Psoriasis

[Val Koganski]

Any suggestion on the treatment of 26 y.o. female with generalized psoriasis. Already on Semaglutide, BPC/KPV, Omega-3, Akkermansia for 3 months with no significant changes. Staying on gluten free diet.

Completed Xifaxan/Alinia for SIBO.

Going to start Larazotide

Thank you

[Kristyna Dorris]

Obviously, support needs to be comprehensive, and many imbalances need to be considered. Bile salt supplementation can be helpful (https://pubmed.ncbi.nlm.nih.gov/10827473/), Breaking down endotoxins is crucial when dealing with small intestinal bacterial overgrowth (SIBO). In cases of psoriasis, researchers often observe a decrease in gut bacterial diversity, characterized by an increase in Firmicutes and a decrease in Bacteroidetes. Additionally, many individuals experience an overgrowth of fungi in the gut.

To effectively address these issues, a comprehensive support plan is essential, taking into account various imbalances. One helpful approach, I find, is bile salt supplementation. Often when individuals are on GLP-1s bile support is helpful for detoxification as well, supporting Excretion: Lipophilic chemicals are primarily excreted via bile.

[Val Koganski]

Would you consider TUDCA or Ox Bile, as Suprachol is not available in USA?

Thank you.

[Kristyna Dorris]

TUDCA is what I usually recommend. Ox bile works as well.

[Anthony Castore]

There are some great suggestions here! I am not the expert but, I had a few thoughts that may be helpful.

Psoriasis involves systemic inflammatory pathways, dysregulated immune metabolism, and microbiome imbalances, which require a targeted and comprehensive approach. Current interventions often need refinement to address the deeper cellular and immune dysfunctions. Psoriasis typically involves hyperactivation of inflammatory pathways like NF-κB, STAT3, and mTOR, alongside oxidative stress and altered keratinocyte proliferation. These processes can be modulated with interventions that regulate cellular pathways, improve mitochondrial function, and reduce systemic inflammation.

Peptides such as thymosin alpha-1 can help balance immune responses and suppress autoimmune-driven inflammation by improving T-cell function and regulating cytokine production. GHK-Cu is beneficial for reducing oxidative stress, enhancing ECM remodeling, and repairing skin damage, and can be used both systemically and as a topical preparation for localized relief.

Supplements such as NAD+ precursors, 1-MNA, and 5-amino-1MQ can provide significant support for mitochondrial function. NAD+ precursors like NMN or NR at 300-500 mg daily enhance mitochondrial efficiency and energy production, while 1-MNA provides anti-inflammatory and endothelial-protective effects by reducing systemic vascular inflammation and improving nitric oxide bioavailability. 5-amino-1MQ is particularly effective in inhibiting NNMT, thereby reducing fat storage and improving overall energy metabolism, making it beneficial for systemic inflammation and metabolic regulation. Apigenin, at 400 mg taken an hour before bed, can be added to downregulate CD38, an enzyme that depletes NAD+ stores, further preserving mitochondrial function and improving cellular repair processes.

Additional supplements such as sulforaphane upregulate NRF2 for antioxidant and anti-inflammatory effects, and curcumin (preferably BDMC, a more potent form) provides effective NF-κB inhibition at doses of 500 mg taken two to three times daily with piperine for enhanced absorption.

Psoriasis is often driven by a Th1/Th17-dominant immune profile, and balancing this dominance can be achieved through immune modulation. Low-dose naltrexone at 4.5 mg nightly helps regulate cytokines like IL-17 and IL-23, which are heavily implicated in psoriasis. For further modulation, interventions like vagal nerve stimulation with devices such as gammaCore or auricular acupuncture can provide systemic anti-inflammatory effects by enhancing parasympathetic tone. Red light therapy, using wavelengths between 630–660 nm for 10-15 minutes daily, can suppress keratinocyte hyperproliferation, improve mitochondrial health, and enhance skin repair processes.

