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As barometers all over the islands hover closer to 40oC than 30oC we are gripped by a collective urge to bare as much skin as possible as we alternate between acquiring the perfect tan and showing it off.

And yet in the midst of this national obsession with the shade of our skin, there are those among us who steadfastly refuse to bare anymore skin than is absolutely necessary - and with good reason. Ask anyone who has ever suffered from an allergic rash and they will be able to recall, sometimes even years after the event, the lengths they went to in their attempts to cover the offending red patches.

When the issue is confined to a temporary problem it's very inconvenient to the sufferer, but for anybody suffering with a skin condition, the problem can be very severe indeed. The list of skin conditions is an interminably long one, but possibly one of the most debilitating conditions is psoriasis.

Our skin is constantly being renewed in a perfectly synchronised cycle of cell regeneration coinciding with the shedding of dead skin cells. In psoriasis, the cycle goes somewhat awry and new skin cells are generated much faster than necessary causing unsightly patches of plaque to build up on the affected area.

In most cases, psoriatic plaque will first appear on the elbows and knees and for many patients this will be the worst of their problem. An unfortunate one per cent of the population, however, will develop moderate to severe psoriasis with the plaque spreading to other areas of the body and in very severe cases covering as much as 80 per cent of a person's skin.

Although psoriasis is not contagious one patient describes as "looking as though it definitely should be" and people are sometimes wary about coming into direct contact with somebody with visible signs of the condition.

Lucienne Tabone, public relations officer of the Psoriatic Association Malta, knows of countless incidents of psoriasis patients being asked to leave swimming pools and, in one case, a supermarket as they were upsetting other patrons.

An estimated 20 to 30 per cent of psoriasis patients will go on to develop psoriatic arthritis and that's where life can become extremely challenging indeed. Here the condition attacks the joints causing them to disfigure and possibly leading to partial or complete disability.

Treatment for psoriasis varies according to the severity of the condition. In mild cases, topical creams will usually relieve the symptoms but more severe cases will require more heavyweight medication.

Symptoms of psoriasis are often relieved to some extent by phototherapy ultraviolet treatment (PUVA) which is available at Boffa Hospital. Patients undergo an annual course of the treatment over a period of weeks and the effects of the treatment will last for a number of months. A patient who has PUVA therapy in spring may well find that the first signs of psoriasis will start to appear in late autumn.

As with all medications, this treatment is not suitable for all patients and a percentage of patients will find that over the years, the effects start to wear off sooner than before. As the treatment's efficacy diminishes doctors will either prescribe an alternative treatment or a suitable medication to be used in conjunction with PUVA.

The next step on the treatment path introduces medication such as methotrexate - a chemotherapy drug that suppresses the body's immune system slowing down the excess regeneration of skin cells. The side effects of this class of medication vary from person to person. Some patients report experiencing flu-like symptoms for a couple of days after taking the medication while others sail through the experience without any adverse effects whatsoever.

While these medications will serve their purpose in most cases for a period of years, they are not suitable for everyone and come with some heavy handed side effects to boot. After prolonged use of these so-called second line agents, some patients may experience problems with their liver functions and, for some, the drug will no longer be effective against their conditions.

Until approximately five years ago, this was the end of the road, and anybody unfortunate enough to experience an adverse reaction to the medication or those who where unable to start taking it in the first place, had no other options available to them.

In 2004, however, a treatment that had been successfully used to treat rheumatoid arthritis for six years was licensed to treat patients suffering from moderate to severe psoriasis. A class of vaccines known as biologics has emerged and they are having remarkable results.

Biologics differ to more traditional medicines in that they only target the problematic cells making them much safer to use than conventional drugs. They, too, can have some serious side effects against which patients are monitored very carefully but those who are being treated with biologics generally agree that life has improved drastically for the better.

The treatment is administered in one of two ways; most are available as vaccines which can be self-administered while one is administered via a drip. The choice of drug depends on the patient's previous medication and medical history.

At a price tag in the region of €14,000 (Lm6,000) per patient per year, this treatment is definitely not cheap and the fact that only a handful of psoriasis patients currently using the treatment has caused ripples of discontent in some quarters.

Patients point to an apparent discrepancy between the procedures involved in using biologics for rheumatoid arthritis and psoriasis which has led some psoriasis patients to feel they are being discriminated against. Presently, a rheumatologist may prescribe biologics for a patient and, after completing the necessary paperwork, obtaining the drug on the national health system is trouble free. A dermatologist wishing to prescribe the same medication to a patient suffering from psoriasis must apply for authorisation for each patient.

Lawrence Scerri, Head of Dermatology within Boffa Hospital explains the criteria establishing whether a patient can be prescribed biologics.

"Principally the patient must be diagnosed with moderate to severe psoriasis and must have exhausted the second line agent options available. This means that the medication must either be proving ineffective; the patient has developed side effects that prohibit the use of such medication or their use is contra-indicated because of the patient's history."

