INTRODUCTION:

Psoriasis originates from the Greek language which means "itching". It is a lifelong autoimmune disease and examined by white or red colour patches on the skin. These patches are typically itchy and scaly to the person ^[1]. In psoriasis there is a chronic inflammatory skin condition which results in imbalance in the immune system and increased epidermal proliferation. It is identified by patches on skin and these patches are basically red in color, dry, itchy and scaly to the patient. The severity of psoriasis varies by identifying the small, localized patches and sometimes the patches cover the whole body of a person^[2].

Psoriasis is linked with insightful functions on the body, psychological changes as well as difficulty in normal living life and some important complications. Nowadays, many effective treatments are available for psoriasis but few are costly. All the required treatments for psoriasis are accessed under the supervision of a specialist^[3]. Psoriasis is a genetically identified immune-mediated and inflammatory skin disease mediated by T-helper cells from (Th1-Th17). It commonly affects each individual and the males are affected more than females. In psoriasis, it extensively affects the patient’s life and also affects their families physically, emotionally and socially. In the mean point the WHO made a recent Global Report on Psoriasis which showed that there are various research gaps in psoriasis regarding epidemiology, etiology, relationship with complications and ways to treat psoriasis^[4].

Types or sign and symptoms of Psoriasis:

Psoriasis can be classified into the following types and the sign and symptoms of psoriasis with their description are listed below in Table No.1^[5].

Table No. 1: List of various types of Psoriasis with their sign and symptoms

S. No.	Types of Psoriasis	Sign and Symptoms	Images
1	Plaque Psoriasis	Red skin lesions (plaques) covered with silvery scales, dryness, itching, pain and swelling.
2	Pustular Psoriasis	Widespread patches on hand, feet or fingers, pus-filled blisters with red in color inflamed skin.
3	Guttate Psoriasis	Small, salmon-pink or red papules (bumps) and itching.
4	Mouth Psoriasis	Peeling skin on the gums, sores or pustules in mouth, pain or a burning sensation when eating.
5	Erythrodermic	Cover the entire body with a red, peeling rash that can itch or burn intensely.
6	Psoriatic arthritis	Scaly skin, Inflammation, swelling and pain in the joints.
7	Scalp Psoriasis	Silvery-white scales on scalp, Dandruff-like flaking, Dry scalp, Itching, Burning or soreness, Hair loss.
8	Inverse Psoriasis	Smooth, inflamed patches on skin, Heat, Trauma and infection.
9	Nail Psoriasis	Pitting of the nails, abnormal nail growth and discoloration or loosening of nails.

Causes of Psoriasis:

The causes of psoriasis are yet not fully cleared, but there are many factors which are responsible for the development of psoriasis. These factors include genetics, environment and the immune system.

Genetic factors:

In our body genes play an important role to control everything in the body, from height to eye colour. The normal function of cells in the body is controlled by genes, so it is important to work genes normally. Around 10% of the normal population has predisposed the genes to psoriasis; but from 10% only 1-3% of the populations develop psoriasis. Also families with some history of psoriasis have been more likely to develop psoriasis^[6].

Environmental factors:

Many environmental factors are generally causing psoriasis. These factors activate genes to produce psoriasis. Some of the responsible factors related to the environment are established below^[7].

Infections:

Streptococcal throat infection, tonsillitis on the throat and some other skin related infection may harm the skin and that can result in produce guttate (small, salmon-pink droplets). The other major types of psoriasis can develop after the time period of two of three weeks during the infection. Injury on skin, like cuts or scrapes can also lead to developing more chances of psoriasis.

Stress:

Stress is very common and it can cause mental illness which may affect the body to produce many products. The stress enhances the inflammatory response to our skin. According to researchers it is the important factor for stress induced psoriasis.

Medication:

Ace-inhibitors, Beta-blockers, Lithium, Synthetic Antimalarial medications, Quinidine, Indomethacin, NSAIDS, Interferons etc. So, the group of these medications can activate the disease condition^[8].

Life style:

Our skin is a major part of the body and also it is the major organ of our body, it works as a protective tool from external harms on the body. So, due to less awareness regarding personal care in our daily life style which include diet, exercise, sleep and obesity, air pollution, more alcohol consumption, smoking. Consuming alcohol in small or extra amounts may enhance the production chances of psoriasis and continuously smoking can also make the disease worse.

