DVM, MS, CVA, CVCH, CVFT, CCRP
Dr. Ronald Koh received his veterinary degree in Taiwan and completed a specialty internship and master’s program in acupuncture/integrative medicine at the University of Florida. Dr. Koh is an assistant professor at Louisiana State University School of Veterinary Medicine, where he established the Integrative Medicine and Rehabilitation Service. He recently completed the practice experience pathway for the American College of Veterinary Sports Medicine and Rehabilitation. His research and clinical focus have been on acupuncture, integrative therapies, rehabilitation, and supplements for pain management, neurologic disorders, geriatric conditions, and hospice care. In spare time, he enjoys spending time with his family and his cat, and traveling.
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Increasing numbers of pet owners and veterinarians are turning to integrative and complementary medical modalities for the relief of clinical signs and improved quality of life for their pets and patients.1 Acupuncture and Chinese herbal therapy (CHT), 2 of the 4 practices that comprise traditional Chinese veterinary medicine (TCVM), are among the most commonly used forms of integrative medicine. While these 2 practices have shown benefit in dogs with certain inflammatory skin diseases,2 to date, no veterinary clinical trials have been conducted to investigate their effect in autoimmune dermatoses (ADs). Frequently, their efficacy against autoimmune diseases has been inferred from laboratory testing on animal models and human clinical trials.3-15 This article introduces the use of TCVM as an adjunct modality for autoimmune skin diseases in veterinary patients, based on available information and author recommendations.
ADs are diseases characterized by a specific humoral or cell-mediated immune response against healthy skin tissue, resulting in primary damage to this tissue.16 In dogs and cats, primary ADs (excluding hypersensitivity) comprise <5% of all dermatoses; the prevalence of ADs may be higher in certain canine breeds.16 Common ADs include discoid lupus erythematosus, vesicular cutaneous lupus erythematosus, and pemphigus foliaceus.
Many potent immunosuppressive drugs are available for the management of ADs.17 However, their prolonged use is known to have harmful side effects and they are ineffective in a proportion of patients.17 In addition, some drugs can be expensive, especially when used in combination therapy. Accordingly, an increasing number of pet owners and veterinarians are using TCVM modalities for their pets and patients with ADs.
What Is TCVM?
TCVM, an adaptation and extension of traditional Chinese medicine used in humans, has been used as the primary healthcare system in Chinese agricultural culture for thousands of years.2 Currently, it is considered a complementary or integrative therapy and has been used in combination with Western medicine to effectively treat many conditions, including ADs. TCVM reflects the understanding of the laws and balance of nature and applies them to the body.2 If the body is in balance, it is in good health.
TCVM includes the use of acupuncture, CHT, Tui-na (a form of massage technique), and food therapy based on the physiologic theories of Zang-fu (viscera), Qi (vital energy), Xue (blood), Yin-Yang, and Jing-luo (channels and collaterals).18 Yin and Yang are opposite energies essential to balance and a healthy body. Generally, anything that is active, moving, ascending, bright, hot, fast, and daytime relates to Yang. Yin characteristics are receptive, resting, descending, dark, cold, slow, and nighttime. Within the body, Yang provides energy, warmth, and vivaciousness, while Yin nourishes, cools, and calms.
The 4 methods of diagnosing illness used by the TCVM practitioner are observation (e.g., mental state, tongue), auscultation and olfaction (e.g., breathing, mouth or body smells), inquiry (e.g., medical history, clinical signs, lifestyle), and palpation (e.g., pulses, acupuncture meridians).18 TCVM emphasizes a holistic approach, with individualized or “patient-centered” treatment based on pattern differentiation through the evaluation of the patient’s health condition and signs rather than solely on a Western diagnosis. For example, 2 dogs with identical conventionally diagnosed ADs may be considered to have 2 very different patterns in TCVM, which are treated with different acupoints and herbal formulas. A dog with a red, dry tongue; fast pulse; warm body; dry skin; and cool-seeking behavior would be identified as having a “heat or deficient Yin” pattern, and the treatment strategy would focus on clearing the “heat” or nourishing the Yin. Contrariwise, a dog with a pale, wet tongue; slow pulses; cool body; and warm-seeking behavior would be diagnosed with a “cold or deficient Yang” pattern, which would benefit from warming the Yang and dispelling the “cold.”
In general, acupuncture and CHT are used to help the body restore balance to relieve pain, reduce inflammation, and promote tissue healing, in addition to specifically addressing the clinical signs that are unique to each individual.
TCVM Etiology of Autoimmune Dermatoses
According to TCVM, the etiology of ADs involves heat, damp, and blood stasis, more commonly described as a deficiency of the Yin or blood that enables the lesion to manifest.19,20 Specifically, it describes ADs as “a deficiency in the disease origin and an excess in the disease manifestation.”19 Yin and blood deficiency manifest as reduced skin immunity or skin barrier defects. Since sunlight exposure generally exacerbates AD lesions, it is believed that these diseases are commonly caused by heat toxins.19,20 Heat toxins enter the body and deplete the Yin, impede the channels and vessels, and corrode the sinews, muscles, joints, and skin, subsequently giving rise to the multiplicity of signs associated with ADs.19,20 Therefore, heat toxins and Yin deficiency may play a central role in ADs.
