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TREATMENT OF VITILIGO WITH CHINESE HERBS

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

Vitiligo is a skin condition characterized by white patches (hence, its alternative name, leukoderma; leuko = white; derma = skin). These skin patches are missing the skin pigment melanin; in most cases, the condition is triggered by sunburn. Normally, excessive sun exposure first causes skin reddening, followed by peeling of the outer skin layers, and formation of darker skin in the exposed area ("tanned" skin). However, in some cases, a reaction occurs in which the melanin production is blocked and the skin loses its color. The patches of white are usually at the site of the burn, but it is also possible for additional patches to begin appearing elsewhere. Genetic factors are believed to contribute to susceptibility to experiencing vitiligo, and the condition might be triggered by conditions other than sunburn, such as viral infections and physical trauma to the skin. The disorder appears to have an autoimmune characteristic, in which melanocytes (melanin producing cells) are attacked and destroyed. Vitiligo first appears by age 20, though it can begin later.

The primary treatment for vitiligo for the past several decades has been PUVA (psoralen and ultra-violet A). Psoralen is a chemical compound derived from herbs, especially from Psoralea cordyfolia, a Chinese herb that has been used for centuries to treat vitiligo. There is a broad group of related chemical components, called psoralens, which have the same basic action (see illustration below). Ultra-violet A is light in the UV spectrum that is one frequency range that causes sunburn (in fact, most lotions that block sun burn previously had been designed to block the more intensive UV-B light, but it was recently found that this is insufficient protection, so UV-A blocking is currently advertised for all new products). Psoralens are photo-activators: they make normal skin more susceptible to sunburn. Combining psoralens and sunlight would cause sunburn; in the therapeutic setting, the amount of psoralen and the amount of UV-A is carefully controlled to avoid sunburn and to attempt to rejuvenate affected malanocytes. In traditional practice, the amount of psoralen applied and the amount of UV exposure from sunlight was not controlled, and probably led to variable responses that could be minimized by carefully observing the effects each day.

PUVA therapy is not very satisfactory except for small patches; while some people respond well, the majority attain only partial pigmentation and are not happy with the results (1). The therapy is disruptive, in that it may need to be applied repeatedly (with individual office visits) for many weeks. Over-the-counter, self-applied psoralens have been developed as an alternative; while more convenient, this doesn't necessarily improve the outcomes. The PUVA method is most effective when vitiligo is limited to only one or two clearly defined patches, and less useful when there are multiple patches.

Chinese medicine has been applied to treating vitiligo, and many of the treatments involve combine topical and internal use of psoralea seed extract, rich in psoralens. As with PUVA, there is limited success by this method. However, herbal formulas aimed at treating autoimmune disorders and those aimed at systemic improvements (especially in the blood components) may have a better effect. Reports of successful treatment appear from time to time in the Chinese medical literature and some clinics advertise their treatments with before and after pictures of successful cases. Complex patent herbal medicines and topical applications for vitiligo-aside from psoralea extracts-have been produced by several factories. Some of the Chinese therapies offered are depicted in the following pages, based on their presentation via websites, with editing to improve their clarity. After the descriptions from five clinical sites (in no special order), a summary of the therapies and their effects is provided along with the descriptions found in Chinese medical texts.

1. Dr. Ming's TCM Medical Center, Hua Xi Xiao Yuan, Huaihua City, Hunan (2)

The main therapeutic principle for treating vitiligo is nourishing the kidney, promoting blood circulation, and dispelling pathogenic wind. There are three alternative recipes for internal use and a topical therapy.

Compound Tablet of Tribulus: the main herbs are tribulus, spirodela, ho-shou-wu, xanthium, tang-kuei, scorpion, carthamus, and cnidium. The herbs are ground into fine powder to make tablets. Take 10 grams each time, three times a day.

Recipe by physician Yang Hengyu: the main herbs are astragalus, tang-kuei, peony, red peony, raw rehmannia, cooked rehmannia, ho-shou-wu, lycium, cuscuta, cnidium, tribulus, angelica, persica, and carthamus. The herbs are to be decocted in water for oral administration.

