Use of common Chinese herbs in the treatment of psoriasis 使用中草药治疗银屑病

Use of common Chinese herbs in the treatment of psoriasis

T.W.Tse

Medecins Sans Frontieres,Kowloon,Hong Kong

Summary

Chinese herbal medicines have been shown to be effective in the treatment of atopic eczema.However,the Western scienti?c ?medical literature has not fully examined the potential usefulness of herbal treatments in the management of psoriasis.This article aims to provide an Eastern insight into psoriasis,considering the diagnosis of psoriasis using Chinese medical terminology and its treatment using herbal medicine,as well as how these herbs might work.

Concepts in traditional Chinese medicine

In principle,traditional Chinese medicine (TCM)contends that good health is maintained by the dynamic balance of the Yin and Yang cycle,and the ?ve elements of the body:Wood,Fire,Earth,Metal and Water.1–4In addition,one needs an adequate and free ?ow of Qi (the most basic material from which the human body is formed and life is maintained)and Blood (the basic component of the human body essential in maintaining normal func-tion)in order to protect the body from disturbance by the six common pathogens,namely Wind,Cold,Dampness,Dryness,Heat and Fire.

Classi?cation of psoriasis In TCM

In TCM,psoriasis is commonly classi?ed into three main syndromes,namely Blood Heat,Blood Dryness and Blood Stasis.5–7

Blood Heat syndrome

Patients are characterized by an acute onset of an eruption of numerous active,bright red lesions,which spread quickly and have irregular plaque or guttate

patterns.Affected skin sticks ?rmly to its base and scales are easy to peel off leaving bleeding areas.Itching can be severe.

Blood Dryness syndrome

This refers to more chronic cases with circumscribed or coalescent plaques,with affected skin appearing pale or dull red in colour.Skin lesions are thicker and more adherent with fewer scales.They are dif?cult to peel,but if they are peeled off there is no obvious bleeding.New lesions are rare.Skin is often dry and cracked.Nails are dry and dull looking.

Blood Stasis syndrome

This comprises a static phase,although it includes chronic relapsing skin lesions with an asymmetrical distribution.Plaques may be irregular in size,hard,thick and scaly with a clear margin.Individual lesions are dull red in colour and ?rmly attached to the skin.The large scales are dif?cult to peel and there is no bleeding.

Clinical studies of the use of Chinese herbal medicine in psoriasis

For this review,controlled clinical trials in psoriasis using Chinese herbal medicine were obtained from the biomedical databases:Medline ò(1966–April 2001)and EmBase ò(1981–April 2001).Keywords for the search were ‘psoriasis’,‘herbal medicine’and ‘traditional Chinese medicine’.Data were also obtained from the

Correspondence:T.W.Tse,Medecins Sans Frontieres,5B,Laichikok Bay Garden,272Lai King Hill Road,Kowloon,Hong Kong.Tel.:852********.Fax:852********.E-mail:tsz910@https://www.360docs.net/doc/ed12704786.html,

Accepted for publication 18March

2003

Chinese Information Service System on Traditional Chinese Medicine(https://www.360docs.net/doc/ed12704786.html,,which covers Chinese medical journals from1984onwards). Keywords in the Chinese search were‘psoriasis’and ‘silvery scales disease’.Only seven clinical trials were found,all of which were carried out in China.

Of these seven studies,four prescribed different combinations of herbs according to the patients’TCM syndrome diagnoses.However,these trials contained many inadequacies in the design,diagnostic cri-teria,8,9,11,12,14sampling,blinding,8–14standardization of treatment duration,8,10,14and information on the type of herbs used and their dosage.8,9,12

However,the literature searched did contain a greater number of uncontrolled studies.Indeed,20studies, each involving over100patients,were identi?ed (Table1).In these trials,174different Chinese herbs were used.The10most commonly used herbs are detailed in Table2.Four of these(Rehmannia glutinosa, Dictamnus dasycarpus,Paeonia lacti?ora and Glycyrrhiza uralensis)have also been shown to have a bene?cial effect in treating atopic eczema.15,16

Table1Details of uncontrolled clinical studies of TCM for the treatment of psoriasis published in the Chinese literature.

1Chang CL,Huang CY,Yao YC et al.200cases of psoriasis treated with Chinese medicine.Chin Med J1974;4:205–7(in Chinese).

