Lori-Ann Holbrook endured the symptoms of psoriatic disease for 20 years before receiving concurrent diagnoses of psoriasis and psoriatic arthritis in 2012. Because her symptoms manifested one at a time — a skin lesion here, an itchy patch there, isolated joint pain, general fatigue — it took awhile to put the pieces together.
Then when a stressful move to New Jersey triggered all of her symptoms simultaneously, Holbrook disclosed everything to her primary care physician, who referred her to a rheumatologist and then a dermatologist to confirm both diagnoses.
As her doctors began prescribing medication to help her find relief, Holbrook realized it was going to take a multifaceted treatment plan to alleviate her full range of symptoms. Topical ointments seemed to help her plantar (foot) psoriasis, but she had to try several medications — including Aleve (naproxen), Ridaura (auraofin) and Azulfidine (sulfasalazine) — before finding relief from psoriatic arthritis through Remicade (infliximab) and methotrexate.
“None of the medications before that were effective at all, and some of the side effects were really off-putting,” Holbrook said. “Only immunosuppression therapy and chemo give me some relief.”
But those carry side effects too and might only grant temporary remission from chronic pain and recurring plaques. Stress as minor as a confrontation at work can trigger a flare for her within an hour. During flares, her doctor increases her dosage and adds prednisone, which helps with inflammation but causes “rapid weight gain, high blood pressure and persistent edema (or swelling)” for Holbrook.
Seeking to better manage her pain and stress, with the input of her doctors, Holbrook began incorporating complementary therapies to augment her medications while warding off their undesirable side effects.
“I knew I might not be able to give up my meds, but I decided every little thing I could do to keep my immune system calm was good,” said Holbrook, who blogs about “a day in the life of a city girl living with psoriatic arthritis.”
Like Holbrook, other patients with psoriatic disease, in consultation with their physicians, are exploring holistic therapies to complement their treatments, further alleviate symptoms and improve their overall well-being. With chronic diseases like psoriasis and psoriatic arthritis, practitioners and patients agree that every bit of relief helps.
“Complex diseases require complex solutions — specifically, multiple approaches working together,” said Roger Batchelor, DAOM, LAc, associate professor of acupuncture in the classical Chinese Medicine program at the National University of Natural Medicine in Portland, Oregon. “Most patients need ongoing care from several professionals for a chronic health challenge like psoriasis.”
From the inside out
Diagnosed with psoriasis at a very young age, Elissa Weinzimmer found relief in topical steroids for most of her life until she moved from California to colder climates in Canada. The shift in weather, combined with the stress of her master’s thesis, triggered a flare in March 2014. When phototherapy didn’t work, Weinzimmer’s doctor prescribed methotrexate, which caused other complications and inspired her to explore natural remedies with fewer side effects.
To help her in her quest for wellness, she started working with a functional medicine practitioner — a healthcare provider who addresses the whole person, not one set of symptoms at a time — to address her overall wellness.
Like Holbrook, Weinzimmer’s first steps into holistic treatment were supplements and dietary changes, beginning with an elimination diet to identify which foods triggered issues for her. Weinzimmer overhauled not just what she ate but how, by following Ayurveda, an ancient Indian system of striking balance through digestion, yoga, meditation and acupressure massage.
“I decided that maybe my body was trying to tell me something,” Weinzimmer, a vocal health educator in New York City, wrote on her blog. “Maybe … it would be worthwhile to dig deeply to figure out what was off balance inside of me … (and take) a comprehensive, whole-body look at things.”
Don’t fear the needles
People are often apprehensive about trying alternative treatments because there’s not much scientific research about the effectiveness of things such as acupuncture, meditation or yoga specific to psoriatic disease. That’s why it’s important to consult with your physician before beginning any therapy because psoriatic disease — and its treatments, both conventional and complementary — affects people differently.
Across all diseases, medical doctors might refer patients to acupuncture, according to Batchelor. Still, even he was skeptical the first time a psoriasis patient came to see him in 1989 for acupuncture, an ancient practice in which thin, sharp needles are inserted into specific points in the body to release natural painkillers like serotonin.
“My first psoriasis patient had more confidence than I did that acupuncture would work,” Batchelor said. But after three months of treatments, in conjunction with cortisone, which is used to relieve inflammation, the patient’s plaques and severe itching cleared. “It taught me that acupuncture works for [psoriasis], and that if you reduce the toxic load any way you can, then you have a fighting chance.”
