Psoriasis and Aging

Paul S. Yamauchi

Contents Abstract
Psoriasis is the most prevalent immune-
Epidemiology, Comorbidities, and Quality
of Life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 mediated disorder when compared to other
inflammatory conditions such as rheumatoid
Therapeutic Approaches to Treating Psoriasis
in the Elderly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
arthritis, Crohn’s disease, multiple sclerosis,
and atopic dermatitis. As the population of
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
people who are 65 years and older in the
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 world continues to increase, the incidence of
elderly people suffering from psoriasis will
also increase in a proportionate manner. The
frequency of comorbidities associated with
psoriasis will consequently rise as the psoriasis
population continues to age. Despite new
advances in the treatment of psoriasis, there is
no permanent cure for psoriasis. However, the
newer biological agents that are more targeted
in the pathogenesis of psoriasis are very effica-
cious and hold great promise for safely treating
elderly psoriatic patients. This article will dis-
cuss the epidemiology of psoriasis in the
elderly population, the different comorbidities
associated with psoriasis that occur during
aging, and the various treatments that can be
employed to treat psoriasis contingent on the
degree of severity as well as patient
characteristics.

P.S. Yamauchi (*)

Dermatology Institute and Skin Care Center, Santa
Monica, CA, USA
David Geffen School of School of Medicine at UCLA,
Los Angeles, CA, USA
e-mail: paulyamauchi@yahoo.com

# Springer-Verlag Berlin Heidelberg 2015 1

M.A. Farage et al. (eds.), Textbook of Aging Skin,
DOI 10.1007/978-3-642-27814-3_156-1
2 P.S. Yamauchi
Epidemiology, Comorbidities,
and Quality of Life
While the exact incidence of psoriasis in the
elderly population is not certain, psoriasis is prev-
alent in this age category. In a US population-
based study, the highest rate of occurrence of
psoriasis occurred in the 60- to 69-year-old
age-group (113/100,000 population) [1]. Another
study demonstrated that the prevalence of psoria-
sis was 3.9 % at a tertiary referral center com-
prised of 16,924 geriatric outpatients
[2]. However, the prevalence of psoriasis in
another study in patients 60 years of age and
older was about 0.1 % (47 of 46,623 cases)
[3]. The average age was 67  1 years in this
study ranged from 60 to 85 years with a 9:1
male-to-female ratio. The average time course of
psoriasis was 25  2 months and associated
comorbidities were found in 27 cases (57.5 %).
The most observed type of psoriasis in that study
was chronic plaque psoriasis and 25.5 % of cases
were classified as severe.
As the population of people aged 65 years and
older continues to increase, the importance of
psoriasis in the elderly is underscored by the fact
that the numbers of geriatric patients with this
chronic condition and the comorbidities associ-
ated with psoriasis will also continue to rise in a
comparative manner [4]. Demographic studies
have shown that the elderly will constitute up to
25 % of the US population by 2025 [5] and up to
34 % in Europe by 2050 [6].
One study assessed the clinical characteristics
of elderly-onset psoriasis (over 60 years) com-
pared to early onset (before 30 years and middle-
age onset (between 30 and 60 years) groups
[7]). The elderly-onset patients comprised 3.2 %
of total patients (129 out of 4049) and showed a
lower incidence of family history and the severity
of the psoriasis was generally found to be milder
compared with early and middle-age onset
groups. The proportion of guttate type and gener-
alized pustular psoriasis type was found to be
decreased significantly, while the incidence of
erythrodermic psoriasis was increased. The loca-
tion of the psoriasis varied by age-group with the
rate of scalp increased in the elderly group but
plaque psoriasis on the extensor surfaces of the
extremities and the trunk was decreased signifi-
cantly. There was no significant difference in the
degree of pruritus on psoriatic lesions and nail
involvement between the three age-groups.
Psoriasis is not simply a chronic skin disease
but a condition that is associated with major
comorbidities [8]. These include psoriatic arthritis
(PsA), cardiovascular disease, metabolic syn-
drome, lymphomas, malignancies, and depres-
sion. PsA occurs in 30 % of patients with
psoriasis and tends to occur 10 years after the
initiation of the skin symptoms [9]. The onset of
PsA typically ranges between the ages of 32 and
60 years, and therefore there is a higher incidence
of PsA in the elderly [10]. In a US population-
based study, the prevalence of PsA in patients who
were older than 65 years was 20 years [11].
