Moderate to Severe Psoriasis in Older Adults: Recommendations on Management From the Psoriasis Working Group of the Spanish Academy of Dermatology and Venereology (AEDV)

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"apellidos" => "Carrascosa" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "f" "identificador" => "aff0030" ] ] ] ] "afiliaciones" => array:6 [ 0 => array:3 [ "entidad" => "Departamento de Dermatología, Hospital Marina Baixa de Villajoyosa, Alicante, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Dermatología, Hospital Universitario San Juan, Alicante, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Departamento de Dermatología, Hospital General Universitario Dr. Balmis – ISABIAL-UMH, Alicante, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Departamento de Dermatología, Hospital Universitario Clínico San Cecilio, Granada, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Departamento de Dermatología, Hospital Universitario Infanta Leonor, Madrid, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Departamento de Dermatología, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Recomendaciones del Grupo de Psoriasis de la Academia Española de Dermatología y Venereología sobre el manejo del paciente de edad avanzada con psoriasis en placas moderada-grave" ] ] "textoCompleto" => "IntroductionDue to the chronic nature of psoriasis and the increasing life expectancy of the population, older adults constitute a growing subgroup among patients with this disease.<a class="elsevierStyleCrossRef" href="#bib0280">1</a> It is estimated that 13% of patients with psoriasis experience their first symptoms after 60 years of age, and that approximately 15% of this subgroup develop moderate to severe disease.<a class="elsevierStyleCrossRef" href="#bib0285">2</a>However, since elderly patients are usually excluded from clinical trials, only limited evidence is available on the efficacy and safety of therapy in this subgroup.<a class="elsevierStyleCrossRef" href="#bib0290">3</a> Furthermore, the management of psoriasis in this population is more complex owing to the increased risk of adverse effects (AE) in older patients and the greater prevalence of comorbidities, polypharmacy and immunosenescence.<a class="elsevierStyleCrossRef" href="#bib0295">4</a> As a result, biologic therapies are prescribed more often in younger than in older patients<a class="elsevierStyleCrossRefs" href="#bib0280">1,2</a> and there may be an unjustified tendency to undertreat elderly patients.<a class="elsevierStyleCrossRef" href="#bib0300">5</a>These circumstances have given rise to the need for a therapeutic approach that can afford the dermatologist greater confidence and security in the management of psoriasis in older patients. The aim of the present study was to develop evidence-based recommendations on the management of moderate to severe plaque psoriasis in patients aged over 65 years.Material and MethodsA Delphi exercise was carried out with members of the Psoriasis Group of the Spanish Academy of Dermatology and Venereology (AEDV). The questionnaire used in the first round was developed on the basis of a review of the literature and the advice of a scientific committee composed of 6 expert dermatologists (JM, JCRC, IB, LG, SMC, PC). The initial questionnaire comprised 34 statements. The members of the expert panel rated their degree of agreement on a 9-point Likert scale. Consensus was defined as at least 75% of the panelists expressing some degree of agreement (7–9) or disagreement (1–3). Statements on which the panel did not reach consensus in the first round were restated in the second round.ResultsThe questionnaire was sent to all the members of the Psoriasis Group (n=151); a response was received from 51 members in the first round (33.8% response rate) and 38 of those (74.5%) in the second round (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Consensus was achieved on 22 of the 34 statements (13 in the first and 9 in the second round) (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). Based on these results, the scientific committee proposed 17 recommendations, grouped into 5 blocks according to topic (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).<elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia>Block 1. Quality-of-life AssessmentRecommendation 1. Develop health-related quality-of-life (HRQoL) questionnaires specifically tailored to elderly patients with moderate to severe plaque psoriasis.Given that psoriasis affects the HRQoL of older patients physically, socially and emotionally,<a class="elsevierStyleCrossRef" href="#bib0305">6</a> treatment should be directed toward improving all those areas.<a class="elsevierStyleCrossRefs" href="#bib0310">7,8</a> HRQoL should, therefore, be assessed during follow-up. While a number of different tools are currently used to assess HRQoL in these patients,<a class="elsevierStyleCrossRefs" href="#bib0320">9,10</a> the one most often used is the Dermatology Life Quality Index (DLQI).<a class="elsevierStyleCrossRef" href="#bib0330">11</a> However, many older patients find it difficult to complete these questionnaires on their own due to vision problems or difficulty understanding the questions. This means that they have to depend on a family member or caregiver to complete the questionnaires, which can limit the usefulness and/or the validity of the tool. Furthermore, some of the items included (for example items relating to sexual activity, work or sports) may not be very relevant and can distort the results.Recommendation 2. Assess the HRQoL of people living with elderly patients who have moderate to severe plaque psoriasis.The impact of psoriasis is not limited only to the patient but can also affect family members and people living with the patient, who may play an important role in their care.<a class="elsevierStyleCrossRef" href="#bib0335">12</a> For this reason, the HRQoL of people living with the patient should also be assessed and the best tool for this purpose is the Family Dermatology Life Quality Index (FDLQI).<a class="elsevierStyleCrossRef" href="#bib0335">12</a>Block 2: Supplementary EducationRecommendation 3. Provide patients with supplementary education concerning aspects of the disease specific to older age on a regular basis during follow-up.The needs of older patients differ from those of younger adults owing to the specific characteristics of the aging process.<a class="elsevierStyleCrossRef" href="#bib0340">13</a> It is, therefore, crucial to foster the development of targeted support programs and visual educational materials adapted to this subgroup.Block 3: VaccinationRecommendation 4. Consider routine vaccination against herpes zoster (HZ) in elderly patients with moderate to severe plaque psoriasis.The Spanish Ministry of Health recommends vaccination with the new recombinant and adjuvanted HZ subunit vaccine (HZ/su) for people over 65 years of age, irrespective of underlying diseases or prescribed medication<a class="elsevierStyleCrossRefs" href="#bib0345">14,15</a> (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>) given that the prevalence of HZ infection increases with age.<a class="elsevierStyleCrossRef" href="#bib0355">16</a> Moreover, autoimmune diseases, such as psoriasis,<a class="elsevierStyleCrossRef" href="#bib0355">16</a> and certain systemic drugs, for example TNF-α inhibitors, are associated with a higher risk of reactivation.<a class="elsevierStyleCrossRefs" href="#bib0360">17–21</a><elsevierMultimedia ident="tbl0020"></elsevierMultimedia>Block 4: Evidence GenerationRecommendation 5. Promote research and studies of real-world clinical practice that include older patients with moderate to severe psoriasis.Since very little scientific evidence is currently available on the natural course of psoriasis and its associated comorbidities in elderly patients,<a class="elsevierStyleCrossRef" href="#bib0385">22</a> studies are needed of real-world clinical practice that include this older cohort to generate evidence on the natural history of the disease in this subpopulation and on the effectiveness and safety of available treatments.Block 5: TreatmentRecommendation 6. Prioritize the simplification of treatment regimens when choosing a therapy.Elderly patients have specific therapeutic needs. Safety and the simplicity of administration should be prioritized when choosing treatment.<a class="elsevierStyleCrossRefs" href="#bib0390">23,24</a> Treatments with a better safety profile and simpler administration protocols are recommended for these patients.<a class="elsevierStyleCrossRef" href="#bib0400">25</a>Recommendation 7. Long-term single-drug topical therapies should not be considered a first-line treatment option, especially in elderly patients with physical limitations who have no one to assist them in the application of the treatment.Topical therapies are associated with fewer AEs and drug interactions than systemic drugs, a significant advantage in polymedicated patients.<a class="elsevierStyleCrossRef" href="#bib0405">26</a> However, the risk of skin atrophy associated with the use of topical steroids is higher in the elderly population.<a class="elsevierStyleCrossRefs" href="#bib0310">7,26</a> Moreover, long-term adherence to topical therapy tends to be low<a class="elsevierStyleCrossRef" href="#bib0410">27</a> and these treatments may be inappropriate if the patient has physical limitations and no one to assist them in the application of the treatment.<a class="elsevierStyleCrossRef" href="#bib0405">26</a>Recommendation 8. Older patients should generally be prescribed lower doses of conventional systemic treatment than those used in the younger population and clinical and laboratory monitoring should be more frequent.The use of conventional systemic treatment as a first-line therapy in elderly patients with psoriasis remains a subject of debate. Due to the poor tolerability and organ-specific cumulative toxicity<a class="elsevierStyleCrossRef" href="#bib0410">27</a> of conventional systemic drugs and the risk in older adults of myelosuppression due to immunosenescence,<a class="elsevierStyleCrossRef" href="#bib0310">7</a> special care should be taken with these drugs in older patients.