Keratolysis exfoliativa or hand eczema?

Keratolysis exfoliativa also known as focal palmar peeling is a common disorder that is rarely reported and often overlooked as hand eczema.  Hand dermatitis can be a very difficult condition to diagnosis due to the numerous conditions that mimic one another when presenting on the hands.  This is where a thorough intake can give the practitioner clues leading them to a proper diagnosis and ultimately an effective treatment.  Conditions such as psoriasis, tinea, pompholyx eczema, contact dermatitis, keratolysis exfoliativa, and hand eczema can sometimes make pin pointing a diagnosis difficult due to the sometime subtle appearance of these conditions.  When lesions are present elsewhere in addition to the hands, some of these conditions can be ruled out.  Unfortunately, this isn't always the case and makes attention to all the subjective and objective details an essential so that the patient can receive an appropriate treatment.

Keratolysis exfoliativa is a condition that often presents during the summer due to the hot weather that will bring on palmar sweating (hyperhydrosis).   It is thought that excessive palmar sweating may be a contributing factor to the presentation of this condition.  It is also thought that this condition may be a precursor to pompholyx eczema.  The presenting symptoms often begin with small, superficial air-filled vesicles that appear on the fingers and/or palms.  There is typically not much itching however, some individuals will have an initial bout of itching that will then subside which is atypical for hand eczema or pompholyx eczema where itching is very prominent.  These small blisters will break and lead to collarete peeling and can expand leading to loss of large layers of the stratum corneum.  As this layer of tissue is lost, erythema and dryness can present in the areas lacking the stratum corneum.  Keratolysis exfoliativa is also known as recurrent focal palmar peeling since the condition cycles through an active phase and then transitions into a brief period of resolution followed by another cycle.  This cycle can continue to repeat itself for an indeterminate period and often times requires treatment if it is interfering with an individual's daily activities.  For some, the active flares are nothing more than a few air-filled vesicles that break open and clear without causing much change to the skin of the palms.  However, others can have very active flares leading to the loss of large portions of the stratum corneum on the fingers and palms leading to tender hands which can interfere with their daily activities.

Triggers for this condition can often come in the form of contact irritants of the hands.  In these cases, it is imperative that these known irritants be avoided so that the skin may settle and heal.  Sometimes these irritants may seem very benign such as the hand soap that is being used or even water.  In these cases, trying very bland and simple soaps until one is found that shows no signs of irritating the skin.  In cases where water may act as an irritant, it is best to try and reduce the amount of hand washing that is done throughout the day.  Also, using lukewarm water is always best as cold or hot water will stress the skin and this is what we want to avoid.  Any stress to active skin will set off an inflammatory response leading to a relapse of the condition.

In the case of keratolysis exfoliativa, topical steroids are ineffective in treating this condition unlike hand eczema or psoriasis.  I've found in my practice that internal Chinese herbs and topical Chinese herbal ointments can be very effective in controlling the active condition and preventing a recurrence.  If this is a condition that has been affecting your life, this is a good treatment option to consider to address the root cause of the inflammatory cycle. 

Red, Itchy, and Scaly Skin

Inflammation can affect any part of our body.  But when it affects our skin we become aware of its presence at the very early stages of inflammation.  Being that this organ system is visible to us, we are quick to notice subtle changes on our skin surface as opposed to when inflammation is primarily in our joints.  Sometimes, these mild irritations of the skin pass just as quickly as they may have surfaced.  But for some individuals, they start to develop repeated irritation to the skin that begins to overlap and become chronic in nature.  At this stage, many that have been patiently watching this transition of their skin may choose to intervene with treatment. 

