Treatment of Psoriatic Arthritis With Acupuncture, Turmeric (Curcuma longa), Sarsaparilla (Smilax officinalis) and Vitamin D: A Case Report

Abstract

Objective

The purpose of this case report is to analyze the treatment of a patient with psoriatic arthritis (PsA) using natural medicine.

Clinical Features

A 73-year-old woman complained of PsA in her second and third digits with gradual onset over a 6-month period. PsA was manifesting as dactylitis with moderate to severe stiffness and edema in her proximal and distal interphalangeal joints and the surrounding soft tissue. A radiographic image revealed narrowing of the proximal and distal interphalangeal joints, mild erosion, and periosteal thickening.

Intervention and Outcome

Traditional Chinese Medicine-style acupuncture was combined with 500 mg of turmeric curcumin (Curcuma longa root extract) with 3 mg of black pepper extract (Piper nigrum) that was standardized to contain 95% curcuminoids, 425 mg of sarsaparilla root (Smilax officinalis) powdered capsules that were not standardized and 10,000 IU vitamin D3 as cholecalciferol oil capsules once a day. She received 2 acupuncture treatments in combination with the supplements. She experienced an increased range of motion and a reduction in edema and stiffness. She continued to experience a reduction in symptomatology while supplementing with turmeric curcumin, sarsaparilla root, and vitamin D₃, which might have helped to control her symptoms. Supplementation with these agents may have helped to maintain the swelling and stiffness at a tolerable level for the past year.

Conclusion

The natural modalities administered to the patient might have been able to reduce her symptoms of PsA and maintain them at a tolerable level. Acupuncture, turmeric, sarsaparilla root, and vitamin D₃ could be viable natural alternatives for the treatment of PsA.

Introduction

Psoriatic arthritis (PsA) is an autoimmune condition manifesting as chronic inflammation involving the joints with or without lesions appearing on the skin or nails.¹ PsA is categorized as a rheumatic disease characterized by spondylitis, enthesitis, dactylitis, or peripheral arthritis.¹ There are several different forms of PsA that exist, including oligoarthritis, polyarticular arthritis, arthritis mutilans, distal interphalangeal joint arthritis, and axial disease.¹ Oligoarthritis is the most prevalent of the forms of PsA that occurs; it involves arthritis of 2 to 4 joints in the first 6 months of the disease, and it is typically asymmetric.¹ Polyarticular arthritis is the next most frequently occurring condition, accounting for an estimated 15% to 20% of cases; it is present in 5 or more joints.¹

This disease typically targets the population between the ages of 40 and 50 years.² However, a smaller incidence has occurred in very young children and older adults.² The prevalence of PsA is 0.16% in the United States with an incidence of 7.2 per 100 000 people.² However, 40% to 60% of individuals who develop this condition experience erosions resulting in joint deformity.² This condition is not gender specific, with a male-to-female ratio ranging from 0.7:1 to 2.1:1.² The possible risk factors associated with PsA are drug use, joint trauma, which typically occurs as a child, and bacterial and viral infections.² PsA can be initiated by emotional stress as well.² Unfortunately, the evidence explaining the risk factors and onset of the condition is minimal.

In conventional medicine, the treatment of PsA consists of pharmaceuticals. The primary management strategy uses biologic disease-modifying antirheumatic drugs to hinder the progression of the disease and alleviate pain.³ The mechanism of action of these pharmaceuticals varies depending on the agent administered; however, their predominant effect is reducing inflammatory mediators and inducing apoptosis of defective autoimmune cells.³ Despite the high level of efficacy, these medications tend to be less available to patients because of high cost.³ Nonsteroidal anti-inflammatory drugs may be another treatment option, but they are usually effective only for mild cases of PsA, and they might not improve symptoms.⁴