<a class="elsevierStyleCrossRef" href="#bib0330">11</a>Recommendation 9. Treatment with methotrexate should be started at low doses (5–7.5mg) and increased gradually while closely monitoring tolerance, efficacy, and toxicity. Methotrexate is not recommended in patients taking non-steroidal anti-inflammatory drugs, diuretics, isoniazid, or a number of other medications, including penicillins, sulfonamides, antiepileptics, colchicine, dipyridamole, ethanol, sulfonylureas, and trimethoprim–sulfamethoxazole.Advanced age is associated with a greater prevalence of comorbid diseases, such as dyslipidemia, diabetes, renal insufficiency, and obesity, all of which increase the risk of toxicity associated with methotrexate.<a class="elsevierStyleCrossRefs" href="#bib0380">21,28</a> Consequently, it has been suggested that treatment with methotrexate should be started at low doses, with gradual dose escalation if deemed necessary.<a class="elsevierStyleCrossRefs" href="#bib0330">11,26</a> The Summary of Product Characteristics states that treatment with methotrexate is not recommended if the patient is already receiving any of the drugs listed above.Recommendation 10. In older patients, acitretin should generally be administered at lower doses than those indicated for younger adults, particularly at the start of treatment.In elderly patients, acitretin is less effective than other drugs,<a class="elsevierStyleCrossRefs" href="#bib0380">21,29</a> but it is not an immunosuppressant and therefore it plays a unique role in the strategies used in the management of psoriasis.<a class="elsevierStyleCrossRef" href="#bib0425">30</a> However, clinicans should bear in mind that older adults can be particularly affected by certain AE's, including the following: (1) dryness of the skin and mucosa, which may aggravate the xerosis characteristic of this age group<a class="elsevierStyleCrossRef" href="#bib0425">30</a>; (2) hypertriglyceridemia, which increases cardiovascular risk<a class="elsevierStyleCrossRef" href="#bib0430">31</a>; and (3) acitretin's contraindication for patients with renal or hepatic insufficiency,<a class="elsevierStyleCrossRef" href="#bib0380">21</a> diseases that are more prevalent in older patients. While there are no differences in acitretin dosing regimens for older and younger patients, lower doses are more effective in older adults.<a class="elsevierStyleCrossRef" href="#bib0380">21</a>Recommendation 11. Treatment with ciclosporin is not recommended for the treatment of moderate to severe psoriasis in elderly patients.The risk of renal toxicity, serious infections, and cancer increases with age.<a class="elsevierStyleCrossRefs" href="#bib0330">11,25</a> Older patients are also at increased risk for hypertension and other AEs associated with this drug.<a class="elsevierStyleCrossRefs" href="#bib0310">7,29</a> As the pharmacokinetics and/or pharmaco-dynamics of ciclosporin can be affected by certain drugs commonly prescribed to older patients, great caution must be exercised when prescribing ciclosporin in this cohort.<a class="elsevierStyleCrossRef" href="#bib0380">21</a>Recommendation 12. As an isolated factor, age should not be considered a limitation when considering biologic therapy for the management of psoriasis.No age-related variations in treatment efficacy have been observed in moderate to severe psoriasis.<a class="elsevierStyleCrossRefs" href="#bib0285">2,32</a> Despite this, in clinical practice, fewer biologic drugs are prescribed to elderly patients.<a class="elsevierStyleCrossRef" href="#bib0285">2</a>Recommendation 13. Biologic agents are, on the whole, more effective and better tolerated than conventional systemic treatments.Spanish Treatment Appraisal Reports<a class="elsevierStyleCrossRefs" href="#bib0440">33–38</a> have positioned biologic drugs as a second-line treatment for patients with moderate to severe psoriasis for use only when conventional systemic treatments and/or PUVA are contraindicated, not tolerated, or fail to achieve an acceptable response. However, biologic therapy is associated with greater efficacy, a lower probability of organ-specific toxicity, and greater convenience in terms of administration than conventional systemic agents.<a class="elsevierStyleCrossRefs" href="#bib0310">7,21,25,39</a>Few AEs associated with biologic therapies have been reported in the geriatric population.<a class="elsevierStyleCrossRefs" href="#bib0280">1,29,32,40–42</a> Owing to their greater safety and tolerability,<a class="elsevierStyleCrossRefs" href="#bib0380">21,27,39,40,44</a> biologic agents are a more appropriate long-term treatment than conventional systemic treatments in this population.<a class="elsevierStyleCrossRef" href="#bib0490">43</a>In any event, elderly patients should always be closely monitored because of the increased risk of infection<a class="elsevierStyleCrossRef" href="#bib0310">7</a> and because severe AEs tend to be more common in this cohort, irrespective of the type of treatment prescribed.<a class="elsevierStyleCrossRef" href="#bib0285">2</a> However, biologic agents are a safe and effective option when appropriate prophylactic measures are taken.Recommendation 14. Due to the convenience of their dosing regimens, drugs targeting interleukin (IL)-12/23p40 and IL-23p19 are a good option in both first and subsequent lines of treatment.In patients of advanced age with moderate to severe psoriasis, IL-23 inhibitors are a safe and effective option<a class="elsevierStyleCrossRef" href="#bib0435">32</a> which also improves HRQoL.<a class="elsevierStyleCrossRefs" href="#bib0380">21,2,43–48</a> Furthermore, it is likely that the risk of infection is lower with IL-12/23p40 and IL-23p19 inhibitors than with first generation biologic agents and conventional systemic drugs.<a class="elsevierStyleCrossRef" href="#bib0310">7</a> They also have the added advantage of more convenient administration protocols.Recommendation 15. When a case of psoriasis has proved refractory to several therapies (conventional systemic drugs or biologics), IL-17 and IL-23p19 inhibitors should be considered as a safe and effective treatment option.IL-17 inhibitors have been shown to be safe and effective in elderly patients.<a class="elsevierStyleCrossRef" href="#bib0400">25</a> The main AEs reported in older patients on these drugs do not seem to differ from those reported in younger cohorts despite the higher prevalence of comorbidities in the elderly population.<a class="elsevierStyleCrossRef" href="#bib0500">45</a> Oral candidiasis is the only AE associated with the use of IL-17 inhibitors that could have a higher incidence in this subgroup.<a class="elsevierStyleCrossRef" href="#bib0410">27</a>Recommendation 16. Use other biologic agents rather than TNF-α inhibitors in patients who have demyelinating disease, heart failure (HF), latent tuberculosis infection (LTBI) in the absence of chemoprophylaxis, hepatitis B virus (HBV) infection, lupus erythematosus or other autoimmune diseases. When considering the use of TNF-α inhibitors in this subpopulation, the patient's cardiac function must first be assessed clinically.Caution must be exercised when considering the prescription of TNF-α inhibitors in patients with chronic infections and carriers<a class="elsevierStyleCrossRefs" href="#bib0410">27,49</a> of HBV or LTBI, and also in patients with a history of HZ. Treatment with TNF inhibitors is associated with a small, but significant, increase in the risk of reactivation of the varicella zoster virus,<a class="elsevierStyleCrossRef" href="#bib0380">21</a> especially in patients with weakened immune systems.They should also be used with caution in patients who have lupus erythematosus or other autoimmune diseases<a class="elsevierStyleCrossRefs" href="#bib0410">27,49,50</a> and in patients with grade I-II NYHA HF.<a class="elsevierStyleCrossRef" href="#bib0310">7</a> Finally, moderate to severe HF (NYHA III-IV) and the presence of demyelinating disease are absolute contraindications to their use.Recommendation 17. When patients achieve remission, physicians should try to optimize the biologic drug regimen (decreasing doses or increasing intervals) with respect to the regimen specified in the Summary of Product Characteristics.The current guidelines of the Psoriasis Group recommend prioritizing safety and consider optimization strategies to be appropriate in patients who achieve remission.