Eczema (atopic dermatitis) is the most common skin condition among children worldwide. Traditional Chinese medicine (TCM) practitioners have been treating it for thousands of years, and those treatments are just as effective for children today.
Skin conditions are difficult to ignore. Atopic dermatitis is a common, chronic, life-altering disease that affects the skin. Atopic dermatitis is often referred to as "eczema" (and these terms are used interchangeably throughout the article).
Eczema is a general term for several types of inflammation of the skin (of which atopic dermatitis is the most common). The word "dermatitis" means inflammation of the skin and "atopic" refers to a group of diseases where there is a tendency to develop other allergic diseases such as asthma and hay fever. Eczema comes from the Greek word meaning 'weeping skin' and is the most common skin disease in children. In Chinese, the name for eczema is Shi Zhen ('damp sore').
Worldwide eczema affects 12-25% of children. Of these children, 49-75% will develop eczema before they are 6 months old and 80-90% before they are 5 years old. There are three phases of eczema and this article we will discuss the first two – the infantile and childhood phase. The discussion of these two stages will relate to any eczema sufferer whose first onset of eczema was before puberty. About 6 out of 10 children will continue to have eczema after puberty and 10-15% of adults continue to suffer from their childhood eczema. Over 2 million Canadians and 15 million Americans suffer from eczema.
Changes in the reported prevalence of childhood eczema since World War 2 were studied in 3 national cohorts of children born in 1946, 1958, and 1970. The overall rates of this disease rose from 5.1% in children born in 1946, to 7.3% in those born in 1958, to 12.2% in the 1970 cohort.
Since 1970, the prevalence of eczema has nearly tripled. The latest research from England of 14,000 children born in the 90's showed that 1/3 of these children developed this disease by the age of 3 years old. This, coupled with the chronic and recurring nature of the disease, has made it difficult for Western physicians to treat and frustrating for children and their parents. Eczema often starts in babies when food is first introduced or when new foods are introduced. Eczema is most common in children who have family members with asthma, allergies and/or eczema.
According to a recent study, more than 50 per cent of eczema sufferers are not satisfied with their current treatment1. There is no cure for this disease in modern medicine and management of this disease is the only treatment available. Traditionally in modern medicine eczema has been treated or managed with moisturizers to rehydrate the skin, topical corticosteroids for inflammation, oral antihistamines to control the itch, and when there is infection, antibiotics. Topical corticosteroids have been used for 30 years to treat eczema but they are not an ideal treatment because they do not produce a cure and they have side effects. The unpredictable nature of eczema and lack of a good treatment in Western medicine makes it difficult to manage and some people simply give up on searching for an effective treatment. What everyone does not know is that Traditional Chinese Medicine is very effective in the treatment of this disease and can reduce the discomfort and severity of their eczema. TCM offers a long-term solution to this chronic disease and because it treats the root-cause of the disease it can often produce a cure for pediatric eczema.
TCM and Atopic Dermatitis (Eczema)
Chinese medicine has been proven over 2000 years to be effective in treating various diseases including eczema. Many clinical studies have been completed on the effectiveness of various Chinese herbal formulas in the treatment of eczema. Unfortunately, these studies are completed in China and therefore written in the Chinese language making them not accessible to modern medical doctors. [This is why I learned to read Chinese to access this vital information!]. However, because of the remarkable success TCM doctors in England were having in the treatment of stubborn cases of eczema that would not respond to many types of conventional treatment, various skin doctors started to take notice. Doctors have a natural antipathy towards anecdotal evidence and so there seemed little else to do but to set up a proper scientific study in English. Multiple studies were conducted and reported in British medical journals. All studies concluded that Chinese herbal medicine was an effective treatment for atopic dermatitis and there were no side effects to these treatments.
One of these research projects (placebo-controlled double-blind trial) was a one year study2 of 37 children suffering from eczema conducted at The Hospital for Sick Children, London, England. This study revealed that Chinese herbal medicine offered an effective treatment particularly for those children who failed to respond to modern medical treatments. At the end of the study, 18 (49%) had at least a 90% reduction in the severity of their atopic dermatitis after 8 weeks of treatment. Another 5 cases (14%) improved to a lesser degree during the same length of time.
