treatment for psoriasis with modified goeckerman …despite the recent advances in treatment for...

113 Dermatol Sinica, Sep 2005

Treatment for Psoriasis with Modified Goeckerman Regimen-One Year Experience in Southern Taiwan-

Chih-Sheng Lai Po-Han Huang Ji-Chen Ho

Despite the recent advances in treatment for psoriasis, it is still challenging in treating patientswith moderate to severe psoriasis. The Goeckerman regimen, which was introduced by Goeckerman in1925, is still considered to be one of the most effective and relatively safe therapies for patients. Westarted the modified Goeckerman regimen for treating moderate to severe psoriatic patients in Taiwan inMarch, 2002. 89 patients had been treated from March 2002 to May 2003. Among them thirty-twopatients with more than 5% body surface area psoriatic lesions, who had neither systemic therapy in thepast 6 months nor concurrent oral antipsoriatics during this treatment, were collected. The mean psoria-sis area and severity index (PASI) scores declined from 19.4 12.4 to 4.4 3.6 during therapy, and themean duration of remission was 10.2 5.6 months. There was no severe side effect though mild localburn and itching were fairly common. Herein we present the preliminary data and comparison to othertherapies in the literature.(Dermatol Sinica 23: 113-120, 2005)

Key words: Psoriasis, Goeckerman regimen, Tar, Ultraviolet, Phototherapy

1925

2002

2002 2003 89

32

19.4 12.4 4.4 3.6 10.2 5.6

( 23: 113-120, 2005)

From the Department of Dermatology, Chang Gung Memorial Hospital, Kaohsiung, TaiwanAccepted for publication: March 10, 2005Reprint requests: Po-Han Huang, M.D., Department of Dermatology, Chang Gung Memorial Hospital,123, Ta-Pei Road,Kaohsiung, Taiwan, R.O.C. TEL: 07-7317123 ext. 2424 FAX: 07-7317123 ext. 2421

Dermatol Sinica, September 2005 114

INTRODUCTIONPsoriasis is a distressing, chronic disease

that affects skin and joints with estimatedprevalence varies from 0.1 to 2.8% in the gener-al population in published reports.1, 2 The preva-lence in the Mongoloid race was estimatedabout 1% in spite of the climate geographic dif-ference.3 The therapies for this disease hadmuch advances in the past decades but it is stillchallanging in treating moderate to severepatients. We introduced the modifiedGoeckerman regimen in March 2002 and estab-lished our psoriasis day care center at the sametime. Herein we present our preliminary data ofthe past 1 year. This report is not intended to bea well controlled study but to share our experi-ence in treating psoriasis with the modifiedGoeckerman regimen.

MATERIALS AND METHODSPATIENTS

Patients with moderate to severe chronicplaque type psoriasis (body surface area >5%)who had poor response to previous therapy andcould follow the treatment schedule of our pso-riasis center were enrolled in the day care pro-gram. Those who were allergic to tar prepara-tion or could not tolerate the odor of tar wereexcluded. Patients who took other systemicmedications for psoriasis during or within 6

months before enrollment were excluded in thispreliminary report. 32 patients were collectedbetween March 2002 to May 2003 (Fig. 1).

DAY CARE PROGRAMTar preparation at different concentrations

was applied to the whole body surface exceptthe face and genitalia, and occluded withclothes or plastic tapes for at least 5 hours. Afterthat, the patients took a shower to wash off tarand received phototherapy with broad bandultraviolet B (UVB) thereafter.

TAR PREPARATIONPolytar emollient (tar 7.5%, coal tar 2.5%,

cadeoil 7.5%, Arachis oil extract of crude coaltar 7.5%, Stiefel) or coal tar and salicylic acid(1g contains strong coal tar solution 0.1ml, sali-cylic acid 20mg, Otsuka-Taiwan) were used.The concentration of tar preparation e.g. polytaremollient was diluted to 2% for most patientsand 1% for patients with marked erythema. Ifthere was no obvious irritation or discomfortafter 3 consecutive treatments, the concentrationwas increased to 5%. After another 3 treatmentsthe concentration was added to 10% and thenkept till the end of treatment. Genital area wasspared of tar and treated with mid-potent topicalsteroid if lesions present (few of our patientshad genital lesions).