<a class="elsevierStyleCrossRef" href="#bib0525">50</a>DiscussionThis document, authored by the AEDV Psoriasis Group, offers a series of practical recommendations for the management of moderate to severe plaque psoriasis in elderly patients. The initial list of recommendations was based on a review of the literature. These were submitted to a panel of experts, who reached consensus on the final proposal using the Delphi method.The aim of these recommendations is to support decision-making by physicians and other professionals involved in the care process (pharmacists and/or managers), with the ultimate aim of improving health outcomes in elderly patients who have moderate to severe plaque psoriasis. The expert panel highlighted the importance of the following in this cohort: (1) evaluating the HRQoL of both patients and family members; (2) strengthening support measures and offering assistance with treatment; (3) simplifying the treatment regimen; and (4) considering biologic therapy, which has been shown to be a safer and more effective option than conventional systemic therapies.Consensus was not reached on some of the statements considered in the Delphi study. Although there is evidence to support the efficacy and safety of phototherapy in elderly patients,<a class="elsevierStyleCrossRefs" href="#bib0380">21,51</a> consensus was not reached on its use as a first-line treatment in this setting. Similarly, although there is evidence supporting the efficacy and tolerability of treatment with dimethyl fumarate in these patients,<a class="elsevierStyleCrossRef" href="#bib0535">52</a> the complexity of the dosage regimen, the elevated incidence of gastrointestinal AEs, and the need for periodic analytical monitoring<a class="elsevierStyleCrossRef" href="#bib0540">53</a> make it difficult to consider this drug an ideal option in older patients. Finally, while the safety profile of apremilast may appear interesting in this age cohort,<a class="elsevierStyleCrossRef" href="#bib0435">32</a> the complex initial dosing regimen, the high frequency of gastrointestinal AEs, and its relatively lower efficacy compared to biologic therapy<a class="elsevierStyleCrossRef" href="#bib0545">54</a> limits its prioritization over other alternatives.The present study has some limitations inherent in the methodology used, which bases consensus on the experience of an expert panel. The recommendations are based on the methodological procedure described, and their application should be contextualized within the Spanish healthcare system.ConclusionsThis consensus exercise allowed us to define specific recommendations for managing moderate to severe plaque psoriasis in elderly patients. These recommendations will enable prescribing dermatologists to take decisions with greater confidence and will raise awareness about the available scientific evidence among other actors involved in the care of these patients.FundingThe project was conceived and funded by the Spanish Academy of Dermatology and Venereology with an unlimited grant from Almirall. No person connected with Almirall has participated in the development of the proposed recommendations or in drafting this manuscript." "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres1979642" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1702493" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1979641" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1702494" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and Methods" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Results" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Block 1. Quality-of-life Assessment" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Block 2: Supplementary Education" ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "Block 3: Vaccination" ] 3 => array:2 [ "identificador" => "sec0035" "titulo" => "Block 4: Evidence Generation" ] 4 => array:2 [ "identificador" => "sec0040" "titulo" => "Block 5: Treatment" ] ] ] 7 => array:2 [ "identificador" => "sec0045" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0050" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0055" "titulo" => "Funding" ] 10 => array:2 [ "identificador" => "xack693849" "titulo" => "Acknowledgments" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2023-04-25" "fechaAceptado" => "2023-05-06" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1702493" "palabras" => array:7 [ 0 => "Plaque psoriasis" 1 => "Moderate–severe psoriasis" 2 => "Aged" 3 => "Advanced age" 4 => "Consensus" 5 => "Delphi process" 6 => "Therapeutics" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1702494" "palabras" => array:7 [ 0 => "Psoriasis en placas" 1 => "Psoriasis moderada-grave" 2 => "Anciano" 3 => "Edad avanzada" 4 => "Consenso" 5 => "Delphi" 6 => "Tratamiento" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Managing moderate to severe psoriasis in older adults is complex due to factors characteristic of the later years of life, such as associated comorbidity, polypharmacy, and immunosenescence. This consensus statement discusses 17 recommendations for managing treatment for moderate to severe psoriasis in patients older than 65 years. The recommendations were proposed by a committee of 6 dermatologists who reviewed the literature. Fifty-one members of the Psoriasis Working Group of the Spanish Academy of Dermatology and Venereology (AEDV) then applied the Delphi process in 2 rounds to reach consensus on which principles to adopt. The recommendations can help to improve management, outcomes, and prognosis for older adults with moderate to severe psoriasis." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "El abordaje terapéutico de pacientes de edad avanzada con psoriasis en placas moderada-grave es complejo debido, entre otros factores, a las comorbilidades asociadas, a la polimedicación y a la inmunosenescencia propias de este grupo de edad. En el presente documento se recogen 17 recomendaciones para el manejo de la psoriasis moderada-grave en pacientes de edad avanzada (>65 años). Estas recomendaciones han sido propuestas por un comité científico de seis dermatólogos a partir de una revisión de la literatura científica y consensuadas entre 51 miembros del Grupo de Psoriasis de la Academia Española de Dermatología y Venereología mediante dos rondas de consulta Delphi. En los pacientes con psoriasis moderada-grave de edad avanzada, estas recomendaciones pueden mejorar su manejo, los resultados y el pronóstico." ] ] "multimedia" => array:6 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Variable \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Value (total=51) \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Female, % (n) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">51.0 (26) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mean age (SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">49.8 (8.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Years working as a specialist, mean (SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21.1 (9.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Autonomous Community where currently practicing, % (n)</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Andalusia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13.7 (7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Aragon \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.9 (2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Asturias \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.9 (2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Balearic Islands \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.0 (0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Canary Islands \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.9 (2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cantabria \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.0 (1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Castile-La Mancha \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.0 (0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Castile and Leon \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.0 (0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Catalonia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">23.5 (12) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ceuta and Melilla \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.0 (0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Valencia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13.7 (7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Extremadura \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.0 (1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Galicia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.9 (2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">La Rioja \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.0 (0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Madrid \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17.6 (9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Murcia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.0 (1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Navarre \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5.9 (3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Basque country \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.9 (2) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3295035.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Sociodemographic and Professional Variables." ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Abbreviations: A, agreement (7, moderately agree; 8, agree; 9, strongly agree); D, disagreement (1, strongly disagree; 2, disagree; 3, moderately agree); IL, interleukin; TNF, tumor necrosis factor; U, undecided (4, mildly disagree; 5, neither agree nor disagree; 6, mildly agree).*Agreement achieved in first round of the Delphi exercise.Bold face indicates consensus (>75% of participants in agreement or disagreement)." "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><elsevierMultimedia ident="202310020500088981"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><elsevierMultimedia ident="202310020500088982"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "Results of the Delphi Method." ] ] 2 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Abbreviations: HRQoL, health-related quality-of-life; IL, interleukin; PUVA, psoralen UVA; TNF, tumor necrosis factor." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Quality-of-life Assessment \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Recommendation 1. Develop HRQoL questionnaires specifically tailored to elderly patients with moderate to severe plaque psoriasis. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Recommendation 2. Assess the HRQoL of people living with elderly patients who have moderate to severe plaque psoriasis. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Supplementary Education \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Recommendation 3. Provide patients with supplementary education concerning aspects of the disease specific to older patients on a regular basis during follow-up (for example, patient support programs, visual educational materials, nurse visits, etc.). \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Vaccination \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Recommendation 4. Consider routine vaccination against herpes zoster in elderly patients with moderate to severe plaque psoriasis. