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) rst 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 deciencydryness, and retoxin 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 insufciency of these two organs is reected 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 rst 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 rst 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.

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

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BASIC TERMS OF TRADITIONAL CHINESE MEDICINE

ore than 2000 years ago, TCM developed the physiologic theories of zang and fu (viscera), jing luo (channels and collaterals), qi, xue (blood), and body uids.4 The concept of Qi refers to two different aspects: (1) rened, nutritive substance owing through the body and (2) the general function of the internal organs and tissues. Qi exists in every part of the body. Zong-Qi (pectoral Qi) is gathered in the chest. Yuan-Qi originates from the kidney. Ying-Qi circulates through the blood vessels. Wei-Qi protects the supercial portion of the body against external pathogenic factors warming up the inner organs and moistening the skin.5 According to TCM, an abundance of wei-qi makes the skin soft, smooth, and strong. Controversially, a deciency of wei-qi causes skin dryness, muscle weakness, and greater liability to the external pathogenic factors. Physiologically, the channels and collaterals perform the role of transporting qi and blood, thereby connecting the interior and exterior, resisting exogenous factors, and safeguarding the functions of the organs. Since the channels and collaterals connect the viscera inwardly and the body surface outwardly, pathogenic factors can move between the viscera and the body surface.6 For instance, pathogenic factors from the supercial portion of the body can enter it, thereby bringing harm to the visceral organs, while a pathogenic change in the visceral organs can also be conveyed to the surface, thereby causing certain skin diseases. In this respect, by judging the particular area of certain skin lesions and by examining the route and network of channels and collaterals in the body, practitioners can determine which inner organ corresponds to which diseased area. Dermatoses vary greatly, however, in terms of pathologic changes, several external factors can cause the disease. In TCM these factors include wind, dampness, heat, poison, dryness, blood stasis, and deciency of the liver-qi and kidney-qi.7 The classic TCM concepts refer to psoriasis as blood heat, which subsequently developed into blood dryness and blood stasis.8 The damage of skin by heat is manifested by reddened skin, erosion, pustule, scorching, itching, and pain. In addition, these symptoms may be accompanied by constipation and dark urine, as well as heat sensation and thirst. Dryness leads to skin xerosis,

squamae, atrophia, trichoxerosis, and trichomadesis, usually accompanied by severe itching. The skin damage under the category of Blood Stasis is manifested by petechia, ecchymosis, violet-red or dark-red spots, pigmented spots, thickened and hardened skin, and verrucous vegetations. These changes may also be accompanied by purple lips, tongue ecchymosis, and menstrual disorders as well. The subjective symptoms include pain, numbness, and bradyesthesia.9

ETIOPATHOGENESIS AND CLINICAL SYNDROMES OF PSORIASIS FROM THE VIEW OF TCM

ccording to TCM, different pathogenic mechanisms for psoriasis exist. These include: blood and wind heat, re-toxins, blood stasis, blood deciency dryness, and bi syndrome. Blood and Wind Heat Etiopathogenesis The excessive blood heat is an internal factor that causes psoriasis. Erythema and the spread of lesions depends on the predominance of heat in the blood. Disease often results from the invasion of wind (an external pathogenic factor), which dries the blood and increases the bodys inner temperature. Eruption and white scales result from excessive wind heat; the subsequent drying may cause nutritional muscle and skin deciencies, as well as severe itching. The Auspitzs sign and Koebner phenomenon are easy to obtain. The blood-heat type of psoriasis most often affects people younger than 40 years of age.10

