Oral (Systemic) Botanical Agents for the Treatment of Psoriasis: A Review

Abstract

Introduction:

Patients with psoriasis often use botanical therapies as part of their treatment. It is important for clinicians to be aware of the current evidence regarding these agents as they treat patients.

Methods:

A systematic literature search was conducted using the PubMed, MEDLINE, and EMBASE database for randomized clinical trials assessing the use of botanical therapeutics for psoriasis. The search included the following keywords: “psoriasis” and “plant” or “herbal” or “botanical.” Citations within articles were also reviewed to identify relevant sources. The results were then further refined by route of administration, and the oral (systemic) botanical agents are reviewed herein.

Results:

A total of 12 controlled and uncontrolled clinical trials addressing the use of oral, systemic botanical agents for psoriasis were assessed in this review. While overall evidence is limited in quantity and quality, HESA-A, curcumin, neem extract, and, to a lesser degree, Traditional Chinese Medicine seem to be the most efficacious agents.

Conclusion:

The literature addresses a large amount of studies in regards to botanicals for the treatment of psoriasis. While most agents appear to be safe, further research is necessary for evidence-based recommendation of oral botanical agents to psoriasis patients.

Introduction

Psoriasis is a chronic, relapsing inflammatory skin disease characterized by redness, silvery scales, flaking, pruritus, skin tightness, pain, and bleeding. It carries a strong physical and emotional burden, and affects more than seven million adults in the United States.¹ Currently available treatments for psoriasis include topical agents such as emollients, tars, topical corticosteroids, vitamin A and vitamin D analogs, and, for more severe disease, systemic agents such as apremilast, corticosteroids, methotrexate, cyclosporine, mycophenalate mofetil, and biologic agents. While newer biologic agents can decrease body surface area affected by at least 10%, <10% of psoriasis patients report using systemic or biologic therapies.^2,3 Adverse effects, need for consistent laboratory monitoring, and loss or lack of efficacy are commonly cited reasons for the decreased use of systemic agents.³ Treatment dissatisfaction presents a major barrier to achieving optimal care for psoriasis patients.⁴

Up to 62% of patients with psoriasis turn to complementary and alternative medicine (CAM) to supplement or replace traditional treatments.⁵ CAM agents include botanical treatments, Traditional Chinese Medicine (TCM), dietary supplements, climatotherapy, and mind–body interventions, of which botanical agents are most commonly used for psoriasis.^5,6 In addition to dissatisfaction with traditional Western treatments, patients may choose CAM therapeutics due to a perceived lower side-effect profile or a preference for “natural” agents.⁷

Patient preference is an important part of a treatment decision, as the most effective treatments are those that the patient chooses to use on a regular basis. Patients may rely upon alternative therapies in addition to conventional therapies. A systematic review of the literature was performed in order to provide an up-to-date review of the current clinical evidence regarding the use of oral botanical agents for psoriasis. The review also aimed to identity which agents showed the most efficacy for use in psoriasis.

Methods

A systematic English-language literature search was conducted of PubMed, MEDLINE, and EMBASE through August 2016 to collect evidence-based data on the various botanical treatment modalities for psoriasis. Key search terms included (“botanicals,” “plants,” “herbs,” “traditional medicine,” “complementary medicine,” “Traditional Chinese Medicine,” or “Ayurveda”) and “psoriasis.” The initial search yielded 1973 articles. Selection criteria were limited to controlled and uncontrolled clinical trials testing only plant-based oral treatments for psoriasis. Blinding was not necessarily an inclusion criterion. Studies that were not in English, did not conduct trials on humans, or did not test plant-based treatments were excluded from the review. Reference lists in review articles were searched to identify any additional studies.^8
–10 Search terms were also used in combination. After critical evaluation of the remaining articles, 34 articles were selected that met criteria, and the review was further restricted to 12 articles that tested oral or systemic botanical agents. A flow chart depicting the selection criteria for trials is provided in Figure 1. Table 1 offers a comprehensive summary of each of the trials with different oral botanicals for plaque psoriasis.

