Elderly patients are a group with a high frequency of psoriasis. Their disease burden has negative impacts on their quality of life. While there is a clear need to treat these patients, there are challenges in doing so. This work seeks to define the challenges that exist in treating elderly Medicare patients, as well as to provide treatment suggestions for providers to follow if they encounter one or more of these challenges. Providers face the following challenges when creating treatment plants for elderly patients with psoriasis: difficulty in obtaining drug coverage through Medicare, increased medical comorbidities, and polypharmacy. Providers aim for regimens that are affordable, safe, and efficacious, but it is not always clear how to achieve this combination, especially in elderly Medicare patients. This work is relevant in that it aims to explain the logistical roadblocks posed by Medicare coverage and provide solutions for commonly encountered issues in the treatment of a disabling and common disease in a high-risk population. Specifically, alternative treatment options to biologics and small-molecule inhibitors are discussed and include topical therapies, phototherapy, methotrexate, acitretin, and cyclosporine and for psoriatic arthritis include corticosteroids and leflunomide. The specific risks and benefits of these therapies in the elderly population are provided, allowing providers to make patient-specific decisions about optimal regimens.

These days, the important role of retinoids in adult brain functionality and homeostasis is well accepted and has been proven by genomic as well as non-genomic mechanisms. In the healthy brain, numerous biological processes, e.g., cell proliferation, neurogenesis, dendritic spine formation as well as modulation of the immune system, have been attributed to retinoid signaling. This, together with the finding that retinoid metabolism is impaired in Alzheimer's disease (AD), led to preclinical and early clinical testing of natural and synthetic retinoids as innovative pharmaceuticals with multifactorial properties. Acitretin, an aromatic retinoid, was found to exert an anti-amyloidogenic effect in mouse models for AD as well as in human patients by stimulating the alpha-secretase ADAM10. The lipophilic drug was already demonstrated to easily pass the blood brain barrier after i.p. administration and evoked increased nest building capability in the 5xFAD mouse model. Additionally, we analyzed the immune-modulatory capacity of acitretin via a multiplex array in the 5xFAD mouse model and evaluated some of our findings in human CSF derived from a pilot study using acitretin. Although several serum analytes did not display changes, Interleukin-6 (IL-6) was found to be significantly increased in both-mouse and human neural material. This demonstrates that acitretin exerts an immune stimulatory effect-besides the alpha-secretase induction-which could impact the alleviation of learning and memory disabilities observed in the mouse model.

Systemic therapy in patients with concurrent psoriasis and chronic hepatitis B is a challenging task for both dermatologists and gastroenterologists since there is a high risk for hepatitis B virus (HBV) reactivation and hepatic toxicity under biological therapy. The therapeutic management of a patient with psoriasis and infection with the HBV is a challenge as the classical systemic treatment (methotrexate, acitretin, cyclosporine) shows a high risk of immunosuppression and/or hepatic toxicity and the biological therapy is endangered by the possibility of HBV reactivation. We present the case of a patient with moderate-severe psoriasis and chronic hepatitis B for whom we assessed the risk-benefit relation and considered useful to initiate the anti-TNF therapy concomitantly with the antiviral therapy with entecavir. The therapeutic algorithm included initiation of anti-TNF therapy with etanercept 2×50 mg/week combined with entecavir, an antiviral treatment administered continuously since the diagnosis of the HBV hepatitis, with hepatic function and viral load monitoring. After 3 months of therapy with etanercept the patient was given a dose of etanercept of 50 mg/week combined with entecavir 0.5 mg/day which he continued until week 36 when psoriatic lesions had cleared (PASI=0.6; DLQI=0). No adverse effects were registered and there was no evidence of HBV viral replication or changes in viral markers. We wish to emphasize that the use of etanercept in a patient with psoriasis and hepatitis B is a successful therapeutic alternative which may be safely used concomitantly with entecavir, with regular monitoring of viral load and hepatic function tests.