Full Length Research Paper
ABSTRACT
Psoriasis is an incurable, chronic, recurrent immune-mediated in?ammatory dermatosis characterized by epidermal hyperplasia and excessive in?ltration of in?ammatory cells into the dermis and neovascularization. The study aimed to provide a systematic review on the in vitro, in vivo, and clinical studies to support traditional uses of herbal medicine for psoriasis treatment. The systematic review was performed by combining three databases, that is, PubMed, ScienceDirect, and Scopus, using the search terms “Psoriasis” AND “Herbal medicine” AND/OR “Traditional medicine.” Full-text articles included after the screening were further evaluated by applying the predefined eligibility criteria. One hundred and twenty research articles were included in the analysis. The included articles involve 94 herbs used as a single herbal extract (n=58 plants) or isolated compounds (n=54 compounds) or as compositions in traditional medicine formulas (n=24 formulas). Most were related to plants or recipes used in Traditional Chinese Medicine (TCM) (63 articles and 207 plants). Research targeting inflammatory and proliferative processes in disease pathogenesis, development, and progression has been an extensive area. The antipsoriasis activity of most plants was mainly through the effects on inflammatory molecules and signaling pathways and immune cells (T-cells, dendritic cells, monocytes, neutrophils, and macrophages), as well as apoptotic molecules and signaling pathways. Plants targeting other signaling molecules should be further investigated.
Key words: Psoriasis, herbal medicine, inflammation, signaling pathways, immunomodulation.
Abbreviation: 5-LOX; 5-lipoxygenase, AMPK; AMP-activated protein kinase, AP-1; Activator protein 1, CB; Cytochalasin B, COX; Cyclooxygenase, CSF-1; Colony stimulating factor 1, DAS-28; Disease Activity Score-28, DC; Dendritic cells, EAT; Experimental autoimmune thyroiditis model, FAK; Focal adhesion kinase, FMLP; N-formyl-methionyl-leucyl-phenylalanine, GM-CSF; Granulocyte-macrophage colony-stimulating factor, HSP90: Heat shock protein 90, ICAM-1; Intracellular adhesion molecule 1, IFN-g; Interferon gamma, IL; Interleukin, IMQ; Imiquimod, JNK; The c-Jun NH2-terminal kinase, LPS; lipopolysaccharide, LTB4; Leukotriene B4, MAPK; Mitogen-activated protein kinase, MyD88; Myeloid differentiation factor 88, NF-kB; Nuclear factor-κB, NO; Nitric oxide, NPSI; Nail psoriasis severity index, PASI; Psoriasis Area Severity Index, PBMC; Peripheral blood mononuclear cell, PCNA; Proliferating cell nuclear antigen, PGE2; Prostaglandin E2, RORγt; Retineic-acid-receptor-related orphan nuclear receptor gamma, ROS; Reactive oxygen species, STAT3; Signal transducer and activator of transcription 3, TA; Triamcinolone acetonide, TCM; Traditional Chinese medicine, Th; T helper cell, TLR; Toll-like receptor, TNF-a; Tumor necrosis factor-alpha, TNFAIP3; Tumor necrosis factor, alpha- TPA; 12-O-Tetradecanoylphorbol- 13-acetate, VCAM; Vascular cell adhesion molecule, VEGF; Vascular endothelial growth factor, YAP; Yeast-associated protein.INTRODUCTION
Psoriasis is an incurable, chronic, recurrent immune-mediated in?ammatory dermatosis characterized by epidermal hyperplasia and excessive in?ltration of in?ammatory cells into the dermis and neovascularization (Mason et al., 2013). Clinical presentation includes erythematous scaly rash patches (itching and flaking skin) that affect the scalp, trunk, extensor surfaces of the limbs, and the genital area. The global prevalence rate is approximately 2-3% (Parisi et al., 2013). Although the disease seldom leads to death, it significantly impairs the quality of life due to chronic complications, that is, pruritic erythema and thick loose scales, as well as comorbidities such as arthritis, cardiovascular diseases, metabolic disorders, and psychological depression (Scheiba et al., 2011). Multiple factors such as genetics, inflammation, metabolism, autoimmunity, environment, and infection are associated with psoriasis (Ayala-Fontanez et al., 2016).