In clinical practice, Chinese medicine is customized to the individual but for the sake of research, in the above study the treatment had to be standardized for each patient. To minimize the error introduced by prescribing identical medicine for all patients, only those cases with a particular type of eczema according to the Chinese pattern discrimination were selected for the clinical trial. Although not ideal from a holistic perspective, all patients received the same herbal prescription. The only allowance made for individuality was in terms of dosage. I believe the results would have been even better if the study allowed the practitioner to further modify the patient's prescription based on their clinical presentation. Also it is important to remember the results obtained were spectacular given the circumstances and considering this study included only very severe cases of eczema.
Symptoms of Atopic Dermatitis (Eczema)
Regardless of how minor or severe a person's eczema is, everyone has the same basic symptoms – dry skin, sore rashes, and terrible itching. The management and prevention of 'flare-ups' can be both frustrating and uncomfortable, especially for a young child. When atopic dermatitis is severe, it can lead to serious health problems and negatively affect their quality of life by interfering with normal, everyday activities.
Symptoms (signs) vary from person to person. Extreme itching (pruritus) is the most important symptom of atopic dermatitis. Scratching and rubbing in response to itching irritates the skin and leads to the other common symptoms of eczema such as redness of the skin, swelling, cracking, "weeping" clear fluid, and finally, dryness (xerosis), crusting and scaling. Itching is a particular problem during sleep when conscious control of scratching is lost.
The appearance of the skin that is affected by atopic dermatitis depends on the amount of scratching and the presence of secondary skin infections. One other type of lesion common in atopic dermatitis is lichenification, which appears when the skin over time becomes thick and leathery due to repeated damage from scratching and rubbing. It is also common for individuals with eczema to have a higher incidence of asthma and hay fever (i.e. allergic rhinitis) with 30% of these patients presenting with these associated diseases.
According to modern medicine the symptoms of atopic dermatitis discussed above are associated with malfunction of the body's immune system and appear when the body reacts to elements in the environment which would normally be harmless. Scientists have found that people with atopic dermatitis have a low level of a cytokine (a protein) that is essential to the healthy function of the body's immune system and a high level of other cytokines that lead to allergic reactions. For example in atopic dermatitis, the immune system may fight against common house-dust mites or pollen allergens causing the skin to become red, itchy and inflamed.
In most cases, the severity of this disease fluctuates with sometimes the disease being worse (called exacerbations or flare-ups) followed by periods of time when the skin improves or clears up (called remissions). In some cases, the itching and redness is so serious and intense sufferers scratch themselves until they bleed, increasing the risk of secondary infection.
Commonly, eczema can produce a vicious cycle. Something irritates the child's skin, making it red and inflamed and because it itches, the child scratches it. The outer protective layer of the skin is lost. The affected area is even more sensitive to irritants, and dries out easily. The child's skin continues to be exposed to whatever it was that triggered the initial episode and the rashes develop. The cycle perpetuates itself.
Several studies suggest that atopic eczema has a more profound effect on the quality of life than other skin diseases, such as acne and psoriasis. Children may experience sleep disturbance due to the "itch-scratch-itch" cycle and lack of confidence due to low self-esteem. Families of sufferers also experience sleep loss. If eczema runs in the family, it is more likely to be a lifelong condition. Even so, it is often worse in the first years of life and therefore is important to treat at this time.
Stages of Atopic Dermatitis (Eczema)
Distribution and morphology (described above) of the lesions of eczema vary with age.
- Infantile Phase (up to 18-24 months): When atopic dermatitis occurs during infancy and childhood, it affects each child differently in terms of both onset and severity of symptoms. In infants, atopic dermatitis typically begins around 6 to 12 weeks of age. It may first appear around the cheeks and chin as a patchy facial rash, which can progress to red, scaling, oozing skin. After this, the skin tends to become thick, dry and scaly. Once the infant becomes more mobile and begins crawling, exposed areas such as the inner and outer parts of the arms and legs, may also be affected. At this stage, the severity tends to fluctuate with a number of factors including: acute respiratory disease, teething, bacterial infections, emotional stress, climatic changes, diet and immunization (sometimes this is when it first appears). Fewer than half of these cases will clear by 18 months. The infant is often restless and irritable because of the intense itching and discomfort of the disease at this stage.
