Seminars in Integrative Medicine, Vol 1, No 3 (September), 2003: pp 145-150

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Psoriasis is a chronic, relapsing skin disease that has been known for thousands of years. Practitioners of traditional Chinese medicine (TCM) first described psoriasis 1600 years ago. The precise etiology and pathogenesis of psoriasis are not known, although there are many hypotheses. Several commonly accepted points of view in TCM for the etiopathogenesis of psoriasis exist. These include syndromes of blood and wind heat, blood stasis, 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, the 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 eliminate the stagnation and activation of blood. Several methods of treating psoriasis with acupuncture are described in this article. These include the following: choosing points according to the syndromes, choosing points according to the location of lesions, which points should be treated in all patients suffering from psoriasis, bloodletting from the root of the ear and from the three kui points, application of a plum-blossom needle, and cupping therapy. The important place of auriculotherapy in the treatment of psoriasis is also reviewed.

TRADITIONAL CHINESE MEDICINE PRINCIPLES IN THE PATHOGENESIS AND TREATMENT OF PSORIASIS VULGARIS
EMIL ILIEV, MD
AND

VALENTINA BROSHTILOVA, MD

INTRODUCTION
soriasis is a common, chronic relapsing skin disorder that has been known to people for thousands of years. In ancient times, psoriasis was believed to be a type of leprosy. In fact, psoriasis was regarded as leprosy even in the Bible. Although Celsus (25 BC to 45 AD) was the first to describe psoriatic lesions, it was not until the nineteenth century that Willan and Hebra were able to classify psoriasis as an independent disease.1 In 610, Ganxian from Chao Yuan Fang first described the TCM viewpoint for psoriasis in his booklet, Zhu Bing Yuan Hou Lun (Discussion Regarding the Origin of Symptoms). In 1617, Baichuang from Chen Shi Gong tried to explain the pathogenesis of this disease in his study called Wai Ke Zheng Zong (The Real Origin of Surgery).2 Through the ages, the Chinese people 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 At this time in China, psoriasis is called Yin xie bing (“the disease of the silver squames”). The precise etiology and pathogenesis of psoriasis remains unknown, although there are many hypotheses. TCM holds several commonly accepted points of view regarding the etiopathogenesis of psoriasis.

P

From the Department of Dermatology and Venereology, Faculty of Medicine, Sofia, Bulgaria. Correspondence: Dr. Valentina Broshtilova, Department of Dermatology and Venereology, Faculty of Medicine, 1 St. Georgi Sofiisky str, Sofia 1341, Bulgaria. © 2003 Elsevier Inc. All rights reserved. 1543-1150/03/103-0004$30.00/0 10.1016/S1543-1150(03)00027-9

