ABSTRACT
Before World War II, in the days of Dr. Goeckerman and Dr. Ingram, the mainstay of Western medicine for the treatment of psoriasis was limited to coal tar, anthralin, and ultraviolet B (UVB) phototherapy, supplemented by various adjunctive therapeutic measures such as salicylic acid and moisturizers. However, in the past half-century since the end of World War II, numerous therapeutic options have been devised to enrich the therapeutic armamentarium. These range from topical steroids in all different strengths, intralesional steroids, calcipotriene, tazarotene, and PUVA phototherapy to various systemic agents, such as methotrexate and the most recent FDA-approved addition, cyclosporine (Neoral). Despite this virtual explosion in therapeutic options, the management of psoriasis remains a challenge to clinicians. This is because of several peculiarities of psoriasis. First, although psoriatic plaques usually look similar from patient to patient, the way in which they respond to any particular treatment may be highly unpredictable. It is not unusual for one patient to respond beautifully to one medication, while the exact same medication has no efficacy for another patient with identicallooking psoriatic plaques. Moreover, even in patients who seem to have relatively responsive psoriatic lesions, one can frequently identify certain plaques that are much more resistant to treatment than the others. This is truly a mystery of psoriasis. For example, two psoriatic plaques with similar appearances might be treated with a systemic agent or phototherapy, and one plaque resolves completely while the other responds partially or not at all. These commonly observed phenomena defy currently popular genetic and immunological theories on the pathogenesis
of psoriasis, since each individual is presumed to have the same genetic and immunological characteristics throughout his or her body. To improve resistant psoriasis, treatment modalities frequently need to be used creatively, with the sequential use of different combinations.
