Natural Remedies for Scleroderma - Thorne Research

Review Sclerodermathat PABA, usually administeredas potassium para-aminobenzoate(KPAB), was an effective treatmentfor scleroderma. In patientswho received this treatment, theskin gradually became softer andthinner, with consequent increasedrange of motion. 3 In 1961, this sameinvestigator presented data on 104consecutive patients treated with12 g KPAB daily. Ninety-sevenpatients (93.3%) showed moderateto-considerableimprovement of theinvolved skin. Some patients had acomplete remission; in those cases,therapy was discontinued for up to8.5 years without a recurrence. Mostpatients, however, showed somesigns of residual activity and treatmentwas continued indefinitely. 4In 1988-1989, Zarafonetiset al presented a retrospective analysisof 390 scleroderma patients whohad received adequate treatmentwith KPAB. “Adequate treatment”was defined in the analysis as 12 or12.5 g per day for three months to20.6 years (average, 4.2 years). Therate of decline in pulmonary function(vital capacity) was significantlyless in these patients than in thosewho had been inadequately treatedor never treated with KPAB. 5 Inaddition, five-year (88.5% versus69.8%) and 10-year (76.6% versus56.6%) survival rates were significantlyhigher in adequately treatedpatients than in those who had neverbeen treated. 6While other investigatorshave confirmed the effectiveness ofPABA or KPAB, 7,8 a double-blindtrial found that administration ofFigure 1. CREST SyndromeTelangiectasia(dilated capillariesin the face, hands,or mouth)12 g KPAB daily for 48 weeks had no effect on theskin lesions of scleroderma. 9 However, the patients inthat study had longstanding disease (mean duration,8.67 years), which may have been too advanced torespond to KPAB.Esophagitis (reflux as a resultof poorly functioning musclesin the esophagus)Raynaud’sphenomenon(spasm of thearterioles inthe fingers,toes, nose,tongue, or ears)Calcinosis(calcium deposits underthe skin of knees, elbows,or fingers appear as hardwhitish nodules)Sclerodactyly(thickening and tightnessof skin on the fingersor toes makes themlook shiny and puffy)Alternative Medicine Review u Volume 11, Number 3 u 2006 Page 189Copyright © 2005 Thorne Research, Inc. All Rights Reserved. No Reprint Without Written Permission. Alternative Medicine Review Volume 10, Number 4 December 2005

SclerodermaReviewTable 1. Scleroderma SubtypesSubtypeDiffuseLimitedLocalized to the skinCharacteristicsrapidly progressiveslowly progressive (may include calcinosiscutis, Raynaudʼs phenomenon, esophagealinvolvement, sclerodactyly, andtelangiectasia)morphea, linear sclerodermaAlthough KPAB was well tolerated by mostscleroderma patients, this compound is not innocuous.Rare cases of hepatotoxicity and one death dueto toxic hepatitis have been reported in patients receivinglarge doses of PABA or KPAB. Fever or rashmay occur at doses greater than 12 g per day. Largedoses may also cause hypoglycemia; treatment shouldtherefore be interrupted during periods in which foodintake is inadequate.Vitamin EOxidative stress was significantly increasedin patients with scleroderma compared with healthycontrols, suggesting that free-radical-induced oxidativeinjury occurs in scleroderma. 10 Antioxidants suchas vitamin E might, therefore, be beneficial. VitaminE is also believed to stabilize lysosomal membranes,potentially inhibiting events involved in the autoimmuneprocess. 11 In addition, vitamin E may have anantifibrotic action, suggested by its beneficial effectin patients with Peyronie’s disease and Dupuytren’scontracture.In case reports, vitamin E supplementationresulted in improvements in the skin of sclerodermapatients, although non-dermatological aspects of thedisease did not improve. 12-15 Various components ofscleroderma, including morphea, calcinosis cutis,and Raynaud’s phenomenon, responded to vitaminE. The dose of vitamin E in these reports rangedfrom 200-1,200 IU per day. In some cases, vitamin Ewas also applied topically. One patient successfullytreated was a 45-year-old male with Raynaud’sphenomenon, probable early scleroderma, and ulcerationand gangrene of the fingertips. He received 800IU oral vitamin E daily and applied the vitamin (50IU per mL) to the ulcerated fingers twice daily. Theulcerations became less painful after two weeks andhealed almost completely within one month. 