Psoriasis – and General AutoImmune Considerations

(This is a sample entry from the SAFM Q&A Treasure Chest, a tool with hundreds of entries to support students with their client needs. Students gain unlimited access with enrollment in SAFM’s functional medicine training.)

Student Question:

My client has terrible ongoing psoriasis on legs, arms, head, behind, and now new break outs on lower back. She’s been seeing a  few dermatologists for her outbreaks for many, many years.  She’s been on all the creams, lotions, and potions and also does UV light treatments, but none of the practitioners she’s seen so far are focused on root cause assessments.  I know to focus on the gut here re: autoimmune root cause. What are the most important links between food and psoriasis I need to consider (alas, no practitioner has mentioned food to her yet at all)?  What about overall  autoimmune considerations through the functional medicine lens?  What are tools I can use to educate my client?   Thanks!

SAFM Response:

Psoriasis is an autoimmune disease in which the immune system causes keratinocytes to hyperproliferate and produce inflammatory mediators.  The result is scaly, dry skin patches which can occur almost anywhere on the body.   It is an inflammatory process in which the immune system (specifically T-cells) secretes cytokines which drive the cells into this overgrowth, especially via aggressive Th-17 mediated inflammation. Of note, psoriasis is typically both autoimmune (driven by T cell responses) and autoinflammatory (driven by innate immune system reactivity).

As with most diseases of either type, the gut plays a centrol role in etiology and trigger. Systemic lipopolysaccharide-driven inflammatory/autoimmune activity via enhanced intestinal permeability is often involved in psoriasis.  Recent clinical research has provided more evidence of the role of translocation of microbial DNA in promoting chronic autoimmune activity, including that of psoriasis.  Research demonstrates higher levels of LPS in these patients’ bloodwork  and topical support (or even phototherapy) is not going to alleviate this driver.  Opportunistic microbial overgrowths (e.g., C. albicans, H. pylori) are common contributors to increased gut mucosal inflammation, immune dysregulation, and then loss of barrier function.

Foods that contain gluten and dairy proteins and likely other grains as well (even gluten-free ones, which can be cross-reactive with wheat/gluten) are often involved in exacerbating inflammatory behavior.  Beyond the role of zonulin in promoting “leaky gut”, a common hallmark of psoriasis is autoimmune reactivity to transglutaminase enzymes, a downstream effect of cross-reactivity from gluten in the gut to an enzyme in the skin (and a powerful example of the gut-skin axis at work). At least short-term (4-6 mos) full avoidance of exacerbating foods is often required for regression (and perhaps longer depending on duration of the healing process).  But getting to the true root causes of her unique case of intestinal permeability and healing the gut are both crucial for sustainable improvement.

Many factors can contribute to enhanced intestinal permeability. It is well understood that poor bile function is involved in many cases of psoriasis too, not surprising given the role of bile in degrading LPS to minimize systemic reactivity in the presence of enhanced intestinal permeability. This is a related post in our SAFM Clinical Tips area which will interest you about the potential value of bile acid support for these patients.  Alcohol intake is also a common contributor to mucosal oxidative damage and excessive inflammation and permeability that patients with psoriasis may be especially sensitive to experiencing.

Hydration (not just water but electrolytes as well) is key for overall skin health and is a commonly overlooked foundational requirement.

Appropriate dietary fat intake is also key for creating pro/anti-inflammatory balance; psoriasis has been shown to respond well to omega-3 supplementation (3-4g/day) in a notable number of cases.

There is also often disease improvement when addressing impaired digestion, especially impaired protein digestion. Perhaps low stomach acid (e.g. check total protein, ferritin, serum B12) and/or, as above, perhaps bile acid insufficiency (think thoroughly about possible connections… e.g. no gallbladder, history of gallstones, high alkaline phosphatase, high fecal fats on stool test or lighter-colored stools that consistently float)?

There is also evidence of copper/zinc imbalance in many psoriasis patients, and Vitamin A sufficiency is important for antioxidant function, collagen support for skin renewal/healing, and immunoregulatory balance.

