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How Do You Treat Psoriasis in Your Practice?
P
soriasis is a chronic dermatologic conditionthat appears in red, scaly, and itchy patches. It can be seen on the scalp, elbows, knees, and/or the trunk. This condition occurs in more than 3 million patients per year in the United States. The etiology of psoriasis is that it stems from a possible immunologic disorder. About 30% patients with psoriasis experience further problems such as inflammatory arthritis, cardiometabolic ailments, and mental health ill- nesses. Topical therapies remain the foundation for treating mild psoriasis; for moderate-to-severe plaque psoriasis, various kinds of biologics that inhibit tumor necrosis factor–a, p40IL-12/23, interleukin (IL)–17, and p19IL-23 could be considered for treatments.1
In our clinical services, the psoriasis acupuncture point choices include LI 4 (Hegu), LI 11 (Quchi), SP 10 (Xuehai), GV 14 (DaiZhui), and SP 9 (Yinlingquan). This is based upon classical Traditional Chinese Medicine (TCM) principles in which the temporal solution is to disperse the Wind. Furthermore, Blood is nourished to dissipate the patient’s Blood Stasis and reduce the pa- tient’s Heat. We provide acupuncture treatment once per week for 6 sessions of treatment. Clinical improve- ment can be seen after the third treatment. We continue once per month acupuncture treatment to achieve longer- lasting effects.
Utilizing acupuncture therapy in patients with psoriasis, can achieve clinically and statistically significant improve- ments.2Acupuncture-related techniques could be considered as short-term adjuvant therapy for patients with psoriasis.3
Acupuncture treatment for psoriasis is uncomplicated, con- venient, and effective, with long-lasting therapeutic effects as well as minimal side-effects.4
We adviseIndigo naturalis,which is a TCM herb well- known as a topical therapy for psoriasis. A controlled trial to evaluate the efficacy and safety of I. naturalis in patients with refractory plaque-type psoriasis was conducted.5Sig- nificant reductions in scaling, erythema, and induration scores were noted with topical application of I. naturalis ointment. In this study, 74% of patients reported clearance or near-clearance of their psoriasis in their indigo ointment- treated lesions. For plaque-type psoriasis, topicalI. natur- alis ointment was considered to be a safe, and effective therapy.
In another study, a significant improvement in Psoriasis Area and Severity Index scores from baseline were observed inI. naturalis-treated patients, compared with patients who were given a placebo.I. naturalistreatment resulted in down- regulation of the IL-17 pathway. Based upon anin vitrokera- tinocyte assay, tryptanthrin, a component ofI. naturalisexerted an IL-17-inhibitory effect.6
REFERENCES
1. Armstrong AW, Read C. Pathophysiology, Clinical presentation, and treatment of psoriasis: A review.JAMA. 2020;323(19):1945–
1960.
2. Coyle M, Deng J, Zhang AL, et al. Acupuncture therapies for psoriasis vulgaris: A systematic review of randomized con- trolled trials.Forsch Komplementmed. 2015;22(2):102–109.
3. Yeh ML, Ko SH, Wang MH, Chi CC, Chung YC. Acupuncture- related techniques for psoriasis: A systematic review with pairwise and network meta-analyses of randomized con- trolled trials.J Altern Complement Med. 2017;23(12):930–
940.
4. Xiang Y, Wu X, Lu C, Wang K. An overview of acupuncture for psoriasis vulgaris,2009–2014.J Dermatolog Treat. 2017;
28(3):221–228.
5. Lin YK, Chang CJ, Chang YC, Wong WR, Chang SC, Pang JH. Clinical assessment of patients with recalcitrant psoriasis in a randomized, observer-blind, vehicle-controlled trial using Indigo naturalis. Arch Dermatol. 2008;144(11):1457–1464.
6. Cheng HM, Wu YC, Wang Q, et al. Clinical efficacy and IL-17 targeting mechanism ofIndigo naturalisas a topical agent in moderate psoriasis. BMC Complement Alternat Med. 2017;
17(1):439.
