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.        

The Power of Chinese Herbal Medicine

The effectiveness of Chinese herbal medicine in the treatment of dermatological conditions is hard to deny.  I was just thinking about an elderly patient who was told by the medical community that she would inevitably need to have her lower leg amputated due to gangrene.  Being a very strong woman, and confident in natural treatment approaches she decided that she would only agree to having the gangrene area removed surgically but leave the remainder of the foot and leg to heal on its own.  At first, she was not allowed this option but the surgeon finally decided that he would be willing to honor her wishes.  She mentioned to me that they told her numerous times that she would not heal from the surgery due to the poor blood flow at the foot and that they really would need to amputate further up the leg where the circulation would be less impeded in order for her to heal.  She was adamant that she would only agree to having the gangrene tissue removed and the remainder of the foot to heal naturally.    

When first observing her legs, it was clear that the circulation into her lower extremities was impeded.  There was a purplish hue to the legs, mild edema, varicosities, and a cool sensation when palpating the feet.  We worked together using acupuncture and Chinese herbal formulas internally for approximately 2 years.  Over this time period there was gradual improvement at the surgical site and of the lower extremities.  The edema decreased, the tissue of the legs became a pinker hue, and the feet became more perfused with blood giving them a warmer sensation.  There were some set backs during the course of the treatment but we worked through those issues as they arose by modifying the herbal formula.

More recently, a small lesion on the top of the foot would not completely close, while the remainder of the foot had healed from surgery.  There were recurrent infections occurring over the lesion site that were not allowing the tissue to heal.  When these infections occurred, I advised her to see her vascular team so that they could culture and prescribe an appropriate antibiotic.  Over time it appeared evident that the antibiotics were stopping the infections but they would reoccur some time later.  These recurrent infections were slowing the wound healing at this small lesion and left it lingering as an open ulcer.  We decided that she would continue with the antibiotics topically as they were prescribed but she would also begin a topical herbal compress.  The two treatments would complement one another very well.  Within a single week, she returned to the office to show me the lesion.  It had literally scabbed over and the tissue was showing signs of closing!  I was astonished at the speed at which her foot was healing and so were the nurses and doctors on her vascular team.  In fact, they still tell her that no one ever expected her foot to heal as it has from the surgery.  They were all quite sure that she would have had to have her foot amputated post-surgery.  I'm just glad that I was able to be a part of her healthcare and allow her to save her leg and foot and keep her mobility and independence.

Unfortunately, far too few people are aware of this treatment approach and never have an opportunity to explore this option.  I hope through this blog and my practice that this treatment approach gains more attention in the public eye.  The treatment of dermatological conditions with Chinese herbs requires specific training and education and without these skills it is much more difficult to effectively treat these stubborn conditions.  Over the years I've successfully treated a number of stasis eczema cases as well as ulcerations on the lower extremities.  Cases of ulcerations take time to heal and therefore require patience on the part of the patient.  Compliance with the treatment protocol often times leads to complete resolution of the ulcer.  These conditions typically require the use of both internal and external herbal treatments to achieve optimal results.  Wishing you good health. 

Balancing Stress to Benefit Your Skin

Here in the Pacific Northwest we were fortunate to have a long lasting stretch of warm and sunny days that seemed endless.  However, fall has come, and with the changing of the seasons comes the arrival of the holidays.  Often the arrival of these times of gathering and festivity brings an element of stress into our lives.  Whether it is the expectations we place upon ourselves or it's the last minute scramble to prepare for the upcoming holiday, the stress of the holidays is something that most everyone can relate to.  Unfortunately, when we are unable to manage our stress effectively it begins to take a toll on our health.  In addition, our eating habits over the holiday seasons typically worsen.  On top of this, with all the preparation for the gatherings we often find ourselves falling out of our typical fitness routines.  Between the poor diet, decrease in exercise, and stress, it is clear that the holiday season can have a negative impact on our health.  