Shou Wu Decoction: the main herbs are ho-shou-wu, black sesame seed, peony, red peony, albizzia, raw rehmannia, cooked rehmannia, prunella, astragalus seed, gentiana, carthamus, polygala, tang-kuei, salvia. The herbs are to be decocted in water for oral administration.

External Treatment [note: this formulation contains toxic heavy metals and is not suitable for use outside China]: Grind 5 grams each of realgar, sulfur and typhonium tuber, 2 grams of litharge, 15 grams of cnidium fruit and 0.5 grams of calomel into fine powder and mix with vinegar for application on the affected part, twice a day, the or use ginger to dip powder to rub the affected part, twice a day. The patient must be treated this way for more than 3 months.

2. Xianchen Institute for Vitiligo (3)

The pathogenic factors of vitiligo are mainly: heat in the blood or bodily heat; invasion by exogenous wind or damp, which invade into the skin resulting in disorder of the circulation of qi and blood at the surface; and blockage of the channels and vessels (thus, the blood cannot nourish the skin leading to qi-stagnation and hair-orifices blocked). Because the hair-orifices are blocked, the affected skin looks glossy.

Vitiligo usually develops rapidly in the spring and summer. In some cases a feeling of itching precedes expansion of the white patches. If a patient's constitution is worsened by bad morale or by some exogenous factors, the pathological conditions advances continuously. Quite a few patients miss the best time for treatment of the disease, when it first appears, trusting that it will simply resolve spontaneously; once the area affected becomes bigger than the original spots, the time required to cure the disease will be longer.

We believe that to treat the ailment completely, one should rely on traditional Chinese medicine to regulate the qi and blood, clear away the heat, activate the blood circulation, and dredge the channels and vessels in order to support the healthy energy and strengthen the body resistance. A series of vitiligo-resolving medicines developed by the Xianchen Institute for Vitiligo are manufactured with genuine Chinese herbs, which are non-toxic, produce no side effects, and require a relatively short term of treatment to attain a rapid and permanent effect. The herb preparations are applied topically and taken orally in convenient form; as a result of treatment, there is rarely a recurrence of vitiligo and there is a high rate of improvement, reaching 98% and a cure rate over 80%. Vitiligo is a kind of obstinate ailment, so the treatment time period might be long; however, the disease isn't incurable. During the course of treatment, one should follow closely the instructions for using the herbs, and maintain a good mental state, to get the desired results. Persons with vitiligo should avoid direct sun exposure and prolonged living in a damp environment, avoid air conditioning when sweating, maintain a regular living habit, and avoid some potentially irritating foods such as shrimp, crab, lamb, chili and other spices. If white patches begin to appear, they should be treated as earlier as possible.

The following series of vitiligo-resolving patent drugs (made by the Pharmaceutical Center of the Affiliated Hospital at Heilongjiang College of Traditional Chinese Medicine) are used at the clinic.

Vitiligo-Resolving Capsule: for oral use, to regulate qi and blood, clear away heat, promote blood circulation, dredge the channel and vessels, and support the resistance to disease. The red box is contains the herbs to be taken on odd days and those in the green box on even days; do not use these herbs during pregnancy.
Vitiligo-Resolving Liniment: for external application, to promote qi, dredge the channels, extinguish wind, and resolve dampness. The frequency and duration of applying the liniment are not limited, however the time for administration on each affected site every day should total not less than two hours: longer application is better. 100ml a bottle.
Vitiligo-Resolving Lotion: Granules prepared in hot water for use in washing the affected skin; it is used to dredge the channels and vessels, activate qi and blood circulation, and open the hair-orifices (sweat pores). This is mainly used when the disease has been present a long time, and affects a large area, or when the hands and feet are affected. 250g a bag.
Vitiligo-Resolving Lotion: Liquid for external use, its actions are to dredge and vitalize the channels and vessels, promote qi and blood, and open hair-orifices. It is suitable for relatively recent onset of vitiligo affecting a small area. 120ml a bag.
Vitiligo-Resolving Paste: This paste is used to promote qi, dredge the channels, extinguish wind, and resolve phlegm. This serves as a substitute preparation for the liniment when the affected part is an area not suitable for treatment with a thin liquid wash. 10g a box.