The course of treatment that an individual may choose can vary greatly.  Most often I find that patients will initially seek out an over the counter treatment in an attempt to alleviate the itch or subdue the red inflamed skin.  When very mild in nature, the itching can often times be soothed with these over the counter medications.  But these individuals will often times find themselves needing to use more and more over time with a decrease in effectiveness.  These ointments are typically mild steroid creams (hydrocortisone) and as with all cortisone, the body develops a tolerance to the substance.  When this occurs larger and larger doses or higher potency creams are needed to deliver an effect similar to that which was initially achieved.  If self treatment fails to provide the relief they want, many find themselves visiting a Dermatologist or their General Practitioner in hopes of controlling the inflammatory cycle their skin is caught in.  Unfortunately, many times these individuals are only prescribed additional steroids in higher potency.  These substances can be very effective at quenching the inflammation, however once they are discontinued the skin can experience a rebound flare.  A nice analogy would be a pot of oats that is boiling on the stove.  To stop the oats from overflowing, you place a lid on it and press down firmly to keep the oats contained in the pot.  But once you remove the lid (steroids), the oats can flow over much more aggressively due to the building pressure (rebound flare).  Instead a better approach would be to turn the flame down and gently stir the oats to dissipate the heat.  This is the approach that is used when treating inflammation with Chinese medicine.  In Chinese medicine, topical and internal herbs are used to address the unique form of inflammation that is occurring within an individual.  No two formulas are constructed the same to treat an inflammatory skin condition due to the unique nature of the inflammation in each individual.  The goal with treatment is to rebalance the immune response so that individuals can discontinue the herbs and have their skin stabilize.  This treatment is very unique in that it can stabilize the skin and patients can go into remission.  Often times, patients will find that if their skin does become active again, that it is minimal and settles quickly. 

What I have described above is something that I've repeatedly observed in practice.  Let me present a quick case to illustrate what I discussed earlier.  An elderly male had come to see me after trying several courses of external and internal steroids to address his red, itchy, and scaly forehead and scalp.  He had been diagnosed with eczema, but after examining his skin and taking his history it was clear to me that he was suffering from psoriasis.  He was at his wits end with his skin.  Everything he had tried only provided mild relief and when he discontinued them his skin flared excessively to the point that he would need to try stronger steroids.  At one point the rebound flare was so severe with facial swelling that he was put on a high dose of internal prednisone in an attempt to reduce the flare.  This proved effective at reducing the swelling but had no affect on his psoriasis.  After going through multiple courses of steroids, he became fed up with the cycle of events and decided to take a different treatment approach.  The presentation of his skin and his history revealed what is called Blood Heat with wind in Chinese medicine.  To address his psoriasis he was given a Chinese herbal treatment that included an internal herbal formula that he would consume twice per day, as well as a topical ointment that he would use twice per day.  Over the course of 8 weeks on the herbal medicine his psoriasis had cleared and there was an improvement in many of his other symptoms as well.  Following this short course of treatment he was able to discontinue the herbs without any aggravation of his skin.  This particular case was a quick response to treatment, especially for an autoimmune condition.  But it goes to show that there can be a quick change in inflammation brought about solely through the use of herbal medicine. 

Chinese herbal medicine probably isn't the first thing that pops into your mind when thinking of treatments for eczema, psoriasis, rosacea, acne, or other skin conditions.  Due to people's unfamiliarity with Chinese medicine, it is normally a last resort for most individuals after being patient for years addressing their skin with other modalities.  Because Chinese medicine works to rebalance the immune response, time is needed to bring about this change.  So patience must be practiced when taking on this treatment approach.  Improvement is observed along the way and this is often enough motivation for patients to push on with the treatment.  Those that do are most often rewarded in the end with skin that is much more stable or remains in remission, and they are able to free themselves from the use of steroids. 

Psoriasis

Psoriasis is the most common autoimmune disorder in the U.S.  It affects about 2 percent of the population and 30% of those affected by this condition report having relatives with psoriasis.  Psoriasis is most often seen in those between the ages of 15-30 and those in their 50s and 60s.  There are numerous forms of psoriasis including plaque psoriasis, guttate psoriasis, pustular psoriasis, psoriatic arthritis, and in severe cases erythrodermic psoriasis.  Of these various forms, plaque psoriasis accounts for about 90% of the cases seen.