Natural therapies may be a more affordable and viable substitute or adjunct for the treatment of PsA. Unfortunately, there is a limited amount of evidence supporting the use of these remedies. Turmeric (Curcuma longa), sarsaparilla (Smilax officinalis), vitamin D, and acupuncture are capable of attenuating inflammation. Turmeric (C. longa) is capable of suppressing the effects of nuclear factor kappa B (NF-кB) and other inflammatory mediators, such as tumor necrosis factor-α (TNF-α), interleukin (IL)-1β, and IL-6.⁵ Currently, there is no research on the effects of sarsaparilla (S. officinalis). However, other sarsaparilla (Smilax) species have been shown to reduce inflammation by impeding the release of IL-6, TNF-α, IL-1β, and cyclooxygenase-2 activity.⁶ In addition, sarsaparilla (Smilax) species contain flavonoids that are capable of downregulating NF-кB by 61.7%.⁷ Vitamin D has been shown to decrease the activity of transcription factor NF-кB and inflammatory mediators TNF-α and IL-6.⁸ Lastly, acupuncture is capable of inhibiting the expression of NF-кB and the release of TNF-α, C-reactive protein, and other inflammatory cytokines.^{9, 10, 11} Acupuncture also potentiated the effects of IL-10, which is an anti-inflammatory cytokine.¹¹

In addition to the anti-inflammatory effects of these therapeutic modalities, turmeric (C longa), sarsaparilla species (Smilax), vitamin D, and acupuncture may have the potential to mitigate symptoms associated with autoimmune inflammatory disorders. Turmeric (C longa) demonstrated the ability to reduce inflammation and symptoms of autoimmune collagen-induced arthritis.¹² Turmeric (C longa) might have produced these positive effects because of its immunomodulatory activity through the regulation of T lymphocytes.^13,14

According to the Physician's Desk Reference for Herbal Medicines and other scholarly texts, sarsaparilla species have effects on inflammation and immune function that have been used for the treatment of autoimmune diseases, including psoriasis.^{15, 16, 17} Unfortunately, there are no studies using sarsaparilla (S officinalis) for autoimmune diseases; however, there is evidence that certain species of sarsaparilla can regulate the immune system by inhibiting the synthesis of T lymphocytes and IL-2 and by normalizing the CD4-to-CD8 ratio.¹⁸ A deficiency of vitamin D has been positively correlated with the development of some autoimmune diseases.^19,20 In addition, vitamin D has the potential to suppress the generation of aberrant white blood cells (WBCs) involved with an autoimmune response.^20,21 Research shows that acupuncture can normalize the immune system by controlling the concentrations of CD3, CD4, and CD8 T lymphocytes and by balancing T helper cell 17 levels.²² In a clinical trial, acupuncture reduced symptomatology associated with rheumatoid arthritis (RA) and autoimmune-generated systemic inflammation.^23,24

Unfortunately, information pertaining to the efficacy of turmeric (C longa), sarsaparilla (S officinalis), vitamin D, and acupuncture for the treatment of PsA is sparse. The purpose of this article is to discuss a case of PsA that was treated with a combination of turmeric (C longa), sarsaparilla (S officinalis), vitamin D, and acupuncture.

Case Report

A 73-year-old woman complained of PsA in the second and third digits of her left hand. She noticed the gradual onset of edema and stiffness in her proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints and the surrounding soft tissue over the past 6 months. She experienced pain only with movement of her fingers; however, the pain was minimal and tolerable. She made an appointment with a rheumatologist who diagnosed PsA categorized as oligoarthritis. The rheumatologist recommended biological disease-modifying antirheumatic drugs. Because of the expense and potential adverse effects associated with the medication, she elected to pursue a more natural approach. She rated the stiffness as a 5 on a numeric scale from 0 to 10, with 0 being the least stiff and 10 being the stiffest in both digits. Her pain with movement was rated at a 1 on a numeric scale from 0 to 10, with 0 being the least painful and 10 being the most painful. Her swelling was rated at a 7 on a numeric scale from 0 to 10 with 0 being the least swollen and 10 being the most swollen in both digits.

