How Aging Affects Psoriasis Presentation and Treatment Decisions

Daniel Butler, MD, a board-certified dermatologist and vice chair of education at the University of Arizona, leads the Inflammatory and Aging Skin Research Program. His work examines aging as a risk factor for inflammatory skin diseases and how growing older changes disease presentation, pathophysiology, and patient care. Butler emphasized psoriasis management and insurance access as areas where clinicians need age-specific awareness.

How Aging Shapes Disease Presentation and Care

Butler said aging shapes every level of dermatologic practice, from basic science and pathophysiology to how patients interact with the medical system. He cautioned against treating older and younger patients as clinically interchangeable, emphasizing the importance of recognizing the unique needs of older populations.

"While age is just a number, the moniker of getting older affects everything," said Butler. "It affects our basic science, our pathophysiology, [how] diseases present, and perhaps most importantly, it changes how we interface with our medical system."

He noted the effect can be subtle, such as needing extra time to explain what a specialty pharmacy is and why a prescription may not go directly to a local pharmacy, or substantial enough to reshape an entire visit, even when the diagnosis itself is straightforward.

Recognizing Psoriasis Onset in Older Adults

Butler said that although geriatric dermatology falls within general dermatology, clinicians still need to recognize the unique needs of older patients. He pointed to psoriasis as a condition with a second peak later in life, including among patients in their 60s, 70s and even 80s who may present with the disease for the first time.

"Is it the joint pain? Is it the visual? Is it a mix of the two? Sometimes, does it even bother them?" said Butler.

He said these questions, alongside a patient's insurance coverage and out-of-pocket costs, should inform treatment decisions.

Insurance Costs Remain a Barrier for Advanced Therapies

Butler described how Medicare coverage before the Inflation Reduction Act could leave some patients with psoriasis facing steep bills for advanced therapies, even after receiving a coverage agreement.

"The patient would then get a $30,000 to $60,000 bill. I even had one patient get a $100,000 bill, because Medicare says, we approve it, but you have to pay for it out of pocket," said Butler.

Butler said the Inflation Reduction Act has since lowered out-of-pocket maximums to between $2,000 and $3,000. Still, he noted that these costs can strain patients on fixed incomes, particularly if a substantial bill arrives at the beginning of the year.

Clinicians and APPs need to understand these prescribing nuances and counsel patients accordingly, Butler said, helping them navigate costs and ensuring expectations are addressed at the point of care.

"It's much more nuanced than that in this population," said Butler.