Addressing microbiome health is critical, as it plays a central role in immune regulation and the gut-skin axis. While Akkermansia is helpful, expanding probiotic diversity with strains such as L. plantarum, L. rhamnosus, and B. infantis can provide additional support for balancing Th1/Th17 dominance. Sodium butyrate at 1-2 g daily supports gut barrier integrity and downregulates systemic inflammation through its role as an SCFA. Postbiotics and prebiotic polyphenols, such as those derived from pomegranate or ellagic acid, can enhance microbiome function further. Larazotide acetate should be continued to support tight junction repair and reduce LPS-driven inflammation.

An overpopulation of Akkermansia muciniphila has the potential to contribute to the breakdown of the digestive lining and exacerbate autoimmune conditions, although this is context-dependent and not commonly observed. Akkermansia muciniphila is generally considered a beneficial gut bacterium, playing a key role in maintaining gut barrier integrity by metabolizing mucin, the primary component of the gut’s mucus layer. This process releases short-chain fatty acids, like acetate and propionate, which nourish intestinal cells and support immune homeostasis.

However, an overgrowth of Akkermansia muciniphila can lead to excessive mucin degradation, which may thin the protective mucus layer. This thinning can expose the epithelial lining to harmful bacteria, toxins, and antigens, leading to increased gut permeability, also known as “leaky gut.” Increased permeability allows larger molecules, such as lipopolysaccharides and dietary antigens, to cross into the bloodstream. This can trigger systemic inflammation and exacerbate autoimmune conditions like psoriasis, rheumatoid arthritis, or lupus, as the immune system mounts an inflammatory response to these antigens, perpetuating the autoimmune cycle.

An overabundance of Akkermansia muciniphila can disrupt the balance of the microbiome, reducing its diversity and weakening the gut’s ability to regulate immune responses. Factors contributing to overgrowth include high doses of Akkermansia muciniphila supplements, diets high in mucin-stimulating foods, or reduced competition from other beneficial microbes, such as Faecalibacterium prausnitzii, which help maintain equilibrium.

Managing overpopulation of Akkermansia muciniphila involves balancing the microbiome by focusing on diverse probiotic and prebiotic strategies that support a wide array of beneficial bacteria, not just Akkermansia muciniphila. Including strains like Bifidobacterium and Lactobacillus can promote epithelial health and anti-inflammatory effects. Reducing mucus overproduction by adjusting dietary or environmental factors is important to prevent excessive feeding of Akkermansia muciniphila. Repairing the gut barrier with butyrate or other short-chain fatty acids can strengthen tight junctions, while peptides like BPC-157 and KPV can reduce inflammation and restore barrier integrity. Larazotide acetate may also be helpful if increased permeability is suspected.

Monitoring for inflammatory markers like CRP, IL-6, and gut permeability markers such as zonulin can guide the approach. Stool testing to measure microbiome diversity and Akkermansia muciniphila levels ensures they remain within a healthy range. While Akkermansia muciniphila is generally beneficial, balance is critical, especially in individuals with compromised gut barriers or autoimmune predispositions. A targeted approach to gut health is essential to avoid unintended consequences and restore homeostasis.

Dietary changes focusing on sirtuin-activating foods such as dark leafy greens, berries, and olive oil, or trialing an autoimmune paleo or low-histamine diet, may help eliminate potential triggers. Optimizing omega-3 fatty acid intake with 3–5 g/day of EPA/DHA and considering gamma-linolenic acid for synergistic anti-inflammatory effects can further support systemic health. Intermittent fasting with a 16:8 window can also be used to reduce systemic inflammation and support immune regulation.

Skin barrier repair is another important focus. Topical ceramides and urea-based moisturizers can strengthen the skin barrier and improve hydration. Evaluating and optimizing vitamin D levels to ensure serum 25(OH)D is above 50 ng/mL with supplementation of 5,000–10,000 IU daily if needed can also provide anti-inflammatory and immune benefits. Stress management is critical as well, given the close link between psoriasis and stress, with mindfulness practices or yoga being highly effective in some patients.