2Li https://www.360docs.net/doc/ed12704786.html,e of Chinese herbs to treat143cases of psoriasis.Jilin Zhong Yi Yao1988;4:17(in Chinese).

3Li https://www.360docs.net/doc/ed12704786.html,e of Li Xue Jie Du Tang to treat155cases of psoriasis.Liau Ning Chung Yi Tsa Chih1991;1:28–9(in Chinese).

4Xu MY,Lau https://www.360docs.net/doc/ed12704786.html,e of Chinese herbs to treat300cases of psoriasis.Zhong Guo Min Jian Liao Fa1997;4:46(in Chinese).

5Jing https://www.360docs.net/doc/ed12704786.html,e of Wen Yang Huo Xue Hua Yu Tang to treat100cases of psoriasis.Shaanxi Zhong Yi1997;18:208(in Chinese).

6Su https://www.360docs.net/doc/ed12704786.html,e of Zhong Yao Xiao Yin Ling Xilie to treat108cases of psoriatic vulgaris.Pract J Integrating Chin Modern Med1997;

11:363–4(in Chinese).

7Li https://www.360docs.net/doc/ed12704786.html,e of Zang Fu Bian Zheng Fen Xing to treat1000cases of psoriasis.Shaanxi Zhong Yi1998;19:60–1(in Chinese).

8Zhan https://www.360docs.net/doc/ed12704786.html,e of Bai Bi Tang and psoriatic dressing solution to treat265cases of psoriasis.Liaoning J Trad Chin Med1998;25:315(in Chinese). 9Bai https://www.360docs.net/doc/ed12704786.html,e of Yin Xiao Chong Ji to treat105cases of psoriasis vulgaris.Liaoning J Trad Chin Med1998;25:365(in Chinese).

10Chui https://www.360docs.net/doc/ed12704786.html,e of Xiao Zhi Fang to treat146cases of psoriasis vulgaris.Chin J Derm Venereol1998;12:376(in Chinese).

11Jiang JH.Chinese herbs used orally and topically to treat100cases of psoriasis.Xhe Jiang Zhong Yi Tsa Chih1998;33:408(in Chinese). 12Xie https://www.360docs.net/doc/ed12704786.html,e of‘Tui Yin Tang’to treat106cases of psoriasis.J Pract Trad Chin Med1999;15:13(in Chinese).

13Wang https://www.360docs.net/doc/ed12704786.html,e of Hua Tuo Yin Xiao Jing to treat100cases of psoriasis.Lishizhen Med Material Med Res1999;10:623–4(in Chinese).

14Yu https://www.360docs.net/doc/ed12704786.html,e of Yin Xiao San to treat200cases of psoriasis.Hubei Zhong Yi Tsa Chih1999;21:509(in Chinese).

15Sun https://www.360docs.net/doc/ed12704786.html,e of Kang Yin Chong Ji to treat104cases of psoriasis vulgaris.Chin J Dermatol1999;32:135(in Chinese).

16Ma https://www.360docs.net/doc/ed12704786.html,e of Di Huang Xiao Yin Tang to treat150cases of psoriasis vulgaris.Shaanxi Zhong Yi Han Shou1999;4:27–8(in Chinese).

17Li https://www.360docs.net/doc/ed12704786.html,e of Liang Xue Jie Du Run Fu Tang to treat200cases of psoriasis.Shaanxi Zhong Yi1999;20:494(in Chinese).

18Wei https://www.360docs.net/doc/ed12704786.html,e of Zi Cao Bie Jia Si Wu Tang to treat162cases of psoriasis.Zhong Yi Tsa Chih J Trad Chin Med2000;41:97–8(in Chinese). 19Ma https://www.360docs.net/doc/ed12704786.html,e of Bian Zheng Zhi Liao to treat312cases of psoriasis vulgaris.Hunan Guiding J TCMP1999;5:21(in Chinese).

20Jin N,Wu JH,Wu MW et https://www.360docs.net/doc/ed12704786.html,e of Huo Xue Dai Pao Cha to treat287cases of psoriasis.Shanghai Yi Ke Da Xue Xue Bao1999;26: 309–10(in Chinese).

Table2The ten herbs most commonly used in treating psoriasis and their different names.

