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. 2025 Dec 10;27(1):9–16. doi: 10.1007/s40257-025-00992-2

Nutrition and Psoriasis: The Latest Evidence and How to Approach Nutrition in Clinical Practice

Andrea Leung 1,✉,#, Allison Kranyak 1,#, Georgia Marquez-Grap 1, Tina Bhutani 1
PMCID: PMC12860837  PMID: 41369865

Abstract

Psoriasis is a chronic immune-mediated skin condition that is associated with cardiovascular disease, obesity, and other comorbidities. While highly linked to genetics, psoriasis is also significantly impacted by environmental and lifestyle factors. Nutrition and diet are areas of considerable interest for patients, providers, and researchers alike, as patient diets may have a significant impact on disease activity and severity. Diet is also a major modifiable lifestyle factor that patients are empowered to explore and optimize in the management of their psoriasis. In this Therapy in Practice, we summarize the most up-to-date research on various diets proposed to have benefits for patients with psoriasis and conclude with a discussion on how providers may integrate nutrition into clinical practice. The Mediterranean diet emphasizes whole fruits, vegetables, grains, and healthy fats. Given the anti-inflammatory effects and cardiovascular benefits of the Mediterranean diet, it is a good option for patients with psoriasis. A low-calorie diet is often recommended for individuals who are overweight or obese, and there is a strong association between obesity and psoriatic disease activity and progression. For patients with a diagnosis of celiac disease or seropositivity of immunoglobulin A or immunoglobulin G antigliadin antibodies, a gluten-free diet could be beneficial in reducing psoriasis severity. Diet can have a significant role in the management of psoriasis, and patients and providers should work collaboratively to create a sustainable, safe, and effective diet.

Key Points

Healthful dietary change is a potentially worthwhile adjunct to traditional psoriasis treatments, particularly a shift to the Mediterranean diet.
Any counseling on nutrition should be done with attention to a patient’s co-morbidities.
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Introduction

Psoriasis is a chronic, systemic inflammatory skin disease that has been associated with an increased risk of cardiovascular, cerebrovascular, and metabolic disease [1]. A “Western” diet (high fat, high sodium, high protein, and high sugar) and obesity has been linked to autoimmune and immune-mediated diseases, including psoriasis [2]. In a cross-sectional case-control observational study, adult men with psoriasis recorded 7-day food diaries more consistent with a Western diet than that of healthy controls [3]. Additionally, a Western diet was shown to worsen imiquimod-induced psoriasiform dermatitis in mice [4]. Obesity, type 2 diabetes mellitus, and unfavorable adiposity and waist-to-hip ratio have even been revealed by a systematic review and Mendelian randomization study as potential causal factors for psoriasis [5]. Given how nutrition can affect weight, metabolic parameters, and overall systemic inflammation [6, 7], the impact of different diets and the impact on psoriasis has been studied.

In 2018, the National Psoriasis Foundation (NPF) published dietary recommendations based on a systematic review for patients with psoriasis and psoriatic arthritis. From the available literature at that time, only weight reduction with hypocaloric diets in overweight or obese patients could be strongly recommended. They also recommended a gluten-free diet in those who test positive for serologic markers of gluten sensitivity (immunoglobulin G [IgG] tissue transglutaminase and immunoglobulin A [IgA] endomysial antibody), and weakly recommended vitamin D supplementation in those with psoriatic arthritis (but not psoriasis only). The NPF acknowledged that based on low-quality data, select foods and dietary patterns may affect psoriasis and concluded that individuals may consider a trial of a Mediterranean diet (MeD) as an adjunctive measure [8].

Since the NPF published their recommendations, there have been more original studies and reviews on diet and psoriasis looking further at the MeD as well as time-restricted eating, ketogenic diets, and vegan/vegetarian diets. We aim to highlight up-to-date evidence on how diet may impact psoriasis. Furthermore, we acknowledge that it can be difficult to address nutrition with patients, as diet can be a sensitive subject that is not always easily addressed in short patient visits. Thus, we discuss effective tools to incorporate dietary guidance for interested patients into psoriasis care. We also touch on socioeconomic and social barriers to dietary change.

