Tierney’s Story (circa 1994)
Tierney Ratti did not formally chronicle her PRP journey beyond the following letter.
30 November 1994
Dear Lady and Gentlemen:
After being diagnosed with pityriasis rubra pilaris in October, I contacted the National Organization for Rare Disorders, Inc., and was given your names as others with this disease. I have spoken at length with Mr. Pack and Mr. Reid about our individual cases, and treatments. It was recommended that I contact you and give a history of my disease, so here it goes.
PERSONAL DATA
I am an Iowa-born and raised 35-year-old white (Irish) female, 5’4″, currently 140 pounds (normally 115-125 lbs), married, with two children (Alex 4 years, and Samantha 10 months). I moved to Virginia 8 years ago. I am a stay-at-home mom, and, when I have a spare minute or two, I am a self-employed bookkeeper/secretary for a real estate developer. I don’t drink as I get sick every time I imbibe too much, I don’t smoke, and I don’t do any drugs. I have never been one to exercise much, but after the birth of my last child I was walking a mile every day until my skin hurt too much.
I do have allergies. As a teenager I received cortisone shots every hay fever season to relieve the symptoms. I discontinued them a year before college (possible reason for occurrence of second episode of skin problems??). For the past five years I have been getting monthly allergy shots (of the antigens which I’m allergic to) which have alleviated most of the allergic symptoms. As a very young child I became very run down, was hospitalized with infectious asthma, and received a series of gamma gobulin shots — I had a full recovery. My maternal grandfather who died in 1959 is said to have had skin problems, but there are no details about it other than that it embarrassed him and he always wore long-sleeved shirts. I have a brother that has skin problems, but he says the doctor says its just eczema.
DISEASE HISTORY
My first problem with my skin was around age 12-13 when my scalp was affected. It was at the time diagnosed as seborrhea, and was treated with a yellow medicated shampoo (sulfur maybe?). I don’t remember any other physical problem areas at that time. The second outbreak was when I began college and at that time it was my face that was primarily involved. I don’t remember going to the doctor for treatment at that time, but I do remember using a prescription hydrocortisone, so I must have gone to Student Health for the problem. Whenever I noticed flaking, or itching, an application or two of the hydrocortisone would alleviate the problem. Both of these episodes occurred during pretty stressful times in my life — my skin just added to it.
Everything was under control until immediately after the birth of my son (December 1990). I had lost a baby the previous year (ruptured ectopic pregnancy), and I had a very difficult time becoming pregnant the second time. In the beginning, my ob-gyn thought I had another ectopic pregnancy, so I had an emergency surgery to rule that out, and blood tests every other day to make sure the pregnancy was progressing normally. Half-way through the pregnancy I was diagnosed with gestational diabetes (I’m a diet-controlled diabetic only while pregnant). Labor was induced a week early because I hadn’t been feeling the baby move. After 13 hours of labor, I had an emergency C-Section, and the baby was placed in NICU with IVs.
Needless to say, it was a pretty stressful time in my life. The baby ended up being ok, but my face started to itch constantly while I was in the hospital. About two weeks later I went to my family doctor, and was told that I had seborrhea on my face, a fungus under my finger and toe nails, and a rash of some kind on my arm (aren’t family doctors wonderful??). I continued to get worse. My toe nails became so painful that I had to cut holes in the tops of my shoes in order to wear them, and my face was one large flake.
I contacted a dermatologist and was then promptly diagnosed with psoriasis, and later diagnosed from biopsies as also having parapsoriasis and guttate psoriasis. During this episode only my arms, face, scalp, nails, and upper torso were involved. Because I was nursing my baby, treatment was pretty limited. I received UVA light treatments 2-3 times a week, and various lotions, creams, and ointments. Something worked because I cleared almost entirely within 6 months, but the doctor had me continue the UVA for an additional 2 years (money hungry doctor????).
