Report

Clinical study of psoriasis occurring over the age of

60 years: is elderly-onset psoriasis a distinct subtype?
Hyuck Hoon Kwon, MD, In Ho Kwon, MD, and Jai Il Youn, MD, PhD

Department of Dermatology, Seoul

National University College of Medicine,
Seoul, Korea
Correspondence Jai Il
Youn, MD, PhD Department of
Dermatology
Seoul National University College of
Medicine
28-Yongon-dong
Chongno-gu
Seoul 100-744
Korea
E-mail: jaiil@snu.ac.kr
Funding: Seoul National University
Hospital.
Conflicts of interest: None declared.

Abstract
Background Previous studies demonstrated clinical differences of early- and late-onset
psoriasis. However, epidemiological data and clinical characteristics of psoriasis occurring
in geriatric patients have been rarely studied.
Objective Assessment of epidemiology and clinical features of psoriasis first occurring over
the age of 60 years, so-called elderly-onset psoriasis, based on clinical data.
Materials and methods Among 4049 patients visiting our psoriasis clinic for the last
27 years, patients were first divided into early- (onset age before 30 years) and late-onset
psoriasis (onset age after 30 years) based on our previous studies. Then, patients of lateonset psoriasis were further divided into middle age-onset group (onset age between 30
and 60 years) and elderly-onset group (onset age over 60 years). Clinical characteristics of
elderly-onset psoriasis were compared with early- and middle age-onset groups. We
acquired the data both by physicians assessments and patients responses.
Results Elderly-onset patients comprised 3.2% of total patients, 129 out of 4049. They
have shown a lower incidence of family history (P < 0.05). The severity assessed by PASI
score, body surface extent, and activity of individual lesions demonstrated that psoriasis of
the elderly-onset group was generally milder compared with early- and middle age-onset
groups (P < 0.05). In clinical phenotypes, the proportion of guttate type and generalized
pustular psoriasis type decreased remarkably, while that of erythroderma type increased
(P < 0.05). There was a significant change in the body part of origin comparing early- and
middle age-onset groups (P < 0.05). The proportion of scalp increased, while that of knee
elbow and trunk decreased significantly (P < 0.05). Patients subjective sensation of
disease course improved statistically comparing early- and middle age-onset groups
(P < 0.05). There was no significant change in the degree of pruritus on psoriatic lesions
and nail involvement (P > 0.05).
Conclusion The elderly-onset group demonstrated milder disease courses and some
changes in clinical phenotypes and body part of origin compared with early- and middle
age-onset groups. Therefore, it seems that patients whose onset of psoriasis was over the
age of 60 years might have distinct clinical features in some clinical aspects.

Introduction
Psoriasis sometimes occurs in elderly patients. Bell et al.1
reported that about 13% of the newly diagnosed psoriasis
cases were in the age class 6069 years in a populationbased study. Farber and Nall2 demonstrated that about
4.9% of patients experienced psoriasis first in their lives
over 60 years old, and the proportion might increase in
aging society. In Korea, the fraction of people who are
over 60 years in the general population increased significantly from 6.1% to 14.5% during the last 27 years.
However, clinical studies of psoriasis initiating in this
2012 The International Society of Dermatology

specific age group have been rarely conducted. In our pre3,4

vious large-scale studies, we reported that early- and
late-onset psoriasis showed distinct clinical characteristics
59
as in previous large studies. We also reported that age
30 years could be a division criterion of early- and lateonset in Korean patients based on HLA-Cw* 0602 geno10
type frequencies. Defining the specific age of elderly
could be difficult and rather subjective, but age 60 years
could be a rational criterion considering onset age distri1,2,59
bution patterns of previous studies.
The purpose of
this study is to demonstrate clinical features of psoriasis
occurring over age 60 years, so-called elderly-onset
International Journal of Dermatology 2012, 51, 5358

