Herbal Treatment for Management of Psoriasis: An Overview

 

Ravindra G. Gaikwad, Anilkumar J. Shinde*, Ashok A. Hajare

Department of Pharmaceutics, Bharati Vidyapeeth College of Pharmacy, Kolhapur, Maharashtra India – 416013.

 

ABSTRACT:

Psoriasis is an inflammatory skin condition characterised by scaling with inflammation (pain, edema, warmth, and redness) that results in regions of thick, red skin covered in silvery scales. These spots can be itchy or painful. Systemic treatment, topical therapy, and phototherapy are all now used to treat psoriasis. These treatments have a variety of negative and perhaps fatal side effects. Patients with psoriasis are more likely to acquire other conditions such as psoriatic arthritis, anxiety and depression, cancer, metabolic syndrome, cardiovascular disease, and Crohn's disease. The majority of people use herbal medicine because it is readily available, inexpensive, and effective. Many plants have promising features, including significant results in the treatment of psoriasis. The present study plans to emphasize such plants, herbal formulations, and associated therapy, which could add value to the development of a better, safe, and efficacious formulation to treat psoriasis that may help new researchers in this field.

 

 

 

INTRODUCTION:

Psoriasis is a well-known chronic, non-infectious, inflammatory dermatitis characterised by an acute exanthematous plaque bearing more adherent, silvery scales. Psoriasis is an organ-specific autoimmune syndrome activated by the cellular immune system^1,2. Word Psoriasis is derived from the Greek word "psora", meaning "itch", and "sis" means "action," that is, "roughly itching condition." Psoriasis is divided into five types: guttate psoriasis, inverse psoriasis, plaque psoriasis, pustular psoriasis, and erythrodermic psoriasis. Along with it is also observed in case nail and psoriasis arthritis. The major characteristics are redness, irritation, and blistering patches on the skin³.

 

Pathophysiology of Psoriasis:

T-cell mediated cutaneous inflammation develops in psoriasis when activation is dependent on two signals. Surface proteins and antigen-presenting cells like dendritic cells and macrophages mediate this signal throughout cell-cell interaction.

 

T-cells that have been activated go from lymph nodes and into the circulation onto the skin region, where they release cytokines that cause pathological change. Other cytokines, such as TNF- and IL-8, are produced locally by keratinocytes and neutrophils. The growth of keratinocytes at that site is stimulated which leads to T-cell production and activation⁴.

 

ETIOLOGY OF PSORIASIS:

Immunological Factors:

In an autoimmunity situation, the body attacks itself. Psoriasis is an autoimmune disease. Invading WBCs assault and obliterate invading bacteria and scrap infection. In psoriasis, T cells attack the skin cells. This assault may cause the skin cell construction procedure to go into overdrive. The speed-up of skin cell construction causes fresh skin cells to expand excessively. The hyper proliferated skin cells are come towards the exterior skin, wherever they piled up⁵.

 

Genetic Factors:

One of the causes of psoriasis is the genetic component supported by family aggregation. The 1^st and 2^nd generations of sick people have an amplified frequency of emergent psoriasis. Whereas dizygotic twins have a two-to-three-fold amplified possibility, monozygotic twins have a two-to-three-fold amplified possibility⁶. Wide linkage report of families affected by psoriasis has so far detected at least 60 chromosomal loci linked to psoriatic susceptibility. PSORS1 is situated on chromosome 6P21, contained by the main histocompatibility complex^7,8. PSORS1 is a risk factor exposed to more than 50 single- nucleotide polymorphisms (SNPs) that are connected to        psoriasis^9-11.

Environmental Factors:

Environmental factors such as ultraviolet rays, mechanical injury, different infections chemical injury, prescribed drug, and smoking may trigger psoriasis. Psychological stress is also one of the reasons for psoriasis^12,13.

