The Treatment of Psoriasis by TCM

Psoriasis is a common, chronic, recurrent disease of the skin characterised by rounded circumscribed dry erythematous, scaling patches of various sizes, covered by multilayer greyish white or silvery white scales which appear repeatedly on the erythema. Similar descriptions of it can be found in some traditional Chinese medicine classics, which term the disease white sore (bai bi), loose skin tinea (song pi xuan) and dry tinea (gang xuan). The course of psoriasis is inconsistent, following an irregular chronic course marked by remissions and exacerbations of unpredictable onset and duration. Two of the chief features of psoriasis are its tendency to recur and persist. Psoriasis occurs with equal frequency in both sexes. The onset of psoriasis is at a mean age of 27 years, but the range is wide, from a few months to the 70s. It has been shown that around 1% of the population has psoriasis. There appears to be a genetic predisposition and Caucasians seem to be more affected than other races. It is uncommon in those of Afro-Caribbean origin. American Indians and native Fijians do not have psoriasis. In Western medicine, the cause of psoriasis is still not clear, although it is believed to be a hereditary skin condition, triggered by infections or psychogenic factors. In traditional Chinese medicine, psoriasis is considered to be due to invasion of pathogenic wind which incubates in the yin and blood, or accumulation and stagnation of qi and blood caused by emotional upset. These transform into heat, and wind and heat struggle in the skin. Psoriasis may also be caused by impairment of the Liver and Kidneys, or by disharmony between the Penetrating (Chong) and Conception (Ren) vessels, between the yin and the blood or between the yin and yang in the zangfu. Internal Treatment
1. Flaming of heat-evil at the qi and blood levels combined with wind Main clinical manifestations Erythema and scales (see glossary of terms) appear continuously, expanding and spreading throughout the skin of the body. The lesions are flushed and swollen. The scales are easily shed when scratched. Itching is sometimes intense. Generalised symptoms may include aversion to heat, restlessness, thirst, a bitter taste in the mouth, sore throat, slight fever, constipation, and yellow and scanty urination. The tongue is reddened or dark red with a thin yellow or white coating, and the pulse is rapid and taut or slippery. Key points of differentiation ¥ generalised erythematous lesions. ¥ aversion to heat. ¥ intense itching and thirst. ¥ taut, slippery and forceful pulse. ¥ a crimson or red tongue with a yellow coating.

Treatment principle Clear heat, resolve toxins and expel wind. Prescription Cool the Blood and Expel Wind Decoction (Liang Xue Xiao Feng Tang). Ingredients Sheng Di Huang (Radix Rehmanniae Glutinosae) 30g Sheng Shi Gao (Gypsum) 15g Bai Mao Gen (Rhizoma Imperatae Cylindricae) 30g Xuan Shen (Radix Scrophulariae Ningpoensis) 9g Zhi Mu (Radix Anemarrhenae Asphodeloidis) 12g Bai Shao (Radix Paeoniae Lactiflorae) 9g Jin Yin Hua (Flos Lonicerae Japonicae) 15g Niu Bang Zi (Fructus Arctii Lappae) 9g Jing Jie (Herba seu Flos Schizonepetae Tenuifoliae) 9g Fang Feng (Radix Ledebouriellae Sesloidis) 9g Gan Cao (Radix Glycyrrhizae Uralensis) 6g Modifications • If the onset is acute, the lesions are bright red and guttate, there are only a few scales, there is dryness in the mouth and the patient has a sore throat, then increase the dose of Jin Yin Hua (Flos Lonicerae Japonicae) and add Ban Lan Gen (Radix Isatidis seu Baphicacanthi) and Da Qing Ye (Folium Daqingye).

¥ If the lesions have changed from guttate to macules with a great deal of desquamation and they are concentrated on the upper part of the body, especially the scalp, then add Chan Tui (Periostracum Cicadae) and Sheng Ma (Rhizoma Cimicifugae). ¥ If the lesions are concentrated on the lower part of the body, the patient feels a tightness in the chest, they are tired and have no appetite and the tongue is white and greasy, then add Yi Yi Ren (Semen Coicis Lachrymajobi) and Han Fang Ji (Radix Stephaniae Tetrandae)1.

