TCM Differentiation of Common Psoriasis

Psoriasis is a chronic, recurrent, inflammatory skin disease that affects approximately three percent of the population. It is thought to be a genetic disease with immune-mediated skin lesions that (according to western scientific medicine) has no cure. The various types of psoriasis are categorized according to morphology or by location of lesions. The most common morphologies include: chronic plaque psoriasis ("common" psoriasis), guttate psoriasis, pustular psoriasis, erythrodermic psoriasis and psoriatic arthritis (may or may not have skin lesions). More than one form of psoriasis can be present concurrently, and one type can transform into other types. Common plaque psoriasis is the type most often seen in the clinic.

Psoriasis is characterized by hyperproliferation of skin cells and thus is often referred to as "The Living Cancer." The skin under the lesions in this disease has a cell turnover rate that is seven times faster than normal skin cells. In normal healthy skin, it takes 28 days for a cell to progress from the deeper layers of the epidermis outward to the surface where it then dies and is shed. But in the lesions of common psoriasis, this process is sped up and occurs in only four days. These cells then build up on the surface of the skin and scaly plaques are formed.

Western medicine has very few helpful solutions to offer psoriasis patients beyond immunosuppressant drugs, but Traditional Chinese Medicine can have a profound impact on your patients if you differentiate correctly. There are numerous TCM patterns associated with the various forms of psoriasis. Let's look at the four patterns seen most commonly in the clinic: Heat in the Blood, Blood Deficiency, Qi & Blood Stasis and Disharmony of the Chong & Ren Mai.

Heat in the Blood Stirs Up Wind, is the most frequently seen pattern of common psoriasis. In this acute stage, the lesions appear abruptly and are usually bright or dark red. This stage is progressive, meaning the lesions are increasing in size and/or number of lesions. They eventually develop white or silvery scales that shed easily when dry, revealing the characteristic Auspitz's sign (little dots of blood that appear when you pull the thin scale off). The skin often will be itchy, too, but this may not be true in every case. The lesions can spread to normal skin if scratched. Other accompanying symptoms may include: constipation, dark urine, thirst, and irritability. Female patients may also complain of heavy periods. The patient's tongue will likely be red with a yellow coat, and the pulse may be rapid. The treatment principal is to Clear Heat, Cool Blood, Eliminate Wind (and Resolve Toxins).

When a patient has Heat in the Blood Stirs Up Wind, the episode appears abruptly and/or is progressive. But Blood Deficiency Leads to Wind and Dryness occurs during the stable phase of common psoriasis - the lesions are not growing in size and there are not many new lesions appearing. The skin is not bright red; rather the lesions are a paler red or even dull pink. They are drier and have white (or silvery) scales and may be itchy. Accompanying symptoms can include: pale complexion, lassitude/fatigue, insomnia, dry skin (not just the psoriasis lesions), dry hair, dry eyes and brittle nails. In women, the period might have scanty flow or there might be amenorrhea. The patient's tongue will most likely be pale with a thin coat (or none at all) and it may be dry. The pulses will be thin or wiry. In this pattern, the treatment principal is to Nourish (Liver) Blood, Dispel Wind, and Moisten Dryness.

When there is Qi & Blood Stasis involved in psoriasis, the lesions typically are darker in color. The lesions can appear dull red, purple or even brown. From a little distance they may even look like a bruise (but unlike typical bruises, the border between the lesion and the healthy skin will be very clearly demarcated). They often have silvery-white scales and tend to be thicker than the lesions seen in the other patterns; some older lesions may resemble oyster shells. In this phase, the old lesions are usually fixed in size and not many new lesions are appearing. The degree of itching can vary from intensely itchy to not itchy at all. Women with Qi & Blood Stasis may have painful periods (often with clots) or heavy periods. The patient's tongue might be dull purple or dark red or there may even be purple spots. The patient's pulse is choppy or wiry/choppy, and deep (esp. if the stasis has existed for a very long time). In the case of Qi & Blood Stasis, the treatment principal is obviously to move qi and blood. If there is much itching, herbal treatment should also include herbs to Dispel Wind.

