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Progress and prospects in the management of Psoriasis and developments in

Phyto-therapeutic modalities

Article  in  Dermatologic Therapy · March 2019

DOI: 10.1111/dth.12866

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 Progress and prospects in the management of Psoriasis and developments in Phyto-
therapeutic modalities

Muhammad Daniyal1, Muhammad Akram2, Rida Zainab2, Naveed Munir3,4, Syed

Muhammad Ali Shah2, Bin Liu5, Wei Wang1, Muhammad Riaz6, Farhat Jabeen7
Accepted Article
1
TCM and Ethnomedicine Innovation & Development International Laboratory, Innovative
Materia Medica Research Institute, School of Pharmacy, Hunan University of Chinese Medicine,
Changsha, 410208, China
2
Department of Eastern Medicine and Surgery, Directorate of Medical Sciences, Old Campus,
Allama Iqbal Road, Government College University Faisalabad, 38000, Pakistan
3
College of Allied Health Professionals, Directorate of Medical Sciences, GC University
Faisalabad, 38000, Pakistan
4
Department of Biochemistry, Government College University Faisalabad, 38000, Pakistan
5
Hunan Province Key Laboratory of Plant Functional Genomics and Developmental Regulation,
College of Biology, Hunan University, Changsha 410082, China
6
Department of Allied Health Sciences, Sargodha Medical College, University of Sargodha,
Sargodha- Pakistan
7
Department of Zoology, Government College University Faisalabad

Running title: Management of Psoriasis

Conflict of interest:
Authors don’t have any conflict of interest.

Abstract
Objectives: The aim of this study is to review the efficacy of herbal and allopathic drugs used to
manage and treat psoriasis. Methods: The review has been compiled using reference materials
from major databases, Online Journals, Science Direct, Scopus, Open J Gate, Google Scholar
and PubMed. Key Findings: Psoriasis is a common skin disease affecting 2 - 3% of the world’s
population. It is cosmetically debilitating and chronic disease which occurs both in developing
and developed countries. It can affect any part of the body, but the most common sites are the
elbows, knees, and scalp. It is usually treated with synthetic medicine either given systematically
or applied locally. The prescribed synthetic medicines used for the treatment of psoriasis are
associated with severe side effects and complications, thus researchers around the world are
trying to explore new, more effective, and safer drugs from natural resources. Conclusion:
Medicinal plants are safe and efficacious and most of the people all over the world rely on herbal
medicine due to their easy availability, low cost and efficacy for treating psoriasis. A number of
medicinal plants having therapeutic potential with high efficacy used in the treatment of psoriasis
have been described. Moreover, studies should be conducted to isolate and investigate the
mechanism of actions of phytochemicals responsible for anti-psoriasis potential.
Keywords: Psoriasis, medicinal plants, drugs, efficacy, treatment of psoriasis, literature review

This article has been accepted for publication and undergone full peer review but has not
been through the copyediting, typesetting, pagination and proofreading process, which
may lead to differences between this version and the Version of Record. Please cite
this article as doi: 10.1111/dth.12866
This article is protected by copyright. All rights reserved.
 Introduction
Psoriasis is the major autoimmune skin disorder characterized by deregulated epithelial
cells proliferation and chronic dermatitis (Martin et al., 2017). Approximately one-third
of all traditional plants have the capacity to treat skin diseases compared to only 1-3 % of
Accepted Article
modern drugs. Skin diseases are categorized into acute and chronic conditions. Chronic
skin diseases are difficult to cure but can be managed by medicines, and numerous
medicinal plants are used to treat them. Acquired immunodeficiency syndrome (AIDS),
cardiovascular disorders, enteropathy and myopathy are the associated co-morbidities of
psoriasis (Oliveira et al., 2015). Changes seen in psoriatic arthritis resemble symptoms of
rheumatoid arthritis (Gladman et al., 2005). Psoriasis is characterized by redness of skin
and irritation. Psoriasis is one of the most common skin diseases. In pathological point of
view, it is chronic dermatitis, with rapid uncontrolled epithelial cell proliferation on the
surface, and hyperemia, and dense lymphocytic-infiltration on the corium side.
Essentially, the disease can start in any stage of the life and persists for a long period of
time with permanent or periodic eruptions (Calara et al., 2017). It is cosmetically
debilitating and chronic disease. The prevalence of psoriasis is 0.3 percent in Chinese
population (Cai et al., 2017). Caucasians are commonly affected with psoriasis with an
estimated prevalence of 60 cases per 100,000 in a year (Naldi & Gambini, 2007). In
Certain American African populations and Native American population, psoriasis is rare
or absent. Prevalence is 1.5-3 percent in Scandinavia and Northern European population
and in the United States, numbers of new cases are approximately 150,000-260,000 per
year. Worldwide prevalence of psoriasis is 2-3% (Gisondi & Girolomoni, 2017). Further,
it was found that there were 114521 psoriatic patients out of 75, 33,475 total patients
received in general clinics in the United State with different skin complications.
Prevalence of psoriasis in the USA is 2 to 3% while 2% in Australia. Worldwide new
reported cases of psoriasis are approximately 150,000 every year. Lithium causes
psoriasis by decreasing the level of cyclic AMP. Intracellular calcium decreases due to
cyclic AMP deficiency and ultimately decreased intracellular calcium level decreases
muscles contraction and increases keratinocytes proliferation (Zeichner, 2010). Psoriasis
is a type of chronic autoimmune disorder that occurs due to abnormal signal transduction
of cell-mediated immune response and ultimately leads to an unregulated proliferation of
keratinocytes in skin epithelial tissue. Psoriasis might affect all age groups and common
sites involved include glans penis, intergluteal cleft, lumbosacral areas, scalp, knees, and
skin of elbow. Prevalence of psoriasis and psoriatic arthritis largely vary according to
ethnicity and geographical area and was reported that psoriasis is more prevalent in obese
people and smokers as compared to other population. This disease is equally found in
both male and females. It has been observed that psoriasis occurs in bone marrow
transplant recipients, if donor was suffering from psoriasis. Therefore, there is need to
keep recipient on immunosuppressant drugs to prevent psoriasis in recipient. Psoriasis is
associated with co-morbidities such as psoriatic arthritis, crohn’s disease, cancer,
metabolic syndrome, type 2 diabetes mellitus, increased cardiovascular risk, depression,
and decreased quality of life (Oliveira et al., 2015). The study suggests that smoking may
be a risk factor for initiation of psoriasis (Herron et al., 2005). Most common type of
psoriasis is a plaque that is about 80%. The least common form of psoriasis is erythro-

