Keywords

Introduction

Traditional healing or medicine refers to the “knowledge, skills and practices based on theories, beliefs and experiences indigenous to different cultures, used in the maintenance of health and in the prevention, diagnosis, improvement or treatment of physical and mental illness” [1].

Traditional Chinese medicine (TCM) is an important system of traditional medicine that has been in practice for more than 3,000 years. It has helped to maintain health and relief ailments for millions of people in Asia, long before the advent of modern medicine.

Historical Perspective

The earliest references to skin diseases [2, 3] were scattered among various works and artifacts. Inscriptions on bone excavated from the Shang dynasty (c. 1700–1100 B.C) were thought to describe a skin condition akin to scabies. The Yellow Emperor Inner Classic represented the culmination of medical knowledge during the Spring-Autumn and Warring States periods (c. 770–221 B.C). Signs and symptoms of various skin diseases were chronicled in remarkable detail, and attempts were made to elaborate on their likely etiology in relation to the four seasons.

Imperial physician Zhang Zhong-Jing of the Han Dynasty expanded on the earlier texts and wrote the Discussion of Cold-induced Disorders (c. 196) and Concise Prescriptions from the Golden Casket. Skin disorders such as urticaria and exfoliative dermatitis were mentioned. It also contained the first historical account of an ailment characterized by mouth, eye, and genital lesions which bore striking resemblance to what is presently known as Behcet’s syndrome.

This was taken a step further in the Discussion of the Origins of Symptoms of Diseases (c. 610), in which Chao Yuan-Fang alluded to the entity of contact dermatitis. Followed by Sun Si-Miao in Thousand Ducat Formulas in which he described in great detail his observations of leprosy, making him the first leprosy expert of his time. The first comprehensive compilation in Precise Treatment of Patterns (c. 1602) by the Ming Dynasty physician Wan Ken-Tang categorized skin disease according to anatomical regions and described them in such detail that it became the de riguer text. The first atlas of skin disease, Profound Insights on External Disease, was penned (c. 1604) by Shen Dou-Yuan.

Up till the opium war (c. 1840), much of the people of China relied on TCM for healing and disease prevention. Following the influx of western influence, modern medicine was introduced into China. However, despite the increasing influence of modern biomedical science, TCM continued to remain an integral part of the psyche of the commoner. Schools and institutions specializing in TCM were continually being established. In fact, modern technology has accelerated TCM research [4], and methods of diagnosis and treatment were improved through the integration of traditional and modern medicine.

Principles of TCM

TCM differs in substance, methodology, and philosophy from modern medicine as we know it. It is not surprising that Western doctors continue to harbor misgivings about TCM and its standards.

In essence, TCM views the human body as an entity in equilibrium [3]—comprising a system of qi (energy) and yin-yang (balance). Although the concept may seem strange to western practitioners, TCM draws a parallel with well-established scientific concepts of metabolism (analogous to qi), immunity, and homeostasis (analogous to yin-yang).

TCM respects the holistic approach to health and the interrelationship of the mind, body, and the environment. Despite disease manifestations being external, their root causes are complex and involve the internal imbalance between yin and yang. In healthy individuals, yin and yang are in balance, and illness occurs when there is imbalance. The Chinese also recognize five elements: earth, water, fire, wood, and metal. These elements undergo transformative phrases that can affect one another. Each element is related to specific organs. In general, dysfunction of organs leads to various diseases. TCM recognizes the flow of qi through the body and identifies excess or deficiency of qi “as an important factor to the lead up of a disease.”

Pathogenic Factors

Internal Causes

Emotional

The seven pathogenic emotions are elation, worry, anger, pensiveness, sadness, fear, and terror. Under normal conditions, these physiological phenomena will not cause disease. However, if the emotions are too stressful and constant, or the patient is too sensitive to stimulation, then they may induce acute and long-term changes that result in diseases. Pathogenic emotional factors are considered capable of disturbing the functional activities of qi, for example, according to an ancient saying, “Anger makes the qi rush upward, overjoy makes the qi circulate slowly, grief consumes qi, fear cause qi to flow downward, fright makes qi flow disorderly, overthinking leads to qi stagnation.”

