Psoriasis in older adults presents specific challenges that require careful consideration from a healthcare provider. The skin naturally thins and becomes more fragile with age, increasing sensitivity and the risk of side effects from potent topical medications. Furthermore, seniors often have multiple other health conditions (comorbidities) and take several medications (polypharmacy), increasing the risk of adverse drug reactions and complications. A personalized, stepwise approach, often starting with the least invasive options, is key to successful management.
Topical treatments for mild to moderate psoriasis
For many elderly patients, especially those with mild to moderate disease, topical treatments are the preferred first-line therapy. These medications are applied directly to the affected skin to reduce inflammation and slow down excessive skin cell growth. It's crucial to select and apply these with care due to the increased fragility of older skin.
Commonly recommended topical options
- Corticosteroids: These reduce inflammation and are available in various strengths. Mild formulations, like hydrocortisone, are often used for sensitive areas, while stronger ones may be used for tougher patches. Long-term or heavy use of strong corticosteroids can lead to skin thinning, bruising, and infection in aging skin, so a doctor must supervise use carefully.
- Vitamin D Analogues: Synthetic vitamin D compounds like calcipotriene or calcitriol slow skin cell growth and reduce inflammation. They can be used alone or combined with corticosteroids. Calcitriol may cause less irritation and is a good option for sensitive areas.
- Calcineurin Inhibitors: Medications such as tacrolimus and pimecrolimus suppress immune activity in the skin and are effective for thin-skinned areas like the face, skin folds, and genitals. They are less likely to cause skin thinning than topical steroids but may cause initial irritation.
- Salicylic Acid: Available in shampoos and creams, salicylic acid helps remove scales and soften thick plaques. It is often used in combination with other topical medications to improve absorption.
- Emollients and Moisturizers: Regular and generous application of moisturizers is fundamental to managing psoriasis in older adults. Aging skin is naturally drier, and emollients reduce scaling and itching while maintaining the skin's protective barrier. Products containing ceramides, lipids, or urea can be particularly beneficial.
Phototherapy: Light-based treatment
For patients with moderate to severe psoriasis, phototherapy (light therapy) is a safe and effective option. It involves exposing the skin to controlled doses of ultraviolet (UV) light to slow down skin cell production.
Types of phototherapy
- Narrowband UVB: This is a common and effective type of phototherapy that uses a specific wavelength of UV light. Treatments are usually administered two to three times a week at a clinic, though some patients may use home units under a doctor's supervision.
- PUVA: This method combines a light-sensitizing medication (psoralen) with exposure to UVA light. While effective, it carries a higher risk of side effects, including increased risk of skin cancer over time. It is used more cautiously in the elderly, if at all.
Systemic and biologic therapies for severe cases
When topical treatments and phototherapy are insufficient, systemic and biologic medications may be necessary for moderate to severe psoriasis. Treating older patients with these medications requires extra caution due to the higher risk of side effects, drug interactions, and pre-existing comorbidities.
Comparison of systemic treatment options for elderly patients
| Feature | Traditional Oral Systemics (e.g., Methotrexate, Cyclosporine) | Newer Oral Agents (e.g., Apremilast) | Biologics (e.g., TNF, IL-17, IL-23 Inhibitors) |
|---|---|---|---|
| Mechanism | Suppresses the entire immune system. | Targets specific inflammatory pathways. | Blocks specific immune proteins responsible for psoriasis. |
| Risks in Elderly | Higher risk of liver and kidney problems; significant drug interactions; potential for bone marrow suppression. | Lower risk of serious adverse events; generally well-tolerated. | May increase infection risk; long-term data in older patients is still evolving but generally considered safe for many. |
| Monitoring | Frequent lab testing (blood counts, liver/kidney function) required. | Fewer monitoring requirements compared to traditional systemics. | Screening for infections (e.g., TB) required; ongoing monitoring for adverse effects. |
| Administration | Oral pills. | Oral pills. | Injections or intravenous (IV) infusions. |
| Suitability | Use with caution, especially in patients with organ impairment or extensive polypharmacy. | Favorable safety profile for elderly patients and those with comorbidities. | Often considered safer long-term than traditional systemics, particularly IL-17 and IL-23 inhibitors. |
Adapting treatment for comorbidities and lifestyle
Successful psoriasis management in the elderly involves more than just medications. It requires tailoring the treatment plan to the individual's specific health needs and lifestyle. For instance, patients with reduced mobility might have difficulty applying creams to certain areas or attending clinic-based phototherapy sessions. In these cases, support from caregivers or selecting simpler treatments becomes crucial. A healthy lifestyle, including a balanced diet and stress management, is also vital for controlling flare-ups and managing related health conditions.
Conclusion
Treating psoriasis in the elderly is a dynamic process that depends on a patient's overall health, the severity of their condition, and their personal treatment goals. A dermatologist, often in conjunction with other healthcare providers, will create an individualized plan that prioritizes safety and tolerability. By carefully considering comorbidities, polypharmacy, and the fragility of aging skin, clinicians can select the most appropriate treatment, from gentle topical moisturizers to targeted biologics, to effectively manage symptoms and improve the patient's quality of life.
Acknowledgment
For additional support and resources on managing psoriasis, individuals can visit the National Psoriasis Foundation.
