You Can Win in Skin
Steve Marsden
DVM ND MSOM Lac Dipl.CH CVA AHG
Veterinarians have many effective pharmaceuticals for the short term treatment of
chronic dermatitis. When we toughen the criteria by which we measure success in skin
disease, drug therapy often fails to satisfy. Adverse reactions are common, and risk of
recurrence is high once the drugs are withdrawn.
Chinese herbal medicine presents a therapeutic alternative to pharmaceutical
management of skin disease, and for which favourable clinical trial data exists1. As an
example, the efficacy of the formula Zemaphyte TM in human atopic dermatitis has been
demonstrated in two double-blind placebo-controlled randomized clinical trials2, 3.
Chinese herbal formulas do not contain large amounts of any one active ingredient.
Enduring clinical improvements are achieved from the formulas acting in multiple ways
simultaneously. As an example, Zemaphyte has antioxidant properties and inhibits C23
expression. C23 is the term for an IgE receptor on lymphocytes that is upregulated in
humans with atopy and which amplifies the normal antigenic response. The formula also
acts in other ways that, en masse, combine additively or even synergistically to favour
resolution of skin disease.
While Zemaphyte is not commonly helpful in small animals, other formulas do appear to
be clinically effective. Many animals can be apparently cured of their allergic dermatitis
after many months of continuous herb use, followed by short use on an as needed basis
for the next year or so as seasonal allergies come and go. The following table provides
the author’s starting dose recommendations for liquid, tablet and granular extracts for the
formulas discussed in this paper:
BID Dose
BID Dose
Weight (kg) Weight (lbs) BID Dose (mls)* (550 mg tabs)** (tsp granular extracts)***
0.25
4
10
0.30
1.00
0.50
8
20
0.45
1.50
0.75
12
25
0.60
2.00
1.00
23
50
0.90
3.00
1.50
32
70
1.20
4.00
2.00
/5
150
1.80
6.00
3.00
120
250
2.40
8.00
* At the present time, only Kan Veterinary Essentials provides the formulas in liquid form
** Tablets available from Kan Veterinary Essentials
*** Required dose of granules from Natural Path Herb Company may be as little as half these
amounts, due to their higher purity and lack of excipients
The diversity of inflammatory skin disorders in small animals can be divided into a
handful of broad patterns of inflammation. These patterns are marked by apparent
differences in skin circulation:



Reduced cutaneous circulation, associated with many cases of recurrent
superficial pyoderma and seborrhoea sicca
Chronic unresolved inflammatory responses that may be diet driven, vaccineinduced, or of unknown cause
Markedly increased peripheral circulation, associated with more severe acute
inflammatory responses. This form of inflammation appears to be propelled by
consumption of a processed diet in general rather than by specific food sensitivity
or allergies
Reduced Cutaneous Circulation
In this pattern, exogenous pathogens appear to be taking advantage of relative reductions
in peripheral perfusion and immune surveillance, resulting in a reduced presence of
histiocytes, white blood cells and other elements of cutaneous immunity. Example
conditions include:
 Localized demodex infestations
 Localized dermatophyte infection
 Superficial pyoderma
Seborrhea sicca is another common manifestation. The skin naturally looks dry in this
pattern and may even exhibit alopecia if peripheral blood flow is sufficiently
compromised. The coat feels coarse; the tongue is often pale or a washed-out lavender
color; and the pulse at the femoral artery proximal to the knee feels relatively attenuated.
The lesions are never particularly severe, and appear to shift in location.
Other clinical features include a dry nature to the lesions (as opposed to moist
pyodermas); seborrhoea sicca; a responsiveness of the dog’s coat and dryness issues to
essential fatty acid supplementation; a prevalence of lesions on the dorsal or lateral
surfaces of the torso; and a worsening of the skin condition between the months of
November to May. The extremities will feel cool, including the paws and ears.
