We would like to thank the staff of the UCSF Psoriasis and Skin Treatment Center for their work especially our Goeckerman Coordinator, Sarah Hulse R.N.

1. Evaluation and Preparation
<ol>
	<li>Perform a complete history and physical prior to initiating therapy. In the history and physical, document important information such as current/past medications, response to past psoriasis therapies, any history of adverse reactions to ambient sunlight or phototherapy, severity of pruritus, and sleep quality.</li>
	<li>Set up a clinic room with all the necessary material for dermal application of medications and occlusion [See Materials Section and Figure 1]. Also, place other materials in the room such as gloves, plastic wrap, socks, and scrubs/pajama gowns.</li>
	<li>Assess the patient for diffuse and intense erythema prior to starting therapy.</li>
	<li>If the patient exhibits widespread or intense erythema, perform a "cool down" procedure (see below) until the erythema is significantly reduced. If no widespread or intense erythema is seen, proceed to the "phototherapy + tar" step.</li>
</ol>
2. Cool Down (If Needed)
<ol>
	<li>Apply topical corticosteroids to the affected areas. Apply triamcinolone 0.1% ointment to the trunk and extremities, desonide 0.05% cream/ointment to the face/axillae/groin, and fluocinolone 0.01% oil or triamcinolone 0.1% lotion to the scalp. Reserve clobetasol 0.05% ointment for areas with the most intense inflammation.</li>
	<li>Occlude the topical medications with plastic wrap for the trunk and extremities, impermeable gloves for the hand and shower caps inside socks for the feet, and a shower cap for the scalp.</li>
	<li>Cool down the patient until the erythema is significantly reduced (range from 3-14 days).</li>
</ol>
3. Phototherapy + Tar
<ol>
	<li>After the patient finishes the cool down period, administer phototherapy daily in the morning prior to the application of crude coal tar [Figure 2]. Phototherapy options include narrowband UVB (most commonly used in psoriasis) or broadband UVB (most commonly used in eczema). Determine the initial phototherapy dose by Fitzpatrick skin type [see Table 1 and Table 2].</li>
	<li>Slowly titrate the subsequent phototherapy doses upwards as tolerated. Dosing regimen and schedule need to be individualized based on patient response to phototherapy.</li>
	<li>After phototherapy, apply 2% crude coal tar (CCT) in aquaphor topically to affected areas of the body [Figure 3]. If patient has scalp involvement, apply 20% liquid carbonis detergens (LCD) in nutraderm to the scalp.</li>
	<li>Initially, use 2% CCT (lowest strength). On subsequent treatment days, increase the strength of the tar as tolerated by the patient from 2% to 5% and then to 10% to achieve better results.</li>
	<li>For thickened areas of psoriasis, use tar compounded with salicylic acid (2%/5%/10% salicylic acid) to help reduce the scaling and induration of the plaques. Initially use preparations of 2% salicylic acid with 10% CCT, and titrate the percentage of salicylic acid up as tolerated by the patient on subsequent days. Salicylic acid may be contraindicated in patients with diabetes or gastric ulcers.</li>
	<li>Occlude topical tar in the same manner as described in step 2.2 for the cooling down procedure.</li>
	<li>Keep topical medications on the skin for at least 4 hr. After a minimum of 4 hr, remove the occlusion materials and wash off the tar in the shower with mineral oil and soap [Figure 4].</li>
	<li>Give the patient 20% LCD in aquaphor and 20% LCD in nutraderm to apply on the body and scalp, respectively, at home.</li>
	<li>Patients with eczema tend to have sensitive skin. Use 2% CCT initially for eczema patients. Be careful when titrating up to 5% CCT, as patients with eczema tend to have sensitive skin. Do not use 10% CCT (or any percentage of CCT higher than 5%) and do not use any preparations with salicylic acid.</li>
</ol>
4. Daily Assessment
<ol>
	<li>Each day, perform an evaluation and assess the patient's skin and response to treatment. Evaluate specifically for sensations of burning, which can indicate the patient's inability to tolerate light therapy, or itching, which can indicate irritation from the tar and/or plastic wrap.</li>
	<li>If a patient exhibited signs of burning (burning sensation, significant increasing erythema, or rarely increased itch as a harbinger of impending burn if dosimetry is increased further), decrease phototherapy dose or do not give phototherapy that day, as it may have been caused by a phototoxic reaction to the previous UV light dose.</li>
	<li>It is not uncommon for patients to have different regional anatomical responses and tolerability to phototherapy. For optimal treatment, adjust the amount of phototherapy dose exposed to different regions of the body according to patient's response. For example, if a patient experiences mild burning of the trunk, then first treat the entire body with the lowered phototherapy dose, than cover the trunk, and give additional light to the extremities.</li>
</ol>
5. Discharge Planning and Maintenance
<ol>
	<li>Continue Goeckerman therapy until disease is cleared and patient is ready to be discharged.</li>
	<li>Place patients on a maintenance program, which can include outpatient phototherapy and topical medications</li>
	<li>Administer outpatient phototherapy three times a week (for at least the first month). Eventually the frequency is gradually tapered down to twice a week and then once a week)</li>
	<li>Outpatient topical medications include: Triamcinolone cream/ointment to the body twice daily, Clobetasol to recalcitrant lesions (if needed) twice daily, 20% LCD in aquaphor to the body and 20% LCD in nutraderm to the scalp.</li>
	<li>Within a month of discharge, schedule a follow up physician visit with the patient to monitor disease state.</li>
</ol>