53

54

Report

Characterization of elderly-onset psoriasis

psoriasis, mainly by comparing with early- (onset age

before 30 years) and middle age-onset groups (onset age
between 30 and 60 years).
Materials and methods
Patients
Among the total 4049 patients visiting our psoriasis clinic
between April 1983 and January 2010, 129 consecutive
patients whose disease onset was at over 60 years were
included in this retrospective analysis (76 male and 53 female,
mean age 65.4 5.4 years, range 6084 years). The average
time taken from the first onset of disease to visiting our
psoriasis clinic was 2.39 3.5 years. This study was approved
by the hospital institutional review board.
Study design
All medical information was recorded at the patients first time of
presentation using a psoriasis chart and patients questionnaire.
In the psoriasis chart, dermatologists in the psoriasis clinic
evaluated patients clinical characteristics, including age of onset,
family history, PASI score, extent of involvement, activity, clinical
phenotypes, and nail involvement. Unlike all other data presented
in this study, we only have a PASI database of 3356 out of a total
of 4049 patients because complete PASI score was rated from
November 1989. We empirically set the criterion of severe
psoriasis as PASI score higher than 15. The extent of
involvement was defined as follows, according to the
11,12

classification suggested by Molin:

mild (<5% involvement of
whole body surface area); moderate (530% involvement of
whole body surface area); and severe (more than 30%
involvement of whole body surface area). Activity was defined as
follows, according to the classification suggested by Haftek
et al.:13 mild (stationary skin lesions for the last month); moderate
(peripherally spreading plaque lesions with occasionally small
papules); and severe (rapidly developing new lesions from the
periphery of plaques or normal skin, or newly developing
pustules). In most patients, clinical photos of whole lesions were
taken, and the extent and activity were reviewed by other
dermatologists. Clinical phenotypes were classified with plaque
type, guttate type, generalized pustular (GPP) type, pustulosis
palmaris and plantaris (PPP) type, and erythroderma type.
Plaque type was further classified as nummular type (when the
individual skin lesion predominant in a patient is 15 cm in
diameter) and large plaque type (when the individual skin lesion
predominant in a patient is more than 5 cm in diameter). Nail
involvement was defined as morphological changes of fingernails
and/or toenails, such as onycholysis, subungal hyperkeratosis,
and nail pitting. Even a slight change in nail during a whole
disease course was considered as a nail involvement.
In the patients questionnaire, patients answered the prepared
questionnaire before practice, and the responses were reviewed
by dermatologists from our clinic. The contents of the

Kwon, Kwon, and Youn

questionnaire were as follows: the body part where psoriasis

first observed (multiple choice in the following body parts: scalp,
face, trunk, extremity, kneeelbow, handfoot, and other areas);
associated symptoms such as pruritus on psoriatic skin lesions
[multiple choice composed of none, mild (degree of felt
sometimes), moderate (degree of interrupting daily life), and
severe (degree of difficult to sleep)], and subjective sensation of
disease course since onset of disease (multiple choice
composed of improved, stationary, wax and wane, and
aggravated; patients were recommended to consider whole
aspects of the disease, such as disease severity, working
activity impact and quality of life). The total enrolled patients
were first divided into early- and late-onset groups, according to
our previous report.10 Then, the late-onset group was further
divided into middle age-onset group (onset age between 30 and
60 years) and elderly-onset group (onset age over 60 years).
Clinical information from the elderly onset group (N = 129) was
reviewed, and each category of our data was compared with
the early-onset group (N = 2764) and middle age-onset group
(N = 1156).
Statistical analysis
Pearsons chi-square test and the Fischer exact test were used
to analyze categorical variables. Categorical values were
denoted as frequencies and percentages. Continuous data were
described as mean, standard deviation, standard error, median,
and 95% confidence interval for the mean and range. Missing
values were not included in the statistical calculation. All
significance tests were two-tailed. For all analyses, probability
values of 5% or less were regarded as being statistically
significant. Statistical analysis was performed using software
(SPSS package for Windows, Release 17.0.1; SPSS, Chicago,
IL, USA). Statistical review was conducted in Medical Research
Collaborating Center in Seoul National University Hospital.

