The combined treatment of Manual and Electro-Acupuncture
in Chronic Urticaria: A case study
DR. EMAD TUKMACHI, MBChB, DTM (Dublin), PhD (London), MD(MA), MBAcC
Acupuncture Clinic, North Staffordshire Nuffield Hospital, Clayton Road, Newcastle-Under-Lyme, Staffordshire, ST5 4DB.
This case study reports on the successful use of combined manual and electro-acupuncture in the management of chronic urticaria. The theory and effectiveness of acupuncture in the treatment of chronic urticaria is also evaluated, concluding that acupunctureoffers both a fertile field of study for clinical allergy researchers and a potentially effective intervention for dermatologists.
Acupuncture, chronic urticaria, skin allergy.
Urticaria is relatively common, affecting 15 to 25 per cent of the population once in their lifetime, with 20 per cent still having problems 10 years after the initial onset (Soter, 1991). Most patients presenting with urticaria do not require rigorous laboratory investigations and their symptoms often respond to prescription of antihistamines. Urticaria is classified as acute or chronic, based on the duration of symptoms and the presence or absence of inducing stimuli.
Chronic urticaria is a benign cutaneous disease of uncertain origin, for which patients frequently visit allergy or dermatology clinics. It is characterised by transitory, pruritic and erythematous wheals, occuring at least twice a week for longer than six weeks (Greaves, 2000). Initially, wheals have pale centres surrounded by rings of erythema, whereas slightly older lesions are more uniformly pink in colour. Some patients may also develop swelling of the lips, tongue or other areas of the body. Approximately one in 1000 people develops CU at some stage in their life. It is twice as common in women as in men. Patients with CUmay depend on medication for years to relieve their symptoms, or else may not improve at all with medical treatment.The pathogenesis of CU was once considered to be related to an idiosyncratic or allergic reaction to drugs, food or other environmental antigens, but these theories have not been supported by evidence (Kaplan, 2002). Although not a life-threatening disease, CU may cause major impairment to an individual's quality of life and thus its impact on the patient should not be underestimated. In a study by O'Donnell et al. (1997) the effects of CU on daily living, social interaction, rest and work were found to be similar to those experienced by patients with heart disease.
Causative factors of urticaria:
Conventional medications: specific drugs may cause or exacerbate urticaria such as aspirin, nonsteroidal anti-inflammatory drugs, opioids, penicillins, sulfonamides, codeine, polymyxin, quinine, curare, dextran, bacitracin and ACE inhibitors.
Foods: Shellfish, strawberries, chocolate, nuts, eggs, fish, cow's milk, alcohol, wheat, yeast, tomatoes, shellfish and certain baked goods have all been found to trigger urticaria.
Close contact with an inciting agent: Contact urticaria can be be triggered by latex (especially in health care workers), plants, animals (e.g. caterpillars, pet dander etc.), cosmetics, perfumes, textiles, ammonium persulfate (used in hair bleach) and jellyfish. Insect bites are the most common cause of papular urticaria - whilst patients who are bitten by mosquitoes are likely to be aware of the source of their problem, patients with scabies, bedbug bites or flea bites may not realise the cause of their reaction). Showering and exercise may also make urticaria worse.
Pyschological factors: Although the role of emotions remains controversial, psychological factors are reported to play a role in some patients.
Genetic diseases: Urticaria can be associated with genetic diseases such as hereditary angio-oedema, cholinergic urticaria with progressive nerve deafness and familial cold urticaria (amongst others).
Infections, autoimmune disease, systemic disease and malignancy: Urticaria may be associated with a number of diseases such as hepatitis B, herpes simplex, lupus erythematosus, cryoglobulinemia, juvenile rheumatoid arthritis, autoimmune thyroid disease, hyperthyroidism, polycythaemia vera and rheumatic fever. Little evidence exists to support the idea that chronic urticaria is a cutaneous sign of occult internal malignancy.
Table 1: Aetiological factors of urticaria (see Volonakis et al., 1992)
There are three main types of CU:
Physical urticaria (where the rash is triggered by a physical stimulus, e.g. dermatographism, cholinergic urticaria or pressure urticaria).
