Pathological

Communication

Biosci. Biotech. Res. Comm. 9(3): 391-398 (2016)

Psoriasis: Role of dietary management in diminution of

its symptoms

Choudhary S.

*, Pandey A.

, Khan M.K.

, Khan S.

, Rustagi S.

and Thomas G.

Department of Molecular and Cellular Engineering, JSBB, Sam Higginbottom Institute of Agriculture,

Technology and Sciences, Allahabad, India

Department of Soil Science and Plant Nutrition, University of Selcuk, Konya, Turkey

Department of Food Science and Technology, WSFDT, Sam Higginbottom Institute of Agriculture, Technology

and Sciences, Allahabad, India

ABSTRACT

Psoriasis is a common chronic skin disease mediated by T-cell with atypical proliferation of keratinocytes. The in u-

ence of environment and stress as a cause of psoriasis cannot be undermined. The recent research on diet in psoriasis

as cause and cure has gained momentum with several studies correlating it with aetiology and pathogenesis of the

disease. Various dietary intolerances have added to the cause and concern of the disease. The alcohol dependence of

patients with psoriasis has led to its worsening. Trials on Gluten free diet (GFD) in psoriasis patients has established

the reason for its avoidance in the diet, the association between celiac disease (CD) and psoriasis proba bly due to Th1

cytokines is highlighted but in absence of substantial literature cannot be established. Importance of several vitamins

and their analogs has also been discussed with insight on vitamin D as a possible medicine in treatment of psoriasis.

Likewise, the diet rich in eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) like  sh oil was found to

improve the clinical condition of patients. The signi cance of antioxidants and antioxidant therapy to remove the

toxic waste and its positive impact on patient with psoriasis has been established.

KEY WORDS: DIET, DIETARY INTOLERANCE, KERATINOCYTE, PSORIASIS, T-CELL

391

ARTICLE INFORMATION:

*Corresponding Author: saumyachoudhary.biotech@gmail.com

Received 27

July, 2016

Accepted after revision 10

Sep, 2016

BBRC Print ISSN: 0974-6455

Online ISSN: 2321-4007

Thomson Reuters ISI ESC and Crossref Indexed Journal

NAAS Journal Score 2015: 3.48 Cosmos IF : 4.006

reserved.

Online Contents Available at: http//www.bbrc.in/

INTRODUCTION

Psoriasis is common chronic, relapsing, dis guring,

in ammatory and proliferative skin disorder where

keratinocytes divide and move more quickly from the

stratum basale to the stratum corneum. Psoriasis usually

varies in duration, periodicity of  ares and extent. The

interaction between multiple gene susceptibility loci, the

immune system, and various environmental factors are

held responsible for the pathogenesis of psoriasis. Lowes

392 PSORIASIS: ROLE OF DIETARY MANAGEMENT IN DIMINUTION OF ITS SYMPTOMS BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS

Choudhary et al.

et al., (2008)

have discussed the major role of T cells

expressing cytokine interleukin 17 in psoriasis. Gener-

ally, it is most commonly understood as a T-cell-medi-

ated disease involving interferon-g and tumor necro-

sis factor-alpha as key pro-in ammatory players. For

many years, the impact of nutrition in the treatment of

psoriasis has been widely studied. Nutritional aspect of

psoriasis off late has been one of the main interests of

researchers and the associated comorbid conditions has

renewed their concern in nutrition as a mode to recover

comorbid conditions as well to underlying skin disease

(Ricketts et al. 2010). Araujo et al. 2009

and Wolters,

2005

suggested the importance of diet in the etiology

and pathogenesis of psoriasis.

This review aims to highlight the constructive role

of various essential dietary contents in diminution of

the symptoms of psoriasis and also the adverse impact

of dietary habits on severity of psoriasis. This review

aims to highlight the constructive role of various essen-

tial dietary contents in diminution of the symptoms of

psoriasis and also the adverse impact of dietary habits

on severity of psoriasis

GLUTEN-FREE DIET IN PSORIASIS

Gluten is a protein commonly present in the cereal

crop wheat, rye, barley, triticale, oats, spelt and kamut

(Wolters, 2005). It is interesting to note that in gluten

sensitive people, intake of gluten sources can lead to

mucosal in ammation and villous atrophy with crypt

hyperplasia. Baum et al. (2001) and Connon, (1999) have

discussed the responsible toxic compounds i.e. gliadin

in wheat gluten, secalins in rye, and hordeins in barley

grouped under prolamins.

