10.5826/dpc.1204a190
Background: Due to the chronic, recurrent nature of Psoriasis vulgaris (PV) and lack of definitive treatment for the disease, patients often resort to alternative treatments. Physicians seem to have low awareness of this issue.
Objectives: To elicit the perceptions of 1,621 PV patients on complementary and alternative medicine (CAM) and examine factors reported to worsen PV.
Methods: The patients’ sociodemographic characteristics, Psoriasis Area Severity Index (PASI), Dermatology Life Quality Index (DLQI), disease duration, and severity were recorded, and the patients’ CAM use was questioned in detail. The patients were also asked about factors that worsened PV and their experiences with a gluten-free diet.
Results: Of the patients, 56.51% had used CAM. The mean age, illness duration, PASI score,s and DLQI of those using CAM were significantly higher. CAM use were significantly higher in those with facial, genital involvement, and arthralgia/arthritis. The patients mostly referred to CAM when PV became severe (46.4%). Of the CAM users, 45.52% used herbal topicals. The physicians of 67.03% did not inquire whether they used CAM. Of the participants, 37.73% considered that stress worsened their disease. Gluten-free diet did not affect PV symptoms in 52.22%.
Conclusions: Patients’ CAM use is often overlooked by dermatologists. Our results showed that more than half the patients used CAM and did not share this information with their physicians. Therefore, the awareness of physicians should be increased and patients should be asked about the use of CAM and directed to the appropriate medical treatment options by physicians.
text/xml
2160-9381
2252
en
Erkan Alpsoy
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
stress
Patient Use of Complementary and Alternative Medicine for Psoriasis Vulgaris and Factors Believed to Trigger the Disease: A Multicenter Cross-Sectional Study with 1621 Patients
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2022-10-31
2021-12-15
2022-10-31
2022-12-02
e2022190
Dermatol Pract Concept
Background: Due to the chronic, recurrent nature of Psoriasis vulgaris (PV) and lack of definitive treatment for the disease, patients often resort to alternative treatments. Physicians seem to have low awareness of this issue.
Objectives: To elicit the perceptions of 1,621 PV patients on complementary and alternative medicine (CAM) and examine factors reported to worsen PV.
Methods: The patients’ sociodemographic characteristics, Psoriasis Area Severity Index (PASI), Dermatology Life Quality Index (DLQI), disease duration, and severity were recorded, and the patients’ CAM use was questioned in detail. The patients were also asked about factors that worsened PV and their experiences with a gluten-free diet.
Results: Of the patients, 56.51% had used CAM. The mean age, illness duration, PASI score,s and DLQI of those using CAM were significantly higher. CAM use were significantly higher in those with facial, genital involvement, and arthralgia/arthritis. The patients mostly referred to CAM when PV became severe (46.4%). Of the CAM users, 45.52% used herbal topicals. The physicians of 67.03% did not inquire whether they used CAM. Of the participants, 37.73% considered that stress worsened their disease. Gluten-free diet did not affect PV symptoms in 52.22%.
Conclusions: Patients’ CAM use is often overlooked by dermatologists. Our results showed that more than half the patients used CAM and did not share this information with their physicians. Therefore, the awareness of physicians should be increased and patients should be asked about the use of CAM and directed to the appropriate medical treatment options by physicians.
Erkan Alpsoy
2022/10/31
10.5826/dpc.1204a190
e2022190
Akdeniz University, Faculty of Medicine, Department of Dermatological and Venereal Diseases
2160-9381
stress
en
e2022190
Coyle M, Deng J, Zhang AL, et al. Acupuncture therapies for psoriasis vulgaris: a systematic review of randomized controlled trials. Forsch Komplementmed. 2015;22(2):102-109
Patient Use of Complementary and Alternative Medicine for Psoriasis Vulgaris and Factors Believed to Trigger the Disease: A Multicenter Cross-Sectional Study with 1621 Patients
https://dpcj.org/index.php/dpc/article/download/2252/1774
       Patient Use of Complementary and Alternative
         Medicine for Psoriasis Vulgaris and Factors
       Believed to Trigger the Disease: a Multicenter
          Cross-Sectional Study With 1621 Patients
Melek Aslan Kayıran1, Ayşe Serap Karadağ2, İlteriş Oğuz Topal3, Selma Emre4, Esra Adışen5,
 Sevilay Kılıç6, Nuray Keskin5, Asude Kara Polat7, Bengü Çevirgen Cemil8, Mualla Polat9,
   Oğuz Yılmaz10, Hilal Ayvaz11, Filiz Topaloğlu Demir12, Sezgi Sarıkaya Solak13, Derya
Uçmak14, Sema Aytekin15, Mehmet Salih Gürel1, Algün Polat Ekinci16, Kübra Nursel Bölük16,
Neslihan Şendur17, Tuğba Özkök Akbulut18, Günseli Öztürk19, Ayda Erbas19, Erkan Alpsoy10


