Combination therapy with low-dose etretinate and eicosapentaenoic acid for psoriasis vulgaris

Herring roe oil in treatment of psoriasis - influence on immune cells and cytokine network

Background

Psoriasis is a chronic immune-mediated skin disease with systemic inflammation and comorbidities. Although the disease severity may vary over time, many patients suffer from mild to moderate disease. Often local treatment will be sufficient to control the symptoms, but they may have several side effects. ω-3 polyunsaturated fatty acids have shown promising results in clinical trials with mild-to-moderate psoriasis.

Methods

We explored the impact of phospholipid bound docosahexaenoic acid and eicosapentaenoic acid in a 3:1 ratio on immune cells and cytokine networks in peripheral blood of patients with psoriasis. We investigated the inter-relation of plasma cytokine levels and disease severity in 58 patients, and explored the status of circulating immune cell activity in 18 patients with non-severe psoriasis before and during herring roe oil supplementation. Plasma concentration of 22 cytokines was measured by Luminex technology and circulating immune cells were analyzed by multicolor flow cytometry.

Results

CCL2 levels decreased over time, and IFN-γR1 increased, possibly related to the action of ω-3 polyunsaturated fatty acids. We observed a shift from naïve to effector CD4+ T cells and decreases of CD38 expression on CD4+ and CD8+ T cells, CD56bright NK cells and CD14+CD16- classical monocytes.

Conclusions

These findings support the beneficial effect of herring roe oil supplementation.

Single-cell transcriptomic landscape of immunometabolism reveals intervention candidates of ascorbate and aldarate metabolism, fatty-acid degradation and PUFA metabolism of T-cell subsets in healthy controls, psoriasis and psoriatic arthritis

Introduction

The modulation of immunometabolic pathways is emerging as a promising therapeutic target for immune-mediated diseases. However, the immunometabolic features of psoriatic disease and the potential targets for immunometabolic intervention in the different T-cell subsets involved in its pathogenesis remain unclear.

Methods

In this study, we analyzed circulating blood single-cell data from healthy controls (HC), psoriasis (PSO), and psoriatic arthritis (PSA) patients, and revealed their metabolic features of T-cell subsets: CD4+ central memory T cells (TCMs), CD8+ effective memory T cells (TEMs), regulatory T cells (Tregs), mucosal-associated invariant T cells (MAITs ), and γδ T cells. Pearson test was performed to determine the linkages between differential metabolic and inflammatory pathways. Based on these results, we also analyzed the potential impacts of biological antibodies on differential metabolic pathways by comparing the immunometabolism differences between PSA patients without and with biological treatment.

Results

Our results suggest that upregulation of ascorbate and aldarate metabolism, as well as fatty acid degradation, may enhance the immune suppression of Tregs. Enhanced metabolism of alpha-linolenic acid, linoleic acid, and arachidonic acid may inhibit the pro-inflammatory functions of CD4+ TCMs and CD8+ TEMs in PSO and PSA, and protect the immune suppression of Tregs in PSA. We propose that supporting ascorbic acid and fatty acid metabolic pathways may be an adjunctive reprogramming strategy with adalimumab and etanercept therapy.

Discussion

These findings not only provide insights into immunometabolism characteristics of psoriatic disease, but also offer preliminary options for the auxiliary treatment of psoriasis.

Oxidative Stress Induced by High Salt Diet—Possible Implications for Development and Clinical Manifestation of Cutaneous Inflammation and Endothelial Dysfunction in Psoriasis vulgaris

Although oxidative stress is recognized as an important effector mechanism of the immune system, uncontrolled formation of reactive oxygen and nitrogen species promotes excessive tissue damage and leads to disease development. In view of this, increased dietary salt intake has been found to damage redox systems in the vessel wall, resulting in endothelial dysfunction associated with NO uncoupling, inflammation, vascular wall remodeling and, eventually, atherosclerosis. Several studies have reported increased systemic oxidative stress accompanied by reduced antioxidant capacity following a high salt diet. In addition, vigorous ionic effects on the immune mechanisms, such as (trans)differentiation of T lymphocytes are emerging, which together with the evidence of NaCl accumulation in certain tissues warrants a re-examination of the data derived from in vitro research, in which the ionic influence was excluded. Psoriasis vulgaris (PV), as a primarily Th17-driven inflammatory skin disease with proven inflammation-induced accumulation of sodium chloride in the skin, merits our interest in the role of oxidative stress in the pathogenesis of PV, as well as in the possible beneficial effects that could be achieved through modulation of dietary salt intake and antioxidant supplementation.

