Medicinal Plants to Calm and Treat Psoriasis Disease

Psoriasis is a chronic and inflammatory multifactorial disease. For psoriasis treatment, topical chemical agents are applied, in spite of inefficient effects or less effectiveness. But medical plants can be one of the alternative treatment methods. In the field, herbal creams are the most used. In fact, they are helping to inhibit leukotriene formation, inflammation and blocks cyclooxygenase enzymes, then heal skin wounds due to the plant's flavonoids and tannins. The aim of this study is the making of new herbal cream for treating psoriasis. In the mentioned cream, synergistic effects of medicinal herbals extracts were evaluate on damaged skin. Some of these extracts include Santalum album, Arctium lappa, Matricaria chamomilla, Glycyrrhiza glabra, Lavandula angustifolia, Avena sativa, Aloe barbadesis, Pinus eldarica and Cydonia seed-Mucus. Cream was prepared by mixing water-in-oil (W/O) and was proposed to five patients who suffer from psoriasis. Results were remarkable. All five patients were satisfied from itching inhibition and skin inflammation in first week. After 2weeks applying cream, fading skin redness and increasing skin flexibility and repair were noticeable. An important point in this cream was the mixed herbal extract with high effectiveness than each of them alone. In fact, S. album and L. angustifolia were caused softening of skin corneous layer. Flavonoids and tannins in G. glabra, A. lappa, P. eldarica and A. sativa are effective for treating skin lesions such as psoriasis. Polysaccharides in A. barbadensis and mucilage in C. seed-Mucus not only are healing skin wounds but also their malic acid make peeling skin dead cells. Moreover, pectin and provitamins (A) act as antioxidants and prevent damage of skin healthy cells. Herbal β-sitosterols are factor of fading skin redness and anti-itching, abisabolol (M. chamomilla) as anti-inflammation; blocks cyclooxygenase enzymes and inhibits leukotriene formation to prevent redness. In fact, this treatment cream is effective for collagen synthesis, wound improvement, epidermal-moisture maintenance, inflammation relief and boost immune system and will inhibit psoriasis common symptoms in shortest time and no side effect.


Introduction
In most societies, especially the third world, the importance of skin diseases is often overlooked. This is on the terms that they are usually not life threatening, but they are beauty threatening and a significant problem all over the world.
Some skin diseases are as follows: eczema, fungal/yeast infections, bacterial infections, viral infections, parasitic infections, autoimmune disease and miscellaneous skin disease [1]. Among the types of the mentioned skin diseases, psoriasis and eczema (such as seborrhoeic eczema) can be one of the varieties of autoimmune diseases that environmental factors intensify their symptoms [2][3][4][5][6][7]. Also, these diseases, especially psoriasis, are so important, throughout the world due to the direct impact on quality of life. So, 1day of the year is allocated to it-World Psoriasis Day Consortium [8,9].
According to NORD (National Organization for Rare Disorders) definition, psoriasis can be classified as a rare inflammatory chronic recurrent skin disease [7,8]. It can say that 125million people worldwide (about 2-3% of the total population) have psoriasis. Moreover, statistics of the national psoriasis foundation in 2014 showed that psoriasis prevalence in African Americans was 1.3% compared to 2.5% of Caucasians, while in Bulgaria, it was 0.2-3% [8,10].
Psoriasis is the diseases that has great impact on patient's life (physically, psychologically and socially) and studies have shown that the impact of this disease on quality of life is similar to diseases such as diabetes, hypertension, heart diseases, the type of cancers, arthritis and depression [11,12]. So, talking about this disease, its symptoms and treatment of common types and novel such as herbal extracts (alternative of chemical drugs), is important. But, it is firstly necessary to explain the structure and function of skin. In fact, knowing the skin structure helps better treatment disease.

Structure and functions of the skin 2.1. Skin definition
The definition of skin in English and Medical dictionary describes as the external layer of the body. But this description is inadequate. In fact, the skin is external covering that holds organs and protection of human tissues against environmental factors [13,14]. In a normal state, the immune system within the skin is quiet and relatively inactive. If the skin is challenged in any way (bacteria, fungus, etc.), a range of immunological cascades are set in motion. In some conditions such as psoriasis disease, these immunological changes are not within a normal range and cause severe inflammation and hyper-proliferation of skin cells [15]. The skin plays an important role in all fields, especially in the esthetics. Also, the skin color represents the racial disparity and it is symbolic of different cultures and ethnic differences.