FIG. 1.

Flowchart of selection of clinical trials.

Table 1.

Overview of Clinical Studies with Oral Botanicals for Psoriasis

Treatment and study (Jadad score)	N, type of psoriasis	Treatment regimen and control (C)	Study endpoints	Results/efficacy	Adverse effects
Non-TCM oral botanical agents
Alga Dunaliella bardawil capsules Greenberger et al.¹³ (3)	34, mild, chronic plaque psoriasis	One capsule/day for 12 weeks (C): placebo capsules	PASI and DLQI score	▪ At 6 weeks, reduction in mean PASI score was significantly higher in the Dunaliella group (61.3%) than it was in the placebo group (34%; p = 0.002) ▪ DLQI change did not reach significance (8.5% for Dunaliella vs. 5.9% for control group)	None
Curcumin tablet (meriva) and methylprednisolone aceponate (MA) 0.1% ointment Antiga et al.¹⁷ (4)	63, mild to moderate plaque psoriasis	Arm 1: MA 0.1% ointment once/day on lesions; 2 g/day of meriva Arm 2: MA 0.1% ointment, once/day on lesions; matching placebo tablets. Duration: 12 weeks (C): MA 0.1% ointment; placebo tablets	PASI score	▪ At baseline, median PASI values were 5.6 for arm 1 and 4.7 for arm 2 ▪ At 12 weeks, median PASI for arm 1 was 1.3 (p < 0.05 compared with baseline); median PASI for arm 2 was 2.4 (p < 0.05 compared with baseline). ▪ Reduction of PASI values was higher in arm 1 patients than it was in arm 2 patients (p < 0.05). ▪ Arm 1 patients also had a significant reduction of IL-22 serum levels from baseline (35.2) to 12 weeks (21.1; p < 0.001), compared to no change in IL-22 levels in arm 2 patients	One patient in arm 1 had diarrhea
Curcumin 500 mg capsules Kurd et al.¹⁶ (1)	12, moderate to severe plaque psoriasis	9 capsules (4.5 g/day) of curcumin for 12 weeks (C): None	PASI score and PGA.	▪ Only two subjects who completed the trial achieved PASI 75 or a PGA of excellent at week 12	GI upset or heat intolerance/hot flashes
HESA-A Ahmadi et al.¹⁹ (4)	28, chronic plaque psoriasis	25 mg/kg tablet twice/day for 6 months (C): Placebo tablet	Clinical determination of psoriasis severity	▪ At 6 months, 64.2% had clearance of psoriatic plaques and 35.8% had mild disease in the treatment group ▪ The placebo group showed no disease improvement	None
Barikbin et al.²⁰ (0)	19, chronic plaque psoriasis	30 mg/kg tablet/day for 4–30 weeks (C): None	PASI score	▪ Mean PASI score at baseline of 13.04 ▪ At end of study, mean PASI score reduced to 9.60 ▪ PASI score reduced in 73.7% and increased in 26.3% during the study ▪ Statistically significant correlation between the duration of treatment and PASI improvement (p = 0.024)	None
Marine oil and evening primrose oil combination Oliwiecki and Burton¹⁴ (3)	37, chronic stable plaque psoriasis	12 capsules/day for 24 weeks. In the first 4 weeks, all patients took placebo. (C): Placebo (liquid paraffin)	Investigator assessment of erythema, scaling, and overall severity	▪ No significant improvement in clinical severity of psoriasis or change in transepidermal water loss	None
Neem extract Pandey et al.²² (5)	50, uncomplicated plaque psoriasis	One capsule three times a day; 5% crude coal tar and 3% salicylic acid in Vaseline base ointment once/night. Sun exposure for 15 min the next day, for 12 weeks. (C): Placebo capsules along with same topical regimen	PASI score	▪ Mean PASI at baseline for treatment group 18.87 ± 7.36, while that of placebo group was 19.91 ± 6.48 ▪ Both groups showed decreased PASI scores ▪ Mean PASI score was significantly better for neem group compared with placebo group at 8 weeks (9.7 vs. 12.24; p < 0.05) and 12 weeks (4.74 vs. 9.47; p < 0.001)	None
