Complementary and Alternative Medicine for Psoriasis: What the Dermatologist Needs to Know

Whitney Talbott; Nana Duffy

Am J Clin Dermatol. 2015;16(3):147-166.

Abstract and Introduction

Abstract

Complementary and alternative medicine (CAM) use is common among patients with psoriasis. CAM modalities include traditional Chinese medicine (TCM), herbal therapies, dietary supplements, climatotherapy, and mind/body interventions. In this review, evidence from clinical trials investigating the efficacy of CAM for psoriasis is reviewed. There is a large amount of evidence from controlled trials that have shown that the combination of TCM with traditional therapies for psoriasis is more efficacious than traditional therapies alone. Herbal therapies that have the most evidence for efficacy are Mahonia aquifolium and indigo naturalis, while there is a smaller amount of evidence for aloe vera, neem, and extracts of sweet whey. Dietary supplementation in patients with psoriasis demonstrates consistent evidence supporting the efficacy of fish oil supplements. Zinc supplementation has not been shown to be effective; however, some evidence is available (albeit conflicting) for vitamin D, vitamin B12, and selenium supplementation. Overwhelming evidence supports the effectiveness of Dead Sea climatotherapy. Finally, mindfulness-based stress reduction can be helpful as adjuvant treatment of psoriasis. There are potential benefits to these modalities, but also potential side issues. Concerns with CAM include, but are not limited to, contamination of TCM products with heavy metals or corticosteroids, systemic toxicity or contact dermatitis from herbal supplements, and ultraviolet light-induced carcinomas from climatotherapy. Dermatologists should be aware of these benefits and side effects to allow for informed discussions with their patients.

Introduction

Complementary and alternative medicine (CAM) is defined by the National Center for Complementary and Integrative Health (NCCIH) as ''a group of diverse medical and health care systems, practices and products that are not currently considered to be part of conventional medicine''.^[1] CAM for psoriasis includes traditional Chinese medicine (TCM), herbal therapies, dietary supplements and dietary modifications, climatotherapy, and mind/body interventions. CAM use among psoriasis patients is common, with prevalence estimations varying between 42 and 69 %.^[2–6] Herbal therapies seem to be the most commonly used modality.^[2,3,7] Most often, patients use CAM as 'complementary' therapy, as opposed to 'alternative' therapy, i.e. rather than using CAM as monotherapy, most patients are taking CAM in combination with traditional treatment modalities in an effort to do everything possible to control their disease.^[3] Other reasons patients choose CAM include a preference for 'natural' approaches to their skin disease, a perceived lower risk of side effects, and dissatisfaction with the efficacy or toxicity of traditional medicine.^[8] Studies have shown that patients do not willingly offer information regarding CAM use to their physicians;^[3,5,9,10] therefore, the onus is on the physician to ask questions regarding CAM use. Interestingly, even though patients do not frequently offer information regarding CAM use, they are willing to discuss it if asked and, in fact, expect their dermatologists to have a basic knowledge of CAM.^[11]

In the US, the demographic profile of patients who use CAM for skin disease (not specifically psoriasis) tends to be White females between the ages of 26 and 50 years, who have at least a high-school diploma.^[1,12] The demographics of CAM use specifically among patients with psoriasis is not well understood and has not been investigated on a population-based level in the US.

The aims of this review are to first highlight the evidence for efficacy of CAM modalities in the treatment of psoriasis and, second, to provide the reader with clinically relevant considerations with regard to the implementation of CAM, reported drug interactions, and known side effects of CAM therapies. A PubMed search was performed using the terms 'psoriasis' and 'complementary and alternative medicine', as well as search terms for other, more specific CAM modalities such as 'fish oil' and 'traditional Chinese medicine'. Lists of references were consulted for additional articles. The discussion of efficacy was limited to randomized controlled trials (RCTs).

