Review of Medical Nutrition Therapy for Psoriasis

[Guest guest]

Medical nutrition therapy as a potential complementary treatment for

psoriasis —- five case reports

 

http://www.findarticles.com/p/articles/mi_m0FDN/is_3_9/ai_n6228168

 

Alternative Medicine Review, Sept, 2004 by Amy C. Brown, Michelle

Hairfield, Douglas G. Richards, David L. McMillin, Eric A. Mein, Carl D.

Nelson

 

Amy C. Brown, PhD, RD--Assistant Professor of Human Nutrition,

Department of Human Nutrition, Food & Animal Sciences, University of

Hawaii at Manoa

 

Introduction

 

Psoriasis is a chronic, inflammatory skin disease characterized by

thickened, silvery-scaled patches. (1) Its cause is not yet known, but

numerous studies link it with inflammatory and immune mechanisms most

likely associated with a genetic predisposition that can be triggered by

stress. (2)

 

Because there is no cure for psoriasis, the multiple treatment options

currently available only attempt to reduce the severity of symptoms.

Non-pharmacological therapies include sunlight and stress avoidance,

while pharmacological treatments are either topically applied in the

form of creams or lotions, orally ingested, or injected. Most patients

are treated with topical therapies sometimes combined with phototherapy

and/or systemic medications.

 

Topical applications include:

 

* Anthralin--A synthetic substance made from a coal tar derivative used

since the 19th century; however, it is a highly irritating substance

that needs to be thoroughly washed off after each session.

 

* Calcipotriol--A synthetic form of vitamin [D.sub.3] that inhibits cell

proliferation but may elevate serum calcium.

 

* Corticosteroid treatment--Common steroids such as Diprolene, Psorcon,

Temovate, and Ultravate improve psoriatic lesions, but side effects

include skin thinning, hair follicle infections, facial redness,

rosacea, a worsening of diabetes mellitus, and reduced endogenous

steroid production.

 

* Topical retinoids--Some patients experience partial clearing of

psoriasis with topical retinoids, but often abandon therapy due to skin

reddening and irritation.

 

* Topical Tacrolimus and Pimecrolimus--These topical treatments

represent a new class of nonsteroidal topical immunomodulators; however,

only a few studies have been performed and side effects include a

burning sensation.

 

Oral medications are usually reserved for severe psoriasis cases because

of potentially serious side effects. Among the systemic therapies

associated with significant side effects are acitretin, methotrexate,

cyclosporine, hydroxyurea, and thioguanine. Individuals on these

medications must be closely monitored and the medications cannot be used

for long-term treatment. (3) Other systemic therapies include monoclonal

antibodies, (4) protein specifically targeting memory T cells, (5)

fumaric acid esters, (6) novel retinoids, and macrolactams. (7) In

addition to potential side effects, current oral and topical treatments

are often only a partial or temporary solution.

 

Annual medical treatment costs for psoriasis in the United States are

estimated at approximately $1.6-3.2 billion. The need exists for more

effective treatment options with fewer side effects.

 

One such option is medical nutritional therapy. Although the American

Dietetic Association promotes no specific diet for psoriasis,

researchers have reported the effect on psoriasis of modifying various

aspects of the diet. Strong scientific evidence exists for a gluten-free

diet; (8-9) some scientific evidence exists for a vegan diet, (10) rice

diet, (11) and supplementation with fish oil (12) and vitamin D; (13)

and weak scientific evidence exists for a low protein diet, (14)

fasting/starvation, (15) and supplementation with evening primrose oil,

(16) taurine, (17) and zinc sulfate. (18-19)

 

Psoriasis patients showed significant improvement after six months when

fed a gluten-free diet. (8) Naldi et al and Kavli et al noted in

epidemiological studies that increased intake of fresh fruits and

vegetables is linked with a decreased prevalence of psoriasis. (20,21)

Pagano published a book for the general public (partially based on Edgar

Cayce's readings) describing a diet composed primarily of fresh fruits

and vegetables, with small amounts of fish, fowl, and lamb. (22)

 

The present study explores the effectiveness of a treatment protocol,

based on Edgar Cayce's readings on psoriasis, that includes a dietary

regimen, herbal supplements, and addressing intestinal permeability.

