Psoriasis affects more than 8 million Americans and 125 million people worldwide. The effects of this dermatologic appearance extend deeper than the cosmetic appearance of the skin: 60% of individuals with psoriasis report their disease harms their quality of life. Despite its widespread prevalence and serious consequences, psoriasis remains without a cure.
This article delves into an integrative treatment protocol, presenting innovative and personalized strategies to manage symptoms and identify the underlying factors of psoriasis, ultimately aiming to alleviate the significant burden this disease imposes on health. (35)
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What Is Psoriasis?
Psoriasis is a chronic autoimmune skin disorder that causes cells to build up rapidly on the skin's surface. This accumulation of skin cells leads to thick, silvery scales and red, inflamed patches that can be itchy, painful, and sometimes even bleed. Psoriasis is not contagious and varies in severity from person to person.
Normally, skin cells go through a cycle of growth and shedding over the course of about a month. This process is greatly accelerated in psoriasis, with new skin cells being produced in a few days rather than weeks. These excess cells then accumulate on the skin's surface, leading to the characteristic symptoms of the condition. Psoriasis can affect any body part, including the scalp, elbows, knees, and nails. (1)
Types of Psoriasis
Plaque psoriasis is the most common form of psoriasis, affecting about 80% of those with psoriasis. It is characterized by raised, inflamed, itchy, painful red skin patches with silvery-white scales. Plaques often appear on the scalp, knees, elbows, belly button, and lower back. (29)
Inverse psoriasis affects 25% of people with psoriasis. It develops in skin folds, such as the underarms, under breasts, and buttocks. It looks inflamed and raw, appearing as deep-red or darkened smooth skin. (17, 29)
Guttate psoriasis affects roughly 8% of people with psoriasis and is characterized by small, round, discolored spots on the arms, legs, and torso. (29)
Pustular psoriasis accounts for about 3% of psoriasis cases. White pus-filled pustules surrounded by inflamed skin may appear on certain body parts, such as the hands and feet, or cover most of the body. (29)
Erythrodermic psoriasis is the rarest and potentially life-threatening form of psoriasis. This type of psoriasis causes intense skin discoloration, making it look burned, and shedding of skin layers in large sheets. Other symptoms during a flare may include severe itching and pain, rapid heart rate, fever, dehydration, and nail changes. (29)
Psoriasis Signs & Symptoms
The signs and symptoms of psoriasis will vary depending on the type a person is affected with. The most common symptoms include:
- A patchy rash that ranges in appearance from spots of dandruff-like scaling to eruptions over the majority of the body
- Rashes varying in color from shades of purple to pink with gray or silver scales
- Small scaling spots
- Dry, cracked skin that tends to bleed easily
- Itching, burning, or soreness of the skin
- Cyclic rashes that flare for weeks to months before subsiding
Psoriasis can also affect the nails. When it does, psoriasis will cause pitting, abnormal nail growth, and discoloration of fingernails and toenails. Psoriatic nails might separate from the nail bed or even crumble. (34)
Patients with psoriasis are at a higher risk for other health conditions, including (17):
- Psoriatic arthritis
- Inflammatory bowel disease (IBD)
- Anxiety
- Depression
- Uveitis (inflammation of the eye)
- Cardiovascular and metabolic conditions, including insulin resistance, elevated cholesterol, atherosclerosis, heart disease, and non-alcoholic fatty liver disease (NAFLD)
The Root Causes of Psoriasis
The cause of psoriasis isn't fully understood. It's considered an immune system problem where infection-fighting cells, called T cells, infiltrate the skin, mistakenly attack healthy skin cells, and stimulate the proliferation of keratinocytes, the predominant skin cell type found in the outer layer of skin. This dysregulation in keratinocyte turnover results in the formation of thick plaques. In addition, epidermal skin cells fail to secrete lipids, resulting in flaky and scaly skin. (32)
Researchers believe that both genetics and environmental factors play a role in triggering this immune dysregulation. If you have a family history of psoriasis, you are at higher risk of developing the condition. HLA-Cw6 is a specific genetic marker most strongly associated with psoriasis susceptibility. Other common triggers for psoriasis include infections, cold and dry weather, injury to the skin, smoking and heavy alcohol consumption, and rapid withdrawal of corticosteroids. (32, 34)
Emerging research underscores a robust link between the gut and psoriasis, underscoring the gut's potential to shape the disease's onset and severity. The gut houses a diverse array of microorganisms called the gut microbiota. Studies reveal that individuals with psoriasis may display variations in their gut microbiota composition compared to those unaffected by the condition. This gut-immune system interplay is intertwined, with imbalances in gut microbiota or disturbances in the gut's immune regulation potentially triggering the activation of immune cells implicated in psoriasis development. (17)
Certain studies propose a potential connection between individuals with psoriasis and increased intestinal permeability, or "leaky gut," which could permit harmful substances to enter the bloodstream, inciting immune reactions and contributing to systemic inflammation, potentially exacerbating psoriasis symptoms.