 

Figure 1. Etiolgy of Psoriasis

 

Figure 2. Types of psoriasis: (a) Single plaque of psoriasis; (b) Chronic plaque psoriasis; (c) Inverse psoriasis; (d) Guttate psoriasis; (e)

Pustular psoriasis; (f) Palmoplantar pustulosis; (g) Erythroderma and (h) Psoriatic arthritis

 

Types of Psoriasis:

(a) Single plaques psoriasis:

In case of this type of psoriasis reddish or salmon pink shading, covered with whitish or gleaming scales also, might be thick, flimsy, huge or little shown in Figure 2(a). They are generally active at the edge: quickly advancing sores might be annular, with normal skin in the middle.

(b) Chronic plaques psoriasis:

This type of psoriasis arises generally lying on the skeletal muscle of elbows, scalp, knees, lumbosacral area, and umbilicus, Figure 2(b). It is characterized by the koebner occurrence, in this development of new lesions at sites of pressure. It appears as small to big, well-defined regions of skin that are red, scaly, and thickened.

(c) Inverse psoriasis:

This type of psoriasis is a characterised by site-responsive form of vulgaris. In this inter triginous site are glossy, reddish, and characteristically without of scales, Figure 2(c). Psoriasis vulgaris will almost certainly show several intimately connected except phenotypically and genotypically different situation. It may describe the inconsistency of reaction to treatment, mainly through the T-cell embattled pharmacological agents.

 

(d) Guttate psoriasis:

It is developed in children and adolescents. In this psoriasis papules may be less than one centimeter in span blows upon the trunk, Figure 2(d). This psoriasis develops oneself in and sort-out within 120-130 days of arrival, even though its long-term prognosis is unidentified.

 

(e) Pustular psoriasis:

It is a severe sort of condition in which microscopic monomorphic sterile pustules proliferate within painful reddish skin, Figure 2(e). Fever, intercurrent infection, and the unexpected removal of general and, in some cases, ultra-potent topical corticosteroids may be experienced by the patient.

 

(f) Palmoplantar pustulosis:

This type of psoriasis characterized as recurring inflammatory condition that affects the palms and soles of the feet, Figure 2(f). On the palms of the hands and/or the soles of the feet, affected persons develop small to large sterile blisters filled with a yellow turbid liquid (pustules). Yellowish-brown pustules on soles and palm occurred. Generally, more than 25% of the community among palmoplantar pustulosis too has chronic plaque psoriasis. Palmoplantar pustulosis have diverse demographics to psoriasis vulgaris. Most of women who are current or previous smokers are affected by it. Usually onset occurrence age is 40-50. The hereditary examination has oblique to palmoplantar pustulosis and psoriasis vulgaris has diverse reasons.

 

(g) Erythroderma:

The erythroderma psoriasis, the entire skin is pretentious due to psoriasis. It leads to hypothermia, hypoalbuminemia, and elevated cardiac output. Erythroderma, Figure 2(g), is a condition due to other diseases; include drug eruptions, atopic dermatitis, and cutaneous T-cell lymphoma.

 

(h) Psoriatic arthritis:

Psoriatic arthritis is type of psoriasis characterized by inflammation at joints which may flare and subside, Figure 2(h). Peoples of psoriatic arthritis are affected with the condition of morning stiffness. Even in case of mild skin psoriasis patient can have a significant degree of arthritis. Nail psoriasis seen in nearly in patients with psoriatic arthritis. More than 10% of people by psoriatic arthritis faced skin embodiment of psoriasis.

 

The current available for the treatment of psoriasis includes topical agents, phototherapies and systemic medications. Systemic medication includes methotrexate, cyclosporine, retinoid and corticosteroids. The main difficulty related to using these drugs is they may show to augmented some side effects. Usually, herbal medicines are significant over allopathic drugs to treat skin disorders due to increased activity and lesser side effects¹⁴.

 

The allopathic system of medicine mainly concentrates on disease symptoms, but not on the main reason of the diseased condition. Ayurvedic treatment based on five elements theory, by this, these elements should survive in concord by the ‘fault’, ‘tissue’ and the ‘impurity’. Ayurvedic treatment makes the equilibrium between Dosha, Vatt and Pitta. Allopathy therapy has several side effects; may be every prescribe drug has connected with different side effect. Ayurvedic medicines, on the other hand, are made up of herbal and natural ingredients. As a result, there are no or very few chances of side effects. The use of herbal formulation increased in skin diseases^{15, 16}. The current review was created with the goal of gathering comprehensive information on plants used for the management of psoriasis. There are also some recently marketed formulations and herbal formulations listed.

