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Psoriasis 1
Psoriasis: An exploration of Western Medical perspectives and Naturopathic
and Natural Medical Perspective
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Psoriasis 2
Psoriasis
Introduction
Psoriasis is an autoimmune skin infection typified by mediated hyper-
proliferation of keratinocytes resulting in patches of thick red skin appearing with itchy silvery white scales centered around knees, elbows, scalp, palm trunk, and soles of feet. It is one of the most common skin infections affecting approximately 125 million, primarily Caucasian and Scandinavian (Kim et al., 2017). The disease reduces the quality of life of the patients following an increase in morbidity and a noticeable increase in other conditions such as arthritis, mental disorders, and cardiometabolic diseases. However, research in the disease over the past 15 years has contributed a lot to understanding skin biology and the pathogenesis of Psoriasis, leading to the development of highly advanced and effective therapies and
giving critical insights into the pathogenesis of other chronic inflammatory diseases. The infection has a global prevalence affecting individuals of all ages, with notably higher epidemiological occurrence among the non-black population (Egeberg
et al., 2019). The disease has a strong genetic predisposition with its most common form, psoriasis vulgaris, known as plaque psoriasis, resulting from genetic susceptibility in the presence of a specific risk allele, HLA-C*06:02 with environmental predisposing factors such as streptococcal infection, obesity, smoking
or stress acting as a trigger (Parisi et al.
, 2013). Pathogenesis
Psoriasis is characterized generally by sustained inflammation leading to unrestricted keratinocyte proliferation and dysfunctional differentiation, with the psoriatic plague exhibiting acanthosis covering the inflammatory infiltrates made of
Psoriasis 3
dermal dendric cells, neutrophils, T cells, and macrophages (Rendon & Schäkel, 2019). Pathophysiology
In Guttate psoriasis, it is theorized that streptococcal superantigens stimulate the growth of T cells on the skin with a strong correlation between streptococcal M proteins and keratin 17 proteins (Rendon & Schäkel, 2019). Pustular Psoriasis exhibits an increased IL-1β, IL-36α, and IL-36γ expression, much higher than psoriasis vulgaris. TNF-α, NFκB, IL-6, and IL-8 expression on psoriasis-affected nails
closely resemble inflammatory markers found on lesional psoriatic skin (Rendon & Schäkel, 2019).
Epidemiology
Psoriasis is a common skin ailment affecting approximately 2% of the American population and 2-3% globally (Sewerin et al.
, 2019) and reaching as high as 8-11% in some northern European countries (Egeberg et al., 2019). The disease is also cross-generational, affecting between 0.91 and 8.5% of adults and 0-2.1% of children worldwide (Parisi et al.
, 2013). However, several observational studies have shown a high proportion of undiagnosed Psoriasis, indicating a potentially significant underestimation of the actual number of patients. Another interesting observation is that the rise in life expectancy and improvement in management therapies and healthcare services might be accredited to the increase in the disease burden coupled with dramatic sociographic changes in the last fifty years, such as population growth and aging (Damiani et al.
, 2021).
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Psoriasis 4
Aetiology
Overwhelming evidence shows that there is a genetic component in the predisposition to the disease with a potential mediating influence from the environment. Epidemiological data and familial association have suggested a hereditary transmission. Nonetheless, this association remains undefined and does not follow simple autosomal patterns. Ortonne, 1996 indicated that this association is
not direct; instead, it follows a multifactorial inheritance, requiring an environmental stimulus to manifest (ORTONNE, 1996). Bahcetepe et al. 2013 analyzed the role of HLA antigens in the etiology of Psoriasis. They concluded an association between HLA antigen and the early onset of the disease, identifying the most significant risk factor as HLA-Cw6 antigen (Bahcetepe et al.
, 2013). Hereditary studies have shown a strong genetic correlation with parent-child research, showing that the risk of Psoriasis in a child with one affected parent is 14%, rising significantly if both parents
are affected to 40% (Barker, 2019). Thus supporting the predominant assumption.
Allopathic treatment
Once the disease is diagnosed based on clinical manifestations and an investigation into the family history of Psoriasis, dermatologists settle on appropriate therapeutic regiments meant to improve nail, skin, and joint lesions and generally improve the patient's quality of life, given that presently; there is no available cure for
the condition; treatment modalities are meant to alleviate symptoms (Gaál et al.
, 2009). Depending on the type and severity of the symptoms, treatments range from topical interventions to systemic treatments (Zhu et al.
, 2022). Mild Psoriasis (less than 10% of the Body surface area (BSA)) is localized, topical therapies such as calcineurin inhibitors, corticosteroids, and Vitamin D3 analogs, among others
Psoriasis 5
(Ahmed et al.
, 2023). In more severe cases, systemic treatment is preferred, with sufficient attention paid to comorbidities in the treatment regime (Neema et al.
