Integumentary system (hair, skin, nails)
- Written by Carina
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From a natural medicine perspective there are dietary, lifestyle, supplement & herbal medicine advice that will address the causes of psoriasis & alleviate the symptoms.
Psoriasis is known as a classic hyperproliferative autoimmune disease of the skin. It occurs when the immune system sends out faulty signals that speed up the growth cycle of skin cells. The rate of cell division very high (1,000 times > normal skin). From a naturopathic perspective psoriasis is caused a toxic allergen, protein maldigestion, increased intestinal permeability, bowel toxicity, excess inflammation, leading to excess polyamines in the gut causing an imbalance of cAMP : cGMP and excess phosphodiesterase inhibitors (the enzyme involved in breaking down cGMP).
Classification od Psoriasis
The symptoms of psoriasis can manifest in a variety of forms.
- 1. Nonpustular
- Psoriasis vulgaris (chronic stationary psoriasis, plaque-like psoriasis)(L40.0) is the most common form of psoriasis. It affects 80 to 90% of people with psoriasis. Plaque psoriasis typically appears as raised areas of inflamed skin covered with silvery white scaly skin. These areas are called plaques. It characteristically involves the scalp, the extensor surfaces (backside of the wrists, elbows, knees, and ankles), and sites of repeated trauma.
- Psoriatic erythroderma involves the widespread inflammation and exfoliation of the skin over most of the body surface. It may be accompanied by severe itching, swelling and pain. This form of psoriasis can be fatal, as the extreme inflammation and exfoliation disrupt the body's ability to regulate temperature and for the skin to perform barrier functions.
- 2. Pustular
Pustular psoriasis appears as raised bumps that are filled with noninfectious pus.
Inverse psoriasis (flexural psoriasis, inverse psoriasis) appears as smooth inflamed patches of skin. It occurs in skin folds, particularly around the genitals (between the thigh and groin), the armpits, under an overweight abdomen (panniculus), and under the breasts (inframammary fold). It is aggravated by friction and sweat, and is vulnerable to fungal infections.
Nail psoriasis produces a variety of changes in the appearance of finger and toe nails. These changes include discolouring under the nail plate, pitting of the nails, lines going across the nails, thickening of the skin under the nail, and the loosening (onycholysis) and crumbling of the nail. Psoriatic arthritis involves joint and connective tissue inflammation. Psoriatic arthritis can affect any joint, but is most common in the joints of the fingers and toes. This can result in a sausage-shaped swelling of the fingers and toes known as dactylitis.
Psoriatic arthritis can also affect the hips, knees and spine (spondylitis). About 10-15% of people who have psoriasis also have psoriatic arthritis.
In plaque psoriasis, skin rapidly accumulates at these sites, which gives it a silvery-white appearance. Plaques frequently occur on the skin of the elbows and knees, but can affect any area, including the scalp palms of hands and soles of feet, and genitals. In contrast to eczema, psoriasis is more likely to be found on the outer side of the joint (ie. elbows and knees).
Fingernails and toenails are frequently affected (psoriatic nail dystrophy) and can be seen as an isolated symptom. Psoriasis can also cause inflammation of the joints, which is known as psoriatic arthritis. Between 10% and 40% of all people with psoriasis have psoriatic arthritis.
Depending on the severity and location of outbreaks, individuals may experience significant physical discomfort and some disability. Itching and pain can interfere with daily functions.
Quality of life
Individuals with psoriasis often feel self-conscious about their appearance and have a poor self-image. Psychological distress can lead to significant depression and social isolation.
Psoriasis is usually graded as mild (affecting less than 3% of the body), moderate (affecting 3-10% of the body) or severe.
There is currently no cure, but various treatments can help to control the symptoms. Many of the most effective agents used to treat severe psoriasis carry an increased risk of significant morbidity including skin cancers, lymphoma and liver disease.
However, the majority of people's experience of psoriasis is that of minor localized patches, particularly on the elbows and knees, which can be treated with topical medication.
Individuals will often experience flares and remissions throughout their lives. Controlling the signs and symptoms typically requires lifelong therapy.
Psoriasis is one of the oldest illnesses of humans and simultaneously one of the most misunderstood. Some scholars believe psoriasis to have been included among the skin conditions called tzaraat in the Bible.
Western Medical Cause of Psoriasis
The cause of psoriasis is not fully understood. There are two main hypotheses about the process that occurs in the development of the disease.
