Managing moderate-to-severe psoriasis in the elderly

Managing psoriasis in the elderly can be difficult for physicians, who must consider comorbidities, the resulting polypharmacy, and progressive functional impairment of several organs. Indeed, topical agents are the first-line treatment for limited disease. Phototherapy is recommended if topical drugs are not sufficient and the patient has multiple comorbidities and risk factors that make them a poor candidate for an oral or injectable systemic agent. The most important pharmacokinetic alteration in the elderly population is the decreased excretory capacity of the kidney; thus, cyclosporine should be considered a last resort treatment, and the administered dose of methotrexate should be lowered according to the reduction in estimated creatinine clearance. Acitretin can be used in the absence of severe renal insufficiency, paying attention to lipid profile, treating eventual hyperlipidemia, and closely monitoring liver enzymes. Available data on biological drugs in the elderly are limited. Biologics are associated with a small but significant overall risk of infections. However, there is no convincing evidence that the relative risk of infection with anti-tumor necrosis factor (TNF)-α therapy increases with age. Nevertheless, the package inserts for biologics recommend caution when administering these medications to the geriatric population, due to the high baseline risk of infection in such patients. Etanercept seems to be well tolerated, possibly because of its lower immunosuppressive characteristics compared with other biologics. However, studies with larger sample sizes are needed to confirm its safety.