INTRODUCTION:

Many medicinal plant species worldwide are used in traditional medicine for treating different diseases. The world health orgnisation (WHO) has estimated that about 80% of the population living in the developing countries depends tremendously on traditional medicine for their primary health needs. More than half of the world population still depends tremendously on medicinal plants and plants offer the active ingredients.

Human skin is the largest organ in the body. It forms the first guard line. Its three main layers are epidermis, dermis and hypodermis (subcutaneous tissue). Each layer offers a distinctive role in the homeostasis of the skin. They vary in thickness throughout the body and from person-to-person (Shadi t zari et al 2015). Presenting a total area of approximately 2m². Being the most exposed part to the external environment, it is more prone to the ill-effects of radiation and ultraviolet rays (Sanjay kumar Raut et al 2017).

Many medicinal plants are commonly used to treat skin diseases such as eczema, psoriasis, vitiligo, cellulitis, herpes and cancer. Herbal medicine is as old as civilization. Application of traditional herbal medicine is widespread in different regions of the world. It is more common in villages and desert areas where medical services are less accessible. Herbal treatments are generally perceived as effective and have few side effects. Research on herbal drugs in terms of controlled clinical trials in humans is stilllimited. Herbal clinical research optimistically opens new therapeutic avenues (Shadi t Zari et al 2015).

India is one of the largest producers of medicinal herbs and is rightly called thebotanical garden of the world as it is sitting on a gold mine of well-recorded and traditionally well practicedknowledge of herbal medicine. About 17,000 species of Indian flora about 7500 species of higher plants are reportedto possess medicinal value and in other countries it is projected about 7% and 13%. There are estimated to bearound 25,000 effective plant-based formulations, used in folk medicine and known to rural communities in India (Sunita verma et al 2016).

Psoriasis is a chronic autoimmune human skindisorder that is characterized by excessive proliferationof keratinocytes, scaly plaques, severe inflammation, and erythema. A wide range ofconventional medical therapies to treat psoriasisis established, from topical therapies [steroids, vitaminD analogues, psoralen, 5-aminolevulinicacid, salicylates, fumaric acid esters, anthralins(dithranol), tacrolimus, retinoids–e.g tazarotene]and systemic medications (methotrexate, cyclosporine, retinoids, 6-thioguanine, mycophenolatemofetil, troglitazone and new biologic agents,such as adalimumab, alefacept, efalizumab, etanercept,infliximab), through to phototherapy orcombinations of those. However, most of these therapies cause a number of side effects, and limitedin efficacy, inconvenience, cutaneous atrophy, organ toxicity (hepatotoxicity, nephrotoxicity, teratogenicity), carcinogenicity, and broadbandimmunosuppression, which are limitingtheir long-term use. In turn, a short-termtreatment of psoriasis causes its remission afterfinishing the treatment or only relieves the patientʼs condition. Moreover, psoriasis is often accompaniedby other diseases, such as depressiveillness, cardiovascular disease, and a seronegativearthritis known as psoriatic arthritis. Therefore, the invention of new alternative treatmentsdesirable. It seems that several herbal drugs can meet these requirements and have to be seen aspromising new agents for psoriasis treatment. Herbal products are greatly accepted by patientsbecause they are believed to be safer than conventionaltherapeutics. Moreover, herbal productspresent a great structural diversity and multidirectionalmechanisms of action, which is notcommonly seen in synthetic compounds. Herbaldrugs may become an effective treatment forpsoriasis, causing lower costs and less side- ortoxic effects in comparison to other therapies. Therefore, researchers are still looking for novelherbal products and/or their active constituentswhich potentially could be used for the treatment of psoriasis insteadof synthetic drugs (Anna Herman et al 2016).

What is psoriasis?

Psoriasis is a chronic, noncommunicable, painful, disfiguring and disabling disease for which there is nocure and with great negative impact on patients’ quality of life (QoL). It can occur at any age, and is mostcommon in the age group 50–69. The reported prevalence of psoriasis in countries ranges between0.09% and 11.4%, making psoriasis a serious global problem (WHO 2016).

Psora, means itch, rash, or skurf. Therefore Psoriasis can be called the itching disease. Psoriasis effects2.5% of the world population and 30% of patients experience arthritic psoriasis effecting the joints. Psoriasis is recognized in the west as an chronic inflammatory autoimmune disease caused by genetics, the immune system and environmental factors (Jasmine nobel et al).

Figure 1: Normal skin and psoriasis affected dead skin cells (Sanjay kuamar Raut et al 2017).

