Pathological
Communication
Biosci. Biotech. Res. Comm. 9(3): 391-398 (2016)
Psoriasis: Role of dietary management in diminution of
its symptoms
Choudhary S.
1
*, Pandey A.
2
, Khan M.K.
2
, Khan S.
3
, Rustagi S.
3
and Thomas G.
1
1
Department of Molecular and Cellular Engineering, JSBB, Sam Higginbottom Institute of Agriculture,
Technology and Sciences, Allahabad, India
2
Department of Soil Science and Plant Nutrition, University of Selcuk, Konya, Turkey
3
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
th
July, 2016
Accepted after revision 10
th
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
© A Society of Science and Nature Publication, 2016. All rights
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,
(c) Biogenic amines like putrescine may also be
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
in
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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