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Evidence Generation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Recommendation 5. Promote research and studies of real-world clinical practice that include older patients with moderate to severe psoriasis. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Treatment \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Recommendation 6. Prioritize the simplification of treatment regimens when choosing a therapy. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Recommendation 7. Long-term single-drug topical therapies should not be considered a first-line treatment option, especially in elderly patients with physical limitations who have no one to assist them in the application of the treatment. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Recommendation 8. Older patients should generally be prescribed lower doses of conventional systemic treatment than those used in the younger population and clinical and laboratory monitoring should be more frequent. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Recommendation 9. Treatment with methotrexate should be started at low doses (5–7.5mg) and increased gradually while closely monitoring tolerance, efficacy, and toxicity. Methotrexate is not recommended in patients taking non-steroidal anti-inflammatory drugs, diuretics, isoniazid, or a number of other medications, including penicillins, sulfonamides, antiepileptics, colchicine, dipyridamole, ethanol, sulfonylureas, and trimethoprim–sulfamethoxazole. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Recommendation 10. In older patients, acitretin should generally be administered at lower doses than those indicated for younger patients, particularly at the start of treatment. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Recommendation 11. Treatment with ciclosporin is not recommended for the treatment of moderate to severe psoriasis in elderly patients. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Recommendation 12. As an isolated factor, age should not be considered a limitation when considering biologic therapy for the management of psoriasis. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Recommendation 13. Biologic agents are, on the whole, more effective and better tolerated than conventional systemic treatments. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Recommendation 14. Due to the convenience of their dosing regimens, drugs targeting IL-12/23p40 and IL-23p19) are a good option in both first and subsequent lines of treatment. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Recommendation 15. When a case of psoriasis has proved refractory to several therapies (conventional systemic drugs or biologics), IL-17 and IL-23p19 inhibitors should be considered as a safe and effective treatment option. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Recommendation 16. Use other biologic agents rather than TNF-α inhibitors in patients who have demyelinating disease, heart failure, latent tuberculosis infection in the absence of chemoprophylaxis, hepatitis B virus infection, lupus erythematosus or other autoimmune diseases. When considering the use of TNF-α inhibitors in this subpopulation, the patient's cardiac function must first be assessed clinically. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Recommendation 17. When patients achieve remission, physicians should try to optimize the biologic drug regimen (decreasing doses or increasing intervals) with respect to the regimen specified in the Summary of Product Characteristics. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3295038.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Recommendations Agreed by Consensus." ] ] 3 => array:9 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Spanish Ministry of Health.<a class="elsevierStyleCrossRef" href="#bib0550">55</a>" "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at4" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Vaccine \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Recommendation \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Tetanus and diphtheria vaccination \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Verify prior vaccination status before starting or completing a tetanus and diphtheria (Td) vaccination regimen in adults. The health services should be contacted to check the patient's vaccination status and, when required, the patient should be vaccinated with 5 doses of Td. A dose of Td should be administered at around 65 years of age to people who received 5 doses during their childhood and adolescence. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pneumococcal vaccination \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pneumococcal vaccination is recommended for all adults 65 years or older with a single dose of pneumococcal polysaccharide vaccine with 23 serotypes (PPSV23).<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Herpes zoster vaccination \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Vaccination with herpes zoster subunit vaccine (HZ/su) is recommended for adults aged 65 years (born in 1958). Two doses should be administered with a minimum interval of 8 weeks. Cohorts between 66 and 80 years of age can then be vaccinated, starting with the population turning 80 years of age.<a class="elsevierStyleCrossRef" href="#tblfn0010">b</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Annual flu vaccination \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">From age 65 years onwards, older adults should be vaccinated with one dose of a flu vaccine during each annual campaign. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3295036.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "The new 20-serotype pneumococcal conjugate vaccine (VNC20) is now available and will gradually replace VPN23." ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "Rare cases of adults ≥50 years of age with no evidence of immunity to varicella should receive two doses of the vaccine. Clinical studies on the use of the varicella vaccine in adults over 65 years of age do not include a sufficient number of cases to determine whether the immune response achieved in this group is similar to that observed in younger people, although on the rare occasions when a person 50 years of age or older is seronegative for varicella, he or she should, in the absence of contraindications, receive two doses of the vaccine." ] ] ] "descripcion" => array:1 [ "en" => "Recommended Routine Vaccination for Adults Aged≥65." ] ] 4 => array:5 [ "identificador" => "202310020500088981" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx1a.jpeg" "Alto" => 4333 "Ancho" => 2661 "Tamanyo" => 1334999 ] ] ] 5 => array:5 [ "identificador" => "202310020500088982" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx1b.jpeg" "Alto" => 4090 "Ancho" => 2649 "Tamanyo" => 1299022 ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:55 [ 0 => array:3 [ "identificador" => "bib0280" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Safety of classic and biologic systemic therapies for the treatment of psoriasis in elderly: an observational study from national BIOBADADERM registry" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "C. Medina" 1 => "G. Carretero" 2 => "C. Ferrandiz" 3 => "E. Dauden" 4 => "F. Vanaclocha" 5 => "F.J. Gómez-García" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/jdv.12688" "Revista" => array:6 [ "tituloSerie" => "J Eur Acad Dermatol Venereol" "fecha" => "2015" "volumen" => "29" "paginaInicial" => "858" "paginaFinal" => "864" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25185962" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0285" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Biologic treatment in elderly patients with psoriasis: a systematic review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "V.K. Sandhu" 1 => "A. Ighani" 2 => "P. Fleming" 3 => "C.W. Lynde" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1177/1203475419897578" "Revista" => array:6 [ "tituloSerie" => "J Cutan Med Surg" "fecha" => "2020" "volumen" => "24" "paginaInicial" => "174" "paginaFinal" => "186" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/31950853" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0290" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Risk of serious adverse events associated with biologic and nonbiologic psoriasis systemic therapy: patients ineligible vs eligible for randomized controlled trials" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "I. Garcia-Doval" 1 => "G. Carretero" 2 => "F. Vanaclocha" 3 => "C. Ferrandiz" 4 => "E. Dauden" 5 => "J.L. Sanchez-Carazo" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1001/archdermatol.2011.2768" "Revista" => array:6 [ "tituloSerie" => "Arch Dermatol" "fecha" => "2012" "volumen" => "148" "paginaInicial" => "463" "paginaFinal" => "470" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22508869" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0295" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Innate immunesenescence: underlying mechanisms and clinical relevance" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J. Hazeldine" 1 => "J.M. Lord" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s10522-014-9514-3" "Revista" => array:6 [ "tituloSerie" => "Biogerontology" "fecha" => "2015" "volumen" => "16" "paginaInicial" => "187" "paginaFinal" => "201" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25009085" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0300" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Response of elderly patients with rheumatoid arthritis to methotrexate or TNF inhibitors compared with younger patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "M.D. Köller" 1 => "D. Aletaha" 2 => "J. Funovits" 3 => "A. Pangan" 4 => "D. Baker" 5 => "J.S. 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Moderate to Severe Psoriasis in Older Adults: Recommendations on Management From the Psoriasis Working Group of the Spanish Academy of Dermatology and Venereology (AEDV)

