Treatment
Ask the Expert

You've got questions? We've got answers—from the leading psoriasis and psoriatic arthritis experts around the United States who serve on the National Psoriasis Foundation Medical Board.

In each issue of our member magazine Psoriasis Advance, we present medical and treatment questions answered by these experts in the popular column "Dr. Tell Me." By reading the questions and answers below, you'll see how our specialists answer those specific tough questions that you can't seem to get answered anywhere else.

Use the links to find questions and answers grouped by topic.

Alternative treatment	Associated diseases & conditions	Combination therapy
Psoriatic arthritis	Psoriasis on specific skin sites	Steroids
Topicals	Triggers	Systemics
Youth

Alternative treatment

Q: Has anyone heard of acupuncture being used to treat psoriasis?

A: Yes, I have heard of acupuncture being used for psoriasis with some success and have indeed personally observed this in China. However, with the excellent creams and ointments together with various wavelengths of ultraviolet light and oral medications we have available, in most instances psoriasis should be significantly improved. If not, be sure to consult with an expert in acupuncture—someone who has had experience in treating psoriasis.

Associated diseases & conditions

Q: I am a 34-year-old woman who has been using clobetasol propionate cream for the past approximately 10 years to treat my guttate psoriasis. Clobetasol propionate cream seems to be the only medication I have found that helps my plaques (which are on all areas of my body). In the past, I tried Dovonex without success. I was recently diagnosed as a "glaucoma suspect" and am curious if perhaps there is an association between long-term clobetasol propionate cream use and glaucoma. If there is an association between the two, can you suggest any other medication(s) that I can discuss with my doctor to treat my psoriasis?

A: Prolonged use of topical steroids around the eyes can result in glaucoma as well as cataracts. Superpotent topical steroids should not be used around the eyes. Psoriasis patients with guttate psoriasis tend to have a very good response to increasing increments of ultraviolet B light. In general, it is impractical to treat patients with moderate to severe psoriasis with topical steroids.

Q: I have heard that the colon affects psoriasis. What research has been done to prove any connection between colon conditions and psoriasis?

A: I know of no correlation between colonic health and pathology with psoriasis.

Q: I have had psoriasis for 20 years (since age 7). I also tend to catch illnesses easily (colds, flu). Is there any connection between the immune system causing psoriasis and resistance to illness?

A: Actually, patients with psoriasis have a statistically significant protection from a variety of infections (Henseler T and Christophers E, Journal of the American Academy of Dermatology 1995; 32:982-986). However the magnitude of this effect is relatively small (approximately 5% reduction). This is thought to be due to the proficiency of T lymphocytes found in psoriasis skin lesions (so-called Th1 lymphocytes) in clearing infected cells. The fact that your case goes against this trend is not surprising, as there is much variation between individuals, and the study quoted averages over thousands of people.

Q: Since developing psoriasis 9 years ago at age 45, I have started to develop bone loss around the teeth requiring several gingivectomies. Is there a connection?

A: Periodontal disease is a rare finding in psoriasis, so I doubt whether there is a connection. For a recent review of this subject, see Brice DM, Danesh-Meyer MJ. Journal of Periodontology 2000; 71:1896-903). For a case report, see Yamada J et al., Journal of Periodontology 1992; 63:854-7).

Q: Can having severe psoriasis cause dehydration? I have all the signs of dehydration and it seems no matter how much fluid I drink, I am still dehydrated.

A: Psoriasis can definitely increase the loss of water across the skin, which is the major source of water loss in the body to begin with. You should use emollients liberally, as they help to reduce water loss across the skin. However, if you drink coffee, tea or alcohol, these can also cause dehydration.

Q: Can psoriasis occur inside the body, for example, on an organ such as the lungs or the liver?

A: In the majority of people, psoriasis involves only the skin, sometimes the scalp and nails, and rarely the mucous membranes. A minority of people, and particularly a minority of affected children, has associated problems with joints, called psoriatic arthritis. No other organs tend to be involved.

Q: Cancer is often defined as the unregulated reproduction of malignant cells. Psoriasis is characterized by the unregulated reproduction of cells. Is there any connection or increased probability here?

A: You are right to say that both psoriasis and cancer are overproliferation of cells. The key difference is that in psoriasis the overproduction of relatively normal skin cells is totally benign, producing the thick plaques and scaling but no malignancy. In cancer, the over proliferation of cells are abnormal and malignant, which means that they are capable of spreading to other body organs and causing problems. Patients with psoriasis have no increased incidence of cancer.

Combination therapy

Q: Can cyclosporine be used in conjunction with ultraviolet light? Also, I stopped using cyclosporine, which I was on for several months with very good results, and am now back on UVB treatment, and it seems like I am not responding as well to the light treatment as I usually do. Can cyclosporine reduce the effectiveness of ultraviolet light?