 1 İstanbul Medeniyet University, Göztepe Prof Dr Süleyman Yalçın City Hospital, Department of Dermatological and Venereal Diseases,
    İstanbul, Turkey
 2 Ataşehir Memorial Hospital, Department of Dermatological and Venereal Diseases, İstanbul, Turkey
 3 Health Sciences University, Prof. Dr. Cemil Taşçıoğlu Hospital, Department of Dermatological and Venereal Diseases, İstanbul, Turkey
 4 Yıldırım Beyazıt University, Faculty of Medicine, Department of Dermatological and Venereal Diseases, Ankara, Turkey
 5 Gazi University, Faculty of Medicine, Department of Dermatological and Venereal Diseases, Ankara, Turkey
 6 Çanakkale 18 Mart University, Faculty of Medicine, Department of Dermatological and Venereal Diseases, Çanakkale, Turkey
 7 Health Sciences University, İstanbul Training and Research Hospital, Department of Dermatological and Venereal Diseases, İstanbul, Turkey
 8 Health Sciences University, Dışkapı Yıldırım Beyazıt Training and Research Hospital, Department of Dermatological and Venereal
    Diseases, Ankara, Turkey
 9 Bolu Abant İzzet Baysal University, Faculty of Medicine, Department of Dermatological and Venereal Diseases, Bolu, Turkey
10 Akdeniz University, Faculty of Medicine, Department of Dermatological and Venereal Diseases, Antalya, Turkey
11 Süleyman Demirel University, Faculty of Medicine, Department of Dermatological and Venereal Diseases, Isparta, Turkey
12 Medipol University, Faculty of Medicine, Department of Dermatological and Venereal Diseases, İstanbul, Turkey
13 Trakya University, Faculty of Medicine, Department of Dermatological and Venereal Diseases, Edirne, Turkey
14 Dicle University, Faculty of Medicine, Department of Dermatological and Venereal Diseases, Diyarbakır, Turkey
15 Health Sciences University, Haydarpaşa Training and Research Hospital Faculty of Medicine, Department of Dermatological and Venereal
   Diseases, İstanbul, Turkey
16 İstanbul University, İstanbul Faculty of Medicine, Department of Dermatological and Venereal Diseases, İstanbul, Turkey
17 Adnan Menderes University, Faculty of Medicine, Department of Dermatological and Venereal Diseases, Aydın, Turkey
18 Health Sciences University, Haseki Training and Research Hospital, Department of Dermatological and Venereal Diseases, İstanbul, Turkey
19 Ege University, Faculty of Medicine, Department of Dermatological and Venereal Diseases, İzmir, Turkey



Key words: psoriasis vulgaris, complementary and alternative medicine, diet, stress, gluten
Citation: Aslan Kayıran M, Karadağ AS, Oğuz Topal İ, et al. Patient Use of Complementary and Alternative Medicine for Psoriasis
Vulgaris and Factors Believed to Trigger the Disease: A Multicenter Cross-Sectional Study with 1621 Patients. Dermatol Pract Concept.
2022;12(4):e2022190. DOI: https://doi.org/10.5826/dpc.1204a190
Accepted: March 1, 2022; Published: October 2022
Copyright: ©2022 Aslan Kayıran et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-
NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use,
distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing interests: None.




