Psoriasis

a. Administrative Aspects
Like atopic dermatitis and endogenous hand eczema, psoriasis and its variants are listed as disqualifying for entry and the pursuit of certain special duty in the Armed Forces of the United States. The reasons are the same as eczema; the notorious unpredictability of the condition. A case of clinically banal psoriasis can sometimes explode into disease of a debilitating nature in the military environment. Waivers should be very judiciously granted for this condition only after consultation with a military dermatologist.

The "three legged stool" of medication, lubrication, and environmental control applies equally well to the treatment of psoriasis (see Eczema above). The novice primary care practitioner inappropriately neglects lubrication in favor of potent topical steroids. Psoriasis perpetuates itself on dry cracked skin. Moisturize, moisturize, and moisturize! Topical steroids are not a substitute for emollients.

Scalp lesions are best approached with sulfur/salicylic acid, zinc pyrithione, or coal tar based medicated shampoos. The key to success here is sufficient contact time. The shampoo must have several minutes in place on the scalp before rinsing. There are a large number of generic and proprietary products on the market: Tarsum, T-Gel, Pentrax, Sebulex, Sebutone, and other dandriff shampoo brands to name but a few.

Ketoconazole shampoo is also useful, but is best saved for situations where conventional shampoos do not help. This product is very expensive and should be used judiciously.

Topical steroid lotions (e.g. betamethasone valearate 0.1%) applied after shampoo are a nice way to deliver medication to lesions within and near hair bearing surfaces such as the scalp and eyebrows.

Do not use systemic steroids to control psoriasis. An impressive "rebound" usually occurs which can be very difficult to treat.