Complementary Therapies in Medicine (2014) 22, 159165

Available online at www.sciencedirect.com

ScienceDirect
journal homepage: www.elsevierhealth.com/journals/ctim

Is dietary supplementation more common

among adults with psoriasis? Results from
the National Health and Nutrition
Examination Survey
Patrick B. Wilson
School of Kinesiology, University of Minnesota, Minneapolis, MN 55455, United States
Received 7 October 2013; received in revised form 2 December 2013; accepted 13 December 2013
Available online 22 December 2013

Summary
Objectives: Individuals with psoriasis are often unsatised with traditional medical treatments
and may be more likely to use dietary supplements as alternative or complementary treatment.
Limited data is available on the prevalence of dietary supplement use amongst individuals
with psoriasis in the general population. The aim was to utilize a representative sample of the
United States to estimate the prevalence of dietary supplement use among adults self-reporting
psoriasis.
Design and setting: Cross-sectional data analysis from the 2009 to 2010 National Health and
Nutrition Examination Survey. Dietary supplementation over the past 30 days was ascertained
and population weights were used to obtain estimates representative of the general population.
Logistic regression was used to determine whether psoriasis was associated with higher odds of
supplement use.
Results: This study consisted of 6211 participants aged 20 years (representing 219 million
Americans). Among the 184 participants reporting psoriasis (representing 6.9 million Americans), 53% reported using at least one dietary supplement, which was not different from
participants without psoriasis (49.5%, P = 0.416). Participants with psoriasis did not have higher
odds of supplement use after adjusting for covariates. Multivitamin/mineral supplements were
the most common dietary supplements used by participants with psoriasis (29.6%), and the most
common reasons for taking them were to maintain and improve health. Only 12 supplements
taken by participants with psoriasis were intended to improve skin health.
Conclusions: Dietary supplementation over the past 30 days was reported by half of adults with
psoriasis amongst the United States general population. Few individuals with psoriasis took
dietary supplements specically to improve skin health.
2013 Elsevier Ltd. All rights reserved.

Correspondence to: 220 Cooke Hall, 1900 University Avenue SE, Minneapolis, MN 55455, United States. Tel.: +1 612 625 5300.
E-mail address: wilso733@umn.edu

0965-2299/$ see front matter 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ctim.2013.12.007

160

Introduction
Psoriasis is a chronic, immune-mediated skin disease that
can signicantly impact quality of life.1,2 Although estimates
vary with the population studied, approximately 23% of
Americans have psoriasis,3,4 and this amounted to approximately $2 billion in health care costs in the United States
for 2004.5 Although there has been immense progress in
psoriasis treatment over the past several decades, many
treatments remain expensive and/or limited in access. Biologics, which will continue to gain more widespread use for
moderate-to-severe psoriasis because of their efcacy, typically cost more than $20,000 per year without insurance
coverage.6 Cost considerations may ultimately contribute
to some psoriasis patients seeking alternative treatments,
including dietary supplements. Beyond cost and access barriers, perception of under-treatment may contribute to
patients seeking alternative or complementary treatments.
One large survey from the general population found that only
50% of individuals with psoriasis were highly satised with
their current treatment and 25% were clearly dissatised.4
Moreover, discordance often exists between practitioners
and patients regarding the severity of a patients psoriasis, and patients frequently believe that those around
themeven their attending physiciansunder-appreciate
the severity of their condition.7
A dietary supplement is dened by the Food and Drug
Administration (FDA) as, a product taken by mouth that
contains a dietary ingredient intended to supplement the
diet.8 The FDA considers dietary supplements to be
under the umbrella of foods since the passage the Dietary
Supplement Health and Education Act.8 Because of their
classication under foods, most dietary supplements can be
sold without prior FDA approval. In addition, the efcacy and
safety of any given dietary supplement does not generally
need to be shown prior to its marketing.8 Dietary supplement use in the United States has been estimated to be
around 50%.9 Given that a substantial proportion of psoriasis
patients remain untreated or under-treated, it is plausible
that individuals with psoriasis are more likely to rely on
supplements as alternative or complementary treatment.
Ultimately, this may result in the prevalence of dietary supplement use being higher among individuals with psoriasis.
While some clinical trials have shown potential benets of
dietary supplementation for psoriasis,1012 interactions with
common anti-psoriatic drugs are a concern. For example,
herbal supplements can increase or decrease the concentration of cyclosporine13 and modify the risk of hepatotoxicity
with methotrexate use.14
Although a fair number of investigations have examined
the prevalence of complementary and alternative treatment use in psoriasis, most of these investigations have used
highly-selective samples, did not report specic dietary supplements taken, and/or did not compare the prevalence of
dietary supplement use to a control population.1522 The
National Health and Nutrition Examination Survey (NHANES)
is a program of studies that utilizes interviews and physical examinations to assess the health of adults and children
in the United States on a continual basis. For 20092010,
self-reported psoriasis diagnosis and detailed information on
dietary supplement use over the past 30 days were assessed.
Therefore, the purpose of this investigation was to estimate

P.B. Wilson
the prevalence of dietary supplement use among individuals
self-reporting psoriasis in the general population, compare
use to individuals without psoriasis, and characterize which
specic supplements were used and why.

