Psoriasis is a very common condition for which the cause remains unknown. As many as ten percent of Americans have some form of psoriasis. While plaques often appear dry, the main problem is a form of intense inflammation of the skin. It is not contagious, but can run in families. It is usually itchy, and can become worse with anything that injures the skin--including scratching! Most people are otherwise healthy, but some have severe joint pain and inflammation which can deform joints (psoriatic arthritis).

"The Singing Detective" is a musical drama produced by the British writer Dennis Potter, who himself had extensive psoriasis and arthritis. The plot follows an aging author with severe psoriasis that has flared covering his entire body (erythroderma). He is admitted to the hospital and his interactions with doctors and other patients are depicted realistically. Because of the harrowing nature of his condition, much of the series follows his imagining a detective story from an earlier time. Amusing musical numbers make this series a unique form of dermatologic entertainment.

We should point out that most people with psoriasis will fortunately NEVER have psoriasis as severely as that shown in these scenes from "The Singing Detective."
A feature film re-make of "The Singing Detective" stars Iron Man himself, Robert Downey Jr., as a crime novelist afflicted with extreme psoriasis and arthritis. Other reviewers can judge this work for its entertainment value. Our concern is not whether the film succeeds in engaging, evoking sympathy, or just causing perky toe tapping. Our question: How well does this "Detective" depict the heart breaking condition known as psoriasis?
What the movie gets right: The appearance of severe psoriasis. Audiences will certainly be taken aback by the initial images of handsome Robert Downey, Jr. covered in dry crusted red scales from head to toe, his hands locked in the throes of arthritis (joint pain). Not since Ralph Fiennes suffered with total body burn scar makeup through most of "The English Patient" has a lead character spent the majority of his on-screen time with seriously bad skin.

Psoriasis is common, but usually affects the knees, scalp, and elbows. These areas usually respond to topical treatments to clear the inflammation. Only rarely do patients develop total body rash (called erythroderma--literally "red skin"). Rarer still are those that get arthritis along with the rash, the only systemic medical problem that may be associated with psoriasis. But it can happen, and clearly the film makers did their research.

Treatment options

The movie correctly sums up the treatments for this type of severe psoriasis with arthritis, including prednisone (a powerful cortisone), tar treatments, and methotrexate (a chemotherapy that can damage the liver). Downey's character has undergone all of these regimens by the film's beginning, and had little benefit or unreasonable side effects. So the team of docs opts for a "retinoid." These vitamin A derivatives, which include accutane (usually for acne), and acitretin can reduce the inflammation of psoriasis, but have their own share of problems. Severe skin and lip dryness, sun sensitivity, and birth defects for pregnant women are the main issues, but resolve when treatment is stopped. Downey's psoriasis improves greatly during the film, but the implication is that the medical treatment is only partly responsible.

Downey gets evaluated by a grim medical team, including a moisturizer-applying nurse played by Katie Holmes.
The guilt, shame, anger, and depression of Downey's character rings true. Most people with even milder skin conditions (such as acne, dandruff, mild eczema) share the psychological feelings of loss of control, lack of cleanliness, and embarrassment. Studies have confirmed that people with psoriasis tend to isolate themselves and are at greater risk for suicidal thoughts. The involvement of a psychiatrist is a reasonable option to address this sense of dislocation. The movie's shrink is a nearly unrecognizable, balding (!) Mel Gibson, showing he underwent nearly as much time in the makeup chair as Downey himself.

Psoriasis has a major psychological impact. Downey wonders why his psychologist looks familiar...
Through the course of the film, Downey's psoriasis improves. He responds to treatment, with a return to normal skin. This is not some Hollywood fantasy. Despite intense skin inflammation, psoriasis usually does not cause permanent scarring of the skin. Emotional scarring can linger, however, especially with the knowledge that psoriasis can return, flaring with little warning or reason.
Apart from the fact that most people with psoriasis don't become crooning investigators in a musical fantasy, there is one serious flaw in the flick. Through his psychotherapy with Gibson, Downey's character opens up, clears out, and disposes of several closets of emotional baggage. As he reconciles the history of childhood trauma, his psoriasis clears as well. The obvious message is that the psychological stressors directly caused his condition. While stress seems to make psoriasis flare, blaming Downey's entire condition on a ticked off inner child isn't fair to those that suffer through psoriasis and survive. Psoriasis has many triggers in addition to stress, including dry skin, infections, and skin injury. Psoriasis can be heart breaking, but heart break is not the sole cause of psoriasis.

What the movie gets wrong: Psoriasis is all mental. Is Downey's skin problem really due to a cranky inner child?
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