Management of Severe Psoriasis in Older Adults

Introduction to Treatment Guidelines

• The American Academy of Dermatology recommends against the use of prednisone shots for severe psoriasis in older adults due to poor long-term efficacy and significant safety concerns 1, 2
• Systemic corticosteroids like prednisone are not considered standard of care for psoriasis management, as they are not mentioned in current treatment guidelines 1, 2, 3

Recommended Topical Treatments

• High-potency topical corticosteroids (class 1-3) are recommended for initial management of localized psoriasis for up to 4 weeks, according to the American Academy of Dermatology 4
• Combination therapy with topical vitamin D analogues (calcipotriene) plus corticosteroids provides superior efficacy compared to either agent alone 4, 5

Recommended Systemic Treatments

• Biologic agents are the preferred systemic treatment for severe psoriasis in older adults who have failed topical therapy, as recommended by the American Academy of Dermatology 2, 3
• The most effective biologics for achieving PASI 90 (90% improvement) in order of effectiveness are:
  • Anti-IL-17 inhibitors (secukinumab, ixekizumab) 2
  • IL-23 inhibitors (risankizumab, guselkumab) 2
  • IL-12/23 inhibitor (ustekinumab) 2
  • TNF-α inhibitors (adalimumab, etanercept, infliximab) 1, 3, 6
• TNF-α inhibitors should be avoided in patients with heart failure, demyelinating disease, or recurrent infections 8, 9
• IL-17 inhibitors should be avoided in patients with inflammatory bowel disease 8, 9

Treatment Algorithm

• The American Academy of Dermatology recommends a treatment algorithm starting with high-potency topical corticosteroids with or without vitamin D analogues 4, 5
• If inadequate response, consider phototherapy (narrowband UVB) as second-line treatment 7
• For moderate-to-severe disease unresponsive to above, consider biologics based on comorbidity profile 2