Erica is a 19-year-old college student, who presented with a severe flare of her chronic plaque-type psoriasis. She describes the lesions as being very pruritic, to the point where she needs to take anti-allergy medication at night in order to fall asleep. The patient worries that she will fail her final examinations coming up next month in English Literature and Evolutionary Biology, two rather challenging courses. Despite tireless efforts to prepare for the exams, her self-assessment tests predict that she will score in the bottom half of each respective class, which is causing her significant distress. In addition, she is the captain of the cheerleading team at her university, and her responsibilities have doubled in the past few weeks due to her co-captain dropping out of the program.

While sharing her difficulties with you, Erica struggles to fight back tears. She is the oldest of three sisters and feels pressured to keep up with her family’s expectation that she remains a role model for her younger siblings. However, her self-confidence is waning as the amounts of work and stress are mounting. Physical exam reveals well demarcated, “beefy red” erythematous plaques with thick micaceous scales symmetrically scattered over the arms, legs, backs, and buttocks. There is noticeable dried blood on the plaques on her shins, where Erica reports that she scratches repeatedly to relieve the severe itch.

Previously, the patient has applied high-potency topical steroids and taken short courses of methotrexate to control similarly severe psoriasis flares. In between these flares, her psoriasis was successfully treated with a combination of a mid-potency topical steroid and calcipotriene cream. Erica has read on the Internet that methotrexate and other systemic medications will damage her internal organs if used too many times. Therefore, she requests you to not prescribe any systemic medications today. She is not a candidate for phototherapy because of her hectic schedule. In consideration of her request and the stressful circumstances surrounding her current psoriasis flare, you suggest trial of a combination of psychological therapy and high-potency topical steroids for 4 weeks. She accepts this experimental treatment and asks for a referral to a psychologist.