Journal of Acuherb in Medicine


Contact Dermatitis

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Contact dermatitis

 

Contact dermatitis describes an acute inflammatory condition of the skin or mucosa that results from contact with certain irritant substances or stimulants. The condition occurs in all ages and both sexes, but there is a higher incidence in children than the elderly and women are more commonly affected than men. A characteristic of the disease is a history of exposure to allergenic substances prior to the inflammatory episode. Such substances or stimulants can include medicated plasters, ointment, lacquer, plants, certain materials used in clothing and contact with animals. The distribution of the lesions on the skin corresponds to the points of contact with the irritant and is largely limited to those areas.

The disease has an acute onset. Typical symptoms include itchiness, a burning sensation, and swelling and tenderness of the lesions. Systemic involvement can occur in severe cases. Once irritants are removed and proper treatment given, the condition will usually resolve within one to two weeks. However, further exposure to the causative agent will cause a re-occurrence.

In traditional Chinese medicine (TCM) contact dermatitis is not recognized as a disease as such, but as a collection of symptoms. From a TCM viewpoint, diseases of the skin are included in the category of surgical trauma and they are described in many ancient surgical classics. As there is no general term in TCM for contact dermatitis, the condition is referred to by names which describe both symptoms and causative agent. Examples of these include: 

“lacquer sore”
“plaster rubella” from Chinese herbal poultices
   
“commode ringworm” (inflammation of the buttocks caused by newly lacquered, old-style commode seats)
“pollen sore”, and
“tar sore”(tar was formerly commonly used in China to waterproof furniture.)

Causes

The lungs and spleen have a powerful influence in contact dermatitis as they are the main organs that promote and support skin function. In TCM, skin and hair are the barriers of exogenous evils invasion, the protective qi that enhances its integrity is regulated by the lungs. Therefore skin diseases are always viewed as indicating a lung disharmony. The spleen is responsible for extracting nutrients from food and for transporting fluids throughout the body, and impaired function can contribute to unhealthy skin and swelling. In TCM, it is considered that contact dermatitis can be caused by both endogenous (originating from inside the body) and exogenous (originating from outside the body) factors.

Inborn susceptibility (endogenous causes) 
The incidence of contact dermatitis is influenced by body constitution and is more likely to occur in individuals with a congenital/inherited predisposition to the disorder. In cases of congenital deficiency, the skin and tissues beneath are loosely bonded. This means that the protective qi is weak and that the body is more prone to a flare-up of fire evil or to the development of  internal wind evil . Contact with certain substances, such as lacquer, drugs, plastic, rubber products, dyes or plants, facilitates transformation of  heat evil internally in the body. The conflict between blood and qi against the heat evil triggers the skin disease.

Environmental pathogen invasion (exogenous causes)
In situations where external pathogens are allowed to invade the body directly, excessive fire evil will develop and accumulate. Circulation of blood and qi in the surface areas of the body becomes disturbed and does not flow smoothly. This in turn damages the integrity and function of the skin causing dermatitis. 

Symptoms

The main symptoms of contact dermatitis are the appearance of a rash accompanied by an itchy, burning sensation and swelling. The rash may develop into clusters of red papules (raised spots) or, in severe cases, blisters. Scratching of the rash causes exudation (leakage) and an exacerbation of the irritation. On rare occasions, swelling and tenderness of the eyelids, lips and perineum can occur.

Contact dermatitis usually results in excessive stimulation of body functions. It is described in TCM as an asthenia syndrome and results from a relatively strong body-resistance in fighting excessive pathogens . The usual presentation in an asthenia syndrome is fever, thirst, irritability, abdominal discomfort, constipation and dark-colored urine. Severity varies with the progression of the disease.

TCM practitioners will examine the sufferer and categorize the symptoms under special syndrome groups known as “disharmony patterns.” Certain disharmony patterns are present during the different stages of the disease. Contact dermatitis can be classified into the following types:

Excessive fire accumulation
This form of contact dermatitis presents with acute onset. The skin at first appears pink, or with a red rash, and there is a distinct margin and edematous accumulation of fluid in the tissues base. The rash then develops into clusters of papules (raised spots) and is accompanied by a burning sensation and itchiness. Associated systemic symptoms include mouth dryness, thirst, fever, irritability, dark urine and constipation.

Excessive fire mixed with dampness 
This is a more serious form of the condition. The red papules are edematous and blisters develop which may be as large as an egg-yolk. If the rash is scratched, fluid will leak out. The rash can be extremely itchy and the lesion may become swollen and create a sensation of burning. Systemic upset includes mouth dryness and poor appetite.