Biology of the skin
The skin is the largest organs in the body, with surface area of 1.8m 2 and making up about 16% of body weight (between 2 and 6kg) [13,14]. It has many functions such as a barrier to protect the body from noxious external factors and to keep the internal systems intact, protection of tissues against microorganisms, ultraviolet radiation and mechanical pressers [13,16]. The skin is also responsible of many body functions such as sense, regulation of body temperature and elimination of waste products by sweating, producing vitamin D, etc. Moreover, skin can prevent the entry of harmful substances in the body and control vital substances of body. Therefore, skin is important to perform the mentioned essential functions.

Skin anatomy
Skin is the dynamic organ in a constant state of change, as cells of the outer layers are continuously shed and replaced by inner cells moving up to the surface [17]. The skin contains the number of accessory organs which assist in its protective role and there are three structural layers to the skin: • Epidermis

• Dermis
• Subcutis (hypodermis) Also, hair, nails, sebaceous, sweat, apocrine glands, etc. are regarded as derivatives of skin ( Figure 1). The thickness of the skin varies depending on the site, with thicker skin being present on areas of the body such as the soles of the feet and palms of the hand. In fact, this thickness depends on epidermis layers such as stratum granulosum [14,18].

Epidermis
The epidermis is the top layer of skin with about 0.1-1.4mm thick (on areas of the body). The main cells of the epidermis are keratinocytes, which produce the protein keratin. This layer is also containing other cells such as Langerhans, Melanocyte and Merkel cells. This layer is  constantly proliferating and shedding millions of dead cells [14,17]. It is estimated that normal skin sheds at the rate of a million cells (every 40min), which equates to around 18kg over a lifetime. This process of skin cell shedding is known as desquamation. It could be noted that desquamation (from stratum basale to stratum corneum) in epidermis is between 28 and 30days [13,19]. Figure 2 shows different layers of the epidermis and Table 1 describes them.

Dermis
The dermis is defined as a tough supportive connective tissue matrix, with physical support and nutrients to the epidermis. Connective tissue consists of a ground substance with protein Figure 2. Epidermal layers.

Stratum basale
The basal cell layer of the epidermis is composed keratinocytes, which are either dividing or nondividing. These cells contain keratin tonofibrils and melanocytes (to synthesize melanin). Also, Merkel cells are also found in the basal cell layer (to create a sensation in the skin such as sense of touch) Aromatic and Medicinal Plants -Back to Nature fibers that contains water and a mixture of large organic molecules (combination of polysaccharides as complex carbohydrates and proteins). The most common type of polysaccharides in this tissue is glycosaminoglycans (GAGS) that include hyaluronic acid [13,16]. In fact, this tissue matrix is called the extracellular matrix that its structure has been shown in Figure 3 [20].
Dermis found immediately below the epidermis and it varies in thickness (about 0.6mm on the eyelids and 3mm or more on the back, palms and soles). The two layers identified within the dermis are the papillary layer and the reticular layer ( Table 2). Also, dermis includes elastin, fibrillin, collagen and laminin ( Figure 3). This layer also contains nerve endings, sweat glands, sebaceous glands, hair follicles and blood vessels [17,19]. Figure 4 shows a cross section of dermis layer.

The types of cells Definitions
Fibroblasts cells An important cell that is involved to repair damaged tissues

Subcutaneous tissue or the hypodermis layer
This layer lies below the dermis and provides support for it. Hypodermis is made up largely of fat cells and connective tissue for protection of internal structures. Moreover, this layer acts as a heat insulator and can be useful against trauma [13,16,19]. Hypodermis schematic has been shown in Figure 5.