<ol>
	<li>Parisi, R., Symmons, D. P., Griffiths, C. E., Ashcroft, D. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Global+Epidemiology+of+Psoriasis:+A+Systematic+Review+of+Incidence+and+Prevalence.">Global Epidemiology of Psoriasis: A Systematic Review of Incidence and Prevalence.</a> The Journal of Investigative Dermatology. , (2012).</li><li>H, G. W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+treatment+of+psoriasis.">The treatment of psoriasis.</a> Northwest Med. 24, 229-230 (1925).</li><li>Koo, J., Lebwohl, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Duration+of+remission+of+psoriasis+therapies.">Duration of remission of psoriasis therapies.</a> Journal of the American Academy of Dermatology. 41, 51-59 (1999).</li><li>Menter, A., Cram, D. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+Goeckerman+regimen+in+two+psoriasis+day+care+centers.">The Goeckerman regimen in two psoriasis day care centers.</a> Journal of the American Academy of Dermatology. 9, 59-65 (1983).</li><li>Lee, E., Koo, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Modern+modified+'ultra'+Goeckerman+therapy:+a+PASI+assessment+of+a+very+effective+therapy+for+psoriasis+resistant+to+both+prebiologic+and+biologic+therapies.">Modern modified 'ultra' Goeckerman therapy: a PASI assessment of a very effective therapy for psoriasis resistant to both prebiologic and biologic therapies.</a> The Journal of Dermatological Treatment. 16, 102-107 (2005).</li><li>Kim, I. H., West, C. E., Kwatra, S. G., Feldman, S. R., O'Neill, J. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparative+efficacy+of+biologics+in+psoriasis:+a+review.">Comparative efficacy of biologics in psoriasis: a review.</a> American journal of clinical dermatology. 13, 365-374 (2012).</li><li>Serrao, R., Davis, M. D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Goeckerman+treatment+for+remission+of+psoriasis+refractory+to+biologic+therapy.">Goeckerman treatment for remission of psoriasis refractory to biologic therapy.</a> Journal of the American Academy of Dermatology. 60, 348-349 (2009).</li><li>Chern, E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Positive+effect+of+modified+Goeckerman+regimen+on+quality+of+life+and+psychosocial+distress+in+moderate+and+severe+psoriasis.">Positive effect of modified Goeckerman regimen on quality of life and psychosocial distress in moderate and severe psoriasis.</a> Acta Dermato-venereologica. 91, 447-451 (2011).</li><li>Dennis, M., Bhutani, T., Koo, J., Liao, W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Goeckerman+therapy+for+the+treatment+of+eczema:+a+practical+guide+and+review+of+efficacy.">Goeckerman therapy for the treatment of eczema: a practical guide and review of efficacy.</a> The Journal of Dermatological Treatment. , (2011).</li><li>Papp, K. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Biologic+therapy+in+psoriasis:+perspectives+on+associated+risks+and+patient+management.">Biologic therapy in psoriasis: perspectives on associated risks and patient management.</a> Journal of Cutaneous Medicine and Surgery. 16, 153-168 (2012).</li><li>Menter, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Guidelines+of+care+for+the+management+of+psoriasis+and+psoriatic+arthritis:+Section+5.+Guidelines+of+care+for+the+treatment+of+psoriasis+with+phototherapy+and+photochemotherapy.">Guidelines of care for the management of psoriasis and psoriatic arthritis: Section 5. Guidelines of care for the treatment of psoriasis with phototherapy and photochemotherapy.</a> Journal of the American Academy of Dermatology. 62, 114-135 (2010).</li><li>de Miguel, R., el-Azhary, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Efficacy,+safety,+and+cost+of+Goeckerman+therapy+compared+with+biologics+in+the+treatment+of+moderate+to+severe+psoriasis.">Efficacy, safety, and cost of Goeckerman therapy compared with biologics in the treatment of moderate to severe psoriasis.</a> International Journal of Dermatology. 48, 653-658 (2009).</li><li>Busse, K., Koo, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Introducing+the+delayed+retinoid+burn:+a+case+report+and+discussion+of+this+potential+risk+of+retinoid-phototherapy+combination+management.">Introducing the delayed retinoid burn: a case report and discussion of this potential risk of retinoid-phototherapy combination management.</a> Journal of the American Academy of Dermatology. 64, 1011-1012 (2011).</li><li>Maughan, W. Z., Muller, S. A., Perry, H. O., Pittelkow, M. R., O'Brien, P. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Incidence+of+skin+cancers+in+patients+with+atopic+dermatitis+treated+with+ocal+tar.+A+25-year+follow-up+study.">Incidence of skin cancers in patients with atopic dermatitis treated with ocal tar. A 25-year follow-up study.</a> Journal of the American Academy of Dermatology. 3, 612-615 (1980).</li><li>Pittelkow, M. R., Perry, H. O., Muller, S. A., Maughan, W. Z., O'Brien, P. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Skin+cancer+in+patients+with+psoriasis+treated+with+coal+tar.+A+25-year+follow-up+study.">Skin cancer in patients with psoriasis treated with coal tar. A 25-year follow-up study.</a> Archives of Dermatology. 117, 465-468 (1981).</li><li>Roelofzen, J. H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=No+increased+risk+of+cancer+after+coal+tar+treatment+in+patients+with+psoriasis+or+eczema.">No increased risk of cancer after coal tar treatment in patients with psoriasis or eczema.</a> The Journal of Investigative Dermatology. 130, 953-961 (2010).</li></ol>

Dr. Koo is a speaker for Abbott, Leo, and Stiefel-GSK. Dr. Koo conducts research for Amgen, Janssen, Novartis, Photomedex, Galderma, and Pfizer. Dr. Koo has no stocks, employment, or board memberships with any pharmaceutical company. No conflicts of interest disclosed for any other authors.

