Understanding Eczema and Topical Steroid Withdrawal (TSW): Insights and a Case Study using Chinese Herbal Medicine

                      M.J Before Starting Herbal Medicine   

                          8 Weeks After initiating Herbal Medicine

Understanding Eczema and Topical Steroid Withdrawal (TSW): Insights and a Case Study using Chinese Herbal Medicine

By David Heron, DACM, L.Ac

This article was written with both patients and practitioners treating patients suffering from eczema and Topical Steroid Withdrawal in mind. In speaking with patients, the author has come to learn that many of those suffering these conditions do not have a thorough understanding of exactly what it is they are suffering from. The author hopes that the reader is able to gain a deeper and clearer understanding of eczema and in particular Atopic Dermatitis and a general understanding of Topical Steroid Withdrawal.  In additon the reader will be introduced to a case study of M.J and 18 year old male who sought treatment of self-diagnosed “Topical Steroid Withdrawal” with Chinese Herbal medicine.

My heart has a special place for severe eczematous patients and their families. On a fairly regular basis, I meet a new patient at my office looking for treatment for eczema/ Atopic Dermatitis and “Topical Steroid Withdrawal”. On the first visit before any words are spoken I can notice redness on their faces, sometimes with swollen eyes, sometimes with large areas of scaling, even peeling skin. The patients are often in loose clothes due to bodily pain due to inflamed skin. As we make our way into the back room, I already know that through no fault of the patient their scaling and peeling skin will fall all over the chairs, exam table and floor. I’ve already planned out extra time to vacuum and to perform extra disinfection after they leave. These patients have often had long health journeys before they’ve made it to the office. They are very interested to see me with the hopes that I can help them and also often at least slightly desperate and at wits end. Over the course of our interview, they tell me about all the ups and downs and events that had led them to the office and at some point in time they ask, with a unique mix of both hope and lingering doubt from previous experiences, if I can treat them with Chinese Medicine and significantly improve their condition? Fortunately, the answer is yes. Seeing dispels doubts and the author has had the benefit of not only seeing but directing and participating in enough positive transformations to confidently say that both Atopic Dermatitis and/or Topical Steroid Withdrawal respond well to Chinese Medicine.

Of the many times this scenario has played out in the author’s office, the author will describe the treatment of one such patient: an 18 year old male named M.J who sought treatment in October 2021 for “Topical Steroid Withdrawal” that developed secondary to the treatment of Atopic Dermatitis.

Before we discuss Topical Steroid Withdrawal, first we must answer what is eczema? Let’s examine all the terms involved to have a clear idea of what exactly we are dealing with when we say Eczema or Atopic Dermatitis, are they the same, and what place does eczema have in a connected landscape of various skin and allergic conditions.

Eczema is a broad term used to describe numerous related but different conditions involving redness, inflammation, itching of the skin, possibly scaling and occasionally the presence of vesicles. Each different type of eczema has different causes, symptoms, or treatments. In common parlance, when people speak of Eczema they are referring to Atopic Eczema also known as Atopic Dermatitis. Dermatitis is another term that is used interchangeably with Eczema for conditions involving skin inflammation and redness. Despite similarities in meaning, certain diseases only tend to be used with either Eczema or Dermatitis in their title. As an umbrella term, aside from Atopic Eczema/Atopic Dermatitis, both eczema and/or dermatitis can refer to the following loosely related but different skin conditions: Seborrheic Dermatitis; Perioral Dermatitis; Nummular Eczema; Pompholyx Eczema / Dyshidrotic Eczema; Stasis Eczema; and Contact Dermatitis. Chinese Medicine can be utilized to treat all of these conditions. However, the rest of this article will only focus on Atopic Dermatitis and it’s complication with Topical Steroid Withdrawal as this is the most prevalent form of eczema.

Atopic Dermatitis as a disease itself has long been present in humans, although it seems it was significantly less prevalent. Chinese Medicine has recognized the disease for about a millenia, naming it Si WanFeng – Wind Of The Four Crooks. The Four Crooks refers to the elbow and knee flexures where itchy inflamed skin (Wind) most typically appears in patients with Atopic Dermatitis. Likewise in the West, as documented by Lio(2014), Atopic Dermatitis lesions have been documented for some time even though a more finalized disease definition has only occurred more recently. 

Atopic Dermatitis presents as generalized dry skin, itch, and rash that often affects the knee and elbow flexures (in children and adults) but is in no way limited to those areas. Atopic Dermatitis is also marked by a tendency to flare up, go into remission, and relapse into a flare up again (Stanway et al, 2023). The acute flare ups present with erythematous (red) and inflamed skin that is itchy. There may be some weeping and exudation of fluid from the inflamed skin. Occasionally there can be vesicles as well. After the active cycle heals there may be some hyperpigmentation (darkening) or hypopigmentation (loss of pigment) along with lichenified skin present, this is especially true after many cycles of flare up. Lichenification is the skin’s response to frequent scratching and rubbing, where the skin becomes rough and hard often leading to the presence of exaggerated skin lines.

Atopic Dermatitis refers to eczema that is secondary to “atopy” or allergy. Johansson et al. (2003) defined atopy as “a personal and/or familial tendency, usually in childhood or adolescence, to become sensitized and produce IgE antibodies in response to ordinary exposures to allergens, usually proteins. As a consequence, these persons can develop typical symptoms of asthma, rhinoconjunctivitis, or eczema.” In simpler terms, atopy refers to people who hyper respond to common allergens that most people do not respond to and are therefore more prone to develop eczema, allergic asthma, and allergic rhinitis/hay fever among other diseases due to these hyper immune responses. The tendency for some individuals to develop all three of these conditions is referred to as the Atopic March.

The Atopic March describes a tendency of some individuals to develop Atopic Dermatitis as an infant and then later in childhood to develop Allergic Rhinitis and Asthma (Bantz et al, 2014). This concept is based on observations that children who often suffer Asthma and/or Allergic Rhinitis often have or had Atopic Dermatitis as a child. Children with eczema were found to have a three times greater chance of developing asthma or allergic rhinitis compared to those without eczema, according to a study by von Klobetzky et al. (2012). Their findings also showed that the likelihood of the other two atopic diseases increased with more severe, persistent, or very early onset eczema. In an earlier study performed by Gustafsson et al (2000), 94 children aged 4 to 35 months old and diagnosed with Atopic Dermatitis lasting at least 3 months were followed up with regularly until they reached age 7. Of these 94 children, at the conclusion of the study 45% were found to have developed Allergic Rhinitis and 43% were found to have developed Asthma. While it is not clear whether Atopic Dermatitis is a necessary step in the development of the other atopic conditions, there is evidence that this occurs in some and that those that suffer one atopic disease are more likely to develop another. A recent study by Gabryszewski et al (2023) produced further evidence supporting the presence of the Atopic March by analyzing the electronic health records of roughly 219,000 children noting a tendency toward co-morbidity amongst children with Atopic Dermatitis, Asthma, Allergic Rhinitis, IgE mediated Food Allergies, Eosinophilic Esophagitis.