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 dermic psoriasis that is 1-2%. Pustular psoriasis is about 5% that is common in adults.
Psoriasis can be categorized into three major forms such as mild, moderate, and severe
depending upon the covered area and severity of the symptoms. In mild form, total
covered area is 5 to 10% while moderate form, covers area between 10 to 20% and severe
form covers more than 20% of the body area. The exact etiology of psoriasis is yet
unknown but some risk factors to develop psoriasis like genetic factors, immune system
Accepted Article
and environmental factors have been reported. It was observed that 30% of people
suffering from psoriasis have psoriasis family history. Pathogenesis of psoriasis is well
understood.
Helper T-cell (Th) 1/Th17 cells infiltration takes place in epithelial tissue which triggers
macrophages and dermal dendritic cells to secrete different cytokines to mediate
inflammation and abnormal keratinocyte proliferation. Infiltration of activated CD4+ and
CD8+ T-cells are responsible for the psoriatic plaque formation. Infiltration of CD4+ T-
cells takes place in the dermis while CD8+ T-cells infiltrate into the epidermis.
Development of lesions in psoriasis is due to the cytokines and chemokines released by
T-lymphocytes. Keratinocyte hyper proliferation with parakeratosis and elongation or
rete ridges, increased blood vessels synthesis, inflammatory cells infiltration like T
lymphocytes, macrophages, neutrophils, dendritic cells and presence of micro abscesses
are the major histological features of psoriasis. Among different types of psoriasis like
pustular psoriasis, inverse psoriasis, psoriatic arthritis guttate psoriasis and erythrodermic
psoriasis, Psoriasis vulgaris or chronic plaque psoriasis is the most common form of
psoriasis (Rana et al., 2012; Mahajan & Handa, 2013). Diet plays important role in
psoriasis pathogenesis and etiology. Some studies indicate that psoriasis symptoms are
reduced by vegetarian diets, low energy diets, and fasting periods. All these diets affect
the metabolism of polyunsaturated fatty acids and suppress the inflammatory response.
Various combined therapies, oral inositol, intravenous omega 3 fatty acids and vitamin D
are effective in psoriasis. Low calorie diet, cyclosporine, thiazolidinedione, retinoids, fish
oil, and ultraviolet B phototherapy are found effective in clinical trials (Ricketts et al.,
2010). This disease causes physical and psychological problems in sufferers. In one
study, it has been observed that thoughts of suicide and self-harm are more in psoriasis
patients than normal persons. Scalp psoriasis is very distressing and patients suffer from
psychological problems. It is not contagious disease but some people report that friends
and colleagues consider that psoriasis is transmitted by shaking hands or skin contact.
This thing makes the patient socially isolated and he suffers from depression (Parisi et al.,
2018). Phototherapy and/or systemic medications are needed to treat moderate and severe
forms of psoriasis. Psoriasis can be treated by exposure to narrowband ultraviolet B (NB-
UVB) radiation. Radiation spectrum having wavelength b/w 311 and 312 nm is known as
NB-UVB and this is more beneficial and effective to treat psoriasis (Goiabeira et al.,
2018). It has been reported that due to anti-proliferative, immunosuppressant and anti-
inflammatory characteristics, UV radiation induces regression or controlling the
evolution of dermatitis (Hönigsmann, 2001; Barbagallo et al., 2001). So, NB-UVB could
be a safe and effective treatment, and a good option to treat psoriasis (Goiabeira et al.,
2018). Capsaicin, glycyrrhetinic acid preparation is applied on affected parts of the body.
Some studies suggest that psoriasis causes a nutritional deficiency in sufferers. The
outbreak of psoriasis increases with an increase in stress and anxiety. Although modern
medicines including cyclosporine, acitretin, apremilast, methotrexate, secukinumab,

