PSORIASIS 1) miscellaneous 2) Ketaconazole 3) Saiko-ka-ryukotsu-borei-to 4) Buspar 5) Pregnancy and prosiasis 6) Calcipotiol and tretinoin 7) Cimetidine 8) Psoriasis in Pregnancy 9) Childhood Psoriasis 10) The role of antibiotics in treatment 11) Antimalarials 12) Miscellaneous 13) Methotrexate 14) Anthralin 15) Tarzarotene 16) Phototherapy 17) Miscellaneous -------------------------------------------------- I need help with an overweight (230lb) 14 year old female with severe psoriasis. it is moderately inflamed but without pustules, and covers 90% of her body. her scalp has diffuse cement like scale. she is very distraugt, won't go out of the house, and is threatening suicide. her psoriasis was limited to her scalp until about 3 months ago. she has not responded to uvb, and there has been no response to empiric systemic antibiotics or antifungals (diflucan). i suppose puva would be the next best option, but i need to do something with quicker results. any thoughts on accutane, mtx, steroids, other. of course, topical options have been tried extensively, and she has recently developed some striae over her shoulders. --------------- ------------- MISCELLANEOUS ------------- As a "crisis-buster" cyclosporine is often useful, assuming you have some level of comfort with the drug. Haven't used it in a 14 y.o. but had good response in an 18 y.o. Still not comfortable with it longer than 6-12 months, so MTX or PUVA likely still looms in the future. Others would argue that the post-CSA rebound is severe enought to make it a poor choice: at least in my far from extensive experience I haven't yet had big problems with this. No Steroids! Mark Ling MD ------------ How about putting her on a very low calorie diet? During WWII, people who were on protein-deficient, calorie-deficient diets lost their psoriasis, which they regained when they went back on a normal diet. Just as MTX poisons the psoriasis before it poisons the patient, you can starve the psoriasis before the patient suffers from starvation. She will look and feel much better at half her present weight! Yelva Linfield MD ----------------- At our Psoriasis Treatment Center, it is likely that we would treat her as an inpatient for about 1 week followed by a 3-5 week course of Goeckerman treatments. If a prolonged remission ensued, great. If not, we would consider home UVB to maintain the remission. The psychologic support at a Psoriasis Treatment Center may be of particular value. Steve Feldman MD ---------------- Regarding the obese suicidal 14 yr old female with 90% psoriasis, I would suggest re-PUVA, with short term Accutane substituted for Tegison due to Accutane's shorter half life. In addition, consider Drithoscalp with shower cap occlusion as tolerated to her "cement-like" scalp. Phili Hughe MD -------------- Regarding the recent request re nail psoriasis I would add that intalesional injections of 2.5 mg TMC in the proximal nail fold on a 4 to 6 week interval can be most useful for nail psoriasis of the matrix type, not of the nail bed type or distal onycholytic type. I have at least 2 patients going at any one time and we get could results and amazingly well tolerated. You can use a little cold spray at first but after a awhile it seems to be part of the routine. Caveat is to not get a level too deep where you inject below the nail and separate the nail from the proximal matrix since this causes acute pain and local hemorrhage which has to grow out. Relating to the query on the obese 14 year old I find the problem to multi focal. Having live through this 3 times in the last several years I will generally state that 14 year olds, esp girls are not well balanced anyway. Anytreatment for this young lady should be done along with appropriate psychological support because if the tx doesn't work you have a more depressed child. Doesn't it remind you of the VA derm clinic chicken or egg argument "Does alcohol cause psoriasis or psoriasis cause alcoholism?" As far as retinoids in this patient you may be doomed to failure because the lipids will likely go off the scale. My experience with accutane in obese teens is that they quickly send their trigs skyward. Certainly all the other suggestions are excellent and we all wish you luck. L.J. Gregg MD ------------- In regards to psoriasis of the nails, I have found that Temovate applied BID to the proximal nail fold is as effective as injecting it, and far less painful. Steven D. Emmet, M.D. --------------------- I would add my opinion that serum androgens need checking and that spironolactone may be of some value but I have never found it to be good mono therapy, even at 200mg/day. I currently figure accutane courses using the 125mg/kg dose using the formula Wt. in kg x 125mg divided by the daily dose then divided by 7 to get the # of weeks. I also agree with the earlier writer that higher doses may be of value since when we started using accutane in the 80's I was using 2mg/kg and none of those patients relapsed that I know of. Cost , side effects and current package inserts and articles support the 125mg/kg total dose as providing the best balance, not necessarily the most long remissions. L.J. Gregg MD ------------- How about Dovonex/PUVA? Safer then retinoids or MTX, and appears to have promise. Daniel F Mitchell MD -------------------- I have been treating patients with psoriasis for more than 45 years. I have seen only one male patient with psoriasis of the nuchal scalp! All the rest are women. Has anyone seen male patients with psoriasis of the nuchal scalp? And, if it is uncommon in men, why? Jerry Litt MD ------------- Sorry. Although I do not have 45 years of experience treating psoriasis, I have at least ten patients in my practice with psoriasis of the nuchal scalp. Here in Montreal, I get these patients mostly during the winter, when men wear either tuques (hats made of synthetic materials), headbands made out of synthetic material or fur hats. I wonder if there is a link either to irritation, or hypersensitivity to material. But what is always striking to me is that the nuchal scalp is the most significantly affected in these men. Warren Winkelman, MD, FRCPC Department of Dermatology Montreal General Hospital ------------------------- I currently have a 70 yr. old male patient with nuchal psoriasis which goes into remission with a couple of hot quartz light treatments. Other approaches (anthralin, tar, steroids) have failed. Philip Hughes, M.D. ------------------- Update on a case I put on this list about 6 months ago. a suicidal 15 year old with total body psoriasis. she had failed all treatment, including puva. after much deliberation, cyclosporine was chosen over mtx. she did not respond to5mg/kg/day, and became toxic with neurologic side effects including loss of balance. she was referred to dr. john koo of univ. of calif san francisco, and cleared within 25 day with crude coal tar 2-5%. she could not tolerate even small amounts of uvb. her treatment was undertaken at a psoriasis day care center. she will continue coal tar (lcd totally uneffective) at home. William Liss MD ---------------------- Sulfasalazine 3g/d works well for about 1/3 of patients after a couple of months, and can also help psoriatic arthritis. Can cause temporary infertility in men while they are taking it. Ranitidine 300 bid works ok for about 1/3 - 1/2 after up to 6 months - had an AIDS patient resistant to other Rx do great on it. I use the 75 mg / 5 ml syrup for kids [minty taste - they seem to like it] - works for molluscum contagiosa also. Dovonex w/10% urea and sometimes also 2.5% HC bid on and around but NOT UNDER nails works great if used faithfully [I might post the photos when I get my web page up and running]. Th also works well on really thick plaques, and sometimes also on pustulosis palmaris et plantaris. I've used Dovonex cream on the face, in the axillae and genital area and also on the scalp with good results and no big problems in lots of patients. I've sent ~8 patients for tonsilectomy, and had only one who didn't improve much [but even she was pleased to have less sore throats]. Don't forget intralesional kenalog 3 mg/ml for tough spots [up to 6 ml every month]. Remind patients that they don't HAVE to get 100% cleared up - just as much as they want, and remind them that you can sometimes get 90% of your side effects trying to get rid of the last 10% of your symptoms [this advice is useful in a