Co-morbidities that are also low grade peripheral inflammatory disorders that don’t
resolve may include KCS (keratoconjunctivitis sicca) and lymphocytic thyroiditis.
Si Wu Xiao Feng Yin (Four Materials Eliminate Wind Combination)
The formula to treat this disorder in dogs (for it rarely occurs in cats) is Si Wu Xiao Feng
Yin (Four Materials Eliminate Wind Powder, Natural Path Herb Company; Dry Derma
Relief, Kan Herb).
Bai Xian Pi
Dictamnus root bark
Bo He Ye
Peppermint
Chai Hu
Bupleurum root
Chi Shao
Red Peony root
Chuan Xiong
Ligusticum rhizome
Da Zao
Jujube
Dang Gui Shen
Chinese Angelica root
Du Huo
Pubescent Angelica root
Fang Feng
Ledebouriella root
Jing Jie
Schizonepeta
Sheng Di Huang Rehmannia root
Figure 1. Si Wu Xiao Feng Yin
It achieves its benefits in part by stimulating the bone marrow to produce more red and
white blood cells, particularly through the actions of Dang Gui. It also contains ample
aromatic herbs, the volatile oil content of which mobilizes the circulation to the periphery
and acts as a broad spectrum antimicrobial. Lastly, Rehmannia has an anti-inflammatory
effect that hastens resolution of skin lesions, including even mild allergic dermatitis.
Case Management
Adverse effects may be seen with this formula if the inflammatory response turns out to
be more acute than originally appreciated, or is due more to a systemic tendency towards
heightened inflammation (e.g. ‘food allergy’). Stronger anti-inflammatory formulas are
needed, such as Si Miao San (Four Marvels Combination). The intensity of any adverse
effects to Si Wu Xiao Feng Yin are mild and include seborrhoea oleosa, erythema that is
more widespread than previously, and exudates that are more moist in nature.
Persistent Subacute Inflammation
One of the main ingredients in Si Wu Xiao Feng Yin is Rehmannia glutinosa. As a single
herb, Rehmannia has been shown to significantly reduce dermatitis scores, ear thickness,
and serum histamine levels in laboratory animal models of atopic dermatitis. Histological
analysis demonstrated decreased thickening of the dermis and epidermis, along with
reduced dermal infiltration by inflammatory cells. Much of the credit for this effect
probably stems from Rehmannia’s ability to inhibit not just inflammatory cytokines like
IL-4 and TNF-α, but also VCAM-1 and ICAM-14.
The latter two compounds are cell adhesion molecules that facilitate entry of white blood
cells into the interstitium. White cell ingress requires they must first be ‘tethered’ to the
endothelium as they flow past. Leukocytes are then activated by chemoattractants on the
endothelium which in initially results in adhesion being more firm and ultimately allows
transendothelial migration into tissue. While ‘selectins’ are responsible for initial
tethering, adhesion is governed by β2 integrin (ICAM-1) and α4 integrin (VCAM-1).
Interference with adhesion molecules is a novel and important mechanism by which
herbs exert their anti-inflammatory effects5. Another example of a plant that inhibits
ICAM-1 is Salvia miltiorrhiza. Both Rehmannia and Salvia are components of a major
formula to address chronic persistent or severe dermatitis, known as Qing Ying Tang
(Clear the Nutritive Combination, Natural Path Herb Company; Cool the Blood
Combination, Kan Herb).
Qing Ying Tang (Clear the Nutritive Combination)
Besides interfering with the migration of white blood cells into the skin, Qing Ying Tang
has several other physiological effects. It is anti-inflammatory, by virtue of its content of
Gardenia, Rhubarb and Coptis. Coptis in particular is a potent inhibitor of IL-6.
Additionally, the formula is mildly antibacterial by virtue of its content of Forsythia fruit
and Honeysuckle flowers.
Qing Ying Tang is thus suited to relatively severely inflamed and secondarily infected
skin, even autoimmune disorders like lupus, deep pyodermas and furunculosis.