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 adalimumab, ixekizumab, etanercept, infliximab, and ustekinumab are effective but they
have some side effects (Gisondi et al., 2017; Vide & Magina, 2017). Medicinal plants are
safe and efficacious (Deng et al., 2013). In developing countries, most people rely on
herbal medicine due to their easy availability, low cost, more efficacies and not well
reported side effects.
Accepted Article
Management of Psoriasis
Herbal treatment
Polyphenols present in plants are effective in the treatment of psoriasis due to
significantly high antioxidant activity (García-Pérez et al., 2010). Antioxidants reduce the
nitric acid level and hydroxyl or free radical present in the blood of patients with
psoriasis. Other properties of polyphenols are anti-proliferative and anti-inflammatory.
Polyphenols have the ability to inhibit calgranulins A and B genes that are involved in the
inflammatory process. Vegetarian diet, low energy diet, and fasting food period reduce
symptoms of psoriasis. Fish oil provides a beneficial effect on psoriasis due to the
presence of vitamin E and omega 3 fatty acids. Cannabis is also effective in psoriasis due
to its anti-inflammatory effect (Bhuchar et al., 2012). Medicinal plants are prescribed in
skin disorders and their efficacy is established (Dewet et al., 2013). Home remedies are
being used in skin disorders since ancient times. Most of the synthetic drugs have
originated from natural sources. The use of herbal treatment for psoriasis has been report
by various studies and in literature (May et al., 2012). However, there is a need to
document these plants with their known efficacy, so that herbal physicians and psoriasis’s
patient could take advantages of alternative medicine (Capella et al., 2003). Plant whose
in vitro, in vivo or clinical efficacy has been established are Glycyrrhiza uralensis, Aloe
vera (Syed et al., 1996), Memecylon malabaricum (Dhanabal et al., 2012), Capsicum
annuum, Psoralea corylifolia and Mahonia aquifolium. Matricariae flos, Calendulae flos,
Hamamelidis folium, Quercus cortex, Violae tricolor, Salviae folium, Echinaceae herba,
Dulcamarae stipites, Arnicae flos, Symphyti rhizome, Melaleuca hypericifolia, Melissae
folium, Momordica charantia, Azadirachta indica, Arctium lappa, Calendula officinalis,
Matricaria recutita, Glycyrrhiza glabra, Caesalpinia bonduc (Muruganantham et al.,
2011). Plants serve as symptomatic treatment of psoriasis and also suppress the disease
for a long period. A herbal formulation (Psirelax) containing grape seed oil, jojoba oil,
sweet almond oil, sunflower seed oil and quince seeds were investigated for its efficacy
and safety to treat chronic plaque psoriasis. A study showed that Psirelax is effective in
the treatment of psoriasis and no side effects were reported. Psirelax was applied
topically to reduce disease severity. Psirelax contains seeds and herbal oil that have the
potential of emulsifying and oiling the skin with possible immune modulating and anti-
inflammatory effect (Shiri et al., 2011). Sunflower seed oil present in Psirelax contains
essential fatty acids such as linoleic acid that have properties to enhance skin barriers. A
sunflower oleodistillate is reported to decrease inflammation and enhance the lipid
synthesis in the epidermis in an animal model. Peroxisome proliferative activated
receptor alpha is activated by sunflower oleodistillate that improve barrier function,
enhance keratinocytes differentiation and enhance the metabolism of lipid in the skin.
Sunflower efficacy has been studied in atopic dermatitis. Angelica sinensis contains
psoralen and furocoumarin. Psoralen decreases epidermal DNA synthesis. In one study,

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 two third patients with psoriasis got relief after oral administration of Angelica sinensis
extract (Koo & Arain, 1998).

Caesalpinia bonduc
Caesalpinia bonduc belongs to Caesalpiniaceae family. It contains bonducine, palmitic
acid, stearic acid, and phytosterol. It is used in asthma, malaria, inflammation, leprosy,
Accepted Article
and rheumatism. It is anti-periodic, anti-spasmodic, tonic, anthelmintic, febrifuge, and
emmenagogue. There was reported efficacy of Caesalpinia bonduc leaves for use in the
treatment of psoriasis. This study justifies its use as anti-psoriatic agent. Leaves of this
plant are useful in psoriasis and an anti-psoriatic activity was reported (Muruganantham
et al., 2011). Anti-psoriatic activity was tested by using mouse tail test in Swiss albino
mice. The dose of the extract was 500 mg/kg body weight. Epidermal thickness and
percentage orthokeratotic values were used as parameters. A further fraction of this
extract was used at a dose of 250 mg/kg in Swiss albino mice. In vitro anti-proliferative
and anti-lipoxygenase activities were also tested. Significant orthokeratosis was produced
by butanol fraction and water fractions. Significant reduction in epidermal thickness was
observed in mice treated with both fractions of the plant extracts as compared to the
control group. Anti-proliferative and anti-lipoxygenase was also significant. This study
validated its use in the treatment of psoriasis (Muruganantham et al., 2011).

Nigella sativa
Nigella sativa belongs to family Ranunculaceae. The anti-psoriatic activity of Nigella
sativa was compared with standard drug tazarotene gel. Ethanolic extract of Nigella
sativa exhibited more epidermal thickness in test group animals than the control group in
the treatment of psoriasis in mouse tail model (Dwarampudi et al., 2012).

Ulmus rubra
Ulmus rubra is used in wounds, boils, cystitis, and irritable bowel syndrome. A study
conducted on five patients, ranging from mild to severe psoriasis at the study onset,
improvements in all measured outcomes were observed over a six-month period when
measured by the Psoriasis Area and Severity Index (PASI) (Brown et al., 2004).

