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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