Original Article | Dermatol Pract Concept. 2022;12(4):e2022190                                                                            1
Authorship: All authors have contributed significantly to this publication.
Corresponding author: Melek Aslan Kayıran, MD, İstanbul Medeniyet University, Göztepe Prof Dr Süleyman Yalçın City Hospital,
Department of Dermatological and Venereal Diseases, Eğitim Mah. Kadıköy/İstanbul 34722, E-mail: melekaslan@gmail.com




    ABSTRACT           Introduction: Due to the chronic recurrent nature of psoriasis vulgaris (PV) and lack of definitive
                       treatment for the disease, patients often resort to alternative treatments. Physicians seem to have low
                       awareness of this issue.
                       Objectives: To elicit the perceptions of 1,621 PV patients on complementary and alternative medicine
                       (CAM) and examine factors reported to worsen PV.
                       Methods: The patients sociodemographic characteristics, Psoriasis Area Severity Index (PASI), Der-
                       matology Life Quality Index (DLQI), disease duration, and severity were recorded, and the patients
                       CAM use was questioned in detail. The patients were also asked about factors that worsened PV and
                       their experiences with a gluten-free diet.
                       Results: Of the patients, 56.51% had used CAM. The mean age, illness duration, PASI scores and
                       DLQI of those using CAM were significantly higher. CAM use was significantly higher in those with
                       facial, genital involvement, and arthralgia/arthritis. The patients mostly referred to CAM when PV
                       became severe (46.4%). Of the CAM users, 45.52% used herbal topicals. The physicians of 67.03%
                       did not inquire whether they used CAM. Of the participants, 37.73% considered that stress worsened
                       their disease. Gluten-free diet did not affect PV symptoms in 52.22%.
                       Conclusions: Patients CAM use is often overlooked by dermatologists. Our results showed that more
                       than half the patients used CAM and did not share this information with their physicians. Therefore,
                       the awareness of physicians should be increased and patients should be asked about the use of CAM
                       and directed to the appropriate medical treatment options by physicians.




Introduction                                                             CAM are those suffering from psoriasis, acne, alopecia, and
                                                                         verruca [8].
Complementary and alternative medicine (CAM) is defined                       Psoriasis vulgaris (PV) impairs the quality of life (QoL)
as various medical and healthcare systems, practices, and                and psychological state of patients due to its repetitive na-
products that are currently outside the scope of standard                ture, ability to settle in specific parts of the body such as
medical therapy [1,2]. This definition includes treatment                the face and genitals, accompanying comorbidities, and per-
methods used instead of conventional treatments, as well as              sistence for many years if left untreated. Patients sometimes
those used as accessory or complementary to conventional                 refer to CAM methods because they are tired of conventional
treatments [3].                                                          treatments and/or disease recurrence or they experience side
    Interest in CAM methods, which date back centuries, is               effects related to medical treatments.
increasing day by day. One of the reasons for this is easy ac-                In the current study, we aimed to determine the frequency
cess information about these methods with the introduction               of CAM use in PV patients, preferred CAM methods, their
of the internet into daily life. Another reason is that modern           reasons to refer to these methods, whether they would recom-
treatments are expensive since they enter the market after               mend CAM to other patients, and factors that they thought
extensive research and experiments, and substantial infor-               worsened their disease. To our knowledge, this study was con-
mation is available concerning possible serious side effects             ducted with the largest sample to investigate this topic and
[4]. The use of CAM for any reason is seen in almost one                 represents the whole society with a holistic approach with
in two people, and this rate further increases in individuals            the participation of PV patients from all regions of Turkey.
with chronic diseases [4,5].
    Although the frequency of CAM use due to dermato-                    Methods
logical diseases varies from one country to another, it is re-
ported globally to range from 28.9% to 69% [6,7]. The most               Study Population
commonly used CAM methods in dermatological diseases                     The study included voluntary literate at least 18-years-old
worldwide have been reported as homeopathy, herbal treat-                PV patients who were followed-up in 18 different derma-
ments, and other food supplements [5]. However, these pref-              tology outpatient clinics in different regions of Turkey be-
erences can also differ according to the geographical area. It           tween January 1, 2020 and July 1, 2020. The patients signed
has been reported that the patient groups that most resort to            a statement of written informed consent about the study.



