1 Western medical aetiology and pathology

There is no known cause for psoriasis. It may be related to immune function disorder, genes, infection and emotional disorder. Disordered immunity has some involvement in the process of psoriasis. T cells, unlike B lymphocytes, do not produce antibodies. However, if T cells become activated, an immune response is initiated, leading to the development of skin lesions. One part of this response includes the release of cytokines. Cytokines act on keratinocytes to induce changes characteristic of psoriasis. Indeed, cytokines from lesional psoriatic T-cell clones directly alter in-vitro keratinocyte phenotype through induction of intercellular adhesion molecule 1 (ICAM-1) and HLA-DR cell-surface expression.¹ Furthermore, the cytokines enhance keratinocyte growth. Essentially, cytokines stimulate skin cells to reproduce and mature at an accelerated rate. They cause other reactions, including inflammation, the activation of additional T cells, the recruitment of T cells into the skin and the release of more cytokines. The end result is a cycle of skin cells growing too fast, moving to the surface of the skin, and piling up as dead cells. The epidermal layer of the skin thickens, resulting in psoriasis. Redness develops as blood vessels expand and multiply, and blood flow to the skin increases.

Psoriasis is an immunologically mediated disease in which activation of T lymphocytes is central to the inflammation in the dermal microenvironment, and the epidermal hyperproliferation is secondary to the inflammatory events that follow a T helper cell type 1 (Th1) immune response.¹ Psoriasis is the most common Th1 type of immunological skin disease.

2 Diagnosis by Western medicine

Diagnosis of psoriasis usually occurs by visual inspection, although a skin biopsy is sometimes needed to confirm the diagnosis. Generally, laboratory studies are not performed, unless the patient also has other autoimmune diseases.

There are several types of psoriasis, but the most common form, plaque psoriasis, causes dry, red skin lesions covered with silvery scales. These usually itch or feel sore, and may occur anywhere on the body, including the genitals, the soft tissue inside the mouth, and fingernails and toenails. However, plaques are most common on the knees, elbows, trunk, palms, soles and scalp. A patient may have just a few plaques, or many. The skin may also crack and bleed.

3 Chinese medical aetiology and pathology

Psoriasis is not a Chinese medicine diagnosis, but the symptoms and signs of psoriasis are described as Bai Bi , Bi Feng and Song Pi Xuan , all of which refer to the skin conditions of psoriasis.

A patient may have a constitution of Fire flaring due to Yin deficiency following the invasion of Wind-Heat. The external and internal pathogenic Heat together impair Yin. As Yin is deficient, it cannot nourish the skin. As a result, the skin becomes damaged, causing dry skin, itching and peeling. Or, Heat-Toxin can invade directly and impair the skin. In this case, the skin becomes red and there is a clear boundary line between damaged and normal tissues. Or, the existence of Liver Qi stagnation over a long period of time turns into Fire, which then singes the already damaged Yin. The deficient Yin cannot nourish the skin, and psoriasis develops.

In short, psoriasis results from constitutional Yin deficiency allowing pathogenic Heat or Heat-Toxin to invade the body and trigger psoriasis, or emotional disorder causes Liver Qi stagnation, leading to Fire flaring and damaging the skin. Regardless of whether the Fire is excess or deficient, it will singe the Blood and cause Blood stasis; when Liver Qi stagnation occurs, the Qi cannot push Blood smoothly through the vessels, leading to Blood stasis.

The pathogenic change is always the result of Yin deficiency coupled with excess Heat, Heat-Toxin, deficient Fire due to Yin deficiency, or Liver Qi stagnation, and Blood stasis.

4 General treatment principle

Dispel Wind, clear pathogenic Heat, remove Blood stasis and smooth Liver Qi.

Differentiation and Treatment

1 Wind-Heat

Clinical Manifestations

A red halo around erythematous lesions on the skin, scaly and peeling skin, red papules, severe itching and the recent development of skin lesions. The tongue is red with a thin white or yellow coating. The pulse is taut and rapid.

Treatment Principle

Expel pathogenic Wind, clear pathogenic Heat and Toxin, and cool the Blood.