Metabolic syndrome has clearly been associ-
ated with psoriasis and is defined as the presence
of three of the following components: abdominal
obesity, insulin-resistant diabetes, decreased HDL
cholesterol, hypertriglyceridemia, and hyperten-
sion [8, 12, 13]. Psoriasis has been shown to be
associated with metabolic syndrome in the
elderly, and those patients tend to have had a
longer disease duration than those without meta-
bolic syndrome [14]. Patients who develop severe
psoriasis at a younger age in their 20s may be at
increased risk for the development of multiple
cardiovascular risk factors and myocardial infarc-
tions [15, 16]. A European study evaluated the
epidemiology and associated comorbidities of
2210 adults with psoriasis with focus on the
elderly patients greater than 70 years of age and
in patients with very late-onset psoriasis after the
age of 70 [17]. The epidemiological and clinical
features of early- and late-onset psoriasis with an
emphasis on potential outcomes in the
comorbidities were evaluated. Out of the total of
2210 adults, 212 (9.5 %) patients were elderly
with a higher frequency of females, a later onset
of the disease, a lower frequency of family history
of psoriasis, but a higher incidence of guttate and
inverse psoriasis. Hypertension, diabetes,
dyslipidemia, and major cardiovascular events
were higher in the elderly group, but not tobacco
Psoriasis and Aging
usage. Fifty eight (2.7 %) patients had late-onset
psoriasis which occurred more frequently in
women and older. Patients with psoriasis are also
at higher risk of developing arrhythmia, particu-
larly if psoriatic arthritis is present that is indepen-
dent of cardiovascular risk factors [18].
An observational, multicenter study demon-
strated there was an increased prevalence of fam-
ily history of psoriasis, psoriatic arthritis, and
depression in patients with early-onset psoriasis
[19]. Conversely, late onset of psoriasis was more
frequently associated with obesity and elevated
waist circumference compared with the early-
onset form. Elderly patients over the age of
75 years with late-onset psoriasis were shown to
be at high risk for obesity compared with individ-
uals at the same age with an early-onset disease.
The late onset in developing psoriasis may sug-
gest that obesity is an acquired comorbidity that
may be a predisposition for the development of
psoriasis in the elderly population.
Several case–control studies have demon-
strated an increased prevalence of nonalcoholic
steatohepatitis in patients with psoriasis, which
may be of relevance in the proper selection of a
systemic agent [20]. A large prospective
population-based cohort study compared the inci-
dence of nonalcoholic steatohepatitis which was
diagnosed by ultrasonography in patients with
psoriasis versus those without psoriasis [20]. A
total of 2292 participants with a mean age
76.2 years were included. Of those, over half
were women, the mean body mass index was
27.4, and 118 of the subjects (5.1 %) had psoria-
sis. The prevalence of nonalcoholic
steatohepatitis was 46.2 % in patients with psori-
asis compared to 33.3 % of the control group
without psoriasis. After adjustment for alcohol
consumption, cigarette smoking, and metabolic
syndrome, psoriasis remained a significant predic-
tor of nonalcoholic steatohepatitis. The elderly
population suffering from psoriasis was 70 %
more likely to develop nonalcoholic
steatohepatitis than those without psoriasis.
It has clearly been established that patients
suffering from psoriasis have lower quality-of-
life indices compared to the general population
[21, 22]. Psoriasis exhibits higher burdens both
3
physically and mentally when compared to other
major medical conditions including cancer, hyper-
tension, arthritis, depression, diabetes, and cardio-
vascular disease [23]. A cross-sectional study on
305 psoriatic inpatients where the mean age was
71 years was compared based on clinical and
social demographic determinants [24]. Psycholog-
ical distress was higher in psoriatic patients
greater than 70 years of age. It is important for
health care providers to be cognizant of the spe-
cific impact of psoriasis in the elderly group ver-
sus the younger-aged patients.
Therapeutic Approaches to Treating
Psoriasis in the Elderly
The choice of the various therapeutic options for
psoriasis in the elderly is based on the severity of
the psoriasis, symptoms such as itching and burn-
ing that reduces the quality of their life, prior
therapies, and the level to which the appearance
of the psoriasis bothers the patient [25]. Drug
interactions must be carefully taken into account
since elderly patients can be on multiple medica-
tions that can potentially interact with systemic
agents used to treat psoriasis. In addition, serious
medical conditions such as cancer, chronic infec-
tions, diabetes, and others may be a contraindica-
tion to systemic and biological agents if they are
contemplated to treat more severe psoriasis.
