Traditional Chinese Medicine principles in the ethiopathogenesis and treatment of psoriasis vulgaris

Emil Iliev, MD. Valentina Broshtilova, MD
Department of Dermatology and Venereology, Faculty of Medicine, Sofia
1 St Georgi Sofiisky str
Sofia, 1431
Bulgaria
Tel: + 359 2 9230 493
Fax: + 359 2 9520241
e-mail: broshtolova@mail.bg

Summary

Psoriasis is a chronic relapsing skin disease, known to people for thousands of years. The practitioners of traditional Chinese medicine describe psoriasis some 1600 years ago. The precise etiology and pathogenesis of psoriasis are not known although there are many hypotheses. There are several commonly accepted points of view in TCM as for etiopathogenesis of psoriasis: syndrome of Blood and Wind Heat, syndrome of Blood Stasis, syndrome of Blood.deficiency- Dryness and Fire-Toxin Heat. In all cases the physician should pay attention to the color of psoriatic lesions. While suffering from psoriasis Liver and Kidneys are specifically affected and the insufficiency of these two organs is reflected on the level of Blood and nourishment. Physiotherapy is the main therapeutic method of TCM for treatment of psoriasis and is directed to elimination of stagnation and activation of Blood. Several methods for treatment of psoriasis with acupuncture are described- choosing points according to the syndromes; according to the location of lesions; points, which should be treated in all patients suffering from psoriasis; bloodletting from the root of ear and from the three kui points; application of plum-blossom needle and cupping therapy. The important place of auriculotherapy in the treatment of psoriasis is reviewed.

Key words: psoriasis, therapy, traditional Chinese medicine

Introduction

Psoriasis is a common, chronic relapsing skin disorder, known to people for thousands of years.

In ancient times it was thought to be a kind of leprosy; in fact, it was regarded as leprosy even in the Bible. Although Celsus (25 BC- 45AD) was the first to describe psoriatic lesions, it was not until the 19th century that Willan and Hebra were able to classify it as an independent disease. 1 In 610 Ganxian from Chao Yuan Fang in his tractates Zhu Bing Yuan Hou Lun (Discussion on the origin of symptoms) first described the traditional Chinese medicine (TCM) point of view for psoriasis. Many centuries later, in 1617, Baichuang from Chen Shi Gong in his study Wai Ke Zheng Zong (The real origin of surgery) tried to explain the pathogenesis of the disease. 2 Through the ages the Chinese have referred to this condition by many names: Bai bi (white dagger sore), She shi (snake lice) and Song pi xuan (pine skin tinea). 3 Nowadays in China, psoriasis is called Yin Xie Bing (the Disease of the Silver Squames).

The precise etiology and pathogenesis of psoriasis are not known although there are many hypotheses. There are several commonly accepted points of view in TCM as for etiopathogenesis of psoriasis.

Basic terms of TCM

Over 2000 years ago, TCM developed the physiological theories of Zang and Fu (viscera), Jing Luo (channels and collaterals), Qi, Xue (blood) and body fluids. 4 The concept of Qi refers to two different aspects: as refined nutritive substance flowing through the body and as the general function of the internal organs and tissues. Qi exists in every part of the body: Zong-Qi (pectoral Qi) is gathered in the chest, Yuan-Qi originates from the Kidney, Ying-Qi circulates through the blood vessels, while Wei-Qi protects the superficial portion of the body against external pathogenic factors warming up the in ner organs and moistening the skin. 5 According to TCM an abundance of Wei-Qi makes the skin soft, smooth and strong. Controversially, the deficiency of Wei-Qi causes skin dryness, muscle weakness and greater liability to the external pathogenic factors. Physiologically, the channels and collaterals Jing Luo perform the role of transporting Qi and Blood, connecting the interior and exterior, resisting exogenous factors and safeguarding the functions of the organs. Since the channels and collaterals connect the viscera inwardly and the body surface outwardly, pathogenic factors can move between the viscera and the body surface. 6 For instance, pathogenic factors from the superficial portion of the body can enter it, bringing harm to the visceral organs, while pathogenic change in the visceral organs can also be conveyed to the surface, causing certain skin diseases. In this respect, by judging the particular area of the certain skin lesion and examining the route and network of channels and collaterals in the body, it is possible to decide which inner organ the diseased area belongs to.