These stress triggers in our lives can often be aggravating factors for new and pre-existing skin conditions.  This is especially upsetting during seasons when we want to look our best, as we get together to celebrate with friends and family.   In response to these stressors, the skin can flare.  So why is this?  Stress often disrupts our immune response and affects our adrenal glands.  Within our immune system there is an inflammatory response (innate immune response) and an adaptive immune response.  Often times stress can cause the immune response to fall in favor of a more intense inflammatory response leading to an aggravation of one's skin.  However, don't view inflammation as a negative process.  It is essential for an effective immune response.  Without it white blood cells wouldn't know where to go to fight off infections and repair damaged tissue.  Think of it as a signal to flag down the repair crew of our body.  The key is to have a balanced inflammatory response, rather than one that is over reactive. 

So where do the adrenal glands play in this picture?  With long-term stress and a high paced life, the adrenal glands can become weakened due to the continual demand that is placed on them.  Over time, they can't keep up and they begin to decline in function.  With this decline comes a decline in cortisol in the body.  Cortisol acts as an anti-inflammatory in our body and can thereby manage excess inflammation that may arise.  However, with a decline in this management system, the increase in inflammation in the body cannot be adequately controlled. When this occurs we begin to see the skin become more active with the appearance of new lesions. 

In Chinese Medicine, stress is also identified as a trigger for numerous skin conditions but is often discussed using different terminology.  When stress occurs, the liver Qi becomes stagnant or doesn't flow smoothly.  With impeded flow of Qi in the body, heat begins to generate.  Over time this heat builds up and creates stagnant heat which can be viewed as inflammation.  This is the very basic foundation of this concept of liver Qi stagnation generating heat.  There are many other elements that can play a role in this pathology which can further perpetuate this concept of stagnant heat or aggravate the condition.  A concept known as dampness which often arises from a weakened digestive tract, poor eating habits, or inactive lifestyle can often aggravate the presence of heat.  By adding an element of dampness, flow is impeded even further and leads to the generation of more heat, often described as damp heat.  This brief explanation of stress induced stagnant heat gives you an introduction to the concept in Chinese medicine.  Unfortunately, there isn't enough time in this article to discuss all the variants of stress induced stagnant heat.

From both a biomedical and Chinese medicine view, it is clear that stress can disrupt the balance of our body leading to inflammation or stagnant heat.  Conditions such as nummular eczema, pompholyx eczema, seborrheic dermatitis, lichen simplex, rosacea, acne, perioral dermatitis, psoriasis, herpes simplex, pityriasis versicolor, and even some forms of urticaria all have a connection to emotional stress.  This illustrates the vast array of conditions that can be affected by this omnipresent factor in our lives. 

With the trigger being stress, thinking of ways in which to reduce this element is crucial for effective and long-term management.  The number one self care tip is to maintain an active lifestyle by exercising for a minimum of 30 minutes a day.   Studies have shown that regular exercise has a favorable effect on the immune response and is an effective means of stress relief.  Second, trying to maintain a predictable sleeping schedule where you go to bed at the same time and wake at a similar time.  This goes for the weekends as well.  While sleeping our body produces growth hormone which not only assists with growth and development but also triggers a healing response in the body.  So it is essential to ensure that adequate sleep is a part of the daily regimen to encourage this natural healing process.  Third, diet should be considered, since a poor diet will lead to fatigue, poor health, and ultimately poor skin quality.  In particular, overconsumption of sugar has a suppressive effect on the immune system.  On top of the list of food items to avoid are excess sugar, processed foods, fried foods, greasy foods, hot and spicy foods, caffeine, shellfish, and alcohol.  Often times people will have particular food sensitivities as well, and it is imperative that these foods be removed from the diet to avoid any additional inflammation that may be triggered by the consumption of these items. 

For some, these fundamental changes make a big difference in skin quality.  However, sometimes strict adherence to these measures proves ineffective.  When these lifestyle changes prove to be inadequate in controlling a person's dermatological complaint then further intervention is warranted.  The use of Chinese herbs is a safe and effective treatment approach that is often overlooked when seeking help for skin problems.  Herbs are used both internally and externally to address the affected areas.  Before formulating a treatment approach the skin is closely examined and a thorough history is taken to determine the root cause of the disease.  Each person will require an individualized treatment designed to meet their own skin needs.  For example, if the lesions on the body are showing more weeping or erosion, then the formula is directed at addressing more damp heat and if the lesions present with more dryness and erythema then a blood heat treatment is necessary.  Lesions that are very active and present with vesicles or pustules would require the addition of herbs to address more fire toxin in the presentation.  The treatments can become very refined, as no two individuals have exactly the same skin concerns. 