Improper Diet

Diet that is too spicy or high in fats is believed to cause dysfunction of the spleen, resulting in internal build up of toxin, leading to conditions such as acne, furuncles, and carbuncles.

Imbalance of Activity and Rest

Overwork consumes qi resulting in fatigue, whilst overly sedentary lifestyle causes qi stagnation.

Intolerance

Some individuals are constitutionally more sensitive to exposure to various factors. This is seen in conditions such as contact dermatitis, caused by hypersensitivity to substances coming into contact with the skin, and urticaria, which displays intolerance, for instance to certain drugs, foods, or airborne substances.

External Causes

Six Excesses: wind, cold, heat, dampness, dryness, fire.

Spring-wind, summer-heat, summer-fire, later summer-dampness, autumn-dryness, and winter-cold are the six variations in the climate of the four seasons. They are also known as the “six climatic factors” or the “six exogenous qi.”

The human body has the ability to adapt to climatic variations. However, when bodily resistance is too low to adapt to climatic changes or if there is an abnormal altering of the weather which surpasses the body’s adaptability, then disease occurs. These forms of climatic qi are all considered to be exogenous pathogenic factors.

Diseases which are not caused by exogenous pathogenic factors, but have symptoms similar to the syndromes of wind, cold, summer-heat, dampness, and dryness are termed internal heat, internal damp, internal dryness, and internal fire. These endogenous pathogenic factors are the outcome of dysfunctions of the organs.

Wind is a significant etiological factor in TCM methodology. It is often described as a vehicle that delivers external triggers deeper into the body, thus aggravating disease states. It potentiates the other climatic factors of dryness, dampness, and heat. Examples of skin disease that are related to wind include urticaria, pruritus, eczema, and seborrheic dermatitis. Internal wind is connected to liver; therefore TCM physicians would focus treatment on nourishing the blood and liver.

Cold causes stagnation of blood and qi. In extreme cases, cold causes blood stasis resulting in cold-induced injuries such as chilblain and panniculitis. Internal cold results from imbalance of yin-yang and loss of internal heat.

Heat, which is more prevalent during the summer months, results in increased sweating and loss of body fluids. Acute heat-related conditions include miliaria.

Dampness occurs when individuals are exposed to damp or wet environments. Due to the “sinking nature” of damp, it is often accompanied by heaviness and fatigue of the limbs. On the other hand, internal dampness is often caused by dysfunction of the spleen’s functions, resulting in symptoms such as intense itching, swelling, or blistering.

Dryness predominates during the autumn and winter seasons and is termed cold-dryness, while prolonged dry spell in summer leads to warm-dryness. Skin diseases caused by dryness causes skin to crack and scale. The hands, feet, and mucous membrane are the most susceptible. Dryness arising from internal source is believed to be related to lung insufficiency which results in internal heat, thereby consuming body fluids. Prolonged use of bitter medicine can also result in internal dryness.

Fire and heat arise from excess of yang. Heat may be climatic as in wind-heat, dry-heat, or damp-heat. On the other hand, heat can be produced internally as a result of organ dysfunction or overstimulation of emotions. Skin diseases that are believed to be caused by internal heat include aphthous ulcers, shingles, acne, rosacea, and melasma.

Pestilences

Diseases that were contagious “through the mouth and nose” were described as early as the Ming dynasty by Wu You-Xing in his Treatise on Febrile Pestilences (c. 1642). The treatise notably included small pox, chicken pox, and rubella.

Arthropods and Parasites

These are divided into insect bites and stings, visible parasites such as mites and lice, and microscopic parasites such as leprosy and leishmaniasis.

Physical Agents

These include skin disorders arising from cuts, burns, and physical trauma.

TCM Methodology in Dermatology

•TCM emphasizes a holistic approach in the diagnosis and management of diseases.

•TCM seeks to identify and correct the imbalances of a person’s constitution which contribute to outward manifestation of disease.

•TCM may have an adjunctive role in treatment of chronic skin diseases for which the pathomechanism is not completely understood, and satisfactory cure is currently unavailable.

TCM uses a holistic approach in the diagnosis and management of disease states. Therapy is not skin focused, but body focused. Therefore, the TCM practitioner always seeks to identify the inadequacies in a person’s constitution that have resulted in imbalance of the core elements of a person’s well-being.

