Adapting the Goeckerman Regimen for Psoriasis Treatment in Kenya: A Case Study of Successful Management in a Resource-Limited Setting

Introduction

Goeckerman therapy was developed in 1925 and remains a highly effective treatment for moderate-to-severe psoriasis, including patients who have tried and failed other therapies.^1,2 Traditional Goeckerman therapy combines exposure to ultraviolet B (UVB) light with the application of crude coal tar (CCT) until disease clearance, but for a minimum of six weeks.³ Currently, only a few institutions in the USA still employ Goeckerman therapy as injectable biologic therapies now offer a less time intensive, but extremely efficacious option for treating psoriasis.⁴ In developing countries, where access to newer psoriasis medications is limited, alternative therapies like the Goeckerman regimen could provide an effective treatment option outside biologics.^5,6 Recognizing the need for accessible psoriasis treatments in developing countries, Moi Teaching & Referral Hospital (MTRH) in Eldoret, Kenya, developed a modified Goeckerman regimen in collaboration with the University of California San Francisco (UCSF) suitable for its healthcare context (Table 1).

Table 1 Modified Goeckerman Regimen for Psoriasis Treatment, Detailing Cool-Down Procedures, Phototherapy, Tar Application Protocols, Daily Monitoring, and Discharge and Maintenance Plans

Table 2 Initial Dosing and Subsequent Increase Protocols for Narrow Band UVB (NBUVB) Phototherapy Based on the Fitzpatrick Skin Type

This adaptation was specifically designed for patients who travel long distances for treatment, condensing the therapy into an intensive two-week program. The original Goeckerman regimen is administered for at least six weeks. It involves an initial evaluation, a possible cool-down phase with topical corticosteroids for erythema, followed by daily narrow band (most commonly used for psoriasis) or broadband UVB phototherapy and CCT (potentially compounded with salicylic acid) application.³ In contrast, the modified regimen streamlines the process to accommodate the logistical challenges faced by patients in remote areas. This includes an initial evaluation, a potential remote cool-down period before hospital admission, and a daily, condensed schedule of phototherapy and CCT or other topical applications based on available resources. We present a case of a patient with severe psoriasis successfully treated with a modified Goeckerman regimen at the MTRH.

Case Report

A 55-year-old female traveled 350 kilometers (217 miles) from her home to MTRH, Eldoret, Kenya, with a four-month history of progressive, painful skin redness, scaling, and severe pruritus covering most of her body (Figures 1–3). The lesions initially started with a single plaque on her left arm, then rapidly progressed, and within two months affected most of her skin. She reported associated chills, weight loss, edema, and difficulty maintaining body temperature. She was treated with topical and oral corticosteroids with minimal improvement. The patient had a medical history of treated hypertension and was also recently treated for Entamoeba histolytica infection with metronidazole (400 mg, TID) for ten days. The patient reported no history of dermatologic diseases and had no known drug allergies. Physical examination revealed widespread erythema, scaling, generalized edema, and skin exfoliation on Fitzpatrick skin type VI. A skin biopsy showed confluent parakeratosis and hypogranulosis, regular acanthosis, Munro’s microabscesses, and thin supra-papillary plates. The papillary blood vessels were dilated and surrounded by lymphocytic cell infiltrate. Based on both clinical presentation and histopathology, the patient was diagnosed with erythrodermic psoriasis.

Figure 1 Widespread erythema, pronounced scaling around patient’s eyes and forehead.

Figure 2 Extensive erythema and scaling on patient’s left arm, with patches of skin exfoliation visible against Fitzpatrick skin type 6.

Figure 3 Severe erythema, scaling, and signs of skin exfoliation across patient’s lower back, buttocks, and legs.

The patient was admitted for inpatient care, and treatment included a series of narrow-band UVB phototherapy sessions and application of topical medication (clobetasol propionate ointment 0.001% and triamcinolone acetonide ointment 0.025%) under cling wrap occlusion to enhance treatment effectiveness. The treatment took place over nine days (Table 3), with phototherapy sessions administered on days 1, 3, 6, 8, and 9, adjusting the dosage based on the Fitzpatrick skin type (Table 2). The patient responded positively to the therapy within the first three days, showing significant improvements such as cessation of itching and better vision due to reduced psoriasis around the eyes. Adverse effects, such as burning, were monitored throughout the treatment course. Marked improvement was observed in 10 days.

Table 3 Phototherapy Schedule and Adjunctive Topical Medications Used by the Treatment Team, Highlighting Progress and Adjustments

At discharge, the patient was prescribed LINOTAR 1% coal tar gel to use at home. After completing the treatment, the patient returned home and resumed her normal daily activities. A follow-up after one month revealed no active lesions and post-inflammatory hyperpigmented patches that were not causing discomfort, as seen in Figures 4 and 5. For maintenance, the patient intermittently continued the use of topical treatments (clobetasol, triamcinolone, and LINOTAR 1% coal tar gel). Her psoriasis remains under control, for at least four months since treatment, at the time of writing this report.

Figure 4 Significant resolution of lesions on patient’s face, with restored skin integrity and evident post-inflammatory hyperpigmentation around the eyes, on the nose, and forehead.

Figure 5 Significant resolution of lesions on patient’s arms two weeks post-treatment.

Discussion

The modified Goeckerman regimen, implemented at Kenya’s Moi Teaching & Referral Hospital in collaboration with UCSF, has demonstrated its efficacy in treating severe psoriasis within a challenging healthcare context. The classic Goeckerman regimen has largely been supplanted by newer therapies in the Western word, most notably biologics. However, there is less access to these medications in sub-Saharan Africa due to affordability and lack of infrastructure necessary to ensure biologics are kept at appropriate conditions, such as consistent and reliable refrigeration, to protect against breakdown of the medication.⁷ Though the modalities used in Goeckerman therapy do not require the stringent environmental conditions that biologics do, it does require the valuable resource of time in exchange for an impressively long remission period ranging from an average of nine and a half months to over one year.³ Of note, a recent report showed that 50% of psoriasis patients who discontinued biologics after achieving skin clearance were still disease-free or being managed by solely topical therapies after two years.⁸ This suggests that improving even temporary access to biologics until skin clearance could also provide long-lasting relief for many patients.

This case shows how in a both resource-limited and time-limited situation, the Goeckerman regimen may be shortened from six to two weeks and still be potentially effective. However, the modified regimen could have been even further enhanced with the application of CCT during treatment, such as in traditional Goeckerman therapy. Potential adverse effects include erythema from burns caused by UV therapy and skin irritation from coal tar or plastic wrap.³ These potential adverse effects are managed by daily assessments and lowering the phototherapy dose or CCT concentration if needed.

Conclusion

The successful management of a 55-year-old female patient who traveled a significant distance for treatment underscores the regimen’s potential as a viable and effective option for patients in developing countries, where access to systemic psoriasis therapies may be limited. This intensive regimen not only accommodated the logistical challenges faced by patients living in remote areas but also achieved remarkable clinical outcomes and improved the patient’s quality of life. This case highlights the importance of adapting established therapies to meet local healthcare needs and the potential for such modified treatments to bridge gaps in access to care.