 

1. Silybum marianum:

The plant Silybum marianum is generally known as milk thistle plant. It belongs to the family Asteraceae. Silymarin is the main active constituent of Silybum marianum seeds. Silymarin is a flavolignan mixture of silybinin, silychristin, silydianin, and isosilybinin. Silybum marianum is used as an anti-inflammatory, hepatoprotective, antioxidant, immunomodulatory, and anti-fibrotic¹⁷. In the market, silymarin is available in different form of formulations for treatment of variety of diseases. The topical gel of silymarin was prepared by using methanol as a co-solvent, carbopol/HPMC used as a gelling agent & methyl/propyl paraben act as a preservative^{18, 19}. In pathogenesis of psoriasis, abnormal level of cAMP and leukotriene has been observed. Silymarin can remove endotoxin from the liver and inhibit the synthesis of phosphodiesterase. Silymarin also inhibits leukotriene²⁰. Silybin used in various cosmetics and dermatological preparations. Silymarin did not show phototoxicity²¹.

 

2. Coleus forskohlii Linn:

The family of Coleus forskohlii is Lamiaceae. It has fasciculate roots and is one of the sources of diterpenoid forskolin. It is an imperative medicinal plant in the ayurvedic system. It is used to management of cardiovascular disorders, asthma, eczema, hypertension and psoriasis. This plant promotes cell division. It increases isoform selectivity by acting on adenylyl cyclase to improve the intracellular level of cAMP. Coleus oil is effective against Propioni bacterium acnes. It is effective against skin infection, yeast culture and eruptions²². The herbal root extract of Coleus forskohlii incorporated into the gel. Propylene glycol acts as a penetration improver and sodium CMC act as a gel forming agent. The physical appearance, rheological properties, drug content, and rapid stability testing were all used to characterize the formulation. Drug concentration leftovers are unaffected by storage space for 90 days at 40°C²³.

 

3. Pongamia pinnata Linn:

The family of Pongamia pinnata is Fabaceae and generally known as ‘Karanj’. It contains flavonoid and fixed oil. It is a versatile plant due to its chemical constituents, Pongamia pinnata sprouts and fruits used in folk remedies for abdominal cancer; the seeds for keloid tumors and powder of plant for tumors. The oil used in the preparation of liniments and skin preparations. The juice of leaves used in dyspepsia, cold, diarrhea, cough, flatulence, leprosy and gonorrhea. Karanj root meant for clean-up gums, teeth, and ulcers. It is used in anti-plasmodial, anti-inflammatory, anti-nociceptive, anti-lipid oxidative, anti-hyperammonic, anti-diarrheal, and antioxidant²⁴. Oil of karanj is a source of biodiesel²⁵. Karanj oil shows antipsoriatic activity. QRT-PCR is used to confirm cytokines attentiveness in the blood serum²⁶. Gel has been prepared by means of methylsulphonylmethane crush and seed oil of Pongamia pinnata Linn. The prepared gel shows good antipsoriatic activity. The activity of the gel was evaluated by using the HaCaT cell line and mouse tail model²⁷. Aqueous bark extract of plant Pongamia pinnata was incorporated in commercial preparation SUEX gel, used for psoriasis treatment. This new formulation successfully reduces retention of stratum granulosum and epidermal thickness. This gel shows that the attendance of the water extract of the bark shows an enhancement in the effectiveness of the ointment (SUEX GEL) used in the management of psoriasis²⁸. Karanjin and pongapin furanoflavone was isolated from the air-dried root bark, both isolated compounds show antipsoriatic activity²⁹.