and safeguarding the functions of the organs. fire-toxins. blood stasis. punctiform or oval. different pathogenic mechanisms for psoriasis exist. and menstrual disorders as well. Since the channels and collaterals connect the viscera inwardly and the body surface outwardly. ecchymosis. M squamae. Blood and Wind Heat Etiopathogenesis The excessive blood heat is an internal factor that causes psoriasis. muscle weakness. pathogenic factors from the superficial portion of the body can enter it. scorching. a deficiency of wei-qi causes skin dryness. the channels and collaterals perform the role of transporting qi and blood. thickened and hardened skin.9 ETIOPATHOGENESIS AND CLINICAL SYNDROMES OF PSORIASIS FROM THE VIEW OF TCM A ccording to TCM. Disease often results from the invasion of wind (an external pathogenic factor). the subsequent drying may cause nutritional muscle and skin deficiencies. while a pathogenic change in the visceral organs can also be conveyed to the surface. and trichomadesis. Controversially. practitioners can determine which inner organ corresponds to which diseased area. these symptoms may be accompanied by constipation and dark urine. These changes may also be accompanied by purple lips.5 According to TCM. erosion. by judging the particular area of certain skin lesions and by examining the route and network of channels and collaterals in the body. and body fluids. thereby causing certain skin diseases. Zong-Qi (pectoral Qi) is gathered in the chest. Some patients complain of thirst. as well as heat sensation and thirst. Dermatoses vary greatly. Itching is severe. Erythema and the spread of lesions depends on the predominance of heat in the blood. and bi syndrome. The patient’s pulse is rapid and thin. and deficiency of the liver-qi and kidney-qi. usually accompanied by severe itching. jing luo (channels and collaterals). The subjective symptoms include pain. and pain. Dryness leads to skin xerosis. New lesions continue to appear. pustule. and deep-colored urine. blood stasis. TCM developed the physiologic theories of zang and fu (viscera). silver squames and tiny bleeding points.8 The damage of skin by heat is manifested by reddened skin. Wei-Qi protects the superficial portion of the body against external pathogenic factors warming up the inner organs and moistening the skin. dampness. however. constipation. Yuan-Qi originates from the kidney.4 The concept of Qi refers to two different aspects: (1) refined. Eruption and white scales result from excessive wind heat.6 For instance. The therapeutic approach tries to clear the heat and cool the blood by activating it. In TCM these factors include wind. The skin damage under the category of Blood Stasis is manifested by petechia. heat. several external factors can cause the disease. dryness. an abundance of wei-qi makes the skin soft. Physiologically. pathogenic factors can move between the viscera and the body surface. numbness. violet-red or dark-red spots. and strong. In addition. itching. These include: blood and wind heat. and greater liability to the external pathogenic factors. xue (blood). blood deficiency– dryness. Anxiety and excitability are often symptoms. The tongue is covered with either a yellow or yellowish grimy coating. thereby connecting the interior and exterior. The blood-heat type of psoriasis most often affects people younger than 40 years of age. tongue ecchymosis. . The lesions are numerous.146 ILIEV ET AL BASIC TERMS OF TRADITIONAL CHINESE MEDICINE ore than 2000 years ago. smooth. nutritive substance flowing through the body and (2) the general function of the internal organs and tissues. which subsequently developed into blood dryness and blood stasis. and bradyesthesia. In this respect. dryness of the tongue. resisting exogenous factors. The Auspitz’s sign and Koebner phenomenon are easy to obtain. atrophia. and verrucous vegetations. thereby bringing harm to the visceral organs. trichoxerosis.7 The classic TCM concepts refer to psoriasis as blood heat. pigmented spots. These lesions also have numerous thin.10 Clinical Syndrome This syndrome is the clinical equivalent to guttate and nummular psoriasis in traditional Western medicine. Ying-Qi circulates through the blood vessels. and extremely red. qi. Qi exists in every part of the body. which dries the blood and increases the body’s inner temperature. as well as severe itching. poison. in terms of pathologic changes.

