Treatment settings.

A ny discussion of psoriasis treatments must include the setting in which such treatments are administered. Traditionally these comprise in patient hospitalization, ambulatory day-care-center treatment such as with the Ingram or Goeckerman regimens, outpatient phototherapy with ultraviolet B (UVB) or with psoralen and ultraviolet A (PUVA), and home care under the supervision of a physician in a private office or clinic-based facility; however, the milieu encompasses far more than the physical setting. Self care, patient education, group therapy, stress reduction techniques, and other support systems are important adjuncts to all of these therapies. Climatotherapy or heliotherapy is an option for selected patients, particularly those in Europe and those who can travel to the Dead Sea or other spa-treatment facilities. Historically, there has been a shift from inpatient hospitalization for severe widespread psoriasis to outpatient treatment with the availability of new modalities such as calcipotriene, PUVA, etretinate, and cyclosporine, among others. Changing health-care systems, particularly with regard to managed care in the United States, have promoted outpatient care and emphasized the roles of the dermatologist as consultant to the primary care physician. Medical informatics, including the use of computerized software systems to effect medical decision making and systems that provide immediately accessible medical records are being increasingly utilized. Telemedicine, a new approach, is well suited to a visually oriented specialty such as dermatology that can serve those in remote areas. Factors affecting choice of treatment include the severity and extent of disease, degree of disability, response to previous treatment, and personal considerations, such as convenience and cost (Table 1). First and foremost, the type of psoriasis is a prime factor in determining the treatment setting.’ Different options are presented to patients with localized plaques, generalized plaques, erythrodermic, palmoplantar and pustular psoriasis (Table 2). With the current use of combination and rotational therapies, treatment settings are likely to overlap or change over time with any individual patient. In the geriatric patient, issues of physical