Topical agents are frequently prescribed for
elderly patients as first-line therapy due to their
nonsystemic nature [26]. Because the application
of topical agents can be cumbersome, especially
in difficult-to-reach areas as well as larger-body-
surface areas, compliance may be reduced, espe-
cially if the elderly patient requires assistance
[27]. The only data for elderly patients with pso-
riasis are for the topical application of a
calcipotriol/betamethasone dipropionate combi-
nation product that was found to be effective
irrespective of age [27]. Although topical cortico-
steroids remain widely used for the treatment of
psoriasis, the elderly population may be at higher
risk of steroid-induced adverse events including
atrophy, purpura, telangiectasia, secondary skin
4 P.S. Yamauchi
infections, rebound phenomenon, and
tachyphylaxis [28].
Phototherapy is an appropriate treatment for
elderly patients with psoriasis because of its min-
imally invasive nature (NPF). However, logistical
considerations should be taken into account when
recommending phototherapy to elderly patients
such as the availability of transportation to the
phototherapy unit two to three times per week
and ensuring that the patient is able to stand ade-
quately during the session without any physical
consequence. In addition, any concomitant medi-
cations when recommending phototherapy need
to be verified to avoid drug-induced photosensi-
tivity, especially in the elderly who might be on a
variety of medications.
Traditional systemic agents including metho-
trexate may be effective to treat psoriasis in the
elderly. However, the usage of methotrexate must
be carefully considered in the elderly. The dose of
methotrexate needed to control severe psoriasis in
patients older than 50 years may need to be
decreased compared to younger patients due to a
reduction of creatinine clearance that is correlated
with advanced aging [29]. The clearance of total
methotrexate is inversely proportional to age in
patients with rheumatoid arthritis and methotrex-
ate clearance due to decreased renal function
[30]. Although acute myelosuppression is rela-
tively uncommon with methotrexate, rare deaths
may occur as a result. Myelosuppression with
methotrexate occurs more commonly in the
elderly and diligent monitoring of the complete
blood is essential [31]. Although drug interactions
are not common with methotrexate; the
coadministration of trimethoprim with methotrex-
ate is contraindicated irrespective of age due to a
potential serious adverse event of myelosup-
pression. Care may need to be exercised when
nonsteroidal anti-inflammatory agents are pre-
scribed to elderly patients who are on methotrex-
ate due to potential decreased renal clearance
[32]. In a retrospective study of 7615 patients
with psoriasis and 6707 patients with rheumatoid
arthritis, patients given methotrexate had a signif-
icantly reduced risk of vascular disease compared
with those not given methotrexate after adjusting
for age, sex, comorbidities, and other medications
[32]. Reduction in vascular disease also was
observed among patients who took low to moder-
ate cumulative doses of methotrexate [32].
Although there are no specific outcome studies
on the use of oral retinoids such as acitretin to treat
psoriasis in the elderly, the risk of elevated tri-
glycerides should be considered but the risk may
be acceptable since elevated lipid levels can gen-
erally be successfully treated [26]. As the cardio-
vascular risk of hyperlipidemia generally takes
several years to progress, the risk of acitretin-
induced hyperlipidemia may be less significant
in elderly patients with psoriasis. Xerosis and
hair loss are also side effects exhibited by acitretin
that the elderly population may not tolerate
very well.
Cyclosporine may be warranted in the elderly
population for severe flare-ups of psoriasis or the
development of erythrodermic or pustular psoria-
sis. However, because cyclosporine is a powerful
immunosuppressant that can induce hypertension,
nephrotoxicity, and interacts with several medica-
tions, great caution should be exercised in pre-
scribing this medication to elderly patients with
psoriasis. The glomerular filtration rate should be
measured at baseline before the initiation of
cyclosporine [26].
The utilization of biologic agents has revolu-
tionized the treatment of psoriasis and psoriatic
arthritis. Their high degree of efficacy, mainte-
nance of response, and long-term safety through
selective immunomodulation has made biologics
one of the mainstays of therapy. There are a few
reports in the literature describing the efficacy and
safety of biologic agents specifically in the elderly
population.
