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New Derm Asking For Too Much
from Lizzie H.

Dear Ed: I am a 21 year old female who has been living with psoriasis for 21 years. I was diagnosed at age 5 months. Growing up I received UV treatments along with topical corticosteroids. I did that until I was about 10. For no apparent reason I stopped the treatments; never going into remission. 

I have also tried the dreaded coal tars and other messy creams.

About 4 years ago I was put on Tazorac with much improvement.

Recently I started the UVB light treatment that targets certain areas, mainly my hands and feet. Since I do have P all over my body I wonder if this is actually a beneficial treatment because I do not receive light treatments on all my body?

I have had the same dermatologist for 21 years. I decided to take action and consult with a new dermatologist, a specialist in psoriasis, this past month. I went to his office and he took one look at me and could not determine if I had psoriasis or not. Again he is a specialist at a university and has been treating P patients for 40 years. He said due to the patterns of the P, which is linear in my case he could not determine if I had P without a biopsy. He would like me to wait 2 months without using any treatments and then  come back for a biopsy of my skin.

My skin is red and has pretty much stayed the same for many many years. I never had plaque psoriasis to the extent of other P sufferers. I have been able to keep my skin quite thin. My question is what would you do in my case? I currently had all my medical records sent to this new derm. I don’t want to stop treatments. I am not sure why he could not perform a biopsy at my first visit. Please understand I do want to be properly diagnosed.  Who knows?  I might have P on top of something else.

This derm would also like me to attend a conference in the summer with some other derms so they can evaluate my case. Again, I don’t want to wait because I firmly believe I have P.  I do respond to P treatments, but I have never fully cleared up, not even close.

I know this physician can help me out, I just wish it would be now and I hope with my medical records there he can review them and determine that I do indeed have P and then I can start a new treatment like PUVA or methotrexate. I am actually really interested in Amevive and hope to try that as well. –Lizzie H.

*****

Ed’s Response:  Your case has me scratching my head (well, your case and my scalp P).  I don’t ever second-guess derms and there must be a compelling reason why this derm wants you to (a) stop all treatments for two months and (b) have a skin biopsy.  Your P must not be behaving in accordance with this fellow’s experience.  He may very well be looking for something in addition to P; or, he may suspect that a part of your problem is over-use of previous P medicines or therapies.  I find it interesting that he is already asking you to accompany him to a conference (as a guinea pig) before he’s seen the biopsy results.  It almost sounds as though he has strong suspicions of something specific but isn’t willing to say more at this time.

All I can tell you, Lizzie, is what I think I would do if my derm asked of me the same things.  My first retort would be, “What will you do if I say no to stopping all treatments, taking the biopsy and accompanying you to the conference?  What’s my next choice?”  If he honestly thinks more conventional therapy is not a good idea for you (until more is known), he will say so and decline to treat you accordingly.  He might try again to compel you to take his advice and submit to his requests.  Or, he might suggest you find another doctor.

I, like you, would be interested in Amevive (or any of the new biologics) and I would want to know why your doctor might not be.  These are too new for P treatment to be considered “conventional,” you haven’t had them before ... if your problem has to do with overuse of conventional therapies, wouldn’t trying one or more of the biologics be logical? 

Lizzie, you must let us know how all this turns out.  This is definitely one for the books.  -Ed

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