Chapter Ten
Armchair Philosophy
2008 Postscript:  More on Derms and Self-reliance ... There is NO CURE to buy — yet

A few summers ago I became acquainted with a tomcat that, at first, liked simply to sleep in the shade of my back patio, but eventually learned that by being friendly he could earn food. In no time at all we were tight pals. He's definitely not a feral cat — humans normally don't become “pals” of feral cats — but I do believe he lives most if not all of his life outdoors, roaming where he wants, when he wants.

Late that first summer of our acquaintance I noticed sores forming behind his ears. He was scratching the backs of his ears constantly. First he scratched his fur away, then he broke the skin, then he prevented the ensuing sores from healing by constantly scratching away the scabs. It was ugly and undoubtedly painful. I began to worry about infection and, when it became obvious the cat was in a vicious no-way-out situation with his self-destructive scratching, I finally called a vet.

The vet concluded: “Ear mites.”

Of course! I thought, slapping palm to forehead. It wasn't a skin problem. The poor animal was scratching through his ears to get at the annoying insects in his head. We subsequently and successfully tackled the problem using a prescription that killed the mites.

All of this got me thinking about my psoriasis. (No, I didn't experiment on myself with the ear mite medication). You look at damaged skin on an animal and you invariably assume a life-threatening situation. Yes, most critters with skin (a soft tissue) separating the rest of their bodies from their environment — as opposed to those much more resilient organisms with shells and exoskeletons — will periodically damage it, and all successful vertebrate species have evolved complex methods of healing such damage.

Sores that don't heal through normal mechanisms (e.g., refraining from scratching, keeping the wound clean, etc.) often indicate an underlying cause, something that attending to the skin itself won't solve. (Is this beginning to sound familiar? Do you have lesions that behave similarly?)

My friend the tomcat had some severe skin problems not as a result of any innate problem with his skin but because of his ear mites. His skin damage was incidental to the root problem.

So, I asked myself. What could psoriasis be incidental to? Research seems to be homing in on a solution to that question. Psoriasis now appears to be a genetic proclivity. It appears to have to do with an elaborate immune system, governed by genetic code, gone just slightly haywire.

Why should my skin “assume” it has to grow fourteen times faster than normal on some parts of my body and just some of the time? What goofy signals are being generated (and how) that “fool” my natural defense mechanism into extensive damage control where there is no damage?

Since answers to these questions are, for the moment at least, still elusive, for my own peace of mind I resorted to a little armchair philosophy. Simply for the sake of argument, I'll share that philosophy.

I begin by accepting as correct what current research suggests: Psoriasis happens because our genetic code enables our immune system to behave inappropriately. That is to say we are hardwired so that our skin occasionally thinks it has to commence extraordinary reproduction in certain places when, in fact, it doesn't and shouldn't.

Were we anything other than human on this planet, such a condition might be fatal. No, I'm serious. Think about it. None of my medically prescribed regimens cures psoriasis; at most they just subdue it, and they don't do that very well much of the time. It is my combination of intellect and prescribed therapies (which are a product of our society) that prevents me from spiraling down into a potentially fatal cycle like my tomcat friend.

This is not so far-fetched. I can't begin to count the mornings I've noted blood stains on my sheets. Without “modern medicine” and our socially learned habits of personal hygiene, how long could I suffer these lesions without becoming infected by something serious?

In short, my psoriasis is definitely not contributing to my ability to survive, nor is it a meaningless aberration. Without the “security” of my intellect and my society, my psoriasis could be life threatening. If tom didn't have his ear mites cleared out, the wounds to his ears from scratching might have become devastatingly infected.

All right, you might ask. If we're so “superior” at surviving as a species, why are we carrying around this potentially fatal genetic code? The answer is simple albeit cryptic: Because we can.

The psoriasis that might kill us if we lived like wild animals is, because of our humanity, embarrassing but bearable.

Before I “prove” this, you must understand the sense in which I use the expression, “our humanity.” In this context, I think of “our humanity” as that aspect of our environment which we fabricate and control.

Species survive on this planet when they can assimilate their genetically-driven (or “hard wired”) behaviors into their environment. Species other than human exhibit “social behaviors,” but, when these species succeed, their social behaviors are determined by a happy compatibility between their genetics and their environment. Species become endangered when their hard wiring is no longer compatible with their environment, hence their behaviors no longer preserve and protect them. If those behaviors could override the dictates of environment (like our humanity does) we wouldn't have so many endangered species. (We’d also have a lot more competition for life-sustaining resources.)

