Atopic+Dermatitis+(Si+Wan+Feng)

//Western Diagnosis// chronic itching superficial inflammation of the skin often associated with personal or family history of related disorders like asthma, hay fever

Etiology
1. unknown

Signs & Symptoms
1. itching, redness 2. weepy, crusted lesions a. may all begin in first few months of life 3. worsened by stress, environmental changes, wool

Diagnosis
1. clinical

Treatment
1. avoid known offending agents 2. avoid soap and water 3. antihistamines 4. corticosteroids - topically and/or orally 5. EPO 8-12 caps/d 6. zinc 30 mg TID 7. vit. A 50,000 IU/d 8. beta carotene 9. vit. E 400 IU/d 10. quercetin, hesperidin

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========================================================= TCM Pathology

Atopic Dermatitis/Si Wan Feng
A chronic, recurrent, pruritic and inflammatory skin disease associated with genetic factors and is also known as hereditary allergic dermatitis. Characteristics include: -Family history of susceptibility to asthma, hay fever, urticaria, and eczema. -Allergy to heterologous protein -High serum immunoglobin (IgE) levels -An increase in the number of eosinophil leukocytes in the blood.

In TCM, this disease is known as Si Wan Feng (Four Bends Wind), where the bends refer to the antecubital and popliteal fossae (1)

**Symptoms**
Main sites involved: cheeks, forehead and scalp. may spread to trunk and limbs -Fat babies who tend to sweat are more likely to suffer from an exudative-type condition. Lesions manifest as erythema and a dense distribution of pinpoint papules, papulo-vesicles and vesicles with exudation. Thick or thin yellow crusts form when the exudate dries up. A moist, bright red erosive base will often show once crusts fall off due to rubbing or scratching provoked by itching. -Thin, weak babies are more likely to suffer from a dry-type condition. Lesions are characterized by pale red or dark red erythematous patches, a dense distribution of small papules without vesicles, dryness without obvious exudation, and a greyish-white bran-like scales on the surface of the lesions. Slight infiltration, lichenification, fissuringm scratch marks, or bloody crusting will be present in a persistant condition.
 * Infantile Stage (1 month - 2 years):**

Main sites involved: antecubital and popliteal fossae, neck, wrists, and ankles -Lichenification, excoriations and dry skin are frequent -Sleep may be affected - In some, small, firm papules are found on back and extensor aspects of the limbs; excoriation may lead to blood crusting and pigmentation
 * Childhood Phase (3-12 years):**

Main sites involved: antecubital and popliteal fossae, anterior and lateral aspects of the neck -circumscribed dry lesions appear with inifiltration, thickening and lichenification, and pigmentation as a sequel -Hands may also be involved after contact with irritants.
 * Adolescent and Adult Phase (12 years - early 20's):**

Relevant Biomedical Conditions
Atopic Dermatitis Hereditary allergic dermatitis

Differential Diagnosis

 * Infantile Seborrheic Eczema:** This often occurs in babies shortly after birth. Lesions manifest as greyish-yellow or brownish-yellow oily scales partially or completely covering the scalp (known as cradle cap). Itching is present, but not pronounced.


 * Contact Dermatitis:** This is difficult to differentiate, especially in the chronic stage of atopic dermatitis. Identification of possible causes is usually the best guide to differentiation and treatment. Individuals with a history of atopic eczema are often more susceptible to irritants causing dermatitis.

Etiology and Pathogenesis
This condition is due to constitutional insufficiency and deficiency of the Lungs and Spleen complicated by external contraction of wind, dampness and heat, which are obstructed in the skin and flesh. An enduring condition will cause damage to Yin and body fluids resulting in Yin deficiency and Blood-Dryness

-The mothers preference for fatty, sweet, spicy, or fried food or overindulgence in fish and seafood during pregnancy or lactation will result in impairment of the Spleen's transportation function and the generation of damp-heat in the interior. The mother will pass on the heat toxins and turbid substances in the blood to the baby through breast-feeding. If this is complicated by improper feeding and nursing after birth, damp-heat may move to the skin and flesh to cause the disease. Dampness tends to predominate in plump babies, heat in thin and weak babies.

