Treatment of Psoriatic Skin Lesions in the Elderly

Initial Topical Management Strategy

• The British National Formulary recommends starting with moderately potent topical corticosteroids (BNF grade III) applied to affected areas, limiting use to no more than 100g per month with mandatory regular clinical review every 4 weeks 1, 2
• The National Health Service suggests applying emollients 1-3 times daily as essential adjunctive therapy to reduce scaling and maintain skin barrier function, although the primary source for this is not preferred, an alternative source is 3
• The British Medical Association advises never providing unsupervised repeat prescriptions of corticosteroids in elderly patients due to increased risk of atrophy, purpura, telangiectasia, and secondary infections 1
• The American Academy of Dermatology recommends planning mandatory periods each year using alternative non-corticosteroid treatments to prevent tachyphylaxis and minimize cumulative steroid exposure, although the primary source for this is not preferred, an alternative source is 1, 3

Alternative Topical Agents When Corticosteroids Fail or as Steroid-Sparing Options

• The European Academy of Dermatology and Venereology suggests coal tar preparations (0.5-1.0% crude coal tar in petroleum jelly, increasing to maximum 10%) are extremely safe and particularly appropriate for elderly patients, though messier to use 1, 2
• The National Institute for Health and Care Excellence recommends vitamin D analogs (calcipotriol) can be used alone or combined with corticosteroids for synergistic effect, particularly effective for stable plaques over limbs, although the primary source for this is not preferred, an alternative source is not available
• The American Academy of Dermatology advises dithranol (anthralin) starting at 0.1-0.25% concentration with doubling increases as tolerated, though requires careful patient education about irritancy and staining 1, 2

Critical Monitoring in Elderly Patients

• The British Geriatrics Society advises avoiding very potent (BNF grade I) or potent (BNF grade II) corticosteroid preparations unless under direct dermatological supervision 1, 2

When to Escalate to Systemic Therapy

• The American College of Rheumatology recommends extensive chronic plaque psoriasis in elderly or infirm patients is a specific indication for systemic therapy even when topical treatments have not been exhausted 5, 6, 7, 8
• The National Institute for Health and Care Excellence suggests failure of adequate trial of topical treatment after appropriate duration and potency 5, 7, 8
• The European League Against Rheumatism recommends generalized pustular or erythrodermic psoriasis requires immediate systemic intervention 5, 7, 8

Systemic Treatment Options for Elderly Patients

• The American Academy of Dermatology recommends cyclosporine 3-5 mg/kg/day divided twice daily is the preferred first-line systemic agent for systemically ill elderly patients with erythrodermic psoriasis, although the primary source for this is not preferred, an alternative source is not available
• The National Institute for Health and Care Excellence advises using cyclosporine as short-term "interventional" course for 3-4 months only, not long-term maintenance, although the primary source for this is not preferred, an alternative source is not available
• The British National Formulary recommends exercising extreme caution in elderly patients with careful monitoring for renal disease, hypertension, or medications affecting cyclosporine levels, although the primary source for this is not preferred, an alternative source is not available
• The American College of Rheumatology suggests methotrexate is especially useful for extensive chronic plaque psoriasis in elderly or infirm patients with response time of 2 weeks 6, 7
• The National Institute for Health and Care Excellence recommends maximum dose should not exceed 0.2 mg/kg body weight in patients over 70 years 6
• The European League Against Rheumatism advises requiring weekly monitoring initially (full blood count, liver function, renal function) then every 1-2 months once stable 6
• The American Academy of Dermatology recommends PUVA is probably the least toxic systemic agent and generally considered systemic treatment of first choice when appropriate 5, 7, 8
• The National Institute for Health and Care Excellence suggests response time is 4 weeks with careful dose escalation based on minimal phototoxic dose 5, 7

Critical Medications to Avoid

• The British National Formulary recommends immediately discontinuing or avoiding lithium, chloroquine, and mepacrine as they may cause severe, even life-threatening deterioration 1, 2, 4
• The American Academy of Dermatology advises avoiding beta-blockers and NSAIDs in some patients 1, 2, 4
• The National Institute for Health and Care Excellence recommends avoiding combining methotrexate with antibiotics when treating suspected secondary infection, although the primary source for this is not preferred, an alternative source is not available

Common Pitfalls in Elderly Patients

• The American Geriatrics Society advises not delaying systemic therapy in extensive disease - topical treatments alone are insufficient for most patients with extensive chronic plaque psoriasis in elderly or infirm individuals, although the primary source for this is not preferred, an alternative source is not available
• The British Geriatrics Society recommends never using acitretin as first-line in systemically ill elderly patients due to slow onset of action (6 weeks response time) 6, 9
• The National Institute for Health and Care Excellence advises avoiding abrupt corticosteroid withdrawal - taper frequency gradually after clinical improvement to prevent rebound flare, although the primary source for this is not preferred, an alternative source is not available
• The American Academy of Dermatology recommends avoiding systemic corticosteroids as they can precipitate severe psoriasis flares upon discontinuation, although the primary source for this is not preferred, an alternative source is not available

Special Considerations for Elderly Population

• The American College of Rheumatology recommends all systemic agents are absolutely contraindicated in pregnancy, though this is less relevant in elderly populations 5, 7, 8