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Success of Goeckerman Treatment in 2 Patients With Psoriasis Not Responding to Biological Drugs

Success of Goeckerman Treatment in 2 Patients With Psoriasis Not Responding to Biological Drugs Goeckerman treatment was effective for 2 patients referred to Mayo Clinic with psoriasis not responding to treatment with biological agents. In patient 1, psoriasis flaring during etanercept therapy cleared completely with Goeckerman treatment; in patient 2, psoriasis not responding to etanercept and alefacept therapy cleared with Goeckerman treatment and with the initiation of highly active antiretroviral therapy (HAART) for newly diagnosed human immunodeficiency virus (HIV). Report of Cases Case 1 Patient 1 was a 22-year-old man who had a 5-year history of psoriasis that was recalcitrant to treatment with topical corticosteroids, methotrexate, and psoralen UV-A (PUVA). He received etanercept therapy for 18 months before presentation and reported mixed results, but his lesions never completely cleared. While taking etanercept, he had an acute flare of symptoms, with multiple guttate psoriatic plaques covering about 70% of his skin. A throat swab tested positive for Streptococcus pyogenes; a course of cephalexin was initiated (Keflex, 500 mg, 4 times daily; Advancis Pharmaceutical Corp, Germantown, Maryland). Etanercept therapy was stopped, and the patient began a 21-day course of the Goeckerman treatment with tars and phototherapy. By the end of the therapy, the psoriatic plaques had completely cleared, with only residual postinflammatory hyperpigmentation. Case 2 Patient 2 was a 38-year-old man who presented with a 9-month history of psoriasis involving 90% of his skin. Over the 7-month period before presentation, treatment with the following medications had been tried sequentially to control his psoriasis, but there was no response: cyclosporine, methotrexate, etanercept, and alefacept. Evaluation revealed that he was HIV positive. Therapy with the biological medications was stopped, and HAART and Goeckerman treatment were initiated. On completion of the Goeckerman treatment (3 weeks following presentation), his psoriasis had completely resolved, leaving postinflammatory hyperpigmentation. Comment Psoriasis treatment with the use of artificial UV-B and crude coal tar in a petroleum base was first reported by Goeckerman in 1925.1 He observed that the regimen not only cleared psoriasis but also resulted in long remissions. In 1983, Menter and Cram2 reported a multicenter study of 300 patients with severe psoriasis who received the Goeckerman treatment. There was a mean of 90% improvement in the psoriasis in 18 days. In 90% of the patients, the skin remained clear for at least 8 months; in 73%, clearance lasted for at least 1 year. Menter and Cram2 also found that the cost-effectiveness was comparable with that of PUVA therapy. Similar efficacy was reported by Jordan et al3 in 1981 for patients who used home-based tar and UV-B treatments in a modified Goeckerman treatment. These cases demonstrate that psoriasis does not always respond to biological drugs. In those cases, underlying causes of recalcitrant psoriasis, such as HIV infection, should be sought. Goeckerman treatment remains effective for extensive psoriasis and should not be abandoned. Correspondence: Dr Davis, Department of Dermatology, Mayo Clinic, 200 First St SW, Mayo Clinic, Rochester, MN 55905 (davis.mark2@mayo.edu). Financial Disclosure: None reported. References 1. Goeckerman WH The treatment of psoriasis. Northwest Med 1925;24229- 231Google Scholar 2. Menter ACram DL The Goeckerman regimen in two psoriasis day care centers. J Am Acad Dermatol 1983;9 (1) 59- 65PubMedGoogle ScholarCrossref 3. Jordan WP JrClarke AMHale RK Long-term modified Goeckerman regimen for psoriasis using an ultraviolet B light source in the home. J Am Acad Dermatol 1981;4 (5) 584- 591PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Dermatology American Medical Association

Success of Goeckerman Treatment in 2 Patients With Psoriasis Not Responding to Biological Drugs

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References (4)