-Constitutional weakness plus the child's preference for an inappropriate diet of fish, seafood and spicy food will damage the Spleen and Stomach and result in the generation of damp-heat. Where this damp-heat moves outward to accumulate in the skin and flesh and is complicated by invasion of pathogenic wind, damopness or heat, or toxic substances such as dust mites or pollen, red papules and vesicles may appear suddenly. Where impairment of the Spleen's transformation function results in damp-heat accumulating in the interior, this damp-heat may be retained over a long period, resulting in a chronic disease with repeated occurence.

-Congenital (Earlier Heaven) insufficiency leads to Liver and Kidney Deficiency. Lack of proper care after birth (Later Heaven) results in damage to the Spleen and Lungs. Damage to the Spleen leads to deficiency of the source for generating transformation of Qi and Blood; damage to the Lungs causes weakness of Wei Qi. As a result, it is easy for external pathogenic factors to invade. At the initial stage, these factors are obstructed in the skin and interstices, causing dryness and itching; at the later stage, Yin is damaged and blood is consumed, making the skin rough and leathery.

Treatment Principles

 * Damp-Heat in Infant's (Predominance of Dampness)****:** Clear heat, transform dampness and alleviate itching.
 * Fetal-Heat:** Clear heat from the heart and guide out reddish urine, support the Spleen and foster Yin
 * Damp-Heat:** clear Summer Heat, eliminate Dampness, release the exterior
 * Spleen and Stomach Deficiency:** support Zheng Qi while releasing the exterior
 * Blood Dryness:** clear Heat, relieve toxicity, release the exterior

Damp-Heat in Infant's (Predominance of Dampness) [1]
Particularly in fat babies. //Main sites involved:// face, head, neck but may spread to other areas. //Lesions:// erythema, papules and vesicles with thick exudation As the disease develops, crusts appear and itching becomes increasingly pronounced, leading to disturbance of sleeping patterns.
 * Additional Symptoms:** constipation, short voidings of yellow urine
 * Tongue:** pale red, thin yellow coat
 * Pulse:** slippery, rapid
 * Treatment Principles:** Clear heat, transform dampness and alleviate itching.
 * Acupuncture Treatment:**
 * Herbal Treatment:** Xie Huang San Jia Jian

Fetal Heat [1,2]
Particularly in thin, weak, undernourished babies with a yellow complexion. //Main sites involved:// scalp, face, and neck but may spread to the trunk and limbs //Lesions:// papules and large pale red or dark red erythematous patches covered by oily scales or crusts. The skin is rough and itchy, disturbing sleep. Scratching will cause slight bleeding or result in the formation of bloody crusts.
 * Additional Symptoms:** indigestion, vomiting of milk shortly after feeding, loose stools possibly w/ undigested food
 * Tongue:** pale red, scant coat
 * Pulse:** moderate
 * Treatment Principles:** Clear heat from the heart and guide out reddish urine, support the Spleen and foster Yin
 * Acupuncture Treatment:**
 * Herbal Treatment:** San Xin Dao Chi San Jia Jian

Damp-Heat [1,2,3]
//Main sites involved:// antecubital and popliteal fossae //Lesions:// pinpoint papules, papulo-vesicles and vesicles, some of which coalesce Slight infiltration and severe itching are likely. Bleeding or exudation follows rupture of skin after scratching. The skin is rough and itchy, disturbing sleep. Scratching will cause slight bleeding or result in the formation of bloody crusts. //Chu Shi Wei Ling Tang Jia Jian// [1,2]
 * Tongue:** red tongue, thin yellow coat
 * Pulse:** soggy, rapid
 * Treatment Principles:** Clear heat and dispel dampness, support Zheng Qi and alleviate itching
 * Acupuncture Treatment:**
 * Herbal Treatment:**