Current knowledge on the pathogenesis of psoriasis, however, remains incomplete. Although the molecular mechanisms involved are complex, growing evidence suggests that significant pathological changes are abnormal proliferation and differentiation of epidermal keratinocytes, excessive in?ltration of the immune/ in?ammatory cells-- T cells (Th17, Th1, and Th2), dendritic cells (DCs), macrophages and neutrophils and increased skin angiogenesis (Chamian et al., 2004). The sequence of pathological events in psoriasis is thought to start with an initiation phase in which triggering factors (e.g., skin trauma, infection, drugs, strong sunlight, physiological stress, and smoking) lead to activation of the immune system, followed by the maintenance phase consisting of the chronic progression of the disease (Rendon et al., 2019). The premature maturation of keratinocytes induced by an inflammatory cascade in the dermis results in rapid changes in skin cells. The immune cells move from the dermis to the epidermis and secrete pro-inflammatory cytokines such as IL-1β, IL-6, IL-12, IL-22, IL-23, IL-17A, and IFN-γ (Chan et al., 2006). These inflammatory signals then stimulate keratinocytes to proliferate and secrete cytokines such as IL-1, IL-6, and TNF-α, which signal downstream inflammatory cells to arrive at the site of inflammation and stimulate additional inflammation (Albanesi et al., 2018). Besides, a defect in regulatory T cells and regulatory cytokine IL-10 is also suggested to be involved in psoriasis pathogenesis (Owezarczyk-Saczonek et al., 2018).
The current treatment of psoriasis is limited by adverse drug reactions/toxicity, disease recurrence, and drug resistance. There is no satisfactory or effective cure for psoriasis. The available treatments, both local and systemic, which have to some extent, proved effective are coal tar, Dithranol (anthralin), calcipotriol, corticosteroids, photochemotherapy (PUVA, psoralens with long-wave ultraviolet radiation), retinoids, methotrexate, and other cytostatic drugs (e.g., hydroxyurea and cyclosporine). All have limited clinical efficacy with adverse drug reactions. Patients with mild-to-moderate psoriasis are usually treated with topical treatments, while systemic therapy, monoclonal antibodies, or phototherapy is reserved for patients with the moderate-to-severe disease (Martin et al., 2019). Identification of new and effective antipsoriatic agents with few adverse effects, particularly those from herbal medicine remains a research hotspot in dermatology to date.
The study aimed to provide a systematic review and analysis of the evidence-based research (in vitro, in vivo, and clinical studies) of herbal medicine for psoriasis treatment.
MATERIALS AND METHODS
The systematic review was performed by combining three databases, that is, PubMed, ScienceDirect, and Scopus. The search terms applied were “Psoriasis” AND “Herbal medicine” AND/OR “Traditional medicine.” All articles were retrieved and downloaded to the EndNote X9 database (Thomson Reuters Company, Canada) for further analysis. They were initially screened by titles and abstracts to exclude irrelevant articles. Full-text articles included after the screening were further evaluated by applying the predefined eligibility criteria. The inclusion criteria were articles (i) published during 2001 and March 2020; (ii) available as full texts in English; and (iii) with in vitro/in vivo/ex vivo/clinical studies related to herbal or traditional medicine with antipsoriasis activity. The exclusion criteria were articles: (i) related to other skin diseases; or (ii) duplicated articles; or (iii) with unclear methodology or insufficient information, or (iv) review articles, letters to the editor, editorials, systematic analysis, or meta-analysis.
Two reviewers extracted data independently and resolved the disparity by discussion and suggestion from the third reviewer. The information obtained for analysis were the first author’s name and year of publication, name of plant and part used, traditional use for psoriasis or other diseases, and/or pharmacological activity, tested extract/compound/formulation, objective(s) of the study, type of study (in vitro/in vivo/clinical), and key results and conclusions.
RESULTS
A total of 1,822 articles from PubMed, ScienceDirect, and Scopus databases were downloaded to the EndNote database. Five hundred and seventy-four articles were excluded, and further analysis of the titles and abstracts of the remaining 1,248 articles led to the exclusion of 917 articles (excluded, based on title and abstract). Finally, 120 articles were included in the analysis. The flow diagram of the study inclusion and exclusion is presented in Figure 1, and the study summary is provided in Tables 1 and 2.
