Integrative View of Atopic Dermatitis Part II: The TCM Basics

[This article was originally written for Acupuncture Today January, 2012, Vol. 13, Issue 01.  This basic overview of eczema is a composite of the information available in other posts on this blog.  It is intended as a more concise summary for practitioners to reference, though the list of tips at the end are for both practitioners to be aware of as well as directly useful for those who suffer from eczema.]

With regard to Traditional Chinese Medicine (TCM), there are many possible TCM patterns that correspond to the western diagnosis of atopic dermatitis (eczema).  In chronic cases, a rather complex overlapping of multiple syndromes can be present.  Practitioners should differentiate based on the presentation of lesions and patient history, and not just adhere to the list of TCM patterns I cover here.  Treatment should definitely include internal herbal medicine as atopic eczema definitely has underlying imbalances that cannot be effectively treated just using topical substances; though topical herbs can be quite helpful to ease symptoms such as itching, oozing, flaking and redness.  Diet improvements must also be considered for each patient.

In both infants and children, the most common TCM pattern for AD/eczema is Damp Heat.  For internal herbal treatment, it is important to determine which pathogenic factor is more predominant: Damp or Heat.  More exudate or weepy/oozing lesions indicate more Damp.  When Heat predominates, there may be more redness but there will also be more itching and dryness.  Chubbier babies who tend to sweat more tend to be more prone to a Damp condition.  Their eczema will likely have more exudate and lesions will form yellow crusts when they dry.  Thinner or weaker babies have a tendency to develop the drier type of eczema where Heat is more predominant (some sources differentiate this from Damp Heat and call it Fetal Heat).  In this type, the lesions will not be very weepy and there will be more dry, flaky crusts that look like white or gray “bran-like” scales on top of the lesions.  There might be cracking (fissuring) of the skin or even bloody scabs if scratching is intense.  In infants who are dependent on formula or in children who have a poor diet (lots of sugary foods, milk and dairy products, fatty or greasy foods), there will also be underlying Deficiency of Spleen and Stomach. The TCM pattern of Damp Heat accounts for most cases of acute eczema regardless of the age of the patient.  Both Damp Heat and Deficiency of Spleen and Stomach are a possibility in subacute stages of eczema.

The TCM pattern of Heat in the Blood is also a possibility during the childhood phase of AD/eczema as well as the adolescent/adult phase.  Though some Damp Heat may also be present, this pattern presents as the drier type of eczema, with more redness and more intense itching than when there is only Damp Heat.  Heart Heat is typically the underlying source of the Heat in the Blood.  Heat in the Blood pattern can occur in the acute or subacute stages of eczema.

Most chronic stages of AD/eczema are seen in the adolescent/adult phase.  The skin may exhibit lichenification: it is thicker, drier, rougher, and may have scaling.  Itching can be intense, especially at night which can lead to insomnia.  These cases are most often (but not always) diagnosed in TCM as Blood Dryness Due to Damaged Yin with Accumulation of Dampness.  This develops over a long period of time from Damp Heat.  The Heat damages Yin.  When the Damp accumulates in the skin and oozes out, this exudation also damages Yin.  This all eventually leads to dryness.  At first, the patient’s tongue may be puffy and moist with scalloped sides (signs of Dampness) but the moisture will decrease over time, cracks may form in the center and a red tip or sides may begin to develop (signs of dryness and Yin deficiency).  There may also be Blood Stasis which is indicated if the lesions remain hyperpigmented after healing.  This condition can be quite complicated to diagnose and to treat.  We must first Eliminate Dampness but caution must be used so as not to exacerbate the Blood Dryness and the developing Yin Deficiency. Next treat the source of the Dampness (usually Spleen Qi Deficiency) and then also Nourish & Move Blood and Nourish Yin.  It is sometimes necessary to both Eliminate Dampness and Nourish Blood and Yin at the same time.

In addition to addressing the patterns described above, most eczema presentations are also accompanied by Fire Toxins and Wind.  Herbal formulas for AD/eczema should also include herbs to Resolve Toxins (to treat the over-proliferation of staph bacteria that so often is present in the lesions) and to Dispel Wind (to address the itching).   While many cases of AD/eczema can benefit from herbal treatment combined with acupuncture, in cases with lesions over most of the body or cases with significant erythema (redness and inflammation), it sometimes may be best to avoid acupuncture since placement of the needles can sometimes aggravate symptoms locally, especially on the delicate skin of the face.

Tips to Improve AD/Eczema: (print out for your patients)

FOR KIDS, TEENS and ADULTS:

• Steer clear of common food allergens (a frequent trigger for atopic eczema): eggs, milk, peanuts, soybeans (including tofu), fish (esp. shellfish and shrimp), and wheat (or other gluten-containing foods like oats, barley and rye).  You may want to research food allergies to get more information or seek the help of a health care practitioner to help you determine which foods you may be allergic to.
• Avoid foods that are fatty, spicy or fried.  Don’t overindulge in sweets.  Don’t eat too much fish or seafood, esp. shrimp. Don’t consume too much dairy either (including milk, cheese, yogurt).  From the TCM perspective, excess consumption of any or all of these foods weaken the energy of the Spleen and encourage the development of energetic Dampness and Damp-Heat, a common underlying cause of eczema.
• Although eating too much fish seems to worsen eczema, increasing intake of fish oil (for the essential fatty acids) seems to help.  Try cod liver oil 3-4 grams daily for one month then cut back to 1 to 2 grams daily.  Flax seed oil is also an option: 1 tsp, 3 times per day (great as salad dressing if you dislike to swallow it alone).
• Take good quality probiotics (healthy bacteria for your gut) between meals.  They are a very important factor in keeping the immune system healthy.  Available at health food stores, usually kept refrigerated.
• If you also have airborne/respiratory allergies (dust mites, mold, seasonal pollens, animal dander, etc.) avoid those allergens as best you can.  Also stay away from people with colds/flu.  If you have any type of immune response it can trigger a flare-up of your eczema.
• Fluctuations in hormones can trigger eczema, so if you have irregular periods or thyroid issues, keep them well managed.
• Avoid over-washing your hands or over-bathing.  Keeping your skin clean is important, but over-cleansing can strip your skin of moisture and actually make your eczema worse.
• While eating oats may trigger eczema if you are allergic to gluten, bathing with oats can really reduce itching.  Try adding 2 cups of rolled oats (oatmeal) to your bath.  Soaps and lotions containing oats are good, too.
• Avoid glycerin soaps or lotions high in glycerin if you live in a really dry climate.  Glycerin is a humectant and is said to attract moisture to the skin.  This is great if the climate you are in is humid but if the air is drier than your skin, a humectant will leach water from your skin into the air.  Not helpful if you want to keep your skin from drying out.
• Apply moisturizer immediately after bathing.
• Avoid contact with wool: clothing, coats, socks, blankets, upholstery.
• Avoid extreme temperatures for air as well as water that contacts your skin.  Wash with lukewarm water, avoid really hot and humid climates, stay covered-up in very cold, windy or dry conditions.
• Stay happy!  Emotional stress and upset can exacerbate your skin problems, esp. eczema.  Deal with your stress in healthier ways than stuffing emotions or letting minor annoyances stress you out.  Try acupuncture, yoga or other form of regular exercise.  Walking each day will help more than you may think (take your dog with you
• If you have herpes simplex infection, get it under control.
• Apply only high quality skin care products to your face and body.  Cheap cosmetics and lotions often contain harsh or even dangerous ingredients.  Products with high alcohol content will also irritate skin.
• Ointments and lotions formulated specifically for skin with eczema can be helpful to reduce itching and soothe skin.