The mechanism of oral tolerance to dietary protein is

basically governed by three major underlying principles:

1. Functional Unresponsiveness to the antigen

2. Apoptosis

3. Immune suppression by regulatory T cells

Action of regulatory T-cells varies according to the type

of regulatory cells. Firstly, Natural Tregs those act in a

contacted approach and express CD25 and transcrip-

tional factor FOXP3. Secondly, Adaptive Treg Type 1

Cells (TR1) unlike Tregs, work in contact independent

fashion and may or may not express CD25 AND FOXP3.

TR1 and TH3 cells preferentially synthesize immuno-

suppressive cytokine IL-10 and TGF-B respectively to

maintain homeostasis of responses to foreign antigens

including gliadin (Vojdani et al. 2008).

In case of intolerance, luminal antigens  nds response

from gut associated lymphoid tissue that may lead to

production of Immunoglobulin like IgA and IgM anti-

bodies, pro-in ammatory cytokines and subsequently

tissue damage or autoimmunity (Sollid, 2002). The type

of hypersensitivity whether immediate or delayed to

gluten is characterized by IgE mediated region or IgG,

IgM, IgA plus T-cell reaction to gluten when tolerance

to gluten is either not established properly or broken in

these conditions (Maloy & Powrie, 2001; Bu et al. 2001

Sollid, 2002, Schwartz, 2003, Matsuo et al. 2005 and

Knoechel et al. 2006).

It is believed that gluten sensitive intestinal disease

is apparently marked with very few or no gastrointes-

tinal symptoms and laten gluten sensitivity and pso-

riasis is associated (Duggan, 2004; Lef er et al., 2003;

Michaelsson et al. 1993 and Nelson, 2002). Various stud-

ies have correlated celiac disease and psoriasis (Wolters,

2005 and Michaelsson et al. 2000).This correlation can

be attributed to the fact that both conditions involve

Th1 cytokines in the pathogenesis of the disease process.

Interleukins, IL-1 and IL-8 released from rapidly divid-

ing keratinocytes are thought to activate the Th1 in am-

matory cascade (Ojetti and Aguilar, 2003).

Addolorato et al., 2003 in a case report stated about

the signi cant improvement in patient with celiac dis-

ease and psoriasis immediately after starting gluten free

diet (GFD) routine. Similarly, in another study reported by

Michaelsson et al., 1993, GFD helped in recovering psori-

asis with no CD but with IgA and ⁄or IgG AGA. However;

some authors Addolorato et al. 2003 and Collin & Reunal,

2003

deny any positive association due to limited litera-

ture. Bhatia et al., (2014), in their study concluded that

gluten-free diet may potentially be bene cial in celiac

antibody positive psoriasis patients, all though insisted

on more well-powered studies to con rm this.

HISTAMINE INTOLERANCE

Histamine (2-[4-emidazolyl] ethylamine) was discovered

in 1910 by Dale and Laidlaw and identi ed as a media-

tor of anaphylactic reactions in 1932 (Santos,1996,

Steinhoff et al. 2004). Histamine is synthesized by pyri-

doxal phosphate (vitamin B6)-containing L-histidine

decarboxylase (HDC) from amino acid histidine and

are categorised under biogenic amines. Histamine is

released by different human cells especially basophils,

mast cells, platelets, histaminergic neurons, lymphocytes

and enterochromaf n cells and is stored in vesicles or

granules released on stimulations The disequilibrium of

accrued histamine and capacity for histamine degrada-

tion has resulted into histamine intolerance. Various

theories have been  oored as mechanism leading to the

histamine intolerance (Maintz & Novak, 2007).

Possible

theories for the underlying conditions are:

(a) Endogenous histamine overproduction caused

by allergies, mastocytosis, bacteria, gastroin-

testinal bleeding,

BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS PSORIASIS: ROLE OF DIETARY MANAGEMENT IN DIMINUTION OF ITS SYMPTOMS 393

Choudhary et al.