Botanical name Other possible botanical names English names Pharmaceutical names Rehmannia glutinosa Chinese foxglove(raw)Radix rehmanniae crudae Angelica sinensis Ligusticum acutilobu Chinese angelica Radix angelicae sinensis Salvia miltiorhiza Salvia przewalskii Red-rooted sage Radix salviae miltiorhizae

Dan shen root

Dictamnus dasycarpus Dictamnus albus Chinese dittany Radix dictamni

Densefruit pittany root bark Cortex dictamni

Smilax glabra Glabrous greenbrier Rhizoma smilacis galbrae Oldenlandia diffusa Hedyotis diffusa Spreading hedyotis Herba hedyotis diffusae Lithospermum erythrorhizon Arnebia euchroma Arnebia Radix arnebiae

Arnebia guttata Groomwell root Radix lithospermi

Paeonia lacti?ora Paeonia obovata Peony(root)Radix paeoniae lacti?orae

Paeonia veitchii Radix paenoiae sinjiangensis

Paeonia albi?ora

Carthamus tinctorius Saf?ower Flos carthami

Glycyrrhiza uralensis Glycyrrhiza galbra Liquorice?licorice Radix glycyrrhizae

Use of Chinese herbs in psoriasis?T.W.Tse

Chinese herbs most commonly used in treatment of psoriasis

Rehmannia glutinosa (dried root)

Rehmannia glutinosa ,illustrated in Fig.1,has TCM effects of clearing Heat,cooling Blood,nourishing Yin and promoting the formation of body ?uid.It relieves symptoms such as irritability,dry mouth and thirst (Blood Heat type of psoriasis).It can also be used for treatment of various other skin rashes.17–20

There are only two relevant articles on R.glutinosa available.Kim et al .21showed that the aqueous extract from the steamed root of R.glutinosa could signi?cantly inhibit the release of histamine from rat peritoneal induced mast cells.Also,tumour necrosis factor-alpha (TNF-a )production in rat peritoneal induced mast cells was inhibited in a dose-dependent manner.Subse-quently,Kim et al .22demonstrated the inhibitory effect

of the steamed R.glutinosa root on TNF-a and interleu-kin 1(IL-1)secretion from activated mouse astrocytes.Current understanding of the pathogenesis of psoriasis suggests that factors that inhibit the degranulation of mast cells and reduce the production of TNF-a 23,24and IL-125–27may have bene?cial anti-in?ammatory effects in the management of psoriasis.

Angelica sinensis (root)

According to the principles of TCM,A.sinensis corrects de?ciency,activates Blood,and replenishes Blood.It prevents the creation of Internal Wind and Dryness which can cause skin malnutrition.It also relieves symptoms of Blood Stasis which can manifest as psoriasis.17–20

An experiment has been performed to examine the effects of A.sinensis solution on in vitro production of IL-2.28Results showed an increase in IL-2secretion from stimulated mouse spleen mononuclear cells.How-ever,the amount of increase was inversely related to the concentration used.Also,the experiment showed that,when indomethacin was given at a high concentration,the production of IL-2was inhibited.Clearly,further studies are needed,using a wider range of concentra-tions of A.sinensis ,to determine whether IL-2can be inhibited at higher concentrations.In therory,on the basis of current data,one might expect that A.sinensis alone could potentially worsen psoriasis by promoting IL-2production.29

Another component of A.sinensis ,however,may have anti-in?ammatory properties.Ferulic acid has been shown to have a signi?cant inhibitory effect on carra-geenin and acetic acid induced in?ammation compared to an indomethacin control group.30,31Hence,A.sinensis may exert its bene?cial effects on psoriasis through this putative anti-in?ammatory mechanism.Moreover,another low-molecular-weight polysaccharide compo-nent of A.sinensis has been shown to have a possible immunomodulatory effect,together with a mitogenic effect in mouse spleen lymphocytes in vitro .32

Salvia miltiorrhiza (root)

In TCM,https://www.360docs.net/doc/ed12704786.html,tiorrhiza has the effect of activating Blood to eliminate Blood Stasis,cooling and nourishing Blood,and also calming the mind.It can treat skin rashes and plaques caused by Blood Stasis and Internal Heat (as in psoriasis),as well as other in?ammatory or infective lesions.17–20

The anti-in?ammatory effects of https://www.360docs.net/doc/ed12704786.html,tiorrhiza have been demonstrated through its effects on inhibition

of

Figure 1Rehmannia glutinosa.Reproduced with permission from the Royal Horticultural Society,London,UK.