While western medical science is progressively becoming more subspecialized, more organ specific, and categorical, TCM in contrast emphasizes the patient as a whole entity. It respects the influence of both intrinsic and extrinsic forces in the induction of disease and restoration of health.

Physical examination comprises of inspection of the patient’s skin, complexion, physique, and tongue condition. Next the patient is questioned on various symptoms: if he is hot or cold; sweating, thirst, appetite, stools, and so forth. Finally, the TCM practitioner palpates the patient’s wrist to feel the quality of the pulse so as to assess overall health.

TCM diagnosis is a syndrome complex that describes the imbalances of the elements. For example, an eczema patient could be having a damp-heat pattern, while another eczema patient could be experiencing a qi deficiency syndrome, yet another patient with eczema could belong to the fire-heat syndrome. The TCM practitioner would then prescribe a treatment regimen according to the disease pattern (Table 47.1).

Table 47.1 Principles of TCM dermatological diagnosis
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TCM Treatment with Herbs

Skin diseases are considered an outward manifestation of dysfunction of the organs, channels, and bodily substances (qi, blood, and fluids). Therefore treatment includes external application of medication as well as systemic therapy using oral herbal medicines.

The utilization of herbal medicines [5] to tonify the body and restore health is a concept that vastly differs from the practice of modern medicine. Modern drugs are largely single-entity compounds designed to treat specific conditions. They are highly successful in addressing acute conditions, such as infections, in a fast and predictable manner. This leads to a favorable outcome within the shortest period of time. In contrast, TCMs are decoctions of up to 20 different types of herbs that are customized for different patients. The principle is restoring and maintaining balance. This approach is more appropriate to disease prevention and the treatment of chronic diseases, where western medicine has only been able to alleviate. Most Chinese formulations contain a mixture of herbs. There are different methods of classifying the ways in which these can be combined. When combined, two biologically active substances can be observed to have the following effects: mutual accentuation, mutual enhancement, mutual counteraction, mutual suppression, and mutual incompatibility. The principal ingredient is a substance that provides the main therapeutic thrust; the second principal ingredient enhances or assists the therapeutic actions of the first. The rest serve to treat accompanying symptoms, moderate the toxicity of the primary herbs, or exert a harmonizing effect.

Internal Treatment

Decoctions

Decoctions are prepared by placing medicinal herbs in water or other liquids (e.g., wine) and boiled for a specified length of time. The liquid is then ingested. Decoctions are absorbed quickly by the body and are able to exert an immediate onset of action.

Pills

Pills are prepared by combining finely powdered herbs for ease of consumption and storage, as well as standardization of dosages.

External Treatment

Powders

These are usually prepared by grinding together dried medicinal substances into a powder of fine consistency. They are either sprinkled directly on the affected area or combined with medicinal herbs to make a poultice. They function to disinfect, reduce inflammation, remove necrotic tissue, and promote wound healing.

Washes

Washes are prepared by decocting herbs, then applying the liquid as a swab, compress, or bath. They provide soothing relief for itch and pain, reduction of exudation.

Ointments

Ointments are prepared by combining powdered herbs with a greasy vehicle such as petroleum jelly. They are rubbed on the affected areas to lubricate and protect dry skin, barrier effects, and promote healing.

Plasters

Plasters are oil- or wax-based medications affixed onto a backing material and then applied topically. They can exert external effects such as promote suppuration, promote healing, or clear necrosis. They can also exert an internal effect to harmonize the qi and blood, dispel wind and cold. Administration of plasters is known to cause allergic contact dermatitis in sensitized individuals.

TCM and Atopic Dermatitis

Historical Perspective

The earliest record of eczema was that of “milk ringworm,” which most resembled infantile dermatitis. This dated back to the Sui Dynasty (c. 581–618 A.D).

Later during the Qing dynasty (c. 1644–1911), the “four bends wind” concept was presented. As the name suggested, eczematous skin lesions occurred in the flexural aspects of the arms and legs. Extreme itching and recurrent episodes with copious oozing were included in the description. Subsequently, other dermatitis subtypes such as seborrheic dermatitis, scrotal eczema, and hand eczema were described in significant detail.