Psoriasis is a common, persistent skin disorderestimated to affect between 2% and 4% of thepopulation in western countries. It is a non-infectious, inflammatory disease of the skincharacterised by well-defined erythematous plaqueswith large, adherent, silvery scales usually on theelbows, knees, back and scalp. The main abnormality in psoriasisis increased epidermal proliferation due to excessivedivision of cells in the basal layers. Cell turnover isnormally 28 days, but in psoriasis the transit time of keratinocytes through the epidermis is shortened to five or six days. Psoriasis does not usually itch and rarely hurts exceptwhen cracks appear in dry, roughened patches on thepalms or the soles of the feet. It can causeconsiderable embarrassment and distress, lead to shyness, feelings of isolation and depression (Shan Y et al 2016). The main symptoms are irritation, redand flaky patches of skin. Patches are most often seen onthe elbows, knees and middle of the body, but can appearon scalp and elsewhere in the body. The skin may be itchy, dry and covered with raised thick silvery flaky skin pink redin color. Other symptoms include genital sores, joint pain, thickening and browning of nail and severe dandruff on thescalp (Kamelsh Kumar Singh et al 2014).

Common types of Psoriasis And their Manifestation

Psoriasis vulgaris (plaque psoriasis)

The most common type of psoriasis, affectsbetween 58% and 97%of all patients.Inflammatory red, sharply demarcated, raised, dry,differently sized plaques, usually covered by silveryor white scales.Involves the scalp and the area behind the ears,the extensor surfaces of the forearms and shins(especially elbows and knees), trunk, face, palms,soles and nails.

Figure 2

Intertriginous psoriasis (psoriasis in folds and genital areas)

Affects between 12% and 26% of all cases of psoriasis. Deep-red or white, flat, sharply demarcated, wet patches or plaques, scales are usually absent. Affects almost exclusively flexural body sites – axillae, antecubital fossae, inframammary creases, umbilicus, groins, genital area, gluteal cleft, popliteal fossae and other body folds.

Guttate psoriasis (droplet psoriasis)

Affects between 0.6% and 20% ofindividuals diagnosed with psoriasis and usuallyoccurs in childhood and adolescence. Reddish, drop-like papules and plaques, mainlyinvolving the trunk, arms and legs.Onset is associated with streptococcal infectionof the upper respiratory tract and prior skinsymptoms.

Figure 3

Pustular psoriasis:

Affects between 1.1% and 12% of allcases of psoriasis. Coalescing pustules, filled with non-infectious pus. Involves either small areas such as palms of thehands, fingertips, nails and soles of the feet, or theentire body surface can occur as a single episodeafter a trigger.

Figure 4

Erythrodermic psoriasis:

Affects between 0.4% and 7% of allcases of psoriasis. Fiery redness and exfoliation of most of the bodysurface. The most serious type of psoriasis, potentially lifethreatening,because it can lead to hypothermia,hypoalbuminemia and high output cardiac failure(WHO 2016).

Figure 5

Principles of psoriasis management:

Psoriasis is by nature a chronic, incurable disease with an unpredictable course of symptoms and triggers. The consequence is often life-long treatment, therefore, all treatments must meet high quality criteria thatare not only efficacious, but also safe over long periods. As the cause of psoriasis is still unknown, treatmentis only available to control symptoms. Treatments include a range of topical and systemic therapies as well as phototherapy. It also involves treatment for reducing pain and disability from arthritis and other manifestations.

Care for patients with psoriasis requires more than management of the skin lesions and joint involvement. The complexity of psoriasis means that prescribing drugs in isolation is insufficient to control the disease and a holistic, whole person approach to care is needed. Management of psoriasis also includes screeningfor associated diseases such as hypertension, dyslipidemia, diabetes mellitus and cardiovascular disorders as well as their complications such as myocardial infarction and stroke. Psoriasis patients are more likely to suffer from depression and anxiety disorders and have an increased rate of suicidal ideation. Screening at regular intervals for these associated diseases and for co-medication to prevent drug-druginteractions or drug-triggered psoriasis as well as recognition of trigger factors and their treatment are anessential part of psoriasis management.

1. Treating the skin manifestations.

2. Treating the whole person: beyond the skin manifestations.

3. Understanding Several triggering factors have been identified leading to the first manifestation of psoriasis.

4. Barriers to quality care

Patients suffering from psoriasis face many barriers when dealing with health professionals and healthsystems.

5. Inadequate access to health care.

6. Lack of awareness of health professionals.

7. Lack of standardized tools for diagnosis and treatment.

8. Cost and availability of essential medicines (WHO 2016).

Herbal Drug for The Treatment of Psoriasis.

