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Integrative approach to skin problems in pets

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Integrative therapies for skin disorders in pets encompass many treatment modalities. These include, but are not limited to, Traditional Chinese Veterinary Medicine (acupuncture, Chinese herbs and food therapy), laser, homeopathy, Western herbs, nutraceuticals, essential oils, and hyperbaric oxygen therapy. In general, it may take a combination of treatments to manage a patient’s skin disorders. It is important to have patience when treating skin problems, especially if the condition is chronic and severe. This article reviews common integrative modalities with a focus on Traditional Chinese Veterinary Medicine for treating inflammation and pruritus of the skin in pets.

Skin problems in pets

The skin is the largest body organ and serves as a protective barrier against harmful effects from the environment. Many internal imbalances manifest in the skin. When a pet’s skin is healthy, the client rarely thinks about it, but when problems occur, they can take a serious toll on the animal’s health.

In veterinary practice, skin diseases, including food allergies, atopy, ear infection, and auto-immune dermatitis, are the most challenging problems to treat. Pruritus (itching of the skin) is the most common clinical sign associated with skin disease, and it can cause serious disruptions to the pet’s well-being. It can also cause significant distress in the owner.1 Although Western medication will help relieve skin itch and inflammation, effective long-term control of pruritus is often not achieved.2 As well, some medications could potentially cause undesirable adverse effects.3

Both pet owners and veterinarians recognize a need for additional safe and efficacious therapeutic options to treat skin disease – especially complementary and integrative therapies.

Traditional Chinese Veterinary Medicine (TCVM)

TCVM, which uses acupuncture combined with herbal medicine and food therapy, seems to be effective for treating various skin disorders in animal patients. It stresses the importance of catering therapy to the needs of each individual, unlike Western therapeutic approaches that are standardized for all patients.

In TCVM, external pathological factors such as Wind, Dampness, Dryness or Heat can invade the body and cause skin disorders. Internal imbalances are differentiated into patterns such as Blood Stagnation, Disharmony of Liver and Kidney, or Blood Deficiency, and are often reflected in skin disorders. When skin problems are generated by internal imbalance, the underlying problem must be addressed in order to clear up the surface manifestation and prevent future problems. The pattern diagnosed will determine the best mode of treatment using herbs, acupuncture and diet therapy.

Acupuncture

Acupuncture includes dry needling, aquapuncture, electro-acupuncture, acupressure, moxibustion, and laser application) aims to restore the body’s natural balance by stimulating homeostasis.

In humans, the meta-analysis demonstrates acupuncture’s potential for the treatment of dermatological conditions in achieving positive patient outcomes, including dermatitis, urticaria, chloasma, pruritus and hyperhidrosis, compared with placebo acupuncture, alternative treatment options, and no intervention.4

In dogs, acupuncture has been shown to enhance the efficacy of antibiotics treatment for otitis.5 At one-year follow-up, 93% of the dogs that received acupuncture did not have recurrent disease, compared with the 50% that received placebo acupuncture.5

While the exact mechanism remains unclear, studies have shown that acupuncture can exert anti-inflammatory effects through a complex neuro-endocrino-immunological network of actions, including inhibition of histamines and down-regulation of pro-inflammatory cytokines, neuropeptides and neurotrophins that enhance and prolong inflammatory response in the body. Acupuncture is well tolerated by most animals and is generally safe with no to mild side effects when performed by a certified veterinary acupuncturist. Typically, six to ten acupuncture treatments are needed in a short period, initially, after which the spacing of sessions may be lengthened once the skin condition has improved. Some patients may require long-term therapy with acupuncture.

Herbals

Herbals are a rich source of active ingredients and can be effective for the treatment for different skin diseases. Recent research indicates that some herbs offer considerable medicinal benefits. Herbal substances can possess an anti-inflammatory action by inhibiting the formation of cytokines and eicosanoids, and inflammatory reaction cascade.7 A few randomized, controlled trials have demonstrated significant results in the use of herbal therapies for the treatment of dermatologic disorders in humans and dogs.8-11

While most herbs are generally considered safe, many can be quite toxic if taken incorrectly. It is recommended that herbs only be used under the direct recommendation and supervision of a certified veterinary herbalist.

Followings are some acupuncture and Chinese herbal medicine treatment methods for skin problems:12-15

1. Wind-Heat

Patients with a Wind-Heat pattern tend to be worse in the spring and summer, have dry hair coat and skin, and are often thirsty and cool-seeking. Most often, these are young to middle-aged individuals with allergic hypersensitivities and atopic dermatitis. Violent scratching may cause oozing blood and crust formation. The tongue is red and dry, and the pulse is superficial, wiry and rapid.

Treatment principle: Clear Heat, cool Blood, eliminate Wind to stop itching.

