Nutritional interventions for psoriasis patients

By Kellie Blake, RDN, LD, IFNCP

Psoriasis is a T-cell mediated autoimmune disease affecting two to three percent of the population.  The root causes of psoriasis may be many, but at its core is an inflammatory process.

The outward signs of psoriatic disease are lesions on the skin, but this disease also affects the body systemically. Comorbidities of psoriasis include metabolic syndrome, cardiovascular disease, type 2 diabetes, high blood pressure, hepatic steatosis, depression, and inflammatory bowel disease. About 30 percent of those with psoriasis will also experience joint involvement in the form of psoriatic arthritis.  Symptom improvement and reversal is possible when the root causes of psoriasis are corrected.  Nutrition-related changes to address gut health, metabolic dysfunction and to correct vitamin D deficiency can work synergistically to provide powerful symptom relief.

As reported in a 2018 review in the European Review for Medical and Pharmacological Sciences, compared to controls, psoriasis clients have a lower abundance of Akkermansia muciniphilia, bacteria helpful in reducing inflammation. In addition, increased intestinal permeability and gut dysbiosis are often present. Before other nutrition-related interventions can be successful, a healthy gut must be restored. 

Gut healing can be accomplished using the 5-R protocol. Begin with an elimination diet customized to the client for a minimum of four weeks to remove possible allergens and inflammatory foods that disrupt the gut lining. Remove the top food allergens which include soy, corn, dairy, wheat and gluten, peanuts, fish and shellfish, and be mindful of additives, caffeine, alcohol, and known inflammatory ingredients like omega-6 oils, trans-fats, and grain-fed red meats. Reinoculate the gut with valuable probiotic bacteria with supplements, food, or a combination of both. Some great food sources include sauerkraut, homemade pickles, apple cider vinegar with mother, and kimchi. If needed, replace digestive enzymes and hydrochloric acid to aid digestive function and add zinc, vitamin E, and l-glutamine to facilitate repair of the gut lining. Finally, clients will need to be educated on the importance of rebalancing their lifestyle to promote and maintain overall gut health and barrier integrity. 

Once a healthy gut has been established, focusing on weight and metabolic health can be the next step in improving psoriasis symptoms. Obesity and metabolic disease can worsen psoriasis symptoms and reduce the response to traditional psoriasis therapy but may also trigger the disease. In a 2015 study in the Journal of Translational Medicine, male psoriasis clients were found to have diets higher in simple carbohydrates, total fat, and omega-6 fats and  lower consumption of proteins, complex carbohydrates, monounsaturated fatty acids, omega-3 fats, and fiber. This dietary pattern is associated with increased inflammation, mental health disease, autoimmunity, obesity, and other chronic diseases. Implementing measures to improve weight, blood sugar control, and reverse metabolic disease will likely lead to symptom improvement and could potentially prevent new psoriasis cases. For normal weight psoriasis clients with no documented symptoms of metabolic disease, a proactive approach to prevention is indicated.

One option for symptom relief and improved metabolic health is to transition psoriasis clients from the elimination diet to a long-term modified Mediterranean diet.  In a 2018 study, in JAMA Dermotology, psoriasis patients following the Mediterranean diet were found to have fewer and less severe psoriasis flares. 

Since trigger foods will still need to be avoided, use the information gained during the elimination diet to tailor the MD for each psoriasis client. Traditionally, the Mediterranean diet includes high intake of extra virgin olive oil, which is associated with lower psoriasis severity, vegetables, fruits, nuts, seeds, beans, eggs, and fatty fish, wild-caught preferably. The Mediterranean diet also encourages the use of whole grains and some dairy products. Consider educating clients to continue to avoid gluten, dairy, and eggs in some cases due to their association with increased intestinal permeability and inflammation in those with autoimmune conditions. Long-term avoidance of alcohol may also be necessary as heavy alcohol use is known to exacerbate psoriasis symptoms.

Low vitamin D levels are associated with obesity and metabolic disease, but are also common in psoriasis clients due to nutrient loss from the disrupted epidermal layer. Vitamin D has immune-modulating and anti-inflammatory effects but is also important in maintaining homeostasis in the skin barrier. Topical vitamin D is often used in combination with topical steroids for plaque psoriasis, but oral vitamin D supplementation is also likely necessary as there are very few good food sources of vitamin D. Assess vitamin D status initially and supplement to maintain a vitamin D level of 50 to 80 ng/mL. 