The included articles involve 94 herbs used as a single herbal extract (n=58 plants) or isolated compounds (n=54 compounds) or as compositions in traditional medicine formulas (n=24 formulas). Table 3 provides detailed information on the herbal composition in traditional medicine formulas or decoction. Most were related to plants or recipes used in Traditional Chinese Medicine (TCM) (63 articles and 207 plants). Most studies were conducted in vitro (n=31), followed by in vivo (n=30) in animals, and clinical studies in patients with different types of psoriasis (n=18).
DISCUSSION
Molecular signaling associated with psoriasis and potential drug targets
A dysregulated crosstalk between epidermal keratinocytes and immune cells leads to in?ammation, abnormal proliferation, and differentiation of keratinocytes, the hallmark of psoriasis (Benhadou et al., 2019). The activation of T cells, DCs and their upregulation of pro-in?ammatory factors are considered to mainly affect the pathogenic development of psoriasis (Flatz et al., 2013). The pro-in?ammatory cytokines IL-6, IL-23, IL-22, IL-17A, IFN-γ and TNF-α, have an essential role in in?ammation and also affect hyperproliferation and terminal differentiation of keratinocytes (Kouris et al., 2014). Other inflammatory mediators, psoriasis-associated genes and the signaling molecules/pathways that significantly accelerate the inflammatory processes of psoriasis include growth factors (TGF-β), arachidonic acid-derived lipid mediators (COX-2, LOX-5, LOX-15, and LTB), IL-23/IL-17 axis, IL-23/Th17 axis, the signal transducers and activators of transcription (STAT) signaling pathway, NF-kB signaling pathway, Janus kinase/signal transducer and activator of transcription (JAK/STAT) pathway, toll-like receptor (TLR), MyD88, TLR-NF-kB inflammasome pathway, TLR7/8-MyD88-NF-kB NLRP3 inflammasome pathway, NF-kB, MAPK, PI3K/Akt inflammasome pathway, p38 MAPK/NF-kB p65 pathway, ERK1/2 pathway, IL-22 and p38 MAPK pathway, CDC6 protein, coiled-coil α-helical rod protein 1 (CCHCR1), Yes-associated protein (YAP), steroidogenic acute regulatory protein (StAR), vitamin D receptor (VDR), intercellular adhesion molecule-1 (ICAM-1), and vascular cell adhesion molecule-(VCAM-1) (Chirioozzi et al., 2018). Angiogenesis is the critical pathological process of psoriasis which is associated with disease development (Creamer et al., 2007). Pathological angiogenesis observed in psoriasis promotes and maintains in?ammation, while in?ammation is an established inducer of angiogenesis (Costa et al., 2007).
The role of herbal medicine in psoriasis
Complementary and alternative medicine is a common option in self-medicating patients who have psoriasis, with 30-40% of patients using or having used these remedies in combination with conventional psoriasis therapy (Jensen et al., 1990). Herbs used in traditional medicines for psoriasis include mainly those from Asia, particularly China (traditional Chinese medicine: TCM), India (Ayurveda), and Thailand. Some are also used in traditional medicines in European countries and Mexico (Shenefelt, 2011). Nevertheless, their traditional use was, in most cases, arbitrary, without scientific proof of their effectiveness and safety. Besides, their traditional applications vary from country to country without standardization. Further research is needed to clarify their effects and, hopefully, provide new options to psoriasis patients. Interestingly, the results of the systematic review indicate that research on herbal medicine as an alternative treatment for psoriasis is an intensive research area. Various in vitro, in vivo, and clinical study approaches were applied to support their potential clinical uses for psoriasis. For the in vitro study, Spontaneously Transformed Human Keratinocyte Cell Culture (HaCaT) has extensively been used to study the epidermal homeostasis and pathophysiology of psoriasis. Due to their highly similar physiological characteristics to those of normal human keratinocytes, HaCaT cell is a widely used model to study the proliferation and differentiation of human epidermal cells and the pharmacological activity of psoriasis treatment (Deyrieux et al., 2007). The principal model for in vivo studies is the imiquimod (IMQ)-induced psoriasis-like model in mice. IMQ is a toll-like receptor (TLR7/8) agonist which is a potent immune activator that causes activation and maturation of DCs when applied to the skin of mice (Kim, 2009). IMQ-induced psoriasis-like mouse model has been widely used to mimic in?ammation-type psoriasis critically dependent on the IL-17 and IL-23 cytokine axis, and these models are of bene?t for facilitating research on the mechanisms of potential treatments for psoriasis (Rodriguez et al., 2017). Clinical studies to evaluate the clinical efficacy of herbal medicines in patients with different types of psoriasis are usually based on the primary efficacy parameters, including Psoriasis Area and Severity Index (PASI), DAS28 score, and Disease Activity in Psoriatic Arthritis (DAPSA) (Feldman and Krueger, 2005; Tucker et al., 2019).