Aggravating factors that may be part of the patient’s history include a breed
predisposition and/or annual vaccination.
Clinical presentations calling for Qing Ying Tang may range from mild to severe,
although the itch is almost invariably refractory. Lesions are often persistent, ranging
from maculopapular rashes to excoriation and ulceration. Exudates may be minimal or
form thick serous encrustations.
With such a wide range of presentation, the most reliable guide indicating suitability of
Qing Ying Tang is a strongly toned and usually deep femoral pulse that is relatively
resistant to compression.
Additionally, there are usually few other concomitant symptoms and co-morbidities,
unless the condition is autoimmune, in which case musculoskeletal and respiratory
symptoms may also be seen. There are rarely any digestive signs. The tongue is often a
dark purple-red or muddy red tongue color. Symptoms are commonly aggravated in the
late summer, fall and winter.
Milder presentations in dogs and cats also exist, in particular a focal skin eruption that
persists or recurs in the same spot over months or years. Lesions may have the typical
nasty encrusted appearance, or simply show up as a well localized region of persistently
cropped hair, a few scabs, and some purpling of the skin during healing. Even though
these lesions may have recurred for years, they are often gratifying to treat.
Sheng Di Huang Rehmannia root
Jin Yin Hua
Honeysuckle flower
Xuan Shen
Scrophularia root
Chi Shao Yao
Red Peony root
Zhi Zi
Gardenia fruit
Da Huang
Rhubarb root and rhizome
Huang Lian
Coptis rhizome
Lian Qiao
Forsythia fruit
Dan Shen
Salvia root
Dan Zhu Ye
Lophatherum
Mai Men Dong
Ophiopogon root
Figure 2. Qing Ying Tang
Case Management
Improvements may be seen within the first few weeks of treatment, although full
recovery may require many months. The formula is compatible with conventional
treatments like antibiotics.
As pathology grows milder, one of the other formulas discussed in this article may be
better suited to the evolving clinical presentation. In the event that a new formula seems
indicated, animals are at first managed with both formulas, and then if improvements
continue to accrue, the switch to the new formula can be completed.
Food Allergies
A second group of formulas addresses the patient with tendencies to chronic
inflammation evident at multiple epithelial surfaces, including often the gastrointestinal
tract. In these patients, it appears that a systemic tendency to inflammation exists, that
heightens what would normally be a subclinical response to an irritant or stimulus. The
medical record ends up being peppered with instances of otitis external, colitis, dermatitis,
conjunctivitis and cystitis as though inflammation is roving around the body.
Veterinarians have a reflexive tendency to assume that dogs and cats with concomitant
skin and GI problems have a food allergy. Underlying the tendency to acquire food
allergies, though, is a chronic low grade GI inflammation in which the gut is made more
porous and the animal’s brush border digestive capacity less robust. The net impact of
these two changes is to allow increased exposure of gut lymphoid tissue to antigen-sized
food molecules, which eventually results in sensitization to that food. Diets with novel
protein sources do lessen inflammation somewhat, until a new allergy is acquired.
More enduring results are obtained when the cause of the food allergy acquisition, the socalled ‘leaky gut’, is addressed. The unresolved inflammatory response responsible for
poor gut wall integrity seems to be of the same ilk as the patient’s unresolved dermatitis,
allowing one herbal formula to address both conditions simultaneously.
The mode of action of these formulas is to correct the role of metabolism in driving
unresolved inflammatory responses. Diets that are rapidly digestible, particularly if
carbohydrate-based, increase insulin secretion which, in turn, reinforces current
inflammatory tendencies. This link between diet and inflammation has been established
in many species including humans, horses, and laboratory animal models. The herbs to
correct the problem are often insulin-sensitizing, and work best if given at the same time
as an unprocessed non-carbohydrate-based insulin sensitizing diet.
