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For patients who need or want alternative approaches for treating psoriasis, balenotherapy, curcumin, indigo naturalis, fish oil supplementation, and dietary control may provide effective relief, either alone or as integrative therapy.
Dr. LioIncurable diseases that are poorly understood, have limited conventional therapeutic options, or have treatments with real or perceived side effects are prime candidates for alternative approaches. Psoriasis, with its long history of suffering and confusion, nicely fits into this category. Indeed, for centuries, patients with psoriasis were treated as literal lepers, and were required to carry a bell or clapper to announce their approach.1 The medical side of that coin is perhaps best summarized by the pithy words of Paul Bechet: “Psoriasis is an antidote for dermatologists’ ego.”2
Despite the truly spectacular advances in both the pathophysiology and therapy of psoriasis, there are still many unanswered questions and there is still no cure.3 And, as we wade through an embarrassment of riches of conventional therapeutic options, there remains-perhaps surprisingly-significant patient dissatisfaction with their treatments.4 This, too, opens the door to exploration of alternatives. Further, the notion that these powerful biologic agents-which truly do appear to be safer than their predecessors5-still have the potential for side effects, with one recent study reporting more than one quarter of respondents experiencing a serious adverse event secondary to a biologic agent for psoriasis, though this admittedly included a large portion of patients on infliximab.6
With such an extensive armamentarium for psoriasis, many of the things we will discuss below may better serve as complementary or adjunctive therapies rather than act as alternatives. Judging by a recent survey finding that nearly 50% of psoriasis patients had used a form of alternative medicine in the preceding year, this may be happening already for many of our patients without our knowledge.7 This approach-taking the best of conventional medicine along with helpful unconventional remedies-is a very nice approximation of the definition of “integrative medicine.”
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Bath therapy (balneotherapy) is an ancient practice, but it emerged as a modern treatment modality in Europe in the 1800s.8 Balenotherapy involves immersion in mineral water baths or pools, often in the context of warm weather (climatotherapy), sun exposure (heliotherapy), and a generally relaxed atmosphere away from the stress of everyday life, I might add.9
The Dead Sea has long been touted as beneficial for patients with skin ailments, particularly those with psoriasis. Over several weeks, patients relax at spas along the Dead Sea and soak in the sun and salt water. In a study of 740 patients treated at the Dead Sea for four weeks, the investigators reported complete clearance in 70%.10 This extends beyond simple skin clearing as well: a study of 119 patients found that there was marked improvement in quality of life for both psoriasis and psoriatic arthritis patients who received therapy at the Dead Sea for up to 3 months after their departure.11
A very inexpensive version of this can perhaps be approximated at home, without having to travel to the Middle East. The high salt content of the Dead Sea can be mimicked by adding sodium bicarbonate (plain old baking soda) to the bath. Verily, a study of 31 patients with psoriasis (mild to moderate) were randomized to receive either daily baths with sodium bicarbonate (they dissolved 350-500g-about a cup-in the tub) or placebo for 3 weeks.12 Statistically significant improvements were observed in the sodium bicarbonate group compared to placebo. Although the mechanism of action is unclear, there are no significant safety risks, and the cost is several orders of magnitude less than even the most economical biologic agent.
Cold water fish such as sardines, salmon, and herring contain significant amounts of omega-3 fatty acids. Their oil is particularly rich in eicosapentaenoic acid (EPA) and deocosahexanoic acid (DHA), both of which appear to possess anti-inflammatory properties and have been widely studied in multiple inflammatory diseases, including psoriasis.13
In a double-blind randomized controlled trial of 28 patients with psoriasis, there was a significant improvement in the fish oil group but none in the olive oil control group in itch, scale, and erythema at 8 weeks.14 A larger trial, however, of 145 patients over 4 months of patients with moderate to severe psoriasis taking fish oil versus a corn oil group (predominantly omega-6 fatty acids) did not see a significant change in the PASI score in either the experimental group of the control.15
In another trial, 20 patients with guttate psoriasis were randomly assigned to receive daily infusions with either a n-3 fatty acid-based lipid emulsion or a conventional n-6 lipid emulsion. The severity of disease decreased markedly in all patients of the n-3 group within 10 days, compared with only moderate improvement was observed in the n-6 group.16
Such variability suggests that perhaps there is a subtype of psoriasis that responds to fish oil, but until we can better identify who may benefit, it is difficult to recommend it to most patients.