Tripterygium wilfordii Hook F (TwHF) Wu et al.²⁴ (5)	115, moderate to severe plaque psoriasis	TwHF 20 mg three times a day with placebo tablet once daily (to mimic Acitretin) (C): Acitretin 30 mg daily, along with a placebo tablet three times a daily (to mimic TwHF)	75% improvement in PASI score (PASI 75) at weeks 2, 4, and 8	▪ Median PASI score improved in TwHF group by 50.4% compared with baseline (p < 0.0001) and in acitretin group by 42.7% compared with baseline (p < 0.0001) ▪ No significant difference in median PASI improvement between groups (p = 0.317) ▪ No significant difference in PASI 25, PASI 50, PASI 75, or PASI 90 response between groups at 2, 4, and 8 weeks (p > 0.05)	TwHF: significant increase in AST and triglyceride levels Acitretin: significant increase in ALT, cholesterol, and HDL levels
Traditional Chinese Medicine
TCM—Yinxieling decoction (radix rehmanniae recen, angelica sinensis, curcuma zedoary, chloranthus spicatus, rhizome, and others) Dai et al.²⁸ (1)	120, plaque psoriasis	Oral ingestion twice/day for 8 weeks (C): placebo (water mixed with caramel)	PASI scores, TNF-α, and IL-8 levels	▪ Decrease in PASI score from baseline to 8 weeks was significant (p < 0.05) in patient groups ingesting decoction vs. not significant in placebo group (p > 0.05) ▪ Decrease in TNF-α and IL-8 levels from baseline to 8 weeks was significant (p < 0.05) in patient groups ingesting decoction vs. not significant in placebo group (p > 0.05)	None reported
TCM (formula consisting of indigo naturalis, ephedra, ginger, cinnamon, mustard seed, and others) Ho et al.²⁹ (4)	61, chronic plaque psoriasis	Weekly ingestion of TCM, methotrexate (MTX), or placebo capsules for 6 months MTX dose was administered up to 30 mg/week (C): MTX and placebo	PASI score, PGA, and PDI	▪ Mean PASI at baseline was 22.0 ± 11.3 in MTX group, 18.9 ± 8.2 in TCM group, and 20.4 ± 10.8 in placebo group ▪ A 6 months, the scores were 5.7 ± 8.5 for MTX group, 16.0 ± 9.8 in TCM group, and 13.9 ± 10.1 in placebo group, yielding an improvement of 73.9%, 15.1%, and 32%, respectively ▪ MTX significantly more effective than TCM and placebo ▪ No significant difference between TCM and placebo ▪ MTX showed greater improvement in PGA and PDI	MTX: nausea, vomiting, trans-aminitis TCM: infections, GI upset, liver function abnormalities Placebo: infections and increased liver enzymes
TCM (formula consisting of dandelion, forsythia fruit, isatis, imperata rhizome 30 g, and others) Zhang et al.³⁰ (2)	80, plaque psoriasis	Group A: One acitretin 20–30 mg capsule/day and one TCM capsule/day for 8 weeks Group B: One TCM capsule/day for 8 weeks (C): Acitretin and TCM	PASI scores	▪ Group A baseline PASI 12.32 ± 3.20 vs. PASI after treatment: 3.81 ± 2.62 (p < 0.01) ▪ Group B baseline PASI 11.34 ± 2.86 vs. PASI after treatment: 4.50 ± 3.19 (p < 0.01) ▪ Compared to pretreatment in same group ▪ No significant difference between groups ▪ Efficacy in Group A was 84.2% vs. 68.2% in Group B (p < 0.01)	Group A: Dryness in mouth and eyes, cheilitis, pruritus, acral desquam-ation Group B: Diarrhea
TCM (formula consisting of Tufuling, Daqingye, Beidougen—multiple Rhizoma species) Song et al.²⁷ (0)	15, plaque psoriasis	Oral treatment ingested twice a day and ointment applied twice a day for 3 months (C): none	Skin biopsies with immunofluorescence analysis before and after treatment, PASI scores, and plaque index	▪ Patients with both acute and chronic disease showed significant decrease in PASI score and plaque index (p < 0.01) ▪ Patients with acute disease had improvement of PASI score from 30.0 to 3.0, and plaque index drop from 8.6 to 1.3 from baseline to 3 months (p < 0.01) ▪ Patients with chronic disease had PASI score drop from 16.1 to 7.3, and plaque index drop from 7.4 to 3.4 from baseline to 3 months (p < 0.01) ▪ Before starting with TCM therapy, all biopsies from the lesions showed Pso p27 positive cells ▪ After 3 months, 11 of 15 biopsies did not detect Pso p27 antigen	No serious side effects

