Late-Onset Psoriasis - An Overview

Introduction:

Psoriasis, a persistent skin condition influenced by genetic and environmental factors, impacts the skin, joints, and even nails. Onset can occur at any age, with childhood not exempt, but it commonly emerges between 15 to 25 years and 50 to 60 years. While prevalent in individuals with lighter skin, its reach extends across diverse ethnic backgrounds. Approximately one-third of those grappling with psoriasis share familial ties with others affected, pointing to a genetic association. Psoriasis is categorized into two primary types:

• Early-onset Psoriasis (EOP), commencing before the age of 40.

• Late-onset Psoriasis (LOP) initiating at age 40 or beyond.

What Is Late-onset Psoriasis?

Psoriasis that manifests later in life, known as late-onset psoriasis, typically emerges at age 40 or beyond. The precise origins of psoriasis remain elusive, though a blend of genetic and environmental elements is thought to contribute. The immune system's misdirected assault on healthy skin cells is a pivotal aspect of psoriasis, giving rise to its distinctive symptoms. Late-onset psoriasis may be sparked or intensified by factors such as stress, infections, specific medications, and fluctuations in weather. While symptoms can vary significantly among individuals, prevalent indications encompass crimson skin patches adorned with silvery scales, accompanied by itching and discomfort.

What Is the Cause of Late-onset Psoriasis?

The exact cause of psoriasis remains elusive, underscoring the complexity of its origins. Onset likely results from a blend of genetic and environmental factors. Some factors that may contribute to the development of late-onset psoriasis are:

• Genetic Factors: Genetics have a strong influence on the development of psoriasis. Late-onset psoriasis, however, may or may not be solely attributed to genetic factors.

• Environmental Contributors: Stress, skin injuries (burns, cuts), and medication, especially steroid withdrawal, contribute to late-onset psoriasis.

• Hormonal Influence: Hormonal changes, particularly during menopause, can play a role in triggering late-onset psoriasis.

• Lifestyle Impacts: Excessive alcohol consumption, smoking, and obesity heighten the risk of developing psoriasis.

What Are the Clinical Features of Late-onset Psoriasis?

Psoriasis that emerges later in life typically appears as plaque psoriasis, presenting distinctive red patches of skin adorned with silvery-white scales, creating a raised and well-defined texture. These distinctive plaques vary in size, often boasting sharp edges, and can appear on any part of the body, with a preference for areas like lower legs, scalps, knees, and elbows. Other clinical features include:

• Scaling Phenomenon: Excessive skin cell turnover in psoriasis leads to the accumulation of dead skin cells, presenting as silvery or white flakes in a scaling pattern.

• Inflammatory Signature: Inflammation is a hallmark as the immune system attacks healthy skin, resulting in redness and associated inflammation.

• Pruritus Troubles: Itching is a pervasive consequence of late-onset psoriasis, and the urge to scratch can exacerbate the condition, leading to discomfort and pain.

• Joint Affliction: Psoriatic arthritis may accompany late-onset psoriasis, instigating inflammation, stiffness, and joint swelling, culminating in pain and reduced mobility.

• Nail Transformations: Late-onset psoriasis can induce nail changes, including pitting, thickening, discoloration, or even separation from the nail bed.

What Is the Difference Between Late Onset and Early Onset Psoriasis?

Late-onset and early-onset psoriasis diverge in several key aspects.

1. Age: Firstly, the age of onset distinguishes them, with late-onset psoriasis emerging typically around or beyond the age of 40, while early-onset psoriasis can manifest before 40, especially between 15 and 35 years.

2. Sex: Gender plays a role, as males are more susceptible to late-onset psoriasis than females, whereas the contrast is noted in early-onset psoriasis.

3. Genetic Factors: Genetic factors contribute significantly, with the HLACw6 allele playing a pivotal role in early-onset psoriasis development. Early-onset psoriasis is consistently linked to genetic predisposition, while late-onset psoriasis may or may not exhibit a positive association. Environmental triggers and concurrent health conditions predominantly influence late-onset psoriasis.

4. Family History: Regarding family history, early-onset psoriasis consistently presents a familial link, while late-onset psoriasis may or may not have such a connection.

5. Type of Psoriasis: The types of psoriasis prevalent in both groups include chronic plaque psoriasis and palmoplantar psoriasis (these conditions impact the hands and feet, leading to challenges in mobility), but guttate psoriasis (manifests as scattered, small plaques distributed across the skin) is exclusive to early-onset cases.

6. Sites Involved: In terms of affected sites, both late-onset and early-onset psoriasis commonly involve the leg region and scalp.

7. Nail Involvement: This is more pronounced in early-onset psoriasis than in late-onset cases.

8. Koebnerization: In Koebnerization, new skin lesions develop on unaffected skin due to trauma or injury, is more prevalent in early-onset psoriasis than in late-onset cases.

9. Joint Involvement: This is observed in both groups, manifesting as arthralgia and/or arthritis.

10. Comorbidities: Notably, late-onset psoriasis is associated with a higher prevalence of comorbidities such as hypertension, diabetes, and dyslipidemia compared to early-onset psoriasis.

What Is the Management of Late-onset Psoriasis?

Managing late-onset psoriasis presents similarities to addressing other forms of psoriasis, yet nuances emerge due to the individual's age and potential comorbidities. Considerations tailored to the unique aspects of late-onset cases are essential. The following strategies offer comprehensive management:

1. Lifestyle Adjustments: Identify triggering factors such as smoking, alcohol, stress, obesity, or certain medications. Vigilance in avoiding these factors is crucial. Establishing a healthy lifestyle, encompassing a balanced diet, regular exercise, and sufficient sleep, becomes paramount.

2. Topical Treatments: Mild cases often benefit from topical interventions. Utilize topical corticosteroids to mitigate inflammation. Emollients, moisturizers, coal tar preparations, Salicylic acid, vitamin D derivatives like Calcipotriol, and Calcineurin inhibitors contribute to the treatment arsenal.

3. Phototherapy: Exposing the skin to ultraviolet light proves effective. Options include excimer laser, targeted phototherapy, UVB (type B ultraviolet) phototherapy, and PUVA (psoralen plus ultraviolet-A radiation), each catering to specific needs.

4. Systemic Therapy: In severe cases, systemic interventions are imperative. Medications such as Methotrexate, Acitretin, or Ciclosporin offer viable solutions. Caution is advised against systematic steroids due to potential flare-ups during withdrawal.

5. Biological Therapy: Derived from living material, biological agents play a crucial role. Adalimumab, Etanercept, and Infliximab are among the biological therapies available, showcasing effectiveness in late-onset psoriasis management.

Conclusion:

In summary, navigating late-onset psoriasis requires a comprehensive and nuanced strategy. It is crucial to acknowledge the parallels with other types of psoriasis while also considering the specific considerations linked to age and potential concurrent health issues. Establishing a holistic approach begins with lifestyle adjustments, encompassing the identification and avoidance of triggering factors.