Impaired Skin Barrier In Atopic Dermatitis

Why might Atopic Dermatitis as an infant or child, lead to other allergic diseases? One common theory is due to the observed impairment of the skin barrier in patients with Atopic Dermatitis. Patients with Atopic Dermatitis are found to have different lipid compositions and organization in the top layer of the epidermis, called the stratum corneum,  which does not allow the skin to retain moisture properly or for a proper barrier to develop (Hadi et al, 2021). In addition it has been found that approx 50% of Atopic Dermatitis patients suffer a genetic variant that leads to filaggrin deficiency (Bantz et al, 2014). This is relevant as filaggrin is a protein in the stratum corneum which helps create a barrier and promotes proper hydration in the skin. Therefore, it is believed that due to this impaired skin barrier, microscopic antigens or allergens floating in the air, including dust from food, that typically would not penetrate the skin are able to enter the body leading to immune sensitization of that allergen. This will later lead to an allergic response in future exposures to those allergens.

Who Develops Atopic Dermatitis?

Atopic Dermatitis is the most common inflammatory skin condition in the world. It is prevalent in greater than 15% of the world’s population and has been steadily growing as countries undergo greater industrial development and prosperity. According to data from the National Eczema Association (n.d.), Atopic Dermatitis is a significant concern among the pediatric population, with approximately 9.6 million children in the U.S. suffering from it. Alarmingly, a third of these cases present as moderate to severe cases. Since 1997, the prevalence of Atopic Dermatitis in children has seen an upsurge, increasing from 8% to 15% in the U.S. However, Atopic Dermatitis is not confined to the realm of pediatric health issues, as 16.5 million U.S. adults, which equates to 7.3% of the adult population, are living with this condition, with almost 40% of these cases being moderate to severe. AD generally makes its first appearance early in life, with 80% of those affected experiencing symptoms before they reach six years old. Yet, the condition isn’t exclusive to early onset, with one in four adults reporting the onset of symptoms in adulthood. Intriguingly, some individuals even report a late onset, after 60 years of age (6%).

Atopic Dermatitis affects those of every race. Studies on the U.S population seem to vary slightly as to which group Atopic Dermatitis is most prevalent in. However, interestingly Silverberg et al (2013) examined allergy rates in foreign born Americans and found that those born outside the U.S have approximately a 50% reduced chance of developing Atopic Dermatitis. However, after being in the U.S for 10 years the study found that the rates of allergies including Atopic Dermatitis was significantly greater than those that lived in the U.S for 2 years or less.

How does Atopic Dermatitis/ Eczema Present?

While Atopic Dermatitis can present at any age, we typically see it present initially in infancy. In infants Atopic Dermatitis can first present as Seborrheic Dermatitis of the scalp, axilla, and groin area (Stanway et al, 2023). Unlike Cradle Cap, which involves a non-inflammatory, non-itchy yellow scaling of the scalp in babies, Atopic Dermatitis will involve an inflammatory rash in those areas that often spreads to the face, especially the cheeks and often the dorsum or backs of the hands. Fortunately, Chinese Medicine offers some relatively easy topical treatments for infants that will be discussed further below.

As children progress in age, the location of the eczema lesions starts to move toward the more typical location of the elbow and knee flexures but is in no way limited to these areas. The neck is another area often affected by eczema, with chronic inflammation leading to slight hyperpigmentation and lichenification of the neck that is often referred to as dirty neck syndrome due to the appearance. The lower eyelids are another area often affected and complicated by rubbing. As children age and have a greater ability to scratch, lichenification often usually develops in highly pruritic areas. If Atopic Dermatitis, continues into adulthood it can continue to present as previously but also present in varying forms with papular and discoid eruptions, significant lichenification, and loss of or thinning of the eyebrows due to both inflammation and/or rubbing and scratching of the eyebrows (Stanway et al, 2023).

There are numerous complications that can occur with Atopic Dermatitis. Infections are common complications of Atopic Dermatitis that seem to occur due to both the impaired skin barrier function and the abnormal immune response inherent to eczema (Stanway et al., 2021). Common infections include infection with Staphylococcus Aureus typically seen as Impetigo, Molluscum contagiosum which is common in children, and Eczema Herpaticum. Fungal co-infections are also common, typically by the yeast Malassezia. However, the author has also seen numerous co-infections with dermatophytosis (Ring Worm or Tinea) in severe Atopic Dermatitis and Topical Steroid Withdrawal patients. 

You can consider hyper and hypopigmentation as complications as well. While these are harmless to the patient’s physical health, lingering discoloration of the skin can add a further burden to some patient’s mental health. Both hypopigmentation and hyperpigmentation can come as a result of the dermatitis itself, however improper use of steroids can also lead to more enduring even permanent hypopigmentation.

Erythroderma is an important complication to discuss. Erythroderma refers to a widespread and intense reddening of the skin (erythema) due to inflammation. Erythroderma often precedes exfoliation or peeling of the skin (Ngan et al., 2016). Erythroderma can occur in various skin diseases, including Atopic Dermatitis. Erythroderma is a common and core aspect of Topical Steroid Withdrawal which we will discuss more below.

Topical Steroid Withdrawal

Topical Steroid Withdrawal (TSW) refers to a serious potential side effect that can occur from the misuse or overuse of topical corticosteroids. TSW, its symptoms, and how frequent it occurs are not known and are the subject of debate. However, over the years there has been a growing number of studies and publications investigating the subject and acknowledging its existence.

TSW is just one name, and currently the most common, that has been to name the phenomena of lingering rebound symptoms that some experience following their cessation of topical corticosteroids is Topical Steroid Withdrawal. However, this phenomena has been called many names including Topical Corticosteroid Withdrawal, Topical Steroid Withdrawal Syndrome, Red Skin Syndrome, and Red Sleeve Syndrome.

What is a Topical Steroid or a Topical Corticosteroid?

Corticosteroids are a class of steroid hormones that are produced in our adrenal cortex. Endogenous corticosteroids, which are naturally produced by the body, play critical roles in a variety of physiological processes, including the regulation of inflammation, the regulation of the immune system,  maintaining proper metabolism, and in maintaining homeostasis under stress conditions. Due to their ability to reduce inflammation and reduce over activity of the immune system, they have been useful as medications. Topical corticosteroids are a type of medication that is applied to the skin to help reduce inflammation and immune response. Topical corticosteroids also cause vasoconstriction of blood vessels which can help reduce erythema, which is partly due to  vasodilation of capillaries in the skin.  Topical corticosteroids have been commonly used to treat conditions like atopic dermatitis, psoriasis, and various other types of dermatitis amongst others. These medications come in various strengths, from mild to very potent, and should be used under the guidance of a healthcare provider to minimize potential side effects.

In the United States, the strength of topical corticosteroids are often grouped into 7 categories. These are the seven categories with an example of each category drawn from Gabros et al (2023) and Ference et al (2009). Please note each category has several more medications than are listed here.

Topical Corticosteroids From The Strongest (Class I) To The Weakest (Class

VII) With Examples:

Class I (Super-High Potency): Examples include Clobetasol propionate 0.05% (Temovate), Betamethasone dipropionate 0.25% (Diprolene).

Class II (High Potency): Examples include Fluocinonide 0.05% (Lidex), Mometasone furoate 0.1% (Elocon).

Class III (Upper Mid-Strength Potency): Examples include Triamcinolone acetonide 0.1% (Kenalog),

Fluocinolone acetonide 0.025% (Synalar).

Class IV (Mid-Strength Potency): Examples include Hydrocortisone valerate 0.2% (Westcort), Triamcinolone acetonide 0.025% (Kenalog).

Class V (Lower Mid-Strength Potency): Examples include Fluticasone propionate 0.05% (Cutivate), Clocortolone pivalate 0.1% (Cloderm).

Class VI (Low Potency): Examples include Desonide 0.05% (DesOwen), Hydrocortisone butyrate 0.1% (Locoid Lipocream and Locoid Lotion).