- 1. Excessive growth and reproduction of skin cells. The first considers psoriasis as a disorder of excessive growth and reproduction of skin cells. The problem is simply seen as a fault of the epidermis and its keratinocytes.
- 2. Immune-mediated disorder. The second hypothesis sees the disease as being an immune-mediated disorder in which the excessive reproduction of skin cells is secondary to factors produced by the immune system.
T cells (which normally help protect the body against infection) become active, migrate to the dermis and trigger the release of cytokines (tumour necrosis factor-alpha TNFα, in particular) which cause inflammation and the rapid production of skin cells. It is not known what initiates the activation of the T cells. The immune-mediated model of psoriasis has been supported by the observation that immunosuppressant medications can clear psoriasis plaques.
The first outbreak of psoriasis is often reported following stress (physical and mental), skin injury, and streptococcal infection. Infections, stress, and changes in season and climate are reported to cause a worsening of symptoms. Excessive alcohol consumption, smoking and obesity may exacerbate psoriasis and make the management of the condition difficult.
Family history involvement is in 50% of cases. Psoriasis has a large hereditary component, and many genes are associated with it, but it is not clear how those genes work together. Most of them involve the immune system, particularly the major histocompatibility complex (MHC) and T cells. The MHC theory is explained by the Hygiene Hypothesis and Molecular Mimicry theory (Antibacterial overuse, vaccinations and less exposure to childhood illnesses leading to a rise in autoimmune disease).
Two major genes under investigation express interleukin-12B; and IL23R on chromosome 1p, which expresses the interleukin-23 receptor, and is involved in T cell differentiation. T cells are involved in the inflammatory process that leads to psoriasis. These genes are on the pathway that ends up upregulating tumour necrosis factor-α and nuclear factor κB, two genes that are involved in inflammation.
In psoriasis, immune cells move from the dermis to the epidermis, where they stimulate skin cells (keratinocytes) to proliferate. Psoriasis does not seem to be a true autoimmune disease. In an autoimmune disease, the immune system confuses an outside antigen with a normal body component, and attacks them both. But in psoriasis, the inflammation does not seem to be caused by outside antigens. Immune cells, such as dendritic cells and T cells, move from the dermis to the epidermis and secrete chemical signals including tumour necrosis factor-α, interleukin-1β, and interleukin-6, which cause inflammation, and interleukin-22, which causes keratinocytes to proliferate.
A diagnosis of psoriasis is usually based on the appearance of the skin. There are no special blood tests or diagnostic procedures. Sometimes, a skin biopsy, or scraping, may be needed to rule out other disorders and to confirm the diagnosis.
Another sign of psoriasis is that when the plaques are scraped, one can see pinpoint bleeding from the skin below. This is called Auspitz's sign.
Western Medical Management of Psoriasis
There are a number of different treatment options for psoriasis. Typically topical agents are used for mild disease, phototherapy for moderate disease, and systemic agents for severe disease.
Mineral oil, and petroleum jelly in bath solutions and moisturisers may help soothe affected skin and reduce the dryness. Medicated creams and ointments applied directly to psoriatic plaques can help reduce inflammation, remove built-up scale, reduce skin turn over, and clear affected skin of plaques.
Ointment and creams containing coal tar, dithranol (anthralin), corticosteroids like desoximetasone(Topicort), fluocinonide, vitamin D3 analogues (for example, calcipotriol), and retinoids are routinely used.
Activated vitamin D and its analogues are highly effective inhibitors of skin cell proliferation.
Sunlight (ultraviolet light) is extremely beneficial (standard medical treatment is drug psoralen plus ultraviolet A – PUVA therapy); ultraviolet B (UVB) alone inhibits cell proliferation and is as effective as PUVA with fewer side-effects; UV may benefit via induction of skin vitamin D.
Phototherapy in the form of sunlight has long been used effectively for treatment. Wavelengths of 311–313 nm are most effective and special lamps have been developed for this application.
Psoralen and ultraviolet A phototherapy (PUVA) combines the oral or topical administration of psoralen with exposure to ultraviolet A (UVA) light. Please note: psoralen is a mutagen. Despite the photocarcinogenic properties of psorale, it had been used as a tanning activator in sunscreens until 1996.