Results
Demographic data

General epidemiology
The epidemiological data of our total patients are shown
in Table 1. In onset age distribution of total enrolled
patients, elderly-onset patients comprised about 3.2%
(Fig. 1). The demographic data of the elderly-onset group
are summarized in Table 2. The percentage of patients
whose onset age was between 60 and 69 years constituted
79.8% of total elderly-onset patients.
Family history

Among 129 total elderly-onset patients, 12 (9.3%)

patients had a family history: eight had first-degree relatives and four had second-degree relatives. Elderly-onset
patients had a statistically lower incidence of family

Table 1 Total enrolled patients analyzed in this study (n = 4049)

Early-onset group (onset age

<30 years)

Middle age-onset group

(30 years onset age
<60 years)

Elderly-onset group (onset

age 60 years)

Total patients

2764 (68.3%)
M: 1427 (51.6%)

1156 (28.6%)
M: 714 (61.8%)

129 (3.2%)
M: 76 (58.9%)

4049
M: 2217 (54.8%)

F: 1337 (48.4%)

F: 442 (38.2%)

F: 53 (41.1%)

F: 1832 (45.2%)

Figure 1 Distribution of total patients (n = 4049) according to the onset age of psoriasis. Elderly-onset patients whose onset

age was over 60 years (n = 129) are depicted in the dark gray column

Table 2 Demographic data of enrolled patients of elderly-

onset psoriasis (n = 129)

Onset age
group

No

M:F

Fraction
(%)a

6064
6569
7074
7579
Over 80
Total

38
22
9
5
2
76

25
18
7
1
2
53

63
40
16
6
4
129

48.8
31.0
12.4
4.7
3.1
100

1.52
1.22
1.29
5
1
1.43

1.6
1.0
0.4
0.2
0.1
3.2

scoring higher than 15 was significantly lower in the

elderly-onset group compared with early- and middle ageonset groups (P < 0.01; Table 3).
Body surface involvement and disease activity of
individual lesions
The extent of psoriasis involvement in the elderly-onset
group was generally milder than early- and middle ageonset groups (P < 0.05). Activity of psoriasis in the
elderly-onset group was also milder than other onset age
groups (P < 0.01; Table 3).

Fraction is the percentage of each age group among total

enrolled patients in our psoriasis clinic (N = 4049).

history compared with both the early-onset group

(30.7%) and middle age-onset group (18.4%; P < 0.05).
Clinical characteristics of elderly-onset psoriasis

Disease severity. PASI score. The PASI score of the

elderly-onset group was generally lower than early- and
middle age-onset groups. The proportion of patients

Clinical phenotype
Clinical phenotypes of each onset age group are shown in
Table 4. The proportion of chronic plaque type constituted
a major fraction (82.1%) in elderly-onset psoriasis. Among
them, nummular type occupied 45.7%, large plaque type
occupied 36.4%, and guttate type occupied 4.7%. We
could also observe rare cases of PPP type (6.2%) and erythroderma type (4.7%), while there was no GPP case in the
elderly-onset group. Compared with the middle age-onset
group, the fraction of erythroderma type increased, while
that of guttate and GPP type decreased (P < 0.05).

Table 3 Comparison of severity between patients of different

onset age groups

ElderlyMiddle
Early
onset
age-onset age-onset
group (%) group (%) group
PASI scorea
Mild (05)
Moderate (515)
Severe (>15)
Body surface extent
<5%
530%
>30%
Disease activityb
Mild
Moderate
Severe

Chi-squared
test
(P-value)

34 (33.0)
42 (40.8)
27 (26.2)

240 (26.1)
372 (40.4)
309 (33.6)

477 (20.4) <0.001

979 (41.5)
878 (37.6)

63 (48.8)
48 (37.2)
18 (14.0)

521 (45.0)
421 (36.4)
214 (18.5)

1202 (43.5)
949 (34.3)
613 (22.2)

73 (56.6)
36 (27.9)
20 (15.5)

539 (46.6)
359 (31.0)
258 (22.3)

1106 (40.0) <0.001

932 (33.7)
762 (26.3)

0.031

Because we started to assess PASI score in the middle of the

study, the above statistics were based on a total of 3356 consecutive patients (2332 early-onset patients, 921 middle ageonset patients, 103 elderly-onset patients).
b
Activity criterion is based on ref. 13 (mild: stationary skin
lesion for the last month; moderate: peripherally spreading
plaque lesions with only occasionally small papules; severe:
rapidly developing new lesions from the periphery of plaques
or normal skin, or newly developing pustules).