The antipsoriasis activities of herbs/herbal medicine were screened or confirmed to support the traditional uses in vitro (Arora et al., 2016; Jiang et al., 2020; Nimisha et al., 2017; Sampson et al., 2001), in vivo (Cabrini et al., 2011; Cuéllar et al., 2001; Jiang et al., 2020; Li et al., 2019; Man et al., 2008; Nishima et al., 2017; Zhang et al., 2019), and clinical studies (Alex et al., 2020; Bernstein et al., 2006; Boca et al., 2019; Cohen et al., 2007; Duan et al., 2019; Ho et al., 2010; Li et al., 2017; Lin et al., 2011; Lin et al., 2014; Lin et al., 2015; Ru et al., 2019; Syed et al.,1996; Wollina et al., 2018; Yan et al., 2015; Yang et al., 2016; Yu et al., 2017; Zhang et al., 2009). TCM plays an important contribution to the research of natural products for psoriasis, followed by Indian traditional medicine (Ayurved). Herbs that have been reported to exert antipsoriasis activities include Angelica spps (Dai et al., 2014), Artemisia anomala (Gao et al., 2019), Astragalus membranace (Deng et al., 2019), Atractylodes macrocepphala (Prieto et al., 2003), Bowswellia carterit (Majeed et al., 2014), Catharanthus (Pattarachotanant et al., 2014), Cellastrus orbiculatus (Zhang et al., 2018), Cimicifuga simplex (Su et al., 2017), Citrus reticulate (Weng et al., 2016), Codonopsis pilosula (Tang et al., 2012), Coptis chinensis (Tse et al., 2006), Cortex mountan (Na Takuathung et al., 2018; Meng et al., 2019), Curcuma aromatic (Li et al., 2020). Curcuma kwangsinensis (Sarafian et al., 2015), Curcuma longa (Saelee et al., 2011), Datura metel (Yang et al., 2019), Evodia rutaecarpa (Li et al., 2019), Forsylthia suspense (Sung et al., 2016), Gloriosa superba (Pattarachotanant et al., 2014), Glycyrrhiza glabra (Xiong et al., 2015), Indigo naturalis (Lin et al., 2015), Lentinus elodes (Prieto et al., 2003), Lithospermum erythrorhizon (Yan et al., 2015), Paeonia lactiflora (Sun et al., 2015), Panax ginseng (Lee et al., 2011), Phellodendron amurense (Li et al., 2017), Poria cocus (Prieto et al., 2003), Radix rubiae (Tse et al., 2007), Rehmannia tinosa (Iliev et al., 2003), Rhododendron brachycarpum (Jeon et al., 2017), Rubia cordifolia (Mok et al., 2013), Ruanunculaceae (Iliev et al., 2003), Salvia miltiorrhiza (Li et al., 2012), Scutellaria baicalensis (Hung et al., 2018), Sinapsis alba (Ho et al., 2010), Smilax glabra (Di et al., 2016), and Tripterygium wilfordii (Wu et al., 2015). Most of the investigated plants were those used in TCM directly for psoriasis or inflammatory diseases. Apart from single plants, several TCM formulas for psoriasis were investigated for their antipsoriasis potential and underlying mechanisms of action. These include Bai Xuan Xia Ta Re Pian (7 herbs) (Pang et al., 2018), Dang-Gui-Liu-Huang Tang (7 herbs) (Nguyen et al., 2018), Herbal Anti-inflammatory Treatment (HAT1, 25 herbs) (Alex et al., 2020), Jueyin (8 herbs) (Ma et al., 2018), Kan-Lu-Hsiaso-Tu-Tan (11 herbs) (Chiang et al., 2020), PAMs (4 herbs) (Dou et al., 2017), Psoriasis 1 (13 herbs) (Sun et al., 2018), PSORI-CM01 (7 herbs) (Han et al., 2017; Wei et al., 2016), PSORI-CM02 (5 herbs) (Chen et al., 2017a; Li et al., 2020), Pso p27 (10 herbs) (Song et al., 2010), Pulain ointments (4 herbs) (Li et al., 2017; Zhou et al., 2019), QoolSkin (4 herbs) (Cohen et al., 2007), Shi Du Ruan Gao (5 herbs) (Yan et al., 2015), Taodan granules (9 herbs) (Ru et al., 2019), Tuhuai (6 herbs) (Man et al., 2008), Wen-tong-hua-yu (6 herbs) (Ho et al., 2010), and White mange mixture (10 herbs) (Gao et al., 2019).