lot of other derm conditions too]. Tazarotene gel [Allergan] is going to be very useful. I wonder if electron beam would be good for the 1 in a thousand with horrendous resistant cases. I wonder about Grenz ray for PPP. KC Smith MD FRCPC Niagara Falls ON ---------------- ------------ KETACONAZOLE ------------ Not necessarily quirky but under appreciated is the role of ketaconozole and perhaps other systemic anti yeast agents in the treatment of intertriginous disease. For the past several years I have used these agents on almost all patients presenting with this pattern or with exacerbations of this pattern and have been able to give great relief. On courses longer that 10 days I do the appropriate studies to r/o liver toxicity. The success with scalp disease that is inflamed is almost as good. I do certainly find cases that also improve with antibiotic tx but not as often and with anti yeast.. L. J. Gregg, MD ---------------- -------------------------- Saiko-ka-ryukotsu-borei-to -------------------------- Treatment for psoriatic lesions on the face My choice is "Saiko-ka-ryukotsu-borei-to" -- the Japanese traditional herbal medicine (Kampo formula - TJ-12 ). Most of the psoriatic patients were treated topically with the ointment containing the vitamin-D derivative and corticosteroid combined with "Ou-ren-gedoku-to"-Kampo TJ-15. PUVA, UVB-irradiation, RePUVA and PUVA combined with the topical vitamin-D derivative were also effective. The facial lesion with a severe form of psoriasis inclusive of psoriatic erythroderma was hard to cure. A 24-year-old man with psoriatic erythroderma who had both the high temperature of 38 to 40 degrees C and the facial lesion of psoriasis from 10 years old was treated by UVB primary in our institution. The temporary improvement was seen, however the heigh temperature and the facial erythema lasted. "Saiko-ka-ryukotsu-borei-to" was administered for sleeplessness, and subsequently the decrease of temperature with a considerable reduction of the face erythema was presented. "Saiko-ka-ryukotsu-borei-to" was thought to be a minor tranquilizer in Kampo, although no distinct cause of improving facial lesions of psoriasis was shown. Several trials of "Saiko-ka-ryukotsu-borei-to" to the psoriatic patients with facial lesions revealed that the effectiveness lasted on the face irrespective of illness on the other sites. Eiichi Yagi MD Akita Red Cross, Japan. ---------------------- That's interesting! But does anyone have any other suggestion for children < 8 y.o. with psoriatic nails? I'm afraid to try Dovonex on fingers of little kids because more of than not Dovonex will end up all over the face and in their mouth. Mychael Luu, M.D. WSU Dermatology --------------- ------ BUSPAR ------ Well, I am usually opposed to anecdotal experience as a reliable source of data, but here goes, apropos of recent conversations regarding Buspar. A 50 y.o woman with severe L hand psoriasis, unresponsive to Temovate, Dovonex, tar, Topical PUVA, colchicine, oral antibiotics. No response for over one year and a half yrs Pt declined retinoids or MTX. She brought in an article in "Good Housekeeping" regarding the role of stress in psoriasis. The author wrote about pts responding to Xanax or other anti-anxiety agents, including Buspar. She has always been anxious, so I agreed to try something like this. I suggested Buspar to avoid the possibility of dependence on Xanax. Three weeks later, on 20mg daily in divided doses, (still on topical PUVA, Ultravate and Dovonex) she is nearly clear, for the first time. Also clearing are a few spots on the forearms not treated in any other way. She has had a beneficial emotional response regarding her anxiety, but I can not believe the skin response is simply due to anxiolytic action in such a short time, after such a long unremitting course. Any comments or similar experiences? Jerry Eisner ------------ I have had several similar experiences with Buspar. Richard Sharpe MD ---------------- Interesting follow up, at least if you are a mouse, regarding Buspar: See below Jerry Eisner McAloon MH, ChandraSekar A, Lin YJ, Hwang GC, Sharpe RJ Buspirone inhibits contact hypersensitivity in the mouse. Arcturus Pharmaceutical Corporation, Woburn, MA 01801, USA. Int Arch Allergy Immunol 1995 May-Jun;107(1-3):437-8 ABSTRACT: We have observed that 8-4-[4-2-pyrimidyl)-1-piperazinyl]butyl]-8- azaspiro [4.5]decane-7.9-dione, an agent commonly known as buspirone HCl, possesses immunosuppressive activity when administered either topically or systemically, as assessed in a mouse model of contact hypersensitivity. Topical or systemic administration of buspirone significantly reduced the tissue swelling and leukocyte infiltration associated with the elicitation phase of contact hypersensitivity. Buspirone is a safe, widely used drug which has a history of use in humans throughout the world. These data demonstrate a previously unknown pharmacologic activity of buspirone. -------------------- Having heard Rick Sharpe's presentation at the SID on Buspar and atopic dermatitis, I am also fascinated by the implications. He claims that there is reasonable evidence that suggests that buspirone may act to modulate the neurocutaneous immune system network in such a way as to impact the underlying mechanism of AD. On the other hand, I think clinically it is clear that "stress" certainly does act to flare AD in some patients. What would be interesting would be a controlled study of buspar versus some anxiolytic without any known immunomodulatory effects (a Valium control group?) to see what the effects would be. Case reports like yours are particularly interesting in this light. BTW, the patents in the US for the use of buspirone in some skin diseases are apparently held by Dr. Sharpe and collegues, according to his conflict of interest disclosure at the meeting. Mark Ling, M.D., Ph.D. ---------------------- I've had enough patients with psoriasis improve (both skin and mind) with SSRIs (notably Zoloft and Effexor) that I am quite quick to offer a trial of treatment. These can lead to reduced alcohol consumption, and perhaps improved mood leads to improved compliance with therapy, so there are several mechanisms of action possible, but the bottom line is that people do better, and thats what its all about (good thing I don't have to answer to some beancounter for every Rx I write!) KC Smith MD FRCPC ----------------- I have recently had a similar experience with Buspar. An Asian patient of mine has had extremely recalcitrant plaque-type psoriasis covering about 20% of his body. Various topical steroids (including megapotent ones), topical tar, anthralin, Dovonex and UVB provided minimal inprovement. I started him on PUVA and he was beginning to show a little improvement, but we had to discontinue PUVA because he began to complain of a severe 'nettling' sensation over his upper back and shoulders. This occurred in the absence of any significant erythema, and I am unsure of its cause. The pt was on no other photosensitizers. Topically he was just using some Lachydrin and bland emollients. His ANA was negative. In any event, PUVA was stopped and the pt was treated with emollients and Pramosone 2.5% cream. The discomfort slowly resolved, but his psoriasis began to gradually worsen again. He confided that he was experiencing a lot of job stress and requested something for his anxiety. I started him on Buspar 5mg TID and restarted Dovonex (which had not been very helpful previously). When he returned 2 weeks later, there was a marked improvement in his psoriasis which has continued. He feels calmer and has decreased the Buspar to BID. I cannot say whether the improvement was due to a pharmacologic action of Buspar, his decreased anxiety, or the fact that the truncated course of PUVA made him more responsive to Dovonex. W. F. Pekruhn M.D. ------------------ ---------------------------------------- BREASTFEEDING AND TREATMENT OF PSORIASIS ---------------------------------------- Any suggestions for treating mild- yet stubborn- psoriasis in a mother who is breastfeeding- besides topical steroids? Mkderm@aol.com --------------- How 'bout local injections of steroids? Dovonex in small quantities? Tar in small quantities? Sunlight? - and what's wrong with a little topical steroid? Mild steroid with occlusion? Jerry Eisner MD --------------- I've used UV-light, Dovonex ointment and Ranitidine 300 mg bid for