Two distinct formulas find use in this syndrome, and vary chiefly in their antiinflammatory activity. The first is Chu Shi Wei Ling Tang (Eliminate Damp with Poria
Stomach Combination; Dispel Damp and Nourish the Skin in the Kan Essentials line).
Chu Shi Wei Ling Tang (Eliminate Damp with Poria Stomach Combination)
Chu Shi Wei Ling Tang (Dispel Damp and Nourish the Skin, Kan Herb; Eliminate Damp
with Poria Harmonize the Stomach Combination, Natural Path Herb Company) was
originally developed to treat shingles in humans. It is anti-inflammatory, but not as
strongly as San Ren Tang (see below). Additional indications include elevated ALT and
azotemia. The formula is derived from Wei Ling Tang (Harmonize the Stomach with
Five Herbs and Poria Combination). In its original form, it is most commonly used to
address subacute inflammation of the pancreas, liver, stomach and small intestine.
A common finding indicating likely efficacy of Chu Shi Wei Ling Tang is aggravation of
GI and potentially even skin complaints by antibiotics; or GI complaints by antiinflammatory drugs. The formula’s aromatic herbs help enhance absorption and
assimilation from the digestive tract, while supporting epithelial circulation.
Normalization of epithelial circulation results in gut and skin inflammation healing
simultaneously.
The specific clinical presentation calling for Chu Shi Wei Ling Tang includes:
 Toned pulses
 A pale or slightly purplish tongue
 Chronic tendencies to soft stool or small bowel diarrhea, but not colitis
 Rashes that are often mild in appearance and shifting in location
 Predominantly ventro-medial lesion distribution
An interesting exception to the last point is if the dog has extensive lichenification.
Where skin is very thickened with connective tissue, allowing secondary overgrowth of
bacteria and yeast, Chu Shi Wei Ling Tang tends to be more effective than any other
formula. It can be used simultaneously with antimicrobials for skin infections and may
help minimize their adverse effects. Chu Shi Wei Ling Tang is the top consideration in a
dog with both skin and GI complaints, where there is a clear response to antimicrobials,
signalling a tendency to bacteria and yeast overgrowth.
In both lichenification and overgrowth, efficacy is likely linked to the formula’s content
of powerful circulation enhancing and antimicrobial aromatic compounds. But it is the
last five herbs in the table below that were added to extend the influence of the parent
formula, Wei Ling Tang, to shingles and to dermatitis. Both Gardenia and Atractylodes
are anti-inflammatory while Kochia fruit contains significant amounts of vitamin A to
promote epithelial integrity.
Bai Zhu
Cang Zhu
Chen Pi
Fu Ling
Hou Po
Ze Xie
Tong Cao
Gan Cao
Sheng Jiang
Da Zao
Rou Gui
Hua Shi
Fang Feng
Zhi Zi
Deng Xin Cao
Di Fu Zi
Atractylodes
rhizome
Atractylodes
rhizome
Citrus peel
Poria
Magnolia bark
Alisma tuber
Rice Paper pith
Licorice root
Ginger rhizome
Jujube
Cinnamon bark
Talc
Ledebouriella root
Gardenia fruit
Rush pith
Kochia fruit
Figure 3. Chu Shi Wei Ling Tang
Case Management
Chu Shi Wei Ling Tang is a mild formula, but can heighten inflammation with its
powerful circulation enhancing properties if the inflammation was more acute than
originally suspected. If this happens, use Si Miao San (Four Marvels Combination),
simultaneously or instead, until the acute inflammatory response has subsided.