Acupoints: LI-4, LI-11, TH-5, GB-20, GV-14, SP-10, Er-jian.

Formula: Xiao Feng San or Wind Toxin. Dose at 0.5 gm per ten pounds orally twice daily.

Food therapy:* Cooling foods such as duck, rabbit, turkey, white fish, broccoli, celery, cucumbers, kelp, spinach, watermelon, bananas, blueberries, brown rice and tofu. Avoid warm and hot foods such as chicken, lamb, venison, ginger, pumpkin, oats and white rice.

2. Damp-Heat

The Damp-Heat pattern is commonly seen in warm humid climates and is often exacerbated during periods of high humidity. Patients often have greasy, malodorous, sebaceous or waxy exudates from the skin or ears. Most often, these cases have localized or generalized skin papules/pustules, pyodermatitis, wet hot spots, or chronic otitis. They are also cool-seeking, restless, have a red tongue with a yellow greasy coating, and a fast and forceful pulse.

Treatment principle: Clear Heat, eliminate Damp, and stop itching.

Acupoints: LI-4, LI-11, GB-34, GB-41, SP-6, SP-9, ST-40.

Formula: Long Dan Xie Gan Tang, Qing Shi Re Tang or Damp Heat Skin for generalized skin lesions; Si Miao San or Lower Jiao Damp Heat for lesions around lower jiao, flank and genitals; Four Paws Damp Heat for lesions on paws; Qing Er Tang or Ear Damp Heat for otitis. Dose at 0.5 gm per ten pounds orally twice daily.

Food therapy:* Cooling foods as mentioned above; also add foods that eliminate Dampness such as barley, celery, kidney beans, mushrooms and turnip. Avoid fatty, oily, sweet, high carbohydrate and dairy foods because they can lead to Damp.

3. Blood Heat

Blood Heat is often due to chronic Blood Stagnation in chronic skin disease. Heat is accumulated when Blood becomes stagnant and results in abnormal skin manifestations, such as red spots, ulcerations, crusting, erythema, depigmentation, bruising or blood spots under the skin without an obvious reason. This pattern is often seen in patients with immune-mediated dermatologic disorders. The tongue is red or purple, or has red or purple spots on it, sublingual veins may tend to be purple, and the pulse is rapid and surging.

Treatment principles: Clear Heat and invigorate Blood to expel Stagnation.

Acupoints: SP-6, SP-10, PC-4, LI-4, LIV-3, BL-17.

Formula: Liang Xue Jie Du or Blood Heat Formula. Add Mu Dan Pi if Blood stagnation is severe. Dose at 0.5 gm per ten pounds orally twice daily.

Food therapy:* Cooling foods as mentioned above; also add foods that help resolve Stagnation, such as ginger, vinegar, turmeric, celery, eggplant, shiitake, hawthorn berry, and pepper. Avoid cold and raw foods as they would stagnate circulation.

4. Liver and Kidney Yin deficiency

Yin deficiency in the Kidney and Liver is commonly seen in chronic skin disorders, especially in geriatric animals. It is often characterized by itching that’s worse at night and in the summer, dry skin with small dandruff, alopecia, excessive panting, cool-seeking behavior, anxiety and restlessness, especially at night. The tongue is red, dry with a thin or no coating, and the pulse is deep, thready, and rapid (weaker on the left side).

Treatment principles: Nourish Yin, Kidney and Liver.

Acupoints: KID-3, SP-6, LIV-8, BL-18, BL-23.

Formula: Yang Yin Zhi Yang or Zhi Bai Di Huang. Dose at 0.5 gm per ten pounds orally twice daily.

Food therapy:* Cooling foods as mentioned above; add Yin tonic foods, such as tofu, black beans, kidney beans, honey, asparagus, spinach and tomato. Avoid warm and hot foods such as chicken, lamb, venison, ginger, pumpkin, oats and white rice.

5. Liver Blood deficiency

Liver Blood nourishes and moistens the skin and a deficiency is often at the root of many skin diseases. Liver Blood deficiency is also commonly a result of deficient Liver and/or Kidney Yin. When Liver Blood is deficient, “Wind” can form in the skin, resulting in itching and skin lesions that suddenly appear or disappear or that move from place to place. It also causes a dry brittle hair coat and skin with dandruff, alopecia, and cracked nails or hooves. The patient has a pale dry tongue and a pulse that is deep, thready and weak (weaker on the left side).

Treatment principles: Nourish Blood and Liver.

Acupoints: SP-10, BL-17, ST-36, BL-18, LIV-8.

Formula: Si Wu Xiao Feng or Yang Xue Qu Feng Tang. Dose at 0.5 gm per ten pounds orally twice daily.

