TREATING SCLERODERMA WITH CHINESE HERBS

by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

Scleroderma is an autoimmune disease where production of antibodies against certain connective tissues produces fibrosis with a thickening and tightening (sclero = hardening) mainly of the skin (derma = skin). The disease is sometimes called systemic scleroderma, because the hardening process can affect other parts of the body, not just skin; for example, the lungs may also become involved. A more limited version of the disease is called localized or circumscribed scleroderma; it may affect only certain areas of the skin.

According to an analysis of autoimmune diseases published in the Journal of the American College of Traditional Chinese Medicine (1), scleroderma is typically associated with qi and yang deficiency and coldness that leads to blood stagnation, the basis of the disease symptoms. The authors point out that the patient may have extremely cold limbs (some suffer from Raynaud's syndrome) and easily suffers from wind-cold disorders; further, there is a tendency to have signs of spleen cold, with poor digestion and loose stools. Blood stasis is revealed not only by the symptoms, but also by purplish tongue coloration. The principles of therapy involve tonifying the deficiency and resolving stasis of blood. A prescription mentioned in the Journal is Yangshen Huoxue Tang (Decoction to Warm the Kidney and Vitalize Blood). It is comprised of herbs to invigorate yang (epimedium, morinda, cistanche, and astragalus), and herbs to vitalize blood and overcome stasis: Tao Hong Siwu Tang with persica replaced by salvia and cinnamon twig (hence: tang-kuei, cnidium, red peony, rehmannia, carthamus, salvia, and cinnamon twig); licorice is added as harmonizing agent.

ITM has included a review of herb therapies used in China in its book Treatment of Difficult and Recalcitrant Diseases with Chinese Herbs (2), based on reports in two Chinese language texts (now out of print): Modern Handbook of TCM Internal Medicine and Compendium of Secret Chinese TCM Formulas. An analysis of the formulas appearing in those books, and in abstracts of other Chinese medical reports appearing in Abstracts of Chinese Medicine, indicates that the herbs commonly included in scleroderma treatments fall into four major categories:

The qi tonics are mainly those used to complete the formulas in the traditional style of prescriptions, and to aid in warming the body and promoting blood circulation. An herb commonly included in formulas but not fitting in the above categories is rehmannia (raw or cooked), which complements both yang tonic herbs (when supplementing the kidney) and blood vitalizing herbs (when also nourishing the blood). Cornus also appears in some formulas for tonifying the kidney, a reflection of the herbs used in Rehmannia Eight Formula (Bawei Dihuang Wan), a basic therapy for yang deficiency.

Most patients in the West come for treatment with advanced disease, having experienced an inability to control it through standard medical procedures. In the Modern Handbook of TCM Internal Medicine, the disease is first divided into early stage (e.g., first six months of symptoms displaying hardening of skin) and advanced stages. For chronic cases involving kidney and spleen weakness, the formula recommended is:

The combination of rehmannia, hoelen, cornus, and dioscorea is from Rehmannia Eight Formula, with curculigo, epimedium, and antler gelatin as yang tonics replacing aconite and cinnamon of the original formulation. Laminaria and vinegar-treated turtle shell are included to resolve masses; they are used here to soften the sclerotic tissue. An alternative formulation is also suggested for cases where kidney deficiency and blood stasis were dominant, in which the spleen tonifying group of codonopsis, atractylodes, and hoelen is deleted and replaced by the blood vitalizing group: tang-kuei, sappan, cnidium, persica, and carthamus.

Additional formulas are suggested for cases where either blood stagnation or qi deficiency are primary factors (that is, without obvious kidney yang deficiency). For example, when blood stagnation is the dominant feature, the recommended prescriptions are Bupleurum and Peony Formula (Jiawei Xiaoyao San) with carthamus and salvia added, or Astragalus and Red Peony Combination (Buyang Huanwu Tang). These formulas lack the kidney warming herbs. In cases where qi deficiency is considered the major underlying cause, modifications of Ginseng and Astragalus Combination (Buzhong Yiqi Tang) are suggested.