Acupuncture for Autoimmune Dermatoses
Recent systematic reviews indicate that acupuncture is a feasible, effective, and relatively safe therapy for humans with psoriasis.4,7,8 Acupuncture involves insertion of fine needles to stimulate specific points on defined channels (meridians) and thereby provide therapeutic effects such as relief of pain, inflammation, and pruritus via neuromodulation and immunomodulation.2-4 The parasympathetic effects of vagus nerve stimulation may be another pathway that leads to the potent anti-inflammatory properties of acupuncture.5 Promisingly, new findings clearly show that vagus nerve stimulation produces a systemic anti-inflammatory effect, which makes it a good target for bioelectronic treatment of autoimmune conditions.6
Chinese Herbal Therapy for Autoimmune Dermatoses
A variety of Chinese herbs have been used in China for centuries for the treatment of autoimmune diseases,20 including ADs.19 In past decades, much research in human medicine has focused on the immunomodulatory effects of herbs and suggested that herbs act as powerful antioxidants and affect immune cells and cytokine production associated with autoimmune responses.9-11
Specifically, a number of herbs, such as radix Curcuma wenyujin, Tripterygium wilfordii, Artemisia annua, and Berberis vulgaris have shown a promising effect in inhibition of the helper T-cell inflammatory response, including Th1 and Th17,9-11 which are now known to be predominant in the pathogenesis of systemic lupus erythematosus (SLE) and psoriasis.12,13 A recent systematic evaluation of 25 randomized controlled human trials supported the use of oral CHT to be as effective as acitretin, and CHT seems to have an add-on effect to acitretin for the treatment of psoriasis vulgaris.14 Meanwhile, a cohort study assessing 23,084 human patients with SLE revealed that oral CHT improved survival in 40.15% of SLE patients with a significantly decreased risk of death (hazard ratio=0.73) compared with patients who did not receive CHT.15
Discoid Lupus Erythematosus in a Dog
A 4.5-year-old, male neutered mixed-breed dog was diagnosed with discoid lupus erythematosus by a veterinary dermatologist. Despite an 8-month course of prednisone (1.7 mg/kg PO q24h), the patient’s nasal lesions were still erythematous, depigmented, and crusted on the dorsal nasal planum, with fissures and depigmentation around and in the nares (FIGURE 1). The owner elected to try TCVM before adding another immunosuppressive agent.
The patient sought out cool areas, and TCVM findings revealed a warm body, red eyes, dry skin, pale tongue, and thin pulses. A pattern of Blood Heat and Blood Deficiency was identified. Based on pattern differentiation, the patient received monthly acupuncture with acupoints and daily CHT, along with prednisone (0.5 mg/kg PO q24h).
After 3 months of TCVM treatments, the nasal lesions were significantly improved (mild depigmentation, erosions, and crusting). They were completely healed after another 3 months of treatment with acupuncture, CHT, and prednisone.
Pemphigus Foliaceus in a Dog
A 3.5-year-old, female spayed Labrador retriever with pemphigus foliaceus was referred for TCVM treatment after 9 months of conventional treatment consisting of 0.1% tacrolimus ointment q12h, Synotic otic solution (zoetisus.com) q24h, and niacinamide (500 mg PO q8h) with minimal improvement. She was also receiving cetirizine (20 mg q24h) for chronic skin allergies.
Canine pemphigus folaceus nasal lesions are characterized by depigmentation and mild, shallow erosions (FIGURE 2). On TCVM examination, the patient had a warm body with warm ears, dry skin with dandruff, dry paw pads, a dry pale tongue, and deep, weak pulses. The patient did not have a preference for cool areas over warm areas. A pattern of Yin and Blood Deficiency was diagnosed.
Based on pattern differentiation, the patient received acupuncture every 3 months with acupoints and daily CHT. All other medications were discontinued. Nine months later, on the fourth visit, the patient’s nasal lesions were completely healed, with normal pigmentation. Her skin allergies were also improved. These case reports illustrate the possibility of benefit for these modalities. These modalities may not be appropriate in all cases, nor should they replace more commonly documented treatments.
As human and laboratory-based scientific literature demonstrate the analgesic, anti-inflammatory, and immunomodulatory effects of acupuncture and CHT, TCVM can be a reasonable adjuvant to conventional therapy in AD patients, especially patients that are resistant to or intolerant of conventional drug therapy. With proper training, TCVM modalities (specifically acupuncture and CHT) can be easily implemented in clinical settings to empower Western practice for better patient-centered care. Practices that do not offer TCVM can refer patients to veterinarians with TCVM, CVA (certified veterinary acupuncturist), CVCH (certified veterinary Chinese herbalist), or CVCHM (certified veterinary Chinese herbal medicine) credentials (BOX 1).