Psoriasis disease
Psoriasis was first distinguished and diagnosed as a chronic inflammatory disease in nineteenth century; prior to, this disease was often mistaken for other disease such as leprosy. Nowadays, psoriasis patients are estimated to be about 2-3% at all world [13,21]. Severity ranges this disease from a fingernail pit to skin lesions (on a part of the skin to a  total body that can be associated with arthritis) [13]. Tables 3 and 4 show the types of psoriasis disease. Psoriasis plays an important role on a patient's quality of life and its negative effect can be seen on the beauty of patient and their mental and physical functioning. The cause of this vexing disease is still not known and clinical studies show hyperproliferation and abnormal differentiation of the epidermis, although this disease can be hereditary [22,23].

Biology of psoriasis disease
Psoriasis is characterized as a disease with over proliferation of keratinocytes such as skin cells (around 3-4days) and cell development with abnormal keratinocyte differentiation. Proliferation of cells is in the basal layer doubles and the normal cell cycle (which is around 28days) and hyperkeratosis (the hyperkeratosis leads to induration or skin thickening) and parakeratosis develop (the granular layer is either absent or reduced) [33]. The color of the

Types of psoriasis
Description of the disease An example of disease picture References

Skin psoriasis
This disease is one of the types of psoriasis. Skin psoriasis known as a papulosquamous disease that includes the types of vulgaris (common type of skin psoriasis), guttate (spots of drop like), inverse (in the underarms, navel, buttocks, etc.), pustular with symptoms of yellowish pus on the skin and small blisters and erythrodermic psoriasis. Table 4. shows completely them [24][25][26][27] Nail psoriasis The common signs of nail psoriasis are pitting and distal onycholysis. Also, pitting, yellowish discoloration and paronychia, hyperkeratosis, onycholysis and severe onychodystrophy are other signs of the disease. Approximately 50% of all patients with psoriasis develop characteristic nail changes as a clinical correlate of psoriatic inflammation of the nail matrix and/or nail bed [28,29] Psoriatic arthritis Psoriatic arthritis (PsA) is a chronic inflammatory joint disease occurring in 6-39% of patients with psoriasis (about 0.1-0.25% of world population). This type of arthritis can develop slowly or rapidly. Psoriasis arthritis (PsA) can be also as severe arthritis similar to rheumatoid arthritis (RA). Moreover, this disease specifications are focal bone erosions at the bones junction [30][31][32]  Inverse psoriasis This type of disease found in the armpits, in the groin, under the breasts and in other areas such as skin folds of the genitals and the buttocks. In this type of psoriasis, lesions appear as bright red that are smooth and shiny Pustular psoriasis This type of psoriasis disease more seen in adult patients. Pustular psoriasis has common symptoms such as rubefaction, white blisters and pus without infection that seen on the hands and feet, or most areas psoriatic plaque may be masked by a covering of silvery, white skin scales. Also, high level of vascular activity within the psoriatic plaques, there is the change in color of the skin and inflammation, itching and redness of skin [13].
In fact, psoriasis is a hyper-proliferative disorder with significant inflammatory components and belies a complex cascade of immune reactions, finally, stimulation of the skin. Indeed, psoriasis is recognized as the most prevalent T-cell-mediated 1 inflammatory condition in humans [13,15,34]. Moreover, TNF plays an important role in inflammatory processes of psoriasis ( Figure 6) [35].

Psoriasis treatment
Psoriasis treatments are divided into two groups [13].
• Topical Topical therapies are generally used to manage mild-to-moderate psoriasis ( Table 5). This type of therapy may be also used to treat more severe psoriasis in combination with systemic regimes, for example, coal tar or short-contact dithranol in combination with UV light.
• Systemic Systemic therapies used to the more severe spectrum of the disease ( Table 6).

Psoriasis and skin's barrier function
Although the psoriasis is a multifactorial disease, the studies show that disruption the homeostasis in skin's barrier can be one of the important factors.
In fact, several factors are effective on the hemostatic [35]:

Skin psoriasis Description of the disease Disease pictures
Erythrodermic psoriasis A particularly form of psoriasis is erythrodermic psoriasis, which affects on the body as an inflammatory disease. The emergence of erythrodermic is to periodically and its symptoms include widespread red lesions Table 4. Different types of skin psoriasis. 1 A T cell or T lymphocyte is a type of lymphocyte (a subtype of white blood cell) that plays a central role in cell-mediated immunity. 1. Structure of heterogeneous from lipid/protein can be one of the main causes in hemostasis. The lipid/protein structure is renewed continuously. So, if this barrier is damaged, the lipid/protein structure causes its rapid regeneration.
3. Epidermal junction (EJ) is important in the formation and maintain of barriers such as epithelial and endothelial and desmosomes bands. The studies show that raising calcium concentration stimulates keratinocytes to form strong cell-cell adhesions.