, 2023). Specific patient conditions are also considered when selecting a choice of systemic therapy (Neema et al.
, 2023). Systemic therapies include phototherapy, methotrexate, cyclosporine, biological agents, and acitretin (Gisondi et al., 2017).
Analysis and evaluation
Neuropathic and Functional Medicine
Possible functional delivers, causes, and risk factors
A study by Abdallah et al. (2021) undertook to establish the functional relationship between the miR-21-3p and IL-22 axis with the onset of Psoriasis through an mRNA-seq analysis (Abdallah et al.
, 2021). From the research, it was noted that, indeed, miR-21-3p and IL-22 axis play a critical role in Psoriasis
(Abdallah et al.
, 2021). The result indicates an overall upregulation in immune response and cellular regulation categories and a downregulation of the differentiation process and interferon-gamma-mediated pathways categories, thus affirming the role played by IL-23 in the pathogenesis of Psoriasis (Abdallah et al.
, 2021).
Wang & Bai (2020) analyzes the role played by dendritic cells in the initiation of Psoriasis. The evidence suggests that unhealthy DC cells act in contrast to healthy cells. This notes that the central function played by Dendritic cells in antiinfection and antitumor response; the study notes that in some cases, abnormal activation of these cells can inadvertently result in these cells playing a role in the pathogenesis of Psoriasis as a result of the damage to keratinocytes resulting in the release of nucleic acids and other microbial peptides (Wang & Bai, 2020). This results in the release of a large amount of IFN-α, which results in the maturation of
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cDC and the definition of monocytes into iDC. Consequently, the mature cDC and rapidly increasing iDC during an inflammation releases IL-23, IL-12, and other cytokines responsible for the activation of T-cells, the primary culprit in the onset of psoriasis (Wang & Bai, 2020). Risk factors
Some specific clinical conditions also predispose a patient to the disease. The
triggers can be divided into extrinsic and intrinsic factors. Outside factors include environmental and lifestyle factors such as air pollution, drugs, smoking, alcohol, infection, vaccination, and mechanical stressors (Lee et al.
, 2018). Intrinsic factors are primarily clinical conditions that predispose or trigger the disease and include diabetes mellitus, metabolic syndrome, mental stress, hypertension, Dyslipidemia, and obesity (Lee et al.
, 2018). Both these categories act as a trigger at the onset of the disease PsA. They can also exacerbate the symptoms' severity mediated by factors such as the patient's age, lifestyle, and concomitant illness (Kamiya et al.
, 2019). It is, however, essential to note that the impact of these factors varies between patients, and scientific understanding of the working mechanism of these risk factors is limited. Further research will be necessary to gain more knowledge and information on the operations of these factors. Laboratory tests for Psoriasis
The diagnosis of Psoriasis is primarily clinical as the disease is considered systemic and multisystemic since it affects another body organ, with the skin being the venue through which it is clinically manifested. As such, the primary laboratory test for PsA is skin biopsy, where a dermatologist inspects the skin to identify the dermatologically distinctive well-demarcated, symmetric, erythematous plaques with overlying silver scales associated with the most common plague Psoriasis (Kim et
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Psoriasis 7
al., 2017). Other forms of Psoriasis also present a distinctive morphology that identifies them from one another. Considering the systemic nature of this disease, tests should incorporate an investigation into the potential comorbidities, including Psoriatic arthritis affecting 30% of PsA patients, with a projected onset of 7-12 since the start of the skin manifestation of PsA. The common identifying feature of Psoriatic arthritis is dactylitis, or sausage digit, where the entire number becomes swollen (Mease & Armstrong, 2014). Despite being present in all forms of Psoriasis, patients with nail psoriasis, scalp psoriasis, and intergluteal or perianal Psoriasis are at higher risk (Haroon et al., 2013). Psoriatic arthritis is central in diagnosing and screening PsA as it provides one of the criteria for identifying standardized PsA utilizing Classification Criteria for Psoriatic Arthritis (CASPAR). CASPAR exhibits 99% specificity in identifying PsA (Mease & Armstrong, 2014). Psoriasis has also been associated with psychiatric illnesses, malignancy, cardiovascular diseases, and
diabetes. The study gave promise, identifying inflammatory-related biomarkers based on mean platelet volumes, platelet distribution width (PDW), and monocyte counts, which served as predictors of the presence of the disease (Zhou et al., 2021). The general nature of these outcomes, however, limits its application.
Therapeutics for Psoriasis
Various treatment modes are available against this disease, ranging from topical treatment regimens for mild cases to systemic treatment in more severe cases. However, a new approach to treatment employing unconventional and nutritive therapies is becoming popular, given the notable relationship between disease triggers and lifestyle.