Dietary Intervention and Supplements in the Management of Psoriasis: Current Perspectives

Nutrition is a complex topic encompassing diet and a variety of supplements including vitamins, fish oil, herbal products, and probiotics. Patients with psoriasis display high interest in understanding the potential impact of nutritional modifications on their psoriasis. In this review, we examine the evidence for nutritional interventions in psoriasis and summarize important concepts. We found that certain diets, such as low-calorie diets for obese patients, gluten-free diets for patients with comorbid celiac disease, and the Mediterranean diet, may have benefits for psoriasis patients. Supplements in general do not show strong evidence of benefit, though more studies are required given the heterogeneity of these trials. Finally, the gut microbiome has drawn considerable interest in recent years, with specific probiotics showing promising results for psoriasis patients and warranting further exploration.

The Effect of Lifestyle Changes on Disease Severity and Quality of Life in Patients with Plaque Psoriasis: A Narrative Review

Objective

To evaluate the effect of lifestyle changes on the severity of psoriasis and the quality of life in patients with psoriasis.

Methods

For this narrative review, PubMed, Embase and ClinicalTrials.gov were searched for lifestyle intervention studies with an intervention duration of at least 12 weeks.

Results

Thirty-four intervention studies were included. Most studies performed interventions in the diet of patients with psoriasis (n=9), or added supplements to the diet (n=18). Three studies comprised relaxation techniques and four studies combined relaxation or stress-reducing techniques with an educational program or exercise. No interventional studies were carried out regarding smoking, alcohol and sleep. Especially dietary and relaxation interventions showed promising results with respect to psoriasis severity and dermatology-related QoL, respectively. Regarding dietary supplements, the three largest studies investigating fish oil or vitamin D did not show significant effects.

Conclusion

There is some evidence that dietary and relaxation interventions could be promising with respect to psoriasis severity and dermatology-related QoL, respectively. Furthermore, our review identified important gaps in psoriasis lifestyle research regarding study design and reporting of outcomes.

Dietary habits and perceptions of psoriatic patients: Mediterranean versus Asian diets

BACKGROUND

Mediterranean diets have been reported to improve psoriasis. Asian food has a unique character and differs from Mediterranean diets.

METHODS

This study compared the dietary intake of psoriatic patients and individuals without psoriasis, and investigated the association between diet and psoriasis severity. Data were collected on the frequency of consumption of Mediterranean and Asian diets.

RESULTS

One-hundred psoriatic patients and 100 individuals (age- and sex-matched controls) was conducted. In the case of the anti-inflammatory diets, the psoriatic patients consumed significantly less olive oil, berry fruits, fish, seafood, tree nuts, and eggs than the controls. As to the pro-inflammatory diets, greater quantities of dairy products and soft drinks were consumed by the psoriatic patients than the controls. Regarding Asian food, the patients consumed significantly less pickled foods and brown rice/Riceberry (a rice variety), but more coconut milk, than the controls. In terms of psoriasis severity, the patients with lower severities consumed significantly more vegetables; in contrast, a higher consumption of red meat, belly meat, and instant noodles was associated with greater psoriasis severities.

CONCLUSIONS

Our study adds further information on the role of diets-especially Asian diets-and psoriasis. These data should help patients and clinicians to focus more clearly on diet management.

The Effect of Antioxidant and Anti-Inflammatory Capacity of Diet on Psoriasis and Psoriatic Arthritis Phenotype: Nutrition as Therapeutic Tool?

Chronic inflammation and increased oxidative stress are contributing factors to many non-communicable diseases. A growing body of evidence indicates that dietary nutrients can activate the immune system and may lead to the overproduction of pro-inflammatory cytokines. Fatty acids as macronutrients are key players for immunomodulation, with n-3 polyunsaturated fatty acids having the most beneficial effect, while polyphenols and carotenoids seem to be the most promising antioxidants. Psoriasis is a chronic, immune-mediated inflammatory disease with multifactorial etiology. Obesity is a major risk factor for psoriasis, which leads to worse clinical outcomes. Weight loss interventions and, generally, dietary regimens such as gluten-free and Mediterranean diet or supplement use may potentially improve psoriasis’ natural course and response to therapy. However, data about more sophisticated nutritional patterns, such as ketogenic, very low-carb or specific macro- and micro-nutrient substitution, are scarce. This review aims to present the effect of strictly structured dietary nutrients, that are known to affect glucose/lipid metabolism and insulin responses, on chronic inflammation and immunity, and to discuss the utility of nutritional regimens as possible therapeutic tools for psoriasis and psoriatic arthritis.

