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Psoriasis Australia, from A to Z: a modern functional medicine review

Psoriasis can take many forms and significantly affect your health. The Australian Centre for Functional Medicine is a leading authority for the treatment of all forms of psoriasis.

Psoriasis is a non-contagious inflammatory skin condition characterised by the formation of red scaly patches on the skin, itchiness and flaking of skin cells. While psoriasis can occur anywhere in the body, it occurs most often in the scalp, elbows and knees, and sometimes in nails, joints and other parts of the body. In fact, today psoriasis is considered a systematic pathology, as it may involve various other conditions, from psoriatic arthritis to metabolic disease (Reich 2012).

There are also multiple factors involved with psoriasis, including genetic, environmental and microbial factors. Microbial factors include yeast and fungal overgrowth, gut or skin dysbiosis, and others.

There are also multiple factors involved with psoriasis, including genetic, environmental and microbial factors. Microbial factors include yeast and fungal overgrowth, gut or skin dysbiosis, and others.

 

The most common form of psoriasis is called plaque psoriasis, which accounts for 90% of all psoriasis cases (Griffiths 2007). Other forms of psoriasis also exist, including:

A rare, painful and severe form of psoriasis where small white or yellow blisters form on the skin. These blisters are non-infectious and are filled with pus made up of white blood cells. The blisters will turn brown and crusty over time and may peel off, leaving the skin appearing shiny or scaly.

Found mostly in children and young adult under 30. This type of psoriasis is the second most common after plaque psoriasis and it is characterised by the development of small red patches on the arms, legs, scalp or trunk.

This condition occurs in infants between two and eight months of age, typically in the diaper area. It is commonly diagnosed as diaper rash, which is a generic term that include different skin conditions. Infants who are breastfed or wear breathable and multilayered disposable nappies have a lower prevalence of this condition, compared to babies who wear cloth nappies and/or are not breastfed.

This type of psoriasis affects body folds and genital areas, such as the armpits, groin, under the breasts, navel, penis, vulva, the area between the buttocks and around the anus. Although less common, it can also affect the skin inside the ear canal, behind the ears, through the scalp, and the skin on elbows and knees.

A severe form of psoriasis extending over large portions of skin and requiring urgent treatment. This condition typically occurs in skin regions with pre-existing psoriasis. Certain pre-existing conditions can also promote the development of erythrodermic psoriasis, including certain infections and low levels of calcium.

What causes psoriasis in Australia?

The aetiology (causes) of psoriasis are not fully understood. It is thought to be the consequence of an immune malfunction, which in conditions like plaque psoriasis, causes skin cells to regenerate at accelerated rates. This accelerated rate of skin turnover results in the formation of plaques and scales, typical of the condition.

While it is currently thought that immune malfunction may be the driving cause behind psoriasis, it is not clear what causes these immune problems. Both genetic and environmental factors are thought to play a role in the pathogenesis of psoriasis. The composition of the gut microbiota, bacterial and fungal overgrowth, and gut dysbiosis have also been linked to this condition.

Your genetic background has an important role in your propensity to develop psoriasis, which may explain why Europeans have a prevalence as high as 11.4%, whereas Japanese have a prevalence of no more than 0.4% (Michalek 2017). Genetic factors are estimated to account for 70% of a person’s susceptibility to this disease (Ogawa 2020).

 

Genetic studies have identified multiple genes related to psoriasis, with a large proportion of these genes belonging to the major histocompatibility complex (MHC) region (Capon 2017). Genes belonging to the MHC region produce cell surface that are essential for the functioning of the adaptive immune system.

 

Because of the significant genetic background of psoriasis, understanding your family history is important. Having one or both parents with psoriasis, for example, will greatly increase your chances of developing this condition.

