Childhood pustular psoriasis —— A case of a patient treated with traditional Chinese medicine

Liu Jun(刘君), Zhang Juncha(张俊茶), Pan Lijia(潘丽佳), Zhang Xiaoqi(张晓琪), Du Xiaoyi(杜潇怡), She Yanfen(佘延芬)＊, and Gao Weijuan(高维娟)＊

Childhood pustular psoriasis —— A case of a patient treated with traditional Chinese medicine

Liu Jun(刘君), Zhang Juncha(张俊茶), Pan Lijia(潘丽佳), Zhang Xiaoqi(张晓琪), Du Xiaoyi(杜潇怡), She Yanfen(佘延芬)＊, and Gao Weijuan(高维娟)＊

Generalized pustulous psoriasis is characterized by the sudden onset of diffuse erythema, with a scattering of pustules, sometimes with fever and others symptoms. It is a relatively rare disease1. The treatment of traditional western medicine have various adverse drug reactions and easy to recur. Meanwhile, this report describes a 12-year-old female patient of generalized pustulous psoriasis with a satisfactory effect of traditional Chinese medicine.

Generalized pustular psoriasis; Traditional Chinese medicine; Satisfactory effects

INTRODUCTION

Generalized pustular psoriasis (GPP) is a rare type of psoriasis first described in 1910 by Von Zumbusch and it is considered the most severe type of this disease2. GPP in children is rare. Baker et al3. had done a clinical and epidemiological study of 104 cases with only 5 cases of children. In china, there were less than 100 children with GPP described in medical literature in ten years4-6This article reports a 12-year-old female case diagnosed as GPP and treated with western medicine, but the efficacy was unsatisfied.

However, she was treated with Chinese herbal decoction combined with acupuncture, and cupping therapy in our clinic with satisfied curative effect.

CASE REPORT

Female patient, 12 years old, had taken part in a swimming class in summer holiday, skin erythema appeared in October, 2012. The skin lesion exacerbationed and presented pruritic punctuated papules and pustules spread on her body, including both arms and legs, abdomen, neck, chest and back, then she was finally admitted to hospital in April, 2013.

Relevant laboratorial examinations indicated that there were polymorphonuclear leucocytes of 49.9 (Reference Value-RV: 50.0 to 70.0); platelets of 378 mil/mm3(RV: 100 to 300 mil/mm3); albumin and globulin ratio of 1.45 (RV:1.50 to 2.50 ); phosphorus of 1.61(RV: 0.8 to 1.60). Chest X-ray was normal and no histology test was carried out. In hospital. The patient was medicated with glucocorticoids including injection, oral, and topical ointment for one month. The symptoms were temporally alleviated, but patient’s condition rebounded following stopping medication. So the patient came to our outpatient clinic in June 2013, and wanted to cure her disease with traditional Chinese medicine.

The patient was treated with Chinese herbal decoction orally combined with acupuncture, and cupping therapy. The Chinese herbal prescription was composed of 20 crude drugs, such as Jinyinhua (Honeysuckle) 30g, Lianqiao (Forsythia suspense) 30g, Zicao (Lithospermum) 30g, Huaihua( Sophora flower) 30g,Shengdi (Rehmannia) 10g, Chishao (Radix paeoniae rubra) 10g, Danpi (Cortext moutan) 10g, Baijili (Tribulus terrestris) 10g, Baixianpi (Cortex dictamni) 10g, Huzhang (Polygonum cuspidatum) 10g, Shepi (Snakeskin) 10g, Jiangcan (Stiff silkworm) 10g, Chantui (Periostracum cicada) 6g, Difuzi (Belvedere fruit) 10g, Shechuangzi(Fructus cnidii) 10g, Huangqi (Astragalus membranaceus)10g, Dangshen (Codonopsis pilosula)10g, Danggui (Angelica sinensis)10g, Shuiniujiao (Cornu bubali) 30g, Daimao (Turtle) 20g.The crude drugs were boiled in 200mL water for 30 minutes (Shuiniujiao and Daimao were boiled 60 minutes). All crude drugs were decocted twice to obtain oral decoction for one day. What’s more, antelope horm silk 30g decocted for drinking tea. Meanwhile, the patient was treated with blood letting of ear acpoints, back cupping therapy and for three days. We chose the Erjian acpoint, which was behind the era and the earlobe for blood letting intravenously.And then we chose the reaction area of liver, spleen, stomach, lung, ovary, paranephros, shenmen, fengxi in ear, for auricular-plaster therapy. As for back cupping therapy, we chose the acupoints of dazhui, feishu, geshu for pricking blood, which was followed by cupping.After two months, the aforementioned symptoms disappeared. The relevant laboratorial examinations of blood and urine were normal. No skin lesion reappeared as yet.