16Vitamin DA 1940 report described three patients withlocalized scleroderma who improved after treatmentwith vitamin D2 at a dose of 10,000-12,500 IU perday for 1-3 months. 17 That report did not attract muchinterest, possibly because of the potential for highdosevitamin D2 to cause toxic effects. More recently,several studies have demonstrated the effectivenessof orally administered 1,25-dihydroxycholecalciferol(calcitriol), the biologically active form of vitamin D,as a treatment for scleroderma. Calcitriol has severalactions that might be expected to slow or reverse thedisease process, including immunoregulatory effectsand inhibition of fibroblast growth and collagen synthesis.A 35-year-old woman with a two-year historyof localized scleroderma was given calcitriol forsix months. The initial dose was 0.25 mcg per day forone week, increased by 0.25 mcg per day each weekuntil a dosage of 1.25 mcg daily was reached in thefifth week. Thereafter, 0.5 mcg per day was given forfour months. After six months of treatment, the skinlesions had almost completely resolved. 18Page 190 Alternative Medicine Review u Volume 11, Number 3 u 2006Copyright © 2005 Thorne Research, Inc. All Rights Reserved. No Reprint Without Written Permission. Alternative Medicine Review Volume 10, Number 4 December 2005

Review SclerodermaThree patients with generalized morphea received0.5-0.75 mcg calcitriol daily. After 3-7 monthsof treatment, joint mobility improved and skin extensibilityincreased. No adverse effects were seen. Theimprovement persisted after discontinuation of therapyduring a 1- to 2-year follow-up period. 19Seven children (ages 3-13 years) with linearscleroderma received 0.25 mcg calcitriol daily for oneweek; this was increased every week to a maximumof 0.5-1.25 mcg per day, depending on body surfacearea and response to treatment. Dietary calcium intakewas restricted to 600 mg daily. Five of sevenpatients showed good-to-excellent improvement oftheir lesions. One patient had a partial relapse after19 months, but responded well to a second course oftherapy. No significant side effects were seen. Theauthors suggested that calcitriol be tried for at leastthree months in children with linear scleroderma beforeintroducing more aggressive therapy. If improvementis seen, this treatment may be continued for 6-9months. 20 Eleven scleroderma patients were treatedwith 0.25 mcg calcitriol daily during the first week;calcitriol was increased by 0.25 mcg daily each weekuntil urinary or serum calcium levels became elevated.The mean final dose was 1.75 mcg per dayand the maximum dose was 2.5 mcg per day. Aftertreatment periods ranging from six months to threeyears, significant improvements in skin thickness andextensibility were observed. No serious side effectswere seen except for transient hypercalciuria (alwaysbelow 350 mg per day), which responded to a temporaryreduction in the dosage. 21Twenty patients with morphea were randomlyassigned to receive, in double-blind fashion, calcitriol(0.75 mcg per day for six months, followed by 1.25mcg per day for three months) or placebo for ninemonths. The severity of the skin condition decreased19 percent in the calcitriol group and 29 percent inthe placebo group (difference not significant). 22Thus, most but not all clinical trials haveshown that calcitriol treatment improves the skinmanifestations of scleroderma. However, in additionto being expensive, calcitriol can cause hypercalcemia,hypercalciuria, and other side effects requiringfrequent monitoring with laboratory tests. Whilecalcitriol treatment would be worthwhile in selectedcases, vitamin D3 (cholecalciferol) might be a viablealternative for many patients, even though it has notbeen subjected to clinical trials. In addition to beinginexpensive and less toxic than vitamin D2, vitaminD3 is 3.4-9.4 times as potent in humans as vitaminD2. 