A: Patients with an acute psoriatic flare clearly benefit from cyclosporine. However, the U.S. Food and Drug Administration only approves of cyclosporine use in psoriasis for up to one year. So, in a "crisis" cyclosporine is very useful. The question in management is where to go next. What I find effective is to add Soriatane to the cyclosporine. As the patient improves, gradually taper the dose of cyclosporine while initiating ultraviolet light. In direct answer to your question, cyclosporine can be used with ultraviolet light, and I do not believe cyclosporine reduces the effectiveness of ultraviolet light.

Q: My dermatologist suggests a combination of light therapy and methotrexate. I found in the Physician's Desk Reference that this combination should not be done. Should I refuse this treatment?

A: This is an interesting question. The concern here is that because methotrexate inhibits an enzyme involved in DNA synthesis, and because phototherapy can damage DNA, that there could be a risk of increased DNA damage with this combination therapy. Actually, there are no studies documenting that the combination of methotrexate and UVB is either safe or unsafe. There is one study suggesting that the combination of methotrexate and PUVA is safe and effective (Journal of the American Academy of Dermatology 1982; 6:46-51). Before discarding this therapy, I suggest that you discuss your concerns in more detail with your dermatologist.

Psoriatic arthritis

Q: I have psoriatic arthritis. I have had just about every major joint injected with steroids. My left knee has been injected six times total since 1992, most recently four months ago. It has swollen up again and my doctor told me I could have an unlimited number of injections per joint. However, I have heard conflicting information as to the number of times a joint can be injected. Any recommendations?

A: There is no doubt that injecting steroids into a joint affected with psoriatic arthritis will produce a good improvement. There is no hard and fast rule as to how often the joint can be injected any more than how often steroids should be injected into plaques of psoriasis on the skin. The development of atrophy and thinning that may be seen from steroid injections in the skin is not directly related to similar findings in joints of psoriatic arthritis that have been injected with steroids.

Q: I am a 37-year-old female who has had psoriatic arthritis for approximately 11 years. I treat the arthritis with naproxen and 12.5 mg of methotrexate once a week. I have been on methotrexate on and off since 1991. I now have two discs in my lower back that are causing some radiculopathy in both legs and feet. My neurosurgeon thinks that the cause of the degeneration is the arthritis and is reluctantly thinking about a double fusion to stabilize the lower back. Should I go off the methotrexate before this surgery and, if so, how long before surgery can be considered?

A: It does appear that you have degeneration in the disc of your back. If your neurosurgeon is considering a back fusion, I would personally discontinue your methotrexate for two weeks, which is the same advice I give everyone undergoing significant surgery. Thus, one week before the operation plus the one week after the operation should alleviate concerns that surgeons usually have about slow healing, infection, etc. There is, however, really no evidence that methotrexate will cause problems with the surgery, provided your blood tests are normal.

Psoriasis on specific skin sites

Q: I am currently on my second week of Soriatane and the dry skin is driving me up the wall. Can you recommend anything for dry skin, scalp and lips?

A: I recommend Carmex or Blistex over Chap Stick for dry lips. For dry skin, try applying about a tablespoon of apricot kernel oil to wet skin right after bathing, then dry off. In my experience, plant oils are superior to mineral oil for moisturizing. For your scalp, Derma-Smoothe FS (a prescription medication) contains peanut and mineral oil along with 0.01% fluocinolone acetonide (a mid-potency steroid), and this may help you to moisturize and suppress your psoriasis at the same time. Cool to tepid tub baths can be very soothing, with or without Aveeno bath (oatmeal extract).

Q: Are there any concerns or cautions about applying certain types of ointments and creams to specific areas of the body? For example, is it acceptable to apply Fluocinonide, Desonide, Hydrocortisone, tar or salicylic acid to the groin or behind the ears?

A: Areas of thin skin such as the groin, armpits, buttocks and breast folds are sensitive to regular use of cortisone creams, especially the stronger ones. It is important to consult with your dermatologist as to the comparative strengths of the cortisone preparations you are using. Thus, too strong a steroid will cause thinning and even bruising and stretch marks if used too frequently in body folds. There are some newer noncortisone creams (Protopic or Elidel) that do not have this side effect and may be helpful in these areas.

Q: Since this outbreak of psoriasis on my face, my skin itches and lines have appeared on my face. I was wondering if anyone else has had this facial dryness and what they did for it. I am allergic to many things, including vitamin E, aloe and vitamin C.

A: Psoriasis is not uncommon on the face and may indeed cause sufficient dryness to produce itching and temporary lines on the face. Because of the inflammation associated with psoriasis, many cream-type preparations may sting or burn without you specifically being truly allergic to the cream. Using prescription creams on the face (e.g., weak cortisone creams or prescription noncortisone creams) together with a more moisturizing/emollient over-the-counter cream (not lotion), such as Cetaphil or Eucerin, should help alleviate your problem.

