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When all treatments fail, the temptation is to continue the therapeutic ascent towards strategies that are increasingly less well assessed, albeit very useful at times: combining small doses of methotrexate with small doses of cyclosporine, fumaric acid, Imurel, Hydrea or Cell Cept. (mycophenolate mofetil).[|I would be concerned about combining small doses of methotrexate with Imuran®, Hydrea®, or Cell Cept®, but would consider using these three drugs as “second tier” drugs on occasion.|auteur215]

Before embarking on such ventures, it is very important to reconsider the situation in depth:

  • Are there nutritional, psychological or drug-related factors causing the disease to self-perpetuate or worsen?
  • Is the patient deriving indirect benefit from his illness and does he really wish to get better? Or, to put it subtler, what advantages is the patient managing to wangle from his illness?
  • Would it not be useful to sent the patient off for a cure at a spa or to hospitalize him?
  • Does the psychological suffering brought upon by psoriasis not call for some form of management of its own, as it can play a self-perpetuating role?

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