23 The vitamin D2 dosage range of 10,000-12,500IU per day reported to be effective against sclerodermawould correspond to approximately 1,100-3,700IU of vitamin D3 daily. Studies in healthy humanssuggest that 4,000 IU vitamin D3 per day for 2-5months is a safe level of intake. 24 Patients receivinghigh-dose vitamin D3 for long periods of time andthose being treated with calcitriol should be monitoredfor signs of toxicity.Evening Primrose OilEvening primrose oil (EPO) contains a highconcentration of gamma-linolenic acid (GLA), whichis a precursor to prostaglandin E1 (PGE1). In patientswith Raynaud’s phenomenon associated with scleroderma,intravenously administered PGE1 increasedcapillary blood flow and appeared to promote ulcerhealing. 25 Because PGE1 is unstable and must be administeredintravenously, an effective orally activealternative would be desirable.Four women with scleroderma of 5-13 years’duration received 1 g EPO three times daily for oneyear. Pain in the hands and feet was reduced, ulcershealed, and skin texture and telangiectasia improved.26 Twenty-one patients with Raynaud’s phenomenon(with or without scleroderma) received, indouble-blind fashion (randomization not specified),6 g EPO per day, providing 540 mg GLA daily, orplacebo for eight weeks. The EPO group experiencedfewer attacks than the placebo group, and the differencereached statistical significance at six and eightweeks (p

SclerodermaReviewdifference between groups. 28 The authors concludedthat EPO/fish oil did not improve vascular symptomsin patients with scleroderma; however, the conclusionis open to question for two reasons. First, the“placebo” in the study was sunflower oil, a source oflinoleic acid, which can be converted in vivo to GLA.It is possible, therefore, that both EPO/fish oil andthe placebo were beneficial. Second, the EPO/fish oilpreparation also provided 30 mg lithium per day. Becauselithium appears to interfere with essential fattyacid metabolism, 29 it may have blocked a beneficialeffect of EPO/fish oil.Although more definitive studies need to beconducted, the available evidence suggests that EPOmay be beneficial in the treatment of scleroderma andthe associated Raynaud’s phenomenon.EstriolSeveral lines of evidence led a group of investigatorsto consider estriol as a possible treatment forscleroderma: the condition affects women primarily,it sometimes improves during pregnancy, urinary estriollevels rise during late pregnancy, and estriol hasa softening effect on the uterine cervix. Two women(ages 48 and 59 years, respectively) with sclerodermawere treated with estriol for 10 months. The first patientreceived 10 mg per week subcutaneously; thesecond received 2 mg per day orally, followed by 10-20 mg per week subcutaneously, after the oral dosewas discontinued because of urticaria. Skin softeningwas noted on all involved areas in both patients, andwas accompanied by increased mobility of large andmedium-sized joints, a lessening of cyanosis on fingersand extremities, and marked histologic improvementof affected skin. 30Until more is known, it would seem reasonableto reserve estriol therapy for postmenopausalwomen or for premenopausal women with evidenceof estrogen deficiency.N-AcetylcysteineTwenty patients with Raynaud’s phenomenonsecondary to scleroderma received a five-daycontinuous infusion of N-acetylcysteine during thewinter, starting with a loading dose of 150 mg per kgbody weight given over two hours, followed by 15mg per kg body weight per hour for the remainder ofthe treatment period. During the ensuing eight weeks,the frequency and severity of attacks decreased significantlycompared with baseline. Of the 17 patientswith digital ischemic ulcers, eight experienced completehealing. Side effects were considered by the authorsof the study to be minor and reversible. 