psoriasis on pregnant and nursing women with generally good results and no problems. KC Smith MD FRCPC ----------------- Perhaps you could use coal-tar preparations and UVB. I am not aware that this could pose a problem in breastfeeding. Dr. Annette Wegman Sydney, Australia ----------------- The following may be used during lactation: calcipotriene topical methoxsalen and UVA (oral is contraindicated by mfr) UVB topical steroids (not on nipple--may cause hypertension in infant. Barbara R. Reed, MD ------------------- Try light. Sun, tanning bed, etc. I assume you have checked out the safety of tars and Dovonex. Diane Thaler MD ---------------- There is no data on the use of coal tar during breastfeeding and the American Academy of Pediatrics as well as manufacturers give no recommendations for or against its use. However it is a carcinogen and usually use during breastfeeding is not recommended. Barbara R. Reed, MD ------------------- -------------------------- CALCIPOTRIOL AND TRETINOIN -------------------------- While attending the 57th annual meeting of the SID I heard a very interesting presentation by S Kang, et al. entitled "Activation of the vitamin D-responsive 24-hydroxylase gene by 1,25(diOH) D3 is synergistically enhanced by retinoid-X-receptor ligand 9-cis-retinoic acid and by the 24-hydroxylase inhibitor ketoconazole in human skin in vivo" (JID 106:831 abs #153, 1996). This presentation raised the following question I'd like to ask of you clinicians. What has been your experience in treating psoriatic patients topically with calcipotriol in combination with tretinoin? Dan Bucks PhD ------------- Haven't tried retinoic acid with Dovonex. Soriatane (acetretin) seems additive but not synergistic. I'm loing forward to trying adapalene gel, which is a beta- and gamma retinoic acid receptor (RAR) selective retinoid with much less irritancy than retinoic acid. Adapalene should be available here soon, being marketed by Galderma primarily for acne, but of course we are allowed to use it for anything that seems reasonable. Tried some on my face recently and NO IRRITATION AT ALL. Usually I can't tolerate retinoic acid. KC Smith MD FRCPC ----------------- ---------- CIMETIDINE ---------- Anecdotal report: Patient with psoriasis, guttate and plaque and nails, for four years. After three and one half weeks of cimetidine 800mg/day has usable nails-he can open lids again (creamer containers at his morning coffee stop). They are growing, less crumbly, less dystrophic. Diane Thaler ------------ How are the plaques and guttate lesions responding? Has anything else changed (alcohol intake, etc.) ? Walter H. Wood, M.D. -------------------- He opted for TMC/LCD topically. All lesions are gone or 80% better. I didn't inquire about his alcohol intake. That I usually save for a future visit, when I know the patient better, if they are not responding to treatment. Unless, of course, it we are starting mtx. Diane Thaler ------------ ----------------------------------------- PSORIASIS AND PREGNANCY ---------------------------------------- I have a 30 y/o with erythrodermic and very labile psoriasis involving 75% of her cutaneous surface. In past it has been pustular. She flares with infections and with psycho-social stress. The only reliable tx has been mtx in short couses. She is now pregnant and severely flared. Has responded partially to erytromycin and mild topical steroids after cool compresses but her skin remains very painful. Social situation a mess, getting divorce, etc. Managed care pcp not helpful when trial of hospitaliztion suggested-between her pregnancy and her erytroderma I could see the possiblity of high output cardiac failure. Any wsdom would be appreciated. L.J. Gregg, MD ------------- At the Sandimmune Neoral conference in Rome last month there was a followup study on some children whose mothers were treated with cyclosporine during the pragnancy and all the kids turned out ok. If you are thinking of giving CyA send me your fax # and I'll try to find the abstract for you. I think MTX in the last half of pregnancy would be reasonable, as long as renal function is good. During the 1st half UV-B or PUVA could be used, but you'd probably have to start at a low dose of UV because of the erythroderma. KC Smith MD FRCPC ------------------ If stronger topicals don't do it in a while and the gyn is worried then this might be the one in a million pustular psor patients who need systemic steroids to get things under control. Withdrawal will be difficult, UVB might help prevent the expected reflare of disease. Is there a high risk OB involved? This might give reason for hospitalization. Guy Webster ----------- Your pregnant patient could be treated safely with tar and UVB. PUVA would probably be clinically safe but is officially contraindicated in pregancy. I would be hesitant to use anthralin in her near-erythodermic state, but it could be tried along with the UVB if the tar/UVB failed. Dovonex (100 gm/wk) could be" thrown in" if she has several hundred dollars burning a hole in her pocket. Philip Hughes, M.D. ----------------- consider hospitalization with wet dressings & topical steroids(medium strength) for at least 5-10 days. if better then continue with same or add 1%cct with or without UVB(patient should not be erythrodermic if this is used as a followup treatment). since the patient is pregnant i would also get an ultrasound of the pelvis especially if not already done in the past 3 months. good luck. thomas f. downham ii, md ----------------- Cyclosporine is FDA Pregnancy Category C, associated with SGA babies but not as severe problems as Methotrexate. MTX is FDA Pregnancy Category X. Would try to avoid throughout pregnancy--big risk legally if anything goes wrong. Psoralens (oral) not a huge problem, but in light box need to watch temperature esp early pregnancy. For more info, call Teratogen Information Services, 206-543-2465. For about $5 for each drug, they will give you the down-and-dirty on every drug you are considering. Barbara R. Reed, MD ------------------- CyA and MTX are listed as category C and X (and I should have put that in my note), but as a practical matter its good to know that they can be used if necessary in pregnancy (especially later pregnancy) if the risks of not using them are great enough, and there are plenty of references to the successful use of both in pregnancy. Thanks for the tip about the teratogen info service - I'll give it a place of honor in my Rolodex. KC Smith MD FRCPC ----------------- Tough situation, especially with extreme post-inflammatory hyperpigmentation that will result. This could be disfiguring for decades. Assuming you've used griseofulvin, dapsone, etc. one might consider starting @ alternate day steroid dosing WITH low-dose CsA around 2-4 mg/kg. Once clear, would wean the CsA allowing the steroids to maintain remission, then wean them. I've used CsA with steroids in patients with pustular psoriasis after they had been hospitalized by their FP and treated with IV steroids only to flare then be sent to Derm. Tough problem but this may help. Would check bone age w/ films, and rough estimate of creatinine clearance with standard formula: CrCl = total 24 HR Creatninie (mg.)