The Evidence Supporting Dietary Interventions for Psoriasis

Mediterranean Diet (MeD)

The MeD is a plant-forward diet emphasizing fruits, vegetables, whole grains, and healthy fats resembling a classic diet for those living in the regions surrounding the Mediterranean sea [9]. Extra virgin olive oil is a central part of the diet, in addition to fish/seafood rich in omega-3 polyunsaturated fatty acids (PUFAs). Foods like red meat, dairy, and processed sweets are limited in the MeD. The MeD has many health benefits, including a lower risk of cardiovascular disease, metabolic syndrome, and even some types of cancer [10, 11]. Many of the nutrients abundant in the MeD have anti-inflammatory and anti-oxidant effects, lending to a widespread uptake in its recommendation as a healthy diet for several chronic diseases.

More recent research has investigated its role in the therapeutic management of inflammatory skin conditions such as psoriasis and atopic dermatitis. In 2018, the NPF recommended adults with psoriasis to consider a trial of the MeD based on low-quality evidence [8]. A cross-sectional case-control observational study of 62 patients with mild-to-severe psoriasis aimed to investigate psoriasis and adherence to and similarity of diets to the MeD revealed that patients with psoriasis have a lower adherence to the MeD [12]. Korovesi et al. also demonstrated an inverse correlation between the MeD adherence and psoriasis disease activity in a cross-sectional study of 69 patients with mild-to-severe psoriasis (p < 0.001) [13].

A closer look at the MeD reveals several beneficial nutrients. Omega-3 PUFAs, commonly found in fish, nuts, and plant-based oils, are rich in the MeD and play an important role in modulating systemic inflammation and reducing the progression of coronary heart disease [14]. This can also be beneficial, given the inflammation and cardiovascular disease associated with psoriasis [15, 16]. Omega-3 PUFAs also play an inhibitory role by suppressing T helper-17 cell differentiation [17]. Studies have attempted to evaluate omega-3 PUFA and fish oil supplementation in the treatment of psoriasis, resulting in mixed recommendations. As a monotherapy in the treatment of psoriasis, fish oil and omega-3 PUFAs were found to have no effect on the Psoriasis Area and Severity Index (PASI), lesion area, or pruritus [18]. A 2019 meta-analysis of ten randomized controlled trials involving 560 participants found that supplementation with omega-3 PUFAs was associated with a significant reduction in PASI scores by − 1.58 (95% confidence interval [CI] − 2.24, − 0.92; p = 0.02), with significant improvements in erythema, itching, and scale in those taking a higher dosage [19]. Although an improvement of − 1.58 in PASI may be clinically insignificant for those who start at severe PASI scores, the improvements noted in studies where higher doses were employed are promising. However, given these mixed results, the overall MeD, rather than isolated components, is likely what helps reap its benefits.

The MeD is also rich in phytonutrients, including polyphenols and flavonoids, which have potential anti-inflammatory and antioxidant effects [15]. Found in fruits, vegetables, and extra virgin olive oil, these nutrients play a crucial role in preventing oxidative stress and therefore inflammation, which can be beneficial in psoriasis [15, 18]. A review of in vitro and in vivo studies found that extra virgin olive oil and its polyphenols could improve disease symptoms in immune-mediated inflammatory diseases such as psoriasis through immune modulation [20]. Additionally, a diet rich in fruits, vegetables, whole grains, and fish, such as the MeD, has been shown to lower C-reactive protein levels, a marker of systemic inflammation [15].

The MeD as also been shown to support a healthy gut microbiome, and may even correct gut dysbiosis in patients with psoriasis [21]. In a review of the gut microbiome in patients with psoriasis on the MeD, Kranyak et al. highlighted studies in which following the MeD for longer (range from 2 weeks to 2 years) led to a greater likelihood of beneficial changes to the microbiome, whereas two studies in which individuals followed the MeD for 4 or 7 days did not promote changes [21–23]. The authors suggest that the MeD may positively alter the microbiota in many ways, promoting an immune-regulated and anti-inflammatory state potentially beneficial for psoriasis [21].