(b) Increased exogenous ingestion of histidine or

histamine by food or alcohol,

attributed with the role of displacing histamine

from its mucosal mucine linkage, resulting in

increase of free absorbable histamine in circu-

lation.

(d) The most important theory credited with the

cause of histamine intolerance is an impaired

enzymatic histamine degradation caused by

genetic or acquired impairment of the enzy-

matic function of DAO or HNMT.

Enzyme DAO is the main enzyme for metabolism of

ingested histamine (Bieganski et al. 1980; Bieganski et

al. 1980; Bieganski et al. 1983; Bieganski, 1983 and Sat-

tler et al. 1988). A Reduced DAO activity may lead to

impaired histamine degradation resulting in excess of

histamine causing numerous symptoms mimicking an

allergic reaction. Intake of histamine rich food (Wantke

et al. 1994) alcohol (Wantke et al. 1996; Zimatkin &

Anichtchik, 1999 and Sattler & Lorenz,1990) or drugs

(Wantke et al. 2001; Sattler et al.,1987; Jarisch, 2004 and

Jarisch & Wantke,1996) release histamine or block DAO

may aggravate diarrhoea, headache, (Wohrl et al. 2004)

congestion of the nose, asthmatic wheezing (Wantke et

al.1994; Zimatkin & Anichtchik;1999 and Pollock et al.

1991) hypotension, arrhythmia, urticaria, psoriasis, pru-

ritus,  ushing, and other skin related conditions in these

patients (Schmidt et al. 1990). Because of the multifac-

eted symptoms, the existence of histamine intolerance

is frequently underestimated, or its symptoms are mis-

interpreted.

Psoriasis and alcohol consumption allocate multi-

faceted and multi-factorial relation. However, the rela-

tion between the alcohol consumption and the disease is

not yet signi cantly clear, however; evidences do sug-

gest psoriasis triggers under alcoholic in uence (Rick-

etts et al. 2010; Jankovic et al. 2009; Kirby

et al. 2008;

Poikolainen

et al. 1999 and Tobin & Kirby, 2009). Several

authors (Jankovic et al. 2009 and Gupta et al. 1989) have

suggested that men with family history of psoriasis are

more susceptible to the skin disorder. Many research-

ers have established the positive correlation between the

disease severity and alcohol abuse (Kirby et al. 2008;

Poikolainen et al. 1999 and Tobin & Kirby, 2009), poor

diagnosis in psoriasis and less effective treatment (Gupta

et al. 1989 and Higgins & Vivier, 1994).

Different studies conducted worldwide have also

agreed to the cause of associated hepatotoxicity in pso-

riasis medications that have been stated more frequently

amongst the highly alcohol dependent patient (Gronhoj

et al. 2000 and Montaudi et al. 2011). Effect of alcohol

dependence on psoriasis patients has elevated alcoholic

liver disease, (Tobin & Kirby, 2009) anxiety, depression

(Kharaeva et al. 2009), cardiovascular disease (Stücker

et al. 2001)

and solid tumor risk (Richard et al. 2013).

In order to understand whether modi cation of alcohol

intake in patients with psoriasis affects disease course or

not a systemic study is required.

VITAMINS IN PSORIASIS

Vitamin A

The effective role of various topical and systemic vita-

min A derivatives has been established in the treatment

of psoriasis. Retinoid receptors can be divided into reti-

noic acid receptors and retinoid X receptors, and each

family has , , and  subtypes.This receptor helps reti-

noid to inhibit the growth of hyperproliferative keratino-

cytes and induce their terminal differentiation. The sec-

ond generation of aromatic retinoids, etretinate and

acitretin, have been established as an effective systemic

therapies of psoriasis and other keratinization disorders.

Similarly, an increase in squamous cell carcinoma and

keratoacanthoma was also reported by (Touraine et al.

1973) in extract of psoriatic lesion. Retinoic acid (RA)

and its synthetic analogs, (Peck and DiGiovanna, 1994)

have been successful in treating a number of epidermal

disorders, including photo-damage, malignancies, acne,

and psoriasis and other disorders of keratinisation.

