The Patient With Those Embarrassing Plaques

Désirée A. Lie, MD, MSEd


January 22, 2013

The Patient With Those Embarrassing Plaques

Adam is a single, 35-year-old banking executive with mild-to-moderate psoriasis since his twenties. The condition has been a source of anxiety that has embarrassed him, and he dresses carefully to conceal the skin plaques on his elbows and knees. His self-esteem is negatively affected, and the condition interferes with his personal social life, especially his dating life. He avoids swimming and outdoor summer activities. He prefers to stay at home on weekends rather than go out with friends. His symptoms have recently become worse, with new inflammation of plaques on his lower back, exacerbated by anxiety and stress. He is not interested in trying coal tar as he considers it "messy and smelly." Up to now, his condition has been moderately well controlled with topical triamcinolone ointment and emollients, though on occasion he has received both ultraviolet B (UVB) phototherapy and ultraviolet A plus psoralen (PUVA)from a dermatologist. Although he is aware of systemic treatments for psoriasis, such as methotrexate and newer immunonodulators, he has done quite a bit of reading on the Internet and is concerned about long-term adverse effects, including the risk for fungal, viral, and bacterial infections as well as cancer. He is not interested in trying them at present. He would like to start a family eventually but is frustrated by what he perceives as limitations imposed by his psoriasis.

He would like to consider using alternative adjunct therapies for episodic control and seeks your advice on what to try first.