Redefining alternative therapies as integrative adds benefits for patients with psoriasis

Therapeutic options for psoriasis have grown exponentially over the past few decades with scores of topical, oral and biologic drugs now available.

While dermatology specialists now have a myriad of options to prescribe, many patients are still reluctant and may opt for alternative, nonpharmacological options.

These can range from traditional Eastern therapies — such as herbal supplements and acupuncture — to diet, exercise, meditation or mindfulness.

While some benefits can be extracted from alternative therapies, it is important to note their limitations and know how to best use them, which can often be in conjunction with therapies prescribed by specialists.

“Patients are really motivated to try to use non-pharmacologic treatments for various reasons,” eplains Tina Bhutani, MD, MAS, associate professor of dermatology, co-director of the Psoriasis and Skin Treatment Center and director of the Dermatology Clinical Research Unit at the University of California, San Francisco. “But the distinction between alternative medicine and complementary medicine is important. I do think many of these things might have benefits, not on their own necessarily, but they’re great adjunctive treatments.”

Therefore, there has been a push within the medical field to redefine “alternative” therapies as “adjunctive” or “integrative” instead.

Defining Alternative Therapies

Pharmacological treatments are often thought of as “conventional” medicine, in contrast to alternative medicine, but according to Raja Sivamani, MD, MS, AP, adjunct associate professor of dermatology at University of California, Davis, and at Pacific Skin Institute where he practices as an integrative dermatologist, and directs clinical studies at Integrative Skin Science and Research, it should all be considered medicine.

“I think these definitions are important. When it comes to therapies and psoriasis ... when we take an integrative approach, it’s not just looking at pharmaceuticals and the conventional approach, but at other factors that can give the patients more control and in fact, control other aspects of their health beyond psoriasis,” Sivamani said.

A 2018 survey conducted by the National Psoriasis Foundation aimed to uncover the types of alternative or complementary therapies used by patients with psoriasis, as well as patient motivation to seek out alternative therapies.

Of 219 patients who completed the survey, 41% reported using alternative therapies and 39.5% reported using complementary therapies, with patients who had more severe disease being more likely to seek them out.

These therapies included vitamins, dead sea bath salts, cupping, herbals or botanicals, yoga, acupuncture, laser therapy and meditation.

These data reinforced a previous review that found complementary and alternative medicine usage increasing in 10 different countries studied, but there are geographical differences in the types of alternative therapies used.

In this study, homeopathic treatments, acupuncture, chiropractic manipulation and phytotherapy or herbal remedies were the most commonly used.

Patients reported trying complementary or alternative therapies due to side effects or failure with traditional medications.

“There is a lot of hesitancy about Western medicine and a lot of this is based on commercials we see on TV or advertisements where the list of side effects seems so large and things like death are listed, so I understand their hesitancy in taking these treatments,” Bhutani said.

Diet and Supplements

A connection between obesity and psoriasis has long been detailed in the literature, with individuals with psoriasis more likely to develop obesity or already have obesity.

Mary McGonagle, DO, FAOCD, co-founder of integrativederm.org, an educational platform for patients to explore integrative approaches to skin diseases, described how randomized trials looking at dietary weight loss have found a reduction of body mass by as little as 5% significantly improved psoriasis severity and quality of life.

“The results of the dietary weight loss on psoriasis were so good that the National Psoriasis Foundation recommended it in those with psoriasis who are also overweight or obese, in combination with standard treatments,” she said.

The NPF recommends a trial of the Mediterranean diet for patients with psoriasis due to four observational studies that found severity improvement in those who have followed it. Subjects of ketogenic, gluten-free and intermittent fasting diet studies showed similar results, although they have not been studied as in depth as the Mediterranean diet, according to McGonagle.

“More studies are being done in diet and weight loss and they’re showing that there’s a connection between diet and specific types of food and how they can affect psoriasis,” she said.

Additionally, many patients turn to herbal remedies or supplements to control their psoriasis symptoms.

Curcuminoid C3 — the active component of the spice turmeric — fish oil and shark cartilage are some of the oral supplements often used, whereas aloe, oregano oil, B12 cream and celastrol — a triterpenoid derived from traditional Chinese medicine — are commonly used topical therapies.

No direct link has been found between most vitamins and dietary supplements and psoriasis, although some studies suggest some benefits. For example, a 2021 study of celastrol detailed its anti- inflammatory properties, whereas a 2008 study of curcuminoid C3 had two patients experience “excellent responses” but an overall low response rate.

However, since none are regulated by the FDA, the National Psoriasis Foundation recommends patients discuss these options with their health care provider before starting any herbal regimen.

“None of these treatments are FDA approved or really monitored in any way,” Bhutani said. “There’s a lot of inconsistencies in strengths and formulations, so I would caution people to use these treatments carefully.”

Meditation and Mindfulness

More recently, many have begun to look at how mindfulness practices and meditation can affect not only quality of life and mood, but also physical symptoms of disease.

With stress often being a catalyst to psoriasis outbreaks, there is a thought that the use of mindfulness could assist in reducing that stress and therefore improving psoriasis symptoms.