Food therapy:* Blood tonic foods such as beef, liver, heart, pork skin, sardines, salmon, eggs, carrots, kidney beans, black beans, beets, parsley, dates. Avoid cooling and raw foods.

*All food therapy must be formulated by a veterinarian or veterinary nutritionist to meet the individual patient’s nutritional needs.

Other integrative therapies

a) Laser therapy, with 630nm (red) and 830nm (near infrared) wavelengths, appears to have a wide range of applications for skin conditions, especially where the stimulation of healing, reduction of inflammation and cell death, and skin rejuvenation are required.16 Laser therapy at 808nm once a day for five days significantly improved pyogranulomatous pododermatitis in dogs even at two months of follow-up.17

b) Homeopathy may offer an effective and side effect-free treatment for various skin conditions, especially seborrheic, atopic and auto-immune dermatitis. It may help reduce pruritus, and in some cases showed complete resolution of the skin condition, allowing for the discontinuation of conventional treatments.18

c) Topical administration of essential oils and fatty acids, either as a daily spray (Dermoscent Atop 7) or a weekly spot-on (Dermoscent Essential 6) has shown to decrease pruritus in canine atopic dermatitis.19

d) Hyperbaric Oxygen Therapy was reported to successfully treat some inflammatory diseases, including atopic dermatitis, implying that HBOT may exert immune-regulatory effects in skin diseases (for general discussion of HBOT, see the Winter 2015 issue of IVC Journal).20

e) Omega 3 fatty acids have anti-inflammatory effects and are shown to have beneficial effects in various skin diseases. DHA and EPA inhibit the activation of pro-inflammatory cell signals, and reduce the leukotrienes and prostaglandins that play a role in dermatitis.21

f) Probiotic supplementation (bifidobacteria and lactobacillus) could be considered an integral part of the multimodal therapy for the long-term efficient management of canine atopic dermatitis22 by modulating the immune response and mitigating allergic reactions.23

g) Antioxidants and flavonoids, found in dark berries and some plants, protect against free radical damage, have anti-inflammatory properties, strengthen connective tissue, and may help reduce allergic reactions.23 Antioxidant agents to be considered include melatonin and vitamins A, C, D and E.23 Melatonin can be used to facilitate a better night’s sleep and to reduce skin inflammation. Vitamin A is involved in the growth and repair of epithelial cells. Vitamin C is vital for the production of collagen and can act as an antihistamine. Vitamin D helps boost immunity and heal damaged tissues. Vitamin E removes free radicals and helps ease dryness. Quercetin, a naturally-occurring polyphenol, shows antioxidant, anti-inflammatory and anti-allergic activities for atopic dermatitis.24

h) Bovine colostrum, rich in immunoglobulins, growth factors and other active compounds that stimulate the immune system, has been used anecdotally to successfully treat various skin conditions in animals.

In summary, integrative medicine can be an excellent adjunctive or primary therapy for dermatologic disease, especially in chronic cases unresponsive to conventional therapy. In addition, integrative modalities such as TCVM can also help restore the body’s balance, offering a more permanent resolution to chronic cases. Nevertheless, there is a need for more research to evaluate and confirm the efficiency and safety of various integrative therapies.

References

1Halliwell RE, Schwartzman RM. “Atopic disease in the dog”. Vet Rec 1971;89: 209–14.

2Scott DW, Miller WH, Griffin CE. “Skin immune system and allergic skin disease”. In: Muller and Kirk’s Small Animal Dermatology. Philadelphia: WB Saunders; 2001. p. 543–666.

3Paradis M, Scott DW, Giroux D. “Further investigations on the use of nonsteroidal and steroidal anti-inflammatory agents in the management of canine pruritus”. J Am Anim Hosp Assoc 1991;27:44–8.

4Ma C, Sivamani RK. “Acupuncture as a Treatment Modality in Dermatology: A Systematic Review”. J Altern Complement Med. 2015 Sep;21(9):520-9.

5Sa ́nchez-Araujo M, Puchi A. “Acupuncture prevents relapses of recurrent otitis in dogs: a 1-year follow-up of a randomised controlled trial”. Acupunct Med 2011; 29:21–6.

6McDonald JL, Cripps AW, Smith PK, Smith CA, Xue CC, Golianu B. “The anti-inflammatory effects of acupuncture and their relevance to allergic rhinitis: a narrative review and proposed model”. Evid Based Complement Alternat Med. 2013;2013:591796.

7Xu XJ, Banerjee P, Rustin MH, Poulter LW. “Modulation by Chinese herbal therapy of immune mechanisms in the skin of patients with atopic eczema”. Br J Dermatol. 1997 Jan;136(1):54-9.

8Sheehan MP, Atherton DJ. “A controlled trial of traditional Chinese medicinal plants in widespread non-exudative atopic eczema. Br J Dermatol 1992;126: 179–84.