PASI, Psoriasis Area and Severity Index; DLQI, Dermatology Life Quality Index; PGA, Physician Global Assessment; TCM, Traditional Chinese Medicine; MTX, Methotrexate; N, number of subjects that were included in each trial; GI, gastrointestinal; TNF-α, tumor necrosis factor alpha; IL-8, interleukin 8.

Assessment of the quality of the clinical trials included in the review was determined by the score of Jadad et al. (Table 1).¹¹ The Jadad quality measure assigns a score to clinical trials that ranges from 0 to 5, where 0 indicates inferior quality and 5 indicates superior quality. It addresses three primary components for a trial: randomization, double-blinding, and a description of withdrawals or dropouts. Randomization and double-blinding gain an additional point each if there is a description of the methods used to form the randomization or the double-blinding.

Results

The studies were conducted in academic hospitals around the world. The countries represented were the United States, Israel, Italy, Iran, the United Kingdom, India, and China. The severity of psoriasis that was treated ranged from mild to severe chronic plaque psoriasis. Most trials used the Psoriasis Area and Severity Index (PASI) tool to measure the severity of psoriasis (ex. PASI 75 is the percentage of patients who achieve 75% improvement from their baseline score). The age of patients in these studies overall was at least 18 years.

Alga Dunaliella bardawil

D. bardawil is a specific type of motile, unicellular green algae that is found in marine waters. The algae accumulates high concentrations of β-carotene, a retinoid precursor with a safe adverse effect profile.¹² Synthetic retinoids have long been used for the treatment of psoriasis, but are limited by potential side effects. Greenberger et al. reported the results of a controlled clinical trial examining daily intake of one Dunaliella capsule compared to placebo capsule in 34 patients with mild, chronic plaque psoriasis.¹³ After 6 weeks of treatment, there was a significantly higher reduction in the mean PASI score in the Dunaliella group compared with the placebo group (61.3% vs. 34%, respectively; p = 0.002). The difference in the Dermatology Life Quality Index (DLQI), however, was not significant. There were no significant changes in liver function tests or in lipid profiles among patients, and no adverse events were reported.

Marine oil and primrose oil

Essential fatty acids and their metabolites found in oils may be involved in the pathogenesis of psoriasis. Marine oil and primrose oil, rich in omega-3 and omega-6 fatty acids, respectively, may have the ability to reduce the production of proinflammatory eicosanoids that are involved in the pathogenesis of psoriasis. Oliwiecki and Burton reported the results of a clinical trial comparing combination marine oil and evening primrose oil to placebo in 37 patients with chronic stable plaque psoriasis.¹⁴ All patients received placebo capsules for the first 4 weeks of the study and were then randomized to continue placebo or take the trial medication, 12 capsules daily for 24 weeks. While no adverse effects were reported, the researchers did not note any significant improvement in the clinical severity of psoriasis with the combined marine oil and primrose oil capsules (p > 0.05).

