problem skin disorders - amazon s3 · 2 davidovici bb, wolf r. clin dermatol 2010; 28(1): 12-16 28...

Problem Skin Disorders

© Kerry Bone 2012 MH232 1


Kerry Bone Co-Founder and Director Research & Development MediHerb Adjunct Associate Professor, University of New England Australia

Our Co-Presenters This Evening

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Val Allen

David McLeod

Monica Cocchiara


  Atopic dermatitis (eczema)

  Acne

  Rosacea

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Problem Skin Disorders: Traditional Considerations   Elimination of waste through skin resulting from

poor lymphatic, liver, bowel and kidney clearance   “Stagnant heat” apparent in all hot, red, itch

rash conditions   Liver, blood cleansing, lymphatic support and

frequently immune support necessary to return skin to good health

  I generally find patients experiencing dermatitis, rosacea or acne present with a white, coated tongue indicating congestion and sluggish lymphatic clearance

  Lymphatic congestion from iris indications frequently confirms the above findings Thanks to Val Allen 4

Atopic Dermatitis

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What Causes Atopic Dermatitis (AD)?   AD arises as a result of an interaction between

our makeup and our environment   It is now recognised that certain genetic defects

in the epidermal barrier occur in many AD sufferers

  Specifically, loss-of-function mutations in the structural protein filaggrin, with resultant enhanced transepidermal water loss, are consistent with a new unifying hypothesis1

  The resultant diminished epidermal defence to allergens and microbes is followed by polarised Th2 lymphocyte responses with resultant chronic inflammation

1 O'Regan GM et al. J Allergy Clin Immunol 2009; 124(3 Suppl 2): R2-6 6



What Causes Atopic Dermatitis?

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Pathophysiology of Atopic Dermatitis   Innate immune responses are also defective in

AD, leading to increased susceptibility to viral, bacterial and fungal infections1

  An example of this is the almost 90% rate of colonisation of the skin with Staphylococcus aureus in AD patients, compared with only 5% colonisation in healthy people

  Circulating NK cells are significantly reduced in AD patients and are functionally defective, as observed by the reduced release of interferon-gamma

1 Dokmeci E, Herrick CA. Semin Cutan Med Surg 2008; 27(2): 138-143 8

Atopic Dermatitis and Dysbiosis   The authors of a comprehensive study suggested

that their experience shows that correction of the intestinal and dermal dysbiosis, along with appropriate nutritional support and immune modulating therapy are essential steps in the management of AD1

  However, a Cochrane review failed to find evidence that conventional therapy against S. aureus was clinically helpful in people with AD that is not clinically infected2

1 Ionescu G et al. J Advance Med 1990; 3(1): 47-58 2 Bath-Hextall FJ et al. Br J Dermatol 2010; 163(1): 12-26 9



Atopic Dermatitis and Dysbiosis   A meta-analysis of 21 studies found that current

intestinal parasite infection was protective against allergic sensitisation1

  This supports the “old friends” hypothesis, a modification of the hygiene hypothesis, where exposure to certain relatively harmless micro-organisms (including helminths) supports immunological regulation via gut-associated T regulatory and regulatory dendritic cells2

  A less diverse gut microbiota, with high counts of Bacteroides, Clostridium, Enterobacteriaceae and Staphylococcus early in life has been associated with an increased risk for AD3

1 Feary J et al. Allergy 2011; 66(4): 569-578 2 Rook GA, Brunet LR. Gut 2005; 54(3): 317-320 3 Vael C, Desager K. Curr Opin Pediatr 2009; 21(6):794-800 10

AD: Lifestyle and Diet

Based on the preceding discussion, the following lifestyle and dietary changes can be recommended:   Measures to eliminate exposure to house dust

mite antigen should be instituted   Harsh soaps and detergents should be avoided,

including those used for washing clothes   Simple or multiple exclusion diets should be

considered, based on the clinical information. Elimination of cow’s milk (and related dairy products) is a good starting diet

  Care should be taken to substitute protein and calcium in young children

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AD: Lifestyle and Diet   If there is no symptom improvement in about