scaly and dry. This forms skin eruptions. At the initiation of the disease. infections. In addition. the tongue may be unusually red and have a thin white coating. such as tonsillitis and laryngitis. psychosomatic stress. The lesions are pale-red and thin and do not tend to extend or resolve. seasonal changes. The nails are severely affected. in TCM.10 Clinical Syndrome This is the classic. wind– heat and wind– cold cause an imbalance of yin and blood. a famous TCM practitioner. Some lesions may resolve gradually. the deficiency of yin and blood. The lesions are pale and thin. pale-red lesions form with tiny pustules on top. The principle of treatment consists of enriching the blood (and yin). The most important symptom is xerostomia. yellow or yellowish-brown scales. Itching could be severe. since the metacarpal and metatarsal joints are injured the most. which does not allow the fire and toxins to be expelled from the body that is heating them to extreme temperatures. yellow scales. These are the internal predisposing factors. trigger psoriasis. The pulse is hard.TRADITIONAL CHINESE MEDICINE AND PSORIASIS VULGARIS 147 Fire–Toxin Etiopathogenesis Fire–Toxin is an external mechanism that causes a rapid course of the disease characterized by an intensive erythema and an excess of new lesions. the patient’s pulse is rapid. The Auspitz’s phenomenon can rarely be obtained. Most patients experience a strong burning sensation. the blood statis hypothesis received attention. Within the context of genetic predisposition towards imbalance. The therapeutic approach requires elimination of stasis and activation of blood. The course is usually prolonged. This leads to meridian and collateral obstruction and stagnation. which remain in the body longer. xerosis develops. transformed in the muscles and skin as wind– dryness. Expelling . constipation. and arthralgia are signs of blood stasis. If the skin is affected. The tongue is dark-red to purple in color with plenty of petechiae. relapsing form of nummular. psoriasis is attributed to wind and heat. mechanical traumas) cause a blockade in the upper layers. thereby causing an imbalance of yin and blood. The lesions are dark-red. Blood Deficiency–Dryness Etiopathology In the opinion of Gu Buo Hua. insomnia. white coating. which provokes wind and dryness so that the skin loses its nourishment. Patients often suffer from inflammatory diseases of the upper respiratory tract. Patients complain of vertigo. The pulse is moderate and loose. The Auspitz’s sign is easily obtained. which are often covered with thick. and palmoplantar psoriasis. Auspitz phenomenon. then small. These lesions are usually covered with silver squames. which leads to a stagnation of qi and a blockage of blood. The causal basis of psoriasis is a preexisting deficiency at the nutritive and blood levels. When blood heat is blocked in the superficial skin layers. Clinical Syndrome The most significant symptom of bi syndrome is arthralgia. improper diet. Bi syndrome results from the invasion of wind and dampness in the joints. Bi Syndrome Etiopathology This syndrome is rarely seen and corresponds to psoriatic arthritis. Tiny pustules tend to form. blood heat is considered the most important pathogenic factor for psoriasis. chronic-relapsing form of psoriasis. The disease either ceases to extend or extends slowly. and constipation. According to the blood statis hypothesis. or gyrate psoriasis.10 Clinical Syndrome Blood stasis corresponds to a chronic. This form is therapeutically resistant. It comes from the stagnation of heat in the blood. geographic. The tongue is pinkish in color and covered with a thin.7 In summary. indurative. They complain of graveolent feces. pustular. Blood Stasis Etiopathogenesis In recent decades. The pulse is rapid and filiform. Squames. as well as moistening the dryness. thick.11 Clinical Syndrome This syndrome corresponds to erythroderma. The lesions are red plaques covered with thick. As to lingual diagnosis. a purple tongue. They have a weak constitution. and do not itch. and severe joint pain. The tongue is intensively red with a greasy coating. external factors (eg.

Additional .13. One treatment course extends for 10 days and is followed by a 10-day break. Li 4 (he gu). Sp 10 (xue hai). Li 4 (he gu).15 the major psoriatic acupuctural points are GV 14 (da zhui). Bl 40 (wei zhong) is a coordinating point that is appropriate for all forms of psoriasis. Li 4 (he gu). treatment in two more points is required—Li 20 (ying xiang) and GV 25 (su liao). TW 6 (zhi gou) and Li 11 (qu chi) are additional points. this procedure should be performed two or three times daily for 30-minute intervals. Li 11 (qu chi). GB20 (feng chi). face. and St 36 (zu san li). Sp 10 (xue hai) and Sp 6 (san yin jiao) can also be used.148 ILIEV ET AL the heat seems a proper therapeutic approach. Sp 6 (san yin jiao). because it is directed towards eliminating stagnation and activation of blood-xue. In addition. Sp 10 (xue hai). a course can then be repeated for a maximum of four times. and Sp 6 (san yin jiao) points. Gummi Olibanum. Semen Persiace. Li 11 (qu chi). For skin that is more greatly affected. According to other scientific sources. and an activation of blood. TW 6 (zhi gou). Rhizoma sparganii.11. The major points used to treat low extremity involvement include Sp 10 (xue hai). Radix salivae Miltiorrhizae.5g 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 The fire–toxin pattern requires formulas for the elimination of toxins and the cleansing of 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 9g to 15g Radix Paeniae rubrae 9g to 15g Radix Paeniae lactiflorae 9g to 15g Flos Carthami tinctorii 9g to 15g Semen Persicae 9g to 15g Herba Buchnerae cruciatae 15g to 30g Rhizoma Sparganii stoloniferi 9g to 15g Rhizoma Curcumae ezhu 9g to 15g Radix Aucklandiae lappae 3g to 9g Pericarpium Citri reticulatae 9g to15g The Overcome Psoriasis formula could be used to treat the 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 used to treat psoriasis with acupuncture are described.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. The orthodox pinning technique requires a proper de-qi effect. Bl 13 (fei shu). According to the dermatologic status of the patient. and Rhizoma Ligustici herbal products as tinctures and decocts are most commonly used. and Sp 6 (san yin jiao).14 The treatment of lesions affecting the upper extremities. Remission periods require elimination of stasis. and scull takes place in acupuncture points Li 11 (qu chi). Lesions disseminated over the body are treated in GV 14 (da zhui). Radix Rubiae. enforcement of qi. TREATMENT Phytotherapy Phytotherapy is considered the most effective TCM psoriatic treatment. Radix Angelicae Sinensis.