Our humanity is our edge. If environment ever gets the better of us, it's not likely to be nature's environment, but the one we've created just for ourselves. [Isn't our current global warming an example of this? -Dewke, 5/29/2008]

To take the next step in this argument we must make another leap of faith. That is, we must accept the basic tenets of evolutionary theory, most particularly, “survival of the fittest.” Simply put, that tenet means that the better equipped we are to survive in our environment at birth, the more likely we are to survive and propagate. When we survive and propagate we pass along that which equipped us to do so as well as all our other genetic attributes. When we're born aberrant (in Darwinian theory, at least) our aberration has a slim chance of being helpful — most likely our aberration is either hurtful or irrelevant. If it's lucky enough to be helpful, fine, we'll survive and propagate it. If it's hurtful, we're likely not to survive and therefore not propagate (at least not as much). If it's irrelevant we'll probably survive and propagate it. [Ailments typically attacking the aged, such as various forms of dementia and many other heritable diseases, are probably genetic proclivities that persist because they are not triggered until AFTER we have propagated. -Dewke, 5/29/2008]

All of this makes perfect sense (to me at least) when you consider species existing in social groups that react to, but cannot alter their environment. Our humanity changes this prescribed order, which Darwin called “natural selection.”

Our humanity tends to protect aberrations regardless of whether they're helpful, hurtful or irrelevant. Think about it. As humans, we have created systems, institutions, patterns of behavior — in short, social systems or societies — that have had profound — and, we're realizing just recently, often profoundly negative — effects on our environment. Whether for better or for worse they have served to keep us, essentially, as we are.

But HAVE they?

I tend to believe the human species hasn't always harbored psoriatics. I further venture psoriasis didn't “happen” within our species until we were already protected by those systems, institutions and patterns of behavior I'm lumping under the expression “our humanity.”  Why do I believe these things? Without our humanity, psoriasis could very well have been fatal, or at least a “dead end” disease. It would have been fatal if we let the lesions crack, bleed, become infected. It would have been a dead end if no one cared to mate with us.

Our humanity overrides these considerations. Our humanity allows our psoriasis to be more-or-less irrelevant. So we live normal life spans, we keep our lesions clean and supple (at least some of the time). We hide our lesions when we can, and, most importantly, we mate and propagate more psoriatics.

Now we get down to the real armchair theorizing. I think that our humanity, which for the time being allows us almost as much effect upon our environment as it has upon us, largely ignores the fact that differentiation (or mutation, or diversification) is going to happen anyway.

The ugly truth of the matter is that the more our humanity keeps environmentally controlled natural selection at bay (by making it irrelevant) the more aberrant our population is likely to become.

Think about it. By thumbing our nose at nature, essentially saying our humanity will compensate for our physical aberrations, we're giving nature free reign to propagate all sorts of genetic abnormalities. It's a denial of the natural selection process.

A psoriatic living an aboriginal life in the outback of Australia might have a tough time “coming-of-age,” finding a mate, propagating his problem ... but not in Manhattan, or Denver, Chicago, Des Moines, Paris, Moscow or Beijing ... not anywhere our society lets us treat the symptoms, write books like this one, and make the condition a thing warranting sympathy but not threatening survival.

Why do we have psoriasis? Because we can. Our humanity has permitted it.

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Now we need to take another leap. When I joined the U.S. Coast Guard in 1969 I'd never seen an ocean except in movies. Flying into San Francisco Bay for the first time, at night, was a breathtaking experience for me. It was so beautiful! I took a cab from San Francisco International Airport to Alameda, across the bay. While we were on the Oakland Bay Bridge I became mesmerized by the lighted hills of Oakland and sighed.

“That's something to behold,” I said aloud to the cab driver.

“Yeah,” he said. “Like a cancer spreading over an otherwise perfectly healthy mountain.”

I was, at the time, stunned by the sordid implications of his reasoning. Since then I've come to realize the brilliance of his vision (though not necessarily the correctness of it).

The Bay Area, or any metropolitan area for that matter, is a perfect example of human society circumscribing environment. Where once condors flew there is now a nighttime brilliance of lights that perhaps only our species finds comforting.

Okay, so where is all this going? My armchair philosophy suggests that, because of our humanity, a few million of us are allowed to propagate this irritating skin condition called psoriasis. Essentially the same humanity that put the lights on the hills of Oakland is the one that allowed my genetic anomaly to be passed down through generations.