Psoriasis that is resistant to topical treatment and phototherapy is treated by medications taken internally by pill or injection. Patients undergoing systemic treatment are required to have regular blood and liver function tests because of the toxicity of the medication. Pregnancy must be avoided for the majority of these treatments. Most people experience a recurrence of psoriasis after systemic treatment is discontinued.
The main traditional systemic treatments are
- 1. Methotrexate, cyclosporine (immunosuppressant drugs)
- 2. Retinoids (synthetic forms of vitamin A)
There is a new wave of drugs called biologics. Biologics are manufactured proteins that interrupt the immune process involved in psoriasis. These drugs are known as interleukin antagonists.
Two drugs that target T cells are efalizumab and alefacept. Efalizumbad suppressed the immune system's ability to control normally harmless viruses, which led to fatal brain infections. Efalizumab was voluntarily withdrawn from the US market in April, 2009 by the manufacturer. Both drugs block the way dendritic cells use to communicate with T cells as a way of controlling inflammation.
Monoclonal Antibodies Therapy
Several monoclonal antibodies (MAbs) target cytokines, the molecules that cells use to send inflammatory signals to each other. TNF-α is one of the main executor inflammatory cytokines.
Naturopathic Causative Factors of Psoriasis
Imbalance of cAMP : cGMP.
In naturopathic terms psoriasis is seen an immune disorder that results in hyperproliferation of skin cells as seen in psoriatic patients. Hyperproliferation of skin cells due to an imbalance of cAMP:cGMP.
Cell division is controlled by delicate balance of cyclic AMP (cAMP) and cyclic GMP (cGMP), which are used for intracellular signal transduction. Signal transduction refers to the movement of messages within and out of the cell itself.
Decreased cAMP and increased cGMP are found in skin of psoriatics. Increased cGMP is linked to increased proliferation while increased cAMP is linked to enhanced cell maturation and decreased proliferation.
Causes of Decreased cAMP
- Bowel toxins- polyamines
- Essential Fatty Acid deficiency
- NSAIDS, aspirin, cortisone and beta-adrenergic blockers cause a decrease in cAMP
Causes of increased cGMP
- Candida albicans overgrowth
- Gut toxins (endotoxins, streptococci, Candida albicans, yeast, and IgE and IgA immune complexes)
- Excess Vitamin C - Limit vitamin C intake to 1000 mg per day and biotin intake to 50 mcg per day, both can exacerbate psoriasis in larger doses.
- Caution with herbs that contain inulin (Dandelion, Echinacea, Burdock) and Ginseng as they can increase cGMP levels. Please note I use dandelion and burdock with great success psoriasis in my practice.
Protein maldigestion leading to excess polyamines in the gut
Incomplete digestion or poor absorption increases amino acids/polypeptides in bowel, which are then metabolised by bowel bacteria into toxins. Proteins in food are ‘polyamines’. Psoriatics have increased levels of the toxic metabolites of arginine and ornithine which are ‘polyamines’ (putrescine, spermidine, cadaverine).
- Inhibit formation of cAMP
- Inducing excess cell proliferation
Lowering skin and urinary polyamines results in clinical improvement. Natural compounds inhibit formation of polyamines .
Gut derived toxins including endotoxins (compounds from cell walls of Gram-negative bacteria), streptococci, Candida albicans, yeast, and IgE and IgA immune complexes) increase cGMP, thus promoting proliferation.Candia albicans overgrowth is a major factor. Fibre adheres to toxins and promotes their removal
Leukotriene excess due to excess consumption of food high in arachidonic acid
Arachidonic acid binding sites are many times greater than normal in psoriatics. Arachodonic acid is broken down to inflammatory compounds called leukotrienes in the body. Individuals with psoriasis also have greater that normal production of leukotrienes in their skin. Leukotrienes promote increased cGMP by increasing guanylate cyclase activity.
Excess phosphodiesterase inhibitors
Phosphodiesterase is the enzyme involved in breaking down cGMP. Phosphodiesterase inhibitors prevent the degradation of cGMP, thereby enhancing or prolonging its effects. Xanthines, caffeine, theobromine, found in tea and coffee are phosphodiesterase inhibitors. While these compounds are nonselective phosphoesteridase, inhibitors meaning that they are involved in the breakdown both cAMP and cGMP, it is well worth giving up tea and coffee consumption for two weeks and seeing how it affects your skin.
Impaired liver function
Increases the absorption of histamine and sulphur dioxide and the liver load. There is often a history of constipation. The liver filters and detoxifies portal blood from bowels. If liver is overwhelmed by excess bowel toxins or if there is a decrease in liver’s detoxification processes, toxin level increases.