Indigo naturalis has long been used in Traditional Chinese Medicine for psoriasis and other skin conditions.17 It may work by regulation of keratinocyte differentiation and proliferation, skin barrier repair, and likely has anti-inflammatory properties.18, 19
There have been several studies of indigo, including one of 42 patients with plaque psoriasis who were randomized to indigo naturalis ointment or placebo for 12 weeks. There was significant improvement in erythema, scaling, and induration in the experimental group, demonstrating a clinically relevant effect for indigo.20 Another study focused on the difficult problem of nail psoriasis, and had 31 patients apply indigo extract in oil to the affected nails on one hand and an olive oil control on the opposite hand for 12 weeks. Remarkably, the Nail Psoriasis Severity Index (NAPSI) improvement was superior in the indigo naturalis group, and no adverse effects were reported.21 The only point that gives pause is that all of the studies reviewed here originated from the same author: further, independent studies would be very useful to ensure that this is a viable treatment option.
The turmeric plant (Curcuma longa), a member of the ginger family, contains diferuloylmethane, better known as curcumin. It has a long history of both oral and topical treatments in dermatology, and has been shown to have anti-inflammatory, antioxidant, and even antimicrobial properties.22 Perhaps akin to the pharmacologic mechanism of some of the biologic agents, curcumin has been shown to inhibit Tumor Necrosis Factor (TNF).23
A randomized placebo-controlled trial of 60 patients with moderate psoriasis took either 3g per day of curcumin or placebo for 12 weeks. Forty-nine patients completed the study and, of those, there was a significantly better improvement in the PASI score in the curcumin group.24 An open-label trial of 1.5g of curcumin TID for 12 weeks was carried out with only 12 patients. Of the eight who completed the study, two were noted to have had greater than 80% improvement.25 With such small numbers, however, it is difficult to be sure of this finding. Importantly, this is a lot of curcumin! As a reference, diets high in turmeric only correspond to 60-100mg of curcumin daily, or less than 10% of the studied doses. This makes the concept of “eating one’s way to health”-at least with respect to curcumin-fairly unlikely. Speaking of eating, however…
Diet remains a contentious area in atopic dermatitis, but mystery equally surrounds its role in psoriasis. Patients seem to be extraordinarily interested in this question, yet the data is not totally cohesive.
There is little debate that psoriasis can be improved by low-calorie diets, unpleasant as they may be. A study of 82 patients randomized 42 to low-energy diet while the other 40 remained on hospital food. After one month, patients on the low-energy diet had significantly improved skin compared to control.26
Slightly less austere, a vegetarian diet is thought to be beneficial outside of pure caloric restriction. In a study of 20 patients with arthritis and various inflammatory dermatoses, a low-energy diet followed by a vegetarian diet resulted in significant improvement which persisted during the vegetarian phase.27 One theory as to why this may be helpful is the decreased consumption of arachidonic acid which results in lower leukotriene B4 production.28
Gluten is implicated in several conditions, and is currently very fashionable to avoid, no matter the malady. In psoriasis, however, there is significant literature supporting its role, particularly in those who have antigliadin antibodies (AGA). A 3-month gluten-free diet in 33 AGA-positive and six AGA-negative patients with psoriasis was carried out. Thirty patients with AGA completed the gluten-free diet period and showed a highly significant decrease in mean PASI score, while no improvement was found in the AGA-negative patients. AGA values were reduced after the gluten-free diet in 82% of those patients who improved. Then, after the gluten-free diet, patients consumed their ordinary diet for three months and it was found that the psoriasis deteriorated in 18 of the 30 patients with AGA, suggesting that this is a real effect in these patients.29
A recent review concludes, however: “…[A] gluten-free diet may potentially be beneficial in celiac antibody positive psoriasis patients, but additional more well-powered studies are needed to confirm this.”30
By the shining light of modern therapies for psoriasis, much of the heartbreak of this ancient disease has been chased back into the shadows. However, there are those for whom these powerful medicines are not helpful or not wanted, and others who desire a more gentle adjunctive treatment for their skin. In these cases, balenotherapy (either in a beautiful locale or perhaps at home with a bathtub and baking soda), fish oil supplementation (for some, perhaps), topical indigo, oral curcumin, and finally, a low-calorie, gluten-free, and/or vegetarian diet may offer some enticing alternatives for those who seek them.