Methods
Participants
This analysis includes individuals aged 20 years participating in the 20092010 NHANES. NHANES uses
complex, multistage, probability sampling to achieve
a representative sample of the non-institutionalized,
civilian population of the United States. Oversampling
of racial/ethnic minorities, low-income persons, and
elderly is done to increase the reliability and precision of estimates. NHANES sampling procedure uses four
stagescounties, segments, households, and individuals.
Households are mailed a letter informing residents that
an interviewer will visit their home, and individuals with
in households are randomly selected based on designated
age-sex-race/ethnicity screening subdomains. If eligible
individuals are identied, interviewers attempt to recruit
these individuals. After the household interview is conducted, participants are invited to receive an examination
at a mobile examination center. The age cut-off of 20 years
was selected to ensure that participants had complete data
on covariates and to limit the study inferences to adults. The
National Center for Health Statistics Ethics Review Board
approved the protocols and informed consent was obtained
from participants.

Psoriasis
Self-reported psoriasis diagnosis was assessed in the home
by trained interviewers using a Computer-Assisted Personal
Interviewing system. Participants were asked if they had
ever been diagnosed with psoriasis by a healthcare provider.
Participants were not asked to report psoriasis clinical subtype or the severity of their psoriasis.

Dietary supplement use

NHANES collects information about the use of prescription and nonprescription dietary supplements and antacids
during the preceding 30 days. A dietary supplement
questionnaire was conducted during the home interview.
Participants were asked if they had taken a dietary supplement over the past 30 days and were shown a card
listing examples of dietary supplements, such as multivitamins/minerals (MVM), herbals, and sh oil. Participants
that answered yes were asked to show the interviewer
the dietary supplement container(s) or report the details
if unavailable (about 2025% of cases). Participants were
also asked if they had taken any non-prescription antacids.
Antacids used as medication were not counted as dietary
supplements. Additionally, participants were provided with
a list of potential reasons for taking each dietary supplement (e.g. improve health, maintain health, improve skin
health/dry skin) and could also generate their own reasons.

Is dietary supplementation

161

Participants were allowed to select multiple reasons for taking each dietary supplement. Dietary supplement nonusers
were considered as those who did not report taking a dietary
supplement over the past 30 days. MVM, omega-3 fatty
acid, and herbal supplement use among participants with
psoriasis were also specically quantied since these categories of supplements have been frequently reported in
other populations.9,23,24 Supplements labeled as B-vitamin
complexes were considered MVM supplements and those
labeled as sh oil, axseed oil, or krill oil were considered
omega-3 fatty acid supplements.

Other variables
Age, education, gender, race/ethnicity, smoking status, and
medical co-morbidities (arthritis, coronary heart disease,
cancer) were self-reported at the home interview. Education was recoded into a dichotomous variable (high
school vs. >high school). Participants were asked if they had
smoked at least 100 cigarettes in their life (to establish eversmoker) and about current smoking habits. Participants were
considered smokers if they reported currently smoking at
least on some days. Height and weight were used to calculate body mass index (BMI). For participants with psoriasis
reporting herbal supplement use, prescription drug data les
were reviewed to identify medications that could potentially
interact with herbals.

Statistical analysis
Analyses were conducted using SPSS Complex Samples (version 21, IBM, Armonk, NY). NHANES-supplied interview
population-weights were used to account for the complex
sampling design and interview nonresponse. Frequency of
dietary supplement use is reported as both unweighted
counts and population-weighted prevalences. Reasons for
taking dietary supplements are reported as unweighted
counts because multiple reasons can be given for each
dietary supplement, complicating population weighting.
Means and standard errors (via the Taylor linearization method) were calculated for the continuous variables
BMI and age and were compared between those with and
without psoriasis. The general linear model function was
used to compare continuous variables by entering them as
dependent variables and psoriasis diagnosis as a factor. In
unadjusted analyses, differences between proportions for
categorical variables were compared using the RaoScott
likelihood Chi-square test. Logistic regression was used to
assess whether psoriasis was associated with higher odds of
dietary supplement use while controlling for age, gender,
education, and race/ethnicity.9 Statistical signicance was
set at P < 0.05.