2                                                                             Original Article | Dermatol Pract Concept. 2022;12(4):e2022190
Procedure                                                             average, and percentage values. Among the patients with a
The study approval was obtained from the university ethi-             history of CAM use, age, PASI, DLQI, duration of illness,
cal committee (18.12.2019/0528). The study protocol was               and amount of smoking were tested with the independent
registered at https://www.clinicaltrials.gov with the number          samples t-test, and the remaining variables were evaluated
NCT04207216. The survey items were prepared by the re-                with the chi-square test.
searchers that planned the study. The Psoriasis Area Severity
Index (PASI) and clinical data concerning the disease were
                                                                      Results
noted by the physicians. Then, the patients were asked to
complete the survey and the Dermatology Life Quality Index            A total of 1,621 patients, 741 women, and 880 men, were
(DLQI) without time limitation [9,10]. The survey questions           included in the study. The demographic characteristics of the
are shown in Supplementary Table.                                     patients are summarized in Table 1. 916 patients (56.51%)
                                                                      had used CAM for PV at some time in their lives.
Statistical Analysis                                                     Considering the seven regions of Turkey, CAM use was
The study data were analyzed using the SPSS IBM software              high in the Marmara region (29.1%), in which the popula-
package (IBM Corp. Released 2013. IBM SPSS Statistics                 tion is more educated and has higher income, and this was
for Windows, Version 22.0.). The results were obtained                followed by the central Anatolia region (13.9%) where the
at the 95% confidence level. Demographic data and other               capital, Ankara, is located. Considering the treatments that
measurements were expressed using descriptive statistics,             had been used or were currently used by the patients, CAM



              Table 1. CAM use of the patients according to their demographic characteristics
                                        and disease involvement.
                                                   CAM use present          CAM use absent           P            Overall
                                                       N          %            N           %                     N             %
 Age                   Mean                      42.54 ± 15               45.71 ± 12               0.000      44 ± 15
 Gender                Female                        415         56.01        326        43.99     0.725        741          45.71
                       Male                          501         56.93        379        43.07                  880          54.29
 Marital status        Married                       654         55.52        524        44.48     0.102       1178          72.90
                       Single                        218         59.89        146        40.11                  365          22.60
                       Divorced                       42         57.53         31        42.47                  73            4.50
 Education level       Literate, primary             359         53.03        318        46.97     0.047        677          42.30
                       or middle school
                       High school, college          340         56.86        258        43.14                  598          37.30
                       University or higher          200         61.16        127        38.84                  327          20.40
 Monthly income        Below $300                    207         53.63        179        46.37     0.374        386          23.90
 levela                $300-650                      483         57.78        353        42.22                  836          51.70
                       $650-1300                     177         54.97        145        45.03                  322          19.90
                       Above $1300                    46         62.16         28        37.84                  74            4.60
 PASI                  Mean                        6.5 ± 6.1               5.8 ± 6.2               0.029    6.2 ± 6.15
 DLQI                  Mean                      10.2 ± 13.4               8.3 ± 9.3               0.001    9.3 ± 11.8
 Disease duration      Mean                        16 ± 11                  14 ± 11                0.007     15 ± 11.3
 (years)
 Smoking status        Non-smoker                    530         59.42        362        40.58     0.129        892          55.03
                       Smoker                        386         52.95        343        47.05                  729          44.97
 Alcohol               None                          760         56.51        584        43.42     0.986       1345          82.97
 consumption           Regular                        19         57.58         14        42.42                  33            2.04
                       Social                        137         55.92        107        43.67                  245          15.11
 Family history of     Absent                        355         58.58        251        41.42     0.102        606          37.40
 psoriasis             Present                       557         54.88        452        44.53                 1009          62.20