/ serum Creat (mg.) X 0.07 Serum Creat should be drawn @ completion of 24 hr urine collection. Jay M. Barnett ---------------- Kevin Smith has already been kind enough to give me his input but I'd love additional feedback from the non-American list readers regarding their policy with women who desire pregnancy following treatment with acetretin (AKA Soriatane, Neotigason, etc). How long to wait? Is determination of acetretin and etretinate levels useful? Mark Ling, M.D., Ph.D. ---------------- I was at the meeting of the Scottish Derm Soc this summer where one of the guest lecturers was Dr. Anders Vahlquist from Sweden. He has a lot of experience with etretinate and acitretin. There, they do biopsy the fat to look for any residual stores or levels of etretinate in woman who have been on the drug and are now considering pregnancy. A positive value wouldn't be of much comfort of course even if the woman had been off the drug several years. A negative or non-detectable level may make you feel better. I'm not sure if the test is clinically (or even experimentally) available in the USA, but the drug manufacturers should know. Claire L. Haycox, M.D., Ph.D., ---------------------- I've used Dovonex on pregnant women, and on a ~ 6 month old baby without problems. The little bit the baby might get nursing if she puts it on her nipples wouldn't worry me at all - it's degraded on the first-pass anyway. Wouldnb't worry about topical corticosteroids either - the benefits to the baby from nursing are far greater than the tiny theoretical risk from 'roids on the nipple - maybe someone knows a topical corticosteroid which would be degraded on the first pass, to eliminate that theoretical risk. I personally wouldn't hesitate to use PUVA or CyA if necessary - again I think the risks to the kid are vanishingly small. KC Smith MD FRCPC ----------------- At six months pregnancy, the risk of teratogenicity is pretty much over, since organogenesis is usually complete in the first five weeks or so. High amounts of calcipotriene in animals is associated with bony skull abnormalities, but I doubt this level could possibly be achieved with the small areas involved. Topical steroids would be fine, but should be avoided during nursing since hypertension of the infant is a risk. UVB is also fine, not a risk unless she becomes physically uncomfortable due to standing or heat. Again, the time for teratogenic risk from the heat is over. Topical methoxsalen with UVA would also be fine, if appropriate. Tar is an unknown; carcinogenic in animals. I try to avoid during pregnancy and nursing. You can get detailed information through TERIS, Teratogen Information Service, 206 543 2465 ( $5 per summary). If your University subscribes to Reprotox (check with the OBG dept) there is an online reference source available (202 293 5946). Barbara R. Reed, MD ----------------- A 26 y.o woman, six months pregnant, comes in for treatment of = psoriasis. She has psoriatic plaques near her nipples and wishes to = control this prior to the birth of the baby. She also has ps on her scalp. She recalls that triamcinolone with 4%LCD helped her in the distant = past. Has never used Dovonex. What topical therapies do we feel most comfortable and uncomfortable = with in pregnancy? Are we concerned about the teratogenicity of Dovonex in lab animals? Do = we feel tar is safe - for scalp, for skin? Topical steroids have = demonstrated safety in general. What about our other modalities, = including UVB (not PUVA)? How do members of the group modify their = treatment of pregnant patients with psoriasis? =20 I advised the young woman I would poll our group with this issue. Jerry Eisner ----------- I believe the National Psoriasis Foundation has a pamphlet for patients which specificall addresses the safety of various treatment measures in pregnancy. Fortunately, I have not encountered any severe psoriatics lately with psoriasis so this issue is not one upon which I am "up-to-date". UVB certainly would seem a reasonable option for widespread disease. Mark Valentine -------------- I'm looking at the NPF Conception, Pregnancy and Psoriaisis brochure: it is an interview with Eugene Van Scott: It starts off with this bit of wisdom: "Q. How do you counsel your patients who are contemplating having a baby? A. I recommend they go off treatment. The only treatment regimen I like to use on ly pregnant patients, or women trying to get pregnant, is Vaseline and sunlight. There are many birth defects that occur today that are unexplained. This means the physician and the patient could experience unresolved feelings of guilt over something they might have done. Unless a therapy is known to be absolutely without risk to a fetus, one should avoid any exposure to possibly deleterious (harmful) materials. One then minimizes risk of future emotional anguish." Kevin C. Smith MD FRCPC ------------------- I think that Dr. Van Scott's strict approach for treatment of psoriasis in women intending to become pregnant or during pregnancy is unnecessarily restrictive (Vaseline and sunlight), and I wonder if he ever had a daughter with psoriasis. Barbara R. Reed, MD ---------------- --------------------------------- CHILDHOOD PSORIASIS --------------------------------- I recently saw an unfortunate 5-year old caucasian with widespread psoriasis. The plaques cover roughly 25-30% of his body surface, affecting the limbs, trunk, scalp, groin, and sides of the face. The problem has been ongoing for around 6 months with no known antecedent illness, no sunburn or other potential Koebnerizing phenomenon, and no family history. He was started initially on Zetar baths with a minimum of improvement, then came to our clinic. Given this type of case, I was wondering what the approaches taken by our members would be -- Chris Scholes ----------- I've had a number of kids do well with Dovonex cream and ointment (including on the face), and the lotion works great on the scalp. You might also use Elocom (Elocon, mometasone) several times a week. Kids tolerate CyA very well, and I've used MTX without difficulty (but the parents etc. usually find systemic Rx quite upsetting. I point out that the side effects of the disease are a lot worse than the likely side effects of the treatment, and in this prespective they usually agree with Rx, and stick with it when they see that it is safe and effective.) KC Smith MD FRCPC ------------------- UVB, UVB, UVB. Mark Ling, M.D., Ph.D. ----------------- Mark, have you not had luck with antibiotics? What about an ASO titer? Or do you feel the putative antigen is long gone? Diane Thaler ----------- I like UVB, too. Goeckerman may also be a good choice if UVB alone is ineffective. I especially like UVB because with early psoriasis, you can expect it to be a long-term problem, and home UVB is a long-term solution. Lastly, I was fooled once by zinc deficiency, but that child was much younger. Steve Feldman, MD ---------------- My experience repeated now many times is that even in "classic" presentations of guttate psoriasis, the disease almost always seems to continue no matter whether the putative triggering infection has been cleared. I have to strain to remember even one patient whose psoriasis went away after the strep throat was Rx'd. Keep in mind though that the large majority of my patients are adults: perhaps this occurs more in kids. If you believe that superantigen functions to induce a clone/clones of T cells which are autoreactive, then it's not surprising that they should be able to disseminate and perpetuate the disease driven by the putative autoantigen, even after the initial superantigen has gone. Mark Ling, M.D., Ph.D. --------------------- I have had about a 30% good response of psoriasis to antistreptococcal antibiotics in munchkins (n=10); I rarely try it in adults. I routinely get titers in guttate psoriasis that are negative. Michael Fetterman ---------------- Interesting note on guttate ps. Had a female patient in her 40's with many episodes, triggered by strep., often caught from kids in the family. Her episodes would be severe and last months. Sometimes required MTX for control. Stopped her episode by giving her daily low dose PCN, like pts with rheumatic fever used to get. No problems in a couple of years now. Jerry D. Eisner ---------- ------------------ ANTIBIOTICS ------------------ The Shelleys "D&D Cocktail" has worked very well for me in stubborn, extensive psoriasis. (D&D=Diflucan & Duricef). Many times, women will tell me that under this regimen, they have not had a recurrence of their intermittent vulvovaginal candidiasis and their psoriasis has cleared remarkably. Erythromycin has also worked for me in childhood psoriasis. Try them, you'll like them! Jerry Litt --------- Jerry, did you do any tests to prove they were strep triggerred. I am being a little nitpicky here because everyone seems to have different experiences on this one. What is the mix and how often do they imbibe? Diane Thaler ----------- Jerry: Interesting. Does the patient have her tonsils? Many of us have had patients with chronic psoriasis clear once the tonsils were removed...obviously, probably secondary to chronic strep...or is there another antigen? Elliot Puritz ---------- What dose of Diflucan and Duricef are used? Jerry Eisner -------- Sorry, havent seen the patient in a couple of years. Hope she just didn't have a recurrence and go to another doc :>) I wonder, would I rather take Penicillin or have my tonsils out if I thought each was equally effective. I must admit to frequently putting new psoriasis patients of almost any age on a few