The investigations of antipsoriasis potential of herbal medicine have also been reported from Thailand (Wanachawee Recipe consisting of 8 herbs) (Na Takuathung et al., 2017; Na Takuathung et al., 2018) and Germany (Soratinex Herbal Complex consisting of 22 herbs) (Wollina et al., 2018). Most herbs or herbal formulas produce antipsoriasis by acting on inflammatory signaling molecules/pathways. The antipsoriasis activity was investigated mainly through the effects on inflammatory molecules and signaling pathways and immune cells (T-cells, dendritic cells, monocytes, neutrophils, and macrophages) (Bader et al., 2016a; Bader et al., 2016b; Brieva et al., 2001; Chang et al., 2010; Cheng et al., 2017a; Chen et al., 2017b; Cuella et al., 2001; Dai et al., 2014; Deenonpoe et al., 2019; Di et al., 2016; Esquivel-Garcia et al., 2020; Jeon et al., 2013; Jeon et al., 2017; Kang et al., 2016; Lee et al., 2019; Leng et al., 2018; Li et al., 2019a; Li et al., 2019b; Li et al., 2019c; Li et al., 2019d; Liu et al., 2018; Liu et al., 2019; Lv et al., 2020; Na Takuathung et al., 2017; Na Takuathung et al., 2018 Nguyen et al., 2018; Pang et al., 2018a; Pang et al., 2018b; Suravanan et al., 2012; Wang et al., 2015; Wang et al., 2018; Wang et al., 2019; Wee et al., 2005; Xie et al., 2018; Ye et al., 2016; Yehuda et al., 2009; Yu et al., 2017; Su et al., 2017; Zhao et al., 2016b), as well as apoptotic molecules and signaling pathways (Brieva et al., 2001; Cuellar et al., 2001; Gao et al., 2019; Han et al., 2017; Jiang et al., 2020; Li et al., 2012; Li et al., 2019b; Mok et al., 2013; Na Takuathung et al. 2017; Na Takuathung et al., 2018; ; Pattarachotanant et al., 2014; Shi et al., 2019; Sun et al., 2019; Sung et al., 2013; Tang et al., 2018; Tse et al., 2007; Wang et al., 2019; Wee et al., 2005; Xie et al., 2018; Yang et al., 2019; Zhao et al., 2016a, and the oxidative system (Chen et al., 2017a; Pang et al., 2018; Shi et al., 2019; Weng et al., 2019). Few studies investigated the effects of herbal medicines on the angiogenesis process (Chang et al., 2015; Chang et al., 2019; Iliev et al., 2003) and other molecular targets/signaling pathways. Figure 2 summarizes key signaling molecules involved in the pathogenesis of psoriasis including key herbal medicines. Tables 2 and 3 summarize herbs/herbal medicine that has been reported for their antipsoriasis potential in vitro, in vivo, and clinical studies
Plants that modulate inflammation and immune response
Plants that interfere with the production or activity of pro- inflammatory cytokines/mediators through various signaling pathways and steps in the immune cells and/or keratinocytes include Acanthus mollis (Bader et al., 2016a), Artemisia arborescens (Bader et al., 2016a), Aloe vera (Leng et al., 2018), alpha oasis (Ye et al., 2016), Amphipterygium adstringens (Na Takuathung et al., 2018), Bai Xuan Xia Ta Re Pian formula (Pang et al., 2018) Caesalpinia bonduc (Murunganantham et al., 2011), Chunghuldan (Wee et al., 2005), citrus plants (Deenonpoe et al., 2019), Cnidium officinale (Lee et al., 2018), Conifers Li et al., 2019), Curcuma longa (Kang et al., 2016), Curcuma kwangsiensis (Liu et al., 2018), Enicostema axillare (Saravanan et al., 2012), Eruca sativa (Vehuda et al., 2009), Euphorbia kansui Radix (Kim et al., 