Readers' questions are answered as examples of general problems commonly met in practice. It is a good rule in medicine that only their own doctors know the patient well enough to pontificate on the case as there are often other factors unknown to strangers.

My daughter, 27 years old, has suffered from psoriasis since her teens. We have tried everything but to no avail. Is there any latest treatment of psoriasis that you would recommend? So far the best treatment is couple of weeks by the sea but the psoriasis comes back once she returns to England. Please help. Marcelan Stickland, London

I am sorry to hear about your daughter. There can be no worse age than the teens for a woman to develop psoriasis or other skin troubles. You don't tell us which treatment she has had. The simple treatments for psoriasis have the intention of preventing the rapid turnover of skin that is the root cause of trouble. There are a host of products that will do this including the traditional coal tar products. Fortunately these are made in far less messy forms than they were and are therefore more likely to be used. They are more likely to have fewer side effects to the skin including irritation than dithranol that is available in various creams and other forms. Dithranol is an excellent standard remedy but unlike the coal tar derivatives may cause skin irritation in some people. Vitamin D analogues such as tacalcitol or calcipotriol are extremely useful but can't be used by someone of your daughter's age if there is any chance of her becoming pregnant.

I found with my patients that a very useful preparation was Dovobet, which is a combination of a vitamin D analogue and the steroid betamethasone. I had mild psoriasis on my elbows and scalp for thirty or forty years and latterly always used betamethasone. Fortunately, unlike your daughter, it wasn't serious enough to cause any troubles, in fact my children when small took delight in exhibiting my elbows to their young friends. Suddenly to all intents and purposes it disappeared and is now barely discernible and even the pitting of my fingernails is hard to detect.

We don't know at which hospital your daughter is being treated and how much it is interfering with her life. I have the impression that her psoriasis is severe and that a large section of her skin surface is involved. Discuss any question of referrals with your own GP. It is important that she not only goes to a specialist dermatologist but also to one who has an interest in psoriasis, discuss this with your own GP. There are newer systemic treatments that can have dramatic effects on unresponsive resistant psoriasis but they are unfortunately not without possible side effects. The TNA alpha inhibitors such as Enbrel etanercept and Remicade infliximab or Raptiva efalizumab, a selective T cell modulator, can have a dramatic effect. My own opinion is that it is worthwhile taking a risk if a young person's life is being spoilt by it.

For hospital use only, and only under the direction of a specialist who is used to using them and being aware of troubles they occasionally cause, are the preparations known as the retinoids, such as Neotigason acitretin. They have been used with success in treating extensive psoriasis that has failed to respond to the standard methods of treatment.

Methrorexate, which is better known for its use in some rheumatic diseases, is also useful in treating cases that have proved resistant to other forms of treatment. Other immune suppressant drugs include cyclosporin. Finally, simple light therapy or PUVA - light therapy after taking a skin sensitiser - are useful but possible side effects, including the inevitable slight risk of triggering skin cancers, must always be taken into account.

The difficulty is that not all doctors understand the effect that psoriasis that is very widespread or very visible may have on a patient's life, and that heavy treatments for severe cases may be necessary for this reason.

Is there anything superior to Dovonex or Dovobet in the treatment of mild to moderate psoriasis? Name and address withheld

At this level of mild to moderate psoriasis Dovobet or Dovonex are, I think, as good as any other preparation. As I told our first correspondent I always personally used betamethasone, which is a component of Dovobet. It is a bit more effective than betamethasone alone as it also contains vitamin D analogue.

One of the tricks of keeping psoriasis in order is to know what causes a flare up. The severity of the psoriasis has a habit of waxing and waning. Any infection can make it worse, heavy alcohol consumption certainly will as will smoking, emotional stress especially if the stress is unpleasant but also jolly occasions such as marriages and christenings may cause a flare up. You will have discovered that warmth and sun help but remember that sunburn and any other superficial damage to the skin can trigger a flare up.

Until recently beta blockers were obligatory treatment for any patient for high blood pressure or heart problems, now some of their roles have been superseded by other drugs but they are still widely and correctly used to treat many cardiovascular conditions. It is not widely known why beta blockers may make psoriasis worse.

