NMT150 wk 3

Dermatitis – Skin Rash

• Dermatitis is a general term that describes a common skin irritation, which can be caused by virus, bacteria, fungus, irritant, or allergen etiologies.
• Most common types of dermatitis: Atopic dermatitis, Contact dermatitis, Seborrheic dermatitis, Cradle cap, and Diaper rash.

General Signs & Symptoms

• Pruritus
• Dry skin
• Erythema
• Bumps or raised patches

Botanical Treatment Strategies

• Identify and treat the cause
• Prevent/treat infection
• Soothe irritation
• Reduce pruritus
• Prevent spreading and/or recurrence

Herbal Actions (Topical)

• Emollients
• Vulneraries
• Antimicrobials / Antiseptics
• Anti-inflammatories
• Anti-pruritics
• Lymphatics
• Astringents
• Connective tissue tonics

Materia Medica – Topical

• Aloe barbadensis
• Arnica montana
• Avena sativa
• Calendula officinalis
• Centella asiatica
• Glycyrrhiza glabra
• Hamamelis virginiana
• Matricaria recutita
• Plantago spp
• Stellaria media
• Symphytum officinale
• Urtica dioica

Calendula Officinalis (Marigold / Calendula)

• Part used: Flowerheads & petals
• Main Actions: Antimicrobial, lymphatic, antiseptic, anti-inflammatory, vulnerary, demulcent/emollient
• Main Constituents: Flavonoids (isohamnetin & quercetin) & carotenoids (xanthophylls), saponins, polysaccharides, VO, mucilage & resins
• Pharmacology: Stimulates drainage of enlarged and inflamed lymph nodes, immuno-stimulatory activity, vulnerary activity, antifungal activity
• Pharmacy: Infusion, tincture, creams, ointments, poultices, suppositories, fresh plant succus applied BID or PRN
• Safety: Generally a safe herb, caution for Asteraceae family allergy

Centella Asiatica (Gotu Kola)

• Part used: Aerial
• Main Actions: Anti-inflammatory, CT builder, vulnerary, adaptogen, nervine tonic
• Main Constituents: Saponins (asiaticoside, madecassoside, brahmoside), flavonoids (quercetin & kaempferol), allantoin, VO, alkaloids, phytosterols
• Pharmacology: Speeds up skin collagen formation and angiogenesis, anti-inflammatory action, anti-allergy activity, increased antioxidant levels
• Pharmacy: Infusion, tincture, standardized extracts, topical creams, ointments, and poultices
• Safety: Toxicity associated with internal use, GIT upset, contact dermatitis, sedation, headaches, carcinogenic concerns with long-term topical use

Plantago Lanceolata & Major (Plantain / Toadstool / Ribwort)

• Parts used: Leaves
• Main Constituents: Mucilage, tannins, flavonoids (baicalein, hispidulin, scutallarein and plantaginin), resins, alkaloids, allantoin, iridoid glycosides, saponins, minerals: Zn, K+, Mg, P
• Main Actions: Anti-microbial, lymphatic, anti-inflammatory, astringent, anti-hemorrhagic, emollient, vulnerary, connective tissue tonic, anti-pruritic
• Pharmacology: Emollient, vulnerary, and anti-inflammatory, promotes cell proliferation, induces transition of fibroblasts into myofibroblasts, inhibits COX and LOX

Herbal Pharmacy for Skin Rash

• Poultices: solid herb in some form (mashed/blended/cut), placed directly on skin, held in place with cloth
• Pastes: mixture of powder in a liquid base, keep herbs on the surface for a longer period of time, but contents are not well absorbed
• Creams/lotions: suspensions of oil in water blended together, often absorbed faster and more moistening for the skin

Internal Considerations for Dermatitis

• Herbal actions to consider for internal use: Alteratives, Hepatics, Lymphatics, Anti-microbials, Adaptogens & nervine tonics / relaxants, Anti-inflammatories
• Herbal options with dermatological benefit: Arctium lappa, Galium aparine, Glycyrrhiza glabra, Iris versicolor, Rumex crispus, Trifolium pratense, Urtica dioica

Authenticity

• Authenticity is the alignment of head, mouth, heart, and feet: thinking, saying, feeling, and doing the same thing consistently.
• It is the courage to be imperfect and vulnerable, believing that we are fundamentally worthy of love and acceptance, just as we are.
• Practicing authenticity invites more grace, gratitude, and joy into our lives, even when it's hard.