With regard to serum vitamin A level in psoriatic

patient con icting research is reported. Serum vitamin

A levels were reported to be decreased in patients with

“common psoriasis” (Majewski et al. 1989),

severe eryth-

rodermic, and pustular psoriasis (Marrakchi et al. 1994)

and in patients with both active and inactive psoriasis

(Rocha et al. 2001). Rollman et al., 1985

and Safavi et al.,

1992

con rmed no difference in levels of vitamin A in

patients with and without psoriasis.

In psoriatic lesions; highly increased concentrations

of endogenous retinoids have been implicated (Ricketts

et al. 2010), established the increased action of a cyto-

solic enzyme catalyzing the formation of RA from retinol

in extracts from psoriatic skin and Rollman & Vahlquist,

(1985)

reported a signi cant increase in 3, 4 didehydro-

retinol (a precursor of ddRA) in psoriatic lesions. Simi-

larly, an increase in squamous cell carcinoma and kera-

toacanthoma was also reported in extract of psoriatic

lesions (Reichrath et al. 2007 and Bos & Spuls, 2008).

In psoriatic lesions; highly increased concentrations

of endogenous retinoids have been implicated (Ricketts

et al. 2010), established the increased action of a cyto-

solic enzyme catalyzing the formation of RA from retinol

in extracts from psoriatic skin and Rollman O. & Vahl-

quist, 1985

reported a signi cant increase in 3, 4 dide-

hydroretinol (a precursor of ddRA) in psoriatic lesions.

394 PSORIASIS: ROLE OF DIETARY MANAGEMENT IN DIMINUTION OF ITS SYMPTOMS BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS

Choudhary et al.

The epidermal changes in few benign dermatoses like

psoriasis quietly resemble the features as observed in the

de ciency of Vitamin A so a local abnormal retinoid

metabolism has been incriminated in its pathogenesis

(Richard et al. 2013).

Vitamin B9 (FOLIC ACID)

Person affected with psoriasis has an increased incidence

of folic acid de ciency. This elevated de ciency can be

attributed to the elevated homocysteine levels (Kural et

al. 2003 and Malerba et al. 2006)

decreased intestinal

absorption caused by in ammation (Najarian & Gottlieb,

2003; Scarpa et al. 2000 and Schatterman et al. 1995)

and increased use by skin epidermal cells (Malerba et

al. 2006; Najarian & Gottlieb;2003 and Gisondi et al.

2007).

Folate de ciency is also implicated in psoriasis

severity. As suggested by Malerba et al. 2006 in a case

control study, signi cantly increased level of plasma

homocysteine and diminished plasma folate levels were

established among patients with psoriasis compared to

healthy controls. Malerba et al. (2006) compared plasma

homocysteine levels and folate levels with scores of PASI

and a direct correlation was established with plasma

homocysteine levels whereas folate levels were inversely

linked. Antithrombotic and Cardio protective role of

folate supplementation in psoriatic patients has been

assumed by Gisondi et al., 2007; however in absence of

adequate evidence this claim cannot be supported.

Vitamin B12

The  nding on role of Vitamin B12 in the treatment

of this disease is still on a super cial stage. Baker and

Comaish, 1962

and Ruedemann, 1962 have adjudged its

ef cacy in the treatment when levels of vitamin B12 in

psoriatic plaques were low. Various studies have estab-

lished the ef cacy with intramuscular and systemic vita-

min B12. The bene t in topical vitamin B12 was also

demonstrated recently. Stucker et al. 2001

has categori-

cally cited a prospective randomized clinical trial and

assessed the effects of topical calcipotriol cream against

vitamin B12 cream on a certain group of patients suf-

fering with chronic plaque psoriasis. However the results

were not so exciting for Vit.B12 when calculated on

PASI score as the bene cial effects in the vitamin B12

group were slower to develop. Even though slower in

chronic patients, but, still it can be researched for use in

the early stages of the treatment.