The presentation of her condition consisted of dactylitis of her second and third digits caused by the swelling of the joints and soft tissue, which is characteristic of PsA. Radiographic images of both hands were taken by the rheumatologist. The left hand revealed swelling of the soft tissue of her second and third digits with narrowing of the DIP and PIP joints, mild erosions, and periosteal thickening. She was able to flex her fingers slightly with minimal pain, but her range of motion (ROM) was impeded by the severity of the swelling. Her ROM for flexion at her PIP joint in her second and third digits were 7° and 4°, respectively. There were no dermatologic manifestations of psoriasis.

The patient was postmenopausal, and she experienced night sweats and stress incontinence. Her tongue was crimson and swollen with teeth marks and a slight yellow coat, and her pulse was wiry bilaterally. The tongue and pulse assessments helped to determine that her Traditional Chinese Medicine (TCM) diagnosis was kidney yin deficiency and blood stagnation with damp heat.

The treatment strategy used a combination of acupuncture with 3 separate supplements. The supplements were 500 mg of turmeric curcumin (Curcuma longa root extract) with 3 mg of black pepper extract (Piper nigrum) that was standardized to contain 95% curcuminoids, 425 mg of sarsaparilla root (Smilax officinalis) powdered capsules that were not standardized and 10,000 IU vitamin D₃ as cholecalciferol oil capsules once a day. The choice of supplements was based on availability at the office and local merchants. The primary acupuncture points selected for the treatment were to nourish the kidney, improve circulation, and resolve damp heat. The points consisted of auricular shen men, auricular kidney, auricular spleen, auricular fingers, yintang, PC 6 (Neiguan), LU 9 (Taiyuan), HT 7 (Shenmen), SP 6 (Sanyinjiao), SP 10 (Xuehai), KD 3 (Taixi), KD 6 (Zhaohai), ST 36 (Zusanli), LR 3 (Taichong), LR 5 (Ligou), LI 4 (Hegu), and 2 Ashi points on both sides of the PIP and DIP joints in the second and third digits. She began using the combination of herbs and vitamin D 2 days after the first treatment.

Immediately after the first treatment, pain with movement was alleviated at a 0 out of 10, stiffness was reduced to a 3 out of 10, and swelling was reduced to a 4 out of 10 on a numeric scale, with ROM using a goniometer measured at 12° and 9° for her second and third digits, respectively. Upon arrival for the second treatment, she reported that pain with movement was still a 0 out of 10, stiffness was a 4 out of 10, and swelling was a 5 out of 10 on a numeric scale with 36° and 32° of flexion in her second and third digits, respectively, as measured by a goniometer. Directly after the second treatment, stiffness was reduced to a 3 out of 10, swelling was reduced to a 4 out of 10, and ROM was increased to 57° and 46° for her second and third digits, respectively, according to the goniometer reading. No further treatment was rendered.

A follow-up telephone call was made 4 weeks after the second treatment. She reported that she continued to supplement with 500 mg of turmeric curcumin (Curcuma longa root extract) with 3 mg of black pepper extract (Piper nigrum) that was standardized to contain 95% curcuminoids, 425 mg of sarsaparilla root (Smilax officinalis) powdered capsules that were not standardized and 10,000 IU vitamin D₃ as cholecalciferol oil capsules once a day.

After 1 year, the patient returned to the office with a new complaint. At that time, a re-evaluation of her PsA symptoms was performed. She continued to supplement with 500 mg of turmeric curcumin (Curcuma longa root extract) with 3 mg of black pepper extract (Piper nigrum) that was standardized to contain 95% curcuminoids, 425 mg of sarsaparilla root (Smilax officinalis) powdered capsules that were not standardized once a day and 5,000 IU vitamin D₃ as cholecalciferol oil capsules twice a day. She specified that her pain was still a 0 out of 10 with movement, and swelling and stiffness remained controlled at a 1 to 2 out of 10. The movement of her fingers was marginally affected. The patient provided permission to have this case report published.

Discussion

In this case, the patient had oligoarthritis, which is the type of PsA with the greatest incidence. However, the unusual aspect of this case is that it occurred in a 73-year-old woman who is older than the typical age range of 40 to 50 years. There is limited evidence supporting the administration of acupuncture, turmeric (C longa), sarsaparilla (S officinalis), and vitamin D for the treatment of PsA, yet in this case, she experienced an improvement in her clinical symptoms, which might have resulted from the treatment modalities. Consequently, the positive effects observed in this report might indicate that turmeric (C longa), sarsaparilla (S officinalis), vitamin D, or acupuncture could be viable alternatives to pharmaceutical agents for the treatment of PsA. However, more research needs to be conducted.