Of related interest:
Disclosures: Dr. Lio reports no relevant disclosures.
1. Glickman FS. Lepra, psora, psoriasis. J Am Acad Dermatol. 1986 May;14(5 Pt 1):863-6.
2. Behcet PE. Psoriasis, a brief historical review. Arch Dermatol Syph. 1936 Feb;33(2):327-334.
3. Leonardi CL. New Therapies for Psoriasis. Semin Cutan Med Surg. 2016 Jun;35(4 Suppl 4):S71-3.
4. Korman NJ, Zhao Y, Pike J, Roberts J, Sullivan E, Kemhus M. Satisfaction with current psoriasis treatment: misalignment between physician and patient perceptions. Dermatol Online J. 2016 Jul 15;22(7). pii: 13030/qt7405k1nn.
5. Reich K, Mrowietz U, Radtke MA, Thaci D, Rustenbach SJ, Spehr C, Augustin M. Drug safety of systemic treatments for psoriasis: results from The German Psoriasis Registry PsoBest. Arch Dermatol Res. 2015 Dec;307(10):875-83.
6. Lopes LC, Silveira MS, de Camargo MC, de Camargo IA, Luz TC, Osorio-de-Castro CG, Barberato-Filho S, Del Fiol Fde S, Guyatt G. Patient reports of the frequency and severity of adverse reactions associated with biological agents prescribed for psoriasis in Brazil. Expert Opin Drug Saf. 2014 Sep;13(9):1155-63.
7. Damevska K, Neloska L, Nikolovska S, Gocev G, Duma S. Complementary and alternative medicine use among patients with psoriasis. Dermatol Ther. 2014;27(5):281–3.
8. Matz H, Orion E, Wolf R. Balneotherapy in dermatology. Dermatol Ther. 2003;16:132–40.
9. Verdolini R, Bugatti L, Filosa G, Mannello B, Lawlor F, Cerio RR. Old fashioned sodium bicarbonate baths for the treatment of psoriasis in the era of futuristic biologics: an old ally to be rescued. J Dermatolog Treat. 2005 Feb;16(1):26-30.
10. Harari M, Shani J. Demographic evaluation of successful antipsoriatic climatotherapy at the Dead Sea DMZ clinic. Int J Dermatol. 1997;36:304–308.
11. Kopel E, Levi A, Harari M, Ruzicka T, Ingber A. Effect of the Dead Sea climatotherapy for psoriasis on quality of life. Isr Med Assoc J. 2013 Feb;15(2):99-102.
12. Katz U, Shoenfeld Y, Zakin V, Sherer Y, Sukenik S. Scientific evidence of the therapeutic effects of dead sea treatments: a systematic review. Semin Arthritis Rheum. 2012;42(2):186–200.
13. Nicolaou A. Eicosanoids in skin inflammation. Prostaglandins Leukot Essent Fatty Acids. 2013;88(1):131–8.
14. Bittiner SB, Tucker WF, Cartwright I, Bleehen SS. A double-blind, randomized, placebo-controlled trial of fish oil in psoriasis. Lancet. 1998;1(8582):378–80.