Fig.1Flow chart of patient selection.

115 Dermatol Sinica, September 2005

tial lesions, which was near the median value ofprevious literatures. Because our patients werefollowed at different hospitals in Taiwan, someof the data were got by telephone contact withthe patients.

PATIENT OVERALL SATISFACTIONAt the end of follow up the patient s over-

all satisfaction about this therapy was assessedwith visual analogue scale (0-10) which wasobtained by telephone contact.

RESULTSThere were 20 males and 12 females

included in this report. The average duration oftreatment was 5.3 2.4 weeks (range 2-14

PHOTOTHERAPYBroad band UVB (NBC HOUVA II,

PHILIPS UVB TL100W/12) was used with ini-tial dose around 35-50 mJ/cm2 according to theskin type and degree of erythema. The dose wasthen increased 10-15% each time till mild ery-thema but no obvious burn was noted. Thepatients received 5 times of therapy per week.

CONCURRENT THERAPYTopical calcipotriol ointment or scalp

lotion (0.005%) was routinely used in allpatients after phototherapy. Tazarotene gel(0.1%) was used in thick plaques of 16 patients.Mid to low potency topical steroids were pre-scribed only to relieve irritations from tar prepa-rations or mild burn following phototherapy.Otherwise, topical steroids were prohibited.

MAINTENANCE THERAPYPatients who completed the course of

modified Goeckerman s regimen were suggest-ed to keep phototherapy 1-3 times per week andthe frequency was decreased gradually if condi-tion was stable. Topical calcipotriol andtazarotene were used as needed. Topicalsteroids were still prohibited except relief ofburn following phototherapy. If relapseoccurred, systemic medications were prescribedor modified Goeckerman regimen was doneagain.

RELAPSE OF DISEASESince there was no consensus on the defi-

nition of relapse and the criteria varies greatly,we defined relapse as more than 5% body sur-face area involvement or more than 30% of ini-

Fig. 5Two of the patients before and after treatment.

Fig. 2The PASI score during therapy.

Fig. 3Percentage of patients achieved 50% improvement in PASIscore (PASI 50) and 75% improvement of PASI score (PASI75) in all patients and in whom initial PASI score >10.

Fig. 4Percentage of patients achieved PASI50 and PASI75 strati-fied by initial PASI score. A: initial PASI<10; B: initial PASI10-20; C: initial PASI>20


Table 2. Side effects during therapy.

Case number(n=32) Percentage(%)

Burn (localized) 23 72

Burn (generalized) 1 3

Itching 18 56

Irritation 3 9

Marked lichenification 2 6

Lentigines 5 16

Table 1. Basic data of the patients.

Mean SD Range

Male : Female 20:12

Age 38.8 15.1 6-72

Age of onset 28.5 13.8 3-56

Duration of psoriasis (year) 9.6 5.5 2-24

Family history 2 in 29

Duration of treatment (week) 5.4 2.4 2-14

Final dose of Whole body(n=32) 409.0 211.8 40-900

UVB(mJ/cm2) Legs(n=14) 466.7 230.8 110-900

weeks) and the final dose of UVB in averagewas 409.6 208 mJ/cm2. Their demographicdata had shown in Table 1.

PSORIASIS AREA AND SEVERITY INDEX(PASI) SCORES DURING THERAPY

The mean PASI score at the initial and theend of the therapy was 19.4 12.4 and 4.43.6. The mean PASI score at initial was 23.3511.9 for the more severe subgroup (BSA>10%).The changes of PASI in each week were shownin Fig. 2. The percentage of patients whoachieved 50% improvement (PASI 50) and 75%improvement (PASI 75) were shown in Fig. 3,and the percentage of patients achieved PASI 50and PASI 75 subclassified according to the ini-tial PASI scores were shown in Fig. 4. Two ofthe patients photographs before and after treat-ment were shown in Fig. 5.