Ketogenic Diet (KD)

The ketogenic diet (KD) consists of a high-fat and low-carbohydrate intake. Weight/fat loss and improvement of metabolic health are two goals of the KD [24]. The daily carbohydrate intake in a KD is ~ 20–50 g/day or less than 10% of the total daily caloric intake while 70–80% calories are derived from fat. This aims to induce a state of internal ketosis so that ketones and fatty acids are used as the primary energy source [25]. Research has investigated the role of the KD in the management of psoriasis, and results are mixed. While some studies have found no significant improvements for psoriasis on the KD, a randomized controlled trial by Lambadiari et al. revealed beneficial outcomes from the KD. Twenty-six patients were randomly assigned to an 8-week MeD or KD; following completion and a subsequent 6-week washout interval, the two groups were crossed over to the other diet for another 8 weeks. Results revealed that the both the MeD and KD were associated with a reduction in weight and fat (p < 0.01) and PASI (p = 0.04) [26]. However, only the KD was associated with reduced disease activity in psoriatic arthritis (p = 0.004), and a reduction in levels of proinflammatory cytokines such as interleukin-6, interleukin-17, and interleukin-23 (p < 0.05) [26]. However, it has been strongly established that weight management and loss can improve psoriasis severity in patients who are overweight and obese [27]. Thus, it is difficult to discern if improvements in psoriasis are due to weight loss alone [15, 28].

The very low-calorie ketogenic diet (VLCKD) is a variation of the KD, in which individuals follow a KD that is 500 kcal below their calculated dietary requirement. Castaldo et al. investigated this diet in 37 drug-naïve (i.e., never treated, excluding the use of topical emollients) patients with psoriasis who were overweight or obese, and found that those who underwent a 10-week, two-phase weight-loss program consisting of a 4-week protein-sparing VLCKD diet (< 500 kcal/day) followed by a 6-week balanced, hypocaloric (25–30 kcal/kg of ideal body weight/day), MeD-like diet experienced notable reductions in weight and PASI scores at week 10 with a mean change in PASI of − 10.6 (95% CI − 12.8, − 8.4; p < 0.001) [29]. They also found that improvements in PASI scores were not correlated with the amount of weight loss achieved [29]. Castaldo et al. conducted a follow-up study of 30 patients with psoriasis who followed a VLCKD for 4 weeks. Similar to the first study, they found PASI significantly decreased by approximately 50% following the VLCKD. The authors also investigated the Dermatology Life and Quality Index, a quality-of-life questionnaire completed by patients regarding psoriasis symptoms scored from 0 (no impact on quality of life) to 30 (severe impact), which showed a significant reduction in the score and impact on quality of life following the VLCKD (p < 0.05) [30].

Low-Calorie Diet (LCD)/Hypocaloric Diet

As previously mentioned, weight loss in individuals with psoriasis who are overweight or obese can both improve pre-existing psoriasis and psoriatic arthritis symptoms and potentially prevent the onset of psoriasis in individuals with obesity [27]. Because of this, several researchers have investigated the efficacy of a low-calorie diet (LCD) or hypocaloric diet in the management of psoriasis.

Mahil et al. conducted a meta-analysis of six randomized controlled trials investigating LCDs in combination with psoriasis treatments [27]. They found that patients with obesity on a LCD were more likely to achieve a reduction in their PASI score compared with those on a regular diet [− 2.59, 95% CI − 4.09 to − 1.09] [27]. Low-calorie diets have also been shown to correlate with an improved response to systemic treatments for psoriasis [31, 32].

Intermittent Fasting (IF)

Intermittent fasting (IF) is an umbrella term for a variety of dietary patterns centered around periods of eating and fasting. Intermittent fasting has been linked to improved weight and metabolic outcomes [33]. Intermittent fasting consists of multiple timing schedules for temporary food avoidance, including alternate-day fasting and time-restricted feeding in which food is consumed over a 6-h period while fasting for the remaining 18 h [33]. Intermittent fasting has been associated with several health benefits equated to those of LCDs, including decreases in weight and improvements in dyslipidemia and blood pressure [33–35]. It is proposed that IF can also be anti-inflammatory owing to the increase in adiponectin secretion in response to IF; adiponectin exhibits anti-inflammatory effects, resulting in a reduction in local and systemic inflammation [33, 35]. These benefits may be especially relevant to patients with psoriasis given the high rate of metabolic comorbidities.

