Psoriasis and Nutrition
By Kate Jackson
Today’s Dietitian
Vol. 7 No. 4 P. 40

Antioxidants, gluten-free, probiotics… Read about the various dietary approaches to healing this autoimmune disorder.

A decades-old television commercial brought the phrase “heartbreak of psoriasis” into the American lexicon. Since then, a variety of treatment methods have been heralded, yet no cure has been found. For many, the painful, life-altering disease remains a heartbreak. That may smack of Madison Avenue hyperbole, but the disease—which is both painful and often unsightly—can be enormously distressing and disruptive to the lives of those afflicted—approximately 2% of Americans of all ages.

In its most common form, the chronic inflammatory disease causes scaly, red patches of thickened skin. These itchy and painful plaques can appear anywhere but are most often seen on the knees, elbows, hands, feet, back, scalp, and around fingernails and toenails. The plaques may come and go, brought on by a variety of triggers or exacerbating factors, including stress, cold or dry weather, infections, alcohol, and the use of certain medications. Worse, psoriasis is often accompanied by psoriatic arthritis, which can cause disabling joint pain and inflammation.

A variety of topical treatments—most often steroids such as cortisone, as well as salicylic acid and coal tar—have been used with limited success. These approaches are not without negative effects, including further irritation of the skin, and when they are effective, the response is often temporary. Phototherapy—either exposure to sunlight or ultraviolet light, alone or in combination with a drug called psoralen (the latter called PUVA [psoralen plus ultraviolet A light]) helps some patients, yet it puts them at increased risk for skin cancer. Laser therapy may also be used to some effect but often requires numerous sessions. Systemic treatments with medications such as methotrexate or cyclosporine, which attempt to diminish the immune response that gives rise to symptoms, may be used for patients with severe and recalcitrant disease, but these can be toxic and require careful monitoring.

Because research has suggested that psoriasis stems from inflammation that arises from cell-mediated immune responses and cytokine expression, a new generation of treatments attempt to more specifically halt or modulate these immune responses. Still, since they have a powerful effect on the immune system, their use is accompanied by risks as well.

Although research hints at a psoriasis-diet connection and books and Internet sites may promote diets purporting to cure psoriasis, experts insist that there’s no “one-size-fits-all” diet for psoriasis. And while clients are ill-advised to rely on alternative approaches alone and neglect medical therapy in many cases, there are natural therapies that have been shown to be helpful. Although dietary fine-tuning may not cure psoriasis, it can go a long way toward improving general health, which in turn may have benefits for the skin in general, and, more specifically, may help reduce inflammation and have an effect on the immune system that leads to improvement in psoriasis.

“There’s still a lot we don’t know about psoriasis, and there’s no clear consensus about how diet may play a therapeutic role,” says Susan Kundrat, MS, RD, LD, owner of Nutrition on the Move in Urbana, Ill. However, she says, it certainly is sensible to help clients maintain a consistent diet that stresses foods and nutrients that contribute to healthy immunity. Adds Shari Lieberman, PhD, CNS, FACN, clinical nutritionist in private practice, dietitians can use their expertise to help clients supplement their diets in a manner shown to improve the symptoms of psoriasis. The following are some strategies that research has suggested are most helpful, when implemented with expert guidance, for people suffering from this inflammatory skin condition.

Antioxidants
All individuals with psoriasis, says Kundrat, should ensure that their diets are high in nutrients that are important for immunity. In many cases, they will need more of an antioxidant boost than they can reasonably get from their diets. Lieberman, author of The Real Vitamin & Mineral Book, a textbook on nutritional supplementation, advises dietitians to become expert in the therapeutic use of antioxidant supplements and work with clients to find the lowest-effective doses to achieve the desired results.

Even though antioxidant supplementation may be necessary, a diet rich in antioxidants is still an important weapon in the fight against inflammatory illnesses. Kundrat suggests that RDs assess their clients’ intake, make recommendations for dietary improvement, and, when necessary, advise them about supplementation. “You can’t, however, supplement every antioxidant found in food,” says Lieberman. “Your clients would rattle when they walk.”

She suggests working with clients to achieve therapeutic levels of the most important antioxidants, and at the same time helping them clean up their diets to get the maximum antioxidant benefits from food. “By improving their diets and encouraging them to eat plenty of fresh fruits and vegetables,” says Lieberman, “your clients will get a host of antioxidants—flavanoids and other plant compounds—which will reduce free radicals and decrease inflammation.” If you help clients maximize the antioxidant potential of their food, she adds, the fewer pills they will have to take and the greater their compliance will be.

Gluten-Free Diets
Lieberman became intrigued some years ago by the potential benefits of a gluten-free diet for individuals with psoriasis. Aware that when conventional medicine failed gluten-free diets often brought relief to individuals with other inflammatory illnesses such as ulcerative colitis, Lupus, and Crohn’s disease, she investigated and found considerable research to suggest similar benefits for patients with psoriasis. In 2003, for example, Swedish researchers tracked significant clinical improvement after putting psoriasis patients with antibodies to gliadin on gluten-free diets for three months.

Fred Pescatore, MD, MPH, head of the Centers for Integrative and Complementary Medicine in New York and author of The Allergy and Asthma Cure: A Complete 8-Step Nutritional Program, who promotes a gluten-free diet as a means of combatting asthma, suggests that the approach is also useful for clients with psoriasis. Such an intervention is supported by recognition of an apparent association between gastrointestinal abnormalities and a variety of inflammatory conditions.