Case Study

Heather is a 43-year-old surgeon, with a very busy private practice and two young children. She has a history of plaque psoriasis dating back to when she was a teenager. Psoriatic lesions have been located on her scalp, elbows, knees, and shins, with the most troubling areas on her right shin, left elbow, and left knee. She has been under the care of a dermatologist since her diagnosis and has tried numerous tar shampoos, topical steroid creams, sprays, topical vitamin D cream, as well as light therapy. Heather reports her plaque psoriasis as always being present but does worsen during times of increased stress and she has experienced several traumatic life events that have exacerbated her symptoms. She is of normal weight, with no symptoms of metabolic disease, and has an active lifestyle.

Heather initially sought nutrition therapy related to troubling digestive symptoms and fatigue and desired to prevent the long-term complications associated with unmanaged autoimmune disease. In May 2019, a full elimination diet was initiated and continued for three months. Based on lab work, stool testing, and adrenal function panel results, her supplement program included a high potency probiotic, 10,000 international units of vitamin D3 with K2 every other day, digestive enzymes with ox bile and betaine HCl prior to each meal, a whole food multivitamin daily, l-glutamine powder five grams per day for eight weeks, 4000 milligrams omega-3 per day, methylated B complex daily, and 2000 milligrams liposomal vitamin C per day. She also began practicing overnight fasting for twelve hours, meditation, yoga, and high intensity interval training. She has regular acupuncture and massage therapy sessions and maintains a healthy sleep schedule.

In June 2019, Heather stopped all steroidal creams and traditional psoriasis treatments. By mid-July, her right shin lesion was gone, the left elbow that previously had three large lesions, were all minimal, and her worst lesion on the left knee was 75 percent cleared. She also reported significant improvement in her digestive symptoms, sleep, and perceived stress. 

Heather’s long-term nutrition plan includes a tailored Mediterranean diet to avoid processed foods, sugar, nightshades, nuts, seeds, gluten, dairy, alcohol, and eggs as these seem to be triggers. Heather reports, that by making these changes, she no longer has to rely on topical steroid creams or sprays and doesn’t have to use tar shampoos.

Psoriasis is a relapsing and remitting disease. While there is no one nutrition plan appropriate for every psoriasis client, there are some underlying nutrition-related issues to address. Healing the gut, helping clients reach and maintain a healthy weight, improving metabolic health, and addressing vitamin D status are all important considerations for symptom improvement and improved long-term outcomes.

References

Barrea, L., Macchia, P., Tarantino, G., Di Somma, C., Pane, E., Balato, N., Napolitano, M., Colao, A., and Savastano, S. (2015) Nutrition: a key environmental dietary factor in clinical severity and cardi-metabolic risk in psoriatic male patients evaluated by 7-day food-frequency questionnaire.  Journal of Translational Medicine. Retrieved from: https://translational-medicine.biomedcentral.com/articles/10.1186/s12967-015-0658-y

Barrea, L., Savanelli, M., Di Somma, C., Napolitano, M., Megna, M., Colao, A., and Savastano, S.  (2016)  Environmental Risk Factors in Psoriasis:  The Point of View of the Nutritionist.  International Journal of Environmental Research and Public Health. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4962284/

Barrea, L., Savanelli, M., Di Somma, C., Napolitano, M., Megna, M., Colao, A., and Savastano, S.  (2017) Vitamin D and its role in psoriasis:  An overview of the dermatologist and nutritionist.  Reviews in Endocrine and Metabolic Disorders. Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/28176237

Gaby, A.  (2017) Nutritional Medicine, 2^nd Edition Concord, New Hampshire.

Phan, C., Touvier, M., Kesse-Guyot, E., Adjibade, M., Hercberg, S., Wolkenstein, P., Chosidow, O., Ezzedine, K., and Sbidian, E. (2018) Association Between Mediterranean Anti-inflammatory Dietary Profile and Severity of Psoriasis.  JAMA Dermatology. Retrieved from: https://jamanetwork.com/journals/jamadermatology/fullarticle/2687981