The safety and efficacy of biological agents as
well as oral systemic agents were evaluated in
187 consecutive psoriatic patients greater than
65 years of age [33]. At week 12 of therapy, the
Psoriasis Area and Severity Index (PASI)
75 response was achieved by 49 %, 27 %, 46 %,
and 31 % of patients who received methotrexate,
acitretin, cyclosporine, or PUVA, and 64.1 %,
64.7 %, 93.3 %, 57.1 %, and 100 % of patients
who received etanercept, adalimumab, infliximab,
and ustekinumab. The rate of adverse events was
0.12, 0.32, 1.4, and 0.5 per patient-year in the
Psoriasis and Aging
methotrexate, acitretin, cyclosporine, and PUVA
groups and 0.11, 0.35, 0.19, 0.3, and 0.26 in the
etanercept, adalimumab, infliximab, and
ustekinumab groups. In this study, the traditional
oral systemic agents were less effective than bio-
logics in the elderly population and etanercept
was associated with a lower rate of adverse events
when compared to other treatments.
A retrospective study was conducted to evalu-
ate the long-term efficacy and safety profile of
antitumor necrosis factor (anti-TNF) agents in
elderly psoriatic patients [34]. This study included
89 patients aged 65 years and greater with psori-
asis and psoriatic arthritis treated with etanercept
or adalimumab as monotherapy. The proportion
of patients attaining a PASI 50 response was 91.8
and 82.1 % at week 156 with etanercept and
adalimumab treatment respectively. The propor-
tion of patients achieving PASI 75 response was
83.6 and 71.4 % at week 156 with etanercept and
adalimumab, respectively. The overall safety pro-
file and adherence to treatment was good in this
study and long-term treatment with anti-TNF
agents was appropriate in the management of
psoriasis in the elderly population.
A post hoc analysis of two large phase III
randomized placebo trials of etanercept was
performed to analyze the effect of etanercept on
PASI 50, PASI 75, and Dermatology Life Quality
Index (DLQI) in the geriatric and nongeriatric
populations [35]. There were no statistically sig-
nificant differences between the elderly and
young with regard to the number of patients
attaining a PASI 50 or PASI 75 response with
any of the conventional dosing regimens. The
baseline DLQI scores were not statistically signif-
icant between both groups; the change in DLQI
with etanercept was similar in both populations.
A retrospective study evaluated the efficacy
and safety profile of ustekinumab for 1 year in
elderly patients with psoriasis [36]. The study
included 24 psoriatic patients aged over 65 years
with a mean of 73.1 years with moderate to severe
plaque psoriasis. PASI 75 responses were 56.5 %
at week 16, 59.1 % at week 28, and 60.0 % at
week 52. None of the patients developed any
serious infection during the 1-year treatment.
The mean DLQI score at weeks 0, 16, 28, and
5
52 was 7.8, 2.5, 1.4, and 1.2, respectively.
Ustekinumab demonstrated sufficient efficacy
for elderly patients with psoriasis without any
serious infection over the 1-year treatment.
In general, biologic agents may be associated
with a small but significant overall risk of infec-
tions. Despite the labeling of these agents to exer-
cise caution when administering these agents to
the geriatric population due to higher baseline risk
of infections in this population, there is no con-
clusive evidence that the relative risk of infection
with biologic agents increases with age. Current
recommendations are to avoid coadministration of
live vaccines with biologic agents and to avoid
usage of biologic agents during major surgery.
Because the elderly population are more apt to
receive live vaccines such as zoster or to undergo
major surgery such as orthopedic joint replace-
ment or open heart surgery, the timing of the
administration of biologic agents needs to be care-
fully calculated and considered.
Conclusion
The goals of managing psoriasis in the elderly
should be no different than treating the younger
population. Attaining best possible clearance and
improving the quality of life in a safe, efficient,
and cost-effective manner are the fundamental
objectives. There are a few nuances between the
elderly and the young who have psoriasis. The
elderly may be more prone to infections, have
higher occurrences of malignancies, are on more
concomitant medications, undergo major surger-
ies due to aging, and receive live vaccine such as
zoster after the age of 50. These differences must
be considered when managing elderly patients,
particularly when considering an oral systemic
agent or a biologic. Fortunately, the limited data
in the published literature seems to suggest the
differences may not seem as significant as previ-
ously thought.
6 P.S. Yamauchi
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