Joint AAD-NPF Guidelines of care for the management and treatment of psoriasis with topical therapy and alternative medicine modalities for psoriasis severity measures

Psoriasis is a chronic, inflammatory, multisystem disease that affects up to 3.2% of the United States population. This guideline addresses important clinical questions that arise in psoriasis management and care and provides recommendations based on the available evidence. The treatment of psoriasis with topical agents and with alternative medicine will be reviewed, emphasizing treatment recommendations and the role of dermatologists in monitoring and educating patients regarding benefits as well as risks that may be associated. This guideline will also address the severity assessment methods of psoriasis in adults.

Nutrition and Psoriasis

Psoriasis is a chronic inflammatory skin disease characterized by accelerated tumor necrosis factor-α/interleukin-23/interleukin-17 axis, hyperproliferation and abnormal differentiation of epidermal keratinocytes. Psoriasis patients are frequently associated with obesity, diabetes, dyslipidemia, cardiovascular diseases, or inflammatory bowel diseases. Psoriasis patients often show unbalanced dietary habits such as higher intake of fat and lower intake of fish or dietary fibers, compared to controls. Such dietary habits might be related to the incidence and severity of psoriasis. Nutrition influences the development and progress of psoriasis and its comorbidities. Saturated fatty acids, simple sugars, red meat, or alcohol exacerbate psoriasis via the activation of nucleotide-binding domain, leucine-rich repeats containing family, pyrin domain-containing-3 inflammasome, tumor necrosis factor-α/interleukin-23/interleukin-17 pathway, reactive oxygen species, prostanoids/leukotrienes, gut dysbiosis or suppression of regulatory T cells, while n-3 polyunsaturated fatty acids, vitamin D, vitamin B12, short chain fatty acids, selenium, genistein, dietary fibers or probiotics ameliorate psoriasis via the suppression of inflammatory pathways above or induction of regulatory T cells. Psoriasis patients are associated with dysbiosis of gut microbiota and the deficiency of vitamin D or selenium. We herein present the update information regarding the stimulatory or regulatory effects of nutrients or food on psoriasis and the possible alleviation of psoriasis by nutritional strategies.

The Potential Uses of Omega-3 Fatty Acids in Dermatology: A Review

BACKGROUND

A growing interest exists in the relationship between diet and skin disease, with many recent studies identifying a role for omega-3 fatty acids (O3FAs) in various dermatological conditions.

OBJECTIVE

Our objective was to identify the spectrum of uses for O3FA supplementation reported in literature and to evaluate the current level of evidence for its clinical application in skin disease prevention and management.

METHODS

A search was conducted using Ovid MEDLINE for primary literature that examined O3FA intake and skin health. A manual search of reference lists was performed to identify additional articles for inclusion.

RESULTS

A total of 38 studies met eligibility for review, reporting benefits for O3FA supplementation in the treatment of psoriasis, atopic dermatitis, acne, and skin ulcers. Additionally, a reduced incidence of skin cancer and a decrease in the severity of drug-associated mucocutaneous side effects were reported with O3FA supplementation.

CONCLUSION

This review yielded many well-studied benefits of O3FA uses in dermatology. Given its high safety profile, low cost, and ease of supplementation, O3FA is a reasonable supplement that may benefit patients wishing to improve inflammatory skin conditions through diet. Areas of particular clinical interest where supplementation may be valuable include O3FAs for systemic UV photoprotection, as well as adjuvant treatment for acne to reduce both inflammatory lesion count and the severity of mucocutaneous side effects associated with isotretinoin use.

Efficacy of fish oil and its components in the management of psoriasis: a systematic review of 18 randomized controlled trials

Context

Fish oil and omega-3 polyunsaturated fatty acids (ω-3 PUFAs) have anti-inflammatory properties, but their effect on psoriasis and its comorbidities remains inconclusive.

Objective

The aim of this quantitative systematic review was to evaluate the efficacy and safety of fish oil and its components in the treatment of psoriasis and its comorbidities.

Data Sources

PubMed, Embase, Cochrane Central Register of Controlled Trials, China Network Knowledge Infrastructure, China Science and Technology Journal Database, and Wanfang databases were searched from inception to March 30, 2019.

Study Selection

Randomized controlled trials were eligible for inclusion if they measured the effect of fish oil and its components in the treatment of patients with psoriasis.

Data Extraction

Eighteen randomized controlled trials involving 927 study participants were included.