Aloe vera
Aloe Vera belongs to Liliaceae family. It contains loin, isobarbaloin, emodin, aloe-
emodin and beta barbaloin. It is used in constipation, cancer, intestinal worms, cough,
and psoriasis. It is cathartic, hypoglycemic and anti-psoriatic (Dhanabal et al., 2012).
Aloe vera is used in psoriasis topically and to clear psoriatic plaques. Aloe vera contains
some constituents that have keratolytic activity and cause desquamation of plaques.
Efficacy of Aloe vera in the treatment of psoriasis was reported. A double-blind, placebo-
controlled study was conducted in sixty patients to investigate the clinical efficacy of
topical Aloe vera cream to treat psoriasis for 16 weeks. The number of male and female
patients was 36 and 24, respectively. Mean age of the patient was 25.6 years (range18-50
years). Parameters for assessment were the size of a lesion, desquamation, and
erythematic infiltration. There was a significant improvement in the patient with
psoriasis. This drug was well tolerated and no side effects were observed. 83.3% of

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 patients were cured by the use of cream and 6.6% were cured with the placebo (Syed et
al., 1996).

Smilax china
Smilax china contains quercetin that has anti-psoriatic activity. Anti-psoriatic activity of
Smilax china has been reported on HaCaT cell lines. Anti-psoriatic activity of Smilax
Accepted Article
china is evident from the reduction in leucocyte migration and reduction in epidermal
thickness (Singh et al., 2014). Another study reported that methanol extract of Smilax
china showed significant effects on orthokeratosis, anti-inflammatory and maximum anti-
proliferative action on Swiss albino mouse (Vijayalakshmi et al., 2012).

Mahonia aquifolium
Mahonia aquifolium belongs to Berberidaceae family. It contains glycosides, tannins,
steroidal nucleus, saponins, flavonoids, and alkaloids (Picone et al., 2002). It is used in
dyspepsia, inflammation, psoriasis, eczema, and rashes. It has antimicrobial, anti-cancer,
and anti-psoriatic activities. Curcuma longa is also used in the treatment of kidney stones
and infections. A compound present in Curcuma longa inhibit phosphorylase kinase,
present in the epidermis. Higher levels of phosphorylase kinase are associated with
psoriasis. Decreased phosphorylase kinase activity decreases epidermal CD8 + T cells
density and patients get relief from psoriasis (Joe & Lokesh, 1997). Mahonia aquifolium
has been investigated for its efficacy to treat mild to moderate psoriasis in a study with
the population size of 200. That was a randomized, double-blind, placebo-controlled
study. Study duration was 12 weeks. This plant was topically used in comparison with the
control group (placebo) (Bernstein et al., 2006). Mahonia aquifolium is also used to treat
psoriatic plaques. Efficacy of its principle constituents (oxycanthine, berbamine, and
berberine) has been reported on lipid peroxidation and 5-lipoxygenase. It inhibits the
growth of keratinocytes (Müller & Ziereis, 1994).

Silybum marianum
Silybum marianum is called milk thistle and is used in liver disorders. High level of
leukotrienes and cyclic AMP are seen in psoriasis and reduction in these levels may
relieve the patient from psoriasis. Silybum marianum improve the ability of the liver to
inhibit leukotrienes formation, cyclic AMP phosphodiesterase and increase endotoxin
removal. All these factors help to improve psoriasis (Singh & Tripathy., 2014).

Kigelia africana
Kigelia africana belongs to Bignoniaceae family. It is used in arthritis, syphilis, and skin
diseases. It has wound healer, antioxidant, antimicrobial, anti-inflammatory, anti-diabetic,
hypolipidemic, antimalarial and purgative characteristics. Anti-psoriatic effect of
methanol and hexane extracts of this plant for its efficacy to treat psoriasis was
investigated. Study findings showed that the topical application of this plant is effective
in the treatment of psoriasis (Costa et al., 2017). One more study reported that Kigelia
africana treatment showed significant improvement in mouse tail test of albino mice with
decreased epidermal thickness which revealed its anti-inflammatory activity (Oyedeji &
Bankole, 2012).

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 Thespesia populnea
Thespesia populnea belongs to Malvaceae family. It contains lipids, protein, phytosterol,
flavonoids, tannins, glycosides, and carbohydrates. It is used in herpetic diseases, eczema,
psoriasis, and scabies. It is anti-psoriatic, anti-oxidant, wound healer, hepatoprotective,
Accepted Article
hypolipidemic, hypoglycemic, antipyretic, analgesic, anti-inflammatory, antibacterial,
anti-nociceptive, and antidiarrheal. One study showed that use of Thespesia populnea
extract on wistar rats mouse tail model of psoriasis significantly increased the
orthokeratotic region (Shrivastav et al., 2009).