Class VII (Lowest Potency): Examples include Hydrocortisone 1% (Cortizone 10) and Hydrocortisone 2.5% (Hytone cream, lotion, ointment).

Recommended Guidelines And Possible Side Effects Of Topical Steroid Use

It should be noted that steroid medications have been a major medical breakthrough and one that regularly saves lives. However, due to their potent nature they must be used appropriately and thoughtfully. What does that mean for Topical Corticosteroids?

Much of the literature states that topical corticosteroids (TCS) are generally safe when used short term and certain guidelines are followed and that side-effects are rare. Ference et al (2009) state “ultra-high-potency steroids should not be used for more than three weeks continuously. If a longer duration is needed, the steroid should be gradually tapered to avoid rebound symptoms, and treatment should be resumed after a steroid-free period of at least one week.” Ference et al (2009) go on to state that the two lowest classes of topical steroids are safe for up to three months except in the body folds (groin, axilla, etc) and the face and neck. This is because these areas have thinner skin and therefore have significantly higher absorption along with less resistance to thinning of the skin. For instance, Gabros et al (2023) state that the skin around the eyelids is 300 times more absorbent than on the soles of the feet. Further aggravating this in terms of inflamed eczematous skin, Gabros et al(2023) report that inflamed or peeling skin becomes 2 to 10 times as absorbent than usual. Absorption of topical corticosteroids is not desired as they can throw off the body’s own regulation and production of corticosteroids. Regarding thinness of skin, Ference et al(2009) list skin atrophy as the most common side effect of topical corticosteroids which as mentioned above will be more common in thinner skin areas.

What Is Topical Steroid Withdrawal?

M.J After Stopping Topical Steroids

The TSW symptoms listed most often include burning, itching, redness, scaling, swelling, papules, or pustules (Lee, et al2023). Other symptoms commonly also discussed are erythroderma, skin peeling, difficulties with thermal regulation presenting as feeling too hot or too cold, insomnia, pain, and depression amongst others (Ballard, 2022). TSW symptoms often present one to two weeks after the discontinuation of topical steroids, even when the skin appears clear and smooth at the time of discontinuation of the Topical Steroids.

TSW is not limited to patients with Atopic Dermatitis however it does appear to be more common, more severe, and more enduring in these patients. Rapaport (2015) in his Topical Steroid Withdrawal Whitepaper discusses the incidence of TSW in both psoriasis and seborrheic dermatitis cases treated with very prolonged corticosteroid usage. However, one will quickly notice when lookinginto TSW that Atopic Dermatitis patient’s report suffering from TSW at much greater rates than those using topical corticosteroids for other diseases. In the author’s clinical experience, almost all of the patients seeking treatment for TSW initially used topical corticosteroids to treat Atopic Dermatitis. Rapaport et al (1999) note their clinical findings that their atopic patients with TSW “suffer a more stormy course” than their TSW patients with Seborrheic Dermatitis. This article will refer mostly to TSW complicating Atopic Dermatitis however the treatment for TSW complicating other skin diseases would have many similarities.

What Causes Topical Steroid Withdrawal?

Large Patch Of Peeled Skin Within An Even Larger Area Of                              Erythematous Maculopapular Rash Prior To TCM Treatment

The exact pathomechanisms behind TSW and it’s symptoms are not yet known. There are however a few hypothesis. Rapaport et al (1999) hypothesized that the noted severity of TSW in Atopic Dermatitis could partly be due to a build up of various metabolites including Nitric Oxide which build up to counteract the vasoconstricting effect of the Topical Corticosteroids. Other hypothesis include tachyphylaxis (the reduced effect of topical steroids with continued use), upregulation of glucocorticoid receptor b, continued repression of endogenous cortisol production by keratinocytes in the skin even after stopping topical corticosteroids, and a cytokine cascade following discontinuation of topical steroids (Lee et al, 2023). These are some of the most prevalent hypotheses currently. 

The Debate: Where Does Eczema end and Topical Steroid Withdrawal Begin

For years, it seems the accepted thought on progressively worsening Atopic Dermatitis that was either becoming less responsive to topical steroids and/or significantly flaring following discontinuation of topical steroids was that the eczema was just severe and possibly even stronger steroids were needed or even a course of oral corticosteroids to bring down the flare up. To be clear, previously the flare ups were contributed to an underlying progressively worse Atopic Dermatitis and not due to a complication of the topical steroids.However, for years patient’s and some practitioners have felt that the worsening skin symptoms they were seeing were actually due to the topical steroids and not the underlying Atopic Dermatitis. Over the years there seemed to be two converging factors leading to greater recognition of the occurrence of TSW. One has been continued publication of scholarly articles documenting its existence, such as the numerous articles published by father and daughter Marvin and Vicki Rapaport, MD amongst other authors. The other has been the development of social media and online forums allowing for those suffering from Atopic Dermatitis to discuss what has been going on with them. Bowe et al (2022) note that across all social media platforms they saw a 274% increase in the hashtag #topicalsteroidwithdrawal when comparing the year 2016 with 2020.

The Author’s Experience And Observations

Statistically the author does understand that as stated above Topical CorticoSteroids (TCS) are generally safe when precautions are taken. However, the author has seen numerous cases which lead him to think that the guidelines should be more stringent. Of course, not practicing as a conventional dermatologist skews the population that seeks the author’s assistance to those who were not helped by conventional medicine.

Of the many TSW patients the author has seen there seem to be two camps: those whose use of topical steroids was prolonged and probably excessive and those whose use of topical steroids were well within the guidelines yet both led to similar results. For instance, the author has patients who clearly state that they felt they had to ignore the guidelines given with their prescription TCS and applied them too often, for too long, and on too many places because they had to try and stop the itch. Unfortunately, some patients report being instructed by their doctors to use the TCS in ways and locations far outside what guidelines recommend. For instance, one patient the author treated was provided compounded TCS and told it was safe for regular use on her face for over a decade. On the other side of the spectrum, the author is currently treating a young male patient who used OTC TCS for dermatitis lesions on the dorsums of his hands and his groin. After this the physician provided prescription Betamethasone for better results however within 1 week the patient reported burning with showering that led him to discontinue all TCS. Then 1 week after stopping the prescription TCS the patient reports developing an exudative (“oozing”) rash on his chest and redness, inflammation, and peeling with erosion throughout his genitoanal region. In other patients, even limited use of prescription TCS on their hands led to inflammation of the face and neck upon discontinuation. While it’s unclear what percentage of TCS users these patients represent, the severity of their suffering and the reactions to TCS are worth examining so that we can prevent this occurrence in other patients. 

What Do Atopic Dermatitis Patients Say About TSW

Survey studies designed by researchers and answered by patient’s provide unique insights into the phenomena and prevalence of the symptoms associated with TSW. A recently published survey by Barta et al (2022) aimed to examine what eczema patients reported were the cumulative effects of topical steroid use, both positive and negative. The survey took place from November 2020 until January 2021. It was multinational, answered by 2160 patient’s or caregivers, and included questions regarding Topical Steroid Withdrawal (TSW).

The study used the term Topical Steroid Withdrawal Syndrome (TSWS). TSWS was defined as such to survey participants: ““a prolonged and severe rebound characterized by flushed burning skin, severe itch, edema (swelling), and profuse shedding of skin. Leading up to TSWS, one needs to use more steroids in higher potencies to manage flares. Upon discontinuation of steroids, one develops new, more severe symptoms. Symptoms typically dissipate and skin improves over an extended period of time after abstaining from steroids.”

