Keywords

Introduction

Interest in complementary and alternative medicine (CAM) has significantly increased in Western countries. A 2002 report from data collected by the Centers for Disease Control and Prevention (CDC) estimated that 36% of adults in the United States used some form of CAM therapy that year [1]. CAM are a group of therapies that are used in addition to, or as an alternative to, conventional treatment. Many of those therapies lack evidence-based data to support their use [2, 3]. Traditional Chinese medicine (TCM) originated in China more than 2000 years ago, and it is one of the most common alternative therapies currently used [1, 4]. TCM is composed of a mixture of cultural philosophies, principles, and practices that include herbs, acupuncture, moxibustion, massage, cupping, and dietary modification [3, 5]. Patients with acne and rosacea may try CAM/TCM to reduce their personal healthcare costs, to avoid medication-associated side effects, or because they desire a more “natural” solution [6]. Acne is a chronic skin condition characterized by comedones, inflammatory papules, nodules, pustules, cysts, and scarring, mainly on the face, chest, and back [3, 4]. The cause is multifactorial, with contributions from bacterial colonization, increased sebum production, altered keratinization, hormonal imbalance, and inflammation [3, 5, 7]. Rosacea is a chronic inflammatory skin condition characterized by capillary dilation, diffuse erythema, papules, and pustules, located mainly on the cheeks and nose [8]. In this chapter, we will summarize the evidence for different forms of TCM that have been used for acne and rosacea.

Acne

Fen ci refers to the name given in Chinese to acne vulgaris, and it means white thorns, referring to the pustules seen in acne vulgaris [9]. TCM postulates that the cause of acne is excessive heat in the lungs or stomach, and increased moisture and blood stasis, leading to a buildup of toxins and inactivity of qi (vital energy) [3, 9, 10]. Therapies such as herbal medicines, acupuncture, and cupping, among others are thought to be helpful to regulate the flow of qi, eliminate moisture and toxins, and enhance immunologic function to induce remission in acne [3, 5, 9, 11]. Additionally, it has been thought that acupuncture may play a role in endocrine function by regulating androgen levels and thus diminishing sebum production [3]. In a 2011 study in Taiwan, 91,129 patients chose to use TCM to treat acne, and 99% of these patients used this modality as their primary therapy [5].

Herbal Remedies

Callicarpa

Callicarpa , also known as beautyberry and Zizhu, belongs to the Verbenaceae family and is known for its anti-inflammatory, hemostatic, neuroprotective, antioxidant, analgesic, and antimicrobial effects [12]. Forty-eight different species have been identified, and these are typically found in the south of China [12]. Each species of Callicarpa is used according to its therapeutic effects, which vary depending on its slight differences in taste and metabolites [12]. In dermatology, Callicarpa has been historically used for a wide variety of conditions, such as measles, furuncles and carbuncles, bruises, pruritus, desquamation, scabies, ulcers, eczema, psoriasis, and acne [12]. The anti-inflammatory, immunologic, and analgesic activities of Callicarpa have been studied and are attributed mainly to inhibition of cyclooxygenase-2 (COX-2), interleukin-1β (IL-1β), intercellular cell adhesion molecule-1 (ICAM-1), and vascular cell adhesion protein-1 (VCAM-1) [12]. Antioxidant activities are attributed to one of its metabolites—flavonoids—but also to its IC50 (concentration required to inhibit 50% of radical) values of hydrogen peroxide (H202) [12]. Antimicrobial effects are observed against Staphylococcus aureus, Salmonella typhi, and Streptococcus pneumoniae secondary to the inhibitory properties of its ethanol component [12].

In acne vulgaris, the safety profile of Callicarpa has been studied in 126 patients. Sixty-four patients were treated with a combination of the herbal remedy in an oral formulation plus adapalene gel (concentration was not disclosed), and 62 patients were treated only with adapalene. In terms of total lesion count, the group receiving both treatments showed better outcomes (85.94% total efficacy) compared to the control group (71.49% total efficacy), as well as fewer adverse events (10.9% vs 35.4%) [12]. In this study, oral Callicarpa extract was well tolerated, and side effects were mostly limited to nausea [12].