Traditional medicines hold a great promice as source of easily available effective therapy for skin diseases to the people, particularly in tropical developing counties, including India. It is in this context that the people use several plant derived preparations to cure skin diseases. Herbal remedies for psoriasis are increasingly popular and mainstream (Ashwin B. Kuchekar et al 2011).

Topically used herbal products for the treatment of psoriasis

Many herbal topical formulations have been marketed worldwide to prevent psoriasis. There are many advantages of using natural drugs, including patient compliance, less side-effects, easy availability, low-costs, andmore than one mode of biochemical action for psoriasis treatment. Therefore, researchers are searching for new herbal products, which have the potential to be an alternative for synthetic drugs in psoriasis therapy.

Table 1 Herbal products used for the topical treatment of psoriasis – animal studies

Plant

Animal

Model of

the study

Pharmacological data

Effect

Cassia tora

(Singhal M et al 2012)

albino

mice

UVBinduced

psoriasis

Methanolic C. tora extract (0.05%, 0.1%, 0.2%) in O/Wcreams;

positive control: tretinoin (0.05%) in base cream;

treatment: single dose of creamswith different concentrations

of extract/tretinoin/cream base/crude extract

O/Wcreams with extracts exhibited a

significant reduction in percentage of

relative epidermal thickness as compared

to tretinoin

Kigelia

africana

(sausage

tree)

(Oyedeji FO et al 2012)

albino

mice

mouse tail

model of

psoriasis

Ointments containing 200, 100 and 50 mg/ml of methanol extracts from stem, leaves, and fruit of K. africana;

control: vehicle and placebo;

treatment: 0.1 ml of the ointment, contact time of 2–3 h,

once daily for 2 weeks

stem methanol extracts induced orthokeratosis

in parakeratotic areas ofmouse

tail with significant effects on epidermal

thickness

Nigella sativa

(Dwarampudi LP et al 2012)

BALB/c

mice

mouse tail

model of

psoriasis

95% ethanolic extract of N. sativa desolved in water; ratio 1: 2;

control: placebo;

positive control: tazarotene gel (0.1%);

treatment: once daily for 14 days, contact with the skin for 2 h

extract produced equivalent epidermal

differentiation in degree of orthokeratosis

as tazarotene

Rubia

cordifolia

(Lin ZX et al 2010)

BALB/c

mice

mouse tail

model of

psoriasis

Ethanolic extract was fractioned sequentially with hexane,

ethyl acetate (EA), n-butanol, and water;

1%, 2% and 5% EA fraction of extract was formulated into gel;

control: placebo;

positive control: 1% w/w dithranol in gel;

treatment: twice a day, 7 times aweek for 4 consecutiveweeks

EA fraction dose-dependently increased

granular layer and epidermal thickness;

potency of keratinocyte differentiation

5% EA fraction is similar to that of dithranol

gel

Scutellaria

baicalensis

(Wu J et al 2015)

BALB/c

mice

mouse tail

model of

psoriasis

Creams with 1%, 3%and 5%baicalin isolated From S. baicalensis;

control: placebo;

negative control: 2,4-dinitrofluorobenzene-induced contact

hypersensitivity (CHS);

positive control 1: 0.1% tazarotene cream;

positive control 2: 0.03% tacrolimus ointment;

treatment: twice daily for 4 weeks

creams with baicalin inhibit CHS reaction

at a less significant magnitude than that

of tacrolimus ointment;

5% baicalin cream promotes epidermal

differentiation and normal keratization

of keratinocyte in mouse similar to that

of tazarotene cream

Smilax china

(Vijayalakshmi A et al 2012)

Swiss

albino

mice

mouse tail

model of

psoriasis

Methanol extract and isolated flavonoid quercetin;

positive control: retinoic acid

flavonoid quercetin shows significant

orthokeratosis, anti-inflammatory, and

maximum antiproliferant activities

Thespesia

populne

(Shrivastav S et al 2009)

Wistar

rats

mouse tail

model of

psoriasis

Cream with 100 mg of each extract (ethanolic, pet-ether, butanolic,

ethyl acetate) and 50 mg of each isolated compound

(TpF-1 and TpF-2 as flavonoids, TpS-2 as sterole);

positive control: 0.05% tretinoin cream;

treatment: once daily, 5 times a week for 2 weeks

pet-ether extract and TpF-2 increased

orthokeratotic region

Wrightia tinctoria

(Raj BA et al 2012)

albino

mice

mouse tail

model of

psoriasis

Hydro alcoholic extract of W. tinctoria leaves;

control: vehicle;

positive control: isoretinoic acid;

treatment: once daily for 14 days

extract produced significant degree of

orthokeratosis compared to isoretinoic

acid and increased the epidermal thickness

compared to control

Table 2 Herbal products used for the topical treatment of psoriasis – clinical studies.

