Psoriasis is a chronic, remitting and relapsing, immunemediated inflammatory skin disorder with a strong genetic predisposition. It is among the most common immunemediated diseases in humans, affecting 2.6% of the US population, and has significant social and economic impact. Current topical therapies used to manage psoriasis include steroids, vitamin D derivatives, retinoids, immunosuppressants, anthralin, coal tar ointment, and several other agents.
These drugs often have adverse effects that may be poorly tolerated. Light therapy includes ultraviolet B phototherapy or psoralen and ultraviolet A (PUVA) photochemotherapy. However, increased rates of nonmelanoma skin cancer have been observed following PUVA therapy. Systemic therapies for psoriasis include methotrexate, cyclosporine, oral retinoids, and biologic therapies.
A recent report reviewed the effectiveness and safety of the biologics alefacept, efalizumab, etanercept, and infliximab. In addition to the reported adverse effects of the drugs, it was found that up to 40% of patients did not use their medication as directed.
Hyperbaric oxygen (HBO2) treatment is defined as breathing pure (100%) oxygen under conditions of increased atmospheric pressure. This results in elevated arterial oxygen tension to 2,000 mmHg or greater, which provides tissues with abundant oxygen. Possible complications of HBO2 therapy include barotrauma, oxygen toxicity (affecting the central nervous system and lungs), claustrophobia and anxiety, and ocular effects such as myopia and cataract.
HBO2 promotes proliferation of fibroblasts, epithelial cells, and blood vessels in a wound. It can increase the killing ability of leukocytes and is lethal to certain anaerobic bacteria. Furthermore, it inhibits toxin formation by certain anaerobes, increases the flexibility of red cells, reduces tissue edema, and conserves intracellular ATP.
The Undersea and Hyperbaric Medical Society and the Federal Center for Medicare and Medicaid Services have approved the use of HBO2 in 14 indications including gas gangrene, necrotizing soft-tissue infections, diabetic foot ulcer, compromised grafts and flaps, bone infection, intracranial abscess, anemia and blood loss, crush injury, carbon monoxide and cyanide poisoning, radiation complications, decompression sickness, and gas embolism.
HBO2 has potential effects on mediators of inflammation and the immune response. The recent reviews support the contention that HBO2 has anti-inflammatory and immunosuppressive properties. These properties make this treatment a potentially useful intervention that should be tested in the management of psoriasis and psoriatic arthritis.
The results presented in the case report “Therapeutic effect of hyperbaric oxygen in psoriasis vulgaris: two case reports and a review of the literature”, demonstrate the effectiveness of HBO2 in alleviating signs and symptoms of psoriasis in two patients. No adverse effects were reported during or after treatment with HBO2.
HBO2 suppresses the proliferation of macrophages and the formation of foam cells in atherosclerotic lesions. HBO2 also intensifies the suppressive function of T lymphocytes, normalizes cell-bound immunity, and decreases the serum concentration in immune complexes. The immunosuppressive effects of HBO2 include suppression of autoimmune symptoms, decreased production of IL-1 and CD4+ cells, and increased percentage and absolute number of CD8+ cells. In addition, long term HBO2 exposure suppresses development of autoimmune symptoms such as proteinuria, facial erythema, and lymphadenopathy.
HBO2 decreases the CD4:CD8 ratio and proliferation of lymphocytes, and activates neutrophils to migrate to regions of high oxygen tension. HBO2 suppresses TNF-a production induced by lipopolysaccharide, lipid A, and phytohemagglutinin A. A marked decrease in IL-1 and IL-2 production, and a significant decrease in prostaglandin E2 production have been observed. The positive clinical effects that HBO2 has in the treatment of chronic inflammation may relate to its effects on secretion of IL-1, IL-6, and TNF-a.
The effects of HBO2 on prostaglandin, nitric oxide, and cytokines involved in wound pathophysiology and inflammation in particular were recently reviewed. That review indicates that HBO2 has important effects on the biology of cytokines and other mediators of inflammation. HBO2 causes downregulation of cytokines and upregulation of growth factors.
It transiently suppresses stimulus-induced proinflammatory cytokine production and affects the liberation of TNF-a and endothelins. Vascular endothelial growth factor levels are significantly increased with HBO2 therapy, whereas levels of prostaglandin E2 and cyclo-oxygenase-2 mRNA are markedly reduced. Therefore, the anti-inflammatory and immunosuppressive properties of HBO2 might account for its efficacy in the cases presented.
Butler G, Michaels JC, Al-Waili N, Finkelstein M, Allen M, Petrillo R, Carrey Z, Kolanuvada B, Lee BY, Riera AG, Michaels CC, Urteaga G. Therapeutic effect of hyperbaric oxygen in psoriasis vulgaris: two case reports and a review of the literature. J Med Case Rep. 2009 Aug 10;3:7023.
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