Mahonia

Mahonia belongs to the Berberidaceae family, containing 590 different species mainly found in the Northern Hemisphere and South America [13]. In dermatology, Mahonia root and stem have been used for the treatment of dermatitis, burns, ulcers, and acne [13]. Antimicrobial activity against Propionibacterium acnes (P. acnes) has been documented [14]. A review described the effects of Mahonia in a study of 92 patients with acne treated either with oral Mahonia or minocycline hydrochloride (dose not disclosed). In the Mahonia group, 31 patients displayed resolution of their acne lesions, with a total effective rate (complete clearance of lesions) of 98.28% compared to 91.18% in the control group, which was not statistically significant [13]. This implies that, in this small study, oral Mahonia was as at least as effective as minocycline. Larger studies are needed to confirm these findings and further investigate the safety and efficacy of Mahonia species for acne.

Green Tea

Green tea and specifically its polyphenols, epigallocatechin-3-gallate (EGCG) and catechin, display anticarcinogenic, anti-inflammatory, anti-lipogenic, and antimicrobial activities [7, 15, 16]. Green tea may have utility in acne vulgaris by modulating sebum production, lipogenesis, inflammation, and growth of P. acnes [7]. The effects of catechin have also been studied in vitro, demonstrating a reduction of the level of P. acnes-enhanced toll-like receptor 2 and interleukin-8, leading to a reduction in inflammation [16].

The anti-inflammatory and anti-lipogenic properties exerted by EGCG through effects on IGF-1 have been described in animal studies [15]. A study compared the effects of EGCG with all-trans retinoic acid on the sebaceous gland size in rabbits. A reduction in sebaceous gland size was evident in both groups [15].

While there is some data to suggest efficacy of EGCG and catechin in vitro and in animal studies, human studies are limited in the English literature. In a randomized, double-blind, placebo-controlled clinical trial, 80 women between the ages of 25 and 45 years with moderate to severe acne were randomized to receive either an oral preparation of 1500 mg decaffeinated green tea extract or placebo [7]. Sixty-four women completed the study. Inflammatory and noninflammatory lesion counts were recorded at baseline and 4 weeks after beginning treatment. After 4 weeks of treatment, a significant reduction in the number of inflammatory lesions was found between groups (green tea group compared to placebo group) in the following locations: nose (1.0 ± 0.8 vs 1.5 ± 1.2, p-value 0.03), perioral area (1.7 ± 1.3 vs 2.7 ± 1.9, p-value 0.04), and chin (2.3 ± 1.8 vs 3.7 ± 3.4, p-value 0.03). There were no significant between-group differences for inflammatory lesion counts in other areas, nor were there significant between-group differences for total lesion counts [7]. No major side effects were observed over the 4 weeks of the study.

Arctium lappa

Arctium lappa , also known as burdock or lappa, belongs to the Asteraceae family [17]. Historically, Arctium lappa roots have been used by European herbalists to treat acne because of their antioxidant, immunomodulatory, and antimicrobial properties [17]. An observational, uncontrolled interventional study evaluated the change in acne lesion count after taking oral Arctium lappa 6c (potency), four pills of 40 size, four times a day for 1 week, followed by placebo for one additional week, in 32 subjects (20 men and 12 women) [17]. The 1-week treatment was not repeated, but patients were followed for 6 months. Outcome was assessed by a homeopathic doctor using the Global Acne Grading System to identify the type and number of lesions. A statistically significant improvement in total inflammatory and noninflammatory lesion count was observed, with a total lesion count at baseline of 20.3 compared to 10 at the end of the study (p-value 0.001), potentially due to the antimicrobial properties of lappa against P. acnes [17].

Myrica rubra

Myrica rubra , also known as bayberry, belongs to the Myricaceae family, and it is known for its antimicrobial properties against P. acnes [18]. Its antioxidant and anti-inflammatory effects on sebocytes stimulated by P. acnes have been studied in vitro, and it has been shown to be effective at suppressing P. acnes-induced cytokine production by regulating toll-like receptors [18]. No human studies have been reported in the English literature for Myrica rubra as a treatment for acne.