Results
A total of 13,272 individuals were invited to participate during recruitment, of which 8397 were aged 20 years. Among
these adults, 6218 agreed to be interviewed, representing a
response rate of 74%. After excluding individuals with incomplete data, 6211 participants aged 20 years comprised

Figure 1 Prevalence of dietary supplementation for gender,

education, and age by psoriasis diagnosis.

the analytical sample, representing 219 million Americans.

Of the analytical sample, 184 participantsrepresenting
6.9 million Americansreported a diagnosis of psoriasis.
The population-weighted prevalence of psoriasis was 3.2%.
The characteristics of the participants by self-reported
psoriasis diagnosis are reported in Table 1. Participants
with psoriasis were more likely to be non-Hispanic white,
be a current smoker, and report a previous diagnosis of
cancer.
Overall, there was no signicant difference in the prevalence of dietary supplement use by psoriasis diagnosis, as
53.0% and 49.5% of those with and without psoriasis reported
use over the past 30 days (P = 0.416; Table 2). Furthermore, the distribution of total supplements used was similar
between those with and without psoriasis, with the vast
majority of participants taking 03 dietary supplements.
Only 7.8% of participants took 4 dietary supplements over
the past 30 days. Dietary supplement use among participants reporting arthritis did not vary by psoriasis diagnosis.
Among participants reporting arthritis, 59.3% of participants
with psoriasis compared to 62.2% of participants without
psoriasis reported dietary supplement use. Analysis of supplement use by other co-morbdities was not completed
because of low counts among participants with psoriasis.
Fig. 1 shows the prevalence of dietary supplement use
for gender, education, and age by psoriasis diagnosis. More
women reported taking dietary supplements compared to
men (P < 0.001), as did those who had greater than a high
school education (P < 0.001). The prevalence of dietary
supplement use also increased with age (P < 0.001), with
67.8% of those aged 60 years reporting dietary supplement use. In the logistic regression model, psoriasis was
not associated with signicantly higher odds of dietary supplement use after adjusting for age, gender, education,
and race/ethnicity (odds ratio 1.13, 95% condence interval
0.811.56; P = 0.450).
Table 3 shows the prevalence of MVM, omega-3 fatty
acid, and herbal supplement use among participants with
psoriasis. MVM supplements were the most common type
of dietary supplement reported, with approximately 30% of
participants with psoriasis taking them. The most common

162

P.B. Wilson

Table 1

Demographic characteristics and co-morbidities of the participants by psoriasis diagnosis.

Psoriasis Na = 184 (%)b

Age (years)
BMI (kg/m2 ) (N = 174; 5815)c
Gender, female
Race/ethnicity
Mexican American
Other Hispanic
Non-Hispanic white
Non-Hispanic black
Other race/ethnicity
Education
High school or less
Current smoker
Co-morbidities
Arthritis
RA
OA
PsA
Cancer
CHD

No psoriasis Na = 6027 (%)b

P-value

48.8 1.6
29.4 0.4
89 (44.7%)

46.9 0.5
28.7 0.1
3122 (52.0%)

0.248
0.143
0.103
0.001

21 (4.7%)
17 (3.2%)
121 (81.9%)
17 (6.0%)
8 (4.3%)

1116 (8.7%)
615 (5.1%)
2854 (67.5%)
1103 (11.6%)
339 (7.2%)

100 (47.9%)
60 (29.5%)

3098 (41.6%)
1285 (20.0%)

0.169

78 (34.4%)
21 (26.1%)d
18 (23.7%)d
3 (7.1%)d
35 (19.5%)
15 (5.6%)

1595 (23.5%)
295 (15.6%)d
496 (36.5%)d
5 (0.6%)d
585 (9.6%)
239 (3.0%)

0.003
0.072

0.014
0.258

BMI, body mass index; CHD, coronary heart disease; OA, osteoarthritis; PsA, psoriatic arthritis; RA, rheumatoid arthritis.
a N represents unweighted counts.
b Percentages are weighted to U.S. population.
c BMI not available for some participants.
d Prevalence among individuals with arthritis.

reasons for taking MVM supplements were to maintain and

improve health, and only one of the MVM supplements was
intended to improve skin health/dry skin. The prevalences
of omega-3 fatty acid and herbal supplement use were
9.2% and 3.8%, respectively. The most common reason given
for taking omega-3 fatty acid supplements was to improve
heart health, while herbals were taken for a variety of
reasons.
Table 4 shows the 12 dietary supplements that were
specically intended to improve skin health/dry skin among
participants with psoriasis, with vitamin E being the most
common supplement used for that reason. Finally, Table 5
lists the specic herbal supplements taken amongst participants with psoriasis, along with prescription medications
taken. Among the eight participants taking herbal supplements, ve reported use of at least one prescription
medication.