The Xianchen Clinic is near the ITM office in Harbin, headed by Dr. Fu Kezhi, who visited the clinic to learn more. This is his report (4):

I just went to visit Doctor Wang Xianchen at his office of Hengfa Pharmaceutical Ltd Co. I got some information about the treatment for vitiligo from him regarding use of his preparation which has been approved as a patent drug, Heilongjiang Medicine Disinfectant (2002) No. 0632, by Heilongjiang Drugs Administration. The drug is manufactured at another factory in Harbin and sold in batches by his own Hengfa company on the markets. Since 1988, he has set up a clinic in Harbin, named Wang Xianchen's Institute for Vitiligo.

Dr. Wang Xianchen is a dermatological physician of traditional Chinese medicine through self-study, and his formula in treating vitiligo was based on his own prescription handed down from his family ancestors. In 1996, he attended an international Symposium of TCM in Los Angeles and then in 1997 in Hong Kong, where he had given a report of his "Clinical observation on 300 cases of vitiligo treated with a secret prescription handed down from my family ancestors." In 1999, he published a research article "Vitiligo-resolving capsule in treating 349 cases of vitiligo" in the Chinese Journal of Traditional Medical Science and Technology.

The commercial name of his patent drug is Xiao Dian Ling (Vitiligo-Resolving Liniment), which was prepared in liniment form. The drug is frequently used to treat vitiligo patients at his private clinic, occasionally, an ultraviolet irradiation might be necessary to be applied at the same time. However, for most of vitiligo patients, especially those with better physical constitution, only the liniment is needed, and used for a course of 2-4 months, while the ultraviolet irradiation is unnecessary. If a patient applies the preparation strictly according to Dr. Wang's instructions, it produces a better result; for responsive cases, the effectiveness of the treatment is improved further by applying the liniment for a longer time continuously. If a foreign patient wants to purchase the vitiligo drugs for the treatment of his illness, first, the patient should send a colored picture showing of the affected part and provide relevant medical history by a registered letter sent by air-mail (EMS) to Dr. Wang's office at the Hengfa Pharmaceutical Co., mail address: 1^st Qianshan Road, Building No. 15-A, 5^th Flat, High New Technique Area, Nangang District, Harbin 150090, China, then he can give advice to the patient about how to use the drugs for his illness. The price of the Xiao Dian Lin is Chinese $139 a bottle (about US $16.80/bottle). The information accompanying the vitiligo-resolving liniment is as follows:

XIAO DIAN LING
An External Applying Liniment to Resolve Vitiligo

Ingredients: ho-shou-wu, cnidium fruit, pomegranate rind, carthamus, artemisia, pseudolarix, pharbitis, and portulacca.

Description and Properties: a brownish liquid, 100 ml per bottle; shelf-life, two years.

Actions and Uses: it has a strong action killing bacteria and fungi, eliminating pathogenic skin bacteria, such as staphylococcus, colibacillus, candida albicans, etc., and suppresses various bacterial infections that may occur at the site of vitiligo.

Administration and Dosage: for externally applying only, dip a little of the liquid with a sterilized cotton roll-swab to rub rotationally by clockwise, 20-30 minutes a time, three or four times a day, the more times the better results, totally, at least two hours per day; it should produce no side effects. For an obstinate condition of vitiligo, one can use an infrared lamp or other heat lamp to heat the affected skin area to about 105 ºF first, that can cause the dermal pores to open. Then apply the liquid while rubbing the skin in a circular motion while heating.

Course of Treatment: for a milder case of vitiligo, 1-2 months is a course of treatment, and for the more severe case, 2-4 months is a course (usually, after applying the liniment for one course, one is able to achieve an obvious effect, but the total treatment time may be longer).

Precautions: do not apply in cases with eczema or an allergic condition.

Dr. Wang Xianchen has also recommended herbal formulas for internal use corresponding to the four differentiated syndromes. If the vitiligo developed rapidly or is a more severe case, the formulas can be taken in appropriate amounts while the liniment is being used topically:

Formula 1 (for insufficiency of the spleen and stomach): 10g lotus leaf, 10g chrysanthemum, 20g stir-fried coix, 30g lycium fruit, 50g astragalus, 30g atractylodes, 20g crataegus, 30g cornus, 30g codonopsis, 200g crystal sugar, the ingredients are boiled together and taken as a tea throughout the day as convenient.

