Introduction

Psoriasis is a common condition affecting 0.2% to 4.8% of the population.¹ Psoriasis is a bimodal condition, which means that there are 2 peaks of presentation. The first presentation may occur from age 15-20, and the second at 55-60.¹ There does not seem to be a predominance for gender; it is equally common among men and women.²

There are many variants of psoriasis; these include plaque, palmoplantar, guttate, pustular, erythrodermic, and inverse psoriasis.³ Plaque psoriasis is the most common form.⁴

The cause of psoriasis is unknown; however, it is generally considered to be an autoimmune condition related to T cells.¹ There also is evidence of genetic predisposition.³ Psoriasis can be triggered by chemical or radiation trauma.¹ The condition can also be worsened by drugs such as steroids or NSAIDs, and by cold weather.¹ Physical trauma and stress may exacerbate the condition.⁵

Patients with psoriasis typically have red plaques and silver scales.⁵ These lesions commonly occur on the extensors, especially at elbows and knees.⁵ The specific forms of psoriasis each have their own manifestations. The nails are often affected, which may result in pitting and yellowing.⁵

Psoriatic arthritis is a condition that occurs on the skin surface and is accompanied with joint inflammation. It affects about 5-20% of those experiencing psoriasis.⁵

The pathophysiology of psoriasis is a result of activation of T cells causing an increase in the growth of keratinocytes, which results in thick plaques.¹

There are several differential diagnoses to consider. These consist of contact dermatitis, lichen plants, tinea corpora, pityriasis rosea, and secondary syphilis.⁶ It is important to recognize the signs of psoriasis early to minimize the chance of long-term disability.⁷

For early detection, ultrasound, CT scans, and MRI may be employed to detect any asymptomatic joint inflammation.⁷

There is an array of different treatment options for patients with psoriasis. The treatment is based on whether the patient is suffering from mild or severe psoriasis.⁸ Topical treatments are the most common option for mild cases, and they have the fewest side effects.⁹ For severe cases, systemic treatment is needed.⁹ These treatments consist of topical corticosteroids and Vitamin D3.⁶ Nanoformulations and photo-pharmaceuticals are also possible treatments.⁹ For more severe cases, systemic therapy may need to be employed.⁶ Phytotherapy is a systemic treatment that focuses on UV rays.⁶ Methotrexate and Acitretin are medications used to treat moderate to severe psoriasis; they are associated with more significant adverse effects.⁶ If these systemic treatments fail, then biologic therapy is employed.⁶

Case Report

A 46-year-old female patient had signs and symptoms of psoriasis that she had been diagnosed with 20 years prior by a dermatologist. She had visible red, scaly patches on her forearms, legs, and scalp. Past treatment consisting of medicated topical creams and shampoos proved unsuccessful in reducing her physical symptoms. Following a thorough history and physical exam, a trial of conservative care was started by her chiropractic physician. The chiropractic manipulative therapy (CMT) consisted of high-velocity, low-amplitude full-spine adjusting. Adjustment techniques included Thompson Terminal Point, diversified adjusting, Activator^TM, flexion/distraction and Gonstead. A typical chiropractic manipulative therapy consisted of Thompson terminal point adjustment of the sacrum, lumbar and cervical regions, and diversified technique in the thoracic region. Along with the CMT, IgG testing was ordered. The purpose of this was to test for food sensitivity. Following the test, the sensitive foods were removed from the patient’s diet.

She was treated conservatively for 2 months with chiropractic manipulative therapy and elimination of high-IgG-reactive foods. The reactive foods differ for every patient and can be quite extensive. Some examples of the foods that were removed were wheat, egg, bell peppers, vanilla, cashews, mustard, and winter squash. Within months of removing foods with high IgG reactivity she noticed her psoriasis patches had nearly completely disappeared.

Discussion

Psoriasis is an inflammatory condition affecting multiple systems.⁶ It results from a hyperproliferation of skin cells and increased turnover.¹⁰ The condition mostly affects the skin and the joint.⁶ Based on severity, psoriasis can be characterized as mild, moderate, or severe. Mild has a minimal effect on the quality of life, whereas severe has a severe effect on the quality of life.⁶

The diagnosis of psoriasis is typically made on the patient history and presentation. A skin biopsy may also be useful in atypical presentations.⁶

The most common form of psoriasis is plaque psoriasis, which typically presents with symmetric, red plaques and silver scales.⁶ There are many different forms of psoriasis; each has its own unique characteristics.

The treatments for psoriasis are not universally agreed upon and controversy still exists regarding treatment options. For mild cases of psoriasis, topical agents are the most common treatment. Salicylic acid and corticosteroid are common topicals.¹¹ Anthrax in is a topical therapy use for mild psoriasis; it can results in adverse affects like skin irritation.¹¹ Topical corticosteroids can be used to treat all types of psoriasis; they are often prescribed for longer periods of time, which can result in more adverse effects.¹¹ Phytotherapy uses UVA light to treat psoriasis.¹ For more severe cases, systemic drugs are employed.¹ If the previous treatments fail, then biology therapies are prescribed, which can result in serious infection.¹

Counseling can be used to help reduce patient’s stress, which can worsen psoriasis symptoms.¹² Because psoriasis is categorized as an inflammatory condition, foods may have an impact on the patient’s symptoms. Overproduction of acid can results in psoriatic lesions¹² An anti-inflammatory diet could be suggested in order to combat psoriatic symptoms.¹²

Immunoglobulin E (IgE) testing can be used to determine the presence food allergy.¹³ Immunoglobulin G (IgG) testing is used to determine food sensitivity.¹⁴ Food sensitivity is defined as any symptom related to food. IgG testing is done via a blood draw, and it is measured by the amount of IgG that binds to each food. The results are on a scale ranging from 0, which is no reactivity, to IV, which is extreme reactivity.¹³ The IgG test results show the response of the immune system to specific foods.¹⁴ As a result of this test, a diet is suggested to the patient that lists foods to be eaten and those to be avoided.¹⁴ Some common psoriasis food triggers are sugar, gluten and dairy.¹⁵ The elimination of IgG reactive foods in both patients with asthma and irritable bowel syndrome, which are inflammatory conditions, has been shown to improve patient’s symptoms.¹³

Conclusion

Further research is needed to make any substantial claims regarding IgG testing, removal of sensitive foods, and their effects on psoriasis symptoms. Many patients with psoriasis may benefit from a dietary solution rather than topical or systemic therapies. The results of this case suggest that the use of IgG testing to identify and remove sensitive foods from the patient’s diet resulted in a reduction of psoriatic symptoms. However, more research is still needed to understand the effects of food sensitivity and psoriasis.