The Psoriasis Association estimates that around 1.8 million people in the UK are affected by psoriasis1. Psoriasis is usually described as an immune-mediated, chronic inflammatory disorder that presents with silvery scales on bright red plaques on the skin. It commonly occurs on the knees, elbows and scalp, but different types of psoriasis can also affect other parts of the body. 50% of patients will suffer from some nail changes ranging from ‘pitting’ to complete destruction of the nail2. Many patients experience some associated itching of the affected areas of skin. Psoriasis is also associated with a type of joint condition called psoriatic arthritis which affects 30% of psoriasis patients3. Patients with psoriasis have a higher risk of developing metabolic syndrome and lymphoma depending on the severity of their condition4. Patients with psoriasis may also have a higher risk of developing cardiovascular disorders, non-alcoholic fatty liver disease and Crohn's disease67.
Aside from these associated conditions, patients with psoriasis are at a higher risk of developing depression and anxiety due to the psychological burden that often results from having a skin condition8 .
Psoriasis is a complex and challenging condition to treat and requires an integrative approach. With better understanding of the role of genetics and the immune system in the development of psoriasis, there is some scope for improving the diagnosis and therapeutic management of the condition.
What is psoriasis?
Psoriasis affects men and women equally and often starts at sites of damage or irritation to the skin. The most common type of psoriasis is the plaque type (also known as psoriasis vulgaris). Other types include guttate psoriasis which manifests with scaly, teardrop-shaped spots; inverse psoriasis which may be found in the folds of the skin and pustular psoriasis which may present on the palms and soles of the hands and feet. A more rare form, called erythrodermic psoriasis is a very serious complication of psoriasis.
Plaque psoriasis accounts for almost 90% of cases, so it will be the focus of this discussion9.
What might cause psoriasis?
Psoriasis can be caused by many environmental factors such as mild trauma to the skin, which includes scratches, piercings, sunburn or chemical irritants. Drugs such as ? blockers, lithium, antimalarials and non-steroidal anti-inflammatories, such as Ibuprofen or aspirin, can make psoriasis worse10 . Psoriasis may also be triggered by HIV infection where patients with pre-existing psoriasis often have flare-ups that are difficult to treat11 .
How is psoriasis diagnosed?
A GP or Medical Herbalist can diagnose psoriasis from its clinical presentation. It may also be diagnosed using a Psoriasis Area and Severity Index (PASI) score or physician global assessment (PGA) score to assess the severity of symptoms. A Dermatology Life Quality Index (DLQI) score may also be used to assess the impact of psoriasis on the patient’s quality of life. (Here is a link to an online tool to work out your PASI score). These are effective tools which your GP or Medical Herbalist can use to monitor improvement of the symptoms.
What’s actually going on?
It is widely accepted that the immune system and genetics are involved in the development of psoriasis12 . The skin lesions of psoriasis are thought to be caused by abnormal interactions between different parts of the immune system within the skin cells. For this reason, different therapies focus on affecting these different components of the immune system in an effort to reduce the symptoms.
One aspect of psoriasis is the involvement of two types of white blood cells called T cells and dendritic cells. DNA combined with a molecule called cathelicidin, which is a naturally occurring antimicrobial molecule found in the skin, causes dendritic cells to start releasing chemicals called cytokines. These cytokines cause inflammation and also trigger other types of white blood cell to release similar chemicals leading to hyperproliferation of skin cells and inflammation13 . These mechanisms exist in a normal, inflammatory reaction. In psoriasis, however, this cascade of reactions is amplified by the cells involved attracting more white blood cells to the area14 . And so the cycle continues...
It is now understood that genetics plays a major part in the development of psoriasis. Patients often have a family history of psoriasis which can also determine the severity of the disorder. Patients diagnosed early and with a family history of psoriasis tend to have a more severe pattern of disease than patients who have no family history of psoriasis and who are diagnosed later in life15 .
Certain genes have been identified in patients with psoriasis and these genes have also been associated with type II diabetes mellitus and Crohn’s disease16 .
An evolutionary perspective
In the rapidly developing world of evolutionary medicine, which postulates that some diseases or pathological processes that affect organisms are in fact an attempt by that organism to develop defence mechanisms against certain diseases, psoriasis plaques have been associated with better wound-healing qualities and a greater capacity to fight infection. Psoriasis plaques actually contain a rich abundance of naturally occurring antimicrobial compounds which may be creating a sort of chemical shield to protect against infections17 . It is thought that in some human populations, the genes associated with psoriasis may have been selected as an evolutionary advantage to protect against leprosy, tuberculosis and infections similar to HIV. Also from this perspective, the fact that patients with psoriasis often go on to develop diabetes may show the body’s attempt to react to environmental stresses and warning signs by causing insulin resistance and fat storage18 .
For mild psoriasis, topical therapies such as glucocorticosteroids, vitamin D derivatives, or combinations of both are often sufficient. For patients with moderate to severe psoriasis, treatments are more systemic and may include phototherapy and drugs such as methotrexate and ciclosporin. Medications like etanercept and infliximab are also used to suppress the immune response.
The goal in psoriasis treatment is to treat the systemic inflammation and hopefully improve the patient’s quality of life. Some studies suggest that when psoriasis is diagnosed, patients need to ideally be screened and monitored for associated conditions such as cardiovascular disease and diabetes so that the appropriate treatment and management can be put in place by a multidisciplinary team19 .
Psoriasis is a complex condition that may or may not respond to different therapies. Although some genes associated with psoriasis have been identified, little is known about how these genes are involved in the immune system abnormalities that occur in psoriasis20 . Research is continuing to better understand the mechanisms involved in order to develop more effective treatments and outcomes for patients.