Diet is also emerging as a significant influencer, capable of impacting gut health and consequently influencing psoriasis. Dietary components, including processed foods, high sugar and alcohol consumption, and inadequate intake of nutrient-rich foods, are believed to affect gut microbiota composition and inflammation, influencing psoriasis symptoms. The role of food sensitivities in the development of psoriasis is an area of ongoing research. Most of the available data indicate a high incidence of celiac disease and gluten intolerance in patients with psoriasis.
How to Diagnose Psoriasis
Psoriasis should be diagnosed by a qualified healthcare professional, who will conduct a thorough patient history and physical exam.
Step 1: Clinical Diagnosis
Psoriasis is a clinical diagnosis based on the physical appearance of the rash. Although a biopsy is rarely needed to confirm the diagnosis, it may be recommended to rule out similarly appearing skin conditions.
The extent of the affected surface area classifies the severity of psoriasis. Most experts agree upon the following classification criteria:
- Mild Disease: affects less than 3-5% of body surface area (BSA) and no involvement of the hands, feet, face, or genitals.
- Moderate Disease affects 3-10% of BSA or involves the hands, feet, face, or genitals.
- Severe Disease: affects greater than 10% BSA or involves the hands, feet, scalp, face, or genitals.
Step 2: Digging Deeper with Testing to Understand the Root Cause of Psoriasis
Laboratory evaluation is not required to diagnose psoriasis, but the information derived from the following labs can help craft effective treatment plans to manage the condition, prevent flare-ups, and support healthy skin.
Inflammation
Chronic inflammation is a hallmark of psoriasis, contributing to the increased production of skin cells and the formation of plaques. Inflammation can also affect other body parts, leading to conditions like psoriatic arthritis. Measuring inflammatory markers like CRP and ESR can identify and quantify the presence of inflammation at the time of diagnosis and help objectively track patient progress over time.
Comprehensive Gut Analysis
A comprehensive stool analysis can detect dysbiotic patterns within the intestinal microbiota, evaluate markers of immune function, and quantify inflammation, short-chain fatty acids (SCFAs), and bile acids - all important factors related to the progression and severity of psoriasis.
- GI-MAP + Zonulin by Diagnostic Solutions
- GI360 by Doctor's Data
- GI Effects Comprehensive Profile - 3 day by Genova Diagnostics
Various labs also measure biomarkers related to intestinal permeability to help quantify the degree of leaky gut that may be present and contributing to skin inflammation. One example is the Array 2 panel by Cyrex Laboratories.
Various food testing options exist to screen for dietary triggers related to psoriatic disease. IgA and IgG antibodies are two types of immunoglobulins produced by the immune system. Their presence, assessed with a food sensitivity panel, indicates adverse food reactions that can influence gut and skin health. Given the prevalence of gluten intolerance in patients with psoriasis, a comprehensive panel that screens for celiac disease and non-celiac gluten sensitivity should also be considered. Examples include:
- P88-DIY Dietary Antigen Test by Precision Point
- Array 10 by Cyrex Laboratories
- Celiac & Gluten Sensitivity by Doctor's Data
Stress Hormones
Stress can exacerbate leaky gut, contribute to skin inflammation, and impair skin barrier function. These effects culminate in irritated skin and worsening skin conditions, including psoriasis. Salivary cortisol testing evaluates the circadian secretion of cortisol, the master stress hormone, identifying dysfunctional stress response patterns.
- Adrenal Stress Panel by Ayumetrix
- Diurnal Cortisol by ZRT Laboratory
- Cortisol Only (4-Point Cortisol) by Sanesco
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Treatment Plan for Psoriasis
The general treatment goals for psoriasis include improving the appearance of the affected areas of the skin and nails and enhancing the patient's quality of life. Treatment should be personalized based on disease severity, presence of comorbidities, and patient preferences. Referral to an integrative dermatologist may be helpful for comprehensive care, especially for patients struggling with severe disease.