The Goeckerman Regimen protocol outlined above is utilized at UCSF and can be varied in multiple ways according to the patient's response to therapy. Since the patient is seen and examined every day, the protocol can be individualized for each patient to ensure maximum efficacy. The traditional Goeckerman treatment solely consisted of the use of CCT and UVB phototherapy.2 However, the regimen has been modified to include the use of topical corticosteroids (and at times other topical medications such as calcipotriene, anthralin and tazarotene).5 Pre-existing medications for psoriasis can be continued and can also be beneficial in combination with Goeckerman therapy in helping patients achieve remission with less treatment days. If patients are not responding to the optimal therapy for Goeckerman, patients can be given adjunct systemic medications such as acitretin. Pre-treatment with acitretin (10-25 mg) prior to starting Goeckerman therapy can help decrease the amount of days needed to clear the psoriasis lesions with CCT + phototherapy. It should be noted that acitretin can make a patient photosensitive and the phototherapy dose should be decreased upon initiating acitretin.13
Patients who come in with diffuse erythema should be cooled down prior to any topical tar or phototherapy. It is imperative to not give either of those therapies until the erythema has been significantly reduced and the patient does not show signs of intense erythema of the skin. Furthermore, when a patient experiences burning or discomfort secondary to UV exposure, it is important to stop further UV exposure until the patient's symptoms and any visible inflammation has been greatly reduced. UVB and/or tar can exacerbate the disease and worsen the inflammation if caution is not taken in assessing the patient to make sure that the inflammation is not extreme.
The topical application of tar typically starts at 2% CCT. However, if patients do not have any adverse reactions to the tar, then a stronger tar preparation (5% and then 10%) can be applied topically. CCT compounded with salicylic acid can be used if recalcitrant plaques have significant scaling and induration that is not achieving adequate response to the tar alone. 2% salicylic acid is initially used with 10% CCT, and then increased (to 5% and 10% with 10% CCT) as tolerated. Serious adverse reactions to tar or salicylic acid are extremely rare. If adverse reactions, generally limited to local irritation, do occur, patients are switched to a lower strength of tar or held off of tar. Topical corticosteroids are used to decrease the skin inflammation. If the skin irritation is localized, then the topical steroids can be applied to the localized area and CCT can be applied on the rest of the areas.
The safety profile of Goeckerman therapy is excellent in comparison to oral systemic therapies such as cyclosporine, methotrexate or biologics. As previously noted, Goeckerman therapy also does not carry the same internal risks as biologics such as cancer, serious infections, and increased cardiovascular risk.10 Since the side effects of Goeckerman therapy are minimal, especially in comparison to other systemic medications, the regimen can be used in everyone including the elderly, children, patients with history of cancer, immunosuppressed patients, and patients with other comorbidities. The milder but more common side effects of Goeckerman therapy are folliculitis and phototoxic reactions. Although there may be a concern about the potential carcinogenic effects of topical application of coal tar, clinical studies examining patients on CCT for an extended period of time have not shown an increased risk of skin cancer. In multiple reviews and follow-up studies, there was no increased risk of cancer associated with the use of CCT in comparison to topical steroids in patients with psoriasis or eczema.14-16 Based on the safety and efficacy of the therapy, the Goeckerman regimen is an excellent treatment modality for any patient with moderate to severe psoriasis, eczema, and other severe pruritic and/or inflammatory skin conditions.

Psoriasis is a chronic, immune-mediated inflammatory skin disease affecting approximately 2-3% of the population.1 One-third of the patients experience generalized psoriasis that causes debilitating physical and psychological effects. The Goeckerman regimen, first published in 1925 for the treatment of generalized psoriasis, consists of exposure to ultraviolet B (UVB) light and application of crude coal tar (CCT).2 Though newer internal agents such as biologics have enhanced the treatment of psoriasis, Goeckerman therapy remains as an extremely effective option, while providing a long duration of remission.3,4 In a published study conducted at UCSF, 100% of patients on Goeckerman therapy achieved PASI75 (75% improvement of Psoriasis Assessment of Severity Index [PASI] from baseline) by 3 months.5 In comparison (though not head to head), patients on the most potent biologics achieved only 67-68% PASI75 in 3 months.6 The Goeckerman regimen has a quick onset and has been utilized with success in patients with treatment-resistant psoriasis refractory to phototherapy or internal medications.7 The Goeckerman regimen also has an extremely safe toxicity profile with essentially no internal side effects, which are the more serious risks associated with other psoriasis treatments. Furthermore, the therapy has been shown to have a significant and positive effect on the quality of life of patients with generalized psoriasis.8 
	Goeckerman regimen was formerly administered 24 hr a day at an inpatient facility until the patient was cleared of their psoriasis. However, due to changes in reimbursements and managed care, patients are now treated in daycare facilities for a minimum of 4-8 hr/day and 5 days/week until their disease clears. Goeckerman therapy was initially formulated for the treatment of psoriasis, but a modified version has recently been used for the treatment of other skin conditions such as eczema with success. The following protocol is utilized at UCSF specifically for psoriasis, but slight changes in the procedures can be tailored for eczema, generalized pruritus, prurigo nodularis, pityriasis lichenoides chronica, erythroderma, and other related skin disorders.9
	Though it is one of the oldest therapies available for psoriasis, there is an absence of any published videos demonstrating the process. A video can have a broad appeal as it can be used as a resource for referring healthcare practitioners (primary care physicians and dermatologists) to understand the process and feel comfortable recommending the therapy. A video demonstrating the Goeckerman process will also be instrumental for educating residents and medical students who are not exposed to the regimen since there are only a few institutions left that continue to provide this type of intensive therapy. A video will also be beneficial for prospective patients who are interested in receiving Goeckerman therapy.

