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 overview of a functional medicine approach to psoriasis treatment.

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CC: Red, Scaling Rash Over Elbows, Shin, and Face

Kristin is a 27 yo female who was diagnosed with psoriasis six months ago. She had been on vacation to Mexico and had sustained a sunburn over her back, shoulders, and legs. As the sunburn faded, it was replaced by a scaling, hard, red rash that covered the anterior shins up to her knees, her bilateral elbows, and patches on her cheeks. She saw a dermatologist who diagnosed her with psoriasis and recommended topical steroids. The steroids helped some, but the rash never fully resolved and still covers her legs, elbows, and cheeks. Kristin’s dermatologist has started to discuss stronger medications for her psoriasis, but before Kristin pursues those options, she wanted to explore whether there is anything she can change in her diet, supplement regimen, or lifestyle that might help this now chronic condition.

Additional History

Kristin has had a few other new symptoms pop up within the last year. She is having an issue with constipation and now has to take a magnesium supplement daily and drink two cups of coffee in order to have a bowel movement. She feels bloated and reports looking “very pregnant” within 30 to 45 minutes of eating. She also frequently burps.

She has recently started graduate school and is now working in the day and taking classes at night. She crams in dinner between work and school and reports that she eats ramen noodles or pizza most nights while on the train. She doesn’t eat breakfast and usually has a turkey or salami sandwich at work for lunch.

Functional Medicine Labs

Small Intestinal Bacterial Overgrowth- 3 Hour Breath Test (Genova)‍

Evaluation for Hydrogen: (increase in baseline over 90 min): 52 POSITIVE (expected value is <20)

Evaluation for Methane: peak of 14 POSITIVE (expected value of peak is <10)

Food Sensitivity Testing: Allergix IgG4 Food Antibodies Genova

Other Labs

Lab Analysis:

Kristin’s initial labs were positive for Small Intestinal Overgrowth (SIBO), multiple food sensitivities, elevated inflammatory markers, and evidence of B vitamin deficiencies. We had decided to evaluate Kristin for SIBO based upon her new symptoms of bloating, constipation, and the potential relationship between SIBO and inflammatory skin conditions.

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 SIBO, there is increasing evidence that SIBO plays a potentially causal role in other inflammatory skin conditions such as rosacea.

Hearing Kristin’s history, I thought it was likely that an underlying pathogenic change in her gut microbiome contributed to her persistent psoriasis. Kristin’s SIBO test was positive for elevated levels of hydrogen as well as markedly positive for Methane producing bacteria. Methane is known to slow down gut motility causing slow transit constipation. This excess of Methane producing bacteria likely explains Kristin’s new problem with constipation. The positive SIBO 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 Kristin’s diet, we found that she was eating wheat or corn with almost every meal. This chronic exposure to foods that she is sensitive to may be 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 Kristin’s diet had been over the last year, I suspected that Kristin had multiple nutrient deficiencies beyond what we tested for on her initial labs.

Interventions:

Elimination Diet:

• Kristin’s schedule was extremely busy and her capacity to do an extensive elimination diet was limited. We agreed to remove only wheat and corn from her diet for the next three months.

SIBO Treatment:

For Kristin’s Methane and Hydrogen positive SIBO, I gave her three supplements to take for one month

• Candibactin Candibactin AR
• Candibactin BR
• Atrantil

Nutrient Support:

We asked Kristin to start a multivitamin and an additional B12 supplement. I chose a multivitamin that was high in methylated folate due to her elevated homocysteine.

• Multivitamin: Mitocore by Orthomolecular
• Jarrow B12 1000mcg Lozenge
  

3 Month Follow Up

At our follow-up visit three months later, Kristin had noticed some significant changes. She had completed the one-month supplement regimen for SIBO, was taking her multivitamin and B12 supplement daily, and had adhered to the wheat and corn-free diet.

After one month on this regimen, 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.

She was a bit disappointed in the changes she noticed in her psoriasis. Although the patches on her shins were smaller and less red, they still covered most of her lower legs, and the patches on her elbow and face were unchanged. She was feeling so good overall, but she had hoped for more progress in her psoriasis.

We repeated some of her blood work and found that her inflammatory marker (Crp) had fallen by roughly half, and her homocysteine was trending in the right direction. We offered repeat SIBO testing, but Kristin decided against it since she felt so much better and was wary of additional out-of-pocket costs.

I asked Kristin to continue the wheat and corn free diet and her supplements for another 3 months and to check back in with me.

6 Months Follow Up

At our six-month follow-up, Kristin was excited to show me the changes in her skin. The psoriasis patches on her shins and cheeks began to fade very slowly over the prior three months. She was no longer using the topical steroid and had not been back to see her dermatologist. She continued to have lesions on her elbows, but all other lesions on her face and legs had resolved. She continued to have a renewed sense of energy and had no digestive issues at all. She was very happy with her current regimen and diet and had no desire to make any changes.

Summary

This case study highlights how root cause treatment of GI dysfunction can sometimes have a far-reaching impact on seemingly unrelated health conditions. Kristin had SIBO and a diet that was contributing to her initial poor health. By resolving her SIBO, avoiding just two inflammatory foods, and starting a simple supplement regimen, we were able to help Kristin avoid escalating medications for her psoriasis. 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.