Eczema

Literature Review on:
Clinical and evaluation of Eczema using Traditional Chinese Medicine (TCM) or Western Medicine (WM) to treat the condition. Critically analyse and evaluate studies being made and show the effectiveness and limitations of a TCM treatment for Eczema.
Introduction
Eczema is suffered by 30% of Australians, from children to adults and can be effected by it for short or long periods of time, which effects their lifestyle and health.
One in five children under the age of two are effected, but it can improve with age. It cannot be cured but can be managed and treated. Why people suffer from this condition is unknown, but it is seen that most eczema sufferers have or developed other allergies. It's a condition that gets better or worse over days even months (Liang, Zhang, & Flaws, 1993).

It is important to research this topic as many people suffer from this condition. Also it is an interesting topic as the rash comes and goes and effects people in different ways. Governments puts emphasis on it, as people cannot work and take days off, which costs companies a lot of money. It effects from young to old, but mainly young and younger adults. Also the internal and external environmental factors play an important role that could flare up the condition (Shen, Wu, & Wang, 2007) as its effected by allergies. There is evidence to state that eczema can be helped by acupuncture and Chinese herbal medicine.
Aims
This literature review was written to investigate if TCM can treat and help manage individuals that suffer from the skin condition Eczema, via evidence provided by studies done. It's the results of the studies that will allow readers to be convinced that they can trust TCM as a method of treatment.
Methods
Databases used where: EBSCO and Scholar
Keywords used were: eczema, eczema in TCM, eczema in Western Medicine, effectiveness and limitation of TCM treating Eczema. Systematic reviews in Chinese medicine for eczema, systematic review using acupuncture for Eczema.
The published research will be explained from the most current.
Common strands used: To be aware of the relevant research on eczema and show a range of research.

Eczema Defined
The word eczema is a Greek word (“ekzein”) which translates “to boil”.
Eczema is not a contagious condition but it is common and reacts by the skin becoming inflamed through internal (stress, digestion, infection and inflammation) and external (perfume, wool, over heating, diet, medication, allergies, and the weather), stimuli that causes a reaction, which may lead to the skin to weep, then form a crust with not a clear border. Eczema can be defined as a rash on the skin that can become very itchy and dry ("Action plan from", 2016).

The rash can come and go throughout at any time of the year. The most severe type of eczema is Atopic dermatitis. The rash can be anywhere, but the most common sites are: face, neck, feet, hands, chest, genital, legs and behind creases ("action plan for Eczema", 2016).

The skin is usually dry and scaly and red that causes the skin to itch that can be presented with blisters filled with fluid, which if are scratched can become infected and require antibiotics. The rash may become more irritated, and then improve at any stage. It is more common in young children and if adults have it, then the symptoms get less with age. The cause is not always known but it can be said that the skin cannot repair itself, due to the mutation within the filaggrin (creation of skin barrier) gene ("Action plan from", 2016).

People who suffer from eczema only have one copy of the filaggrin gene, but it is normal to have two copies to help with repair of the skin. Once the skin is effected the moisture evaporates from the skin to create dry and scaly skin and allowing other allergens to enter the pores of the skin ("action plan for Eczema", 2016)

Eczema defined in TCM concepts
There are different types of eczema: acute, subacute, chronic, and atopic dermatitis (inherited that appears in early childhood). Acute eczema is more of polymorphous skin condition and can be more red in appearance that can lead to an itchy rash and can become infected. Subacute eczema consists of small papules that are scaly and start to form a crust that can have previously wept. Due to the dryness (from wind) the skin can become very itchy. Chronic Eczema causes more dryness and the skin becomes more rough or the skin can start to peel off. This type has an obvious border whereas an atopic dermatitis is scalier that can form an infection (Shen, Wu, & Wang, 2007).

TCM describes the reasons as to why the condition can develop for an acute eczema due to wind, dampness or heat effecting the skin. If the rash is chronic then elements of the wind has dried the skin or the effected person has a poor blood circulation. Other indications of chronic eczema are dampness, as the spleen meridian is weak or internal heat effecting the blood (damp heat). It is said that there is dampness within the body and either wind or/and heat. Patients with damp heat tend to have a redder rash, swollen and blistered with fluid, whereas rashes that are more damp/wind show signs of itchiness (Shen, Wu, & Wang, 2007).

Pathogenesis: eczema
Eczema is seen in pathological changes and may not be excluded from each other. Sometimes It can arise from contact of irritants on the skin. The aetiology can be complicated with the combination of internal (stress, insomnia, emotional, infection and digestion issues) and external (sun, light, cold, heat, dryness, damp, profuse sweating, scratching, friction, plant and animals, foods and chemicals/products) factors (Liang, Zhang, & Flaws, 1993).

From a pathology perspective it is a delayed allergic reaction from a combination of the above listed factors. Or some body constitutions may have a weakness towards eczema, or their health is weak and they are reacting to their environment. Eczema is a reaction pattern and different factors cause similar reaction to the skin (Shen, Wu, & Wang, 2007).

