Psoriasis Advance

Dr. Tell Me
Advice from Dr. Jeffrey Sobell
Tufts University School of Medicine, Boston, Mass.
SkinCare Physicians, Chestnut Hill, Mass.

From Summer 2009 Psoriasis Advance

I'm in college, 200 miles away from my dermatologist. Should I visit the campus clinic when I need help with my psoriasis? Find a new doctor?

It depends on the severity of your psoriasis. If you are treated with creams alone and only need refills, then a general provider at the health center may be adequate. But if your disease is flaring or you are on systemic medication, then you are better off seeing a dermatologist. First, see if your college has a dermatologist onsite at the campus clinic. If not, ask your dermatologist for a recommendation. Lastly, there are resources on the web, such as www.psoriasis.org, to help you find one knowledgeable about psoriasis.

At home I was receiving light therapy three days a week. I can't fit that much time into my college schedule. Can light therapy be effective once a week or less?

Light therapy—either ultraviolet light B (UVB) or PUVA (the light-sensitizing drug psoralen combined with ultraviolet light A)—requires treatment two to three times a week to improve active psoriasis. Once the skin is clear, PUVA treatments every one to four weeks can maintain improvement. However, with UVB (or narrow-band UVB), improvement is hard to achieve or maintain with fewer than two sessions a week. Because of your schedule, I suggest you speak with your dermatologist about possibly obtaining an at-home UVB phototherapy unit.

I'm on methotrexate and it's working well. How dangerous is drinking alcohol while I'm taking this medication?

Methotrexate is a common and effective treatment for moderate to severe psoriasis. However, one of the serious side effects of methotrexate is liver damage. The risk of liver damage increases with higher doses of methotrexate and longer treatment durations. It also increases with alcohol ingestion, as this too is a potential liver toxin. It is not certain how much, if any, alcohol is safe while on methotrexate. Thus, most dermatologists advise to abstain completely. Symptoms of liver disease could include abdominal pain, jaundice, dark urine or light stools.

The drug Accutane—which is sometimes used to treat severe psoriasis—stimulates skin renewal. How, then, does it work to improve psoriasis lesions, which basically result from the skin renewing itself too fast?

Accutane (isotretinoin), officially used for severe acne, is related to Soriatane (acitretin), a drug approved for moderate to severe psoriasis. They belong to a family of medications called retinoids which work by correcting defects in cells. In acne, “sticky” cells that line the hair follicles are normalized by retinoids, preventing the pores from becoming plugged up. In psoriasis, skin cells are dividing too rapidly and do not mature fully. Retinoids normalize both of these processes. Accutane is occasionally used for psoriasis "off-label" in women of child-bearing potential because it is cleared from the body faster (retinoids can never be used during pregnancy).

I have psoriasis in my ear canals and have been using Tobradex. My results are good, but I know that Tobradex is mainly used to treat eye infections. Is it safe to use in my ears?

Tobradex is an ophthalmic suspension that combines tobramycin, a topical antibiotic, with dexamethasone, a corticosteroid. It is officially used to treat eye inflammation where infection or risk of infection is present. Topical corticosteroids are commonly prescribed to treat psoriasis in the ears, thus it is likely that the dexamethasone component in Tobradex is responsible for your improvement. My feeling is that Tobradex is likely safe for use in the ears on an as-needed basis for psoriasis. However, like all topical steroids, it is important to be closely monitored by your doctor for potential side effects, particularly thinning of the skin.

I have problems with fluid and swelling behind my eyes. My doctor says it is psoriatic uveitis, a condition caused by psoriasis. Is this possible?

Yes, uveitis does arise in some people with psoriasis. An entity called anterior uveitis, which causes a tender red eye, is seen in 7 to 25 percent of people who have psoriatic arthritis. In people who have psoriasis without arthritis, it is more common to see redness and tearing due to conjunctivitis or inflammation of the eyelid. Thus, I would advise anyone with psoriasis who develops undiagnosed recurrent or ongoing eye symptoms to seek evaluation by an ophthalmologist.