Increased intestinal permeability
Leads to an increase in polypeptide chains, which are converted by the bowel bacteria resulting in an increase in polyamines.
Excess alcohol consumption
Alcohol worsens psoriasis. Alcohol increases toxin absorption by damaging gut mucosa and impairs liver function. Alcohol is often but not always a factor.
Excess consumption of arachidonic acid
Excess consumption of foods high in arachidonic acid such as animal foods leads to excess inflammatory mediators, leukotrienes.
Nutritional Deficiencies in Psoriasis
Psoriatics have increased serum insulin and glucose.
Glutathione peroxidase deficiency in psoriasis
Psoriatics are low in Glutathione peroxidase (GP)
Vitamin D deficiency and psoriaisis
Severe psoriasis patients have very low serum 1,25-dihydroxyxholecalciferol which normalises with oral 1 alpha(OH)D3. Active vitamin D (1, 25-dihydroxyxholecalciferol) plays role in controlling cell proliferation/differentiation.
Selenium deficiency, subsequent low glutathione levels and psoriasis
Selenium is a precursor to glutathione our own antioxidant. Low serum concentrations in whole blood Se are common in psoriasis. The lowest whole blood Se found in male patients with widespread disease of long duration requiring methotrexate and retinoids.
Vitamin A, zinc deficiency and psoriasis
Decreased vitamin A and zinc is common in psoriasis.
Naturopathic Treatment Principles in Psoriasis
- 1. Improve protein digestion
Chew your food 32 times! Herbal bitters taken before meals stimulate gastric acid, bile and saliva. Proteolytic enzymes bromelain, papain, and pancreatic enzymes reduce swelling and help the body eliminate immune complexes
- 2. Increase cAMP
- Eliminate bowel toxins and improve protein metabolism
- Replace essential fatty acid deficiency
- 3. Lower cGMP
- Sarsasparilla, Goldenseal, Coleus and Bitter Melon.
- Eradicate candida
- Eliminate gut toxins
- 4. Reduce leukotrienes
Leukotriene production can be decreased by reducing the intake of arachidonic acid (high in meat and animal fat) and increasing the intake of omega-3 oils (from cold water fish and flax seed oil). Other natural products that can decrease leukotriene production include flavonoids like quercetin, the herb milk thistle, vitamin E, garlic and onions.
- 5. Remove toxic allergen
- Heavy metal, Al, Pb, Cd
- NSAIDS, aspirin, cortisone and beta-adrenergic blockers cause a decrease in cAMP
Regarding Heavy Metal toxicity see Heavy Metal & Plastic Detox plan
- 6. Decrease bowel toxicity
Fibre adheres to toxins and promotes their removal. Promote regularity.
- 7. Improve Liver function
Correcting abnormal liver function is beneficial.
- 8. Reduce excess phosphodiesterase inhibitors in the diet
These are xanthines, caffeine, theobromine, found in tea and coffee.
- 9. The Four Rs
- Remove food allergen
- Replace digestive enzymes
- Reinoculate the bowel flora (pre/probiotics)
- Repair GIT tissue, glutamine, methionine, cysteine, Zn, Vit E, B5, beta carotene, and high fibre diet
- 9. Tonify the nervous system
- 10. Replace nutritional deficiencies
Omega-3 fatty acids
Fish oils are rich in the two omega-3 fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) and also contain Vitamin E. EPA inhibits the synthesis of inflammatory leukotrienes from arachidonic acid.
Chromium is indicated to increase insulin receptor sensitivity as psoriatics have increased serum insulin and glucose.
Glutathione peroxidase (GP) is normalised with oral Se and vitamin E. Alternatively substitute with glutathione.
Selenium oxide as a topical treatment for seborrheic dermatitis, tinea and fungal infection. Selsum blue shampoo for scalp psoriasis.
Psoriasis patients are deficient in Vit D and are better for sunlight. An alternative to direct sunlight try topical 1,25-dih.ydroxyxholecalciferol and oral 1 alpha(OH)D3 may be helpful or take a supplement as directed.
Vit A & Zinc
Psoriasis patients often have low levels of vitamin A and zinc, both necessary for healthy skin.
Vit E and selenium are important to prevent scarring.
Vitamin B deficiency manifests as dermatitis and may be implicated. Take a B complex.
