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Dr. Tell Me: From the first edition
Editor's note: The "Dr. Tell Me" column, a reader favorite for more than a decade, first appeared in the January/February 2003 issue of Psoriasis Advance, the magazine's debut issue. Here is that original column featuring longtime psoriasis researcher Dr. J.T. Elder of the University of Michigan. Dr. Elder answered these same questions for the column in the Winter 2012 issue, which marks the start of 10 years of publishing Psoriasis Advance.
Can stress-related drugs be useful to the treatment of psoriasis?
Stress plays an important role as a trigger factor in psoriasis, but stress-related drugs are not widely used to treat psoriasis, and many of these compounds have significant side effects, including the development of drug dependence. If your psoriasis is quite itchy, then antihistamines such as Benadryl or Atarax may provide some relief. These medications also have a sedative effect. I recommend that you consult with a dermatologist to determine what is best in your particular case.
I recently had a bout with iritis (inflammation of the interior of
the eye—very painful). Did the iritis have anything to do with
the fact that I have moderately severe psoriasis?
It may well have a connection, but it is hard to be sure. Iritis can be a component of Reiter's Syndrome, psoriasis and psoriatic arthritis, and can also appear in the context of several other inflammatory conditions. I strongly advise close follow-up with your ophthalmologist, as iritis can lead to vision loss if not adequately treated.
After problems with PUVA, what would your next choice of
treatment be?
I am assuming that you have moderate to severe psoriasis and that topical steroids and Dovonex do not work well either alone or in combination. UVB is probably not an alternative if the problem you have run into is skin cancer or pre-cancer. If my assumptions are correct, other commonly used alternatives include sulfasalazine and methotrexate. The use of sulfasalazine in psoriasis is relatively new. It works for about one-third of patients who try it. About one-third develop side effects, and it has no effect, good or bad, in about one-third of patients. If it is going to work, or if you are going to have side effects, you will generally know it within about six weeks, so it is worth a try (unless you are allergic to sulfa drugs).
In my opinion, methotrexate is an underused drug. It is highly effective in psoriasis and psoriatic arthritis, inexpensive, and is generally very well tolerated. Methotrexate is really an excellent alternative if you have no history of liver disease, are a non-drinker, and are willing to undergo liver biopsy periodically.
The most commonly encountered side effect of methotrexate is liver fibrosis. The major downside of methotrexate for most patients is the requirement for periodic liver biopsies to monitor for the development of this side effect. It is true that liver biopsy is not always used for this purpose by our colleagues in other specialties. However, dermatologists have more experience with the use of methotrexate in inflammatory diseases than any other specialty, and we know that this side effect, while rare, is very real. Therefore, periodic liver biopsy continues to be my recommendation until a better test for liver fibrosis is developed. Also, periodic liver biopsy continues to be recommended by the American Academy of Dermatology in Guidelines of Care for Psoriasis.
—Originally published in Psoriasis Advance, Volume 1: Number 1, January/February 2003