Psoriasis

Psoriasis is a common, poorly understood condition that affects primarily the skin but may also affect nails. A related condition, psoriatic arthritis, affects joints. The fact that some people with psoriasis improve while taking prescription drugs that interfere with the immune system suggests that the disease might result from a derangement of the immune system. A dermatologist should be consulted to confirm the diagnosis of psoriasis.

Checklist for Psoriasis

Rating Nutritional Supplements Herbs
3Stars Fumaric acid esters Capsaicin cream (topical)
2Stars Fish oil (EPA/DHA) Aloe
1Star Folic acid (only for people who are not taking prescription drugs such as methotrexate that interfere with folic acid metabolism) Barberry
Burdock
Coleus
Oregon grape
See also:  Homeopathic Remedies for Psoriasis
3Stars Reliable and relatively consistent scientific data showing a substantial health benefit.
2Stars Contradictory, insufficient, or preliminary studies suggesting a health benefit or minimal health benefit.
1Star An herb is primarily supported by traditional use, or the herb or supplement has little scientific support and/or minimal health benefit.

What are the symptoms of psoriasis? The hallmark symptom of psoriasis is well-defined, red patches of skin covered by a silvery, flaky surface that has pinpoint spots of bleeding underneath if scraped. The patches typically appear during periodic flare-ups and are in the same area on both sides of the body. In some people with psoriasis, the fingernails and toenails may have white-colored pits, lengthwise ridges down the nail, or yellowish spots, or may be thickened or may separate at the cut end.

How is it treated? Psoriasis is typically treated with a combination of topical medications (e.g., lotions, ointments, creams, sprays, shampoo, watertight [occlusive] tapes), ultraviolet light, and oral medications. The drugs commonly used include corticosteroids (e.g., halobetasol [Ultravate®], mometasone [Elocon®]), synthetic vitamin D (calcipotriene [Dovonex®]), coal tar, anthralin (Dritho®), and synthetic vitamin A (e.g., etretinate [Tegison®]). If it does not respond to other therapies, psoriasis may also be treated with methotrexate (Rheumatrex®), cyclosporine (Neoral®, Sandimmune®), hydroxyurea (Hydrea®), sulfasalazine (Azulfidine®), and thioguanine (Tabloid®).

Dietary changes that may be helpful: Ingestion of alcohol has been reported to be a risk factor for psoriasis in men but not women.1 2 It would therefore be prudent for men with psoriasis to restrict their intake of alcohol or avoid it entirely.

Anecdotal evidence suggests that people with psoriasis may improve on a hypoallergenic diet.3 Three trials have reported that eliminating gluten (found in wheat, rye, and barley) improved psoriasis for some people.4 5 6 A doctor can help people with psoriasis determine whether gluten or other foods are contributing to their skin condition.

Nutritional supplements that may be helpful: Fumaric acid, in the chemically bound form known as fumaric acid esters, has been shown in case studies,7 preliminary trials8 9 10 and double-blind trials11 12 13 to be effective against symptoms of psoriasis. However, because fumaric acid esters can cause significant side effects, they should be taken only under the supervision of a doctor familiar with their use. Nevertheless, these side effects have been reported to decrease in frequency over the course of treatment and, if they are closely monitored, rarely lead to significant toxicity.14

In a double-blind trial, fish oil (10 grams per day) was found to improve the skin lesions of psoriasis.15 In another trial, supplementing with 3.6 grams per day of purified eicosapentaenoic acid (EPA, one of the fatty acids found in fish oil) reduced the severity of psoriasis after two to three months.16 17 That amount of EPA is usually contained in 20 grams of fish oil, a level that generally requires 20 pills to achieve. However, when purified EPA was used in combination with purified docosahexaenoic acid (DHA, another fatty acid contained in fish oil), no improvement was observed.18

Additional research is needed to determine whether fish oil itself or some of its components are more effective for people with psoriasis. One trial showed that applying a preparation containing 10% fish oil directly to psoriatic lesions twice daily resulted in improvement after seven weeks.19 In addition, promising results were reported from a double-blind trial in which people with chronic plaque-type psoriasis received 4.2 g of EPA and 4.2 g of DHA or placebo intravenously each day for two weeks. Thirty-seven percent of those receiving the essential fatty acid infusions experienced greater than 50% reduction in the severity of their symptoms.20