2017), Evodia rutaecarpa (Li et al., 2019), Prunus and soybean (Wang et al., 2019), Illicium verum Sung et al., 2013), Indigo Naturalis (Chang et al., 2010; Cheng et al., 2017a; Lee et al., 2019; Lin et al., 2017), Lithospermum erytrorhizon (Wang et al., 2015), Ruanunculaceae (Bader et al., 2016; Leng et al., 2018; Pang et al., 2018), Viola tricolor (Hellinger et al., 2014), as well as Dan-Gui-Liu-Huang Tang (Nguyen et al., 2018), PSOI-CM01 (Han et al., 2017; Wei et al., 2016), PSORI-CM02 (Chen et al., 2017a) and Yinxieling formulas (Dai et al., 2014). The contribution of various immune cells was confirmed with several herbs or herbal medicines. The effects on T cells (Th17, Th1, and Threg) were reported with Cimicifuga simplex (Su et al., 2017), Conifers (Li et al., 2019), Curcuma longa (Zhang et al., 2019; Kang et al., 2016), Datura metel (Li et al., 2019), Euphorbia kansui Radix (Hellinger et al., 2014), Evodia rutaecarpa (Li et al., 2019), Indigo Naturalis (Lee et al., 2019), Paeonia lactiflora (Zhao et al., 2016a), Polypodium leucotomos (Brieva et al., 2001), PSORI-CM-02 (Li et al., 2020), Ruanunculacea (Bader et al., 2016), Smilax glabra (Di et al., 2016), Triprerygium wilfordii (Zhao et al., 2016b), as well as Dang-Gui-Liu-Huang Tang (Nguyen et al., 2018), Xiaoyin (Xu et al., 2012), and Wanchawee (Na Takuathung et al., 2017), Kan-Lu-Hsiaso-Tu-Tan formula (Chiang et al., 2020), and PSORI-CM02 formula (Li et al., 2020). Associated signaling molecules/pathways involve (i) NF-kB: Acanthus mollis (Bader et al., 2016), Achillea ligustica (Bader et al., 2016), Alpinia galangal (Saelee et al., 2011), Annona squamosal (Saelee et al., 2011), Artemisia arborescens (Bader et al., 2016), Betulinic acid (Liu et al., 2019), Cruciferous vegetables (Weng et al., 2019), C. longa (Saelee et al., 2011), Evodia rutaecarpa (Li et al., 2019), Inula viscosa (Bader et al., 2016), PAMs (Dou et al., 2017), Panax ginseng Radix (Shi et al., 2019), Prunus and soybean (Wng et al., 2019), Quercetin compound (Chen et al., 2017b), Psoriasis 1 formula (Sun et al., 2018), PSORI-CM01 formula (Han et al., 2017; Wei et al., 2016), PSORI-CM02 formula (Chen et al., 2017a); (ii) STAT signaling: Antrodia cinnamomea (Li et al., 2015), Prunus, and soybean (Wang et al., 2019), Tripterygium wilfordii (Zhao et al., 2016b), and Psoriasis 1 formula (Sun et al., 2018); (iii) JAK/STAT pathway: Illicium verum (Sung et al., 2013), Indigo Naturalis (Xie et al., 2013), and PSORI-CM02 formula (Li et al., 2020); (iv) TLR: Boswellia carterii (Wang et al., 2018), Cortex mountan (Na Takuathung et al., 2018), and Evodia rutaecarpa (Li et al., 2019); (v) TLR7-NF-κB inflammasome pathway: Rhododendron brachycarpum (Jeon et al., 2013); (vi) MyD88: Andrographis paniculate (Shao et al., 2016); and Cortex mountan (Meng et al., 2017); (vii) TLR7/8–MyD88–NF-κB NLRP3 inflammasome pathway: Datura metel L. (Yang et al., 2019); (viii) NF-κB, MAPK, PI3K/Akt inflammasome pathway: Rhododendron brachycarpum (Jeon et al., 2017); (ix) p38 MAPK/NK-kB p65 pathway: Ruanunculaceae (Pang et al., 2018); (x) IL-22 and P38 MAPK pathways: Ruanunculaceae (Yu et al., 2017); (xi) IL-23/IL-17 Axis: Vanilla planifolia [143]; (xii) ICAM-1: Glycyrrhiza glabra (Xiong et al., 2015); (xiii) and VCAM-1: Indigo Naturalis (Chang et al., 2010).