There are various environmental factors that can trigger and worsen psoriatic flares, such as HIV infection (Arnett 1991, Alpalhão 2019), the use of medications like lithium, beta-blockers, or anti-malarial drugs, and withdrawal from oral or systemic corticosteroids. More recently, certain drugs like tumor necrosis factor-alpha antagonists and anti-programmed cell death protein 1 immune checkpoint inhibitors have also been linked to the induction or exacerbation of psoriasis (Balak 2017).

 

Beyond drugs, there are other environmental factors that act as triggers for psoriasis. These include:

 

  • UV exposure, which can affect the function of certain immune-related genes (Wolf 2016).
  • Injury to the skin (like cuts or scrapes), which can increase the likelihood of infections (Hajishengallis 2012).
  • Mental stress, which can lead to altered immune functions and abnormal T-cell activation (Naldi 2005).
  • Smoking and exposure to second-hand smoke, because toxins in cigarettes can interfere with the signalling pathways of the immune and nervous systems (Armstrong 2014).
  • Heavy alcohol consumption, which can increase susceptibility to infections, stimulate lymphocyte and keratinocyte proliferation, and increase production of proinflammatory cytokines (Svanström 2019).
  • Diet and obesity, obesity is thought to predispose patients to psoriasis and worsen psoriasis-related inflammation (Kunz 2019).
  • Exposure to heavy metals – certain environmental pollutants, like cadmium, can increase levels of inflammatory markers, affecting the function of the immune system and potentially influencing psoriasis development. One study, for example, found that psoriasis patients had significantly higher levels of blood cadmium (Liaw 2017).

Psoriasis Australia and other diseases

If you have psoriasis, you have an increased chance of developing other conditions, including eye problems, type 2 diabetes, high blood pressure, heart disease, other autoimmune conditions, and mental health problems like depression.

Studies have shown that eye conditions like conjunctivitis, blepharitis and uveitis are more common in people with psoriasis (Chaiyabutr 2020; Demerdjieva 2019).

Multiple studies have shown that type 2 diabetes is more common in patients suffering from psoriasis (Holms 2019).

Research has linked psoriasis with the development of myocardial infarction and ischemic heart disease (Lai 2016; Shiba 2016).

Depression, anxiety, and suicidal behaviour are associated with psoriasis, in great part because of how psoriasis affects a patient’s physical and mental well-being (Wu 2018).

Another major health problem associated with psoriasis is arthritis, a condition that affects both skin and joints.

Focus on psoriatic arthritis in Australia

People suffering from psoriatic arthritis experience similar skin symptoms as with regular psoriasis, but in addition they suffer from swelling of their joints, ligaments, tendons, and eyes.

 

From a medical standpoint, psoriatic arthritis is defined as a chronic, immune-mediated, inflammatory arthropathy, or disease of the joints. This condition causes inflammation in the joints and associated tissues, and it is also associated with increased mortality from cardiovascular disease.

  • Skin and nail disease
  • Dactylitis, which is an inflammation of the fingers of toes
  • Uveitis, a form of eye inflammation affecting the middle layer of tissue of the eye wall
  • Osteitis, an inflammation affecting bones. There are various forms of this condition, depending on which bones are affected, including osteomyelitis, osteitis, alveolar condensing osteitis. osteitis deformans, osteitis fibrosa cystica and osteitis pubis.
  • Pain, swelling and stiffness in the joints, buttocks, lower back or neck
  • Pain in the tendons (The tissue attaching muscles to bones), including the back of the heel, or the sole of the foot.
  • Nail problems, including thickening, colour change or separation from the skin
  • Pain and redness in the eyes.

Environmental and genetic factors have important roles with the pathogenesis of psoriasis, but they are not the only factors involved. Bacteria living in our gut and skin have been shown to play important roles in psoriasis development. For example, the onset of yeast or fungal overgrowth, dysbiosis, have been linked to psoriasis.