Since there are so many of us genetically-inclined psoriatics (about seven million of us in the U.S. alone), there must have been a common branch somewhere way back when. Wherever the gene mutation happened that said “Make your skin think it's wounded when it isn't” had to start somewhere. And that's our common ancestor, folks. Yours and mine.

Genes, even bad ones, have this geometric process of propagating, and our culture lets it happen. Therefore there is only one direction to choose. Perhaps we can learn to alter the consequences of our proclivity towards psoriasis, or block its triggers, develop proactive rather than reactive regimens for treating it. To accomplish this we must surely march in the direction of more humanity. We must tame the a variable.

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I wrote “Armchair Philosophy” at 3:00 in the morning. By 6:30, when my dearly beloved joined me in the land of the awake, nobody could have said anything to me that would not have engendered a “philosophical” response. I was into waxing speciously (as you can tell). The first thing my significant other did in her groggy morning state was knock down the paper towel dispenser that hangs beneath one of our kitchen cabinets. “I hate this thing,” she mumbled.

“It's an object,” I said. “You, on the other hand, are an intelligent being. You are capable of mastering your environment. That paper towel dispenser ought not be controlling you; you should be controlling it.”

“Fine,” she said, yawning. “It's outta here.”

Wouldn't it be nice if we could be so cavalier about bad genes?

About derms and self-reliance

Electing to become a doctor means you dedicate your life to the wellness of others. Who can criticize the nobility of such a dedication? Now imagine you're specializing in dermatology and your leading professor says to you, “There's a  percentage of your patients whom you won't be able to make well, but you can't count on them dying off — that is, going away — either. They'll linger in your office for years seeking relief and, maybe, you can provide it for a few weeks or months at a time, but the relief you engender is never permanent, never a cure; and the more radical the treatment regimen you prescribe, the more likely other ugly things are going to happen to them; things that will ultimately make you send them to other doctors for other solutions.”

Depending on what kind of person you are to begin with, you, the derm student, are going to react to this news in one of two ways. One, you may think, “How tragic,” and you may get a little weepy-eyed about the cures you're not going to get to make happen. But two, you might think, “Ah! Job security!”

Believe me, I've been to derms whose bedside manner has appeared to reflect each of these attitudes towards psoriatics. I've been to some derms whose attitude seemed to be, There's nothing I can do, so don't waste my time. I've been to some whose optimism about their ability to treat me seemed purely motivated by how much income I might represent over the next few decades. And I've been to others who wanted earnestly to help me. It appears to be in the nature of the earnest ones to push for ever more radical treatments. This is to be expected. Though they know they cannot, yet, effect a cure, they know there are ways to palliate the symptoms — a spectrum of increasingly dangerous ways to do so. They ask themselves, How bad does my patient feel about her condition? How drastic need be the counter measures? 

There have been moments over the course of my evolving psoriasis that I have cursed my derms. And there have been moments when I blessed them profusely. Thinking back over my flaking history, I come up with only one summation: It's up to me.

Derms know — all of them know — that they are, for the time being at least, treating the lesions, not beating the disease. What they can do for us and to us is palliative, at best. Unfortunately, many of the countermeasures they have at their disposal can be as wicked as the disease itself. Yeah, if you itch yourself into a bleeding frenzy your derm is apt to prescribe something drastic, like a systemic remedy that can kill your liver (subsequently your entirety), blind you, make you give birth to aberrant babies....

Sometime after my psoriasis was diagnosed, the second or third derm I went to wanted to prescribe a retinoid (a systemic medicine that works to curb lesion growth through effects that evidently are not completely understood).

“Before we put you on this drug,” this derm said, “We need to get a blood work-up on you and also have your eyes examined.”

That was my first clue that retinoids were a serious countermeasure. I have a skin problem. Nonetheless, I went to the lab for the blood test and went to the eye doctor for an exam.

The blood test cost me fifty dollars and revealed some liver function abnormalities. The eye exam concluded that I was almost twice as blind as my then-current lens prescription accounted for (which subsequently resulted in my first pair of bifocals and a second pair of glasses for work at the computer — cha-ching!). And, because of the lab work and a report by the eye doctor, my derm would not prescribe the psoriasis-fighting regimen he had in mind.

I'm grateful, in retrospect, that all of this happened. A lesser derm might have just launched me on the liver spoiling, blinding regimen, in which case I'd either be dead or sightless today. Who knows?

