goal is to decrease the itching and limit the risk for immunosuppression, apremilast is an ideal medication, according to Dr Butler. “On a similar theme but for a different treatment, phototherapy is a great option in older adults when transportation and mobility permits. But during the [COVID-2019] pandemic, this was too much exposure to the healthcare system, so we stayed away from it,” he said.
Review of Recent Literature
Di Caprio and colleagues published a review of topical and systemic therapies that have been investigated in trials involving older patients with psoriasis.2 The researchers concluded that apremilast has a satisfactory safety profile and low risk for drug interactions and is an appropriate treatment in this age group. In addition, biologic agents such as tumor necrosis factor (TNF)-α and IL-12/23, IL-17, and IL-23 inhibitors are safe long-term options in older adult patients, although specific recommendations in guidelines for older adult patients are lacking.
Bakirtzi et al reported that biologic agents and apremilast showed adequate efficacy in 154 patients with psoriasis aged 65 years or older.3 The researchers found that secukinumab, ustekinumab, and brodalumab led to fast-acting results, and secukinumab, ustekinumab, infliximab, adalimumab, and brodalumab showed sustained efficacy. Within the cohort, 19.5% of patients reported side effects, including lower respiratory system infections and hepatic enzyme elevation, similar to the incidence and severity of AEs in younger patients in relevant clinical studies.
In a systematic review of clinical trials and studies that investigated the safety and efficacy of biologic agents in older adult patients with moderate to severe psoriasis, Sandhu et al found that the efficacy between younger adult patients and older adult patients was similar for all biologic classes.4 The study authors noted that the available literature on the safety and efficacy of biologic agents in older adult patients supports the use of these agents in this population, although serious AEs and discontinuation due to AEs were more common in older adult patients.
Ricceri and colleagues conducted a retrospective study of biologic therapies in 266 patients with psoriasis aged older than 65 years who received etanercept, adalimumab, infliximab, golimumab, certolizumab pegol, ustekinumab, or secukinumab.5 Participants’ scores on the Psoriasis Area and Severity Index (PASI) ranged from 4 to 54 (mean ± SD, 16.5±7.1) at baseline and changed after treatment to 3.7±8 at week 16, 1.6±2.1 at week 28, and 1.2±2.1 at week 52. Patients reported a total of 25 adverse events during the observation period, with infection and malignancies the most commonly occurring. The investigators concluded that age alone should not limit therapeutic options for older adult patients with psoriasis.
In another review of the efficacy and safety of systemic treatments in older adult patients with psoriasis, Di Lernia and Goldust concluded that apremilast and biologic agents are safe for long-term management of the disease.6 Etanercept, adalimumab, ustekinumab, secukinumab, ixekizumab, and brodalumab were not associated with a higher risk for AEs.
Individualized Patient Approach
Providing effective treatment for older adult patients with psoriasis ultimately involves achieving clinical control of the disease as well as limiting the physical and psychological effects of psoriasis. Individualized care based on disease severity and the patient’s health can help optimize the overall results.
“The best advice when treating older adults with psoriasis is to listen to what is distressing them about their disease rather than just looking at the disease,” said Dr Butler. “Ask patients if they are sleeping, if they are able to maintain their favorite activities. Ask about their quality of life with the disease. The answer to these questions in older adults should be paramount to treatment decisions and can give a hesitant provider the needed evidence to feel comfortable clinically monitoring in cases of severe disease where the patient is unbothered, or escalating treatment in patients with significant quality of life impairment.”
Older adults “are a vulnerable population, and their quality of life is very important,” said Dr Alavi. “If systemic therapy is indicated, biologics are one of the safest options for this patient population and require limited monitoring. There is an increased risk of infection in [older adults] and caution is needed when using anti-TNF therapy or even anti-IL-12-23.”
References
1. How to Treat Psoriasis at Age 65 and Beyond. American Academy of Dermatology Association. https://www.aad.org/public/diseases/psoriasis/treatment/stage/65-beyond. Accessed April 12, 2021.
2. Di Caprio R, Caiazzo G, Cacciapuoti S, Fabbrocini G, Scala E, Balato A. Safety concerns with current treatments for psoriasis in the elderly. Expert Opin Drug Saf. 2020;19(4):523-531. doi: 10.1080/14740338.2020
3. Bakirtzi K, Sotiriou E, Papadimitriou I, et al. Elderly patients with psoriasis: long-term efficacy and safety of modern treatments. J Dermatolog Treat. Published online August 20, 2020. doi:10.1080/09546634.2020.1809623
4. Sandhu VK, Ighani A, Fleming P, Lynde CW. Biologic treatment in elderly patients with psoriasis: a systematic review. J Cutan Med Surg. 2020;24(2):174-186. doi:10.1177/1203475419897578
5. Ricceri F, Bardazzi F, Chiricozzi A, et al. Elderly psoriatic patients under biological therapies: an Italian experience. J Eur Acad Dermatol Venereol. 2019;33(1):143-146. doi:10.1111/jdv.15139
6. Di Lernia V, Goldust M. An overview of the efficacy and safety of systemic treatments for psoriasis in the elderly. Expert Opin Biol Ther. 2018;18(8):897-903. doi:10.1080/14712598.2018.1504016