 

4. Thespesia populnea Linn:

Thespesia populnea Linn belonging to the family Malvaceae; traditionally used to treat scabies, psoriasis, ringworm, eczema and herpetic diseases³⁰. The ground bark is boiled in coconut oil; it is useful superficially in management of scabies and psoriasis. Different parts of the plant possess antibacterial, anti-inflammatory, antioxidant, antifertility, and purgative activity. The bark contains carbohydrates, tannins, glycosides, triterpenoids, flavonoids, fixed oil and phytosterols. The cream made by different extract and isolated compound shows antipsoriatic activity. The petroleum ether extract of bark shows the highest activity than other extracts. Every extract of plant (100 mg) & separated compounds (50 mg) were used for the formulation of a cream, by adding liquid paraffin (10 ml) and beeswax (3 g) and used topically³¹.

 

5. Memecylon malabaricum Cogn:

The plant Memecylon malabaricum family of Melastomaceae is used to treat a variety of ailments such as inflammatory, bacterial infections, diabetes conditions, herpes simplex, skin disorders, chickenpox, and psoriasis. It contains steroids, saponins, flavonoids, tannins, and alkaloids. Memecylaene isolated from leaves possesses potent anti-inflammatory activity. Extract of leaves shows in vitro antipsoriatic activity. This extract shows good inhibition of lipoxygenase. Memecylon malabaricum decoction shows thymidine phosphorylase inhibition³².

 

6. Cassia tora Linn:

Cassia tora leaf is rich by anthraquinone glycosides. Traditionally it is profess that used in the cure of skin diseases and psoriasis. Luteolin-7-O-β-glucopyranoside, formononetin-7-O-β-D-glucoside and quercetin-3-O-β-D- glucuronide was isolated from the tora leaf. The ethanolic extract of Cassia tora leaf was evaluated for antipsoriatic activity. Ethanol extract and isolated compound exhibit a momentous fraction decrease of epidermal thickness. Luteolin, quercetin and formononetin was isolated and used as marker³³. Oil in water cream was prepared with methanolic extract and tested using ultraviolet-B-induced psoriasis in the rat. Acute dermal toxicity, sensitivity, and grittiness were tested. According to the study, acute dermal toxicity was observed, and the creams were appropriate and safe at a dose of 2000 mg/kg ³⁴.

 

7. Givotia rottleriformis Griff. Ex Wight:

Plant Givotia rottleriformis Griff. Ex Wight belongs to the family Euphorbiaceae. An ethanolic extract of bark contains carbohydrates, alkaloids, glycosides, proteins, saponins, and flavonoids³⁵.Luteolin-7-O-β-D-glucuronide, rutin, and kaempferol 3-O-[2-O-(6-O-feruloyl)-β-Dglucopyranosyl]-β-D-galactopyranoside flavonoids are extracted and evaluated. Isolated flavonoid shows antipsoriatic activity by HaCaT human keratinocytes cell line³⁶. Ethanolic extract of Givotia rottleriformis bark shows effective antipsoriatic activity. The extract shows major decrease in the epidermal thickness representing to delay the hyperproliferation³⁷.

 

8. Wrightia tinctoria:

Plant Wrightia tinctoria belongs to family Apocynaceae. This herb contains various secondary metabolites like alkaloids, triterpenoids, steroids, flavonoids, lipids and carbohydrates. Hydroalcoholic extract of leaves of Wrightia tinctoria shows antipsoriatic activity which is evaluated by means of mouse tail test. The extract shows the important quantity of orthokeratosis³⁸. The oil extracted from herb Wrightia tinctoria incorporated in beads formulations, which shows excellent activity. The beads formulation was prepared from extracted oil, acacia powder, and pectin and sodium alginate polymer³⁹. The most significant bioactive principles in seeds are quercitin, lupeol, α-amyrin, β-amyrin, wrightial and β-sitosterol. The nanosponge of Wrightia tinctoria was prepared from methanolic seed extract and these were incorporated into a gel base and used as a topical gel⁴⁰.

