What NPs and PAs Should Know About Psoriasis Care in Older Adults

Daniel Butler, MD, vice chair of education at the University of Arizona and leader of the Inflammatory and Aging Skin Research Program, studies how aging influences inflammatory skin disease. In a recent NPPA Connect interview, Butler discussed what nurse practitioners (NPs) and physician assistants (PAs) should consider when caring for older adults with psoriasis, including differences in disease presentation, patient counseling, treatment selection, and access to advanced therapies.

What APPs Should Know About Caring for Older Adults

Butler said age can influence every level of dermatologic practice, from basic science and pathophysiology to how patients interact with the health care system. For NPs and PAs caring for older adults, those differences may be subtle or may significantly change how a visit is approached.

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

One practical example is navigating specialty pharmacies. An older patient may need additional counseling to understand why a prescription will not be sent directly to their local pharmacy or what steps are required to obtain treatment. Butler emphasized that clinicians may need to spend additional time helping patients navigate these processes.

Older Adults Are Not Just “Older” Younger Patients

A common misconception, according to Butler, is that older and younger patients should be approached in exactly the same way. Although geriatric dermatology remains part of general dermatologic practice, he said clinicians still need to recognize and respond to the needs of this distinct patient population.

“The misconception is sort of hiding in plain sight, and that's that older adults and younger adults are the exact same,” Butler said.

For APPs, recognizing these differences can help inform everything from the initial assessment to counseling and treatment decisions. Butler emphasized that aging may have little impact on the management of some patients while substantially changing the approach required for others.

Recognizing Psoriasis Later in Life

Psoriasis can also present for the first time later in life. Butler highlighted a second peak of psoriasis onset among patients in their 60s, 70s, and even 80s, making it important for clinicians to recognize potential disease in patients without a previous psoriasis history.

Once psoriasis is identified, Butler encouraged clinicians to look beyond visible disease and determine what is most important to the individual patient. Joint pain may be the primary concern for some patients, whereas others may be more bothered by visible plaques or a combination of symptoms. Some older adults may not be particularly bothered by their psoriasis at all.

Understanding those priorities should play a role in determining how clinicians approach treatment, Butler said.

Navigating Treatment Costs and Patient Expectations

Treatment selection can become more complex when insurance coverage and out-of-pocket costs enter the conversation. Butler described how, before the Inflation Reduction Act, Medicare could approve an advanced psoriasis therapy while leaving a patient responsible for tens of thousands of dollars in out-of-pocket costs. He recalled bills ranging from $30,000 to $60,000 and one reaching $100,000.

“Medicare says, we approve it, but you have to pay for it out of pocket,” Butler said.

Butler noted that the Inflation Reduction Act has since reduced out-of-pocket maximums, but even substantially lower costs can remain difficult for older adults living on fixed incomes. A bill of several thousand dollars arriving early in the year, for example, may still make an otherwise appropriate therapy financially inaccessible.

For NPs and PAs, Butler said understanding these nuances is an important part of prescribing for older adults. Clinicians should be prepared to counsel patients about potential costs, help them navigate the treatment process, and establish realistic expectations during the visit.

“It's not as easy as, I see the disease. Here's the medication. It's much more nuanced than that in this population,” Butler said.