2. Blood-heat and Blood-stasis plus generalised symptoms Main clinical manifestations The skin lesions are less severe than in the first type and the swelling is not as pronounced. The course of the disease is slow, with new lesions appearing sporadically. Psoriasis lesions of this type are usually purple red macules that are moist and covered by a thick layer of tightly adhering scales. The tongue is red or purple red with a thin yellow coating and the pulse is slippery, or thready, slippery and forceful. Key points of differentiation ¥ the lesions are moist and the macules a purple red colour. ¥ the macules are covered by scales with new lesions appearing sporadically. ¥ slippery pulse, red tongue with a yellow coating.

Treatment principle Remove pathogenic heat from the blood, regulate the circulation of qi and resolve toxins. Prescription Psoriasis No. 1 Decoction (Niu Pi Xuan Hao Fang). Ingredients Tu Fu Ling (Rhizoma Smilacis Glabrae) 30g Sheng Di Huang (Radix Rehmanniae Glutinosae) 30g Ban Lan Gen (Radix Isatidis seu Baphicacanthi) 15g Da Qing Ye (Folium Daqingye) 15g Xuan Shen (Radix Scrophulariae Ningpoensis) 9g Mai Men Dong (Tuber Ophiopogonis Japonici) 9g Jin Yin Hua (Flos Lonicerae Japonicae) 9g Lian Qiao (Fructus Forsythiae Suspensae) 9g Huang Qin (Radix Scutellariae Baicalensis) 9g Dang Gui (Radix Angelicae Sinensis) 9g Hong Hua (Flos Carthami Tinctorii) 9g Modifications • If the eruptions develop into dark red plaques and the tongue is purple red with ecchymosis, then add Chi Shao (Radix Paeoniae Rubrae), San Leng (Rhizoma Sparganii) and E Zhu (Rhizoma Curcumae Zedoariae). • If the pulse is full, add Sheng Shi Gao (Gypsum) and Zhi Mu (Radix Anemarrhenae Asphodeloidis).
3. Noxious-heat and Blood-stasis Main clinical manifestations The lesions are dark red or hyperpigmented and covered by dark, thick, hard and adherent scales. Occasionally, the scales are rough like an oyster shell. Long-standing lesions may overlap, causing the skin to take on a map-like appearance. Sometimes these large lesions may be affected by itching, pain and fissuring. In some cases, the joints do not function properly. The lesions persist for a prolonged period (tens of years). The tongue is dark purple and is covered by a yellow and greasy coating or a turbid greasy coating. The pulse is deep-slippery and forceful. Key points of differentiation ¥ large thickened psoriatic plaques. ¥ stubborn lesions. ¥ dryness in the mouth. ¥ constipation. ¥ deep-slippery and forceful pulse. ¥ purple red tongue with a yellow and greasy coating.

Treatment principle Clear heat and promote diuresis, remove blood stasis and resolve toxins. Prescription Psoriasis No.2 Decoction (Niu Pi Xuan Er Hao Fang). Ingredients Tu Fu Ling (Rhizoma Smilacis Glabrae) 30g Yin Chen Hao (Herba Artemisiae Capillaris) 15g Sheng Di Huang (Radix Rehmanniae Glutinosae) 15g Jin Yin Hua (Flos Lonicerae Japonicae) 15g Lian Qiao (Fructus Forsythiae Suspensae) 15g Sheng Shi Gao (Gypsum) 15g Pu Gong Ying (Herba Taraxaci Mongolici cum Radice) 10g Zi Hua Di Ding (Herba Violae cum Radice) 10g San Leng (Rhizoma Sparganii) 10g Ye Ju Hua (Flos Chrysanthemi Indici) 10g Modifications • If the lesions are dry and fissured and covered with some dry scales, the pulse is thready and rapid, there is dryness in the throat and the tongue is red with thin yellow dry coating or lack of coating, then omit Tu Fu Ling (Rhizoma Smilacis Glabrae) and Yin Chen Hao (Herba Artemisiae Capillaris) and add Shu Di Huang (Radix Rehmanniae Glutinosae Conquitae), Bai Shao (Radix Paeoniae Lactiflorae), Tian Men Dong (Tuber Asparagi Cochinchinensis) and Mai Men Dong (Tuber Ophiopogonis Japonici).