Q: I have psoriasis in my ears and I have a reaction to the plastic in my hearing aids. Are there any suggestions for the easing of this condition? I'm not sure whether the weeping/itching is due to the hearing aids, or is it just due to putting anything in my ears?

A: It is possible you are allergic to the plastic in your hearing aids; however I have a suggestion for you. Paint as much of the hearing aid as possible (the area which contacts your skin but that does not interfere in the performance of the hearing aid) with clear nail polish. Paint five coats; let each coat dry for a couple of minutes before the next application. See if this "barrier coat" helps. If not, get a prescription for Vytone cream [Iodoquinol, distributed by Dermik Labs, 800.727.6737] and apply a few times a week prior to putting your hearing aid in.

Q: Can psoriasis occur in the ears and cause hearing loss?

A: Lesions of psoriasis in and around the ear, particularly in the ear canal, can cause an accumulation of scaling. This scaling, when combined with normal ear wax, can sometimes produce the physical blockage of the external ear canal leading to some decrease in hearing. The simple cleaning of the ear canal with the home use of an ear syringe or having the ear canals cleaned professionally by a physician will alleviate this problem.

Q: My teen-age son has a lot of psoriasis on his face, especially around his eyes. He is very embarrassed by this, yet my doctor and I are worried about the continuing use of steroid ointments on the face, especially around the eyes. Is there any alternative?

A: Topical steroids have been the first-line agents for handling psoriasis, but are associated with a risk of local side effects, particularly thinning of the skin, and the face and fold areas (groin, armpits) are at greatest risk. In addition, topical steroids can penetrate the thin eyelid skin and can theoretically cause problems with the eyes, such as cataracts or glaucoma, with chronic use.

Two newer agents may be helpful for facial psoriasis and pose no risk of skin thinning or eye problems. Both are prescription medications. The first is a derivative of vitamin D3 called calcipotriene (brand name Dovonex), available in a cream or ointment form. The second is tacrolimus (brand name Protopic), recently available in an ointment. The only risks are that calcipotriene can cause irritation and tacrolimus is sometimes associated with burning or itching during the first days of application. Both are best applied twice daily.

Q: My 5-year-old daughter was just told she has psoriasis. Her feet are my main concern. There are sections under her toes that look like someone cut slits in the cracks. Sometimes she complains of how much it hurts her to walk.

A: Wearing shoes that fit well without causing friction may be helpful. There are also a variety of products available for treating the thick, cracking and often painful lesions of psoriasis on the feet.

One recommendation is to apply Super Glue (yes, the kind found in hardware stores) to the cracks. This can seal the crack, decrease the spontaneous pain as well as the discomfort with applying medication, help to speed healing, and decrease the risk of invasion by bacteria that leads to infection. Be careful when applying it, however, because super glue can stick your fingers together—get it just where you want it and let it dry for a minute.

Because the skin of the bottom of the feet is so thick—and even thicker with the psoriasis—low strength steroid ointments just will not do the trick. For active disease, I will tend to prescribe the superpotent strengths of steroids for up to two weeks, then often continue them more intermittently, such as twice weekly.

Tar solutions are also very helpful for the bottom of the feet. My patients get great benefit from soaking their feet for 20 minutes in a tar solution (one capful per cake pan of lukewarm water), followed by either a steroid ointment or thick emollient at night.

Steroids

Q: I would like to know if the Xenical medicine 120mg Orlistat (Roche) produces some type of reaction on psoriasis patients.

A: Xenical can alter cyclosporine levels in psoriasis patients; otherwise I know of no associations with psoriasis.

Q: If a person is using cyclosporine, is it okay to have a flu shot or some other type of immunization?

A: Cyclosporine works to some degree by suppressing immunity. Vaccinations may be less effective while taking cyclosporine. Some vaccines are made of live agents, which have been attenuated (which means made less active). These types of vaccines should be avoided while taking cyclosporine. If it becomes necessary to vaccinate due to high-risk situations, such as foreign travel to countries where disease is epidemic, it may be advisable to stop the cyclosporine for a short time around the time the vaccines are given. The cyclosporine can then be started again after a few weeks once immunity to the vaccinated agent has developed.

Q: My wife has been using several different topical steroid medications for years that are fairly effective at controlling her psoriasis. I have heard that oral steroids can lead to bone loss and possibly osteoporosis. Is this the same for topical steroids? Should my wife talk to her doctor about this?

A: It is very true that oral steroids can lead to bone loss, osteoporosis and many other systemic side effects. In addition, many patients with psoriasis who take oral steroids find that, although the psoriasis may very temporarily improve, the psoriasis can come back much worse than it was before and even sometimes in the more severe pustular form when the dose is reduced or stopped.

