REVIEW Topical Herbal Formulae in the Management of Psoriasis: Systematic Review with Meta-Analysis of Clinical Studies and Investigation of the Pharmacological Actions of the Main Herbs Shiqiang Deng, 1 Brian H. May, 1 Anthony L. Zhang, 1 Chuanjian Lu 2 * and Charlie C. L. Xue 1,2 1 School of Health Sciences, and Traditional and Complementary Medicine Research Program, Health Innovations Research Institute, RMIT University, Bundoora, VIC 3083, Australia 2 Guangdong Provincial Academy of Chinese Medical Sciences & Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China This systematic review and meta-analysis of randomized controlled trials (RCTs) examined the topical use of multi-herbal formulations for the management of psoriasis vulgaris. Studies were identified from PubMed, Cochrane library, EMBASE, and the Chinese databases CNKI and CQVIP. Methods were according to the Cochrane Handbook and meta-analyses used RevMan 5.1. Nine studies met the inclusion/exclusion criteria. The comparisons were with placebo and/or anti-psoriatic pharmacotherapy (APP) with two studies having three arms. The pooled meta-analysis data indicated the topical herbal formulae improved overall clinical efficacy (de- fined as 50% improvement or greater) when compared with: topical placebo (plus oral herbal co-intervention); topical APP alone; and topical APP (plus pharmaceutical co-intervention). Improvement was evident in Modified Psoriasis Area and Severity Index (PASI) score when topical herbal formula was compared to placebo (plus oral herbal co-intervention). No serious adverse events were reported. The most commonly used herbs were Sophora flavescens root and Lithospermum erythrorhizon root. Experimental studies reported that these herbs and/or their constituents have anti-inflammatory, anti-proliferative, anti-angiogenic, and tissue repair actions. These actions may at least partially explain the apparent benefits of the topical multi-herbal formulations in psoriasis. Copyright © 2013 John Wiley & Sons, Ltd. Keywords: psoriasis; topical; herb; systematic review; meta-analysis; inflammation; proliferation; angiogenesis; Sophora flavescens; Lithospermum. Abbreviations: AP-1, activating protein-1; APP, anti-psoriatic pharmacotherapy; Bax protein, Bcl-2-associated X protein; Bcl-2 family proteins, B-cell lymphoma 2 family of apoptosis regulator proteins; CD, circular dichroism; CEBO, Compound E-Bei ointment; CHK, cultured human keratinocytes; CI, confidence interval; CM, Chinese medicine; CNKI, China National Knowledge Infrastructure; COX- 2, cyclooxygenase-2; CQVIP, Chinese Scientific Journals Full Text Database; DNFB, 1-fluoro-2, 4-dinitrofluorobenzene; HaCaT cells, human epidermal keratinocytes; HeLa cells, a cell from a sample taken from a woman called Henrietta Lacks and was named using the two initials of her first (He) and last (La) names; HL-60, human promyelocytic leukemia cells; HM, herbal medicine; HMC, human mast cells; IFN, interferon; IgE, immunoglobulin E; IL, interleukin; iNOS, inducible nitric oxide synthase; IkB, I kappa B kinase; LPS, lipopolysaccharide; MCP-1, monocyte chemotactic protein-1; mRNA, messenger RNA; NF-kB, nuclear factor kappa-light- chain-enhancer of activated B cells; NHEK, normal human epidermal keratinocytes; NK-1R, neurokinin-1 receptor; NP-kB, nuclear factor-k-gene binding; PASI, Psoriasis Area and Severity Index; PCA, passive cutaneous anaphylaxis; PFS, prenylated flavonoid- enriched fraction; RCTs, randomized controlled trials; RevMan 5.1, Review Manager 5.1; RR, risk ratio; SAE, serious adverse event; SMD, standardized mean difference; TCM, traditional Chinese medicine; TNF-a, tumour necrosis factor-alpha; WM, Western medicine. INTRODUCTION Psoriasis affects approximately 2% of the global pop- ulation (Christophers, 2001; National Survey Organi- zation of Psoriasis Epidemiology, 1989). Although conventional treatments are effective, unwanted side effects can impact on the long-term management of psoriasis (Traub and Marshall, 2007). Complementary and alternative medicine, including herbal medicine (HM), is used by about 50% of psoriasis sufferers in Europe and America, often in conjunction with conventional anti-psoriatic pharmacotherapy (APP) (Baron et al., 2005; Fuhrmann et al., 2010; Jensen, 1990; Smith et al., 2009a). HM is commonly used in Asian countries under advice of dermatologists (Lin, 1993; Ouyang, 2007). A number of reviews have assessed the evidence for HM use in psoriasis. These include: HMs for psoriasis (Smith et al., 2009b; Steele et al., 2007; Traub and Marshall, 2007); HMs used topically (Li et al., 2012); HMs used internally (May et al., 2012); and acitretin combined with HMs (Feng and Xu, 2008). Other re- views have focussed on the pharmacological actions of specific HMs (Reuter et al., 2010; Tse, 2003). * Correspondence to: Chuanjian Lu. and Charlie Xue, Guangdong Pro- vincial Academy of Chinese Medical Sciences and Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China. E-mail: luchuanjian888@vip.sina.com (C. Lu), charlie.xue@rmit.edu.au (C. Xue) PHYTOTHERAPY RESEARCH Phytother. Res. (2013) Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/ptr.5028 Copyright © 2013 John Wiley & Sons, Ltd. Received 09 April 2013 Revised 21 May 2013 Accepted 24 May 2013