External Treatment
1. Universally Linked Ointment (Pu Lian Gao) Ingredients Huang Qin (Radix Scutellariae Baicalensis) 50g Huang Bai (Cortex Phellodendri) 50g Vaseline 400g Method Grind the first two herbal ingredients into fine powder and make an ointment by mixing the powder with vaseline.
2. Bathing once a day in a hot spring or in a decoction made from the following ingredients: Ku Shen (Radix Sophorae Flavescentis) 60g Tu Fu Ling (Rhizoma Smilacis Glabrae) 30g Yin Chen Hao (Herba Artemisiae Capillaris) 30g Da Huang (Rhizoma Rhei) 30g Ye Ju Hua (Flos Chrysanthemi Indici) 30g Zi Hua Di Ding (Herba Violae cum Radice) 30g Gan Cao (Radix Glycyrrhizae Uralensis) 30g Method Each day stay immersed in the bath for thirty to forty minutes. Acupuncture
1. Body acupuncture Main Points: Dazhui DU-14 Feishu BL-13 Hegu L.I.-4 Quchi L.I.-11 Xuehai SP-10 Sanyinjiao SP-6 Secondary points: ¥ Fengchi GB-20, Renying ST-9 for lesions of the head and face. ¥ Zhigou SJ-6 for lesions of the upper limbs. ¥ Zusanli ST-36, Fenglong ST-40 for lesions of the lower

limbs. Method: Apply moderate stimulation, retain the needles for 30 minutes and manipulate them once every few minutes. Treat every other day.
2. Ear Acupuncture Main points: Lung, Shenmen, Endocrine, Kidney, Adrenal Gland. Secondary points: Heart, Large Intestine. Method: Apply moderate stimulation and retain the needles for 30 minutes. Treat every other day. The seed-embedding method is also applicable.
3. Needle Weizhong BL-40 bilaterally with a 28 gauge needle Apply strong reducing manipulation for 1-2 minutes, then retain the needles for an additional 5 minutes. Upon with drawing the needles, squeeze 1-2 drops of blood from the opening. Treat every other day. Cupping Main points: Dazhui DU-14 Taodao DU-13 Ganshu BL-18 Pishu BL-20 Secondary points: Quchi L.I.-11 Sanyinjiao SP-6 Method: Cupping may be applied alone or following acupuncture at these points. Treat once every other day. Discussion

• In general, the longer the patient has suffered from psoriasis the longer the length of treatment. Generally speaking, the course of treatment for the first and second types will be shorter than for the third type. Average courses of treatment for the different patterns are as follows:

i. Flaming of heat-evil at the qi and blood levels combined with wind: 2-3 months.

ii. Blood-heat and blood-stasis plus generalised symptoms: 3-4 months.

iii. Noxious-heat and blood-stasis: 4-6 months. ¥ Some patients have to continue treatment for longer, possible over a year, especially those who have had lengthy treatment with Western medicine such as steroids (tablets or creams), as the psoriatic lesions become very stubborn. If after a few weeks of treatment the symptoms start to improve, the patient may need to take the treatment consistently until it has cleared completely. ¥ If appropriate, it is possible to prescribe two of the three decoctions together by mixing a half dose of each, according to the principles of differential diagnosis. ¥ Some common difficulties that may present during treatment:

i. Plateau in recovery Initially the patient recovers, but after a few weeks or months this recovery ceases or the condition actually worsens. This can be treated by adding Wu Wei Xiaodu Yin (Antiphlogistic Decoction of Five Ingredients): Jin Yin Hua (Flos Lonicerae Japonicae) 12g Pu Gong Ying (Herba Taraxaci Mongolici cum Radice) 9g Ye Ju Hua (Flos Chrysanthemi Indici) 9g Zi Hua Di Ding (Herba Violae cum Radice) 9g Zi Bei Tian Kui (Herba Begonia Fibrislipulatae) 9g Most cases will recover again in one or two weeks. If necessary, change to another decoction or modify the original prescription according to a good differential diagnosis. ii. Relapse or recurrence Stress, overwork, seasonal changes, certain foods and

some infections are examples of common reasons for relapse or recurrence of psoriasis. It is necessary to ascertain the trigger(s) for the relapse and advise the patient accordingly. Wu Wei Xiaodu Yin or a prescription to drain dampness can be added, or alternatively acupuncture can be offered in addition to the herbal treatment. To deal with a recurrence, the prescription that the patient had during the last course of treatment prior to recovery should be selected. If this is successful after 710 days, the treatment should continue until full recovery occurs. If this prescription is not successful, Wu Wei Xiaodu Yin or a prescription to drain dampness, or a recipe to invigorate blood circulation and eliminate blood stasis can be added, or acupuncture may be applied. These will usually have a satisfactory result. Prevention ¥ Take enough rest, refrain from overworking and avoid too much mental stress. ¥ Try not to scratch the affected area. During onset, the affected area should be bathed in hot water or with alkali soap. ¥ Refrain from eating the following foodstuffs: seafood such as fish and shrimp, beef, lamb, spicy foods, alcohol and caffeinated drinks such as coffee, tea and coca-cola, as these are likely to induce or intensify psoriasis. ¥ Sound nutrition should be maintained. Eat more vegetables and fruit in order to keep the bowel movements regular. ¥ Try to trace any triggering factors and thereby reduce relapses.