Urticaria secondary to an underlying medical condition.
Chronic idiopathic urticaria (with no obvious cause and characterised by daily occurrence of wheals and itching for at least six weeks).
The most important physiological component in the pathogenesis of urticaria is the mast cell. Mast cells contain inflammatory mediators, of which histamine is the most important, in addition to various cytokines that modulate the inflammatory response. Stimulation of the mast cells results in production of histamine and prostaglandin mediators that cause wheal formation, vasodilatation and erythema. Itching is usually initiated by the secretion of mediators from dermal mast cells, including histamine, proteases, interleukin-1 and tumour necrosis factor-alpha. Involvement of these other mediators may explain why anti-histamine medication is not always effective. The common pathological pathway between urticaria and CU is a local increase in the permeability of capillaries and small venules triggered by mediators released as a consequence of mast cell degranulation. This degranulation may result from immunological or non-immunological triggers. The diagnosis of CU depends its type (Table 2) and its clinical features (Table 3).
Physical CU (defined alphabetically by triggering stimulus)
· Adrenergic urticaria
· Aquagenic urticaria
· Cholinergic Uricaria
· Cold Urticaria
Delayed pressure urticaria
· Exercise-induced anaphylaxis
· Localized heat urticaria
· Solar urticaria Vibratory angio-oedema
Secondary CU (secondary to an underlying medical condition)
Chronic idiopathic urticaria
Table 2: Primary subgroups of chronic urticaria
Clinical features of CU
Patients with CU usually present with pruritus that leads to scratching. The itching with CU is unique in that it is relieved more by rubbing than by scratching, and is more commonly accompanied by purpura rather than excoriation (Greaves, 2000). This is followed by the appearance of wheals of between one and five millimetres in diameter. The wheals can become larger, up to 20 centimetres in diameter, in which case they are clear in the centre. The skin may show erythema (the result of dilation and congestion of the superficial capillaries) and oedema (resulting from excessive accumulation of serous fluid) (Grattan & Black, 2003). The wheals have a clearly defined border, are harmless and do not leave any lasting marks, even without treatment. However, caution is advised as allergic reactions can progress to involve more serious symptoms, such as difficulty in breathing. Also, once a patient has been sensitised, their reaction may be worse on subsequent exposure to a specfic allergen.
Diagnosis of CU
A. Physical exam and medical history:
1.Signs of CU (wheals):
- Sudden appearance of small round wheals, rings or large patches that may itch, change shape and be surrounded by a red flare.
- Different shapes but with a clear border between normal and affected skin.
- Distributed throughout the body or restricted to specific areas (face, neck or limbs).
- Once gone, wheals leave no trace.
2. Symptoms of CU:
- Significant sensations of itching and burning.
3. Triggers of CU:
- Physical factors: cold or heat
- Foods or additives
- Psychological factors
B. Diagnostic tests: blood and allergy tests to rule out underlying conditions, such as:
1. Autologous serum skin test: injecting a sample of the patient’s blood serum under the skin.A positive test shows an urticarial wheal at the site of injection, indicating that histamine is being released in response to a factor in the patient's own serum.
2. Autoimmune thyroid disease test:anti-thyroid antibody test (in cases of hypothyroidism).
3. Full blood count to identify eosinophilia (caused by allergy or parasitic infestation) and low white blood count (from systemic lupus erythematosus).
4. Skin-prick testing and blood tests for specific allergy (RAST, or radiollergosorbent test, or CAP [chloramphenicol] fluoroimmunoassay).
5. Skin biopsy (if wheals are prolonged) to identify vasculitis.
Clinical features of CU
About one in 1000 people in the UK population develop CU at some stage in their life. It is more common in women than men. Some patients experience urticarial rashes for months or even years.
- Characterised by recurrent eruptions of itchy wheals of at least six weeks duration.
- While most CU is categorised as idiopathic, in roughly one third to one half of patients autoimmunity appears to drive the disease process. Of patients with autoimmune CU, more than half have functional autoantibodies against the high-affinity IgE receptor located on skin mast cells.