Several lines of research support this systemic approach. Comorbidity

studies link intestinal pathology with a variety of skin conditions,

including psoriasis. (23-25)

 

Although there is evidence in cases of psoriasis for structural

abnormalities in the intestine, (26-28) the data specifically linking

intestinal permeability to psoriasis is mixed. Humbert et al compared

intestinal permeability of psoriasis patients with healthy controls

using the [sup.51]Cr-labeled EDTA absorption test, and found the

psoriasis group had significantly increased bowel permeability. (29) On

the other hand, Hamilton et al used the cellobiose/mannitol differential

sugar absorption test, and although these latter researchers found an

abnormal recovery ratio in seven of 29 psoriasis patients, they

concluded this rate was similar to a control population. (30) The

present study continues to explore this question.

 

The concept of increased intestinal permeability as a cause of psoriasis

is based on the premise that substances from the diet larger than those

normally absorbed can enter the circulation and initiate an immune

system response resulting in psoriatic lesions. Until the early 20th

century, " autointoxication " was widely accepted and various therapies

(such as colonic irrigation) were commonly used for a variety of

systemic disorders. Unsupported by scientific evidence, autointoxication

tell out of favor several decades ago. (31) However, the growing body of

information linking intestinal disease, excessive intestinal

permeability, and systemic illness has revived the theory. (32,33) The

concept of autointoxication gains support from several case studies

suggesting hemodialysis and peritoneal dialysis are effective in the

treatment of psoriasis. (34-37)

 

The conceptual basis of the present study is derived from the systems

approach of Edgar Cayce, as described by Landsford and McMillin et al.

In essence, the model focuses on excessive intestinal permeability (or

the " leaky gut syndrome " ) as a primary factor in the pathogenesis of

psoriasis. (38,39) According to this theory, various factors cause the

walls of the small intestine to " thin " or become disturbed in some way

that allows " toxic " substances to be absorbed into circulation. These

substances eventually find their way into the superficial circulation

and lymphatics and are eliminated through the skin, producing the

plaques of psoriasis. (39) This study is based on a slightly different

hypothesis, in that the current researchers suggest it is the immune

system reacting to larger-than-normal substances absorbed by a

compromised intestinal tract actually causing the skin to react in much

the same way it does to common allergens. The approach in the present

study combines the dietary treatment approach of Edgar Cayce, based on

Meridian Institute publications, with evaluation of psoriasis symptoms

and the measurement of intestinal permeability.

 

Subjects

 

This study was undertaken at the Meridian Institute, Virginia Beach,

Virginia, involving five participants recruited by a notice in Venture

Inward magazine. The criteria for inclusion included a medical diagnosis

of psoriasis and the ability to travel to the clinic for required

appointments; there were no exclusionary criteria. Some subjects were

using treatments before and during the study (noted specifically under

each case), and the protocol did not require them to change treatments.

Accordingly, no one changed a previous course of treatment during the

study, but simply added the study protocol. Subjects consisted of five

patients diagnosed with chronic plaque psoriasis (two men and three

women: mean age 52 years: range 40-68 years).

 

Methods and Materials

 

Each subject attended a 10-day, live-in program during which time bowel

permeability and psoriasis symptoms were assessed by a dermatologist,

and the subjects were trained to carry out the therapy protocol at home

for six months. The dietary protocol included a diet rich in

alkaline-forming fresh fruits and vegetables (Table 1) and daily use of

saffron tea and slippery elm bark water. The raw herbs, American yellow

saffron (Carthamus tinctorius) and slippery elm bark (Ulmus fulva) were

packaged by and obtained from The Heritage Store, Virginia Beach, and

prepared according to instructions, as follows:

 

* Saffron tea: 4 ounces of boiling water poured over a pinch of saffron

and steeped for 15 minutes, consumed one-half hour before a meal.

 

* Slippery elm water: a pinch of raw herb placed in a glass of cool

water, allowed to sit for five minutes, stirred, and consumed without

straining.

 

An initial cleansing included external castor oil packs applied over the

abdomen to improve elimination via the bowel, (40) colon hydrotherapy

(colonic irrigations) to further assist with elimination, and spinal

adjustments for each subject during the 10-day live-in program. Subjects

also received instruction on maintaining regular use of castor oil

packs, and were encouraged to receive further colonic irrigations and

spinal adjustments (based on availability of local clinicians).

