The COVID-19 pandemic spurred a notable increase in herbal supplement use, with sales of these products reaching $11.3 billion in 2020 — a 17% growth from the previous year. Immuno-supportive supplements, marketed as natural remedies that could enhance immune defenses, became especially popular.1 Patients with chronic health conditions were particularly drawn to these products for their perceived health benefits.1,2 However, emerging evidence suggests that while these supplements may support general health, they also carry risks for patients with autoimmune diseases, potentially exacerbating symptoms and triggering disease flares.3,4,5
The following review explores the benefits and risks of using herbal supplements for autoimmune disease management, with a focus on autoimmune skin conditions. It examines patient motivations, common supplement types, and the role of health care providers in guiding patients to balance traditional practices with safety considerations.
Herbal Supplement Use Among Patients With Autoimmune Diseases
Patients with autoimmune diseases, particularly those with skin-related conditions such as dermatomyositis (DM) and cutaneous lupus erythematosus (CLE), report significant herbal supplement use. In a study by Faden et al involving of 673 participants with autoimmune skin conditions, 32% included herbal supplements in their health regimen.1 This trend aligns with broader patterns of complementary and alternative medicine (CAM) use among patients with chronic illness seeking self-management options.1,3,6
The demographic patterns in supplement use are revealing. Younger patients and those from diverse ethnic backgrounds are more likely to use herbal supplements, with the highest usage (42%) among those aged 18 to 29 years and lower rates (23%) found among those aged 65 years or older. Additionally, usage rates vary significantly by ethnicity, with Hispanic patients reporting the highest usage (58%), compared with 30% of non-Hispanic White patients and 31% of Black patients, suggesting that cultural practices heavily influence CAM use within certain communities.1
Motivations for Use
Patients often turn to herbal supplements due to dissatisfaction with conventional treatments, which may have adverse side effects or limited symptom relief. 1 Results from a focus group study by Welz et al found that many patients seek autonomy in managing their health, incorporating CAM as either a complement to or substitute for standard treatments.1,7 This trend reflects a growing desire among patients with chronic diseases for nonpharmaceutical options that empower them in their health care journey.1-3
Cultural beliefs also play a strong role in supplement use, particularly among Hispanic and Asian communities where traditional medicine practices are often prioritized.1 This highlights the need for health care providers to be sensitive to cultural influences when discussing supplement use, which requires personalized and respectful patient guidance.
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Herbal supplement use often reflects cultural traditions, with higher usage found among certain ethnic groups. Providers should respect these cultural practices, fostering open communication that aligns health needs with personal values.
Commonly Used Herbal Supplements and Their Immunostimulatory Effects
Many patients view herbal supplements as gentler alternatives to pharmaceuticals.3,6 However, widely used herbs — including spirulina, elderberry, ashwagandha, chlorella, echinacea, and alfalfa — possess immunostimulatory properties that can worsen autoimmune symptoms, posing risks to patients with conditions like DM and CLE.1,5
Spirulina
Spirulina, marketed as a “superfood” for its high protein and antioxidant content, stimulates immune pathways such as toll-like receptor 4, which drives inflammation.1,3 Studies have shown that spirulina-treated cells from patients with DM produce elevated levels of proinflammatory cytokines.3 In a study by Ravishankar et al involving 450 patients, 14.6% of those with DM reported using spirulina, compared with 4.1% of patients with CLE and 4.3% of controls.6 Furthermore, 47% of users with DM reported disease flares linked to spirulina intake, based on the analysis by Faden et al.1
Elderberry
Elderberry, common in immune support products, is valued for its flavonoid content; however, it can significantly boost cytokine production, potentially heightening inflammation among patients with autoimmune diseases. Notably, Faden et al reported that 62% of patients with DM and 50% of those with CLE using elderberry experienced flares, making it a high-risk supplement for those managing autoimmune conditions.1
