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Fifteen Years Without An Explanation
from Rick

Dear Ed: I just visited you site for the first time, linked to it from about.com.  I am a 43 year-old male who has had psoriasis for about 15 years.  None of my physicians ever really explained what this was, some gave me creams or ointments that never worked.

About a year ago I began to have unexplained soreness and pain; finally after bouncing from doctor to doctor, a rheumatologist told me I had Psoriatic Arthritis.  It has taken me almost a year to learn about this condition and be versed enough to make decisions regarding my treatment.  I am in the middle of the MTX [methotrexate] debate right now.  I have taken just about every anti-inflammatory known to man, to no avail.  One can only take so much Darvocet....

Anyway, I look forward to exploring your site and related links.  Thanks for providing this forum.  Take Care, -Rick

*****

Ed’s Response:  Fifteen years sounds like an awfully long time, Rick.  But the delayed diagnosis is such a common story, lately I’ve been rethinking my usual belligerent, down-on-doctors attitude. 

P isn’t a diagnosis any doctor wants to make.  For reputable doctors it comes along with a confession that I can’t cure it.  At the same time, P isn’t always an easy diagnosis to make, either.  Most doctors that I’ve encountered and read about — particularly derms — want a history of the symptoms.  Some insist on having a personally witnessed history of the symptoms before they’ll say, conclusively, that a patient has P.  It seems to me that P diagnosis is not made by a momentary assessment of lesions — there’s not a swab test or a microscopic exam that’s conclusive in and of itself.  And, even if P is suspected, a topical corticosteroids may be prescribed that works well for many similar but less intractable conditions.  If, as is often the case, the corticosteroid makes the lesion go away … well … let’s not say it’s P, meaning it will probably come back, until it actually does.

My current derm made a seemingly snap diagnosis many years ago, but when I reconsider the situation, it really wasn’t a snap decision at all.  During that first appointment we spent a long time talking about how my condition started, progressed, and what every other doctor I’d seen had tried.  It was the visible evidence weighted by my history that leveraged my new derm’s diagnosis.  I don’t mean to downplay the real physical evidence.  It is true that, at the time, I was manifesting several of the classic P symptoms simultaneously: flaking red lesions, scalp involvement and nail involvement.  Taken together, these build a strong case for P with or without the history.  But I think when they can, derms lean heavily on the history, too.

Good luck on your MTX Debate.  As you probably know from reading my Methotrexate Journal, I have been where you are and it was the nearly debilitating pain of my PA that finally drove me to try MTX.  That was about two and one-half years ago.  I was on MTX for eight months during which time my plaque P abated but did not disappear; but my PA did, for all practical purposes, disappear. When I began to flare again — that is, the skin lesions began to get worse and the arthritis pain returned — my derm talked me into switching to cyclosporine instead of increasing my dosage of MTX.  The threat here, of course, was that cyclo is not so well known for PA abatement as MTX, even though it might do better at clearing my skin.  I recorded my experiences for the first few months on cyclosporine in another Diary.  I was lucky, the PA stayed away and my plaque P went into complete remission.  I had a great year.  Cyclo isn’t recommended for more than 12 months of continuous use and it was obvious I should cease at around this time when my blood pressure began to creep up.

I’ve been back on MTX for a few months now.  Though I’m taking 5 mgs per week more than I did when I stopped taking MTX a year ago (now 25 mgs/week), there has been no apparent improvement in the plaque psoriasis — in fact, there has been some worsening.  The good news is the PA has stayed away, as I expected it would when MTX therapy resumed (I was lucky it hadn’t returned while I was on cyclo). 

This month I’m supposed to have a liver biopsy, another precaution to MTX therapy that I’ve not looked forward to.  If it happens as scheduled, I’m sure I’ll have something to say about it in next month’s “Briefing.”  I understand if the biopsy reveals no abnormalities (i.e., sclerosis) I can continue the MTX, albeit with frequent blood work-ups and, later, another liver biopsy … and so on.  The question will become, how bad must the plaque P become before MTX stops being “worth it?”  We shall see.

In the meantime, Rick, if the debate falls out in favor of MTX for you, I hope it will stop your PA like it did mine.  Stay in touch!  -Ed

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