Table of Content

Archive

Winter 2015, Vol. 23 No. 4

Hong Kong J. Dermatol. Venereol. (2015) 23, 159-160


Editorial

Management of psoriasis in the elderly: further research needed

CK Hoe 何正綱

With an increasing ageing population, the proportion of elderly patients with psoriasis will continue to rise. As one must take into account age-related changes in pharmacokinetics, polypharmacy and possible drug interactions, drug-induced exacerbations of psoriasis, social, financial considerations as well as self-capability; psoriasis in this subgroup of patients is arguably more complex. It has also been found that erythrodermic psoriasis and acute pustular psoriasis are more common in the elderly.1 Yet this is a relatively neglected area and there have been few studies in this area. We are all aware of the age-related changes in pharmacokinetics in this group of patients. For example, age-related changes in the skin including increased dryness, decreased hydration of the stratum corneum and lipid content will affect percutaneous absorption of topical medications.2 Similarly, changes in renal and liver function will affect drug metabolism and distribution. There is as yet relatively little data on how this affects medications for psoriasis.

Co-morbidity is another issue in elderly patients. We are well aware of the decrease in renal and liver function in the elderly patient and it has been shown that systemic treatments are less frequently used in elderly patients who tend to be maintained on topical therapy. In addition, hypertension, dyslipidaemia, diabetes mellitus and cardiovascular disease are common in the elderly,3 who are often taking medications for these conditions and the concern over drug interactions further affects the decision for systemic therapy. This affects not only the physician but also the patient who may be reluctant to take systemic therapy due to concern over side-effects. However, it has been shown that the incidence of side effects and efficacy in elderly patients (>65 years old) were not statistically different from those of younger (18-64 years old) patients.4 Similarly, phototherapy has been found to be safe and well-tolerated in patients over 65 years old.5 Obviously, one must ensure that the patient is able to stand for the required period of time.

Topical treatments are first-line therapy for all age groups and have the advantage of avoiding systemic side effects, in general. However, they are only effective if consistently applied correctly, posing a challenge to the elderly. There is evidence that compliance with topical treatment is affected if deemed too time-consuming as shown in the original article in this issue. In a busy clinic, it is all too easy to just hand out a prescription and forget about the practical aspects in this subgroup. For example, will the elderly patient with an arthritic shoulder who lives alone really be able to apply topical treatment to psoriasis on the back? One must also bear in mind that many elderly patients may have financial difficulties as well as addressing any concerns (psychological or social). Therefore, a holistic approach is essential and topical treatment regime should not be over-complicated. A clear explanation of the condition and therapy to the patient and caregiver preferably at the first consultation is important to ensure ongoing compliance.

In this issue, Ruiz-Villaverde et al discuss the issues that need to be considered with each treatment modality in the management of psoriasis in the elderly. This further illustrates the fact that cases need to be assessed individually when choosing the most suitable treatment modality and not just on the basis of age alone. Clearly, further study into this subgroup of patients is needed to provide better guidelines and experience for clinicians.

CK Hoe
何正綱

References

1. Yosipovitch G, Tang MB. Practical management of psoriasis in the elderly: epidemiology, clinical aspects, quality of life, patient education and treatment options. Drugs Aging 2002;19:847-63.

2. Flammiger A, Maibach H. Dermatological drug dosage in the elderly. Skin Therapy Lett 2006;11:1-7.

3. Phan C, Sigal ML, Estève E, Reguiai Z, Barthélémy H, Beneton N, et al. Psoriasis in the elderly: epidemiological and clinical aspects, and evaluation of patients with very late onset psoriasis. J Eur Acad Dermatol Venereol 2014 Nov 11. doi: 10.1111/jdv.12850. [Epub ahead of print]

4. Garber C, Plotnikova N, Au SC, Sorensen EP, Gottlieb A. Biologic and Conventional Systemic Therapies Show Similar Safety and Efficacy in Elderly and Adult Patients With Moderate to Severe Psoriasis. J Drugs Dermatol 2015;14:846-52.

5. Powell JB, Gach JE. Phototherapy in the elderly. Clin Exp Dermatol 2015;40:605-10.