One category of skin diseases with interesting visual manifestations is the “lichen” group, so named because the different types resemble the lichen that grows on rocks and trees. They are generally dry, rough, thickened, or hardened clusters of skin bumps or plaques, and rather than showing the fiery-red inflammation of psoriasis, eczema, and other forms of dermatitis, these tend more toward brown, purplish, or grayish hues. Already, this grabs the attention of the TCM dermatologist, who focusses closely on such clues in order to match them with the most appropriate herbs. Let’s look at four common skin lichens.
LICHEN SIMPLEX CHRONICUS
This is the most common skin lichen, known also as neurodermatitis. It is a condition with a huge stress component, and one where the scratching itself is largely responsible for the condition. No one knows the exact cause, but patients that I’ve treated nearly always report that it arrives on the heels of a particularly difficult time in their lives.
It may start innocuously enough with a couple of small red bumps, but the hallmark of the illness makes itself known quite quickly – the itch that the patient feels is entirely out of proportion to the way the skin looks. And so they keep scratching and scratching, and in fairly short order, the skin thickens and coarsens, turns darker, and the skin creases visible within the lesion become more pronounced. The lichen may remain localized to a single spot, or spread to a few other areas that are easily reached and scratched. This last clue really shows us how much the scratching keeps lichen simplex alive.
Lesions do not develop, for instance, on the upper back, where no one but a yogi could reach them. The nape of the neck, where it is easy to have an absentminded itch, or the shins, especially in people who sit at a desk a lot and can easily access them, are favourite places. Lastly, lichen simplex lesions tend to develop on one side, according to whether the patient is right or left-handed. For this reason, aside from the herbal treatment, it is extremely important for the patient to become conscious of how quickly their hand goes for the lesions, even when they are mildly itchy, and to cover up the spots for harder access. This will go a long way toward shortening the treatment. Mindfulness meditation can be directly beneficial in bringing awareness to this automatic stress response.
Still, herbs are needed, and strong ones at that. Because we don’t see much redness with this condition, the “heat-clearing” cleansing herbs often mentioned in dermatology take a back seat to herbs which nourish and lubricate the blood in order to “water” the dry rough skin, as well as herbs that treat blood stagnation. Anything thick and plaque-like needs to be broken up by these herbs, which are also used for accumulations such as certain masses and fibroids. Common herbs include prepared rhemannia root, dong gui root, and peach pit. Minerals such as pearl shell, oyster shell, and fossilized bone powder, all rich in calcium, are used to calm the mind if anxiety and sleeplessness are extreme. Occasionally, soothing creams or acupuncture at the site of the lesions are also used, in order to calm the hyper-irritable itch response of the local nerve endings.
With all of these protocols in place, we can expect the great majority of cases to be completely cured, although it may take up to a month to see any change, and several more months to finish the treatment, according to the severity of each case.
A related condition, prurigo nodularis (“nodular itch”), manifests with thick, warty nodules that itch unbearably. Chinese medicine is one of the very few effective treatments for this maddening – and much more severe – variant of lichen simplex, and one that showcases the use of animal substances in Chinese herbalism. None of the animals used in this context are endangered. In fact, we use the skin that living cicadas and snakes naturally slough off. These are very powerful medicines for intractable itch when plant medicines alone are insufficient. This is not superstition or witchcraft – science has shown that many animals, and often their skins, secretions, or venom, contain powerful and complex medicinal compounds. Toads, leeches, earthworms, bee venom, and silkworms continue to be studied in the East and West for this purpose.
This is a lichen that primarily affects the genitals of women. It manifests initially with white, soggy-looking spots and blisters, which, over time, destroy the elasticity of the skin of the labia and make it brittle, crinkly, and very easy to tear. The area burns and stings, and the condition makes intercourse nearly impossible. Needless to say, there is a great emotional impact on sufferers. In TCM, we use herbs internally as well as externally. Of late, I have realized the sizeable role that external treatment plays in the resolution of this problem. The external wash, or sitz bath, can bring about a faster improvement, and the patient is encouraged to continue and to not give up prematurely, as lichen sclerosus is stubborn, but well worth treating. Stemona root, sophora root, and other herbs specific to the genital area are the mainstay of treatment. Internally, we must decongest the liver, stop dampness from seeping downward, and correct the blood circulation so that the tissue can heal. Liver congestion is the main cause of lichen sclerosus, which is in turn caused by persistent emotional stress such as anxiety, conflict, depression, or overwork. Complete remission may take many months of patient treatment, but is achievable in a majority of cases.
Chronic eczema, which persists for years with repeated cycles of inflammation, may eventually become “lichenified.” The intense redness and fire of the acute phases eventually dessicate and evaporate the fluids that nourish the skin. The lesions are now thicker, drier, pale red or brownish, and the creases in the skin become accentuated, as with lichen simplex.
When this affects the hands, there may also be painful cracking and fissuring of the skin. Such eczemas are notoriously difficult to moisturize effectively with any sort of salve, oil, or cream. Relief is obtained for mere minutes before the dryness returns. In TCM herbalism, we proceed by moisturizing and repairing the skin internally with strong, lubricating blood tonics such as rhemannia, fleeceflower and scrophularia root, as well as light toxin-scattering herbs such as honeysuckle flower.
It's wonderful to see the skin begin to rebuild its moisture, and to watch the suppleness and elasticity return little by little. The lichenified plaques that seemed so rooted in the skin start to dissipate over several months, and will be gone without a trace once the treatment is complete.
Lichen planus (LP) manifests with purplish or brownish bumps, covered in fine whitish scales. The cause is unknown, but stress, hepatitis C infection, pharmaceutical drug reactions, and autoimmunity are all implicated. The bumps usually appear on the insides of the arm, but can also show up as whitish ulcers and erosions in the mouth. In fact, it can vary considerably from its textbook presentation, with a bewildering array of exceptional manifestations. Conditions such as this one really bring home the advantage of having access to another diagnostic system, such as TCM, when no clear “cause” is found in the conventional system and the symptomatology is so varied. In such cases, I allow the old TCM adage, “treat what you see,” to guide me. This allows me to be nimble and adapt to the case at hand, not to preconceived notions or generalities.
For instance, if the lesions are large and nodular, I like to use dandelion and violet, based on their established use for lesions that are “hard as nails.” If the bumps are purplish, then surely the blood is stuck to some degree, and blood-moving medicines such as red paeony root and curcuma tuber are primary. Emotional tension will bring out the liver-calming herbs such as bupleurum root.
If the LP is confined to the skin, it is much easier to treat, and we have its natural prognosis on our side, as up to 50% of cases clear on their own. Herbal treatment can speed this up. Oral lesions can persist much longer if untreated, and these are the patients who stand to benefit most from a herbal approach.
You might have noticed the multiple references to stress in this article. The longer I work with people, and the longer I observe my own health, the more clearly I see the truly toxic effect that persistent emotional tension has on us. The consequences of this on skin diseases are startling, especially because they can be seen, unlike the more insidious internal damage.
And interestingly, I see many of these effects among health-conscious people, those running themselves ragged, always trying to do the right things: the relentless rushing, especially that of “supermoms;” the impossible perfectionism and over-ambition of many professionals; the ideology of compulsive exercise and body worship; the excessive worry about everything we eat; and the lack of time for emotional intimacy and connection.
All of the above fails what I've come to think of as the “white-knuckle test.” More than any complicated theories, this basic test will tell us whether we are living an emotionally healthy life or not.