Notable results of the Barta et al (2022) study regarding the use of Topical Corticosteroids (TCS) are as follows: half of all participants reported stopping TCS because they were not effective; only 14% of adults and 25% of children reported stopping TCS due their eczema resolving; 50% of adults and 40% of children reported worsening or new symptoms of the condition while taking over-the-counter (OTC) TCS while 67% of adults and 57% of children reported worsening or new symptoms while using prescription TCS; 27% of adults and 19% of children reported side effects while using OTC TCS but 49% of adults and 42% of children reported side effects using prescription TCS.

The survey responses regarding Topical Steroid Withdrawal Syndrome were just as eye-catching. 79% of adults and 43% of child caregivers reported symptoms consistent with TSWS. The percentages are higher, 90% and 54%, in patients who applied prescription TCS to their face or genitals. Of those reporting TSW symptoms, 44% of children and 28% of adults reported recovering.

It’s worthwhile to detail the exact symptoms that the patients who reported suffering from TSWS reported suffering. The following symptoms and % (adult %; children %) of TSWS patients reporting them were printed in the Barta et al (2022) survey study:

Burning skin                                                                                                                              91% of adults; 77% of children

Skin flushing bright red or darkening depending on skin tone                       90% of adults; 86% of children

Profuse skin peeling and flaking                                                                                     90% of adults; 78% of children

Bone deep itch with periodic episodes of intense, severe itching                   87% of adults 76% of children

Oozing and weeping skin                                                                                                    84% of adults 70% of children

New hypersensitivity of the skin to water, movement, moisturizer, fabrics, temperature, sunlight, etc                                                                                                                                                                   84% of adults; 69% of children

Intense emotional fluctuations, depression, anxiety                                           81% of adults; 56% of children

Loose skin or skin folds (“elephant wrinkles”)                                                       80% of adults; 67% of children

Insomnia and altered body clock                                                                                    80% of adults; 62% of children

Fatigue                                                                                                                                          79% of adults; 53% of children

Thermoregulation altered (feeling too cold or too hot)                                      77% of adults; 60% of children

Red or darkened “sleeves” depending on skin tone (arms/legs becoming darkened and

inflamed, usually sparing palms/soles)                                                                       75% of adults;  70% of children

Eye dryness and irritation                                                                                                   69% of adults; 43% of  children

Swelling of limbs and face                                                                                                   65% of adults; 49% of children

Nerve pain, sometimes described as “sparklers” or “zingers”                          64% of adults; 43% of children

Hair loss (head or body)                                                                                                       60% of adults; 47% of children

Enlarged lymph nodes throughout the body                                                               57% of adults; 54% of children

Appetite changes                                                                                                                        56% of adults; 55% of children

Thoughts of suicide                                                                                                                   47% of adults; 11% of children

 

What About Flare Ups?

In the author’s experience, frequent flare ups is a symptom that is often reported by patient’s reporting Topical Steroid Withdrawal. In fact, the author has witnessed without a doubt that many of these patient’s do flare up more often than let’s say your average eczema patient. By “flare up” what is meant is a period of intense often spreading erythema, heat sensations, burning skin, intense itch, often insomnia, etc. However, what is not clear or agreed upon is how long these flare ups will last. The patient has had more than one patient arrive at his stating something along the lines of “I know that this will last like 5 to 8 years, I just want to to be more liveable”. While the author in no way doubts that there may be patient’s who have suffered that long, it is important to not define the typical course of this disease by it’s most extreme outliers. This type of thinking and talking only adds to the documented depression and suicidal ideation that can accompany this disease. In terms of outliers, one should also be aware of those who recover with treatment in a few weeks, such as M.J who will be discussed further below.

From the author’s experience which should be taken for what it is -one individual clinician’s experience – “TSW”, it’s symptoms and “flare ups” can be completely treated or significantly reduced in six months with Chinese Medicine. At 6 months the author has observed some patient’s have improved significantly however due to the severity of where they started, still have symptoms that interfere with normal daily life or may be prone to occassional less severe flare ups without full on erythroderma of large areas. In these cases further treatment is given. In the author’s experience, at the 1 year mark the author has seen some occasional patients with lingering but less severe symptoms typically affecting limited areas such as the hands, or lips, or neck, or eyes, etc that fluctuate in intensity of inflammation versus 40 t0 75% of their body inflamed and peeling for which they originally sought contact. While the author believes most patient’s can see improvement in a few months time with Chinese Medicine, more discussion within the TCM community and more research needs to be done to confirm this opinion.

Please allow the author one more opinion or observation which he feels is a clinical pearl. Do not always assume that the flare up is a regular “TSW Flare”. Be sure to rule out a co-infection of bacteria or fungus. Patients suffering these co-infections will experience spreading erythema and papules, feverish heat sensations, increased itch or in other words symptoms similar to TSW that the untrained eye might not be able distinguish. Due to the extensive damage to the skin barrier these patient’s suffer through inflammation and scratching paired with fluid discharge and often reduced bathing habits, the conditions seem ripe for co-infection.

As noted above, steroids as a class of medications have overall made a net positive contribution to our collective well being, still it seems that there is enough evidence to warrant at least a re-evaluation of the guidelines of their usage in the treatment of Atopic Dermatitis. In addition, non TCS treatments should be considered. Atopic Dermatitis has been treated by Chinese Medicine for about a millennium and TSW has been treated by Chinese Medicine practitioners for at least 40 years in clinical practice. The author will detail these treatments below.

Atopic Dermatitis and Topical Steroid Withdrawal In TCM

As stated earlier, one Chinese Medicine Disease name for Atopic Dermatitis is Si Wan Feng. Si Wan Feng (Atopic Dermatitis) is differentiated in Chinese Medicine from the other forms of eczema with each eczema type having their own disease name. Similar to Western Medicine TCM recognizes the three distinct phases of Atopic Dermatitis: infant, childhood into adolescence, and adult.

Chinese Medicine sees the etiology of Atopic Dermatitis as a combination of varying factors: constitutional weaknesses, possible pathogens absorbed in the womb, and pathogenic factors from the environment. Broadly speaking, constitutional insufficiency and deficiency of the Spleen and Lungs play a role (Xu, 2004). This allows for pathogenic factors of Wind, Dampness, and Heat to outwardly and inwardly affect the patient. Other factors also include Toxin. The chronic presence of damp-heat always in eczematous patient leads to dryness, further blood and yin deficiency, and even blood stasis (Al-Khafaji, 2016). These factors lead to disease and all play out in varying patterns depending on a combination of the individuals other constitutional tendencies, their lifestyle, their environment, and even their attempted treatments.

Disease names like Wind Of The Four Crooks consist of more than just putting a name to a certain presentation of skin lesions. Proper identification of skin disease allows the practitioner to match the pathology that the patient is suffering to a large body of knowledge that has been collected and synthesized by practitioners over a millenia about countless patients who suffered similar pathologies.  In a sense, proper disease diagnosis gives the practitioner access to a “dossier” of the known characteristics and tendencies of that disease and the various ways it tends to play out and present itself in a variety of individuals.  In the case of Wind Of The Four Crooks (Atopic Dermatitis) and it’s complications this knowledge has been distilled over a few hundred years constantly being fine tuned during the process providing practitioners with not only information about the disease but also what treatment principles have worked to bring patients suffering Wind Of The Four Crooks into harmony and what herbs have worked to execute those treatment principles. 