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Nutrition-Based Approach
Given the contribution of metabolic syndrome and its components (obesity, Dyslipidemia, diabetes, and hypertension) in triggering and exacerbating the symptoms, dietary intervention is critical in the treatment regimen of PsA (Lee et al.
, 2023). Various studies have indicated potential therapeutic value from diet therapy on a psoriatic patient both in addressing the symptoms and preventing blowouts. Such medicines complement pharmacological or other treatment methods to improve patient outcomes. Dietary therapies aimed at combating the disease include;
1.
Vitamin D3
– generally, patients with Psoriasis indicate deficient levels of Vitamin D3 in blood serum of 1.25-(OH)
2
D
3, with at least half of psoriatic patients showing Vitamin D3 deficiency in summer and as high as 80% in winter, thus lending credence to the relationship between low Vitamin D3 and Psoriasis. Studies have shown positive patient feedback on a Vitamin D3 supplement of 0.25µg twice daily for half a year (Gaál et al.
, 2009). Another study also showed improved PASI for patients on high-dose vitamin D3 (35,000IU/day) therapy for six months (Finamor et al.
, 2013). The mechanism of operation of vitamin D is such that it inhibits the proliferation of keratinocytes, decreases psoriasin, and increases the synthesis of transglutaminase, involucrin, filaggrin, keratin, and loricrin in the skin (Barrea et al.
, 2017). Furthermore, vitamin D deficiency is associated with concomitant
cardiovascular diseases and obesity in Psoriasis, and therefore, supplementation of Vitamin D not only improves the symptoms of Psoriasis but also significantly contributes to the general patient condition (Wasiluk, D, Ostrowska, L, Stefańska, 2012)
Psoriasis 9
2.
Antioxidants
– Psoriatic lesions cause chronic inflammations, which affect the formation of superoxide anions and free radicals, impeding oxidation balancing and resulting in oxidation stress, which may contribute to the formation of atherosclerotic plaque (Baran et al.
, 2017). Reactive oxygen can also increase psoriasis inflammation by damaging vascular endothelial cells, increasing capillaries' permeability, and allowing inflammatory cell transition
(Baran et al.
, 2017). The operation mechanisms of antioxidants are through tentative chemical transformations, which prevent the formation of harmful free radicals (Barrea et al.
, 2017). Psoriasis patients can derive antioxidants through consuming foods rich in vitamin C, flavonoids, Vitamin A, β-carotene, and Vitamin E, such as vegetables, carrots, tomatoes, and fruits.
3.
Carbohydrates
– one of the major causes of oxidative stress is a high intake of simple sugars, thus exacerbating the symptoms of Psoriasis to the detriment of the patients. To reverse this, a patient should incorporate high fiber with a low glycaemic index in their food intake, benefiting from the systemic anti-inflammatory properties of dietary fiber, improving digestion, helping in weight reduction, and reducing oxidative stress (Kanda et al., 2020).
4.
Gluten-free diet
– in an atypical outcome, patients with Psoriasis are three times more likely to suffer from celiac disease. Similarly, celiac patients are more likely to suffer from Psoriasis than the general population. An ordinary coincidence is that Psoriasis, coeliac disease, is an autoimmune disease just like celiac where the body reacts by attacking itself, with both cases resulting in inflammation of the skin in Psoriasis and small intestine in celiac disease
(Bhatia et al.
, 2014). While there is no concrete proof of a relationship
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between gluten consumption and Psoriasis, nutritionists have not shied away from recommending this treatment regime, though controversially.
5.
The ketogenic diet
– is based on increasing fat consumption (at the rate of 75%-80% Fat – 5%-10% from carbohydrates – 15-25% protein) to increase ketone bodies and thus improve anti-inflammatory effects while reducing blood sugar levels. The ketogenic diet lends credence to its effectiveness in improving symptoms of psoriatic patients through the more potent anti-
inflammatory properties due to medium-chain-triglycerides (MCTs) and high amounts of omega-3 fatty acids (Sternberg et al.
, 2020). Furthermore, Very-
Low-Calories Ketogenic Diets (VLCK) can also help in weight loss, cited as a risk factor in Psoriasis.
Complementary therapies
1.
Mindfulness and meditation
– Psoriasis affects not only the physiological well-
being of the patient but also their psychological health. Therefore, successful management of the condition requires a holistic approach integrating the treatment of comorbidities and opportunistic infections to improve the patient's
life. Bartholomew et al. (2022) examined the physical and psychological benefits of meditation and mindfulness as a focused therapy in patients with moderate to severe Psoriasis. Generally, there is a positive correlation between meditation and mindfulness as a therapy for patients suffering from atopic dermatitis (Bartholomew et al.
, 2022). In the case of Psoriasis, the study found that five out of six patients posted an improvement in severity index after either 8 to 12 weeks, signifying a potentially helpful addition to the treatment of the condition.
Psoriasis 11
2.