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Table 1. Randomized clinical trials comparing traditional Chinese medicine with conventional anti-psoriatic pharmacotherapy (trials were identified from four published meta-analyses [14–16, 22])
Study, location; duration, follow-up	Trial design (sample size, n)	TCM ingredients, dosage, administration	APP (conventional antipsoriatic therapy) dosage, administration	Outcome measures: results	AEs
Trials with oral CHM as primary intervention
Liu et al. [78], Huangshi, China; 4 weeks, NS	Oral CHM + topical APP (42) vs. topical APP (42)	Commercial Binghuang Ointment, qd (night) for 4 weeks	Tazarotene 0.05 % gel, 2× day, for 4 weeks	Reduction in PASI: T>C (p<0.05)	Slight itching and burning (T: 3, C: 5)
Zhang [79], China; 4 weeks, no follow-up	Oral CHM + acitretin (56) vs. acitretin alone (56)	CHM decoction (Qing Ying Tang), tid, no individual modification	Oral acitretin capsules: 10 mg tid	TER based on lesions reduction 75 %: T>C for TER; ES for 75 % lesion reduction: RR 1.64 (CI 1.23–2.19)	NS
Zheng [80], China; 8 weeks, no follow-up	Oral CHM + acitretin (60) vs. acitretin alone (60)	CHM decoction (Xiao Yin Ke Bi Tang), bid, no individual modification	Oral acitretin capsules: started at 20 mg/day, then increased to 30–40 mg/day, then decreased to 10–20 mg/day	TER based on PASI 60; PASI score: T>C for TER and PASI score; ES for PASI 60: RR 2.00 (CI 1.21–3.32); ES for PASI score: MD -2.45 (CI -3.60 to -1.30)	Mild in both groups: GI reactions in both groups; leukocyte decrease in C group only; no SAE
Luo [81], China; 6 weeks, no follow-up	Oral CHM + acitretin + co-interventions (74) vs. acitretin + co-interventions^b (100)	CHM decoction (no formula name), bid, no individual modification	Oral acitretin capsules: 0.5 mg/kg per day; IV complex glycyrrhizin, 30 ml qd; topical calcipotriol, bid	TER based on PASI 60: T>C for TER; ES for PASI 60: RR 1.71 (CI 1.30–2.24)	Mild in C group only, caused by pharmacotherapies; no SAE
Wang et al. [82], Changchun, China; 6 weeks, NS	Oral CHM + topical and systemic APP (22) vs. topical and systemic APP (20)	Herbal bath as 3000 ml bath for 20–30 min 1×day for weeks 1–2, then 1 × 2 days for weeks 3–4, then 2× week for weeks 5–6	Salicylic acid cream 2× day, methotrexate, oral 5–15 mg/week	Overall clinical efficacy^a: T>C (χ² = 8.24, p<0.05)	Hair loss (T: 1), slightly increased ALT (T: 1 = 50 U/L; C: 1 = 55 U/L), stomach discomfort (T: 1, C: 2)
Wu [83], China; 12 weeks, no follow-up	Oral CHM + acitretin + co-interventions^b (79) vs. acitretin + co-interventions^b (79)	CHM decoction (Yin Xie Kang), qd, individual modification according to symptoms	Oral acitretin capsules: 0.5 mg/kg/day; boric acid ointment, bid	TER based on PASI 60; PASI score; liver and kidney function: T>C for TER and PASI score; ES for PASI 60: RR 1.32 (CI 1.11–1.57); ES for PASI score: MD −4.03 (CI −4.97 to −3.09)	Mild in both groups, dry and scaly skin, due to pharmacotherapy, T<C; no SAE
