Abstract

The objective of this study was to evaluate the scientific evidence on stevia, including expert opinion, folkloric precedent, history, pharmacology, kinetics/dynamics, interactions, adverse effects, toxicology, and dosing. This review serves as a clinical support tool. Electronic searches were conducted in 10 databases, 20 additional journals (not indexed in common databases), and bibliographies from 50 selected secondary references. No restrictions were placed on the language or quality of the publications. All literature collected pertained to efficacy in humans, dosing, precautions, adverse effects, use in pregnancy and lactation, interactions, alteration of laboratory assays, and mechanisms of action. Standardized inclusion and exclusion criteria were used for selection. Grades were assigned using an evidence-based grading rationale. Based on the availability of scientific data, two indications are discussed in this review: hypertension and hyperglycemia. Evaluation of two long-term studies (1 and 2 years in length, respectively) indicates that stevia may be effective in lowering blood pressure in hypertensive patients, although data from shorter studies (1-3 months) did not support these findings. A pair of small studies also report positive results with respect to glucose tolerance and response, although the relatively low methodological rigor of these experiments limits the strength of these findings. Further investigation is warranted in both indications.

Chances are that you or someone you know has fibroids. Fibroids (also called myomas) are benign tumors that grow in the smooth muscle cells in the uterine wall (the myometrium). They can form on the inside or outside of the uterus; above, below, or on the side of it. They’re present in 25-40 percent of women in their childbearing years, and about 40 percent of women have one or more fibroids when they reach menopause. As a physician, I’ve cared for thousands of women with fibroids-including myself-treating them with everything from diet to drugs to hormone replacement to surgery.
Most
women with fibroids don’t even know they have one until their doctor discovers it during an annual pelvic exam. These benign growths are amenable to lifestyle changes such as diet, taking certain herbs, exercise, and changes in emotional patterns. Lifestyle modifications are likely to have an impact because fibroids are very sensitive to changes in hormone levels in the body. Your hormones can be influenced by everything from dietary modifications to changes in your thoughts
and emotions!

The
good news is most fibroids don’t cause symptoms, don’t require any fancy treatment,
and almost never require a hysterectomy, despite what you may have heard. Unfortunately,
fibroids are the number one indication for hysterectomy in this country. And many
times the ovaries, a woman’s source of testosterone, are removed along with the
uterus to prevent possible ovarian cancer in the future. Though I certainly understand
the rationale for this, many women suffer from unexpected side effects from ovarian
removal and subsequent low testosterone levels, which result in a loss of sex
drive and decreased vitality.

Of
course, depending upon the size, number, and location of the fibroid, some women
experience pain, heavy bleeding, or pressure. If the fibroid is large, 10 cm.
or greater, the lower abdomen can swell slightly and make it appear that a woman
is a few months pregnant, which is what happened to me. Even if her fibroids are
causing problems, there’s a lot that a woman can do besides taking drugs, having
surgery, or undergoing the new Ex Ablate ultrasound procedure. (See below.)
In
his excellent and comprehensive book Healing Fibroids: A Doctor’s Guide to a Natural
Cure (which he co-wrote with Elena Oumano for Fireside, 2002), Allan Warshowsky,
M.D. (a board certified ob-gyn colleague and friend of mine), gives you everything
you need to know to decrease fibroid symptoms naturally. If you have fibroids,
I urge you to read his book. You’re likely to find just the solution you’re looking
for. And keep in mind that the lifestyle changes you adopt to heal your fibroids
will also improve the health of every cell in your body! Here are a few points
from Healing Fibroids. There are many other fantastic insights in the book.

*
Decrease or eliminate “white” foods. Foods such as white bread, cookies,
cakes, and pasta increase insulin, which changes the way estrogen is metabolized,
creating compounds that are more likely to cause cellular inflammation and fibroid
symptoms, including enhanced growth of existing fibroids. (Further evidence of
the diet-estrogen-fibroid connection is the fact that fibroids are more common
in overweight women.)