Participants were advised on the importance of regular elimination and

were encouraged to maintain regularity with the high fruit and vegetable

diet (Table 1). Emotional counseling was also encouraged, with special

emphasis on developing a positive attitude toward healing and viewing

physical healing as part of a holistic process. The participants

returned home, applied the protocol on a daily basis, and kept daily log

sheets for six months.

 

Outcome Measures

 

The following four measurable outcomes were administered immediately

before and after six months of therapy: Psoriasis Area and Severity

Index (PASI) scores assessed by a medical doctor, Psoriasis Severity

Scale (PSS) self-assessed by subjects, (41) before/after photograph

comparisons by a medical doctor, and the lactulose/mannitol test of

intestinal permeability.

 

The PASI standardized evaluation is a single number calculation

representing severity of symptoms and area of coverage. (1) PASI scores

range from 0-72, with lower scores indicating less severe symptoms

and/or a smaller area of coverage. The PSS is a six-item subjective

evaluation of psoriasis symptoms by the patient, (41) which is

significantly correlated with objective measurement by a physician. (42)

A lower score indicates less severe symptoms. The lactulose/mannitol

test of intestinal permeability involves drinking a solution of two

sugars; the normal bowel is relatively impermeable to lactulose, but

relatively permeable to mannitol. A high lactulose/mannitol ratio in the

urine indicates excess leakage of lactulose across the intestinal wall.

This test is sensitive, low cost, simple to perform, and has the

advantage of a simple enzyme assay. (43) It has been shown to have good

repeatability and to be a reliable intestinal permeability test for

sugars. (44) After an overnight fast, the participants voided a pre-test

urine sample and then ingested the test solution provided by Great

Smokies Laboratory (63 Zillicoa Street, Asheville, NC 28801). Urine was

collected at the Meridian Institute for six hours in polyethylene

bottles. Intake of at least 100 mL of water each hour was encouraged to

ensure adequate urine production; food was allowed after four hours. The

analysis was performed by Great Smokies Laboratory.

 

Results

 

Five participants returned for the six-month assessment and all showed

improvement in PASI and PSS scores, and decreased intestinal

permeability. The mean PASI score dropped from 18.2 to 8.7; the mean PSS

score dropped from 14.6 to 5.4; and the mean lactulose/mannitol ratio

dropped from 0.066 to 0.026. Because statistical analysis is not

meaningful with five participants, each is addressed as a separate case

study with the results for each participant summarized in Table 2.

 

Case 1

 

Case 1 was a 40-year-old woman exhibiting mild psoriasis on hands,

elbows, and feet beginning in 1991. She used no other treatments,

systemic or topical, throughout the course of the study. In the

before/after pictures, Case 1 demonstrated major improvement. Her most

prominent symptom--rough, red areas on her hands and elbows--were

completely cleared. Psoriasis was still present on her feet. She also

showed improvement on the two measures of psoriasis symptoms (Table 2).

Her lactulose/mannitol ratio, which had been high (0.134) at the

beginning, was normal (0.038) after six months. Regarding compliance

with the protocol, Case 1 showed excellent compliance with the diet and

the teas, good compliance with the colonics, and minimal compliance with

the adjustments and castor oil packs.

 

Case 2

 

Case 2 was a 68-year-old man exhibiting moderate-to-severe psoriasis,

initially presenting in 1985. Case 2 used no medications during the

study. Photography showed large areas of reddened skin, with prominent

white scaly areas. The before/after pictures of Case 2 revealed

substantial healing. Most notable was the complete disappearance of the

white scales on his back, although there were still large red areas. He

also showed improvement on the two measures of psoriasis symptoms (Table

21). His lactulose/mannitol ratio, which had been high (0.084) at the

beginning of treatment, was normal (0.022) after six months. Case 2 had

excellent compliance with the diet, teas, and adjustments; good

compliance with the colonics; and minimal compliance with the castor oil

packs.