It is important to note that the condition was not resolved, but her symptoms were ameliorated; this might be due to her condition being a chronic inflammatory autoimmune condition and the therapeutic modalities producing anti-inflammatory and immunomodulatory effects. Although there is no evidence that these treatment modalities are effective for reducing the symptoms of PsA, data exist demonstrating that acupuncture, vitamin D, and turmeric (C longa) are effective therapeutic approaches for the alleviation of symptoms associated with psoriasis, which might indicate that they could have positive effects on other chronic inflammatory autoimmune diseases.^{25, 26, 27, 28}

Unfortunately, the type of treatment that could have had an effect on the attenuation of her symptoms cannot be determined, as each herb was used in conjunction with vitamin D and acupuncture. However, acupuncture was administered only twice during the preliminary treatment. Immediately after acupuncture treatment, there was a reduction in stiffness and swelling on a numeric scale and an increase in her ROM, which could be a result of its immediate anti-inflammatory action. It is impossible to decipher the acupuncture points that might have produced these effects. Evidence from a prior study shows that local acupuncture points are effective for reducing inflammation and swelling of the joint.²⁹ This finding signifies that the acupuncture Ashi points in the PIP and DIP joints themselves might have had the greatest influence. In addition, a study by Tam et al³⁰ found that distal points decreased joint swelling in patients with RA. Consequently, the Ashi points in PIP and DIP joints in combination with the distal points might have worked synergistically to alleviate the edema and stiffness and to improve ROM.

There is not much evidence related to the effects of individual acupuncture points on swelling. According to TCM theory, PC 6 (Neiguan), LU 9 (Taiyuan), HT 7 (Shenmen), SP 6 (Sanyinjiao), SP 10 (Xuehai), LR 3 (Taichong), LI 4 (Hegu), and LR 5 (Ligou) are all points that can be used to circulate energy and blood and to dissipate swelling.³¹ Although not much research has been conducted using individual points, there are journal articles exemplifying the effects of certain acupuncture points when used in formulas. The mechanism is not established, yet studies demonstrate that in combination with other points SP 6 (Sanyinjiao), SP 10 (Xuehai), and LI 4 (Hegu) can attenuate edema.^32,33 Other studies have shown that PC 6 (Neiguan), SP 6 (Sanyinjiao), and LR 3 (Taichong) were found to alter circulation when applied distally, indicating that they could have an effect on blood flow to the tissues, which could mitigate edema.^34,35 Unfortunately, there are no research articles using LU 9 (Taiyuan), HT 7 (Shenmen), or LR 5 (Ligou) in formulations for circulation, swelling, or inflammation. Interestingly, a study by Kim et al showed that HT 7 (Shenmen) reduced inflammatory mediators, which could indirectly decrease swelling associated with joint pathologies.³⁶

ST 36 (Zusanli), KD 3 (Taixi), and KD 6 (Zhaohai) might have produced additional therapeutic effects. In TCM theory, ST 36 (Zusanli) is used to eliminate dampness, which is the pathogen responsible for edema, whereas KD 3 (Taixi) and KD 6 (Zhaohai) could be beneficial for bone health because the kidney organ is associated with bone health.³¹ Two studies have shown that ST 36 in combination with other points has the ability to reduce edema in the body associated with joint inflammation.^30,32 KD 3 (Taixi) is classified as a Shu Stream point, which has been used classically for pathologies of the joint.³¹ Unfortunately, there is no evidence showing that KD 6 (Zhaohai) can reduce edema or improve ROM. However, a study has demonstrated that KD 3 (Taixi) can be used with other points to reduce edema and inflammation, indicating that it might have potentiated the anti-inflammatory and antiemetic effects of the other points.³³

The contribution of the auricular acupuncture points and yintang to the therapy is unknown. There has been no research using auricular acupuncture or yintang for the treatment of PsA. In TCM theory, shen men, auricular spleen, and yintang are administered to promote relaxation.³¹ Evidence supports the use of auricular therapy and yin tang to decrease stress and anxiety.^37,38 Studies indicate that long-term inflammation can evoke a stress-related response.³⁹ Consequently, although auricular acupuncture and yintang might not have had a direct effect on the reduction of symptoms experienced by the patient, they may have indirectly helped to reduce stress associated with inflammation.