Plants that act on apoptosis, cell differentiation, and angiogenesis processes and oxidative stress
Apart from anti-inflammatory activities, antiproliferative including activities on cell apoptosis and cell differentiation activities were reported for Artemisia anomala (Gao et al., 2019), Celastrus orbiculatus (Zhou et al., 2011), Prunus and soybean (Wang et al., 2019), Gloriosa superba and Catharanthus roseus (Pattarachotanant et al., 2014), Leguminous plants Sophora ?avescens, S. alopecuroides, S. subprostrata (Shi et al., 2019), Radix rubiae (Tse et al., 2007), Rubia cordifolia (Mok et al., 2013), Salvia miltiorrhiza Bunge (Jia et al., 2020; Tang et al., 2018), Salvia miltiorrhiza Radix (Li et al., 2012), Scutellaria baicalensis (Wu et al., 2015), Zanthoxylum nitidum (Yang et al., 2019), as well as Dang-Gui-Liu-Huang Tang (Sun et al., 2019), PSORI-CM01 (Han et al., 2017; Wei et al., 2016), PSORI-CM02 (Chen et al., 2017a), and Wannachawee (Na Takuathung et al., 2018) formulas. Anti-oxidative activities were demonstrated for Artemisia anomala S. (Gao et al., 2019), Cruciferous vegetables (Weng et al., 2019), Indigo Naturalis (Lin et al., 2013), Melissa officinalis (lemon balm) (Dimitris et al., 2020), Lagenaria siceraria (Zhang et al., 2016), quercetin compound (Chen et al., 2017b) and Sinapis alba (Yang et al., 2013). Studies on anti-angiogenesis activities were limited to only a few herbs, that is, Indigo Naturalis (Chang et al., 2015; Chang et al., 2019) and Panax ginseng Radix (Zhou et al., 2015). Flavonoid from Bryophyta, Pteridophyta, Pinophyta, Magnoliophyta (Lv et al., 2020) reverses the effects of IFN-γ, inhibition of expression and exosome secretion of HSP90, and regulation of the proportion of immunocytes. Melissa officinalis (Dimitris et al., 2020) and Vernonia anthelmintica (Dogra et al., 2018), act on essential fatty acids, primarily linoleic acid palmitic acid, oleic acid, and stearic acid.
Key herbal medicine used in psoriasis
The most well-studied plants were Indigo Naturalis (Chang et al., 2015; Chang et al., 2019; Chang et al., 2010; Cheng et al., 2017a; Lee et al., 2019; Lin et al., 2007; Lin et al., 2008; Lin et al., 2009; Lin et al., 2011; Lin et al., 2013; Lin et al., 2014; Lin et al., 2015, Ruanunculaceae (Pang et al., 2018; Yu et al., 2017), Aloe vera (Arora et al., 2016; Leng et al., 2018; Syed et al., 1996), and C. longa (Arora et al., 2016; Kang et al., 2016; Zhang et al., 2019), Indigo Naturalis or Qing Dai is obtained from the aerial part/stem/leaf mainly of Strobilanthes formosanus Moore or, in some cases, Baphicacanthus cusia, Polygonum tincyorium, and Isatis indigotoca. It is widely used in TCM for psoriasis, inflammatory diseases, and leukemia. Topical Indigo Naturalis ointment has proved safe and effective for plaque-type psoriasis (Cheng et al., 2017a) and nail psoriasis (Lin et al., 2014; Lin et al., 2015), at least in part by modulating the proliferation and differentiation of keratinocytes in the epidermis and inhibiting the infiltration of T-lymphocytes and subsequent inflammatory reactions. Its three major active compounds, indirubin, indigo, and tryptanthrin, act on multi-targets of various key pathogenesis processes of psoriasis, particularly inflammation, apoptosis, and angiogenesis. The anti-inflammatory activity was shown to be through suppression of TNF-α-induced VCAM-1 expression via inhibition of AP-1/c-Jun activation (Chang et al., 2010), inhibition of γδ T cell-mediated inflammatory responses involving IL-17 secretion, and JAK3/STAT3 activation (Lee et al., 2019; Xie et al., 2018). Indigodole A, C, trypthanthrin, and indirubin significantly inhibit IL-17 production of Th17 cells both in vitro and psoriasis patients (Lin et al., 2007). The antiproliferative activity of plant extract and tryptanthrin was shown to be through G2/M phase arrest, suppression of migration, and tube formation through inhibition of Akt and FAK pathway (Chang et al., 2015). The anti-angiogenesis was demonstrated to be mainly through suppression of apelin expression through MAPK/ERK and PI3K/Akt signaling (Chang et al., 2019). Other underlying mechanisms of antipsoriasis activity include inhibition of O2 generation and elastase release activity in neutrophils (at least in part mediated by inhibition of MAPK activation and regulation of calcium mobilization) and enhancement of claudin-1 expression and tight junction function in keratinocytes (Mason et al., 2013). Ruanunculaceae (root) is used in TCM for immunomodulatory activity.