 

Case 3

 

Case 3 was a 47-year-old woman with moderate psoriasis beginning in

1997. She also presented with general health problems, specifically

hepatitis C. She was overweight and noted her diet was poor and she

craved and consumed many sweets. Case 3 used Clobetasol propionate

(topical for scalp), Diprolene cream, Gingko, occasional UV light, and

Allegra for allergies, both prior to and during the study. Improvement

was difficult to detect in the before/after photographs. Her before

photos revealed some psoriasis, while her after photos revealed no

psoriasis. At the start of the study, she had moderate psoriasis over

half her body, specifically her trunk and lower extremities, and slight

psoriasis on the head and upper extremities. She showed substantial

improvement on the two measures of psoriasis symptoms (Table 2). Her

lactulose/mannitol ratio, which was in the normal range (0.034) at the

onset of the study, was still normal, but lower (0.019), after six

months. Case 3 also noted much improvement in her hepatitis C condition,

although no medical record of the improvement was provided. Case 3

demonstrated excellent compliance with the castor oil packs; good

compliance with the diet and the teas; and minimal compliance with the

adjustments and colonics.

 

Case 4

 

Case 4 was a 44-year-old man, demonstrating mild psoriasis on scalp and

fingers that had begun when he was five years old. He also complained of

arthritis (type not specified). Prior to and during the study, Case 4

used Lipitor- for high triglycerides, Dovonex ointment, and one aspirin

daily as a blood thinner. In the before/after pictures, change was

difficult to perceive as his symptoms were barely visible. He showed

improvement on the two measures of psoriasis symptoms (Table 2). The

PASI score was zero, indicating no psoriasis symptoms at follow-up. His

lactulose/mannitol ratio, which was in the normal range (0.047) at the

beginning, was still normal, but lower (0.024), after six months. Case 4

maintained excellent compliance with the teas; fair compliance with the

diet; and minimal compliance with the colonics, adjustments, and castor

oil packs.

 

Case 5

 

Case 5 was a 59-year-old woman with severe psoriasis covering 60 percent

of her body, initially presenting in 1953. Her psoriasis symptoms at the

onset of the study were the most severe in the group. She also reported

problems with osteoarthritis and abdominal bloating, especially at

night. Case 5 reported using a steroid cream (type not specified)

topically. In the before/after photographs, Case 5 had clearly visible

improvement. Her most prominent symptom, red patches covering much of

her back, had diminished in size and redness. She also showed

improvement on the two measures of psoriasis symptoms (Table 2). Her

lactulose/mannitol ratio was at the low end of the normal range (0.029)

at the beginning and remained low (0.026) after six months. Regarding

compliance with the protocol, Case 5 had excellent compliance with the

diet, teas, and castor oil packs: and minimal compliance with the

adjustments and colonics.

 

Discussion

 

The five psoriasis cases, ranging from mild to severe at the beginning

of the study, improved on all measured outcomes over a six-month period

when measured by the PASI criteria, the PSS, and the lactulose/mannitol

test of intestinal permeability. These results suggest a treatment

regimen based on Edgar Cayce's readings on diet and herbal teas or a

related type of medical nutritional therapy may be an effective

alternative or complementary (not exclusionary of conventional

intervention) treatment for psoriasis. This study used a protocol

including diet (high in fresh fruits and vegetables, small amounts of

protein from fish and fowl, fiber supplements, olive oil, and avoidance

of red meat, processed foods, and refined carbohydrates) and herbal teas.

 

Two of the five participants had abnormally high permeability; the

intestinal permeability of all five decreased. The most difficult aspect

of the treatment protocol for most participants was compliance with

dietary restrictions. When, for various reasons such as travel, they did

not adhere to the diet, the psoriasis symptoms partially returned,

confirming the importance of this aspect of the treatment approach.

 

Psoriasis is characterized by epidermal hyperproliferation. (1) In

normal skin, the cells of the epidermis continually divide and move to

the surface of the skin, and are then sloughed off. This process

normally takes approximately 28 days. In psoriatic skin, however, this

process is accelerated and occurs in four days, with a 30-fold increase

in new epidermal cells. The skin is thicker and the cells are less

mature, resulting in scaling. Psoriatic skin is red and inflamed due to

dilation of capillaries in the dermal layer surrounded by white blood

cells. (45) The biochemical basis for the control of cell proliferation

is via a delicate balance between two signaling compounds, cyclic

adenosine monophosphate (cAMP) and cyclic guanosine monophosphate

(cGMP). Increased levels of cAMP and decreased levels of cGMP are

associated with enhanced cell maturation and reduced cell proliferation,

(46) advantages in the care and management of psoriasis. Compared to

unaffected skin, psoriatic plaques have been shown to contain decreased

levels of cAMP and increased levels of cGMP, (46) which may contribute

to epidermal hyperproliferation.