Publisher
American Medical Association
Copyright
Copyright © 2007 American Medical Association. All Rights Reserved.
ISSN
0003-987X
eISSN
1538-3652
DOI
10.1001/archderm.143.7.950
pmid
17638750
Publisher site
See Article on Publisher Site

Abstract

Goeckerman treatment was effective for 2 patients referred to Mayo Clinic with psoriasis not responding to treatment with biological agents. In patient 1, psoriasis flaring during etanercept therapy cleared completely with Goeckerman treatment; in patient 2, psoriasis not responding to etanercept and alefacept therapy cleared with Goeckerman treatment and with the initiation of highly active antiretroviral therapy (HAART) for newly diagnosed human immunodeficiency virus (HIV). Report of Cases Case 1 Patient 1 was a 22-year-old man who had a 5-year history of psoriasis that was recalcitrant to treatment with topical corticosteroids, methotrexate, and psoralen UV-A (PUVA). He received etanercept therapy for 18 months before presentation and reported mixed results, but his lesions never completely cleared. While taking etanercept, he had an acute flare of symptoms, with multiple guttate psoriatic plaques covering about 70% of his skin. A throat swab tested positive for Streptococcus pyogenes; a course of cephalexin was initiated (Keflex, 500 mg, 4 times daily; Advancis Pharmaceutical Corp, Germantown, Maryland). Etanercept therapy was stopped, and the patient began a 21-day course of the Goeckerman treatment with tars and phototherapy. By the end of the therapy, the psoriatic plaques had completely cleared, with only residual postinflammatory hyperpigmentation. Case 2 Patient 2 was a 38-year-old man who presented with a 9-month history of psoriasis involving 90% of his skin. Over the 7-month period before presentation, treatment with the following medications had been tried sequentially to control his psoriasis, but there was no response: cyclosporine, methotrexate, etanercept, and alefacept. Evaluation revealed that he was HIV positive. Therapy with the biological medications was stopped, and HAART and Goeckerman treatment were initiated. On completion of the Goeckerman treatment (3 weeks following presentation), his psoriasis had completely resolved, leaving postinflammatory hyperpigmentation. Comment Psoriasis treatment with the use of artificial UV-B and crude coal tar in a petroleum base was first reported by Goeckerman in 1925.1 He observed that the regimen not only cleared psoriasis but also resulted in long remissions. In 1983, Menter and Cram2 reported a multicenter study of 300 patients with severe psoriasis who received the Goeckerman treatment. There was a mean of 90% improvement in the psoriasis in 18 days. In 90% of the patients, the skin remained clear for at least 8 months; in 73%, clearance lasted for at least 1 year. Menter and Cram2 also found that the cost-effectiveness was comparable with that of PUVA therapy. Similar efficacy was reported by Jordan et al3 in 1981 for patients who used home-based tar and UV-B treatments in a modified Goeckerman treatment. These cases demonstrate that psoriasis does not always respond to biological drugs. In those cases, underlying causes of recalcitrant psoriasis, such as HIV infection, should be sought. Goeckerman treatment remains effective for extensive psoriasis and should not be abandoned. Correspondence: Dr Davis, Department of Dermatology, Mayo Clinic, 200 First St SW, Mayo Clinic, Rochester, MN 55905 (davis.mark2@mayo.edu). Financial Disclosure: None reported. References 1. Goeckerman WH The treatment of psoriasis. Northwest Med 1925;24229- 231Google Scholar 2. Menter ACram DL The Goeckerman regimen in two psoriasis day care centers. J Am Acad Dermatol 1983;9 (1) 59- 65PubMedGoogle ScholarCrossref 3. Jordan WP JrClarke AMHale RK Long-term modified Goeckerman regimen for psoriasis using an ultraviolet B light source in the home. J Am Acad Dermatol 1981;4 (5) 584- 591PubMedGoogle ScholarCrossref

Journal

Archives of DermatologyAmerican Medical Association

Published: Jul 1, 2007

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