*
Eat soy and flax. Nearly all women can benefit from taking phytoestrogens-plant-based
hormones found in soy and flaxseed. Not only are phytoestrogens a safe alternative
to synthetic hormones, these phytoestrogen-rich foods decrease the effects of
estrogen levels naturally by blocking the estrogen receptors on the cells in fibroids
and other estrogen-sensitive tissues. Studies have shown that eating soy and flax
helps the body produce smaller amounts of unhealthy estrogens. Flaxseed is high
in both fiber and omega-3 fats, which help reduce inflammation and tumor growth
throughout the body and rid the body of toxins, including excess estrogen.

*
Consider herbs. There’s a wide variety of herbs that help balance estrogen levels
naturally. These include chasteberry, dong quai, and black cohosh-all of which
have been used for centuries for various gynecological conditions. Dr. Warshowsky’s
book contains a comprehensive list of the herbs that work best for fibroids and
includes instructions for exactly how to take them. (I also address the subject
of herbs for menopausal symptoms in my book The Wisdom of Menopause [Bantam, 2001].)

*
Add a tincture of time. Perimenopause and menopause are nature’s own treatment
for fibroids. Falling estrogen levels that occur in late perimenopause often shrink
fibroids considerably. And nothing further needs to be done! Watchful waiting
is especially good for women who have no symptoms from their fibroids or don’t
even know they have them!

When
Natural Methods Aren’t Enough
There is a new ultrasound treatment for fibroids
called ExAblate, which was approved in the fall of 2004 by the FDA. ExAblate is
a new device that combines MRI imaging to map out uterine fibroids followed by
high-intensity, focused ultrasound that heats up and destroys fibroid tissue.
Fibroid tissue is very well suited to this treatment because the blood vessels
in fibroids help the body dissipate the excess heat that’s generated. The procedure
is done on an outpatient basis and is noninvasive, leaving the uterus and ovaries
intact. It involves lying on your abdomen in an MRI tube for up to three hours
while ultrasound waves heat up and destroy the uterine tissue. Side effects may
include blisters on the abdominal skin, cramping, nausea, and some pain that can
be managed with over-the-counter medication.
I had my fibroid surgically removed
during perimenopause some years ago, but didn’t undergo a hysterectomy. (Though
I had no symptoms, I simply got tired of looking pregnant-mine was very large-and
I didn’t want to continue to “dress around my fibroid.”) However, if
ExAblate had been available at the time, I would have strongly considered this
treatment.
Studies show that ExAblate successfully reduces fibroid symptoms
in about 70 percent of women, but that 20 percent will require additional surgery
within a year. The FDA reports that though the procedure successfully reduces
symptoms in the majority of women, these symptoms will return in some women. And
so will the fibroids. This is why I also recommend that all women suffering from
fibroids do their best to adopt the kind of lifestyle changes mentioned above-you’ll
be able to reduce fibroid symptoms over the long term and improve how your hormones
are metabolized. Still, I feel that ExAblate is a major step forward and a very
exciting use of technology.
Please Note: ExAblate should not be used by those
who want to get pregnant because not enough data is available to determine what
happens to the uterine wall and lining following the procedure. For more information
about ExAblate, you can call 866-392-2528 or check out the InSightec Website,
the company that developed the technology, at http://www.uterine-fibroids.org.

Symptoms
Always Carry a Bigger Message
There are many treatments available for fibroids,
including drugs, surgery, and the newer high-tech ultrasound treatment known as
ExAblate. Regardless of which one(s) you choose, it’s important to understand
that fibroids, like all conditions, don’t just jump out of the closet and land
on you (or your uterus). They’re a signal from your inner wisdom that something
in your life needs to be addressed. This doesn’t mean that you need to obsess
or make a career out of them, but it does mean that you’ll be happier and healthier
if you regard them as messengers and then heed the message. (It might be as simple
as losing ten pounds!)