The point of all this is that if you are psoriatic, you're like a luckless roll of the dice. You got it, kitten; learn to live with it. Find a derm who will go with your flow. By that I mean, find a derm who is, at the onset of your relationship, honest about the limitations of what he or she can bring to the table.

Then, you must take charge. The derm I'm seeing these days said to me early on — with refreshing forthrightness — that he could prescribe ever more dangerous treatments, but opting for them would be my call. You see, most psoriasis is not life-threatening. The derms aren't empowered by oath to coerce us psoriatics into any particular regimen, because we can elect to live with the lesions. A flaming period will rarely land us in ER under “code red” conditions, and derms know this. This is a strikingly different situation than that of the doctor treating a patient with dangerously high blood pressure. That doctor knows her patient is risking stroke or heart attack — that is, life-threatening consequences — and can aggressively prescribe whatever remedy is in order. Our affliction, on the other hand, tends to dirty carpets and make us generally repulsive in a social sense; period.

Psoriasis, like ugliness, is rarely fatal. Psoriasis, when compared to the rest of the human symphony of disorders and diseases, too often sums up to be little more than a tremendous annoyance — and this means a good derm's hands are tied. And when your doctor's hands are tied, you and only you can be in charge.

So, how are you supposed to “take charge?” I suppose that depends on the severity of your condition and the amount of “discomfort,” both physical and psychological, it causes. In my case the most useful thing has been maintaining a record of what I've tried, what's worked, when it worked (time of year), and when it stopped working.

Over the years now that I've fought psoriasis, by paying attention to it and keeping records I've learned that I can count on seasonal flare-ups.

Drastic weather changes cause me to flame. And it doesn't seem to matter whether the change is from hot to cold or cold to hot.  Also, any damage done to my skin will either create a new lesion or cause nearby lesions to flame. For example, I don't dare pack a snowball with my bare hands lest I'm prepared for an eruption of pustular psoriasis within a week or two.

Though it's hard to track, I believe there is some truth to the “ninety days” theory about psoriasis and unusual stress. The theory predicts some degree of flaming will occur three months after some stressful trauma.  It's a fact that about ninety days after my second wife left me — and literally cleaned out our house while I was out of town — my psoriasis flared mightily. (This beside the fact that some weeks after her departure she said to me, “Now that I'm gone, I'm sure your psoriasis will clear.”)

Lots of psoriatics report that improved “general health” helps their psoriasis. This is a kind of naturalistic approach that I've been unable to correlate with the waning and waxing of my own psoriasis. There've been periods when I felt “in tip-top shape” and still flamed mightily; periods when I've been ill and either my psoriasis waxed or waned — in other words, no discernable correlation.

If it's true that “stress” is a common trigger for psoriasis, then it makes intuitive sense that when you're feeling good your psoriasis might acquiesce, because when you feel good you're less stressed. But the lack of correlation in my own case between “good health” and my psoriasis drives me to focus on other patterns, other triggers (like weather, which I can almost prove is a factor in my case).

Derms in general can't be of much help when it comes to “understanding” the causes or the patterns of your psoriasis. Sure, their literature suggests a litany of standard countermeasures: for example, “You drink alcohol? Stop drinking alcohol.” (And then they say under their breaths, And we'll see what happens.) Or, “You eat a lot of red meat? Stop eating so much red meat.” (Followed by the same tentative after statement.)

I'm not putting the derms down. Maybe alcohol is one of your triggers. Maybe red meat is one of your triggers. The important thing is for you to determine this yourself. To do this you experiment, give the experiments some time, and record the outcome. After awhile, if you're like me, the data reveals patterns you can use to predict (and perhaps avoid) some of those flame times.

Over the past six years I've been treated by a few derms. I reflect back upon our relationships with varying degrees of fondness, from contempt (no fondness whatsoever) to admiration (much fondness). My current derm is a keeper. He'll let me call for prescription renewals for several months before he asks me how I'm using the topicals and what the results have been. I know why he asks, because most topicals can be “overused” and start to create more problems than they solve. I've sent my derm faxes in which I've explained how, why and when I apply my topicals and he invariably renews the prescriptions and lets me carry on.

As fond as I am of my current derm, I want to say this: No derm has taught me all that I need to know about living life as a psoriatic. I feel that I'm in control for two reasons: The first is that I elected to be proactive about my psoriasis. The second is the on-going education I receive from the National Psoriasis Foundation, based in Portland, Oregon. The Foundation’s web site, periodicals, brochures and booklets about particular aspects of psoriasis and treatment regimens constitutes a library you must possess if you're going to be proactive about your life with psoriasis.  If you’re not already a member, visit http://www.psoriasis.org and do consider joining.