Dr Scerri goes on to explain that finding the right balance of medication can take time as reactions will vary from person to person. Patients taking PUVA treatment will necessarily have to fit this into their schedule, which he acknowledges can be inconvenient. Inconvenience, however, is not enough justification to switch to biologics.

"There is no escaping the fact that this is costly treatment and as such we must use it wisely. If the condition is being controlled through the use of the second line agents, which are very potent drugs in themselves, this is perfectly acceptable."

Natasha Muscat Azzopardi within the Department of Health also dismisses claims of discrimination saying "the system we currently use for authorising medicines has been in use for many years and it causes some anomalies in their use but all patients who need medication get it, it's just the procedure that differs.

"The present structure is such that some medications which have been in use for a period of years to treat a condition are licensed for prescription without the need for any prior approval. In the case of rheumatoid arthritis the biologics have achieved this status.

For psoriasis, however, we are still at the stage where we need to approve its use on a patient by patient basis. As more and more patients are prescribed this treatment, the restrictions will be eased as has happened with countless "new" medicines in the past.

"The system goes back to the days when new medicines were few and far between but today, we are seeing medicines being licensed regularly and this system is no longer workable. We are in the process of introducing a new system whereby drugs which are licensed for prescription under the national health service are instantly available to all patients who qualify to take them," Dr Muscat Azzopardi added.

For anybody suffering with psoriasis the knowledge that, if they should need it, this medication will be available to them will be as welcome as a cool breeze on an August afternoon.

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Testimonials of two patients

Kelly* and Anthony* are both in their 40s and have both suffered from psoriasis since adolescence. Their experiences of the condition, however, are markedly different.

Anthony developed the condition when he was 18 and although he was determined that the condition would not keep him from doing anything he wanted to do, he admits that it still had a drastic effect on his day to day life.

"Psoriasis is more than just an unsightly rash, the plaque itself can become very sore and I was constantly itchy. By the time I was in my 30s, about 60 per cent of my body was covered by plaque and at times sleeping was a challenge because of the pain caused by the sheets rubbing against my skin.

"I can't say that psoriasis stopped me doing anything but it definitely made life more uncomfortable. Summer was a mixed blessing; the sun limited the rash naturally but wearing summer clothes meant that the rash that remained was very visible.

"People recoil when they see a rash such as the one I had; it looked as if I had a contagious disease, and you just can't go around telling perfect strangers that they have nothing to fear.

"Swimming was a nightmare; I refused to swim in a pool and would only go to the beach if there was no way I could avoid it. Even then, I would opt for a place as far from the crowd as possible.

"As the condition became more severe, I was shedding skin at an alarming rate and my wife and I had to vacuum the entire house every day. The dead skin showed up against dark clothes so I would always wear light colours when I could.

"Although I was taking the second line agents, they were no longer as effective as they once were and I was extremely conscious of people's reactions to me. I guess that, in reality, most of the time people were unaware of my psoriasis but I always felt as if people were watching me, wondering what was wrong."

Sitting in the sunshine, Anthony shows no sign of the condition that has plagued him for most of his life; and he puts this down to the fact that he has been taking biologics since 2007. The difference the medication has made to his quality of life is amazing.

"I feel freed from psoriasis, being able to sit at a table like this without trying to hide under the table is a relief. For the first time in years, I am not constantly fighting the urge to scratch myself and I have had the best sleep I can ever remember."

"I have a young son and it's reassuring to know that, if he has inherited the condition, his life need not be blighted by it. I know that I'm fortunate in that the condition I have is not life threatening nor is it disabling so I'm thankful to be having this medication that has so drastically improved my life."

Kelly has also had psoriasis since adolescence and is very conscious of her condition.

"The plaque appears mainly on my legs and you'll never catch me wearing shorts or skirts when the rash is visible. Over the past few years the condition has gotten worse so I've been using PUVA since 2004.

"I usually schedule my course of treatment for the spring as that means I'm almost completely clear of any rash until late October or early November. I don't mind the rash so much during the winter months as I usually prefer to wear trousers or jeans anyway.

"Last year, the effects of the PUVA had worn off by mid-September so this year my dermatologist has prescribed methotrexate alongside the PUVA treatment.

"As long as the treatment continues to work, I'm happy to stick to my current regime. The staff at the PUVA clinic are very helpful and will do their best to schedule appointments that are convenient for us. Personally I prefer to schedule my treatment for first thing in the morning, right after the children have left for school and they have always managed to accommodate me.

"Of course, psoriasis is uncomfortable to say the least but as long as I make time for my treatment during the day the condition is kept under control. Just like taking a daily shower, applying the prescribed creams and attending for PUVA treatment is a matter of routine for me."

* Names have been changed to protect identities.

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