Patient's Query
Hello doctor,
My wife is 52 years old and has been living with psoriasis for the past 15 years. Over the last two years, since she entered menopause, her psoriasis has worsened significantly.
She now has thick, scaly plaques covering nearly 40 % of her body, including the scalp, elbows, knees, back, and genital area, which has made intimacy painful.
Her dermatologist initially prescribed methotrexate, but this caused elevated liver enzymes and persistent nausea, so it had to be stopped.
She was then treated with Adalimumab injections, which worked very well for about eight months, but she later developed antibodies and the medication lost its effectiveness.
She has now been prescribed Ixekizumab, but insurance approval has been delayed, and we have been waiting for over six weeks.
During this time, her plaques frequently crack and bleed, staining her clothes and bedsheets. She also has psoriatic arthritis affecting her hands and feet, making walking and daily work difficult.
She takes Naproxen twice daily for joint pain, but it is causing stomach problems. Her self-esteem has been severely affected, and she avoids swimming, social activities, and wearing short-sleeved clothing even in summer.
She previously tried UV phototherapy, but it caused darkening of the affected areas and did not result in significant improvement.
My questions are:
Can hormone replacement therapy help improve psoriasis symptoms that worsen during menopause?
Additionally, should we be concerned about an increased cancer risk due to long-term use of multiple immunosuppressive treatments?
Kindly suggest.
Hello,
Welcome to icliniq.com
I understand your concern. I am truly sorry to hear what your wife is going through.
Psoriasis becoming severe during menopause is more common than many people realise, and the combination of extensive skin disease and psoriatic arthritis can deeply affect self-esteem, relationships, and daily functioning.
You have shown patience and persistence in navigating her treatment, and I hope this explanation helps guide you further regarding your concerns.
During menopause, estrogen levels decline. Estrogen normally has a mild anti-inflammatory effect and helps maintain skin barrier health. When estrogen levels fall, psoriasis flares can become more frequent, and the skin becomes drier and more prone to cracking and bleeding.
HRT (hormone replacement therapy) is not a standard treatment for psoriasis, but some women do experience improvement because estrogen increases skin hydration and reduces inflammation. Improvement has been reported in approximately 50 per cent of women with psoriasis.
HRT may be considered if she is also experiencing menopausal symptoms such as hot flashes or mood changes, as you mentioned; she has been menopausal for the past two years. Before starting HRT, she should be screened for:
Breast cancer or a family history of breast cancer.
Clotting disorders.
Uncontrolled hypertension.
Liver disease.
Your wife has undergone the following treatments. Methotrexate was discontinued due to liver toxicity. Adalimumab initially worked well but later lost effectiveness due to antibody formation. Ixekizumab, an IL-17 inhibitor, is highly effective for both skin disease and psoriatic arthritis.
In many cases, IL-17 inhibitors provide 80 to 90 per cent clearance. They are particularly effective for thick plaques involving the scalp, genital areas, and nails. These medications also improve joint pain.
Unfortunately, delays of several weeks due to prior authorisation are common. If delays continue, bridge therapy with oral apremilast may be considered, as it is non-immunosuppressive.
A short taper of steroids may be used only during arthritis flares. While naproxen can help with pain, it does not prevent joint damage. Since she is experiencing stomach-related side effects, alternatives include:
Switching to Celecoxib, which is gentler on the stomach.
Adding a proton pump inhibitor such as Omeprazole 20 to 40 milligrams once daily before breakfast to reduce gastric acidity
Long-term studies have not shown a significant increase in overall cancer risk with biologic therapies used for psoriasis, including TNF(tumour necrosis factor) inhibitors, interleukin-17 inhibitors, and IL-23 inhibitors.
The risk of skin cancer is slightly higher, mainly in patients with prolonged exposure to psoralen plus ultraviolet A phototherapy or significant sun exposure. In your wife’s case, she has had only one course of phototherapy.
For managing skin lesions, especially in sensitive areas, you can follow these helpful measures;
Hydrocortisone one per cent ointment for delicate folds, used short-term.
Calcineurin inhibitors such as Pimecrolimus or Tacrolimus.
Petrolatum or zinc-based barrier creams before intimacy.
Warm soaks to soften scales before applying medications.
Avoiding harsh soaps and using hydrating cleansers
For thick plaques, urea 20 to 40 per cent ointment can be applied. Salicylic acid, three to six per cent may be used, but should be avoided over large body areas due to absorption risk.
Coal tar shampoo can be applied for scalp involvement, and gentle debridement should be done only after adequate soaking.
I hope this information is helpful. Please feel free to follow up if you have any further questions.
Was this conversation helpful?
Answered byDr. Misha Saghir
Medically reviewed byiCliniq medical review team
Same symptoms don't mean you have the same problem. Consult a doctor now!
Disclaimer: No content published on this website is intended to be a substitute for professional medical diagnosis, advice or treatment by a trained physician. Seek advice from your physician or other qualified healthcare providers with questions you may have regarding your symptoms and medical condition for a complete medical diagnosis. Do not delay or disregard seeking professional medical advice because of something you have read on this website. Read our Editorial Process to know how we create content for health articles and queries.