The Patient's Guide to Psoriasis Treatment. Part 4: Goeckerman Therapy

Adapting the Goeckerman Regimen for Psoriasis Treatment in Kenya: A Case Study of Successful Management in a Resource-Limited Setting

Introduction

 Goeckerman therapy, which combines ultraviolet B (UVB) light with crude coal tar (CCT), remains highly effective for moderate-to-severe psoriasis. While it is rarely still used in the USA as effective biotherapeutics have become more readily available, it offers an alternative therapy in developing countries with limited access to newer medications. Moi Teaching & Referral Hospital (MTRH) in Eldoret, Kenya, in collaboration with UCSF, developed a modified Goeckerman regimen suitable for local healthcare needs, condensing the treatment into an intensive two-week program.

Case Report

 A 55-year-old female with erythrodermic psoriasis traveled 350 kilometers to MTRH. After the diagnosis was confirmed, she underwent a nine-day inpatient treatment with narrow-band UVB phototherapy and topical medications under occlusion as a modified Goeckerman regimen.

Response to Treatment

 Significant improvement was observed within three days, with full recovery in ten days. Follow-up one month later showed no active lesions, and her psoriasis remained controlled for four months with topical treatments.

Conclusion

 The modified Goeckerman regimen at MTRH, in collaboration with UCSF, effectively treated severe psoriasis in a challenging healthcare context. This case highlights the potential for adapting established treatments to improve patient outcomes in developing countries with limited access to systemic therapies.

Effects and mechanisms of polycyclic aromatic hydrocarbons in inflammatory skin diseases

Polycyclic aromatic hydrocarbons (PAHs) are hydrocarbons characterized by the presence of multiple benzene rings. They are ubiquitously found in the natural environment, especially in environmental pollutants, including atmospheric particulate matter, cigarette smoke, barbecue smoke, among others. PAHs can influence human health through several mechanisms, including the aryl hydrocarbon receptor (AhR) pathway, oxidative stress pathway, and epigenetic pathway. In recent years, the impact of PAHs on inflammatory skin diseases has garnered significant attention, yet many of their underlying mechanisms remain poorly understood. We conducted a comprehensive review of articles focusing on the link between PAHs and several inflammatory skin diseases, including psoriasis, atopic dermatitis, lupus erythematosus, and acne. This review summarizes the effects and mechanisms of PAHs in these diseases and discusses the prospects and potential therapeutic implications of PAHs for inflammatory skin diseases.

Updated view of tars for psoriasis: what have we learned over the last decade?

Tars are one of the most effective, unknown, and oldest therapies for psoriasis. They include coal tar (CT) and biomass-derived products. These treatments, particularly the CT, have proven to be cost-effective with long remission times compared to other systemic or topical treatments. However, they have hardly evolved in recent years, as they are not well-embraced by clinicians or patients because of concerns regarding cosmesis and safety. This review summarizes current knowledge about the chemical characterization, mechanism of action, toxicity, and clinical studies supporting the use of tars for psoriasis over the last decade. Trends within these above aspects are reviewed, and avenues of research are identified. CT is rich in polycyclic aromatic hydrocarbons, whereas biomass-derived tars are rich in phenols. While the activation of the aryl hydrocarbon receptor is involved in the antipsoriatic effect of CT, the mechanism of action of biomass-derived products remains to be elucidated. No conclusive evidence exists about the risk of cancer in psoriasis patients under CT treatment. Large, randomized, double-blind, controlled clinical trials are necessary to promote the inclusion of tars as part of modern therapies for psoriasis.

308-nm Excimer Lamp vs. Combination of 308-nm Excimer Lamp and 10% Liquor Carbonis Detergens in Patients With Scalp Psoriasis: A Randomized, Single-Blinded, Controlled Trial

Background: Scalp psoriasis is usually refractory to treatment. Excimer devices have been proved to be a promising therapeutic option in psoriasis. Greater efficacy of phototherapy can be achieved by concurrent use of coal tar derivatives.

Objective: We aimed to compare efficacy and safety between 308-nm excimer lamp monotherapy and a combination of 308-nm excimer lamp and 10% liquor carbonis detergens in the treatment of scalp psoriasis.

Methods: In this randomized, evaluator-blinded, prospective, comparative study, 30 patients with scalp psoriasis received either 308-nm excimer lamp monotherapy or a combination of 308-nm excimer lamp and 10% liquor carbonis detergens twice per week until complete remission of the scalp or for a total of 30 sessions. Efficacy was evaluated by the improvement of Psoriasis Scalp Severity Index (PSSI) score, itch score, and Scalpdex score.

Results: Both treatments induced significant improvement in PSSI score with greater reduction observed in the combination group. At 30th visit, a 75% reduction in PSSI (PSSI75) was attained by 4 (28.6%) and 9 (69.2%) patients treated with monotherapy and combination therapy, respectively (P < 0.05).