intercellular adhesion molecules. Bl 18 (gan shu). These approaches are as flexible in use. Acupunctura 3:3-10 (in Bulgarian). St 40 (feng long) can be taken in consideration for lower extremity lesions. and Bl 20 (pi shu) are used for thoracic and abdominal lesions. Stoyanov P: Psoriasis vulgaris from the view of TCM-etiopathogenesis and treatment.16 The ear points are located on its dorsal surface in a straight line. Lin L. Lin L. or injectable forms. De-Hui S. 1995. 2000 11. Zhaohui L: in Wu L (ed): Treatment of Psoriasis with TCM. pp 978-979 6. This procedure is performed every second day. GV 13 (tao dao). and GB 34 (yang ling quan) play roles in the treatment of lesions on the groins. GV 10 (ling tai). Beijing. Germany. Fischer–Springer. Sp 10 (xue hai). 1967 2. Plum-Blossom Needle Once daily. pp 28-32 10. China. Zhaohui L: in Wu L (ed): Treatment of psoriasis with TCM. Jiang. Arain S: TCM for the treatment of dermatologic disorders. pp 251-263 8. The major auricular points are lung. Heart and colon are considered additional. Hong Kong. and safe. mechanism of action. ren. China. Germany. Hai Feng Publishing Co. 1998 13. For patients. Hong Kong. cytokines and haemorheology have been investigated. as well as in the additional Bl 13 (fei shu). and adverse effects of various TCM treatment options. REFERENCES 1. 1999. Koo J.18 CONCLUSION T CM is an alternative method of therapy that can be administered in oral. Lin XR: Psoriasis in China. pp 103105 7. 1998. Hautarzt 18(2):74-75. In the case of many lesions. while GV 14 (da zhui). Xiu-Fen W. Berlin. Lin L. Lin L. pp 221-227 4. China. Xiu-Fen W. Wang N (eds): Manual of Dermatology in Chinese Medicine.17 Cupping Therapy and Acupuncture A needle can be cupped in the major GV 14 (da zhui). TW 6 (zhi gou) is appropriate for upper extremity involvement.. China. Peace Book. Xiu-Feu W. Blue Poppy Press. Intuitively plausible.. Si 2 (qian gu) is mostly used to treat lesions on the upper extremities. endocrine. Disseminated lesions over the body are treated in the GV 14 (da zhui) and GV 13 (tao dao) points. pp 224-228 . CO. China. called the inner middle kui.Hui L. current studies lack depth and scope in the methods. 1990. Arch Dermatol 134:1388-1393. De-Hui S. Ting-Liang Z. Boulder. 1993. Bloodletting Bloodletting from the root of the ear and from the three-kui points is performed. 1990. WA. 1990. Bl 15 (xin shu). WA. Eastland Press. The proper technique requires letting of few drops once daily and preferably in the morning. Hillenbrand N: in Urtban (ed): Leitfaden TCM.TRADITIONAL CHINESE MEDICINE AND PSORIASIS VULGARIS 149 points for facial and head lesions include GB 20 (feng chi) and St 9 (ren ying). Zhaohui L: in Wu L (ed): Treatment of Psoriasis with TCM. Focks C. Li I. the various TCM approaches in treatment are proving beneficial for many chronic inflammatory skin diseases. shen men. and adrenal. Hai Feng Publishing Co. and Bl 23 (shen shu) points. Eastland Press.19 Many experimental studies are currently be conducted to determine the cellular and molecular mechanisms of TCM psoriatic treatment modalities being performed. De-Hui S. St 34 (liang qiu). Tappeiner J: On the 150th birthday of Ferdinand von Hebra. p 217 12. Bl 21 (wei shu). highly efficient.20 The relationship between the type of psoriasis based on TCM syndrome differentiation and laboratory parameters. the lesions are tapped persistently with a sterilized plum-blossom needle circling from the edge to the center until minor blood drops appear. topical. such as platelet activation molecules CD 62P and CD 63. More systemic and precise analysis should be conducted for better understanding the efficacy. Lesions on the neck are preferably treated in TW 17 (yi feng). pp 76-88 14. the lesions may be pricked in turn. Iliev E. Wang N: in Hendry Kotzting (ed): Handbuch der Dermatologie in der Chinesischen Medizin. Seattle. 1995. Bl 18 (gan shu).. Seattle. Tai W: in Li K (ed): Practical Traditional Chinese Dermatology. Higher Educational Press. 1995: 320-329 5. Hai Feng Publishing Co. Bayer Wald. The palmar side of the middle-finger proximal interphalangeal joint possesses three major bloodletting points. pp 7-11 3. TCM has become increasingly popular as a mode for treating dermatologic diseases. Hong Kong. Feng H (eds): The English–Chinese Encyclopedia of Practical TCM. Flaws B: A Handbook of TCM Dermatology. 1990. 1993 9. Hong Kong.21-24 However. J Dermatol 20:746-755. Wang N (eds): Manual of Dermatology in Chinese Medicine.