Allopathic treatment
Psoriasis affects the 2-3% of people Worldwide. Psoriatic arthritis is 5-40% among
patients with psoriasis. Quality of life of patients with psoriasis is affected. There are
three types of management of psoriasis. Topical drugs are applied on the skin.
Phototherapy is also effective in psoriasis. Systemic therapy may be done alone or in
combination with topical therapy or phototherapy. Currently used medicines for the
treatment of psoriasis include hydroxyurea, immuno-modulator, retinoids, cyclosporine,
methotrexate, corticosteroids, vitamin D analogs, vitamin A analogs, topical steroids,
anthralin, tar, moisturizers, and emollients. Phototherapy is an option to treat psoriasis but
there is risk of skin cancer by exposure to ultraviolet radiation. Ultraviolet radiation is
considered carcinogen. Therapies are being developed to target the specific steps in
psoriasis pathogenesis. Cyclosporine and methotrexate are already in use for the
treatment of psoriasis. Drugs such as chloroquine and hydro chloroquine cause psoriasis
by inhibiting transglutaminase enzyme. Such type of psoriasis is treated with
glucocorticoids, vitamin D, and corticosteroids. Calcineurin inhibitors act on calcineurin
phosphatase and block the production of inflammatory products by this way calcineurin
inhibitors are used in the treatment of psoriasis (Marsland & Griffiths et al., 2002).
Psoriatic arthritis occurs in 40 % of patients but this process takes 5-10 years after
cutaneous manifestation that affects the quality of life of patients with psoriasis. Some
agents such as etanercept, efalizumab, and alefacept have been approved for management
of psoriasis. Infliximab and adalimumab have been investigated via clinical trial phase II
and III (Winterfield et al., 2005). Retinoid, cyclosporine A and methotrexate exert side
effects and sufficient improvement in disease is not observed by use of these drugs
(Weger, 2010). Cortisone cream is applied at affected part of the body. Coral tar cream or
ointment is also applied at psoriatic area. Dandruff shampoos are also useful in psoriasis.
Moisturizers are effective in psoriasis. Vitamin A and D are also prescribed along with
other medicines. Non-steroidal anti-inflammatory drugs (NSAIDs) are used in arthritis
and pain. Patients with psoriasis or psoriatic arthritis also use NSAIDs. NSAIDs cause
inhibition of arachidonic acid metabolism by cyclooxygenase pathway and leukotrienes
are accumulated that aggravate psoriasis. It is important for physicians to aware about
NSAIDs which are also possible cause of psoriasis. Antibiotics are given for infected
areas. The purpose of treatment is to reduce symptoms and prevent infection. Shampoos,
creams, ointments, and skin lotions are used as topical drugs. Salicylic acid is used in the
form of ointment to remove the scaling (Carroll et al., 2005). It reduces hyperkeratotic

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 and scaling lesions (Pullmann et al., 1975). It may be used in combination with coal tar or
dithranol (Van et al., 2001). Coal-tar preparations are useful in psoriasis but are
unpleasant to use. Scalp lesions are treated with coal tar shampoo. Coal tar baths are
needed for extensive lesions. It is used to remove the build-up of dead skin cells from the
surface of the skin (Zeichner, 2010). Thioguanine is prescribed in psoriasis. But it has
some side effects such as anemia. This drug is contraindicated in pregnant woman
Accepted Article
because it causes birth defects (Kelly et al., 2015). Cyclosporine is taken orally. It
suppresses the immune system. Symptomatic treatment is quick, but symptoms re-appear
after discontinuing this drug. This drug is prescribed in those patients who cannot tolerate
or respond other drugs. Side effects of this drug include high blood pressure and
impairment of renal functions. This drug is not given to immunocompromised patients
(Maza et al., 2011). Anthralin applied topically alleviates inflammation and increases in
the skin cells. It is applied once a day in chronic psoriasis and washed out after 15-30
minutes of application. It is contraindicated in acute psoriatic lesion due to its irritation
effect (Miller, 1985). Corticosteroids are usually used to treat psoriasis . It is effective in
mild to moderate psoriasis to reduce inflammation and swelling. It is more effective when
given systematically. Prolonged use of corticosteroid causes skin atrophy and adrenal
suppression (Horn et al., 2010). Dithranol cream and Tazarotene ointment stops skin cells
being replaced so quickly (Swinkels et al., 2002). Moisturizers are useful in itching and
vitamin A is included in these ointments which promote the regeneration of epithelium
(Kaur et al., 2008). Patients with psoriasis have high level of tumor necrosis factor in
their blood responsible for inflammation in psoriasis. Tumor necrosis factor stimulates
cytokines production and molecules adhesion by keratinocytes and hence the immune
cells recruitment. Anti- tumor necrosis treatment block TNF ultimately inhibiting the
interaction between keratinocytes and immune cells. One category of treatment reduces
interaction of TNF with its receptor e.g. Infliximab neutralizes TNF-𝛼. This treatment
prevents cytokines production involved in inflammation. Adalimumab is recommended
as a treatment option for adults with plaque psoriasis and usually recommended when the
disease is severe or psoriasis has not responded to standard drug (Strober et al., 2011).
Calcipotriene is derivative of vitamin D and can be prescribed in mild to moderate
psoriasis. It is available in ointment form that is applied on skin two times a day. It is not
applied on face due to its irritating effect. If it is combined with corticosteroid, then it
reduces irritation of skin (Gold, 2009; Kircik, 2009). Hydroxyurea is less effective than
cyclosporine and methotrexate. Thrombocytopenia, leucopenia, and anemia are possible
side effects of hydroxyurea. It is not prescribed to pregnant women because it causes
birth defects in embryo (Smith, 1999). Hydrotherapy is used to supply mineral, heat and
moisture to the skin. Blood circulation is improved by use of warm water. Water
containing minerals and Sulphur directly alleviate the symptoms of psoriasis due to
healing effect (Merial-Kieny et al, 2011). In case of severe psoriasis, systemic treatment
is recommended that affects the immune system of the body. Commonly used drugs are
adalimumab, alefacept, etanercept, infliximab, and stelara. Reoccurrence of psoriasis is
common that occurs after few months or weeks. Ecterinate is used in extensive lesions of
psoriasis. Some adverse effects such as hair loss, myalgia, dryness, cracking of lips and
skin, and hepatotoxicity have been seen. Methotrexate is used in psoriasis. It inhibits
dihydrofolatereductase reducing the level of folic acid and inducing adenosine 1 that is
anti-inflammatory agonist. Methotrexate is also effective in psoriatic arthritis. Side

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 effects of methotrexate include nausea, vomiting, fatigue, headache, liver fibrosis, and
myelosuppression. Ultraviolet rays and phototherapy are useful in psoriasis but have few
side effects. Phototherapy is used as second line treatment in psoriasis when topical drugs
fail to work. Phototherapy is continued for many weeks and time of exposure is gradually
increased to inhibit skin burning. In phototherapy, skin is exposed to ultraviolet light
carefully. Phototherapy is given alone or before giving drugs that makes the skin
Accepted Article
sensitive to light (Lapolla et al., 2011).