The key, he said, is to be straightforward with practitioners about what you’re experiencing and expecting.
When Holbrook first tried acupuncture, she didn’t mention psoriatic disease; she only mentioned her goal of weight loss. After a painful first treatment, she found another acupuncturist, who asked about her medical history and tailored the treatment to her condition, resulting in a more relaxing experience.
“With things like acupuncture, the more feedback the better because we’re looking for what helps you feel a little better, and that doesn’t happen if you’re toughing it out,” Batchelor said. “Be like a scientist; pay attention to what changes and what doesn’t.”
Batchelor said in his experience, patients often notice less itching after three to six weeks of treatment, as well as emotional benefits including improved mood, increased energy and better sleep.
If the needles agitate your skin, as they did for Holbrook, or if you and your doctor are concerned they might, acupressure might be preferable. It works on the same principle, but the practitioner applies pressure with his hands instead of needles.
A report published in Acupuncture & Electro-Therapeutics Research in 1992 detailed the treatment of 61 psoriasis patients who didn’t respond to conventional medicine. After an average of nine sessions of acupuncture, half of the patients experienced complete clearance of skin lesions. Another quarter saw two-thirds clearance.
More recent research has studied acupuncture’s pain relief potential for conditions such as osteoarthritis, migraines and fibromyalgia, but research specific to psoriatic disease has been minimal. However, anecdotal evidence is sufficient for some, like Holbrook and Weinzimmer, to discuss it with their physicians and give it a try.
“The biggest benefit of acupuncture for psoriasis is that even if it doesn’t give a total cure, it can still help,” Batchelor said. “We look at the totality of symptoms and treat everything at the same time.”
When pain and stiffness from psoriatic arthritis constrict movement in daily activities, physicians may recommend physical therapy. Patients come to physical therapists like Lauren Piljic, P.T., DPT, to reduce their pain — or their dependence on assistive devices such as walkers.
Many of them are as skeptical of exercise as they are of acupuncture, she said.
“A lot of people are fearful of moving because they think exercise is going to make them worse, but it’s the complete opposite,” said Piljic, assistant section manager of the Orthopedic Physical Therapy Center at the Hospital for Special Surgery in New York City. “Pain is a vicious cycle because when we have pain, we don’t want to move, but then you become stiffer, which leads to more pain. Moving can actually loosen things up and decrease pain.”
She said arthritic patients generally prefer low-impact exercises, such as walking or swimming, that don’t put as much stress on the joints. The goal is 30 to 45 minutes of moderate activity four to five days a week, but “start at your own pace and slowly work up. And always speak to your physician before starting any type of exercise” to manage other risk factors and make modifications during flares, Piljic said.
Exercising mind and body
Mind-body practices that incorporate gentle movements with stretching, breathing and meditation — such as yoga, tai chi and qigong — can offer the physical benefits of exercise with the added bonus of relaxation.
“Many alternative therapies, such as yoga or meditation, could have other benefits such as reducing stress,” said Wilson Liao, M.D., associate professor of dermatology at the University of California San Francisco School of Medicine. “Stress can trigger the immune system, which results in psoriasis flares, so reducing stress can improve both the physical and mental aspects.”
The National Center for Complementary and Integrative Health at the U.S. National Institutes of Health is researching how mind-body practices, such as yoga and meditation, affect the way the brain perceives and manages chronic pain. One of its studies, published in the journal Cerebral Cortex in 2014, revealed that regular yoga alters brain anatomy to increase pain thresholds over time. In the study, yoga practitioners tolerated pain more than twice as long as non-yogis.
“Most people just see yoga as physical,” said Holbrook, who practices gentle yoga when her psoriatic arthritis isn’t flaring. “The physical aspect helps keep me more limber, but it also has a relaxing mental component.”
While yoga involves holding certain poses, tai chi uses gentle, flowing movements and deep breathing to relieve tension. A growing body of research is revealing its potential for stress reduction and pain management.