15. Søyland E, Funk J, Rajka G, Sandberg M, Thune P, Rustad L, Helland 424 S, Middelfart K, Odu S, Falk ES, et al. Effect of dietary supplementation with very-long-chain n-3 fatty acids in patients with psoriasis. N Engl J Med. 1993;328(25):1812–6.
16. Grimminger F, Mayser P, Papavassilis C et al. A double-blind, rand- omized, placebo-controlled trial of n-3 fatty acid based lipid infu- sion in acute, extended guttate psoriasis. Rapid improvement of clinical manifestations and changes in neutrophil leukotriene pro- file. Clin Invest 1993; 71:634–43.
17. Koo J, Arain S. Traditional Chinese medicine for the treatment of dermatologic disorders. Arch Dermatol. 1998;134:1388–93.
18. Lin Y, Leu Y, Huang T, Wu Y, Chung P, Su Pang J, Hwang T. Anti-inflammatory effects of the extract of indigo naturalis in human neutrophils. J Ethnopharmacol. 2009a;125(1):51–8.
19. Lin Y, Chen H, Yang Y, Fang Y, Su Pang J, Hwang T. Indigo naturalis upregulates claudin-1 expression in human keratinocytes and psoriatic lesions. J Ethnopharmacol. 2013;145(2):614–20.
20. Lin Y, Chang C, Chang Y, Wong W, Chang S, Pang J. Clinical assessment of patients with recalcitrant psoriasis in a randomized, observer-blind, vehicle-controlled trial using indigo naturalis. Arch Dermatol. 2008;144(11):1457–64.
21. Lin Y, See L, Huang Y, Chang Y, Tsou T, Lin T, Lin N. Efficacy and safety of indigo naturalis extract in oil (Lindioil) in treating nail psoriasis: a randomized, observer-blind, vehicle-controlled trial. Phytomedicine. 2014;21(7):1015–20.
22. Gupta SC, Patchva S, Aggarwal BB. Therapeutic roles of curcumin: lessons learned from clinical trials. AAPS J. 2013;15(1):195–218.
23. Aggarwal BB, Gupta SC, Sung B. Curcumin: an orally bioavailable blocker of TNF and other pro-inflammatory biomarkers. Br J Pharmacol. 2013;169(8):1672–92.
24. Antiga E, Bonciolini V, Donciani D, Verdelli A, Righeschi C, Volpi W, Bilia AR, Caproni M. Clinical and biological activity of curcumin in patients with psoriasis vulgaris. Presentation, 23rd European Academy of Dermatology & Venereology Congress, 8–12 Oct 2014
25. Kurd SK, Smith N, VanVoorhees A, Troxel AB, Badmaev V, Seykora JT, Gelfand JM. Oral curcumin in the treatment of moderate to severe psoriasis vulgaris: a prospective clinical trial. J Am Acad Dermatol. 2008;58(4):625–31.
26. Rucevic I, Perl A, Barisic-Drusko V, Adam-Perl M. The role of the low energy diet in psoriasis vulgaris treatment. Coll Antropol 2003; 27 (Suppl. 1): 41–8.
27. Lithell H, Bruce A, Gustafsson IB et al. A fasting and vegetarian diet treatment trial on chronic inflammatory disorders. Acta Derm Venereol (Stockh) 1983; 63:397–403.
28. Wolters M. Diet and psoriasis: experimental data and clinical evidence. Br J Dermatol. 2005 Oct;153(4):706-14.
29. Michaelsson G, Gerde Ìn 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.
30. Bhatia BK, Millsop JW, Debbaneh M, Koo J, Linos E, Liao W. Diet and psoriasis, part II: celiac disease and role of a gluten-free diet. J Am Acad Dermatol. 2014 Aug;71(2):350-8.