Results

Monotherapy with fish oil or ω-3 PUFAs had no effect on the Psoriasis Area and Severity Index (PASI) score (P = 0.47), lesion area (P = 0.34), or pruritus (P = 0.62). Fish oil or ω-3 PUFAs combined with conventional treatments, however, resulted in a decreased PASI score (mean difference [MD], −3.92; 95%CI, −6.15 to −1.69; P = 0.0006) and lesion area (MD, −30.00; 95%CI, −33.82 to −26.18; P < 0.0001). Safety evaluation suggested no between-group differences. Fish oil and its components reduced certain risk factors for obesity, cardiovascular disease, and metabolic disease in patients with psoriasis and also regulated several inflammatory mediators.

Conclusions

Overall, when combined with conventional treatments, fish oil and its components may have beneficial effects on psoriasis and its comorbidities, including obesity, cardiovascular disease, and metabolic disease.

Systematic Review Registration

PROSPERO registration number CRD42019128631.

Effects of fish oil supplement on psoriasis: a meta-analysis of randomized controlled trials

BACKGROUND

Fish oils, which contain omega-3 polyunsaturated fatty acids as the active ingredients, possess anti-inflammatory activities and may have therapeutic potential in diseases with an inflammatory etiology. Fish oil supplement has been advocated for treating psoriasis which is a chronic inflammatory dermatosis.

OBJECTIVE

We aimed to investigate the effects of fish oil supplement on psoriasis.

METHODS

We searched CENTRAL, Embase and MEDLINE on 24 January 2018 for randomized control trials (RCTs) on the effects of fish oil supplement in treating psoriasis. The Cochrane Collaboration's tool was used to assess the risk of bias of included RCTs. We performed a random-effects model meta-analysis to obtain the pooled treatment effect estimates.

RESULTS

We included 13 RCTs with 625 participants. Three RCTs involving 337 participants provided usable data for meta-analysis. Fish oil supplement did not significantly reduce the severity of psoriasis when assessed by Psoriasis Area and Severity Index score (mean difference - 0.28; 95% confidence interval - 1.74 to 1.19).

CONCLUSION

The current evidence does not support the use of fish oil supplement in treating psoriasis.

Dietary Behaviors in Psoriasis: Patient-Reported Outcomes from a U.S. National Survey

INTRODUCTION

Psoriasis patients demonstrate high interest in the role of diet on their skin condition. However, data are lacking to describe dietary interventions among psoriasis patients and associated outcomes. This study aims to identify common dietary habits, interventions and perceptions among patients with psoriasis, and to examine patient-reported skin outcomes in response to these interventions.

METHODS

We administered a 61-question survey to the National Psoriasis Foundation membership asking psoriasis patients about dietary habits, modifications, skin responses, and perceptions.

RESULTS

A total of 1206 psoriasis patients responded to the survey. Compared to age- and sex-matched controls, psoriasis patients consumed significantly less sugar, whole grain fiber, dairy, and calcium (p < 0.001), while consuming more fruits, vegetables, and legumes (p < 0.01). Eighty-six percent of respondents reported use of a dietary modification. The percentage of patients reporting skin improvement was greatest after reducing alcohol (53.8%), gluten (53.4%), nightshades (52.1%), and after adding fish oil/omega-3 (44.6%), vegetables (42.5%), and oral vitamin D (41%). Specific diets with the most patients reporting a favorable skin response were Pagano (72.2%), vegan (70%), and Paleolithic (68.9%). Additionally, 41.8% of psoriasis respondents reported that a motivation for attempting dietary changes was to improve overall health.

CONCLUSION

This national survey is among the first to report the dietary behaviors of patients with psoriasis. The data provided from this large cohort may benefit patients and clinicians as they discuss the role of diet in managing both psoriasis and associated cardiometabolic comorbidities.

Psoriasis treatment: Unconventional and non-standard modalities in the era of biologics

Psoriasis is a potentially debilitating inflammatory dermatosis affecting 0.2%-4.8% of the population worldwide causing a significant occupational, personal or psychosocial morbidity to these patients for life. The basic aim of psoriasis therapy is to control the disease to maximum possible extent and improve the patient’s quality of life. Management of triggers for flare-ups, lifestyle modifications, and dietary supplements are often recommended. Intermittent or rotational therapy with frequent alterations in treatment options is usually needed to reduce toxicity of anti-psoriatic drugs in the absence of safer alternatives. Currently, several biological agents categorized as either T-cell targeted (e.g., Alefacept, Efalizumab) or cytokine modulating (e.g., Adalimumab, Infliximab, Etanercept) are available for treating severe psoriasis. However, their high cost is often precluding for most patients. The usefulness of systemic (methotrexate, cyclosporine, acitretin or several other therapeutic agents) or topical (tar, anthralin, corticosteroids or calcipotriol ointments, phototherapy with or without psoralens) therapies has been well established for the management of psoriasis. The literature is also replete with benefits of less used non-standard and unconventional treatment modalities (hydroxycarbamide, azathioprine, leflunomide, mycophenolate mofetil, isotretinoin, fumarates, topical calcineurin inhibitors, peroxisome proliferator-activated receptors agonists, statins, sulfasalazine, pentoxifylline, colchicine, grenz ray therapy, excimer laser, climatotherapy and balneophototherapy, peritoneal dialysis, tonsillectomy, ichthyotherapy, etc.). These can be used alternatively to treat psoriasis patients who have mild/minimal lesions, are intolerant to conventional drugs, have developed side effects or achieved recommended cumulative dose, where comorbidities pose unusual therapeutic challenges, or may be as intermittent, rotational or combination treatment alternatives.