Table 4 Comparison of clinical phenotypes between patients

groups (32.3%), the difference was not

important (P > 0.05).

statistically

The body part of psoriasis origin

Distribution of body parts where psoriasis was first
observed in patients of different onset age groups is summarized in Fig. 2. In elderly-onset patients, scalp (36.8%)
was the most frequent site, followed by extremity
(19.3%), handfoot (16.8%), kneeelbow (14.3%), face
(9.2%), and trunk (4%). Analyzing with two other onset
age groups, the general pattern of initially affected site
was
different
in elderly-onset
psoriatic
patients
(P < 0.05). Especially, the involvement of scalp was significantly increased compared with the early- and middle
age-onset groups, while that of kneeelbow and trunk
decreased (P < 0.05).
Pruritus on psoriatic skin lesions
In elderly-onset patients, 32 (25.4%) out of a total of
126 patients experienced no symptom of pruritus around
psoriatic lesions, while 50 (39.7%) patients complained
about mild symptoms, 25 (19.8%) patients complained
about moderate symptoms, and 19 (15.1%) patients complained about severe symptoms. Compared with earlyand middle age-onset groups, the proportion of patients
suffering from moderate to severe pruritus that would
interrupt normal daily life did not present any significant
differences (P > 0.05; Fig. 3).

of different onset age groups

Guttatea
Nummular b
Large plaquec
GPP
PPP
Erythroderma
Others

Elderly-onset
group (%)

Middle age-onset
group (%)

Early-onset
group (%)

5 (3.9)
59 (45.7)
47 (36.4)

85 (7.4)
585 (50.6)
341 (29.5)

297 (10.8)
1597 (58.2)
715 (26.0)

0
8
7
3

(0)
(6.2)
(5.4)
(2.3)

15
80
27
23

(1.3)
(6.9)
(23)
(2.0)

29
39
15
54

Subjective sensation of disease course compared with

onset time
Patients were asked at their first visit to our clinic about
their psoriasis course compared with their first onset time
(Fig. 4). Thirty-six (30%) out of a total of 121 patients
reported as improved state, while 22 (18.2%) patients

(1.1)
(1.4)
(0.5)
(2.0)

Guttate: when the individual lesion predominant in a patient

is <1 cm in diameter.
b
Nummular: when the individual lesion predominant in a
patient is 15 cm in diameter.
c
Large plaque: when the individual lesion predominant in a
patient is more than 5 cm in diameter.
GPP, generalized pustular; PPP, pustulosis palmaris and plantaris.

Nail involvement
Nail involvement was observed in 36 patients (27.9%)
among 129 elderly-onset patients. Although nail involvement was less than early- (35.1%) and middle age-onset

Figure 2 The body part where psoriasis was first observed in

the elderly-onset age group compared with the middle ageonset group and early-onset age group

In our population, the proportion of elderly-onset

patients was lower than the aforementioned data from
Caucasians.1,2,5 Among various factors involved, the
difference in average life expectancy could be one of the
important reasons considering national census data of
different countries at the time of epidemiological research.
People from USA and Western Europe were expected to
live 26 years longer than Korean people during the
period of research. Lower incidence of family history in
the elderly-onset group corresponded well with previous