Use of Chinese herbs in psoriasis ?T.W.Tse

carrageenin-induced rat paw oedema,as well as on neutrophil chemotaxis.33Three different tanshinone pigments from https://www.360docs.net/doc/ed12704786.html,tiorrhiza have been shown to have signi?cant inhibitory effects on the production of both interferon-gamma(IFN-c)and IL-12from antigen-primed lymph node cells and activated macrophages, respectively.The tanshinones also inhibited the degran-ulation of a cultured mast cell line.34Thus,https://www.360docs.net/doc/ed12704786.html,tiorrhiza may play a role in the treatment of psoriasis through its effects on IFN-c35–37and IL-1238suppression as well as mast cell degranulation.

Dictamnus dasycarpus(root cortex)

This herb can clear Heat,dry Dampness,and repel Wind.D.dasycarpus is especially suitable for skin lesions caused by Damp Heat(one of the pathogens in psoriasis).It is also good for relieving itching.17–20 Both D.dasycarpus and Smilax glabra(see below)have been shown to selectively inhibit delayed type hyper-sensitivity responses(DTH)in mice,39properties that may account for their effectiveness in the treatment of psoriasis.These two herbs also have a hepatoprotective effect on induced DTH hepatic injury and are even capable of reversing some liver abnormalities to normal levels,both biochemically and histopathologically.39 Apart from their clinical effects,the potential hepatic protective activity of these herbs may explain why combinations of herbs are often used in the treatment of one disease in https://www.360docs.net/doc/ed12704786.html,binations of Chinese herbs may produce a‘mutual counteraction’through one herb reducing the toxic effects of another.

Smilax glabra(underground stem)

Smilax glabra is useful for clearing Heat,removing Dampness,detoxifying body pathogens,and relieving stiff joints.It is particularly effective in removing Damp Heat pathogens,for example clinical signs of weeping skin lesions.17–20

Besides its inhibitory effects on DTH,as discussed above,S.glabra also signi?cantly reduces the in?am-matory oedema induced by carrageenan.This anti-in?ammatory action may be a direct result of inhibiting the synthesis or release of prostaglandin E2.40 Oldenlandia diffusa(whole plant)

Oldenlandia diffusa has the potential to clear Heat and toxic pathogens in the body,and remove Dampness.It can be used when there are Damp Heat symptoms and in?ammatory or infective skin lesions.17,18,20

This herb has a weak proliferative effect on human T lymphocytes and can enhance cytotoxic T-lymphocyte activity.It can also stimulate immunoglobulin produc-tion by B cells,IL-1production by monocytes41and macrophage production of IL-6and TNF-a.42However, such T-cell stimulation and IL-643and TNF-a44–46 production may theoretically have a deleterious effect on psoriasis.Therefore,whether O.diffusa may be helpful in the treatment of psoriasis has yet to be determined.

Lithospermum erythrorhizon(root)

This herb has the effect of cooling Blood,activating Blood,and detoxifying pathogens in the body,bene?ts brought about through clearing Internal Heat(one of the concepts in TCM).L.erythrorhizon can be used in patients with dark purplish skin rashes(sign of Blood Stasis)or other cutaneous lesions caused by Internal Heat.17–20 A mixture of L.erythrorhizon and Gycyrrhiza(see below)with Ginseng radix,Angelicae radix,Houttuyniae berba,Astragali radix,Cnidii rhizoma and Coicis semen(a Chinese prescription called Shi-Ka-Ron)has been shown to completely suppress the production of IL-1a and TNF-a in mouse macrophages.47However,that study did not clarify whether the suppression was caused by the herbs themselves or by direct cytotoxicity resulting from the high herbal concentration.

Theoretically,an increase in IL-1a25–27,48and TNF-a44–46can worsen psoriasis.However,the effect of L.erythrorhizon in the body in TCM theory is to bring out any residual skin rashes so that Internal Heat can be cleared.In essence,this means inducing a?are-up to obtain subsequent clearance and remission.

