What's the best management plan for a psoriasis patient trying to quit vaping, with itching, a history of alcohol use, and an upcoming hospital stay, while their relative undergoes a stem cell transplant?

Management Plan for Psoriasis Patient with Vaping Cessation, Itching, and Alcohol Use

Continue the current topical psoriasis regimen with repeat prescriptions, initiate varenicline for vaping cessation with baseline blood work and close neuropsychiatric monitoring, prescribe antihistamines for nocturnal pruritus, and strongly counsel on alcohol reduction given its documented role in worsening psoriasis and potential interaction with varenicline. 1, 2, 3

Psoriasis Management

Topical Therapy Continuation

• Maintain the current topical regimen as this patient has stable chronic plaque psoriasis that is well-controlled with topical agents 1
• Continue the spray formulation for knees/elbows and alcohol-free steroid cream for facial psoriasis, as the patient reports good efficacy with these agents 1
• Most patients with stable chronic plaque psoriasis should be managed in primary care with topical agents rather than systemic therapy 1
• Provide repeat prescriptions with regular clinical review to ensure no unsupervised refills 1

Critical Alcohol Counseling

• Alcohol is a documented trigger that can precipitate or worsen psoriasis and must be addressed as a priority 1, 2, 4
• The British Medical Journal guidelines explicitly identify alcohol as capable of causing severe deterioration of psoriasis 1, 2
• Reducing alcohol consumption may directly improve psoriasis control and is essential before the extended hospital stay 1, 2

Vaping Cessation with Varenicline

Initiation Protocol

• Obtain baseline blood work before starting varenicline as planned, including complete blood count, liver function tests, and renal function 3
• Varenicline is appropriate for this motivated patient with a clear deadline (relative's stem cell transplant) and prior success with the medication 3

Critical Safety Monitoring

• Implement intensive neuropsychiatric monitoring given the FDA black box warning for serious neuropsychiatric adverse events including depression, suicidal ideation, aggression, and unusual behavior 3
• Advise the patient and family members to immediately report any agitation, depressed mood, behavioral changes, or suicidal thoughts 3
• Warn explicitly about the interaction between varenicline and alcohol - postmarketing reports document increased intoxicating effects, unusual/aggressive behavior, and amnesia when combined 3
• Instruct the patient to significantly reduce alcohol consumption while on varenicline until tolerance is established 3
• Monitor for seizures, particularly in the first month of therapy, though this patient has no documented seizure history 3

Practical Considerations

• Schedule follow-up within 2-4 weeks of initiating varenicline to assess tolerance and neuropsychiatric symptoms 3
• The upcoming extended hospital stay provides a structured environment that may support cessation efforts
• Consider whether hospital staff should be informed about varenicline use for continuity of monitoring

Pruritus Management

Antihistamine Selection

• Prescribe sedating antihistamines for nocturnal itching episodes, as these provide both antipruritic effects and sleep benefits 5
• Non-sedating antihistamines can be used during daytime if needed 5
• The itching may be related to psoriasis itself or represent a separate atopic component requiring symptomatic management 5

Critical Pitfalls to Avoid

Medication Interactions with Psoriasis

• Do not prescribe beta-blockers, lithium, chloroquine, or NSAIDs as these can cause severe, even life-threatening deterioration of psoriasis 1, 2, 4
• If the patient requires pain management, avoid NSAIDs and consider alternative analgesics 1, 4

Systemic Therapy Contraindications

• This patient does NOT require systemic psoriasis therapy - stable plaque psoriasis responding to topicals should remain on topical management 1
• If systemic therapy were ever considered, methotrexate would be contraindicated due to alcohol use and potential hepatotoxicity 1
• Cyclosporine would be inappropriate given no indication for "rescue" therapy 1

Alcohol-Varenicline Interaction

• The combination of varenicline with continued alcohol use poses significant risk for unusual behavior, increased intoxication, and amnesia 3
• This interaction must be explicitly discussed and documented, with strong recommendation for alcohol cessation or dramatic reduction 3

Monitoring Schedule

Short-term (2-4 weeks)

• Assess varenicline tolerance and neuropsychiatric symptoms 3
• Evaluate antihistamine efficacy for pruritus 5
• Reinforce alcohol reduction counseling 1, 2, 3

Medium-term (Before Hospital Stay)

• Confirm vaping cessation progress 3
• Ensure adequate supply of psoriasis medications for extended hospital stay 1
• Verify blood work results are stable on varenicline 3
• Assess psoriasis stability - alcohol reduction should improve control 2