- B1 red, itchy skin
- B2 cheilosis due to riboflavin deficiency
- B6 hormonal symptoms
Avoid excess Iron
Excess iron can aggravate inflammation and increase free radicals
Diet for Psoriasis
- Limit sugar, meat, animal fats, and alcohol
- Increase dietary fibre and cold-water fish
- Eliminate gluten
- Identify and address food allergies
- Normalise weight
Eat foods high in betacarotene
Psoriasis is inversely related to intake of carrots, tomatoes, fresh fruits and index of intake.
Low-fibre diet linked to increased gut-derived toxins; fibre of fruits, vegetables, whole grains, and legumes bind toxins and promote their excretion.
Fasting and vegetarian diets help psoriatics, due to decreased gut-derived toxins and polyamines.
Eliminate foods that are highly allergic
Eliminate foods that are highly allergic such as dairy, citrus, wheat, corn, eggs and soy and potentially solanaceae and salicylates. Conduct an oligoantigenic diet and oral food challenge. There is no such thing as a machine that tests for food allergy!
Herbal Medicine for Psoriasis
Forskolin helps to alleviate psoriasis by normalizing the cAMP /cGMP ratio.
Berberine alkaloids of Goldenseal hydrastis canadensis and Berberry berberis vulgaris inhibit bacterial decarboxylase enzyme, which converts amino acids into polyamines. Helps to decrease cGMP levels.
Sarsasparilla and Bitter Melon.
Helps to decrease cGMP levels. Aqueous extract of Similax sarsaparilla is effective in psoriasis, particularly chronic, large plaque-forming variety, improved psoriasis in 62% of patients and completely cleared another 18% (80% benefited); benefit due to sarsaparilla components binding and excretion endotoxins; severity and response correlate well with level of circulating endotoxins. Control of gut-derived toxins is critical. Support faecal excretion and proper handling of absorbed endotoxins by liver.
Silymarin, flavonoid of Silybum marianum, is used to treat psoriasis by improving liver function, inhibiting inflammation, and reducing excess cellular proliferation.
Herbs to be used with caution in psoriasis
Herbs that contain inulin, Dandelion, Echinacea, Burdock and Ginseng, can increase cGMP levels.
Lifestyle Advice for Psoriasis
Psoriasis is positively linked to body mass index
Topical treatments for psoriasis
Botanical alternatives to hydrocortisone are glycyrrhetinic acid from licorice (glycyrrhiza glabra), chamomile (Matricaria chamomilla), and capsaicin from cayenne pepper (Capsicum frutescens).
Liquorice root Glycyrrhiza glabra contains glycyrrhetinic acid effect is similar to topical hydrocortisone; superior to topical cortisone, especially in chronic cases; can potentiate effects of topical hydrocortisone by inhibiting 11-beta-hydroxy-steroid dehydrogenase with catalyses conversion of hydrocortisone to inactive form.
Chamomile Matricaria chamomilla essential oil contains flavonoid and essential oil components which are anti-inflammatory and anti-allergic.
Cayenne pepper Capsicum frutescens contains capsaicin which when topically applied, stimulates and then blocks small-diameter pain fibres by depleting pain neurotransmitter substance P, which is elevated in the skin of psoriatics and activates inflammatory mediators in psoriasis. Topical (0.025 or 0.075% ) capsaicin is effective in reducing scaling and redness, burning, stinging, itching. Symptoms diminished or vanished with continued application.
Ichthyotherapy is practised at some spas in Turkey, Croatia, Hungary and Serbia. Doctor fish living in outdoor thermal pools are encouraged to feed on the psoriatic skin, only consuming the affected areas. The outdoor location of the spa may also have a beneficial effect. This treatment can provide temporary relief of symptoms. A revisit to the spas every few months is often required. This treatment has been examined in two small clinical trials, with positive results.
It has been suggested that cannabis might treat psoriasis, due to the anti-inflammatory properties of its cannabinoids, and the regulatory effects of THC on the immune system .The adverse effects of cannabis might be overcome by use of more specific cannabinoid receptor medications, to inhibit keratinocyte proliferation.
Induction of localised elevation of temperature (42-45 degrees) in affected area by ultrasound and heating pads is effective.
Relaxation techniques, meditation, Qi Gong, yoga, painting, exercise.
Carina Harkin BHSc.Nat.BHSc.Hom.BHSc.Acu.Cert IV TAE.