In a study performed at our center at the University of California San Francisco, PASI75 response (a 75% improvement in the Psoriasis Assessment Severity Index) was achieved in 100% of patients receiving Goeckerman (n = 25) over a 3-month time period.⁵ 24/25 patients needed only 2 months to achieve PASI75, while the remaining patient obtained a PASI75 response at 3 months. In another study, Menter et al. administered the Goeckerman regimen for 300 patients and 100% of the patients achieved 90% or more clearing of their baseline psoriasis lesions. The average amount of treatment days for patients to achieve more than 90% clearing in the second study was only 18 days.⁴ PAS75 response by 3 months of therapy is considered the standard tool to assess the efficacy of a treatment modality for psoriasis. Though biologics are the new development in psoriasis treatment, their reported efficacy is 67-68% of patients achieving PASI75 at 3 months.⁶ Furthermore, biologics are associated with potential serious internal risks such as internal cancer, serious infections (tuberculosis, coccidioidomycosis, histoplasmosis, etc.) and cardiovascular risk.¹⁰ Goeckerman therapy avoids any of these serious internal risks while still being extremely efficacious. The use of topical tar and phototherapy has a synergistic effect. The synergism is a result of tar, being a photo sensitizer, and is supported by studies documenting a higher efficacy of combination therapy in comparison to phototherapy alone.¹¹

The Goeckerman regimen usually proceeds for 20-30 sessions, resulting in clearing or more clearing of psoriasis. Although individual results may vary, typically after ten days of treatment we observe that patients experience decreased scaling and induration of their plaques. After twenty treatments we typically observe complete flattening of the plaques with only the presence of residual erythema. After 30 treatments, we observe complete clearance of the psoriasis lesions, including residual erythema, with only the presence of possible post-inflammatory pigmentation alterations. Patients also experience a significant improvement of their itch during the therapy. If a patient has recalcitrant psoriasis and is not showing improvement of their plaques, the therapy can be extended as needed. Furthermore, if a patient does not respond at all with topical CCT and phototherapy, the diagnosis of psoriasis should be reevaluated and confirmed by a skin biopsy (especially to rule out mycosis fungoides and pityriasis rubra pilaris).

Goeckerman therapy has one of the longest reported remission times of any psoriasis treatments. After completing Goeckerman therapy, the average length of remission can be anywhere from 9.5 months to over a year.^4,12 Therefore patients can expect to maintain a response to the therapy for up to a year. However, since psoriasis is a chronic, life-long disease, the disease tends to recur in patients, especially in those who discontinue any type of therapy including topical medications and/or outpatient phototherapy. Patients who have severe, recurrent psoriasis repeat the Goeckerman regimen as needed, which is usually on a yearly (or longer) basis. Repeated admissions often require fewer treatment days to achieve clearance as patients tend to become more prompt in seeking help and patients also do not develop physiological resistance (tachyphylaxis) to the therapy

Attached are photos of a patient with severe psoriasis plaques prior to be being treated with Goeckerman therapy [Figure 5a]. Though his mild erythema is still present, there is significant decrease in scale and induration of his plaques after 4 weeks of treatment [Figure 5b]. After completing a full course of therapy, patients can expect a complete clearance of their lesions [Figure 6a and 6b].

Table 1. Narrow Band UVB dosing protocol for Psoriasis. Guidelines for initial dosing, dosing increases on subsequent visits, and dosing adjustments for missed visits *mJ = millijoules.

Table 2. Broadband UVB dosing protocol for Psoriasis. Guidelines for initial dosing, dosing increases on subsequent visits and dosing adjustments for missed visits *mJ = millijoules.

Figure 1. The Supplies for Goeckerman Therapy. The medications and supplies needed for the topical application of tar and corticosteroids (Clockwise). Front Middle: Clobetasol Propionate 0.05%; Front Left: Fluocinolone Acetonide 0.01% Oil; Left: Hydrophillic Ointment; Top Left: Moisturizing Lotion; Middle Left: Jar of 20% Liquid Carbonis Detergens in Aquaphor Ointment with the cap open; Back Middle: Plastic wrap for the occlusion of topical medications; Middle Right: Jar of Crude Coal Tar 2% in White Petrolatum Ointment with the cap open; Ointment; Bottom Middle Right: Triamcinolone 0.01% Ointment; Top Right: Mineral Oil for washing topical medications off; Front Right: 20% LCD lotion.

Figure 2. Narrowband UVB Station. Left is the narrowband UVB light box where patients enter and receive UVB phototherapy. Right is the attached computer station for the charting of phototherapy dosing and patient’s response to phototherapy.

Figure 3. Application of Crude Coal Tar. The nurse is applying crude coal tar to the entire body prior to occlusion with plastic wrap.

Figure 4. Shower. The shower for washing off the topical medications with mineral oil and soap. Shower is equipped with safety mats to prevent the floor from getting slippery. Safety handles are also present and important, especially for the elderly.

Figure 5. Response to Goeckerman Therapy After Four Weeks. (A) Prior to treatment, the patient with thick plaque type psoriasis over the upper back. Notice the induration, thick scale, and prominent erythema of the plaques. (B) After 4 weeks of Goeckerman treatment, the patient with decreased scale and induration as a result of therapy. Residual erythema is still present.

Figure 6. Response to Gockerman Therapy After Six Weeks. (A) Prior to treatment, the patient with severe plaque type psoriasis over the back. (B) Clearance of psoriasis lesions after completing Goeckerman therapy.