Formula 2 (debility of qi and blood and deficiency of the kidney): 20 pieces of apricot seed, 50g rice, 50g fresh lotus rhizome, 50g dioscorea, 50g lycium fruit, 50g cornus, 50g jujube, 70g astragalus, 50g tang-kuei. The ingredients are cooked together into a rice gruel; add an appropriate amount of crystal sugar. Take the preparation in the morning and at night.

Formula 3 (blood heat and bodily heat): 100g fresh taro rhizome, 100g round-grained nonglutinous rice, 100g celery, 100g jujube, 50g lotus seed, 10g lonicera flower, 150g crystal sugar. The ingredients are cooked together and taken in the morning and at night.

Formula 4 (kidney yin or yang deficiency): 5 sparrows, 30g cuscuta, 15g rubus, 20g lycium fruit, 20g dioscorea, 20g longan, and 30g scrophularia root. The ingredients are cooked together and taken in the morning and at night.

3. Binzhou Vitiligo Institute In Shandong Province (5)

The Binzhou Vitiligo Institute pursues research, medical treatment, and new medicine development. Under the direction of Dr. Cheng Aihua, we devoted many years to the research of vitiligo and adopted the theory: "treat the dark and light together." That is, treating the whole skin, not just the whitened skin. The research indicates that the medicine developed here can improve microcirculation, adjust autoimmune mechanisms, promote the metabolism of skin cells, and regenerate the melanin. The technology has received science and patent awards in China.

The method of treatment described in 1995 ("New theory in the field of treating vitiligo") involves regulating the qi of the lungs, balancing all the organic functions of organism, and regulating the whole body. We believe that vitiligo is not only the local pigment being lost, but also a kind of general skin change. So, in the course of the treatment, we pursue regulating the whole body, while also treating the skin locally. Our aim is not only to darken the lesion but also lighten the other darkened skin. The locally applied external remedy is aimed at promoting melanin production so that the color of the white patches will become normal gradually. And this is effective for all kinds of vitiligo. The internal remedies are melanin regeneration liquor, melanin regeneration capsule, and melanin regeneration pill; the external remedy is called the melanin regeneration salve. The clinical experience with thousands of patients shows that a certain affect occurs after taking the medicine for just 1-4 days, while the total duration of treatment is often just 2-3 months, though more advanced cases with larger patches may take 3 months or more. The rate of effective treatment is over 98% and the rate of cure is over 84%. The condition rarely recurs.

4. Vitiligo Research Institute of the Shanxi College of Traditional Chinese Medicine (6)

The scientific research personnel at the Vitiligo Research Instituted developed traditional Chinese medicine preparations for vitiligo-a series of Xiaobaidan (reduce white preparation) based on Chinese medicine and pharmacology, combining their clinical experience for many years and consulting the achievements in modern Chinese pharmacology research.

5. Liaoning Qiushi Vitiligo Research Center, Liaoyang, Liaoning Province (7)

Based on an analysis of 2,597 cases of vitiligo, we determined that the cure rate using Chinese medicine therapies for vitiligo with recent onset (within three months) is about 95%; for intermediate cases (more than 3 months, up to 3 years) it is 57%; and for late cases (more than 4 years duration of the condition) it is 33%. No current treatment modalities can offer 100% cure. According to our clinical observations and follow-up, the recurrence rate is only 0.5 % after a complete cure has been achieved.

Most formulations in the special clinics and hospitals are self-made proven recipes. Such preparations were originally approved by drug administrative authorities from the city government, but now from the provincial as well as city governments. Using these proven recipes with flexibility, various hospitals have treated many difficult diseases. The patient should ask the hospital for data on the treated cases, especially examining photos of the patients with vitiligo. The photos should be inspected closely to determine the authenticity. The genuine photos will have clearly-focused images and the fine structure of the skin surface can be clearly visualized, such as the skin fields, villous hair, and follicular orifices. The margins of the lesions are generally sharply defined yet irregular in shape. But for those photos that have been tainted or manipulated technically, the color, the margin and the shape of the lesion are usually unnatural and the image unclear. Therefore the manipulated photos can be identified upon close examination however modified.