Conclusion
Psoriasis is a chronic disease of the skin and various factors are involved in its
pathophysiology which have made difficult to treat psoriasis satisfactory till date. In view
of the fact that psoriasis as an autoimmune disease, so only medication is not effective
rather than proper management. Moreover, development of drastic side effects was
observed in patients on prolong treatment with allopathic medicines, although treated by
local and systemic drugs. So to treat and manage the psoriasis effective and safer drugs
that could be used as alternative medicines are required. Herbal medicines are gaining
popularity due to their easy availability, high efficacy and safety. T cell activation,
counter-offensive strategies, inhibition of cytokines and T cell trafficking are the main
targets for screening of plant extracts and herbal remedies. The mechanism of many
plants has been established. Other plants should be investigated further for active
constituents responsible for their use in psoriasis. In future, gene-based treatment and
stem cell therapy could be available that inhibits the gene specific for psoriasis.

Acknowledgement
We are very thankful to Hunan Province Universities 2011 collaborative Innovation
Center of Protection and Utilization of Hu-xiang Chinese Medicine Resources, Hunan
Provincial Key Laboratory of Diagnostics in Chinese Medicine, National Natural Science
Foundation of China (81673579 and 81874369), Hunan Provincial Department of
Science and Technology (2018SK2113) and State Administration of TCM (ZYBZH-Y-
HUN-23).

References
Barbagallo, J., Spann, C.T., Tutrone, W.D., &Weinberg, J.M. (2001). Narrowband UVB
phototherapy for the treatment of psoriasis: a review and update. Cutis, 68, 345-
347.
Bernstein, S., Donsky, H., Gulliver, W., Hamilton, D., Nobel, S., & Norman, R. (2006).
Treatment of mild to moderate psoriasis with Relieva, a Mahonia aquifolium
extract—a double-blind, placebo-controlled study. American Journal Of
Therapeutics, 13(2), 121-126.
Bhuchar, S., Katta, R., & Wolf, J. (2012). Complementary and Alternative Medicine in
Dermatology. American Journal of Clinical Dermatology, 13(5), 311-317.
Brown, A. C., Hairfield, M., Richards, D. G., McMillin, D. L., Mein, E. A., & Nelson,
C.D., (2004). Medical nutrition therapy as a potential complementary treatment
for psoriasis-five case reports. Alternative Medicine Review, 9(3), 297-307.

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This article is protected by copyright. All rights reserved.
 Cai, L., Gu, J., Zheng, J., Zheng, M., Wang, G., Xi, L‐Y., & Wang, Y. (2017). Efficacy
and safety of adalimumab in Chinese patients with moderate‐to‐severe plaque
psoriasis: results from a phase 3, randomized, placebo‐controlled, double‐blind
study. Journal of the European Academy of Dermatology and Venereology, 31(1),
89-95.
Calara, P. S, Althin, R., Carlsson, K.S., & Schmitt, E. (2017). Regional differences in the
Accepted Article
prescription of biologics for psoriasis in Sweden: A register-based study of 4168
Patients. BioDrugs, 31(1), 75-82.
Capella, G., Luigi, B., & Finzi, A.F. (2003). Complementary therapy for psoriasis.
Dermatologic Therapy, 16(2), 164-174.
Carroll, C. L, Clarke, J., Camacho, F., Balkrishnan, R., & Feldman, S. R. (2005). Topical
tacrolimus ointment combined with 6% salicylic acid gel for plaque psoriasis
treatment. Archives of dermatology, 141(1), 43-46.
Costa, R., Albergamo A, Pellizzeri, V., & Dugo, G. (2017). Phytochemical screening by
LC-MS and LC-PDA of ethanolic extracts from the fruits of Kigelia africana
(Lam.) Benth. Natural Product Research, 31, 1397-1402.
Dewet, H., Nciki, S., & Vuuren, S. F. (2013). Medicinal plants used for the treatment of
various skin disorders by a rural community in northern Maputaland, South
Africa. Journal of Ethnobiology And Ethnomedicine, 9(1), 51-55.
Deng, S., May, B.H., Zhang, A.L., Lu, C., & Xue, C.L. (2013). Plant extracts for the
topical management of psoriasis: a systematic review and meta‐analysis. British
Journal of Dermatology, 169(4), 769-782.
Dhanabal, S. P., Muruganantham, N., Basavaraj, K. H., Wadhwani, A., & Shamasundar,
N. M. (2012). Antipsoriatic activity of extracts and fractions obtained from
Memecylon malabaricum leaves. Journal of Pharmacy and Pharmacology,
64(10), 1501-1509.
Dhanabal, S.P., Priyanka D. L, Muruganantham, N., & Vadivelan, R. (2012). Evaluation
of the antipsoriatic activity of Aloe vera leaf extract using a mouse tail model of
psoriasis. Phytotherapy Research, 26(4), 617-619.
Dwarampudi L.P., Palaniswamy, D., Nithyanantham, M., & Raghu, P.S. (2012).
Antipsoriatic activity and cytotoxicity of ethanolic extract of Nigella sativa seeds.
Pharmacognosy Magazine, 8, 268-272.
García-Pérez, M., Royer, M., Duque-Fernandez, A., Diouf, P. N., Stevanovic, T., &
Pouliot, R. (2010). Antioxidant, toxicological and antiproliferative properties of
Canadian polyphenolic extracts on normal and psoriatic keratinocytes. Journal of
Ethnopharmacology, 132(1), 251-258.
Gisondi, P., & Girolomoni, G. (2017). Patients’ perspectives in the management of
psoriasis: the Italian results of the multinational assessment of psoriasis and
psoriatic arthritis (MAPP) survey. Journal of Dermatological Treatment, 28(5),
390-393.
Gisondi, P., Del G. M., & Girolomoni, G. (2017). Treatment approaches to moderate to
severe psoriasis. International Journal of Molecular Sciences, 18(11), 2427-2430.
Gladman, D.D., Antoni, C., Mease, P., Clegg, D.O., & Nash, P. (2005). Psoriatic arthritis:
epidemiology, clinical features, course, and outcome. Annals Of The Rheumatic
Diseases, 64(2), 4-17.