Other factors:

Cold weather, Obesity, Folate and vitamin B12 deficiency

SOME DISEASE COMPLICATIONS WITH PSORIASIS:

Celiac disease:

In the current scenario, about 1% of the general population is affected by celiac disease and also affects 4.3 percent of patients with psoriasis. In celiac disease the severe adverse reaction occurs when they consume gluten in the body. Both these diseases are correlated with each other and perform a complicated dysfunction in our immune system.

Mouth Problems:

In the study we can find that people who is suffering from psoriasis have been more chances to produce problems related with mucous membranes in our oral cavity. Commonly the symptoms are seen like fissures on tong or lesions in our gums and around the cheeks. The mouth related problems in psoriasis could develop from some genetic factors and these factors might occur due to exposure by similar factors like stress and consumption of alcohol.

Inflammatory Bowel disease:

According to Scientists there is a correlation between the following triggers eg: psoriasis and inflammatory bowel disease (IBD), ulcerative colitis and Crohn’s disease. In the study it has to be found that family history of a patient has been more chances to develop this disease. The genetic factors in psoriasis and IBD are commonly equal.

Vitamin D deficiency:

The deficiency of vitamin-D is commonly occurring because of the imbalance in the immune system. Some of the physicians are advising the patient to take vitamin-D supplements for improving the symptoms which show psoriasis. Vitamin-D in the body could affect psoriasis from developing large range mild to severe symptoms^[9].

Psoriatic arthritis (PsA):

In the survey of National Psoriasis Foundation (NPA) the people with psoriasis likely to develop arthritis is up to 30% in all investigated cases of psoriasis. It can affect the skin and joints of a person. If we have psoriasis then earliest signs of PsA have been noticed in red color or swelling on the joints. The various joints of our body are picked up by PsA like fingers of hand and foot, elbows and spine. Some other symptoms are found like stiffness and pain in the affected area and commonly pain can occur at morning time^[10].

Parkinson’s disease:

If the person is affected by psoriasis then it will surely develop this disease. The main source to develop Parkinson’s disease is the harmful effect of constant inflammation on the site of neuronal tissue. Parkinson's is the neurodegenerative disorder and commonly affects our brain. Ultimately, it can cause the various symptoms like tremors, rigid limbs, balance issues, and gait problems at the site of disorder^[11].

Metabolic syndrome:

It is a multifaceted body reexamined by the various risk factors related cardiovascular and particularly the person is at higher risk of developing insulin resistance and central adiposity during psoriasis. Furthermore, related factors are found eg: hypertension, abdominal obesity, dyslipidemia and bigotry of glucose. When these factors are connected with each other relatively the patient has a higher frequency of cardiovascular risk^[12]. Some of the following metabolic syndrome discussed below.

Central obesity:

Obesity is allied with superior levels of constant inflammation and has an important function in the production of metabolic syndrome and this syndrome is likely to be developing the other gears of this syndrome. Metabolic condition and obesity happen generally in patients who are suffering from psoriatic arthritis and they can unfavorably affect the severity of disease activity and response to the remedy^[13].

Insulin resistance and diabetes mellitus:

In numerous studies it has to be found that the increased risk of diabetes mellitus (DM) is also occurring in patients with psoriasis. In psoriatic arthritis PsA condition the utilization of anti TNF-α was linked with reduced risk of producing diabetes mellitus DM (OR=0.62) as compared with the utilization of other disease furnishing drugs (not including methotrexate) ^[13].

Systemic arterial hypertension:

The accumulated changes are seen in renin angiotensin aldosterone system during psoriasis. Various researchers and reviewers have examined the mechanism of enhancing the prevalence of hypertension with psoriasis patients and difficulty is found to manage the disease ^[14].

Cardiovascular disorder:

Person with psoriasis is at higher risk of cardiovascular disorder and particularly it affects those patients who are suffering from onset of severity of disease at an early age ^[15].

Kidney disease:

When the symptoms of psoriasis are moderate to severe then there are chances to produce kidney disease. Our kidneys can filter or remove the wastes from the body by urine. At this time if the kidneys don’t work correctly, then this waste can build up in our body ^[11].

EPIDEMIOLOGY OF PSORIASIS:

In the survey of the International Federation of Psoriasis Associations (IFPA) there is almost 3% of the world's population affected with some types of psoriasis and that’s approx. 125 million people. When we studied for India, the range of more than 10 million cases of psoriasis annually observed. That’s why it comes under a very common category and it is our moral duty to work more on the effective treatment and management of Psoriasis. According to research the occurrence of psoriasis in the USA is around 2%. The increasing rates of psoriasis have been investigated in peoples of Faroe Islands; the prevalence in the population is about 2.8%. The occurrence of psoriasis is less in some ethnic groups like Japanese and likely it could be absent in indigenous Australians and Indians from the origin of South America ^[16].