The clinical manifestation of effective treatment begins with shrinking of the white patches from the periphery to the center. The margin of the white patches becomes clear (blurred margin is a sign of disease progression). The color of the skin around the white patches is slightly darker than the normal skin. Dark spots (pigmented islands) within the white patches may also appear. About 65% of the patients will show effects within 1 month, 85% within 2-3 months. It is very rare that patients do not show any sign of improvement for more than 3 months. Beyond the initial improvements, the size of the dark spots increases and subsequently coalescence to form large pigmented patches. The smaller patches will disappear and the larger ones will decrease in size significantly. For those who experience a full cure, there is complete disappearance of patches. The repigmented areas may be hyperpigmented and thus appear darker than the surrounding normal skin. The complete recovery of skin color may take more than 3 months. If no effects are observed after 3 months of therapy, then a change of therapy should be contemplated.

During the course of treatment, the patient should be examined by the doctor once a month. Only by careful evaluation of the patient's condition can a doctor adjust the medicine to the patient's symptoms. If a monthly visit to the doctor is not possible, photos of the skin lesions should be sent for examination every 1-2 months. A regular telephone interview (once a month at least) or correspondence with the doctor is necessary to inform the doctor the condition of the disease and reactions to therapy. If the patients can co-operate with the doctors during treatment relatively good results can often be anticipated even for some severe patients.

In the early stage of illness (within 3 months of appearance of the patches) a cure may be achieved with 3-10 months of therapy, on average within 7 months. For intermediate stage (4 months to 3 years), 6 months to 2 years of therapy may be required for a cure, on average within 1 year. For late stage (>4 years) one to 4 years may be needed for a cure, 2 years on average. The size of the lesions also affects the expected duration of treatment: for localized, small patches of grain-size to finger-nail sized lesions, 3-10 months may be needed for a cure; for a single palm-sized lesion, 8-14 months may be required for a cure; and for lesions of 2-3 palm-sized patches, 10-16 months may be required. For large, disseminated lesions, 2-4 years may be required. Since vitiligo is a disease with many complicated factors, few can be cured within 3 months even though positive results appear within that time. Most patients need long courses of treatment, usually between 8-16 months to completely resolve all patches of vitiligo. The patients are advised against impatience for a quick result, otherwise the anxiety might lead to the opposite of what one desires. The doctor's orders should be strictly followed and the prescribed drugs should not be used at one's own will, especially the topical agents. The prolonged use or abuse of any kinds of topical agents will cause adverse stimulation of the skin, leading to injuries with thickening and aging of the skin, making the subsequent treatment more difficult. To prevent the thickening and aging of the skin caused by topical agents, it is best to use these drugs under the doctor's supervision and with regular examination.

The lesions on the face are quick to respond to therapy. The lesions with descending order of response to therapy are: face, head, neck, back, chest, hips, waist, abdomen, hand-foot and mucous membrane. Lesions around joints of the limbs, hands and feet, and mucosal surfaces require long therapy and the cure rate is low. The effects of treatment are superior in children and adolescent patients compared to middle and old aged patients, but for early lesions no difference in effectiveness can be observed based on age. Patients with ease and stability of mind have better effects than those with psycho-neurological dysfunction such as mental stress, melancholy and insomnia.

Cases that resist cure are those with widespread lesions that have been without color for a prolonged period. Because of the complete depletion of melanocytes in this type of vitiligo, autologous epidermal grafting must be used for complete cure. For generalized patients and for patients with involvement of joints, limbs, hands and feet skin as well as those with unstable conditions, a cure is difficult to achieve. The most difficult type is the universal type (lesions appearing all over the body) with a cure rate of less than 5%. For some patients even though there was no cure, there may be marked improvement and effective control of the disease progression.

