Commentary
PSORIASIS DAY CARE CENTER DAVID L. CRAM, M.D.
In February 1973 the Department of Dermatology of the University of California Medical Center at San Francisco opened the first Psoriasis Day Care Center (PDCC) in the United Slates. The concept was not a new one—Charles Grupper of the Rothschild Foundation in Paris and John T. Ingram of Newcastle Upon Tyne, England had originated the idea in Europe several years before.' The PDCC is, by its design, a hospital of a unique type where patients with severe psoriasis are treated intensively during the day and allowed to return home at night. II is hospital in-patient treatment which cannot be practically provided for the patient in his home or in the average dermatologist's office. By allowing the patient to return home each night, w e have reduced overhead costs to a point where we can provide this hospital-level care at about one-lhird the average cost of room and care for the usual hospitalized patient with psoriasis. Therapy consists of the application of various tars and ultraviolet light. Patients are treated from 9 am to 4 pm daily for a 6-day week over a period of 2 to 4 weeks. Clearing of the skin 80% to 100% is expected in this time period. Significant remissions have been observed in 80% of our patients for an average period of 12 months.
From the Department of Dermatology and Psoriasis Day Care Center, University of California School of Medicine, San Francisco, California
In the future, photochemotherapy, if it proves safe and successful, could be included in the therapeutic regimen, with psoralens and black light used in the manner reported.- The features of this treatment form an ideal regimen for psoriasis day care programs. The center nurse has the responsibility for teaching as well as for giving the patient the proper care necessary to insure the remission of his disease. The average patient with extensive psoriasis is acutely aware of his appearance and usually is depressed and irritable. He may feel publicly ostracized because people have erroneously believed that he had a contagious disease. Therefore, the nursing staff must have special awareness of the patient's need for compassion and understanding. This points up 2 important features of this specialized day care center. Eirst, the patient receives much more personal attention than is often possible in the typical inpatient unit, where the dermatologic problem may be viewed as a lower priority than the possible life577
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threatening illnesses and disabilities of other patients. This is an extremely important factor in achieving the best possible remission of psoriasis. Second, through their close association with each other, the psoriasis patients develop a relationship that encourages a more positive outlook. This center is designed to meet the needs of the patient—to keep him or her as an active, functioning member of society. The patient is able to receive the necessary extensive treatment previously only available with an inpatient hospitalization, without the need for spending a significant time away from family. Disability days can be reduced and the family's basic living pattern can continue.
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with a significant avoidance of financial and psychological disruption. There are currently 7 other centers in operation in the world, most of these at major medical centers. For psoriasis patients, day care centers are a logical approach to care. However, this concept could be applied equally to other skin diseases now treated by 24-hour a day hospitalization. References 1. Earber, E. M., Jacobs, P. H., Cox, A. J., et al.. Int. Psoriasis Bull. 1(3):1, 1974. 2. Parrisb, j . A., Fitzpatrick, T. B., and Tanenbaum, L., Photochemotherapy of psoriasis with oral methoxsalen and long wave ultraviolet light. N. EngI. J. Med. 291:1207, 1974.
"Besnier's prurigo" and "diffuse neurodermatitis" have been mentioned already in an historical context, and these and synonyms of similar background have been, and remain, in frequent use. "Fruh- und spatexsudatives Eczematoid" was introduced by Rost (1928); "asthma-eczema" owes its origin to the frequent association with asthma; and "endogenes Ekzem/' a term previously used in a wider sense, was chosen by Korting (1954) to characterize the disease. "Neurodermatitis constitutionalis sive atopica" was favored by Schnyder and Borelli (1967), but "atopic dermatitis" is the prevalent term in the U.S.A. and in the U.K. and is gaining popularity in most countries because it avoids eponyms and the suggestion of a 'neural' etiology. Consequently, this is the name that the author has chosen to use in this book. However, this also is an unfortunate choice of term, even when it is considered in the light of the definition as modified by Coca in 1953: "Atopy comprises a group of allergic diseases that are subject to a common hereditary influence and in which the atopic reagins are often demonstrable." The flaw lies in the conclusion from recent experience that the disease can no longer be considered as a typical atopic disease (see also Chapter 5). In conclusion, it must be made clear that not all dermatologists accept the term atopic dermatitis. Synonyms in use at present include: In the U.S.A.: Atopic eczema, eczema In France: Fczema constitutionnel (Broc, 1927), prurigo Besnier In Germany: Neurodermatitis constitutionalis, endogenes Ekzem In Scandinavia: Prurigo Besnier.—Rajka, C: Atopic Dermatitis. Major Problems in Dermatology 3:2, 1975.