Yang et al. [84], Xiangfan, China; 4 weeks, 6 months	Oral CHM + topical APP (82) vs. topical APP (47)	Herbal bath decocted in water adequate for a body bath. Frequency of use not specified	Halcinolone acetonide cream 2× day, thymosin IV solution 40 mg/day	Overall clinical efficacy^a: T>C (χ² = 4.649, p<0.05) Follow-up relapse: T: 1 (3.55 %), C: 2 (18.2 %)	No obvious issues
Yang et al. [85], Luzhou, China; 4 weeks, NS	Oral CHM + topical and systemic APP (58) vs. topical and systemic APP (46)	Herbal steam with additions of various herbs according to individual syndromes Applied using specific device, 20 min/day for 5 days, 2 days' break, for 4 weeks	Hydrocortisone butyrate cream 2 × day, urea cream 29 days, acitretin capsules, oral 30–40 mg 1× day	Overall clinical efficacy^a: T>C (χ² = 9. 91, p<0.01)	(T/C): dry mouth, dry lips and chapped lips (44/46), dry eyes (28/38), dry skin on body (22/34), epistaxis (4/6), body itching (13/19), desquamation (11/25), increased ALT (2/8), hyperlipidemia (1/1)
Feng et al. [86], Beijing, China; 3 weeks, NS	Oral CHM + topical APP (32) vs. topical APP (33)	Herbal bath, various herbs totaling 20 g in 2000 ml water, 20 min, 19 days, for 3 weeks	Kangminzhiyang cream (triamcinolone acetonide) 2× day, ammonium glycyrrhizinate IV solution 150 mg/day	Reduction in lesion area: T>C (χ² = 5.54, p = 0.019); clearance time: T<C (χ² = 4.32, p = 0.001); lesion score: itching T<C (χ² 2.72, p = 0.008), scaling T<C (χ² = 2.84, p = 0.006), erythema and induration (not significant)	Slight dizziness and palpitation (T: 2)
Mao and Mao [87], China; 8 weeks, 3 months	Oral CHM + acitretin + co-interventions^b (31) vs. acitretin + co-interventions^b (31)	CHM decoction (no name), bid, individual modification according to psoriasis vulgaris stage	Oral acitretin capsules, 10 mg bid; oral 'Diyin' tablets, five tablets bid	TER based on PASI 60; recurrence rate; liver and kidney function: T>C for TER; ES for PASI 60: RR 1.09 (CI 0.81–1.46)	Mild skin dryness, pruritus, T/C: (1/3); no SAE
Han et al. [88], Huangshi, China; 4 weeks, NS	Oral CHM + topical APP (43) vs. topical APP (32)	Commercial Binghuangfule ointment qd	Clobetasol cream qd	PASI T ≈ C (χ² = 0.327, p<0.05); overall clinical efficacy^a: T ≈ C (χ² = 0.040, p>0.05); follow-up relapse: T: 5 (26.32 %), C: 8 (47.06 %)	Skin pigmentation (C: 1), hypopigmentation and skin atrophy (C: 2), Malassezia folliculitis (C: 3), skin pigmentation (T: 2)
Tang [89]; Hangzhou, China; 10 times (over 10–20 days), NS	Oral CHM + topical APP (36) vs. topical APP (36)	Herbal bath of various herbs, each 60 g of raw herbs. In warm bath, 1:40,000, 30 min qd or bid, total 10× as a course	Dexamethasone ointment, salicylic acid ointment, and triamcinolone acetonide acetate ointment, slow injection of procaine 4–6 mg/kg plus vitamin C 300 mg in 300 ml saline once a day for 10–15 days as a course, warm water bath qd or 1 × 2 days (only for the control group)	Overall clinical efficacy^a: T>C (χ² = 5.796, p<0.05)	NS