Step 1: Reduce Inflammation and Hyperkeratinization
Various topical and oral pharmacologic options for treating psoriasis can be used on their own or in combination. Each medication has its own benefits and potential side effects, so patients should work closely with their healthcare providers to determine the most appropriate treatment. The classes of medications typically prescribed for treating psoriasis include:
- Corticosteroids
- Vitamin D analogs
- Calcineurin inhibitors
- Retinoids
- Biologics
Phototherapy leverages the healing power of light to reduce symptoms and improve skin appearance. This treatment involves regularly exposing the skin to ultraviolet (UV) light under medical supervision. There are several types of phototherapy, with narrowband UVB being the most common due to its efficacy and safety profile. This method uses a specific wavelength of light to slow the rapid growth of skin cells characteristic of psoriasis. Treatments are usually administered several times a week, with improvements often seen within a few weeks. (36)
Turmeric and its powerful constituent, curcumin, have been studied for their anti-inflammatory and antioxidant properties. Research has identified that turmeric can alter inflammatory cytokine expression, clinically translating to reduced psoriasis flares. Two systematic reviews have found that turmeric supplementation (up to 3 grams of curcumin per day) in topical and oral forms effectively alleviates psoriasis symptoms (31, 39).
Vitamin D modulates various divisions of the immune system, and deficiency is an independent risk factor for psoriasis; vitamin D levels have been measured to be seven times lower in patients with psoriasis compared to healthy controls. In addition to regular exposure to sunlight, serum vitamin D levels can be optimized with dietary supplementation. Large-scale studies are needed to more definitively determine the efficacy, optimal dosing, and adverse effects of oral vitamin D administration in patients with psoriasis. However, the small published studies report improvements in psoriatic lesions with vitamin D supplementation.
An anti-inflammatory, healthy diet supports healthy skin and reduces risk factors for heart disease. The Mediterranean diet has shown positive impacts on psoriasis and cardiovascular health. This diet involves eating whole foods that are anti-inflammatory, nutrient-dense, and rich in healthy fats. Studies have supported a dose-response relationship between adherence to the Mediterranean diet and improving psoriatic symptoms.
Step 2: Heal the Gut
Addressing gut health goes beyond the skin's surface to target underlying mechanisms fueling systemic inflammation and skin lesions.
In addition to an anti-inflammatory diet, experimentation with elimination diets can also be considered. Because food sensitivities vary between individuals, customizing an elimination diet based on suspected or lab-identified food sensitivities is recommended. It is generally advised to eliminate food triggers for 6-8 weeks before reintroducing foods back into the diet. During each phase of this elimination-rechallenge plan, patients should pay close attention to changes in their psoriasis symptoms to determine whether a food is triggering their skin.
Bile acids aid in healthy digestion, supporting gut health and function. Emerging research suggests they also have therapeutic effects in treating psoriasis through their immunomodulatory effects and influencing the differentiation of keratinocytes (18, 37)
Dysbiosis of the skin microbiome is associated with psoriasis; psoriatic lesions have a higher abundance of Streptococcus, reductions in Propionibacterium, and a general lack of microbial diversity (43). Oral and topical probiotics can rebalance the gut and skin microbiome to manage psoriasis. A systematic review concluded that treatment with oral probiotics (Lactobacillus and Bifidobacterium species) improves psoriasis area and severity index (PASI) scores.
Risks of Untreated Psoriasis
Leaving psoriasis untreated can lead to a range of serious health complications. Beyond persistent skin lesions and discomfort, chronic inflammation associated with psoriasis can exacerbate systemic inflammation, contributing to additional chronic health risks, such as:
- Psoriatic arthritis
- Cardiovascular disease
- Diabetes
- Depression
Furthermore, the psychological burden of untreated psoriasis, including low self-esteem and social isolation, can severely impact quality of life.
Psoriasis Case Study
You can read about a real case study here:
How Kristin Radically Improved Her Psoriasis With An Elimination Diet And Supplements
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Key Takeaways:
- An integrative medicine approach empowers patients and practitioners to uncover the underlying drivers of psoriasis and address the intricate interplay of genetics, lifestyle, environment, and immune responses.
- Individualized strategies that embrace the power of nutrition, gut health, stress reduction, and immune modulation offer a more holistic and sustainable approach to psoriasis management – one that seeks to enhance skin health and restore the body's intricate equilibrium.
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