FOR BABIES:

• Keep their nails trimmed short (to break the cycle of itch-scratch-secondary infection of lesions).
• Keep the skin creases and folds of chubby flesh clean (legs, buttocks, groin, arms, armpits, neck).
• Avoid contact with wool blankets/clothing.
• If mom is breast feeding, mom should avoid foods that are fatty, overly sweet, spicy or fried.  Don’t overindulge in fish or seafood, esp. shrimp.  Don’t consume too much dairy either (including milk, cheese, yogurt). From the TCM perspective, these foods encourage the development of energetic Dampness and Damp-Heat.
• Don’t feed your infant/toddler the above foods.  Also avoid common allergens: eggs, milk, peanuts, soybeans, wheat and fish (already mentioned above).
• Keep baby clean, but don’t over-bathe them as too much washing can cause dehydration of skin and worsen the condition.
• Ointments and lotions formulated specifically for skin with eczema can be helpful to reduce itching and soothe skin.
• Mittens (or socks) on their hands at night can reduce scratching in their sleep.

If there is enough interest, I will also write a Part III in which I share specific herbal formulas for treatment.

Grrr!…Why Does It Keep Coming Back?

My face suffers from rosacea.  So I use the Zi Zai facial products faithfully (the Honey & Herb Scrub, the RosaceaHerbal facial toner and the weekly clay & herb mask).  However, right around Thanksgiving, I suddenly got really lazy.  I ran out of the toner (all I have to do is grab more from the stock at Zi Zai’s office but I haven’t), I have been too tired many nights to wash my face before bed, and I just haven’t made the time each week to do the clay & herb facial mask.  So guess what?  The redness returned to my cheeks and I have several little acne-like zits with more popping up each day…Grrr!  The Zi Zai products had been working so well to keep my symptoms in check.  Why did they come back so quickly?

Does it mean the Zi Zai products don’t work?  Does it mean I must be addicted to using those products?  Does it mean the rosacea is getting worse?  No, no and no.  The swift return of symptoms indicates that the underlying imbalance that has caused this condition to develop in the first place still exists.  It reminds me yet again that our skin is one organ that is part of a larger system.  And my larger system needs some tweaking.  This cannot come from slathering stuff on the outside.  I must treat it from within.  For me, this means I will schedule regular acupuncture appointments for myself and I will start taking internal herbs to address the systemic energetic imbalance of my system as a whole.  And I need to resume eating healthier foods, too.

I am one of the most impatient people you will ever meet.  I want results and I want them now.  I know what needs to change to get those results, so I believe that if I make those changes, the results certainly ought to follow rather soon thereafter, right?  No, it is not that easy or that quick.  I must learn to be more patient.  After all, every day I do things or am exposed to things that alter the balance of my body (chemically, emotionally, energetically).  So each day I must not only do things to counteract those negative influences, I must also do things that positively affect my health if I want to improve my skin.

So let this be a gentle reminder to all of you who have been frustrated with your skin, or those who expect sudden improvements when you try a new product, or those who are simply impatient like me: keep up with your skin care routine (don’t slack, even for a day) and be sure to address the health of your body as a whole.  Pay attention to the habits you have or the things you are exposed to that may be chipping away at your health each day (stress at work, eating crappy processed foods, staying out in the sun/elements too long, having unhealthy emotional relationships, not exercising your body, etc.).  Replace those unhealthy things with healthier choices and maintain or develop a good beauty routine.  Because beauty really does come from the inside.

Intergrative View of Atopic Dermatitis Part I: The Biomedical Basics

[This article was originally written for Acupuncture Today December, 2011, Vol. 12, Issue 12.  This basic overview of eczema is a composite of the information available in other posts on this blog.  It is intended as a more concise summary for practitioners to reference.]

WHAT IS ECZEMA?

Before we can differentiate eczema according to TCM, we must define exactly what we mean by “eczema”.  “Eczema” and “dermatitis” are two terms that are often used interchangeably but this is inaccurate and misleading and causes much confusion for patients and practitioners alike.   “Dermatitis” simply means “inflammation of the skin” and refers to many types of inflammatory skin diseases.  Skin inflammation that is also “eczematous” will have all of the following components: erythema (redness and inflammation), scale, and vesicles.  So “eczema” (or “eczematous inflammation” or “eczematous dermatitis”) can refer to any of a group of non-infective inflammatory reactions of the skin that have erythema, and develop scales and vesicles.  It is an acute, subacute or chronic (relapsing) inflammatory skin condition that is characterized by itching (pruritis).  The lesions range from pink to red, and when scratched will become weepy and crusted.  As the condition progresses, dryness of skin becomes more predominant and lichenification (hyperplasia of the skin) can occur due to repeated scratching or rubbing of the sites.

The most common forms of dermatitis (some of which can be eczematous) are: contact dermatitis (includes irritant contact dermatitis, allergic contact dermatitis, allergic contact dermatitis due to plants, and non-allergic contact dermatitis), atopic dermatitis (this is the dermatitis most commonly referred to as “eczema”), dyshidrotic eczematous dermatitis (a type of hand and foot dermatitis, a.k.a. “Pompholyx” or “vesicular palmer eczema”), neurodermatitis (a.k.a. lichen simplex chronicus), seborrheic dermatitis (a.k.a. “cradle cap” in infants), and photodermatitis.  Photodermatitis refers to inflammation of the skin that occurs when a topically applied substance is then exposed to sunlight.  This includes phytophotodermatitis (a skin reaction from exposure to plants + sunlight) as well as phototoxic and photoallergic dermatitis.

Of the above-mentioned types of dermatitis, the types that most popularly get referred to as “eczema” are atopic dermatitis and allergic contact dermatitis.  Arguably, most dermatologists will reserve use of the term “eczema” to be used interchangeably only with atopic dermatitis.  This distinction is made because underlying cause of each of these conditions is completely different and they have different long-term effects.  Allergic contact dermatitis is a type IV (cell-mediated, delayed) hypersensitivity reaction and the inflammation in the skin can be completely healed as long as exposure to the offending agent is identified and avoided.  Atopic dermatitis/eczema, however, has a much more complicated etiology (multiple underlying causes) and may possibly be associated with type I hypersensitivity (which is an immediate IgE antibody response).    Atopic dermatitis (AD)/eczema tends to become a chronic condition and is much more complex to treat.  This is the condition referred to as eczema that you will see most commonly in the clinic.  The condition usually begins in infancy (though it can manifest anytime) and may continue to recur in adulthood.  Diagnosis of AD/eczema is made based on clinical presentation, patient history, and (possibly) blood tests since IgE serum levels are elevated in many cases (though this is not a definitive criteria).  But be alert: many patients will come to you with a diagnosis of eczema (usually from their general practitioner) that is not truly atopic dermatitis (AD).   If it turns out that they actually have contact dermatitis and the causative substance can be found (though this may take some serious detective work), their rash can be resolved much more easily and you can spare them possibly years of frustration and discomfort.  Be sure to take a thorough health history of your patient so you do not make assumptions and so you perhaps can flush out what other practitioners may have missed.