The vitiligo clinic of our hospital has made preparations for the treatment of vitiligo for more than 20 years. Over 7,000 patients have been treated at our clinic with the following preparations selected according to the specific condition presented by each patient:

• Anti-vitiligo (Xiaobailing) powder: 8g twice a day, taken with warm water.
• Guiqi anti-vitiligo dissolvable granules: different preparations are available based on different recipes according to differential diagnosis; 8 g per sachet, one sachet a time, twice a day for adults.
• Guiqi anti-vitiligo capsules: different preparations are available based on different recipes, as above. For adults: 6 capsules, twice a day.
• Anti-vitiligo (Xiaobaiquban) bolus: 1 bolus, twice a day.
• Anti-vitiligo decoction: decocted from herbal medicines, suitable for certain patients, such as those with rapid dissemination, or cases complicated with rheumatism, psoriasis or other skin diseases. The decoction can be modified according to the patients' symptoms and signs.
• Anti-vitiligo tincture.

The treatment of vitiligo by Chinese herbal medicine in our hospital is based on an overall analysis of the symptoms and signs according to the theories of traditional Chinese Medicine. The recipes are selected according to the clinical types of the disease, the basic recipe contains these ingredients:

In the recipe ho-shou-wu, tang-kuei, and lycium have the function of nourishing the liver and kidney, nourishing and regulating blood; while cnidium and red peony can activate blood circulation to dissipate blood stasis, and when used in combination with cinnamon twig, can penetrate the skin and hair and reach the four limbs, clearing and activating the channels and collaterals, and removing blood stasis and promoting regeneration. Dictamnus and kochia can remove the wetness-heat from the skin; licorice root can coordinate the actions of various components in the recipe and in combination with astragalus can reinforce their mutual function, supplementing qi and invigorating vital function as well as detoxifying.

Modern pharmacological research has demonstrated that cinnamon twig can dilate blood vessels and enhance microcirculation. Astragalus, ho-shou-wu, lycium, and cordyceps can regulate the body immune function and maintain homeostasis. All of the ingredients when used in combination can nourish the liver and kidney, invigorate qi and nourish blood, dispel pathological qi and qi stagnation, and remove wetness, invigorate blood, activate blood circulation and dissipate blood stasis, clear channels and collaterals and remove patches. This internal therapy is the treatment of the primary aspect of the disease. The topical herbal preparations are made by soaking angelica and cinnamon bark in ethanol. Angelica can promote melanocyte regeneration while cinnamon bark is acid-sweet and warming, so it can dissipate blood stasis and promote blood circulation; it can dilate peripheral blood vessels and increase local blood flow when applied topically. This topical treatment will activate the melanocytes and treat the external aspect of the disease. When the above oral and topical therapies are used in combination, both the principal and secondary symptoms will be treated at the same time. After 3 months treatment with Chinese herbal medicine, the treatment can be supplemented with epidermal autografting to increase the number of melanocytes in the lesion areas, promote healing of the white patches, and shortening the treatment duration while increasing the cure rate.

SUMMARY AND ANALYSIS OF TREATMENT CLAIMS

The Chinese medical treatment of vitiligo is reasonably well represented by these five institutes that specialize in the field. Because the recipes used are valued by their developers, there is a hesitancy to provide ingredients list or, at least, complete ingredients lists and details of processing. Fortunately, a certain amount of information has been conveyed that gives insight into the treatment methods and outcomes.

The theories used for treatment of vitiligo involve general principles of Chinese medical theory. It is proposed that the patient who suffers from this condition has a deficiency syndrome (particularly a blood deficiency and kidney/liver deficiency), which is what allows the person to be susceptible to the skin abnormality. It is also proposed that there is blockage of the circulation of qi and blood, with blockage of the channels of circulation (blood vessels, meridians). Generally, such blockage is involved in diseases that persist and progress, and it is pointed out that blood stasis plays an important role in stubborn cases of vitiligo. It is mentioned that wind or wind-damp contributes to the disease. The general theory of traditional Chinese medicine is that external pathological influences, such as wind, penetrate the skin, particularly via the pores (described as sweat pores or hair pores or hair orifices) to cause disease. Wind is able to penetrate because of the deficiency, and the disease progresses and is retained by congestion and stagnation of qi and blood circulation induced by the wind, damp, and other pathological factors. This description could be applied similarly to eczema, psoriasis, and other skin diseases that arise in one area, and then spread, persisting for years if not effectively treated. Autoimmune processes have been suggested as a contributor to these various persisting skin diseases.