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

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FireToxin Etiopathogenesis FireToxin is an external mechanism that causes a rapid course of the disease characterized by an intensive erythema and an excess of new lesions, which are often covered with thick, yellow scales. This form is therapeutically resistant. It comes from the stagnation of heat in the blood, which does not allow the re and toxins to be expelled from the body that is heating them to extreme temperatures.11 Clinical Syndrome This syndrome corresponds to erythroderma, pustular, and palmoplantar psoriasis. The lesions are red plaques covered with thick, yellow or yellowish-brown scales. Tiny pustules tend to form. The Auspitzs sign is easily obtained. The nails are severely affected. Patients often suffer from inammatory diseases of the upper respiratory tract, such as tonsillitis and laryngitis. They complain of graveolent feces, constipation, and severe joint pain. Most patients experience a strong burning sensation. As to lingual diagnosis, the tongue may be unusually red and have a thin white coating. In addition, the patients pulse is rapid. Blood Stasis Etiopathogenesis In recent decades, the blood statis hypothesis received attention. According to the blood statis hypothesis, psoriasis is attributed to wind and heat, which remain in the body longer, thereby causing an imbalance of yin and blood. This leads to meridian and collateral obstruction and stagnation. Squames, Auspitz phenomenon, a purple tongue, and arthralgia are signs of blood stasis.10 Clinical Syndrome Blood stasis corresponds to a chronic, relapsing form of nummular, geographic, or gyrate psoriasis. The course is usually prolonged. The disease either ceases to extend or extends slowly. Some lesions may resolve gradually. The lesions are dark-red, thick, indurative, scaly and dry, and do not itch. The most important symptom is xerostomia. The tongue is dark-red to purple in color with plenty of petechiae. The pulse is hard. The therapeutic approach requires elimination of stasis and activation of blood.

Blood DeciencyDryness Etiopathology In the opinion of Gu Buo Hua, a famous TCM practitioner, the deciency of yin and blood, transformed in the muscles and skin as wind dryness, trigger psoriasis. At the initiation of the disease, wind heat and wind cold cause an imbalance of yin and blood, which leads to a stagnation of qi and a blockage of blood. This forms skin eruptions. The lesions are pale and thin. The Auspitzs phenomenon can rarely be obtained.10 Clinical Syndrome This is the classic, chronic-relapsing form of psoriasis. The lesions are pale-red and thin and do not tend to extend or resolve. These lesions are usually covered with silver squames. Itching could be severe. Patients complain of vertigo, insomnia, and constipation. They have a weak constitution. The tongue is pinkish in color and covered with a thin, white coating. The pulse is moderate and loose. The principle of treatment consists of enriching the blood (and yin), as well as moistening the dryness. Bi Syndrome Etiopathology This syndrome is rarely seen and corresponds to psoriatic arthritis. Bi syndrome results from the invasion of wind and dampness in the joints. Clinical Syndrome The most signicant symptom of bi syndrome is arthralgia, since the metacarpal and metatarsal joints are injured the most. If the skin is affected, then small, pale-red lesions form with tiny pustules on top. The tongue is intensively red with a greasy coating. The pulse is rapid and liform.7 In summary, in TCM, blood heat is considered the most important pathogenic factor for psoriasis. When blood heat is blocked in the supercial skin layers, xerosis develops. The causal basis of psoriasis is a preexisting deciency at the nutritive and blood levels, which provokes wind and dryness so that the skin loses its nourishment. These are the internal predisposing factors. Within the context of genetic predisposition towards imbalance, external factors (eg, seasonal changes, psychosomatic stress, improper diet, infections, mechanical traumas) cause a blockade in the upper layers. Expelling

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the heat seems a proper therapeutic approach. Remission periods require elimination of stasis, enforcement of qi, and an activation of blood.