Supplementing with fish oil also may help prevent the increase in blood levels of triglycerides that occurs as a side effect of certain drugs used to treat psoriasis (e.g., etretinate and acitretin).21

Folic acid antagonist drugs have been used to treat psoriasis. In one preliminary report, extremely high amounts of folic acid (20 mg taken four times per day), combined with an unspecified amount of vitamin C, led to significant improvement within three to six months in people with psoriasis who had not been taking folic acid antagonists;those who had previously taken these drugs saw a worsening of their condition.22

Although some doctors have been impressed with the effectiveness of flaxseed oil (usually 1 to 3 tbsp per day) against psoriasis, there have been no published trials to support that observation.

The vitamin D that is present in food or manufactured by sunlight is converted in the body into a powerful hormone-like molecule called 1,25-dihydroxyvitamin D. That compound and a related naturally occurring molecule (1 alpha-hydroxyvitamin D3) have been found to reduce skin lesions when given orally to people with psoriasis.23 Topical application of these compounds has also been effective in some,24 25 26 27 but not all,28 29 trials. These activated forms of vitamin D are believed to help by preventing the excessive proliferation of cells that occurs in the skin of people with psoriasis. Because these potent forms of vitamin D can cause potentially dangerous increases in blood levels of calcium, they are available only by prescription. Toxicity is usually less of a problem with activated vitamin D applied topically than with activated vitamin D taken orally. The use of these compounds (under the supervision of a qualified dermatologist) may be considered in difficult cases of psoriasis. The form of vitamin D that is available without a prescription is unlikely to be effective against psoriasis.

Are there any side effects or interactions? Refer to the individual supplement for information about any side effects or interactions.

Herbs that may be helpful: Cayenne contains a resinous and pungent substance known as capsaicin. This chemical relieves pain and itching by depleting certain neurotransmitters from sensory nerves. In a double-blind trial, application of a capsaicin cream to the skin relieved both the itching and the skin lesions in people with psoriasis.30 Creams containing 0.025 to 0.075% capsaicin are generally used. There may be a burning sensation the first several times the cream is applied, but this usually become less pronounced with each use. The hands must be carefully and thoroughly washed after use, or gloves should be worn, to prevent the cream from accidentally reaching the eyes, nose, or mouth and causing a burning sensation. The cream should not be applied to areas of broken skin.

A double-blind trial in Pakistan found that topical application of an aloe extract (0.5%) in a cream was more effective than placebo in the treatment of adults with psoriasis.31 The aloe cream was applied three times per day for four weeks.

In traditional herbal texts, burdock root was believed to clear the bloodstream of toxins.32 It was used both internally and externally for psoriasis. Traditional herbalists recommend 2 to 4 ml of burdock root tincture per day. For the dried root preparation in tablet or capsule form, the common amount to take is 1 to 2 grams three times per day. Many herbal preparations will combine burdock root with other alterative herbs, such as yellow dock, red clover, or cleavers. Burdock root has not been studied in clinical trials to evaluate its efficacy in helping people with psoriasis.

Although clinical trials are lacking, some herbalists use the herb, coleus, in treating people with psoriasis.33 Coleus extracts standardized to 18% forskolin are available, and 50 to 100 mg can be taken two to three times per day. Fluid extract can be taken in the amount of 2 to 4 ml three times per day.

An ointment containing Oregon grape (10% concentration) has been shown in a clinical trial to be mildly effective against moderate psoriasis but not more severe cases.34 Whole Oregon grape extracts were shown in one laboratory study to reduce inflammation often associated with psoriasis.35 In this study, isolated alkaloids from Oregon grape did not have this effect. This suggests that there are other active ingredients besides alkaloids in Oregon grape. Barberry, which is very similar to Oregon grape, is believed to have similar effects. An ointment, 10% of which contains Oregon grape or barberry extract, can be applied topically three times per day.

Are there any side effects or interactions? Refer to the individual herb for information about any side effects or interactions.