Authenticity vs Attachment

• The need for authenticity can compete with the need for attachment, leading to beliefs that we are not acceptable or lovable as we are.
• Suppressing our authenticity to meet our attachment needs can lead to:
  • Minimizing, dismissing, or invalidating our own experiences
  • Putting others' needs before our own
  • Developing compulsive needs to fulfill duty and responsibility
  • Suppressing strong emotions
  • Disconnecting from our physical experience and bodily sensations
  • Believing we are responsible for others' feelings

Reflecting on Authenticity

• Questions to reflect on our authenticity:
  • Am I in touch with my bodily experience and emotions?
  • Do I honor and meet my own physical and emotional needs?
  • Who do I think I am supposed to be?
  • In what ways do I judge myself and others?
  • What do I believe about myself that tells me my experience is wrong?

Authenticity and Trauma

• Authenticity can heal trauma, as seen in the 18-minute video "Authenticity Can Heal Trauma" by Gabor Mate, MD.

Attachment

• Attachment is a survival need, hard-wired into our mammalian biology.
• It provides a perceptual template that shapes our worldview, influencing our brains, emotions, thoughts, and relationships.
• Secure attachment is essential for emotional regulation, trust, and a healthy sense of self.

Secure vs Insecure Attachment

• Secure attachment: consistent, predictable, nurturing caregiving, leading to a sense of safety and trust.
• Insecure attachment: inconsistent, unpredictable, chaotic interactions, leading to adaptations that promote attachment but may lead to negative outcomes later in life.
• Three insecure styles of attachment:
  • Anxious style: safety in the presence of another, preoccupied with relationships, high dependence, and low avoidance.
  • Avoidant style: safety in disconnection from others, equating intimacy with loss of independence, low dependence, and high avoidance.
  • Disorganized style: no template for safety, resulting in chronic tension between connection and disconnection, high dependence, and high avoidance.

The Common Denominator

• The common denominator in insecure styles of attachment is an insecure sense of self, rooted in shame.

TCM Organs and Vital Substances

• TCM organs ensure the production, maintenance, replenishment, transformation, and movement of Vital Substances.
• Understanding organ functions is crucial to understand pathology.

Introduction to TCM Organs

• Zang organs are Yin and store essences of the body.
• Fu organs are Yang and are involved in the digestion and processing of food and fluids.
• Each internal organ is correlated to a particular emotion, tissue, sense organ, mental faculty, color, climate, taste, smell, and more.

TCM Lung Function

• Lungs govern Qi and respiration.
• Lungs extract 'clean Qi' for the body and spread it to nourish tissues and promote physiological processes.
• Lungs diffuse and descend Qi to distribute Defensive Qi, warming the skin and muscles, and protecting the body from external pathogenic factors.
• Lungs control the skin and the space between skin and muscles, regulating pores and sweating.
• Lungs manifest in body hair, nourishing and strengthening it.
• Lungs open into the nose, and the nose is the opening of the lungs.
• Lungs control nasal mucous, lubricating and moistening the nose.
• Lungs house the Corporeal Soul or 'Po', the physical manifestation of the soul.

TCM Large Intestine Function

• Large Intestine controls passage and conduction, receiving digested food from the small intestine and transforming it into stools.
• Qi has a downward movement, and stagnation of Qi often affects the Large Intestine, resulting in distension and constipation.
• Large Intestine transforms stools and reabsorbs liquids.
• The mental aspect of letting go is a key function of the Large Intestine, affecting the capacity to let go of the past and calm the mind.

