Question:
I have been plagued with psoriasis for the past 15 years. For the first 10
years, I applied topical steriods that helped, but the disease grew
progressively worse. About 5 years ago, my doctor prescribed ultraviolet
light therapy that greatly improved my condition. In fact, if I was
conscientious and applied the steriods in conjunction with regular treatments
of UV, my skin would virtually clear. But usually, I am not extremely
conscientous and depending on the weather, my skin condition varies. Several
weeks ago my doctor discovered and subsequently removed a basal cell carcinoma
on my left arm. Since the cause of the basal cell could be the UV light, my
doctor has advised me that light therapy will increase my risk of skin cancer
and therefore no longer an option for my psoriasis treatment. Meanwhile, the
condition of my skin has deterioated. As an alternative, the doctor wants me
to begin the oral medication, Soriatane. From the information derived from the
brochure and the Internet, the side effects seem to outweigh the benefits of
this relatively new medication.
Therefore, I am left with the dilema which I am seeking advice. Should I opt
to begin taking Soriatane, knowing the potential side effects and not knowing
if it will help the condition, or should I continue to use UV treatments and
natural sunlight, knowing that I am at greater risk for skin cancer??
Answer:
Most of us are not
using monotherapies in psoriasis treatment these days. We should
talk about this a little further. Nothing astounding here, so if
you don't have a few minutes, just move on, that's okay.
Psoriasis needs to be attacked from as many standpoints as you can,
safely. Just as battles are usually not won with a single type of
military weapon, we often use two or three different types of
therapy (or more) in the same patient. We often ask the patient to
serve as her/his own control, by treating with one substance on the
right leg, another on the left leg, another on the right arm and yet
another on the left arm!! Then we watch over weeks and see what
happens. Nobody is like the last patient you treated. That is,
indeed, why they call this the "practice" of medicine. I practice
every day, and in three lifetimes could not learn enough to help you
all.
Take diet for instance. Shamedly, I know almost nothing about it!!
A year-and-a-half ago when I checked in here, I thought I was amidst
a bunch of kooks, there was so much dietary talk going on.
Vitamins, herbs, diets, all of which I thought was a bunch of
bulls***. Welllllllll, I've had to retract that piece of crow and
eat it many times, as reports continue to filter in that some are
helped by various concoctions of foods or non-foods. Now I just
skirt the question, out of ignorance. I still have a gut reaction
that they don't do a hill-o-beans for this disease, but I cannot
prove that. They are cheap and generally harmless, and if you want
to try the safe-sounding ones, do it!
As for medical treatment (as we so cavalierly say, until one of you
"herbalists" comes up with some "gimmick" like digitalis from
foxglove, or some miracle like yew bark for cancer, and we
"medical-ists" have to sit red-faced in the corner), we tend to use
toxic therapies in limited amounts, like topical steroids, MTX, UV,
neoral, others. But we've found out long ago that a little bit of
two poisons or three poisons, even, is better than pushing one
poison into a patient until we make them sick.
This is why we seldom use Soriatane, for instance, as a
monotherapy. Doing so means you have to push the patient to "sticky
skin syndrome," and severe hair loss, and I'm sorry, but most women
patients I know would rather have their hair than complete absence
of plaques. Just my trained observation.
We use topical steroids, basically, to make patients comfortable.
We know they'll do better for a while, but we know they will flare
(sometimes badly) when we discontinue them. We use Tazorac rarely,
but often combine it with a topical steroid.
We like therapies like anthralin and the newer form, micanol,
because there are no steroids in it, and we can us it in the SCAT
mode (short contact anthralin therapy) to decrease staining and
irritation (though it does work better when a little irritation is
produced.)
We often will continue UV light in lower doses while instituting low
dose Soriatane. This allows reduction of both agents, and
subsequent toxicities from either.
Get the picture? We try to make this damnable disease a little less
noticeable and the patients a little more comfortable and a little
less itchy, until the blessed researchers come up with a better
mousetrap, like the fusion protein vaccines just around the corner,
or who knows what else in the many pipelines around the world.