Curcumin

Curcumin (dihydroferuloyl-methane), the active ingredient found in the spice turmeric, may have utility in the treatment of psoriasis by acting on the main component of psoriasis pathogenesis, T cell mediated inflammation. It is thought to inhibit nuclear factor kappa B (NF-κB), keratinocyte proliferation, phosphorylase kinase, and angiogenesis.¹⁵ Kurd et al. performed an uncontrolled clinical trial assessing the efficacy of curcumin capsules, 4.5 g daily for 12 weeks, in 12 patients with moderate to severe plaque psoriasis.¹⁶ Only two subjects achieved PASI 75 or a PGA of excellent at week 12. Adverse events included gastrointestinal upset or heat intolerance. Antiga et al. reported the results of a clinical trial on methylprednisolone aceponate 0.1% ointment with adjuvant curcumin tablet compared to methylprednisolone aceponate 0.1% ointment with placebo tablets in 63 patients with mild to moderate plaque psoriasis.¹⁷ Patients were divided into two arms: arm 1 received methylprednisolone ointment, once daily on the lesions, plus 2 g per day of curcumin tablets, while arm 2 received methylprednisolone ointment and placebo for 12 weeks. At 12 weeks, both arms had significant improvement in median PASI compared with baseline (p < 0.05). However, reduction of PASI was higher in arm 1 (curcumin) than it was in arm 2 (placebo) patients (p < 0.05). One patient in arm 1 had diarrhea.

HESA-A

HESA-A is a compound manufactured and available in Iran. HESA-A is composed of mineral constituents (50%), organic herbal constituents (45%), and water (5%). The herbal components include Carum carvi (Persian cumin) and Apium graveolens (celery). This compound has anticancer effects, and may have anti-inflammatory and anti-proliferative properties that could be used in the treatment of psoriasis.¹⁸ Ahmadi et al. reported the results of a controlled clinical trial comparing HESA-A to placebo in 28 patients with chronic plaque psoriasis.¹⁹ Patients were assigned to take either a 25 mg/kg HESA-A tablet or placebo tablet twice daily for 6 months. After 6 months, researchers noted that 64.2% had clearance of psoriatic plaques and 35.8% had mild disease remaining in the HESA-A group, while the placebo group showed no disease improvement. Barikbin et al. performed an uncontrolled trial on HESA-A with 19 patients with chronic plaque psoriasis.²⁰ Patients took a 30 mg/kg tablet daily for 4–30 weeks. At the conclusion of the study, the PASI score had decreased in 73.7% of patients but increased in 26.3%. The only statically significant correlation was between the duration of treatment and PASI improvement (p = 0.024). No adverse events were reported in either study.

Neem

Azadirachta indica, also known as neem, is an evergreen tree that is native to India, where it has long been used for agricultural and medicinal purposes. One of the major components of neem leaf is nimbidin, which is believed to have hypoglycemic, anti-ulcer, and antitumor effects, and is a more effective inhibitor of prostaglandin synthetase than acetyl salicylic acid.²¹ Pandey et al. reported the only clinical trial assessing the use of neem for plaque psoriasis.²² The trial involved 50 patients with uncomplicated plaque psoriasis who were instructed to take either placebo or neem leaf extract capsules three times daily with the addition of a topical regimen that included 5% crude coal tar and 3% salicylic acid in a Vaseline base for 12 weeks. While both groups showed decreased PASI scores indicative of response to the topical regimen at treatment endpoints, the mean PASI score was significantly better for the neem group compared with the placebo group at 8 weeks (9.7 vs. 12.24, respectively; p < 0.05) and 12 weeks (4.74 vs. 9.47, respectively; p < 0.001). No adverse events were reported.