4.
In epidermal keratinocytes, both extracellular and intracellular Ca 2+ can be important to cell differentiation and proliferation.
According to the above-mentioned descriptions, the choice of drug for treating disease plays an important role. In the meantime, there are certain groups of drugs will in some cases trigger an onset or aggravate psoriasis such as lithium, chloroquine-based antimalarials, betablockers, etc.
For example, one of the effective therapeutics for people with severe bipolar disease is lithium, which makes sometimes discontinuing it because of worsening psoriasis. The studies show that supplement inositol (found in plants) can be used as alternative therapy to decrease severity of both diseases compared to lithium. So, therapeutic methods and new medicines such as stem cell therapy, use of herbal extracts, etc. can be effective in reducing or eliminating this disorder [36].

Systemic therapies Definition
Phototherapy UVB In psoriasis disease, exposure to ultraviolet radiation can be improved lesions. But, around 10% of patients, who have light sensitive, exposure to UV radiation can cause their psoriasis to worsen or develop. UVA and UVB are an example of this type of treatment. In fact, they suppress the immune response within the skin and thus dampen down the cascade of immunological changes, which occur to trigger psoriasisPossible side effects of PUVA and UVB include nausea, pruritus, dizziness, headache, erythema (burning), skin cancer, malignant melanoma, squamous cell carcinoma (SCC) and basal cell carcinoma PUVA

Methotrexate
Methotrexate is a relatively old treatment (since the late 1960s) and its efficacy is relatively few. In fact, it is an anti-proliferative drug and it affects cell DNA, so stops proliferation skin cells. Side effects of methotrexate include leukopenia and thrombocytopenia, oral and plaque ulceration, lower levels of folic acid, teratogenicity, hepatotoxicity and pulmonary toxicity Cyclosporin Cyclosporin is as a relatively modern treatment for psoriasis. Mechanism of Cyclosporin is through effect on the T-cells and helping to inhibit the stimulation of cytokines and cell proliferation. But, like methotrexate, it does have potent systemic side effects that most concern is those related to nephrotoxicity and the resultant kidney function damage and hypertension

Retinoids
Retinoid which is known as acitretin, by altering keratinization and epidermal differentiation, is used as anti-proliferative, anti-inflammatory and anti-keratinizing effects on. Retinoids are complex drugs with many possible side effects. They can affect hepatic function and lead to hyperlipidemia. Also highly teratogenic and therefore not suitable for pregnant women or women who are considering becoming pregnant. Other side effects include dry mucous membranes including eyes, lips and throat Table 6. The types of systemic therapies.

Vitamin D analogs
Vitamin D3 is naturally synthesized in the epidermis. The mechanism involves natural UVB falling on the skin and converting 7-dehydrocholesterol into vitamin D, which then binds with vitamin D binding protein. The synthetic vitamin D analogs (calcipotriol, tacalcitol and calcitriol) inhibit cell proliferation and encourage the skin cells to mature normally Vitamin A Vitamin A also known as a topical retinoid and suitable for mild-to-moderate plaque psoriasis. It seems that vitamin A can modulate cell proliferation and increase differentiation. Its main side effect is skin irritation Emollients As psoriasis is a dry skin condition, a key of treatment for all types of psoriasis (except perhaps inverse psoriasis) is emollient therapy. Emollients will not stop hyper-proliferation; however, they reduce the signs of scaling and may be applied topically and/or used for washing Coal tar Coal tar is one of the oldest treatments for psoriasis. The studies have shown that mechanism of coal tar may be by reducing epidermal thickness and by suppressing epidermal DNA synthesis. The main potential side effects associated with coal tar include skin irritation and folliculitis. (In the some of the studies, coal tar is as mutation factor) Dithranol Dithranol affects the synthesis of cell DNA and has a pronounced anti-proliferative effect. It also appears to have a rapid effect on the normalization of epidermal proliferation. Its side effects include irritation and staining

Alternative therapeutical method
Plants have been used by men from prehistoric times to get rid of suffering and curing ailments such as skin disease.
Nowadays, herbal resources play a very important role in the management of the skin and inflammatory diseases and herbal medicine is promoted as one of the alternative therapeutical methods for healing skin diseases such as psoriasis [37].