Wang et al. [90], China; 24.7 days average, 1 year	Oral CHM + topical APP (675) vs. topical APP (200)	Yin Xie Ling ointment, 0.3 mm thickness, qd	Dichlorodiethyl sulphide (1:10,000 in petroleum jelly), 0.3 mm thickness, qd	Overall clinical efficacy^a: T>C (90.7>84 %, p<0.05); mean inpatient time to lesion clearance: T<C (24.7<32.5 days); follow-up relapse: T<C (13<76 %)	'Allergic response rate' T\C (1.93/5 %)
Trials with topical CHM as primary intervention
Yang et al. [91], Qingdao, China; 8 weeks, NS	Topical CHM + oral APP (96) vs. topical APP + oral APP (86)	Liubaibaibi cataplasm: apply enough cataplasm to cover the lesions for 6 h, bid	En Fu cream (clobestasol): bid Co-intervention: folic acid (10 mg): oral, tid; vitamin E (0.2 g): oral, tid	Clinical efficacy based on reduction of PASI score: T>C (χ² = 5.0, p<0.05)	No SAE, mild itching and burning (T = 4, C = 5)
Xu J [92], Beijing, China; 8 weeks, 3 months	T1: topical HM + oral HM (30) vs. T2: topical HM + oral HM (30) vs. C: topical placebo + oral HM (30)	T1: Conventional Qinbai Ruangao (ointment) T2: Fine Qinbai Ruangao (ointment)	C: white vaseline ointment. Clean the affected skin, then apply the ointment, bid Co-intervention: Liangxue Huoxue Tang (decoction) in 400 ml decoction, oral, bid	Clinical efficacy: T1/T2>C (p<0.05), T1 ≈ T2 (p>0.05); reduction of modified PASI scores: T1/T2>C (p<0.05), lesion area rating: T1 ≈ T2 ≈ C; single-symptom scores (erythema, scaling, infiltration, and itching): all T1/T2<C (p<0.05); single symptom time to improvement: all T1/T2<C (p<0.05)	Slight erythema and irritation (T1 = 2, T2 = 1, C = 1)
Zhou et al. [93], Beijing, China; 4 weeks, NS	Topical CHM + oral CHM (51) vs. topical placebo + oral CHM (49)	New Pulian Ointment	Placebo ointment: mainly contained Jian qu (Massa Fermentata Medicinalis bid Co-intervention: conventional clearing heat and cooling blood decoction qd	RER:T>C(χ² = 13.0998, p = 0.0003); TER: T>C (χ² = 12.7298, p = 0.0004); PASI scores: T<C (p<0.05); score of erythema, infiltration, and lesion area: all T<C (p<0.01); score of scaling: T ≈ C (p>0.05); score of itching: T<C (χ² = 8.1145, p = 0.0044)	AEs: none
Zhu et al. [94], Sichuan, China; 2 weeks, NS	Topical CHM (41) vs. topical APP (44)	Xiaoxuanling formula bid	Tretinoin cream (0.025 % Diwei cream: vitamin A acid cream) bid	Clinical efficacy based on PASI: T ≈ C (χ² = 2.125, p = 0.05)	T: slight tingling sensation (7), C: slight burning (6)
Song et al. [95], Beijing, China; 4 weeks, 0.5 years	T: topical CHM + oral CHM (60) vs. C1: topical APP + oral CHM (29) vs. C2: topical placebo + oral CHM (29)	CEBO bid	C1 (WM): Daivonex ointment (calcipotriol) bid; C2 (placebo): vehicle of CEBO bid	Modified PASI scores: T<C2 (p<0.01), C1<C2 (p<0.01), T<C1 (p<0.01) Clinical efficacy: T>C2 (p<0.01), C1>C2 (p<0.01), T ≈ C1 (p>0.05) Single symptom scores: T<C2 (p<0.01), C1<C2 (p<0.01) Time to symptom improvement: (1) itching: T<C1/C2 (p<0.01); (2) erythema, scaling, and induration: T/C1<C2 (p<0.01); (3) lesion area: T ≈ C1 ≈ C2	T: slight erythema and irritation (2), C1: erythema and lesion enlarged (2), C2: none
