Treating Red Skin Syndrome with Traditional Chinese Herbal Medicine

Over the last few months, several of my eczema patients have brought up Red Skin Syndrome and asked for my thoughts on it.

This syndrome was named by a California dermatologist, Dr. Marvin Rapaport, who concluded after decades of dermatology practice that Red Skin Syndrome happens as a result of long-term use of topical steroids in the treatment of eczema. This is especially true in the case of atopic eczema (atopic dermatitis) – the most likely of the eczemas to turn into red skin syndrome as a result of topical steroid use. In fact, it was determined that the use of these steroids, steadily and long-term (over months and years), makes eczema much worse. This happens because the skin develops a tolerance, and indeed an addiction to the steroids, requiring higher potencies and more frequent applications in order to have any effect.

With this type of long-term topical steroid use, the dermis and epidermis become thinned, damaged, more inflamed, and inelastic; they lose their ability to modulate inflammation and immune response, and to properly respond to temperature, humidity, irritants, and allergens. In addition, the microbial flora of the skin may also be disrupted; our skin flora is very much similar to the gut flora in that it is populated my many good bacteria and essential oils which control bad bacteria like staphylococcus, and regulate proper immune response in the skin.

However, if the sufferer attempts to stop the steroids, there is significant rebound inflammation, with ever-worsening redness, itching, flaking, and oozing – symptoms altogether much worse than the original presentation ever was.

According to Dr. Rapaport, some key features of red skin syndrome include:

• A long history of topical steroid use, increasingly ineffective;
• Severe, long-term, and often body-wide eczema that is very red;
• The inability to stop or reduce steroids without significant rebound and worsening of symptoms;
• Burning, pricking pain in the affected skin, fever and chills when severe;
• Thinning skin that looks waxy plastic, with paper cuts or deep fissures, or thick, wrinkled (lichenified) skin that looks much older than the patient’s age;
• Paradoxical symptoms of dryness and wetness – i.e. weeping from dry looking fissures;
• And the classic sign, according to proponents of this syndrome: a sleeve of red skin on the forearms, most visible on the inside, and stopping at the wrist. Palms tend to be white, but the back of hands and tops of feet are very red.

As a practitioner who has seen hundreds of eczema cases, I recognize this presentation right away. It is the most severe of the cases that I see and, initially in my practice, it was the most difficult to manage. Now, after years of practice and having learned some crucial lessons along the way, I’m much better at treating it.

Treatment Strategy

Patients with this condition usually decide they want to stop the topical steroids, but are not sure how to go about it, so making a plan about this is the first step. The Red Skin Syndrome Association (www.itsan.org) recommends ‘cold turkey’ withdrawal, but I strongly disagree with this. The flare-up produced by suddenly stopping steroid use can create a runaway train which is much harder to control, and which may even require hospitalization, especially in the case of children.

It is infinitely better to wean off methodically and slowly, over a few weeks, while introducing the herbal therapy that will take over from the steroids. I do this much more slowly now than I used to do. There may still be a period of discomfort as the skin adjusts to the changed circumstances, but it will be nowhere near as bad as the cold turkey, overly rushed, approach. The tortoise will definitely beat the hare on this one.

In terms of the Traditional Chinese Medicine treatment itself, red skin syndrome presents some unique challenges.

Firstly, the use of steroids, while not entirely controlling the condition, may nonetheless be masking or distorting some of the presentation. So I have come to understand that my diagnosis will be rapidly evolving over the first few weeks. Reducing the steroids bit by bit will be like peeling an onion; once the steroids are out of the picture completely, the naked truth about the patient’s baseline will be revealed: how much the skin tends to weep, how stubborn the condition is, its own peculiar cycles, how responsive to treatment, and the worst affected areas, triggers, etc.  At this point, the real therapeutic duel begins by matching the herbs, as exactly as possible, to the patient’s true presentation –  this is the lynchpin to any curative TCM treatment.

I have also learned to be more patient, and not to expect the same fast response from this treatment for red skin syndrome as the response usually seen from treatment of the less complicated eczemas. It will necessarily be a longer road; for some a year or more will not be out of the question – especially if there is a considerable amount of skin damage. But this year of therapy will be characterized by steady improvement throughout, with more and more areas of the skin returning to normal, and flares occurring both further apart, and less severe each time.

The Role of Herbs

Another change I’ve made when treating this particular condition is to try to simplify my herb formulas. This is not always easy to do as the severity and multiplicity of symptoms seem to beg for a big arsenal. But I’ve learned that, when possible, ‘less is more’ in this regard; the treatment will be better tolerated long-term, and it will be easier to judge what is happening when fewer ingredients are used, especially during the crucial first few weeks of substituting herbs for steroids.

Paying close attention to the taste of herbs is also important. It is best to select herbs that are cooling and detoxifying without being too bitter, or to toast bitter herbs in the oven to make them less so. This is because, while bitter herbs are very cleansing, detoxifying, and anti-inflammatory, they are also drying, and this may easily become a problem for someone whose skin is already dried and atrophied from years of steroid use. Some favorite sweet and cold herbs are Lonicera flower and stem, Coix seed, Smilax rhizome, Alisma rhizome, and Poria mushroom.

After three months or so, we should be able to reach cruising altitude with red skin syndrome. In my experience, the flying analogy is apt as it’s the take-off and landing of treatment that are the trickiest to execute. Landing – i.e. coming close to a complete cure and looking to wrap up treatment – can have its pitfalls, both psychological and therapeutic. At landing, we often change the formula from anti-inflammatory herbs to moistening and repairing herbs, but doing this too soon can elicit a new flare-up. Timing is everything.

Lastly I pay attention to, and ask questions about, what kind of moisturizers people with red skin syndrome use, as these may unwittingly be making things worse. The rule of thumb is: the more redness and weeping there is, the more water-based the moisturizer needs to be (or none at all).

When oily products like shea butter, coconut oil, or beeswax/oil salves and ointments are used on such skin, they will insulate and trap the heat, and ooze – making things worse, with many developing pustules as well. The fact that these products may be all natural is beside the point; their oiliness is the problem. Matching moisturizers to the season is also important. Where an oily ointment may have a deleterious effect during hot, sweaty and humid summer conditions, it may be helpful in the winter. This is another example of the Traditional Chinese medicine mindset: customize, customize, customize – and assess everything in the context of the moment.

I also recommend washing less, certainly avoiding soap as much as possible, but even plain water. Our chlorinated water can dry the fragile eczema skin too much, setting up an unnecessary cycle which will only seem to require more heavy moisturizers, and so on.

In fact, the notorious and seemingly indomitable dryness of eczema is due to Toxic Heat raging in the blood and scorching the fluids. Once this Fire Toxin is subdued, moisture will return to the skin remarkably quickly, and the skin will now be able to retain it on its own, with barely any moisturizer needed. Think of a pot of water that keeps boiling dry on the stove. Yes, you can keep adding more water, but better yet – through Traditional Chinese Medicine, you can finally turn off the heat.