<table border="1">
	<tbody>
		<tr>
			<td>Name of Medication </td>
			<td>Company</td>
			<td>&nbsp;</td>
			<td>&nbsp;</td>
		</tr>
		<tr>
			<td>2% Crude Coal Tar in White Petrolatum or Cetaphil</td>
			<td>Compounded at Pharmacy</td>
			<td>&nbsp;</td>
			<td>&nbsp;</td>
		</tr>
		<tr>
			<td>5% Crude Coal Tar in White Petrolatum or Cetaphil</td>
			<td>Compounded at Pharmacy</td>
			<td>&nbsp;</td>
			<td>&nbsp;</td>
		</tr>
		<tr>
			<td>10% Crude Coal Tar in White Petrolatum +/- 2/5/10% Salicyclic Acid</td>
			<td>Compounded at Pharmacy</td>
			<td>&nbsp;</td>
			<td>&nbsp;</td>
		</tr>
		<tr>
			<td>10% Crude Coal Tar in Cetaphil</td>
			<td>Compounded at Pharmacy</td>
			<td>&nbsp;</td>
			<td>&nbsp;</td>
		</tr>
		<tr>
			<td>20% Liquid Carbonis Detergenis in Nutraderm</td>
			<td>Compounded at Pharmacy</td>
			<td>&nbsp;</td>
			<td>&nbsp;</td>
		</tr>
		<tr>
			<td>20% Liquid Carbonis Detergenis in Aquaphor or Cetaphil</td>
			<td>Compounded at Pharmacy</td>
			<td>&nbsp;</td>
			<td>&nbsp;</td>
		</tr>
		<tr>
			<td>Triamcinolone 0.1% ointment/cream/lotion</td>
			<td>Prescription Medication - Generic</td>
			<td>&nbsp;</td>
			<td>&nbsp;</td>
		</tr>
		<tr>
			<td>Desonide 0.05% cream/ointment</td>
			<td>Prescription Medication - Generic</td>
			<td>&nbsp;</td>
			<td>&nbsp;</td>
		</tr>
		<tr>
			<td>Fluocinolone 0.01% oil</td>
			<td>Prescription Medication - Generic</td>
			<td>&nbsp;</td>
			<td>&nbsp;</td>
		</tr>
		<tr>
			<td>Clobetasol 0.05% ointment/cream</td>
			<td>Prescription Medication - Generic</td>
			<td>&nbsp;</td>
			<td>&nbsp;</td>
		</tr>
		<tr>
			<td>Hydrophillic Ointment</td>
			<td>Over the Counter - Generic</td>
			<td>&nbsp;</td>
			<td>&nbsp;</td>
		</tr>
		<tr>
			<td>Mineral Oil</td>
			<td>Over the Counter - Generic</td>
			<td>&nbsp;</td>
			<td>&nbsp;</td>
		</tr>
		<tr>
			<td>Name of Equipment </td>
			<td>Company</td>
			<td>&nbsp;</td>
			<td>&nbsp;</td>
		</tr>
		<tr>
			<td>Narrow-Band Phototherapy Unit</td>
			<td>National Biologic Corporation</td>
			<td>&nbsp;</td>
			<td>&nbsp;</td>
		</tr>
		<tr>
			<td>Broad-Band Phototherapy Unit</td>
			<td>National Biologic Corporation</td>
			<td>&nbsp;</td>
			<td>&nbsp;</td>
		</tr>
	</tbody>
</table>

the goeckerman regimen for the treatment of moderate to severe psoriasis

Psoriasis is a chronic, immune-mediated inflammatory skin disease affecting approximately 2-3% of the population. The Goeckerman regimen consists of exposure to ultraviolet B (UVB) light and application of crude coal tar (CCT). Goeckerman therapy is extremely effective and relatively safe for the treatment of psoriasis and for improving a patient's quality of life. In the following article, we present our protocol for the Goeckerman therapy that is utilized specifically at the University of California, San Francisco. This protocol details the preparation of supplies, administration of phototherapy and application of topical tar. This protocol also describes how to assess the patient daily, monitor for adverse effects (including pruritus and burning), and adjust the treatment based on the patient's response. Though it is one of the oldest therapies available for psoriasis, there is an absence of any published videos demonstrating the process in detail. The video is beneficial for healthcare providers who want to administer the therapy, for trainees who want to learn more about the process, and for prospective patients who want to undergo treatment for their cutaneous disease.