Studies have investigated the effects of IF in the setting of the fasting that occurs during Ramadan, in which individuals fast during daylight hours and eat two meals: one before sunrise and one after sunset. An observational study of 108 patients with psoriasis who fasted during Ramadan found that patients experienced a significant reduction in their PASI score after 1 month (p < 0.0001); however, body mass index was not reported, making it difficult to discern if results are from the dietary pattern or from weight loss. [36] Another study of IF/Ramadan fasting in 37 patients with psoriatic arthritis found that after a month of fasting, there was a significant reduction in C-reactive protein (p < 0.0001), Bath Ankylosing Spondylitis Disease Activity Index (p = 0.0078), PASI (p < 0.0001), and disease activity in psoriatic arthritis (p < 0.0001). [37] Improvement in enthesitis (p < 0.0001) and a decrease in dactylitis severity scores (p < 0.0001) were also significant.[37]

Gluten-Free Diet (GFD)

The gluten-free diet (GFD) is another diet individuals may follow out of necessity, like in celiac disease (CD). The GFD restricts foods high in gluten, such as wheat, rye, and barley grains, pastas, and breads. Researchers have investigated the benefit of a GFD, especially as data have shown an increased risk of psoriasis in patients with CD (odds ratio = 1.8) and an increased risk of CD in patients with psoriasis (odds ratio = 2.16) [38, 39].

While several studies support the benefit of a GFD in patients with psoriasis, more conclusive research has found that the main benefit is for patients with psoriasis who either have CD or are seropositive for IgA or IgG antigliadin antibodies, which are commonly used to diagnose CD and are found to be higher in patients with psoriasis [40]. Michaëlsson et al. conducted a study of 33 adults with psoriasis who were seropositive (had IgA and/or IgG antibodies to gliadin) and six adults with psoriasis who were seronegative. Results showed that adults with psoriasis and antigliadin IgA or IgG seropositivity had significant improvements in PASI scores after 3 months on a GFD, with 60% of these patients experiencing worsening of psoriasis symptoms after returning to their ordinary diet [41]. This study also found that adults with psoriasis with normal antigliadin IgA or IgG did not experience differences in their psoriasis while on a GFD [41]. Similar results were found when the study was replicated in 123 adult patients with palmoplantar pustulosis [42]. Additionally, there is an association between CD and psoriasis, but universal screening for CD in patients with psoriasis is not recommended. While the utility of universal screening has not been studied in large-scale studies of patients with psoriasis, antigliadin antibody testing has limited utility and a high rate of false positives [43, 44]. If patients display symptoms of CD, such as chronic gastrointestinal symptoms, or have a family history, screening should be recommended based on discussions with their primary care provider and in alignment with current screening recommendations for the general population.

Vegan/Vegetarian Diet

Vegan and vegetarian diets have also been investigated in their potential role in managing psoriasis. Rich in fruits and vegetables, these diets are high in antioxidants (polyphenols, beta-carotene, and vitamins E, A, and C), which are protective against free radicals [45]. Additionally, these diets eliminate/limit foods that may trigger psoriasis, including dairy, meat, and eggs [46]. A US-based survey of patients with psoriasis asked respondents about dietary modifications that led to full clearance or improvement of psoriasis. Amongst the list of dietary removals that led to psoriasis improvement were dairy (47.7%), shellfish (39%), pork (35.6%), and red meat (30.4%) [46]. It is important to note that these are patient-reported outcomes and did not account for other potential changes in psoriasis management.