Fibroids
often represent creativity that hasn’t been birthed yet, or creativity (such as
a job or relationship) that’s being directed down a dead-end path. I’ve written
about this extensively in both Women’s Bodies, Women’s Wisdom and The Wisdom of
Menopause. Addressing the lifestyle and mind/body factors that favor fibroid growth
in the first place will also help prevent recurrence. And if you eventually need
a medical procedure for your fibroids, your health will have improved greatly
and you’ll heal much faster.

Subscribe
to Dr. Northrup’s Newsletter today! (Link to:http://www.drnorthrup.com/newsletters/index.php

Provided from the September/October 2005 Issue of The Dr. Christiane Northrup Newsletter with Permission from Hay House, Inc., pg. 6.

* Danshen (Salvia miltiorrhiza), a traditional Chinese herb, showed mild antithrombotic effects in rats (and so may not apply to humans), and is known to inhibit platelet aggregation and other clot-reducing activity (Yao Xue Xue Bao, 1993; 28: 241-5). Suggested dosage: 20 mg/kg body weight.

* Ginkgo biloba has anticoagulant properties, whether or not combined with anticoagulant drugs (Am Surg, 2001; 67: 33-5; Biochem Mol Biol Int, 1995; 35: 125-34). Suggested dosage: 120-240 mg/day (divided into two or three doses).

* Goldenseal, Oregon grape root, and barberry (Berberis vulgaris) root bark, all containing berberine, can treat and prevent irregular heart rhythms caused by ischaemia. In one study, 100 heart patients took berberine from one or more of these herbs. Monitoring showed that 62 per cent of them had 50 per cent or greater, and 38 per cent had 90 per cent or greater, improvement in their symptoms (Chung Hua Hsin Hsueh Kuan Ping Tsa Chih, 1990; 18: 155-6, 190). Suggested dosage (to be modified when necessary) for Berberis vulgaris tincture: 15 mL in water three times daily after food.

* Hawthorn, as used in the Crataegus-based homoeopathic preparation Cralonin, was found to be as effective as ACE inhibitor/diuretic drug treatments for most mild cardiac problems (Eur J Heart Fail, 2003; 5: 319-26). Extremely well tolerated, it is used for angina, heart rhythm disorders and minor forms of congestive heart failure. Controlled studies of Crataegus have revealed the following effects: increased coronary and peripheral blood flow, decreased arterial blood pressure and heart rate, and improved contractility of the heart muscle (Planta Med, 1981; 43: 105-20, 209-39, 313-22). Suggested dosage (all three times daily): dried berries, 0.3-1 g or in an infusion; liquid extract 1:1 in 25 per cent alcohol: 1-2 mL; tincture 1:5 in 45 per cent alcohol: 1-2 mL.

* Chamomile, motherwort, horse chestnut, fenugreek and red clover herbal supplements, contain coumarin, from which the blood-thinner warfarin and other anticoagulants are derived (J Clin Pharm Ther, 2002; 27: 391-401). Suggested dosages: chamomile, 400-1600 mg/day (divided); horse chestnut, 300 mg/day; fenugreek, 50 g twice daily (powdered seeds); red clover, 80 mg/day.

* Bilberry, dong quai, feverfew, ginseng, turmeric, meadowsweet and willow herbal supplements have antiplatelet activity (J Clin Pharm Ther, 2002; 27: 391-401). Suggested dosages: bilberry, 80-240 mg/day (divided); dong quai, 200 mg two or three times daily; feverfew, 100-250 mg once to three times daily; ginseng, 1-2 g/day (root), 100-300 mg/day (extract); turmeric, 100-500 mg three times daily with food; meadowsweet, 2 tsp dried herb in 5 oz water, soaked for 10 min; willow, 60-240 mg/day.

A Varicose veins usually develop in the legs. When the valves in the veins do not function properly, the blood pools in the veins, especially when standing for long periods, resulting in these swollen veins. Apart from being cosmetically unsightly, they can be painful – causing throbbing or cramping – and may cause itching or a burning sensation on the skin.