4 to 6 weeks, different foods in turn could be eliminated such as eggs, peanuts or seafood1

  Various multiple exclusion diets are available1 These typically involve avoidance of dairy products, eggs, nuts, pork, bacon, shellfish, yeast and fruit. (Such diets can be severe and should not be instituted as a first resort)

  The diet should otherwise be well balanced with plenty of plant fibre and should not contain excessive amounts of junk food, sugar and refined carbohydrate

1 Ursell A. Practitioner 1994; 238: 284-288 12



AD: Herbal Treatment Goals

  Echinacea root will help to balance the immune response. Experience shows that it does not aggravate AD

  Boosting the innate immune response with Echinacea, Andrographis and other immune herbs may help to control Staph. aureus infection

  Antiallergic herbs (such as Albizia, Baical Skullcap and nettles) and anti-inflammatory herbs (such as Licorice and Bupleurum) can help to control symptoms

  Bitter herbs and Ginger will improve digestion (if indicated)

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AD: Herbal Treatment Goals

  Long-term treatment with depuratives such as Burdock, Clivers, Yellow Dock and Sarsaparilla

  Evening Primrose Oil as a source of gamma linolenic acid can correct an essential fatty acid imbalance, confer anti-inflammatory effects and support the epidermal barrier (but omega-3 fatty acids should also be co-prescribed)

  Topical treatment with anti-inflammatory and antiseptic herbs. The antiseptic herbs will help to control skin microflora imbalance and infection with Staph. aureus

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AD: Herbal Treatment Goals   Topical Calendula, Myrrh, Tea Tree oil, Golden

Seal and Echinacea will help to control microbial levels

  Licorice, Chamomile and St John’s Wort oil have topical anti-inflammatory activity

  Hemidesmus and Rehmannia can be used to modulate the Th-2 cell response

  Gut dysbiosis and deficient Tregs should be addressed using the bowel flora protocol (BFP)

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Bowel Flora Protocol (BFP)

  This novel protocol is based on a weed, feed and seed approach

  It is based on a weekend/week day cycle   For best results 6 to 10 cycles should be carried

out   The weeding phase uses key antimicrobial herbs

(weekends)   The feeding phase is week days

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Bowel Flora Protocol

  The key antimicrobial herbs such as Oregano and Anise oils, Phellodendron and (optionally) Garlic provide the weeding

  Ulmus rubra (Slippery Elm) provides the feeding treatment, but this is done in conjunction with Vitis vinifera (Grape Seed) and Camellia sinensis (Green Tea) to depress pathogenic bacteria

  Combine with the appropriate diet depending on the pattern of dysbiosis and optionally use an evidence-based probiotic to enhance clinical results

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Eczema - Atopic Dermatitis Diet   Family history often reveals links to asthma and

hayfever in rotation with eczema, in these cases consider food sensitivities to dairy, oranges, tomatoes, wheat

Favourite Herbs   Calendula, Golden Seal, Helichrysum and Rosehip

Oil Nutritional Support   Potassium chloride (white tongue, sluggish

lymphatics)   Iron phosphate (hot, dry, itchy rash)   Evening Primrose Oil   Fish oil (older skin)

Thanks to Val Allen 18



Very Successful Tonic for Eczema

Red Clover 1:2 30 mL Yellow Dock 1:2 20 mL Burdock 1:2 20 mL Dong Quai 1:2 20 mL Sarsaparilla 1:2 10 mL 100 mL


Childhood Eczema Although we see many adults with eczema, babies are probably the most common and more severe cases I see. As communication is an issue LOOKING and OBSERVING the child is crucial in selecting the correct herbs for Rx Digestion: signs of lactose, fructose or wheat intolerance; parasites; leaky gut syndrome etc. • What do nappies look like • Colic, reflux, vomiting • Is baby crying after feeding • If breastfed, what is mum eating or drinking

Thanks to Monica Cocchiara 20

Childhood Eczema Proposed causes:   Iatrogenic: medication, vaccines   Allergies: foods (dairy, wheat, yeast etc.);

contact allergens (pets, plants, grasses etc); additives & preservatives

  Toxins: chemical exposure, heavy metals, alcohol

  Immunological: what is general immune response to common colds? Does eczema present after a cold/flu?