Aloe vera
Aloe vera (L.) Burm. f. syn. Aloe barbadensis Miller is most biologically active among 400 species [38]. According to report of World Health Organization, this medicinal herb is the best source to prepare natural drugs ( Figure 7). The plant is native to southern and eastern Africa. Then, it was introduced into area of northern Africa and other countries.
Aloe vera is from the lily family (Liliaceae). Different parts of the plant, especially its gel, are effective on the body. Gel from the Aloe vera plant can help to reduce redness and scaling associated with psoriasis. Aloe vera contains anthraquinones, steroids, saponins, mucopolysaccharides and salicylic acid. Active ingredients Aloe vera include anthraquinone and acemannan that have antibacterial activity and therapeutic of psoriasis disease. Moreover, salicylic acid as a component in this plant has keratolytic effect to remove psoriatic plaques [39][40][41].

Silybum marianum
Silybum marianum (L.) Gaertn., common name milk thistle, of the family Asteraceae is a herbaceous annual species of considerable medicinal importance. Having origin in Mediterranian regions of North Africa, middle East and Europe, the species is now found distributed as a weed worldwide. All parts of the plants are edible. Germinated seed raised as sprouts and young fleshy stems and leaves have been in use as antioxidant-rich salad. Seeds of the plant are known to be used in traditional medicine for more than 2000years for the treatment of liver and gallbladder ailments and to protect live from poisoning by toxins, such as from alcohol, toxic mushrooms, insect stings and snake bites [42].
This plant is very well known for its hepatoprotective activity. Since the numerous changes have been detected in the liver of patients with psoriasis, including steatosis, periportal inflammation, fibrosis, necrosis and cirrhosis, Silybum marianum can be affect for skin disorders such as psoriasis [38]. Since the abnormally high levels of cyclic adenosine monophosphate (cAMP) and leukotrienes seen in psoriatic patients, one of the therapies methods can be regulate these levels. The role of silymarin in treating psoriasis is improvement of endotoxin removal by the liver, inhibition of cAMP phosphodiesterase and leukotriene synthesis [43][44][45][46]. This plant oil has been also suggested a vitamin E, α-linolenic acid and linoleic acid reach source [47,48].

Burdock
Medicinal species of Burdock are Arctium lappa, Arctium minus, Lappa major or Bardanae radix. This plant is derived from the Greek with common names of akujitsu, arctii, bardana, beggar's buttons, burdock root, great burdock, burr, burr seed, chin, clot-burr, hardock, hare burr, hurrburr, kletterwurzel, lampaza, lappa and lappola. Burdock is in the family of compositae/Asteraceae (daisy). Burdock has been also used in numerous countries throughout history to treat problems arthritis and skin disorders. This plant is one of the key herbal ingredients in the twentieth-century cancer remedies [49].
The Chinese used burdock to treat upper respiratory infections. In fourteenth-century Europe, a combination of burdock and wine was used to treat leprosy. Also, Burdock is used for fevers, a variety of dermatologic conditions (eczema, psoriasis, scrapes and burns), syphilis, etc.
• Polysaccharides and mucilages such as xyloglucan.

Devil's claw
Harpagophytum procumbens (Pedaliaceae) or Devil's claw found in southern Africa (South Africa, Namibia, Botswana). Preparations of the secondary roots have gained a reputation as an antiinflammatory and antirheumatic agent to relieve pain and inflammation in people with arthritis and similar or skin disorders.

