Everyone is equal before the disease, and even special populations may suffer from psoriasis, such as pregnant women, children, patients with hepatitis B and psoriasis with tuberculosis. As a special group, special treatment plans need to be formulated to improve the efficacy and reduce the adverse effects, so as to maximize the benefits for patients.
Next, we will talk about the specific treatment plans for different special populations.
I. Personalized treatment plan for children with psoriasis
Clinically, for the treatment of children’s psoriasis, there are four main treatment modalities, taking into account the age, gender, etiology, lesion site, as well as the child’s compliance and psychological development characteristics.
1.Topical treatment: Hormone is the preferred treatment drug. Hormone has strong anti-inflammatory and anti-proliferative effects and significantly slows down itching and scaling, etc., but prolonged use will lead to skin atrophy, capillary dilation, acne and other adverse reactions.
Therefore, hormone use should be combined with other non-hormonal medications or used intermittently.
Other non-hormonal drugs include vitamin D analogs and topical calcium-regulated neurophosphatase inhibitors.
Among them, vitamin D analogs include osteopontin and tacalcitol, which are safe and effective, well tolerated, and suitable for children with mild to moderate plaque psoriasis.
However, the adverse effects are mainly pruritus and local irritation, so they should be avoided on the face, genitalia and folds.
Topical calcium-regulated neurophosphatase inhibitors mainly include tacrolimus ointment and pimecrolimus cream, which are especially suitable for the face, groin and other areas.
2.Phototherapy: For older children with psoriasis whose local medication is ineffective, phototherapy is a safe and effective method, especially for children with moderate to severe psoriasis whose skin lesions account for more than 15% to 20% of the body surface and limited palmoplantar pustular psoriasis.
3.Systematic treatment: For severe plaque, pustular and erythrodermic psoriasis, local treatment is not effective, and can be combined with oral retinoic acid drugs.
However, long-term application will cause early epiphyseal closure and ligament ossification, and triacylglycerol and liver enzymes will be elevated in some children.
Therefore, children should be monitored for routine blood, liver and kidney function and blood lipids during the medication period, and X-ray examinations of the long bones and spine should be performed for children who have been on medication for >1 year.
In addition, immunosuppressants such as methotrexate and cyclosporine can be taken according to the situation.
4.Biological agent treatment: Biological agents used for children with psoriasis mainly include etanercept, infliximab, adalimumab, etc. Among them, etanercept has good safety and tolerability, and is well tolerated and effective in the treatment of moderate to severe plaque psoriasis in children.
Second, personalized treatment plan for psoriasis during pregnancy
There will be changes in the condition of psoriasis patients during pregnancy, and psoriasis can affect the outcome of pregnancy. Pregnant women with severe symptoms of psoriasis have a significantly higher delivery rate of low-weight babies than healthy ones, so they need to be actively treated during pregnancy, and there are four types of treatment methods.
1.Topical treatment: Emollients and moisturizers are recommended as simple and safe topical medications as they have few adverse effects and are therefore commonly used as first-line medications for psoriasis patients during pregnancy.
Topical topical glucocorticoids (hormones) are Class C drugs for pregnant women in the U.S. Food and Drug Administration (FDA) classification and can be applied appropriately according to medical advice.
However, topical use of potent hormones can increase the risk of low birth weight in the fetus. Therefore, pregnant women should avoid topical application of high doses of strong hormones.
2. Phototherapy: Narrow-spectrum medium-wave ultraviolet (NB-UVB) is usually considered as one of the effective methods.
However, some scholars believe that high cumulative doses of NB~UVB will cause degradation of folic acid and reduce serum folate concentration in psoriasis patients.
And folic acid deficiency in pregnant patients will increase the risk of fetal neural tube defects, so folic acid should be supplemented and its concentration should be tested regularly during phototherapy.
3. Systemic therapy: There are few clinical data on the use of cyclosporine for psoriasis in pregnant women, mostly from patients who received immunosuppressive therapy after transplantation.
