Treating older adults with
psoriasis can be challenging owing to comorbidities, concomitant medication use, and consequent safety risks. Although many studies focus on the effectiveness and safety of systemic antipsoriatic
therapies in the general population, their effectiveness in older adults with
psoriasis has not been systematically assessed.
Objective: A systematic literature search was conducted in Embase, MEDLINE, and the Cochrane Central Register of Controlled Trials (CENTRAL) on November 11, 2019. No date limit was used. Randomized clinical trials, cohort studies, large case series, and meta-analyses assessing efficacy (or effectiveness) and/or safety of systemic antipsoriatic
therapies in patients 65 years or older were included.
Findings: The initial search yielded 11 096 results, of which 31 unique articles with 39 561 patients were included in analysis. Overall, limited data were available per systemic agent, and overall quality of the included studies on conventional systemic
therapies was low. At the end of the induction phase (12-16 weeks after start of treatment), a reduction of 75% in
Psoriasis Area and Severity Index was achieved in 49% of 74
methotrexate sodium users 65 years or older, 46% to 52.6% of 178 older
cyclosporin users, 27% to 47.8% of 108 older
acitretin users, 15.6% to 64% of 256
etanercept users 65 years or older, 66.7% to 93% of 43
infliximab users 65 years or older, 60.7% to 65% of 100
adalimumab users 65 years or older, 56.5% of 46
ustekinumab users 65 years or older, and 86.4% of 67
secukinumab users 65 years or older. Effectiveness of
acitretin,
etanercept,
adalimumab, and
secukinumab appeared not to be associated with age; studies regarding other systemic antipsoriatic
therapies did not provide age group comparisons. Older age was significantly associated with renal function deterioration in
cyclosporin users and with
lymphopenia in
fumaric acid esters users (hazard ratio, 2.42; 95% CI, 1.65-3.55; P < .001).
Infections were the most frequently reported adverse event in patients 65 years or older using biologics, but no significant association with age was found.
Conclusions and Relevance: On the basis of limited available evidence, age alone should not be a limiting factor in
psoriasis management. Awareness of comorbidities and concomitant medication use is very important, as well as appropriate dosing and frequent laboratory and clinical monitoring. More real-world evidence and (sub)analyses of prospective cohort studies on the effectiveness and safety of systemic
therapies in older adults are critical to optimize personalized, effective, and safe antipsoriatic management in this growing patient group.