In a study performed at our center at the University of California San Francisco, PASI75 response (a 75% improvement in the Psoriasis Assessment Severity Index) was achieved in 100% of patients receiving Goeckerman (n = 25) over a 3-month time period.5 24/25 patients needed only 2 months to achieve PASI75, while the remaining patient obtained a PASI75 response at 3 months. In another study, Menter et al. administered the Goeckerman regimen for 300 patients and 100% of the patients achieved 90% or more clearing of their baseline psoriasis lesions. The average amount of treatment days for patients to achieve more than 90% clearing in the second study was only 18 days.4 PAS75 response by 3 months of therapy is considered the standard tool to assess the efficacy of a treatment modality for psoriasis. Though biologics are the new development in psoriasis treatment, their reported efficacy is 67-68% of patients achieving PASI75 at 3 months.6 Furthermore, biologics are associated with potential serious internal risks such as internal cancer, serious infections (tuberculosis, coccidioidomycosis, histoplasmosis, etc.) and cardiovascular risk.10 Goeckerman therapy avoids any of these serious internal risks while still being extremely efficacious. The use of topical tar and phototherapy has a synergistic effect. The synergism is a result of tar, being a photo sensitizer, and is supported by studies documenting a higher efficacy of combination therapy in comparison to phototherapy alone.11
The Goeckerman regimen usually proceeds for 20-30 sessions, resulting in clearing or more clearing of psoriasis. Although individual results may vary, typically after ten days of treatment we observe that patients experience decreased scaling and induration of their plaques. After twenty treatments we typically observe complete flattening of the plaques with only the presence of residual erythema. After 30 treatments, we observe complete clearance of the psoriasis lesions, including residual erythema, with only the presence of possible post-inflammatory pigmentation alterations. Patients also experience a significant improvement of their itch during the therapy. If a patient has recalcitrant psoriasis and is not showing improvement of their plaques, the therapy can be extended as needed. Furthermore, if a patient does not respond at all with topical CCT and phototherapy, the diagnosis of psoriasis should be reevaluated and confirmed by a skin biopsy (especially to rule out mycosis fungoides and pityriasis rubra pilaris).
Goeckerman therapy has one of the longest reported remission times of any psoriasis treatments. After completing Goeckerman therapy, the average length of remission can be anywhere from 9.5 months to over a year.4,12 Therefore patients can expect to maintain a response to the therapy for up to a year. However, since psoriasis is a chronic, life-long disease, the disease tends to recur in patients, especially in those who discontinue any type of therapy including topical medications and/or outpatient phototherapy. Patients who have severe, recurrent psoriasis repeat the Goeckerman regimen as needed, which is usually on a yearly (or longer) basis. Repeated admissions often require fewer treatment days to achieve clearance as patients tend to become more prompt in seeking help and patients also do not develop physiological resistance (tachyphylaxis) to the therapy
Attached are photos of a patient with severe psoriasis plaques prior to be being treated with Goeckerman therapy [Figure 5a]. Though his mild erythema is still present, there is significant decrease in scale and induration of his plaques after 4 weeks of treatment [Figure 5b]. After completing a full course of therapy, patients can expect a complete clearance of their lesions [Figure 6a and 6b].
<table border="1">
	<tbody>
		<tr>
			<td>Skin Type</td>
			<td>Initial Dose</td>
			<td>Subsequent Increase</td>
			<td>Missed Visit Dosing</td>
			<td>All Skin Types</td>
		</tr>
		<tr>
			<td>I</td>
			<td>130 mJ*</td>
			<td>15 mJ</td>
			<td>1-7 days</td>
			<td>Increase per skin type</td>
		</tr>
		<tr>
			<td>II</td>
			<td>220 mJ</td>
			<td>25 mJ</td>
			<td>8-11 days</td>
			<td>Hold dose constant</td>
		</tr>
		<tr>
			<td>III</td>
			<td>260 mJ</td>
			<td>40 mJ</td>
			<td>12-20 days</td>
			<td>Decrease by 25%</td>
		</tr>
		<tr>
			<td>IV</td>
			<td>330 mJ</td>
			<td>45 mJ</td>
			<td>21-27 days</td>
			<td>Decrease by 50%</td>
		</tr>
		<tr>
			<td>V</td>
			<td>350 mJ</td>
			<td>60 mJ</td>
			<td>28 or more days</td>
			<td>Start over</td>
		</tr>
		<tr>
			<td>VI</td>
			<td>400 mJ</td>
			<td>65 mJ</td>
			<td>&nbsp;</td>
			<td>&nbsp;</td>
		</tr>
	</tbody>
</table>
Table 1. Narrow Band UVB dosing protocol for Psoriasis. Guidelines for initial dosing, dosing increases on subsequent visits, and dosing adjustments for missed visits *mJ = millijoules.
<table border="1">
	<tbody>
		<tr>
			<td>Skin Type</td>
			<td>Start Dose Range</td>
			<td>Subsequent Increase</td>
			<td>Missed Visit Dosing</td>
			<td>All Skin Types</td>
		</tr>
		<tr>
			<td>I</td>
			<td>10-20 mJ*</td>
			<td>10-20 mJ</td>
			<td>1-7 days</td>
			<td>Increase per skin type</td>
		</tr>
		<tr>
			<td>II</td>
			<td>20-30 mJ</td>
			<td>20-30 mJ</td>
			<td>8-11 days</td>
			<td>Hold dose constant</td>
		</tr>
		<tr>
			<td>III</td>
			<td>30-50 mJ</td>
			<td>30-50 mJ</td>
			<td>12-20 days</td>
			<td>Decrease by 25%</td>
		</tr>
		<tr>
			<td>IV</td>
			<td>40-60 mJ</td>
			<td>40-60 mJ</td>
			<td>21-27 days</td>
			<td>Decrease by 50%</td>
		</tr>
		<tr>
			<td>V</td>
			<td>40-60 mJ</td>
			<td>40-60 mJ</td>
			<td>28 or more days</td>
			<td>Start over</td>
		</tr>
		<tr>
			<td>VI</td>
			<td>50-100 mJ</td>
			<td>50-100 mJ</td>
			<td>&nbsp;</td>
			<td>&nbsp;</td>
		</tr>
	</tbody>
</table>
Table 2. Broadband UVB dosing protocol for Psoriasis. Guidelines for initial dosing, dosing increases on subsequent visits and dosing adjustments for missed visits *mJ = millijoules.
<img alt="Figure 1" src="/files/ftp_upload/50509/50509fig1.jpg" /> 
Figure 1. The Supplies for Goeckerman Therapy. The medications and supplies needed for the topical application of tar and corticosteroids (Clockwise). Front Middle: Clobetasol Propionate 0.05%; Front Left: Fluocinolone Acetonide 0.01% Oil; Left: Hydrophillic Ointment; Top Left: Moisturizing Lotion; Middle Left: Jar of 20% Liquid Carbonis Detergens in Aquaphor Ointment with the cap open; Back Middle: Plastic wrap for the occlusion of topical medications; Middle Right: Jar of Crude Coal Tar 2% in White Petrolatum Ointment with the cap open; Ointment; Bottom Middle Right: Triamcinolone 0.01% Ointment; Top Right: Mineral Oil for washing topical medications off; Front Right: 20% LCD lotion.
<img alt="Figure 2" src="/files/ftp_upload/50509/50509fig2.jpg" /> 
Figure 2. Narrowband UVB Station. Left is the narrowband UVB light box where patients enter and receive UVB phototherapy. Right is the attached computer station for the charting of phototherapy dosing and patient's response to phototherapy.
<img alt="Figure 3" src="/files/ftp_upload/50509/50509fig3.jpg" /> 
Figure 3. Application of Crude Coal Tar. The nurse is applying crude coal tar to the entire body prior to occlusion with plastic wrap.
<img alt="Figure 4" src="/files/ftp_upload/50509/50509fig4.jpg" /> 
Figure 4. Shower. The shower for washing off the topical medications with mineral oil and soap. Shower is equipped with safety mats to prevent the floor from getting slippery. Safety handles are also present and important, especially for the elderly.
<img alt="Figure 5(A)" src="/files/ftp_upload/50509/50509fig5.jpg" /> 
Figure 5. Response to Goeckerman Therapy After Four Weeks. (A) Prior to treatment, the patient with thick plaque type psoriasis over the upper back. Notice the induration, thick scale, and prominent erythema of the plaques. (B) After 4 weeks of Goeckerman treatment, the patient with decreased scale and induration as a result of therapy. Residual erythema is still present.
<img alt="Figure 6(A)" src="/files/ftp_upload/50509/50509fig6.jpg" /> 
Figure 6. Response to Gockerman Therapy After Six Weeks. (A) Prior to treatment, the patient with severe plaque type psoriasis over the back. (B) Clearance of psoriasis lesions after completing Goeckerman therapy.

Watch this Scientific Journal Video about The Goeckerman Regimen for the Treatment of Moderate to Severe Psoriasis at JoVE.com

The Goeckerman Regimen for the Treatment of Moderate to Severe Psoriasis

Psoriasis is a chronic, immune-mediated inflammatory skin disease. The Goeckerman regimen, formulated for the treatment of psoriasis, consists of exposure to ultraviolet B (UVB) light and application of crude coal tar (CCT). The following protocol is for the administration of Goeckerman therapy for the treatment of moderate-to-severe psoriasis.

Psoriasis is a  chronic, immune-mediated inflammatory skin disease affecting approximately 2-3%  of the population. The Goeckerman regimen consists of ...