                                                                                                                     Table 1 continues



Original Article | Dermatol Pract Concept. 2022;12(4):e2022190                                                                       3
                     Table 1. CAM use of the patients according to their demographic characteristics
                                         and disease involvement. (continued)
                                                                       CAM use present                    CAM use absent                          P                     Overall
                                                                              N             %                N                 %                                    N                %
    Joint pain                  Pain present, no                          238              62.30             144             37.70            0.003                382            23.60
                                arthritis
                                Pain and arthritis                        115              62.16             70              37.84                                 185            11.40
                                present
                                Absent                                    561              58.68             488             51.05                                1049               65
    Nail involvement            Absent                                    525              54.63             436             45.37            0.067                961            59.30
                                Present                                   391              59.24             269             40.76                                 660            40.70
    Scalp involvement Absent                                              393              55.20             319             44.80            0.364                712            43.90
                                Present                                   523              57.54             386             42.46                                 909            56.10
    Facial                      Absent                                    720              54.71             596             45.29            0.002               1316            81.20
    involvement                 Present                                   196              64.26             109             35.74                                 305            18.80
    Hand                        Absent                                    569              56.06             446             43.94            0.642               1015            62.60
    involvement                 Present                                   347              57.26             259             42.74                                 606            37.40
    Genital                     Absent                                    677              54.55             564           45.45%             0.004               1241            76.60
    involvement                 Present                                   238              62.80             141             37.20                                 379            23.40
    Skin-fold                   Absent                                    681              55.28             551             44.72            0.079               1232            76.00
    involvement                 Present                                   235              60.41             154             39.59                                 389            24.00
a
Income level was calculated based on the exchange rate at the time of the study.
CAM = Complementary and alternative medicine; PASI = Psoriasis Area Severity Index; DLQI = Dermatology Life Quality Index.



              45.52%


                          31%
                                 26.86%
                                                25%

                                                      16.70% 16.16% 14.19%13.86%
                                                                                           8.84%
                                                                                                   8.08% 3.71%
                                                                                                               3.49%
                                                                                                                              1.53% 1.31% 0.98% 0.76% 0.44% 0.22%
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    Figure 1. CAM methods preferred by the patients. More than one response allowed (total percentage exceeds 100%). CAM = comple-
    mentary and alternative medicine.



use was higher in the groups of cyclosporine (64.02%),                                          and within the first year of the disease (9.4%). The patients
biological agents (64%), phototherapy (62.87%), and                                             had mostly heard of CAM methods from their acquaintances
­methotrexate (60.78%).                                                                         (33.95%) or relatives (28.49%), and through the internet
      The CAM methods preferred are summarized in                                               (23.91%). Those that heard from their dermatologists con-
Figure 1. They resorted to these methods most commonly                                          stituted 12.34% of the sample. The duration of CAM use was
after the fifth year of the disease (32%) and within the first                                  reported to be 1-6 months by 24.78% of the patients and 2-4
to fifth years of the disease (27.3%). This was followed by                                     weeks by 24.56%. For 31.77% of the patients, the CAM
the groups that started to use CAM methods from the time                                        practitioner did not have any CAM training while 33% did
of diagnosis (18.8%), before consulting a doctor (11.24%),                                      not know about the practitioner training and 31% were not



