GETTYSBURG MEDICAL NEWS
THE CLINICAL VIEW
By: Phillip E. Hoffsten, M.D.
24 February 2000

PSORIASIS

A gentleman was recently seen in the clinic with concerns about a rash that had developed over the previous several years. The rash tended to occur on his elbows and his knees and occasionally around the belt line. Sometimes the rash would become quite red and inflamed and very scaly. Sometimes it would crack and bleed in addition to being very itchy. He had noted that if he got a bruise or an irritated area that this would tend to develop a scaly, itching plaque in addition. The problem seemed to get better in the summer but he had never been completely rid of it. He was seen because he was concerned about the nature of the rash and because the problem seemed to be getting worse and becoming more objectionable. He mentioned that on one occasion when he went swimming in the local pool, the lifeguard raised questions as to whether or not he had a contagious skin disease. This had resulted in significant self-consciousness and embarrassment on his part. He was now reluctant to be in a situation where his skin was exposed.

This is a classic story consistent with an individual who has psoriasis. As with all of the clinical case examples mentioned in these columns, this person is a composite of several different individuals and not a single person that would be identifiable in our community. Nonetheless, this composite exemplifies the type of problem that individuals with psoriasis have.

The individuals are usually adults over age 16 and sometimes having the condition develop when they are in their 5O’s. Both men and women have an equal incidence of the disease. It tends to be improved in the summer with greater sun exposure and it tends to get worse in the winter with less sun exposure. Many years ago, Dr. Koebner noticed that individuals with psoriasis tended to develop plaques of red scaly rash in areas where the skin would be irritated such as around the belt line, on the knees or on the elbow or if an injury occurred some place. This is now known to physicians as “Koebner’s phenomenon”.

Unfortunately, some people that have psoriasis also develop an arthritic condition in which the ends of the fingers become quite involved. Frequently, the fingernails will have pits and be very brittle.

Many times individuals with psoriasis are not really aware of the diagnosis. They simply know that they have red plaques that develop intermittently. This condition can be effectively treated. Even individuals with more than half the body covered with plaques can be completely cleared of psoriasis with various medications.

For those individuals with relatively little involvement, the use of a steroid cream applied locally several times a day can be very helpful in alleviating the itch and irritation that comes from a psoriasis plaque. Steroid creams are rarely effective in completely resolving the plaque but can definitely decrease the irritation and itching that comes with the psoriasis plaques

An over-the-counter medication called Exorex has been found by many patients to be effective in alleviating the plaques of psoriasis. Exorex is two different creams. One is applied to help the plaque be resolved and the other is applied to help keep it gone. I have several patients with this condition who use nothing more than this. This product is available through your local pharmacy without a prescription.

Another cream preparation that can be very helpful is called Dovonex. This is an ointment that is applied twice daily over the psoriasis plaques. It is a vitamin D like product that slows down the rapid growth of the skin which causes the psoriasis plaque. Dovonex is unfortunately relatively expensive.

There are medications that can be taken by mouth the most common of which is Methotrexate. Methotrexate does have significant side effect problems but can be safely used if supervised by a clinician. Methotrexate is taken most safely as three doses 12 hours apart once a week. As an example, the individual would take two pills on Saturday morning, two pills Saturday night, and then two more pills on Sunday morning. The use of 15 mg per week of Methotrexate has not been associated with side effects in my experience. We are nonetheless very respectful of this medication and monitor blood and liver tests to insure that side effects do not occur. Usually the psoriasis condition will resolve in the course of two to six weeks after the medication is started and will remain gone as long as the medication continues to be used. Higher doses may be tolerated in some patients if needed.

More cumbersome and certainly more expensive than the use of creams or pills, is the use of ultraviolet light therapy. The ultraviolet light therapy is very effective when used with a medication called Psoralen. The person takes the Psoralen pill and then sits in the ultraviolet light. The Psoralen sensitizes the individuals skin to the ultraviolet light and very effectively treats the psoriasis.

Unfortunately, psoriasis is basically a hereditary condition. If both parents have the condition, there is a 40% chance that their children will have it also. If only one parent has the condition, there is about a 10% chance that their children will have the condition. It has what is called variable penetrance. This means that even though the person may well carry the gene for psoriasis, it does not necessarily express itself with skin plaques. Even if it does express itself with skin plaques, it is not predictable as to where these will develop, how long they will last, or what seems to precipitate the problem other than local trauma to the skin. Thus, unfortunately, if the persons rids themselves of the psoriasis plaques and then medications are stopped, the likelihood of recurrence is substantial and prolonged preventive treatment is going to be necessary.

When the above methods are ineffective, there are additional measures that can be taken probably best supervised through a specialist, a dermatologist. Your local clinic can be very useful in helping with the diagnosis of psoriasis and suggestions for therapy which is effective in the vast majority of cases. 

As a closing note, I recently received an inquiry as to whether or not individuals mentioned in these columns gave written permission for use of the information in regard to their case. As I mentioned above, the clinical examples used in these columns are provided for illustration purposes only. They do not represent one particular individual but rather are a composite of signs, symptoms and clinical course that exemplifies the condition being discussed. I know that it is very easy to identify with various aspects of the some of the cases and think that perhaps they are being used as an example in these columns but that is not the case nor the intention. Please do not ever believe that a person is being singled out as an example in these columns.