PSORIASIS DAY CARE CENTER DAVID L. CRAM, M.D.
In February 1973 the Department of Dermatology of the University of California Medical Center at San Francisco opened the first Psoriasis Day Care Center (PDCC) in the United Slates. The concept was not a new one—Charles Grupper of the Rothschild Foundation in Paris and John T. Ingram of Newcastle Upon Tyne, England had originated the idea in Europe several years before.' The PDCC is, by its design, a hospital of a unique type where patients with severe psoriasis are treated intensively during the day and allowed to return home at night. II is hospital in-patient treatment which cannot be practically provided for the patient in his home or in the average dermatologist's office. By allowing the patient to return home each night, w e have reduced overhead costs to a point where we can provide this hospital-level care at about one-lhird the average cost of room and care for the usual hospitalized patient with psoriasis. Therapy consists of the application of various tars and ultraviolet light. Patients are treated from 9 am to 4 pm daily for a 6-day week over a period of 2 to 4 weeks. Clearing of the skin 80% to 100% is expected in this time period. Significant remissions have been observed in 80% of our patients for an average period of 12 months.
From the Department of Dermatology and Psoriasis Day Care Center, University of California School of Medicine, San Francisco, California
In the future, photochemotherapy, if it proves safe and successful, could be included in the therapeutic regimen, with psoralens and black light used in the manner reported.- The features of this treatment form an ideal regimen for psoriasis day care programs. The center nurse has the responsibility for teaching as well as for giving the patient the proper care necessary to insure the remission of his disease. The average patient with extensive psoriasis is acutely aware of his appearance and usually is depressed and irritable. He may feel publicly ostracized because people have erroneously believed that he had a contagious disease. Therefore, the nursing staff must have special awareness of the patient's need for compassion and understanding. This points up 2 important features of this specialized day care center. Eirst, the patient receives much more personal attention than is often possible in the typical inpatient unit, where the dermatologic problem may be viewed as a lower priority than the possible life577
578
INTERNATIONAL JOURNAL OE DERMATOLOGY October 1975
threatening illnesses and disabilities of other patients. This is an extremely important factor in achieving the best possible remission of psoriasis. Second, through their close association with each other, the psoriasis patients develop a relationship that encourages a more positive outlook. This center is designed to meet the needs of the patient—to keep him or her as an active, functioning member of society. The patient is able to receive the necessary extensive treatment previously only available with an inpatient hospitalization, without the need for spending a significant time away from family. Disability days can be reduced and the family's basic living pattern can continue.
Vol. 14
with a significant avoidance of financial and psychological disruption. There are currently 7 other centers in operation in the world, most of these at major medical centers. For psoriasis patients, day care centers are a logical approach to care. However, this concept could be applied equally to other skin diseases now treated by 24-hour a day hospitalization. References 1. Earber, E. M., Jacobs, P. H., Cox, A. J., et al.. Int. Psoriasis Bull. 1(3):1, 1974. 2. Parrisb, j . A., Fitzpatrick, T. B., and Tanenbaum, L., Photochemotherapy of psoriasis with oral methoxsalen and long wave ultraviolet light. N. EngI. J. Med. 291:1207, 1974.
"Besnier's prurigo" and "diffuse neurodermatitis" have been mentioned already in an historical context, and these and synonyms of similar background have been, and remain, in frequent use. "Fruh- und spatexsudatives Eczematoid" was introduced by Rost (1928); "asthma-eczema" owes its origin to the frequent association with asthma; and "endogenes Ekzem/' a term previously used in a wider sense, was chosen by Korting (1954) to characterize the disease. "Neurodermatitis constitutionalis sive atopica" was favored by Schnyder and Borelli (1967), but "atopic dermatitis" is the prevalent term in the U.S.A. and in the U.K. and is gaining popularity in most countries because it avoids eponyms and the suggestion of a 'neural' etiology. Consequently, this is the name that the author has chosen to use in this book. However, this also is an unfortunate choice of term, even when it is considered in the light of the definition as modified by Coca in 1953: "Atopy comprises a group of allergic diseases that are subject to a common hereditary influence and in which the atopic reagins are often demonstrable." The flaw lies in the conclusion from recent experience that the disease can no longer be considered as a typical atopic disease (see also Chapter 5). In conclusion, it must be made clear that not all dermatologists accept the term atopic dermatitis. Synonyms in use at present include: In the U.S.A.: Atopic eczema, eczema In France: Fczema constitutionnel (Broc, 1927), prurigo Besnier In Germany: Neurodermatitis constitutionalis, endogenes Ekzem In Scandinavia: Prurigo Besnier.—Rajka, C: Atopic Dermatitis. Major Problems in Dermatology 3:2, 1975.