Recomendaciones del Grupo de Psoriasis de la Academia Española de Dermatología y Venereología sobre el manejo del paciente de edad avanzada con psoriasis en placas moderada-grave

J. Mataixa, L. Garcíab, I. Belinchónc,

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belinchon_isa@gva.es

Corresponding author.

, J.C. Ruiz Carrascosad, P. de la Cuevae, J.M. Carrascosaf

a Departamento de Dermatología, Hospital Marina Baixa de Villajoyosa, Alicante, Spain

b Departamento de Dermatología, Hospital Universitario San Juan, Alicante, Spain

c Departamento de Dermatología, Hospital General Universitario Dr. Balmis – ISABIAL-UMH, Alicante, Spain

d Departamento de Dermatología, Hospital Universitario Clínico San Cecilio, Granada, Spain

e Departamento de Dermatología, Hospital Universitario Infanta Leonor, Madrid, Spain

f Departamento de Dermatología, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Spain

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        "titulo" => "Recomendaciones del Grupo de Psoriasis de la Academia Espa&#241;ola de Dermatolog&#237;a y Venereolog&#237;a sobre el manejo del paciente de edad avanzada con psoriasis en placas moderada-grave"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Due to the chronic nature of psoriasis and the increasing life expectancy of the population&#44; older adults constitute a growing subgroup among patients with this disease&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">1</span></a> It is estimated that 13&#37; of patients with psoriasis experience their first symptoms after 60 years of age&#44; and that approximately 15&#37; of this subgroup develop moderate to severe disease&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">However&#44; since elderly patients are usually excluded from clinical trials&#44; only limited evidence is available on the efficacy and safety of therapy in this subgroup&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">3</span></a> Furthermore&#44; the management of psoriasis in this population is more complex owing to the increased risk of adverse effects &#40;AE&#41; in older patients and the greater prevalence of comorbidities&#44; polypharmacy and immunosenescence&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">4</span></a> As a result&#44; biologic therapies are prescribed more often in younger than in older patients<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">1&#44;2</span></a> and there may be an unjustified tendency to undertreat elderly patients&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">These circumstances have given rise to the need for a therapeutic approach that can afford the dermatologist greater confidence and security in the management of psoriasis in older patients&#46; The aim of the present study was to develop evidence-based recommendations on the management of moderate to severe plaque psoriasis in patients aged over 65 years&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Material and Methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">A Delphi exercise was carried out with members of the Psoriasis Group of the Spanish Academy of Dermatology and Venereology &#40;AEDV&#41;&#46; The questionnaire used in the first round was developed on the basis of a review of the literature and the advice of a scientific committee composed of 6 expert dermatologists &#40;JM&#44; JCRC&#44; IB&#44; LG&#44; SMC&#44; PC&#41;&#46; The initial questionnaire comprised 34 statements&#46; The members of the expert panel rated their degree of agreement on a 9-point Likert scale&#46; Consensus was defined as at least 75&#37; of the panelists expressing some degree of agreement &#40;7&#8211;9&#41; or disagreement &#40;1&#8211;3&#41;&#46; Statements on which the panel did not reach consensus in the first round were restated in the second round&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Results</span><p id="par0025" class="elsevierStylePara elsevierViewall">The questionnaire was sent to all the members of the Psoriasis Group &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>151&#41;&#59; a response was received from 51 members in the first round &#40;33&#46;8&#37; response rate&#41; and 38 of those &#40;74&#46;5&#37;&#41; in the second round &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Consensus was achieved on 22 of the 34 statements &#40;13 in the first and 9 in the second round&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; Based on these results&#44; the scientific committee proposed 17 recommendations&#44; grouped into 5 blocks according to topic &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Block 1&#46; Quality-of-life Assessment</span><p id="par0035" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">Recommendation 1&#46; Develop health-related quality-of-life &#40;HRQoL&#41; questionnaires specifically tailored to elderly patients with moderate to severe plaque psoriasis&#46;</span></span></p><p id="par0040" class="elsevierStylePara elsevierViewall">Given that psoriasis affects the HRQoL of older patients physically&#44; socially and emotionally&#44;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">6</span></a> treatment should be directed toward improving all those areas&#46;<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">7&#44;8</span></a> HRQoL should&#44; therefore&#44; be assessed during follow-up&#46; While a number of different tools are currently used to assess HRQoL in these patients&#44;<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">9&#44;10</span></a> the one most often used is the Dermatology Life Quality Index &#40;DLQI&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">11</span></a> However&#44; many older patients find it difficult to complete these questionnaires on their own due to vision problems or difficulty understanding the questions&#46; This means that they have to depend on a family member or caregiver to complete the questionnaires&#44; which can limit the usefulness and&#47;or the validity of the tool&#46; Furthermore&#44; some of the items included &#40;for example items relating to sexual activity&#44; work or sports&#41; may not be very relevant and can distort the results&#46;<span class="elsevierStyleVsp" style="height:0.5px"></span></p><p id="par0045" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">Recommendation 2&#46; Assess the HRQoL of people living with elderly patients who have moderate to severe plaque psoriasis&#46;</span></span></p><p id="par0050" class="elsevierStylePara elsevierViewall">The impact of psoriasis is not limited only to the patient but can also affect family members and people living with the patient&#44; who may play an important role in their care&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">12</span></a> For this reason&#44; the HRQoL of people living with the patient should also be assessed and the best tool for this purpose is the Family Dermatology Life Quality Index &#40;FDLQI&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">12</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Block 2&#58; Supplementary Education</span><p id="par0055" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">Recommendation 3&#46; Provide patients with supplementary education concerning aspects of the disease specific to older age on a regular basis during follow-up&#46;</span></span></p><p id="par0060" class="elsevierStylePara elsevierViewall">The needs of older patients differ from those of younger adults owing to the specific characteristics of the aging process&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">13</span></a> It is&#44; therefore&#44; crucial to foster the development of targeted support programs and visual educational materials adapted to this subgroup&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Block 3&#58; Vaccination</span><p id="par0065" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">Recommendation 4&#46; Consider routine vaccination against herpes zoster &#40;HZ&#41; in elderly patients with moderate to severe plaque psoriasis&#46;</span></span></p><p id="par0070" class="elsevierStylePara elsevierViewall">The Spanish Ministry of Health recommends vaccination with the new recombinant and adjuvanted HZ subunit vaccine &#40;HZ&#47;su&#41; for people over 65 years of age&#44; irrespective of underlying diseases or prescribed medication<a class="elsevierStyleCrossRefs" href="#bib0345"><span class="elsevierStyleSup">14&#44;15</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41; given that the prevalence of HZ infection increases with age&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">16</span></a> Moreover&#44; autoimmune diseases&#44; such as psoriasis&#44;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">16</span></a> and certain systemic drugs&#44; for example TNF-&#945; inhibitors&#44; are associated with a higher risk of reactivation&#46;<a class="elsevierStyleCrossRefs" href="#bib0360"><span class="elsevierStyleSup">17&#8211;21</span></a></p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Block 4&#58; Evidence Generation</span><p id="par0075" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">Recommendation 5&#46; Promote research and studies of real-world clinical practice that include older patients with moderate to severe psoriasis&#46;</span></span></p><p id="par0080" class="elsevierStylePara elsevierViewall">Since very little scientific evidence is currently available on the natural course of psoriasis and its associated comorbidities in elderly patients&#44;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">22</span></a> studies are needed of real-world clinical practice that include this older cohort to generate evidence on the natural history of the disease in this subpopulation and on the effectiveness and safety of available treatments&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Block 5&#58; Treatment</span><p id="par0085" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">Recommendation 6&#46; Prioritize the simplification of treatment regimens when choosing a therapy&#46;</span></span></p><p id="par0090" class="elsevierStylePara elsevierViewall">Elderly patients have specific therapeutic needs&#46; Safety and the simplicity of administration should be prioritized when choosing treatment&#46;<a class="elsevierStyleCrossRefs" href="#bib0390"><span class="elsevierStyleSup">23&#44;24</span></a> Treatments with a better safety profile and simpler administration protocols are recommended for these patients&#46;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">25</span></a><span class="elsevierStyleVsp" style="height:0.5px"></span></p><p id="par0095" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">Recommendation 7&#46; Long-term single-drug topical therapies should not be considered a first-line treatment option&#44; especially in elderly patients with physical limitations who have no one to assist them in the application of the treatment&#46;</span></span></p><p id="par0100" class="elsevierStylePara elsevierViewall">Topical therapies are associated with fewer AEs and drug interactions than systemic drugs&#44; a significant advantage in polymedicated patients&#46;<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">26</span></a> However&#44; the risk of skin atrophy associated with the use of topical steroids is higher in the elderly population&#46;<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">7&#44;26</span></a> Moreover&#44; long-term adherence to topical therapy tends to be low<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">27</span></a> and these treatments may be inappropriate if the patient has physical limitations and no one to assist them in the application of the treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">26</span></a><span class="elsevierStyleVsp" style="height:0.5px"></span></p><p id="par0105" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">Recommendation 8&#46; Older patients should generally be prescribed lower doses of conventional