A  Comparative Review on Conventional and Traditional medicine in the Treatment of Psoriasis

Sakthi Priyadarsini S*, Vani PB, Kumar PR

Department of Pharmacognosy, SRM College of Pharmacy, SRM Institute of Science and Technology, Kattankulathur-603203.

ABSTRACT:

Psoriasis is characterized by hyperproliferation of cells with itchy and painful skin patches due to the failure of replacement of dead skin cells every three to four weeks that occur in a normal skin. Therapeutic strategies for psoriasis depend upon the severity and location of lesions. Conventional treatments include phototherapy, photochemotherapy and systemic therapy involving biologicals and immunomodulators. The synthetic drugs in use for treating psoriasis are associated with severe adverse effects. Patient affordability, intolerance, drug resistance, serious adverse events play a crucial role in the choice of systemic therapy. Eventhough biologicals might be life saving in cases of severe psoriasis, risks of infection in particular reactivation of latent tuberculosis and possibilities of cancer on prolonged treatment demands safe and efficient alternative treatments. Easy availability, better patient tolerance, affordability, multiple modes of biochemical action and acceptability strengthens the use of natural products for psoriasis. This comparative review documents the existing natural treasure with various plant extracts and secondary metabolites reported as antipsoriatic agents over conventional drugs and their associated adverse effects in the management of psoriasis.

INTRODUCTION:

Psoriasis is considered as a multifactorial autoimmune disorder affecting 1-3% of world’s population, prevalent in temperate rather than tropical climate.^[1] It is characterised by hyperproliferation of cells with itchy and painful skin patches due to the failure in the replacement of dead skin cells every three to four weeks that occur in a normal skin. This disfiguring and highly stigmatizing inflammatory disease can affect the entire skin including scalp, nails and genital area under arms, under breasts, insides of knees and elbows.^[2] The disease manifestation affects the various aspects of day to day life and project a greater psychological impact on the lives of family members.^[3] Inspite of its emotional stress and poor self-esteem affecting the quality of life the disease still remains underexplored and undertreated.^[4,5]

While the synthetic drugs currently used for psoriasis are associated with severe adverse effects, the promising, safe and effective alternative treatments strengthen the use of natural drugs for psoriasis. In this review we document the potential herbal extracts and its active metabolites in the treatment of psoriasis in comparison to the conventional treatment.

Clinical features:

The common clinical features include sharp demarcated chronic erythematous plaques with silvery white scales in scalp, elbows, knees, umbilicus and lumbar area. Psoriasis exists in the form of plaque, guttate, pustular, inverse, erythrodermic and psoriatic arthritis. Plaque psoriasis also called as psoriasis vulgaris, is the common form of psoriasis characterised by sharply demarcated, coin shaped nummular plaques. Plaque psoriasis can be rupoid or ostraceous. Rupoid plaques are highly hyperkeratotic and appear as limpet shells whereas ostraceous plaques resemble oyster shells with concave centers.^[6] In Guttate psoriasis, small tear drop lesions ranging from 10 to more than 100 erupt over the trunk in a centripetal fashion. This type of psoriasis mostly affects children or adolescents having a family history of psoriasis followed by group-A streptococcal infections of upper trunk and proximal extremities.^[6,7] In flexural (inverse) psoriasis, well demarcated reddish shiny plaques are seen and are devoid of scales.^[6]

In Pustular psoriasis, reddish painful blisters of non infectious pus appear on the skin, which coalesce forming sheets triggered by withdrawal of corticosteroids, respiratory tract infections and local irritants.^[2,8] Erythrodermic psoriasis involves generalized inflammatory erythema occurring in more than 90% of skin surface area.^[8,9] Psoriasis also occurs in the form of joint inflammation exhibiting symptoms of arthritis in the case of psoriatic arthritis.^[2]

Disease Histopathology:

In a psoriatic skin, cutaneous cells show several pathological changes. At its earliest manifestation, elongation and dilatation of blood vessels with edema and lymphocytic infiltration resulting in scattered neutrophils are observed at the edge of mounds of parakeratosis. During the advanced stages, thickening of stratum spinosum and hyperplasia with elongated rete ridges are seen. The major diagnostic features are munromicroabscesses and spongiform pustule of Kogoj. At its later stages, lesions are orthokeratosis and also characterized by intact granular layer and exocytosis of inflammatory cells.^[10-12]

Genetic Background:

Psoriasis remain to be a chronic inflammatory dermatosis associated with altered growth and differentiation of resident skin cells with increased susceptibility to more than 1300 genes.^[13] Out of the most extensively studied regions, the psoriasis susceptibility 1 (PSORS1) region was most associated accounting for 35% to 50% of the disease heritability.^[14,15] DNA sequencing and ancestral haplotype mapping of PSORS 1 suggested human leukocyte antigens-C (HLA-C) as the causative gene and normal HLA-Cw6, the susceptible allele to be strongly associated with psoriasis at its early onset with higher incidence of guttate type^.[16,17]

Triggering factors:

Tonsillar streptococcal pyrogens in addition to bacterial, viral, fungal infections remain a causative factor responsible for psoriasis.^[18] Psychological and emotional stress play a crucial role in triggering psoriasis.^[19,20,21] Drugs including beta blocker, lithium, synthetic antimalarials, NSAIDs and tetracyclin in addition to smoking, alcohol intake, excess body weight, weather and climate also exacerbate psoriasis.^[18,22,23] These factors play an inducing role with genetically susceptible patients in the development of psoriasis.