weeks of cephalexin while I am trying to clear them in other ways. I have had several patients feel they do worse off the antibiotic, though of course this is anecdotal. However, I know there are a few articles (and I recall some posters at the AAD meeting in '90 or "91) that suggested the empiric use of a wide variety of antibiotics was associated with improvement, even with neg evidence of strep. I suspect there is more than one organism that can stimulate psoriatic eruptions, and that psoriasis, like LP, can be a reactive dermatosis. History of pos strep screens just prior to episodes but I cannot recall particulars. Pos strep screens in kid(s). Can't recall (2 years ago) if ASO's were indicated. I remember only that I thought there was adequate data to suggest strep actually was preceding the events. Point well taken. Jerry Eisner ---------- I've sent 6 - 12 patients with psoriasis and big tonsils (mostly adults) for tonsillectomy in the past few years, and most have improved to some extent and in some cases greatly. I can think of only one who did not think it was worthwhile. KC Smith MD FRCPC ----------------- All new psoriasis patients, or just those with a guttate flare? Does anyone out there put patients on ketoconazole for psoriasis? Yelva Lynfield ------------- Did the Shelleys write this up? If so, do you recall the reference? I have a patient who responded very nicely to sulfasalazine until she became allergic to it. Walter H. Wood, M.D. ---------------- Several years ago I tried sulfasalazine in everyone who walked through the door. I hoped and wished alot that it would work. It didn't, not in anyone. Not with psoriasis. Not with psoriatic arthritis. I am glad someone found it useful. Diane Thaler ---------- Re antibiotics in psoriasis: I treat mostly new onset, young, or with = evidence of possible source of infection such as sinuses, teeth, skin = etc. Guttate lesions make me think of treating empirically, even if = strep screen is neg.=20 Also, more generalized psoriatics in whom I am considering MTX or = Etretinate will often get a few weeks of oral antibiotics first. Seems = worth a try in view of the alternatives. Few successes here, though. I attempted to get citations via Medline for empiric use of antibiotics = but could not find any. I recall posters from AAD a few years ago = suggesting the more general value of antibiotics without strep. Anyone = recall articles or have other similar experience? I do not use ketoconazole. Jerry Eisner ---------- I have a group of patients who are doing well on Sulfasalazine, some on it as long as 5 years. They need to take enteric coated sulfasalazine 3 - 6 grams daily. Like with lots of stuff (eg. Trental) a lot of "treatment failures" are really compliance failures. I tell them at the start that "This is NOT a cure - if it works you have to kke taking it or your problem will come back. If you don't like it or it doesn't work, or if it quits working, let me know, because there are other treatments I can offer you; but for some people this is cheap, safe and effective." Had one guy whose rheumatologist put him on it for psoriatic arthritis. Worked fine, but chatyting with the patient one day I learned that he and his wife were have a hard time starting a pregnancy. Sulfasalazine can inhibit sperm motility, so I suggested to the rheum that the sulfasalazine be stopped for a while, and the guy's wife got pregnant in due course. Something to keep in mind. KC Smith MD FRCPC ----------------- There is a psoriasis clinic in the South somewhere that uses antibiotics exclusively, for months and months, with more than modest success. One of the docs gave a talk 2-3 years ago at the Academy, and it was also taped. If ayone is really interested, I will search for the tape. Diane Thaler ------------ In 1994, at the 6th International Psoriasis Symposium in Chicago, William Rosenberg (Tennessee) stated: "The use of antimicrobial therapy is based on the principle that psoriasis is the end manifestation of the skin's defense system attempting to eliminate microorganisms via activation of the alternative complement pathway in the epidermis." "Therefore, clearing of psoriasis can be accomplished by eliminating or reducing the responsible microbial foci." Jerry Litt ---------- Anecdote on antimicrobials and psoriasis: I went to an Academy meeting two years ago put on by some Texes academics extolling the virtues of antimicrobials in psoriasis. My response rates have been minimal with empiric antibiotics and antifungals, but a biologist came in yesterday, and said the keflex he took was the first "miracle" he has ever experienced. Cleared 98%, and has stayed that way. One may want to keep antimicrobials in their bag of tricks for the treatment of psoriasis. William.Liss ----------- As starters (and this is all empiric, trial-and-error), for an adult with widespread psoriasis that has been recalcitrant to all other forms of therapy, I would prescribe Diflucan 200 mg daily along with Duricef (or erythromycin) 500 mg twice daily. After 3 or 4 weeks there should be a positive response, at which point you reduce the Diflucan to 100 mg daily. Then as the patient progresses, reduce the Durice (or erythromycin)f; cut the Diflucan to q.o.d., etc. I have patients who are on erythromycin, 500 mg twice weekly, which holds their psoriasis in check. And their Diflucan has been stopped. That recent squib on Keflex was most interesting. Jerry Litt --------- Doing well means almost completely clear and happy with the treatment. By the way, I've noted that nail psoriasis will sometimes improve with high dose (~6 g / day) EC-sulfasalazine; but now I use Dovonex ointment with 10% urea and 2.5% HC as a first line Rx. KC Smith MD FRCPC ----------------- On the subject of omeprazole and psoriasis: There is a letter (ref. 1) regarding clearing of psoriasis on omeprazole. I would like to know if anyone on the RxDerm list has seen similary clearing with omeprazole? Hasselkus W [Healing of chronic psoriasis vulgaris while using omeprazole (letter)] Abheilung einer chronischen Psoriasis vulgaris unter Omeprazol. [NO ABSTRACT ONLINE] In: Dtsch Med Wochenschr (1993 Jan 12) 118(1-2):46 Rhett Drugge, M.D. -------------- ------------------------ ANTIMALARIALS ------------------------ The use of chloroquine in psoriasis isn't strongly contraindicated. Cyclosporine would probably work to control both conditions. Cyclosporine is the treatment of choice in combination with prednisone in renal transplants of ESRD for young women with SLE nephritis. It is preferred over azathioprine plus prednisone. The refs are all included Tokuda M Kurata N Mizoguchi A Inoh M Seto K Kinashi M Takahara J Effect of low-dose cyclosporin A on systemic lupus erythematosus disease activity. In: Arthritis Rheum (1994 Apr) 37(4):551-8 Lesavre P Bach JF Effects of cyclosporine in severe systemic lupus erythematosus. In: J Pediatr (1987 Dec) 111(6 Pt 2):1063-8 Thirteen patients with severe steroid-resistant or steroid-dependent forms of systemic lupus erythematosus were treated with cyclosporine (average dose 5 mg/kg/d) for an average period of 12 months. In eight patients the disease activity decreased, as substantiated by the reduction in the amount of steroid required to control the clinical manifestations. Interruption of cyclosporine treatment was associated with relapse or worsening of disease in five subjects. These favorable clinical results occurred in the absence of changes in the levels of antinuclear, anti-double-stranded deoxyribonucleic acid autoantibodies or plasma complement components; plasma IgG concentration increased significantly. Six patients had signs of moderate cyclosporine nephrotoxicity that disappeared when the administration of the drug was discontinued. Hypertension was the most serious side effect observed in eight subjects; in every case it was controlled by antihypertensive medicine. These data indicate that cyclosporine may be beneficial in the treatment of some patients with severe forms of systemic lupus erythematosus. Kuflik EG Effect of antimalarial drugs on psoriasis. In: Cutis (1980 Aug) 26(2):153-5 This study was undertaken to determine whether the use of antimalarial drugs is truly contraindicated in patients with psoriasis. Forty-eight patients in Vietnam were examined, treated, and tested. All had been taking prophylactic antimalarial medication, and some were given additional