In women whose psoriasis seems to be related to their menstrual cycle, pregnancy or childbirth, there is probably Disharmony in the Ren and Chong Vessels. This pattern of disharmony is not exclusive to women, but it is much less common and less obvious to diagnose in men. In this pattern, the psoriasis lesions often appear before pregnancy but disappear during pregnancy only to reappear after giving birth. In some patients, the condition becomes aggravated before the period (or possibly immediately after). The lesions are typically bright or pale red, with silvery scales. They are widely distributed over the body. Itching is usually not as severe as in other patterns. Accompanying signs and symptoms can include PMS, painful or irregular periods, general malaise, or dizziness. The tongue can vary but usually will be red or purplish with a thin coating. You might also suspect this pattern in women who are perimenopausal or if there are fluctuations in hormone levels that seem to affect the psoriasis. This pattern can combine with other TCM patterns, too. The main treatment principal here is to regulate the Chong & Ren Mai. If there are additional TCM patterns present (such as Blood Deficiency or Qi & Blood Stagnation), be sure to address those as well.

In my clinical experience, I have found herbal treatment to be far superior to acupuncture in the treatment of psoriasis. When formulating herbal prescriptions, the main focus of your treatment should be based on the proper TCM differentiation. But in all cases of psoriasis, regardless of TCM pattern, I always include herbs that have been found to have anti-neoplastic properties.

Because of the over-proliferation of skin cells that is characteristic of psoriasis, it is helpful to add these herbs to your formula whether treatment is internal or external. Some of these herbs include: Da Qing Ye, Qing Dai, Tu Fu Ling, Ku Shen, Zi Cao Gen, and Bai Hua She She Cao. If there is much itching, be sure to add herbs that Dispel Wind such as Fang Feng (which Dispels Wind without being drying), Jing Jie, Ju Hua, Chan Tui, Ku Shen, Bai Xian Pi, or Bai Ji Li (use caution with Bai Ji Li topically because it may actually cause a rash). If there is significant scaling, add herbs that help moisten the skin (Moisten Blood & Yin): Dang Gui, He Shou Wu, Bai Shao, Shu Di Huang, Tian Men Dong, or Mai Men Dong. For most chronic skin diseases that involve Heat in the Blood, I will also add herbs to Clear Heat and Resolve Toxins, such as Jin Yin Hua, Lian Qiao, Zi Hua Di Ding or Pu Gong Ying.

Many patients who have had psoriasis for a long time know little about their disease or how to manage it. It is imperative that you educate your patients on the following points:

1. Avoid Prednisone use: Common psoriasis can transform into the erythrodermic type (potentially life-threatening form) if triggered by certain factors. Use of internal (systemic) corticosteroids (such as Prednisone) has been identified as one possible trigger. Other possible triggers can include sunburn, strongly irritant topical medications, or allergic skin reactions to medications (including to drugs not used in the treatment of psoriasis). Certain medications can also trigger a form of psoriasis called guttate psoriasis.
2. Be cautious with topical cortisone cream: Sudden withdrawal of internal or topical steroids (including cortisone creams) can exacerbate common psoriasis or trigger it to transform into another life-threatening form of psoriasis known as Von Zumbusch (a pustular type of psoriasis). Other triggers of Von Zumbusch psoriasis may include pregnancy, blood pressure medications, iodides and Indomethacin (an NSAID).
3. Avoid getting the common cold or other infections. Psoriasis can get worse during and after infections. A form of psoriasis called guttate psoriasis can appear abruptly after respiratory infections or strep throat.
4. Avoid injury/trauma to skin. This includes sunburns as well as surgical scars, abrasions, cuts, and other wounds.
5. Avoid alcohol, spicy orgreasy foods, sugary foods/sweets, and shellfish (esp. shrimp). Some sources say to avoid most fish but this is debatable since the omega-3 fatty acids contained in some fish are helpful.
6. Stop smoking.

References

1. Chinese Medical Herbology and Pharmacology by John Chen and Tina Chen.