Eczema – A Common Skin Complaint

Eczema is a generic term used to describe inflammatory conditions of the skin and is the most common skin condition affecting Australians – in fact, eczema affects one in three Australians at some stage throughout their lives.¹ The most common form of eczema is atopic eczema, where the skin rash is caused by an allergic reaction. Eczema can affect people of all ages, but is most common in young children, typically starting within the first 12 months of life.

Recognising Eczema: Signs & Symptoms

Eczema most commonly appears on the face, neck, and the insides of the elbows, knees and ankles.  Symptoms vary depending on the person and type of eczema, but typically include:

·         Dry, reddened skin that itches or burns.

·         Blisters and/or oozing lesions.

·         Dry and/or scaly, thickened skin. 

·         Moderate to severe itching (Note: This is a key diagnostic factor, if an itch is not present, chances are that the skin disorder is not eczema).

What Triggers Eczema?

Trigger factors for eczema include:

1.           Substances that come in contact with the skin, causing irritation and immune activation (e.g. soaps, cosmetics, jewellery, detergents, certain types of clothing).

2.           Environmental allergens (e.g. pollens, dust, animal dander).

3.           Changes in climate may affect some eczema sufferers.

4.           Psychological stress may also trigger outbreaks of eczema.

5.           Foods can also trigger eczema, particularly chemical food additives (such as preservatives and colourings), dairy, wheat, eggs, nuts, seafood and/or citrus fruits.

Western Medicine’s Perspective

From a Western medicine perspective, eczema is considered to be an allergic condition, with abnormal function of the immune system being the major pathophysiological driver of this condition. Patients suffering from eczema often have a personal and/or family history of eczema, asthma and/or hay fever, as these are all allergic conditions associated with similar immunological dysfunctions. Western medical treatment focuses on controlling the inflammation caused by this immunological disturbance.  Therefore, your patients with eczema may already take one or more of the following medicines:

·         Topical corticosteroids (this is the most common form of eczema treatment).

·         Sedating antihistamines that induce sleep and reduce itchiness.

·         Antibiotics that treat secondary infections.

·         Oral corticosteroids.

·         Systemic immunosuppressants

An Unbalanced Immune System

Western healthcare practitioners view eczema as an immunological issue, with an unbalanced immune response being the core dysfunction.  Essentially eczema is associated with a T-helper 2 (Th2) excess state. T helper cells are the principal regulatory cells of the immune system. There are three main types of T helper (Th) cells: Th1, Th2 and Th3. Th1 cells regulate the body defense against bacteria, viruses and fungi, and are largely responsible for attacking and killing tumor cells. Th2 cells promote the production of antibodies against foreign matter (allergens, parasites) in the bloodstream. Th3 cells provide immune control through regulating excess Th1/Th2 activity.

These T helper cells regulate themselves by having an opposing effect. Whenever there is an excessive activity of one T helper type, this causes suppression of the other. In this way we can imagine the immune system as regulated in a see-saw manner.  When these immune cells are working in harmony, the immune system functions normally (see Figure 1).  However, in atopic conditions such as eczema, there is an imbalance with Th2 dominance causing the signs and symptoms we see in our patients (see Figure 2). The imbalance in Th1/Th2 function is rather like a see-saw out of balance. If the see-saw can be brought back into balance, this can achieve marked improvements in the disorder.  TCM has been shown to help restore balance to this immune see-saw.

Figure 1: A Balanced Immune System.                  Figure 2: A Th2 Excess State is Seen In Eczema.

How Can Traditional Chinese Medicine Help Eczema Sufferers?

Most Western treatment methods treat the symptoms of eczema and do not prevent its recurrence; they also tend to have side effects. Due to these factors, many eczema sufferers turn to natural medicine and Chinese Medicine for alternative treatment options. A recent clinical trial, conducted in London clearly demonstrated the power of Chinese Medicine in the treatment of eczema: 37 children completed a double-blind placebo-controlled trial of a specific formulation of Chinese medicinal herbs for atopic eczema. At the end of the one-year trial, 18 (49%) enjoyed at least a 90% reductions in eczema activity scores.² These results can be even greater if dietary and lifestyle changes are also implemented.