31S-AdenosylmethionineFifteen patients with scleroderma received600 mg S-adenosylmethionine per day intravenouslyfor two months, followed by 400 mg three times perday orally. After four months, 10 patients showed asignificant improvement in skin induration. In threepatients who underwent skin biopsy, a significant reductionin the thickness of the dermal layer was seen.No improvement was seen in esophageal disease or inRaynaud’s phenomenon. 32BromelainA 32-year-old woman with early biopsyprovenscleroderma was treated with enteric-coatedbromelain (Ananase), first 160 mg per day and later80 mg per day. After three months, she was able toclose her hand 85 percent, compared with 50 percentbefore treatment. Swallowing function, whichhad been impaired for several years, also improved.These improvements were maintained during a oneyeartotal treatment period. 33The product used in this study is no longercommercially available. Non-enteric-coated bromelainwould presumably be partially inactivated bygastric enzymes after ingestion. While clinical experiencesuggests that currently available bromelainproducts do have biological activity, dosage comparisonswith Ananase are difficult.Avocado/Soybean ExtractOne practitioner has reported good resultsusing an unsaponifiable fraction of avocado/soybean(ASU [Piascledine 300; Pharmascience Laboratories,Courbevoie, France]) in more than 100 patients withextensive plaque-like morphea or linear scleroderma.If treatment was initiated at an early stage of linearscleroderma, then contractures, atrophy, and deformitiesof the extremities were avoided. The usual doseof ASU was 300 mg daily for six months, but somepatients were treated for 1-2 years. In severe cases,Page 192 Alternative Medicine Review u Volume 11, Number 3 u 2006Copyright © 2005 Thorne Research, Inc. All Rights Reserved. No Reprint Without Written Permission. Alternative Medicine Review Volume 10, Number 4 December 2005

Review SclerodermaTable 2. Alternative Treatments for SclerodermaTREATMENTFiberPara-aminobenzoic Acid(PABA)Vitamin EVitamin DGLA (sources: blackcurrant, borage, or eveningprimrose oil)EstriolN-acetylcysteineS-adenosylmethionine(SAMe)BromelainAvocado/Soybean Extract(unsaponifiable)Zinc/CopperDOSAGEUse with caution12 g/day KPABA (potassium-PABA)200-1,200 IU/day orally; topicalapplication0.25-1.25 mcg/day calcitriol OR1,000-4,000 IU/day D3(not studied)540 mg/day GLA (evening primroseoil used in the studies)2 mg/day orally OR 10-20mg/week subcutaneouslyIV infusion of 15-150 mg/kg/hourfor five daysIV infusion of 600 mg/day followedby 400 mg three times daily80-160 mg/day enterically coated300-600 mg/day15-60 mg/day zinc; 1-4 mg/daycopperRATIONALEDecreased colonic motilityAnti-fibroticAntioxidant; anti-fibroticImmunoregulatory; inhibitionof fibroblast growth andcollagen synthesisConverts to prostaglandin E1to increase capillary flow anddecrease inflammation; especiallyfor patients with concomitantRaynaud’s phenomenonMechanism unknownMechanism unknownMechanism unknownMechanism unknownMechanism unknownCorrect a deficiency600 mg per day was used. No side effects were observed.34 The interpretation of this report is complicatedby the fact that the patients were given procainepenicillin before starting treatment with ASU. Accordingto some researchers, an infectious agent mayplay a role in the causation of scleroderma, 35 and thedisease has been reported to improve after treatmentwith penicillin alone. 36Zinc/CopperMarkedly reduced zinc levels were found inerythrocytes, platelets, and granulocytes of patientswith scleroderma. 37 While the clinical significanceof these findings is not clear, loss of taste function(suggestive of zinc deficiency) has been reported inscleroderma patients during treatment with penicillamine.38 The interaction between penicillamine andAlternative Medicine Review u Volume 11, Number 3 u 2006 Page 193Copyright © 2005 Thorne Research, Inc. All Rights Reserved. No Reprint Without Written Permission. Alternative Medicine Review Volume 10, Number 4 December 2005