Aside from knowledge of the disease, a unique feature of Chinese Medicine is the ability to fine tune both diagnosis and the treatment according to presenting patterns and stages. Pattern diagnosis allows the practitioner to further fine tune their diagnosis and treatment to match the presenting constellation of symptoms at that particular patient. For instance, an Atopic Eczema patient with fluid discharge (“oozing”) from around the ears, inflamed skin in the axilla (under the arms) and groin is recognized to be different than a patient suffering dry, inflamed lesions in the four crooks and chest lets say. The treatment principles and herbs used to help the “oozing” patient might aggravate the dry patient. Those are just two such examples of numerous possible presentations of Atopic Dermatitis. Much like peeling an onion, the pattern diagnosis can be adjusted as symptoms change and improve. The change in diagnosis, leads to a change in the treatment principles and therefore a change in the prescribed herbs. 

The following are some typical patterns seen in Atopic Dermatitis. Infant Atopic Dermatitis is often seen to be due to the patterns of either Damp Heat or Fetal Heat. Fetal heat refers to a heat acquired from the mother during pregnancy. In the childhood and adult phases of Atopic Dermatitis, common patterns include Blood Heat with Wind, Damp Heat, and Blood and Yin Deficiency with Dry Wind (Al-Khafaji, 2021). Another important pattern seen very often in severe eczema and Topical Steroid Withdrawal is Toxic Heat In The Qi, Ying and Blood Level.

Treatment of Atopic Dermatitis with Traditional Chinese Medicine centers around oral administration of daily herbal medicine. Topical herbal ointments also play an ancillary role. Herbal formulas are constructed based on the disease, the pattern, timing and phase of the disease, and the specifics of the individual presentation including any of the complicating factors listed above. This will be illustrated in the case study below.

Herb Baths For Infants With Atopic Dermatitis: While oral administration of herbs can be used in infants and is necessary in severe cases, herbal baths and creams can often suffice to treat infants in the first few months of their lives. The author treated his daughter when only a few weeks old with an herbal bath of Da Huang, Huang Bai, Huang Qin, and Ku Shen to treat a mild presentation of papules and erythema on the cheeks and mild cradle cap where the scalp became red around the scales. The author washed his daughter in the bath initially every day and then every other day for approx 7 days. A western herbal ointment with Mallow root was also used. The rash cleared quickly. The author however does not recommend that formula for everyone, different presentations could warrant different herbs. 

Case Study Intro : M.J , 18, Male

The rest of this article reviews the case of M.J an 18 year old Male who sought treatment for “Eczema” and “Topical Steroid Withdrawal (TSW)” in October 2021.

Case History

M.J was seen initially on October 15, 2021 and was accompanied by his father. M.J was seen twice per month until the first week of January 2022. Following that, M.J was then seen every 4 to 6 weeks until the first week of May 2022 after which treatment ended. The patient was followed up with via e-mail in July 2023 before the author wrote this article to be certain there were no unreported flare ups.

M.J was treated with Chinese Herbal Medicine in granular extract form. At the time of treatment with Chinese Medicine M.J was not using any other form of treatments. After the patient’s skin had improved significantly with herbal medicine a moisturizing but anti-inflammatory Chinese Herbal lotion was introduced for use mainly on the patient’s body. The patient alo received Red Light Therapy at some visits.

M.J: History Of The Disease and Treatments Prior To TCM

M.J reports suffering from atopic dermatitis since he was 3 or 4 years old. The patient reports the lesions were often in the knee flexures (behind the knee), on his calves, on his forearms and elbow flexures, and under his arms in the axilla. M.J reports that his skin was “rough and dry, kind of like sandpaper”. The patient reports that as a child he hardly ever experienced fluid discharge. However, M.J reports as he got older he could more easily scratch until fluid was produced. As per M.J topical steroids were his main treatment up until he was about 16, both over the counter or prescription strength depending on the period of time. The patient reports that the eczema progressively worsened as he got older. Suspicious that topical steroids were actually leading to a decline in his skin or at least were not helping, M.J reports first stopping topical steroids approx 2 years prior to seeing the author. M.J reports that stopping the steroid led to a significant flare up of his skin.

M.J’s first major skin flare occurred after stopping Topical Steroids. M.J reports developing dark burning weepy lesions all over his chest and back. Suffering significantly, M.J was treated with oral prednisone and was put on topical steroids once again.

Attempted Treatment Through Diet

Following that flare up, M.J states that he made significant efforts to live a healthier life. The patient is approx 6′ 1″ and reports that he previously weighed “280 lbs”, “ate a lot of hot wings” , and was chronically “constipated”. At the first visit, the patient weighed only 189 lbs. The patient reports that he stopped eating fast food, started eating a lot of vegetables, ate a lot of wild salmon, and started exercising regularly as long as his skin did not prevent him from doing so.

The efforts that M.J made to improve his lifestyle should be applauded. While they were not on their own enough to heal his skin, I do believe these were necessary changes that allowed for fast improvements once he started taking Chinese Herbs. 

After a period of many months having made these dietary changes, M.J states that he stopped using Topical Steroids again.

The Beginnings Of The Current Flare Up

Dermatitis With Secondary Exudate and                                              Crusting

As per M.J, he tried to reduce topical steroid use again during Spring 2021 resulting in a significant outbreak by the Summer 2021. The patient reports he again developed a deep red burning rash on his chest and back and progressively worse lesions on his neck and face. M.J initially began to suffer a deeply erythematous maculopapular rash (one large dark red elevated lesion) that covered the anterior neck. With time, the skin on the front of M.J’s neck eventually eroded and became a large open wound with significant fluid discharge emitting from it.

At the start of this outbreak the patient started to develop red papules on his cheeks, almost acne like. However, these lesions continued to progress until they covered his whole face. Eventually, M.J’s face was covered in white and slightly yellowish scales with crusting from mild fluid discharge.

Attempted Treatment With No Moisture Therapy

No Moisture Therapy is a popular method of treatment for severe eczema and TSW which involves limiting moisture on the skin and even the intake of fluids. (The author does not advocate limiting the intake of fluids if not under direct supervision.) M.J stated that he stopped applying topical moisturizers since the beginning of this flare up and also limited the number of showers he took. The patient was drinking liquids and not completely limiting oral intake of liquids. The patient expressed the feeling that not moisturizing did help his skin however the progress was nowhere close to being enough for him to solely rely on that method of treatment.

As M.J was progressively getting worse he saw his medical team and ended up taking oral Prednisone again in August 2021. However, M.J reports that the second round of prednisone did not bring a full recovery like the first round did. M.J also reports that soon after he noticed that his skin was starting to decline again with his face becoming red, scaling, and peeling. M.J stated that he did not want to do yet another round of oral steroids or to restart topical steroids. The patient continued with the No Moisture Therapy and pursued new treatments. This led to the patient to pursue treatment with Chinese Medicine and brought him to the author’s office on October 15, 2021.

Further Information Found On Inquiry

Heat and Sleep: At the initial visit the patient stated that he ran warm at all times and would sweat very easily. M.J reported feeling uncomfortable in strong sunlight or any type of heat and that his skin declined further after exposure to sun or heat.

M.J stated that he felt even warmer at night than during the day and that he had not been able to sleep. The patient reported near total insomnia during the night since the flare up started. M.J stated that he was unable to sleep until about 5 A.M or 6 A.M every day, after being completely sleepless during the night. The patient also reported that itching intensified at night which also added to his insomnia.

