Efficacy, safety, and cost of Goeckerman therapy compared with biologics in the treatment of moderate to severe psoriasis

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.

Joint AAD-NPF Guidelines of care for the management and treatment of psoriasis with topical therapy and alternative medicine modalities for psoriasis severity measures

Psoriasis is a chronic, inflammatory, multisystem disease that affects up to 3.2% of the United States population. This guideline addresses important clinical questions that arise in psoriasis management and care and provides recommendations based on the available evidence. The treatment of psoriasis with topical agents and with alternative medicine will be reviewed, emphasizing treatment recommendations and the role of dermatologists in monitoring and educating patients regarding benefits as well as risks that may be associated. This guideline will also address the severity assessment methods of psoriasis in adults.

Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis with phototherapy

Psoriasis is a chronic inflammatory disease involving multiple organ systems and affecting approximately 3.2% of the world's population. In this section of the guidelines of care for psoriasis, we will focus the discussion on ultraviolet (UV) light-based therapies, which include narrowband and broadband UVB, UVA in conjunction with photosensitizing agents, targeted UVB treatments such as with an excimer laser, and several other modalities and variations of these core phototherapies, including newer applications of pulsed dye lasers, intense pulse light, and light-emitting electrodes. We will provide an in-depth, evidence-based discussion of efficacy and safety for each treatment modality and provide recommendations and guidance for the use of these therapies alone or in conjunction with other topical and/or systemic psoriasis treatments.

Membrane and soluble Toll-like receptor 2 in patients with psoriasis treated by Goeckerman therapy

BACKGROUND

Toll-like receptor (TLR) 2 belongs to the large TLR receptor family comprised of at least 10 members with different roles in innate immunity. Psoriasis is recognized as a T-cell driven immune-mediated systemic inflammatory disease with a skin manifestation. An effective therapeutic approach to treat psoriasis is Goeckerman therapy (GT). The aim of this study was to assess both the kinetics of the expression of TLR2 on blood cells and the concentration of soluble (s)TLR2 in serum of patients with psoriasis and to examine the effect of GT on both TLR2 expression and sTLR2 level.

METHODS

Both membrane and sTLR2 were determined in 20 patients and 20 healthy controls. sTLR2 was evaluated by enzyme-linked immunosorbent assay. Flow cytometry method was used to determine the expression of membrane TLR2 of monocytes and granulocytes.

RESULTS

The serum level of sTLR2 was significantly lower (P < 0.0001) in patients both before and after GT compared to the control group. Compared to the membrane expression of TLR2 on monocytes of healthy blood donors, TLR2 expression was significantly higher in patients both before and after GT (P = 0.0001). Similarly, TLR2 expression on granulocytes was significantly higher in patients both before (P = 0.0061) and after (P < 0.0001) therapy than in control.

CONCLUSIONS

Membrane and soluble TLR2 may be involved in the pathogenesis of psoriasis. Both remained unchanged by GT.

Cost-of-illness in psoriasis: comparing inpatient and outpatient therapy

Treatment modalities of chronic plaque psoriasis have dramatically changed over the past ten years with a still continuing shift from inpatient to outpatient treatment. This development is mainly caused by outpatient availability of highly efficient and relatively well-tolerated systemic treatments, in particular BioLogicals. In addition, inpatient treatment is time- and cost-intense, conflicting with the actual burst of health expenses and with patient preferences. Nevertheless, inpatient treatment with dithranol and UV light still is a major mainstay of psoriasis treatment in Germany. The current study aims at comparing the total costs of inpatient treatment and outpatient follow-up to mere outpatient therapy with different modalities (topical treatment, phototherapy, classic systemic therapy or BioLogicals) over a period of 12 months. To this end, a retrospective cost-of-illness study was conducted on 120 patients treated at the University Medical Centre Mannheim between 2005 and 2006. Inpatient therapy caused significantly higher direct medical, indirect and total annual costs than outpatient treatment (13,042 € versus 2,984 €). Its strong influence on cost levels was confirmed by regression analysis, with total costs rising by 104.3% in case of inpatient treatment. Patients receiving BioLogicals produced the overall highest costs, whereas outpatient treatment with classic systemic antipsoriatic medications was less cost-intense than other alternatives.