Results from in vitro studies have shown that elderberry induces inflammatory cytokines such as interleukin (IL)-1b, tumor necrosis factor alpha, and IL-6, with levels increasing up to 45-fold.1,8
Other Immunostimulatory Herbs
- Ashwagandha is an immune stimulant. Although its use is less commonly reported than spirulina or elderberry, it has been associated with autoimmune flare-ups among patients with DM.1
- Chlorella, a nutrient-dense algae, enhances cytokine production, which can overstimulate the immune system. Natural killer cell activity may increase with chlorella intake, which can increase the risk for disease exacerbation.3
- Echinacea stimulates macrophages and cytokine production and has been linked to disease flares, as seen in cases of pemphigus vulgaris.3
- Alfalfa, which contains L-canavine, has triggered lupus-like symptoms in animal studies and can provoke autoimmune responses, especially at higher doses.3
Potential Benefits: Immune Support and Holistic Wellness
While empirical support for herbal supplements use in autoimmune disease is limited, some patients report benefits, particularly with anti-inflammatory herbs like turmeric.1 In the analysis by Faden et al, turmeric was the most frequently used supplement, with 17 patients (7 with DM and 10 with CLE) reporting use. No adverse effects were noted, and 1 patient with DM even experienced symptom improvement.1
Herbal supplements may also provide essential nutrients, which are valuable for patients with dietary restrictions or nutrient deficiencies related to their conditions. For instance, chlorella and spirulina are nutrient-dense, and elderberry offers antioxidant benefits due to its high flavonoid content.3
Beyond physical benefits, herbal supplements can enhance psychological well-being, giving patients a sense of control that supports resilience and holistic wellness.1
Risks of Herbal Supplement Use
For patients with autoimmune diseases, particularly those with skin conditions, herbal supplements can present significant risks by unintentionally amplifying immune responses and triggering disease exacerbations.
Increased Disease Exacerbation Rates
A primary concern is the elevated risk for flares among patients with DM using herbal supplements.1,5 Faden et al reported that patients with DM were 4.19-times more likely to experience a disease flare following herbal supplement intake, compared against those with CLE. Approximately 31% of patients with DM who used herbal supplements reported a flare or new symptoms, compared with 10% of patients with CLE. Elderberry was linked to the highest flare risk, with 62% of patients with DM and 50% of patients with CLE experiencing exacerbations.1
Symptom Confusion and Self-Management Challenges
The overlap between autoimmune disease flares and side effects from immunostimulatory supplements can cause diagnostic confusion. Patients may misinterpret worsening symptoms as a progression of their autoimmune disease rather than as a reaction to supplements. This misattribution complicates disease management, as patients may persist in using these supplements, inadvertently worsening their symptoms and health.3,5,6
Recommendations for Patients and Health Care Providers
Given the potential risks, health care providers should actively discuss supplement use with patients. A proactive, culturally sensitive approach supports safety, autonomy, and evidence-based care.3,6
Routine patient assessments should include questions about herbal supplement intake, especially for patients with DM and CLE who face higher risks for flares. Early identification of supplement use enables providers to manage potential adverse effects.1
Providers should clearly explain the immunostimulatory risks associated with supplements like spirulina and elderberry, which are marketed as immune-boosting but may cause flares.1
Safer natural options, such as turmeric, can be recommended when possible. Turmeric’s anti-inflammatory properties and lack of immune overactivation make it a safer option for patients seeking natural remedies.1
Herbal supplement use often reflects cultural traditions, with higher usage found among certain ethnic groups. Providers should respect these cultural practices, fostering open communication that aligns health needs with personal values.1
Integrating CAM With Conventional Care
As herbal supplement use rises, understanding the risks and benefits is essential for patient care. While supplements like spirulina and elderberry pose risks, other options may support wellness. Providers should foster a respectful, open dialogue, supporting patient autonomy and safety through the use of culturally sensitive, evidence-based guidance.
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