A review of plant-based diets by Min et al. found that plant-based foods may improve inflammatory diseases in many ways, such as supporting the gut microbiome, promoting anti-inflammatory effects, providing skin barrier support, and improving patient glycemic control [47]. They also found that animal products like red meat and belly meat exacerbate psoriasis, while foods within the MeD and those rich in carotenoids and flavonoids alleviated psoriatic symptoms [12, 48–50]. There exists hesitancy surrounding vegan/vegetarian diets because of concerns of nutritional deficiencies. However, the authors highlight several, abundantly available, plant-based food sources and supplements that can provide additional nutrients such as riboflavin, vitamin B12, vitamin A, omega-3 PUFAs, and proteins.

Supplementation

As vitamin supplementation is an area of high patient interest and growing investigation, it is important to consider the quality and strength of existing research. Oral vitamin D is not to be confused with topical vitamin D analogs, such as calcipotriene. Oral vitamin D is not recommended in the treatment or prevention of psoriasis, given the lack of high-quality evidence supporting the benefits of its supplementation [8]. The same rationale applies to many other popular supplements, such as vitamin B12 and selenium, which lack evidence in favor of their benefit [51]. Omega-3 PUFAs and fish oil, as discussed above, have shown mixed results in studies. Rather than individual supplementation, incorporating dietary omega-3 PUFAs as in the MeD provides a holistic and health-promoting approach.

Discussion

Nutrition, Clinical Risks, and Overall Health

Any change in diet affects the whole person, not just their skin. Thus, it is important for providers to consider other potential health benefits/disadvantages when counseling a patient on diet.

The MeD has no known downside from a health perspective. The MeD has several possible benefits, including reducing the risk of type 2 diabetes, atherosclerosis, and cognitive decline [52]. A KD, however, has the potential to do harm given its high fat intake and lack of important nutrients and fiber. The KD diet, although known to cause weight loss, has been associated with increased levels of cholesterol, including low-density lipoprotein, which is an important risk factor for atherosclerosis [53]. Furthermore, the ketogenic diet has been found to potentially lower testosterone in male individuals [53].

Low-calorie diets have only been shown to be helpful in those who are overweight or obese, and therefore, may be inappropriate for those who are of normal body mass index, and would be harmful in those who are underweight. Although studies on IF and psoriasis suggest a potential benefit, the overall health effects are complex. Time-restricted eating has been shown to be metabolically beneficial in men and women with polycystic ovarian syndrome, but there may be significant downsides for certain women, particularly those who are pre-menopausal [54]. For instance, skipping breakfast in women has been shown to worsen postprandial glycemia, while the same is not true for men [54]. Fasting behavior is also a risk factor for eating disorders; thus, IF would not be appropriate for patients with a history of anorexia, bulimia, orthorexia, or other eating disorders [55]. A GFD removes several whole grains, which are important sources of fiber, and should not be recommended unless someone has CD or antigliadin IgA or IgG seropositivity. Universal antigliadin antibody screening is not recommended for patients with psoriasis, unless they display the chronic and relapsing gastrointestinal symptoms of CD or have a family history of CD. It is also important to consider potential nutritional deficiencies that may accompany a vegan or vegetarian diet and the importance of supplementation with nutrients such as vitamin B12 if a patient would like to eat plant based.

Food sensitivities and allergies are also important to consider and can result in significant gastrointestinal symptoms. Patients frequently inquire about screening for these sensitivities and allergies. While some studies have found an improvement in symptoms with a dietary change, such as a GFD for patients with psoriasis and CD (an autoimmune disease), there remains controversy regarding testing for food sensitivity. Previous literature has identified limitations and potential misuse of food sensitivity assays, as they can be unpredictable, unstandardized, and overemphasize irrelevant immunoglobulin antibodies that can lead to unnecessary food avoidance [56–58]. Rather than formal food sensitivity testing, a careful history should be taken of a patient’s symptoms, chronicity, and reproducible relationship to food. If a true food sensitivity or allergy is suspected, a referral to allergy-immunology or gastroenterology may be helpful [56].

Given the potential effects on multi-organ systems with dietary changes, any change should be made with careful consideration of other co-morbidities. Fortunately, the MeD is well studied with no obvious detrimental effects and thus can be recommended for interested patients as an adjunctive measure to potentially help their psoriasis.

