After my historically‑known‑to‑work over‑the‑counter remedies had apparently no effect on my facial rash, I finally relented and went to my first derm in Lexington. I remember the occasion well. The doctor was a young woman — couldn't have been more than a year or two out of school. Her diagnosis was that the nose problem and the forehead problem were two different things. She was willing to attribute the forehead problem to allergies — probably because I was so cocksure that's what it was. But she frowned and squinted and scraped and ran off to examine bits of my nose under the microscope. Then she scared me to death. “This could be cancerous,” she said.

My, wasn't that pleasant news!

After significant wailing and gnashing of teeth (on my part) she recommended, and I gladly concurred, that before we jump to conclusions we should try to freeze (i.e., “kill”) the affected skin on my nose and see if healthy skin grew back.

To “freeze” the skin on my nose she used a super- cooled gas (I believe it was hydrogen [see Postscript, below]) that she squirted on my nose in bursts from what looked like a fancy aerosol can. She said it would sting. It didn't.

For my forehead she prescribed a mild corticosteroid cream — one of those used as a more or less universal ointment for rashes and other mild skin irritations.

Then she told me to come back in two weeks.

My nose returned to normal in a handful of days — much to my relief. My forehead was also considerably improved by the time I returned two weeks later. The young derm and I smiled at each other.

It was a true Kodak moment.

But a month or so after that, I looked like Rudolph the Reindeer, again — with a red bandana across his forehead. And now I was getting desperate; trips to go on, new people to meet, and all this “noise” interfering with my main body language transmitter!

My third visit to the young derm was anything but a Kodak moment. I ranted and raved, she frowned and — I'd swear — almost got weepy eyed. That's when the word “psoria­sis” was mentioned for the first time. She was beginning to think the forehead might be psoriasis, and she wanted to freeze my nose again.

I let her freeze my nose again and, fortunately, again it cleared. She prescribed a different — but still low‑potency — corticosteroid cream for my forehead, and again it cleared a little. So I went off on my travels doing the best I could to conceal the forehead by combing my hair low and grateful that my frozen nose was, at least for the moment, more or less normal looking.

But a week or so after I returned to Kentucky the nose was red and bumpy again, and the forehead lesions were crimson. I decided it was time to go after a bigger gun.

I called friends and obtained referrals and finally made an appointment to see another derm — this one with a reputa­tion, a man “known about town.”

This derm pulled no punches. He said it was all psoriasis. He prescribed yet another cream and a thrice daily regimen of applications.

In the years that have passed since then, I've learned how to keep the facial lesions under control. The nose, fore­head, and two lesions under my beard on either side of my chin, when they are not flaming, get treated once a day with a mild corticosteroid cream. When the lesions begin to flame (i.e., turn red) they get treated three times a day.

The battle now is not to get rid of the facial lesions, because no one knows how to do this, yet. The battle, now, is simply to keep them quiet and as invisible as possible.

After about three years of being able to control my facial lesions, I was “pressured” into shaving off my beard. That warrants some explanation. My beard contains a lot of white hair. Most people concur it makes me look five to ten years older than I am. I was forty-three the last time I shaved clean and strangers were guessing me to be in my “late forties or early fifties.” The problem was being compounded by salt and pepper grey showing up in my hair, too.

To be honest with you, I didn't view any of this as much of a problem until, at age forty-three, I found myself single again. Suddenly, all the white and grey made me look “distin­guished” to women in their late forties and beyond, and “extinguished” to any female younger than I was. For awhile, this didn't bother me, either (after all, both my former wives had been older than me, one by four months, the other by two years). One would say I “rather fancied” mature ladies.

But when you are forty-three and suddenly find yourself single, and by virtue of your appearance any woman younger than you calls you “Uncle Ed,” you begin to wonder.

At the time I “came clean” (i.e., lost the beard) I was dating a fifty-five year old, a fifty year old, and a forty-seven year old. I was wanting to date two thirty-five year olds and two forty-two year olds, but these four youngsters were the ones who referred to me as “Uncle Ed” (the extinguished).

So, one evening, fortified by copious quantities of self pity, I took the scissors and the razor to my face and revealed . . . a much younger man with two hideous psoriatic lesions on his chin!