The goal of any treatment for varicose veins is to improve blood flow to the heart. The usual medical line is that the only alternative is surgery, in which the physician ‘strips’ out the offending vein and creates a tiny circulation bypass in place of the vein. However, there are a huge number of disadvantages:

* Surgery for varicose veins is neither curative nor preventative. Even early surgery of uncomplicated veins will not prevent the development of future varicosities (J R Coll Surg Edinburgh, 2001; 46: 154-8)

* Varicose veins recur in 10 per cent of those who have had them surgically stripped, in 10 per cent of those who have had radiofrequency ablation (using heat to seal off the vein), in 6 per cent of those who have had them removed by lasers and in up to 50 per cent of those who have undergone sclerotherapy (injecting an irritant solution into the vein, causing it to scar over and eventually become absorbed by the surrounding tissues (Healthwatch, CBS News, 22 January 2003)

* The surgery itself has risks, including blood clots, haematomas, nerve injury and, with sclerotherapy, an obstructed blood flow or leaking of the irritant solution into surrounding tissues

* A greater risk of deep vein thrombosis (DVT), but only if you are having major abdominal or pelvic surgery (BMJ, 1996; 312: 198).

Thankfully, there is a host of alternative measures that can help prevent or treat varicose veins without the need for surgery, including:

* all the simple measures that work the legs and avoid blood-pooling – elevating the legs while sitting; avoiding tight clothing around the ankle, calves and groin; avoiding high heels, which don’t work the calf muscles as much as low heels do; avoiding standing or crossing your legs for long periods of time; and losing weight if you are overweight

* walking, cycling and rowing – all of which cause the leg muscles to contract and push blood back to the heart. Best of all is swimming, as the water pressure helps drive the blood back to the heart. Also, being horizontal while you swim allows the veins to empty

* all the simple measures that work the legs and avoid blood-pooling – elevating the legs while sitting; avoiding tight clothing around the ankle, calves and groin; avoiding high heels, which don’t work the calf muscles as much as low heels do; avoiding standing or crossing your legs for long periods of time; and losing weight if you are overweight

* walking, cycling and rowing – all of which cause the leg muscles to contract and push blood back to the heart. Best of all is swimming, as the water pressure helps drive the blood back to the heart. Also, being horizontal while you swim allows the veins to empty

* a judicious use of compression therapy, usually support hosiery – preferably the pantyhose-type of stockings – to control symptoms, although some people may find wearing such tight garments rather uncomfortable (BMJ, 2002; 324; 689-90).

The best alternative treatments include:

* bilberry as supplements or even the fruit itself. These reduce the fragility of the blood vessels and, added to the daily diet of pregnant women, can prevent and treat varicose veins (Minerva Ginecol, 1981; 33: 221-30). These fruit are also antiangiogenic – they can reduce the growth of blood vessels that may lead to varicose veins and tumours (Biochemistry [Mosc], 2004; 69: 75-80). Take 80-160 mg three times a day (standardised to contain 25 per cent anthocyanidins)

* bioflavonoids, which have a long history of success for varicose veins. This includes rutin, found in citrus fruit, orange/yellow vegetables, buckwheat or as supplements (Am J Ophthalmol, 1948; 31: 671-8), and hesperidin (suggested therapeutic dose ranges are 50-500 mg/ day; for citrus: 500-5000 mg/day)

* pennywort (gotu kola, Centella asiatica) can reduce swelling and other symptoms of heaviness in the lower legs (Angiology, 1987; 38: 46-50), and significantly improve itching, swelling and night cramps (Clin Ther, 1981; 99: 507-13). For varicose veins, studies have used 30-60 mg twice a day

* red-vine-leaf extract (Folia vitis viniferae; grape leaf), reduced lower leg volume and calf circumference in patients with chronic venous insufficiency (Arzneim Forsch, 2000; 50: 109-17). The usual dose is 360-720 mg/day

* bromelain, the proteolytic enzyme in pineapples, can also be taken as a supplement. It can also help prevent the hardening and lumpiness of the tissues around the varicosities as it promotes fibrin breakdown. Take 500-750 mg two to three times a day