ETIOLOGY OF AD/ECZEMA

The etiology of atopic dermatitis/eczema is not clearly understood from the western biomedical perspective.  In most cases AD/eczema appears in infancy.  Though there has been no proof yet that AD/eczema is inherited, studies show that babies are more than 80% likely to develop it if both parents have it.  Developing AD/eczema after the age of 20 is relatively uncommon though still possible.

According to the National Eczema Association, it is estimated that over 30 million Americans suffer from this form of eczema.  Though the exact cause is unknown, approximately 85% of people with eczema are found to have elevated serum IgE levels.  IgE antibodies in the blood indicate that eczema seems to be the result of a Type I hypersensitivity response.  Type I hypersensitivity is a type of immediate allergic response.  For reasons that are poorly understood (scientifically), some people are predisposed to having allergic reactions (respiratory, eye, digestive or skin symptoms) to substances that do not cause a reaction in other people.  So people who develop AD/eczema also tend to have asthma and/or allergic rhinitis (seasonal or year-round allergies).

In many cases of eczema (especially in children), the itchy rash gets worse with exposure to certain foods such as milk, eggs, soybeans, fish and wheat.  Inhalants, like dust mites or pollen, that cause other allergy symptoms (like sneezing, runny/stuffy nose, itchy eyes, sore throat), can also cause eczema to flare.  Another factor that may be involved with the cause or exacerbation of eczema is Staphylococcus aureus bacteria.  “Staph” bacteria are present on our skin in normal concentrations all the time.  In acute flare-ups of eczema there is often a much higher number of staph bacteria present on the skin.  These bacteria secrete toxins that seem to act as “super-antigens” (substances that cause the body to produce antibodies in response to their presence) and result in an immune response that produces inflammation and makes the eczema worse.

Other factors that exacerbate or trigger eczema:  skin dehydration (like from frequent bathing, over-washing of hands, dry climates), hormonal changes (like pregnancy, menstruation, thyroid problems), infections (staph, streptococcus, herpes simplex, candida), unfavorable external conditions (dry or cold weather), physically irritating fabrics (esp. wool clothing or blankets), and emotional stress.

Table 1:  Factors that exacerbate or trigger eczema:

• Milk
• Eggs
• Peanuts
• Soybeans
• Fish
• Wheat
• Dust mite allergies
• Pollen allergies
• Over-washing hands
• Frequent bathing
• Pregnancy
• Menstruation
• Thyroid imbalances
• Infections (staph or strep or herpes simplex)
• Dry, cold weather (decreased humidity)
• Sweating
• Wool clothing or blankets
• Emotional stress (this is not a cause of eczema, but certainly makes it worse)

PHASES OF AD/ECZEMA

There are a couple of ways to categorize the phases (stages) of eczema: by patient age and/or by duration of illness.

By patient age:

• Infant Phase (under age 2): Babies rarely are born with eczema, but the first signs of AD/eczema typically appear by the 3^rd month in infants.  Babies with rashes should always be evaluated by a physician (preferably a dermatologist) and in this case it is helpful to differentiate eczema from seborrheic dermatitis (“cradle cap”) and from miliaria rubra (“heat rash”) since we use different herbs for each case.  In the infantile phase of eczema, lesions most often appear on the cheeks, forehead and scalp, though may include the limbs and torso.  It often shows up in winter as dry, red, scaly cheeks or chin (which tends to get more irritated due to drooling and wiping).  It can look like the cheeks got rosy from sudden exposure to cold, but the redness does not go away.  Itchiness can lead to scratching which worsens the lesions.  They can become crusty and the discomfort from itching can lead to much crying and disturbance of sleep for the baby (and subsequently, the parents!).
• Childhood Phase (age 3 to age 12/puberty):  In this phase lesions most often are seen in the creases at the elbows and knees, around the neck, and at wrists and ankles.  Poor eating habits begun during this phase make it more likely that the patient will continue to suffer eczema during adolescence.  Scratching must be avoided so the tender skin does not become lichenified and so the rash does not become significantly worse.
• Adolescent/Adult Phase (puberty to early 20′s and beyond):  The lesions are most often found in the creases at the elbows and knees as well as around the neck.  Skin becomes drier and thicker where scratched.  Commonly, hands become involved after coming into contact with irritants or with hand washing that occurs much more frequently than in the earlier phases.  Inflammation of eyelids often develops since the skin is so delicate and frequently gets rubbed subconsciously.

By duration of illness:

• Acute eczema (original onset or an acute flare-up): Original onset of AD/eczema typically occurs in infancy and most cases appear by the early 20′s.  Acute flare-ups can occur at any time during the course of the disease.  Various types of skin lesion may be present during this phase: erythema (redness and inflammation), papules (tiny bumps), and vesicles (little bumps filled with fluid).  During this stage, lesions are progressing in severity of symptoms, growing in number, and/or covering a larger area or more areas of the body.  The lesions can quickly become infected, especially with frequent scratching.
• Subacute eczema:  In this phase, there is less redness and swelling, fewer vesicles or less exudate, smaller papules (bumps), and more dryness developing.  Subacute eczema can revert back to the acute stage if it becomes more severe or it can linger on to develop into chronic eczema.
• Chronic eczema: This stage occurs when the illness has existed for some time.  The lesions are drier, thicker, rougher, have scaling, and there may be more fissuring or cracks in the skin (or accentuation of the creases in the palms of hands).  Lesions may stay hyperpigmented (darker) or hypopigmented (lighter) after healing.

In Part II of this article we will examine the etiology of AD/eczema from the perspective of TCM as well as TCM pattern differentiation.  If there is enough interest, I will also write a Part III in which I share specific herbal formulas for treatment.

Poison Ivy: If You Can’t Avoid It, How to Treat It with TCM

Poison Ivy turns colors earlier than many other plants along the Front Range of Colorado, making it really easy to spot.

When I was 12 years old, my best friend Ali and I went leaf collecting in October.  We found the most beautiful leaves blazing with red, orange, yellow AND purple all on one leaf!  They were probably the most beautiful leaves we had ever seen.  We meticulously placed our collection in an album and admired our work with great satisfaction.   The next day our hands and faces swelled and itched and then we broke out in a terrible oozing rash all  over.  Those gorgeous leaves we had so proudly collected were poison ivy.  Ali’s dad tried to scold us and educate us on the identification of poison ivy, but he kept snickering because he knew we were paying the price for our ignorance and we would NEVER make that mistake again.  I was out of school for over a week and had to have steroid injections to bring the swelling down.  My face was so swollen you could only see the tip of my nose and my hands were gnarled with knobby, witch-like fingers that bubbled with ooze.  The blisters were also on the whites of my eyes and in my mouth and throat.  The discomfort was unbearable.  UNBEARABLE.