systemic treatment than those used in the younger population and clinical and laboratory monitoring should be more frequent&#46;</span></span></p><p id="par0110" class="elsevierStylePara elsevierViewall">The use of conventional systemic treatment as a first-line therapy in elderly patients with psoriasis remains a subject of debate&#46; Due to the poor tolerability and organ-specific cumulative toxicity<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">27</span></a> of conventional systemic drugs and the risk in older adults of myelosuppression due to immunosenescence&#44;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">7</span></a> special care should be taken with these drugs in older patients&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">11</span></a><span class="elsevierStyleVsp" style="height:0.5px"></span></p><p id="par0115" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">Recommendation 9&#46; Treatment with methotrexate should be started at low doses &#40;5&#8211;7&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#41; and increased gradually while closely monitoring tolerance&#44; efficacy&#44; and toxicity&#46; Methotrexate is not recommended in patients taking non-steroidal anti-inflammatory drugs&#44; diuretics&#44; isoniazid&#44; or a number of other medications&#44; including penicillins&#44; sulfonamides&#44; antiepileptics&#44; colchicine&#44; dipyridamole&#44; ethanol&#44; sulfonylureas&#44; and trimethoprim&#8211;sulfamethoxazole&#46;</span></span></p><p id="par0120" class="elsevierStylePara elsevierViewall">Advanced age is associated with a greater prevalence of comorbid diseases&#44; such as dyslipidemia&#44; diabetes&#44; renal insufficiency&#44; and obesity&#44; all of which increase the risk of toxicity associated with methotrexate&#46;<a class="elsevierStyleCrossRefs" href="#bib0380"><span class="elsevierStyleSup">21&#44;28</span></a> Consequently&#44; it has been suggested that treatment with methotrexate should be started at low doses&#44; with gradual dose escalation if deemed necessary&#46;<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">11&#44;26</span></a> The Summary of Product Characteristics states that treatment with methotrexate is not recommended if the patient is already receiving any of the drugs listed above&#46;<span class="elsevierStyleVsp" style="height:0.5px"></span></p><p id="par0125" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">Recommendation 10&#46; In older patients&#44; acitretin should generally be administered at lower doses than those indicated for younger adults&#44; particularly at the start of treatment&#46;</span></span></p><p id="par0130" class="elsevierStylePara elsevierViewall">In elderly patients&#44; acitretin is less effective than other drugs&#44;<a class="elsevierStyleCrossRefs" href="#bib0380"><span class="elsevierStyleSup">21&#44;29</span></a> but it is not an immunosuppressant and therefore it plays a unique role in the strategies used in the management of psoriasis&#46;<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">30</span></a> However&#44; clinicans should bear in mind that older adults can be particularly affected by certain AE&#39;s&#44; including the following&#58; &#40;1&#41; dryness of the skin and mucosa&#44; which may aggravate the xerosis characteristic of this age group<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">30</span></a>&#59; &#40;2&#41; hypertriglyceridemia&#44; which increases cardiovascular risk<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">31</span></a>&#59; and &#40;3&#41; acitretin&#39;s contraindication for patients with renal or hepatic insufficiency&#44;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">21</span></a> diseases that are more prevalent in older patients&#46; While there are no differences in acitretin dosing regimens for older and younger patients&#44; lower doses are more effective in older adults&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">21</span></a><span class="elsevierStyleVsp" style="height:0.5px"></span></p><p id="par0135" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">Recommendation 11&#46; Treatment with ciclosporin is not recommended for the treatment of moderate to severe psoriasis in elderly patients&#46;</span></span></p><p id="par0140" class="elsevierStylePara elsevierViewall">The risk of renal toxicity&#44; serious infections&#44; and cancer increases with age&#46;<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">11&#44;25</span></a> Older patients are also at increased risk for hypertension and other AEs associated with this drug&#46;<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">7&#44;29</span></a> As the pharmacokinetics and&#47;or pharmaco-dynamics of ciclosporin can be affected by certain drugs commonly prescribed to older patients&#44; great caution must be exercised when prescribing ciclosporin in this cohort&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">21</span></a><span class="elsevierStyleVsp" style="height:0.5px"></span></p><p id="par0145" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">Recommendation 12&#46; As an isolated factor&#44; age should not be considered a limitation when considering biologic therapy for the management of psoriasis&#46;</span></span></p><p id="par0150" class="elsevierStylePara elsevierViewall">No age-related variations in treatment efficacy have been observed in moderate to severe psoriasis&#46;<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">2&#44;32</span></a> Despite this&#44; in clinical practice&#44; fewer biologic drugs are prescribed to elderly patients&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">2</span></a><span class="elsevierStyleVsp" style="height:0.5px"></span></p><p id="par0155" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">Recommendation 13&#46; Biologic agents are&#44; on the whole&#44; more effective and better tolerated than conventional systemic treatments&#46;</span></span></p><p id="par0160" class="elsevierStylePara elsevierViewall">Spanish Treatment Appraisal Reports<a class="elsevierStyleCrossRefs" href="#bib0440"><span class="elsevierStyleSup">33&#8211;38</span></a> have positioned biologic drugs as a second-line treatment for patients with moderate to severe psoriasis for use only when conventional systemic treatments and&#47;or PUVA are contraindicated&#44; not tolerated&#44; or fail to achieve an acceptable response&#46; However&#44; biologic therapy is associated with greater efficacy&#44; a lower probability of organ-specific toxicity&#44; and greater convenience in terms of administration than conventional systemic agents&#46;<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">7&#44;21&#44;25&#44;39</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">Few AEs associated with biologic therapies have been reported in the geriatric population&#46;<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">1&#44;29&#44;32&#44;40&#8211;42</span></a> Owing to their greater safety and tolerability&#44;<a class="elsevierStyleCrossRefs" href="#bib0380"><span class="elsevierStyleSup">21&#44;27&#44;39&#44;40&#44;44</span></a> biologic agents are a more appropriate long-term treatment than conventional systemic treatments in this population&#46;<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">43</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">In any event&#44; elderly patients should always be closely monitored because of the increased risk of infection<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">7</span></a> and because severe AEs tend to be more common in this cohort&#44; irrespective of the type of treatment prescribed&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">2</span></a> However&#44; biologic agents are a safe and effective option when appropriate prophylactic measures are taken&#46;<span class="elsevierStyleVsp" style="height:0.5px"></span></p><p id="par0175" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">Recommendation 14&#46; Due to the convenience of their dosing regimens&#44; drugs targeting interleukin &#40;IL&#41;-12&#47;23p40 and IL-23p19 are a good option in both first and subsequent lines of treatment&#46;</span></span></p><p id="par0180" class="elsevierStylePara elsevierViewall">In patients of advanced age with moderate to severe psoriasis&#44; IL-23 inhibitors are a safe and effective option<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">32</span></a> which also improves HRQoL&#46;<a class="elsevierStyleCrossRefs" href="#bib0380"><span class="elsevierStyleSup">21&#44;2&#44;43&#8211;48</span></a> Furthermore&#44; it is likely that the risk of infection is lower with IL-12&#47;23p40 and IL-23p19 inhibitors than with first generation biologic agents and conventional systemic drugs&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">7</span></a> They also have the added advantage of more convenient administration protocols&#46;<span class="elsevierStyleVsp" style="height:0.5px"></span></p><p id="par0185" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">Recommendation 15&#46; When a case of psoriasis has proved refractory to several therapies &#40;conventional systemic drugs or biologics&#41;&#44; IL-17 and IL-23p19 inhibitors should be considered as a safe and effective treatment option&#46;</span></span></p><p id="par0190" class="elsevierStylePara elsevierViewall">IL-17 inhibitors have been shown to be safe and effective in elderly patients&#46;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">25</span></a> The main AEs reported in older patients on these drugs do not seem to differ from those reported in younger cohorts despite the higher prevalence of comorbidities in the elderly population&#46;<a class="elsevierStyleCrossRef" href="#bib0500"><span class="elsevierStyleSup">45</span></a> Oral candidiasis is the only AE associated with the use of IL-17 inhibitors that could have a higher incidence in this subgroup&#46;<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">27</span></a><span class="elsevierStyleVsp" style="height:0.5px"></span></p><p id="par0195" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">Recommendation 16&#46; Use other biologic agents rather than TNF-&#945; inhibitors in patients who have demyelinating disease&#44; heart failure &#40;HF&#41;&#44; latent tuberculosis infection &#40;LTBI&#41; in the absence of chemoprophylaxis&#44; hepatitis B virus &#40;HBV&#41; infection&#44; lupus erythematosus or other autoimmune diseases&#46; When considering the use of TNF-&#945; inhibitors in this subpopulation&#44; the patient&#39;s cardiac function must first be assessed clinically&#46;</span></span></p><p id="par0200" class="elsevierStylePara elsevierViewall">Caution must be exercised when considering the prescription of TNF-&#945; inhibitors in patients with chronic infections and carriers<a class="elsevierStyleCrossRefs" href="#bib0410"><span class="elsevierStyleSup">27&#44;49</span></a> of HBV or LTBI&#44; and also in patients with a history of HZ&#46; Treatment with TNF inhibitors is associated with a small&#44; but significant&#44; increase in the risk of reactivation of the varicella zoster virus&#44;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">21</span></a> especially in patients with weakened immune systems&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">They should also be used with caution in patients who have lupus erythematosus or other autoimmune diseases<a class="elsevierStyleCrossRefs" href="#bib0410"><span class="elsevierStyleSup">27&#44;49&#44;50</span></a> and in patients with grade I-II NYHA HF&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">7</span></a> Finally&#44; moderate to severe HF &#40;NYHA III-IV&#41; and the presence of demyelinating disease are absolute contraindications to their use&#46;<span class="elsevierStyleVsp" style="height:0.5px"></span></p><p id="par0210" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">Recommendation 17&#46; When patients achieve remission&#44; physicians should try