Now, let’s talk more generally about the functional medicine concepts and interconnectedness likely involved in chronic autoimmune activity…  Autoimmune triggers are usually multifaceted and include some or all of the following:

1. Dysbiosis – or imbalance – of microbes in the gastrointestinal tract (may be something infectious like simmering Clostridia, yeast overgrowth, a parasite, or simply an insufficiency of or imbalance in indigenous gut bacteria).  One of the major drivers for dysbiosis is antibiotic use, especially multiple extended courses over time. However, medications, toxins, stress, food choices, low Vitamin D, maldigestion, and many other factors may be involved.  A comprehensive, DNA-assay stool test may help to characterize what is at play specifically.
2. Food sensitivities.  Food triggers are very often involved in autoimmune activation and exacerbation.  Gluten and dairy are the most common mediators, and thus, a thorough food elimination experiment can be very helpful (must be “cold turkey” full elimination to be effective though, at least for a while, not just reduction).  This is a detailed write-up on food sensitivities.  To allow food sensitivities triggered via loss of gut barrier function to heal, it is necessary to repair the gut lining using key nutrients such as l-glutamine, glycine, quercetin, and/or mucilaginous herbs (e.g. slippery elm, okra, marshmallow).
   • Of note, to expand on the strong gluten connection, psoriasis also often has strong connections to inflammatory bowel disease, including celiac disease.  Thus consider 100% gluten-free is an important early priority (as well as patient education about this key consideration). Again, tissue transglutaminase is often upregulated in psoriasis, which may promote overt damage to mucosa and the cross-reactive autoimmune damage from the gut to the skin as highlighted above. Unfortunately transglutaminase is often included as an unlabeled additive, specifically in processed animal proteins (aka “meat glue”) and gluten-free bread products.
3. Toxin build-up, caused either by ongoing exposure (overload) and/or poor detoxification ability of certain substances (e.g. mercury) that promotes build-up and sequestration in the body. Heavy metal toxicity (especially in combination with antioxidant insufficiency) is often a component of psoriasis interconnectedness.
4. Nutrient deficiencies that impair the immune system or detoxification (e.g. vitamin D, zinc, copper, Vitamin A, folate (B9), B12). These might be driven by insufficient nutrient intake, impaired gastrointestinal digestion and/or absorption, or genetic variability in cellular use of nutrients (e.g.  individuals positive for the GSTM1 or MTHFR gene variants (that is, “SNP”s  in which someone has poor glutathione synthesis or a methylation (detox processes) issue due to enzyme impairment).  Again, consider in particular excessive copper relative to zinc and also inadequate Vitamin A (especially in the context of Vitamin D supplementation).
5. Stress.  Ongoing, chronic stress can promote immune system dysregulation (under-reactive to infectious agents and hypervigilant to normally tolerated aspects of environment) and is usually involved on some level in autoimmune activation.  This stress might be mental-emotional or it might be physiological (e.g. prior surgery, sleep apnea, chronic anemia, major car accident or other physical trauma, other autoimmune activation, pathogenic microbe, toxicity, chronic viral infection).
   • Keep in mind that for some individuals, the primary stressor in their environment is the unrelenting, negative self-talk in their own minds.  Especially where poor self-worth or self-rejection due to physical dysfigurement or an inability to heal may be an ongoing component of mindset/beliefs.
6. Impaired cortisol secretion where the body has insufficient cortisol to balance/calm an over-reactive immune system and supply our own anti-inflammatory defense mechanism (unfortunately quite common in overworked, under-rested, sedentary adults, especially those with persistent viral infections and/or food sensitivities that present an aggressive, multifactorial collection of stressors on a day-over-day basis)
7. Genetic predispositions may also be involved, though these are often related to the above items (e.g., immune hypervigilance to gluten, impaired detoxification pathways, low Vitamin D receptor activity, poor conversion of beta carotene to fully formed Vitamin A) rather than being a singular, genetic driver for the autoimmune activity itself.

In terms of client education, we encourage you  to make use of AI as an excellent, at-hand research assistant. You can specify the particular interests or considerations for a particular patient and quickly be pointed to resources. Then your valuable time and expertise can be focused on vetting vs. searching.

You might be interested in this excellent general post on the topic  from Dr. Mark Hyman for a broad introduction and discussion of common drivers.  This is an easy-to-follow article in this vein  from Chris Kresser that might be inspiring to your client and which also lists some general applicable-to-all suggestions.  Dr. Alessio Fasano has completed ground-breaking research to demonstrate that intestinal permeability – and thus likely gluten sensitivity – is a part of the trigger for autoimmune disease activation. For an appreciably more savvy client (and perhaps you as well), consider this write-up.