10
This article is protected by copyright. All rights reserved.
 Goiabeira, M. F., Nunes, D. C., Machado, A. P., Silveira, O., Pinto, É. B., Einecke, Y. S.,
& Amin, G. A. (2018). Assessment of patients with psoriasis undergoing
treatment with narrowband UVB phototherapy in the State University of Pará,
Brazil. International Archives of Medicine, 11, 45-50.
Gold, L.F. (2009). Calcitriol ointment: optimizing psoriasis therapy. Journal Of Drugs In
Dermatology, 8(8), 23-27.
Accepted Article
Herron, M. D., Hinckley, M., Hoffman, M. S., Papenfuss, J. H., Christopher, B., Callis,
K. P., & Krueger, G. G. (2005). Impact of obesity and smoking on psoriasis
presentation and management. Archives Of Dermatology, 141(12), 1527-1534.
Hönigsmann, H. (2001) Phototherapy for psoriasis. Clinical Experimental
Dermatology, 26, 343-350.
Horn, E.J., Domm, S., Katz, H.I., Lebwohl, M., Mrowietz, U., & Kragballe, K. (2010).
Topical corticosteroids in psoriasis: strategies for improving safety. Journal of the
European Academy of Dermatology and Venereology, 24(2), 119-124.
Joe, B., & Lokesh, B.R. (1997). Effect of curcumin and capsaicin on arachidonic acid
metabolism and lysosomal enzyme secretion by rat peritoneal macrophages.
Lipids. 32(11), 1173-1180.
Kaur, I., Dogra, S., Jain, R., & Kumar, B. (2008). Comparative study of calcipotriol
(0.005%) ointment and tazarotene (0.05% and 0.1%) gel in the treatment of stable
plaque psoriasis. Indian Journal of Dermatology, Venereology, and Leprology,
74(5), 471.
Kelly, J. B., Foley, P., & Strober, B. E. (2015). Current and future oral systemic therapies
for psoriasis. Dermatologic Clinics, 33(1), 91-109.
Kircik, L. (2009). Efficacy and safety of topical calcitriol 3 microg/g ointment, a new
topical therapy for chronic plaque psoriasis. Journal Of Drugs In Dermatology,
8(8),9-16.
Koo, J., & Arain, S. (1998). Traditional Chinese medicine for the treatment of
dermatologic disorders. Archives Of Dermatology, 134(11), 1388-1393.
Lapolla, W., Yentzer, B.A., Bagel, J., Halvorson, C. R., & Feldman, S. R. (2011). A
review of phototherapy protocols for psoriasis treatment. Journal of the American
Academy of Dermatology, 64(5), 936-949.
Mahajan, R., & Handa, S. (2013). Pathophysiology of psoriasis. Indian Journal of
Dermatology. Venereology, and Leprology,. 79(7), 45-50.
Marsland, A.M., & Griffiths. C.E. (2002). The macrolide immunosuppressants in
dermatology: mechanisms of action. European Journal of Dermatology, 12, 618-
622.
Martin, J. C., Wolk, K., Bériou, G., Abidi, A., Witte-Händel, E., Louvet, C., & Renauld,
J. C. (2017). Limited presence of IL-22 binding protein, a natural IL-22 inhibitor,
strengthens psoriatic skin inflammation. The Journal of Immunology, 198(9),
3671-3678.
May, B. H., Zhang, A. L., Zhou, W., L., Chuan-jian, D., Shiqiang, E., & Xue, C.L.
(2012). Oral herbal medicines for psoriasis: a review of clinical studies.Chinese
Journal Of Integrative Medicine, 18(3), 172-178.
Maza, A., Montaudié, H., Sbidian, E., Gallini, A., Aractingi, S., Aubin, F., & Jullien, D.
(2011). Oral cyclosporin in psoriasis: a systematic review on treatment modalities,