Gao et al. [96], Qingdao, China; 8 weeks, NS	Topical CHM + oral APP (192) vs. topical APP + oral APP (184)	Liubai Baibi cream	En Fu cream (clobestasol) bid Co-interventions^b: folic acid (10 mg): oral, tid; Vitamin E (0.2 g): oral, tid	Clinical efficacy based on reduction of PASI score: T>C (χ² = 36.15, p<0.01)	No SAE, mild itching, and burning (T = 7, C = 9)
Lu and Miao, 2004 [97], Shenyang, China; 18 days, NS	Topical CHM (31) vs. topical APP (22)	Queyin tincture in water with 75 % alcohol, 1000 ml, for 2 weeks, then filter and set aside Lesion on the limbs/chest– back used as target area (7.5–30 cm²) bid	Piyanning tincture (compound fluocinonide tincture): lesion on the limbs/chest–back used as target area (7.5–30 cm²) bid	Clinical efficacy based on reduction of symptom score: T>C (p<0.05)	NS
Wang et al. [98], Changsha, China; 8 weeks, 1 year	Topical CHM (112) vs. topical APP (56)	1# Herbal bath formula (for blood-heat syndrome) 2# Herbal bath formula (for blood-deficiency syndrome) 30 g 1#/2#: In 180–200 L water boiled for 20 min, then filter into warm liquid for bath, 20 mins, bid	0.1 % Anthralin ointment bid (in the morning and at night)	Global PASI: T<C (p<0.001) Clinical efficacy: T>C (χ² = 6.25, p<0.05) Relapse comparison: T<C (χ² = 5.50, p<0.05)	NS
Trials with bath CHM as primary intervention
Shi et al. [99], Beijing, China; 56 days, NS	CHM bath plus phototherapy (170) vs. phototherapy alone (168)	CHM bath: 20 min, qod: NB-UVB: consistent with control intervention	NB-UVB (310–315 nm): 0.2–0.4 J/cm² as initial dosage, increased by 0.1 J/cm² each time, qod	TER based on PASI 60: TER T: 84.7 %; C: 70.2 % (p<0.01)	Mild redness, pruritus (T: 11/170; C: 29/168); skin pigmentation in all (resolved without medical assistance within 3 months); no SAE
Wang et al. [100], Kaifeng, China; 28 days, NS	CHM bath plus phototherapy (50) vs. phototherapy (50); co-interventions used also	CHM bath: 30 min, qod; NB-UVB: consistent with control intervention; urea emollient after NB-UVB, qd	NB-UVB (310–315 nm): 0.3–0.5 J/cm² as initial dosage, increased by 10–20 % each time, qod; urea emollient after NBUVB, qd	TER based on PASI 60: TER T: 86.0 %; C: 72.0 % (p<0.05)	Mild skin dryness, burning pain after NB-UVB (T: 4/50; C: 5/50); no SAE
Wu et al. [101], Chengdu, China; 40 days, NS	CHM bath plus phototherapy (75) vs. phototherapy (65); co-interventions used also	Halometasone emollient for 1-week pre-trial treatment: qd; CHM bath: 15–20 min, qod; NBUVB: consistent with control intervention; urea emollient, qd	Halometasone emollient: consistent with treatment intervention; NB-UVB (310–315 nm): 0.5–0.6 J/cm² as initial dosage, increased by 0.1 J/cm² each time, qod; urea emollient, qd	TER based on PASI 60; PASI score: TER T: 78.67 %; C: 56.92 %, (χ² = 10.54, p<0.01); PASI score T: 9.24 ± 2.17; C: 5.46 ± 1.86	Slight light skin dryness, burning pain after NBUVB (T: 2/75; C: 3/65); no SAE
