Goal of psoriasis care is symptom control with least toxic treatment

DEAR DR. ROACH: I have psoriasis. I have used clobetasol for 22 years. The psoriasis is not severe, but it’s constant. Should I be concerned about using this treatment for so many years? The only time it cleared up (and that was for two years) was when I had to take steroids for poison ivy. The doctor would not put me on a low dose of steroid to see if the psoriasis would stop completely and will not use other treatments, because both my brother and sister died of cancer. Any suggestions? I had two co-workers with psoriasis that was much worse than mine, and for some reason it disappeared for both of them after 20 years. — R.M.

ANSWER: For mild to moderate psoriasis, a skin disorder that most commonly manifests with scaly plaques, the goal of care is to control symptoms using the least toxic therapies available. That means topical therapies, like clobetasol cream or ointment, and other treatments — for instance, vitamin D-like or vitamin A-like drugs. These are very safe to use long-term for most people, if used correctly under supervision (clobetasol, a powerful steroid, used in the wrong place, especially the face, can cause permanent atrophy). If you have had good response to these, they are your best choice. However, it sounds like you haven’t had as good a response as you want.

I am curious about your response to the oral steroids you took for poison ivy. Normally, we treat moderate to severe poison ivy with a week or so of oral steroids. If just that much gave you two years of freedom from psoriasis, then I don’t understand why your doctor can’t give you a short course of steroids on a very-infrequent basis.

For severe psoriasis, systemic treatments are essential; however, they do have risks. Steroids are not a usual systemic treatment for psoriasis. Methotrexate, a drug used for cancer and in serious autoimmune diseases, is well-studied and tolerated by most. Vitamin A relatives, like acitretin (Soriatane), are very effective. Biological therapies, like etanercept (Enbrel), also have a clear place in treating severe psoriasis, but all of these drugs have potential for harm, including an increased risk of certain types of cancer.

In your case, I would consider getting a second opinion from a dermatologist with expertise in psoriasis. If the advice is the same, you can feel confident in the advice; if not, you will need to decide which course to follow.

DEAR DR. ROACH: You recently had a column where you did not recommend alprazolam (Xanax) as a long-term sleep aid. What are the negative effects of using it that way? — A.T.

ANSWER: Alprazolam is in the class of drugs called benzodiazepines, which includes Valium, Klonopin and Halcyon. They are effective at getting people to sleep more quickly, and increase total sleep time by 30-60 minutes. Alprazolam is very short-acting (although there is a long-acting form now) and is not indicated for insomnia.

I don’t recommend benzodiazepines because they increase the rate of falls, especially in the elderly, because they can cause memory loss and because they can cause confusion and dependence.

I try to avoid prescribing sleeping medications, and most people with occasional difficulty sleeping do well with sleep hygiene advice: Having a regular sleep schedule, not trying to force sleep, avoiding alcohol and caffeine near bedtime and not using bright lights or computer screens before bed are part of this. If I do prescribe a sleep medication, I recommend using it no more than every other day and for no more than two weeks. People who need more than that, I refer to a sleep specialist.

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Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu or request an order form of available health newsletters at 628 Virginia Dr., Orlando, FL 32803. Health newsletters may be ordered from www.rbmamall.com.