Combination Preparations

Oftentimes, a preparation of multiple herbs is given to patients in order to take advantage of potential synergistic effects [19, 20]. The preparations consist of a mixture of herbs such as those previously mentioned, plus Oldenlandia diffusa, Angelica, Sophora flavescens, and others [19, 20]. Examples of these preparations include Zhen Ren Huo Ming Yin, Huang Lian Jie Du Tang, Tuo Li Xiao Du Yin, Wen Qing Yin, Gan Lu Yin, Pi Pa Qing Fei Yin, Fu Fang She She Cao He Ji, Dang Gui Ku Shen Wan, and Tao Hong Si Wu Tang [9, 19]. In TCM, it is thought that when acne is caused by excessive heat in the lungs and stomach, oily skin, dry mouth, thirst, and constipation result. For these patients, a combination of herbs known as Pi Pa Qing Fei Yin and Dan Di Tang is often used [9]. Several small studies have evaluated the efficacy of such formulations for the treatment of acne vulgaris and acneiform drug reactions secondary to medications, such as epidermal growth factor receptor (EGFR) inhibitors [19, 20]. Preparations that claim to be antimicrobial include a mix of kampo extracts known as Keigairengyoto, Huang Lian (Rhizoma coptidis), and Gan Cao (Radix glycyrrhizae), which have been shown to be effective against P. acnes and S. epidermidis, possibly secondary to its antioxidant actions on infiltrated neutrophils [21,22,23]. In a case–control study evaluating 120 men and women with acne vulgaris, the treatment group (86 subjects) received a compounded mixture of oldenlandis in a dose of 200 mg twice daily, while the control group (34 subjects) were treated with Dang Gui Ku Shen Wan orally at a dose of 6 grams twice daily. The treatment group had a reported cure rate (defined as disappearance of all acne lesions) of 44.19% compared to 29.41% in the control group (p-value < 0.05) [20].

The most commonly reported side effects in patients with acne treated with these herbal remedies include dizziness, nausea, abdominal pain, diarrhea, pruritus, dryness, and burning sensation [3, 5, 20].

Acupuncture

Acupuncture is one of the TCM modalities that dates back to ancient China, and consists of inserting solid thin needles in specific points in the skin, with the aim of correcting an imbalanced flow of qi through channels known as meridians [6, 9, 11]. The use of acupuncture in dermatology has been widely used in China, and patients with acne often pursue this treatment [24,25,26,27]. The most common acupoints for acne are Hegu (LI 4), Quchi (LI 11), Yinlingquan (SP 9), Xuehai (SP 10), Sanyinjiao (SP 6), Zusanli (ST 36), Taichong (LR 3), Zhongwan (CV 12), Tianshu (ST 25), Shangxing (GV 23), Taiyang (EX-HN5), and Yangbai (GB 14) [10]. A study compared the efficacy of acupuncture with helium–neon laser with a power density of 25 mW/cm2 for the treatment of acne vulgaris. Sixty-eight patients (both men and women) were divided into two groups, one treated with helium–neon laser auricular irradiation (20 min per session for a total of ten sessions on predetermined auricular points with a distance of 30–50 cm from the skin) plus acupuncture (once daily for ten sessions) and the other group treated only with acupuncture (once daily for ten sessions). The acupoints used in the acupuncture sessions were LI4, LI11, GV23, EX-HN5, ST36, and GB14.The combination of laser plus acupuncture was more effective, with a cure rate defined as complete disappearance of acne lesions, of 77.8% in the treatment group compared to 46.9% in the control group [10]. A Cochrane database systematic review summarized the results of two studies that evaluated the efficacy of acupuncture in the treatment of acne and compared this approach to traditional Western medicine therapies. Neither of these individual studies is available in the English literature, but according to the systematic review, the treatment of acne vulgaris with acupuncture vs oral antibiotics or oral retinoids proved to be similar among groups, with no statistical inferiority of acupuncture compared to Western medicine [3]. Adverse effects have not been widely studied, but pruritus, erythema, contact dermatitis, and pain are the most commonly reported symptoms after acupuncture therapy [3].

Cupping

Cupping is a technique that consists of suctioning skin areas in order to mobilize blood flow and promote healing [11]. The efficacy of cupping for the treatment of acne has been studied alone and compared with retinoids, oral tetracyclines, and herbal preparations [3]. A Cochrane database systematic review described a study not available in the English literature that compared the acne remission rate of cupping with oral tetracycline in 60 subjects (men and women). The ashi points (defined as points that are needled based on where patients have pain or where there is obvious inflammation) in the first lateral line of the bladder channel on the back were pricked ten times with a three-edged needle to identify the ideal sites for cupping (points that bled). Cupping was then used only on those sites once a day for a total of ten treatments over 1 month. Achromycin 1 gram daily was given to the control group during the same period of time. Remission was defined as clearance of 95% or more of the lesions with only mild hyperpigmentation and scars remaining. A statistically significant improvement was observed in patients treated with cupping (RR 2.50, 95% CI 1.31–4.77, p = 0.005) [3]. Skin bruising and discoloration were the most commonly reported side effects [3].