  Stress

Thanks to Monica Cocchiara 21



Case History from Monica

4 month old baby Presented with chronic eczema from 4 weeks old. Fully breast fed. Vaccinated. Mother was non-smoker and had a balanced diet. Baby did not respond to first basic skin treatment I prescribed. Next treatment we looked at mum. • Mum was put on a lactose free diet as she was

drinking 3 glasses of cow’s milk daily. • Hair analysis showed that mum was high in lead

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Case History from Monica Mum Rx Galium 30 (for lymphatic cleansing) Silybum 50 (heavy metals, galactogogue, detox) Echinacea 20 (immune, cleansing) Sig 5ml bd

Slippery elm 2 caps bd Essential fatty acids 1bd

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Case History from Monica Baby Rx Lappa root 20 Galium 30 Trifolium 30 Echinacea 20 Sig 2 drops bd Evening primrose oil 1drop bd Next visit in 6 weeks baby’s skin was clear. I suggested that the lactose should be avoided when food was later introduced. As baby’s skin only aggravated when mother had lactose in high amounts in her diet. Otherwise, 2 years later her skin was still eczema free 24



Panel Discussion and Questions

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Acne

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Seborrhoea

Comedones

Papules

Pustules

Pathogenesis of Acne   Acne is a disorder of the sebaceous follicles

(sebaceous glands associated with hair follicles), which are located on the face, chest and back. Several factors play a pivotal role in the pathogenesis of acne: •  androgen dependence •  excessive sebum production (lipogenesis) •  abnormal follicular differentiation (retention

hyperkeratosis) •  increased colonisation with Propionibacterium

acnes •  inflammatory processes

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Diet and Acne   Despite the popular conventional view that

diet is not related to acne, several experts in the field are encouraging a reassessment of this position, partly because the data refuting any association are weak1

  For example, one review pointed out that acne is virtually unknown in traditional hunter-gatherers2

  The review goes on to suggest an association between dairy products (from the protein, not the fat) and dietary fat (especially in terms of increased sebum production)

1 Costa A, Lage D, Moisés TA. An Bras Dermatol 2010; 85(3): 346-353 2 Davidovici BB, Wolf R. Clin Dermatol 2010; 28(1): 12-16 28

Diet and Acne

  Another review considered that there was compelling evidence that high glycaemic load diets may exacerbate acne1

  The view is growing that acne can be regarded as an indicator disease of the exaggerated insulinotropic effects of modern western diets2

  Especially milk- and whey protein-based products contribute to elevations of postprandial insulin and basal IGF-1 plasma levels

1 Bowe WP, Joshi SS, Shalita AR. J Am Acad Dermatol 2010; 63(1): 124-141 2 Melnik BC. Nestle Nutr Workshop Ser Pediatr Program 2011; 67: 131-145 29

Acne and Dietary Strategy

  Appropriate dietary strategies for acne, as supported by the above evidence, stress the avoidance of high glycaemic index foods and dairy products

  The diet should also not contain excessive levels of fat and be rich in plant fibre

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Acne: Herbal Treatment Goals   Depurative herbs are again the mainstay of

treatment. In particular Calendula and Burdock may reduce excess sebum production, but other important depuratives for acne include Yellow Dock, Poke Root and Oregon Grape

  A more effective immune response will help to control levels of P. acnes. Echinacea has been traditionally used in acne, possibly for this reason, Andrographis is also useful

  Chaste tree given to men and women has shown benefit in acne in early clinical trials, possibly due to its hormonal effects

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Acne: Herbal Treatment Goals   Linseeds contain lignans that may raise SHBG   Studies have found that consumption of Licorice

can lower testosterone levels, but high doses may be necessary, especially in men

  Other internal herbs used to treat acne include Garlic and Golden Seal

  Case observations and even clinical studies have shown that insulin and antidiabetic drugs appear to cause clinical improvement in acne.1 It has even been suggested that acne is "skin diabetes“