SIDE EFFECTS DURING THERAPYBecause of aggressive phototherapy, local-

ized burn was frequently seen (23 in 32patients, 72%). However, more generalized firstdegree burn was seen in only one patient (3%).Itching was also common. In 32 patients, therewere 18 (56%) patients experienced moderate tosevere itching during therapy, especially atnight. Besides, irritation due to tar preparation,marked lichenification, and obvious new lentig-ines lesions (>5 new lesions) were occasionallyseen. The side effects and their frequency werelisted in Table 2.

FOLLOW-UP DATA28 of 32 patients were contacted and

traced their condition after therapy at clinics orby telephone. The mean follow-up time was14.1 3.3 months (range 5-18). The averageduration to relapse was 10.2 5.6 months. If thepatients were subclassified according to the ini-tial PASI score to PASI <10 (n=9), PASI 10-20(n=10), and PASI >20 (n=9), the mean durationto relapse were 11.5 5.5, 13.2 3.9, and 5.64.8. (Table 3). There were 15 patients still in theremission status at the end of the follow up. Themost common site to relapse was the scalp(n=13). the overall satisfaction evaluated withvisual analogue score (0-10) was 8.8 1.3. Thefollow-up data was summarized in Table 3.

DISCUSSIONPsoriasis is a chronic immune-mediated

disease that bothers the patients very much.Despite the advances of psoriasis treatment inthe past decades, it is still challenging. Manypatients, and even some dermatologists whotreat them, are frustrated because of unsatisfiedresult with most treatment modalities.According to the past literature, theGoeckerman treatment, which firstly describedby Goeckerman in 1925, or its modifications(Table 4), is one of the most effective and safesttreatments for psoriasis patients with severe ordisabling disease.4 Therefore we have intro-duced the modified Goeckerman regimen sinceMarch 2002. Because we would like to provide


a day care program and make the best use of thephotosensitivity of tar preparation, a one-day 5-hour tar occlusion with following light therapywas designed. However, there was no controlledtrial to compare different modifications of theGoeckerman regimen.

While selecting our patients, severity wasobviously an important factor. However, therewas no standard criteria for the definition ofseverity in psoriasis.5 Most authors or clinicaltrials defined severity by body surface areainvolvement or the PASI scores, but othersthought that quality of life and subjective per-ception should be important issues.5 We selectedour patients by both body surface area involve-ment and patients' need which could be catego-rized as moderate or severe. The criteria weused (>5% BSA) was similar to the definitionof the National Psoriasis Foundation in which2%-10% BSA was categorized as moderate andmore than 10% BSA was severe.6 The mildersubgroup of our patients were either withlesions over the critical areas (face, hands, etc.)or with poor response to previous therapies.Therefore they were enrolled in the treatmentwith modified Goeckerman regimen.

Table 3. Follow-up data.

Mean SD Range

Duration of follow up (months)(n=28) 14.4 3.3 5-18

Duration to Total (n=28) 10.2 5.6 1-18

relapse Severe group Initial PASI >10 9.7 5.6 1-18

(months) (months)(n=19)

Subclassified Initial PASI <10 11.5 5.5 2-18

by PASI (months)(n=9)

Initial PASI 10-20 13.2 3.9 8-18

(months)(n=10)

Initial PASI >20 5.6 4.8 1-14

(months)(n=9)

First site to recur (n=28)* Scalp: 13; legs: 6; trunk: 3; arm: 1;

face: 1; nonspecific: 1

URI or stressful event before relapse (n=28)* 2

Patient satisfaction (VAS 0-10) 8.8 1.3 5-10*including patients with focal recurred lesions but not fulfill the definition of relapse

