To treat or not to treat... with coal tar
It's smelly, messy and often inconvenient. Yet some doctors and patients favor a modernized version of an older psoriasis treatment called the Goeckerman regimen that uses coal tar and ultraviolet light.
For many years, residing in sunny California appeared to be just what Honor Simpson's skin needed. Having plaque psoriasis since childhood, Simpson enjoyed a long remission she attributed to warm oceanside living.
But that all changed by 2003 for the now 67-year-old, whose home is just north of Santa Barbara.
"I don't know what happened, but I broke out in psoriasis on about 80 percent of my body," said Simpson, who grew increasingly frustrated and depressed when she couldn't find a dermatologist willing to administer the one form of treatment she knew would clear her skin.
The treatment? A once widely used method called the Goeckerman regimen that dates back to the 1920s. In its modernized version, it involves applying ointment or cream made from coal tar, a coal byproduct, to a patient's skin and exposing the patient to ultraviolet radiation with light therapy. They work together to clear the patient's skin. It's an intensive regimen, requiring daily treatment, usually over the course of three to four weeks.
As a child in Europe, Simpson was prescribed a similar regimen twice; it cleared her full-body flare both times within weeks. Despite the messiness and unpleasant smells that typically come with applying this treatment—not to mention the time commitment involved—Simpson is convinced it's the most effective for her psoriasis.
As a retiree who maintains her British citizenship—since she retired in 2003, Simpson and her husband spend six months of the year in England—she was able to receive a modernized version of the Goeckerman therapy in her homeland.
Worth the hassle?
Only a handful of medical facilities in the United States offer the modernized Goeckerman regimen for managing psoriasis—a far cry from the hundreds of centers that did so decades ago.
As newer treatment options have become available, most notably biologic drugs, physicians and patients have turned away from the Goeckerman regimen, which even proponents acknowledge can be inconvenient for patients.
Leading dermatologists disagree about its effectiveness, according to Dr. Warwick Morison, a professor of dermatology at Johns Hopkins Medical School in Baltimore, Md., who treats psoriasis patients at his 25-year-old photodermatology clinic. Morison, who, with a colleague, has studied the effectiveness of the Goeckerman regimen versus simply using narrow-band ultraviolet light B (UVB) to treat psoriasis, doesn't believe it's a treatment option worth prescribing.
"Having investigated it, I think that it's unpleasant and very time-consuming," he said. "I think the Goeckerman regimen is therapeutic, undoubtedly it is. It gives you reasonable remission for months. But is it longer than UVB alone? I know of no evidence of that. The remission with Goeckerman is about the same as with UVB alone."
Even so, some dermatologists and psoriasis patients like Simpson believe the Goeckerman regimen does indeed work well, particularly for those individuals who prefer not to use biologic drugs or simply can't due to their cost or because of existing health conditions. Some dermatologists believe that the combination of ointment or cream made from coal tar and ultraviolet light work especially well together to treat psoriasis.
"Sometimes when new treatments come along, everyone jumps on the bandwagon," said Dr. Thomas Anderson, medical director of the Day Treatment Center and associate professor of dermatology at the University of Michigan Medical School in Ann Arbor, Mich. "But Goeckerman has a lot of advantages over biologics. One of the biggest ones is that you're not on it forever."
'No question it's effective'
Simpson wasn't comfortable using a biologic drug to combat her psoriasis. "Even though I was over 80 percent covered, because my psoriasis lesions were very thin I was able to use a product that resembles a thick creamy moisturizer containing…a coal tar solution," she said. "This product cleared 90 percent of my psoriasis within three weeks. It has an aroma similar to Vick's VapoRub and (the unpleasant smell) was not an issue for me."
Jim Cole, 40, of Plymouth, Mich., has been a patient at the Day Treatment Center in Ann Arbor for the past 22 years. To manage his guttate psoriasis, Cole typically visits the center once a year for a three-week period. He lives within 20 miles of the center and takes disability leave from his job in human resources to have the therapy.
"There's no question it's effective for me—I definitely swear by it," said Cole, who spent time at the center this past spring. "Right now you'd be hard-pressed to see any psoriasis on me."
Cole also has been taking the biologic drug Enbrel for the past four years and does outpatient phototherapy two to three days a week, though he lowers the dosage of these two therapies come summer when his skin generally is clear because of the greater amount of natural sunlight.
"Almost like clockwork the psoriasis creeps up on me during the colder months. He credits Enbrel for clearing his skin. "In conjunction with the modified Goeckerman…it helps maintain me for a solid six months."
Given how well the treatment works for him, Cole isn't bothered by the messiness and unpleasant smell that comes with the daily coal tar application.
Anderson would like more patients like Cole to consider using Goeckerman therapy. The three-week, tar-and-light treatment is intensive, but provides quick relief for many patients, allowing them to don shorts and participate in summer activities without being self-conscious about skin plaques.
"We treat on a daily basis five to 10 patients and we're looking to expand as word gets out and patients are starting to understand that biologics either aren't working for them or they are looking at other options," he said.
A less costly option
Anderson points to a recent article in the International Journal of Dermatology that stated the average course of biologics is $22,000 to $59,700 per year, while Goeckerman therapy costs $10,000 to $12,000. The Day Treatment Center works with insurance companies and payment plans can be established for those without coverage, he said.
"The institution has always tried to work with patients to set up payment options and do whatever we can," he said. Patients come from throughout the Midwest and other parts of the country to have the therapy. "We encourage patients to look into their particular state if they can get assistance…We're hoping, as time goes on, more patients can get health insurance."
The Psoriasis and Skin Treatment Center at the University of California, San Francisco (UCSF) also offers Goeckerman therapy. "For us, because we have it on site, we prescribe it all the time," said Dr. Tina Bhutani, a clinical fellow at the center, adding that it is a safe and effective treatment option.
Bhutani said that at any given time center staff is administering Goeckerman to 10 to 15 psoriasis patients. She said a 12-week clinical trial done at the center revealed that 100 percent of patients saw at least a 75 percent improvement in their skin because of the Goeckerman regimen. This compares to 40 to 80 percent improvement with biologics, she said.
"The average remission is about a year," she said. "That's an average. A lot of people go much longer."
The University of Michigan's Anderson also touted the therapy's potential long-term remission for psoriasis patients. Remissions can last up to 10 years, but many patients require treatment every year or two, he said.
"The biggest thing is logistics because patients have to come in Monday through Friday from 8 to usually about 2 to 3 p.m. for a minimum of four weeks," Bhutani said. "It gets difficult when somebody has a job."
Even so, plenty of patients make it work, she said. "We have many patients who have been able to get medical leave. We have a lot of students who do it during summer when they're on summer vacation. Elderly folks, too…We would probably prescribe it a lot more if patients were able to give the time commitment."
Most patients at the UCSF center live in California, Bhutani said. But some have come from other parts of the U.S., Canada and the Middle East.
"It can be anybody. It's patients who don't want to take an internal agent. And don't want to risk having the immune system suppressed (by using a biologic drug)," she said. "Goeckerman is a great option for kids and it's a great option for pregnant women."
For Honor Simpson, who wanted to treat her psoriasis with the Goeckerman regimen, returning to England was the only way she could feasibly get the treatment. She's currently managing her psoriasis with an in-home narrow-band UVB unit, but wishes the Goeckerman treatment were more readily available in the U.S.—for herself and others who struggle with psoriasis.
"I had to leave my family—my husband, my daughter and my grandson—and went back to England. Within four weeks, my skin was almost clear. And then I continued another three months with narrow-band UVB. After staying there for six months, I came back here and my skin was absolutely clear."