The Chinese term for eczema translates directly to “damp rash.” This is derived from the exudation seen in acute eczema. TCM attributes this to internal imbalances, leading to excess dampness and heat. According to TCM, atopic dermatitis (AD) is caused by a congenitally “weak” constitution, which predisposes the individual to extrinsic aggravators such as dietary, lifestyle, and climatic changes. As eczema becomes recurrent and chronic, excessive dampness is said to consume the blood and body fluids (immunological dysfunction), generating dryness, dyspigmentation, and lichenification. At the organ level, AD is also related to dysfunction of the spleen and stomach.

Therefore, while western diagnosis is skin limited, TCM diagnosis strives to clarify the disease syndrome complex underlying it, according to the principles of TCM discussed above.

The Increasing Appeal of TCM

To date, AD remains a frustrating disease for both patients and doctors alike. As the pathophysiology of AD has not been fully established and there is no apparent cure, treatment has been largely symptomatic. Therapy has, thus far, focused on relief of flares with topical corticosteroids and calcineurin inhibitors, as well as skin barrier therapy with emollients. More severe disease would necessitate oral corticosteroids and immunosuppressive agents, which are associated with significant risk of adverse events.

The limitation of western medicine has prompted increasing number of patients to turn to TCM [4], in part due to the perceived safety of TCM by patients and in part due to the appeal of pedagogy of TCM in restoring balance and potentially curing the disease.

However, the complexities of herbal decoctions and granules, the different routes of administration, and auxiliary treatments such as acupuncture and massage have proven daunting for western doctors to regard TCM with any amount of credibility. It also does not help that early studies were mainly found in Chinese publications, thus reducing accessibility. With the need for more objective evidence and validation, TCM is now being extensively studied in clinical trials and pharmacological studies.

Herbs [3] such as Cortex Moutan Radix (Danpi), Radix Paeoniae Alba (Bai Shao), Potentilla chinensis Ser (Weilingcai), and Radix Glycyrrhizae (Gan Cao) are common treatments for allergy. Flos Lonicerae (Jinyinhua) and Herba Menthae (Bohe) clear ‘damp-heat’ from the exterior; Cortex Moutan (Danpi) clears ‘heat’ from blood while Rhizoma Atractylodis (Cangzhu) and Cortex Phellodendri (Huangbai) clear the ‘damp-heat’ from the interior. Pharmacological studies indicate that these herbs have anti-allergic, anti-inflammatory, and sedative action for relief of itchiness.

Clinical Efficacy

To date there are seven randomized controlled trials [6] (one comparing Chinese herbal medicine and western medicine with western medicine alone; six comparing Chinese herbal medicine with placebo) and more than 200 clinical trials investigating the efficacy of TCM in AD.

Cheng et al. [7] studied the efficacy of a common herbal preparation Xiao Feng San (comprising of Glycyrrhiza uralensis (Gancao), Saposhnikovia Divaricate (Fangfeng), Schizonepeta tenuifolia (Jingjie), Atractylodes lancea (Cangzhu), Angelica sinensis (Danggui), Rehmannia Glutinosa (Dihuang), Clematidis Armandii (Chuanmutong), Cryptotympana pustulata (Chantui), Linum usitatissimum (Yamazi), Anemarrhena asphodeloides (Zhimu), Gypsum Fibrosum (Shigao), Sophora flavescens (Kushen), Articum lappa (Niubangzi)) commonly used in the Asian context for the treatment of AD. In a double-blind, randomized control trial of 71 patients (8–23 years) with severe AD affecting >20 % body surface area, there were statistically significant improvement in pruritus, erythema, surface damage, and sleep scores. No side effects were experienced in all the patients, suggesting that TCM would be a potentially beneficial and safe adjunctive therapy for patients with recalcitrant AD.

Huang et al. [8] found a combination of western medicine and TCM to be superior to western medicine alone in children aged 3–11 years, in improving clinical scores. Shi et al. [9] demonstrated that the TCM Jiawei Danggui decoction improved AD scores through modulation of inflammatory cytokines such as IL-4, IL-10, and IL-12. More recently, an open-label clinical study [10] involving a novel combination of oral and topical TCM therapy in 94 patients showed significant improvement in severity of AD. Serum IgE level and eosinophil counts were significantly reduced at the end of the study.

