By Dr Susanne Farwer, GP and SAS doctor dermatology, South Yorkshire
Complementary and alternative medicine (CAM) use is very popular among people with psoriasis and up to 69% of patients have tried it in one form or the other. Most patients use CAM as ‘complementary’ rather than ‘alternative’ therapy, i.e. in combination or as an adjunct to conventional therapy in an attempt to try everything possible to control their disease.
CAM is a very fascinating yet controversial field, but the quantity of evidence from well-designed, methodological robust trials is constantly growing. The term comprises therapies such as herbal therapies, dietary supplements, Traditional Chinese Medicine (TCM), nutrition, climatotherapy and mind-body interventions. It is important to keep an open mind as there are potential therapeutic benefits to these approaches but also potential side effects that we need to be aware of to help us make informed choices. The preference for ‘natural’ approaches and a perceived lower risk of side-effects makes this specialty very attractive to patients, but I would like to point out that ‘natural’ does not mean safe and we will discuss this in more depth in this blog.
The Institute for Complementary and Natural Medicine offers a wealth of information and administers the British Register of Complementary Practitioners (BRCP), a multidisciplinary register of therapists who have demonstrated competence to practice, if you consider going down this route. Today I would like to provide you with some thoughts to consider regarding the implementation of CAM to help you decide which treatment option is best for you.
What herbal therapies have been used in psoriasis and are they safe?
Herbal remedies are plant derived substances and can either be used topically or taken orally. Many herbal ingredients have been studied in the context of psoriasis and moderate evidence of efficacy has been found for Mahonia aquifolium also known as Oregon grape extract, Indigo naturalis and aloe vera used in cream or gel formulations. These extracts are thought to have anti-inflammatory and immunomodulating properties.
The problem with herbal medicinal products is that there is a risk of contamination with other herbs, heavy metals, pesticides etc. especially if these products are purchased online from non-UK suppliers. And like conventional treatments, there is always the risk of contact allergy and photosensitivity.
Oral herbal medicines that have been investigated for psoriasis include sweet whey and neem tree and both have been shown to improve psoriasis when compared with the control group. However, it’s important to be aware that many of these studies do not strictly follow the scientific rigour and results still have to be interpreted with a degree of caution.
If you would like to try herbal medicine, make sure you check for a Traditional Herbal Registration number on the box. This is a nine digit number awarded by the Medicine and Healthcare product Regulatory Agency (MHRA) and ensures that the product complies with UK quality standards relating to safety and quality. In other words: No THR number means no license and that nothing is known about its ingredients, manufacturing process, safety and side effect profile.
Are any dietary supplements worth a try?
Nutritional supplementation for psoriasis has gained a lot of attention in the popular and scientific literature and the vast amount of information can be quite bewildering. If you consider investing your money in supplements please familiarise yourself with the evidence out there.
Of the nutritional supplements reviewed, omega-3 fatty acids showed moderate evidence of benefit in randomised, controlled trials, a study design that is regarded as the gold standard to find out if a treatment has an effect. The range of improvement with omega-3 was a 40-75% reduction in PASI scores, basically in redness, thickness and scaling. Fish oil seems to be particularly beneficial in combination with light therapy or retinoids. However, be aware that if you decide to take fish oil as monotherapy on its own, it needs to be taken for quite a while (up to 6 months) before an improvement in psoriasis can be noticed.
Cold-water fish such as sardines or herrings are the best source of omega-3 fatty acids but you need to consume six ounces daily to get a sufficient amount of fish oil into your system. Alternatively, capsules are a more convenient way for many to get the omega-3 on board. But what is the right dose? Unfortunately, there is no conclusive answer. In the studies that showed positive results the average dose used was 4g EPA (one of the active molecules in the oil) and 2.6g DHA (another active molecule in the oil). Increased intake of fish oil can cause fishy aftertaste, nausea and loose stools which can be minimised by keeping the capsules refrigerated. In higher doses omega-3 oils are also known to have anti-platelets effect (just like aspirin) and can increase the risk of bleeding. If you are considering taking omega-3 capsules, make sure you check that the product has been tested for its mercury content/purity to get a high quality supplement.
For those of you who are on systemic treatment and are experiencing nausea as a common side-effect, there is good evidence that root ginger can be used to alleviate this.
Our all-time friend vitamin D showed promise, particularly in psoriatic arthritis, but the evidence is not clear cut and further research is on its way. There is little evidence to support the use of vitamin B12, selenium or zinc in treating psoriasis.
In this context I would really like to emphasise the importance of adopting a healthy lifestyle as the mainstay of disease management. We now know that obesity is associated with the development of psoriasis (and psoriasis of increased severity) and fat tissue acts like an organ that produces multiple chemicals leading to chronic inflammation. The good news though is that a balanced diet in combination with an active lifestyle not only makes you feel better but also reduces your inflammatory load.