San Ren Tang (Three Seeds Combination)
Xing Ren
Apricot seed
Yi Yi Ren
Coix seed
Hua Shi
Talc
Ban Xia
Pinellia rhizome
Bai Dou Kou
Round Cardamon
Dan Zhu Ye
Lophatherum
Hou Po
Magnolia bark
Tong Cao
Rice Paper pith
Figure 4. Three Seeds Combination
San Ren Tang is the least commonly prescribed of all the formulas in this paper, but is
still effective when an animal presents with some of the following symptoms:
 Chronic colitis and/or constipation
 Vomiting
 Dyspepsia or bloat
 Conjunctivitis
 Nasal congestion
 Reverse sneezing
 Moist or productive cough
 Waxy ears
The pulse of animals benefiting from the formula is almost invariably toned, and the
tongue purplish.
San Ren Tang has no significant antimicrobial effects, but is a worthwhile consideration
when there are both respiratory and digestive symptoms concomitant with skin disease. It
is a stronger anti-inflammatory and insulin sensitizer than Chu Shi Wei Ling Tang, but its
physiological effects are largely restricted to epithelial surfaces.
In this formula, Cardamon and Coix support peripheral circulation. Coix has both direct
anti-inflammatory effects and counters the tendencies to insulin resistance that result in
inflammation. The other herbs act on the respiratory and digestive tracts as much as the
skin.
San Ren Tang is a first consideration whenever small papules are observed in the
temporal region of the scalp of cats, near the anterior ear margin. Diet change accelerates
improvements. Its content of Lophatherum lends the formula a calming influence that can
enhance its efficacy where agitation seems a component of the pathology (e.g.
psychogenic itch and hyperesthesia).
In dogs, San Ren Tang is a first choice for otherwise uncomplicated seborrhea oleosa and
excess ear wax accumulation
Acute Inflammation
Acute inflammation, like chronic inflammation, appears diet driven and may be triggered
by just about any irritant. The medical history of affected animals appears to once again
be one of roving inflammation. In mid-summer (May and June), these inflammatory
episodes are more likely to be acute than chronic in nature, since skin circulation is
generally maximal at this time of the year.
The acute nature of the inflammation can be confirmed by palpating the pulse. While
chronic inflammation is characterized by weaker, deeper but still toned pulses, acute
inflammation is characterized by more superficial bounding, forceful and even toneless
pulses.
As with diet-driven subacute inflammation, lesions in acute inflammation tend to be
especially prominent on the ventro-medial surfaces of the torso and limbs. Alopecia may
occur because of the severity of the inflammation.
In addition, there may be systemic inflammatory tendencies affecting also the pancreas,
intestinal tract, bladder, colon, bile ducts and ears. The patient (usually a dog and
especially a Retriever) can manifest other problems typical of metabolic syndrome, such
as obesity and hyperadrenocorticism.
An occasional tendency to seizures is not uncommon, as is osteoarthritis, particularly in
the stifle or lumbosacral joints. Pain at the lumbosacral region can be severe.
The patient commonly exhibits increased appetite or thirst (or both, in some cases). The
paws and ears feel warm, in contrast to patients benefiting from previously discussed
formulas. The animal may be heat intolerant and exhibit a red or even dark red
discoloration on the underside of its tongue.
The usual formula used to treat this condition is Si Miao San (Four Marvels
Combination).
Si Miao San (Four Marvels Combination)
Four Marvels Combination (Natural Path Herb Company, Kan Herb) is a simple but
powerful formula. It is the most commonly used Chinese herbal formula in veterinary
medicine, testifying to the frequency with which veterinarians treat acute inflammation. It
contains:
Cang Zhu
Atractylodes rhizome
Huai Niu Xi Achryanthes root
Yi Yi Ren
Coix seed
Huang Bai
Phellodendron bark
Figure 5. Four Marvels Combination
Phellodendron and Coix are both strong anti-inflammatories; Phellodendron is also
antimicrobial and an antioxidant. It has additive or even synergistic effects with
antibiotics used for skin disease. From a metabolic perspective, Phellodendron is a
stimulant of Kreb’s cycle activity that results in increased lipid metabolism while
Atractylodes promotes insulin sensitization.
