Practical management of psoriasis in the elderly: epidemiology, clinical aspects, quality of life, patient education and treatment options.

Psoriasis in the elderly will constitute a significant challenge for the practising physician in this new millennium. Special considerations for the elderly include drug-induced or drug-aggravated psoriasis, especially for patients receiving polypharmacy or with recent worsening or poor response to conventional therapy. Other frequently encountered forms of psoriasis in the elderly include psoriatic arthritis and its complications, inverse psoriasis and potentially life-threatening complications such as erythrodermic or acute pustular psoriasis, where early recognition and systemic therapy is critical. Faced with an array of topical and systemic drug therapy options, it is of paramount importance that the physician remains focused on the holistic management of the patient, in order to achieve optimal compliance and benefit. This can be achieved through careful attention to quality-of-life issues, especially since many elderly patients may have other medical, social and economic comorbidities that can further negatively affect their overall quality of life. It is also essential that the severity of psoriasis be assessed on a more balanced, holistic scale that incorporates both physical and psychological parameters, such as the Salford Psoriasis Index. The patient and caregiver education should be multi-faceted, regularly conducted and practically orientated. Treatment goals should be kept simple and individualised for each patient, based on concomitant comorbidities, potential adverse effects, existing quality of life, self-care capability, drug history, caregiver situation, financial needs, feasibility for follow-up and patient's preferences. Topically applied medications, such as topical corticosteroids, salicylic acid, tar and dithranol preparations, calcipotriol and tazarotene, are the favoured first-line therapeutic options in the elderly. Narrowband ultraviolet B phototherapy is also well established as a standard therapy for psoriasis. Systemic therapy with agents such as methotrexate, acitretin and cyclosporin should be judiciously reserved for severe, extensive cases in view of their lower therapeutic index in the elderly. The ambulatory psoriasis treatment centre is an integral part of the overall cost-effective management of patients with psoriasis that can function as a 'one-stop' treatment and resource centre for the elderly patient.