Conventional treatment for Psoriasis:

The conventional treatment for psoriasis depends upon the severity and location of lesions. First line topical treatments were suggested for mild to moderate psoriasis. This includes corticosteroids, vitamin D3 analogues and calcipotriol betametasone dipropionate combination products. Calcipotriol, a vitamin D3 analogue is the choice for plaque psoriasis and scalp psoriasis. Around 57 adverse effects were reported in a randomized, double blind, right/left comparison study of calcipotriol and betamethasone valerate involving 345 patients with psoriasis vulgaris.^[24-26] Phototherapy with PUVA is associated with phototoxic reactions along with erythema, pruritis and epidermal dystrophy.^[27-29]

Hepatic, renal, myelosuppressive, infectious and lipidemic disturbances, mild gastrointestinal intolerance and fatigue were observed in a retrospective review on systemic psoriatic therapy including 753 patients.^[30] Acitretin is the drug of choice for pustular and erythrodermic psoriasis. Teratogenecity, hepatitis, hyperlipidemia, pancreatitis, pseudotumorcerebri in addition to mucocutaneous side effects viz., cheilitis, skin peeling, alopecia were reported in patients treated with acitretin.^[31,32] The immunosuppresants including methotrexate and cyclosporine were also reported with serious toxicities and significant adverse effects.^[33-40] The systemic biologic agents specifically target the components of immune system involved in the pathophysiology of psoriasis. TNF-α inhibitors as in etanercept, infliximab and adalimumab or interleukin IL-12/23p40 inhibitors, ustekinumab are reported with incidences of tuberculosis reactivation and malignancy.^[41-50] Conventional drugs for psoriasis along with their associated adverse effects were tabulated in Table 1.

Table 1: Anti Psoriatic Drugs under Conventional treatment

Table 2: Anti-psoriatic plants and their mechanism of action

Givotia rottleriformis

Role of traditional medicine in Psoriasis:

Plant resources in the form of extracts, fractions, isolated compounds or formulations have been widely used in the treatment of psoriasis. Natural drugs from the plants has many advantages such as easy availability, non toxic, better patient tolerance, fewer side effects, affordability, more than one mode of biochemical action and acceptability.^[51] Selected medicinal plants reported for psoriasis were tabulated along with the mechanism of action.^[52-62] (Table 2)

DISCUSSION AND CONCLUSION:

Past few decades had been very crucial in the drug development and treatment of psoriasis. The current therapeutic guidelines is not completely convincing for the patients due to their behavioral and psychological side effects disturbing the quality of life.^[65,66] The understanding of immunological pathways with their efficacy and long term safety validates the current therapy with biologicals. Eventhough biologics are safe and well tolerated, the adverse effects associated with them including serious oppurtunistic infections, development of active tuberculosis, lymphoma, leukemia, and melanomas are also a matter of concern. ^[67,68,69]

Steroids suppress immune system and inflammation but when discontinued provokes the inflammatory response if the allergens are not neutralized. Side effects associated with long term usage include reduced secretion in pituitary and adrenal gland leading to thinning of dermis layer, loss of melanin, microvascular proliferation of skin.^[70] It was considered that insufficient intake of antioxidants can also be a cause for the development of the disease.^[71]

Polyphenols known for its anti-inflammatory and anti-proliferative activity were found to downregulate calgranulins A and B genes thereby reducing the inflammation in immortalised keratinocytes.^[72] Indirubin from Indigo naturalis has been reported for the treatment of nail psoriasis and plaque psoriasis. ^{[73, 74, 75]} It was found that the indirubin act by upregulation of claudin-1 expression in human keratinocytes.^[76]

Isoliquiritigenin, a flavanoid component of liquorice also provides a promising effect in the treament of psoriasis by exhibiting NF-κB suppression activity thereby downregulating IL-6 and IL-8 cytokine.^[77,78,79] Studies suggested that isoflavone extract from soybean cake proved to be a potential anti-psoriatic agent. The therapeutic efficacy was attributed to its in vitro effects in normal human epidermal keratinocytes by inhibiting IL-22, IL-17A, and TNF-α-induced MAPK, NF-κB, and JAK-STAT activation.^[80] Thus these studies associated with cytokine gene polymorphisms, dose, efficacy, molecular mechanisms of natural compounds prove their potential and promising role in psoriasis.

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Received on 20.12.2019           Modified on 13.02.2020

Accepted on 24.04.2020         © RJPT All right reserved