 

[Clyde Boswell]

Psoriasis:

• Check vitamin D level and I will often run these patients quite high 80-120
• Check a zonulin: If I do test I typically do a blood spot and a stool sample (KMBO gut barrier and Diagnostic solutions stool). If positive 500mcg larazotide 2-4 times per day.
• Med therapy pro/darm reapir: 1 scoop twice a day for 3-4 months
• Short chain fatty acids + Lactulose
• Thymosin alpha 1: I use this in almost all of my patients with psoriasis.
• If lesions are on the face, behind ear ect, consider topical rapamycin
• Consider use of Red light therapy (My patients go to Mayo Clinic for red light and have had good results)

For severe cases I use a biologic (skyrizi) and have recently been adding TA1 and the other protocols listed above.

Sorry for short response, but this has worked well in my practice in the past.

[Mitchell Fleisher, M.D., D.Ht., D.A.B.F.M.]

The above are quite reasonable suggestions.

If not already performed, comprehensive food allergy testing is extremely important.  I highly recommend the Cyrex Labs arrays 2, 3, 4, 5 and 10; 3, 4 and 10 when done together are called 10C.

Also, assess the microbiome for dysbiosis and parasitosis.  I use the Comprehensive Parasitology profile from GDX.  Also, see https://academy.fullscript.com/pages/gut-health-and-microbiome-tests

I have had success with severe psoriasis cases utilizing the following:

Constitutional Homeopathic Medicine (with a very experienced practitioner)

Strict food allergy dietary modifications

Microbiome repair depending upon the precise nature of the dysbiosis.  The indicated Homeopathic bowel nosodes are extremely beneficial in this regard.

Also, addressing dysbiosis and parasites with phytonutrients rather than toxic drugs; see the Protocol for Parasitosis within http://www.alternativedrmcare.com.

Guttides 1 to 2 capsules BID

Larazotide 1 to 2 capsules BID

Thymosin Alpha-1 0.25 ml SQ Qam

GHK-Cu (2 mg/ml) cream apply 1-2 ml BID to affected areas

In resistant, severe cases, use Rapamycin/GHK-Cu 0.002/0.2%/GM cream once daily until under control, then use GHK-Cu (2 mg/ml) cream

ASTAXANTHOL 4 capsules BID (from PGL, 800-527-9512, order code #7876)

ValAsta 3 capsules BID/TID; from https://valasta.net/?ref=CIRM1

Blessings for the new year!   DrM

 

[Val Koganski]

Thank you for everyone’s suggestions.

Val Koganski, MD

[Giovanni Silva]

(Yu, BMC Cancer, 2023; Al-Hendy, J Clin Endocron Metab. 2016)

Pt.’s with psoriasis have down regulated vit. D receptors (VDRs). The authors found that Beta-catenin and Wnt5a were upregulated in psoriasis patients. Several studies have shown that Vit D downregulates the Wnt/B-catenin pathway.

Also, dysfunction of the Wnt/B-catenin pathway is associated with cancer, Alz., osteoporosis, atherosclerosis, MI, PD (Liu, Signal Transduc Target Therapy, 2022).

Vit. D has profound anti-inflammatory and anti-autoimmune functional via activation of VDR. VDR function is crucial for the downregulation of IL-23, which is known to be an essential player in psoriasis.

“Immunohistochemical expression of VDR and Wnt signaling pathway molecules in psoriasis” Acta Dermatovenerol Alp Pannonica Adriat. 2023 Dec;32(4); 129-133. Ismael A, et al.

[Clyde Boswell]

Absolutely!
this is why Skyrizi is one of the few biologics I use due to the select activity on IL23.
Really need to check the LFTs initially and after 6 months of use. Then 3 months thereafter. Most patients are receiving too high of a dose initially from GI or Derm.

[Kristelle Reyes]

Hello @vkoganskicomcast-net,

Here’s a video response from Dr. Seeds’ January Office Hours at 17:42. Please watch by clicking the link below:

https://ssrpinstitute.org/ssrp-members-videos/

Thank you! ?

[Author]

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