Because CHT products are not rigorously regulated, veterinarians must remain vigilant when selecting CHT for patients to ensure the quality and safety of such products. CHT should be used only by practitioners who have received appropriate training. Finally, the efficacy of TCVM needs to be better defined through more adequately sized randomized controlled studies to bridge the gap between complementary medicine and evidence-based medicine.
1. Memon MA, Shmalberg J, Adair HS, et al. Integrative veterinary medical education and consensus guidelines for an integrative veterinary medicine curriculum within veterinary colleges. Open Vet J 2016;6(1):44-56.
2. Budgin JB, Flaherty MJ. Alternative therapies in veterinary dermatology. Vet Clin North Am Small Anim Pract 2013;43:189-204.
3. Ma C, Sivamani RK. Acupuncture as a treatment modality in dermatology: a systematic review. J Altern Complement Med 2015;21(9):520-529.
4. Xiang Y, Wu X, Lu CJ, Wang K. An overview of acupuncture for psoriasis vulgaris, 2009-2014. J Dermatolog Treat 2017;28(3):221-228.
5. Lim HD, Kim MH, Lee CY, Namgung U. Anti-inflammatory effects of acupuncture stimulation via the vagus nerve. PLoS One 2016;11(3):e0151882.
6. Yang EJ, Sekhon S, Beck KM, et al. Neuromodulation in inflammatory skin disease. Dermatol Ther (Heidelb) 2018;8(1):1-4.
7. Coyle M, Deng J, Zhang AL, et al. Acupuncture therapies for psoriasis vulgaris: a systematic review of randomized controlled trials. Forsch Komplementmed 2015;22(2):102-109.
8. Yeh ML, Ko SH, Wang MH, et al. Acupuncture-related techniques for psoriasis: a systematic review with pairwise and network meta-analyses of randomized controlled trials. J Altern Complement Med 2017;23(12):930-940.
9. Asadi-Samani M, Bagheri N, Rafieian-Kopaei M, Shirzad H. Inhibition of Th1 and Th17 cells by medicinal plants and their derivatives: a systematic review. Phytother Res 2017;31(8):1128-1139.
10. Ma HD, Deng YR, Tian Z, Lian ZX. Traditional Chinese medicine and immune regulation. Clin Rev Allergy Immunol 2013;44(3):229-241.
11. Huang CF, Lin SS, Liao PH, et al. The immunopharmaceutical effects and mechanisms of herb medicine. Cell Mol Immunol 2008;5(1):23-31.
12. Talaat RM, Mohamed SF, Bassyouni IH, Raouf AA. Th1/Th2/Th17/Treg cytokine imbalance in systemic lupus erythematosus (SLE) patients: correlation with disease activity. Cytokine 2015;72(2):146-153.
14. Cataldi C, Mari NL, Lozovoy MAB, et al. Proinflammatory and anti-inflammatory cytokine profiles in psoriasis: use as laboratory biomarkers and disease predictors. Inflamm Res 2019;68(7):557-567.
15. Zhang CS, Yang L, Zhang AL, et al. Is oral Chinese herbal medicine beneficial for psoriasis vulgaris? A meta-analysis of comparisons with acitretin. J Altern Complement Med 2016;22(3):174-188.
16. Ma YC, Lin CC, Li CI, et al. Traditional Chinese medicine therapy improves the survival of systemic lupus erythematosus patients. Semin Arthritis Rheum 2016;45(5):596-603.
17. Bizikova P. Immune-mediated dermatologic disorders. In: Côté E, Ettinger SJ, Feldman EC, eds. Textbook of Veterinary Internal Medicine: Diseases of the Dog and Cat. 8th ed. Philadelphia, PA: W.B. Saunders; 2017:2161-2186.
18. Viviano KR. Update on immunosuppressive therapies for dogs and cats. Vet Clin North Am Small Anim Pract 2013;43(5):1149-1170.
19. Xie H, Preast V. Diagnostic methods. In: Traditional Chinese Veterinary Medicine Fundamental Principles. 2nd ed. Reddick, FL: Chi Institute Press; 2013:205-260.
20. Hou W, Xu G, Wang H. Overview of Chinese medicine and autoimmune diseases, and the role of Yin deficiency. In: Hou W, Xu G, Wang H, eds. Treating Autoimmune Disease with Chinese Medicine. [Kindle ed.] London, UK: Elsevier Health Sciences; 2014:13-52.
21. Flaws B, Sionneau P. The Treatment of Modern Western Medical Diseases with Chinese Medicine: A Textbook & Clinical Manual. Boulder, CO: Blue Poppy Press; 2005:517-527.