9Sheehan MP, Rustin MH, Atherton DJ, et al. “Efficacy of a traditional Chinese herbal therapy in adult atopic dermatitis”. Lancet 1992;340:13–7.

10Nagel TM, Torres SM, Horne KL, et al. “A randomized, double-blind, placebo- controlled trial to investigate the efficacy and safety of a Chinese herbal product (P07P) for the treatment of canine atopic dermatitis”. Vet Dermatol 2001;12: 265–74.

11Ferguson EA, Littlewood JD, Carlotti DN, et al. “Management of canine atopic dermatitis using the plant extract PYM00217: a randomized, double-blind, placebo-controlled clinical study”. Vet Dermatol 2006;17:236–43.

12De-Hui S, Xiu-Fen W, Wang N. Manual of Dermatology in Chinese Medicine. Seattle, WA. Eastland Press 1995:1-50.

13Yan Zhou-Ping, Liu Dai-Hong. Zhong Yi Pi Fu Bing Zhi Liao Xue. Chinese Medicine for Dermatology. Beijing, China. China Traditional China Medicine Publisher 2011:18-42.

14Huisheng Xie. Chinese Veterinary Herbal Handbook (2nd edition). Reddick, FL. Jing Tang Publishing 2008:36-7.

15Xie H, Priest V. Xie’s Veterinary Acupuncture. Ames, Iowa: Blackwell Publishing 2007:316-8.

16Avci P, Gupta A, Sadasivam M, Vecchio D, Pam Z, Pam N, Hamblin MR. “Low-level laser (light) therapy (LLLT) in skin: stimulating, healing, restoring”. Semin Cutan Med Surg. 2013 Mar;32(1):41-52.

17Perego R, Proverbio D, Zuccaro A, Spada E. Low-level laser therapy: Case-control study in dogs with sterile pyogranulomatous pododermatitis. Vet World. 2016 Aug;9(8):882-7.

18Hill PB, Hoare J, Lau-Gillard P, et al. “Pilot study of the effect of individualized homeopathy on the pruritus associated with atopic dermatitis in dogs”. Vet Rec 2009;164:364–70.

19Tretter S, Mueller RS. “The influence of topical unsaturated fatty acids and essential oils on normal and atopic dogs”. J Am Anim Hosp Assoc. 2011 Jul-Aug;47(4):236-40.

20Kim HR, Kim JH, Choi EJ, et al. “Hyperoxygenation attenuated a murine model of atopic dermatitis through raising skin level of ROS”. PLoS One. 2014 Oct 2;9(10):e109297.

21Mueller RS, Fieseler KV, Fettman MJ, et al. “Effect of omega-3 fatty acids on canine atopic dermatitis”. J Small Anim Pract. 2004 Jun;45(6):293-7.

22Marsella R, Santoro D, Ahrens K. “Early exposure to probiotics in a canine model of atopic dermatitis has long-term clinical and immunological effects”. Vet Immunol Immunopathol. 2012 Apr 15;146(2):185-9.

23“A double-blind, placebo controlled-trial of a probiotic strain Lactobacillus sakei Probio-65 for the prevention of canine atopic dermatitis”. J Microbiol Biotechnol. 2015 Nov;25(11):1966-9.

24Ji H, Li XK. “Oxidative Stress in Atopic Dermatitis”. Oxid Med Cell Longev. 2016;2016:2721469.

Dr. Ronald Koh is an assistant professor and section chief of the Integrative Medicine & Rehabilitation Department at the Louisiana State University School of Veterinary Medicine. He received his veterinary degree in Taiwan and completed a specialty internship and Master’s program at University of Florida College of Veterinary Medicine. He is certified in acupuncture (CVA), Chinese herbal medicine (CVCH), food therapy (CVFT), and canine rehabilitation (CCRP). Dr. Koh is currently working toward the board certification of American College of Veterinary Sports Medicine and Rehabilitation (DACVSMR). His interests include using acupuncture, Chinese medicine and rehabilitation for pain management, neurological disorders, geriatric conditions, and hospice.

Dr. Ronald Koh is an assistant professor and section chief of the Integrative Medicine & Rehabilitation Department at the Louisiana State University School of Veterinary Medicine. He received his veterinary degree in Taiwan and completed a specialty internship and Master’s program at University of Florida College of Veterinary Medicine. He is certified in acupuncture (CVA), Chinese herbal medicine (CVCH), food therapy (CVFT), and canine rehabilitation (CCRP). Dr. Koh is currently working toward the board certification of American College of Veterinary Sports Medicine and Rehabilitation (DACVSMR). His interests include using acupuncture, Chinese medicine and rehabilitation for pain management, neurological disorders, geriatric conditions, and hospice.