During the course of treatment with Chinese herbs, the formula will need to be modified to address changes in the skin.  As the lesions begin to clear, the formula will be changed to correctly address the current presentation.  It can almost be viewed as guiding heat out of the body.  So as the damp heat is cleared, there may be more blood heat present that must then be cleared using different herbs.  If dryness plays a part in the picture, then specific nourishing herbs would be introduced only after the heat has been removed.  If the dry element is addressed too early the skin may become irritated.  It is these individualized and fluctuating treatment approaches that make Chinese medicine so powerful in addressing these acute and chronic skin conditions. 

If you or someone you care about is struggling with a skin condition, try to think about the ways in which stress, diet, exercise and sleep can be improved.  Assess your level of stress.  Whether it is a family reunion, holidays, weddings, or just day to day stressors, think about how stress may be impacting your health and skin.  Are you getting enough exercise?  Are you sleeping adequate hours and soundly?  How is your diet, and are you eating too many of the foods that can cause problems for your skin?  If you already have these lifestyle elements in place, or if you get them into place and are still having problems with your skin, then consider implementing a supportive treatment such as Chinese herbal medicine.  Your skin is a reflection of your underlying health, and working towards achieving clear skin in a holistic way will help you take steps toward overall wellness, improved self esteem, and stress reduction.   

  

I've tried Chinese herbs for my skin

Chinese medicine is a vast and complex form of medicine.  The treatment approaches with Chinese herbs can be very complex and require much training and skill to properly formulate an effective treatment.  So going to any acupuncturist in your area to address your skin complaint isn't a wise decision.  Dermatology in Chinese medicine requires specific training and knowledge to properly diagnosis and treat the condition.  So if your intentions are to treat your skin naturally, seek out a skilled practitioner, such as myself, that has specialized in this field of study in order to receive an appropriate herbal treatment.

Just as the allopathic medical community has specialization, so does the field of Acupuncture and Chinese medicine.  Some practitioners have a practice focusing more on fertility and gynecology, some men's health, others more pain management, or dermatology; the list goes on.  But the thing to remember is don't just assume that the Acupuncturist or Chinese medicine practitioner you go to see has training or specializes in dermatology.  And don't assume that all Acupuncturists practice Chinese herbal medicine, for many have minimal training in the the use of herbs.  So, you may have tried Chinese herbs to address your skin but did you seek out a qualified Chinese medicine practitioner that specializes in Dermatology?

Evolving Traditional Chinese Medicine Treatments

Last month I traveled to London to study with my mentor Mazin Al-Khafaji.  It was interesting to note the ways in which his treatment approaches have shifted ever so slightly.  Even with his already highly effective treatments, he was finding that certain herbal combinations and their use in particular dermatological presentations could produce a more desirable outcome.  It goes to show that attention to details in the progress of our patients is a must to maximize the treatment results.  Not only this but it gives us insight into what herbs are helping with a particular aspect of the skin presentation.  Once we find a result that can be repeated, we can evolve our medicine to better address the pathology of modern day skin disorders.

I often find myself reviewing and comparing my formulas in clinic to look at how the skin is shifting in relation to modifications made to the formulas.  This is often enlightening and gives me a better understanding of when the formula needs a shift in focus so that the patient can continue on the path of healing.  This process is necessary to continue to benefit our patients and to evolve our medicine.  Just as disease evolves and shifts, so do our bodies and so should our medicine.  If we rely solely on classical formulas and never question the efficacy of our treatments we will fall behind.  I would like to quickly say that the classics are full of wealth and we often look to them for guidance, but we still must follow the progress of our patients so that the treatment is properly tailored to the current presentation.  Even the herbal formulations of Zhang Zhongjing shifted over the years as different treatment approaches evolved in Chinese medicine.   This is a trend that should continue so that we can optimize the efficacy of Chinese medicine.