I discontinued the UVA while pregnant with my second child. During the first pregnancy I noticed that my moles (present before) had become hard and crusty resembling warts, sometimes itchy, and would at times crust off, leaving me bleeding. After delivery they disappeared and appeared like normal moles. This happened again at the beginning of my second pregnancy and continued throughout. At this point it’s hard to tell what they look like but I think they look semi-normal.
CURRENT EPISODE
My pregnancy with my second child was definitely not as eventful as the previous one, but I was still diagnosed with gestational diabetes (also diet controlled). This labor was also induced two weeks early (9 lb 8 oz baby!!), and again I went through 13 hours of labor only to have another emergency C-Section. My daughter was placed in NICU with IVs, but was ok. I left the hospital commenting on how wonderful my skin was: no itch, no rash, no redness; it felt soft, hydrated, and perfect — what a novelty!
Three weeks later my mother-in-law passed away, and about two weeks after that it started again, only this time it was different. I was nursing this baby also and my nipples began to crack and bleed. I contacted a lactation consultant and the baby’s pediatrician — diagnosis: possible thrush (yeast infection) and/or reoccurrence of the psoriasis. Just in case, the baby and I were treated for the thrush (topical anti-fungal cream on my nipple), and I was instructed to also use 1% hydrocortisone on my breast.
At this point my hands were peeling extensively, but because of a newborn at home, and another child still in diapers, I thought it was just from frequent hand washing. Then a rash began on my forearms, later moving to my face. At that point I contacted a dermatologist (a different one), and by the time I was seen (about two weeks after it all began) everything from my waist up was involved, and all of my nails.
Because of the breast feeding, he was limited as to treatment. When I informed him of the previous UVA treatments, he was baffled — he knew of no reason why that treatment would work without the psoralen. I was promptly given UVB treatments trice weekly, and various lotions, creams, and ointments. I finally got myself to look presentable, but the involved area was growing by leaps and bounds.
All the standard treatments would work up to a certain point and then begin to fail. About once a month the UVB and ointments/creams would cause me to burn. I had/have a lot of faith in my doctor — he is Harvard educated, his partner Yale. They took more biopsies, had them compared with the biopsies taken 3 years before, and the results came back psoriasis. They suspected pityriasis rubra pilaris, but with the treatment for PRP being pretty much the same as for
I was told by my lactation consultant, the baby’s pediatrician, and all other so-called experts to discontinue breast feeding and take care of my skin, but being the stubborn Irish girl I am, I thought that a pretty selfish thing for me to do to my baby, and I waited until she weaned herself at 7 months.
Immediately, my doctor had me try Dovonex and it appeared to work — 4 weeks later it began to burn me. So I switched to other spots on my body and concentrated on them — again, 4 weeks later it began to burn again. All this time I was still getting UVB treatment 2-3 times a week, and never got above 3 minutes a session. Every time I would get a burning sensation on my skin, the doctor would decrease my UVB time and then begin to gradually increase it approx. 10 seconds a visit. The second time that the Dovonex burned me, my doctor gave me a name of a professor of dermatology at the Medical College of Virginia in Richmond (Dr. William Jordan), and had me make an appointment. I promptly went to see Dr. Jordan, and while sitting in the waiting room, he had me diagnosed, but waited until after examination to give me the diagnosis of pityriasis rubra pilaris.
SIDE EFFECTS
As for my side effects of this disease, I think the worse one has been the itching. On a regular daily basis, sometimes continually all day, I get what I call itch-attacks. One spot will itch, and while scratching it, hives appear and move all over my body, and the itching is so intense I feel like a dog going after a flea. As I scratch I can literally feel the histamines being released (like a flush that goes throughout my body). My husband tells me to just not scratch — HA. My doctor isn’t much help with this — he just suggests that my skin is too dry and I need to apply more lotions and/or soak in the tub. Whenever I try his suggestion, the hives appear almost instantly, and the itching is worse than ever. By the time the episode is over I’ll have scratched most of my body, ripping my skin in the process. I take Benedryl nightly for the itching, and depending upon the severity that day, I take between 50-100 mg. If it’s really bad, I take 2-4 hydroxyzine at bedtime. Because of the two small children I’m unable to bear the drowsiness that antihistamines cause.