Metal Element: Lung and Large Intestine

• Emotional sound: Weeping or crying
• Emotions: Sadness, grief
• Sense: Smell
• Season: Autumn
• Climate: Dry and cold
• Odor: Rotten
• Flavors: Pungent and spicy
• Mucous: Secretion
• Illness sound: Coughing

Lung Functions

• Governs Qi and Respiration
• Controls Descending and Dispersing Qi
  • Descends Qi to the Kidney
  • Disperses Qi throughout the body, especially skin and pores
• Ensures availability of Wei Qi throughout the body
• Regulates Water Passages or Channels
  • Water descends (like to the Kidneys)
  • Vapor circulates or ascends (like to the skin and hair)
• Controls Skin
  • Manifests in body hair
  • Opens into the nose
  • Affects nasal mucous
• Houses the Po (Corporeal Soul)
  • The 'physical' soul
  • Affected by grief and sadness

Wind-Cold and Wind-Heat

• Wind-Cold:
  • Aversion to cold and/or wind
  • Occipital stiffness and aches
  • Sneezing
  • Cough
  • Runny nose with white discharge
  • Slight or no fever
  • Tongue: Thin, white coat
  • Pulse: Floating, tight
• Wind-Heat:
  • Aversion to cold (Wei Qi warms, so an impairment makes it susceptible to cold)
  • Itchy and sore throat
  • Swollen tonsils
  • Thirst
  • Sneezing
  • Cough
  • Runny nose with slight yellow mucus
  • Slight sweating
  • Pulse: Floating and rapid

Lung Qi Deficiency

• Causes:
  • Chronic cough or asthma
  • Insufficiency of Qi production
• Symptoms:
  • Feeble cough or asthma
  • Dizziness
  • SOB, worse on exertion
  • Low and/or hoarse voice
  • Fatigue
  • Pale face
  • Watery or thin/clear sputum
  • Catches colds easily
• Tongue and Pulse:
  • Tongue: Pale with a thin, white coating
  • Pulse: Weak or empty pulses, especially right cun position

Lung Yin Deficiency

• Causes:
  • Prolonged cough
  • Heat disorders that injure the Lung
  • Prolonged dryness
• Symptoms:
  • Dry cough
  • With small amounts of sticky sputum
  • With blood-tinged sputum
  • Afternoon fever
  • Malar flush
  • Night sweats
  • Dry mouth and throat
  • Heat sensation in 5 centers
• Tongue and Pulse:
  • Tongue: Red body with a dry coat or little coating, and maybe cracks or peeling
  • Pulse: Rapid and thready

Lung Cold, Lung Heat, Lung Dryness, and Phlegm-Damp Retention

• Lung Cold:
  • Causes: Pathogenic cold in the Lung, Wind Cold
  • Symptoms: Cough, Asthma, Thin, white sputum, Absence of thirst, Runny nose with clear mucus
  • Tongue and Pulse: Tongue: White coat, pale body, Thin in Wind Cold, Thicker in Pathogenic Cold, Pulse: Slow, strong, and tight
• Lung Heat:
  • Causes: Pathogenic Heat, Pathogenic Cold turning to Pathogenic Heat in the Lung, Wind Heat
  • Symptoms: Cough, Asthma, Yellow sticky sputum, Thirst, Sore throat, Chest pain, Scanty, concentrated urine
  • Tongue and Pulse: Tongue: Red body & thin, yellow coat, Pulse: Rapid and strong
• Lung Dryness:
  • Causes: Pathogenic Dryness, Stomach Yin Deficiency, Wind Heat, Wind Dryness
  • Symptoms: Dry cough with little sputum, Chest pain, Dry skin, Thirst, Hoarse voice, Dry nose and throat
  • Tongue and Pulse: Tongue: Dry tongue with thin coating, Pulse: Rapid and thready
• Phlegm-Damp Retention:
  • Causes: Pathogenic Wind, Cold & Damp, Prolonged Cough or Asthma, Spleen dysfunction of transportation
  • Symptoms: Cough with frothy or white, sticky sputum, Sputum is easy to expectorate, SOB, Dislikes lying down, Stuffiness and fullness in the chest
  • Tongue and Pulse: Tongue: Pale with a white, sticky coat, Pulse: Wiry, slippery, and strong

Large Intestine Functions

• Receives food and drink from the Small Intestine and extracts fluids from it
• Excretes stools
• Mentally in charge of "Letting Go"

LI Damp Heat, LI Heat Consumption of Fluid, Cold Invading LI, LI Dryness, LI Qi Stagnation, and LI Collapse

