Multiple studies suggest that both mild and severe psoriasis increases the risk of cardiovascular disease, such as myocardial infarction and stroke [4, 5]. The relative risk of cardiovascular death for 60-year-olds with severe psoriasis was estimated at 1.92 (1.41–2.62) [4]. A recent review of literature from the Medical Board of the National Psoriasis Foundation suggests that some psoriasis therapies can decrease cardiovascular disease. Treatments found to decrease cardiovascular risk include methotrexate, tumor necrosis factor inhibitors, and long-term use of ustekinumab [6].

Recently, older psoriatics were found to be more likely to have nonalcoholic fatty liver disease (NAFLD), independent of covariates in both a retrospective and cross-sectional study [7]. The presence of NAFLD should alert physicians to potential liver toxicity with particular treatments for psoriasis such as methotrexate or acitretin, warranting either close monitoring during treatment or avoidance of these hepatotoxic drugs altogether. In addition, NAFLD is associated with metabolic syndrome and is an independent predictor of cardiovascular disease.

Topical corticosteroids are the first-line and likely the safest option to treat psoriasis patients. However, the use of topical steroids in geriatric patients poses additional concerns. The risks of increased skin fragility, atrophy, purpura, steroid rebound, skin infections, and telangiectasias are apparent in all ages, but these risks are pronounced in older patients because of the physiologic changes of aging skin [8–10]. Therefore, while the use of topical steroids is recommended as the first-line treatment for elderly individuals by the National Psoriasis Foundation, topical steroids should be prescribed with caution, and clinicians should consider following up with their patients at least once every 3 months to monitor for atrophy [11].

Problems with compliance can further complicate the prescription of topical steroids in the geriatric population. Time and difficulty of application must be considered in light of a patient’s physical limitations; patients may struggle with regular use. Prior to prescribing, clinicians should therefore ensure that patients are capable of applying topical agents or be able to receive necessary assistance. Back applicators available from drug stores can help with difficult-to-reach areas such as the back. Combined topical agents may reduce the steps needed for application of two separate drugs in patients with musculoskeletal difficulties. One proven option is combined calcipotriol and betamethasone dipropionate, which is applied once a day and has been proven safe and effective, especially in elderly patients [12].

Phototherapy is safe and recommended for geriatric patients, although its ability to decrease cardiovascular risk is unproven. Important considerations include the patient’s ability to travel to a phototherapy center three times per week as well as physical limitations which may make standing in a phototherapy booth difficult [11]. For instance, older patients in wheelchairs may not be able to stand for the duration of treatment and transportation as well as coordination with caregivers is critical for effective treatment. Narrowband ultraviolet B radiation can be a good choice for older patients with moderate to severe psoriasis if they are able to tolerate positioning in the photo-booth.

Prior to an initial phototherapy session, as well as in subsequent visits, clinicians should conduct a thorough review of the patients’ medication list to evaluate for any potentially photosensitizing agent [11, 13]. Phototherapy staff should be reminded to review this list before treatment, paying special attention to any new medications. Phototherapy can be a good choice for patients wishing to avoid drug interaction from concomitant medications.

Response to internal medication can be quite variable in geriatric patients because age-dependent changes in normal physiology alter responses, reactions, and metabolism: organs gradually lose functional capacity, homeostatic mechanisms become slow, fat content increases, and water volume decreases [14]. For traditional systemics, the general rule is to start at a low dose and titrate slowly on the basis of the therapeutic response. Frequent follow-up is recommended to assess adverse effects and degrees of response.

Methotrexate can be used safely in elderly patients, but the predominant concern is its use with concurrent age-related impaired renal function. Creatinine clearance decreases with age and thus may lead to increased serum concentrations of the medication if dosing is not adjusted by kidney function [15]. For this reason, methotrexate should be initiated at a lower dose than that used for younger psoriasis patients [16]. In addition, elderly patients on methotrexate should be reminded to stay well hydrated. Since these patients have an increased risk of dehydration, methotrexate blood levels may increase to toxic levels.

An additional concern with using methotrexate is the potential for life-threatening myelosuppression. Elderly individuals are often myelosuppressed at baseline, putting them at great risk for these rare but serious adverse events [17]. Typically, a 5 mg “test” dose of methotrexate is given before regular dosing is started. Laboratory evaluations including liver function testing and blood counts are performed before and after the test dose.

Methotrexate can interact with a variety of medications. The most dangerous of these interactions is with the antibiotic trimethoprim, which can result in a fatal reaction [18]. A thorough evaluation of potential interactions with concurrent medications is required for any patient who is starting on a treatment regimen.

Acitretin is the only internal medication that does not have immunosuppressive qualities and is thus appropriate for the geriatric population, although its ability to reduce the rate of cardiovascular events remains to be demonstrated. Additionally, oral retinoids may discourage neoplasm by enhancing cell maturation and differentiation [19

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