- Childhood disease (18-24 months-puberty): In childhood, the rash tends to occur behind the knees and inside the elbows; on the sides of the neck; around the mouth; and on the wrists, ankles, and hands. Another Chinese name for atopic eczema is Si Wan Feng which means "Four Flexure (or Bends) Wind". This name indicates that TCM recognizes the tendency of this disease (at this stage) to occur behind the knees and inside the elbows. Often, the rash begins with red, bumps (i.e. papules) that become hard and scaly when scratched. The face is less frequently affected at this stage. Due to the chronic nature of this disease at this stage, problems with schooling may occur. The eczematous lesions tend to be replaced by lichenification.
In some children, the disease goes into remission for a long time, only to come back at the onset of puberty when hormones, stress, and the use of irritating skin care products or cosmetics may cause the disease to flare.
Treatment of Atopic Dermatitis Based on TCM Patterns
In TCM, the symptoms of pediatric atopic dermatitis are divided into three different patterns or groups of symptoms. The treatment principles are different for each pattern. The two main patterns described are wet, 'weeping' (i.e. damp heat) eczema and dry, scaly (i.e. blood heat with wind or spleen vacuity/blood depletion) eczema. The third pattern mentioned in TCM literature is called Foetal heat. Note that all forms of eczema are related to heat/dryness, which emphasizes the prominent superficial inflamed or red nature of the skin that is so common in atopic dermatitis. TCM treatment is based on differentiating whether the lesions are dry or damp, the stage of the eczema and what areas are affected.
This is the earliest presentation of eczema which usually begins on the face (see Infantile Phase discussed above). This pattern is similar to the damp-heat pattern discussed below but is differentiated by its presence in the infantile phase and etiology. The TCM treatment for this pattern is different than the damp-heat pattern. The symptoms of this pattern indicating dampness in TCM include edematous (swollen) papules, exudative and weeping lesions with secondary crusting (is usually pronounced) of the skin. Symptoms indicating heat include red lesions, thirst, pronounced heat during the sleeping, nocturnal restlessness and crying, constipation or foul smelling diarrhea. Examination of the tongue and finger vein may also indicate the presence of dampness and heat in the body. At this stage the intense itching often causes disturbed sleep. According to TCM, itching (in all three patterns of eczema) indicates the presence of wind.
The pattern of Fetal Heat in TCM is caused by the individual's constitution which is acquired from their parents. Fetal Heat is the TCM concept that a form of pathological heat can be passed to the child from the mother in the womb. This pathological heat can manifest as various diseases when the child is born and atopic dermatitis is one of the most common. Fetal heat begins as pathological heat in the mother prior to being passed to the child. This heat may be generated or affected by the intake of certain foods during pregnancy and/or the general constitution of the mother. This stage of this disease has also been linked to the intake of dairy. A study in the journal of Clinical and Experimental Allergy (2002) indicated that diet during pregnancy influences the fetal immune system in such a way as to affect the incidence of childhood atopy. Also, family history of atopic eczema was found to be the strongest risk factor to develop this disease.. The fact mentioned earlier that 49-75% of children who develop eczema do so in the first 6 months. In modern medicine, recent studies have shown that if both parents have eczema or have a history of eczema there is a 80% chance their child will also have the disease.
The Chinese medicinals chosen for this pattern are based on the treatment principles to clear fetal heat, resolve toxins, disinhibit dampness and dispel wind (i.e. alleviate itch).