Medical Acupunctureis pleased to continue this regular fea- ture,Clinical Pearls,which we have found to be very useful for, and practical to, the readership, and very popular. All of us are confronted with clinical challenges, especially when dealing with therapeutic strategies. We hope this ongoing collection of Clinical Pearls will be easily accessible and ready to put into action for the benefit of our patients, and even ourselves. How often do we ask our colleagues: ‘‘How do you treat.?’’ This time, we posed the question:‘‘How do you treat psoriasis in your practice?’’Herein lie your contributions. We trust that our readership will continue to participate in this section by either asking the questions or supplying the ‘‘Pearls.’’ If you have a ‘‘question’’ you would like to see answered, please send it to our managing editor,Yael Ben- Porat, at: [email protected] We encourage and welcome your input and participation. Please address your answers to
‘‘Pearls’’ to our managing editor,Yael Ben-Porat, at: yaelbenporat@
me.com
MEDICAL ACUPUNCTURE Volume 33, Number 2, 2021
#Mary Ann Liebert, Inc.
DOI: 10.1089/acu.2021.29172.cpl
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Address correspondence to:
Yuan-Chi Lin, MD, MPH Medical Acupuncture Service Boston Children’s Hospital Harvard Medical School Boston, MA USA E-mail:[email protected] Chung-Jen Chen, MD Kaohsiung Municipal Ta-Tung Hospital and Graduate Institute of Natural Products Kaohsiung Medical University Kaohsiung Taiwan E-mail:[email protected]
P
soriasis is a chronic immune-mediated diseasewith a primary dermal manifestation of a chronic plaque in the remission phase. Psoriasis is also a systemic disease often accompanied with joint injuries.1Moderate-to-severe psoriasis carries a increased risks of metabolic syndrome and atherosclerotic cardiovascular disease. Clinical classifica- tions of this condition can be divided into 4 types: (1) vul- garis; (2) arthropathic; (3)erythroderma; and (4) pustular.1 The prevalence of psoriasis accounts for 0.1%–11.8% of the world’s population, which means that there are*60 cases/100,000 of the worldwide population.1
Treatment guidelines in the United States are conventional systemic therapy, topical biologic therapy, phototherapy, and photochemotherapy. Clinical practice guidelines recommend topical treatments, such as topical corticosteroids, vitamin D analogues, and topical retinoids for mild psoriasis. Systemic treatment (retinoid acid, methotrexate [MTX], or biological agents) is recommended for moderate-to-severe psoriasis.2 These treatments can provide short-term improvement, but most cause serious adverse events that limit long-term use.3 Among patients with psoriasis in 1 study, 52.3% reported dissatisfaction because of inefficient therapy and adverse re- actions.3There are currently no conventional drugs that pro- duce a safe and long-term therapeutic effect.4
Acupuncture, a nonpharmacologic therapeutic modality, involves use of thin needles at acupuncture points to treat medical problems. This modality can be used to activate nerve fibers and peripheral afferent receptors, produce sensory interactions at various levels of the central nervous system, and release various transmitters and modulators, thus producing anti-inflammatory signals as well as neuro- endocrine and neuroimmune signals.5Currently, psoriasis treatment can involve acupuncture therapy. Some system- atic reviews have reported the benefit of acupuncture nee- dling, but the studies were of relatively low method quality.3
One experimental trial showed that acupuncture needling, electroacupuncture (EA), and fire needling significantly ameliorated skin lesions and inhibited keratinocyte prolif- eration and proinflammatory cell infiltration. The thera- peutic effects of these 3 methods were similar to using the positive control drug MTX; however, the MTX treatment group developed the lowest epidermal thickness.3Based on existing research results, we hypothesized that the possible mechanism of acupuncture in psoriasis treatment might be due to its regulatory impact on immune-cell function; in that study, EA was comparatively more beneficial for reducing inflammatory responses that might be related to decreases in local neuropeptides.3
Diagnostic Criteria
In the acupuncture treatment of psoriasis, all patients first confirmed the diagnosis by a dermatologist, then the se- verity of the disease were evaluated by using the Psoriasis Area and Severity Index (PASI), which criteria are: mild psoriasis (PASI below 8); moderate psoriasis (PASI be- tween 8 and 12); and severe psoriasis (PASI more than 12).6 The PASI scores were evaluated by dermatologist during the first admission and at the end of treatment.
Case Illustration
Ms. S, age 38, with an 8-year history of psoriasis came to the acupuncture department. She was diagnosed with psoriasis and referred by a dermatologist and. A physical examination was conducted by the dermatologist; this patient had an initial PASI score was 19.5. She was treated with topical and systematic (MTX) drugs. In the acupuncture department, the doctor evaluated the condition and checked for acupuncture contra- indications (e.g., a pacemaker, or use of anticoagulant drugs).
Figure 1 shows the patient’s psoriasis prior to treatment.