chloroquine in an attempt to elicit an exacerbation. Although in twenty patients (41.7 percent) the condition showed some degree of worsening from the antimalarial medication, in only three patients (6.3 percent) was there worsening without further improvement from topical therapy. The higher dosage of chloroquine caused no exacerbations. Due to the absence of severe exacerbation noted in this study, the use of antimalarial drugs is not strongly contraindicated in those with psoriasis. el-Shahawy MA Aswad S Mendez RG Bangsil R Mendez R Massry SG Renal transplantation in systemic lupus erythematosus: a single- center experience with sixty-four cases. In: Am J Nephrol (1995) 15(2):123-8 Rhett Drugge ---------- I've seen quite a few exacerbations of psoriasis with Plaquenil, chloroquine and also with diltiazem (which has a chemical structure similar to PLQ and CLQ), so I'd at least warn the patient that this could happen, and if there is a bad exacerbation of psoriasis MTX or CyA might be needed to get is under control. Abel et al: JAAD 5;1986: 1007-1022 review article Thiers: Geriatric Derm 3 (supp B);1995: 17B-20B review. According to Stuart Maddin's Skin Therapy Letter May 96 SDZ-281-240 0.1% and 1% cream has been effective in trial for psoriasis, and another derivative ASM 981 is being tried for eczema, so it looks like topical tacrolimus may have some competition. KC Smith MD FRCPC ---------------- The antimalarial/psoriasis issue is suspect, at least to me. I've treated similar patients with plaquinil with no flares of psor. I'd worry more about prednisone triggering pustular psor. Perhaps methotrexate or CSA deserves consideration too. Guy Webster ------------- ----------------------- MISCELLANEOUS ----------------------- I just saw a patient this morning who had absolutely intractable inverse psoriasis. He was completely clear. Here's what I treated him with this past month: Buspar 10mg po BID Psorcon oint mixed with Dovonex HS The reason I write: This is the third patient in a row who has cleared on this regimen.These are folks who nothing seemed to work on. Thanks to this group for the tip on Buspar. Haines Ely --------- Does anyone recall a recent published listing or review of the medications known to exacerbate psoriasis? A patient of mine came in with a "cure" which consisted of avoidance of dietary pork, taking red clover extract tablets, and avoidance of alcohol. The avoidance of alcohol I agreed with, but the rest...??? Walter H. Wood, M.D. -------------- One of my patients recently asked me about Exorex, an OTC alternative medicine treatment program for psoriasis, marketed by Caribe Farmaco International exclusive distributors. My impression is that it includes topical tar and banana peel extracts as well as psychological support. Has anyone had any experience with this or reports from patients about effectiveness? Walter H. Wood, M.D. ---------------- -------------------- METHOTREXATE -------------------- For the past couple of years I've been writing all MTX Rxs as follows: Take UP TO x tablets once a week instead of the old way: Take x tablets once a week. By simply putting in "UP TO" -- and instructing and encouraging the patients to take LESS if they can get away with it: * the rate of MTX consumption has fallen by 30-50% (my estimate), *the patients seem happier (perhaps because they are "empowered" and more "in control"; *and of course the risks are lower at the lower doses many of them feel their way down to. In fact, very few patients are taking the maximum prescribed dose (eg. 6 tabs once a week). They are motivated to minimize the dose, because at a cumulative dose of 600 tabs (1.5 grams) they have to go to the liver doctor, and have a liver Bx if he wants one. I still check an SGOT once a month, regardless of dose. How do the rest of you feel about this. Kevin C. Smith MD FRCPC ----------------- I like your idea of giving patients control to reduce their methotrexate dose. Philosophically, my goal with treatment of severe psoriasis is to balance the severity of the disease against the severity of the side effects of the medication. This is different for each patient, since they respond differently to identical levels of psoriasis. Thus, the idea of establishing a maximum dose and letting (encouraging) them to decrease it from there makes good sense to me. I tell them at a dose of 2Omg/week they are looking at a liver biopsy every year, at 15mg/week every 2 years, at 10mg/week every 3 years, at 7.5 mg/week every 4 years, at 5mg/week every 6 years and 2.5mg/week every 12 years. When we finish this conversation on MTX dose, I'd like to hear the group's opinion on home UVB phototherapy, another way to give patients control over their psoriasis. Steve Feldman, MD, PhD ----------------- Is there a GI discussion list we could pose the liver biopsy question to. Atleast at UW, they have been very reticent to do them recently. Do you feel the Rheumatological experience does not apply. I am in the habit of obtaining labs including cbc and plt after each dose increase-this might be a problem with the ups and downs of Dr. Smith's. Do the patients realize there is quite a lag time? I think home UVB is great, and I get the HMO to pay for the bulbs when the patients live too far away for PUVA etc in town. It is also nice for older people-they can avoid snowy drives in Winter. Diane Thaler ------------ I do this once in a while too, but with the cavaet that they must not switch doses any more frequently than every three weeks or so. IMO psor responds too slowly to allow quicker dose changes. If they change weekly they won't ever be able to tell what dose controlled their disease. Guy Webster ----------- I think Guy is right that the dose shouldn't be adjusted more often than every 3 weeks -- but having said that I've got maybe 100 patients running their own MTX and I've never told them to stick to the same dose for 3 weeks before changing and they do fine. I tell them that if they see a problem coming that they know will flare the psoriasis (eg. stress, URI) they may wish to increase the MTX pre-emptively (but I don't use big words like that with patients) to GET AHEAD of the problem -- eg. "If you are pretty sure it's going to flare, don't WAIT for trouble, just go ahead and increase the MTX right away to get ahead of it - the TOTAL long term dose will usually be LOWER that way." They seem to grasp that concept, and like I say, as a practical matter this approach works for me. It would be interesting to compare a couple of practices (eg. Guy's and mine) to see which way gives the lowest long term rate of MTX consumption. I don't have any idea how that would turn out. Kevin C. Smith MD FRCPC --------------- saw a 20 yr old female yesterday with a 2 year history of rapidly progressive type of extensive plaque psoriasis affecting large proportion of the scalp right up to hairline (50%),face esp forehead(30%), both ant and post chest wall, upper limbs (30%) lower limbs (35%), suprapubic right up to the genitalia. also have disabling arthritis for 1 year affecting both knees and MCP joints both hands. right index finger MCP swelling with fixed flexion deformity. She have tried various topical therapy (topical steroids, tar, etc ) and indomethacin. Surprisingly, there is no family history of psoriasis . neither does she have recurrent tonsillitis. Any help from the group is much appreciated. thanks. henry foong mrcp -------------- If resources are available and if there's no contraindication the combination of cyclosporine about 3 mg / kg with methotrexate 10 - 15 mg po once a week can be very effective and well tolerated. The two meds are synergistic, and this allows you to use relatively low doses of each. Topical meds like Dovonex and topical corticosteroids should of course also be used to reduce the long-term need for systemic medications. I also give 1 - 2 mcg of one-alpha-vitamin-D qhs to patients like this. *One-alpha is cheap, *its not metabolically active until it is processed in the liver to 1,25-OH-D3 (so there's none of the direct stimulation of calcium uptake from the gut that you get with calcitriol (Rocaltrol), and *giving it hs further decreases the effect on calcium uptake. Kevin C. Smith MD FRCPC ---------------------- 1. When there is arthritis with psoriasis, I usually let the rheumatologists treat the arthritis. If they use methotrexate, it makes my job of controlling their psoriasis a lot easier. 