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38.7K Views.  University of Southern California. Psoriasis is a chronic, immune-mediated inflammatory skin disease. The Goeckerman regimen, formulated for the treatment of psoriasis, consists of exposure to ultraviolet B (UVB) light and application of crude coal tar (CCT). The following protocol is for the administration of Goeckerman therapy for the treatment of moderate-to-severe psoriasis.

Video: The Goeckerman Regimen for the Treatment of Moderate to Severe Psoriasis

The Measurement and Treatment of Suppression in Amblyopia

Amblyopia, a developmental disorder of the visual cortex, is one of the leading causes of visual dysfunction in the working age population. Current estimates put the prevalence of amblyopia at approximately 1-3%1-3, the majority of cases being monocular2. Amblyopia is most frequently caused by ocular misalignment (strabismus), blur induced by unequal refractive error (anisometropia), and in some cases by form deprivation.
Although amblyopia is initially caused by abnormal visual input in infancy, once established, the visual deficit often remains when normal visual input has been restored using surgery and/or refractive correction. This is because amblyopia is the result of abnormal visual cortex development rather than a problem with the amblyopic eye itself4,5 . Amblyopia is characterized by both monocular and binocular deficits6,7 which include impaired visual acuity and poor or absent stereopsis respectively. The visual dysfunction in amblyopia is often associated with a strong suppression of the inputs from the amblyopic eye under binocular viewing conditions8. Recent work has indicated that suppression may play a central role in both the monocular and binocular deficits associated with amblyopia9,10 .
Current clinical tests for suppression tend to verify the presence or absence of suppression rather than giving a quantitative measurement of the degree of suppression. Here we describe a technique for measuring amblyopic suppression with a compact, portable device11,12 . The device consists of a laptop computer connected to a pair of virtual reality goggles. The novelty of the technique lies in the way we present visual stimuli to measure suppression. Stimuli are shown to the amblyopic eye at high contrast while the contrast of the stimuli shown to the non-amblyopic eye are varied. Patients perform a simple signal/noise task that allows for a precise measurement of the strength of excitatory binocular interactions. The contrast offset at which neither eye has a performance advantage is a measure of the "balance point" and is a direct measure of suppression. This technique has been validated psychophysically both in control13,14 and patient6,9,11 populations.
In addition to measuring suppression this technique also forms the basis of a novel form of treatment to decrease suppression over time and improve binocular and often monocular function in adult patients with amblyopia12,15,16 . This new treatment approach can be deployed either on the goggle system described above or on a specially modified iPod touch device15.

Amblyopia is a developmental disorder of the visual cortex that is often accompanied by strong suppression of one eye. We present a new technique for measuring and treating interocular suppression in patients with amblyopia that can be deployed using virtual reality goggles or a portable iPod Touch device.

Amblyopia, a developmental disorder of the visual cortex, is one of the leading causes of visual dysfunction in the working age population. Current ...

Slow-release Drug Delivery through Elvax 40W to the Rat Retina: Implications for the Treatment of Chronic Conditions

Diseases of the retina are difficult to treat as the retina lies deep within the eye. Invasive methods of drug delivery are often needed to treat these diseases. Chronic retinal diseases such as retinal oedema or neovascularization usually require multiple intraocular injections to effectively treat the condition. However, the risks associated with these injections increase with repeated delivery of the drug. Therefore, alternative delivery methods need to be established in order to minimize the risks of reinjection. Several other investigations have developed methods to deliver drugs over extended time, through materials capable of releasing chemicals slowly into the eye. In this investigation, we outline the use of Elvax 40W, a copolymer resin, to act as a vehicle for drug delivery to the adult rat retina. The resin is made and loaded with the drug. The drug-resin complex is then implanted into the vitreous cavity, where it will slowly release the drug over time. This method was tested using 2-amino-4-phosphonobutyrate (APB), a glutamate analogue that blocks the light response of the retina. It was demonstrated that the APB was slowly released from the resin, and was able to block the retinal response by 7 days after implantation. This indicates that slow-release drug delivery using this copolymer resin is effective for treating the retina, and could be used therapeutically with further testing.

This paper details how Elvax 40W can be used as a slow-release method for drug delivery to the adult rat retina. The protocol for preparing, loading, and delivering the drug-resin complex to the eye is described.

Diseases of the retina are difficult to treat as the retina lies deep within the eye. Invasive methods of drug delivery are often needed to treat these ...

Network Analysis of Foramen Ovale Electrode Recordings in Drug-resistant Temporal Lobe Epilepsy Patients

Approximately 30% of epilepsy patients are refractory to antiepileptic drugs. In these cases, surgery is the only alternative to eliminate/control seizures. However, a significant minority of patients continues to exhibit post-operative seizures, even in those cases in which the suspected source of seizures has been correctly localized and resected. The protocol presented here combines a clinical procedure routinely employed during the pre-operative evaluation of temporal lobe epilepsy (TLE) patients with a novel technique for network analysis. The method allows for the evaluation of the temporal evolution of mesial network parameters. The bilateral insertion of foramen ovale electrodes (FOE) into the ambient cistern simultaneously records electrocortical activity at several mesial areas in the temporal lobe. Furthermore, network methodology applied to the recorded time series tracks the temporal evolution of the mesial networks both interictally and during the seizures. In this way, the presented protocol offers a unique way to visualize and quantify measures that considers the relationships between several mesial areas instead of a single area.

This protocol describes a procedure to track the evolution of mesial network measures in temporal lobe epilepsy (TLE) patients. It is based on the combination of intracranial recordings with a novel numerical technique for data analysis. Specifically, we present a protocol for network analyses of foramen ovale recordings.

Approximately 30% of epilepsy patients are refractory to antiepileptic drugs. In these cases, surgery is the only alternative to eliminate/control ...