4                                                                                                       Original Article | Dermatol Pract Concept. 2022;12(4):e2022190
interested in the practitioner education. The patients most       on which food and habits are affecting psoriasis are listed
resorted to CAM methods when their disease became severe          in Table 3.
(46.40%) while 31.55% stated that they referred to these             A gluten-free diet was followed by 5.55% of the patients
methods when they had mild PV, 24.56% when they expe-             at some time in their lives. Of the patients with this history,
rience joint pain, 20.09% when the disease recurred, and          52.22% thought that removing gluten from their diet did
14.41% when they had no hope about getting better.                not affect their PV symptoms while 21.11% believed that
    While 54.5% stated that they would not recommend              it helped relieve their rash, 26.67% itch, 4.44% joint pain,
these methods to other patients, 11.55% were positive             5.56% nail symptoms.
about recommendation, and the remainder were indecisive.
CAM had no effect on PV for 56.55% of the patients and
                                                                  Conclusions
worsened the disease according to 8.33% whereas 28.38%
thought they had benefitted from treatment. The remainder         In previous studies conducted with psoriasis patients, the use
made no comment about the effect of CAM on PV. The an-            of CAM was reported at a rate of 41%-69% [11-18]. Our
swers about the reason why they received CAM are summa-           rate of 56.51% was similar to previous studies. In addition,
rized in Table 2.                                                 there was no significant difference in CAM use according to
    The physicians of 67.03% of the patients did not ask          gender and financial status, which is in agreement with the
whether they had used CAM, and 48.91% of the patients did         literature [17]. In the current study, the patients using CAM
not spontaneously inform their doctors that they had received     were significantly younger (42.5 and 45.7 years, respectively;
such treatment. The patients who shared this information          P = 0.000) and had a significantly longer mean disease dura-
stated that their physicians recommended stopping the CAM         tion (15.8 and 14.3 years, respectively, P = 0.007) compared
treatment (27.65%), did not interfere (26.61%), or mentioned      to those without a history of CAM use, which is also consis-
that there was no harm in continuing to use CAM (20.79%).         tent with previous research [12,17]. Generally, people that
The remaining 24.95% did not care or were unresponsive.           were younger but who had a longer disease duration were
    When the patients that had not used CAM were asked            determined to seek alternative treatment options.
for their views concerning these methods, 56.17% did not             In our study, the patients with a minimum university level
find them reliable and safe, 28.94% thought they were non-        tended to have a higher rate of CAM use. This contradicts
sensical and useless, 28.37% found them expensive, and            with a previous study indicating no relationship between ed-
24.26% were concerned about side effects. When asked              ucation level and CAM use [16]. In Turkey, individuals with
whether they would use CAM in the future, 60.85% stated           higher education participate more in work life and they are
that they would not use them, 25.39% would use if they            more likely to do an online research and access these meth-
were sure they would do no harm, 23.12% might use, and            ods. This may contribute to higher use of CAM in our highly
6.95% were thinking about using them.                             educated patients.
    56.69% of the patients thought that various foods af-            The patients using CAM had significantly higher PASI and
fected PV while 28.74% did not consider that any food or          DLQI than those that did not use (PASI = 6.5 and 5.8, respec-
habit had a worsening effect on PV. The patients thoughts         tively; DLQI = 10.2 and 8.3, respectively). Previous studies



                                      Table 2. Patients reasons for receiving CAM.
                                                                                                            N            %
 Saw no benefit of modern drugs for psoriasis                                                              177         19.32
 Thought it would prevent disease recurrence                                                               242         26.42
 Became tired of medical therapies and decided to look for an alternative method                           334         36.46
 Natural and safe with no side effect                                                                      275         30.02
 Cheaper                                                                                                     33          3.6
 More reliable and effective than medical therapies                                                          18          1.97
 Easily available                                                                                            64          6.99
 Don’t know                                                                                                111         12.12
 Other                                                                                                       68          7.42
 Total                                                                                                    1322

More than one response allowed (total percentage exceeds 100%).
CAM = complementary and alternative medicine.



Original Article | Dermatol Pract Concept. 2022;12(4):e2022190                                                                  5
                        Table 3. Patients thoughts on food and habits affecting psoriasis.
                                                                                                             N             %
 Sunflower seeds                                                                                            222          13.70
 Nuts                                                                                                       141            8.70
 Hot-tasting food                                                                                           510          31.46
 Spicy food                                                                                                 489          30.17
 Milk, dairy products                                                                                        50            3.08
 Packaged food, such as crisps                                                                              233          14.37
 Fried food                                                                                                 285          17.58
 Offal                                                                                                       31            1.91
 Food and beverages with coloring, such as coke                                                             238          14.68
 Sugar, chocolate                                                                                           142            8.76
 Fatty food                                                                                                 171          10.55
 Chicken                                                                                                     28            1.73
 Red meat                                                                                                    61            3.76
 Fish, fish oil                                                                                              23            1.42%
 Hormone-injected vegetables/fruit                                                                           69            4.26
 Alcohol                                                                                                    228          14.07
 Wheat, wheat products                                                                                       51            3.15
 Eggplant                                                                                                   136            8.39
 Tomato                                                                                                     365          22.52
 Ketchup, mayonnaise                                                                                        107            6.60
 Paste, sauces                                                                                              163          10.06
 Smoking                                                                                                    280          17.27
 Gluten                                                                                                      54            3.33
 Stress                                                                                                     563          34.73
 Lack of sleep                                                                                              202          12.46
 Other                                                                                                       88            5.43
 Total                                                                                                    4930