Lin et al. [102], Hefei, China; 49 days, NS	CHM bath plus phototherapy (95) vs. phototherapy (90); co-interventions used also	CHM bath: 20–30 min, three times a week; NBUVB: consistent with control intervention; Bing Huang Fu Le ointment after NB-UVB, qd	NB-UVB (311 nm): 0.3–0.5 J/cm² as initial dosage, increased by 0.1 J/cm² each time, 110 s, three times a week; Bing Huang Fu Le ointment after NB-UVB, qd	TER based on PASI 60; PASI score: TER: T: 96.7 %; C: 70 %, (χ² = 17.69, p<0.01); PASI score T: 11.15 ± 8.11; C: 14.74 ± 9.05	Redness (T: 9/95; C: 22/90; χ² = 4.44, p<0.05); pruritus (T: 11/95; C: 26/90; χ² = 4.94, p<0.05); skin dryness (T: 15/95; C: 17/90; p>0.05); no SAE
Wu et al. [103], Guangzhou, China; 90 days, NS	CHM bath plus phototherapy (40) vs. phototherapy alone (39)	CHM bath: 15–20 min, qod; NB-UVB: consistent with control intervention	NB-UVB (311–315 nm): 0.3–0.5 J/cm² as initial dosage, increased by 0.1 J/cm² each time, qod	TER based on PASI 60; PASI score: TER T: 75.00 %; C: 51.28 %,(χ² = 4.78, p = 0.029); PASI score: T: 4.21 ± 1.22; C: 6.45 ± 2.27	Skin dryness, pruritus (T: 5/40; C: 5/39); skin pigmentation in all; no SAE
Gu et al. [104], Urumqi, China; 28 days, 6 months	CHM bath plus phototherapy (89) vs. phototherapy (96); co-interventions used also	CHM bath: 30 min, qod; NB-UVB: consistent with control intervention; Pu Lian ointment, bid	NB-UVB (311 nm): 0.3 J/cm² as initial dosage, increased by 0.1 J/cm² each time, qod; Pu Lian ointment, bid	TER based on PASI 60; relapse rate during follow-up: TER T: 94.38 %; C: 84.38 %, (χ² = 4.8, p<0.05); relapse rate during follow-up: T: 10.81 %; C: 30.30 % (p<0.05)	Mild redness, pruritus, and skin dryness (T: 10/89; C: 23/96; χ² = 5.10, p<0.05); skin pigmentation in all (resolved without medical assistance within 2 months); no SAE
Cui et al. [105], Beijing and Anshan, China; 56 days, NS	CHM bath plus phototherapy (62) vs. phototherapy alone (57)	CHM bath: 20 min, qod; NB-UVB: consistent with control intervention	NB-UVB: 50 % of MED as initial dosage, increased by 0.1 J/cm² each time, maximum dosage 2.5 J/cm², twice a week	TER based on PASI 60; PASI score TER: T: 96.77 %; C: 71.93 %, (χ² = 27.755, p<0.01); PASI score: T: 4.16 ± 7.40; C: 11.40 ± 11.64; NB-UVB average dosage: T: 9.95 ± 4.76 J/cm²; C: 12.77 ± 5.05 J/cm² (p<0.01)	Adverse events (redness, pruritus) rate: T: 4.84 % (3/62); C: 31.58 % (18/57) (χ² = 119, p<0.01); no SAE
Liu et al. [106], Shijiazhuang, China; 40 days, NS	CHM bath plus phototherapy (40) vs. phototherapy alone (40)	CHM bath: 30 min, qod; NB-UVB: consistent with control intervention	NB-UVB (311–313 nm): 0.08 or 0.1 J/cm² as initial dosage, increased by 0.01–0.03 J/cm² each time, qod	TER based on PASI 60 (T: 95.0 %, C: 82.5 %, p<0.01)	NS