TREATMENT
Phytotherapy Phytotherapy is considered the most effective TCM psoriatic treatment, because it is directed towards eliminating stagnation and activation of blood-xue. Radix salivae Miltiorrhizae, Semen Persiace, Rhizoma sparganii, Gummi Olibanum, Radix Rubiae, Radix Angelicae Sinensis, and Rhizoma Ligustici herbal products as tinctures and decocts are most commonly used.11,12 A formula recommended for blood and wind heat pattern includes Modied Rhinoceros Horn and Rehmannia Decoction: Xi jiao di huang jia jian Cornu Rhinoceri 1.5g 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 ofcinalis 15g Gypsum 15g Calcitum 15g Radix Adenophorae seu Glehniae 10g Tuber Ophiopogonis Japonici 10g Radix Scrophulariae Ningpoensis 10g The retoxin pattern requires formulas for the elimination of toxins and the cleansing of body uids 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 lactiorae 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 deciency dryness clinical syndrome: Ke yin fang Radix Rehmanniae Glutinosae 30g Radix Scrophulariae ningpoensis 30g Semen Cannabis sativae 10g Rhizoma Menisperi daurici 10g Radix Sophorae avescentis 10g Acupuncture Several methods used to treat psoriasis with acupuncture are described.13,14 The treatment of lesions affecting the upper extremities, face, and scull takes place in acupuncture points Li 11 (qu chi), TW 6 (zhi gou), GB20 (feng chi), Li 4 (he gu). In addition, Sp 10 (xue hai) and Sp 6 (san yin jiao) can also be used. For skin that is more greatly affected, treatment in two more points is requiredLi 20 (ying xiang) and GV 25 (su liao). The major points used to treat low extremity involvement include Sp 10 (xue hai), Sp 6 (san yin jiao), and St 36 (zu san li). TW 6 (zhi gou) and Li 11 (qu chi) are additional points. Lesions disseminated over the body are treated in GV 14 (da zhui), Li 11 (qu chi), Li 4 (he gu), Sp 10 (xue hai), and Sp 6 (san yin jiao) points. Bl 40 (wei zhong) is a coordinating point that is appropriate for all forms of psoriasis. The orthodox pinning technique requires a proper de-qi effect; this procedure should be performed two or three times daily for 30-minute intervals. One treatment course extends for 10 days and is followed by a 10-day break. According to the dermatologic status of the patient, a course can then be repeated for a maximum of four times. According to other scientic sources,15 the major psoriatic acupuctural points are GV 14 (da zhui), Bl 13 (fei shu), Li 4 (he gu), Li 11 (qu chi), Sp 10 (xue hai), and Sp 6 (san yin jiao). Additional

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points for facial and head lesions include GB 20 (feng chi) and St 9 (ren ying). TW 6 (zhi gou) is appropriate for upper extremity involvement. St 40 (feng long) can be taken in consideration for lower extremity lesions. The major auricular points are lung, shen men, endocrine, ren, and adrenal. Heart and colon are considered additional. Bloodletting Bloodletting from the root of the ear and from the three-kui points is performed.16 The ear points are located on its dorsal surface in a straight line. The palmar side of the middle-nger proximal interphalangeal joint possesses three major bloodletting points, called the inner middle kui. The proper technique requires letting of few drops once daily and preferably in the morning. Plum-Blossom Needle Once daily, the lesions are tapped persistently with a sterilized plum-blossom needle circling from the edge to the center until minor blood drops appear. In the case of many lesions, the lesions may be pricked in turn.17 Cupping Therapy and Acupuncture A needle can be cupped in the major GV 14 (da zhui), GV 10 (ling tai), as well as in the additional Bl 13 (fei shu), Bl 15 (xin shu), Bl 18 (gan shu), Bl 21 (wei shu), and Bl 23 (shen shu) points. Disseminated lesions over the body are treated in the GV 14 (da zhui) and GV 13 (tao dao) points. Si 2 (qian gu) is

mostly used to treat lesions on the upper extremities. Sp 10 (xue hai), St 34 (liang qiu), and GB 34 (yang ling quan) play roles in the treatment of lesions on the groins, while GV 14 (da zhui), GV 13 (tao dao), Bl 18 (gan shu), and Bl 20 (pi shu) are used for thoracic and abdominal lesions. Lesions on the neck are preferably treated in TW 17 (yi feng). This procedure is performed every second day.18

CONCLUSION

CM is an alternative method of therapy that can be administered in oral, topical, or injectable forms. For patients, TCM has become increasingly popular as a mode for treating dermatologic diseases. Intuitively plausible, the various TCM approaches in treatment are proving benecial for many chronic inammatory skin diseases. These approaches are as exible in use, highly efcient, and safe.19 Many experimental studies are currently be conducted to determine the cellular and molecular mechanisms of TCM psoriatic treatment modalities being performed.20 The relationship between the type of psoriasis based on TCM syndrome differentiation and laboratory parameters, such as platelet activation molecules CD 62P and CD 63, intercellular adhesion molecules, cytokines and haemorheology have been investigated.21-24 However, current studies lack depth and scope in the methods. More systemic and precise analysis should be conducted for better understanding the efcacy, mechanism of action, and adverse effects of various TCM treatment options.