More than one response allowed; total percentage exceeds 100%.



similarly reported a higher rate of CAM use in patients with          CAM use varies by country and culture. Patients often
high PASI scores [12,16,18]. This suggests that as the disease     try treatments that are easier to access in areas where they
duration and severity increase and the QoL deteriorates, pa-       live. Our patients mostly used herbal topicals (45.52%), food
tients are more willing to try different treatment options.        supplements (31.0%), and hot springs/baths (26.86%) while
    QoL in PV patients may vary according to the involve-          they least referred to hypnosis and homeopathy treatments,
ment areas. In our study, CAM use was significantly higher in      which are not common in Turkey. Previous studies showed
those with facial (64.26%) and genital involvement (62.8%)         that herbal topicals (36.80-73.13%) were among the most
and those with arthralgia (62.30%) and arthritis (62.16%).         preferred CAM method [11,12,14-18,20]. In addition, as in
In another study, CAM use was found to be high in the pres-        our study, food supplements were among the frequently pre-
ence of scalp and facial involvement [18]. Previous publica-       ferred CAM methods in many studies [14,17]. This shows
tions did not detect a difference in the use of CAM among          that despite differences depending on the geography, patients
patients with arthritis [17,18]. Psychosocial effects are more     tend to rely more on drugs derived from plants. Herbal treat-
commonly observed in patients with lesions located in visible      ments are also officially accepted in Far Eastern countries.
areas and intimate areas, as well as those with arthropathic       In Korea, all herbal, acupuncture and bath treatments are
psoriasis [19]. This situation may also create an important        classified under the name of oriental therapy and subject to
barrier for patients to present to health institutions to be ex-   license, and their use is legally approved [15]. Herbal medi-
amined by physicians and explain why our patients felt the         cine formulas are included in traditional Chinese treatments
need to refer to CAM methods.                                      and used for psoriasis [21]. Since natural spring waters are