It has also been suggested in TCM to massage the skin to help promote circulation of blood to the skin and exercise to strength the body and allow for more oxygen (qi) in the blood vessels (meridian). Also to consider house hold chemicals used and make some lifestyle changes and diet requirements (Liang, Zhang, & Flaws, 1993).

In TCM the factors that cause eczema is mainly divided into three main areas: external pathogenic factors, especially wind that causes the itchy skin, dampness that slows the recovery of the lesions situated mostly on the lower part of the body or heat which is indicated as skin that is red and swollen that could lead to infection by toxins (Shen, Wu, & Wang, 2007).

The next factor out of the three is the internal factor which presents disharmony of the heart (red itchy rash), spleen (damp), and kidney (chronic condition) meridians, which can lead to issues with metabolic system and dampness coming out of the skin (pus). The last category is dietary as foods that are spicy, greasy and rich can effect the body to cause damp heat that will flare up the rash (Liang, Zhang, & Flaws, 1993).

Eczema defined in Western Medicine
Other forms of treatment are used such as evening primrose oil, sea water, coconut oil, fermented cod liver oil, magnesium baths, cold compression with moisturised skin and coal tar cream to ease the itch and rash. It has been found that eczema can be caused by the body lacking omega-3 and omega-6. It has been found that taking fish oil, zinc, probiotics can help or even B-group multi vitamin with vitamin C can help, also limited stress that can help minimise outbreaks. There is a brand called Fusion Health (Vitex) that make capsules that combine a blend of western and Chinese herbs to help with such skin conditions ("action plan for Eczema", 2016).

It is highly recommended to have a bath in warm water (even using minimal bleach to kill bacteria on top of the skin) using soap free cleansers to soak in and make sure not to over heat the body and be mindful of exposing the skin to harsh chemicals or cosmetics that may be non hypoallergenic. Mainly keeping the stress to a minimal
and good personal hygiene and exercise to minimize stress. It is also recommended to keep the skin moisturised ("Action plan from", 2016).

Most people buy over the counter antihistamines and hydrocortisone creams to help with the inflammation and itch. If the condition is more extreme then the doctor can prescribe corticosteroids, immunosuppressant’s and immunomodulators.
It is wise to visit a dermatologist, pharmacist, TCM practiosioner, doctor or the Eczema Association of Australia ("action plan for Eczema", 2016) to get help.

Evaluation on research
A systematic review of randomised clinical trials in humans only (1999) was written on the treatment of eczema using Chinese herbal medicine. Trials without patient control groups were not considered. The aim of the study was to review evidence whether chinse herbs work or not. The method taken was to research literature that showed randomised clinical trials on this matter, in the end two trials were found.

Both trials showed that Chinese herbs helped than placebo treating the eczema. The weakness that was evident in the studies, showed that adverse effects had not been documented. In conclusion, it is not clear to state that Chinese herbs help as we don't know the harms it can cause and it is not convincing as the harm can outweigh the good in the long run.

The two trial that was used was Sheehan and Atherton (1992) which used 37children and 31 adults, that either received a herbal mixture or placebo. The placebo mix had plant matter that had a similar smells and taste to the Chinese herbs and it was shown that the ones who took Chinese herbs and continued taking them showed better results than the ones that stopped taking the herbs. More studies are needed to clarify safety, effectiveness, cost effectiveness and action of treatment by taking Chinese herbs (Armstrong & Ernst, 2001).

The Cochrane skin group conducted a database of Systematic Reviews 2013, published by John Wiley and Sons, Ltd. Randomised control trials were being selected by authors on Eczema treatments using the great database from the United Kingdom. Only 95 studies fit the selection criteria as 88 studies were published regarding atopic eczema and focusing on Chinese herbal, psychological, diet, supplements and education.

One of the weaknesses was that the selection criteria for reviews picked had not been assessed well enough and should have filtered through the studies in a better manner that were published on the database for public domain to give out information, which is helpful to people gathering information on eczema. The review was not convincing that the research was strong as there were to many issues filtering the useful trials (Nankervis et al., 2015).

In September 2015 a systematic review was done that aimed to analyse the evidence on the use of acupuncture to treat dermatologic conditions and one being atopic eczema and dermatitis. Methods: A systematic search of MEDLINE, EMBASE, and the Cochrane Central Register was conducted. Studies looked at clinical trials, controlled studies, case reports and comparative studies.

Studies using moxibustion, electro acupuncture, or blood-letting were not considered which can lead to weakness as to see what works best or in combination with acupuncture. Results expressed that 17 of 24 studies showed that acupuncture indicated improvements in outcome measurements compared with placebo acupuncture and alternative treatment option which was convincing. Future studies should be double-blinded to get a better result (Chelsea, Siva Mani, & Fib, 2016).

For twelve years a study was conducted to see the benefits of Chinese herbs with skin conditions. The study looked at other medical benefits as well. It was mentioned that the use of herbal medicine was as far dated back as 2100 BC. The lack of scientific evidence has been a weakness in studies to help convince people to take them to help with skin conditions such as eczema. The Chinese’s Medicine University of Jong LKing had a mission to use science to prove how herbs are effective. They tested herbs that could help conditions such as heart disease, eczema/dermatitis, asthma, immunomodulation and osteoporosis.