Treatment of skin diseases with Chinese medicines is almost always with topical therapies and internal therapies, and vitiligo is no exception. Some doctors emphasize the topical treatment, others emphasize the internal treatment, but both appear important to the prompt and complete resolution of vitiligo. It is possible, even likely, that most or all of the topical therapies include either psoralens or other photosensitizers; an example, is the liniment made with angelica (baizhi) and cinnamon bark, angelica contains psoralens.

The internal remedies are said to be adjusted according to the traditional diagnostic category of the patient, and may be adjusted further with progress of the treatment. Some ingredients mentioned in the therapies are astragalus, lycium, ho-shou-wu, red peony, tang-kuei, and cnidium; the first three are used to tonify qi and blood, the latter three are used to vitalize circulation of qi and blood. Such ingredients are commonly used in treatment of autoimmune disorders with inflammation, such as systemic lupus and scleroderma, both of which involve changes in the skin.

Concern was raised for the mental state of the patient as something that could influence the outcomes. Those who are able to remain calm and mentally stable are thought to have a good chance of success, while those who are anxious or depressed and who are not patient with the treatment are expected to have a poor chance. Indeed, the latter group of patients may experience treatment failures due to noncompliance with the regimen, as much as any psychophysical adverse effects of the mental state on their skin condition.

Descriptions of treatment time and success appear contradictory in some presentations, with mention of difficulty of treatment and prolonged course of treatment, and, in nearly the same breath, claims of rapid effects and high cure rates. However, the presentations have in common the theme that some results are usually attained within a few days or weeks of beginning treatment, and then the full treatment may involve several months even for relatively mild cases of recent onset, to several years for cases that are severe and have persisted for years. Ultimately, the success rate is deemed high; if there is not a complete resolution, a shrinkage of patch size and number is seen, and if there is not complete repigmentation, a partial darkening of the patches is seen. Consistently, it is claimed that once the improvement takes place, relapse is unlikely.

The term "cure" used in the translated Chinese works may have a different connotation in China than here. For example, if the white patches develop some color (but not returned fully to normal) and if most white patches disappear (but a few small ones remain), this would be counted as a cure in China, or, at least, as an instance of effective treatment; here, it would be considered an improvement, but the disorder would be said to remain as uncured and the treatment might be deemed a failure on that account.

Outside of China, topical therapies are not readily available from practitioners of Chinese herb medicine, but the internal therapies are easy to get, as the ones described here are made of commonly used ingredients. The clinics in China usually offer foreign patients the option of making a brief consult by mail or e-mail and purchasing the products directly. Costs for treatment materials sent from China can reach $500 per month, based on prices that have been quoted recently. Some caution must be used in getting the topical therapies from China, as they may contain toxic ingredients; even though the clinics report no side effects, it is still possible that rare adverse reactions could occur.

Dr. Wang Xianchen, of the Xianchen Institute for Vitiligo was interviewed directly by Dr. Fu Kezhi (an ITM member who had known him previously and was working in the same city of Harbin). The therapies appear to be legitimate, licensed preparations from a well-established pharmaceutical factory, and information about ingredients was provided upon request. Dr. Wang had graduated from the Heilongjiang College of Traditional Chinese Medicine in 1984, and established the vitiligo center in 1988. He comes from a family lineage of traditional Chinese medicine doctors and began work with a family recipe. Although it is not possible, at this time, to vouch for the other organizations listed here, there is no a priori reason to doubt that they too have developed workable treatment methods. The Liaoning Vitiligo Institute offered a caution that results claimed by various clinics should be examined carefully, including checking the provided photos to make sure they have not been altered.

Vitiligo in Medical Books and Research Reports in the Chinese Literature

The text Practical Traditional Chinese Dermatology (8) presents the traditional view of how skin disorders, including leukoderma, may arise:

Qi can maintain the warmth and blood can maintain the moisture of the body; qi is the leader of blood and blood is the source of qi. If qi and blood are well-adjusted, the skin and muscles may be well nourished and moistened, the skin color may be kept normal and even, and the hairs may be normal in appearance, too. If qi and blood cannot be well adjusted, the distribution of nutrients and moisture will be uneven and the white patches may appear. The disharmony of qi and blood may be produced by different causes and it may display different manifestations, and the disease may be divided into the following syndromes.