6                                                                      Original Article | Dermatol Pract Concept. 2022;12(4):e2022190
abundant in Turkey, bath/spa treatments are among the fre-       52.9% of PV patients who followed a gluten-free diet re-
quently preferred treatments. Similarly, studies conducted       ported that they observed some improvement in their disease
in Korea (44.3%) and Israel (46%) reported that bath/spa         [23]. In our sample, 52.22% following a gluten-free diet did
treatments were used frequently [12,15]. In addition, herbal     not consider any effect on psoriasis while 3.33% of all pa-
products and salts used in bath were frequently preferred        tients thought that gluten exacerbated PV. This is lower than
methods in other studies [16,17].                                the rate of those reporting that gluten affected their disease
    Among the reasons for using CAM, our patients com-           (7.2%) in a USA study [23].
mented that they sought an alternative treatment method             Although most physicians do not pay any attention to
(36.46%), considered it natural (30.02%), and thought it         CAM treatments, there are many studies on this subject in the
would prevent PV recurrence (26.42%). Nineteen percent           literature. Cochrane reviews, meta-analyses and systematic
considered that the modern drugs did not help. In general, it    reviews reveal the presence of studies investigating products
was seen that the patients were worn-out due to the repeti-      containing fatty-acid containing oils, oral and topical herbal
tive nature of psoriasis and referred to CAM with the hope       medicine, marine medicines such as fish oil, acupuncture,
of achieving a full cure. In addition, there were many pa-       selenium, vitamin D, zinc, avocado oil, climatotherapy, and
tients that believed that these treatments had no side effects   mind/body interventions in the psoriasis treatment [21,18-
or health risk. Similarly, in previous studies, patients fre-    31]. These studies report findings of anti-inflammatory, an-
quently stated that they resorted to CAM methods because         tiproliferative and immunomodulatory effects of the herbal
they try everything to eliminate their disease, were unhappy     treatments as a complementary option to conventional ther-
with conventional treatments’ results, and found CAM to be       apies [28]. However, it is advised that care should be taken in
safe [12,15-17,22].                                              terms of hepatotoxicity, and the benefits of these treatments
    Although our patients mostly received recommendations        are low and the methodologies of these studies are usually
for CAM treatments from their acquaintances (33.95%),            weak [21,28]. It is also suggested that there is no solid ev-
some also read about them on the internet (23.91%) and           idence concerning the benefits of vitamin D, zinc, selenium,
were recommended by their dermatologists (12.34%). In            topical vitamin B12, and avocado oil while evidence pre-
previous studies, patients generally found out about CAM         sented on oil, aloe vera, fish oil, climatotherapy and mind/
through their acquaintances, friends and the internet, with      body interventions is conflicting, and acupuncture is not ef-
dermatologist recommendations being reported at a rate of        fective [29].
only 3.40%-4.48% [15,17]. This difference can be attributed         In our study, 67.03% of the patients stated that their phy-
to the varying practices of physicians in terms of CAM use       sicians did not inquire about their CAM use, and 48.91%
and recommendations according to geographical differences.       did not inform them about CAM use if not prompted by
    Thirty-five percent stated that stress was the factor that   their physicians. As a result, it was seen that most physicians
most worsened PV. This was followed by those considering         were unaware of CAM being used by their patients. CAM
that the consumption of hot and spicy foods, tomatoes, and       use without the physician knowledge can lead to undesir-
smoking had a negative effect on psoriasis. The rate of those    able side effects and make it difficult for the physician to de-
who thought that their food preferences did not affect was       termine the underlying cause of these effects. Similar to our
43.31%. Afifi et al reported this rate to be 37% and de-         results, a previous study reported that the rate of physicians
termined sugar (13.8%) and tomato (7.4%) to be the food          asking their patients about CAM use was very low (10%)
that most increased the disease severity [23]. A considerable    and only 22% of the patients shared this information with
proportion of our patients (22.52%) thought that tomato          their physicians [12].
worsened their symptoms, but there was a higher rate of             Due to the chronic and recurrent nature of PV, more
those considering hot (31.46%) and spicy (30.17%) foods          than half the patients seek CAM methods. This tendency is
to have a negative effect, which was much higher than re-        more common in patients with a severe disease, poorer QoL,
ported before (2%-5%) [23]. Since dietary habits can differ      increased disease duration, arthritis/arthralgia, and facial,
between countries, the higher rate of our patients believing     genital involvement. We determined that the patients used
that hot and spicy foods and tomato worsened their disease       CAM because they thought that these methods were natural
compared to previous studies can be explained by the more        and safe and had no side effects, and they were exhausted
frequent consumption of such food products in Turkey.            with the process of undergoing conventional treatments and
    There are different opinions about the relationship be-      experiencing disease recurrence. Herbal topicals, food sup-
tween psoriasis and gluten. In contrast to those that claim      plements and bath/spa treatments were the most preferred
that there is no relationship between gluten intake and the      CAM methods. The physicians usually did not ask about
risk of developing psoriasis, there are also publications that   their patients CAM use, and almost half of the patients did
link celiac disease with PV [24-27]. In a previous study,        not choose to share this information with their physicians.



Original Article | Dermatol Pract Concept. 2022;12(4):e2022190                                                                 7
The patients considered that stress, consumption of hot and                      psoriasis. Dermatol Ther. 2014;27(5):281-283. DOI: 10.1111/
spicy foods, and smoking worsened their disease, and gluten                      dth.12139. PMID: 24964349.
                                                                           15.   Kim GW, Park JM, Chin HW, et al. Comparative analysis of
did not effect. In light of these data, it is considered very
                                                                                 the use of complementary and alternative medicine by Korean
important that the physicians should question the use of
                                                                                 patients with androgenetic alopecia, atopic dermatitis and pso-
CAM in their patients with chronic diseases and guide them                       riasis. J Eur Acad Dermatol Venereol. 2013;27(7):827-835.
appropriately.                                                                   doi: 10.1111/j.1468-3083.2012.04583.x. Epub 2012 May 23.
                                                                                 PMID: 22620682.
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Original Article | Dermatol Pract Concept. 2022;12(4):e2022190                                                                             9