Poison Ivy in Summer. Can grow as a low ground cover, a large shrub, or creeping vine.

Poison Ivy as an Allergen:

Poison ivy, poison oak, and poison sumac are all plants commonly found in the United States and the resultant rash from contact with these plants is the most common cause of allergic contact dermatitis.  They belong to the family of plants known as Anacardiaceae and the genus Toxicodendron (formerly known as “Rhus” which is why the rash from these plants is still sometimes referred to as Rhus dermatitis). Allergic contact dermatitis due to plants (allergic phytodermatitis) is a Type IV Sensitivity Reaction, meaning you have to be exposed to the substance at least once before developing an allergy to it.  The oleoresins (milky/resinous sap) found in the Toxicodendron plants are referred to as urushiol.  This urushiol is made up of a mixture of chemicals, including a group of haptens called Pentadecylcatechols: these are the specific chemicals within the urushiol that are the sensitizing substances responsible for causing allergic skin reactions from contact with these plants.  The rashes from poison ivy, poison oak, and poison sumac will each look identical regardless of which plant caused it because each of those plants contains the same allergens.  Interestingly, other plants related to poison ivy that can also cause hypersensitivity reactions include cashew nut trees, mango trees, Japanese lacquer trees, and Brazilian pepper.   Unroasted cashew nuts, mango rinds, and furniture lacquer can all cause similar rashes (in older TCM texts, allergic contact dermatitis is actually referred to as “Lacquer Sores”).

The urushiol that contains the allergens in poison ivy can be found in the all parts of the plant: the leaves, the stem, the seeds, the flowers, the berries and the roots.  That means you can get a rash from poison ivy AT ANY TIME OF THE YEAR if you come into contact with ANY PART of the plant.  Not only that, but you have to wash the urushiol off immediately upon exposure (soap and water just fine):  after 10 minutes only 50% of the urushiol will come off, after 30 minutes only 10% will come off, and after an hour you are pretty much screwed because it cannot be removed.  So your best bet is to avoid exposure in the first place.

Avoid Exposure:

Poison Ivy can look like a shrub or vine or ground cover so beware of all its forms.

Being able to clearly identify poison ivy is your key to avoiding it.  This resilient plant can take many forms:  low ground cover, creeping vine (though it technically isn’t an “ivy”), or tree-like shrub.  It is lighter green in spring, dark green in summer, and all sorts of beautiful colors in the autumn.  Its leaflets are almond-shaped and grow in groups of three, hence the warning “Leaves of three, leave it be!”  Some leaflets will have one or a few notches along their edge, but not always.  Often, the leaves will have a sheen to them and they may droop just a little bit.  For more info on identifying this poison ivy, check out this Wikipedia article (I rarely consider Wikipedia a reliable source, but this article gives a useful description of the plant and has good photos).

So obviously, to avoid the itchy rash associated with poison ivy, avoid coming into contact with any part of the plant.  Urushiol can penetrate damp clothing, so wet clothing will not offer full protection from poison ivy.  It is also important to immediately wash any clothing that came into contact with the plant because if you later come into contact with contaminated clothing you can be exposed to the urushiol and still develop a rash.  Pet fur is also something to avoid if your dog or cat may have brushed up against poison ivy as the urushiol can be transferred to your skin if you pet them.   Do not burn poison ivy (any part of the plant) as particulates in the smoke can carry the urushiol and get to your throat.  You CANNOT contract the rash by coming into contact with another person who has poison ivy rash because the blisters do NOT contain urushiol.

Although we are talking about poison ivy, it is worth mentioning that you should also avoid eating unroasted cashew nuts and mangoes that are unpeeled as contact with these foods can expose your lips to the urushiol from those plants.

Clinical Presentation:

A close-up of the characteristic linear lesions with fluid-filled vesicles

Depending on previous sensitization, the poison ivy rash can appear as quickly as 8 hours after contact with the plant or as long as 12 days later.   New lesions can continue to appear for more than a week after the initial rash symptoms develop (this is not due to spreading the urushiol from scratching blisters as the blisters do not contain any urushiol).  Severity of the reaction will vary in the individual based on their level of sensitization, how much urushiol contacted the skin, and where the urushiol contacted skin (some regions of the skin are simply more sensitive).  Linear lesions are the telltale signs of poison ivy rash because they form when the skin brushes against a leaf, drawing it along the skin.  Linear trails of blisters can also be formed when the skin is scratched while the urushiol is still on the skin and thus gets spread along in a line.  If a person brushes up against animal fur that has the urushiol on it then the rash tends to form in a more diffuse pattern.  (Or if you inadvertently collect the leaves and carry them around for a while you will get the rash EVERYWHERE!).

Linear lesions with multiple areas of erythema

Usually the rash starts with itching before any redness or blisters appear.  Itching can be very intense.  If only a small amount of urushiol contacted the skin, then it may only develop some minor erythema (redness and inflammation).  But larger quantities of the urushiol can lead to severe vesiculation (lots of blisters filled with clear fluid).  Scratching can lead to secondary infection of the lesions so try not to scratch even though it itches like crazy!  Blisters can become crusty after rupturing.  Large blisters can be drained but be sure not to rip off the top layer of the blister.  In severe cases, hemorrhagic blister can form (blood in the blisters).

Home Treatment:

Once the allergic substance is removed from contact with the body, allergic phytodermatitis (allergic contact dermatitis due to plants) will usually resolve within 2 weeks all on its own.  But the discomfort from such rashes is worth treating to reduce the intensity of symptoms and to possible decrease the duration of the rash.  Home remedies that offer some soothing relief from itching and inflammation include cool baths with colloidal oatmeal (Aveeno) and the application of cold, wet compresses.  Cold compresses can be applied for 20 to 30 minutes several times per day as necessary to control symptoms for the first few days.  Calamine or Caladryl lotion can be applied but extended use can lead to over-drying of the skin.  I prefer using paste made from French Green Clay (often available for purchase in health food stores).  Mix the green clay with enough water to form a paste the consistency of paint (not as thick as mud or it will be too difficult to spread on, but so watery as to drip while you are applying it).  Let it dry completely (about 10 to 15 minutes) before soaking it off in a cool bath; DO NOT SCRUB IT OFF.   Scrubbing may feel very satisfying in the moment, but it will irritate the skin and worsen the inflammation.

Natural TCM Treatments:

Acupuncture: Both acupuncture and Chinese herbs are helpful to reduce the symptoms of itching and inflammation.  For the practitioner, acupuncture points to choose from include Bai Chong Wo, LI 11, LI 4, TW 2, SP 10, SP 6, BL 40Ying-Spring points along affected channels, or bleeding Jing-Well points along affected channels.  I really like connecting SP 10 to SP 6 with electro-stim to help reduce itching and redness for these kinds of rashes.  Plum blossom tapping around the edges of lesions can reduce itching but do not be too aggressive with it.

