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TCVM – Pattern Differentiation In Dermatology

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As veterinarians, we know that a good diagnostic plan would include a thorough history of the problem (acute, chronic, seasonal, continual), the patient’s age, and any other problems. Skin scrapings and flea combs are used to rule out parasites, including demodectic and sarcoptic mange mites, fleas and lice. Cultures and biopsies may also reveal information leading to a cause of the problem. Endocrine problems, autoimmune disease and allergic skin disease may be among the differentials.

Most clients with dermatology patients seek integrative care when they are concerned about the long term effects of steroids, antibiotics and/or anti-fungals on their pets’ health, or they may seek integrative care if the patient has incompatibilities with medications.

One benefit of approaching these pets from a Traditional Chinese Veterinary Medical (TCVM) point of view is that we do not need a specific “Western” diagnosis, though it may help with determining the pattern of disease. The pattern of disease is developed according to the presentation of the patient and his history. Treatment is determined by balancing the pattern of disease with acupuncture, herbs, laser, food therapy or a combination of these.

Diagnosing skin patterns can sometimes be challenging because they usually involve both excesses and deficiencies, and the skin may not always reflect the interior imbalances. For instance, the skin may have small dry flakes while at the same time there is an interior damp condition (see sidebar) with lipemia and gallbladder sludge.

It might be helpful to look at some of the symptoms that are presented and interpret them according to TCVM. Some of the symptoms may include pruritis, pustules, scales, crusts, ulcers, exudates, blisters, vesicles, papules, hair loss, cysts, nodules, masses, pain or tenderness, hives and skin discoloration.

Evaluate the patient

Age of patient Chronicity of problem Diet Presence of Stress Exposure to Infectious parasites Heredity Other medical problems Medications

Evaluate the skin Dry or Damp Hot or Cold Thick or Thin Odor Discoloration Hair coat quality Location of lesions, constant or moving

Symptom differentiation

Pruritis

Exogenous — invasion of wind, wind cold, wind damp, cold damp, damp heat, damp, wind heat, wind heat dryness, toxic heat, insect bites or parasites, poison ivy (toxin). Acute, excess, may wander or come and go.

Endogenous — food sensitivities, blood deficiency dryness, yin deficiency, toxic heat, toxic damp heat.

Excess — strong itch

Deficiency — tends to be milder

Pain

Excess — strong, worse with pressure

Deficiency — mild, improves with pressure

Exogenous Pain: Cold of the Skin — cramping type pain that improves with warmth Heat — burning type pain

Endogenous Pain: QI Stagnation — Diffuse, moderate, distending pain Blood Stasis — strong, stabbing fixed pain Phlegm — dull pain or sensation of heaviness Deficiency of Blood — mild, dull pain improved with pressure (massage) Yin Deficiency — mild, dull, burning pain Yang Deficiency — dull pain, better with warmth

Discoloration

Light discoloration — deficiency or cold invasion Dark discoloration — blood stasis Light red– exogenous factors Red macules or papules — heat (endogenous, exogenous or toxic)

Nodules

Qi Stagnation — soft, moveable, non-painful Blood Stagnation — hard, immoveable, often painful Phlegm Stagnation — soft, moveable or immoveable with palpable borders

Scales

Exogenous Dryness (acute) Blood Deficiency and Dryness (chronic) — thin and dry scales on pale rash Heat caused dryness — chronic with red rash Blood Stasis — chronic, thick, dark scales Damp or Damp Heat — acute or chronic; thick, moist or sticky scales (odor with heat)

Scars

Hard, immoveable, often painful (Blood Stagnation)

Blisters or vesicles

Damp heat

Cysts of the skin

Phlegm

Pustules

Damp heat or toxic heat

Crusts, exudates, folliculitis

Damp heat or toxic damp heat

Treatments

• Acupuncture is helpful for eliminating excessive heat and for moving qi and blood. Acupuncture points used often with skin problems are GB 20, GV14, BL17, LIV2, SP10, SP9, SP6, BL22, GB 34, LU9 and LI 11.

• Herbs and food therapy have their forte in treating deficiencies within the body, as well as transformation processes, draining of damp, building of blood, qi, yin, yang and essence.

• Herbal formulas useful for treating skin problems include Long Dan Xie Gan Tang for excessive fire in the Liver and Gall Bladder meridians (including damp, heat otitis). This formula is used to drain dampness and eliminate fire; it can nourish blood without causing stasis and supplements the yin. It should not be used long term by itself and should be used with caution when there’s a deficiency of the Spleen and Stomach.

• Another formula that is helpful is Jia Wei Jiao Yao San. It’s used for Liver qi stagnation with interior heat and an underlying blood and Spleen deficiency. Symptoms usually include a dry hair coat and skin. Dang Gui Shao Yao San might be used to nourish the blood, strengthen the Spleen, and resolve dampness. It is mild in nature and can be used for a prolonged period for chronic blood deficiency.

• Another favorite in the older patient with a deficiency heat causing skin and hair problems is Zhi Bai Di Huang Wan. It is used to nourish and nourish Kidney yin and clear excess heat from the lower jiao. These patients tend to have knee and back problems, pant excessively, especially at night, and have a rapid, thin and wiry pulse caused by a heat deficiency and a lack of fluids and yin to cool the body.