Expression of soluble sCD163 in serum of psoriatic patients is modulated by Goeckerman therapy

BACKGROUND

CD163 is the monocyte/macrophage receptor for haptoglobin-haemoglobin complexes. The aim of this study was to assess the kinetics in the expression of CD163 on monocytes and the concentration of soluble sCD163 in serum of psoriatic patients in order to examine the effect of Goeckerman therapy.

METHODS

sCD163 was measured in 71 patients before and after therapy, and in 57 healthy donors. A subgroup of 40 patients and 25 controls was used to assess the expression of membrane CD163. sCD163 was evaluated by ELISA. Flow cytometry method was used to determine the expression of membrane CD163 on monocytes, expressed as mean fluorescence index (MFI).

RESULTS

Before therapy, the serum level of sCD163 was significantly higher in our patients than in controls (P=0.0154). However, we observed a profound decrease in sCD163 in our patients after therapy (P=0.0037). Similar to sCD163, pre-treatment expression of CD163 on monocytes was significantly more enhanced in patients than that in controls (P=0.0078). There was a trend towards down-regulation of the expression after therapy, nonetheless, the change was not statistically significant compared to the values before therapy (P=0.8666). This was also confirmed by comparison with controls which displayed lower expression of CD163 than patients after therapy (P=0.0019). The disease activity, expressed as PASI score, was significantly decreased in our patients by GT (P=0.0001).

CONCLUSIONS

While sCD163 level in psoriatic patients was diminished after GT therapy, CD163 expression on monocytes was altered only to a minor extent.

Goeckerman therapy for the treatment of eczema: a practical guide and review of efficacy

The Goeckerman regimen, consisting of the application of crude coal tar combined with exposure to ultraviolet radiation, was formulated in 1925 for the treatment of psoriasis. While some centers have adapted the Goeckerman regimen for the treatment of eczema, there are no published reports of its efficacy in this condition. Here, we explain how the Goeckerman regimen has been modified for use in an eczema population at the University of California San Francisco (UCSF). We reviewed the treatment records of eczema patients treated with the modified Goeckerman regimen over a 6-year period at UCSF. We found that the Goeckerman regimen was effective in treating patients with severe baseline disease, inducing a mean remission period of 7.2 months. The treatment was tolerated well with mild folliculitis and occasional ultraviolet B phototoxicity noted as the only adverse reactions. Since the use of Goeckerman as a treatment for severe eczema is both effective and safe, it should be considered an excellent alternative or adjunct to the systemic therapies currently being used.

Results of Goeckerman treatment for psoriasis in children: a 21-year retrospective review

Goeckerman treatment has been used for the management of widespread psoriasis in children for several decades at Mayo Clinic. We aimed to review our institutional experience with the effectiveness of Goeckerman treatment for psoriasis in children. We retrospectively reviewed the records of pediatric patients who underwent Goeckerman treatment over a 21-year period (1983-2003). The main outcome measure was improvement in psoriasis. During the study period, 65 children received Goeckerman treatment for predominantly widespread, recalcitrant psoriasis. The mean age was 11.6 years (range, 3 mos to 18 yrs), and the female-to-male ratio was 2:1. Psoriasis improved in all patients: 55 patients (85%) had >80% clearance of their psoriasis. The only adverse effect was folliculitis, occurring in 27 patients (42%). Mean duration of follow-up was 2.6 years (range, 17 days-18.2 yrs); average duration of remission was 2.6 years (range, 2 mos-12.79 yrs). Goeckerman treatment is an effective treatment for widespread psoriasis in children.