Hong Kong. Zhong Xi Yi Jie He Za Zhi 5(3):151-154. 1998.. Yin GP: Relationship between syndromedifferentiation typing and expression of platelet-activation molecule CD62P and CD63 on platelets in psoriatic patients. Liu HC.. Fischer–Springer. Zhong Xi Yi Jie He Za Zhi 8:588-589. China. Song FR: Plum-blossom needling combined with medicinal fumigation in the treatment of psoriasis. 1987 20. Qin WZ: Determination of cyclic nucleotide and sialic acid in patients with symptoms of blood stasis and its value in assessing the therapeutic effect of drugs for activating blood circulation and removing stasis.150 ILIEV ET AL 15. China. Zhong Xi Yi Jie He Za Zhi 5(3):151-154. pp 980-981 16. Lin L. 1990. p 80 17. Hakagima H: Presentation of diagnostic criteria for the blood stasis symptom complex in dermatology. Zhongguo Zhong Xi Yi Jie He Za Zhi 17(7):417-418. Hong Kong. Germany. J Traditional Chin Med 22(1): 61-66. Hai Feng Publishing Co. Focks C. p 81 19. Hai Feng Publishing Co. Lin L. 1997 22. Zhang H. Zhongguo Zhong Xi Yi Jie He Za Zhi 14(4):210-212. 2002 23. Liu HC: Correlation between types of syndrome differentiation and erythrocyte deformability and membrane ATPase activity in psoriatic patients. 1994 24. 1988 18. 1988 21. Zhaohui L: in Wu L (ed): Treatment of Psoriasis with TCM. Berlin. Hillenbrand N: in Urtban (ed): Leitfaden TCM. Li GY. 1990. J New Chinese Med 20(1):39. Li L: Pathogenesis of Psoriasis. Zhaohui L: in Wu L (ed): Treatment of Psoriasis with TCM. 1985 . Qu X: Advances in experimental studies on treatment of psoriasis by TCM.

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