Canadian Fighting Pustular with Fumaric Acid Treatment
from David F.

Hi Ed.  I have severe pustular P on both feet and the tips of my fingers. My doctor has prescribed Fumaric Acid 5% ointment with Allantoin .5% mix.

When I used it, it seemed to be a miracle, but now the feet are extremely red, full of pustules and generally a real mess. To say the very least, I am discouraged. Usually, come spring/summer, it clears up, but this year it remains very bad. Perhaps it is because we are having an extra cold spring so we are not outdoors as much.

I also have P-arthritis and both ankles are so swollen, I frequently cannot get shoes on. I also have severe arthritis in my hip and both knees. I feel quite down in the dumps as I cannot even accompany my wife on her walks with the dogs because of pain and limited mobility.

My wife and I had been working out (before the feet got so bad) in a heated pool but the SARS scare in Canada has closed the hospital to everyone but inpatients. I will speak to my doctor about Fumaric Acid capsules. Actually, I live in Kingston, Ontario, Canada but the Fumaric Acid comes from British Columbia (over 3000 miles away).

My dermatologist only had light therapy to offer. (I am sunlight sensitive and broke out in a very itchy rash as well as burning my feet!) A friend of ours who is a doctor, was kind enough to contact a pharmacist in British Columbia, who suggested the Fumaric Acid compound.

Nice talking to you because I feel so lost. I am 56, can't work and feel so frustrated.  Sincerely, -David F.

*****

Ed’s Response:  I don’t know much about fumaric acid treatment for psoriasis.  These two references provide some background (and each contains additional links):

          Fumaric Acid Treatment

          Fumaric Acid Esters: Not an “Alternative”

Fumaric acid isn’t used overtly for P treatment in the U.S., either orally or topically, but your experiences seem to suggest that like many other P treatments, it works for awhile then its usefulness diminishes. 

Have your doctors said anything to you about methotrexate?  Down here it is the drug of choice when skin P is compounded by near-debilitating P-arthritis.  In the late 90s my P arthritis got bad enough to threaten me with near immobility — on top of which my skin lesions were flaming mightily — and I finally started methotrexate (also referred to as MTX).  It completely quieted my arthritis and improved my skin considerably (but not totally).  (My MTX Journal is here.)

Because MTX is a toxic immunosuppressive drug, many doctors prefer to limit it as a treatment course.  Mine was one of those doctors.  We agreed at the onset of treatment that I would not take the drug for longer than a year.  True to our commitment, after a year of blessed relief I switched to another powerful systemic, cyclosporine.  Both the doctor and I were fearful the P arthritis would come back.  But it didn’t.  What’s even better, the skin P that didn’t clear under MTX did clear with cyclosporine.  I lived for nearly a year with absolutely no psoriasis symptoms.  I stopped the cyclosporine when my blood pressure began to rise. [My Cyclosporine diary.]

Since then I’ve been on a second course of MTX, again with good but not perfect results.  I phased out the MTX early this year when I tried my first biologic drug, Enbrel which has been bitterly disappointing.  Within the next few weeks my derm and I will have to decide on a new course.

I share all this with you, David, in the hopes that some of these more powerful drugs are available to you.  I think for people with mild-to-moderate psoriasis, and perhaps even cranky but not debilitating P-arthritis, the systemic immunosuppressive drugs are a choice for which decisions can be made either way without stigma.  But when P becomes nearly debilitating, I feel more strongly that the systemics should be considered.  Unless there are good reasons not to try them, I recommend they be considered.

I hope you’ll write again and let us know how you’re doing.  -Ed

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