//Xiao Feng Dao Chi Tang + Long Dan Xie Gan Tang// [3] Modifications: Severe itching: + Zhen Zhu Mu, Ci Shi Poor Appetite: + Huo Xiang, Pei Lan Dry Stool: + Da Qing Ye, Ma Ren

Spleen and Stomach Deficiency [1,3]
More often in children and adults with a weak constitution //Main sites involved:// antecubital and popliteal fossae //Lesions:// papules and vesicles with erosion and exudation Skin is dry and rough with some scaling and localized itching. //Jian Pi Chu Shi Tang + Chu Shi Wei Ling Tang Jia Jian//
 * Additional Symptoms:** pale complexion, lassitude, poor appetite, abdominal distention, diarrhea
 * Tongue:** pale tongue, greasy coat
 * Pulse:** thready, weak or deep, slippery
 * Treatment Principles:** Fortify the Spleen and eliminate dampness
 * Acupuncture Treatment:**
 * Herbal Treatment:**

Blood Dryness [1,2,3]
More often in adult phase //Main sites involved:// elbow, knee and neck //Lesions:// thickening and lichenification with ill-defined borders. Dry and cracked skin is likely. Slight bleeding or exudation after scratching. Itching is severe, especially at night. Skin is dry and rough with some scaling and localized itching. //Zi Yin Chu Shi Tang Jia Jian [1,2]//
 * Tongue:** pale tongue, scant coat
 * Pulse:** thready, rapid
 * Treatment Principles:** Enrich Yin and eliminate dampness, moisten dryness and alleviate itching
 * Acupuncture Treatment:**
 * Herbal Treatment:**

//Yang Xue Run Fu Yin + Zi Yin Chu Shi Tang// [3] Modifications: Thickened and lichenfied lesions: + Wang Bu Liu Xing, Ze Lan Severe itching: + Zaio Ci, Dai Zhe Shi, Duan Long Gu

External Therapy
equal parts Di Yu and Guan Zhong as wet compress 15 minutes 2-4x/day then apply //Qing Dai Gao// [1] //Huang Ai You// [1] //Di Hu Hu// [1] //Qu Shi Wan// [1,2] //Shi Zhen San// [2]
 * Infantile Stage:**

//Hei Dou Liu You Ruan Gao// [1] //Huang Lian Ruan Gao// [1] //Wu Shi Gao// [1] //Hei You Gan// [2] //E Huang San// [2]
 * Childhood Stage (applied 1-2x daily):**

Slight exudation: //Hu Po Er Wu Hu Gao// [1,2] dryness and fissuring: //Run Ji Gao// + //Shi Zhen Fen// [1] Relatively severe itching w/out exudation: //Lu Hu Xi Ji// [1] //Di Yu Er Cang Hu Gao// [2]
 * Adult Stage (applied 1-2x daily):**

Acupuncture
Korean Hand Acupuncture Points: BL-13, SI-3, HT-7, SP-10, LU-7, LI-4, LI-11 2 cases (1): onset at 2 mo., 1 treatment showed improvement on hand lesions, 4 treatments showed lesion improvement on back and legs; patches on hands remained improved. (2) onset at 2 years, 4 treatments showed clearing of lesions on back, face, legs, and 80-90% improvement on forearms [Chung, Y., Dumont, R.; Medical Acupuncture; fall/winter 2000/2001; Vol. 12, No.2]

Clinical Studies
Tadamichi Mitsuma reported 222 cases treated with herbal medicine. 103 males; 119 females; average age 12.0 +- 10.7. More than half were under 10y/o, 62 cases under 5 y/o, 58 cases 5-9y/o 116 effectively treated cases (51 males, 65 females) Xiao Jian Zhong Tang (prescribed for 88% of cases under 15 y/o) was used in 51% of the effective therapeutic cases, thus he concluded for pediatric atopic dermatitis or its modification offered the best treatment Huang Qi Jian Zhong Tang, Gui Qi Jian Zhong Tang were most common (with Xiao Jian Zhong Tang, made up 51% of effective treatments) [Wang, X., Wang, K.; Int. Journal of Oriental Medicine; Vol.22, No.2, pp.96-103, June 1997]