Other integrative approaches that may be helpful: A preliminary trial treated 61 psoriasis patients with acupuncture that did not respond to conventional medical therapies. After an average of nine acupuncture treatments, 30 (49%) of the patients demonstrated almost complete clearance of the lesions, and 14 (23%) of the patients experienced a resolution for two-thirds of lesions.36 A controlled trial of 56 patients with psoriasis found, however, that acupuncture and “fake” acupuncture resulted in similar, modest effects.37 More controlled trials are necessary to determine the usefulness of acupuncture in the treatment of psoriasis.

Stress reduction has been shown to accelerate healing of psoriatic plaques in a blinded trial.38 Thirty-seven people with psoriasis about to undergo light therapy were randomly assigned to receive either topical ultraviolet light treatment alone or in combination with a mindfulness meditation-based stress reduction technique guided by audiotape. Those who received the stress-reduction intervention showed resolution of their psoriasis significantly faster than those who did not.

Hypnosis and suggestion have been shown in some cases to have a positive effect on psoriasis, further supporting the role of stress in the disorder.39 In one case report, 75% resolution of psoriasis resulted from using a hypnotic sensory-imagery technique.40 Hypnosis may be especially useful for psoriasis that appears to be activated by stress.

References:

1. Poikolainen K, Reunala T, Karvonen J, et al. Alcohol intake: a risk factor for psoriasis in young and middle aged men? BMJ 1990;300:780–3.

2. Monk BE, Neill SM. Alcohol consumption and psoriasis. Dermatologica 1986;173:57–60.

3. Douglas JM. Psoriasis and diet. West J Med 1980;133:450 [letter].

4. Michaelsson G, Gerden B. How common is gluten intolerance among patients with psoriasis? Acta Derm Venereol 1991;71:90.

5. Bazex A, Gaillet L, Bazex J. Gluten-free diet and psoriasis. Ann Dermatol Syphiligr 1976;103:648–50 [in French].

6. Michäelsson G, Gerdén B, Hagforsen E, et al. Psoriasis patients with antibodies to gliadin can be improved by a gluten-free diet. Br J Dermatol 2000;142:44–51.

7. Ameen M, Russell-Jones R. Fumaric acid esters: an alternative systemic treatment for psoriasis. Clin Experiment Dermatol 1999;24:361–4.

8. Mrowietz U, Christophers E, Altmeyer P. Treatment of severe psoriasis with fumaric acid esters: scientific background and guidelines for therapeutic use. Br J Dermatol 1999;141:424–9.

9. Kolbach DN, Nieboer C. Fumaric acid therapy in psoriasis: results and side effects of 2 years of treatment. J Am Acad Dermatol 1992;27:769–71.

10. Altmeyer PJ, Matthes U, Pawlak F, et al. Antipsoriatic effect of fumaric acid derivatives. J Am Acad Dermatol 1994;30:977–81.

11. Nugteren-Huying WM, van der Schroeff JG, Hermans J, Suurmond D. Fumaric acid therapy for psoriasis: a randomized, double-blind, placebo-controlled study. J Am Acad Dermatol 1990;22:311–2.

12. Nieboer C, de Hoop D, Langendijk PN, et al. Fumaric acid therapy in psoriasis: a double-blind comparison between fumaric acid compound therapy and monotherapy with dimethylfumaric acid ester. Dermatologica 1990;181:33–7.

13. Mrowietz U, Christophers E, Altmeyer P. Treatment of psoriasis with fumaric acid esters: results of a prospective multicentre study. German Multicentre Study. Br J Dermatol 1998;138:456–60.

14. Nieboer C, de Hoop D, van Loenen AC, et al. Systemic therapy with fumaric acid derivates: new possibilities in the treatment of psoriasis. J Am Acad Dermatol 1989;20:601–8 [review].

15. Bittiner SB, Tucker WFG, Cartwright I, Bleehen SS. A double-blind, randomised, placebo-controlled trial of fish oil in psoriasis. Lancet 1988;i:378–80.

16. Kojima T, Terano T, Tanabe E, et al. Long-term administration of highly purified eicosapentaenoic acid provides improvement of psoriasis. Dermatologica 1991;182:225–30.

17. Kojima T, Ternao T, Tanabe E, et al. Effect of highly purified eicosapentaenoic acid on psoriasis. J Am Acad Dermatol 1989;21:150–1.