Blood deficiency accompanied by wind and dryness accumulation 
With repeated relapses of the disorder, the skin lesions become thickened, dry and scaly. The lesion may also develop lichen-like changes (skin develops a thickened leathery appearance). The severity of the irritation results in scars on the skin from excessive scratching.

Diagnosis

Diagnosis in TCM places importance on determining the circumstances and manifestations of a disease through inquiry and symptom observation. Diagnosis is based on the traditional four examination techniques: 

Questioning The TCM practitioner will establish the medical history of both the patient and his family.
Observation Examination of the physical features of the body, such as the face, tongue, hair, nails, sputum (mucus that is coughed up), and location of pain, all offer clues to the problem. The tongue is a particularly useful indicator of the functioning of the internal organs.
Listening and smelling The smelling of sputum and breath and listening to the sounds produced by the chest offer additional clues to the patient’s health.
Touching Feeling the pulse is a cornerstone of TCM diagnosis and gives the practitioner much information about any bodily imbalance.

Contact dermatitis is commonly diagnosed by the following disharmony patterns: 

Excessive heat accumulation
From the TCM viewpoint, all allergenic substances are regarded as evils or pathogens . Hypersensitive reactions of the body are the result of accumulation of evils, impaired functioning of organs or disruption to the circulation of  blood and qi. The pathogens induce internal changes and encourage the accumulation of excessive heat evil . This disturbs the movement of qi and blood in the skin and gives rise to a burning itchy rash. On examination the tongue is red and covered by a thin layer of yellow fur. The pulse is taut and slippery.

Excessive fire mixed with dampness 
The lungs have an important role as regulator of the protective qi . The spleen provides nutrients for the skin. If the lungs and spleen are functioning poorly, external pathogens can readily invade the body and fire and dampness evilsaccumulate. The evils stagnate on the skin meridians causing the appearance of a bullous or blistered rash with edema and leakage of fluid. On examination, the tongue is red and covered with a yellow greasy fur. The pulse is slippery and rapid.

Blood deficiency and wind and dryness accumulation
If the spleen is not functioning properly, there is a decline in acquired jing (essence) and nutrients in the body and this affects the production of blood. This reduction in blood supply causes the skin to lose nutrients. It becomes prone to the development of wind evil and this can turn into dryness evil. The skin appears dry, scaly and thickened. On examination, the tongue is pink and covered with a thin fur. The pulse is taut, thready and rapid.

Differential diagnosis
Contact dermatitis can be differentiated from other skin disorders such as acute eczema and facial erysipelas (an acute bacterial infection of skin) by the following features:

In acute eczema, the skin lesion may appear in several forms, there is symmetrical distribution in certain locations and the margins of the rash are usually hard to identify. The condition is of longer duration and can become chronic. There is no obvious contact history with particular substance that could be responsible for the skin condition.
Facial erysipelas presents with severe systemic symptoms such as chills, high fever, headache and nausea. The rash appears as a red patch of inflamed skin with underlying swelling. The edge of the patch is palpably raised and clearly defined. There is a burning sensation in the lesion and it is tender but not itchy. There is not contact history.

 

Treatment

Internal Therapy

Traditional Chinese medicine aims at a holistic approach. Skin diseases are associated with internal disharmony between yin and yang and are the superficial presentations of internal damage.

1. Excessive heat accumulation


Therapeutic aim:To eliminate heat and toxic materials, cool the blood and clear the rash.

Prescription 1:
 Puji xiaodu dissolution drink (reduces rashes of the face and head).

ban lan gen isatis root
lian qiao large head atractylodes root
huang qin baical skullcap root
huang lian golden thread
yuan shen figwort root
ma bo puff-ball
niu bang zi great burdock achene
bo he peppermint
jiang can stiff silkworm
chen pi dried tangerine peel
jie geng platycodon root
chai hu Chinese tororwax root
sheng ma cimicifuga rhizome
gan cao liquorice root

Prescription 2: Liangxie jiedu decoction (for rashes on other parts of the body).

shang di dried rehmannia root
chia hao red peony root
jin yin hua honeysuckle flower
lian qiao weeping forsythia capsule
ban lan gen isatis root
pu gong ying dandelion
ye ju hau wild chrysanthemum flower
dan pi tree peony bark
zi cao gromwell root
huang qin baical skullcap root

 

2. Excessive heat mixed with dampness


Therapeutic aim: 
To disperse heat and dampness evils and to eliminate toxins and swelling.