SclerodermaReviewzinc is complex; 39 the drug increases intestinal absorption,urinary excretion, and serum levels of zinc,but might also promote zinc deficiency. Large dosesof zinc may increase penicillamine toxicity, possiblybecause both compounds deplete copper. Long-termzinc supplementation should normally be accompaniedby a copper supplement (1-4 mg per day, dependingon the zinc dose), in order to prevent zincinducedcopper deficiency. 40 If zinc and penicillamineare used together, then the dose of copper should perhapsbe somewhat larger.Combining TreatmentsAll of the treatments described above havebeen studied individually. Because some of themprobably have different mechanisms of action, combinationtherapy might be more effective than anysingle treatment alone. In addition, as is often observedclinically with nutritional therapy, nutrientsused in combination may be effective at lower dosesthan when used individually. That possibility isworth noting with respect to KPAB and vitamin D,the adverse effects of which are dose-related. Nutrientdosages should be chosen with consideration ofthe severity and rate of progression of the illness, andshould be adjusted according to clinical response andtolerance.Table 2 summarizes alternative treatment optionsfor scleroderma.ConclusionAlthough a cure remains elusive, the treatmentsdescribed in this article have the potential toimprove outcomes for patients suffering from scleroderma.In most instances, the improvements werelimited to the cutaneous manifestations of the disease.However, treatment with PABA appeared tohave a favorable influence on the internal pathologyas well, and also reduced long-term morbidity andmortality. The improvement in swallowing functionthat occurred in a patient treated with bromelain suggeststhat this treatment may also have a beneficial effecton internal organ involvement. Because of theirrelative safety and low cost, further investigation iswarranted for the natural remedies discussed in thisreview.References1. Gough A, Sheeran T, Bacon P, Emery P. Dietaryadvice in systemic sclerosis: the dangers of a highfibre diet. Ann Rheum Dis 1998;57:641-642.2. Crinnion WJ. Results of a decade of naturopathictreatment for environmental illnesses: a review ofclinical records. J Naturopathic Med 1997;7:21-27.3. Zarafonetis CJ. Para-aminobenzoic acid therapy inscleroderma and lymphoblastoma cutis. J Lab ClinMed 1948;33:1462-1463.4. Zarafonetis CJ. The treatment of scleroderma:results of potassium para-aminobenzoate therapyin 104 cases. In: Mills LC, Moyer JH, eds.Inflammation and Diseases of Connective Tissue.W.B. Saunders Co.; 1961:688-696.5. Zarafonetis CJ, Dabich L, Devol EB, et al.Retrospective studies in scleroderma: pulmonaryfindings and effect of potassium p-aminobenzoateon vital capacity. Respiration 1989;56:22-33.6. Zarafonetis CJ, Dabich L, Negri D, et al.Retrospective studies in scleroderma: effect ofpotassium para-aminobenzoate on survival. J ClinEpidemiol 1988;41:193-205.7. Grace WJ, Kennedy RJ, Formato A. Therapy ofscleroderma and dermatomyositis. N Y State J Med1963;63:140-144.8. Bushnell WJ, Galens GJ, Bartholomew LE, et al.The treatment of progressive systemic sclerosis: acomparison of para-aminobenzoate and placebo ina double blind study. Arthritis Rheum 1966;9:495-496.9. Clegg DO, Reading JC, Mayes MD, et al.Comparison of aminobenzoate potassium andplacebo in the treatment of scleroderma. JRheumatol 1994;21:105-110.10. Stein CM, Tanner SB, Awad JA, et al. Evidenceof free radical-mediated injury (isoprostaneoverproduction) in scleroderma. Arthritis Rheum1996;39:1146-1150.11. Ayres S Jr, Mihan R. Is vitamin E involved in theautoimmune mechanism? Cutis 1978;21:321-325.12. Ayres S Jr, Mihan R. Vitamin E (tocopherol)– a reappraisal of its value in dermatoses ofmesodermal tissues. Cutis 1971;7:35-45.13. Ayres S Jr, Mihan R. Vitamin E and dermatology.Cutis 1975;16:1017-1021.14. Kraus Z. Fibrosis of the lungs in scleroderma. NutrAbs Rev 1950;20:452.15. Ayres S Jr, Mihan R, Levan NE, et al. Raynaud’sphenomenon, scleroderma and calcinosis cutis:response to vitamin E. Cutis 1973;11:54-62.16. Ayres S Jr, Mihan R, Levan NE. Raynaud’sphenomenon and possibly early scleroderma– response to vitamin E. Arch Dermatol1971;104:570-571.Page 194 Alternative Medicine Review u Volume 11, Number 3 u 2006Copyright © 2005 Thorne Research, Inc. All Rights Reserved. No Reprint Without Written Permission. Alternative Medicine Review Volume 10, Number 4 December 2005