Thirst: Despite significant heat signs, M.J reported no significant thirst.

Bowels: The patient reported regular bowel movements having solved his constipation issues by changing his diet over the previous two years.

Pulse: notably weak for an 18 year old male. The pulse was also somewhat thin. HR: 68 BPM

Tongue: Thin white coat, pinkish red body

Medications: None

Description Of Presenting Lesions:

 

“A picture says a thousand words” while seemingly cliche, is most certainly true, and the author finds this to be especially true in the practice of TCM Dermatology. While the interview was extremely important, just by looking at the patient and the nature of the lesions it was clear that he was most likely suffering severe temperature dysregulation, likely having insomnia, and definitely itching amongst other things. The author will detail here what he saw in detail and then later describe what he took those to indicate about the patient’s health and what treatment principles needed to be employed with what herbs. 

On the face, the patient presented with a mask-like appearance consisting mostly of semi-adherent white exfoliative scales. The scaling was mixed with some crusting that had a mild off-white coloring. No significant yellow crusting was present. There were bloody excoriation marks in some areas of the face as well. The nose was covered in scaling. The lips were peeling. The skin on the face was generally dry.

There was a mild erythema(redness) on the cheeks and around the eyes however it was not immediately evident as the crusts and scaling made it difficult to see. The crusts and scaling stopped at the beard area.

The neck presented with macular erythema that was much easier to see than on the face. The patient reported that the eroded skin on his neck had healed with the oral prednisone two months prior however at the moment the anterior neck presented with a large brightly erythematous macule with slightly laminate (glassy) skin indicating increasing erythema and activity. The photo above might not do this justice. 

The patient’s chest and back appeared checkered as there were active but slightly hyperpigmented plaques (elevated skin) mixed with inactive post inflammatory pigmented macules (flat skin). There were also many excoriated papules (elevated lesions with scratch marks) on the chest and back. The skin on the upper chest and back that was unaffected by papules presented with a mild erythema. The skin unaffected by papules or pigmentation on the lower abdomen and lower back did not present with erythema. Some maculopapular lesions on the chest and back blanched upon pressing them, others did not blanche.

The legs presented with dry skin, scattered excoriated papules, heavily hyperpigmented active papules and hyperpigmented but fading post inflammatory macules. Behind the knees there were healing but still active small plaques that were hyperpigmented, fairly thin but still not flat. There were some excoriation marks behind the knees but not many.

The upper arms and shoulders presented similarly to the chest and back with a mixture of active erythematous papules, plaques, and hyperpigmented macules. The elbow flexures and lower arms presented without many papules, macules or post inflammatory hyperpigmentation. However, the elbow flexures had a very mild and subtle erythema not untypical of eczema.

Differential Diagnosis

TCM Disease Dx: Wind Of The Four Crooks complicated by Topical Steroid Withdrawal Syndrome.

The patient’s history clearly indicates that the patient suffered from Atopic Dermatitis throughout his life: a long history of lesions behind his knees and elbow creases that increased intensity and spread to more regions as he got older. As far as considering the progression and flare ups due to Topical Steroid Withdrawal, of course the history of topical corticosteroid use is one factor, while burning lesions is another. In addition, while eczema can and will present on the face, TSW has almost become synonymous with the presentation of either extreme erythema of the face, neck, and/or arms and/or large areas of red peeling skin including on the entire face.

However, it is always a worthwhile exercise to go through a Differential Diagnosis so that we become sharper in distinguishing the different lesions and sometimes minute differences between skin diseases.

Both Seborrheic Dermatitis and Psoriasis can present on the face and also progress into more severe erythrodermic presentations just as Atopic Dermatitis. All 3 conditions are itchy and all three can affect the face.

With Seborrheic Dermatitis we would have expected a long history of either dandruff, generalized scalp inflammation, lesions around the eyebrows, side of the nose, or on the sternum that for various reasons, including improper treatment, could lead to a severe outbreak on the face that spreads to the body as well. M.J however started as a child with lesions on his body that did not spread to the face until stopping topical steroids. Therefore, M.J does not present with Seborrheic Dermatitis.

With Psoriasis, we would expect a history of psoriatic types of lesions which differ from M.J’s presentation. The papules in Psoriasis are typically thicker with well defined circumscribed edges. With M.J there are papules on the body without scales while on the face there are scales mixed with crusting but without underlying papules. Not only has M.J never had a history of these thick psoriatic type lesions. In addition, psoriasis on the scalp is significantly more common than on it is on the face (Dopytalska, 2018; Egeberg, 2020). Psoriasis on the face only occurs in a minority of cases, although it definitely does occur, but usually not covering the whole face. However, it is plausible that a patient with Erythrodermic Psoriasis could present with exfoliation of the face similar to M.J. Simply looking at photos of the face it may be impossible to tell the underlying disease leading to the erythema. However, taking a simple history and inquiring about the history of the disease and it’s lesions it should be easy to differentiate the two diseases and we know M.J had classical eczematous lesions previously.

In particular, the history of lesions in the four flexures (or you may say the four crooks) amongst other areas clearly indicates that the patient suffered from Wind Of The Four Crooks (Atopic Dermatitis) while the repeated intense flare ups that started after ceasing topical corticosteroids and spread to previously unaffected regions indicates a significant complication of Topical Steroid Withdrawal Syndrome.

TCM Pattern Diagnosis

M.J’s history of recalcitrant Atopic Dermatitis, that flare’s up and spreads rapidly and widely over the body, with burning lesions, the experience of significant heat with insomnia, intolerance to the heat and sun, and exfoliating skin are symptoms of Fire Toxin with Heat In The Blood & Ying Level.

When discussing exuberant heat and the Four Levels of Warm Disease differentiation, Scheid et al. (2009) note that the presence or absence of thirst is an indication of whether heat remains in the Qi Level or has moved to the nutritive level. Heat in the Qi level depletes Stomach fluids leading to thirst. Once the heat progresses further to the Ying level, thirst stops. Despite intense heat all day and especially at night, M.J reported no thirst indicating heat in the Ying level.

Let’s re-examine the lesions as well. The anterior neck presented with bright red/ pink macular erythema with ill defined edges that seemed to be spreading, the author takes to indicate Fire. Some maculopapular lesions on the chest blanched with pressure, indicating Heat in the Qi or Blood Level, while others did not blanch, indicating Extreme Heat (Al-Khafaji, 2016). Other paler lesions indicate just heat without spreading.

While Dampness and Heat are etiological factors in all cases of Atopic Dermatitis, some cases develop presentations more solely driven by these factors. We know that M.J had a long history of lesions under his arms in the axillary cavity and as he got older of fluid discharge and large eroded lesions (his neck). These are all symptoms of a Damp Heat pattern. The dryness the patient presents with can also be considered to be due to Damp Heat as the dampness obstructs the flow of Qi, Blood and nourishment to the skin, while the heat dries out the skin. It would be inappropriate to treat the dryness solely with warm and nourishing tonic herbs to nourish the skin while there is so much activity and active heat signs present. Addressing skin dryness as a pattern itself will take place later in treatment.

All considered, the author took the signs of spreading Heat more seriously than the few areas that were healing, especially given the history and the trajectory of the disease. The pattern is considered Fire Toxin with Heat In The Blood & Ying Level complicated by Damp Heat.

Treatment Principles

The primary CM Treatment Principles employed in this case are to:

1.Drain Pathogens (Acute Phase)

2.Harmonize (Middle Phase)

3.Tonify (Consolidation/Prevention Phase)

(These principles were derived from Mazin Al-Khafaji’s TCM Dermatology Diploma Course). 