I cloistered myself away for two or three weeks while I attacked the lesions with my potions and unguents. Eventually they stopped flaming and the resultant discoloration was such that I figured they would be unnoticeable in dark, smoke filled nightclubs. Even so, the ploy backfired.

My older girlfriends were horrified to be seen with me — not because of the psoriasis, but because I looked about the age of their sons. The youngsters couldn't cope with the fact that this man, who had been their kindly Uncle, suddenly showed up looking like a suitor.

In retrospect, I see that it was a healthy, life changing exercise. Three things came of it. One, I immediately grew the beard back. Two, I threw away my “little black book” and bought a new one with all blank pages. And three, I now tend to those chin lesions — though they be hidden under my beard — with as much dedication as I do the rest of the face lesions because, who knows, there may come another day when vanity drives me to shave away the mask.

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Ed’s Postscript (1/5/2008):  The allergy/psoriasis relationship must still be controversial among health scientists, because drawing connections between the two is still resisted.  The obvious “connection” is the immune system, but right now our position relative to the immune system is somewhat similar to treasure hunters finding the biggest cache ever. Our science has managed to open doors but what they see inside is overwhelming and suggests years of work to truly fathom. It seems like everything is connected to the immune system in some way. The immune system is acted upon and acts upon everything. That being the case, you might argue that hang nails and psoriasis are related (which, come to think of it, would be an easy argument if an aggravated hang nail became a psoriasis lesion in accordance with the Koebner Phenomenon). The point is, things “trigger” allergies and things “trigger” psoriasis. Are they the same things? Maybe. Is there a confluence of the two, allergies and psoriasis, that suggests research in one might yield treatments for both? Maybe. So far, the greatest number of prescription treatments for psoriasis share duties to other diseases or conditions. Methotrexate is a cancer drug, cyclosporine is used to inhibit transplanted tissue rejection, many biologics were first used for the treatment of other autoimmune diseases including arthritis and Crohn’s. The specific processes in the immune system that relate to psoriasis relate to other disorders as well (e.g., tumor necrosis factor, a.k.a. TNF). This is a double-edged sword. We discover new effective treatments for psoriasis from biologic drugs created to treat other disorders, but what else those drugs effect isn’t always known, especially in the long term.

The young dermatologist I went to see first used cryosurgery, using liquid nitrogen (not hydrogen) to freeze the end of my nose. Since then I’ve seen the procedure performed on a grandchild’s warts.  In retrospect, I’m lucky the nose lesion didn’t come back worse than it had been. The nitrogen freezing could have become a Koebner Phenomenon reaction. Named after the doctor who first pointed it out, a Koebner Phenomenon is the emergence of a psoriasis lesion at a place on the skin previously traumatized through some other action. When I had my appendix taken out in ’93, the incisions Koebnerized. My new derm was so tickled by this he took photos.

As it stands, psoriasis on my face — forehead, nose, under the beard — has been the easiest for me to treat successfully with topicals.  The only topical I’ve been prescribed for my face is Westcort® cream, a name brand version of prescription-strength hydrocortisone, a category 4 (weak) steroid for dermatologic uses. (It was also prescribed for use on my genitals.) When I needed fast clearance, I used stronger topical steroids  “outside the limitations of prescription instructions.” I don’t advocate doing this, and I haven’t had to do it often. But I HAVE done it.

My scalp and face lesions have also responded quickly to systemic therapies.  For me these have been methotrexate, cyclosporine, acitretin and, among the biologics, Enbrel, Raptiva and Humira. Since starting the systemic therapies, I’ve not had bad face or scalp flares — something for which I am very grateful. The face lesions did major damage to my self-confidence and scalp lesions were, without question, the most distressing I’ve ever experienced because of the insatiable itching. 

With regard to the girlfriends: the year was 1995, a year I identified earlier as my “year of living dangerously.” Two good things came out of those experiences. First and most importantly, I met and wooed my current wife, Clara. In my heart she rose to the top of the list and restored my faith in life-time commitment. The second thing, which in retrospect becomes a very distant second thing, I learned that psoriasis need not mean the end of intimacy. In fact, it can mean just the opposite.

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Contents of Flake: Confessions...