My psoriasis didn't manifest itself with any severity until I was nearly forty, so there are millions of my brethren who've suffered considerably more — including many who have never known life without psoriasis. For obvious reasons, psoriasis is a disease suffered primarily alone or within the confines of loved ones and close friends. No one has ever casually asked me, “So how's your psoriasis fairing today, Ed?” (I rather hope no one ever will.)

I've had many strangers look at me weirdly — as has every other flaming psoriatic who cannot simply hide — and I live, as do my brethren, every day knowing that something is wrong with me.

In the words of guru Stephen Covey, we all strive to live, to love, to learn and to leave a legacy. That's no less true for us, my cousins. I know it.

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Ed’s Postscript (5/22/2008-7/4/2008 ):  I've mentioned before that the search for genes that might "cause" psoriasis has become complicated because there appear to be several involved genes. I don't understand the biochemistry at work here, but it's simple logic to deduce significant increases in potentials and complexity as the number of variables (genes) increases. Today I must state that the "a variable," as I called it in 1995 in this text, is still being defined. As additional genes that play a role in psoriasis are discovered, the definition grows and a true "cure" grows more distant.

But if we can artificially "correct" the immune system behavior that makes psoriasis happen, isn't that a "cure" of sorts? Consider diabetes: Millions of people with type 1 diabetes live full lives because they inject insulin on a regular basis. A type 1 diabetic has a pancreas that does not manufacture enough insulin (if any) to serve its dual purpose of "unlocking" cells to admit glucose (their primary fuel source) and storing extra glucose as fat. Receiving insulin by injection does not eliminate the problem of a non-functioning pancreas, it simply bypasses the requirement to have one. If the immune system behavior that generates psoriasis symptoms (various inflammations and formation of skin lesions) can be stopped through the use of man-made products, isn't that much the same as insulin for diabetics? It is, I think. And I wish we had a drug that worked as well on psoriasis as man-made insulin works on diabetes.

Another facet of our comparison between diabetes and psoriasis is proximity to a cure. Looking at this facet, there is very little proximity. We know what causes diabetes and we are close to a cure. We know what's required is a replacement of a certain kind of cell — the insulin manufacturing cells — in the pancreas or its ducts. There has been some success with transplanting cells. There have been some encouraging prospects in the use of stem cells "programmed" to grow into the needed cell type.  The former approach is replacing the missing cells, the latter is, effectively, regenerating them. But we don't — at least yet — associate psoriasis with damaged or missing cells. For the time being we associate psoriasis with an immune response "chain" that involves the independent but associated behaviors of several types of lymphocyte. Our biologic medications — the latest entries into the anti-psoriasis armory — prevent specific behaviors of these cells from taking place, either by blocking "signal" molecules they generate or killing the cells that generate them. One of the consequences of this effective approach to thwarting psoriasis symptoms is the possibility of compromising the immune system's ability to fight infection. Virtually all the biologics currently used for psoriasis come with warnings to this effect. So, looking through this facet it is plain to see the biologics are not as "healthy" for psoriatics as insulin can be to type 1 diabetics. (This is not to suggest insulin is harmless! Insulin shock — a consequence of having too much insulin and not enough glucose at the same time — is a serious threat for type 1 diabetics.)

More On Derms and Self-reliance

I need to point out that for the past three years my psoriasis has been treated exclusively under the care of my rheumatologist. During that time I've not had a consultation with my dermatologist. It could be that I won't EVER have another consultation with a dermatologist. This isn't the result of any sort of falling out between us. Between my derm Dr. and his fine PA's I had been totally satisfied with the attention and treatments — that is, until my rheumy came up with the biologic that worked better than anything I have ever tried. Years earlier, my rheumy had been referred to me by my derm; he had not wanted to take full responsibility for the diagnosis and treatment of my psoriatic arthritis. I believe it was his policy with all his psoriasis patients to refer them to a rheumy when PA entered the equation.

At the time I first went to the rheumy, my skin psoriasis was 99.9% in remission, thanks to Raptiva, but my PA was bad, almost debilitating. I went thinking my rheumy would give me cortisone shots into the knees, or prescribe a powerful painkiller; instead, she talked about different biologics, ones that would placate the P-arthritis and, most likely, keep the skin clear, too. She talked me into trying Humira instead of Raptiva, and together she and my derm worked out a strategy for me to "step down" my doses of Raptiva while, at the same time, starting small and "stepping up" to a full dose of Humira. It was a strategy that worked well for me. The skin never rebounded severely (though there was some increase in skin involvement for awhile), and my PA faded away. That's when my hiatus from dermatology began.