 

The improvement of psoriasis symptoms in all five subjects may have been

due to lowering overall protein intake. Because epithelial proliferation

relies on protein, reducing dietary protein may limit the potential

amount of epithelial replication. Also, excess dietary protein may lead

to incomplete protein digestion, leading to the formation of toxic

polyamines as bowel bacteria break down the superfluous polypeptides.

(47-79) Polyamines are elevated in the urine and skin of individuals

with psoriasis, providing support for the concept of autointoxication.

(50,51) Polyamines then inhibit the production of cAMP, leading to

increased cell proliferation. (47-49) Although polyamine and cAMP levels

were not measured in this study, the authors suggest that by lowering

protein intake, polyamine levels in the subjects may have been reduced,

resulting in higher levels of cAMP, decreased cell proliferation, and

ultimately, symptom improvement.

 

In addition, allergic reactions often occur due to dietary proteins. If

a compromised gastrointestinal tract allows protein substances larger

than amino acids to pass into the bloodstream, then the body may react

in an allergic-type fashion, resulting in one of the symptoms of

allergies--a skin manifestation. Since allergic reactions are

inflammatory responses involving the immune system, it is interesting to

note psoriasis is an inflammatory condition that appears to benefit from

newer immune therapies. The fact that a gluten-free diet improves the

condition of some people with psoriasis (8) indicates the

gastrointestinal tract may be involved.

 

Another important aspect of this diet was elimination of alcohol.

Consumption of alcohol is a known trigger of psoriasis flare-ups.

Although the mechanism is unknown, possible reasons for an alcohol

trigger include stress on the liver or alcohol-induced increase in gut

permeability. The fact that dialysis is effective in the treatment of

psoriasis (34-37) indicates there may be substances in the blood,

removed through dialysis, that can exacerbate psoriasis, such as

endotoxins, immune complexes, or other substances related to the body's

immune reaction. The authors believe this elusive mechanism involving

the gastrointestinal tract, liver, and bloodstream holds the key to the

core cause, and therefore effective treatment, for psoriasis. If this is

the case, topical treatments or systemic anti-inflammatory medications

are doing little to treat the cause of psoriasis. Perhaps this is why so

few psoriasis treatments are successful.

 

Generous consumption of fresh fruits and vegetables was also a

significant feature of the diet of the test subjects. The resulting

boost in consumption of fiber may have aided in diminishing psoriasis

symptoms. Both bacteria and yeasts inhabit the bowels and produce

byproducts that may be carried away by fiber components (52) for

elimination. Further hypothesizing the autointoxication theory, some of

these byproducts from the intestine, such as endotoxins, may enter the

systemic circulation due to intestinal hyperpermeability, leading to

higher skin cGMP levels and the resulting rapid skin cell proliferation

seen in psoriatics. (52) By increasing daily fiber intake it is possible

to decrease the absorption of endotoxins, which could reduce cGMP levels

in skin. Some researchers suggest a high-fiber, vegetarian diet also

supports a healthy balance of normal intestinal microflora. Conversely,

a diet high in animal protein encourages the growth of the

microorganisms that produce endotoxins. (53,54)

 

Another aspect of diet that has been researched among psoriasis patients

is the use of omega-3 fatty acid supplementation. Overall, fish oil

consumption results in mild-to-modest improvement in psoriatic symptoms,

(66,55-57) although some studies show fish oil was not superior to corn

oil (58) or olive oil. (59) Psoriatic plaques have been shown to

increase arachidonic acid and leukotriene levels (60) compared to normal

skin. Arachidonic acid is an omega-6 fatty acid contained in animal

products that, when metabolized, produces potent inflammatory

leukotrienes. Leukotrienes are promoters of increased cGMP levels.