Plant

Type of clinical study

Participants

Treatments

Effect

Aloe vera

(Syed TA et al 1996)

placebo-controlled,

double-blind clinical

trial

60 patients

(18–50 years) with

slight to moderate

chronic plaque psoriasis

and PASI scores

between 4.8–16.7

A. vera extract (0.5%) in hydrophilic

cream (n = 30);

base cream (n = 30);

3 times daily (without occlusion)

for 5 consecutive days per week for

16 weeks

A. vera cream had cured 25/30 patients

compared to the placebo

cure rate of 2/30 resulting in significant

clearing of the psoriatic

plaques and decreased PASI score

to amean of 2.2

Aloe vera

(Choonhkaran C et al 2010)

randomized, comparative,

double-blind clinical

trial

80 patients with mild

to moderate plaque

psoriasis

A. vera cream (70% aloe mucilage)

(n = 40);

0.1% triamcinolone acetonide cream

(n = 40);

twice daily for 8 weeks

A. vera cream was found to be

more effective than triamcinolone

acetonide cream

Baphicacanthus

cusia

(Lin YK et al 2007)

vehicle-controlled

clinical trial

14 patients with

chronic plaque

psoriasis

indigo naturalis ointment

(20% B. cusia powder);

vehicle ointment;

once daily for 8 weeks

significant reduction of psoriasis

compared to control

Capsicum

frutescens

(Bernstein JE et al 1986)

comparative, vehiclecontrolled,

doubleblind

clinical tria

44 patients with

moderate to severe

psoriasis

cream with capsaicin isolated from

C. frutescens;

vehicle cream;

once a day for 6 weeks

capsaicin cream was found to be significantly more effective than control

Curcuma longa

(Sarafian G et al 2007)

randomized, prospective

intra-individual,

right–left comparative,

placebo-controlled,

double blind clinical trial

40 patients

(18–60 years) with

mild to moderate

plaque psoriasis

turmeric (hydroalcoholic C. longa

extract) microemulgel;

vehicle;

twice a day for 9 weeks

progressive reduction of thickness, followed by decrease erythema, pruritus, resulting in moderate to acceptable improvement;

in some cases, significant resolution of psoriatic lesions

Hypericum perforatum

(Nazafizadeh G et al 2012)

right–left comparative,

vehicle- controlled,

single blinded (only

patients were blinded)

clinical trial

10 patients

(20–55 years) with

mild plaque psoriasis

H. perforatum (5%) ointment;

vehicle ointment;

twice daily for 4 weeks

improvement in clinical scores

was reported with H. perforatum ointment compared with placebo group

Indigo naturalis

(Lin YK et al 2014)

randomized, vehiclecontrolled,

observerblind

clinical trial

31 patients with symmetrically

comparable

psoriatic nails

Refined I. naturalis extract in oil (Lindioil);

olive oil;

twice daily for the first 24 weeks

reduction of NAPSI scores for the Lindioil group was superior to the reduction in the control group

REFERENCE:

1. Shadi T. Zari and Talal A. Zari A review of four common medicinal plants used to treat eczema. Journal of medicinal Plants Research. Vol.9, pp.702-711, 25 june, 2015.

2. Sanjay Kumar Rout, Bankim Chandra Tripathy and Bikash Ranjan Kar. Natural Green Alternatives to Psoriasis Treatment– A Review.Global Journal of Pharmacy and Pharmaceutical Sciences. August 07, 2017.

3. Sunita Verma. Medicinal plants used in cure of skin diseases. Pelagia Research Library Advances in Applied Science Research, 2016, 7(3):65-67

4. Anna Herman, Andrzej P. Herman. Topically Used Herbal Products for the Treatment of Psoriasis–Mechanism of Action, Drug Delivery, Clinical Studies. August 8, 2016.

5. WHO 2016. Global report on Psoriasis.

6. Jasmine Noble. Psoriasis a review of literature western and ayurvedic perspectives.

7. Shan Y (2016) Treatment and management of psoriasis. Primary Health Care. 26, 3, 32-41. Date of submission: July 15 2015. Date of acceptance: August 25 2015.

8. Kamlesh Kumar Singh, Surendra Tripathy. Natural Treatment Alternative for Psoriasis: A Review on Herbal Resources. Journal of Applied Pharmaceutical Science Vol. 4 (11), pp. 114-121, November, 2014.