I have been treated by both a skin doctor and a joint doctor for my psoriasis, which we now believe is an immune system disease. As I mentioned in the postscript to chapter 6, physicians of immunology are hard to find — at least the sort I think we need are hard to find. Something is bound to change about this; too many diseases are being identified as immunological, and they affect widely diverse systems with a broad palette of symptoms. I would like to think that one day we will have a specialist who can attend to all of these with great efficiency. Some prognosticators suggest there will come a day when simple tests will ID disease types and sub-types and point to specific treatments most likely to work based on the patient's genes. It's unlikely I will live to see that day, but I am happy my grandchildren probably will. I am seeing enough miraculous remission of psoriasis today — based on this first generation of biologics — to be joyfully hopeful about the future. The propensity to flake appears well imbedded in our genes. Stubbornly imbedded in our history. So stuck inside us it might take several millennia before it is bred out — if ever. But drugs that compel the immune system to behave in certain ways will get better, more sophisticated, less dangerous so that one day the most recalcitrant flaker among us will not have to shed one flake from the machinations of his inbred disease.

Meanwhile....

There is NO CURE to buy — yet

Regrettably, psoriasis is one of those diseases that snake oil really can help — if snake oil of any sort comes as an emollient with exfoliative properties. All kidding aside, many flakers who find something that works well for them immediately forget everything they've tried that did NOT work and believe they have discovered a cure FOR EVERYBODY. A few will come right out and say, "MY STUFF won't work for everybody, but you have nothing to lose from trying, and roughly 8 out of 10 of you will have a happy outcome." The most earnest of these folks will conduct some trials (i.e., have half a dozen of their acquaintances with psoriasis try their stuff, get fast positive feedback, compose testimonials) and derive a marketing campaign  by spinning this all together. Most of the time, in my experience, there is usually an ingredient behind all of this, an old ingredient known for a long, long time to work somewhat on psoriasis, but now it is concocted into some new formulation, newly bottled, newly named, etc. These weren't then and aren't now CURES for psoriasis; at best they are palliatives that will work for SOME PEOPLE for SOME TIME; never for everybody; never forever. Well, I've heard about one possible exception: Many years ago I had a short but intense burst of correspondence with a young woman whose grandmother had been "cured" by using apple vinegar. I wrote to her that I knew apple vinegar helped some people for some time, but it wasn't very reliable or long lasting. My correspondent disagreed, citing the fact that her grandmother had been applying the apple vinegar the very same way for years and years and NOT had another flare. After going back and forth with this writer for a few days I finally asked her to describe the severity of her grandmother's psoriasis. I asked, was it mild, moderate or severe? I told her about percentages of skin coverage and how one could consider an area the size of the palm of your hand as 1% of your overall skin. She eventually responded that her grandmother would be considered mild. I pressed for more specifics. Finally, she wrote that her grandmother had one Quarter-sized lesion on an elbow. Period. The apple vinegar cleared that up and, with regular periodic re-applications, it never came back. That's the only exception I've ever heard about. But, as I said, this correspondence was many years ago. If the grandmother is still alive and has, in more recent years, experienced a relapse (a return of the Quarter-sized lesion on her elbow) I would — admittedly selfishly — be a happy man.

What we really need to be thinking about is not "curing" psoriasis in the sense we cure polio and tuberculosis. But disarming psoriasis, which we probably will learn to do in the near future. By "disarming," I mean inhibiting the inflammation, scale formation and joint degradation that various forms of psoriasis are all about. In short, what today's biologics are doing, but doing it better, more reliably and in a much more equitable fashion. By "equitable fashion" I mean at costs that are affordable. We should work for a future in which every flaker has access to the Inhibitor (whatever that might ultimately be). There may come a day when there really IS a CURE. It will probably be some sort of gene therapy, in utero or after birth. But an effective Inhibitor is likely to arise long before that cure is discovered — meaning we will not have to wait to be psoriasis lesion free.

And so to you, my brothers and sisters and cousins in suffering. I say live as sweetly as you can, itch as gently as you can, be kind to everyone (except those who promise a cure). -Ed

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Contents of Flake: Confessions...