to optimize the biologic drug regimen &#40;decreasing doses or increasing intervals&#41; with respect to the regimen specified in the Summary of Product Characteristics&#46;</span></span></p><p id="par0215" class="elsevierStylePara elsevierViewall">The current guidelines of the Psoriasis Group recommend prioritizing safety and consider optimization strategies to be appropriate in patients who achieve remission&#46;<a class="elsevierStyleCrossRef" href="#bib0525"><span class="elsevierStyleSup">50</span></a></p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Discussion</span><p id="par0220" class="elsevierStylePara elsevierViewall">This document&#44; authored by the AEDV Psoriasis Group&#44; offers a series of practical recommendations for the management of moderate to severe plaque psoriasis in elderly patients&#46; The initial list of recommendations was based on a review of the literature&#46; These were submitted to a panel of experts&#44; who reached consensus on the final proposal using the Delphi method&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">The aim of these recommendations is to support decision-making by physicians and other professionals involved in the care process &#40;pharmacists and&#47;or managers&#41;&#44; with the ultimate aim of improving health outcomes in elderly patients who have moderate to severe plaque psoriasis&#46; The expert panel highlighted the importance of the following in this cohort&#58; &#40;1&#41; evaluating the HRQoL of both patients and family members&#59; &#40;2&#41; strengthening support measures and offering assistance with treatment&#59; &#40;3&#41; simplifying the treatment regimen&#59; and &#40;4&#41; considering biologic therapy&#44; which has been shown to be a safer and more effective option than conventional systemic therapies&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">Consensus was not reached on some of the statements considered in the Delphi study&#46; Although there is evidence to support the efficacy and safety of phototherapy in elderly patients&#44;<a class="elsevierStyleCrossRefs" href="#bib0380"><span class="elsevierStyleSup">21&#44;51</span></a> consensus was not reached on its use as a first-line treatment in this setting&#46; Similarly&#44; although there is evidence supporting the efficacy and tolerability of treatment with dimethyl fumarate in these patients&#44;<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">52</span></a> the complexity of the dosage regimen&#44; the elevated incidence of gastrointestinal AEs&#44; and the need for periodic analytical monitoring<a class="elsevierStyleCrossRef" href="#bib0540"><span class="elsevierStyleSup">53</span></a> make it difficult to consider this drug an ideal option in older patients&#46; Finally&#44; while the safety profile of apremilast may appear interesting in this age cohort&#44;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">32</span></a> the complex initial dosing regimen&#44; the high frequency of gastrointestinal AEs&#44; and its relatively lower efficacy compared to biologic therapy<a class="elsevierStyleCrossRef" href="#bib0545"><span class="elsevierStyleSup">54</span></a> limits its prioritization over other alternatives&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">The present study has some limitations inherent in the methodology used&#44; which bases consensus on the experience of an expert panel&#46; The recommendations are based on the methodological procedure described&#44; and their application should be contextualized within the Spanish healthcare system&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conclusions</span><p id="par0240" class="elsevierStylePara elsevierViewall">This consensus exercise allowed us to define specific recommendations for managing moderate to severe plaque psoriasis in elderly patients&#46; These recommendations will enable prescribing dermatologists to take decisions with greater confidence and will raise awareness about the available scientific evidence among other actors involved in the care of these patients&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Funding</span><p id="par0245" class="elsevierStylePara elsevierViewall">The project was conceived and funded by the <span class="elsevierStyleGrantSponsor" id="gs1">Spanish Academy of Dermatology and Venereology</span> with an unlimited grant from Almirall&#46; No person connected with Almirall has participated in the development of the proposed recommendations or in drafting this manuscript&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Managing moderate to severe psoriasis in older adults is complex due to factors characteristic of the later years of life&#44; such as associated comorbidity&#44; polypharmacy&#44; and immunosenescence&#46; This consensus statement discusses 17 recommendations for managing treatment for moderate to severe psoriasis in patients older than 65 years&#46; The recommendations were proposed by a committee of 6 dermatologists who reviewed the literature&#46; Fifty-one members of the Psoriasis Working Group of the Spanish Academy of Dermatology and Venereology &#40;AEDV&#41; then applied the Delphi process in 2 rounds to reach consensus on which principles to adopt&#46; The recommendations can help to improve management&#44; outcomes&#44; and prognosis for older adults with moderate to severe psoriasis&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El abordaje terap&#233;utico de pacientes de edad avanzada con psoriasis en placas moderada-grave es complejo debido&#44; entre otros factores&#44; a las comorbilidades asociadas&#44; a la polimedicaci&#243;n y a la inmunosenescencia propias de este grupo de edad&#46; En el presente documento se recogen 17 recomendaciones para el manejo de la psoriasis moderada-grave en pacientes de edad avanzada &#40;&#62;65 a&#241;os&#41;&#46; Estas recomendaciones han sido propuestas por un comit&#233; cient&#237;fico de seis dermat&#243;logos a partir de una revisi&#243;n de la literatura cient&#237;fica y consensuadas entre 51 miembros del Grupo de Psoriasis de la Academia Espa&#241;ola de Dermatolog&#237;a y Venereolog&#237;a mediante dos rondas de consulta Delphi&#46; En los pacientes con psoriasis moderada-grave de edad avanzada&#44; estas recomendaciones pueden mejorar su manejo&#44; los resultados y el pron&#243;stico&#46;</p></span>"
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                  \t\t\t\t"><span class="elsevierStyleItalic">Years working as a specialist&#44; mean &#40;SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">21&#46;1 &#40;9&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Autonomous Community where currently practicing&#44; &#37; &#40;n&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Andalusia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&#46;7 &#40;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Aragon&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;9 &#40;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Asturias&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;9 &#40;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Balearic Islands&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Canary Islands&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;9 &#40;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cantabria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;0 &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Castile-La Mancha&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Castile and Leon&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Catalonia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23&#46;5 &#40;12&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Ceuta and Melilla&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Valencia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&#46;7 &#40;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Extremadura&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;0 &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Galicia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;9 &#40;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>La Rioja&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Madrid&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17&#46;6 &#40;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Murcia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;0 &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Navarre&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#46;9 &#40;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Basque country&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;9 &#40;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "leyenda" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>&#58; A&#44; agreement &#40;7&#44; moderately agree&#59; 8&#44; agree&#59; 9&#44; strongly agree&#41;&#59; D&#44; disagreement &#40;1&#44; strongly disagree&#59; 2&#44; disagree&#59; 3&#44; moderately agree&#41;&#59; IL&#44; interleukin&#59; TNF&#44; tumor necrosis factor&#59; U&#44; undecided &#40;4&#44; mildly disagree&#59; 5&#44; neither agree nor disagree&#59; 6&#44; mildly agree&#41;&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">&#42;Agreement achieved in first round of the Delphi exercise&#46;</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Bold face indicates consensus &#40;&#62;75&#37; of participants in agreement or disagreement&#41;&#46;</p>"
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                  \t\t\t\t\tvoid\n
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                  \t\t\t\t"><elsevierMultimedia ident="202310020500088981"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
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          "leyenda" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>&#58; HRQoL&#44; health-related quality-of-life&#59; IL&#44; interleukin&#59; PUVA&#44; psoralen UVA&#59; TNF&#44; tumor necrosis factor&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Quality-of-life Assessment</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Recommendation 1&#46; Develop HRQoL questionnaires specifically tailored to elderly patients with moderate to severe plaque psoriasis&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Recommendation 2&#46; Assess the HRQoL of people living with elderly patients who have moderate to severe plaque psoriasis&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Supplementary Education</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Recommendation 3&#46; Provide patients with supplementary education concerning aspects of the disease specific to older patients on a regular basis during follow-up &#40;for example&#44; patient support programs&#44; visual educational materials&#44; nurse visits&#44; etc&#46;&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Vaccination</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Recommendation 4&#46; Consider routine vaccination against herpes zoster in elderly patients with moderate to severe plaque psoriasis&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Evidence Generation</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Recommendation 5&#46; Promote research and studies of real-world clinical practice that include older patients with moderate to severe psoriasis&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Treatment</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Recommendation 6&#46; Prioritize the simplification of treatment regimens when choosing a therapy&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Recommendation 7&#46; Long-term single-drug topical therapies should not be considered a first-line treatment option&#44; especially in elderly patients with physical limitations who have no one to assist them in the application of the treatment&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Recommendation 8&#46; Older patients should generally be prescribed lower doses of conventional systemic treatment than those used in