2. If they do control the arthritis (whether with MTX or non-steroidal antiinflamatories [or with prednisone for that matter]), I still pursue a stepwise approach to the treatment of their skin disease. a. Get them in the National Psoriasis Foundation (at least in countries where it's available) b. Use topicals (this patient's disease is too extensive for topicals alone) c. Ultraviolet B (or day treatment if necessary). This is very safe and effective and facilitates home UVB phototherapy for maintenance. And typically someone with such severe psoriasis at a young age will need some type of maintenance regimen. d. PUVA with or without etretinate (etretinate would be contraindicated in in a woman of childbearing potential). e. Methotrexate. If the rheumatologist put the patient on this for their arthritis, I would still prefer for safety reasons to add UVB than to increase the methotrexate dose to control the skin eruption. f. some combination of above. g. I haven't needed to get comfortable with cyclosporin yet, but it's certainly on the list. Also, for the eruptive nature of this patients disease, I would consider a long-course of antibiotic with staph/strep coverage in the event that somehow it triggered the onset of the disease. Steve Feldman, MD ------------ I would consider the use of sulfasalazine or methotrexate as long as she doesn't plan pregnancy anytime soon. Both of these drugs are helpful in arthritis and the skin manifestations. UVL (PUVA) is a consideration for the cutaneous plaques, but is not too good for the arthritis. Think about consulting with a rheumatologist who may be very helpful in choosing a systemic treatment. Jay Barnett ---------- The severe joint involvement is clear indication for methotrexate. It is getting clearer that "remission-inducing" therapies for inflammatory joint diseases improve the long-term function of patients. Check her HIV titer first, it could have precipitated the psoriasis. Guy Webster ------------- Thanks for all your invaluable comments. I looked up the methotrexate in psoriasis: revised guidelines (JAAD 1988;19; 145-156) again and I found that 'age' is not a relative contraindication. I have always in my practice avoid using methotrexate in young patients. The other unusual indication mentioned is 'Psoriasis that affects certain areas of the body so that economic employment is prevented' Can anyone comment on this? Henry Foong MRCP -------------- ---------------- ANTHRALIN ---------------- The new anthralin product I heard about is Micanol. I used to be very happy with anthralin until something less messy (Dovonex) came out. If the new product is less messy as advertised (and still effective), it will help me. As soon as it was available, I prescribed it to several patients. They haven't returned for follow up yet. When I know more, I'll let you know. If anyone else has some feedback already, I'd love to hear it. Philip Hughes -------------- I've given it out to about 25 patients so far so feedback should be forthcoming soon. I have so far had one patient report a significant irritant reaction to daily use x 15 minutes, so I'm starting at 15 minutes every other day and titrating to tolerance. Hope this stuff is anywhere near as good as they suggest, since scalp psoriasis remains the bain of my practice (at least until tazarotene, I hope). Mark Ling, M.D., Ph.D. -------------- Micanol is fine as long as you don't wash it of yourself with warm water (that melts the base and releases the Anthralin in a form that stains), use cold water instead. I believe full instructions are in the box. - John Uhlemann ------------ ----------------- TAZAROTENE ----------------- Dr. Ling mentioned he is awaiting the releast of tazarotene. What is it please? Barbara R. Reed, MD -------------------- THE JOURNAL OF INVESTIGATIVE DERMATOLOGY Volume 106, Issue 2, February 1996 Tazarotene-Induced Gene 1 (TIG1), a Novel Retinoic Acid Receptor-Responsive Gene in Skin Nagpal, S., Patel, S., Asano, A.T., Johnson, A.T., Duvic, M. and Chandraratna, R.A.S. page 269-274 THE JOURNAL OF INVESTIGATIVE DERMATOLOGY Volume 106, Issue 4, April 1996 TIG1 and TIG2 (tazarotene induced genes 1 and 2) are novel retinoic acid receptor-responsive genes in skin. Nagpal, S., Patel, S., Asano, A.T., Johnson, A., Duvic, M. and Chandraratna, R.A.S. page 818 G. Rialdi ------------ ------------------ PHOTOTHERAPY ------------------ I have had several patients successfully use tripsoralen for tx of large plaque parapsoriasis with sunlight or tanning beds(horror). In a state such as Oklahoma one has to adapt to the fact that many people will come to see you that live 2 and 3 hours away and can't make the 3 hour trip to your office three times a week. The usual starting dose is 10mg(very conservative) and the light exposure modified by skin type but I will usually begin at 10 minutes of 11-2 sunshine or 20 minutes of after 4pm-using this hour minimized the UVB effects and emphasizes the UVA. These times would have to be conservatized for the tropics of course. I subscribe to the usual eye and skin protection regimes after tx. With tanning beds I tell the patient to start out at 1/3 to 1/2 the time recommended by the owner for tanning and increase 5 min a week as tolerated. With sunlight I increase 10 minutes a week to a max of 30 minutes(45 after 4). I have not seen a photo-toxic reaction and have successfully managed several long distance patients in this fashion. This routine was passed on to me by Dr. Mark Everett at Ok U. L.J. Gregg,MD, --------------- In the Philippines, a developing country, a majority of our patients cannot afford to use a PUVA box or cannot find a facility which has one. We have abundant sunlight which is free. Do you think it will help to advise a patient when they expose themselves under the sun to be under a piece of window pane glass? As I recall a ordinary piece of glass can reflect the UVB spectrum? Jonathan Nevin Yu, MD ---------------------- I have been waiting for years for manufacturers to make a cheap hand held photometric device which could be used to measure the accumulated dose of UVA, UVB, and UVC while lying in the sun or under a glass UVB filter. At the designated dose, a beep would tell the patient to turn over and reset the device. This sounds so obvious to me that I am amazed they are not in every drug store already. Patients should have their minimal phototoxic UVA and UVB dose measured by the dermatologist, and then adjust UVA doses based on the individual measurements rather than on some arbitrary time based on skin type. Walter H. Wood, M.D. -------------- ------------------ MISCELLANEOUS ------------------ Would appreciate any suggestions regarding future treatment for the following patient. Pt. is a 42 y.o. obese female whom I've been treating for psoriasis for about 10 years. She has a history of hypertension and diabetes. Initially she was reasonably well controlled with PUVA therapy, but this became less effective and pt. suffered from panic attacks at the time of treatment. She was then well controlled on methotrexate, but eventually dose had to be increased to 30 mg. per week and most recent liver biopsy showed early cirrhosis. Gastroenterologist felt mtx needed to be discontinued. Her plaque type psoriasis has flared significantly and currently I'm treating her with topical dovonex and temovate as well as buspar 10 mg. BID. I've thought about using 6-thioguanine, but have had minimal personal experience with this drug. I might be able to convince her to try PUVA again with anxiotolytics and distractions (such as music with ear phones). Any help would be most appreciated. James G. Rothschild, M.D. ---------------- I just had a patient exactly as you describe. I started D&D (Diflucan and Duricef) three weeks ago as has been suggested (by Dr. Litt or Eisner?) and she called to say that she wanted off of methoxate as her psoriasis was almost gone. By the way, I gave the same cocktail to a patient with the most macerated odiferous intertrigo ever (I could barely be in the room to write out the rx), and, 7 days later her skin is completely normal! Which leads me to ask: how do all of you maintain your obese intertrigo patients, once they are clear. Any favorite recipes? Diane Thaler --------- I'd put a cautious vote in for 6-TG, with some concerns of course over long-term toxicity and the relative dearth of