In the Compendium of Secret Chinese TCM Formulas, there are case reports from the Chinese medical journals. A few of these will be illustrative of the formulations used and the claimed results. Following is a summary of three of the reports involving large groups of patients with scleroderma:

1. Dr. Qin Wanzhang at the Shanghai University of Medical Sciences reported that scleroderma could be effectively treated with blood vitalizers alone, using a formula containing salvia, millettia, leonurus, sappan, cnidium, rehmannia, persica, carthamus, red peony, tang-kuei, lycopus, and turmeric (9 grams each item, except 15 grams each of salvia and millettia). These ingredients, other than lycopus and turmeric, are all commonly mentioned for treatment of this disease. He had the patients take the herbs as a decoction internally and apply the same liquid as a wash to the affected areas. Treatment time was typically 3-6 months. Of the 123 cases of scleroderma so treated, 53 were markedly improved and 67 more were improved; only 3 patients failed to respond.
2. Dr. Wang Dexiang, at the Tianjin College of Traditional Chinese Medicine, reported treatment of 100 cases of scleroderma using a combination of blood vitalizers with several tonic herbs (mainly qi and blood nourishing agents). The formula he administered was: red peony, carthamus, millettia, salvia, citrus, cyperus, codonopsis, astragalus, cinnamon, rehmannia, antler gelatin, ho-shou-wu, and licorice (and modified further according to specific symptoms). The dosage of the herbs used was high, with 15-30 grams of codonopsis, astragalus, rehmannia, ho-shou-wu, and millettia. As a result of treatment that averaged one year in duration (minimum time was 3 months), he reported that 8 were cured, 43 were markedly improved, and 40 improved; 9 failed to respond.
3. In a large-scale investigation with 725 cases of scleroderma, the patients were classified as belonging to one of three groups for differential treatment. The first group was treated with a formula comprised mainly of the blood vitalizing herbs myrrh, frankincense, and curcuma; the second group with alisma, salvia, and sappan, and the third group, which was by far the largest, with tang-kuei, carthamus, cnidium, and pueraria (the formula called Gui Xiong Fang: Tang-kuei and Cnidium Formula). Further details about the third group were reported separately by Dr. Fan Si at the Beijing Joint Hospital. There were 414 cases of scleroderma treated using a tablet prepared with equal proportions of the four herbs mentioned. The herbs were taken in the amount of 4-8 one-gram tablets each time, three times daily (total dose: 12-24 grams). Of the 118 cases that had systemic scleroderma, 41% markedly improved and 56% improved; of the 296 with scleroderma mainly limited to the skin area, 45% were markedly improved and 53% improved. About 3% of the scleroderma patients treated by herbs failed to respond to therapy.

Clearly, the blood vitalizing therapies have become a focus of treatment. These herbs reduce production of fibrous masses and may help reverse the hardening that occurs with fibrin deposition. In Japanese research screening for antifibrotic Chinese herbs, the authors summarized their findings as follows (3):

We have screened several Chinese medicinal herbs for the presence of antifibrotic agents. An aqueous extract of Salvia miltiorrhiza root was found to inhibit collagen secretion by human skin fibroblasts without affecting DNA or non-collagen protein synthesis. We have subsequently purified the material exhibiting the inhibitory activity and identified it as magnesium lithospermate. From its chemical structure, this compound was predicted to be an inhibitor of the post-translational modifying enzymes prolyl- and lysyl-hydroxylases in collagen biosynthesis. Accordingly, it decreased the extent of prolyl- and lysyl-hydroxylations in collagen by approximately 50%. Added to cell extracts it inhibited both prolyl- and lysyl-hydroxylase activities, but only lysyl-hydroxylase activity when added to intact cells. Oral administration of this compound to mice led to a significant reduction of prolyl-hydroxylation in newly-synthesized skin collagen. This naturally-occurring compound thus offers a potential means for treating fibrotic diseases, such as systemic scleroderma and keloid