Lieberman supports the notion, having observed a coincidence of leaky gut syndrome and psoriasis. With leaky gut syndrome, she explains, one has very large holes within the intestines, which begin to absorb intact proteins and other substances that don’t belong in the bloodstream and that the body cannot appropriately process. “We’re supposed to be digesting proteins, fats, and carbohydrates down to the very smallest molecules, so if we start absorbing these larger molecules into our bloodstreams, a number of illnesses can result.” Contributing to leaky gut syndrome, she explains, are a variety of medications, chronic constipation, and a poor diet.

Her clients have had great success after going on gluten-free diets, and she’s heard similar reports from numerous dermatologists. In addition to a difficulty with gluten-containing foods, some individuals with psoriasis, studies suggest, react negatively to certain foods and may benefit from studies or elimination diets to pinpoint the offending foods.

Probiotics
Because such gut abnormalities are often present in individuals with psoriasis, dietitians may want to refer clients for evaluation by a gastroenterologist. At a minimum, however, clients who may have such abnormalities, agree Kundrat and Leiberman, may benefit from a probiotic regime to improve gut function. This, says Kundrat, might be something as simple as incorporating some yogurt or keifer into the diet on a daily basis. It’s not clear that it will have a direct effect on psoriasis, but it’s known to have a beneficial effect in terms of immunity. If a fermented milk product isn’t a good option for some clients, a probiotic supplement may be useful to help ensure the intestinal microbial balance.

Many patients with leaky gut, says Lieberman, have notoriously poor diets and also take or have taken medications that alter their intestinal flora, causing an overgrowth of yeast. Probiotics will help promote balance and restore the intestinal flora. It’s just good nutrition advice for anyone, Kundrat is quick to point out, but it may be especially helpful for psoriasis patients with constipation or intestinal absorption problems.

Herbal Treatments
Let down by ineffective treatments and frustrated by exacerbations and relapses, clients may try anything that offers promise, including herbal remedies that may or may not be effective. Dietitians can help them ensure that there are no contraindications, interactions, or other safety issues associated with the use of herbs.

Kundrat notes, for example, that people with psoriasis may experiment with licorice root, which may not be wise for individuals with high blood pressure or other cardiovascular disease. She advises dietitians to keep an open mind about herbal treatments and to listen and learn from clients. By paying attention to what they’re experimenting with, dietitians can help stay ahead of the curve, becoming more knowledgeable about those remedies and providing clients with solid information about safety, efficacy, interactions, and contraindications. She suggests that RDs forge a relationship with employees at natural food stores who, since they’re in constant touch with customers, are aware of concerns and curiosities.

Omega-3 Fatty Acids
Above all, the most promising dietary intervention for psoriasis, as for other chronic inflammatory conditions, is increasing consumption of omega-3 fatty acids and reducing intake of omega-6 fatty acids. Because omega-3s have been shown in animal research and clinical studies to have anti-inflammatory properties, researchers have theorized that they may help prevent or heal inflammatory and autoimmune diseases such as psoriasis. Studies investigating the use of fish oils to treat patients with these diseases of immunity have been promising, indicating a diminished inflammation and reduced need for anti-inflammatory medications.

These fatty acids, in the form of fish oil, explains Lieberman, bring about an effect similar to that which can be obtained through the use of cortisone because they block arachadonic acid and inhibit inflammation. There’s excellent research, she insists, to support the role of omega-3s in the treatment of psoriasis. Improvement, however, depends on supplementation, which can ensure the necessary higher blood levels of omega-3s that can’t be achieved through food alone. To have an impact on psoriasis, a client would generally need to take more than six and as many as 16 fish oil capsules per day—a tall order.

However, says Lieberman, if the clients can reduce their total intake of fat and thereby reduce their intake of omega-6s, only four to six fish oil capsules would be necessary to improve the symptoms of psoriasis. It’s especially helpful, she explains, to encourage clients to reduce their meat consumption, since meat contains arachadonic acid, an omega-6 that is highly inflammatory.

Although dietary fatty acids may not have a direct impact on the disease, they are still part of an overall healthy diet that can have disease-ameliorating effects. For individuals with psoriasis, says Kundrat, it makes sense to include a wider variety of fats in the diet rather than a diet high in saturated fat, which can be achieved by increasing intake of omega-3s, whether through fish oil supplements, eating fatty fish, or incorporating flaxseed or flax oil or nuts rich in omega-3 into the diet. It’s also beneficial to help clients reduce their intake of saturated fats—particularly trans fats—and instead encourage the consumption of monounsaturated fats. This strategy, she’s found, has been helpful for clients suffering from a variety of inflammatory conditions.

A Total Immune-Enhancing Approach
Whether or not dietary measures can directly improve psoriasis, says Kundrat, it stands to reason that anything that can be done on a consistent basis to enhance immunity will have a beneficial effect on conditions known to be related to immune function. While she stresses the need to look carefully before leaping into mega-supplementation, other immune-boosting dietary measures, when explored under the guidance of a dietitian and on a case-by-case basis—such as increasing consumption of foods rich in antioxidants and omega-3s, decreasing saturated fats, and including probiotics on a daily basis—are not only harmless and generally sound nutrition practices but are also helpful for a host of chronic conditions.

It may be too early to say how much impact they’ll have on psoriasis, but Lieberman swears by them. “In the vast majority of cases I’ve been involved in, there’s definite improvement with fish oil, antioxidants, and a gluten-free diet,” she insists, adding that it won’t take long to assess the benefits. More, perhaps, than any other healthcare provider, dietitians have the expertise to assess the pros and cons of such strategies in each individual case and guide clients to the safe adoption of these strategies for maximum benefit.

— Kate Jackson is a staff writer for Today’s Dietitian.

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