* butcher’s broom, which has a long history of use in countries around the Mediterranean for varicose veins and associated ulcers (Drugs Exp Clin Res, 1988, 14: 277-83). The herb can improve venous tone and poor circulation (Fortschr Med, 1989; 107: 52, 55-8). Take 100 mg three times a day (extract standardised for 9-11 per cent ruscogenin)

* oligomeric proanthocyanidins, or OPCs, are derived from pine bark and grape seed. These antioxidant free-radical scavengers can inhibit enzymes that damage connective tissue and vessel walls (Gaz Med France, 1985; 92: 96-100), and increase venous tone in varicose-vein sufferers (Sem Hop, 1981; 57: 2009- 13). Take 150-300 mg/day

* horse chestnut seed extract (Aesculus hippocastanum) is approved by the German government for venous diseases of the legs. This herb can ease both varicose veins and haemorrhoids, another form of varicosity, especially the swelling. It strengthens blood vessel walls and, as an astringent, can also tone and tighten tissues (Arzneim Forsch, 1979; 29: 672-5). For the best results, take it as early in the condition as possible (BMC Cardiovasc Disord, 2001, 1: 5). Take the equivalent of 50 mg/day of aescin (standardised)

* witch hazel in the form of an ointment is recommended by the German Commission E for varicose veins. Note, however, that the ointment may need to be applied three or more times a day for several weeks before there is any noticeable improvement

* pine bark extract (Pinus maritima) is at least as effective as horse chestnut seed extract for varicose veins. Those taking it have reported both symptomatic relief and a reduction in leg swelling (Phytother Res, 2002; 16 [Suppl 1]: S1-S5). Take 75-300 mg/day for three weeks, then 40-80 mg/day for maintenance

* dietary factors for varicose veins include a high-fibre diet and bulking agents to reduce straining during defaecation. Drinking at least six 8-oz cups of water a day will also help

* nutrients such as aortic glycosaminoglycans (100 mg/day), vitamin C (500-3000 mg/day), vitamin E (200-600 IU/ day) and zinc (15-30 mg/day) are also beneficial

In France, where homeopathy is firmly established, the two most popular remedies for flu or the common cold are both homeopathic. The top seller is the single remedy ‘Oscillococcinum 200’, while the number two slot is firmly held by a mixture, which sells under the cryptic L.52. Both are available in the UK, and their popularity is due to their long-established reliability in ridding sufferers of symptoms without side effects.

Oscillococcinum, discovered accidentally by Dr Joseph Roy during the 1930s, is prepared from very diluted Barbary duck heart and liver, which were – incorrectly, we now know – thought to contain a bacterium, Oscillococcus, associated with flu-like states. Roy’s spurious bacterial theory has now been found to have foundation in fact; game fowl have been proved to be a prime reservoir for human influenza viruses. This remedy’s extraordinary reliability in treating influenza over almost seven decades has been proved with success rates reported in various population samplings from 80-90 per cent, whenever the remedy was taken within 48 hours of the onset of symptoms. Controlled trials were run and published in France (c. f. Thorsons Enclopaedic Dictionary of Homeopathy by this author, HarperCollins, London 1991) demonstrating effectiveness in controlling fever, cough during day and night, runny nose, muscle and joint stiffness, and shivering. This study was backed up on a larger scale (Br J Clin Pharmacol, March 1989; 27: 329-35).

The competing remedy, L.52, is a combination of 10 common cold and flu remedies: Aconitum nappellus, Arnica montana, (Atropa) Belladonna, Bryonia alba, Cinchona officinalis, Drosera rotundifolia, Eucalyptus globulus, Eupatorium perfoliatum, Gelsemium sempervirens and Polygala senega.