Another side effect I have, but one in which I can sometimes laugh about, is the flaking. I told people at Halloween that I was dressed as a flake; and on the rare occasion that I wear a long-sleeved shirt, my husband tells me that I look like I have fairy dust coming out of my sleeve when I move my arms suddenly. I suppose that if I were to keep all of the flakes that come off my body in a day, a would have at least a cupful.
It seems like I’m constantly cold. We keep the heat around 76-78 degrees in the house so that I can remain comfortable, and I have a blanket on my side of the bed only. I also wear socks to bed to help keep warm. The rest of my family is sweating. As for sweating: I think I do, but sometimes it’s hard to tell the difference between sweating and all of the creams/lotions/ointments on my body.
I am beginning to notice that I am very short of patience with my 4 year old and my husband — could this be a side effect of the Methotrexate??
TREATMENT
As of this date, I have been taking methotrexate for six weeks (Tuesday night, Wednesday morning and night). I began with one pill every 12 hours (7.5 mg) for the first three weeks. The fourth week it was 2-1-1 (10 mg), and the past 2 weeks it has been 2-2-1 (12.5 mg). I take 2 dosages at night just in case I’m going to have any side effects from it — I also take the maximum dose of Benedryl or hydroxyzine at bedtime those nights.
My skin turns very red and hurts like a bad sunburn — it’s pretty uncomfortable. I don’t wear long-sleeved shirts because of the pain. So far I haven’t had any hair loss, but I think that I would be ok with that if it meant that my skin would be clear.
When I stopped all topical preparations, except hand lotions, my face went out of control again and became one large flake. I dropped in at the doctor’s office and told him that my face was completely unacceptable and he had to help me get it presentable. I am currently using a corticosteriod on my face only, and the redness and flaking has decreased considerably. The rest of my skin seems to be losing some of its redness and flaking — my husband noticed, I’m not quite so optimistic.
EMOTIONAL EFFECTS
This disease has reeked havoc on my self-esteem. When I had my first episode back in puberty the other kids would tease me. Self-esteem at that time in one’s life is pretty fragile to begin with and mine was completely destroyed because of my skin.
I built it back up until college when my face was attacked by flakes and redness — I had a pretty insensitive boyfriend who would make caustic remarks about it. I had so many other things going on in my life during the third episode that I don’t think I had much emotional involvement with my skin. Now, with at times more than 90% of my body ravaged by PRP, and the pain, itching, and flaking, sometimes it takes all I have just to leave the house.
When I apply lotions at night and my skin hurts so bad that I can’t move, I have just started crying because it just feels so hopeless. It’s been so long (nine months) since I’ve had good skin. I don’t like to go anywhere without my children, especially my baby, because I can pretend that when people stare they’re just looking at my beautiful children. I stand in front of the mirror and try to figure out at what distance it’s noticeable that there is something wrong with my skin — I think it’s about 5 feet.
My doctor said that when I’m on the methotrexate I need to be very careful about pregnancy, and that my husband and I need to use 2 kinds of birth control. There’s no need for that because I don’t want to be touched. All I can think of is how repulsed he must be touching my skin, because I’m repulsed by it. And if I can get past that, then it begins to itch. It’s just a cycle I can’t seem to get out of.
My 4 year old has been known to come up to me and give my skin a kiss and say he’ll take care of it and make it better. I, in all honesty, don’t want PRP to be the focus of my life, but at this time it is. I think that with all the misdiagnoses I’ve gone through with this disease, it’s hard to be very optimistic about the outcome.
IN CONCLUSION
My doctor in Virginia Beach said that while a resident at Harvard he saw PRP a few times, but since being in practice locally (17 years) he has seen PRP 3 times. Dr. Jordan, the Richmond doctor, told my husband and me that at any given time, there are approximately 6 people in the state of Virginia with PRP, and that it occurs in about 1 in 2 million people. Aren’t we lucky?!?!?!?
Sincerely,
Tierney L. Ratti