Herbal Treatment

YIN QIAO SAN and TU FU LING TANG variation

Honeysuckle and Forsythia Powder and Smilax Decoction

Jin Yin Hua Lonicerae Flos 15 g

Tu Fu Ling Smilacis glabrae Rhizoma 20 g

Sheng Di Huang Rehmanniae Radix 15 g

Huang Qin Scutellariae Radix 12 g

Zhi Mu Anemarrhenae Rhizoma 9 g

Zi Cao Arnebiae/Lithospermi Radix 9 g

Chai Hu Bupleuri Radix 6 g

Chan Tui Cicadae Periostracum 6 g

Wu Shao She Zaocys 9 g

The herbs above are decocted in water for oral administration.

Acupuncture

LU-7 Lieque, LI-11 Quchi, SP-10 Xuehai, SP-6 Sanyinjiao and LIV-2 Xingjian.

Supplementary Treatment

If a patient complains of stress and insomnia, add Mu Dan Pi Moutan Cortex, Chai Hu Bupleuri Radix and Bai Shao Paeoniae Radix alba, and needle Du-20 Baihui and Yintang (extra); if the patient has thick skin, add Dan Shen Salviae miltiorrhizae Radix, Tao Ren Persicae Semen and Hong Hua Carthami Flos, and needle SP-10 Xuehai and SP-6 Sanyinjiao; if the patient’s skin lesions are red or bleeding, add Shui Niu Jiao Bubali Cornu and Sheng Di Huang Rehmanniae Radix, and needle BL-17 Geshu and SP-10 Xuehai to cool the Blood-Heat.

2 Blood Stasis

Clinical Manifestations

Silver scales on erythematous lesions. The skin becomes thick and the itchy feeling is less obvious. The tongue is dark red with a thin white coating and sublingual varicosities. The pulse is taut and uneven.

Treatment Principle

Remove Blood stasis, promote Blood circulation and cool pathogenic Heat in the Blood, and disperse Wind and stop itching.

Herbal Treatment

HUO XUE QU FENG TANG variation

Remove Blood Stasis and Expel Wind Decoction

Chi Shao Paeoniae Radix rubra 15 g

Dan Shen Salviae miltiorrhizae Radix 12 g

Tao Ren Persicae Semen 9 g

Hong Hua Carthami Flos 9 g

Dang Gui Angelicae sinensis Radix 9 g

Chuan Xiong Chuanxiong Rhizoma 9 g

Quan Xie Scorpio 3 g

Chan Tui Cicadae Periostracum 4 g

Bai Ji Li Tribuli Fructus 9 g

The herbs above are decocted in water for oral administration.

Acupuncture

BL-17 Geshu, BL-18 Ganshu, SP-10 Xuehai, SP-6 Sanyinjiao and LIV-3 Taichong.

Supplementary Treatment

If a patient has joint pain in the upper body and likes warmth, add Qiang Huo Notopterygii Rhizoma seu Radix and needle Baxie (extra) for the upper body; for the lower body, add Du Huo Angelicae pubescentis Radix and needle Bafeng (extra) to help expel Wind-Dampness and stop pain in the joints.

3 Yin Deficiency with Blood-Heat

Clinical Manifestations

Dry skin with silvery scales on the top of the lesions, thirst, and a dry mouth but without desire to drink. The tongue is red with a thin white coating and fissures. The pulse is deep and rapid.

Treatment Principle

Nourish Yin and remove Blood stasis, expel Wind and stop the itching.

Herbal Treatment

DANG GUI YIN ZI variation

Tangkuei Decoction

Dang Gui Angelicae sinensis Radix 12 g

Sheng Di Huang Rehmanniae Radix 15 g

Bai Shao Paeoniae Radix alba 12 g

He Shou Wu Polygoni multiflori Radix preparata 12 g

Chuan Xiong Chuanxiong Rhizoma 9 g

Jing Jie Schizonepetae Herba 9 g

Fang Feng Saposhnikoviae Radix 9 g

Bai Ji Li Tribuli Fructus 9 g

The herbs above are decocted in water for oral administration.

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