• LI Damp Heat:
  • Causes: Excessive consumption of hot and greasy foods, Pathogenic summer heat, damp and heat
  • Symptoms: Abdominal pain, Offensive stool odor, Tenesmus, Thirst with no desire to drink, Blood and mucus in the stools, Scanty, deep yellow urine, Fever, Sweating
  • Tongue and Pulse: Tongue: Red body with yellow, sticky coating, Pulse: Rapid, slippery, and strong
• LI Heat Consumption of Fluid:
  • Causes: Excessive consumption of hot foods (lamb, beef & alcohol)
  • Symptoms: Constipation with dry stools, Burning sensation in the mouth, Burning and swelling in the anus, Dark, scanty urine
  • Tongue and Pulse: Tongue: Red body with thick yellow or brown, dry coat, Pulse: Full and rapid
• Cold Invading LI:
  • Causes: Chronic exposure to cold weather with abdomen exposed, Sitting on cold, wet surfaces for long periods
  • Symptoms: Sudden abdominal pain, Diarrhea with pain, Feeling of cold, Cold sensation in the abdomen
  • Tongue and Pulse: Tongue: Thick, white coating, Pulse: Deep, wiry, slow, and strong
• LI Dryness:
  • Causes: Blood or Yin deficiency, Elderly, Women after a delivery, Late stages of febrile disease, Dry and warm climates
  • Symptoms: Dry stools, Constipation, Dry mouth and throat, Yellow, scanty urine
  • Tongue and Pulse: Tongue: Dry, red or pale body without coating, Pulse: Thready
• LI Qi Stagnation:
  • Causes: Irregular eating habits, Frustration, anger
  • Symptoms: Abdominal distention & pain, Constipation with bitty stools, Irritability, Aggravated by mood
  • Tongue and Pulse: Tongue: Normal to slightly red sides, Pulse: Wiry on both chi positions
• LI Collapse:
  • Causes: Spleen & Stomach deficiency, Excessive physical work
  • Symptoms: Chronic diarrhea, Cold limbs, Anal prolapse, Hemorrhoids, Fatigue after bowel movements, Mental exhaustion
  • Tongue and Pulse: Tongue: Pale, Pulse: Deep, fine, weak

Bathing Education for Atopic Dermatitis

• Minimal contact with warm (not hot) water for as little time as possible
• Mechanical cleansing is generally superior to antiseptic cleansers
• Avoid adding oils to bath water as it is ineffective
• Pat skin dry instead of rubbing it aggressively

Colloidal Oatmeal

• Colloidal oatmeal suspensions have been shown to have benefits in several studies
• Can be found in soap, shampoo, emollients, or used in bath water
• Avenanthramides in colloidal oatmeal have anti-inflammatory properties and may relieve itching
• May offer a prebiotic effect and improve the dermal microbiome

Emollients

• Also known as moisturizers
• Regular use of emollients should be encouraged at all times except during active flare-ups
• Use emollients immediately after bathing to retain hydration gained (within 3 minutes of drying off)

Choosing an Emollient

• Ceramide-based emollients tend to work best
• Can be as effective as a low-medium potency topical corticosteroid
• Avoid scented emollients
• Avoid emollients with unnecessary botanical ingredients
• Glycerol-based emollients are better tolerated than urea/sodium chloride-based
• Avoid using olive oil
• Avoid emollients with common allergenic preservatives such as parabens, phenoxyethanol, imidazolidinyl urea, methylchloroisothiazolinone, quaternium-15, and formaldehyde

Treatment Goals

• Address presenting symptoms and improve patient comfort
• Support full and speedy recovery to return to regular activities
• Patient education
• Monitor and prevent complications

Food Sensitivity

• 80% of 59 children with Atopic Dermatitis (AD) showed improvement after eliminating cow's milk for 4 weeks
• 74% of 91 children with AD showed improvement on an elimination diet
• 63.5% of 50 adults with AD had positive responses to a 6-week diet excluding pseudo allergens
• Some studies have failed to show the role of food sensitivity in AD
• Conventional medicine: food allergy (sensitivity) rarely plays a role in the etiology of AD

Zinc

• Supplementing with zinc may help reduce eczema severity, especially if there is a deficiency
• Rich sources of zinc: shellfish, beef, and other red meats
• Good plant sources of zinc: nuts and legumes

Vitamin D

• Vitamin D deficiency is associated with the risk of psoriasis and atopic dermatitis
• Supplementing with vitamin D may reduce inflammation and symptoms of eczema
• Cholecalciferol (Vitamin D3): synthesized in the epidermis of the skin from UVB, found in animal sources (saltwater fish, liver, meats, egg yolks, and fortified foods)
• Ergocalciferol (Vitamin D2): found in plant sources (mushrooms, alfalfa sprouts) and fortified foods