Pathogenesis of Eczema from a TCM Perspective

From our perspective as TCM practitioners, eczema is caused by three main pathogenic factors:

·         Wind: Skin disorders caused by wind are characterised by sudden onset and development, change from one place to the other, and generalised itching.

·         Dampness: Manifests as puffiness of skin, vesicles or papules and oozing of fluid.

·         Heat: Tends to manifest as a burning sensation, redness and swelling.

Various combinations of these pathogenic factors produce different forms of eczema.  For example, acute eczema often results from damp heat in the lung and spleen channels, brought on by invasion of external pathogenic wind. Chronic eczema is a progression from acute eczema and tends to be complicated by retained dampness. Infantile eczema has a dry and a wet type, but the overall pathogenesis is brought about by a combination of weakness of spleen and stomach, damp heat and exposure to external pathogenic wind. Eczema of the scrotum is caused by damp-heat in the liver and kidney or invasion of damp toxins due to sitting on damp ground. Eczema around the eyes is caused by wind heat in the spleen channel, or damp heat.

“Out-of-the-ordinary diseases are often caused by phlegm evil. Disorders that resist treatment involve both phlegm and stasis”

Dr. Zhu Liangchun’s “Way of Treating Difficult Disorders”

Pattern Differentiation

Acute Eczema due to Damp Heat

·         Symptoms and Signs: Acute onset, flushed skin, itching, burning heat, blisters, erosion, oozing of yellow fluid. May have thirst and vexation, constipation, short voidings of dark urine, red tongue, yellow coating.

·         Treatment principle: Clear heat and resolve damp.

·         Formula: Variations of Long Dan Xie Gan Tang [Gentiana Combination]: Long Dan Cao [Gentiana], Huang Bai [Phellodendron] to clear heat and dry damp, Yi Yi Ren [Coix], Ze Xie [Alisma], Fu Ling [Hoelen], Bi Xie [Tokora], Hua Shi [Talc], and Che Qian Zi [Plantago] to percolate dampness and reduce swelling, Shan Zhi Zi [Gardenia Florida] and Huang Qin [Scute] to clear heart fire and dry damp, and last but not least Sheng Di Huang [Raw Rehmannia] and Mu Dan Pi [Moutan] to clear heat and cool blood.

·          Also Consider: If the eczema is concentrated in the upper body, add Sang Ye [Mulberry Leaf], Ju Hua [Chrysanthemum], Chan Tui [Cicada] to course wind and clear heat. If itching is severe, add Bai Xian Pi [Dictamnus Desycarpus], Di Fu Zi [Kochia] to dispel wind, clear heat and dispel dampness.

Acute Eczema due to Wind Heat

·         Symptoms and Signs: Flushed skin, papules spreading all over the body but principally in face and upper body, mild erosion, oozing of fluid after scratching.

·         Treatment principle: Predominantly dispel wind and clear heat, moderately dispel dampness.

·         Formula: Sheng Di Huang [Raw Rehmannia] to clear heat, Jing Jie [Schizonepeta], Fang Feng [Siler] to expel wind, Chan Tui [Cicada], Niu Bang Zi [Arctium] to expel wind heat, Cang Er Zi [Xanthium], Di Fu Zi [Kochia] to dispel wind and relieve itching, Zhi Mu [Anemarrhena], Huang Lian [Coptis] and Ku Shen [Sophora Root] to clear heat and dry dampness.

Chronic Eczema

·         Symptoms and Signs: Thickened skin with lichenoid changes, localised skin eruptions with clear borders, small amount of desquamation. Itching, erosion.

·         Treatment principle: Nourish blood, eliminate wind, clear heat, dispel damp.

·         Formula: Si Wu Xiao Feng Tang with modifications. Sheng Di Huang [Raw Rehmannia], Shu Di Huang [Rehmannia cooked], Dang Gui [Angelica Sinensis], Chuan Xiong [Cnidium], Ji Xue Teng [Milettia], Chi Shao [Red Peony], Dan Shen [Salvia] to nourish blood and quicken blood; Jing Jie [Schizonepeta] and Fang Feng [Siler], Bai Xian Pi [Dictamnus Desycarpus], Ku Shen [Sophora Root] to dispel wind, eliminate dampness and clear heat.