Spuls et al. reviewed the systemic treat-ments for severe psoriasis in 1997 and foundthat PUVA was most effective with clearancerate (95-100% improvement) 70% and goodresponse rate (75-100% improvement) 83%,followed by UVB, cyclosporine, and retinoids(etretinate/acitretin) with good response rate of68%, 64%, and 56%.7 MTX was not included intheir review because most literatures were withconcomitant antipsoriatic therapy, outdateddosage, or inadequate documentation. Anotherrandomized controlled study of MTX versuscyclosporine in moderate-to-severe chronicplaque psoriasis in 2003 revealed that roughly60% and 40% of patients treated with MTX and71% and 33% of patients treated withcyclosporine achieved partial (more than 75%reduction in PASI score) and complete (morethan 90% reduction in PASI score) remission.8

Comparing our data to these systemic therapies,it seems that our regimen is not superior sinceonly 66% of patients reach PASI 75. However,an interesting finding is that if the patients aresubclassified with initial PASI score to <10, 10-20, and >20, it seems that the more severe ini-tial condition, the better response during thera-


applied.4 In Mount Sinai Medical Center, 5% tarpreparation was applied at bedtime followed byan early morning soap and water bath. Afterthat, phototherapy was done.11 Another differentregimen used in the University of California,San Francisco (UCSF) and the BaylorUniversity Medical Center, Dallas (BUMC) wasinitial UVB treatment followed by a tar sham-poo, and 2-5% crude coal tar application. Thetar application was repeated twice during theday. Prior leaving the center, patients bathed orshowered off the residual tar.9 The duration ofremission were 1.7 years in male and 1.8 yearsin female in the Mayo Clinic, 125 days(remained clear) in the Mount Sinai MedicalCenter, and longer than 1 year in 73% patientsin the UCSF and BUMC. Our regimen wasmost similar to the Mount Sinai Medical Centerbecause we both applied tar and then wash offbefore phototherapy. This method s advantagemight be that no remaining tar on the skinwould promote UVB penetration and irradiatedat the most photosensitive period after tar appli-cation. The average remission time of ourpatients was a little shorter than these centersbut possibly due to shorter follow-up period.

Table 4. Original Goeckerman regimen and some of its modifications.

Centers Regimen

Original Goeckerman Application of CCT UV radiation (hot quartz)

regimen21 removal tar with olive oil oatmeal and soda bath

Mayo Clinic4 2% CCT in petrolatum applied 3 times a day remove

excess oint with gauze pad saturated with vegetable oil in

the next morning UV radiation (hot quartz) cleansing

soap tub bath

Mt Sinai Medical Center11 Application of CCT or polytar at bedtime early morning

soap and water bath UV radiation emollients as

needed

UCSF/BUMC9 UVB tar shampoo CCT to the general body with

occlusion twice daily 6-7 hr later wash off tar emollients

KCGMH Tar preparation with occlusion 5 hr later wash off the tar

UVB radiation emollients as needed

py is noted (PASI 75 are 33%, 58%, and 91% ineach group), though the duration of remission ismuch shorter in the most severe group (see dis-cussion below). Menter et al. claimed greaterthan 90% improvement was achieved in all their300 patients.9 However, most enrolled patientsare 20% or more of BSA according to the sug-gested guidelines at most psoriasis centers.10

Therefore, the response rate of the more severegroup is quite similar. As to the less severegroups ( less than 20% of BSA), we highly sus-pect if the relatively poor response is due toinadequate treatment in some patients, especial-ly the less severe groups (several patients termi-nated before all lesions cleared because of jobor better looking). Definitely, the majority ofour patients were more satisfied with the modi-fied Goeckerman regimen than previous othersystemic therapy.