Fish Oil

• Research has shown promising findings on the effects of fish oil supplements on eczema

Botanicals in Dermatology

• Key actions of botanicals in dermatology: alterative, hepatic, laxative, and they tend to be cold and bitter
• Key treatment principles: the stronger the presentation, the stronger the required treatment; if there is constipation, get the bowels moving

Key Herbs

• Arctium lappa (Burdock): key herb in dermatology
• Berberis vulgaris (Barberry): key herb with primary actions of hepatic, cholagogue, antimicrobial, bitter, anti-inflammatory, and endocrine modulator (insulin)
• Coptis sinensis (Coptis, Golden thread): key herb with primary actions of antimicrobial, anti-inflammatory, hepatic, and bitter
• Rumex crispus (Yellowdock): key herb with primary actions of alterative, laxative, hepatic, astringent, and mild adaptogen
• Glycyrrhiza glabra (Licorice): key herb with primary actions of adaptogen, anti-inflammatory, demulcent, antiviral, hypertensive, and laxative (in high dose)

Topical Injury and Conditions

• Abrasions: primary botanicals include Comfrey, Calendula, and Plantago; optimal application is topical; sample formula is "Green Salve"
• Ulcers: primary botanicals include Comfrey, Calendula, and Black tea; optimal application is poultice; sample formula is Comfrey and Black tea
• Eczema (dry): primary botanicals include Gotu kola, Astragalus, and Licorice; optimal application is infusion or tincture; sample formula is Gotu kola and Licorice

Sample Case Presentation

• 26-year-old male presents with silver, scaly lesions on the lower legs and hairline, with varying degrees of severity, and is worse during times of stress
• Associated symptoms include low-grade headaches and constipation
• Primary herb indicated is Berberis vulgaris (Barberry) due to its actions on the liver and gallbladder, and its ability to treat inflammatory skin conditions and constipation

Individual Herb Profiles

Berberis vulgaris (Barberry)

• Primary actions: hepatic, cholagogue, antimicrobial, bitter, anti-inflammatory, and endocrine modulator (insulin)
• Constituents: Isoquinoline alkaloids (berberine, hydrastine, berbamine)
• Indications: general infections, GI infections, hepatic or gallbladder conditions, constipation, type II diabetes, PCOS, and any inflammatory skin condition
• Cautions/Contraindications: non-toxic but strongly bitter; avoid during pregnancy and lactation
• Pairs well with: Bupleurum sinensis in hepatic infections, Galega officinalis in type II diabetes, and Chelidonium majus and Peumus boldo in addressing gallstones

Coptis sinensis (Coptis, Golden thread)

• Primary actions: antimicrobial, anti-inflammatory, hepatic, and bitter
• Constituents: Isoquinoline alkaloids (hydrastine, coptisine)
• Indications: chronic or acute skin characterized by inflammation, acute GI infections, chronic sinusitis, and hepatitis
• Cautions/Contraindications: non-toxic but very strongly bitter; avoid during pregnancy and lactation; not generally used more than 3 weeks consecutively
• Pairs well with: Bupleurum sinensis, Rheum palmatum, and Glycyrrhiza glabra

Glycyrrhiza glabra (Licorice root)

• Primary actions: adaptogen, anti-inflammatory, demulcent, antiviral, hypertensive, and laxative (in high dose)
• Constituents: Triterpene saponins (glycyrrhizin)
• Indications: ongoing stress, hypotension, asthma, eczema, chronic or acute bronchitis, emphysema, URTI, post-viral cough, and stomach ulcers (mostly DGL)
• Cautions/Contraindications: CI in hypertension; Preg A, Lact C
• Pairs well with: Rosmarinus officinalis for coughs, Bupleurum sinensis in anti-inflammatory combos, Hypericum perforatum and Melissa officinalis for the topical treatment of herpes infections

Homeopathy Study Notes

Urtica Urens

• Ailments from suppressed nettle-rash
• Itching, burning, and stinging sensations
• Burns and scalds of first and second degree
• Insect bites and stings
• Allergic reaction after eating shellfish
• Rheumatism (RA) associated or alternating with hives-like eruptions
• Uric acid diathesis: gout, kidney stones