Conclusions: Excimer lamp is well-tolerated in patients with scalp psoriasis and liquor carbonis detergens can be used as a combination therapy to improve the efficacy of excimer lamp.

Goeckerman Regimen Reduces Alarmin Levels and PASI Score in Paediatric Patients with Psoriasis

BACKGROUND

Psoriasis is a chronic systemic inflammatory disease with (extra-)cutaneous manifestations. Inflammation is associated with cellular stress and tissue damage which lead to the release of alarmins (signals of danger). Goeckerman regimen (GR) is a highly efficacious treatment consisting of the application of pharmaceutical crude tar and UVB light exposure. The reduction of inflammatory processes in the skin is accompanied by changes in the levels of inflammatory markers - alarmins (HMBG-1, S100A7, S1000A8, S100A9, S100A12, IL-17, IL-22, and IL-33).

METHODS

The alarmin levels in sera of 19 paediatric patients with psoriasis were determined before and after GR using commercial ELISA kits. The Psoriasis area severity index (PASI) was used to determine the disease severity.

RESULTS

GR reduced both PASI and the levels of all measured alarmins. The levels of S100A7, S100A9, IL-22, IL-33, and HMGB-1 were significantly decreased. Positive correlations between IL-22 and PASI, between S100A9 and IL-17, S100A9 and IL-22, and a negative correlation between S100A8 and IL-33 were found.

CONCLUSIONS

Goeckerman regimen is a very effective, safe and low-cost therapy. We confirmed, it modulates the immune system reactivity, ameliorates the severity of the disease and reduces the levels of alarmins reflecting the presence and intensity of inflammation.

The efficacy of UVA1 phototherapy in psoriasis: Clinical and histological aspects

BACKGROUND

Although ultraviolet A1 (UVA1) phototherapy is available for nearly 30 years, only few studies have been conducted for plaque-type psoriasis.

OBJECTIVES

To determine the efficacy and safety of UVA1 phototherapy in psoriasis by assessing the clinical and histological outcomes.

METHODS

This open study enrolled 15 patients with moderate to severe plaque-type psoriasis. All of the patients had skin type IV. A whole-body UVA1 device consisting of 24 lamps, was irradiated at a medium dose of 50 J/cm² three-times weekly for 30 sessions. Topical and systemic psoriasis treatments were discontinued before and during treatment; patients could only use emollients and antihistamines until 1-month post-completion. Psoriasis Area and Severity Index (PASI) scores were determined at baseline; at sessions 10th, 20th and 30th; and 1 month after treatment. Four-millimetre punch biopsies were obtained from the same psoriasis lesion at baseline and session 30th. Changes in histopathological gradings and polymorphonuclear, lymphocyte and Langerhans cell numbers were monitored.

RESULTS

Twelve patients completed the study. The mean age was 41.3 years (range: 25-71). The median PASI scores at baseline, session 30th and 1-month post-treatment were 16 (8.2, 43.3), 11 (4.4, 43.3) and 9.2 (2.7, 36.4), respectively. Although the PASI scores had improved significantly by 1-month post-treatment (P = .006), the histological parameters demonstrated minimal changes. All patients tolerated the phototherapy well and the most common side effect was skin tanning.

CONCLUSIONS

While medium-dose UVA1 phototherapy demonstrated some efficacy in moderate to severe plaque-type psoriasis. However, it might not be an excellent choice.

Review of the mechanism of action of coal tar in psoriasis

PURPOSE

Crude coal tar and its derivatives have been used in modern medicine for the treatment of psoriasis since at least 1925 as part of the Goeckerman regimen. To this day, coal tar remains a safe and highly effective option for the treatment of psoriasis vulgaris. However, the mechanism by which coal tar has its therapeutic effect is unknown. This review summarizes current knowledge of the mechanism by which coal tar has its therapeutic effect in the treatment of psoriasis vulgaris.

MATERIAL AND METHODS

A Pubmed search was conducted on March 13, 2017 for relevant English language journal articles on the subject and were relevant journal articles were included in this review.

RESULTS

Crude coal tar consists of thousands of ingredients, many of which are unidentified. Of these ingredients, the most research has gone into analyzing polycyclic aryl hydrocarbons. These hydrocarbons are thought to be the most likely component of crude coal tar that leads to its effects in psoriasis. Of the aryl hydrocarbons, carbazole has been the most well studied in psoriasis and is hypothesized as being responsible for the treatment efficacy of crude coal tar.

CONCLUSIONS

Polycyclic aryl hydrocarbons, and specifically carbazole, are thought to be the mechanism by which crude coal tar has its effect in psoriasis. However, further research is warranted to fully characterize the mechanism of action of crude coal tar, with the potential to create new therapies for psoriasis.