2-Methacryloyloxyethyl Phosphorylcholine Polymer Treatment of Complete Dentures to Inhibit Denture Plaque Deposition

Removable dentures made of poly (methyl methacrylate) (PMMA) are prone to bacterial adherence and dental plaque formation, which is called denture plaque. Denture plaque-associated infection is a source of serious dental and medical complications in the elderly. 2-Methacryloyloxyethyl phosphorylcholine (MPC) is a well-known biomedical material that exhibits marked antithrombogenicity and tissue compatibility because of its high resistance to protein adsorption and cell adhesion. Therefore, MPC polymer coatings are suggested to have the potential to inhibit plaque deposition on the surface of PMMA dentures. However, coating MPC polymer on the surface of a PMMA denture is a complex procedure that requires specialized equipment, which is regarded as a major barrier to its clinical application. 
Here, we introduce a new MPC polymer treatment procedure that uses poly (MPC-co-BMA-co-MPAz) (PMBPAz) to prevent denture plaque deposition on removable dentures. This procedure enables the MPC coating of PMMA denture surfaces in a simple and stable manner that is resistant to various chemical and mechanical stresses due to the MPC layer of PMBPAz that is covalently bound to the PMMA surface by ultraviolet light irradiation. In addition, the procedure does not require any specialized equipment and can be completed by clinicians within 2 min. We applied this procedure in a clinical setting and demonstrated its clinical utility and efficacy in inhibiting plaque deposition on removable dentures.

Removable poly(methyl methacrylate) (PMMA) dentures are prone to bacterial adherence and plaque formation. Denture plaque-associated infection is a source of serious dental and medical complications in the elderly. This paper introduces a novel protocol to treat PMMA dentures with 2-methacryloyloxyethyl phosphorylcholine polymer, poly(MPC-co-BMA-co-MPAz), to suppress plaque deposition on PMMA dentures.

Removable dentures made of poly (methyl methacrylate) (PMMA) are prone to bacterial adherence and dental plaque formation, which is called denture plaque. ...

Trans-Tympanic Drug Delivery for the Treatment of Ototoxicity

The systemic administration of protective agents to treat drug-induced ototoxicity is limited by the possibility that these protective agents could interfere with the chemotherapeutic efficacy of the primary drugs. This is especially true for the drug cisplatin, whose anticancer actions are attenuated by antioxidants which provide adequate protection against hearing loss. Other current or potential otoprotective agents could pose a similar problem, if administered systemically. The application of various biologicals or protective agents directly to the cochlea would allow for high levels of these agents locally with limited systemic side effects. In this report, we demonstrate a trans-tympanic method of delivery of various drugs or biological reagents to the cochlea, which should enhance basic science research on the cochlea and provide a simple way of directing the use of otoprotective agents in the clinics. This report details a method of trans-tympanic drug delivery and provides examples of how this technique has been used successfully in experimental animals to treat cisplatin ototoxicity.

We present a technique for localized administration of drugs through the trans-tympanic route into the cochlea. Drug delivery through this route would not interfere with the anti-cancer efficacy of the chemotherapeutic drugs such as cisplatin.

The systemic administration of protective agents to treat drug-induced ototoxicity is limited by the possibility that these protective agents could ...

Intense Pulsed Light for the Treatment of Dry Eye Owing to Meibomian Gland Dysfunction

Dry eye disease (DED) is an increasingly common condition and one of the most common complaints of patients. The vast majority of DED is caused by the so-called &#34;evaporative&#34; subtype, that is mainly caused by meibomian gland dysfunction (MGD). Intense pulsed light (IPL) devices employ high intensity pulses of polychromatic lights with a broad range of wavelength (515-1200 nm). IPL treatment has been utilized for years in the field of dermatology, and then its use was applied to ophthalmology for the treatment of MGD. Recently, a new device employing IPL was specifically designed for the periocular application. This procedure determines the thermal selective coagulation and ablation of superficial blood vessels and telangiectasias of the eyelids skin, reducing the release of inflammatory mediators and tear cytokines levels, and improving meibomian glands outflow. IPL treatment is noninvasive and easy to perform, lasts for only a few minutes and can be conducted in an office setting. In the present study, 19 patients underwent 3 sessions of IPL treatment. After treatment, both mean noninvasive break-up time and lipid layer thickness grade significantly increased, as a result of an improvement of tear film stability and quality, respectively. Conversely, no statistically significant changes were found for meibomian gland loss and tear osmolarity. Furthermore, the vast majority of the treated patients (17/19; 89.5% of the total) perceived an improvement of their ocular discomfort symptoms after IPL treatment. Although IPL treatment provides an improvement of both ocular surface parameters and ocular discomfort symptoms after one cycle of three sessions, regular repeated treatments are usually required to maintain the persistence over the time of its beneficial effects.

Dry eye disease is an increasingly common condition, which strongly impair patients&#39; life quality. Recently, a new device employing intense pulsed light, specifically designed for the periocular area, has been shown to improve tear film stability and ocular discomfort symptoms in dry eye disease owing to meibomian gland dysfunction.

Dry eye disease (DED) is an increasingly common condition and one of the most common complaints of patients. The vast majority of DED is caused by the ...

Establishment of a Mouse Severe Acute Pancreatitis Model using Retrograde Injection of Sodium Taurocholate into the Biliopancreatic Duct

The prevalence of acute pancreatitis (AP), especially severe acute pancreatitis (SAP), is increasing in younger age groups annually. However, there is a lack of effective treatments in the current clinical practice. With the easy accessibility of transgenic and knockout strains and their small size, which allows minimal doses of drugs required for in vivo evaluation, a well-established experimental model in mice is preferred for AP research. Moreover, SAP induced through sodium taurocholate (TC) is currently one of the most widely used and best characterized models. This model has been investigated for novel therapies and possible molecular events during the process of AP. Here, we present the generation of an AP mouse model using sodium taurocholate and a simple homemade microsyringe. Moreover, we also provide the methodology for the subsequent histology and serological testing.

A mouse model of severe acute pancreatitis is described herein. The procedure presented here is very rapid, simple, and accessible, thereby potentially allowing the study of the molecular mechanisms and different therapeutic interventions in acute pancreatitis in a convenient way.

The prevalence of acute pancreatitis (AP), especially severe acute pancreatitis (SAP), is increasing in younger age groups annually. However, there is a ...