Vitamin D

In treatment of psoriasis the effectiveness of topical

Vitamin D is well known however the usefulness of oral

supplementation of the vitamin is still ambiguous. This

vitamin has multiple functions; Vitamin D locally func-

tions as hormones by controlling calcium homeostasis

as well have autocrine/paracrine in uence on tissues

that express CYP27B1 and VDR. Vitamin D3 (Calcitriol)

exhibit immunomodulatory properties and through

these properties restricts the T-cell proliferation and Th1

development, modulating antigen presenting cell (APCs)

function, inducing hypo-responsiveness to antigens,

inhibiting production of IL-2, IL-17, IL-8 and interferon,

increasing the production of IL-10 and regulatory T cells

(Arnson et al. 2007 and Adams & Hewison,2008).

It is involved in the regulation of antimicrobial pep-

tides cathelicidin and human defensin 2 (HBD2), which

both participate in the pathogenesis of psoriasis. Vitamin

D’s role in psoriasis is further supported by studies that

con rm the link between VDR polymorphism and pso-

riasis. Although extra physiologic doses of oral vitamin D

may have deleterious effects, supplementation of vitamin

D in patients with insuf ciency may have a role in pso-

riasis, still additional research and studies are needed on

the vitamin D status in patients with psoriasis, (Okita et al.

2002, Dayangac et al. 2007 and Hollox et al. 2008).

POLYUNSATURATED FATTY ACIDS

Polyunsaturated fatty acids are differentiated into two

different categories namely linoleic acid from n-6 fatty

acid family and alpha-linoleic acid from n-3 fatty acid

family on the basis of the  rst double bond counted

from the methyl end. Sun ower seeds are rich source of

linoleic acid and alpha-linolenic acid (C18:3n-3), eicos-

apentaenoic acid (EPA; C20:5n-3) and docosahexaenoic

acid (DHA; C22:6n-3) are the most abundant n-3 fatty

acids in food. Linseed and walnut oil are rich source of

alpha-linolenic acid whereas oily  shes are rich source

of EPA and DHA (Wolters, 2005).

PGE3 and LTB5 are EPA-derived eicosanoids with low

in ammatory action as compared to PGE2 or LTB4, both

formed from AA (Dayangac et al. 2007).

Arachidonic

acid (AA) has been found in high amount in psoriatic

skin lesions and leukotriene B4, which is assumed to

be a mediator of in ammation in psoriasis (Gupta et

al. 1989).This is one of the main reason why eicosa-

noids from AA are thought to aggravate in ammatory

responses whereas EPA derived eicosanoids show anti-

in ammatory properties

(Gil, 2002)Excessive production

of these Arachidonic acid (AA) derivatives has been con-

cerned with many in ammatory and autoimmune disor-

ders and also in psoriatic skin lesions.

As discussed earlier that  sh oil are excellent source

of EPA and DHA , the administration of  sh oil in

patients with psoriasis leads to elevated plasma and

platelet EPA-to-AA ratios and signi cant decrease in

leukotrine B4synthesis by neutrophils is observed that

has resulted in clinical improvement of psoriatic patients

(Ricketts et al. 2010).

BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS PSORIASIS: ROLE OF DIETARY MANAGEMENT IN DIMINUTION OF ITS SYMPTOMS 395

Choudhary et al.

ANTIOXIDANTS IN PSORIASIS

Selenium

Selenium is an essential micronutrient with immune-

modulating and anti-proliferative properties, which

in uences the immune response either by changing the

expression of cytokines and respective receptors or by

making immune cells more resistant to oxidative stress.

Fairris et al. (1989); Roy et al. (1992), Spallholtz et al.

(1990) and Matz et al. (2003)

have

reported the anti-

oxidant, anti-in ammatory effects and UVA and UVB

protective nature of selenium. Several studies and trials

have been done to assess the correlation between sele-

nium status and psoriasis.