Table 2

This study indicates that dietary supplementation is not

more common among adults self-reporting psoriasis in the
United States general population. Overall, approximately
half of all participants reported taking a dietary supplement over the past 30 days, which reafrms estimates of
general population use from the 2003 to 2006 NHANES.9
Furthermore, the frequency of individuals taking multiple supplements (2) was not greater among individuals
with psoriasis. Fleischer et al.17 provides data that is
most directly comparable to this investigation. In total,
317 individuals with psoriasis presenting at the Wake Forest University Department of Dermatology were asked to
report past or current alternative therapy use, including dietary supplementation. Overall, 23% of the sample
reported herbal use and 42% reported vitamin use. Of note,

Prevalence of dietary supplement use among adults with and no psoriasis.

Any supplement use over the past 30 days

Number of supplements used
0
1
23
45
6+
b

Discussion

N represents unweighted counts.

Percentages are weighted to U.S. population.

Psoriasis Na = 184 (%)b

No psoriasis Na = 6027 (%)b

P-value

93 (53.0%)

2824 (49.5%)

0.416
0.632

91 (47.0%)
46 (29.0%)
31 (16.2%)
9 (5.5%)
7 (2.3%)

3203 (50.5%)
1420 (24.1%)
990 (17.5%)
274 (5.1%)
140 (2.7%)

Is dietary supplementation
Table 3

163

Prevalence of use for popular dietary supplements among adults with psoriasis and reasons given for use.
Prevalence Na = 184 (%)b

Multivitamins/minerals

49 (29.6%)

Omega-3 fatty acid supplements (sh oil/axseed oil)

a
c

To maintain health
Supplement diet
To improve health
Prevent health problems
Prevent colds/boost immunity
Get more energy
Skin health/dry skin

19
18
14
7
5
6
1

For heart health

To improve health
Prevent colds/boost immunity
Skin health/dry skin
To maintain health
Prevent health problems

11
4
3
2
2
2

To improve health
Skin health/dry skin
For mental health
Prevent colds/boost immunity
Improve sleep

3
2
2
2
2

18 (9.2%)

Herbals

Reasons given for takingc

8 (3.8%)

N represents unweighted counts.

Percentages are weighted to U.S. population.
Does not equal the number of participants reporting use because multiple reasons can be given for each supplement.

the use of those therapies was signicantly more common

among those with severe disease.17 Another investigation
of approximately 500 psoriasis patients from a Norwegian dermatology department found that 19% and 25% had
tried or currently used herbal remedies and health food
preparations.15 More recently, a study of Korean outpatients
with psoriasis indicated that 33/189 (17.5%) had or currently used health supplements and 60/189 (31.7%) had or
currently used herbal remedies.22
High-quality evidence regarding the efcacy and safety
of specic dietary supplements for psoriasis is generally
lacking. The most extensive clinical trial data exists for
sh oil, with some studies showing positive results while
others have not.25 Interestingly, only two of the omega-3
fatty acid supplements used among individuals with psoriasis in this population were being taken to improve skin
health/dry skin, with the majority being taken for heart

Table 4 Dietary supplements taken to improve skin

health/dry skin among adults with psoriasis (N = 12).
Supplement taken

Count

Vitamin E
Fish oil/axseed oil/omega-3
Vitamin A
Turmeric
Biotin
Multivitamin/mineral
Burdock