the younger population and clinical and laboratory monitoring should be more frequent&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Recommendation 9&#46; Treatment with methotrexate should be started at low doses &#40;5&#8211;7&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#41; and increased gradually while closely monitoring tolerance&#44; efficacy&#44; and toxicity&#46; Methotrexate is not recommended in patients taking non-steroidal anti-inflammatory drugs&#44; diuretics&#44; isoniazid&#44; or a number of other medications&#44; including penicillins&#44; sulfonamides&#44; antiepileptics&#44; colchicine&#44; dipyridamole&#44; ethanol&#44; sulfonylureas&#44; and trimethoprim&#8211;sulfamethoxazole&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Recommendation 10&#46; In older patients&#44; acitretin should generally be administered at lower doses than those indicated for younger patients&#44; particularly at the start of treatment&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Recommendation 11&#46; Treatment with ciclosporin is not recommended for the treatment of moderate to severe psoriasis in elderly patients&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Recommendation 12&#46; As an isolated factor&#44; age should not be considered a limitation when considering biologic therapy for the management of psoriasis&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Recommendation 13&#46; Biologic agents are&#44; on the whole&#44; more effective and better tolerated than conventional systemic treatments&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Recommendation 14&#46; Due to the convenience of their dosing regimens&#44; drugs targeting IL-12&#47;23p40 and IL-23p19&#41; are a good option in both first and subsequent lines of treatment&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Recommendation 15&#46; When a case of psoriasis has proved refractory to several therapies &#40;conventional systemic drugs or biologics&#41;&#44; IL-17 and IL-23p19 inhibitors should be considered as a safe and effective treatment option&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Recommendation 16&#46; Use other biologic agents rather than TNF-&#945; inhibitors in patients who have demyelinating disease&#44; heart failure&#44; latent tuberculosis infection in the absence of chemoprophylaxis&#44; hepatitis B virus infection&#44; lupus erythematosus or other autoimmune diseases&#46; When considering the use of TNF-&#945; inhibitors in this subpopulation&#44; the patient&#39;s cardiac function must first be assessed clinically&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Recommendation 17&#46; When patients achieve remission&#44; physicians should try to optimize the biologic drug regimen &#40;decreasing doses or increasing intervals&#41; with respect to the regimen specified in the Summary of Product Characteristics&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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        "etiqueta" => "Table 4"
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        "fuente" => "<span class="elsevierStyleItalic">Source</span>&#58; Spanish Ministry of Health&#46;<a class="elsevierStyleCrossRef" href="#bib0550"><span class="elsevierStyleSup">55</span></a>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t">Tetanus and diphtheria vaccination&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Verify prior vaccination status before starting or completing a tetanus and diphtheria &#40;Td&#41; vaccination regimen in adults&#46; The health services should be contacted to check the patient&#39;s vaccination status and&#44; when required&#44; the patient should be vaccinated with 5 doses of Td&#46; A dose of Td should be administered at around 65 years of age to people who received 5 doses during their childhood and adolescence&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Pneumococcal vaccination&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Pneumococcal vaccination is recommended for all adults 65 years or older with a single dose of pneumococcal polysaccharide vaccine with 23 serotypes &#40;PPSV23&#41;&#46;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Herpes zoster vaccination&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Vaccination with herpes zoster subunit vaccine &#40;HZ&#47;su&#41; is recommended for adults aged 65 years &#40;born in 1958&#41;&#46; Two doses should be administered with a minimum interval of 8 weeks&#46; Cohorts between 66 and 80 years of age can then be vaccinated&#44; starting with the population turning 80 years of age&#46;<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Annual flu vaccination&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">From age 65 years onwards&#44; older adults should be vaccinated with one dose of a flu vaccine during each annual campaign&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">The new 20-serotype pneumococcal conjugate vaccine &#40;VNC20&#41; is now available and will gradually replace VPN23&#46;</p>"
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              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Rare cases of adults &#8805;50 years of age with no evidence of immunity to varicella should receive two doses of the vaccine&#46; Clinical studies on the use of the varicella vaccine in adults over 65 years of age do not include a sufficient number of cases to determine whether the immune response achieved in this group is similar to that observed in younger people&#44; although on the rare occasions when a person 50 years of age or older is seronegative for varicella&#44; he or she should&#44; in the absence of contraindications&#44; receive two doses of the vaccine&#46;</p>"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Recommended Routine Vaccination for Adults Aged<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>65&#46;</p>"
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          "identificador" => "bibs0015"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Safety of classic and biologic systemic therapies for the treatment of psoriasis in elderly&#58; an observational study from national BIOBADADERM registry"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "C&#46; Medina"
                            1 => "G&#46; Carretero"
                            2 => "C&#46; Ferrandiz"
                            3 => "E&#46; Dauden"
                            4 => "F&#46; Vanaclocha"
                            5 => "F&#46;J&#46; G&#243;mez-Garc&#237;a"
                          ]
                        ]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/jdv.12688"
                      "Revista" => array:6 [
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                        "fecha" => "2015"
                        "volumen" => "29"
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                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25185962"
                            "web" => "Medline"
                          ]
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            ]
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              "identificador" => "bib0285"
              "etiqueta" => "2"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Biologic treatment in elderly patients with psoriasis&#58; a systematic review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "V&#46;K&#46; Sandhu"
                            1 => "A&#46; Ighani"
                            2 => "P&#46; Fleming"
                            3 => "C&#46;W&#46; Lynde"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1177/1203475419897578"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Cutan Med Surg"
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                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/31950853"
                            "web" => "Medline"
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              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Risk of serious adverse events associated with biologic and nonbiologic psoriasis systemic therapy&#58; patients ineligible vs eligible for randomized controlled trials"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "I&#46; Garcia-Doval"
                            1 => "G&#46; Carretero"
                            2 => "F&#46; Vanaclocha"
                            3 => "C&#46; Ferrandiz"
                            4 => "E&#46; Dauden"
                            5 => "J&#46;L&#46; Sanchez-Carazo"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1001/archdermatol.2011.2768"
                      "Revista" => array:6 [
                        "tituloSerie" => "Arch Dermatol"
                        "fecha" => "2012"
                        "volumen" => "148"
                        "paginaInicial" => "463"
                        "paginaFinal" => "470"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22508869"
                            "web" => "Medline"
                          ]
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                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0295"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Innate immunesenescence&#58; underlying mechanisms and clinical relevance"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "J&#46; Hazeldine"
                            1 => "J&#46;M&#46; Lord"
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s10522-014-9514-3"
                      "Revista" => array:6 [
                        "tituloSerie" => "Biogerontology"
                        "fecha" => "2015"
                        "volumen" => "16"
                        "paginaInicial" => "187"
                        "paginaFinal" => "201"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25009085"
                            "web" => "Medline"
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                      ]
                    ]
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                ]
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            4 => array:3 [
              "identificador" => "bib0300"
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Response of elderly patients with rheumatoid arthritis to methotrexate or TNF inhibitors compared with younger patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "M&#46;D&#46; K&#246;ller"
                            1 => "D&#46; Aletaha"
                            2 => "J&#46; Funovits"
                            3 => "A&#46; Pangan"
                            4 => "D&#46; Baker"
                            5 => "J&#46;S&#46; Smolen"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Rheumatology &#40;Oxford&#41;"
                        "fecha" => "2009"
                        "volumen" => "48"
                        "paginaInicial" => "1575"
                        "paginaFinal" => "1580"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0305"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Practical management of psoriasis in the elderly&#58; epidemiology&#44; clinical aspects&#44; quality of life&#44; patient education and treatment options"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "G&#46; Yosipovitch"
                            1 => "M&#46;B&#46; Tang"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.2165/00002512-200219110-00003"
                      "Revista" => array:6 [
                        "tituloSerie" => "Drugs Aging"
                        "fecha" => "2002"
                        "volumen" => "19"
                        "paginaInicial" => "847"
                        "paginaFinal" => "863"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12428994"
                            "web" => "Medline"
                          ]
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Article information

ISSN: 00017310
Original language: English

DOI:10.1016/j.ad.2023.07.016

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