Feverfew
Feverfew is one of the traditional plants to treat arthritis, contact dermatitis, skin difficulties, etc.
Feverfew is an aromatic herb of the Compositae/Asteraceae family. Studies have been shown its effectiveness for treating migraine. This herb inhibits blood platelet aggregation and the release of 5-hydroxytryptamine from platelets. The active ingredients in the herb dried leaves are germacrene and guianane. Parthenolide is also known to be capable of causing some allergic effects, for example, contact dermatitis.

Liquorice
Liquorice (licorice; glycyrrhiza) is the dried unpeeled rhizome and its root. Liquorice is cultivated in Spain, Italy and France. The liquorice extract is usually prepared by extraction with alcohol or masculation in water. The roots of this plant contain about 20% of water-soluble active ingredients and Glycyrrhizic acid, which is comprised 3-5% of the root [46].
The bright yellow color of liquorice root is due to 1-1.5% of flavonoids such as liquiritigenin and isoliquiritigenin. The roots of this plant also include 5-15% of sugars (glucose and sucrose) ( Figure 8). Its anti-pain properties have also been caused that was used as demulcent natural drugs [46].
The recent researches indicate the corticosteroid-like and anti-inflammatory activities in liquorice extracts. Glycyrrhetic acid of liquorice extracts is playing a key role for inhibiting enzymes that is important to convert prostaglandins and glucocorticoids into inactive metabolites and increase levels of prostaglandins such as PGE2 and PGF2α [46]. Table 7 shows various herbs that used in the treatment on skin disorders such as inflammation, eczema, psoriasis, scrapes and burns.
Therefore, various herbs are used in pharmaceutical, food, cosmetic, etc. In this regard, there are a lot of researches to produce natural therapeutical products such as creams, lotions, etc. One of these researches was the making of new herbal cream for treating psoriasis by Izadyari et al. [50]. The herbal extract and oil in the mentioned cream were combined with vitamins. Then, the cream was given to five patients who suffer from psoriasis disease. An important point in this study was combined herbal extracts and vitamins. Table 8 shows the used herbal extracts and oils in this study. Also, Section5 has explained its method.  This vitamin is found in animals and its derivatives such as vitamin D 2 or ergocalciferol are found in plants [46]. Vitamin D deficiency leads to rickets, an inability to calcify the collagen matrix of growing bone and is characterized by a lack of rigidity in the bones, particularly in children. In adults, osteoporosis may occur. Moreover, based on studies in 1982, increased pigmentation of the skin may reduce and mediate factor (ultraviolet radiation) for synthesis of vitamin D [51].  In fact, when light energy or UV is absorbed by a precursor 7-dehydrocholesterol, vitamin D3 is synthesized. But, this form of vitamin D3 is not active. So, it becomes firstly to 25-hydroxyvitamin D3 (calcidiol) by the enzyme 25-hydroxylase in the liver. Then, within the kidney, 25-hydroxycholecalciferol acts as a substrate for 1-alpha-hydroxylase and producing 1,25-dihydroxycholecalciferol, which is the biologically active form of vitamin D3 (Figure 9). Calcitriol is then transported to the bones, intestine and other organs [46,52,53].
This form of vitamin D binds to intracellular receptors and function as one of the transcription factors to modulate gene expression in autoimmune disease such as psoriasis, because vitamin D acts as suppressor of immune system. Therefore, it can use in the topical treatment of psoriasis, for inhibiting the cell proliferation [46,52].

Vitamin A
Vitamin A 1 (retinol) and vitamin A 2 (dehydroretinol) are fat-soluble vitamins found only in animal products, particularly eggs, dairy products and animal livers and kidneys. Dehydroretinol has almost 40% of retinol activity. In fact, there is carotenoid as one of the provitamin in the plants and vegetables, which are changed into retinol in the liver [46].
Vitamin A was applied in the control of psoriasis disease. Derivatives of this vitamin influence on the proliferation rate and the differentiation of epithelia keratin and regulate its disturbances in autoimmune disease such as psoriasis [54].
Vitamin A or retinoic acid is relatively unstable and sensitive to oxidation and light. Antioxidant stabilizers such as vitamin E and vitamin C are sometimes added.