The use of topical steroids for psoriasis is generally considered to be safe and should not directly lead to bone loss or osteoporosis. Systemic absorption of steroids can occur if some of the more potent steroids are used in large quantities over large areas of the body and for prolonged periods of time. Children may be more susceptible to absorption of topically applied steroids than adults.

Systemics

Q: In regards to the drug Amevive: if it took 12 weeks of taking the drug in trial tests, does this mean that patients will have to take it for 12 weeks also and, if this is the case, how will a doctor be able to see a patient for 12 weeks in a row? It is difficult enough as it is to get one appointment.

A: As has been reported on this Web site, the FDA approved Amevive in late January 2003. It is so far the only biologic agent approved for psoriasis. The drug does have to be given in the doctor's office weekly, usually for 12 weeks at a time. It may be given by an intramuscular shot, usually in the arm or the buttock, or by a relatively quick intravenous injection. Amevive cannot be self administered by patients. Most dermatologists' offices that offer Amevive have developed mechanisms so that the patient can get in for the injection and out quickly. Although you do have to get a weekly blood test while on Amevive, you may not need to see the doctor for each visit, depending on the doctor's practice and the state laws about who can administer an intramuscular or intravenous injection. Check the National Psoriasis Foundation Web site for dermatologists in your area who have indicated they are going to prescribe biologics like Amevive.

Topicals

Q: What is the difference between Oxsoralen ultra and Oxsoralen, besides the price?

A: Oxsoralen ultra is better and more reliably absorbed from the intestinal tract. The peak effect of Oxsoralen ultra occurs at about one and a half hours after being taken, while with regular Oxsoralen it is two hours. Although the effect of these drugs is very similar, they are not interchangeable. You should be sure to let your doctor know if there has been a switch in your prescription from Oxsoralen to Oxsoralen ultra or the other way around, since this will affect the length of your PUVA treatment and the scheduling of your medication dose in relation to the time of the treatment.

A: Psoriasis on the scalp may become inflamed, particularly due to scratching and picking. If this takes place on the back of the scalp, one may develop lymph nodes on the sides of the back of the neck. These will usually not be very large unless the scalp truly becomes infected, which is not very common in psoriasis.

Most of the stronger cortisone creams such as clobetasol and Psorcon may cause thinning of the skin with prolonged usage. Thus, they should only be used for a couple of weeks at a time, and thereafter, only one to two days a week in addition to noncortisone creams such as Dovonex or Tazorac five days a week.

Triggers

Q: My mother had a breast biopsy and the doctor used lidocaine. She recently developed psoriasis. Have you heard of individuals reacting to this drug and developing psoriasis?

A: I have not heard of anyone "reacting" to lidocaine with psoriasis. However, individuals with a tendency toward psoriasis may not manifest it until triggered, and stress may be a trigger for psoriasis. More likely, the physical and psychological stress of having a breast biopsy "triggered" that latent tendency for developing psoriasis.

Q: I was diagnosed with a chronic yeast problem (candidiasis) for seven years. I also have psoriatic arthritis that developed three years after the beginning of the yeast problem. I have read that candidiasis could also cause psoriasis and arthritis. Once I eradicate this yeast problem, will my psoriasis and arthritis disappear?

A: It has been well known for years that infections can trigger flares of psoriasis in people who are susceptible. Many years ago, it was actually believed that psoriasis was directly caused by infection. Now we know that infections are just one of the many trigger factors which can be associated with a flare of psoriasis. Two of the common infections that are known to trigger flares are streptococcal (something as simple as a case of strep throat) and Candida, which is the usual cause of a "yeast infection." Treating the infection that may be triggering a flare of psoriasis usually helps, but it is not the case that the psoriasis is likely to disappear altogether upon treatment of infection since often there may be multiple triggers, or no identifiable trigger at all, for any particular flare of psoriasis.

A word of caution about yeast infections: common yeast infections with Candida include oral thrush and vaginal and skin infections. The skin form of yeast infections may show up as a rash in body folds, such as under the arms or breasts or in the groin. Because there is a form of psoriasis called inverse psoriasis, which can be present in these same areas and which may look very similar, it is important to make the distinction since the treatment is very different. Your dermatologist may take a sample of skin to look at under the microscope to clarify the diagnosis. Also, it is possible to have a combination of inverse psoriasis and yeast or another fungal infection at the same time, making the determination of an exact diagnosis even more important.

Youth

Q: Can a person's psoriasis have any affect on an immunization, such as a measles vaccination, so that the person is not protected from the disease?

A: Although psoriasis is considered an immune disorder, there is no evidence that it causes an immune deficiency or affects the ability to handle infections. A child with psoriasis who gets a measles vaccination is expected to mount a normal immune response.