Two randomized placebo-controlled trials [11, 12] were performed to study the effects of Zemaphyte, a decoction of ten herbs useful for treating AD characterized by erythema, lichenification, and plaques of dermatitis in the absence of active exudation or clinical infection. The ten herbs used were Lophatherum gracile (Danzhuye), Potentilla Chinensis (Weilingcai), Tribulus terrestris (Jili), Rehmannia glutinosa (Dihuang), Clematidis armandii (Chuanmutong), Ledebouriella Saseloides (Fangfeng), Dictamnus dasycarpus (Baixianpi), Paeonia lactiflora (Baishao), Schizonepeta tenuifolia (Jingjie), and Glycyrrhizia Glabra (Gancao). These herbs were placed in sachets and boiled to make a decoction that was orally administered daily as a tea. The placebo consisted of a decoction made from several herbs with similar smells and tastes that have no known efficacy in AD. The first study involving 47 children demonstrated a median decrease in erythema score of 51 %, in the treatment group compared with only 6.1 % improvement in the placebo group. The percentage surface involvement also decreased by 63.1 % and 6.2 % for the herb-treated and placebo groups, respectively. No serious adverse effects were found. These children were offered continued treatment, with 18 children completing 1 year of treatment and showed 90 % reduction in eczema activity scores. By the end of 1 year, seven children were able to discontinue therapy without relapse. Asymptomatic elevation of alanine aminotransferase level was noted in two patients, levels returning to normal after discontinuing treatment. Although the sample sizes were limited, results were promising for patients with persistent disease. It should be emphasized that although no serious adverse effects were noted in this study [10], careful monitoring of complete blood cell count and liver function is recommended, as liver failure and even death have been reported with these TCM herbs. However, in a separate study [13] involving 40 patients, investigators did not observe any benefit of Zemaphyte in recalcitrant AD. So far, the sample sizes of these studies are too limited for any real conclusion to be made, and more robust studies are required.

PentaHerbs a proprietary capsule comprising of five different herbs, Paeonia suffruticosa root bark (also known as Cortex Moutan), Phellodendron Chinensis bark (Chuanghuangbai), Lonicera japonica flower (Jinyinhua), Mentha Herba aerial part (Bohe), and Atractylodes lancea rhizome (Cangzhu), was found, in a randomized, double-blind, placebo-controlled study [14], to have beneficial effects on improvement of eczema SCORAD and Children Dermatology Life Quality Index (CDLQI) scores. The use of topical steroid [15] was also reduced by one-third. However, no significant difference in overall clinical scores was found. The PentaHerbs formulation was tested for contaminants [16] such as heavy metals or corticosteroid and found not to contain any. In a separate study [17], the herbal formula, Hochu-ekki-to (comprising of Radix Astragali (Huangqi), Panax Ginseng (Renshen), Rhizoma Atractylodis (Cangzhu), Glycyrrhiza uralensis (Gancao), Angelica sinensis (Danggui), Citri Reticulatae (Baomazipi), Rhizoma Cimicifugae (Shengma), Radix Bupleuri (Chaihu), Zingiber Officinale (Jiang), Fructus Jujubae date (Dazao)) was found to reduce the total equivalent amount of topical corticosteroid usage by 50 % during a 6-month period in a multicentre, randomized, double-blind, placebo-controlled study. However, again there was no statistically significant difference in skin severity scores.

It is important to note that the combinations of herbs used in the various studies were different, giving rise to different pharmacokinetics and pharmacodynamics. There are also concerns that the varied geographic sources of the herbs used in different studies could also have affected the active compounds. Therefore, more RCTs and rigorous pharmacological studies are necessary for stronger evidence regarding efficacy of TCM.

In Vitro Studies

It is known that the specific herbs [18–20] used in these studies have anti-inflammatory, antibacterial, antifungal, antihistaminic, immunosuppressant, and corticosteroid-like effects. Several studies have attempted to elucidate the mechanism of action of individual herbs and their combined effects.

Oral administration of Gypsum fibrosum was shown to increase cutaneous water content in mice [18] via the upregulation of aquaporins. Gypsum fibrosum is a common TCM herb given to relieve “heat,” characterized by excessive thirst, sweating, fatigue, poor concentration, pruritus, and dry skin, in the body.