Figure 3 The degree of pruritus is described according to dif-

ferent onset age groups

reports6,1621 that showed close association between earlier onset psoriasis and higher incidence of family history.
In our study, the elderly-onset group demonstrated
lower PASI scores, less extensive body surface involvement, and milder activity of individual lesions compared
with early- and middle age-onset groups. While we only
had PASI data from 82.9% of the total patients since we
started assessing them in the middle of the study, the
extent and activity of psoriatic lesions recorded for the
total patients showed similar tendencies. These results
suggest that the severity of disease would be getting
milder as onset age increased in late-onset psoriasis, con5,7,9,16,17

sistent with previous reports

that showed a
milder course of late-onset psoriasis compared with earlyonset psoriasis.
In clinical phenotypes, the plaque form of psoriasis was
most prevalent in every onset age group, consistent with
5,18

Figure 4 Subjective consciousness of disease course according

to different onset age groups

reported as stable state, nine (7.4%) patients reported as

wax and wane state, and 55 (45.5%) patients reported as
aggravated state. Compared with the early- and middle
age-onset groups, the proportion of both improved and
stable status increased significantly (P < 0.05).
Discussion
1,2,5

Psoriasis can occur in old age.

Since the report of
7
Henseler and Christophers, much emphasis has been
placed on age-at-onset in demonstrating clinical charac14,15
teristics of psoriasis, and few reports
have illustrated
the clinical features of psoriasis in the elderly, not specifically considering disease onset time. However, clinical
characterization of psoriasis, the lesions of which first
develop in old age, has been rarely scrutinized to the best
of our knowledge. Based on HLA genotype frequency
10
studies in Koreans, we separated whole patients into
early-, middle age- and elderly-onset groups.

previous reports
that there is no considerable difference between age at onset and proportion of major plaque type psoriasis. However, partly consistent with traits
of late-onset psoriasis reported in recent reports,5,6,14,22, 23
erythroderma type increased their proportion while that
of guttate type and GPP type decreased significantly compared with early- and middle age-onset groups. There
was even no patient suffering from GPP type. There was
no significant difference in nail involvement between
onset age groups.
The general pattern in body part of origin was different
between the elderly-onset group and the other onset age
groups. Especially, proportion of scalp involvement
increased, while that of kneeelbow and trunk involvement decreased significantly compared with early- and
middle age-onset groups. To the best of our knowledge,
relation between age of onset and initially affected body
part has been rarely reported. If further epidemiological
research establishes more supporting evidence, it would
provide useful information for clinicians. The proportion
of moderate to severe pruritus in the elderly-onset group
was not significantly higher than that of the early- and
middle age-onset groups. Numerous reports24,25 have suggested a positive correlation between the severity of psoriasis and the degree of symptom. Considering pruritus
is frequently associated with aged dry skin in practice,

the data might be partly explained

of elderly-onset psoriasis. At last,
proportion of elderly-onset patients
course was improved or stabilized
and middle age-onset groups since

by mild disease course

a significantly higher
answered that disease
compared with earlythe onset of psoriasis.

5,7,9

As many reports
have shown that disease course of
late-onset psoriasis was quite milder compared with that
of early-onset psoriasis, elderly-onset patients seemed subjectively relieved from the burden of disease compared
with early- and middle age-onset groups.
There are some limitations in our study. First, the evolution of disease was different between onset age groups.
There are possibilities that differences in clinical features
between onset age groups were partly attributed to the
diverse periods of evolution of psoriasis. Treatments
received before visiting our clinic might also partly interrupt accurate assessment of psoriasis state. Second, some
of the scoring system evaluating the intensity of psoriasis
and symptoms is based on former standards as data had
been acquired for 27 years. Last, some acquired data used
for analysis including onset age and body parts of origin
could be potentially biased, as they were totally dependent on patients memories.
This is the first clinical study of psoriasis occurring over
the age of 60 years. Although our studies had some limitations, we found that the elderly-onset group demonstrated a milder course of disease progression and showed
some characteristic aspects such as clinical phenotypes
and the body parts of origin compared with early- and
middle age-onset groups. These observations suggest that
psoriasis occurring in the elderly group could be different
from that of the middle age-onset group in clinical patterns and pathogenesis. Further epidemiological research
and genetic studies are required to fully elucidate the psoriasis occurring in this age group.
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