Internal Herbal Formula:  The main TCM diagnosis for poison ivy is Wind Damp Heat with Heat Toxins.  The Treatment Principal is to Dispel Wind, Stop Itching, Clear Heat, Dry Damp and Resolve Toxins.  I think herbs are great to treat poison ivy and my patent formula of choice is Xiao Feng San to control itching.  The patent form will work well, but if there are many blisters you may choose to prescribe granules so you can add more herbs to Dry Damp and Resolve Toxins to make it even more effective. [See comments below for additional TCM Differentiation and treatments]

Di’s Poison Ivy Formula: (For Acute Symptoms of Itching with Fluid-filled Vesicles)

Ku Shen 9 grams

Huang Bai 9 g

Shi Gao 15 g

Fang Feng 9 g

Bai Xian Pi 9 g

Xuan Shen 6 g

Cang Zhu 6 g

 

If itching is really severe, also add Bai Ji Li and Chan Tui.  If lesions are really weeping, add Di Fu Zi.  If the rash is mostly on the upper body/face, add Sheng Ma.  For children who can’t stop scratching, add Zi Hua Di Ding to reduce risk of secondary bacterial infection in the lesions.

External Treatment: You can take the above internal formula and use it as a cold compress.  Either make the decoction and let it cool or use powdered raw herbs (not concentrated granules) to make a tea.  Steep a clean cloth in the cooled tea/decoction and apply for 20 minutes at a time, 3 times per day to the affected areas.  You can also make an herbal paste.  I like adding Qing Dai and Shi Gao to a little bit of French Green Clay (cosmetic clay).  Add enough water to form a paste the consistency of paint and spread it on the lesions (be careful – it may temporarily stain fabric).  Allow to dry fully before rinsing off.  Rinse off in a cool shower or bath – do NOT try scrubbing the dried paste off as this will aggravate the already irritated skin instead of helping to ease symptoms.

Have a good home remedy for poison ivy that you’d like to share?  Leave a comment and share your story below.

We Moved!

Sorry I haven’t written a blog post recently but we were quite busy moving our offices.  We moved just 2 blocks from our previous location, so not much has changed.  And as soon as everything (including all our wonderful herbs) are organized again, I can devote more time to blogging and sharing useful info about skin problems and how to help them with TCM.  If you have any requests about blog topics, let us know by emailing us at info@zizaidermatology.com or by posting a comment below.

Incidentally, if you ever decide to move across town (or even just 2 blocks away), rent a dang moving truck and get it all done in one fell swoop.  Making multiple little trips with a pick up truck is a pain in the butt and the time spent is not worth the few dollars you will save.  I can make more money, but I can’t get that time back.  Ah well, live and learn.

Tips to Manage and Improve Rosacea

As we have discussed in earlier posts, rosacea is a chronic inflammatory condition that affects the face. Any kind of heat will make the symptoms worse, so when trying to manage your rosacea, it will be vital to avoid all external and internal sources of heat.  The following is a list of things to avoid that make the symptoms of rosacea worse, followed by a list of things you should do (or do more often) to help improve symptoms and slow the progression of your rosacea.  If you have some tips that have been helpful for you and you don’t see them in this post, please share with us by leaving a comment below.

Things To Reduce or Avoid:

• Reduce all triggers of flushing and blushing.  Things that commonly cause flushing or blushing  include: emotional factors such as anger or embarrassment, stress, heat (sources detailed below), and physical over-exertion.  Biofeedback can very helpful to manage your emotional reactions and reduce your body’s negative responses to stress.
• Reduce exposure to things that heat your face or raise your body temperature.  As best you can, avoid sunlight, over-exertion, hot climates, exercising in hot temperatures (this includes those hot yoga classes that you might really enjoy), hot showers/baths, steam baths, hot tubs, and drinks and foods that are hot in temperature (tea, coffee, soup).  Though I often recommend facial steams as part of a good beauty routine, people who have rosacea should not stick their faces over a pot of steaming water; the benefits do not outweigh the risks of vasodilation.
• Reduce intake of substances that cause accumulation of internal Heat.  Avoid spicy foods, dairy, fried foods, alcohol, and smoking.  These things can also cause direct flushing of the face, so there is more than one reason to avoid them.
• Stop Smoking and avoid alcohol.  I know I just listed these two things, but it is worth repeating.
• Avoid chemical irritants.  Avoid harsh cleansers, cheap cosmetics and lotions or moisturizers with too many chemical ingredients.  Make your own gentle facial scrub from simple, natural ingredients.
• Avoid physical irritants.  Reduce the friction on the delicate skin of your face.  Be gentle when cleansing: don’t scrub too often or too roughly and don’t use pre-made scrubs that are too abrasive.  Dry your face by gently patting it with a soft towel; don’t rub it dry or use a rough paper towel.
• Keep skin clean to avoid secondary bacterial infection, esp. of the nose.
• Reduce direct face contact with pets.  Though Demodex mites in humans are thought to possibly have a correlation to the development of rosacea, they have not been proven to be an actual cause.  Additionally, it is rare for the species of Demodex mite found on dogs to be transmitted to humans.  Nevertheless, don’t rub your face on your pets or let them sleep in your bed.  They have lots of bacteria (and who know what else!) on their fur, so you should keep your sensitive facial skin away from them.
• Reduce your consumption of foods that cause inflammation, such as polyunsaturated vegetable oils (like safflower, sunflower, corn, peanut and soy oils), wheat/gluten, sugars, and simple carbohydrates.  Do your best to eat more foods that have anti-inflammatory affects.

Things To Do To Improve Rosacea:

• Wear sunscreen to avoid getting sunburn.
• Use an apple cider vinegar toner.  Apple cider vinegar is your face’s friend – it helps restore the acidity to the acid mantle.  This acid mantle is the thin, slightly acidic film on the surface of your skin that helps reduce the over-proliferation of bacteria.  This will reduce the pustules and papules (blemishes) that can develop as rosacea progresses.  Make your own toner or purchase our herbal toner formulated specifically for skin suffering from rosacea.  Apply the toner to a dry face after cleansing.
• Apply cool compresses or cooling clay masks.  Cool compresses (especially with herbs) can reduce the sensation of heat and may help minimize erythema.  Use our facial teas formulated specifically for rosacea or make your own chamomile tea and let it cool in the refrigerator for an hour.  Dip a cloth in the cool tea and apply to your face.  Do this daily or after exercise/exertion to reduce the heat in your face.  A weekly mask of cosmetic clay can help sooth skin and draw out toxins (very useful when there are pustules and papules).  Because I actually have rosacea, I formulated wonderful clay & herb facial masks with Chinese herbs that I find more soothing and effective than clay alone.  To learn more about how to use them read this beauty routine post.
• Take a Vitamin A supplement: Up to 10,000 IU daily is safe to take on your own until skin improves.  Consult with your dermatologist or regular doctor if you want to take more than that (some sources suggest 50,000 IU of Vit A is useful for rosacea if taken for a short period).  Then reduce to 5,000 IU daily.  Caution: if you are pregnant, you should consult your healthcare provider before you take any Vitamin A supplementation.
• Take a Vitamin D3 supplement.  While some people are actually deficient in Vitamin D (blood tests can reveal this), I believe people with inflammatory conditions should take in more Vit D3 even if they aren’t deficient and this may be especially true for those with rosacea who avoid sun.  Vitamin D is essential for many reasons, including reducing inflammation and minimizing unhealthy levels of harmful bacteria in the body.  Daily recommended dosages are currently being debated.  The current RDA for adults under age 70 is 600 IU (daily) but some health providers recommend taking as much as 2,000 IU to 4,000 IU daily.
• Take probiotics.  Supplementation with “friendly” bacteria like Lactobacillus acidophilus, Lactobacillus casei, or Bifidobacterium bifidus, can be helpful for inflammatory skin conditions like rosacea because they can aid with digestion to reduce the build-up of pathogenic Heat and they may help reduce the amount of pathogenic bacteria in the body that aggravate inflammation.
• Take a supplement for essential fatty acids (EFAs): fish oil concentrate (3 to 10g daily) or flaxseed oil (1 to 3 tblsp daily) plus Vitamin E (400 IU to 800 IU daily).  Essential fatty acids help reduce inflammation which helps skin stay healthy and reduces inflammation.
• Eat foods high in omega-3 fatty acids: salmon, tuna, sardines, flaxseeds, flaxseed oil, walnuts, kidney beans, pinto beans, spinach, broccoli, cauliflower, winter squash, papaya.  (Click the following links for more foods that reduce inflammation in the body and more tips to reduce inflammation).

Were these tips helpful?  If so, please repost this and share with your friends.  Got more tips to share with us?  We’d love to hear them.  Leave us a comment below.

How to Treat Rosacea with Chinese Herbs and Acupuncture

In a previous post we described the different TCM patterns associated with rosacea.  This post covers how we treat those patterns with Chinese herbal medicine and acupuncture.  Since rosacea is a chronic inflammatory condition, Heat is the most predominant pathogenic factor involved in this skin disease.  Acupuncture and herbs are effective at clearing this pathogenic Heat to help reduce the symptoms of erythema (redness), flushing, acne-like blemishes, and to prevent or minimize progression of the condition.  If you have rosacea, seek treatment as soon as possible because the earlier you halt the progression of this condition the better (bring a copy of this post in to your practitioner if they are unfamiliar with treating this kind of skin issue).  Practitioners should be aware that TCM can be an invaluable help if treatment is persistent.  However, reversal of telangiectasia (vasodilation of capillaries) is highly unlikely and any hypertrophy of the nose (rhinophyma) that occurred prior to treatment will be unchanged. (Laser treatment for unsightly capillaries and cosmetic surgery for rhinophyma may be an option).

The initial and most common underlying TCM pattern seen in rosacea is Accumulation of Heat in the Lungs and Stomach.  This is when there is much flushing but not yet much telangiectasia and not many papules or pustules.  The treatment principal here is to Clear Heat from the Lungs and Stomach.  The herbal formula of choice is Pi Pa Qing Fei Yin (with modifications) which should be comprised of the following herbs (though it varies based on the source text):

Pi Pa Ye         9g

Sang Bai Pi  12g

Huang Qin   9g

Di Gu Pi        9g

Mu Dan Pi   6g

Zhi Mu         6g

Gan Cao      3g

Hong Hua   6g

Shi Gao       18g

This herbal formula has several herbs to Clear Heat from the Lungs and the Stomach, as well as herbs to Cool the Blood and Remove Stasis.  This is important because if the rosacea is allowed to progress, Heat in the Blood will begin to develop and eventually Blood Stasis will form.  By knowing where the disease will go next, we can preempt it and slow or halt its progression.  If there is much flushing with the consumption of alcohol (often this can occur moments after taking a sip), add Zhi Zi (6 to 9 grams).

When the flushing becomes more permanent and dilation of capillaries in the face occurs, the pattern of rosacea is Heat in the Blood and the strategy becomes to Clear Heat (from Lungs), Cool Blood and Move Blood.  Liang Xue Qing Fei Yin (with modifications) is the herbal formula of choice:

Sheng Di Huang  15g

Mu Dan Pi              9g

Huang Qin             9g

Shi Gao                15g

Zhi Mu                   9g

Chi Shao Yao      9g

Sang Bai Pi          9g

Pi Pa Ye                9g

Gan Cao               6g

I am a huge fan of Huai Hua (pagoda flower) and Hong Hua (safflower) for treating the telangiectasia of the face so I always add 6 to 9 grams of each of those two herbs to the above formula as well.

When the rosacea progresses to the pattern of Blood Stasis, the redness of the face is darker, the skin becomes thicker, and there are more pustules.  At this phase, treating rosacea is very much like treating cystic acne.  We need to Invigorate the Blood and Remove Blood Stasis.  A good herbal formula to turn to is Tong Qiao Huo Xue Tang (with modifications):

Dang Gui Wei  9g

Chi Shao Yao  9g

Tao Ren           9g

Hong Hua       9g

Bai Zhi              6g

Chuan Xiong   6g

Sheng Di Huang   9g

Mu Dan Pi       12g

Huai Hua       9g

Sheng Ma      3g

Da Huang      3g

This formula removes Blood Stasis specifically from the head.  I often add Zhi Zi (9g), especially if the patient refuses to stop drinking alcohol.  If there are lots of pustules, I also add Kun Bu and Hai Zao (9 to 15 grams each) to the above formula.  Note that these two herbs are considered incompatible with Gan Cao.  The unmodified formula Tong Qiao Huo Xue Tang is available in patent form from Mayway.

Regardless of the other patterns present, if the patient’s rosacea is worse just prior to or during her period, be sure to also include herbal (and acupuncture) treatment to Regulate the Chong and Ren Mai.  This can be done by switching to a different formula in the second half of the menstrual cycle or by adding a few herbs to the base formulas listed above, or by having the patient come for additional acupuncture prior to her period starting.

Topical herbal options can help reduce redness and prevent papules and pustules from forming.  Our Zi Zai Dermatology webstore has facial masks currently available and we will soon have a facial toner with herbs that have been found to kill Demodex mites (which have been implicated in rosacea, though not proven to be an actual cause).

Acupuncture can be very helpful in the earlier stages of rosacea to Clear Heat from the Lung and Stomach and to reduce flushing and heat rising to the face.  Acupuncture points to choose from include: LI 11, LI 4, LU 5, LU 10, ST 44, ST 36, SP4, SP 6, SP10 to reduce heat rising to the face and to clear organ heat.  Some practitioners will needle the face directly and useful points include Yintang, ST 4, LI 20, Bi Tong, DU 25.  I will choose points on the face when there is much stagnation in the face, especially around the nose, but I typically stay away from them if there is only mild flushing.

Reducing the causes of pathogenic Heat accumulation in the body is very important to the treatment of rosacea.  In our next post we will discuss tips on how to do that so patients can better manage symptoms on their own and improve treatment outcomes.