Initially draining involves Draining Heat and Resolving Toxin (via stools but not in a purgative fashion); Venting Heat and Toxin From the Ying level to the Qi Level; Venting Heat and Toxin To Surface; Clearing the Qi Level, Drying Dampness; Draining Dampnes and Heat via The Urine.

The initial formula employed the following Treatment Principles and Herbs:

The initial and main formula is loosely based on the principles of Wu Ju Tong’s Qing Ying Tang and a formula template taught by Mazin Al-Khafaji for Toxic Heat in The Qi, Ying, and Blood level pattern of Atopic Dermatitis. The formulas were modified significantly to fit the patient’s presentation, which the author feels presented with more Dampness than the original formulas were intended for.

*Bitter and Cold herbs Huang Bai and Huang Lian were used to Clear Heat, Drain Fire, Resolve Toxin, and Dry Dampness

*Salty and cold Xuan Shen and Sweet and Cold Bai Mao Gen both cool the Ying and Blood Level while supporting Yin and Fluids. Typically, large doses of Sheng Di Huang would be used as the main herb for those function. However, due to the patient’s history of a more extreme damp presentation the author preferred to avoid Sheng Di Huang initially despite it being excellent at cooling the blood and nourishing Yin and Fluids. However, the author did use a moderate amount (equivalent to 7 – 9g of raw herb) of Warm and Sweet Shu Di Huang to Nourish Yin and treat deficiency heat. The prolonged nature of the patients eczema over many years and the two recent severe flare ups with extreme heat symptoms and the thin and weak pulse lead the author to believe there was some Yin deficiency.The moistening aspect of these three herbs would also help buffer the necessary dryness of the other herbs used in the formula.

*Acrid, salty, and cold Zi Cao along with Acrid and Cold Mu Dan Pi cool the Ying and Blood and prevent stagnation from dry desiccated blood or blood moving out of it’s normal course due to extreme heat.

*Light, acrid, cold Ye Ju Hua is used to Vent Heat and Toxin from the surface. Ye Ju Hua has an affinity for the face and is useful in Damp Heat presentations as well. Therefore it was used to replace light, acrid, and cold Jin Yin Hua and Lian Qiao from Qing Ying Tang where they help to vent heat from the nutritive to the Qi level and to circulate Qi in general to prevent stagnation (Guo, 2008).

*Cold and acrid Shi Gao was used with cold and sweet Zhi Mu to help venting to the Qi level. Zhi Mu also helps nourish yin and fluids and to moderate the other drying but necessary herbs.

*Bitter and cold Ban Lan Gen was used in moderately large dosage to Resolve Toxin and Drain Heat from the blood. Whereas Ye Ju Hua worked on more superficial levels, Ban Lan Gen works on the Blood Level.

*Bland, sweet, and cold Dong Gua Pi was used to eliminate dampness and heat via the urine. Dong Gua Pi excels at treating damp eroded skin. Bitter and cold Di Fu Zi also promotes urination to drain dampness while its bitterness drains fire. Di Fu Zi is known to stop itching as well. In Qing Ying Tang, light, acrid, cold Dan Zhu Ye is used to vent heat from the Qi level and via urine. Due to differences in the patient’s presentation and concerns of dampness, Dong Gua Pi and Di Fu Zi were used instead.

*Light, acrid, warm/neutral Bai Ji Li scatters Qi from the surface to reduce itch. Bai Ji Li is better for itching in the upper body, while Di Fu Zi has a stronger effect on itching in the lower body.

The herbs were provided in the form of granular extracts, 36 grams in total per day. 14 days of herbs were provided. The patient was instructed to split the daily dosage into 3 or at least 2 separate doses, dissolving the granules in hot water. Exact dosages are not provided as this formula is not presented with the intention of it treating every TSW patient. Therefore do not attempt to copy the formula, TSW sufferers interested in Chinese Medicine should consult a practitioner (www.tcmdermatology.org). 

Discussion Of Results

Visit Two, Two Weeks Later

Two weeks after starting herbs, there is less scaling and less crusting

At the first follow up visit, two weeks later, as we walked back to the photo room M.J’s father seemed upbeat and stated that he thought the “scales on the face are getting thinner”. It was true, the scales on the face had reduced slightly, approx by 30%. As the scales reduced, background erythema was more prominent. M.J reported reduced itching of his face. In addition he reported some slight fissuring around the lips however. The patient reported ongoing itch on his chest and back as well. Upon examination, some of the active lesions on the back from the previous visit were now more hyperpigmented and becoming thinner indicating healing. There was one small area of crusting on the back, and the patient stated that he repeatedly scratched that spot and it eventually began to discharge a minute amount of fluid.

Visually the greatest improvement over two weeks was in the left knee flexure where the previous maculopapular rash had mostly cleared. However, the author believes the biggest improvement was that the patient reported that he fell asleep “at a normal hour” a handful of times over the last two weeks. The patient reported that he was still running warm. M.J still denied any thirst.

The previous formula was modified. Huang Bai and Dong Gua Pi were reduced so as not to be as drying due to the lip fissures and Bai Shao was added to address dry fissures directly. Zi Cao was replaced by Hu Zhang, focusing on greater ability to Resolve Toxicity. Lian Qiao was added for the same reason. Di Fu Zi was removed due to its drying nature and because itch was more severe in the upper body. Bai Ji Li was also replaced as the effect was unclear. Xi Xian Cao and Bai Xian Pi were added to expel Wind Dampness and stop itch.

Visit Three, One Month Since Starting Treatment

After one month taking the herbal formula daily the M.J reported and demonstrated significant improvements in every area. The patient reported almost regular sleep hours and the ability to sleep during the night starting at 10 or 11 P.M. The patient reported a marked reduction in heat but still felt warmer at night.

Scaling and erythema of the face had reduced significantly, and were progressing on pace but were yet to resolve fully.

Itch had reduced on the upper body and the patient now reported that itch on the lower body bothered him more.

The dry fissures around the mouth had resolved completely meaning the Bai Shao and other modifications worked.

The lesions on the back were healing and a very large post inflammatory macule was developing on the entire center of the patient’s back.

A few acne-like papules and pustules were developing on the patient’s back and face. The patient reported a history of acne that had disappeared during the large eczema/TSW flare ups.

The previous formula was modified again. Bai Xian Pi was removed and Di Fu Zi was added due to lower leg itch. Lian Qiao was replaced by Bai Hua She She Cao.

Visit Four, 7 Weeks Into Treatment

The patient presented with significant improvement. Lesions were now roughly 90% clear since starting herbal medicine 7 weeks prior. The patient’s face was mostly clear but he reported some scaling around the eyebrows and hair loss from the area and the scalp. No lesions were seen on the scalp but there was dandruff.

Active lesions on the back had cleared. The macule on the neck had been completely resolved. There was significant post inflammatory hyperpigmentation, with a very mild diffuse rash happening on top in some areas of the back.

The previous formula was modified, severely reducing the dosage of the dry bitter herbs. Xi Xian Cao was removed and Wei Ling Xian was added along with Bai Ji Li, both to scatter wind (and damp in the case of Wei Ling Xian) from the surface of the face and treat the excessive scaling and flaking around the eyebrows.