140 patients; 56 male, 84 female. 7 mo.-53 y/o conditions: 48 very severe, 54 severe, 31 moderate, 7 mild. First confirmed that Western medical therapy did not remit symptoms, then recommended dietary changes, when these did not heal the symptoms, Kampo was added. conclusion: "We have established that our diet and Kampo approach can bring cure for >50% of patients considered t be intractable with the conventional approach... Kampo is reserved as a second line regimen to replace the systemic use of corticosteroids and immunosuppressant agents" The evaluation results after 6 months to one year follow-up |||||| ||
 * ~ Evaluation ||||||~ Kampo (−) ||||||~ Kampo (+) ||
 * ~  ||~ patients (n = 37) ||~ % (group) ||~ % (total) ||~ patients (n = 103) ||~ % (group) ||~ % (total) ||
 * remarkable improvement || 8 || 21.6 || 5.7 || 25 || 24.3 || 17.9 ||
 * improvement || 0 || 0.0 || 0.0 || 30 || 29.1 || 21.4 ||
 * slight improvement || 7 || 18.9 || 5.0 || 21 || 20.4 || 15.0 ||
 * no change || 1 || 2.7 || 0.7 || 14 || 13.6 || 10.0 ||
 * deterioration || 0 || 0.0 || 0.0 || 4 || 3.9 || 2.9 ||
 * drop out || 21 || 56.8 || 15.0 || 9 || 8.7 || 6.4 ||

The evaluation results after 3 years follow-up* |||||| || [Kobayashi, H.; Evid Based Complement Alternat Med. 2004 September; 1 (2) : 145–155]
 * ~ Evaluation ||||||~ Kampo (−) ||||||~ Kampo (+) ||
 * ~  ||~ patients (n = 37) ||~ % (group) ||~ % (total) ||~ patients (n = 103) ||~ % (group) ||~ % (total) ||
 * remarkable improvement || 8 || 21.6 || 5.7 || 38 || 36.9 || 27.1 ||
 * improvement || 0 || 0.0 || 0.0 || 29 || 28.2 || 20.7 ||
 * slight improvement || 1 || 2.7 || 0.7 || 14 || 13.6 || 10.0 ||
 * no change || 0 || 0.0 || 0.0 || 3 || 2.9 || 2.1 ||
 * deterioration || 0 || 0.0 || 0.0 || 0 || 0.0 || 0.0 ||
 * unknown || 7 || 18.9 || 5.0 || 10 || 9.7 || 7.1 ||
 * drop out || 21 || 56.8 || 15.0 || 9 || 8.7 || 6.4 ||
 * Percentages may not sum to 100, because of rounding.

91 patients with atopic dermatitis. 6 month, multicenter, double-blind, randomized, placebo-controlled study. 7 were excluded. 77/84 completed the 24-week treatment course. Use of Kampo treatment in patients with 'Kikyo' (overall deficient constitution) using the formula Hochi-ekki-to [Ren Shen (4g.), Cang Zhu (4g.), Huang Qi (4g.), Bai Shao (3g.), Da Zao (2g.), Chai Hu (2g.), Gan Cao (1.5g.), Gan Jiang (0.5g.), Sheng Ma (1g.), Zhi Ke (2g.) ] overall skin severity score gradually decreased and was sligtly lower in the Hochu-ekki-to group. Total equivalent amount (TEA) of topical ointments used daily was significantly lower (P<0.05) in the Hochu-ekki-to group. [Kobayashi, H.; Evid Based Complement Alternat Med. 2008 January 31 ]