Bakumijiogan, a unique TCM herbal formula, comprising of eight herbs, Rehmannia Radix (Dihuang), Cornus Fructus (Shanzhuyu), Dioscoreae Rhizoma (Shanyao), Alisma Rhizoma (Zexie), Poria Sclerotium (Fushen), Moutan bark (Mudanpi), Ophiopogon japonicus tuber (Maidong), Schisandra chinensis fruit (Wuweizi), was shown to reduce swelling of AD lesions [21] in Nishiki Nezumi Cinnamon (NC) mouse models. This effect was attributed to the downregulation of the T-helper 2 cytokines, namely interleukin-1α (IL-1α) and tumor necrosis factor TNF-α.

PentaHerbs is a formula comprising of five different herbs, which were individually assessed for their effects on mast cell activity. Each herb was found to have various modulating effects on mast cells [18], which included the inhibition of histamine release from mast cells and prostaglandin D2 synthesis. PentaHerbs decreased plasma levels of brain-derived neurotrophic factor (BDNF) and thymus and activation-regulated chemokine (TARC) in children with AD. PentaHerbs suppressed mRNA transcription of BDNF, TARC, interferon-γ, and tumor necrosis factor-α [19] by cultured peripheral blood mononuclear cell (PBMC). These immunomodulatory properties are believed to contribute to the clinical efficacy in AD treatment.

The bark of the birch tree (Betula platyphylla var. Japonica) which is used to treat AD, was studied in NC/Nga mice models [21] for AD. The herb decreased scratching and skin inflammation, as well as immunoglobulin E and interleukin-4 messenger ribonucleic acid (mRNA) levels. The findings suggest that the herb exerts some effect on the suppression of the T-helper 2 cellular response in AD. In the Zemaphyte trials [22], biopsy specimens were obtained from the lesional skin of patients treated with the herbal combination. The investigators observed a statistically significant reduction in CD23 antigen-presenting cells, compared with nonlesional skin.

Indigo Naturalis (Qingdai) [23], a dark-blue powder prepared from the leaves of plants such as Baphicacanthus cusia, Polygonum tinctorium, Isatis indigotica and Indigofera tinctoria, exhibits antiviral, antibacterial, and antitumor properties. It is used in treatment of various inflammatory and infectious diseases, e.g., eczema, aphthae, erysipelas, and herpes zoster. Due to its apoptotic effect [24] and ability to modify the proliferation and differentiation of keratinocytes, it is commonly employed in the treatment of psoriasis. Moreover, indirubin [24], one of the active compounds, has been shown to inhibit the production of interferon-γ, interleukin-6, and RANTES chemokine, involved in psoriasis pathogenesis.

Radix Salvia Miltiorrhiza (Danshen) [25] contains a variety of deterpenoids, phenolics, flavonoids, triterpenoids, and sterols. Its active components have anti-ischaemic, antioxidant, and antitumor activity. It has a significant inhibitory effect on the production of IFN-γ from lymphocytes and IL-12 from macrophages as well as suppression of mast cell degranulation. This herb is thought to exhibit some hepatoprotective effect [26], which is in part due to its ability to improve blood circulation and promote regeneration of liver cells.

Glycyrrhiza uralensis (Gancao) [27], may have protective effect on hepatocytes and gastrointestinal tract, is commonly used as component of various antipsoriatic and anti-eczema preparations. It is believed to prevent side effects commonly observed in the process of herbal therapy application. Moreover, it exerts both immunosuppressive and immune-enhancing activities, which may modulate abnormal immunological processes in eczema. Rehmannia glutinosa (Dihuang), a frequent ingredient in herbal formulas, is a Chinese herb use in the treatment of eczema and psoriasis and various dermatoses. In animal models [28], the root of Rehmannia glutinosa is capable of inhibiting the release of histamine and production of TNF-α and IL-1, and therefore having a positive effect on the treatment of eczema and psoriasis.