Two Quick and Simple Acne Tips

If you have read any of my posts, you know that I always stress the fact that most chronic skin conditions must be healed from the inside out.  As an acupuncturist and herbalist, I use the tools of my trade (acupuncture and Chinese herbal medicine) to improve the overall health of the body as the main treatment for skin problems.  But there are still some really simple things you can do at home to help reduce blemishes and improve the quality of your skin.  Below are 2 simple and inexpensive changes you can do today that will really make a difference to your complexion.  This cleanser and toner are great for skin that suffers from blemishes, acne, uneven skin tone, dryness, or rosacea.  They are also great if you just want to simplify your beauty routine or start using more wholesome, natural products on your skin.

1. Make your own wholesome cleanser.  Stop using harsh chemical facial cleansers or soap.  Instead, make your own facial cleanser using honey and oatmeal (rolled oats – like the kind you buy in the cereal aisle).  Get a small clean jar (glass or plastic is fine, just be sure it is really clean).  Dice up the rolled oats or grind them in a coffee grinder (but not too finely).  Add enough to fill your jar halfway.  Fill the rest of the jar with honey and mix it in.  You now have an awesome facial cleanser that you can use twice daily.  Be sure to apply it to a damp face (otherwise it will be way too sticky) and rub in GENTLE circles then rinse it off.  The honey has wonderful anti-bacterial properties yet won’t dry out your skin and the oats gently exfoliate without irritating your skin.
2. Use a vinegar toner.  Make your own toner using apple cider vinegar (ACV) and distilled water.  In a small bottle, add half distilled water and half ACV.  If that smells too strong for your liking, water it down a bit (two-thirds water, one-third ACV).  Apply to your clean, dry face using a flat round cosmetic pad or cotton ball.  Leave it on – it will dry quickly.  Apply it after every time you wash your face (twice daily).   Apple cider vinegar is your face’s friend – it helps restore the acidity to the acid mantle.  This acid mantle is the thin, slightly acidic film on the surface of your skin that helps reduce the over-proliferation of bacteria.  If you want an even more effective toner, check out our herb-infused AcneHerbal™ Facial Toner.

I can’t make any guarantees, but I think you will be impressed at how quickly these 2 simple tips will improve the texture and appearance of your face (or chest or back) in just a few days.

Rosacea According to Chinese Medicine

The 3 main TCM (Traditional Chinese Medicine) patterns seen in rosacea are Accumulation of Heat in the Lungs and Stomach, Heat in the Blood, and Blood Stasis.  Let’s examine each one individually.

Mild Rosacea (I'm not wearing any makeup here)

In the earlier stages of rosacea, the most common TCM pattern is simply Accumulation of Heat in the Lungs and Stomach.  Heat begins accumulating in the Stomach often due to overindulgence of spicy foods, alcohol or strong tea (this isn’t always the case, though).  The Heat in the Stomach can go directly to the cheeks via the Stomach Channel and/or it “steams” to the Lungs where it eventually rises to the face via the nose.   At first, when the Heat is just beginning to accumulate, the face flushes easily but it is only temporary.  This redness blanches upon pressure (i.e. it becomes white when you press on it).  Eventually the redness becomes persistent erythema that never goes away entirely and gets worse upon exposure to heat (hot water, hot air, rise in body temperature due to exertion or fever).  Patients often report that their face flushes almost immediately after drinking alcohol or eating spicy foods.   Other accompanying symptoms may include dry mouth and nose, thirst, and constipation.  The tongue will likely be red with a thin yellow coat and the pulse will be rapid.  If tiny papules or pustules form (usually on the cheeks or nose) this often indicates Heat Toxins are also present.

Increased redness, more papules, and dilated capillaries

As the condition progresses, the erythema (redness) becomes darker and capillaries become dilated (called telangiectasia).  This is the development of Heat in the Blood.  Pinpoint papules or larger pustules form more fequently (sometimes rosacea and acne are difficult to differentiate, but acne will not have the diffuse erythema or the telangiectasia).   In addition to the redness in the cheeks (and possibly forehead), the bulb of the nose may become red.  In rosacea, this Heat in the Blood is often secondary to Disharmony of the Ren & Chong Vessels.  [According to Traditional Chinese Medicine (TCM) the energy (Qi) in the body circulates through a network of vessels (also called “channels” or “meridians”).  The Chong and Ren vessels are particularly important in woman’s health because fertility and the menstrual cycle depend on the flow of Qi and Blood through these channels.]  When the Chong & Ren Vessels are involved, women will often experience worsening of symptoms or have sensitive facial skin right before or during their periods.  Accompanying symptoms can include drier stools, yellow urine, and irregular menses in women.  The tongue most likely will be the same as in Heat in the Lung and Stomach (red with a thin yellow coating).  The pulse will be rapid and possibly even slippery.

Rhinophyma, a.k.a "W.C. Fields nose"

When the bulb of the nose becomes chronically inflamed and darker red, Blood Stasis has become the predominant pattern.  The skin on the nose may become thicker with more dilated blood vessels, enlarged pores and oily skin.  Rhinophyma might eventually develop (this is irreversible hypertrophy of the nose); this can be very disfiguring and cosmetic surgery is often the only treatment.   There will likely be more papules and pustules on the nose and cheeks and forehead with generally more oily skin.  From the TCM perspective, this Blood Stasis develops from pre-existing Accumulated Heat in the Lungs and Stomach or the Disharmony of the Chong & Ren Vessels.  If Cold or Wind-Cold invades the face (from exposure to cold air or cold water), the skin’s exterior defenses become blocked and the Cold settles in the skin preventing the ventilation of accumulated Heat in the face.  This combo causes local Stasis of the Blood (and Qi).  The patient’s tongue will be dull red or purple and may even have ecchymosis (dark purple spots) with a sticky yellow coating.  The pulse will likely be choppy or wiry.

So how do we treat rosacea with Chinese Medicine?  And what can YOU do to improve your rosacea?  You will have to wait for the next posts to find out!

TCM Differentiation of Common Psoriasis

[This article was originally written for Acupuncture Today June, 2011, Vol. 12, Issue 06 and is intended for practitioners]

Psoriasis is a chronic, recurrent, inflammatory skin disease that affects approximately 3% of the population. It is thought to be a genetic disease with immune-mediated skin lesions that (according to western scientific medicine) has no cure. The various types of psoriasis are categorized according to morphology or by location of lesions. The most common morphologies include chronic plaque psoriasis (“common” psoriasis), guttate psoriasis, pustular psoriasis, erythrodermic psoriasis and psoriatic arthritis (may or may not have skin lesions). More than one form of psoriasis can be present concurrently, and one type can transform into other types. Common plaque psoriasis is the type most often seen in the clinic.

Common Plaque Psoriasis

Psoriasis is characterized by hyperproliferation of skin cells and thus is often referred to as “The Living Cancer.” The skin under the lesions in this disease has a cell turnover rate that is 7 times faster than normal skin cells. In normal healthy skin, it takes 28 days for a cell to progress from the deeper layers of the epidermis outward to the surface where it then dies and is shed. But in the lesions of common psoriasis, this process is sped up and occurs in only 4 days. These cells then build up on the surface of the skin and scaly plaques are formed.