Dermatoses are of great variety, but in terms of pathological changes, there are several external factors that can cause the disease: Wind, Dampness, Heat, Poison, Dryness, Blood Stasis, and Deficiency of the Liver-Qi and Kidney-Qi. 7 The classic TCM concepts refer psoriasis as Blood Heat, subsequently developed into Blood Dryness and Blood Stasis. 8 The damage of skin by Heat is manifested by reddened skin, erosion, pustule, scorching, itching and pain, accompanied possibly by constipation and dark urine, as well as heat sensation and thirst. Dryness leads to skin xerosis, rhagades, squamae, atrophia trichoxerosis, and trichomadesis, usually accompanied by severe itching. The skin damage under the category of Blood Stasis is manifested by petechia, ecchymosis, violet red or dark red spots, pigmented spots, thickened and hardened skin, verrucous vegetations. These changes may be accompanied by purple lip, tongue ecchymosis, and menstrual disorders as well. The subjective symptoms include pain, numbness, and bradyesthesia.9

Etiopathogenesis and clinical syndroms of psoriasis from the view of TCM

According to TCM different pathogenic mechanisms for psoriasis exist:

Blood and Wind Heat. Etiopathogenesis. The excessive Blood Heat is an internal factor for causing psoriasis. Erythema and spreading of lesions depend on the predominance of Heat in the Blood. The disease is often due to the invasion of Wind- an external pathogenic factor, which dries the Blood and increases the inner temperature. Eruption and white scales result from excessive Wind Heat while the subsequent drying may cause nutritional muscle and skin deficiency, and severe itching. The Auspitzís sign and Koebner phenomenon are easy to obtain. More often Blood Heat type affects young people, under the age of 40. 10

Clinical syndrome. This syndrome is a clinical equivalent of the traditional Western medicine guttate and nummular psoriasis. The lesions are numerous, punctiform or oval, intensively red, with plenty of thin silver squames and tiny bleeding points. New lesions continue to appear. Itching is severe. Some patients complain of thirst, dryness of the tongue, constipation and deep colored urine. Anxiety and excitability are often symptoms. The tongue is covered with yellow or yellowish grimy coating. The pulse is rapid and thin. The therapeutic approach tries to clear the Heat and cold the Blood by activating it.

Fire- Toxins. Etiopathogenesis. An external mechanism, which causes rapid course of the disease with intensive erythema and excess of new lesions, often covered with thick, yellow scales. The form is therapeutically resistant. It comes from the stagnation of Heat in the Blood, which does not allow the Fire and Toxins to be expelled from the body heating them to extreme temperature. 11

Clinical syndrome. The syndrome corresponds to psoriatic erythroderma, pustular and palmo-plantar psoriasis. The lesions are red plaques, covered with thick yellow or yellowish-brown scales. There is a tendency of forming tiny pustules. The Auspitzís phenomenon is easily obtained. The nails are severely affected. The patients often suffer inflammatory diseases of the upper respiratory tract such as tonsillitis and laryngitis. They complain of graveolent feces, constipation and arthralgia. Most of them have strong burning sensation. As to lingual diagnosis, there may be redness of the tongue and a thin white coating. The pulse is rapid.

Blood Stasis. Etiopathogenesis. This hypothesis which is brought to view in the recent decades, greatly facilitates the various therapeutic approaches. According to it, psoriasis is attributed to Wind and Heat, which are longer kept in the body to cause imbalance of Yin and Blood, leading to meridian and collateral obstruction and stagnation. Squames, Auspitz phenomenon, a purple tongue and arthralgia are signs of Blood Stasis. 10

Clinical syndrome. It corresponds to a chronic relapsing form of nummular, geographic or gyrate psoriasis. The course is usually prolonged. The disease ceases to extend or extends slowly. Some lesions may resolve gradually. The lesions are dark-red, thick, indurative, scaly and dry, not itchy. The most important symptom is xerostomia. The tongue is dark-red to purple in color with plenty of petechiae. The pulse is hard. The therapeutic approach requires elimination of Stasis and activation of Blood.