·         Also Consider: If the patient has trouble sleeping due to itching, add Zhen Zhu Mu [Concha Margaritifera], Ye Jiao Teng [Polygonum Stem], and Suan Zao Ren [Zizyphus] to extinguish wind and calm the spirit.

Childhood Eczema

·         Symptoms and Signs: Acute or subacute, itching can be severe. Dry eczema: Sparsely or densely distribute papules on flushed skin, desquamation after scratching, mild erosion. Wet eczema: Flushed skin, papules, blisters, erosion, effusion, thick yellow crusts.

·         Treatment principle: Eliminate wind, clear heat, dispel damp.

·         Formula: Xiao Feng Dao Chi Tang with modifications. Niu Bang Zi [Arctium], Bo He [Mentha Leaf], Bai Xian Pi [Dictamnus Desycarpus] to dispel wind, clear heat and eliminate dampness; Huang Lian [Coptis], Fu Ling [Hoelen] to clear heart fire and disinhibit water; Jin Yin Hua [Lonicera], Sheng Di Huang [Raw Rehmannia] to clear heat and cool the blood, Gan Cao [Licorice] to harmonise all other medicinals.

·         Damp type eczema: Add Fu Ling [Hoelen], Che Qian Zi [Plantago], Cang Zhu [Atractylodes] to strengthen the spleen and dry dampness.

·         Dry type eczema: Add Tai Zi Shen [Pseudostellaria], Mai Dong [Ophiopgon], Huang Jing [Polygonatum Root],Bai Mao Gen [Imperata] to benefit qi, protect yin and disinhibit water.

·         Special Notes: Dampness is the predominant pathogenic factor causing eczema in children. In small children, the spleen function has not matured fully yet, and the transformation and transportation functions are rather weak. If the child is not given nutritious, easy to digest food, is overfed or solid food is introduced too early, or the child eats the wrong kinds of food (too sweet, too greasy, or large quantities of processed food), the spleen’s function of transformation and transportation can be impaired, engendering damp heat. If the child is repeatedly exposed to wind evil, external and internal pathogenic factors can combine and wind damp heat toxin enters the skin giving rise to wind damp heat type eczema. Alternatively, the child may be of weak constitution, resulting in spleen vacuity dampness type eczema. If the blood aspect is affected, this may cause spleen vacuity wind dryness type eczema. Formulas often used are Xiang Sha Liu Jun Zi Tang [Saussurea and Cardamon Combination], Er Chen Tang [Citrus & Pinellia Combination], Gui Pi Tang [Ginseng & Longan Combination], Si Jun Zi Tang [Four Major Herb Combination], or Bu Zhong Yi Qi Tang [Ginseng & Astragalus Combination] with additions. Single medicinals added to the base formulas include Ku Shen [Sophora Root] to clear heat and dry dampness, Bai Xian Pi [Dictamnus Desycarpus] to treat depressed and stagnant damp-heat, or Di Fu Zi [Kochia] to expel dampness and stop itching.

Reading the Symptoms and Signs: Case Analyses

31 year old female with widespread atopic eczema.  Her symptoms and Mazin Al-Khafaji’s analysis of the case are detailed below.³

·         Other symptoms and signs: Normal appetite and bowel function. Skin often worsens premenstrually, but normal menstrual cycle. No abnormal thirst. Aside form the burning sensation of her skin, patient does not feel hot. Dry and red tongue, with red prickles on the tip, extending towards the sides. Thin and white coating. Wiry and slightly rapid pulse.

·         Diagnosis: Underlying condition of heat in the blood with wind, complicated with dampness and fire toxin.

·         Treatment strategy: First peeling, as it were the outer layer, before attempting to tackle the core problem. First drain the damp heat and clear the fire with formula based on Long Dan Xie Gan Tang [Gentiana Combination]with modifications.

“…the skin is like an open book, the vast majority of information is there to be deciphered by those who can read the language”

Mazin Al-Khafaji, “Atopic Eczema – Wind of the Four Crooks”