Immediately after her 2 acupuncture treatments, the patient improved, indicating that acupuncture might have helped to reduce the inflammatory process and localized tissue swelling. However, whether individual points or the cumulative effects of the formula contributed most to the reduction in her symptoms cannot be determined. Because she did not receive acupuncture after the second treatment and the swelling and stiffness were controlled, it can be stipulated that turmeric (C longa), sarsaparilla (S officinalis), and vitamin D potentially had an effect on regulating her symptoms.

Vitamin D might be the primary agent that mitigated her symptoms. A few studies have demonstrated a correlation between low levels of serum vitamin D and the development of psoriasis and psoriatic arthritis.^19,40,41 Increasing her vitamin D levels through supplementation theoretically can either reduce inflammation through the arachidonic acid pathway or suppress the production of abnormal WBCs, preventing swelling and stiffness. Unfortunately, the immunoregulatory effect cannot be determined because autoimmune antibody blood work was not performed.

Although vitamin D might have been a major contributor to the alleviation of her symptoms, the anti-inflammatory and immunomodulatory effects of (C longa) and sarsaparilla (S officinalis) cannot be discounted. There is no evidence in the research that turmeric or sarsaparilla are effective modalities for the treatment of PsA. However, a few studies demonstrate that turmeric (C longa) attenuates symptoms associated with other chronic inflammatory autoimmune disorders.^28,42

In a study by Li et al,⁴² the essential oil constituent aromatic turmerone was extracted from turmeric (C longa) for inflammatory psoriasis. The investigators found that aromatic turmerone interfered with the transfer of CD8⁺ T cells to the epidermal layer of the skin; decreased the expression of NF-кB; suppressed the production of IL-17, IL-22, and IL-23; and diminished the release of TNF-α and IL-6, thus ameliorating symptoms.⁴² Analogous to that experiment, a randomized placebo-controlled clinical trial was performed by Bahraini et al²⁸ demonstrating that turmeric administered twice a day for 9 weeks significantly reduced symptomatology associated with scalp psoriasis.

Unfortunately, the role of turmeric as an immunosuppressant for autoimmune diseases is not well defined. However, there is evidence that turmeric (C longa) can reduce inflammation associated with other autoimmune diseases, such as RA and multiple sclerosis.^{12,43, 44, 45} For example, turmeric (C longa) mitigated the inflammatory response associated with RA.¹² The primary mechanism of diminution of symptoms was due to its anti-inflammatory properties, yet in the studies by Taty Anna et al¹² and Kamarudin et al⁴⁶ turmeric (C longa) was as effective as betamethasone, which is an anti-inflammatory and immunosuppressive corticosteroid. An additional study using turmeric (C longa) over a 28-day period, showed a decrease in WBC production to a level that was not significantly different from beta-methasone.⁴⁶

Consequently, although the predominant effects of turmeric (C longa) are anti-inflammatory in nature, these data show that it has some immunomodulatory effects as well. Impeding the transfer of CD8⁺ T cells could have an effect on the autoimmune aspect of PsA. CD8⁺ T cells are immunoregulatory.⁴⁷ Research indicates that dysfunctional CD8⁺ T cell could be responsible for part of the inflammatory response associated with autoimmune conditions.⁴⁷ Therefore, preventing the transfer of these abnormal cells to the skin may potentiate immunomodulatory effects.