In 2010, rheumatologists at Tufts University School of Medicine, in a study called “Tai Chi on psychological well-being: systematic review and meta-analysis,” published in 2010 in BMC Complementary and Alternative Medicine, reported that in 21 of 33 trials, tai chi significantly reduced stress, anxiety and depression, and enhanced mood and self-esteem. A 2016 study published in the Physical Therapy Journal found, based on what the journal termed “moderate quality evidence,” that tai chi was more effective for chronic pain than “usual care,” primarily for patients with osteoarthritis.
Qigong, a simpler, less dynamic form of tai chi, can be more accessible for elderly or arthritic patients.
“You can do this even if you’re in a wheelchair,” said Batchelor, who’s certified to teach six forms of qigong.
According to research conducted in Germany, published in the journal Spine in March 2011, patients with chronic neck pain reported significant relief after three months of qigong, compared with people who had no treatment. Another study, published in the Disability and Rehabilitation journal in 2008, found that fibromyalgia patients experienced pain relief after only seven weeks of qigong, and the benefits continued up to four months after sessions ended.
Because most studies about mind-body exercise examine general pain and stress, more research is needed to determine efficacy, particularly for psoriatic disease. However, that shouldn’t stop patients from talking with their physicians about alternative options for exercise.
Relaxation and meditation
What physical therapy and exercise do to ease physical pain, meditation can do to relieve mental stress. Because stress is a common trigger of psoriasis flares for patients like Weinzimmer and Holbrook, stress management is a key component of complementary treatment. In 1993, the Psoriasis Research Institute issued a statement published in Cutis urging physicians to “augment traditional psoriasis treatment regimens with stress-reduction strategies” such as meditation.
“I think that disease is stress in the body that doesn’t know how to get out. When I get off-balance, my body tends to manifest disease in my skin,” said Weinzimmer, a certified yoga instructor who meditates for 20 minutes twice a day. “Ultimately, meditation has been my greatest tool in bringing myself back to balance. It fills up my tank so I’m less stressed and more adaptable.”
Holbrook starts every day with 15 minutes of meditation using apps such as Buddhify to find guided meditations specific to pain or stress.
“It can be really easy to dwell on physical pain and let it snowball into a terrible day, but [meditation] helps keep things in perspective,” she said.
A scientific study by Jon Kabat-Zinn, Ph.D., found that patients who listened to meditation CDs during phototherapy saw their skin clear four times as fast as patients who underwent light treatment without meditation.
The study, published in 1998 in Psychosomatic Medicine, was key to the Mindfulness-Based Stress Reduction (MBSR) program Kabat-Zinn developed at the Center for Mindfulness in Medicine, Health Care and Society at the University of Massachusetts. The program, which combines mindfulness (or awareness) with meditation and yoga, is used at hundreds of medical centers worldwide.
Researchers at Drexel University in 2009 taught MBSR to 133 people with chronic pain, according to the study, “Mindfulness-based stress reduction for chronic pain conditions,” published in The Journal of Psychosomatic Research in 2010. The patients, especially those with arthritis, reported considerable improvement in pain and physical function after eight weeks. A 2008 study from Arizona State University, published in the Journal of Consulting and Clinical Psychology, found that mindful meditation also improved depression and joint tenderness in patients with rheumatoid arthritis.
Complementary therapies have been transformative for Weinzimmer, who no longer takes methotrexate. And with the backing of her doctor, she almost entirely replaced CeraVe lotion with a natural blend of coconut oil, neem oil and lavender.
Holbrook also applies oils, such as lavender, topically, diffuses oil for aromatherapy and ingests capsules of essential oils, which she said staves off oncoming colds overnight.
The most beneficial oil Weinzimmer ingests is high-potency cannabidiol, or CBD oil, from Elixinol. Because CBD is derived from hemp, not marijuana, it doesn’t contain psychoactive THC.
A study published in the Journal of Dermatological Science in February 2007 found that CBD may offer therapeutic value for psoriasis by slowing the overgrowth of certain skin cells. An earlier study, published in Proceedings of the National Academy of Sciences of the United States of America in 2000, showed in a study using mice that CBD also could have anti-arthritic properties.
When complementary therapies like these are combined with traditional medications, Weinzimmer said, the results can be life-changing.
“Pursuing this path of holistic healing has been about so much more than alleviating flare-ups of psoriasis,” Weinzimmer said. “It’s about learning how to listen to my body and how to be healthy.”