18. Soyland E, Funk J, Rajka G, et al. Effect of dietary supplementation with very-long-chain n-3 fatty acids in patients with psoriasis. N Engl J Med 1993;328:1812–6.

19. Dewsbury CE, Graham P, Darley CR. Topical eicosapentaenoic acid (EPA) in the treatment of psoriasis. Br J Dermatol 1989;120:581–4.

20. Mayser P, Mrowietz U, Arenberger P, et al. W-3 Fatty acid-based lipid infusion in patients with chronic plaque psoriasis: results of a double-blind, randomized, placebo-controlled, multicenter trial. J Am Acad Dermatol 1998;38:539–47.

21. Ashley JM, Lowe NJ, Borok ME, Alfin-Slater RB. Fish oil supplementation results in decreased hypertriglyceridemia in patients with psoriasis undergoing etretinate or acitretin therapy. J Am Acad Dermatol 1988;19:76–82.

22. Oster KA. A cardiologist considers psoriasis Cutis 1977;20:39–40,45.

23. Morimoto S, Yoshikawa K, Kozuka T, et al. An open study of vitamin D3 treatment in psoriasis vulgaris. Br J Dermatol 1986;115:421–9.

24. Morimoto S, Yoshikawa K. Psoriasis and vitamin D3. Arch Dermatol 1989;125:231–4.

25. Kragballe K. Treatment of psoriasis by the topical application of the novel cholecalciferol analogue calcipotriol. Arch Dermatol 1989;125:1647–52.

26. Smith EL, Pincus SH, Donovan L, Holick MF. A novel approach for the evaluation and treatment of psoriasis. J Am Acad Dermatol 1988;19:516–28.

27. Kragballe K, Beck HI, Sogaard H. Improvement of psoriasis by a topical vitamin D3 analogue (MC 903) in a double-blind study. Br J Dermatol 1988;119:223–30.

28. Henderson CA, Papworth-Smith J, Cunliffe WJ, et al. A double-blind, placebo-controlled trial of topical 1,25-dihydroxycholecalciferol in psoriasis. Br J Dermatol 1989;121:493–6.

29. Van de Kerkhof PCM, Van Bokhoven M, Zultak M, Czarnetzki BM. A double-blind study of topical 1 alpha,25-dihydroxyvitamin D3 in psoriasis. Br J Dermatol 1989;120:661–4.

30. Ellis CN, Berberian B, Sulica VI, et al. A double-blind evaluation of topical capsaicin in pruritic psoriasis. J Am Acad Dermatol 1993;29:438–42.

31. Syed TA, Ahmed SA, Holt AH, et al. Management of psoriasis with Aloe vera extract in a hydrophilic cream: A placebo-controlled, double-blind study. Tropical Med Inter Health 1996;1:505–9.

32. Hoffman D. The Herbal Handbook: A User’s Guide to Medical Herbalism. Rochester, VT: Healing Arts Press, 1988, 23–4 [review].

33. Bone K. Clinical Applications of Ayurvedic and Chinese Herbs. Warwick, Queensland, Australia: Phytotherapy Press, 1996, 103–7.

34. Wiesenauer M, Lüdtke R. Mahonia aquifolium in patients with psoriasis vulgaris—an intraindividual study. Phytomed 1996;3:231–5.

35. Galle K, Müller-Jakic B, Proebstle A, et al. Analytical and pharmacological studies on Mahonia aquifolium. Phytomed 1994;1:59–62.

36. Liao, SJ. Acupuncture treatment for psoriasis: a retrospective case report. Acupunct Electrother Res 1992;17:195–208.

37. Jerner B, Skogh M, Vahlquist A. A controlled trial of acupuncture in psoriasis: no convincing effect. Acta Derm Venereol (Stockh) 1997;77:154–6.

38. Kabat-Zinn J, Wheeler E, Light T, et al. Influence of a mindfulness meditation-based stress reduction intervention on rates of skin clearing in patients with moderate to severe psoriasis undergoing phototherapy (UVB) and photochemotherapy (PUVA). Psychosom Med 1998;60:625–32.

39. Shenefelt PD. Hypnosis in dermatology. Arch Dermatol 2000;136:393–9.

40. Kline MV. Psoriasis and hypnotherapy: a case report. Int J Clin Exp Hypn 1954;2:318–22.