9. Ashwin B. Kuchekar, Rohini R. Pujari, Shantanu B. Kuchekar, Shashikant N. Dhole and Payal M. Mule. International Journal of Pharmacy & Life Sciences Psoriasis: A Comprehensive review. June 2011.

10. Singhal M, Kansara N. Cassia tora Linn cream inhibits ultraviolet-Binduced psoriasis in rats. ISRN Dermatol 2012; 2012: 346510

11. Oyedeji FO, Bankole-Ojo OS. Quantitative evaluation of the antipsoriatic activity of sausage tree (Kigelia africana). Afr J Pure Appl Chem 2012; 6:214–218

12. Dwarampudi LP, Palaniswamy D, Nithyanantham M, Raghu PS. Antipsoriatic activity and cytotoxicity of ethanolic extract of Nigella sativa seeds. Pharmacogn Mag 2012; 8: 268–272

13. Lin ZX, Jiao BW, Che CT, Zuo Z, Mok CF, Zhao M, Ho WK, Tse WP, Lam KY, Fan RQ, Yang ZJ, Cheng CH. Ethyl acetate fraction of the root of Rubia cordifolia L. inhibits keratinocyte proliferation in vitro and promotes keratinocyte differentiation in vivo: potential application for psoriasis treatment. Phytother Res 2010; 24: 1056–1064

14. Wu J, Li H, Li M. Effects of baicalin cream in two mouse models: 2,4-dinitrofluorobenzene- induced contact hypersensitivity and mouse tail test for psoriasis. Int J Clin Exp Med 2015; 8: 2128–2137

15. Vijayalakshmi A, Ravichandiran V, Velraj M, Nirmala S, Jayakumari S. Screening of flavonoid “quercetin” from the rhizome of Smilax china Linn. for anti-psoriatic activity. Asian Pac J Trop Biomed 2012; 2: 269– 275

16. Shrivastav S, Sindhu R, Kumar S, Kumar P. Anti-psoriatic and phytochemical evaluation of Thespesia populnea bark extracts. Int J Pharm Pharm Sci 2009; 1: 176–185

17. Raj BA, Muruganantham N, Praveen TK, Raghu PS. Screening of Wrightia tinctoria leaves for anti psoriatic activity. Hygeia J Drug Med 2012; 4:73–78

18. Syed TA, Ahmad SA, Holt AH, Ahmad SA, Ahmad SH, Afzal M. Management of psoriasis with Aloe vera extract in a hydrophilic cream: a placebo-controlled, double-blind study. Trop Med Int Health 1996; 1: 505–509

19. Choonhakarn C, Busaracome P, Sripanidkulchai B, Sarakarn P. A prospective, randomized clinical trial comparing topical aloe vera with 0.1% triamcinolone acetonide in mild to moderate plaque psoriasis. J Eur Acad Dermatol Venereol 2010; 24: 168–172

20. Lin YK, Wong WR, Chang YC, Chang CJ, Tsay PK, Chang SC, Pang JH. The efficacy and safety of topically applied Indigo naturalis ointment in patients with plaque-type psoriasis. Dermatology 2007; 214: 155–161

21. Bernstein JE, Parish LC, Rapaport M, Rosenbaum MM, Roenigk HH Jr. Effects of topically applied capsaicin on moderate and severe psoriasis vulgaris. J Am Acad Dermatol 1986; 15: 504–507

22. Sarafian G, Afshar M, Mansouri P, Asgarpanah J, Raoufinejad K, Rajabi M. Topical turmeric microemulgel in the management of plaque psoriasis; A clinical evaluation. Iran J Pharm Res 2015; 14: 865–876

23. Najafizadeh P, Hashemian F, Mansouri P, Farshi S, Surmaghi MS, Chalangari R. The evaluation of the clinical effect of topical St Johns wort (Hypericum perforatum L.) in plaque type psoriasis vulgaris: a pilot study. Australas J Dermatol 2012; 53: 131–135

24. Lin YK, See LC, Huang YH, Chang YC, Tsou TC, Lin TY, Lin NL. Efficacy and safety of Indigo naturalis extract in oil (Lindioil) in treating nail psoriasis: a randomized, observer-blind, vehicle-controlled trial. Phytomedicine 2014; 21: 1015–1020

Received on 25.10.2019 Modified on 31.12.2019

Res. J. Pharmacognosy and Phytochem. 2020; 12(1):. 57-62.

DOI: 10.5958/0975-4385.2020.00011.4