Besides affecting cytokine production,L.erythrorhizon has a constituent called shikonin that has been shown to have an inhibitory effect on TNF-a-induced angio-genesis,tumour cell-induced angiogenesis and normal programmed developmental angiogenesis.49 Therefore,L.erythrorhizon may have an important effect on vascular proliferation in psoriasis which may account for its clinical bene?ts.Clearly,more studies on the effects of L.erythrorhizon with other angiogenic factors in psoriasis,such as endothelial cell stimulating angiogenesis factor(ESAF)and vascular endothelial growth factor(VEGF),50need to be carried out. Paeonia lacti?ora(root)

Paeonia lacti?ora is able to clear Heat,cool Blood, activate Blood and remove Blood Stasis.Also,it is useful in treating bruises and infected skin lesions.17,18,20

Use of Chinese herbs in psoriasis?T.W.Tse

The only speci?c information available for https://www.360docs.net/doc/ed12704786.html,cti?ora in the treatment of psoriasis is a literature review from Japan in1982.51This account mentioned that https://www.360docs.net/doc/ed12704786.html,cti?ora has a suppressive effect on adjuvant arth-ritis,possibly in association with general anti-in?am-matory properties.51

Carthamus tinctorius(?ower)

Carthamus tinctorius has properties that activate Blood, remove Blood Stasis,relieve pain,and open up blocked meridians(i.e.Stasis). C.tinctorius is useful in dull-coloured skin rashes caused by Blood Heat and Stasis. Also,it can be used to treat infected skin lesions caused by stagnation of Blood.17–20

Extracts from C.tinctorius have been shown to inhibit in?ammation in mice in a dose-dependent manner.52 Another study has shown that a compound from seeds of C.tinctorius,N-(p-coumaroyl)serotonin,can inhibit the production of TNF-a,IL-1a,IL-1b and IL-6from stimulated human monocytes.53It is not known whether this compound is present in the?ower of C.tinctorius,but certainly further investigations on C.tinctorius to determine its speci?c effects on modifying cytokine production would be worthwhile. Glycyrrhiza uralensis(root)

The root of G.uralensis has effects on strengthening Qi, clearing Heat phlegm and relieving pain.G.uralensis has the special effect of harmonizing different herbs within the same formula and reducing their toxic side-effects and pungent taste.It can also be used to treat skin lesions caused by Internal Heat.17–20

This herb possesses both immunosuppressive and immuno-enhancing activities.51The immunosuppres-sive activity may involve suppression of the production of memory cells and antibody processing by macrophages. The immuno-enhancing activity may re?ect enhance-ment of both the primary and secondary responses of antibody formation,as well as T-lymphocyte function. It is noteworthy that TCM texts have claimed that G.uralensis has a special demulcent effect and an ability to reduce the toxicity of other herbs.One study showed that orally administered G.uralensis has a protective effect on cultured damaged rat hepatocytes.54In addi-tion,other components of G.uralensis,Scutellariae radix, Ginseng radix and Coptidis rhizoma have an antidiarrho-eal action.55Since liver toxicity56–58and gastrointesti-nal upset are the main side-effects of Chinese herbs, these effects of G.uralensis may underscore its value as a common component of multiple herbal formulations.Conclusion

This review has discussed the10Chinese herbs most commonly used in treating psoriasis.The rationale for their use in Chinese medical terms relates to their effects on clearing Internal Heat,activating Blood to remove Stasis and strengthening any de?ciencies.The aim is to restore the balanced state of the body to allow the psoriasis to resolve.Most of the key actions re?ect anti-in?ammatory properties,modulation of cytokine pro-duction or inhibition of angiogenesis.All these may be relevant in reducing the severity of psoriasis.Neverthe-less,it is clear that more precise studies are needed to examine modulation of the production of speci?c cytokines,e.g.TNF-a,IFN-c or IL-2from keratinocytes, T lymphocytes or mast cell degranulation.It would be intriguing if different cytokine patterns could be deter-mined for the various TCM syndromes of psoriasis (Blood Heat,Blood Dry and Blood Stasis)so that a tailor-made herbal formula could be derived for speci?c patients’needs.A further issue that needs to be addressed is safety.Limited information is available, and aspects such as blood monitoring for liver func-tion,56–58strategies to deal with product adulter-ation,59,60interactions between Chinese herbal medicines and Western drugs,61heavy metal contam-ination62and long-term toxicity63all need to be fully investigated.

Acknowledgements

I would like to express my appreciation to Dr Sun Yi Jun, Beijing College of Acupuncture and Orthopaedics,China for her assistance in literature research in China. References

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Use of Chinese herbs in psoriasis?T.W.Tse