In relation to eczema it was stated that corticosteroids and anti-histamines were prescribed but this only helps with the rash and itch, where the herbs can help with the immunity and to strengthen the body to stop this reaction and to clear heat in the body to stop the inflammation. The ones who took the herbs had a better result than the ones who were in the placebo group (Liang et al., 2014). The study was convincing and showed strength in the research to prove that Chinese herbs do work.

Another systematic review was conducted on information regarding atopic eczema, using 22 reviews published over a two-year period from 2012 to 2013 looking at how to help and prevent atopic eczema with desensitisation. The study set a purpose on looking how homeopathy, Chinese herbs and clothing can help. In regards to Chinese herbal it was evident that the studies did not show improvement in comparison to placebo which was a strength. The weakness in the study was that it was not concluded that that herbs used externally in conjunction with orally taking herbs worked and therefore was not convincing.

Others limitations that were mentioned was that dust and pet’s can play some major roles with people who get skin conditions. The study lacked information as some patients lacked vitamin d and some took probiotics which could help minimize eczema and some had pets at home (can effect eczema). Also it was not convincing as some had a better diet and others had a diet that could flare the rash and were taking herbs (Madhok, Futamura, Thomas, & Barbarot, 2015).

Effectiveness and limitations of all the research
All of the research that was looked into lacks scientific evidence on the individual herbs even though results are shown in the end of the studies. It is evident that more research is required in this area especially research showing adverse effects of the herbs used for eczema. Another way to enhance studies done for eczema is to consider patient’s constitution and to investigate if they have any allergies or are on any medication prior to testing, to get a clear indication if the herbs really work.

More scientist research is required and when research is done it needs to consider that most people take supplements, have pets, live in a dusty environment and have different diets. Need to consider all factors that surround the patients environment that may have an effect on the eczema condition.

Most articles relate, as they are attempting to see the benefits of using herbs and acupuncture to minimise the condition by eliminating signs and symptoms. They are all looking at boosting the immunity and not just removing symptoms for a short period of time that most people find they are getting with other treatments.

Hypothesis
Acupuncture and Chinese herbal medicine can assist with eczema, but must consider the internal and external factor from the patient to get better results overall.

Conclusion
Eczema is a condition that is suffered by many people, world wide and options need to be given to people as public information as to know what they can do to help themselves. People don't just want a quick fix, they want a permanent solution to this annoying and itchy condition. People need to be educated about their emotions and how to live in order to help with their condition and educate them towards changing their lifestyle and diet.

It is evident that Chinese medicine is effective but more scientific evidence is required on the adverse effects of the individual herbs. There are many treatments available to best suit the individual but the use of acupuncture and herbal medicine can be effective not just for the eczema but for overall health


Reference List
Action plan for Eczema. (2016). ASCIA. Retrieved 1 September 2016, from http://www.allergy.org.au/patients/skin-allergy (/patients

Action plan from. (2016). eczema. Retrieved 1 September 2016, from http://www.eczema.org.org.au/

Armstrong, & Ernst,. (2001). The treatment of eczema with Chinese herbs: a systematic review of randomized clinical trials. British Journal Of Clinical Pharmacology, 48(2), 262-264. http://dx.doi.org/10.1046/j.1365-2125.1999.00004.x
Chelsea, M., Sivamani, R., & Pfab, F. (2016). Acupuncture as a treatment modality in dermatology: a systematic review. Deutsche Zeitschrift Für Akupunktur, 59(1), 31. http://dx.doi.org/10.1016/s0415-6412(16)30010-8

Liang, W., Yew, D., Hon, K., Wong, C., Kwok, T., & Leung, P. (2014). The Indispensable Value of Clinical Trials in the Modernization of Traditional Chinese Medicine: 12 Years' Experience at CUHK and Future Perspectives. The American Journal Of Chinese Medicine, 42(03), 587-604. http://dx.doi.org/10.1142/s0192415x14500384

Liang, C., Zhang, T., & Flaws, B. (1993). A handbook of traditional Chinese dermatology =. Boulder, CO: Blue Poppy Press.

Madhok, V., Futamura, M., Thomas, K., & Barbarot, S. (2015). What's new in atopic eczema? An analysis of systematic reviews published in 2012 and 2013. Part 2. Treatment and prevention. Clin Exp Dermatol, 40(4), 349-355. http://dx.doi.org/10.1111/ced.12591

Nankervis, H., Devine, A., Williams, H., Ingram, J., Doney, E., & Delamere, F. et al. (2015). Validation of the global resource of eczema trials (GREAT database). BMC Dermatol, 15(1). http://dx.doi.org/10.1186/s12895-015-0024-z

Shen, D., Wu, X., & Wang, N. (2007). Manual of dermatology in Chinese medicine =. Seattle: Eastland Press.