Figure: Psoriasis severity chart from 278 adult’s patients ^[17].

Psoriasis can be found at any age which presently occur during birth or older persons, they are mainly affected from psoriasis. The exact issue of the age of onset of psoriasis is not clear, but the studies prove that a common age of onset has been documented in several age groups from 15-20 years at first peak and the second peak happening at 55–60 years^[18].

DIAGNOSIS OF PSORIASIS:

Physical examination:

The diagnosis of psoriasis disease is done on the basis of the environment of the skin and their characteristics^[19]. It is usually done by doing clinical assessment of body symptoms. Now, there is no particular tests are offered to diagnose this disease. Occasionally, biopsy of skin and other parameters are carried out to understand the psoriasis.

Skin Biopsy:

A skin biopsy helps to remove cells or the samples of skin from our body. The taken sample was examined to identify the medical condition. Doctor’s used this technique to diagnose or find out assured conditions of skin and disease^[20]. This could be helpful to find the dermatological situation like discoid eczema, seborrhoeic eczema or pityriasis rosea nail fungus in the body. Furthermore, the diagnosis of joints is basically performed by the use of X-ray and bone scanning methodology.

PASI Scoring:

This most general used parameter is known as Psoriasis Area Severity Index (PASI). Which is helpful to find the severity level of psoriasis, once the symptoms of psoriasis are developed doctor’s will surely want to classify the level of severity and disease condition. The doctor can select the treatment for psoriasis on the basis of severity level. The symptoms are produced on the skin and each symptom can give a different value. The value of PASI is used to identify the PASI score of a person. The PASI scoring is examined on a scale with the range of 0-4, if the PASI value increases then surely the disease will be on higher severity level.

BSA (Body Surface Area):

BSA (Body Surface Area) is the parameter which is used to calculate the surface area of human body. This parameter is helpful to find out the affected area of skin and the surface area must be noticed to identify the severity level of disease from mild, moderate to severe psoriasis.

TREATMENT AND MANAGEMENT OF PSORIASIS:

Nowadays, many treatments methods are accessible to control the overall symptoms of psoriasis. Many options of therapies are obtainable for the treatment and to cure the condition of disease eg: topical, phototherapy and systemic therapy, natural and combination therapies. The growing symptoms of psoriasis can be managed accordingly by eating a regular diet and water intake properly.

Diet:

As per experts minimum 3 litres of water per day is necessary to manage the symptoms of psoriasis. Eating vegetables regularly in our diet can help to control psoriasis. These are not beneficial to control almost disease but may be helpful to decrease the symptoms. People having less intake of water and eating a poor diet can affect the condition of their skin. Oral supplements like vitamin tablets eg: zinc tablets are helpful to decrease psoriasis. Furthermore, Omega-3 fatty acids containing fish oils are thought to reduce inflammation and help to boost the immune system^[21].

Topical Therapies:

Topical agents are used as the main source and also used in combination with other therapies. For Psoriasis affecting >10% BSA and the related severity level from (mild/moderate/severe psoriasis) can be selected to give the right therapy. The ultraviolet (UV) light therapy is also given with topical treatment or other medications. The topical treatments are linked with the application of various semisolid, gels, cream. Lotion, ointment, sprays or foam etc. These preparations for skin are known as topical treatments and listed in Table No.2 ^[22].

Side Effects:

Inflammation, bone thinning, irritation, dryness and itching etc.

Table No.2: List of Topical agents used in the Treatment of Psoriasis.

Drug Name

Formulations

Dose

Corticosteroids:

Clobetasol propionate

Halobetasol propionate

Betamethasone

Mometasone

Ointment, Spray, foam, Lotion, Shampoo.

Ointment

Cream, Gel, Lotion, Foam

Cream, Ointment, Gel.

Lotion, Spray, shampoo, 0.05%, Ointment 0.05% applied on affected area.

Vitamin D3 analogues:

Calcipotriol

Calcitriol

Tacalcitol

Ointment, Cream, Solution.

Ointment

Apply a thin layer of formulation (0.005%) on affected skin twice daily.

Retinoids:

Tazarotene

Gel, Cream and Foam.

0.1% of cream is applied on affected skin and for vulgaris cleans the skin gently.