In a scientific trial conducted by researchers (none of whom were homeopaths) at the department of infectious Illnesses at the Felix Houphouet-Boigny Hospital in Marseilles, a high percentage of patients improved significantly in all categories – bronchial congestion, day and nighttime coughing, runny nose, need to resort to antibiotics after treatment, speed of recovery – compared to a group given a placebo (Casanova et al, ‘L.52: A Flu Treatment,’ Dr Ph Lecocq, pub., Metz: Editions Lehning, 1988).

Harald Gaier

Harald Gaier is a registered naturopath, osteopath and homeopath.

The orthodox approach uses the drug aciclovir, which eases the symptoms, but doesn’t cure it. Alternative medicine, on the other hand, offers a large array of ways to rid yourself of this painful condition.

Orthomolecular medicine
This therapeutic approach suggests 6 g of ascorbic acid together with 1 g of the amino acid L-lysine daily, and a 1-mL intramuscular injection of vitamin B12 twice a week. According to the cases reported, all pain was gone within 24 hours and the lesions had begun to heal (Hoffer A, Orthomolecular Medicine for Physicians, New Canaan, CT: Keats Publishing, 1989). The B12 injections can be replaced by a 20-mcg/day oral dose of B12 taken under the tongue.

Nutritional medicine
Many studies have shown that proteolytic enzymes (160 mg of trypsin, 160 mg of chymotrypsin and 400 mg of papainase), taken five times daily, are as effective as aciclovir against shingles (Fortschr Med, 1995; 113: 39-44; Phytomedicine, 1996; 2: 7-15).

In one Russian study, 150 patients with acute shingles received trypsin alone. Compared with 200 similar patients on the standard antiviral drug therapy, trypsin proved highly effective in reducing symptoms during the acute stage. None of the trypsin group had recurrences or developed postherpetic neuralgia during the three-year follow-up (Vrach Delo, 1991; 3: 86-9).

Supplementation
Adenosine-5’-monophosphate (AMP), a naturally occurring purine nucleotide, is needed for nucleic acid synthesis. Patients with shingles have abnormally low levels of AMP as well as high levels of adenosine triphosphate (ATP) (JAMA, 1977; 237: 871-2).

In one double-blind study, shingles patients received intramuscular 100-mL AMP injections three times a week for four weeks. The AMP reduced herpetic pain almost immediately and, after four weeks, 88 per cent of the AMP-treated patients were pain-free vs 43 per cent with placebo.

To prevent the chest pain that may follow AMP injection, take half the dose, followed 20 minutes later by the other half (Med Sci Bull, 1985; 7: 86-9; Nutr Heal, 1996; 3: 58-61). One concern is that AMP readily converts to adenosine, which can suppress immune function, although these dosages appear to be too small to have any significant effect. Nevertheless, scientific studies haven’t yet ruled out the possibility.

Acupuncture and cupping
Never use acupuncture or cupping (using glass cups to create suction on the skin) on patients with herpes zoster (Shanghai College of Traditional Medicine, O’Connor J, Bensky D, transl, Acupuncture: A Comprehensive Text, Seattle, WA: Eastland Press, 1984: 618).

African medicine
In Africa, the leaf of Plantago major (common plantain), whole or bruised, is applied to the skin affected by shingles lesions.

Experiments have confirmed the plant’s microbial-killing action, which facilitates healing (Int Abstr Biol Sci, 1960; 16: 817). The leaves are also reported to be anti-inflammatory and to aid new skin growth, with no adverse side-effects (Am J Pharm, 1950; 122: 24; Int Abstr Biol Sci, 1959; 15: 5414).

European folk medicine
Applying the fresh juice or pulp of the ordinary leek to the affected skin is said to be soothing and to speed up the healing process (Bartram T, Bartram’s Encyclopaedia of Herbal Medicine, London: Robinson Publishing, 1998: 227).

Homoeopathy
Paraphenylenediamine can bring on the symptoms of herpes in healthy individuals (Ann Homéop Françaises, 1963; 10: 57/777-65/785). Try this first at the 6CH potency.