“There haven’t been as many studies on if meditation impacts psoriasis, however if you ask ‘how does meditation impact your mindfulness and your state of mind,’ there have been a lot of studies that have looked at that,” Sivamani said. “Psoriasis patients may carry a lot of self-depreciation issues, a lack of self-confidence, a feeling of worthlessness. By addressing mindfulness, whether it’s being in the moment to understand how to appreciate gratitude or even meditation to really understand there is a way to process stress, it is going to be helpful because it addresses the other aspects of psoriasis that impact health.”

A systematic review of nine studies investigating the role of meditation and mindfulness on psoriasis QOL and symptom severity was conducted and concluded there is “promising evidence” of improvements using these techniques.

In five of six randomized controlled trials, self-administered PASI scoring was improved after 8 or 12 weeks of meditation or mindfulness interventions, and psychological improvements were shown in patients with psoriasis following mindfulness or meditation in two studies.

Patients undergoing phototherapy for psoriasis experienced faster clearance of their psoriatic lesions clearance if they also used a short mindfulness meditation-based stress release via audiotaped instruction during their sessions.

“Consistent mindfulness or meditation practice can decrease systemic inflammation,” Bhutani said. “We don’t have a lot of large-scale studies specifically in psoriasis to prove the efficacy, but I think there’s a corollary there.”

Challenges of Nonconventional Therapies

There have been very few trials studying some of the other more popular alternative therapies for psoriasis, including dead sea salt scrubs, climatotherapy — or moving to a location where the climate could be beneficial — acupuncture, traditional Chinese medicine and Ayurveda, but all boast anecdotal evidence of benefits for patients.

The lack of adequate study for nonpharmacological psoriasis treatments is the main challenge to finding how effective they could be and which patients could benefit the most.

“Just recently in 2022 there was systematic review of topical Chinese medical herbal medicines and the authors concluded that while treatment did appear to be effective, a definitive conclusion couldn’t be drawn due to the low quality of studies,” McGonagle said.

Nutritional studies are incredibly difficult to conduct due to the necessity of diet adherence or subject recall, McGonagle added.

Additionally, many of the trials of alternative therapies are incredibly small, which makes it difficult to make large conclusions.

“We need larger scale, randomized controlled trials, more diverse clinical trials because we need to incorporate the diversity in order to represent the heterogeneity of psoriasis,” Bhutani said.

In order to conduct these larger trials, however, there needs to be funding available and studies need to be designed in the correct way for the specific therapy being investigated.

“If you don’t have a good knowledge base on how to run a nutrition study or how to deliver an herb properly, it’s very easy to do a study incorrectly and conclude that it doesn’t work,” Sivamani said. “So first, the methodology and having the knowledge base to design the study, and then secondly getting the funding to actually run the study. I think now, especially with many companies interested in creating more evidence for the medical literature, there will be more funding available.

Transitioning the terminology

Many patients will inevitably ask about alternative therapies for psoriasis for many different reasons. Specialists should not only be prepared to talk about these options but be able to explain how they can be used in conjunction with more traditional medicine.

“The point is when we take an integrative approach, it’s not just looking at pharmaceuticals, which is the conventional approach, but that there’s other factors that can give the patient more control and in fact, address patient concerns and their health more completely,” Sivamani said.

Changing the terminology will add to a provider’s armamentarium by including these previous “alternative” treatments.

The name alternative can turn off some practitioners, according to Bhutani, but that should not be the case.

“It can feel uncomfortable talking to patients about these treatments because it’s something that we don’t know a lot about. But I think it is a high priority for patients,” she said. “It is something that helps them to feel in control of their disease.”

• References:
• Bartholomew E, et al. Dermatol Ther (Heidelb). 2022;doi:10.1007/s13555-022-00802-1.
• Frass M, et al. Ochsner J. 2012;12(1):45-56.
• Kabat-Zinn J, et al. Psychosom Med. 1998;doi:10.1097/00006842-199809000-00020.
• Kurd SK, et al. J Am Acad Dermatol. 2008;doi:10.1016/j.jaad.2007.12.035.
• Murphy EC, et al. J Am Acad Dermatol. 2019;doi:10.1016/j.jaad.2019.03.059.
• National Psoriasis Foundation: Dietary Modifications. https://www.psoriasis.org/dietary-modifications/. Updated Dec. 12, 2022. Accessed Jan. 4, 2023.
• Venkatesha SH, et al. Adv Exp Med Biol. 2021;doi:10.1007/978-3-319-41334-1_12.

• For more information:
• Tina Bhutani, MD, MAS, can be reached at the Psoriasis and Skin Treatment Center, 515 Spruce St., San Francisco, CA 94118; email: tina.bhutani@ucsf.edu.
• Mary McGonagle, DO, can be reached at Baldassano Dermatopathology, P.C. 828 Creekview Drive, Penllyn, PA 19422; email: mkmcgonagle@gmail.com.
• Raja Sivamani, MD, MS, MP, can be reached at Pacific Skin Institute, 1495 River Park Drive, Suite 200, Sacramento, CA 95815; email: raja.sivamani.md@gmail.com.