Human Microbiota and Psoriasis: an emerging link

The human microbiota encompasses a vast community of microorganisms that live in our skin, mouth, genitals, and gastrointestinal tract, among other places. These microorganisms, which include mostly bacteria, but also viruses, fungi, archaea, and protozoans, exert an important influence in our health. To learn more about the role of these microbes, jump into our articles on the role of the gut microbiota and other microbes on health. You may also download our e-book on gut health for a comprehensive review of all factors affecting your gut.

In recent years, studies have found support for a link between gut microbiota and skin health, through the inflammatory mediators, metabolites, and the intestinal barrier function – all factors influenced by gut microbiota (Sikora 2020). Studies have found significant differences in the gut microbiota composition of patients with psoriasis, compared to healthy people. For example, studies have reported lower relative abundance of Bacteroidetes, and higher Firmicutes in psoriasis patients, compared to healthy controls (Reviewed in Sikora 2020).

        • Yeast overgrowth (Candida) – Studies have shown that people affected by psoriasis have higher levels of yeast overgrowth (e.g. yeasts). For example, one study analysed the stool and saliva of 50 psoriasis patients and 50 healthy donors. Their results found that yeast overgrowth, specifically by the genus Candida was present in psoriasis patients at significantly higher proportion that in healthy donors. The authors argue that their results support the idea that Candida functions as a trigger to both exacerbation and persistence of psoriasis (Walndman 2001). More broadly, these finding show that yeast overgrowth (from Candida or other fungi) is an important factor to consider in the treatment of psoriasis.

Beyond yeast overgrowth (or fungal overgrowth), studies have shown that the skin microbiota is part of the multiple factors that influence psoriasis, like genetics, and environmental triggers.

        • One study used DNA sequencing technology to estimate the bacterial diversity of healthy skin and skin affected by psoriasis.
              • One of the key findings of this study was a previously unknown correlation between fungi and bacteria diversity in psoriatic skin. The study found that skin affected by psoriasis was characterised by hosting Kocuria, Lactobacillus, and Streptococcus bacteria alongside fungi of the genus Saccharomyces.
              • The study also found that psoriatic skin regions were dominated by distinct microbial species, depending on the site. Psoriatic skin from the back hosted high levels of Brevibacterium and Kocuria The elbow, in contrast, hosted bacteria of the genus Gordonia. These skin samples also hosted high levels of fungi of the genus Malassezia, with distinct species restricted to the back and elbow (Stehlikova 2019).
        • Another study that compared the skin microbiota of psoriasis patients with that of healthy controls found that the skin of the trunk of psoriasis patients hosted higher levels of bacteria of the Proteobacteria group, compared to healthy people (Fahlen 2012).

At the heart of psoriasis pathogenesis is the integrity of the immune system, which is compromised in this disease. Recent studies have shed light on how immunity influence psoriasis.

        • Intestinal barrier integrity – One study investigated intestinal barrier integrity in people with moderate and sever degrees of psoriasis. Compared with healthy people, the study found that patient with psoriasis had higher levels of the biological marker Claudin-3, which is indicative of altered intestinal barrier function. According to the authors of this study, their results suggest that dysfunction of the intestinal barrier in psoriasis may disturb the homeostatic equilibrium normally found between the microbiota and immune system (Sikora 2018).
        • Role of T-cells – T-cells are a type of white blood cells and a core component of the adaptive immune system. Read more about the immune system in this article from the Australian Centre for Functional Medicine Research and Development team. Research studies have shown that T-cells exert an important influence in the pathogenesis of psoriasis. For a recent comprehensive review of the role of the immune system in psoriasis, jump to this recent article.