Figure 1 (the neck before treatment)

Figure 2 (the neck after treatment)

Figure 3 (the hand before treatment）

Figure 4 (the hand after treatment)

Figure 5 (the abdomen before treatment)

Finger 6 (the abdomen 20 days after treatment)

Finger 7 (the abdomen 30 days after treatment)

Figure 8 (the abdomen recovery after treatment)

DISCUSSION

At present, the etiolo gy and pathogenesis of psoriasis are not clear. Infection, mental factors or inappropriate treatment, metabolic or endocrine disorders, immune factors, and hereditary predisposition, etc., may be connected with psoriasis. Compared with adult, GPP is rare in children with atypical genetic background7, and a higher prevalence is in the male sex. In this report, the patient is a 12-year-old female, and have no hereditary predisposition for psoriasis. Her symptoms presented after swimming. We hold that her disease is associated with infection of environmental factors.

Perhaps due to the rarity of the disease, there is few effective drugs and prevention drugs of the disease, and there is no standardized treatment of GPP. A safe and consistently effective treatment for the disease is very important and urgent. At present, the treatment of GPP is mainly oral drugs, including systemic retinoids, cyclosporine A, Glucocorticoid, UVA +psoralen(PUVA), UVBnb, methotrexate(MTX), Tigason, dapsone, and Leigongteng (Tripterygium wilfordii), etc.8-12. Above drugs are effective but hey are with adverse drug reaction in children. For example, MTX and hydroxyurea have the certain side effects. Tigason may have certain effect on children’s bone development. Freekman, etc.13found that two cases of GPP treated with PUVA and they have got acute leukemia and early leukaemia. Hematological malignant change may be PUVA damage hematopoiesis thousand cell DNA. Although corticosteroids has good effect on GPP, symptoms easily repeatedly, and form the vicious circle of bounce-repeatedly added amount with more serious adverse reactions, and there are many death cases died of complications7. Corticosteroids is considered to use only in the condition of other drugs are invalid or intolerable14. There is an opinion on treatment of children GPP, combination of drugs is the best choice, but there are adverse reactions. There is a report that a female patient was treated with MTX, cyclosporine and PUVA method, and then her lesion appeared repeatedly, what’s more this patient has got serious complications15. The traditional treatment of Western medicine is not safe and effective for children.

In this report, the patient was treated with glucocorticoids in hospital but the effect was not obvious with symptoms reappeared. Hormone therapy only temporarily relieved symptoms, rather than curing the disease completely. Chinese herbal medicine treats patients on an individual basis in which the prescription will vary depending on each patient’s clinical manifestation (eg, the tongue, the pulse, individual symptomsand signs)12. According to the diagnosis of traditional Chinese medicine,the most important pathological mechanism of GPP is fire-evil and heat-evil, so we adopted Chinese herbs with clearing heat antitoxicant and relieving itching.The prescription was based on the Xijiao Dihuang decoction to add and subtract. The function of the Xijiao Dihuang decoction is clearing heat and removing toxicity, cooling blood and dissolving purpura.It is mainly used for heat into bloodstream.The Chinese herbs we used can be divided into three parts: clearing heat and cooling blood, clearing heat and removing toxicity,dispelling wind and arresting itching. The Chinese herbs of clearing heat and cooling blood included Zicao, Huaihua, Shengdi, Chishao, Danpi, Shuiniujiao. The Chinese herbs of clearing heat and removing toxicity included Jinyinhua, Lianqiao, Huzhang, Daimao, Ling yangjiaosii. The Chinese herbs of dispelling wind and arresting itching included Baijili, Baixianpi,Shepi,Difuzi,Shechuangzi, Shepi, Jiangcan, Chantui.In addition to these herbs, we also added some qitonifying drug and hematinic,which were Huangqi, Dangshen and Dang gui. This prescription we used Lingyangjiaosi, Daimao and Shuiniujiao to replacing rhinoceros horn, because the rhinoceros horn was foribidden. Huo HM and Xu J used blood letting in treating dermatoses, such as chronic urticarial and acne vulgaris16,17. So we used the blood letting of ear points and back cupping therapy to treat GPP. The mechanism of the treatment is the same with the treatment of dermatoses with blood letting.. Through two months of treatment, the patient recovered and there was no recrudesce up till now. There was neither liver or kidney adverse reaction in the patient.

