This blog piece is primarily about Psoriasis(pronounced soriyasis) which is classified as an auto-immune condition. We will also consider the underlying processes at work in auto-immunity which involve gut health.
There is a lot we know about Psoriasis, but also a lot we do not know, such as specifically what causes it! We know that some people are more at risk of developing it due to their genetic make-up. We also know that psoriasis is an immune-driven condition that has as its hallmark raised plaques/scales on the skin that can look red and very inflamed. When the immune system is over-active skin cell growth increases and a typical four-week skin cycle takes place over just 3-4 days. Rather than being shed, cells pile up and this causes its own localised inflammation, typically on the knees, elbows, top of the buttocks, around the belly button and scalp. The inflammatory process can then affect joints and contributes in around one in three cases to development of psoriatic arthritis (joint inflammation).
There are five sub-types of psoriasis; guttate, pustular, plaque, inverse and erthyrodermic psoriasis, this article is focusing primarily on the plaque type as well as the general psoriatic picture.
The effects of Psoriasis can be experienced body wide. Whilst the plaques themselves have common locations there are other key areas where signs of psoriasis can be seen:
• Genital area- This is very common with as many as 2/3 of those with psoriasis experiencing genital psoriasis at some point.
• Scalp area- Around 60% of those with psoriasis have scalp psoriasis, which most commonly affects the hairline. It may also be an indicator of psoriatic arthritis.
• Facial- Again around 1/3 of those with psoriasis have it on their face.
• Hands/Feet/Nails- Nail changes can be found in around 50% of those with psoriasis and just under 20% with hands/feet affected.
• Skin folds- Under the arms and breasts, or between the thighs are areas that can be affected. There is usually less plaquing and scaliness with a tendency to shiny red/brown skin discolouration.
Psoriasis has been classified as an auto-immune disease, i.e. a condition whereby the immune system causes damage to body tissue. In the last couple of years some antibodies have been identified that appear to be correlated with psoriasis (e.g. ADAMTS-L5 , A6-integrin and LL-37), but these are not yet commercially available for diagnostic testing. Other antibodies, such as anti-CCP, have been found in some forms of psoriasis and not in others, which raises the question as to the individual nature of psoriasis types, genetic risk and potential triggers. HLA-C 0602 has also been identified as a potential gene marker. It may well be that in time the sub-types of Psoriasis have clearer classification, based on specific blood markers and/or antibodies found.
A marker that is not debated in Psoriasis is IL17/TH17. This is the well-known marker for auto-immunity and something that will be raised in those in a Psoriasis flare. A flare can be triggered by many things, including lifestyle factors such as food, stress, weather, temperature and whether there is an illness or other inflammatory process also occurring in the body. This is what makes Psoriasis such an individual condition; the severity, type and duration of a flare can all be dictated by many factors.
For myself when I am feeling run-down or have exposure to mould-related factors I will have a flare. So, ensuring that my environment is one that would offer only minimal exposure to mould-related factors, and ensuring that I don’t become run-down are important in my case for remaining relatively symptom-free. When a flare-trigger is extended then I am more likely to see pitting on my nails. This is just my own individual pattern, but it can take a while to get to the point where your own pattern is identifiable, especially if you have more than one skin condition.
Skin conditions can be quite the picture to unravel. There are several conditions that can all look very similar; Eczema, Psoriasis and Dermatitis Herpetiformis are just three. Eczema has a strong correlation to histamine levels and skin oils and dermatitis herpetiformis (DH)is strongly correlated with consumption of gluten and is known as the ‘skin form of Coeliac Disease’.
As a clinician I work with clients to support their nutritional health. This includes consideration of food-immune reactivity and a focus on gut health and the gut microbiome, both of which can be intimately involved in skin conditions. There are many nutritional factors that can also impact on the skin; nickel reactivity and lithium supplementation can both cause skin irritation with lithium supplementation contributing to a form of Psoriasis. The other factor that is less-well known is excessive intestinal permeability, known colloquially as ‘leaky gut’. The scientist who defined the link between auto-immunity and leaky gut is Alessio Fasano; his latest peer reviewed journal article from 2020 has as its title an adaption to the Hippocrates quote “All disease begins in the (leaky) gut”, the word leaky now added. The piece then has a focus on auto-immunity and chronic inflammatory diseases, specifically relating to the hormone zonulin, which is found to be elevated when the gut is ‘leaky’. Fasano states that when there is a genetic predisposition, and the diet and lifestyle factors are not as protective as they could be (thereby putting the gut at risk of being ‘leaky’), then if there is an environmental trigger, inflammatory processes are dialled up.
This of course leaves the door open for therapeutic interventions that are diet/lifestyle based, and this is why this is such an important area for us to focus. By unravelling our own diet/lifestyle factors that can boost or weaken our health, and being aware of the environmental factors that can affect our immune systems we can do much to optimise our own health, and specifically the health of our skin. Our skin after all is the barrier that is the closest to the outside world, and it is supported by hormones and oils for its integrity, with the immune system close at hand, if required. As Fasano states ‘it is the interplay between us as individuals and the environment in which we live that dictates our clinical destiny’ and whilst the intestines are a large part of that on the ‘inside’ of us, our skin on the outside can reflect what is going on inside and has its own direct battles to face too.
So for any skin condition, we have to consider three key factors:
1. The foundational state of our skin’s health
2. What we might be exposed to when we have a flare
3. Symptomatic responses and/or a deeper dive to consider the gut for more complete resolution
I mentioned cognition earlier in this piece, and it is important to note that when inflammatory processes occur, there is an increased risk of neuro-inflammation, which can lead to feelings of anxiety/low mood/brain fog or can be associated with diagnosable neurological conditions such as depression, chronic fatigue, schizophrenia or autism spectrum disorders. It is not uncommon to have this kind of symptom pattern alongside auto-immune conditions such as Psoriasis. Fasano points out in the article that loss of gut barrier function, increases in bacterial matter leaking through into the bloodstream and activation of the immune system to this debris can all contribute to cognitive changes.
By considering several pieces of the jigsaw we can start to put the picture together for each person’s individual auto-immune process(es). This is supremely important as the process of ‘leaky gut’ puts those at risk of auto-immunity at risk of being diagnosed with more than one condition. It is the ‘leaky gut’ that is the key. By healing and appropriately ‘sealing’ the gut lining, there is the chance that symptoms can be re-balanced, and health optimised. In the case of inflammatory skin conditions this can be enormously empowering.
Author: Louise Carder