Qi stagnation: Mental depression may cause stagnation of liver qi, disturbance of circulation of qi, disharmony of ying (nutritive portion of blood) and blood, poor nutrition of skin and muscles, and then the development of white patches and clinical manifestation of stagnation of liver qi (herbal treatment involves a combination of Siwu Tang and Xiaoyao San);

Liver/kidney deficiency: The deficiency of liver and kidney and the loss of essence and blood may cause damage to the liver and kidney, further depletion of essence and blood, reduction of qi production, and then the appearance of white patches due to reduced supply of warmth and moisture to the skin and hairs; it may consequently produce the clinical manifestations of liver and kidney deficiency (treatment is a combination of Siwu Tang and Wuzi Yanzhong Wan);

Blood stasis: If the white patches linger over months and years and cannot be cured by treatment, they are due to stagnation of blood in the skin, and this stagnation may cause reduction of new blood formation, blockage of the meridians and hair pores, poor nutrition of the skin and muscles, thus producing the clinical manifestations; (treatment is a combination of Siwu Tang and Tongqiao Houxue Tang).

In this description, Siwu Tang (Tang-kuei Four Combination) is an essential component of treatment, nourishing the blood and also vitalizing blood circulation. External therapies are also mentioned in the text, including use of psoralea, or application of sulfur, or a tincture of fresh cuscuta seed.

In an article reviewing 14 works on treatment of vitiligo (9), it was pointed out that there are three groupings of herbs used for the treatment, which include two of those mentioned above and one miscellaneous category: those that nourish the liver/kidney (e.g., ligustrum, lycium, morus fruit, cuscuta, eclipta, epimedium); those that remove blood stasis and promote circulation (e.g., tang-kuei, red peony, cnidium, carthamus, persica, moutan, lithospermum); and those that are thought to promote the pigmentation of skin (tribulus, psoralea, cuscuta, black sesame seed, ho-shou-wu, angelica). For topical therapies, items mentioned include psoralea, cuscuta, tribulus, angelica, mume, sulfur, and various toxic metals (e.g., arsenic and lead compounds).

In a clinical report on treatment of 800 cases of resistant cases of vitiligo (10), the basic therapy described was a pair of formulas for internal use that combined all the above-mentioned methods of therapy, with application of an herb tincture to the white patches, and additional use of moxibustion therapy. The internal formula included bupleurum, tang-kuei, red peony, dalbergia, and pangolin scale to regulate qi circulation and vitalize blood, plus ligustrum and eclipta to nourish the liver and kidney, which was given first for 3-6 months, then followed by a second formula with astragalus, ginseng, tang-kuei, rehmannia, cnidium, cinnamon bark, millettia, psoralea, and epimedium, to nourish the blood, vitalize the blood, and warm the skin. The second formula would also be taken for several months. The topical preparation was based on use of psoralea (exposure to the sun was used to activate the psoralea topical therapy). It was reported that as a result of this therapy, about 70% of the white spots either vanished or were markedly improved.

REFERENCES

1. Kwok YK, Anstey AV, and Hawk JL, PUVA is only moderately effective for widespread vitiligo: a 10 year retrospective study, Clinical and Experimental Dermatology 2002; 27(2): 104-110.
2. http://www.tcmtreatment.com/images/diseases/vitiligo.htm
3. http://www.curevitiligo.com/English/yishu.htm
4. Fu Kezhi, personal communication to ITM, June 2003.
5. http://www.cn-vitiligo.com/english/
6. http://www.shanxi-china.com/english/sxzybdf/index.html
7. http://www.cn81301.com/en/06-6.htm
8. Li Lin, Practical Traditional Chinese Dermatology, 1995 Hai Feng Publishing Company, Hong Kong.
9. Yin Ping, A review of 14 works on treatment of vitiligo, Yunnan Journal of Traditional Chinese Medicine 1994; 15(5): 36-38.
10. Xue Changlian, et al., A clinical report on 800 cases of vitiligo treated with Chinese herb therapy, Acta Medica Sinica 1991; 6(4); 28-29.

September 2003