Case Studies Case 1 Male, age 75, occupation retired. Presenting history and symptoms: The patient had suffered from psoriasis for four years with erythema, papules and scales on his scalp, back, arms, hands and right thigh which were aggravated by heat and stress. He also had a sensation of itching and soreness. Steroid cream had been used on occasions in the past with very little and short-lived success. The tongue was red with a yellow coating, the pulse was taut and forceful. Diagnosis: excessive heat in the blood and qi levels Prescription: Liang Xue Granules (the granular form of Liang Xue Xiao Feng Tang) one sachet (10g) twice a day and Pu Lian Gao (external use) twice a day. Response to treatment: After one week of the granules, 90% of the psoriatic lesions had cleared and this improvement was maintained over the next five weeks. The patient was nearly clear of psoriasis, with just a few pink coloured patches on his hands. The prescription was then reduced by half. Six weeks later, the psoriasis had cleared completely and treat ment stopped. His psoriasis has not recurred since he was cured 15 months ago. Case 2 Male, age 32, occupation unemployed. Presenting history and symptoms: The patient had suffered from psoriasis for ten years with erythema, papules, plaques and scales over most of his body apart from his face, neck and teeth, which were triggered by stress. His grandmother had psoriasis all her life. Steroid cream had been used for five years without success. The tongue was red, and the pulse was surging and forceful. Diagnosis: excessive heat in the blood and qi levels. Prescription: Liang Xue Granules: one sachet twice a day and Pu Lian Gao twice a day. Response to treatment: After a week of the granules the symptoms had started to improve and his improvement was maintained over the next few weeks. The patient's condition then ceased to improve, and gradually most of the lesions developed into large, dark red, thickened plaques. The pulse was deep and slippery, the tongue was moderately dark red with a yellow and greasy coating. The prescription was then changed to half a sachet of Liang Xue Granules in the morning and half a sachet of Psoriasis No. 2 Granules (the granular form of Psoriasis No. 2 Decoction) in the evening. Acupuncture was also given at Dazhui DU-14, Feishu BL-13, Hegu L.I.-4, Sanyinjiao SP-6, Xuehai SP-10 and ear points Adrenal Gland, Endocrine and Lung once a week. After one week of this treatment programme the condition had started to improve again, continuing as marked improvement over the following two and a half months. After a further month on maintained improvement, the psoriasis flared up a second time. The lesions grew slightly larger and redder and some new skin eruptions emerged. The prescription was altered to one sachet of Liang Xue Granules twice a day. Two weeks later, the condition started to improve and continued to do so for another five weeks, by which time it had cleared completely and treatment was stopped. Eight months later the patient returned with another flare-up of his psoriasis. The causes appeared to be stress and overwork. He and his partner had recently had a baby who was premature, and the patient had had to find employment and was working 9-10 hours a day. He was prescribed Liang Xue Granules again for seven weeks. The psoriatic lesions have cleared almost completely to date. Glossary of terms Erythema: redness or inflammation of the skin or mucous membranes. Desquamation: a process in which the cornified layer of the epidermis is sloughed in fine scales. Guttate: an acute form of psoriasis consisting of teardrop-shaped, red, scaly patches measuring 3mm to 10mm, all over the body.

Macule: a small, flat blemish or discoloration that is flush with the skin surface. Plaque: a flat, often raised, patch on the skin.Scales: small thin flakes of keratinized epithelium. Notes 1 The UK Register of Chinese Herbal Medicine currently recommends a maximum dose of 3g. Dr. Zhu Zhi Qiang is a consultant dermatologist at The Chinese Medical Centre in Bath, Somerset in England. He worked as the Senior House Officer in the Dermatology Department of Changzheng Hospital in Tianjin, China, between 1985 and 1995. 14