The use of cyclosporine during pregnancy does not increase the risk of fetal malformation, preterm delivery and low birth weight babies, but may increase the incidence of prematurity. Therefore, the safety of systemic application of cyclosporine during pregnancy in pregnant patients with psoriasis awaits more clinical trials.
4. Biologic therapy: As a new type of drug for psoriasis, tumor necrosis factor (TNF) antagonists such as Isep and infliximab only belong to the FDA classification as Class B drugs for pregnant women.
Studies have shown that pregnant women treated with TNF-α antagonists in the first trimester of pregnancy have a higher probability of major birth defects, preterm birth and significantly lower birth weight compared to those who did not receive them.
The current research on the safety of TNF-α antagonists in pregnant women is relatively limited, so the use of TNF-α antagonists in psoriasis patients during pregnancy is not recommended.
Third, personalized treatment plan for psoriasis in the elderly
The treatment of psoriasis in the elderly requires comprehensive consideration of the disease history, medication history and safety of the treatment plan, and at the same time should be combined with their economic ability and treatment expectations to assess treatment compliance and develop individualized, safe and effective treatment plans to improve symptoms and quality of life.
1. Topical treatment: Topical topical treatment is currently the first-line choice for the treatment of psoriasis in the elderly, especially for patients with limited lesions.
However, in elderly patients with psoriasis, topical glucocorticoids may easily lead to local complications such as skin atrophy, purpura and secondary skin infections, while long-term use may cause systemic adverse effects such as diabetes, hypercalcemia and osteoporosis.
Therefore, medium-acting and potent glucocorticoids should be used with caution in elderly patients, and intermittent topical glucocorticoids combined with other drugs can be chosen for maintenance treatment.
Carbotriol betamethasone compound ointment can effectively control psoriasis vulgaris, and is better tolerated and adhered to in elderly patients.
2.Phototherapy: If the effect of topical medication is not good and elderly patients with psoriasis cannot tolerate systemic medication, phototherapy can be recommended.
Before phototherapy, it should be ensured that elderly patients can comply with the frequency of 2-3 visits per week, and the ability of patients to maintain standing balance independently or with the help of appliances during the treatment should be assessed.
Long-wave ultraviolet light combined with psoralen (PUVA) may also provide relief for psoriasis in the elderly, but because hepatic metabolism of psoralen is slowed in the elderly, there is an increased risk of interaction with other medications such as phenytoin sodium.
The risk of interaction with other drugs such as sodium phenytoin is increased. Considering that phototherapy may cause skin photodamage, actinic keratosis and increased risk of skin cancer in elderly patients, phototherapy should be avoided in elderly patients with pre-cancerous skin lesions or history of skin cancer, excessive frequency of previous phototherapy and history of photosensitizing drug use for psoriasis.
3.Systematic treatment: methotrexate is one of the effective traditional drugs for the treatment of psoriasis and is usually used for moderate to severe psoriasis.
It has been shown to be effective in controlling psoriasis in elderly patients and to provide effective relief at low doses. In view of the reduced metabolism and clearance of drugs in the elderly, it is also recommended that lower doses of methotrexate be used in the initial and maintenance regimens of elderly patients.
However, since methotrexate is mostly metabolized by the kidneys, it is not recommended for elderly patients with impaired renal function or who are also taking drugs that reduce renal clearance efficiency.
4. Biologic therapy: Compared with younger patients, there is no significant difference in the safety and efficacy of biologics in elderly patients with psoriasis, and biologics are less likely to interact with other drugs. For elderly patients with psoriasis requiring polypharmacy, biologics may be the treatment of choice, but elderly patients may be more prone to serious adverse reactions.
References
[1]He Shan,Xu Jinhua,Wu Jinfeng. Clinical phenotypes and treatment strategies of psoriasis in the elderly [J]. Geriatrics and Health Care,2021,27(02):440-443.
[2]Hu Y,Chen M. Treatment of psoriasis in special populations[J]. International Journal of Dermatologic Venereology,2016,42(03):145-148.
[3]Tan Zhouxia. Treatment modalities of psoriasis in special populations[J]. Frontiers in medicine,2017,7(29):89-90.