Radix Angelicae (Danggui) [29] is regarded as an effective agent in treatment of acne, headache, toothache, sinusitis, colds, and flu. It contains furocoumarins [30], actively involved in the inhibition of cyclooxygenase and lipoxygenase pathways of arachidonate metabolism. Since Angelica species are sources of psoralens, they are applied both systemically and topically in psoriasis. The herb is capable of inducing phototoxic reactions in some individuals.

TCM as an adjunctive treatment [31] has been reported to benefit the patients with several other dermatological conditions such as alopecia totalis, Behcet’s disease, psoriasis, and scleroderma (Fig. 47.1).

Fig. 47.1
figure 1

(a–d) Common TCM herbs used in dermatology. (a) Dictamnus Cortex (b) Radix Astragali (c) Smilacis Glabrae Rhizoma (d) Lonicerae Flos

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Adverse Effects of TCM Herbs

Adverse effects to Chinese medicines [32–34] can develop due to response to natural compounds, natural toxins, or to contaminants and adulterations, for example arsenic, steroids, diazepam, diuretics, NSAIDS, and caffeine.

Adverse reactions during treatment range from mild (transient hepatitis, dermatitis) [7] to severe or fatal illnesses (liver failure, anaphylactic shock) [10]. Derangement of liver function is one of the most commonly documented adverse effects of TCM preparations. Moreover, since numerous herbal formulations contain psoralen [34], a photosensitizing compound, their use can result in photosensitivity.

Xu et al. [35] reported a patient who developed lichen planus pemphigoides a few weeks after taking an oral preparation of Chinese herbs. Lim et al. [33] described cases where patients presented with severe cutaneous adverse drug reactions to TCM. One of the patients developed toxic epidermal necrolysis after consuming an unknown TCM powder. Another patient developed allergic contact dermatitis to topical liniment which was later found to contain coumarin, piroxicam, and salicylates. A patient with psoriasis experienced aggravation of skin lesions and hepatitis after consuming TCM adulterated with phenylbutazone and dexamethasone. Wu et al. [36] reported a fatal case of severe adverse drug reaction in a patient with AD who was using arsenic-containing topical herbal ointment over the whole body. As a result, eczema patients who are steroid phobic [37] and shun western medicine in favor of the presumably more “natural” TCM, may be unknowingly exposing themselves to higher cumulative amounts of topical or oral steroid masquerading as TCM.

Acupuncture

Acupuncture is widely used either alone or in conjunction with oral therapy in the treatment of dermatological conditions such as urticaria, eczema, and neurodermatitis. Acupuncture involves the placement of fine needles along specific points along the meridians [38] so as to relieve excess elements, and tonify deficiencies. In TCM, meridians serve as channels through which energy qi is believed to flow through.

In the relief of pruritic dermatoses [39–41], acupuncture reduces itch and wheal response following intradermal histamine injection. It was as effective as oral cetirizine in reducing Type 1 hypersensitivity itch in patients with AD, without causing somnolence and diminished attention focus as seen in the cetirizine group. Acupuncture demonstrated greater itch-abortive effect [42] during peak itch intensity compared to cetirizine. Twice weekly sessions of acupuncture, in combination with Chinese herbal medicine, was found to be reduce Eczema Area and Severity Index and Dermatology Life Quality Index scores [43] in a case series of 20 patients with mild to severe AD.

A possible mechanism for the antipruritic effect of acupuncture is the counterirritation or distraction theory [44], which has been largely studied for analgesic properties of acupuncture. Another plausible explanation might relate to mediators associated with itch [45], such as endogenous opioid peptides. Beta-endorphin and other similar neuromodulators have been implicated in acupuncture analgesia and have been shown to influence itch sensation. On a spinal level, acupuncture seems to have a counterirritation effect via the reduction of prostaglandin E2 levels in brain [46] and serum of lipopolysaccharide (LPS)-injected rats. Prostaglandin E2 is a mediator involved in itch and potentiates the flare reaction to histamine. In a separate study [47], reduction of itch in acupuncture was found to be associated with reduction of allergen-induced basophil activation in AD patients. Neuroimaging studies [48] have demonstrated that acupuncture modulates the limbic and paralimbic brain structure, such as the amygdale, anterior cingulated, and insular cortices, known to process itch sensation in both healthy adults and AD patients.