11
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 risk of kidney toxicity and evidence for use in non‐plaque psoriasis. Journal of the
European Academy of Dermatology and Venereology, 25(2), 19-27.
Merial‐Kieny, C., Mengual, X., Guerrero, D., & Sibaud, V. (2011). Clinical efficacy of
Avène hydrotherapy measured in a large cohort of more than 10,000 atopic or
psoriatic patients. Journal of the European Academy of Dermatology and
Venereology, 25(1), 30-34.
Accepted Article
Miller, A.C. (1985). Anthralin cream as short contact therapy for psoriasis. Cutis, 35(6),
578-582.
Müller, K., & Ziereis, K. (1994). The antipsoriatic Mahonia aquifolium and its active
constituents; I. Pro-and antioxidant properties and inhibition of 5-lipoxygenase.
Planta Medica, 60(05), 421-424.
Muruganantham, N., Basavaraj, K.H., Dhanabal, S.P., Praveen, T.K., Shamasundar,
N.M., & Rao, K.S. (2011). Screening of Caesalpinia bonduc leaves for
antipsoriatic activity. Journal of Ethnopharmacology, 133(2), 897-901.
Naldi, L., & Gambini, D. (2007). The clinical spectrum of psoriasis. Clinics In
Dermatology, 25(6), 510-518.
Oliveira, M., Rocha, B. O., & Duarte, G. V. (2015). Psoriasis: classical and emerging
comorbidities. Anais Brasileiros De Dermatologia, 90(1), 9-20.
Oyedeji, F. O., & Bankole, O. S. (2012). Quantitative evaluation of the antipsoriatic
activity of sausage tree (Kigelia africana). African Journal of Pure and Applied
Chemistry, 6(13), 214-218.
Parisi, R., Webb, R. T., Kleyn, C. E., Carr, M. J., Kapur, N., Griffiths, C. E. M., &
Ashcroft, D. M. (2018). Psychiatric morbidity and suicidal behaviour in psoriasis:
a primary care cohort study. British Journal of Dermatology, 34(6),56-60.
Picone, J. M., MacTavish, H. S., & Clery, R. A. (2002). Emission of floral volatiles from
Mahonia japonica (Berberidaceae). Phytochemistry, 60(6), 611-617.
Pullmann, H., Lennartz, K.J, & Steigleder, G.K.. (1975). The effect of salicylic acid on
epidermal cell proliferation kinetics in psoriasis. Autoradiographic in vitro-
investigations (author's transl). Archiv Fur Dermatologische Forschung, 251(4),
271-275.
Rana, S., Zeeba, J. S., Sujata, J., & Madhur, K. (2012). A comparative study of psoriasis
and psoriasiform lesion on basis of cd4 and cd8 cell infiltration.Our Dermatology
Online/Nasza Dermatologia Online, 3(4), 60-65.
Ricketts, J. R., Rothe, M. J., & Grant-Kels, J. M. (2010). Nutrition and psoriasis. Clinics
In Dermatology, 28(6), 615-626.
Shiri J., Cicurel A.A., & Cohen, A.D. (2011). An open-label study of herbal topical
medication (Psirelax) for patients with chronic plaque psoriasis. Science World
Journal, 6: 13-16.
Singh, K.K., & Tripathy, S. (2014). Natural Treatment Alternative for Psoriasis: A
Review on Herbal Resources.. Journal of Applied Pharmaceutical Science, 4,
114-121.
Smith, C.H. (1999). Use of hydroxyurea in psoriasis. Clinical And Experimental
Dermatology, 24(1), 2-6.
Shrivastav, S., Sindhu, R., Kumar, S., & Kumar, P. (2009). Anti-psoriatic and
phytochemical evaluation of Thespesia populnea bark extracts. International
Journal of Pharmacy and Pharmaceutical Sciences, 1, 34-40.

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 Strober, B. E., Poulin, Y., Kerdel, F. A., Langley, R. G., Gu, Y., Gupta, S. R, & Papp, K.
A. (2011). Switching to adalimumab for psoriasis patients with a suboptimal
response to etanercept, methotrexate, or phototherapy: efficacy and safety results
from an open-label study. Journal Of The American Academy Of Dermatology,
64(4), 671-681.
Swinkels, O.J., Prins, M., Kucharekova, M., Gerritsen, M.P., Van D., & Van, K. (2002).
Accepted Article
Combining lesional short‐contact dithranol therapy of psoriasis with a potent
topical corticosteroid. British Journal of Dermatology, 146(4), 621-626.
Syed, T. A., Ahmad, S. A., Holt, A. H., Ahmad, S. A., Ahmad, S. H., & Afzal, M.
(1996). Management of psoriasis with Aloe vera extract in a hydrophilic cream: a
placebo‐controlled, double‐blind study. Tropical Medicine & International
Health, 1(4), 505-509.
Van K., Peter, C., & Franssen, M. J. (2001). Psoriasis of the scalp. American Journal Of
Clinical Dermatology, 2(3), 159-165.
Vide, J., & Magina, S. (2017). Moderate to severe psoriasis treatment challenges through
the era of biological drugs. Anaisbrasileiros De Dermatologia, 92(5), 668-674.
Vijayalakshmi. A., Ravichandiran, V., Malarkodi, V., Nirmala, S., & Jayakumari, S.
(2012) Screening of flavonoid “quercetin” from the rhizome of Smilax china
Linn. for anti-psoriatic activity. Asian Pacific Journal Of Tropical Biomedicine, 2,
269-272.
Weger, W. (2010). Current status and new developments in the treatment of psoriasis and
psoriatic arthritis with biological agents. British Journal of Pharmacology,
160(4), 810-820.
Winterfield, L.S., Menter, A., Gordon, K., & Gottlieb, A. (2005). Psoriasis treatment:
current and emerging directed therapies. Annals Of The Rheumatic Diseases,
64(2), 87-90.
Zeichner, J. A. (2010). Use of topical coal tar foam for the treatment of psoriasis in
difficult-to-treat areas. The Journal Of Clinical And Aesthetic Dermatology, 3(9),
37.

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