 

9. Wannachawee Recipe:

Wannachawee Recipe (WCR) efficiently used as Thai folk medicine for treatment of psoriasis. Wannachawee Recipe contains 8 Thai herbs as Alpinia galanga Linn Willd, Smilax glabra Wall, Smilax corbularia Kunth, Smilax species, Stemonacollinsae Craib, Rhinacanthus nasutus Linn Kurz., Acanthus ilicifolius Linn. The water extract of this all plant dissolved in DMSO and screened for its antipsoriatic activity. Wannachawee Recipe considerably decreased the mRNA expression ⁴¹.

 

10. Strobilianthes ciliates:

Plant Strobilianthes ciliatus belongs to family Acanthaceae. Strobilianthes ciliatus is extremely prospective remedial plant in ayurveda for the dealing of inflammation and skin problems. Petroleum ether and ethanolic extract of leaf of Strobilianthes ciliatus and ethanolic extract of stem of Strobilianthes ciliatus were evaluated for anti-psoriatic by in-vitro models. Psoriatic activity was screened with MTT assay on HACAT cell lines. Petroleum ether extract of leaf showed high anti-psoriatic activity⁴².

 

 

11. Solanum xanthocarpum:

Plant Solanum xanthocarpum belongs to the Solanaceae. It is members of the dashamula in Ayurvedic medicine. Ethanolic steam extract of Solanum xanthocarpum was incorporated in gel. The gel of ethanolic extract of 2.5,5 and 10 % was prepared and orally 100, 200 and 400 mg/kg screened for antipsoriatic activity by imiquimod-induced psoriatic mouse model. Gel of 10 % and orally 200 and 400 mg/kg shows excellent antipsoriatic activity⁴³.

 

12. Citrus aurantium:

Citrus aurantium is plant from family Rutaceae it contains significant pharmacologically active compounds such as phenethylamine alkaloids, synephrine, tyramine, octopamine, hordenine and n-methyltyramine⁴⁴. It is affluent in flavonoids, vitamin C, and volatile oil. Hexane, ethyl acetate and methanolic extract of Citrus aurantium tested for anti-psoriatic activity by MTT assay. All the extract of plant Citrus aurantium shows major inhibits activity on the proliferative of THP1 cell lines⁴⁵.

 

13. Citrus sinensis:

Citrus sinensis belongs to the family Rutaceae. Cream prepared from ethanol and aqueous extract of Citrus sinensis shows antipsoriatic activity⁴⁶. Citrus sinensis oil was used in preparation of lotion. Psoralea corilyfolia oil, Aloe barbadensis leaves, Ocimum sanctum leaves, Azadirachta indica leaves, Curcuma longa rhizomes), Ammi visnaga fruits, Citrus limonum Peel, and Citrus sinensis oil were used to prepare lotion⁴⁷.

 

14. Curcuma longa:

Curcuma longa belonging to family Zingiberaceae is originating from south‑eastern Asia.  Curcuma longa has long olden times to use as medicine in ayurveda. Curcuma longa is well-known as turmeric. Curcuma longa contains three main curcuminoids such as curcumin, demethoxycurcumin and bisdemethoxycurcumin.

 

Curcuma longa contain volatile oil like tumerone, atlantone and zingiberone⁴⁸. It is a potential plant for treating anti-inflammatory, anti-allergic, antioxidant, antihyperglycemic, and anticancer properties. Molecular study of turmeric includes fingerprinting by RAPD, SCAR, ISSR, and AFLP plays a principal role in developing a molecular marker for the authenticity and diversity of plants⁴⁹. Various products containing Curcuma longa frequently used to treat ringworm, obstinate itching, eczema, and other parasitic skin diseases^{50, 51}.