The acupuncture points used in her treatment were LI 4 (Hegu), LI 11 (Quchi), ST 36 (Zusanli), SP 6 (Sanyinjiao), SP 10 (Xuehai), LR 3 (Taichong), GB 20 (Fengchi), BL 17 (Geshu), and BL 23 (Shenshu) bilaterally. Fine needles were used to stimulate LI 11, SP 6, SP 10, LR 3, GB 20, BL 17, and BL 23. EA was used at LI 4 and ST 36 at a 4-Hz frequency with a continuous wave. All treatments were
FIG. 1. Right lower leg of a patient with psoriasis before acu- puncture treatment. Jakarta, 2018.
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conducted for 20 minutes, twice per week until 12 sessions (6 weeks) were completed. The patient’s PASI scores was evaluated at the first admission and at the end of treatment by the dermatologist. At the end of the therapy sessions, her PASI score changed from 19.5 to 7.5. Figure 2 shows the improvement that the acupuncture treatment produced.
REFERENCES
1. Xie Z-y, Zhou Y, Deng S, Ding W, Duan X-W, Yang L-R.
Effectiveness comparisons of acupuncture for psoriasis: A Bayesian network meta-analysis protocol.Medicine (Baltimore).
2019;98(17):e15356.
2. Coyle M, Deng J, Zhang AL, et al. Acupuncture therapies for psoriasis vulgaris: A systematic review of randomized con- trolled trials.Forsch Komplementmed.2015;22(2):102–109.
3. Wang Y, Fu Y, Zhang L, et al. Acupuncture needling, elec- troacupuncture, and fire needling improve imiquimod-induced psoriasis-like skin lesions through reducing local inflammatory responses.Evid Based Complement Alternat Med.2019;2019:
4706865.
4. Xiang Y, Wu X, Lu C, Wang K. An overview of acupuncture for psoriasis vulgaris, 2009–2014.J Dermatolog Treat. 2017;
28(3):221–228.
5. Cho Z, Hwang S, Wong E, et al. Neural substrates, experi- mental evidence and functional hypothesis of acupuncture mechanisms.Acta Neurol Scand. 2006;113(6):370–377.
6. Schmitt J, Wozel G. The Psoriasis Area and Severity Index is the adequate criterion to define severity in chronic plaque-type psoriasis.Dermatology.2005;210(3):194–199.
Address correspondence to:
Elfrita Maya, MD Medistra Hospital Jl. Gatot Subroto No. 59, RW 4 Kuningan Tim.
Kecamatan Setiabudi, Kota Jakarta Selatan Daerah Khusus Ibukota, Jakarta 12950 Indonesia E-mail:[email protected]
Yoshua Viventius, MD Christina Lanny Simadibrata, MD, MHSc Medical Acupuncture Specialist Program Faculty of Medicine Universitas Indonesia Daerah Khusus Ibukota, Jakarta 10430 Indonesia Hasan Mihardja, MD, MHSc, PhD Center of Development and Application of Traditional Medicine Daerah Khusus Ibukota, Jakarta 10160 Indonesia
P
soriasis is a chronic inflammatory disease char- acterized by plaque-, inverse-, guttate-, pustular-, and erythrodermic-variants, with a prevalence of 2%–4% of the population in Western countries.1. Psoriasis severity de- pends on inherited factors and the environment and can fluctuate with age or other factors, presenting with a few plaques or affecting the entire body surface.2The inflam- matory autoimmune process affects the skin and can affect the joints (psoriatic arthritis).3 Being affected with both forms increases psychosocial and quality-of-life issues.2.Prevention of psoriasis requires maintaining a stable emotional state, avoiding emotional disturbances.
A 50-year-old man presented with multiple itchy erythematous-scaly plaques. Histopathologic testing of the plaques was compatible with psoriasis. The patient underwent phototherapy (psoralen and ultraviolet A and then narrow-band ultraviolet B, for 2 weekly sessions for 18 months) and had moderate resolution of his condi- tion, but no pruritus improvement occurred. He was us- ing 15 mg of methotrexate per week. Due to altered hepatic function, he could not tolerate higher doses of drugs. Progression of his psoriasis worsened, with dif- fuse myalgia, arthralgia, and edema in a knee, and worsening of his psoriasis plaques. After 10 sessions of treatment with acupuncture, his itching and pain were reduced, as were his plaques.