  Hence herbs that control blood sugar should be considered

1 McCarty M. Med Hypotheses 1984; 14: 307-310 32

Acne: Herbal Treatment Goals   Topical treatments can be of benefit, especially

as resistance is growing to antibiotics used in acne1

  A single blind clinical trial found that topical treatment with fresh Basil juice (Ocimum basilicum) was as effective as conventional treatment2

  Topical Tea Tree oil was found to be effective. Calendula and Comfrey are also popular topical treatments

1 Smith EV, Grindlay DJ, Williams HC. Clin Exp Dermatol 2011; 36(2): 119-122 2 Balambal R et al. J Assoc Physicians India 1985; 33(8): 507-508 33



Acne Example liquid formula

Chaste Tree 1:2 15 mL Calendula 1:2 20 mL Burdock 1:2 20 mL Baical Skullcap 1:2 20 mL Poke Root 1:5 5 mL Echinacea root 1:2 30 mL 110 mL

Dosage: 8 mL with water twice a day 34

Acne Diet & Lifestyle   Reduce sugars and yeast   Increase water intake   Encourage regular exercise

Favourite Herbs   Chaste Tree (always male or female), Barberry,

Burdock, Yellow Dock, Blue Flag, Horsetail (scarring, pustular), Andrographis or Echinacea (subcutaneous, cystic), Clivers

Topical Herbs   Golden Seal


Case History from Monica Case 2: Acne 23 year old male Luke presented with severe cystic acne on face chest and back. It first appeared around 14 yrs but has since become more inflamed and painful. I also noted that his sclera was yellow and that his hair was receding more than it should be for some one his age. He did not consume alcohol. And had a fantastic organic diet since he was a child. So there was no room to move with his diet. He was highly anxious and a very light sleeper

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Case History from Monica Rx Smilax 30 Trifolium 20 Serenoa 20 Scutellaria 10 Vitex 10 Sig 7ml bd 6 weeks later his skin was not as painful or as inflamed. Even though he had a good diet he still required cleansing. His yellow sclera was indicative of this for me

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Case History from Monica Rx Smilax 30 Trifolium 30 Serenoa 20 Scutellaria 10 Vitex 20 Sig 7ml bd Zinc 1 tablet hs

7 weeks the inflammation had reduced and his chest and back starting clearing, but still experiencing some breakouts. He was less anxious and sleep had improved

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Case History from Monica Rx Smilax 20 Tribulus 30 Scutellaria 10 Vitex 20 Echinacea 20 Sig 7.5ml bd Zinc 1 tab hs

When I saw him 2 months later his skin was clear. Not one pimple! It took about 7 months of treatment

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Rosacea Types

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Rosacea Epidemiology   Rosacea prevalence is highest (between 2.7

and 10%) in adults of northern European or Celtic heritage

  People with fair skin are mainly affected   Incidence peaks between 30 and 50 years and

may be more common in women   Microbial agents such as Helicobacter pylori are

associated, but controversial   There is a clear association with higher

infestation with the Demodex mite (up to 20 times higher mite counts with rosacea) Steinhoff M et al. J Investig Dermatol Symp Proc 2011; 15(1): 2-11 Chosidow O, Cribier B. Ann Dermatol Venereol 2012; 138(Suppl 3); S179-S183 Alvarez F et al. J Appl Microbiol 2012; 112(1): 159-174 42



Rosacea Pathophysiology

Yamasaki K, Gallo RL. J Dermatol Sci 2009; 55(2): 77-81 43

Rosacea and Digestion

  Gastrointestinal problems are often reported   Dyspepsia, bloating, flatulence, abdominal pain,

and alteration of intestinal habits have been described

  Many case reports associate rosacea with ulcerative colitis, Crohn's disease, coeliac disease, hypochlorhydria, Helicobacter pylori (Hp) gastritis, alteration of intestinal mucosa and lipase deficiency

Parodi A, Paolino S, Greco A et al. Clin Gastroenterol Hepatol 2008; 6(7): 759-764 44

