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Years Without An Explanation
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
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.
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
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
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