Coal Tar

Ointment, Gel, Solution, Shampoo, Soap.

Use with the combination of other drugs twice a day.

Calcineurin inhibitors:

Tacrolimus

Pimecrolimus

Ointment

Cream

Apply a thin layer of 0.03% cream or ointment on affected skin twice a day.

Dithranol:

Anthralin

Cream, Shampoo, Gel.

(0.1-1%) is applied once a day and washed off carefully after 10 minutes to one hour.

Systemic Therapies:

When the severity of psoriasis is from moderate to severe, then surely a doctor will give you the treatments with systemic drugs and these drugs are affecting the body more as compared to other therapies. The systemic agents are obviously used when the severity of psoriasis is 5% to 10% in our body. When other treatments haven't worked properly then systemic therapies are used for curing the psoriasis. Systemic therapies are enlisted in Table No.3^[23].

Side Effects:

Cheilitis, alopecia, Nephrotoxicity, hypertension, infection, renal impairment, hyperlipidaemia, hair loss etc.

Table No. 3: List of Systemic agents used in the Treatment of Psoriasis.

Drugs

Formulations

Dose

Folic acid Antagonist:

Methotrexate

Tablet Injection

Single Dose: 7.5mg/week orally, IM, or IV

Divided Dose: 2.5mg orally, IM, or IV every 12 hours for 3 doses once a week, Maximum weekly dose:20 mg

Systemic Retinoids:

Acetretin

Capsule or Topical Gel

The dose range is 25mg every day to maintaining dose is 50mg daily

Systemic Calcineurin inhibitors:

Cyclosporine

Oral solution

Pills

Capsule

The usual dose is 3-5mg/kg given orally in two divided doses.

Biologicals Therapies:

Biological therapies are delivered to those patients who haven’t enough tolerant capacity. In other words when insensitive or other contraindications are occurred due to systemic therapy. They also have been used in patients with other comorbidities, which rule out the use of systemic therapies^[24]. These therapies can be used as first-line treatments in patients having severe level of psoriasis are established in Table No. 4:

Side Effects:

Minor irritation, Redness, Pain or reaction at injection site etc.

Table No.4: List of Biological agents used in the Treatment of Psoriasis.

Drug	Formulations	Dose
Etanercept (Enbrel)	Subcutaneous injection	For adults is 50mg s.c two times in a week for the starting 3 months of treatment and 50mg injection once a week for protection treatment. The standard paediatric dose is 0.8mg/kg weekly
Infliximab (Remicade)	Intravenous injection	The dose range is 5mg/kg.
Adalimumab (Humira)	Subcutaneous injection	80mg for adults in s.c injection followed by 40 mg given every other week.
Ustekinumab (Stelara)	Subcutaneous or Intravenous injection	Standard dosing for adults ≤100 kg is 45mg given at weeks 0, 4, and every 12 weeks.
Alefacept (Amevive)	Intravenous or Intramuscular injections	7.5mg intravenous (I.V) weekly

Natural Therapies:

The herbal medicines are obtained by natural sources from the plant sources and they do not have any serious side effects as compared to other therapies. They are easily available and very easy to use in the treatment process. Nowadays, herbal resources play an main role in the management of the many skin related inflammatory diseases^[25]. Many herbal alternatives for natural psoriasis treatment and the probable herbs with anti-psoriatic activity have been established in Table No.5; briefly they are reported by some researches.

Side Effects:

Skin irritation, Burning, Pain, Swelling, Itching etc.

Phototherapy:

Phototherapy is one of the main Treatment of moderate to severe levels of psoriasis; particularly it is given to increase the growth rate of treatment. It is commonly available in the market with the product name psoralen plus UV-A, broadband UV-B and narrowband UV-B (NB-UVB). Advantage is its efficacy and safety, as shown by multiple RCTs the NB-UVB phototherapy is frequently used as main treatment for psoriasis. Almost, it can be given to any patient which includes pregnant women and children^[26].

Combination Therapy:

Combination therapy is meant to be used two different therapies at same time period and they can work effectively in severe conditions. Some large numbers of psoriasis therapies are used together and they can establish below in Table No.6^[27].

Advantages of Combining:

Using two treatments at once can have several benefits like fewer side effects, work quickly and longer relief.

Table No.6: List of Combination therapies used in the Treatment of Psoriasis.