Review Scleroderma17. Maynard MT. Vitamin therapy in dermatology.With particular reference to vitamin D inthe treatment of acne and of diseases due toaltered usage of calcium. Arch Derm Syphilol1940;41:842-857.18. Humbert PG, Dupond JL, Rochefort A, et al.Localized scleroderma – response to 1,25-dihydroxyvitamin D3. Clin Exp Dermatol1990;15:396-398.19. Hulshof MM, Pavel S, Breedveld FC, et al.Oral calcitriol as a new therapeutic modalityfor generalized morphea. Arch Dermatol1994;130:1290-1293.20. Elst EF, Van Suijlekom-Smit LW, Oranje AP.Treatment of linear scleroderma with oral 1,25-dihydroxyvitamin D3 (calcitriol) in seven children.Pediatr Dermatol 1999;16:53-58.21. Humbert P, Dupond JL, Agache P, et al. Treatmentof scleroderma with oral 1,25-dihydroxyvitaminD3: evaluation of skin involvement using noninvasivetechniques. Results of an open prospectivetrial. Acta Derm Venereol 1993;73:449-451.22. Hulshof MM, Bouwes Bavinck JN, BergmanW, et al. Double-blind, placebo-controlled studyof oral calcitriol for the treatment of localizedand systemic scleroderma. J Am Acad Dermatol2000;43:1017-1023.23. Armas LA, Hollis BW, Heaney RP. Vitamin D2 ismuch less effective than vitamin D3 in humans. JClin Endocrinol Metab 2004;89:5387-5391.24. Vieth R, Chan PC, MacFarlane GD. Efficacy andsafety of vitamin D3 intake exceeding the lowestobserved adverse effect level. Am J Clin Nutr2001;73:288-294.25. Martin MF, Tooke JE. Effects of prostaglandin E1on microvascular haemodynamics in progressivesystemic sclerosis. Br Med J (Clin Res Ed)1982;285:1688-1690.26. Strong AM, Campbell A, Thomson J. The effectof oral linoleic acid and gamma-linolenic acid(Efamol [G]). Br J Clin Pract 1985;39:444-445.27. Belch JJ, Shaw B, O’Dowd A, et al. Eveningprimrose oil (Efamol) in the treatment of Raynaud’sphenomenon: a double blind study. ThrombHaemost 1985;54:490-494.28. Stainforth JM, Layton AM, Goodfield MJ.Clinical aspects of the use of gamma linolenicacid in systemic sclerosis. Acta Derm Venereol1996;76:144-146.29. Lieb J. Linoleic acid in the treatment of lithiumtoxicity and familial tremor. Prostaglandins Med1980;4:275-279.30. Katayama H, Ohsawa K, Yaoita H. Improvementof progessive systemic sclerosis (PSS) with estrioltreatment. Acta Derm Venereol 1984;64:168-171.31. Sambo P, Amico D, Giacomelli R, et al.Intravenous N-acetylcysteine for treatment ofRaynaud’s phenomenon secondary to systemicsclerosis: a pilot study. J Rheumatol 2001;28:2257-2262.32. Oriente P, Scarpa R, Biondi C, et al. Progressivesystemic sclerosis and S-adenosylmethionine. ClinRheumatol 1985;4:360-361.33. Pierce HE Jr. Pineapple proteases in the treatmentof scleroderma. A case report. J Natl Med Assoc1964;56:272-273.34. Jablonska S. Avocado/soybean unsaponifiablesin the treatment of scleroderma: comment onthe article by Maheu et al. Arthritis Rheum1998;41:1705.35. Cantwell AR Jr, Craggs E, Wilson JW, SwatekF. Acid-fast bacteria as a possible cause ofscleroderma. Dermatologica 1968;136:141-150.36. Mohrenschlager M, Jung C, Ring J, Abeck D.Effect of penicillin G on corium thickness in linearmorphea of childhood: an analysis using ultrasoundtechnique. Pediatr Dermatol 1999;16:314-316.37. Svenson KL, Hallgren R, Johansson E, LindhU. Reduced zinc in peripheral blood cells frompatients with inflammatory connective tissuediseases. Inflammation 1985;9:189-199.38. Keiser HR, Henkin RI, Bartter FC, Sjoerdsma A.Loss of taste during therapy with penicillamine.JAMA 1968;203:381-383.39. Ambanelli U, Ferraccioli GF. D-Penicillamine andzinc. Arthritis Rheum 1978;21:396.40. Fosmire GJ. Zinc toxicity. Am J Clin Nutr1990;51:225-227.Alternative Medicine Review u Volume 11, Number 3 u 2006 Page 195Copyright © 2005 Thorne Research, Inc. All Rights Reserved. No Reprint Without Written Permission. Alternative Medicine Review Volume 10, Number 4 December 2005