In dogs, Si Miao San is almost invariably effective when coupled with diet change in
resolving pituitary-dependent hyperadrenocorticism, another metabolic syndrome
complaint. It is effective at normalizing ALP elevations that increase in mid-summer due
to hepatic congestion or that are present in pre-Cushingoid animals.
Si Miao San can significantly lower the dose of prednisone required to control cutaneous
inflammation, while helping prevent the insulin resistance and metabolic syndromerelated side effects that corticosteroids tend to foster.
Long Dan Er Miao San (Gentian and Two Marvels Combination)
Long Dan Er Miao San (Dry Damp Derma Relief, Kan Herb; Modified Gentiana
Combination, Natural Path Herb Company) is another formula for managing acute
inflammation of the skin.
Sheng Di Huang
Rehmannia root
Dang Gui Shen
Chinese Angelica root
Long Dan Cao
Gentian root
Ze Xie
Alisma tuber
Fu Shen
Poria
Chai Hu
Bupleurum root
Che Qian Zi
Plantain seed
Gan Cao
Licorice root
Huang Qin
Scutellaria root
Zhi Zi
Gardenia fruit
Huang Bai
Phellodendron bark
Cang Zhu
Atractylodes rhizome
Sang Ye
Morus leaf
Bai Xian Pi
Dictamnus root bark
Di Fu Zi
Kochia fruit
Chi Shao
Red Peony root
Mu Dan Pi
Moutan bark
Figure 6. Long Dan Er Miao San
Unlike Si Miao San, the formula provides no digestive support. If pancreatitis, vomiting
or colitis are issues, use Si Miao San. Guiding symptoms to the use of Long Dan Er Miao
San include:
 Inflammation of the ears, eyes and feet
o E.g. otitis externa + pododermatitis + conjunctivitis
 Warm ears and paws
 Reliance on corticosteroids to provide comfort
 Urogenital inflammation
 Cystitis
 Hyperexcitability or dominance aggression
 Glaucoma
 Immune mediated eye disorders
 Liver enzyme elevations
As with Si Miao San, the pulse of patients that will benefit is bounding or slippery. The
tongue is frequently red, dark red, or purple red.
Permanence of Recovery
Skin disease can be gratifying to treat in dogs and cats using Chinese herbal medicine.
Criteria for success include:
 Regular visits to ensure the right formula is still being given
 Vaccination only as absolutely required to maintain immunity, based on titer
testing
 Feeding of unprocessed meat and vegetable diets
Rarely will an animal require a hypoallergenic diet to become itch free when the correct
Chinese herbal formula is administered and the above steps followed.
Six to nine months of consistent therapy will frequently be adequate to resolve a skin
problem, with the very last symptom to disappear being the itch. The following year,
seasonal allergies may briefly recur for a few weeks, but will disappear much more
quickly with the use of the appropriate formula, if the above steps are still being followed.
The year after that, seasonal allergies are not seen as long as an unprocessed non-starchbased diet is in place and unnecessary vaccinations are being avoided.
Integration with Pharmaceuticals
Use of the above formulas does not preclude or interfere with normal pharmaceutical use.
Feel free to continue conventional medications as needed to support the animal, until the
herbs kick in. Where drugs are not effective, simply discontinue them in an appropriate
manner.
References
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Pract. 2010 Apr; 23(2):110-6.
2. Dermatologic Therapy, Vol. 16, 2003, 98–105
3. Int Arch Allergy Immunol. 1994 Jul;104(3):222-6.
4. Sung YY, Yoon T, Jang JY, Park SJ, Kim HK. Topical application of Rehmannia
glutinosa extract inhibits mite allergen-induced atopic dermatitis in NC/Nga mice.
J Ethnopharmacol. 2011 Mar 8;134(1):37-44
5. K. Spelman, R. Aldag, A. Hamman, E. M. Kwasnik, M. A. Mahendra, T. M.
Obasi, J. Morse and E. J. Williams. Traditional Herbal Remedies that Influence
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