Diet and psoriasis, part III: role of nutritional supplements

Patients with psoriasis are increasingly turning to the use of alternative and complementary medicine to manage their psoriasis. Patients often inquire about what dietary supplements may be beneficial, including the use of oral vitamin D, vitamin B12, selenium, and omega-3 fatty acids in fish oils. In this review we examine the extent to which each of these common nutritional interventions has been studied for the treatment of psoriasis. We weighed evidence from both controlled and uncontrolled prospective trials. The evidence of benefit was highest for fish oils. For other supplements, there is need for additional large, randomized clinical trials to establish evidence of efficacy.

Integrative dermatology for psoriasis: facts and controversies

Recommendations for changes in diet and lifestyle are not meant to supplant conventional therapy but to integrate with it and, hopefully, improve response to treatment. At the same time, integrative approaches permit the patient to depend less on more expensive and potentially harmful pharmaceutical and medical approaches. Manipulation of diet and lifestyle may actually diminish the effect of underlying predisposing or etiologic factors and simultaneously treat serious comorbidities. Topics include alcohol, smoking, body composition, sleep and stress, diet and nutrients, and exercise.

Complementary and alternative medicine for psoriasis: a qualitative review of the clinical trial literature

BACKGROUND

Patients with psoriasis often inquire about complementary and alternative medicine in an effort to do everything possible to control the disease.

OBJECTIVE

We sought to review the clinical trial literature regarding complementary and alternative medicine for the treatment of psoriasis.

METHODS

We conducted qualitative systematic review of randomized, clinical trials.

RESULTS

Although many randomized controlled trials were found, both the results and the quality of the studies varied.

LIMITATIONS

The main limitations were the relatively low quality of studies (as assessed by Jadad scores), lack of inclusion of unpublished studies, and the fact that only one author determined inclusion of studies and assignment of Jadad scores.

CONCLUSION

There is a large body of literature in regard to complementary and alternative medicine for the treatment of psoriasis. More work is necessary before these modalities should be recommended to our patients.

Fatty acids from lipids of marine organisms: molecular biodiversity, roles as biomarkers, biologically active compounds, and economical aspects

Because of their characteristic living environments, marine organisms produce a variety of lipids. Fatty acids constitute the essential part of triglycerides and wax esters, which are the major components of fats and oils. Nevertheless, phospholipids and glycolipids have considerable importance and will be taken into account, especially the latter compounds that excite increasing interest regarding their promising biological activities. Thus, in addition to the major polyunsaturated fatty acids (PUFA) such as eicosapentaenoic (EPA) and docosahexaenoic (DHA) acids, a great number of various fatty acids occur in marine organisms, e.g. saturated, mono- and diunsaturated, branched, halogenated, hydroxylated, methoxylated, non-methylene-interrupted. Various unprecedented chemical structures of fatty acids, and lipid-containing fatty acids, have recently been discovered, especially from the most primitive animals such as sponges and gorgonians. This review of marine lipidology deals with recent advances in the field of fatty acids since the end of the 1990s. Different approaches will be followed, mainly developing biomarkers of trophic chains in marine ecosystems and of chemotaxonomic interest, reporting new structures, especially those with biological activities or biosynthetic interest. An important part of this review will be devoted to the major PUFA, their relevance to health and nutrition, their biosynthesis, their sources (usual and promising) and market.

Tazarotene combination treatments in psoriasis

In the hope of increasing efficacy and improving safety, several combination regimens involving tazarotene gel have been explored for the treatment of plaque psoriasis. A number of large-scale studies have shown that the adjunctive use of a mid-potency or high-potency steroid can enhance both the efficacy and tolerability of tazarotene treatment. A small pilot study also suggested improved efficacy when used in combination with calcipotriene. Likewise, the adjunctive use of tazarotene can enhance the efficacy and potentially the safety of treatment with steroids, broad-band and narrow-band UVB phototherapy, and psoralens plus UVA bath therapy.