How can Herbal Medicine help?
A Medical Herbalist will aim to treat and manage psoriasis by addressing the different areas of the patient’s health to improve their quality of life. A Medical Herbalist will aim to:
Decrease inflammation of the skin by using safe and effective topical anti-inflammatories
Support cardiovascular and endocrine health through the use of safe and effective herbal medicines and dietary advice
Decrease systemic inflammation by offering advice about nutrition and appropriate supplementation
Plants which may have a potential therapeutic benefit in the treatment of psoriasis, that have been studied through clinical trials include Oregon grape root (Berberis aquifolium); Neem (Azadirachta indica); Aloe vera (Aloe barbadensis) and Qing dai (Indigo naturalis)21 .
Berberis aquifolium (barberry or Oregon grape) is an evergreen shrub. The active compound is berberine, which is thought to be responsible for its anti-inflammatory and antibacterial properties. There have been several studies which have demonstrated the efficacy of this herb in the treatment of psoriasis. In 2006, Bernstein et al did a clinical trial involving 200 patients with mild to moderate psoriasis22 . The patients who used a topical extract of Barberry showed a significant decrease in their symptoms.
Studies show that Barberry exerts its therapeutic effect by helping to regulate some of the abnormal interactions between parts of the immune system (as discussed earlier) as well as decreasing the rate at which the skin cells proliferate23 . At the Urban Fringe Dispensary, we often use Barberry both as an internal and external treatment as part of a prescription for our patients – and we have had positive outcomes.
Our research has identified several clinical trials involving the use of a Chinese herb called Qing dai, or Indigo naturalis which has shown promising anti-inflammatory effects in the topical treatment of plaque type psoriasis. Indigo naturalis has long been used in China to treat different inflammatory skin conditions24. It is now known that one of its active constituents, indirubin, stops the proliferation of skin cells on psoriasis plaques by actually affecting the genes that are responsible for the dysfunction of these skin cells25 . The herb has no reported side effects, and patients who applied it to psoriasis plaques for 12 weeks reported an improvement in symptoms such as redness, scaling and hardening of the skin26. 74% of the patients from this trial reported that their psoriasis had almost or completely cleared.
One possible solution
This is very exciting research which supports the longstanding use of the herb in topical preparations in China. So, we at Urban Fringe decided to use our knowledge of plant pharmacology to experiment with this vibrant, blue powder to produce a balm for patients with psoriasis. We’ve called it Indigo Balm and it’s available to purchase from the dispensary now.
As well as using evidence-based herbal medicine in our treatment protocol, we also emphasise the important role of nutrition and how it can affect the overall outcome for our patients.
There are several dietary approaches which, when combined with herbal medicine, can help to manage the immune response. Currently there is little robust evidence or clinical trials to support the use of dietary strategies to directly treat psoriasis. However, there is good evidence about the impact that several diets, including the Paleolithic diet, the Ketogenic diet and the Autoimmune diet can have on systemic inflammation and the immune system. It makes sense, therefore, that adopting the appropriate dietary strategy with support from your practitioner could significantly improve your symptoms given that psoriasis is essentially systemic inflammation leading to an inappropriate immune response.
We all have trillions of microbes that live in and on our bodies called our microbiome – we depend on them to live, just as they depend on us. It’s a perfectly symbiotic relationship. When there is a disturbance of this delicate ecosystem within our bodies, it can lead to bacterial overgrowth or gut dysbiosis. It is now thought that this gut dysbiosis is associated with many diseases such as Crohn’s disease, ulcerative colitis, type I and II diabetes mellitus, rheumatoid arthritis and even hypertension27282930313233 . In fact, more and more research is finding that an unhealthy gut microbiome may be a major causative factor in the development of many common diseases. The important issue here is that gut dysbiosis has been implicated in the development of systemic inflammation, which in turn stimulates an inappropriate immune response against the body’s own cells – i.e. autoimmune disease....i.e. psoriasis.
It therefore makes sense, that if you change your diet to improve your gut microbiome, the result will more than likely be a reduction in the internal and external symptoms associated with psoriasis.
We can work with you to help you make the necessary dietary and lifestyle changes you need to improve your psoriasis. There is much robust evidence and good research about the safety and efficacy of herbal medicines in the treatment and management of psoriasis. Combined with our knowledge of nutrition and pharmacology, and our primary objective of treating each patient as an individual, we can agree a holistic plan with our patients to help them reclaim their health and vitality.
A typical treatment protocol would consist of an initial 60 minute consultation, where we discuss your symptoms and talk about your past medical history. We then talk about the different systems in your body and may check your blood pressure and pulse, as well as checking for any other associated conditions. We observe the sites of psoriasis on your body and together we can apply a PASI score. This will help us to monitor your symptoms throughout treatment. At the end of the consultation, we discuss your ideas, concerns and expectations about your treatment, and we will agree a plan to move forward. We may just offer advice about diet and lifestyle, or we may also dispense a prescription of herbal medicine for you. Each case is individual.
We will normally see you for a 30 minute follow-up appointment around four weeks later. Depending on the severity of the psoriasis, you could expect to see some positive results within four to eight weeks. Your motivation and commitment to your treatment is a major factor in the improvement of your symptoms. As with many autoimmune conditions, you would expect to receive support and treatment from your practitioner for at least 4 – 6 months. You may not need consistent follow-up appointments; you may not even need repeat prescriptions. However long your treatment takes, we are here to use our skills to help you make the transition towards a healthier life where you are in control of your health and vitality.