Based on studies and known risks of systemic medications, physicians and patients both face challenges for determining how to adequately treat psoriasis and avoiding increased harm that may outweigh the benefits of treatment. Further research is needed to develop and make possible medications with decreased risk for cancer, infection, and worsening comorbidities. Extensive studies should be carried out to understand the effects of these systemic agents specifically on the geriatric psoriasis population. In addition to research, the management of elderly patients with psoriasis can be improved by educational programs. Currently, many dermatologists are not comfortable with treating the elderly psoriasis patient with these agents and are inadequately treating them by using topical therapies alone. However, a consensus meeting of geriatric dermatology experts should be organized to develop specific guidelines for dermatologists and other physicians about optional treatments for psoriasis in the elderly.
For now, however, without specific guidelines and adequate research into this topic, a more careful management of the elderly patient with psoriasis is needed. A cautious approach can be taken with a thorough history and physical examination. Included in the history, physicians should document all current and past medications as well as drug allergies and side effects of medications to prevent adverse drug interactions and reactions. A careful history of immunosuppressive use is needed to ensure that the cumulative dose of the agent is not beyond the standard recommended by the FDA to cause toxicity to an organ system. The physical examination should be a thorough head-to-toe examination, with particular emphasis on the cardiovascular, respiratory, and musculoskeletal systems. Vital signs should be taken twice, in particular to ensure that the patient does not have hypertension if the physician is planning to prescribe cyclosporine. Extensive laboratory workup is needed to evaluate for hepatic decline (liver function tests), renal insufficiency (creatinine and possibly glomerular filtration rate), hyperlipidemia, electrolytes, low white blood cell count, low platelets, and low red blood cell count that would be considered contraindications for certain systemic therapies.
When prescribing medications, it is important to start with a small dose and then titrate up to higher doses to a defined therapeutic response. Physicians should make an effort to reduce the number of medications the patient needs to take and should regularly check for possible interactions and adverse effects.
For a healthy, active elderly patient with no or limited comorbidities, etanercept can be used for psoriasis treatment with careful monitoring. Etanercept has been the only systemic biologic agent that has shown to be safe in the elderly, possibly due to its lower immunosuppressive ability compared to other biologic agents. However, a larger sample size of psoriasis-specific elderly patients is needed to further confirm its safety.
If an elderly patient has multiple comorbidities and risk factors that make him/her a poor candidate for an oral or injectable systemic agent, phototherapy and strict compliance to topical therapies are recommended. Ultraviolet B (UVB) and psoralen ultraviolet A (PUVA) phototherapy are noninvasive with minimal side effects limited to mild erythema, burning, and blistering. However, the patient may be challenged by the phototherapy box that requires him or her to be able to stand in the unit without mobile support or guard rails to maintain balance. In addition, some geriatric patients lack transportation or have arthritis or hip impairment that prevent them from being able to move themselves to a dermatology clinic for phototherapy. Drug-induced photosensitivity can also occur if a careful drug history is not taken.