The impact of blood vitalizing formulas in scleroderma patients was monitored in a Chinese clinical study (4); the authors summarized their findings:

The blood flow changes of 34 progressive systemic scleroderma (PSS) patients were examined. The amplitude of blood flow proved to be markedly lower in these patients than in healthy subjects. All patients were treated with the basic prescription for PSS as the principal method, combined with infusion of Mailuoning injection [a blood vitalizing herb combination produced by Nanjing Jinling Pharmaceutical Group] in 500 ml of 5% glucose. The course of treatment lasted three months to one year. The result of treatment showed that the abnormal blood flow in the extremities of all patients was improved remarkably. Marked improvement rate and total effective rate were 70.5% and 100% respectively. Significant improvements in clinical and laboratory parameters were observed. It revealed that there was a close relationship between the occurrence and development of PSS and blood circulation. It is assumed that the pathogenic mechanism of PSS is deficiency of vitality [qi] and excess of pathogenic factor (stasis of blood), and the qi tonifying and blood activating, hard lump softening and mass dissolving medicinal herbs according to syndrome differentiation method of TCM should be used.

In an internet presentation by the Chinese Hospital for Chronic and Difficult Diseases (5), herb formulas were presented for three differential diagnoses of scleroderma as follows (each formula is a decoction; the dosages were not given). In all cases, blood stasis was considered an integral part of the syndrome:

1. Blood Stasis Type: The skin becomes hypertrophic and elevated or sunken and hard. It may be red or brown in color. The tongue is light purple; the pulse is rapid.
2. Type of Kidney Deficiency and Blood Stasis: The skin becomes thick and sclerotic or atrophied and thin; accompanied by lower body pain, tinnitus, vertigo, impotence, purplish tongue and deep, fine pulse.
3. Type of Spleen Deficiency and Blood Stasis: The skin is sclerotic and atrophied; accompanied by fatigue, loss of appetite, abdominal pain and distension, loose stool, purplish tongue, thready, moderate pulse.

The formulations provided were as follows (herbs in common highlighted):

These three formulas have salvia, red peony, and tang-kuei in common. This is a blood vitalizing combination that is understood to inhibit fibrosis, and may help shrink existing fibrotic plaques. These herbs are in a context of additional blood vitalizing herbs (e.g., millettia, cnidium, persica, carthamus) and/or kidney tonics or qi tonics. Salvia is the best-known herb for antifibrotic effects, and it has been recommended for treatment of scleroderma even by IV administration. For example, this hospital recommended use of 10 ml of Salvia miltiorrhiza injection with 500 ml of 5% glucose for intravenous drip, once a day for a 10-day course of treatment (a one week break and then another 10 days IV therapy, as needed). It was stated that substantial effects are seen after just one month of treatment.

In sum, blood vitalizing herbs seem to be the key to therapy in treating scleroderma, with tonic herbs used to treat the underlying constitutional cause of blood stasis in those patients showing obvious deficiency signs.

REFERENCES

1. Zhang Wentao and Meng Rou, Autoimmune diseases as treated by traditional Chinese medicine, Journal of the American College of Traditional Chinese Medicine 1982 (1): 39-50.
2. Fruehauf H, The Treatment of Difficult and Recalcitrant Diseases with Chinese Herbs, Institute for Traditional Medicine 1997, Portland, OR.
3. Shigematsu T, et al., Inhibition of collagen hydroxylation by lithospermic acid magnesium salt, a novel compound isolated from salvia root, Biochemistry and Biophysics Acta 1994; 1200 (1): 79-83.
4. Huang PP, Wang SG, and Hua GX, Observation on blood flow changes in 34 cases of progressive systemic scleroderma treated with Chinese herbal medicine, Chinese Journal of Integrated Western and Chinese Medicine 1994; 14(2): 86-88, 68.
5. http://www.tcmtreatment.com/images/diseases/scleroderma.htm

May 2003