experience. Cyclosporine is of course a phenomenally effective drug, with relatively little short-term toxicity. It's just a question of what you're going to do in a year or so. On a related subject, I'm very interested in getting info on any case of MTX-related liver damage. If you get a minute, I'd love to get info on cumulative dose, other liver risk factors, grade of hepatic fibrosis on biopsy, compliance, and alcohol use, to name a few. I'm trying to begin to assemble a "registry" of such cases, but don't have it set up yet. To avoid cluttering up the list feel free to email me directly if you are interested. Thanks! Mark Ling, M.D., Ph.D. ------------------- I have music in all my UV light rooms - distracts patients from the white noise of machines and the disorientation goggles can cause. one-alpha-vitamin-D ***1 mcg ***- 1 or 2 hs can be helpful, as can *ranitidine 300 bid, *enteric coated-sulfasalazine 1 gram tid (I have lots of people taking this with PUVA / UV-B and no on has got photosensitivity yet), and the addition of *Accutane or etretinate to her UV program (if her lipids and contraception will permit). Metoclopramide (Maxeran, Reglan) 5 mg - 1 or 2 with psoralen can settle the stomach nicely and permits some people to continue PUVA. Are the panic attacks related to the psoralen? Try a few treatments without the pills to answer that question. 6-thioguanine is fantastically expensive here in Canada - you'd better get a price and find out about her drug coverage before you Rx. Topical FK-506 will be in phase 3 in January - try to get some from Fujisawa for her. Kevin C. Smith MD FRCPC ------------------- Before using 6TG, Goeckerman treatments may be worthwile. Steve Feldman, MD ---------------- Re: "Difficult Psoriasis-JGR/Arizona Difficult indeed, esp. if pt has renal insufficency due to the diabetes. Consider: Evaluation of BUN/creat/creat clearance If normal: low-dose CsA (Neoral) @3-5 mg/kg tapered to lowest effective dose. Use ACE-inhibitors for any HTN as they will also 'protect' the kidneys from rapid damage and from diabetes (to some extent). Weight loss is a must for both diabetes AND psoriasis: as you know, obese psoriatics don't do well. Good luck. Does patient still have tonsils OR is there any other site or focus that could represent Strep with "internal Koebnerization."? If so- remove them (not yourself- an ENT doc). Consider rotational therapy with CsA and Tegison, watching the triglycerides as the diabetes will elevate them on its own. Patrick Carrington, M.D. --------------------- Have you considered re-PUVA? I've had dramatic success in every pt, with equally dramatic side effects, including sticky skin. But they seem to improve so fast that, by the time the side effects peak, they are much better and it's time to discontinue the tx anyhow. Dan Mitchell, MD ---------------- Why haven't you put her on etretinate? If her triglycerides are high, you might add lopid. Some of our obese diabetics are doing well and losing weight on acarbose. Yelva Lynfield, MD ------------------- on 10/22/96, James G. Rothschild was asking about further treatment suggestions for a 42 y/o obese female with resistant psoriasis. Assuming that she doesn't clear on Diflucan and Duricef...don't forget retinoids (etretinate 25-50 mg/day) and cyclosporin (5 mg/kg starting dose, decrease to 2 mg/kg or less). Make sure she has not recently started taking one of the psoriasis-worsening drugs such as lithium, non-steroidal antiinflammatory agents, beta blockers, others? Pay attention to any drugs whose first use was coincident to the most recent exacerbation. If you got her to lose weight (probably the most difficult of all prescriptions to write) she would improve considerably. I always thought it was an interesting observation that there was little if any active psoriasis in people who were being slowly starved to death by the Nazis in the death camps (or at least that is the rumor that I have heard). Just some thoughts. Mark Naylor, M.D. -------------- I guess tar plus UVB would be out with her panic attacks in the light box. What about cyclosporine Rx (if she hasn't had so many PUVA treatments that skin cancer would be a worry)? How about 585 nm pulse dye laser therapy (just kidding)! Philip Hughes, M.D. ----------------- Remember though that topical FK-506/tacrolimus is being tested for atopic dermatitis, not psoriasis, and to the best of my knowledge there is not an active IND for psoriasis currently. Doubt you'll be able to get it. Mark Ling, M.D., Ph.D. ------------------ I've seen psoriasis with various ACE inhibitors, and I've had people switched to Losarten (Cozaar) (which is acts by a different mechanism) and so far -- no problems (~3 months experience, ~3 cases). Kevin C. Smith MD FRCPC --------------------- I recently had a new PUVA patient suffer severe dizziness from Oxsoralen Ultra on two occasions but has done fine on a higher dose of 8-MOP subsequently. Any comments? It really puzzles me. Philip Hughes, M.D. ------------------- Was it prior to entering the light box where vasodilation can produce syncope? If so, then 'No' I haven't heard of dizziness to Oxsoralen-Ultra vs 8-MOP. I'll be on the lookout for it. Patrick Carrington ----------------- I think one of the Jerry's is the expert here, but I use it in psoriasis and intertrigo . The dose I use has varied from Duricef 500 BID to qd, and Diflucan 200 BID to qd. I would like to find out as well what the duration of rx in psoriasis should be after clearing, as one of my patients has demanded a maintainance dose now that she is clear and lives in fear of the psoriasis returning! PS I do not think this treatment will work in everyone. Diane Thaler --------- The so-called D&D cocktail is an "invention" of Drs. Walter and Dorida Shelley of Toledo who have been treating recalcitrant cases of psoriasis (and other dermatoses) with Diflucan (fluconazole) 100 mg daily along with Duricef (cefadroxil) 500 mg bid. Their results have been excellent when all else fails. My results have been similar. I often change Diflucan to either Lamisil or Sporanox, and will substitute erythromycin for the Duricef. Patients are kept on this regimen for several weeks and the doses of each drug reduced slowly. Jerry Litt -------- Using Retrieve It! this morning in about 5 minutes I was able to find 19 patients (7 women and 12 men) with difficult psoriasis who have tried Buspar (buspirone) up to 20 mg bid for psoriasis over the past 6 months. In asll cases Buspar was simply added to the existing treatment program (eg. methotrexate, Dovonex, topical corticosteroids, PUVA, UV-B). Only 2 patients were sufficiently pleased with Buspar to continue with it (and most were started in June and July, when one would expect psoriasis to be improving anyway). Bottom line: no problems (except one man got dizzy and stopped Rx for that reason.) A few transient responses which were encouraging, but only 2 possible sustained responses. Buspar is not reliable or effective enough for me to continue trying it for psoriasis. Kevin C. Smith MD FRCPC ------------------- Is she still fertile ? If not, Tegison. Michael Fetterman --------------- A patient asked me about a product called Dermalight Psora-Comb, marketed by Uvatec, Inc., 13425 Ventura Blvd, #101, Sherman Oaks, CA 91423 for $490* insurance reimbursable (sic) Does anyone know anything about this? How does it compare to Skin-Cap spray?? Barbara R. Reed, MD ------------------ I have used PSORACOMBS for refractory psoriasis for several years. The patients use them as an in office phototheapy modality daily.It takes about 6 weeks to clear most.I have a few whom I have taught to use at home.I also use the NBC HANDISOL unit.It is more powerful and has a built in timer and shuts off automatically.I feel this is a must for a home use phototherapy device. Bob Aylesworth ---------------- A patient with localized plaque type psoriasis tells me he's practically = cleared with this 'research' product called Burdock folate lotion that = he mail ordered from some company called Total Research in Taylor, MI. = He had tried super-potency steroid that we gave him in the past with = minimal improvement. =20 Has anyone heard of this product or has experience with it? What is it, = anyway. Mychael Luu --------------- I don't know about this product, but burdock root is an oriental vegetable also called Gobo in Japanese cuisine. gary salenger -----------