Visit Five, just over 2 months since starting treatment. Step 2 Harmonize

By the fifth visit on 12/18/2022, the lesions were approximately 95 – 98% clear on the face. Scaling around the eyebrows had improved but remained slightly around the left eyebrow. The patient’s back continued to present with a diffuse mild rash with small scattered papules over previously healed post inflammatory hyperpigmented macules. The patient reported near normal heat and a resolution to his insomnia.

The formula was now modified as the patient had improved significantly and there were no signs of exuberant heat or skin activity. Huang Lian and Huang Bai were removed from the formula. Xuan Shen was reduced as the focus was no longer to clear heat from the blood. The dosages of Shu Di Huang and Bai Shao were increased as the primary focus of the formula became Harmonizing by Tonifying and moving Qi and Blood, while nourishing Yin.  Dan Shen was added to replace Mu Dan Pi as Dan Shen helped Nourish Blood and Move The Blood while resolving post inflammatory hyperpigmentation. Di Fu Zi, Bai Ji Li, and Wei Ling Xian were removed. Jin Yin Hua and Lian Qiao were added to continue to clear toxicity while starting to Tonify deficiency and also to address some developing acne lesions. The dosage of the formula was reduced to 32g per day.

Visit Six, 3 months since Starting treatment

This was the first visit where the patient reported some non-compliance with the regimen noting he failed to take the herbs regularly over the Christmas and New Year’s Holidays. The patient had maintained all previous progress however. He did however, develop some angular cheilitis, which is a dermatitis or irritation of the skin in the corners of the mouth. On inquiry the patient reported eating more sweet baked goods than usual over the holidays as was expected. While Angular Cheilitis has many causes it can often be due to an over growth of Candida Albicans. This is common in eczematic patients and the author sees it in a few patients regularly during the holiday season due increased sugar intake.

The formula continued to be modified to move further towards tonification. A small dose of Sheng Di Huang was added, which with the Shu Di Huang will help address dryness. Huang Qi was added to Tonify Qi and help the other tonic herbs to better nourish the skin. Jin Yin Hua and Lian Qiao were removed and Ji Xue Cao was added due to some mild acne like papules that were improving slowly. Yi Yi Ren was added and the dosage of Bai Hua She She Cao was increased to address the formation of acne. A small dosage of Huang Lian was added to address the Angular Cheilitis.

Visit Seven, Four Months Since Starting Treatment

The patient reports ongoing and sustained significant improvement, approx 95%+. M.J patient had run out of herbs as he needed to push his appointment back and could not come in until two weeks two later than expected. The patient stated the flaking of the left eyebrow was not always present but still occurred. The patient’s back was free from active eczema lesions and was covered in a large pale and fading hyperpigmented macule. The color of the macule was not only fading but had become more uniform across the back.

The patient denied exuberant heat but did report that he had started to feel a little warmer at night. Therefore, the formula was changed despite progress to address the increase in heat before any chance of outbreak developed. As there had been no signs of extreme dampness in quite some time, Sheng Di Huang was now used.

The formula was to clear Blood Heat With Wind. The Wind here referred more to the scaling of the left eyelid however it could have applied to itch but itch was almost absent only occurring immediately after showering. The formula construction was more similar to ones used for Roving Face Wind (Seborrheic Dermatitis) just because the flaking eyebrow was the only real eczematic activity of the skin and previous formulas had failed to fully address it.

The formula was 32g per day, split in two doses in hot water and consisted of: Sheng Di Huang, Shu Di Huang, Bai Mao Gen, Xuan Shen, Shi Gao, Zhi Mu, Mu Dan Pi, Dan Shen, Wei Ling Xian, Bai Ji Li, Niu Bang Zi, Bai Ji Li, and a small dosage of Huang Bai.

Visit Eight, Almost 5 Months Into Treatment

The patient presents approx 95 – 98% clear of eczema. The patient reports that the left eyebrow had settled down and his face was now clear of eczema. There were still some scattered post-inflammatory lesions on his body but they had faded significantly and appeared to continually be reducing. The patient has minor acne on his face and back, although he states that the acne is not as severe as it had been prior to his eczema flare ups. The patient had not been washing his face and was encouraged to as there was no longer any concern of irritating his face. A gentle baby soap was recommended to start with and to ease any fears the patient might have about using soap.

The patient was given a similar formula and was seen twice more, each time reducing the dosage of the herbs.The patient reported occasional very mild eczematous activity, such as a few small papules would present on his arm or face and resolve in a day or two but this also eventually stopped. The patient was last seen in May 2022.

The author communicated with the patient in July 2023, over a year since he was last seen and over a year and half since the last major flare up had resolved with treatment. M.J reports no presence of eczema aside from minor occasional skin irritation behind the knees, etc that resolves on it’s own in a few days time.

Closing Thoughts

How many people out there, suffering like M.J, would benefit from Chinese Medicine? More than 30 years ago, Sheehan et al(1992) published in the Lancet that “we have shown that Traditional Chinese Herbal Therapy affords substantial clinical benefits in patients whose atopic dermatitis has been unresponsive to conventional therapy”. However, just as the many published warnings about the existence of TSW secondary to improper TCS use went mostly on deaf ears, the same seems to have been true with published evidence supporting Chinese Herbal Medicine for the treatment of Atopic Dermatitis.

Chinese Medicine practitioners have been treating TSW for at least 40 years and have been treating erythema, oozing, scaling, peeling and all the various symptoms associated with TSW for thousands of years. Uzun et al (2021) published a great case study of a 7 year old boy suffering from TSW that was treated with Chinese Herbal Medicine. This is not an isolated achievement. Many patients suffering from TSW in the recent past, even before a name was agreed upon to the phenomena, eventually sought help outside of conventional medicine and some Chinese Medicine practitioners have a long familiarity with TSW.

For patient’s suffering from Atopic Dermatitis and/or Topical Steroid Withdrawal the author really does feel for your pain. Hopefully the material here has been helpful to better understand your experience and some of your options. The author has two words of advice: the first and most important thing is to know that you can get better so please hang on and keep going. The second word of advice though would be if you are considering Chinese Medicine that it is good to examine M.J’s improvements but it is also important to observe his behaviors. M.J was patient and persistent. He did not stop treatment after 2 weeks because he still felt a little warm or because there was still itch. Nor did he stop because the herbs tasted badly (the author is 100% certain that the herbs were extremely bitter at the beginning of treatment). Rather at two weeks, he was pleased because he saw some signs of improvement, even if minor. Together M.J and the author went through his symptoms objectively, admitted improvement where it existed, detailed what still needed improvement, adjusted from there and continued on. His father and family also played an important role in being supportive. Some patient’s will need to continue treatment longer than M.J but that’s ok; I would expect at least 6 months however treatment can last longer. Atopic Dermatitis can be managed wonderfully and TSW can be overcome, please do not fall prey to a negative and bleak outlook. Finally, until there is more agreement and understanding about what Topical Steroid Withdrawal is it seems important to keep an open mind, be flexible with changing nomenclature and definitions, don’t point fingers, and keep the health of those suffering as the most important issue. 

If you are looking for help in the SF Bay Area the author would be happy to help you. Please click here to contact us. Readers in another area should consider checking www.tcmdermatology.org for nearby practitioners.

References

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Barta, K., Fonacier, L. S., Hart, M., Lio, P., Tullos, K., Sheary, B., & Winders, T. A. (2023). Corticosteroid exposure and cumulative effects in patients with eczema: Results from a patient survey. Annals of Allergy, Asthma & Immunology, 130(1), 93-99.e10. https://doi.org/10.1016/j.anai.2022.09.031

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