Vitamin C
Ascorbic acid is known as vitamin C ( Figure 10). However, this vitamin is an outstanding antioxidant in human blood plasma [55], but it is synthesized in the body of most animals except human. Also, it is in fresh fruit and vegetables. Vitamin C is a water soluble and can very fast degrade during cooking or in the presence of air [46,55].
Deficiency of this vitamin leads to scurvy disease, muscular pain, skin lesions, etc. Vitamin C is known as essential vitamin for the formation of collagen in skin, bone, tendons and ligaments [46]. Skin lesions characteristic in scurvy disease arises from low levels of hydroxylation in the collagen structure due to the lack of vitamin A [56].
Various doses of vitamin C used for skin burns and help to promote healing wound. This vitamin is very important for the prevention of cancer and its therapy. Finally, should be added, vitamin C works as an antioxidant and helps to provide renewal vitamin E [46].

Vitamin E
Tocopherol is known as vitamin E. It is one of the fat-soluble vitamins, which are found in more plants. Tocopherols exist in seed oils such as wheat, corn, safflower and soybean [46]. The vitamin has antioxidant properties and it can prevent the tissue destruction by radical. So, it can be effective for treating psoriasis ( Figure 11). Vitamin E and its derivatives reduce the effects of aging and help to prevent heart disease [46].

Vitamin B 5
Pantothenic acid is known as vitamin B5 ( Figure 12). This vitamin is water-soluble vitamin. Pantothenic acid, as part of the structure of coenzyme A, is important in metabolisms of carbohydrate, fat and protein. Also, this vitamin can help to treat wound and psoriasis lesions [46].

Material and method
In the mentioned cream, oily and aqueous extracts of medicinal herbal were formulated with vitamins (E, D 3 , B 5 , C, F) to apply on damaged skin. Herbal extracts include oily extracts of Santalum album, Rosa damascena, Arctium lappa, Matricaria chamomilla, Achillea millefolium, Glycyrrhiza glabra, Silybum marianum, Lavandula angustifolia, Foeniculum vulgare and aqueous extracts of Ziziphus spina christi, Avena sativa, Matricaria chamomilla, Aloe barbadensis, Pinus  eldarica and Cydonia seed-Mucus. The cream was prepared according to the water-in-oil (W/O) method. Then, cream was proposed to patients and was suggested to use two times a day ( Figure 13).

Results
Results were remarkable. All five patients were satisfied from inhibition of itching and inflammation of skin in first week. After 2weeks applying cream, fading skin redness and increasing skin flexibility and repair were noticeable. An important point of this cream no side effects and combining herbal extracts and vitamins that each alone has little effectiveness. These results are shown in Charts 1, 2, 3 and 4.  According to the results, it can say that the combination of herbal extracts (oily and aqueous) and vitamins is effective in improving the symptoms psoriasis disease.
For example, flavonoids and tannins in Glycyrrhiza glabra, Arctium lappa, Pinus eldarica and Avena sativa are effective to treat skin lesions such as psoriasis disease and polysaccharides in Aloe barbadensis and mucilage in Cydonia seed-Mucus not only are healing the skin wounds but also their malic acid make peeling skin dead cells. Moreover, provitamins such as vitamin A act as antioxidants and prevent damage of skin healthy cells [50]. Other herbal extracts were significant as collagen synthesis and wound improvement, antibacterial and epidermal-moisture Chart 2. Improvement of psoriasis lesions (in about 83%) for every five patients at the end of 4weeks.
Chart 3. Estimated skin flexibility to be 87% which shows a significant increase after 4weeks.
maintenance. Furthermore, vitamins E, B 5 , F, C and D 3 are used for skin recovery, inflammation relief and boost immune system. It could be noted that this herbal cream will probably inhibit common symptoms of psoriasis in the shortest time.
Nowadays, the using plants developed in many industries. In this regard, the cosmetic industry is not without interest. Tables 9 and 10 show, respectively, the common plants for skin and mostly used formulas for skin disorders. No. Scientific Name English name Used part Application  Table 9. List of plants to apply in cosmetic [57].

Skin disorder
Herbal extract/oil Quantity (ml) % Ingredients in cream