Physical exercises
– Studies have been undertaken to investigate the relationship between physical activities and Psoriasis. Most cases demonstrate that psoriatic patients tend to shy away from physical activities, particularly those with severe forms of the disease. However, a study by Zheng et al. (2018) showed that physical activities tend to reduce the prevalence of Psoriasis, with patients showing symptoms exercising more and
benefiting more from a reduction in the severity of the symptoms (Zheng et al.
, 2018)
Application of Research in Justification of Naturopathic Nutrition Protocol
Naturopathy is a treatment regimen incorporating natural elements based on toxemia, vitality, and the body's self-healing capacity theory. The treatment incorporates contemporary health practices and embraces the philosophy and principles that laid the foundation of naturopathy. Evidence and studies over the years justify and support the rationale for using naturopathy to treat infections and ailments (Baer, 1992). The practice and modalities of naturopathy have been formalized into seven core principles guiding practitioners and blending philosophical
basis with practice. The seven core principles are the healing power of nature (
vas mediatrix naturae
); first do no harm (
primum non nocere
); identify and treat the cause (
tolle causum);
doctors as teachers (
docere
); treat the whole person and prevention (Myers & Vigar, 2019). These seven core principles are based on two basic tenets of the naturopathic philosophy of health: vitalism and holism. A vegan diet has been critically viewed as a potential risk factor in the development of skin disorders due to potential nutritive deficiency. However, a study by Lee et al. (2023) contests this assumption as a myth, arguing that vegan diets can
fulfill all metabolic and nutritional requirements. The study argues that a well-
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balanced vegan diet has the capability of reducing and eliminating inflammatory skin diseases such as acne, Psoriasis, suppurativa, hidradenitis, and atopic dermatitis by providing all necessary nutrients (Lee et al.
, 2023). Murzaku et al. review dietary modifications that can address skin infections, including Psoriasis. This study reviews potential relationships between urticaria symptoms and pseudo allergens, vitamins, and gluten and the effect of alcohol consumption in cutaneous disease presentation, concluding that dietary modification can be implemented as an adjunct prevention and treatment process (Murzaku et al., 2014). Acknowledging metabolic syndrome as one of the comorbidities of Psoriasis, Garbicz et al. (2021) evaluate how diets affect disease progression and symptoms manifestation of PsA, noting that patients should limit their intakes high energy diets such as simple sugars, saturated fats, and gluten and replace them with polyunsaturated fatty acids, antioxidants, and vitamin D supplements. The patient should also embrace dietary provisions with positive effects on the course of the disease, including vegan diets and a Mediterranean diet, with the diet being tailored to pharmacological treatment (Garbicz et al.
, 2021)
The diet also plays a vital role as a trigger and an exacerbator of Psoriasis, particularly in patients with a genetic predisposition to the infection. T lymphocytes are a critical element in the inflammatory pathways and regulatory functions in the immune cells with the potential for abnormality in immunomodulatory mechanism in the T-cells regulated by some metabolites and thus being involved in psoriasis pathogenesis. Su et al. (2023) discuss this relationship with a particular interest in regulating metabolites in glucose, lipid, and amino acid metabolisms and exploring the mechanism and interaction between immune cells and psoriatic metabolism (Su
et al.
, 2023). Bonzano et al. (2023) note that several currently available
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therapeutic approaches can be used in cytokines alteration and dysbiosis of the microbiome, effectively interfering with IL-3/IL-31 dysbiosis, therefore preventing or treating Psoriasis and atopic dermatitis (Bonzano
et al.
, 2023).
Conclusion
The impacts of Psoriasis on patients extend beyond the skin manifestation, affecting the body's mental health and metabolic balance and causing several comorbidities such as cardiometabolic diseases, diabetes mellitus, and arthritis. The financial impact can also extend beyond the ability of most patients and their families, which can be multiple considering the genetic correlation of the disease. It is, therefore, essential that an understanding of the disease pathogenesis, pathophysiology, and epidemiology is undertaken to define the disease characteristics and identify the predisposing factors, thus providing a foundation for a
recommendation of therapeutic interventions that increase the likelihood of patient outcomes and improve the well-being of those affected. The treatment options depend on the disease's severity and the manifestation and presence of comorbidities, which must be treated concurrently. Studies have been initiated to identify the potential applicability of complementary and alternative therapies in treatment prevention and management of the disease, with most offering positive benefits to the patients.
One of the most common alternative therapies is naturopathic nutritional therapy, which implements a dietary approach as a disease management and prevention strategy. Studies have shown the correlation between metabolites and Psoriasis; a dietary intervention has a strong likelihood of reining the disease and preventing an outburst. Available evidence strongly supports the dietary approach as
an alternative therapy, either as a stand-alone intervention or combined with
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traditional treatments. However, more studies need to be done to provide a clearer picture of the mechanism of alternative therapy in psoriasis management.
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