Tripterygium wilfordii Hook F

T. wilfordii Hook F (TwHF) is a Chinese herb that is commonly used for inflammatory and immune disorders, especially in China. Triptolide is the most known potent active ingredient in the herb extract and has immunosuppressive and anti-inflammatory effects in vitro and in animal models.²³ Wu et al. reported the results of a controlled clinical trial comparing TwHF to acitretin in 115 patients with moderate to severe plaque psoriasis.²⁴ Patients were instructed to take TwHF 20 mg three times a day plus a placebo tablet or acitretin 30 mg once a day along with a placebo tablet for 8 weeks. At the end of the treatment, median PASI score improved in the TwHF group by 50.4% compared with baseline (p < 0.0001) and in the acitretin group by 42.7% compared with baseline (p < 0.0001). The difference in median PASI improvement between the groups was not significant (p = 0.317). No serious adverse events occurred, though the TwHF group noted elevated levels of aspartate transaminase and triglycerides, while the acitretin group noted elevated alanine transaminase, cholesterol, and high-density lipoprotein.

TCM

A frequently selected alternative therapy in China and Taiwan, TCM has been used to treat psoriasis for centuries.²⁵ Consisting of both topical and oral formulations, TCM utilizes a mixture of many herbs and many formulations tailored to each patient. Many of the Chinese herbs have been used in the treatment of psoriasis, and possess anti-inflammatory properties and abilities to modulate cytokine production or inhibit angiogenesis.²⁶ Four clinical trials available in the literature fit the criteria for this review. Song et al. conducted an uncontrolled clinic trial with 15 patients with plaque psoriasis assessing both an oral and topical regimen of TCM. An oral decoction was taken twice daily, which consisted of Rhizoma Smilacis Glabrae, Folium Isatidis, Rhizoma Menispermi, Oldenlandia,Rhizoma Curcumae, Rhizoma Polygoni Cuspidati, Cornu Saigae Tataricae, Gypsum Fibrosum, Herba Solani Lyrati, and Herba Duchesneae Indicae.²⁷ Topical treatment included both a herbal bath and applying a herbal ointment twice a day. The bath consisted of Cacumen Platycladi, Rhizoma Curcumae, and Nepal dock root, and the ointment was made from Rhizoma Curcumae oil and Galla Chinensis extract. After 3 months of treatment, patients with both acute and chronic disease showed significant decreases in PASI score and plaque index (p < 0.01). In the largest clinical trial, Dai et al. reported the results comparing Yinxieling decoction (consisting of radix rehmanniae recen, angelica sinensis, radix paeoniae rubra, ligusticum wallichii, radices lithospermi, curcuma zedoary, chloranthus spicatus, rhizome smilacis glabrae, smoked plum, liquorice, and others) to placebo in 120 patients with plaque psoriasis.²⁸ The decoction or placebo was ingested twice daily for 8 weeks. After 8 weeks, there was a significant decrease in the PASI score compared with baseline (p < 0.05) in patient groups taking the decoction, while no significant decrease was noted in the placebo group. Ho et al. reported the results of a controlled clinical trial comparing an oral TCM (consisting of indigo naturalis, ephedra, ginger, cinnamon, mustard seed, and others) to methotrexate (MTX) and placebo in 61 patients with chronic plaque psoriasis.²⁹ Patients took either TCM capsules, MTX (up to 30 mg/week), or placebo weekly for 6 months. After 6 months, improvement was 73.9% for the MTX group, 15.1% for the TCM group, and 32% for the placebo group compared to each respective baseline. MTX was significantly more effective than TCM and placebo, while no significant difference was noted between TCM and placebo groups. Adverse events were reported by 65% of the MTX group, 48% of the TCM group, and 30% of the placebo group. The most common reported events in the MTX group included gastrointestinal upset and liver enzyme abnormalities, while the TCM and placebo groups reported increased incidence of infections and liver function abnormalities. It should be noted that the botanicals selected for this study differ in their traditional nature and function from the other studies. According to TCM, psoriasis is considered a hot disease and is most often treated with cold medicinal agents. Ho's group selected ephedra, ginger, cinnamon, and mustard seed, which are all considered in TCM theory to be hot in nature. Zhang et al. conducted a controlled clinical trial comparing an oral TCM (consisting of dandelion, forsythia fruit, isatis, imperata rhizome 30 g, and others) to acitretin combined with the same TCM in 80 patients with plaque psoriasis.³⁰ Patients were divided into two groups, with group A taking an acitretin 20–30 mg capsule and TCM capsule, and group B taking a TCM capsule once daily for 8 weeks. After 8 weeks, PASI scores significantly improved in both groups compared with each respective baseline (p < 0.01), with no significant difference between groups. However, group A had greater total efficacy compared with group B (p < 0.01). The most common adverse events associated with TCMs were gastrointestinal upset, with diarrhea being most common.