Scratching is an instinctive reaction to itching, and it is particularly difficult for babies and children to resist the urge to scratch. Unfortunately, scratching does not stop the itch, but in addition it also aggravates the skin and makes the condition worse. The skin becomes sore and inflamed and eventually cracks and bleeds. It may then become infected. The only effective way to stop a baby or child from scratching is to stop the itch. Fortunately, Chinese medicine has many herbs in its pharmacy that are effective for stopping the itch. If you stop the itch-scratch cycle then your chance of curing this disease increases immensely. The herbs to stop itching are chosen based on the patients TCM pattern and their presenting skin disease.
The wet eczema (or damp-heat pattern) presents with a red rash, which will develop blisters that eventually burst and weep. Itching is severe. Erosion of the skin is often apparent and blisters are followed by yellow scabs and crust formations. Secondary infections are more common with this pattern. Accompanying symptoms may include a dry mouth with no great desire for fluids, a hot sensation at night usually with sweating, a red tongue with a thick yellow fur and a fast slippery pulse. In comparison to Dry Eczema this pattern tends be more acute and some times is a progression of the first pattern mentioned (Fetal Heat).
The cause of this pattern of atopic dermatitis is related to digestion (spleen/stomach in TCM) malfunction leading to damp-heat accumulation causing inflammation of the skin. Diet is important in the treatment and prevention of atopic dermatitis. TCM medical theory says that children's spleens (i.e. digestion) are inherently immature until they are at least five or six years of age. The spleen and stomach function as a unit, and this means that infants and young children do not digest foods and liquids as efficiently as adults. This is the primary reason why most children develop eczema before the age of 6 years old and also why some cases resolve by themselves. The younger the child, the more immature their digestion is and this is why the first onset of eczema is in the first 6 months and often coincides with the introduction of food.
This disease mechanism of damp-heat could be caused by improper introduction of solid foods or the child has been allowed to eat the wrong diet. Diet is a huge topic, and readers interested in more information about children's diet and general health should purchase Bob Flaw's guide for parents from Blue Poppy Press titled "Keeping Your Child Healthy with Chinese Medicine" . For a general introduction of Chinese dietary therapy for all ages see his book "The Tao of Healthy Eating".
Improper introduction of food includes introducing a particular food to a child before they are able to digest it, introducing more than one food at a time and/or not recognizing when the child reacts negatively (i.e. skin reaction, digestive upset, etc.) to the introduction of a specific food. If the child is unable to digest the food, the digestion does not work efficiently and a turbid residue (i.e. dampness) accumulates within the body. Certain foods are harder to digest than other foods. For instance, many foods that are considered triggers of eczema in modern medicine are considered difficult to digest in TCM and easily lead to dampness in the body. These foods include cow's milk, wheat and peanuts.
The wrong diet includes a diet high in sugars and sweets which will weaken the spleen and cause an accumulation of dampness within the body. Antibiotics are overused in our society, and are known to easily harm the digestion and may lead to dampness in the body. If this dampness lingers and accumulates it will give rise to damp-heat (in the intestines). Once in the intestines this pathological inflammation or damp-heat may be passed to various parts of the body (including the skin) to cause disease (like eczema).
The Chinese medicinals chosen for this pattern are based on the treatment principles to clear heat, disinhibit dampness and dispel wind (i.e. alleviate itching).
This this pattern presents with dry, ill defined, red flat (macular) and raised (papular) lesions, with pronounced scratch marks and possibly bloody scabs. The amount of redness of the dry type indicates the degree of heat. The characteristicly dry nature of this type may be more prominent than the heat aspect and vice versa depending on how the pattern developed. Compared to the above patterns this disease tends to be more chronic in nature. Lichenification (thickening of the skin with accentuated skin creases) is often present at this stage. There is usually a lot of scaling (especially the scalp) and usually there is a complete absence of exudation (i.e. weeping). Severe itching that often disturbs the child's sleep, pronounced thirst, restlessness, agitation and 'feeling of heat' especially at night (usually with the absence of sweating) are also common with this pattern and the tongue is red with a dry tongue coating.