Blood deficiency- Dryness. Etiopathology. In the opinion of Gu Buo Hua, a famous TCM practitioner, the deficiency of Yin and Blood, transformed in the muscles and skin as Wind-Dryness, trigger psoriasis. At the initiation of the disease, Wind-Heat and Wind-Cold cause imbalance of Yin and Blood, leading to stagnation of Qi and a blockade of Blood with formation of eruptions in the skin. The lesions are pale, thin, and the Auspitzís phenomenon can be hardly obtained. 10

Clinical syndrome. This is the classical chronic- relapsing form of psoriasis. The lesions are pale-red, thin, with no tendency to extend or resolve. They are usually covered with silver squames. Itching could be severe. The patients complain of vertigo, insomnia and constipation. They have asthenic constitution. The tongue is pinkish in color, covered with a thin, white coating. The pulse is moderate and loose. The principle of treatment consists of enriching the blood (and Yin) and moistening the dryness.

Bi syndrome. Etiopathology. This syndrome is rarely seen. It corresponds to psoriatic arthritis and is a consequence of the invasion of Wind and Dampness in the joints.

Clinical syndrome. The most significant symptom is arthralgia, as the metacarpal and metatarsal joints are worst injured. If the skin is affected, it forms small, pale-red lesions with tiny pustule on top. The lingual diagnosis points out intensively red tongue with a greasy coating. The pulse is rapid and filiform. 7

In summary, in TCM Blood Heat is considered the most important pathogenic factor for psoriasis. When Blood Heat is blocked in the superficial skin layers, xerosis develops. The causal basis of psoriasis is pre-existing deficiency at the nutritive and blood levels that provokes wind and dryness, such that the skin loses its nourishment. These are the internal predisposing factors. External factors, such as seasonal changes, psychosomatical stress, improper diet, infections, mechanical traumas, etc. in the context of genetic predisposition towards imbalance cause a blockade in the upper layers. Expelling of Heat seems a proper therapeutic approach. Remission periods require elimination of stasis, enforcement of Qi and activation of Blood.

Treatment

Phytotherapy. Phytotherapy is considered the most effective TCM psoriatic treatment. It is directed towards elimination of stagnation and activation of Blood-Xue. Radix salivae Miltiorrhizae, Semen Persiace, Rhizoma sparganii, Gummi Olibanum, Radix Rubiae, Radix Angelicae Sinensis, and Rhizoma Ligustici herbal products as tinctures and decocts are most commonly used. 11, 12 A Formula recommended for Blood and Wind Heat pattern includes "Modified Rhinoceros Horn and Rehmannia Decoction":

Xi jiao di huang jia jian  
Cornu Rhinoceri   1.5 g
Radix Rehmanniae Glutinosae  30g
Dry-fried Cortex Moutan Radicis 10g
Radix Paeniae rubrae 10g
Radix Arnebiae seu Lithospermi   10g
Flos Carthami Tinctorii 10g
Charred Flos Lonicerae Japonicae 15g
Radix Sanguisorbae officinalis 15g
Gypsum 15g
Calcitum 15g
Radix Adenophorae seu Glehniae 10g
Tuber Ophiopogonis Japonici 10g
Radix Scrophulariae Ningpoensis 10g

Fire ĖToxin pattern requires formulas for elimination of toxins and cleaning the body fluids such as "Combined Coptis Decoction to relieve Toxin and Five-Ingredient decoction to eliminate toxin":

Huang lian jie du tang wu wei xiao du yin he cai
Herba Taraxaci Mongolici cum Radice 15g
Flos Lonicerae Japonicae 15g
Herba cum Radice Violae Yedoensitis 15g
Rhizoma Coptidis 6g
Radix Scutellariae Baicalensis 6g
Cortex Phellodendri 6g
Charred Fructus Gardeniae Jasminoidis 6g
Radix Rehmanniae Glutinosae 10g
Radix Paeniae rubrae 10g

 

A Blood Stasis formula is the "Invigorate the Blood and Scatter Stasis Decoction":

Huo xue san yu tang
Lignum Sappan 9-15g
Radix Paeniae rubrae 9-15g
Radix Paeniae lactiflorae 9-15g
Flos Carthami tinctorii 9-15g
Semen Persicae 9-15g
Herba Buchnerae cruciatae 15-30g
Rhizoma Sparganii stoloniferi 9-15g
Rhizoma Curcumae ezhu 9-15g
Radix Aucklandiae lappae 3-9g
Pericarpium Citri reticulatae 9-15g

 

"Overcome psoriasis" Formula could be used in the treatment of Blood deficiency- Dryness clinical syndrome:

Ke yin fang
Radix Rehmanniae Glutinosae 30g
Radix Scrophulariae ningpoensis 30g
Semen Cannabis sativae 10g
Rhizoma Menisperi daurici 10g
Radix Sophorae flavescentis 10g

 

Acupuncture.Several methods for treatment of psoriasis with acupuncture are described.13, 14 The treatment of lesions affecting upper extremities, face, and scull takes place in acupuncture points Li 11(Qu Chi), TW 6 (Zhi Gou), GB20 (Feng Chi), Li 4(He Gu). In addition, Sp 10(Xue Hai) and Sp 6(San Yin Jiao) can be used. Greater affection of skin requires treatment in two more points- Li 20 (Ying Xiang) and GV 25(Su Liao).