Medication type	Combination of Drugs
Topicals + Topicals	Corticosteroids and salicylic acid, Corticosteroids and vitamin D compounds Corticosteroids and tazarotene cream
Phototherapy + Topical therapies	UVB + Topical calcipotriene, UVB + Anthralin and Topical coal tar products
Phototherapy + Phototherapy	UVB + PUVA
Phototherapy + Systemic	UVB + Methotrexate, PUVA + Retinoids
Systemic + Topical Medication	Acetretin + Topical calcipotriene, Cyclosporine + Topical calcipotriene
Phototherapy + Biologics	Narrow-band UVB + Biologics

CONCLUSION:

Psoriasis is considered as a chronic inflammatory skin condition and immune mediated ailment. Further it has to be classified by many types of symptoms and the various key factors are responsible for the development of psoriasis like genetic, immune and other environmental factors. The prevalence of psoriasis has occurred worldwide. The person with psoriasis has some time to face a problem by developing other diseases with psoriasis. We can diagnose psoriasis with skin biopsy, PASI scoring study and physical examination of patients, which include patient history and lifestyle etc. Our main focus is on the treatment and management of psoriasis, we can find that there are many treatment methods available for psoriasis like topical agents, systemic agents, biological agents, natural therapies, phototherapy or some other combination therapy that are helpful in treating psoriasis. The topical agents are applied in the form of gel, cream and ointments. Systemic or biologicals are given in the form of injection or tablet and capsules by oral and parenteral routes. For the phototherapy process the UV rays are used and given with some other agents. Herbal therapies provide a few or lesser side effects as compared to other therapies but they take more time to heal psoriasis. A variety of combination agents are helpful with phototherapy because two combined agents have more potential to heal psoriasis. So, in this article we reviewed the basic fundamentals of psoriasis and their treatment or methodology and will surely be helpful to practitioners, pharmacists, nurses and other people to confirm the right treatment for psoriasis. Our main aim is to provide better and safer or valuable treatment for psoriasis patients.

CONFLICTS OF INTEREST:

No.

REFERENCES:

1. Kurd SK, Gelfand JM. The prevalence of previously diagnosed and undiagnosed psoriasis in US adults: results from NHANES2003-2004.J Am Acad Dermatol. 2009; 60:218-224.

2. Menter A, Gottlieb A, Guidelines of care for the management of psoriasis and psoriatic arthritis. J Am Acad Dermatol. 2008; 58(5): 826–50.

3. Dogra S, Yadav S. Psoriasis in India: Prevalence and pattern. Indian J Dermatol Venereol Leprol. 2010; 76:595–601.

4. Mohammed Nazeer, Surya Ravindran, Geethu Gangadharan and Sebastian Criton. A Survey of Treatment Practices in Management of Psoriasis Patients among Dermatologists of Kerela. Indian Dermatol Online J.2019, 10(4): 437-440.

5. Raychaudhuri SK, Maverakis E, Raychaudhuri SP. Diagnosis and classification of psoriasis. Autoimmunity reviews. 2014 May 31; 13(4): 490-5.

6. Krueger G, Ellis CN. Psoriasis- recent advances in understanding its pathogenesis and treatment. Journal of the American Academy of Dermatology. 2005 Jul 31; 53(1): S94-100.

7. Bowcock AM and Krueger JG. Getting under the skin: The immunogenetics of psoriasis. Nature 2005; 5: 699-711.

8. Nickoloff BJ and Nestle FO. Recent insights into the immunopathogenesis of psoriasis provide new therapeutic opportunities J. Clin Invest 2004; 113: 1664-75.

9. Junko Takeshita. Psoriasis and comorbid diseases epidemiology. Jamacad Dermatol volume76, number (3), March 2017: 377-84.

10. Ogdie A, Weiss P. The epidemiology of psoriatic arthritis. Rheum Dis Clin North Am. 2015; 41: 545-568.

11. Alberti KG, Zimmet P and Shaw J. The metabolic syndrome: A new worldwide definition. IDF Epidemiology Task Force Consensus Group Lancet. 2005; 366: 1059-62.

12. Ogdie A, Schwartzman S, Eder L, Maharaj AB, Zisman D and Raychaudhuri SP. Comprehensive treatment of psoriatic arthritis: managing. Comorbidities and extraarticular manifestations. J Rheumatol. 2014; 41: 2315-22.

13. Voiculescu VM, Lupu M, Papagheorghe L, Giurcaneanu C and Micu E. Psoriasis and Metabolic Syndrome - scientific evidence and therapeutic implications. J Med Life. 2014; (7): 468-71.