What is Traditional Chinese Medicine (TCM) and what is the evidence for its use in psoriasis?
In contrast to Western medicine, TCM is a complex medical system on its own that views the body as an energetic system in dynamic balance. Qi is the life energy which follows a system of channels (aka meridians) to all parts of the body. If the flow of Qi is smooth this will result in balance, harmony and good health. Any form of a disrupted flow will lead to imbalances and impaired health.
The theory behind TCM is to restore balance in the mind, body and spirit. To address these imbalances TCM utilises food therapy/diet, acupuncture, herbal medicine, alongside Chinese exercise and meditation. Yin and Yang are the two polar principles of life in the Chinese philosophy and harmony between them will enable the mind and body to heal itself. In this concept we are all born with a certain amount of Original Qi, which is depleted over time as energy is used by the body and not replaced. In order to not become deficient in Qi, a person must work hard to retain it and follow a Chinese exercise programme along with proper eating and sleeping habits.
Now that we are more familiar with the concept behind TCM, we are also aware that these treatments are designed to be tailored to each individual patient which per se makes evaluation of efficacy in clinical trials quite challenging. Nevertheless, there is a lot of data out there looking at the effect of TCM on psoriasis. Several studies support the use of TCM in the form of oral or topical herbal medicines for psoriasis. However, it is not advisable that patients self-treat without the guidance of an accredited practitioner as there is the risk of systemic toxicity, drug interaction and adulteration.
I can’t afford a visit to the Dead Sea, how can I get a similar effect for my skin at home?
Balneophototherapy or climatotherapy is frequently listed among CAM approaches and involves a visit to the Dead Sea in Israel, bathing in the mineral rich water and lying in the sun which basically mimics the effects of phototherapy. There is some evidence that this is an effective intervention for clearing and inducing remission of psoriasis. However, for the majority of people this is just not practical and affordable.
Research has shown though that having a bath in Dead Sea bath salt - either at home or in a clinical setting - prior to phototherapy, can have a similar effect without having to spend a fortune on travelling. The concept behind this treatment is to utilise the keratolytic and anti-inflammatory effects of Dead Sea minerals in combination with the immune-modulatory properties of UV light.
What is the evidence for meditation and other forms of stress reduction for psoriasis?
Mind-Body intervention is the term frequently used in CAM to describe psychological strategies designed to facilitate the mind’s capacity to affect bodily function and symptoms. A variety of techniques are used ranging from CBT, meditative practice, guided imagery to aromatherapy hypnotherapy, prayer as well as art and dance therapy.
As discussed in my previous blog post, psoriasis can have a significant impact on peoples’ emotional well-being and self-image. It’s no surprise that affected individuals experience a high level of stress, low mood and generalised anxiety. We also know that stress in itself alters the immune system and is linked to a higher load of inflammatory markers. Although the evidence is not conclusive, due to a lack of well designed, randomised controlled trials, several observational studies have shown the benefits of mind-body interventions on disease severity and quality of life.
The University of Manchester conducted a pilot study in 2015 examining the effect of an eight-week mindfulness treatment as an adjunct to usual psoriasis therapy. People who received this intervention reported a significant improvement in both psoriasis severity and quality of life. Almost two decades ago, the father of mindfulness Prof Jon Kabat-Zinn, showed that using mindfulness-based stress reduction audio tapes during phototherapy was associated with a more rapid improvement in psoriasis within the intervention group compared to the control group.
A wide variety of resources are available for you to choose from: various types of meditation practices, relaxation techniques and mindfulness training. I personally believe that it doesn’t really matter what you choose as long as you find something that resonates with you and gives you a sense of calm, focus and happiness as a result. MindBoost is a free customised programme offering a series of physical and mental exercises grouped into three key areas: confidence, mood and focus. I’ve already introduced you to the Headspace App which offers wonderful, simple and well-structured meditations. If you would like to try guided imagery as a means to reduce stress and achieve a more balanced and calm life, Meditainment is a brilliant online place to check out.
One final word of caution:
Whatever type of CAM you want to try, ensure you speak to your GP or dermatologist to ensure these will not interfere with your current treatment regimen or interact with the medication you are taking. Only buy licensed products from a reputable supplier and bear in mind that there are no ‘miracle cures’ and that ‘natural’ does not mean safe. I personally believe that a sensible CAM approach alongside conventional medicine can be a great step toward holistic medicine with better long-term outcomes for patients.
This content is not intended to advise you about your health. Always seek advice from your doctor or other qualified healthcare professionals.
UK/IE MAT-04941. Date of Prep: September 2016