Doses of Selenium have considerate inhibition effect

on DNA synthesis and a stimulatory effect on cellular

proliferation. Low Selenium levels in psoriatic patients

were reported by some researchers (Serwin et al. 2003;

Fairris et al. 1987; Matz et al. 2003; Fairris et al. 1989

and Serwin et al. 2002) and Harvima et al. 1993

their study reported that alone the micronutrient can-

not improve psoriasis. The signi cance of combination

antioxidant therapy in severe erythrodermic or arthro-

pathic psoriasis cannot be undermined. In the trial con-

ducted selenium supplementation with coenzyme Q10

(ubiquinone acetate, 50 mg/d), and vitamin E (natural

-tocopherol, 50 mg/d) revealed quick clinical improve-

ment in erythrodermic and arthropathic psoriatic patient.

Kharaeva et al. (2009) in a statistical study demonstrated

the improvements in measured clinical parameters in

the arthropathic and erythrodermic psoriasis groups

that received the antioxidants compared with the corre-

sponding groups that received the soy lecithin placebo.

Zinc

Burrows et al. (1994) and Smith et al., (2009)

reported

the association of zinc de ciency with psoriatic plaque.

There is little proof regarding the bene t of oral sup-

plementation However; the approval regarding the dose

or administrative ways has not been proposed yet. Still,

the ways and advantages of zinc as an antioxidant in

psoriasis are needed to be worked upon.

Taurine

Amino acid Taurine in early observation was assumed

to be involved in the pathogenesis of psoriasis however

number of studies failed to substantiate the assumption

that taurine in any quantity can aggravate or improve

the medical course of psoriasis. In a series of research

conducted thereafter; various researchers have tried to

establish the role of taurine in psoriasis. Roe (1962) in an

earlier study claimed that 12 patients with chronic pso-

riasis treated with cholestyramine, a bile-acid seques-

trant, all patients experienced clinical improvement and

a simultaneous increase in fecal taurine content. This

implies that exclusion of the amino acid might be related

to clearing of psoriatic skin lesions. In another compara-

tive study, later on by Roe (1965) concluded that high

dose of taurine if administered to patient with psoriasis

resulted in worsening of skin pruritus, erythema, and

scaling within hours of ingestion. However, the same

was absent in the patient without the disease.

The presence of taurine in our regular diet was also

considered and various researchers tried to postulate

whether the dietary intake of amino acid was involved

in the pathogenesis of psoriasis. In another research

performed on 15 patients with mild to severe psoria-

sis and low taurine diet was given resulting in com-

plete healing of 9 psoriatic patients and partial cure in

case of left over patient was achieved during 3-month

period (Roe & Weston,1965).

In yet another contrasting

study performed by Zackheim and Farber, (1968) it was

demonstrated that taurine dose in excess of the amount

found in regular diet was given to 13 psoriatic patients

but only a few experienced aggravation in the diseased

condition.

CONCLUSION

Over the time diet has become an important factor in

etiology and pathogenesis of psoriasis. Various systemic

dietary intolerance has been responsible for the psoriasis

and related skin disorders. Gluten intolerance has been

increase in the population and subsequently Gluten free

diet has been advised by number of researches. A pos-

sible correlation can be linked between psoriasis and

celiac disease due to Th1 association. Even Gluten Free

Diet helped in recovering psoriasis with no Celiac Dis-

ease but with IgA and ⁄or IgG AGA. The disequilibrium

of accrued histamine and capacity for histamine deg-

radation has resulted into histamine intolerance. Intake

of histamine rich food like alcohol can lead to Psoria-

sis trigger and has been positively and widely associ-

ated by number of researchers. Decrease Vitamin A and

Vitamin B9 level has been reported and hence it can be

suggested to enhance level of both the vitamins dietary

intake. Likewise, Vitamin D can be useful in the treat-

ment of Psoriasis but extra dose of Vitamin D should not

be administered as can lead to worsening of the disease.

Vegetable diet for minimum 3 months can be helpful to

psoriasis patients due to low Arachidonic acid (AA) and

Fish oil also seems to improve the clinical symptoms of

Psoriasis. The positive role of antioxidants like selenium,

zinc and taurine has also been established. However; a

condensed research focussing more on pros and cons

of dietary intake is needed so that a clear relationship

between dietary habits can be established with etiology

and pathogenesis of psoriasis.

396 PSORIASIS: ROLE OF DIETARY MANAGEMENT IN DIMINUTION OF ITS SYMPTOMS BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS

Choudhary et al.

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