(16,60) On the other hand, eicosapentaenoic acid (EPA), one of the

active components offish oil, serves as a substrate for the production

of anti-inflammatory prostaglandins. (61) In most of the studies

employing fish oil supplementation, the diets of the subjects involved

were not altered (55,57,62) and results have shown only slight

improvement. This may have been due to the fact that study subjects

continued to eat red meat; hence, arachidonic acid was in competition

with the EPA. In the present study, however, all meat from sources other

than fish, fowl, and lamb were excluded. Although arachidonic acid

levels were not measured in this study, decreasing the intake of red

meat and therefore arachidonic acid, and substituting protein from fish,

consequently increasing EPA levels, may have contributed to decreased

levels of leukotrienes, cGMP, and cellular proliferation.

 

Supplementation with certain herbal teas can improve inflammatory

conditions. Yellow saffron (Carthamus tinctorius) has been shown to

possess anti-inflammatory (63,64) and immune-modulating properties).

(65) Slippery elm (Ulmus fulva) is an herb used traditionally for

digestive difficulties, stomach and intestinal ulcers, and colitis. It

is a demulcent, high in mucilage, noted for its ability to soothe or

protect irritated mucous membranes, and perhaps acts as an inflammatory

agent. (66)

 

In all five cases in this study, intestinal permeability improved during

the course of treatment according to the lactulose/mannitol test (Table

2). However, interpretation of the role of permeability is complicated

by the fact that in only two cases was initial permeability outside the

norms provided by the testing laboratory. It is possible the dietary

regimen employed in this study reduced intestinal permeability to

previously present dietary compounds, despite the fact permeability was

in the normal range in several cases. Further research could be directed

toward analysis of skin cAMP, cGMP, and polyamine levels, as well as

intestinal permeability in response to the Edgar Cayce diet.

 

These preliminary results are interesting and further research is

warranted in order to determine if diet can truly play a significant

role in the observed reduction of psoriatic symptoms. The study should

employ a specific " psoriasis diet " combined with a diet diary prior,

during, and after the study to ensure compliance and to allow dietary

analysis of total nutrients. Measurable outcomes should be evaluated

again four weeks after the diet's cessation to determine the frequency

and severity of relapse.

 

Table 1. Dietary Regimen Employed in the Study

 

Food Type Include Avoid

 

Meat Fish, fowl, lamb Red meat, fried meat,

high fat meats

 

Fruit All fruits Combinations of citrus

fruits and cereals at

the same time

 

Vegetables All vegetables except Tomatoes (and their

nightshade family (see derivatives), white

avoid) potatoes, eggplant,

peppers (except the

seasoning black pepper),

paprika

 

Starch/ Whole grain bread and High sugar foods, high

grains/ cereals starch foods,

cereal combinations of two or

more starchy foods at

the same time

 

Dairy/Fats Limited amounts of nonfat Salted, processed, or

or low-fat dairy products imitation butter;

hydrogenated fats

such as margarine

 

Dessert Fruit High fat foods

 

Beverages Water, fruit and High fructose and/or

vegetable juices, artificial drinks;

saffron tea alcoholic beverages

 

Nuts All nuts None

 

Supplements Saffron tea and slippery Slippery elm water is

elm water (daily) contraindicated for

pregnant women

 

Table 2. Individual Values for Bowel Permeability, PASI Scores,

and PSS Scores for Study Participants

 

Case Number PASI Scores **

 

Pre-therapy Post-therapy

 

1 7.0 4.8

2 30.7 18.4

3 14.0 0.7

4 2.3 0.0

5 37.0 19.8

 

Mean 18.2 8.7

[+ or -] [+ or -] [+ or -]

SD 15.0 9.7

 

Case Number MPSS Scores **

 

Pre-therapy Post-therapy

 

1 7.0 6.0

2 14.0 5.0

3 21.0 3.0

4 7.0 1.0

5 24.0 12.0

 

Mean 114.6 5.4

[+ or -] [+ or -] [+ or -]

SD 7.8 4.2

 

Case Number Lactulose/Mannitol Ratio

 

Pre-therapy Post-therapy

 

1 0.134 * 0.038

2 0.084 * 0.022

3 0.034 0.019

4 0.047 0.024

5 0.029 0.026

 

Mean 0.006 0.026

[+ or -] [+ or -] [+ or -]

SD 0.044 0.007

 

* Outside normal range for lactulose/mannitol ratio of 0.01-0.06.

 

** For PASI and PSS, higher scores indicate more severe symptoms;

all patients showed a decrease in scores.

 

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