Diet

Diet is an important component of TCM. Chinese medical theory states that an unhealthy diet could immediately cause imbalances and thus, when treating acne, a strict yin or yang diet is recommended, which is focused on a balanced diet [28]. Yin foods are generally cold, low in calories, and high in potassium, whereas yang foods are believed to be warm and dry. It is thought that balance or equilibrium should be maintained between yin and yang for ideal health. Cereals, legumes, vegetables, soups, and algae are in the center (equilibrium) and represent the base of a traditional Chinese diet, whereas alcohol, sugar, dairy, eggs, and meat are to be consumed sparingly or avoided completely. A cross-sectional study performed in China evaluated the acne severity and yin and yang diet scores using a quantitative method in 322 patients. Experts evaluated each subject’s diet in an attempt to correlate their yin and yang diet to their signs and symptoms. Yin refers to pale skin and tongue color, deep pulse, and low activity or energy, whereas yang refers to brightly colored or red tongue and a high level of activity. After this assessment, a score was assigned to each subject on a scale of minus 10 to plus 10 (where zero represents a state of balance), and thus a yin or yang predominance was established. The authors found that in patients predominantly following a yin diet, a lower incidence of acne was observed. Those following a yang diet were found to have a higher incidence of acne [28]. Two additional randomized controlled trials assessed dietary interventions in patients with acne [29, 30]. Low-glycemic index diets were compared with high-glycemic index diets in patients with acne. Smith et al. studied 43 men with acne in a randomized controlled study where the treatment group consisted of a low-glycemic diet comprised of 25% protein and 45% low-glycemic index carbohydrates, whereas the control group consisted of a dense-glycemic diet. Acne lesion counts and acne lesion severity were assessed at 12 weeks. The total acne lesion count significantly decreased in the low-glycemic diet group compared to the high-glycemic diet group (−23.5 + −3.9 vs −12.0 + −3.5 p = 0.03) [30]. Similarly, Kwon et al. studied the effects of a low-glycemic load diet in 32 patients (men and women) with mild to moderate acne who were randomly assigned either to a low-glycemic load diet or a control group diet for 10 weeks [29]. Only patients in the intervention group displayed a significant improvement both in their inflammatory and noninflammatory lesions, with acne scores (performed by dermatologists using the Leeds revised acne grading system and digital photography) changing from 2.18 to 1.6 (p = 0.02) [29].

Rosacea

Similar to acne, Chinese medicine theorizes that rosacea is related to blood heat, blood stasis, and accumulation of heat in the lungs and stomach. Hence, the basic treatment principle is to dissipate heat in those areas, remove toxic substances, and activate blood circulation [8]. Herbal remedies and acupuncture are the two most commonly used TCM modalities for rosacea.

Herbal Remedies

Individual herbs and combinations of different preparations have been reported to be effective for the treatment of rosacea. A preparation known as CBX (consisting of loquat leaf, mulberry bark, Scutellaria root, Imperata rhizome, red peony root, safflower, red sage, chuanxiong, Dahurian angelica, motherwort, and Chinese trumpet creeper flower) is believed to be effective for dissipating heat and, thus, treating rosacea [8]. Specifically, safflower, red sage root, and chuanxiong are believed to activate blood circulation and thus remove toxins [8]. One case–control study evaluated the effect of CBX preparation in 68 women with rosacea. All patients were treated with spironolactone 60 mg/day plus minocycline 100 mg/day; 48 of those patients additionally received CBX orally twice daily for 8 weeks. The patients in the CBX group had a reported cure rate of 87.5%, when compared to a cure rate of 45% in the control group with a p-value < 0.01 [8]. Cure rate was defined in this study as remission of 90% or more of lesions including erythema, papules, pustules, and capillary dilation.

Acupuncture

Acupuncture may be a valuable tool for the treatment of rosacea; however, there is a paucity of data to support this approach in the English literature [11, 31]. One reported case describes a patient treated with three acupuncture sessions over 1 week, with needles inserted into the acupoints of Yintang (EX-HN3), bilateral Taiyang (EX-HN5), bilateral Yingxiang (LI20), and Chengjiang (CV 24). She was then followed for 6 months and demonstrated a substantial and sustained improvement in her rosacea, without recurrence [31].

Conclusion

A large proportion of patients are interested in complementary and alternative medicine in general, and traditional Chinese medicine in particular, thus healthcare practitioners should be aware of TCM theory, therapeutic modalities, potential mechanisms of action, and possible side effects. There is still a lack of evidence-based research on this topic. Well-designed, larger randomized controlled studies with longer follow-up are needed in order to evaluate their safety and efficacy. Head-to-head studies comparing these modalities to the available therapies used in Western medicine would be most useful. The available literature demonstrates the potential relevance of TCM for the treatment of dermatological conditions, including acne and rosacea, and how TCM could be used as a complement to Western medicine.