REFERENCES
1. Tappeiner J: On the 150th birthday of Ferdinand von Hebra. Hautarzt 18(2):74-75, 1967 2. Lin L, Zhaohui L: in Wu L (ed): Treatment of Psoriasis with TCM. Hong Kong, China, Hai Feng Publishing Co., 1990, pp 7-11 3. Li I, Feng H (eds): The EnglishChinese Encyclopedia of Practical TCM. Beijing, China, Higher Educational Press, 1990, pp 221-227 4. Lin L, Tai W: in Li K (ed): Practical Traditional Chinese Dermatology. Hong Kong, China, Peace Book, 1995: 320-329 5. Focks C, Hillenbrand N: in Urtban (ed): Leitfaden TCM. Berlin, Germany, FischerSpringer, 1998, pp 978-979 6. Jiang- Hui L, Ting-Liang Z, Flaws B: A Handbook of TCM Dermatology. Boulder, CO, Blue Poppy Press, 1993, pp 103105 7. De-Hui S, Xiu-Feu W, Wang N: in Hendry Kotzting (ed): Handbuch der Dermatologie in der Chinesischen Medizin. Bayer Wald, Germany, 1999, pp 251-263 8. Lin XR: Psoriasis in China. J Dermatol 20:746-755, 1993 9. Lin L, Zhaohui L: in Wu L (ed): Treatment of psoriasis with TCM. Hong Kong, China, Hai Feng Publishing Co., 1990, pp 28-32 10. Iliev E, Stoyanov P: Psoriasis vulgaris from the view of TCM-etiopathogenesis and treatment. Acupunctura 3:3-10 (in Bulgarian), 2000 11. De-Hui S, Xiu-Fen W, Wang N (eds): Manual of Dermatology in Chinese Medicine. Seattle, WA, Eastland Press, 1995, p 217 12. Koo J, Arain S: TCM for the treatment of dermatologic disorders. Arch Dermatol 134:1388-1393, 1998 13. Lin L, Zhaohui L: in Wu L (ed): Treatment of Psoriasis with TCM. Hong Kong, China, Hai Feng Publishing Co., 1990, pp 76-88 14. De-Hui S, Xiu-Fen W, Wang N (eds): Manual of Dermatology in Chinese Medicine. Seattle, WA, Eastland Press, 1995, pp 224-228

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15. Focks C, Hillenbrand N: in Urtban (ed): Leitfaden TCM. Berlin, Germany, FischerSpringer, 1998, pp 980-981 16. Lin L, Zhaohui L: in Wu L (ed): Treatment of Psoriasis with TCM. Hong Kong, China, Hai Feng Publishing Co., 1990, p 80 17. Song FR: Plum-blossom needling combined with medicinal fumigation in the treatment of psoriasis. J New Chinese Med 20(1):39, 1988 18. Lin L, Zhaohui L: in Wu L (ed): Treatment of Psoriasis with TCM. Hong Kong, China, Hai Feng Publishing Co., 1990, p 81 19. Li L: Pathogenesis of Psoriasis. Zhong Xi Yi Jie He Za Zhi 5(3):151-154, 1987 20. Hakagima H: Presentation of diagnostic criteria for the blood stasis symptom complex in dermatology. Zhong Xi Yi Jie He Za Zhi 8:588-589, 1988

21. Li GY, Liu HC, Yin GP: Relationship between syndromedifferentiation typing and expression of platelet-activation molecule CD62P and CD63 on platelets in psoriatic patients. Zhongguo Zhong Xi Yi Jie He Za Zhi 17(7):417-418, 1997 22. Zhang H, Qu X: Advances in experimental studies on treatment of psoriasis by TCM. J Traditional Chin Med 22(1): 61-66, 2002 23. Liu HC: Correlation between types of syndrome differentiation and erythrocyte deformability and membrane ATPase activity in psoriatic patients. Zhongguo Zhong Xi Yi Jie He Za Zhi 14(4):210-212, 1994 24. 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. Zhong Xi Yi Jie He Za Zhi 5(3):151-154, 1985