CONCLUSION

Therefore, the case showed that Chinese herbal medicine is an effective and alternative treatment option for patients with AGG, especially for GPP in children. There was no complications and adverse effects noted during the traditional Chinese medicine treatment. So we are looking forward to Chinese herbal medicine curing more patients with AGG in the future.

REFERENCES

1 Zelickson BD, Mullar SA. Generalized pustular psoriasis. A review of 63 cases. Arch Dermatol, 1991(127): 1339.

2 Khan SA, Peterkin GA, Mitchell PC. Juvenile generalized pustular psoriasis. A report of five cases and a review of the literature. Arch Dermatol, 1972(105):67-72.

3 Baker H , Ryan T J. Generalized pustular psoriasis: a clinical and epidemiological study of 104 cases. Br J Dermat ol, 1968(80): 771.

4 Chen Wei, Zhang Guangzhong, Zhou Dongmei, et al. Experience of professor wang on generalized pustular psoriasis in children. Journal of Sichuan of Traditional Chinese Medicine, 2011, 29(5): 8-9.

5 Tao Jianfeng, Guo Yifeng, Yu Hong,et al. The clinical and pathological analysis of 32 children with Zumbusch pattern of generalized pustular psoriasis. J Clin Pediatr,2007, 25(4): 292-295.

6 Wu Zhuoxuan, Hu Rongyi, Zheng Liang, et al. A case of childhood generalized pustular psoriasis. The Chinese Journal of Dermatovenereology, 2012, 26(2): 179,184.

7 Wang Huiying, Liu Chenghuang. Pustular psoriasis: a clinical analysis of 27 cases. Journal of Clinical Dermatology, 1988, 17: 5.

8 Baker H. Generalized pustular psoriasis. In: Roenigk HH Jr, Maibach HI, eds. Psoriasis. New York: Marcel Dekker, 1991:35-45.

9 Yu HJ, Park JW, Park JM, Hwang DK, Park YW. A case of childhood generalized pustular psoriasis treated with dapsone. J Dermatol, 2001(28): 316-319.

10 Dogra S, Kumaran MS, Handa S, Kanwar AJ. Methotrexate for generalized pustular psoriasis in a 2-year-old child. Pediatr Dermatol, 2005(22):85.

11 Ergin S, Ersoy-Evans S, Sahin S, Ozkaya O. Acitretin is a safe treatment option for infantile pustular psoriasis. JDermatolog Treat,2008(19):341.

12 Al-Shobaili H, Al-Khenaizan S. Childhood generalized pustular psoriasis: successful treatment with isotretinoin. Pediatr Dermatol, 2007(24): 563.

13 Freeman,ect.A case of oral 8 -Mop and UVA rays treatment silver crumbs Patients with acute mononuclear leukemia. Clin Exp Dermotal, 1985,10(2):144.

14 Cui Pangen, L iu X unquan,Chen K un, et al. I An Analysis of 23 Inpatients with General ized Pustular Psor iasis in Children. Chin J Dermatol, 1996, 29(6):405-407.

15 Laura de Sena Nogueira Maehara. Acute respiratory distress syndrome as a complication of generalized pustular psoriasis.An Bras Dermatol, 2011,86(3):579.

16 Huo HM. Efficacy observation on acupuncture combined with bloodletting for chronic urticarial.Zhong guo Zhen Jiu, 2014, 34(1):41.

17 Xu J, Lin R, Wang J, Wu Y, Wang Y, Zhang Y, Xi C, Wu Q.Effect of acupuncture anesthesia on acne vulgaris of pricking-bloodletting cupping: a single-blind randomized clinical trail.J Tradit Chin Med, 2013,33(6):752.

（Accepte: March 17, 2016）

Hebei college of traditional Medicine, Shijiazhuang 050000, China Funding: Natural Science Foundation of Hebei Province (H2013206097)

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