The most common complications reported following acupuncture treatment were cutaneous infections. Mycobacterial and staphylococcal infections were reported. Most of these cases were caused by reusable needles. Other infective complications included septic arthritis, facial erysipelas, and necrotizing fasciitis. Rarely, acupuncture treatment has resulted in organ or tissue injury [49] such as pneumothorax, peripheral nerve injury, spinal cord injury, pseudolymphoma, and pyoderma gangrenosum. Encouragement of conscientious reporting of adverse outcomes following acupuncture by practitioners, and formal training on safe practices and infection control, would reduce complication rate while maximizing patient benefits.

It remains to be further confirmed if acupuncture offers any true benefit in the clinical management of pruritic skin conditions such as AD and chronic urticaria. High-quality RCTs and biomedical research are needed for stronger evidence regarding its efficacy and safety (Fig. 47.2).

Fig. 47.2
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Acupuncture

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Massage Therapy

The traditional art of massage therapy according to the rules of TCM is referred as Tui Na. The technique comprises of various maneuvers such as pushing, kneading, circular rubbing, pinching, and finger pressure. These are performed over the specific pressure points (acupoints) that are located at different parts of the body, along the Meridian lines.

A study involving 240 Chinese infants [50] with AD, who were randomly assigned to massage therapy versus standard therapy, reported both short- and long-term benefits, which were comparable to standard treatment arm. Lower rate of disease recurrence was also observed in the massage therapy group. Twenty children were studied in a randomized, controlled trial comparing standard eczema treatment versus standard treatment and daily 20-min massage sessions. Improvement in symptoms such as pruritus and excoriation, as well as anxiety scores and coping ability were observed. Increased coping ability [51] of the patient in the setting of a chronic disease would be a desirable goal of therapy. Massage therapy likely benefits AD by reducing stress while promoting enjoyable interaction between parent and child, hence improving compliance to topical treatment. The appeal of massage therapy is that it is easily taught to the parent or caregiver, incurs minimal financial cost, and is not known to have any adverse effects. However, it remains unclear whether massage therapy has any true benefit on the overall disease activity (Table 47.2).

Table 47.2 Common acupoints used in treating skin diseases
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Cupping

Glass cups are heated to create a partial vacuum over the skin. The underlying tissues are drawn up and local blood stasis is induced. This is seen as circular areas of ecchymoses on the skin. Conditions which have been found to respond to this therapy include eczema, pruritus, recurrent carbuncles, or furunculosis. Despite the sizeable clinical experience from experts within the field, the present lack of controlled studies remains a main drawback for these methods (Fig. 47.3).

Fig. 47.3
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Cupping

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Future Development and Research

Modernization of Traditional Medicine

TCM encompasses a wide range of practices including some that are familiar to the West, such as herbal medicine and acupuncture, as well as others that remain peculiar to most Westerners such as cupping (heated cup therapy), tuina (massage), qigong (movement and breathing exercises), and moxibustion (burnt mugwort therapy). Investigation into whether these therapies have underlying mechanism of action is now a central task in TCM research.

With more quality controlled trials, characterization of the pharmacokinetics of complex herbal formulations, chemical profiling, and biological assays, it is foreseeable that TCMs credibility stands to increase in the future.

In Hong Kong and China [52], 60 % of the population has consulted TCM practitioner at least once. According to national survey data, as high as 75 % of population in Singapore, Taiwan, South Korea, and Japan used traditional medicine once a year. United States and Europe are experiencing growth in TCM use with imports of TCM products increasing 10 % per year. In the light of increasing recognition of TCM by the World Health Organization (WHO), countries are pursuing integration of traditional medicine with modern medicine. In the white paper presented, WHO highlighted the need to depart from the current apprentice-master training of TCM, moving towards standardization of its education and practice. In 2008, WHO endorsed an international agreement [53] drawn up in Beijing to support the safe and effective use of TCM in modern healthcare. This would ensure that TCM is correctly employed to treat patients, minimizing toxicity from inappropriate usage of herbal medicine. Formal training in TCM is currently offered in universities across the region such as Singapore and Malaysia. In Singapore, there are clinics offering TCM in all acute as well as community hospitals. In Malaysia, there are already twelve hospitals to date that offer both modern and traditional medicine.