14. Mann DL, McMurray JJ, Packer M, Swedberg K, Borer JS and Colucci WS. Targeted anticytokine therapy in patients with chronic heart failure: results of the Randomized Etanercept Worldwide Evaluation (RENEWAL). Circulation. 2004; 109:1594-602.

15. Convit J. Investigation of the incidence of psoriasis amongst Latin-American Indians. In: Proceedings of 13th Congress on Dermatology. Amsterdam: Excerpta Medica, 1962:196.

16. Burch PR, Rowell NR. Mode of inheritance in psoriasis. Arch Dermatol. 1981; 117:251–2.

17. Sanjay kumar Rout1*, Bankim Chandra Tripathy2 and Vikash Ranjan Kar3. Natural Green Alternatives to Psoriasis Treatment- A Review. Glob J Pharmaceut Sci. 2017; 4(1): 555631.

18. Yashuda T, Ishikawa E, Mori S. Psoriasis in the Japanese. In: Farbert EM, Cox AJ, eds. Psoriasis. Proceedings of the 1st International Symposium. Stanford CA: Stanford University Press. 1971:25–34.

19. Mease PJ, Armstrong AW. Managing Patients with Psoriatic Disease: The Diagnosis and Pharmacologic Treatment of Psoriatic Arthritis in Patients with Psoriasis. Drugs. 2014; 74:423-41.

20. Weigle N and McBaneS. Psoriasis. Am Fam Physician. 2013 May; 87 (9): 626–33.

21. Bjorneboe A, Smith AK, Bjorneboe GEA, Thune P, Drevon C. Effect of Dietary Supplementation with n-3 Fatty acids on Clinical Manifestations of Psoriasis. British Journal of Dermatology. 1988; 118:77-83.

22. Brown AC, Hairfield M, Richards DG, McMillin DL, Mein EA and Nelson CD. Medical Nutrition Therapy as a Potential Complementary Treatment for Psoriasis-Five Case Reports. Alternative Medicine Review. 2004; (9):297-307.

23. Schmitt J, Rosumeck S, Thomaschewski G, Sporbeck B, Haufe E and Nast A. Efficacy and Safety of Systemic Treatments for Moderate-to-Severe Psoriasis: Meta-analysis of Randomized Controlled Trials. British Journal of Dermatology. 2014; 170:274-303.

24. Dommasch Ed, Abuabara K, Shin DB, Nguyen J, Troxel AB and Gelfand JM. The risk of infection and malignancy with tumor necrosis factor antagonists in adults with psoriatic disease: a systematic review and meta-analysis of randomized controlled trials. J Am Acad Dermatol 2011; 64(6):1035-50.

25. Ekor M. The Growing use of Herbal Medicines: Issues Relating to Adverse Reactions and Challenges in Monitoring Safety. Frontiers in Pharmacology. 2013; (4):177.

26. Weischer M, Blum A, Eberhard F, Röcken M, Berneburg M. No evidence for increased skin cancer risk in psoriasis patients treated with broadband or narrowband UVB phototherapy: a first retrospective study. Acta Derm Venereol 2004; 84(5):370-4.

27. Cheryl J. Gustafson, Casey Watkins, Emily Hix and Steven R. Feldman. Combination Therapy in Psoriasis. Am J Clin Dermatol 2013: (14):9–25.

Received on 24.06.2020 Revised on 18.07.2020

Asian J. Pharm. Res. 2020; 10(4):286-292.

DOI: 10.5958/2231-5691.2020.00049.0

Herbal plants	Formulations	Dose
Capsicum annuum: Capsaicin	Extract Gel, Cream	Once a day for 6 weeks
Aloe barbadensis: Aloe vera	Cream, Gel, Lotion	Cream 70% of Aloe mucilage twice daily for 8 weeks
Curcuma longa: Turmeric	Gel	Apply the extracted gel formulation for 9 weeks
Mahonia aquifolium Berberine	Cream, Gel	Apply 10% of cream or gel twice a day for 12 weeks
Nigella sativa: Black cumin	Cream	0.1% of cream is applied on affected skin.
Indian madder: Rubia Cordifolia	Gel	Apply 1% w/w of gel twice a day and 7 times in a week.
Cassia tora: Senna tora	Cream	Apply a single dose of cream with different conc. daily
Origanum vulgare: oregano	Oil	Pure oil is diluted with carrier oil <1% and applied on the affected skin.
Smilax china: Smilax	Methanolic extract, Acetate fraction	Dose of 100-200mg/kg body weight is given.