QUESTION: You recently wrote about dandruff and that one’s symptoms could be accompanied by a fungal infection. A long time ago I was told I had psoriasis after I showed the skin specialist a patch of persistent dandruff on my scalp just above the nape of my neck.
He prescribed a Vaseline-type ointment which only softened the patch so that the excess skin came off when washing.
Over the years this patch has grown and my ears also itch. When I scratch my head or my ears extra skin comes off, much larger than dandruff.
After reading your article I used Daktacort which stops my ears from itching but the itch comes back when I don’t use the cream. I can’t say it has improved the scalp, but I do use coconut oil before washing my hair to loosen the dandruff patch. My hair is thinning. Is this alopecia? I have googled this and see there are products in the US that claim to repair damage caused by alopecia.
What sort of doctor should I approach? The gynaecologist says my hormone levels are fine and that the above has nothing to do with hormones. I am very healthy usually and never get sick. I am 63 years old.
ANSWER: Your condition is not an easy one to treat. Psoriasis, which is a multisystem chronic inflammatory disorder with multiple associated comorbidities, often presents with persistent flaking silvery scale of skin on various areas of the body.
Most concerning to you is the symptomatic pruritis or itchiness, as well as your bald spots which accompany the lesions sometimes.
Is there effective treatment?
Yes, excellent treatment is available. We are guided by disease severity, relevant comorbidities, patient preference (including cost and convenience), and efficacy. Lesions on the hand, foot, or face can be bothersome and socially crippling and may require a more aggressive approach.
Topical and systemic therapies are available. There is generally a very poor compliance rate with topical preparations – yet patients expect a wonder drug to cure this chronic condition overnight. This is why I recommend that the patient’s preference is always considered when planning treatment.
Patients start on safer therapies and progress to more aggressive ones if the response is inadequate. Clinicians need to carefully review the risk-benefit profiles of proposed therapies. Follow up evaluation of the individual patient response is key to successful treatment.
Topical therapy may provide symptomatic relief and minimise required doses of systemic medications. Treatment approach is based on classification of severity. Moderate-to-severe psoriasis is typically defined as involvement of more than 5 to 10 percent of the body surface area.
As a general guideline, limited or mild-to-moderate skin disease can often be managed with topical agents which include emollients for hydration, corticosteroids to suppress inflammation, topical Vitamin D analogues like calcipotriene , calcitriol, and tacalcitol.
The application of topical agents to a large area is not usually practical or acceptable for most patients. Systemic therapy is used in patients with moderate-to-severe disease – this group involves systemic immunosuppression with drugs that have rather pronounced side effects and risks. These include Methotrexate, Cyclosporin, Retinoids and a group known as the TNF alpha blockers .
Other supplementary therapy includes phototherapy with ultraviolet light, slowing down keratinisation and acting as an anti-inflammatory.
The location of the disease and the presence of psoriatic arthritis can complicate management. There is ample evidence of efficacy of the newer systemic therapies (“biologics”); however, cost is a major consideration with these agents. Established therapies such as methotrexate and phototherapy continue to play a role in the management of moderate to severe plaque psoriasis. Widespread pustular disease requires aggressive treatment, which may include hospitalisation.
When to get medical help
* On confirmation of the diagnosis.
* When there is inadequate response to treatment according to the physician, patient, or both.
* When it has a big impact on quality of life.
* When the physician is unfamiliar with latest treatment modality: PUVA, phototherapy, or immunosuppressive medications.
* When it’s widespread and severe.
* In cases of psoriatic arthritis, referral and/or collaboration with a rheumatologist is indicated.
The latest findings…
It must be viewed as a multisystem inflammatory disorder with multiple comorbidities. There is a psychosocial impact of psoriasis that has been well described. This is not always proportional to the severity of skin disease or duration of illness.
Patients with mild psoriasis may experience significant impairment of quality of life related to this disease and the sequelae can be difficult to manage on social and professional levels.
The message is clear – early screening and prompt treatment of lifestyle diseases is essential – minimising the potential effect of the chronicity of the Metabolic Syndrome.
* Dr Darren Green, a trusted figure in the field of media medicine, is a University of Stellenbosch graduate who adds innovative spark to health and wellness issues.
He features on 567CapeTalk, and is a regular guest on SABC3 and the Expresso show. Dr Green works as an emergency medical practitioner at a leading Cape Town hospital and completed four years of training as a registrar in the specialisation of neurology.
If you’ve got medical problems, contact the doctor at [email protected], 021 930 0655 or Twitter @drdarrengreen. Catch him in Cape Town on 567 CapeTalk, most Fridays at 1.30pm.
The advice in this column does not replace a consultation and clinical evaluation with a doctor.
Cape Argus