There are several different modificationsof the Goeckerman regimen in the world. In theMayo Clinic, they applied 2% crude coal tar inpetrolatum three times a day and then removedexcess ointment before phototherapy in the nextmorning. After phototherapy a cleansing soaptub bath was given before new ointment was

CCT: crude coal tar; UCSF: University of California, San Francisco; BUMC: Baylor University Medical center;KCGMH: Chang Gung Memorial Hospital, Kaohsiung


There was also at home Goeckerman regi-men which could reduce hospital stay but withshorter remission time (5.1 months).12

One of the most important factors thatpatients care is the duration of remission of aspecific therapy. Since psoriasis is a chronic dis-ease, the duration of remission means the periodthat patients may get off from hospital and med-ication and live a more normal life.According to previous literature, topical corti-costeroids, calcipotriol, or tazarotene main-tained remission for about only 1.5-3 months.13

Other systemic medications did not do better:etretinate may maintain remission before anysign of psoriasis or the appearance of any newlesions for about 8 weeks; cyclosporine treat-ment associated with relapse with PASIreturned to 50% of the baseline in only 6 weeks;and methotrexate had remission time fromabout 10 weeks to 6 months.13 The biologics,which mark the new era of psoriasis treatment,though relatively safe and convenient, have anaverage remission time of 7 months or shorter.14-

17 Phototherapy alone also has average remis-sion time of only 4 to 5 months.13 In the reviewof Koo and Lebwohl, the therapies that hadlongest remission time were phototherapeuticmodalities, especially Goeckerman and PUVAtherapy.13 It s difficult to compare all studiesbecause the definition of remission or relapsevaried greatly. However, it is universally recog-nized that the Goeckerman regimen, or its mod-ifications, may maintain remission much longerthan other systemic therapy except PUVA.Some author claimed that the remission timeafter Goeckerman therapy was as long as 1.4-1.7years.4 Our data was not so good but 15 of 32patients still in remission status at the end of fol-low up. Therefore the mean remission time maybe longer if we keep following these patients.

Another interesting finding in our data wasthat it seemed no obvious difference in the dura-tion of remission between two groups withPASI <10 and PASI 10-20 (11.5 versus 13.2months). However, for the most severe group(PASI >20), the mean duration of remission wasmuch shorter (5.6 months) in spite of the high

percentage (91%) reached PASI 75 at the end oftherapy. We wondered if this could correlate tothe findings reported by Peng Y et al. that thesepatients belonged to the most severe and refrac-tory group (type 6).18

Because of the chronic nature of psoriasis,not only effectiveness but also safety is animportant consideration while treating thesepatients. Although systemic agents such asmethotrexate, cyclosporine, or acitretin mayhave good therapeutic effects, possible sideeffects to liver, kidney, hematopoietic system,or fetus may limit use.19 The modifiedGoeckerman regimen, however, has few sideeffects both in the previous literature and in ourexperience. Common acute side effects includ-ing light sensitivity (5%), tar sensitivity (1%),and folliculitis were reported.12, 20 We found oth-er immediate complications including itching,localized burn, marked lichenification, andobvious new lentiginous lesions. Concernsabout long term complication such as increasedskin cancer incidence have not been observedeven after 25 years follow up.4

There are still some advantages with themode of day care center. First, patient-patientand patient-physician interaction was more fre-quent and some kind of unofficial supportinggroup might develop in such environment.Actually, many patients have had better moodduring therapy not only due to improvement inskin lesions but also due to empathy and sup-ports of other patients. Second, since patientswill stay for hours each day at hospital, thera-peutic group sessions, relaxation and exerciseclasses or other activities may be conducted inthe day care center, as at the UCSF andBUMC.9

Although very effective and safe, however,the modified Goeckerman regimen has somedisadvantages which makes it lesser been usedtoday. First, it is very time-consuming. Eachpatient has to stay at hospital for 6-7 hours perday, 5-6 days per week, and lasting for about 5weeks. Some of our patients that could notreach 75% improvement of PASI score weredue to limitation in time available to stay at our


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hospital. Second, it is too messy for manypatients to accept this therapy. Other disadvan-tages might be encountered including accelerat-ed photoaging which should be concerned dur-ing such therapy.

CONCLUSIONHerein we reported this preliminary data

about our experience of treating psoriasispatients with the modified Goeckerman regimenin Taiwan. Our experience confirmed that themodified Goeckerman regimen is still a goodalternative choice if proper space and equip-ments are available.

treatment for psoriasis with modified goeckerman …despite the recent advances in treatment for...

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