Laparoscopy-endoscopy Cooperative Surgery for the Treatment of Gastric Gastrointestinal Stromal Tumors

In view of the shortcomings of endoscopic or laparoscopic surgeries alone in the treatment of gastric gastrointestinal stromal tumors (G-GISTs), this approach makes an innovative improvement in the treatment of G-GISTs that are less than 5 cm in size. Laparoscopy-endoscopy cooperative surgery (LECS) is used to combine endoscopic and laparoscopic surgeries, fully realizing their respective advantages and avoiding their drawbacks. The main steps are as follows. First, gastroscopy and laparoscopy are combined to confirm the location and boundary of the tumor. Tumor resection is carried out laparoscopically, guided by a gastroscope. The specimen is removed orally and the gastric wound closed laparoscopically. Then, gastroscopy and laparoscopy are combined to determine whether there is wound bleeding, if the suture is satisfactory, and if the gastric cavity is deformed.
LECS has natural advantages in the treatment of G-GISTs that are less than 5 cm in size. The accurate estimation of tumor location and boundary greatly improves the complete resection rate of tumors. The risk of tumor rupture is substantially reduced, and the long-term prognosis of patients is significantly improved. The process allows for accurate resection of the tumor, maximum preservation of normal gastric tissue and organ function, and avoids postoperative gastric deformation. The patient's postoperative rehabilitation is greatly accelerated, and oral feeding can resume on the day of the operation. The specimen is taken out through the mouth to avoid the need for an extended abdominal incision. This greatly reduces the patient's postoperative pain and scarring. The method greatly shortens the postoperative hospital stay (i.e., discharge is possible on the day after the operation), increasing the turnover of hospital beds.

Laparoscopy-endoscopy cooperative surgery is appropriate for the treatment of gastric gastrointestinal stromal tumors less than 5 cm in size. It can achieve the respective advantages of endoscopic and laparoscopic surgeries while avoiding their drawbacks.

In view of the shortcomings of endoscopic or laparoscopic surgeries alone in the treatment of gastric gastrointestinal stromal tumors (G-GISTs), this ...

Microscopic Cyst Resection for the Treatment of Patients Diagnosed with Epididymal Cyst

Epididymal cysts mostly occur in men aged 20-40 years old. Previous reports have covered concerns about postoperative complexes, including postoperative asoedema, hematoma, sustaining pain, and seminal tract obstruction in patients who have undertaken nonmicroscopic epididymal cyst resection or epididymal resection. Nonmicroscopic epididymal cyst surgery is suggested for patients with childbirth plans as a precaution. The treatment of male epididymal cysts via microtechnology is obviously a beneficial option; we took the lead in carrying out microscopic epididymal exploration and cyst resection surgery in China. From September 2017 to April 2021, 41 young and middle-aged male patients diagnosed with epididymal cysts underwent microtechnology treatment in a program titled &#34;microscopic epididymal exploration and cystectomy&#34;. The postoperative follow-up lasted for 3-50 months. The results confirmed that, as microscopic manipulation largely improved visualization of the subtle tissue structures of the epididymis, the cyst could be clearly dissected apart and completely removed intact under the microscope. Bleeding during the operation was significantly reduced (2-3 mL) and wound drainage was not required. According to follow-up data, microscopic treatment significantly reduced the incidence of postoperative scrotal hematoma, edema, and long-term postoperative pain, thereby promising a higher surgical success rate as well as recurrence prevention. Besides, preliminary experience and reflection suggest that microscopic epididymal exploration and cystectomy provide efficient preservation of the epididymal patency through refined treatment, while a better prognosis can be achieved. We recommend that surgery be carried out before the epididymal cyst develops to 0.8 cm in diameter, for fear that a larger epididymal cyst (&#62;0.9 cm in diameter) could cause the complete destruction of all tubules of the ipsilateral epididymis - a more severe case with damage to the testicular output network.

Here, we present a protocol to treat patients diagnosed with an epididymal cyst using microscopic cyst resection. Based on microscopic manipulation, a largely improved visualization of the subtle tissue structures of the epididymis was obtained, so the cyst could be clearly dissected apart and completely removed intact.

Epididymal cysts mostly occur in men aged 20-40 years old. Previous reports have covered concerns about postoperative complexes, including postoperative ...

Network Pharmacology Prediction and Metabolomics Validation of the Mechanism of Fructus Phyllanthi against Hyperlipidemia

Hyperlipidemia has become a leading risk factor for cardiovascular diseases and liver injury worldwide. Fructus Phyllanthi (FP) is an effective drug against hyperlipidemia in Traditional Chinese Medicine (TCM) and Indian Medicine theories, however the potential mechanism requires further exploration. The present research aims to reveal the mechanism of FP against hyperlipidemia based on an integrated strategy combining network pharmacology prediction with metabolomics validation. A high-fat diet (HFD)-induced mice model was established by evaluating the plasma lipid levels, including total cholesterol (TC), triglyceride (TG), low-density lipoprotein cholesterol (LDL-C), and high-density lipoprotein cholesterol (HDL-C). Network pharmacology was applied to find out the active ingredients of FP and potential targets against hyperlipidemia. Metabolomics of plasma and liver were performed to identify differential metabolites and their corresponding pathways among the normal group, model group, and intervention group. The relationship between network pharmacology and metabolomics was further constructed to obtain a comprehensive view of the process of FP against hyperlipidemia. The obtained key target proteins were verified by molecular docking. These results reflected that FP improved the plasma lipid levels and liver injury of hyperlipidemia induced by a HFD. Gallic acid, quercetin, and beta-sitosterol in FP were demonstrated as the key active compounds. A total of 16 and six potential differential metabolites in plasma and liver, respectively, were found to be involved in the therapeutic effects of FP against hyperlipidemia by metabolomics. Further, integration analysis indicated that the intervention effects were associated with CYP1A1, AChE, and MGAM, as well as the adjustment of L-kynurenine, corticosterone, acetylcholine, and raffinose, mainly involving tryptophan metabolism pathway. Molecular docking ensured that the above ingredients acting on hyperlipidemia-related protein targets played a key role in lowering lipids. In summary, this research provided a new possibility for preventing and treating hyperlipidemia.

The present protocol describes an integrated strategy for exploring the key targets and mechanisms of Fructus Phyllanthi against hyperlipidemia based on network pharmacology prediction and metabolomics verification.

Hyperlipidemia has become a leading risk factor for cardiovascular diseases and liver injury worldwide. Fructus Phyllanthi (FP) is an effective drug ...