Plaque psoriasis can develop into a variety of different patterns.  The most common distribution seen are lesions on the extensor aspects of the limbs, especially the elbows and knees.  Some develop psoriasis in isolated regions such as the scalp where it typically stops just outside the hairline or in and around the ears.  Others will develop it more widespread over the abdomen, lumbar region and sacrum, and nails.  Less commonly the lesions can be seen in the genital region, intertriginous regions, palms and soles. 

No matter the location, psoriasis can be safely and effectively treated with internal Chinese herbal treatments.  The treatments are very unique in comparison to other treatments that may be used to address this autoimmune disorder.  This is evident in that no one person's herbal treatment is alike.  The unique presentation of the person and their skin is truly taken into account and guides the practitioner to construct a specific formula to address the pattern of inflammation that is occurring.  Being an autoimmune condition, the patient must be willing to stick with the treatment and not begin treatment with the expectation of being free of psoriasis after a month or two of treatment.  Sometimes miraculous changes occur with herbal treatments where the skin clears significantly after a month of treatment but this is by no means the norm.  These treatments require persistence and patience on the end of the patient.  In my experience, this often pays off and the patients are pleased with the results.

An interesting aspect to these treatments is that they regulate and rebalance the inflammatory response in the body.  Once the skin has remained stable on treatment, discontinuing treatment doesn't typically lead to a flare but instead what is observed is that the skin remains stable while off herbs.  This isn't an observation that is isolated to psoriasis patients but is something that is seen when treating other forms of inflammation including eczema with Chinese herbs.  The inflammatory process is being brought back to a normal state through the use of herbs thereby allowing patients to discontinue treatment while their skin remains stable.

When looking at mainstream approaches to treating psoriasis, what is often seen is the use of internal and external steroids, and/or immunosuppressants (i.e. azathioprine), or biologics (i.e. Enbrel).  This new class of biologics have a long list of side effects and risks that make the treatment a last resort for a lot of people.  Being such a new medication, we are just not aware of all the long term repercussions associated with their use.  When we look at immunosuppressants we run into a similar situation, numerous risks and side effects from the use of the medication.  With azathioprine, there is an increased risk of cancer, bone marrow suppression, and risk of secondary infection associated with its use.  The use of steroids is often the first treatment utilized when treating psoriasis with a mainstream medical treatment approach.  They can be effective to reduce the inflammation and reduce the plaques of psoriasis while they are actively being applied.  However, once these suppressive steroids are stopped, the inflammation that has been suppressed leaps back to life.  This often leads to a stronger flare of the skin and a worsening of the symptoms than prior to the use of the steroids.  This is an all too often scenario that is seen clinically, but is unfortunately the most common treatment that the mainstream medical community offers those with this debilitating immune disorder.  It should also be made clear that steroids cannot be used indefinitely.  Typically, patients develop tolerance to the steroids and so over time the potency must be increased to achieve a similar response.  But not only this, if steroids are continued to be used internally for more than three weeks, there is risk that the adrenal glands will shrink, the bones will become weaker, the patient can develop hypertension, fluid retention, cataracts, and a weakened immune system.  These are just a few of the side effects that can be seen with long term steroid use.  Long term external steroid use will atrophy or thin and weaken the skin leaving the skin unable to heal from injury or from the active psoriasis.  

With all the side effects associated with the various pharmaceuticals used in the treatment of psoriasis it is no wonder that many are seeking out alternative treatments.  Chinese medicine has been used for thousands of years to address this chronic skin condition known as song pi xuan (pine skin dermatosis) or psoriasis and has done it in a safe and effective manner.  In practice I've seen so many patients come in after struggling with the rebound flares of steroid use, where they've become frustrated with the treatment approaches that have been offered.  Many of these patients respond quite well to treatment and are able to manage their skin without the use of steroids but solely through the use of herbal medicine.  This not only relieves them of their psoriasis but allows their skin to heal from the inside out and leaves the skin stronger and healthier.  From my experience and the experience of other Chinese herbal dermatology specialists, this treatment approach is far more desirable in its results.