Discussion

Psoriasis is a notoriously difficult-to-treat chronic skin condition. In a recent psoriasis survey, 25% of dermatologists reported management of psoriasis patients as complicated, and 68% felt that psoriasis patients needed more time and support than other patients did.³ Dermatologists treating moderate to severe psoriasis have undoubtedly encountered patients who have inquired about alternative therapeutics to traditional Western medicine. In the same psoriasis survey, 87.8% of patients and 98% of dermatologists felt a strong or moderate need for better psoriasis treatments.³ As increasing amounts of patients look to CAM modalities to offer relief for their psoriasis, dermatologists should become familiar with evidence-based recommendations for different CAM options. A systematic review of the literature was performed for clinical trials investigating oral botanical therapeutics in the treatment of plaque psoriasis.

This review of both controlled and uncontrolled clinical trials in the literature revealed that the most highly studied oral, systemic botanicals include TCM with four studies, curcumin with two studies, and HESA-A with two studies. Though studies were limited and reliability of the data was low, the oral agents that demonstrated the most efficacious potential include HESA-A, curcumin, and neem extract. TCM was more effective in three out of four studies and thus may have potential for psoriasis treatment as well. Before any of these agents are routinely recommended to patients, further large controlled clinical trials are necessary to evaluate efficacy and safety better.

The most common adverse event for the oral botanicals was gastrointestinal intolerance. Diarrhea was noted as a side effect with curcumin and TCM. Accounts of serious adverse events were absent in most studies or very low in a few, with the most concerning effects including an increased incidence of infections in a specific TCM concoction and significant increase in the level of aspartate transaminase and triglycerides with T. wilfordii Hook. Due to the small duration of use for some herbals, the small size of most studies, questionable reporting, and methodologic weaknesses, strong conclusions cannot be made. There have been several case reports of more concerning cutaneous conditions, nonspecific for treating psoriasis, including lichenoid drug eruptions from oral botanical agents.^31,32

Limitations to this review must be considered. Unpublished/unavailable studies, case reports, case series, retrospective studies, or reports in languages other than English were not included. Many of the clinical trials included cannot be held to the highest methodologic reporting standards, as only one study met criteria for a Jadad score of 5. Another limitation is that there is no confirmation that the products are pure and unadulterated, and the purity of the products used in the studies could not be confirmed. Not every study included utilized a PASI score to measure improvement in psoriasis, making it difficult to compare studies that utilized it against those that did not. Many of the reviewed studies were pilot studies with small sample sizes, and more definitive conclusions require further study in a larger population of patients. Additionally, four of the studies included did not compare treatment to placebo, making it difficult to draw conclusions on efficacy.

In conclusion, while CAM therapeutics demonstrate potential for treatment of psoriasis, the evidence is still in its infancy. As the attention and demand for CAM treatments increase, it becomes critical for dermatologists to be aware of the evidence-based recommendations of efficacy and adverse events with regards to these treatments. Given the early potential benefit that some CAM agents have shown in this review, further rigorous randomized controlled trials are warranted.

Footnotes

Author Disclosure Statement

To the best of our knowledge, no conflicts of interest, financial or other, exist. This manuscript has not been previously published and is not under consideration in the same or substantially similar form in any other peer-reviewed media.

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