(The details and name of this patient have been changed to protect her identity)
Psoriasis is a chronic skin condition that affects millions of people worldwide. It is a common autoimmune disorder that causes thick, red patches of raised skin to form on the body. People who suffer from psoriasis can experience physical, psychological, and emotional distress due to the uncomfortable symptoms. Fortunately, there are a variety of treatments available to help alleviate the symptoms and manage the condition. This case study will provide an illustrate a functional medicine approach to psoriasis that treats the root cause-inflammation.
Chief Complaint: Red, Scaling Rash Over Elbows, Shin, Face and Inner Thighs
Stacey is a 64yo female who was diagnosed with psoriasis six months ago by her Primary Care Physician (PCP) and referred to me because the "creams and lotions" she tried failed. The rash started months before that but would come and go with some improvement in the sun light but now her symptoms were worse with an intense itching even on her face and in her hair.
Additional History:
Stacey has had a few other new symptoms pop up within the last year. She was having an issue with constipation and became dependant on stool softeners and lots of coffee in order to have a bowel movement. She felt bloated and reported looking “very pregnant” within 30 to 45 minutes of eating.
She reported right leg sciatic pain and the inability to get off the floor from a sitting position with her grandchildren who keep her too busy to cook for herself. She crammed in chicken nuggets or pizza most nights while watching her grandkids to save time. She didn't eat breakfast and usually had a turkey or salami sandwich at work for lunch.
Stacey's PCP had already ordered her basic labs that revealed a high fasting blood sugar and low serum vitamin D.
After evaluating her initial labs, It was obvious Stacey needed more extensive testing based on her low vitamin D status, exacerbated rash and gut complaints. I added on bio markers for inflammation, methylation and nutritional deficiencies as well as a gut biome test.
Additional Functional Medicine Labs:
An imbalance of the gut microbiota will lead to gastrointestinal conditions such as irritable bowel syndrome (IBS), inflammatory bowel disease (IBD), and other systemic conditions such as celiac disease, cardiovascular disease, neurological disorders, malnutrition, skin conditions, autoimmune disorders, immune system imbalances, and multiple inflammatory disorders.
While waiting for Stacey's results to come back I counseled her on the triggers that make psoriasis worse: smoking, stress, infection, low calcium, kebnorization (a phenomenon where scratching a lesion will spread the condition), and certain medications like lithium, alcohol, ace inhibitors, and beta blockers to name a few. Additionally, we started her on an Elimination Diet to reduce her overall inflammation.
As suspected Stacey had multiple food sensitivities, elevated inflammatory markers, evidence of B vitamin deficiencies and gut dysbiosis.
A recent study found a relationship between alterations in the gut microbiome and the presence and severity of psoriasis. While there is little known about the specific connection between psoriasis and dysbiosis, there is increasing evidence that a bowel overgrowth of organisms plays a potentially causal role in other inflammatory skin conditions such as rosacea.
Hearing Stacey's history, I thought it was likely that an underlying pathogenic change in her gut microbiome contributed to her persistent psoriasis. Stacey's gut biome test was positive for low good bacteria and high for Methane producing bacteria. Methane is known to slow down gut motility causing slow transit constipation. This excess of Methane producing bacteria likely explains Stacey's new problem with constipation. The positive bacterial overgrowth result also explains the postprandial bloating or “pregnant look” she is experiencing after meals.
Her food sensitivity panel had a few positive flags, most notably wheat and corn. Reviewing Stacey's diet, I found that she was eating wheat or corn with almost every meal. This chronic exposure to foods that she is sensitive to was driving up her inflammatory markers (Crp), contributing to digestive symptoms, and negatively impacting her immune system.
Her homocysteine was elevated, and her serum B12 marker was low, suggesting she has some deficiencies in B vitamins. Given how limited Stacey's diet had been over the last year, I suspected that she had multiple nutrient deficiencies beyond what was tested for on her initial labs.
Interventions
For Stacey's Dysbiosis, we changed her diet to a low-FODMAP diet during which time I prescribed metronidazole for 10 days .
When her treatment was completed we rebuilt her gut with fresh herbs and supplements like berberine, quercetin, and achromasia.
I recomended to Stacey the follwoing supplments including a B complex that was high in methylated folate due to her elevated homocysteine and added a D3, CoQ10 and magnesium to support her immune system.
Follow Up
Stacey was scheduled for a 3 month follow up which was why I was surprised when I saw her back in my office in just 2 months.
Stacey was excited to see me, she had noticed some significant changes! She had completed the 10 day course for dysbiosis, taking her supplements daily, and had adhering to her diet. She excitedly pulled up her sleeves and pants to show me how her psoriasis was much imprved. She reproted her leg pain was gone and she sat on the floor in my office to demonstrate how should could get her self up so easily!
Finnaly, her digestive symptoms had completely resolved. She was now having daily bowel movements and was no longer bloating after meals. Her digestion felt “normal,” and she was very grateful to be feeling comfortable in her body again. She was also noticing significantly more energy. She woke up feeling refreshed and motivated to go for a run most mornings. She wasn’t sleepy in the afternoons and had less difficulty studying in the evenings.
Summary
This case study highlights how root cause treatment of GI dysfunction can have a far-reaching impact on seemingly unrelated health conditions. Stacey had dysbiosis and a diet that was contributing to her initial poor health. We were able to avoid escalating psoriasis medicaiotns by treating her dysbiosis with metronitazole, complete diet chage and simple supplement regimen. Although the science is still in the early days, there is increasing evidence that alternations in the gut microbiome may contribute to inflammatory skin disorders such as psoriasis.
Great article! It is AMAZING the connections between systems of the body, in particular how our gut health really affects everything. And how a non-complicated approach to understanding the issues, tweaking diet and supplements can really work.