Skin care weblog

Medical nutrition therapy as a potential complementary treatment for
psoriasis-five case reports

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

Amy C. Brown
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.

(NOTE: If the tables below don’t display correctly in the email, click on the
link above for the full article)

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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Michelle Hairfield Stein, PhD–Senior Researcher, Tissue Genesis Incorporated,
Honolulul, HI

Douglas G. Richards, PhD–Director of Research, Meridian Institute, Virginia
Beach, VA

David L. McMillin, MA–Clinical Researcher, Meridian Institute, Virginia Beach,
VA

Eric A. Mein, MD–Clinical Researcher, Meridian Institute, Virginia Beach, VA

Carl D. Nelson, DD–Clinical Researcher, Meridian Institute, Virginia Beach, VA

COPYRIGHT 2004 Thorne Research Inc.
COPYRIGHT 2004 Gale Group

Laura

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