Western medicine has very few helpful solutions to offer psoriasis patients beyond immunosuppressant drugs, but Traditional Chinese Herbal Medicine can have a profound benefit for your patients if you differentiate correctly. There are numerous TCM patterns associated with the various forms of psoriasis. This article will discuss the 4 patterns seen most commonly in the clinic: Heat in the Blood, Blood Deficiency, Qi & Blood Stasis and Disharmony of the Chong & Ren Mai.

Heat in the Blood Stirs Up Wind is the most frequently seen pattern of common psoriasis. In this acute stage, the lesions appear abruptly and are usually bright or dark red. This stage is progressive, meaning the lesions are increasing in size and/or number of lesions. They eventually develop white or silvery scales that shed easily when dry, revealing the characteristic Auspitz’s sign (little dots of blood that appear when you pull the thin scale off). The skin often will be itchy, too, but this may not be true in every case. The lesions can spread to normal skin if scratched. Other accompanying symptoms may include: constipation, dark urine, thirst, and irritability. Female patients may also complain of heavy periods. The patient’s tongue will likely be red with a yellow coat, and the pulse may be rapid. The treatment principal is to Clear Heat, Cool Blood, Eliminate Wind (and Resolve Toxins).

When a patient has Heat in the Blood Stirs Up Wind, the episode appears abruptly and/or is progressive. But Blood Deficiency Leads to Wind and Dryness occurs during the stable phase of common psoriasis – the lesions are not growing in size and there are not many new lesions appearing. The skin is not bright red; rather the lesions are a paler red or even dull pink. They are drier and have white (or silvery) scales and may be itchy. Accompanying symptoms can include pale complexion, lassitude/fatigue, insomnia, dry skin (not just the psoriasis lesions), dry hair, dry eyes and brittle nails. In women, the period might have scanty flow or there might be amenorrhea. The patient’s tongue will most likely be pale with a thin coat (or none at all) and it may be dry. The pulses will be thin or wiry. In this pattern, the treatment principal is to Nourish (Liver) Blood, Dispel Wind, and Moisten Dryness.

When there is Qi & Blood Stasis involved in psoriasis, the lesions typically are darker in color: dull red, purple or even brown. From a little distance they may even look like a bruise (but unlike typical bruises, the border between the lesion and the healthy skin will be very clearly demarcated). They often have silvery-white scales and tend to be thicker than the lesions seen in the other patterns; some older lesions may resemble oyster shells. In this phase, the old lesions are usually fixed in size and not many new lesions are appearing. The degree of itching can vary from intensely itchy to not itchy at all. Women with Qi & Blood Stasis may have painful periods (often with clots) or heavy periods. The patient’s tongue might be dull purple or dark red or there may even be purple spots. The patient’s pulse is choppy or wiry/choppy, and deep (esp. if the stasis has existed for a very long time). In the case of Qi & Blood Stasis, the treatment principal is obviously to Move Qi & Blood. If there is much itching, herbal treatment should also include herbs to Dispel Wind.

In women whose psoriasis seems to be related to their menstrual cycle, pregnancy or childbirth, there is probably Disharmony in the Ren and Chong Vessels. This pattern of disharmony is not exclusive to women, but it is much less common and less obvious to diagnose in men. In this pattern, the psoriasis lesions often appear before pregnancy but disappear during pregnancy only to reappear after giving birth. In some patients, the condition becomes aggravated before the period (or possibly immediately after). The lesions are typically bright or pale red, with silvery scales. They are widely distributed over the body. Itching is usually not as severe as in other patterns. Accompanying signs and symptoms can include PMS, painful or irregular periods, general malaise, or dizziness. The tongue can vary but usually will be red or purplish with a thin coating. You might also suspect this pattern in women who are perimenopausal of if there are fluctuations in hormone levels that seem to affect the psoriasis. This pattern can combine with other TCM patterns, too. The main treatment principal here is to Regulate the Chong & Ren Mai. If there are additional TCM patterns present (such as Blood Deficiency or Qi & Blood Stagnation), be sure to address those as well.

In my clinical experience, I have found herbal treatment to be far superior to acupuncture in the treatment of psoriasis. When formulating herbal prescriptions, the main focus of your treatment should be based on the proper TCM differentiation. But in all cases of psoriasis, regardless of TCM pattern, I always include herbs that have been found to have anti-neoplastic properties*. Because of the over-proliferation of skin cells that is characteristic of psoriasis, it is helpful to add these herbs to your formula whether treatment is internal or external. Some of these herbs include: Da Qing Ye, Qing Dai, Tu Fu Ling, Ku Shen, Zi Cao Gen, and Bai Hua She She Cao. If there is much itching, be sure to add herbs that Dispel Wind such as Fang Feng (which Dispels Wind without being drying), Jing Jie, Ju Hua, Chan Tui, Ku Shen, Bai Xian Pi, or Bai Ji Li (use caution with Bai Ji Li topically because it may actually cause a rash). If there is significant scaling, add herbs that help moisten the skin (Moisten Blood & Yin): Dang Gui, He Shou Wu, Bai Shao, Shu Di Huang, Tian Men Dong, or Mai Men Dong. For most chronic skin diseases that involve Heat in the Blood, I will also add herbs to Clear Heat and Resolve Toxins, such as Jin Yin Hua, Lian Qiao, Zi Hua Di Ding or Pu Gong Ying.

Many patients who have had psoriasis for a long time know little about their disease or how to manage it. It is imperative that you educate your patients on the following points:

1. Avoid Prednisone use. Common psoriasis can transform into the erythrodermic type (potentially life-threatening form) if triggered by certain factors. Use of internal (systemic) corticosteroids (such as Prednisone) has been identified as one possible trigger. Other possible triggers can include sunburn, strongly irritant topical medications, or allergic skin reactions to medications (including to drugs not used in the treatment of psoriasis). Certain medications can also trigger a form of psoriasis called guttate psoriasis.

2. Be cautious with topical cortisone cream. Sudden withdrawal of internal or topical steroids (including cortisone creams) can exacerbate common psoriasis or trigger it to transform into another life-threatening form of psoriasis known as Von Zumbusch (a pustular type of psoriasis). Other triggers of Von Zumbusch psoriasis may include pregnancy, blood pressure medications, iodides and Indomethacin (an NSAID).

3. Avoid getting the common cold or other infections. Psoriasis can get worse during and after infections. A form of psoriasis called guttate psoriasis can appear abruptly after respiratory infections or strep throat.

4. Avoid injury/trauma to skin. This includes sunburns as well as surgical scars, abrasions, cuts, and other wounds.

5. Avoid alcohol, spicy or greasy foods, sugary foods/sweets, and shellfish (esp. shrimp). Some sources say to avoid most fish but this is debatable since the omega-3 fatty acids contained in some fish are helpful.

6. Stop smoking.

*Reference: Chinese Medical Herbology and Pharmacology by John Chen and Tina Chen.