Another regulatory effect of turmeric (C longa) is the ability to regulate T helper (Th) cells, which might contribute to its positive effects observed in studies. Imbalances of Th1 and Th2 cells have been implicated in the pathophysiology of autoimmune diseases.⁴⁸ Balancing the levels of these Th cells can reduce symptoms associated with autoimmune conditions.⁴⁸ Turmeric (C longa) has been shown in hypersensitivity reactions to regulate the levels of Th1 and Th2 and alleviate symptoms.⁴⁹ Another study by Xie et al⁵⁰ observed a reduction in Th17 cells that are associated with the inflammatory process of animal models of multiple sclerosis. The modulation of Th cells could be another immunoregulatory mechanism that might have been responsible for controlling edema in the patient with PsA.

The effects that sarsaparilla (S officinalis) had in this case cannot be deciphered. There has not been any research conducted studying the effects of sarsaparilla (S officinalis). However, the Physicians Desk Reference for Herbal Medicines and other texts state that sarsaparilla species have been used for chronic inflammatory autoimmune disorders.^{15, 16, 17} In addition, it should be noted that a few Smilax species have been shown to reduce the symptoms of psoriasis and RA in a tissue culture and 2 animal studies.^{51, 52, 53} There is some evidence that species derived from the same genus can possess analogous therapeutic properties⁵⁴; therefore, sarsaparilla (S officinalis) can produce similar effects. In the absence of research, it is impossible to determine whether sarsaparilla (S officinalis) had any benefit in this case.

Limitations

There are several limitations to this report. The first limitation is that there is not a definitive diagnostic test for PsA. The diagnosis was based on the characteristic signs and symptoms that the patient was exhibiting, a radiographic image taken by the rheumatologist, and a previous diagnosis from a rheumatologist. As the swelling had dissipated, no imaging was performed at her appointment 1 year after her initial visit, which was for a separate condition. Although the presentation appeared to be PsA, it might actually have been caused by a different inflammatory disorder or condition. Another limitation to the report was that a complete blood count was not performed to determine whether there was an elevation in WBCs; it was not done owing to the budgetary constraints of the patient. Consequently, any changes in lymphocyte count that might have been associated with the treatment of a chronic inflammatory autoimmune condition were not observed. All improvements were based on a subjective numeric scale, which is not an exact measurement tool and is based on perspective. It would have been more appropriate to use measuring tape to determine the reduction in the level of swelling that was observed. In addition, the combination of acupuncture, turmeric (C longa), sarsaparilla (S officinalis), and vitamin D were all used; therefore, it is not possible to elucidate the agent that produced the desired therapeutic effects.

Conclusion

Although there is a limited amount of information associated with the use of natural medicine for the treatment of PsA, the combination of acupuncture, turmeric (C longa), sarsaparilla (S officinalis), and vitamin D could be viable options as an alternative or adjunct to pharmaceutical care. The patient experienced a subjective reduction in edema and stiffness, an increase in ROM, and an alleviation of pain in her afflicted digits, which could have been a result of the treatment rendered. Unfortunately, as this was a single case, the true effectiveness of the treatment cannot be established. Additional studies are required to ascertain the true efficacy of each therapeutic modality applied.

Funding Sources and Potential Conflicts of Interest

No conflicts of interest were reported for this study.

Contributorship Information

Concept development (provided idea for the research): B.R.M.

Design (planned the methods to generate the results): B.R.M.

Supervision (provided oversight, responsible for organization and implementation, writing of the manuscript): B.R.M.

Data collection/processing (responsible for experiments, patient management, organization, or reporting data): B.R.M.

Analysis/interpretation (responsible for statistical analysis, evaluation, and presentation of the results): B.R.M.

Literature search (performed the literature search): B.R.M.

Writing (responsible for writing a substantive part of the manuscript): B.R.M.

Critical review (revised manuscript for intellectual content, this does not relate to spelling and grammar checking): B.R.M.

Practical Applications.

• •This study found that acupuncture, turmeric (Curcuma longa), sarsaparilla (Smilax officinalis), and vitamin D helped to reduce and control the swelling and stiffness of the proximal and distal interphalangeal joints afflicted with psoriatic arthritis.
• •There is currently no evidence that any of these modalities would be effective for the treatment of psoriatic arthritis.

Alt-text: Unlabelled box