The major points used in the treatment of low extremity involving, are Sp 10 (Xue Hai), Sp 6 (San Yin Jiao) and St 36(Zu San Li). TW6 (Zhi Gou) and Li 11 (Qu Chi) are additional points. Disseminated over the body lesions are treated in GV 14 (Da Zhui), Li 11 (Qu Chi), Li 4 (He Gu), Sp 10 (Xue Hai) and Sp 6 (San Yin Jiao) points. Bl 40 (Wei Zhong) is a coordinating point that is appropriate for all forms of psoriasis. The orthodox pinning technique requires a proper De-Qi effect and performing of the procedure twice or three times daily in a 30-minute interval. One treatment course includes 10 days and is followed by a ten-day break. Then the course can be repeated with a maximum of four times according to the dermatological status of the patient.

According to other scientific sources 15 the major psoriatic acupuctural points are GV 14(Da Zhui), Bl 13(Fei Shu), Li 4(He Gu), Li 11(Qu Chi), Sp 10(Xue Hai), and Sp 6(San Yin Jiao). As additional points for facial and head lesions GB 20 (Feng Chi ) and St 9(Ren Ying) can be used, TW 6(Zhi Gou) is appropriate for upper extremity involvement and St 40(Feng Long) can be taken in consideration in lower extremity lesions. The major auricular points are Lung, Shen men, Endocrine, Ren and Adrenal. Heart and Colon are considered additional.

Bloodletting. Bloodletting from the root of ear and from the three-kui points is performed.16 The ear points are located on its dorsal surface in a straight line. The palmar side of the middle finger proximal interphalangeal joint possesses three major bloodletting points called the inner middle Kui. The proper technique requires letting of few drops once daily, preferably in the morning.

Plum-blossom needle. Once daily the lesions are tapped persistently with a sterilized plum-blossom needle circling from the edge to the center until minor blood drops appear. In case of many lesions, they could be pricked by turns.17

Cupping therapy and acupuncture. A needle can be cupped in the major GV 14(Da Zhui ), GV 10(Ling Tai) and the additional Bl 13(Fei Shu), Bl 15(Xin Shu), Bl 18(Gan Shu), Bl 21(Wei Shu) and Bl 23(Shen Shu) points. Disseminated over the body lesions are treated in the GV 14(Da Zhui) and GV 13(Tao Dao) points. Si 2(Qian Gu) is mostly used in the treatment of lesions on the upper extremities. Sp 10(Xue Hai), St 34 (Liang Qiu) and GB 34 (Yang Ling Quan) play role in the treatment of lesions on the groins, while GV 14(Da Zhui), GV 13(Tao Dao), Bl 18(Gan Shu) and Bl 20(Pi Shu) are used for thoracic and abdominal lesions. Lesions on the neck are preferably treated in TW 17(Yi Feng). The procedure is performed every second day.18

Conclusion

Traditional Chinese Medicine is an alternative method of therapy that can be administered in oral, topical, or injectable forms. Among some patients it has become increasingly popular as a mode for treating dermatologic diseases. Intuitively sensible, the various TCM approaches in treatment are proven beneficial in the therapy of many complex, chronic inflammatory skin diseases as flexible in use, highly efficient and safe. 19 Nowadays, many experimental studies for finding out the cellular and molecular mechanisms of TCM psoriatic treatment modalities are performed. 20 The relationship between typing of psoriasis based on TCM syndrome differentiation and laboratory parameters such as platelet activation molecules CD 62P and CD 63, intercellular adhesion molecules, cytokines and haemorheology have been investigated. 21, 22, 23, 24 However, the present studies lack depth and scope in the methods. It is our hope that in the future more systemic and precise analysis would be conducted for better understanding the efficacy, mechanism of action and adverse effects of the various TCM treatment options.

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