Goeckerman’s regimen for psoriasis

The Goeckerman regimen was introduced in 1929 for the treatment of psoriasis. The procedure was very messy, time-consuming (up to 10 hours) and required a great deal of persistence. Despite the obvious drawbacks, the Goeckerman regimen proved to be very effective and as such was held as the standard therapy for psoriasis for half a century. However, in the 1970’s it was found that the intermittent use of light radiation alone cleared milder forms of psoriasis. This discovery rendered Goeckerman’s regimen obsolete in most cases of psoriasis, but it remains the standard for severe psoriatic cases that warrant a more intensive treatment plan.

Psoriasis is an immune disorder in which T-cells induce inflammation and excessive proliferation of skin cells. The diseased area consists of cells that are dividing and proliferating at a much quicker rate than normal. It manifests as thick, red colored plaques.

Goeckerman’s regimen is aimed towards reducing the thickness of the skin by slowing down the rapidly diving cells, as well as reducing the inflammation. First, a crude coal tar ointment is applied for 2-10 hours over the affected area then washed off prior to light treatments. The tar used is a black viscous fluid formed from the distillation of heated coals. Coal tar ointment contains properties that inhibit proliferation of the diseased epidermis. However, it’s most unique quality is its ability to photosensitize the skin so that subsequent light radiation is more effective.

After the coal tar ointment has been completely washed off of the affected areas, the patient’s skin is exposed to light in a light box. The light is first absorbed by cells in the outermost layer of the skin—the epidermis. The light absorbed has sufficient energy to change DNA structure in the nuclei of skin cells. When such an alteration occurs, DNA synthesis/replication is temporarily blocked. If DNA is not properly replicated, the cells cannot proceed into cell division. In other words, by stopping or delaying the cell cycle, UV light is limiting the proliferation and thickness of the psoriatic plaque. UV light is also responsible for reducing the inflammatory response generally found in psoriasis.

The Goeckerman regimen is still offered at major dermatology departments for the treatment of severe cases of psoriasis. It is not used in private doctors’ offices due to its complexity. Indicators that could suggest a more aggressive treatment (such as Goeckerman’s regimen) is needed, generally include the involvement of large areas (more than 10% of body surface area) or the involvement of surfaces that result in occupational disability. This treatment has shown substantial improvement in 80% of patients. The most effective form of therapy is through an inpatient clinic where a patient stays overnight in a hospital setting. Remission usually occurs in 2-3 weeks (over a total of approximately 30 treatments) and is maintained with intermittent UVB phototherapy. For some patients, remission may take more time. For people that are unable to stay in a hospital, outpatient treatments are also available.

Psoriasis really has no known cure, only therapies. The purpose of every treatment is to minimize the severity of psoriatic outbreaks so that the illness does not impair the patient’s life. All treatments have potential toxicity. Cold tar can cause acne-like eruptions and skin irritation. It is also known that both crude tar and UVB are carcinogens. Despite the carcinogenic effects, Goeckerman’s regimen may still be the safest option for people with moderate to severe disease as the risks are limited to a very small increase in skin cancer induction. The benefit/risk ratio of therapy must be evaluated in each individual case to ensure that the benefits outweigh the risks.

Marigdalia K. Ramirez-Fort
Ponce School of Medicine
Ponce, Puerto Rico

Alexander Doctoroff, D.O., F.A.O.C.D.
Assistant Chief of Dermatology, Veterans Administration Medical Center
East Orange, New Jersey
Assistant Clinical Professor of Medicine,
University of Medicine and Dentistry of New Jersey.
www.metropolitanderm.com