For patients with psoriatic arthralgia and with symptoms of Heat: the treatment method in Chinese Medicine is to dissipate the Wind, clear the Heat, and remove the Damp- ness, which in modern medical language is equivalent to inducing analgesic and anti-inflammatory effects.4We treat acupuncture points of theTaiyinLung Meridian of the Hand and the Large Intestine Meridian and Taiyin Spleen Mer- idian of the Foot to address this condition.
Acupuncture was used for this patient to treat his skin injury by needling the superficial layer of the skin around the injury. The primary acupuncture points we used in the first sessions included LI 4, ST 36, SP 9, SP 3, K 3, and GB 20. For patients, such as this man, with Blood Deficiency FIG. 2. Right lower leg of patient with psoriasis after 12 ses-
sions of acupuncture treatment. Jakarta, 2018.
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and Wind Dryness, the treatment nourishes the Blood and moisturizes the Dryness, and the main treatments are the foot meridian of the footYangmingand footTaiyin.
Due to the patient’s severe itching, we added K 6 and HT 7 in the sessions that followed.
In our clinical practice, if the diagnosis shows a Wind–
Heat pattern, we attenuate Wind and Heat characteristics, regularize Defensive and Nutritive Qi, and stimulate the Lung’s dispersing function. Points we use in our practice include GV 14, GB 20, GB 31, BL 13, LU 7, LI 4, and SJ 5.
For patients with diminished Qi/Xue, we can add CV 12, ST 36, and CV 6. If intense pruritus is associated with anxiety, we add HT 7 and PC 7.
If there is a deficiency of Xue, the treatment would include dispersing the Wind–Heat and tonifying and nourishing the Blood, nourishing the Yin, and strength- ening the Spleen. Some treatment points include ST 36, SP 6, SP 10, L 8, BL 17, BL 20, and CV 12; or K 8, BL 17, and BL 20. If intense itching is present, H 7, BL 15 can be added. If Dryness Syndrome is present, patients present with dry rough skin that might be red, hot, and itchy. The patient might be thirsty and a dry mouth. This occurs usually secondary to Blood Deficiency. Treatment would include nourishing Yin, eliminating Heat, expelling Wind, and tonifying Blood and Kidney. Points suggested are BL 23, SP 6, K 3, LI 4, SJ 6. For Heat LI 11, LI 4 would be used.
For mixed syndrome cases, the treatment involves tonifying Yin and dispersing Heat in the affected system and removing Blood Stasis. Treatment points include BL 40, SP 10, SP 6, LI 4, and LI 11. For excess Heat, we bleed from the nascent points. For Yin Deficiency, we use K 3 and SP 6 can be added.
Acupoint stimulation should be performed for a mini- mum of 6 weeks to achieve a therapeutic effect. It is necessary to reinforce that the insertion of needles must respect the limits of healthy skin, as dysbiosis is present in injury areas and presents a higher risk of contamination through local acupoint needling. When there are psoriatic lesions in the chosen point region, alternatives should be sought to achieve the therapeutic objectives.
REFERENCES
1. Michalek IM, Loring B, John SM. A systematic review of worldwide epidemiology of psoriasis. J Eur Acad Dermatol Venereol.2017;31(2):205–212.
2. de Korte J, Sprangers MA, Mombers FM, Bos JD. Quality of life in patients with psoriasis: A systematic literature review. J Investig Dermatol Symp Proc.2004;9(2):140–147.
3. Armstrong AW, Read C. Pathophysiology, clinical presentation, and treatment of psoriasis: A review.JAMA. 2020;323(19):1945–
1960.
4. Xiang Y, Wu X, Lu C, Wang K. An overview of acupuncture for psoriasis vulgaris, 2009–2014.J Dermatolog Treat. 2017;
28(3):221–228.
5. Coyle M, Deng J, Zhang AL, et al. Acupuncture therapies for psoriasis vulgaris: A systematic review of randomized con- trolled trials.Forsch Komplementmed. 2015;22(2):102–109.
Address correspondence to:
Marcus Yu Bin Pai, MD Divisa˜o de Clı´nica Neurociru´rgica Instituto Central Hospital das Clı´nicas da FMUSP Aveneida Dr. Ene´as de Carvalho Aguiar 255 5-Andar, Sala 5084 Cerqueira Ce´sar 05403-900, Sa˜o Paulo Brazil E-mail:[email protected] Ricardo Bassetto, MD Integrated Research Center of Chinese Medicine Sa˜o Paulo/SP Brazil Hong Jin Pai Hospital das Clı´nicas da Faculdade de Medicina Department of Neurology Pain Center Universidade de Sa˜o Paulo Sa˜o Paulo/SP Brazil
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