PracticalDermatology

Psoriasis is a chronic immune-mediated skin condition that affects approximately three percent of the population worldwide and may have a notable impact on quality of life.¹ It is thought to be a T-cell mediated condition involving interferon-gamma producing Th1 T-helper cells and Th17 cells that results in keratinocyte proliferation and migration of immature cells toward the stratum corneum.² Topical therapies, such as topical corticosteroids, retinoids, vitamin D analogs, and tar-based preparations, are the mainstay treatment for mild disease.³ Topical therapies are used either as monotherapy or in conjunction with traditional oral systemic agents, biologics, or phototherapy for moderate to severe disease.²

Despite the breadth of available treatments, 52 percent of patients with psoriasis were dissatisfied with their treatment and concerned about treatment inefficacy and adverse effects.⁴ These findings were consistent with Lebwohl et al’s large, multinational, population-based survey of patients with psoriasis and/or psoriatic arthritis (PsA), which found that the health risks of long-term biologic therapy were a concern for 53 percent of patients and that 46 percent of patients perceive current available medical therapy to be potentially worse than the condition itself.¹ As a result, patients often seek complementary and alternative medicine (CAM) treatments for psoriasis, including herbs (the most commonly used modality),^5,6 traditional Chinese medicine (TCM), dietary modifications, climatotherapy, and mind/body interventions.⁶

The public’s interest in alternative therapies for a variety of medical conditions has increasingly grown over the years, and the estimated prevalence of CAM use among psoriasis patients ranges from 42 to 69 percent.^5-9 Lack of efficacy of traditional medicines and side effects have been reported as popular reasons for using CAM.⁷ Additionally, CAM attracts patients because it is frequently available over the counter in the US and often is less expensive than high-technology conventional health care.¹⁰ However, despite this growing popularity, a recent survey study found doctors were the least common source of patient knowledge about CAM (four percent), while the internet (49 percent) and other patients with psoriasis (42 percent) were the most common sources.¹¹ This is because patients often do not willingly offer information regarding CAM use to their physicians because they do not consider CAMs to be pharmacologic.⁹ To this end, it is important for physicians to ask questions regarding CAM use and to be prepared to discuss this topic with patients, considering that herbs are not only pharmacologic but may also interact with conventional medications.

It is also essential for dermatologists to be aware of the available alternative therapies, because patients expect their dermatologists to have a basic knowledge of CAMs while discussing treatment options.¹² Notably, a 2017 survey of dermatologists revealed 66 percent of participants indicated an interest in CAM education with only 10 percent of dermatologists reporting prior CAM training.¹³ This suggests that further educational resources are needed to fill these knowledge and practice gaps.

In an effort to address this need, the article by Hill et al in 2016 previously described a list of herbs with historical use in the treatment of psoriasis.¹⁴ We updated this list with newer herbs utilized by patients in psoriasis management today, with a renewed review of the literature on efficacy. It is our aim to bring an awareness of herbs potentially used by patients with psoriasis and to provide a quick reference for providers who may be interested in learning more about these herbs. It should be noted that there is a lack of evidence supporting the safety of these herbs during pregnancy and lactation as well as in children.

The table provides an “at-a-glance” chart of commonly used herbal treatments for psoriasis, along with their active ingredients and mechanisms of action. Readers should be directed to key references such as websites by WebMD, UptoDate, and Medscape which offer information regarding herbal supplements, side effects, and drug interactions. An expanded version of the table, including listings of Historical Background; Adverse Effects/Herb-drug Interactions; and Clinical Trials Findings is available below.

The authors have no conflicts of interest to report.

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