Multiple factors associated with diet have been shown to influence psoriasis development. For example,

        • Obesity Multiple studies have linked obesity and psoriasis incidence and severity. One study that compared 373 obese patients with healthy control subjects found that obese people had a 2-fold increased risk of developing psoriasis, compared to people with healthy weight (Wolk 2009). Another study that studied the incidence of psoriasis in 399 patients found a linear trend for increasing psoriasis severity and BMI. In other words, higher BMI is associated with more severe psoriasis. Their results also showed that men tended to show this link more prominently than women (Huang 2010).
        • Celiac disease – people with psoriasis have been shown to have a higher prevalence of other autoimmune diseases, like celiac disease. One hypothesis suggests that both celiac disease and psoriasis share similar inflammatory pathways (Reviewed in Bahtia 2014).
        • Diet and exercise – One study found that a 20-week intervention, where obese patients followed a prescribed diet-exercise program, resulted in a significant reduction in psoriasis severity (Naldi 2014).
        • Nutritional supplements – A 2014 review on the use of nutritional supplements for the treatment of psoriasis evaluated the use of oral vitamin D, vitamin B12, selenium, and omega-3 fatty acids from fish oils. The review study found that the strongest evidence for a benefit in psoriasis treatment came from consumption of omega-3 fatty acids from fish oils (Millsop 2014). However, before starting a new dietary regiment, you must consult with a nutrition specialist.

Multiple studies have linked psoriasis with sleep disorders (Shutty 2013; Gupta 2016). In a recent review (Gupta 2016), researchers reported that, relative to healthy people, patients with psoriasis experience an increased prevalence of:

        • Obstructive sleep apnoea – between 36%–81.8% of patients with psoriasis experience this condition, compared to just 2%-4% of the general population.
        • Restless legs syndrome – between 15.1%–18% of patients with psoriasis experience this condition, compared to 5%–10% of European and North Americans without this psoriasis.

As many as 78% of psoriasis patients believe their condition is worsened by stress, according to a review study (Heller 2011). While studies supporting this link only provide correlation evidence, a likely mechanism involved is dysregulation of the hypothalamus-pituitary-adrenal (HPA) and the sympathetic adrenomedullary systems (Evers 2010).As many as 78% of psoriasis patients believe their condition is worsened by stress, according to a review study (Heller 2011). While studies supporting this link only provide correlation evidence, a likely mechanism involved is dysregulation of the hypothalamus-pituitary-adrenal (HPA) and the sympathetic adrenomedullary systems (Evers 2010).

Functional Medicine Australia and psoriasis

At the Australian Centre for Functional Medicine, we apply an updated, comprehensive, and modern approach to functional medicine and psoriasis.

        • We have a research and innovation team that informs clinicians about the latest and best supported clinical research available on psoriasis and we apply this knowledge to our testing, treatments and framework. We have a solid understanding of the current research on psoriasis and apply this knowledge in our treatments.
        • Our approach is backed by years of research and education from world leaders in the fields of autoimmune disease and psoriasis. We apply comprehensive advanced testing (e.g. Blood chemistry, breath, stool, urine) which provides critical information about the mechanisms in your body driving your health and disease.
        • We design personalised treatment plans based on solid results from advanced diagnostic testing, accompanied by a clear understanding of who you are and what life you are trying to live.
 
For the treatment of psoriasis, and depending on each patient, we may design personalised treatment plans involving:
 
        • Optimal diet – this may involve eating whole foods with anti-inflammatory properties, like wild fish and other sources of omega-3 fats, red and purple berries (rich in polyphenols), dark green leafy vegetables, sweet potatoes and nuts.
        • Identifying and removing food that cause allergies or sensitivities.
        • Testing and treating heavy metal toxicity.
        • Testing your gut microbiota status and treating any cases of yeast or fungal overgrowth, gut dysbiosis or small intestinal bacterial overgrowth (SIBO).
        • The use, if necessary, of high-quality supplements, like cod liver oil and fish oil, vitamin D and probiotics as well as anti-inflammatory nutrients like quercetin and grape seed extract.
        • Regular exercise, which has natural anti-inflammatory effects.
        • Stress reduction, which may involve calming techniques such as yoga, deep breathing, biofeedback, or massage, which can reduce stress and anxiety.
        • Sleep management and supplementation, sleep is a core component of a healthy body and an important aspect to address when treating an autoimmune disease.

access your fully comprehensive workup for psoriasis

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