Feasibility and Costs

When discussing changing nutrition as a potential measure for improving any disease, one must consider that different cultural norms, geography, and socioeconomic status may make dietary changes more difficult. Different cultures have different food practices. For instance, Hinduism promotes a vegetarian diet, and thus those who practice Hinduism likely would not want to incorporate fatty fish into their diet like what is recommended in the MeD. Some individuals may feel a deep connection to dishes that have been cooked in their family for generations, regardless of their nutritional value.

Food deserts are regions in which it is difficult to access affordable high-quality food. Food deserts have been shown to disproportionately affect minority neighborhoods [59]. Fast-food restaurants also tend to dominate areas with predominantly black or Hispanic populations [59]. Furthermore, an inverse relationship has been established between food price and obesity levels, indicating that disparate access is contributing to rising obesity levels. Those with a higher socioeconomic status can navigate healthy eating more effectively, regardless of geographic location, as individuals with higher incomes often have the means to travel further distances to access nutritious options.

Additionally, the success of a diet depends on an individual’s ability to adhere to that diet. The KD has been shown to be challenging for adherence [25]. A motivated patient is more likely to adhere to any lifestyle change.

These factors are important when counseling a patient on potential dietary changes that could benefit their psoriasis. Providers should not assume that patients have easy access to fruits, vegetables, whole grains, and other healthful foods. They should also not assume a patient is interested in changing their diet. Asking questions such as:

“Are you interested in how nutrition can impact psoriasis?”

“Do you think you’d be excited about changing your diet and seeing how your psoriasis responds?”

“Are you at a place in your life where dietary changes are feasible?”

can help providers gauge if nutrition counseling is appropriate for a particular patient. Even if a patient has the means and interest, once they learn about what a MeD entails, they may no longer want to pursue dietary change. It is important for providers to treat patients’ psoriasis regardless of enthusiasm for holistic measures and to maintain good rapport.

Time for Counseling

Counseling in dermatology appointments is subject to the time available. The top priority for a provider is to improve their patient’s disease, and nutrition is no replacement for traditional therapies. Thus, time may not allow for providers to counsel their patients with psoriasis on nutrition even if the patient is interested. In our clinical practice, we have a “dot phrase” available for patients to read through on their own time after their appointment that our providers can input into the after-visit summary. This handout summarizes the available evidence on psoriasis and diet, including the MeD, GFD, low-calorie diet, and supplements. Furthermore, once a patient’s disease is under better control, there is more likely to be enough time to discuss nutrition within the confines of the dermatology appointment.

Conclusions

As research on the impact of diet on psoriasis continues to grow, we are learning more about the benefits that different dietary habits can have for patients with psoriasis. Psoriasis treatment often focuses on pharmaceutical options. However, it is also essential to optimize lifestyle factors such as diet and metabolic health, as they not only impact systemic inflammation, psoriasis severity, and treatment response but also contribute to long-term health outcomes and morbidity. Patient education and partnership with healthcare providers to create and maintain a balanced individualized diet can contribute to the therapeutic potential of diet in dermatology.

Funding

No funding was received for this review.

Declarations

Conflicts of interest/competing interests

Tina Bhutani has received research funding from Amgen, Castle, CorEvitas, Novartis, Pfizer, and Regeneron. She has served as an advisor for AbbVie, Arcutis, Aslan, Boehringer-Ingelheim, Bristol Myers Squibb, Dermavant, Galderma, Incyte, Janssen, LEO Pharma, Lilly, Pfizer, Novartis, Sanofi, Sun, Takeda, and UCB. She is a speaker for Amgen, Arcutis, Galderma, Janssen, Lilly, and LEO Pharma. All other authors have no conflicts.

Ethics approval

Not applicable.

Consent to participate

Not applicable.

Consent for publication

Not applicable.

Availability of data and material

Not applicable.

Code availability

Not applicable.

Authors’ contributions

AL: conceptualization, methodology, literature review, manuscript writing, revision, and preparation. AK: conceptualization, methodology, literature review, manuscript writing, revision, and preparation. GM-G: manuscript review. TB: conceptualization, methodology, supervision, manuscript revision and editing.

Footnotes

Andrea Leung and Allison Kranyak contributed equally to the article.

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