 

The antipsoriatic activity of Curcuma longa is due to the existence of antioxidants components in the plant. Curcuminoids of Curcuma (curcumin) has poor water solubility and permeability that limits transdermal absorption. Saponin acts as a surfactant that promotes transdermal absorption. Isolated saponins and curcumin used in different concentration for the formulation of gel. Curcumin and curcumin-saponin incorporated gel show potent antipsoriatic activity⁵². Caffeine synergizes the action of curcumin. Methylxanthine moiety caffeine is proficient to inhibit the phosphodiesterase enzyme. Phosphodiesterase enzyme helps to hydrolysis of cyclic nucleotide elevates the concentration of intracellular cAMP. In psoriasis intracellular, cAMP levels reduced from cutaneous leukocytes. Phosphodiesterase inhibitor caffeine increases intracellular cAMP levels⁵³. Nanosponge based gel of curcumin and caffeine so act as a potential treatment of psoriasis. A crosslinker dimethyl carbonate and polymer beta-cyclodextrin used to prepare nanosponge; this incorporated in topical gel⁵⁴. O/W cream prepare by ethyl alcohol extract of Curcuma shows significant antipsoriatic activity⁵⁵. Curcumin microemulison gel is used in dermatocosmetics⁵⁶. SmartPearls tools, which loads medicine into spongy material to get steady amorphous contemporary relief. Penetration and efficacy enhanced by smartPearl tools with the addition of glycyrrhizic acid⁵⁷.

 

15 Azadirachta indica:

Azadirachta indica is plant from Meliaeae family. The active constituent of Azadirachta indica is nimbidin, nimbolides, salanin, azadirachtin, meliacin, gedunin, nimbin, valassin, meliacin. The seed contains tignic acid, limnoids. Azadirachta indica kernels were used in making soap, pesticide and pharmaceutical industries. Neem shows analgesic, abortifacient, antibacterial, anti-yeast, anthelminthic, anti-inflammatory and antiviral. Azadirachta indica also shows diuretic, antinematodal, antipyretic, antispasmodic, immunomodulators and antinematodal activity⁵⁸. Topical cream consists of the nanostructured lipid carriers of Azadirachta leaves extract; Lawsonia inermis leaves extract, and fruit extract of Mallotus philippensis, which show anti-psoriatic activity⁵⁹. O/W cream of extract of Azadirachta indica leaf extract, Bereris aristata root extract, Psoralia corylifolia seed extract and Hemidesmus indicus root show excellent antipsoriatic activity⁶⁰.

 

Recent drugs available in market:

Psoriasis is a chronic reoccurring disease that required long term therapy. Therapy depends on severity and comorbidity. Nature of the medical sternness of lesions, the fraction of exaggerated body surface region is divided into mild or moderate psoriasis.  Gentle to modest psoriasis treated topically, whereas sensible to severe psoriasis often requires systemic treatment⁶¹.

 

 

Table 1: List of some recent drugs available in market

 

Some herbal formulations available on market include Psoraze Cream (contains Cestrum Diurnum; Ayushavedam), Psoraksha oil (contains Cestrum Diurnum, by Ayushavedam), 4G green powder (contains Cestrum Diurnum; Ayushavedam), Regsor Psoriasis Oil (contains Wrightia Tinctori;, Apptec Inc.), Vasu Cutisora Lotion and Oil (contains Neem, Karanj, Haridra, Kali mirch, Shwet Kutaj, Vasa, Kantakari, Guduchi; Vasu Healthcare), Sornip Cream (contains herbal oil containing 3-O-Acetyl-11-Keto β-Boswellic acid; Cipla), Soricure Cream (contains Wrightia Tinctoria; Indian Herbs Specialities).

 

Many medicines are available in the market and the effectiveness of treatment depends on many factors, including severity of the condition or the time of diagnosis. Though they can cause side effects these herbal remedies are usually safe to use. It is advisable for people to always consult a doctor before using any of the new herbs, herbal remedies, or natural treatments.

 

ACKNOWLEDGEMENTS:

Authors kindly acknowledge Dr. H. N. More the Principal of Bharati Vidyapeeth College of Pharmacy Kolhapur Maharashtra for proving facility to conduct literature work. The authors are also thankful to Chhatrapati Shahu Maharaj Research, Training and Human Development Institute (SARTHI), Pune for providing financial assistance in the work.

 

CONFLICT OF INTREST:

The authors have no conflicts of interest regarding views expressed in this review.

 

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Accepted on 10.03.2022           © RJPT All right reserved

Research J. Pharm.and Tech 2022; 15(3):1385-1392.