The cause of this pattern is often a progression of the first two patterns in which the skin has become drier due to prolonged heat. Moreover, secondary skin changes are present due to prolonged scratching. This pattern can also be caused by a lack of nourishment to the skin. The second cause of this pattern in a child is due to a digestive weakness (i.e. spleen vacuity) giving rise to blood vacuity. In Chinese medicine, blood is made out of the essence of food and liquids digested and refined by the spleen. Blood nourishes the skin and if there is a lack of blood, the skin may become dry, itchy, and scaly. Therefore, the 'clear, bland' diet described in this article is also important to treat and prevent this pattern of eczema as well.
The Chinese medicinals chosen for this pattern are based on what disease mechanism caused the eczema. The treatment principles could either be to clear heat, cool the blood and dispel wind (i.e. alleviate itching) or to fortify the spleen and dry dampness, nourish blood and dispel wind.
Regardless of the TCM pattern, the treatment of eczema is only effective when a partnership develops that includes the patient, family members, and the TCM doctor. The TCM doctor will suggest a treatment plan based on a traditional diagnosis using the Four Examinations. The patient or family member providing care plays a large role in the success of the treatment plan by carefully following the doctor's instructions and paying attention to what aspects of the treatment are or are not helpful.
The TCM practitioner has two main goals in treating atopic dermatitis: healing the skin and preventing flare-ups. The healing of the skin aspect is accomplished mainly via an individually prescribed herbal formula administered internally and a healthy diet based on their pattern discrimination. Sometimes the use of an external herbal wash or compress is also used. The internal formula is professionally prescribed and contains multiple ingredients. The dosage and administration method of the formula varies depending on the age of the child.
In addition, the TCM treatment may be assisted by the patient's developing skin care routines and avoiding substances that lead to skin irritation, trigger the immune system and the itch-scratch cycle. Regular check-ups with the TCM provider allows the practitioner to note any changes in the skin's condition in response to treatment and to make appropriate changes in the herbal formula to increase the rate of improvement.
In most cases of eczema, Western medicine can only temporarily soothe the irritation with balms, or cortisone, the powerful but hazardous anti-inflammatory. Possible side effects of repeated or long-term use of topical corticosteroids include thinning of the skin, infections, growth suppression (in children), and stretch marks on the skin. These steroid creams are really only a 'band aid' solution to this chronic problem. Topical steroids sometimes alleviate symptoms, but do not improve the health of the skin.
Any long-term treatment of disease has to have properties that will make you want to continue using it. That means it must be:
- Effective and provide relief of symptoms.
When prescribed appropriately TCM accomplishes the above criteria. From my experience the compliance of taking the Chinese herbal medicine in children depends on the method of administration and the encouragement of the parents for their child to continue taking their medicine.
- Safe, with few unwanted side effects.
TCM is often superior to modern medicine in the treatment of chronic diseases. According to current research 50% of eczema sufferers are dissatisfied with their current treatment (and the other 50% may not realize there may be a more effective treatment for their condition). Skin diseases (including eczema) are a good example of where Chinese medicine can offer substantial clinical benefits to patients who have been unresponsive to other forms of treatment. The TCM treatment of eczema has less side effects and unlike modern medicine, is curative not palliative, as it aims to eliminate the pathology of the skin disease instead of controlling or suppressing the symptoms.
- Perceptions of Physicians and Pediatric Patients About Atopic Dermatitis, Its Impact, and Its Treatment, Clinical Pediatrics, June 2002, p.323-332.
- Sheehan, M.P., Atherton, D.J., One-year follow up of children treated with Chinese medicinal herbs for atopic eczema. British Journal of Dermatology (ENGLAND) Apr 1994, 130 (4) p488-93
About the Author:
Robert Helmer, D.TCM. has extensive experience in the treatment of skin diseases using Chinese herbal medicine and has published numerous journal and patient education articles on the subject. Helmer's clinical experience includes study in China, the United States, and Germany with well-known TCM pediatricians. He is currently serving as pediatric specialist at the The Children's Clinic, located at The Clinical Centre of Chinese Medicine (www.cccm.co.uk). Helmer's first book, Treating Pediatric Bed-wetting with Acupuncture and Chinese Medicine, was published by Blue Poppy in 2006. Visit his website at www.roberthelmer.ca.