AEs adverse events, APP anti-psoriatic pharmacotherapy (i.e. traditional psoriasis therapy), bid twice daily, C control group, CEBO Compound E-Bei ointment, χ²Chi-squared statistic, CHM Chinese herbal medicine, CI confidence interval, ES effect size, GI gastrointestinal, HM herbal medicines, MD mean difference, NS not stated, PASI Psoriasis Area and Severity Index, qd daily, qod every other day, RER remarkably effective rate, SAEs serious adverse events, T treatment group, TCM traditional Chinese medicine, TER total effective rate, tid three times daily, WM Western medicine (analogous to APP)
^aClinical efficacy scores: based on PASI using the following formula: (PASI pre-care-PASI post-care)/PASI pre-care × 100 %
^bCo-interventions are medications administered to both treatment and control groups

Table 2. Herbals/dietary supplements demonstrating the largest evidence of efficacy from RCTs [14, 15, 107–112]
Common name	Latin name (Chinese name if applicable)	Reported side effects	Known drug interactions	Active compounds; mechanism of action
Aloe	Aloe vera	Dermatitis with topical use, hypokalemia, nephritis, and seizure with oral use	Anti-arrthymics, diuretics, digoxin	Anthraquinone, salicylic acid
Bitter ginseng	Sophora flavescens root (Ku shen)	Hepatotoxic in rat models, estrogenic effects	Any hepatotoxic medication, taxol, ampicillin/gentamicin	Alkaloids (matrine and oxymatrine), flavonoids (trifolirhizin); anti-inflammatory
Broom Cyprus	Kochia scoparia fruit (Di fu zi)	No topical side effects, weight loss, hyperbilirubinemia, photosensitization, and polyuria in animal model (Rankins), increased liver enzymes in steer, listed in the FDA's Poisonous Plant Database	None	Triterpenoid glycosides, saponins, alkaloids; anti-inflammatory
Chinese foxglove	Rehmannia glutinosa (Sheng Di)	Bloating, nausea, loose stool, hypoglycemia, anti-implantation effect in female mice, anti-platelet activity in vitro, listed in the FDA's Poisonous Plant Database	Anti-diabetes medications, contraindicated in pregnancy and chronic liver disease	Catalpol; anti-inflammatory
Chinese skullcap, Baikal skullcap	Scutellaria baicalensis root (huang qin)	May increase statin levels with oral use	Statins	Baicalein, baicalin; anti-inflammatory
Dittany bark	Dictamnus dasycarpus bark (Bai xian pi)	Acute hepatitis with oral decoctions	Methotrexate or any hepatotoxic medication	Alkaloids, triterpenoids, sesquiterpenoids; anti-histamine, anti-inflammatory
Female ginseng	Angelica sinensis root (Dong quai)	Increased INR and prothrombin, widespread bruising, anorexia, gynecomastia, photodermatitis	Anti-coagulants, oral contraceptives	Psoralens, coumarins
Fish oil	Not applicable	Fishy aftertaste, loose stool, nausea, hypervitaminosis A and D, increased LDL and increased bleeding time with oral use	Anti-coagulants, anti-platelets	Omega-3 fatty acids
Indigo	Indigo naturalis (Qing Dai)	Gastroenteritis, hematuria, increased liver function tests and leukopenia with oral use	None	Indirubin
Monnier's snowparsley	Cnidium monnieri seed (she chuang zi)	None known, however listed in the FDA's Poisonous Plant Database	None known	Coumarins; anti-oxidant, antiinflammatory, anti-proliferative to keratinocytes
Oregon grape	Mahonia aquifolium	Pruritus with topical use, coagulant and neurotoxic with oral use	Anti-coagulants, anti-platelets	Berberine
Purple gromwell	Lithospermum erythrorhizon root (Zi Cao)	Hypoglycemia, hepatotoxicity, carcinogenic with oral use	None known	Shikonin; anti-proliferative, tissue-repair, anti-angiogenesis
Red sage	Salvia miltiorrhiza root (Dan shen)	GI reactions, headache with oral use; increased risk for bleeding (increased INR)	Warfarin	Matrine, oxymatrine, flavonoids; anti-inflammatory, anti-oxidant, antiproliferative
Sarsaparilla	Smilax glabra root (Tu Fu Ling)	Gastroenteritis, nephritis	Digoxin, bismuth subsalicylate	Beta-sitosterol
Turkish rhubarb	Rheum palmatum root (da huang)	Oxalic acid crystals, uterine stimulation and mild GI side effects with oral use, acute renal failure with long-term oral use	Digoxin, anti-arrhythmics, contraindicated in pregnancy, contraindicated in patients with renal stones	Anthraquinones, flavonoids, tannins; anti-inflammatory
Veitch's peony	Paeonia veitchii root (Chi Shao)	Nausea, increased bleeding time and uterine contractions with oral use, contact dermatitis with topical use	Anti-coagulants; contraindicated in pregnancy, reduces effectiveness of phenytoin	Paeonol, paeonoside, paeoniflorin; anti-inflammatory, anti-oxidant (CAM and the aging population)

CAM complementary and alternative medicine, GI gastrointestinal, INR international normalized ratio, LDL low-density lipoprotein, RCTs randomized controlled trials

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Complementary and Alternative Medicine for Psoriasis: What the Dermatologist Needs to Know

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