Rosacea and Constipation   A single-patient case study was described

of a young male rosacea patient with a slow gut transit time (GTT) of >70 hours who suffered from periodic constipation

  30 g wheat bran after each meal was prescribed, reducing GTT to 28 hours after 7 days

  After 14 days his rosacea went into remission

Kendall SN. Clin Exp Dermatol 2004; 29(3): 297-299 45



Rosacea: Diet and Lifestyle

  Foods or drinks that cause flushing such as coffee and other hot drinks, alcohol and spicy foods should be avoided

  The diet should be high in plant fibre   Stress levels should be reduced,

since in some patients periods of stress are linked to a worsening of their skin

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Rosacea: Herbal Treatment Goals   The hygiene of the whole gastrointestinal tract

(mouth to anus) is important and any noted problems or defects should be treated

  Attention should be paid to oral hygiene (for example with a mouth rinse containing herbs such as Sage, Echinacea, Propolis and Thyme)

  If H. pylori tests are positive, then appropriate treatment should be instituted (see later)

  If there are symptoms of digestive insufficiency, bitters (but not Ginger because of its potential flushing effect), Coleus and choleretic herbs can be judiciously prescribed

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Rosacea: Herbal Treatment Goals   Constipation needs to be addressed if present

(choleresis will help here)   The bowel flora protocol should be considered   Depurative and immune system herbs are still

an essential aspect of long-term treatment   Herbs which tone the microvasculature such as

Gotu Kola, Grape Seed extract and Bilberry can be of value, particularly in the early stages of the disease, since they may help to combat flushing and correct dilated capillaries

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Rosacea: Herbal Treatment Goals   Topical application of acaricidal herbs which

include Echinacea root, Myrrh and Quassia Bark could be helpful, especially in papulopustular rosacea. Clinical trials now support this

  Care should be taken that the vehicle used to apply these herbs does not irritate the skin

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Herbs and Helicobacter   Current research suggests that herbs can

have only a supportive role in the management of Helicobacter and they are most suitable for cases where antibiotic therapy is not fully successful

  Activity has been demonstrated in vitro for Allium sativum (Garlic), Thymus vulgaris (Thyme), Salvia species (Sage), Cinnamomum species (Cinnamon), Hydrastis (Golden Seal), Arctostaphylos (Bearberry) and Camellia sinensis (Green Tea), among others

  Moderate benefits have been shown in clinical trials for raw garlic, Rheum species (Rhubarb Root), Vaccinium macrocarpon (Cranberry), Nigella sativa (Black Cumin), Broccoli sprouts Bone K. Helicobacter: A Hidden Factor in Cardiovascular, Digestive, Autoimmune and Skin Disorders. Townsend Letter for Doctors 2006; 271/272: 48-50 50

Rosacea Diet & General Observation   I find 75% of cases improve once wheat is

eliminated   Sympathetic nervous system is sensitive   Underlying infection exists in blood stream

Favourite Herbs   Barberry, Astragalus, Echinacea, Golden Seal,

Burdock, Yellow Dock, Chamomile, Sarsaparilla, Clivers.

  In past Chaparral great results




Rosacea

Topical Herbs   Golden Seal, Manuka honey

Nutritional Support   Calcium Phosphate   Potassium Chloride or Sulphate   Zinc   B Vitamin Complex


Case History from Monica Case 3: Male aged 72 yrs rosacea for 20 yrs   LFT showed high GGT and ALT   Ultrasound showed a fatty liver   His testosterone was low   Osteoporosis was also detected Rx Rheum 40 Silybum 40 Vitex 20 Sig 7ml bd

Dandelion tea I cup bd, to replace and reduce his coffee intake 53

Case History from Monica

  8 weeks later his LFTs had reduced and his skin appeared less red and inflamed. He had a very sensitive stomach and he was taking the mix with no problem so I kept the same Rx for a further 8 weeks

  There was no sign of the rosacea so I continued with the Silybum for another 8 weeks until all his LFTs were back in the normal range

  This was a simple but very effective treatment

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problem skin disorders - amazon s3 · 2 davidovici bb, wolf r. clin dermatol 2010; 28(1): 12-16 28...

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