4
2
2
1
1
1
1

health. While the benets of omega-3 fatty acid supplements for cardiovascular disease are intensely debated,
there appears to be a modest benet in terms of cardiovascular events and mortality.26 These cardiovascular
event benets, however, have not been directly examined in
individuals with psoriasis. Given that growing evidence indicates that moderate-to-severe psoriasis may increase the
risk for cardiovascular events,27,28 future research should
evaluate the effects of omega-3 fatty acid supplementation on cardiovascular disease risk factors and events in
psoriasis.
Interestingly, vitamin E was the most common dietary
supplement taken to improve skin health/dry skin among
participants with psoriasis. Vitamin E was not effective at
improving psoriasis severity in one study,29 and importantly,
two meta-analyses have found an increased risk of mortality
with high-dose vitamin E supplementation.30,31 The average dose of vitamin E in this study was 423 IU/day, which
equals the threshold for mortality risk in the meta-analysis
from Miller et al.30 Herbal use was relatively uncommon
among individuals with psoriasis in this population (3.8%).
The greater herbal use reported in past studies may stem
from differences in the populations sampled and survey
question methodology.15,17,22 The previous studies inquired
as to whether individuals had ever tried herbal supplementation (as opposed to over the past 30 days) and represented
clinical populations actively seeking treatment for psoriasis.
Among the eight participants with psoriasis reporting herbal
use, ve reported taking at least one prescription medication. Several of the herbals being takenechinacea, saw
palmetto, garlichave documented drug interactions,3234

164
Table 5

P.B. Wilson
Prescription drugs used among adults with psoriasis using herbal supplements (N = 8).

Participant characteristics (sex, age,

race/ethnicity)

Herbal supplement(s) taken

Prescription drug(s) taken

Male, 25 years, Mexican American

Male, 29 years, Mexican American
Female, 70 years, non-Hispanic white

Valerian root extract, echinacea

Milk thistle
Cinnamon

Male, 74 years, non-Hispanic white

Turmeric, saw palmetto

Female, 48 years, non-Hispanic white

Dandelion root, Xiao Yao Wan,

myrrh gum, burdock
Valerian root

None
Albuterol
Allopurinol, esomeprazole,
simvastatin, furosemide, lisinopril,
potassium chloride
Glipizide, lovastatin, metformin,
metoprolol, ramipril
None

Male, 63 years, non-Hispanic white

Male, 60 years, non-Hispanic white

Male, 50 years, non-Hispanic white

Blend containing garlic, guggul,

Jiaogulan, and artichoke
Milk thistle extract

although extensive research from clinical trials is not available for many herbals.35
Strengths of this study include the use of a representative
sample of the United States population with oversampling
of minority groups and the methodology used to assess
dietary supplementation. The sample represented approximately 219 million Americans, and compared to the previous
studies on this topic, it more accurately reects the distribution of population factors such as age, education, and
race/ethnicity. While there was nonresponse among individuals invited to participate, NHANES-provided sampling
weights were used to adjust for survey nonresponse. Furthermore, since the dietary supplementation interviews
were conducted in participants homes, interviewers were
able to visually conrm most dietary supplements reported
(7580%), which is an improvement upon purely selfreported data. This level of detail on the supplements
used is a clear strength, as previous investigations simply
reported alternative therapy use by broad categories.15,17
Also, the use of a Computer-Assisted Personal Interviewing
system and standardized protocols ensured that interviewer
variability was minimized. Despite these strengths, some
limitations must be acknowledged, such as the lack of psoriasis diagnosis conrmation and the lack of information
on psoriasis severity. Although no data on the accuracy
of psoriasis self-report is available, self-reports of other
chronic diseases have been shown to be accurate.36 Furthermore, data on psoriasis severity was not available
to examine if supplementation use varied with disease
severity. Despite this, a previous report indicates that
NHANES reects typical psoriasis severity distributions, as
approximately one-third of those reporting psoriasis had
12% body surface area involvement, while 1520% had
body surface area involvement greater than 3%.37 Additionally, it cannot be guaranteed that the list of reasons
for taking supplements available to participants captured
motivations related to improving psoriasis. Participants with
psoriasis taking dietary supplements intended to improve
health may have considered their psoriasis as a major

Duloxetine, exenatide, lansoprazole,

losartan, metformin, oxaprozin,
tamsulosin, trazodone, valacyclovir
None
Clonazepam, cyclobenzaprine,
lithium, sertraline

contributor to overall health. Finally, these data should not

be extrapolated to populations actively seeking treatment
at dermatology clinics and other clinical facilities, since they
may perceive their psoriasis to be signicantly worse than
individuals with psoriasis in the general population.
In conclusion, dietary supplement use does not appear
to be more prevalent among adults self-reporting psoriasis in the United States general population. Approximately
half of adults with psoriasis reported taking a dietary supplement over the past 30 days, with MVM supplements being
the most frequently used dietary supplement. Generally, the
most common reasons given for taking dietary supplements
were to improve and maintain health, and use of dietary
supplements specically for skin health was relatively infrequent. Additional clinical trials are needed to evaluate the
safety and efcacy of specic dietary supplements on psoriasis severity and its related co-morbidities.

Funding
None declared.

Conicts of interest
None declared.

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