• Single herbs can be used to enhance these formulas, making them more specific for certain locations in the body and for itching or inflammation.

o For the ears: Huang Bai Phellodendron, Ge Gen Kudzu or Long Dan Cao Gentiana o For the eyes and nose: Hong Hua Carthami, Ju Hua Chysanthemi or Bai Zhi Angelica Dahuricae o For the groun area or whole exterior of body: Ku Shen Sophora or Chan Tui Cicada pericarpium

• Herbs that have some specific action on itching can be added to other prescriptions. These include Cang Er Zi Fructus Xanthii, She Chuan Zi Cnidium, Fang Feng Ledoborellia, or Bai Xian Pi Dictamnus. All would be of value in an herbal pharmacy when addressing dermatologic issues.

• Foods to strengthen the effect of herbals and needling include beef, beets, oats, raw sweet ginger, tumeric and hawthorn berries for nourishing and invigorating Blood. For a phlegm and stagnation condition, shrimp may be used to invigorate Blood and resolve phlegm, as may mustard leaf. Warm, sweet oats will invigorate Qi, while neutral, salty and bitter alfalfa is a detoxicant. Sweet, salty and cool barley tonifies yin and blood and is anti-inflammatory. Cooling meats are turkey, duck, rabbit and cod. More neutral meats are pork, beef, salmon, tuna and mackerel. Cooling grains include millet, barley, brown rice, wheat bran. Neutral grains are corn, sweet rice, soy beans, green beans, kidney beans and black beans. Vegetables that may help with dampness would include radishes, turnips, alfalfa, rye, barley, adzuki beans, celery, corn, garlic, green tea, marjoram, mushrooms and mustard. Owners can have fun working with foods and a crockpot to enhance the results of acupuncture and herbal treatments.

By approaching the dermatology case with acupuncture, herbs and foods, you are treating the imbalance in the body causing the skin problem, and not just treating the symptoms. The root and the branch of the problem are being addressed. Constitution, heredity and diet often determine the nature of imbalances that result in dermatological problems. After symptoms are improved, keeping the body in balance can prevent the recurrence, or the severity of recurrence, of symptoms. Clients appreciate the time and effort when they see improvements in the comfort and vitality of their pets.

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Common dermatologic patterns

Damp – External or internal often in combination with heat. It may present aspapules, vesicles, pustules, ulcerations, serous or yellowish fluid. May also exhibit signs of nausea or severe formication (lick granuloma, hot spot). Large, thick scales. Odor with damp heat condition. Heat, Toxic Heat, Summer Heat — sudden onset of papules, erythema, pustules, redness, swelling, heat, pain, itching. Wind — External or internal. External wind due to external factors and tends to be migrating in nature. Internal wind often generated by yin deficiency of the Liver and Kidney and insufficiency of yin and blood. Extreme itchiness with papules and wheals with tendency to itch until bleeding and rapid dry scab formation. Dryness — external dryness occurs in dry environments. Internal dryness originates from insufficiency of body fluids or insufficiency of blood, generally or locally, and appears as dry skin, flaking, lichenification. Cold — may be environmental or interior due to functional deterioration or to yang qi deficiency.

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Case study

Sea Witch was a six-year-old spayed female Scottish deerhound with hair loss and itching around the eyes and nose, feet and the backs of her legs. The skin had a strong “doggie” odor.

Mildly red skin….heat (excess or deficiency) Thickened skin….damp or phlegm Odor….damp heat Pulse rapid, wiry and thin….heat, stagnation, and deficiency Tongue and gums red….heat Panting….heat or nervousness Pruritis….heat, stagnation, wind

The signs that predominated were heat and damp.

Diagnosis: Deficiency Heat with Damp and Wind

Treatment principle: Eliminate Damp, Heat and Wind Nourish the Blood Move the Blood Note: Eliminate predominant damp prior to nourishing blood, because herbs that nourish blood tend to aggravate dampness leading to more stagnation and heat. Transformation of phlegm and damp with draining herbs and herbs that move through stagnation are helpful.

Treatment: Long Dan Xie Gan Tang was used. This formula addresses heat and toxic heat in the Liver/Gall Bladder Channels, draining heat from the Upper Jiao and eliminating damp and heat through the Lower Jiao by promoting urination. It also has herbs for supplementing the yin (cooling) and the blood without causing stasis. Also, because this formula works in the Liv/GB channels, it drains heat from the ears and eyes.

After heat and damp are resolved, Si Wu Tang is good for Liver Blood deficiency and stagnation with additional herbs for directing to the skin. The formula used in this case was Huo Xue Qu Feng Tang with additional herbs for Blood deficiency wind (itching) and herbs used as envoys to the face and nose (angelica dahuricae bai zhi), ears, face (cortex phellodendri huang bai) for clearing damp, wind and heat; and to the eyes ligustri lucidi nu zhen zi) for yin def heat, and hair loss. Other herbs were ecliptae prostratae han lian cao to nourish blood, yin, and deficiency hair loss and sesame indici hei zhi ma also for nourishing blood and deficiency hair loss.

Dr. Mary Battistella is a 1983 graduate of Auburn University and has been practicing integrative medicine since 1992. She incorporates acupuncture, chiropractics, Chinese herbal medicine, homotoxicology and nutrition into her practice, Kowaliga Whole Health Pet care in Eclectic, Alabama. She completed IVAS certification in acupuncture in 1994, and herbal certification in 2000. She is part of the Integrative Medicine program at the Auburn College of Veterinary Medicine and is on staff at Chi Institute. Dr. Battistella is on the continuing education committee for the AAVA.