I have psoriasis on my scalp, for which I use a prescribed product called Betacap to keep it under control. Also I use polytar shampoo. I am male, 59, and this has just cropped up in the last four years. I get the occasional small outbreak elsewhere, elbows always, leg, stomach or back sometimes. I take plenty of exercise and enjoy beer after squash and some wine in the evening. Would homeopathatic remedies or diet based solutions be helpful? I am 20lbs overweight and am trying to reduce my cholesterol level. Name and address withheld

I am not a great believer in homeopathy, but each to their own and if people find it helpful I encourage them. Homeopathic practitioners are usually wonderful counsellors. I always used and recommended Betnovate or Dermovate scalp applications and Nizoral hair shampoo for severe scalp psoriasis. One of simpler secrets for dealing with scalp psoriasis is not to wear a traditional dark blue or grey suit which show every scale that has been shed, but clothes made of a rougher texture and in a less uniform colour. A good wholesome diet helps, watch the alcohol and take plenty of Omega 3 fish oil, either as fish oil capsules or as oily fish twice a week. You should keep your weight down.

Are there any new treatments for psoriasis of the nails? I only have a few problem areas on my elbows but have had psoriasis of the nails for over twenty years! Name and address withheld

No. I am afraid not. Psoriasis of the nails is one of the most resistant problems. It doesn't matter much if there is minute pitting such as might occur if they had been hit by someone who had fired shot designed to shoot butterflies rather than birds, but nail disfiguration can be very severe, in which case the opinion of an interested consultant dermatologist should be sought. Any of the systemic treatments would help, but remember that they have side effects, and we may not yet know the full extent of some of these.

I have discovered that Indian head massage can help to alleviate the symptoms of psoriasis of the scalp. I also find sunlight to be an almost immediate semi-permanent cure for gutate psoriasis on the skin. Are there any other alternative treatments I can try? Also, would you recommend any foods that improve or worsen psoriasis? Name and address withheld

Infection is one of the trigger factors for guttate psoriasis. The initial attack often follows streptococcal sore throats or chest infections. Any chronic source of infection such as rotten teeth, inflamed gums or infected sinuses should be sought out and treated. As guttate psoriasis is apt to persist, and may be widespread, it is wise not to use more than a medium strength steroid.

Avoid binge drinking, don't smoke and make certain that your Omega 3 intake is up to standard and that you take fish oil capsules or oily fish twice a week. I am glad that the Indian head massage helped, anything that makes a patient with psoriasis feel relaxed and better is likely to be useful.

I saw that you were looking at psoriasis for the next issue and wondered if you had considered Seawater as a helpful, gentle treatment for babies? Ocean Pure www.oceanpure.co.uk is a new seawater cleaning solution that makes a good alternative to wipes for babies. Alex Boland

Bathing in the Dead Sea is excellent for psoriasis but the present political situation may make this difficult. Many skin problems are helped by sea water bathing but I am afraid that I have no experience of transporting sea water to patients, rather than patients to seawater. In the shops by the beaches around the Dead Sea there are many products for sale manufactured from its salty waters. Similar ones are available in the bigger department stores in this country but I haven't used or had experience of Ocean Pure.

I have had psoriasis on my elbows and knees for 20 years in large areas of dry skin, maybe upto two inches across. I also have had much smaller areas, at most the size of a penny, on my legs and torso. Most of these have gone now. The worst of the psoriasis that is left is on my elbows, but I find a liberal coating of olive oil once a week keeps it at bay. I went diving in Egypt twice this summer, and I found the mixture of salt water along with abrasion of wet suit along, no stress, plenty of sun, improved diet and using olive oil as a moisturiser can clear everything in a week.

My real problem is my face. I have tested levels of stress, alchohol and caffeine but can not find any cause. My face is red either side of my nose, above my nose, in between and going into my eyebrows and on my nose. My skin sheds itself maybe once a week. It is dry and itchy. I moisturize every day, sometimes with olive oil, sometimes with Evian oxygenating moisturiser and sometimes with Daktacort on prescription from my doctor. I am a 48 year old male, relatively fit, have been in a relatively unhappy marriage for the last 11-plus years and am nearly divorced. I have three children and have worked for myself for 20 years. Name and address supplied

I am glad that the psoriasis is under control. Patients with psoriasis are of course liable to develop other skin problems, and indeed may be rather more prone to them than the rest of the population. The problems you are having with your naso labial folds of your face, and the area between eyebrows your sounds rather as if you also have some seborrhoic dermatitis. These are classic spots to get this trouble. You have been very wisely prescribed Daktacort, this is the treatment of choice. It is of course impossible to give a diagnosis without seeing a patient but thank you for writing.

• People with psoriasis are well advised to write off for the small pamphlet on psoriasis, Psoriassist, that is produced by a pharmaceutical company. It includes all the addresses, websites and details of the organisations including the Psoriasis Organisation that help patients with psoriasis. It also covers a few of the basic facts.
  Psoriassist 0800 4045 777, 0800 4045 888
  www.psoriassist.co.uk
  The Psoriasis Association 0845 676 0076
  www.psoriasis-association.org.uk