Osteopathy
The headaches and myofascial pain syndrome that accompanies shingles and prevents sleep may be effectively relieved by osteopathy (Travell JG, Simons DG, Myofascial Pain and Dysfunction: The Trigger Point Manual, Baltimore, MD: Williams & Wilkins, 1983).

Herbs
Chinacanthus nutans (or phaya yo in Thai) has been shown to promote healing. In a controlled clinical trial of 51 patients, this herb, in the form of a poultice, was applied five times a day to the skin affected by shingles lesions, for seven to 14 days. This resulted in rapid healing (J Med Assoc Thai, 1995; 78: 624-7). A larger randomised, controlled trial reported the same positive results (Int J Dermatol, 1996; 35: 665-6).

Applying capsaicin (the alkaloid derived from the pod of Capsicum frutescens, cayenne pepper) to the affected skin can relieve long-term pain after an episode of shingles, according to a review of three randomised controlled trials (Fam Pract, 1996; 13: 84-91).

At the very first signs of blisters, applying Melissa (balm) ointment onto the skin can ameliorate the later progression of the shingles outbreak. Tolerance is excellent (Zeitschr Phytother, 1981; VI: 229).

Harald Gaier is a registered homoeopath, naturopath and osteopath.

Fair-skinned people are more prone to it than darker-skinned individuals. Typically, it shows up as thickened red areas covered with silvery scales, usually on the scalp, elbows, knees, back and buttocks. It can also affect fingernails and toenails. The patches usually flare up periodically and symmetrically on both sides of the body.

Psoriasis is considered mild if it affects less than 5 per cent of the body surface, moderate if it involves 5-30 per cent of the skin, and severe if it covers more than 30 per cent.

About one in 10 of those with psoriasis will develop psoriatic arthritis, characterised by painful swelling and stiffness in the joints as well as the usual skin plaques.

What causes it?
Many doctors believe that psoriasis is caused by an accumulation of dead skin cells on the skin surface, the result of skin-cell replication at a rate 1000 times faster than normal. This cell growth is too rapid to allow skin cells to be shed normally. Their accumulation results in the silvery scales typical of psoriasis.

But, as some psoriatics improve while taking prescription drugs that interfere with the immune system, it may be that the too-rapid cell formation reflects immune dysfunction.

Indeed, psoriasis is most likely an autoimmune disorder, probably the result of a T cell-mediated immune response (Arch Dermatol, 1999; 135: 1104-10).

The question is, what triggers the immune response? The tendency to psoriasis is inherited, but a number of other factors appear to cause or contribute. In women, the most common trigger is smoking (BMJ, 1994; 308: 428-9); in men, it is alcohol. But other triggers include incomplete protein digestion, bowel toxaemia, impaired liver function, excess consumption of animal fats, nutritional factors and stress.

Psoriasis can also flare up after bacterial infections such as strep throat, skin injuries and vaccinations as well as with the use of medicines such as lithium, beta-blockers and antimalarials, the heart drug quinidine, systemic steroids (oral or injected) and the non-steroidal anti-inflammatory indomethacin.

What doctors tell you
There are three categories of treatment. Medicated creams and ointments (including corticosteroids, vitamin D or synthetic vitamin A called ‘retinoids’) are the mainstay of treatment for mild-to-moderate psoriasis. Over-the-counter coaltar-containing products and hydrocortisone may also work.

Stronger immunosuppressants such as methotrexate and cyclosporin A are generally only prescribed for the most severe cases. Phototherapy (PUVA) using ultraviolet A and psoralen (a photosensitising agent) is usually reserved for individuals who do not respond well to other therapies.

Methotrexate should not be taken by pregnant women or by those who wish to become pregnant because of their adverse effects on the unborn child. Steroids can cause serious side-effects in all users. Cyclosporin A is toxic to the kidneys; methotrexate is toxic to the liver and bone marrow. Retinoids are associated with birth defects, and PUVA is known to cause cancer and may lead to light sensitivity. High blood pressure, anaemia and immune-system suppression that can lead to infection have also been documented with conventional antipsoriasis treatments.

Pat Thomas