Apis Mellifica

• Affinities: Skin and membranes, kidneys, mind
• Symptoms: Passionate, intense emotions, busy, ambitious, restless, irritable, quarrelsome, jealous
• Fear of birds, apathy, indifference, weepy
• Examples of Apis cases: Sore throat, measles, mumps, kidneys, cystitis

Rhus Toxicodendron

• Affinities: Skin, mucous membranes, fibrous tissue, aponeurosis
• Rheumatism (RA), stiffness, and pain
• Itchy skin, red, chicken pox, herpes, psoriasis, urticaria, cellulitis
• Worse at rest, initial movement, cold damp, better with heat, hot baths, stretching
• Mind: Busy, restless, dreams of travel, work, superstitious or ritualistic behavior

Sulphur

• Affinity: Skin
• Itchy skin < heat, red orifices
• Slouches, stooped, pain from standing
• Keynotes: Opiniated, critical, independent
• Polychrest remedy
• Sulphur types: Nervous, quick-tempered, plethoric, skin sensitive to weather changes
• General symptoms: Burning discharges, hot, hungry for fresh air, periodicity, desires sweets, spicy, fat, meat, alcohol
• Mind: Self-critical, critical of others, high confidence, egotism, selfishness, anxiety for family member, creative mind

Review Questions

• Review question #2: Graphites is the remedy for herpes simplex, where eruptions appear at the corner of the lips and behind the ears
• Review question #3: Not hungry in the morning, until about 11am is a keynote of Sulphur

DERMATOLOGICAL PHARMACOLOGY

Introduction

• Dermatological pharmacology deals with a large number of conditions causing rash, pruritis, or both.
• Treatment for rashes secondary to infectious etiologies focuses on the infection itself.
• Secondary infections are possible.
• For conditions like atopic dermatitis (eczema), pruritis is the most important symptom to control.

Corticosteroids

• There are two main subclasses: glucocorticoids and mineralocorticoids.
• Glucocorticoids affect carbohydrate, fat, and protein metabolism and have anti-inflammatory, immunosuppressive, anti-proliferative, and vasoconstrictive properties.
• Mineralocorticoids are primarily involved in electrolyte regulation by modifying renal excretion mechanisms.
• Both mineralocorticoid and glucocorticoid receptors are expressed in the skin.

Topical Corticosteroids

• The hydrocortisone backbone provides the basic structure from which all other topical corticosteroids are derived.
• Fluorinating or esterifying certain carbons in the four-ring backbone can increase the potency of TCS.

Mechanism of Action

• TCSs interact with intracellular glucocorticoid receptors, leading to gene transcription changes in the nucleus.
• General upregulation of anti-inflammatory mediators and downregulation of inflammatory mediators.
• Vasoconstrictive effect reduces delivery of inflammatory mediators and improves erythema.
• Anti-mitotic effect inhibits cell proliferation and collagen synthesis.
• Immunosuppressant effect.

Adverse Effects

• Many adverse effects are caused by overstimulation of glucocorticoid receptors.
• Stimulation of mineralocorticoid receptors in the skin may reduce the severity of some adverse effects.
• Adverse effects include: perioral dermatitis, stinging or burning sensation, acne, purpura, dermal atrophy, striae, rosacea, delayed wound healing, and skin pigment changes.

Fingertip Units

• Fingertip unit (FTU) is a measure of TCS application developed to help patients apply appropriate amounts.
• One FTU is approximately 0.5 g and covers an area equal to 2 adult handprints with fingers together.
• FTUs required for one application vary by age group and body area.

Topical Drug Vehicles

• Creams: fairly standard, patient-preferred, tend to cause irritation, and are the least effective vehicle for skin penetration.
• Gel: alcohol-based, useful for hairy areas and oily skin, can cause stinging and irritation.
• Lotion: often alcohol-based, evaporates well, useful for larger areas or hairy skin areas, can cause stinging and irritation.
• Ointment: thick, greasy base, best vehicle for skin permeation, causes little to no irritation, emollient effect.
• Foam: aerosolized oil-based formulation, allows application to hard-to-reach areas, tends to leave a greasy residue.

Potency

• TCSs are classified by potency into seven classes, with Class 1 being the highest potency (superpotent or ultra-high class).