Paeony is its total glycosides that exert the activity. It was proved safe and effective when used in combination with acitretin in patients with moderate-to-severe psoriasis by reducing liver damage due to acitretin (Yu et al., 2017). The antipsoriasis activity of paeony was shown to be via p38 MAPK/NK-kB p65 pathway (downregulation of proinflammatory cytokines IL-22 and VEGF) (Pang et al., 2018). In addition, it decreased serum pro-inflammatory factor IL-6 and Th1 cytokine levels and circulating Treg and Th1 percentages (Bader et al., 2016). The main component, paeoniflorin suppressed IL-22 and P38 MAPK pathways (Yu et al., 2017). Aloe vera (leave) and C. longa (rhizome) have been used in TCM, traditional Ayurvedic medicine, and traditional medicine in other countries for psoriasis, bacterial infections, inflammation, as well as for anti-oxidant activities and wound-healing promoters (Shedoeva et al., 2019). The topical application of the extract or cream was shown to be a potential candidate for psoriasis both in experimental or clinical studies through anti-inflammatory activity (inhibition of TNF-α induced proliferation of keratinocytes and over activation of the NF-?B signaling pathway) (Arora et al., 2016; Syed et al., 1996). C. longa has been used for psoriasis, abdominal pain, liver disorders, diabetic wounds, rheumatism, anorexia, menstrual difficulties, and cancer. The active compound curcumin was shown to act on psoriasis through inhibiting hKv1.3 channel, activation of T-cells, and expression of inflammatory cytokines IL-2 and IFN-γ (Kang et al., 2016).
Curcumin-loaded hyaluronan (HA)-modified ethosomes (HA-ES) was successfully developed with propylene glycol as a novel drug carrier for curcumin to targeting CD44 protein in the inflamed psoriasis cells (Zhang et al., 2019). Tripterygium wilfordii Hook f. has been used in TCM for psoriasis, as well as dermatitis, asthma, systemic lupus erythematosus, rheumatoid arthritis, nephritis, Bechet's disease, and for prevention of transplant rejection. The plant contains multiglycosides which exert antipsoriasis activity through down-regulation of the function of Th17 cells (via inhibition of STAT3 phosphorylation) (Zhao et al., 2016b). Triptolide compound was shown to regulate IL-12/IL-23 production in LPS stimulated mouse peritoneal macrophage and inhibit p40 expression and IL12p40 transcription (Zhang et al., 2010).
CONCLUSION
Herbal medicines have a potential role in the treatment of psoriasis. Bioactive natural products are considered to be promising prototypes for the development of new therapeutic agents for psoriasis. The antipsoriasis activities of several plants used in traditional medicine for psoriasis have been confirmed in different experimental models in conjunction with their underlying mechanisms of action at the molecular and cellular levels. Research targeting inflammatory and proliferative processes in disease pathogenesis, development, and progression has been an extensive area. Blocking the generation of an inflammatory infiltrate by interfering with critical molecules of the adhesion process is an attractive strategy to treat psoriasis (for example, the approved drug efalizumab) (Parisi et al., 2013). Controlling these proinflammatory cytokines in DCs would be a breakthrough for psoriasis treatment. Investigation of anti-angiogenesis activities remains attractive to researchers. Herbs//herbal medicine targeting other signaling molecules should be further investigated.
CONFLICT OF INTERESTS
The authors have not declared any conflict of interests.
ACKNOWLEDGMENTS
The authors thank KK for his assistance in the management of all reference citation. The study is supported by the Research Team Promotion Grant, National Research Council of Thailand. The project was supported by Thammasat University (Center of Excellence in Pharmacology and Molecular Biology of Malaria and Cholangiocarcinoma).
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