Prescription: Longdan xiegan decoction.

chai hu Chinese tororwax root
huang qin baical skullcap root
long dab cao Chinese gentian
zhi zi Cape jasmine fruit
che qian zi plantain seed
shang di dried rehmannia root
dang gui Chinese angelica
ze xie oriental water plantain root
gan cao liquorice root

 

3. Blood deficiency and wind anddryness accumulation

Therapeutic aim: To disperse heat and wind evils, nourish the blood and re-hydrate the skin. 

Prescription 1: Xiaofeng powder.

dang gui Chinese angelica
sheng di dried rehmannia root
fang feng divaricate saposhnikovia root
chan tui cicada slough
zhi mu common anemarrhena root
ku shen light yellow sophora root
hu ma common flax
jing jie fine-leaf schizonepeta herb
cang zhu atractylodes root
niu bang zi great burdock achene
shi gao gypsum
gan cao liquorice root


Prescription 2:
 Danggui decoction

sheng di common yam root
chuan xiong Szechwan lovage root
jing jie fine-leaf schizonepeta herb
fang feng divaricate saposhnikovia root
bai ji li puncture vine caltrop fruit
dang gui Chinese angelica
he shou wu fleece flower root
bai shao white peony root
huang qi milk vetch
gan cao liquorice root

External therapy

Of greatest importance in the treatment of contact dermatitis is the identification of the causative agent and its subsequent avoidance. Therapeutic approaches in skin lesions are also important. In order to facilitate healing, any substance used should be mild, non-stimulating and simple to apply. The following are examples:

For simple rashes: Sanhuang lotion or indigo powder lotion.
In cases of severe exudation and erosion of skin lesions: Moist dressings should be applied soaked with the following decoction:
  lu cha green tea
  ma chi xian purslane herb
  huang bai amur cork-tree
  yang di cao emilia sonchi folia
  shi wei pyrrosia leaf
  pu gong ying dandelion
  sang yu mulberry leaf
Where erosion and scarring have occurred on the skin lesion: Indigo emulsion.
In cases of scaling, thickening, coarse or lichen skin: Black soybean-distillate ointment.
Examples follow of some folk prescriptions which can be applied to skin lesions:

1. Fresh ground purslane herb.
2. If vesicles appear on the rash, the following decoction can be used as a wash or soak:
  huang qin baical skullcap root
  huang bai amur cork-tree
  ma chi xian purslane herb
  ming fan alum
 
3. Where the lesion has been scratched and there is exudate, washing or soaking with this decoction is useful:
  shang di yu fresh garden burnet root
  huang bai amur cork-tree
 
4. Fresh ground mung beans.
5. Fresh balsam pear.

Acupuncture and moxabustion
As contact dermatitis is seen as an asthenic (excessive) syndrome, acupuncture given using reduction or purgative therapeutic methods at two to four points can be helpful. Acupuncture points: chi-ze, qu-chi, he-gu, qu-ze, zu-san-li, wei-zhong, san-yin-jiao.

Dietary therapy
A congee made from mung bean and coix (raw Job’s tears) seed can also be beneficial.

 

Prevention

Prevention of contact dermatitis depends on the following:

Investigation of the medical history to identify irritants for future avoidance.
If the irritant is occupation-related, working procedures should be modified or the environment improved to avoid the irritant. Precautionary measures should be re-enforced such as the wearing of protective clothing and gloves to cover the skin if working with an irritating substance.
Hot baths should be avoided when a rash is present as this may make the condition worse. Lesions should not be scratched. If Western drugs are needed, they should be applied only under medical advice.
   

Dietary measures
From the TCM viewpoint, both food and drugs come from the same source and food can vary in character. This means that food can promote health or have an adverse effect on it. Seafood, spicy and hot food trigger the body to produce more wind, heat or dampness evils, which are causative factors in contact dermatitis. In TCM, dietetic restraint is urged, meaning that some foods should be avoided in certain disorders or while certain medicines are being taken. For example, intake of salty food should be limited in persons who are edematous have fluid retention and a greasy diet avoided in cases of diarrhea. For contact dermatitis, a balanced diet should be eaten. Individuals susceptible to this disorder should avoid alcohol, and eat less seafood or spicy and hot food. Drinking plenty of water is also advisable to clean the toxins from the body and prevent illness. 

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