- Patients show typical characteristics of urticarial lesions which last between 30 minutes and 24 hours. The skin lesions are distinct, raised, evanescent dermal wheals surrounded by an erythematous flare. As old wheals disappear, new ones may develop.
- Symptoms may come and go with no apparent trigger.For some patients, specific conditions such as heat, exertion or stress may make symptoms worse.
Table 3: Diagnostic and clinical features of CU
Management of CU with Western medicine
The clinical diagnosis of CU requires that physical, drug-induced and infection-related urticaria be ruled out by taking a thorough history and carrying out the appropriate tests. Until recently, all cases unexplained after taking the medical history and confirmatory diagnostic tests were assigned to the category of chronic idiopathic urticaria. According to the 2006 consensus report on the diagnosis and treatment of CU compiled by the European Academy of Allergy and Clinical Immunology (Akdis et al., 2006), treatment can be broken down into four levels:
Level 1:Patients with dry skin require only basic care. Treatment includes skin moisturisation to help reestablish its protective barrier function and avoidance of triggers (inhaled, food or topical irritants).
Level 2:Patients with mild to moderate CU will require Level 1 treatment along with low- to mid-potency topical corticosteroids. Topical calcineurin inhibitors can also be used in patients older than two years. In addition, practitioners should be vigilant in looking out for complicating factors such as topical bacterial infection.
Level 3:Patients with moderate to severe CU should receive mid- to high-potency topical corticosteroids. Topical calcineurin inhibitors can also be used in patients older than two years.
Level 4:Patients with recalcitrant or severe CU may require systemic therapy such as antibiotics, short courses of steroids and even immune suppression with drugs such as cyclosporine A or azathioprine.
the principle methods of management of CU in Western medicine of involves the following treatments:
· H1 receptor antagonists:These drugs improve pruritus and decrease formation of wheals in mild chronic urticaria by preventing histamine reacting with body tissues through histamine receptors. Moderate to severe CU may benefit from higher doses.
· Combined H1 and H2 receptor antagonists: Some reports indicate that additional benefit is provided by combination therapy with H1 and H2 antagonists in chronic idiopathic urticaria (Monroe et al., 1981; Kaplan, 2002).
· Leukotriene antagonists: A clinical comparative study demonstrated that leukotriene antagonists are effective for cutaneous symptoms in patients with CU caused by food additives (Pacor et al., 2001).
Sympathomimetic agents: Oral sympathomimetics (e.g. terbutaline) are used to reduce erythema and swelling, but have substantial side effects such as insomnia and tachycardia, as well as low efficacy.
Corticosteroids: Indicated when there is an inadequate response to histamine receptor blockers and leukotriene receptor antagonists. Corticosteroids tend to be effective but have substantial side effects.
Experimental therapies: Using low doses of experimental drugs such as cyclosporine.
CU and Chinese medicine
In Chinese medicine CU is known as feng yin zhen (’wind hidden rash’), and is thought to be caused by invasion of pathogenic wind combined with cold or heat. Wind in Chinese medicine is characterised by ‘mobility, change and abruptness’, and feng yin zhen involves wind in the skin causing the sudden appearance of intensely itchy wheals (Liu & Liu, 2009). In Chinese medicine, it is said that the Lungs control the wei (defensive) qi, which prevents pathogens from penetrating the body’s outer defences. The concept of wei qi broadly corresponds to immune functions in Western medicine. If the wei qi is deficient or there are abnormal changes in the weather, external pathogenic wind is able to penetrate the skin, combining with pathogenic cold or heat to manifest as two distinct types:
Wind-cold type: This type of CU is characterised by severely itchy pale-red wheals. It usually manifests against a background of deficient yang qi, presenting with cold manifestations such as chilliness, aversion to wind and cold, and a pale complexion. The tongue is pale and the pulse floating and tight.
Wind-heat type: This type of CU presents with severely itchy, red wheals which are aggravated by heat. There may also be signs of yin deficiency such as low-grade fever, malar flush, warm palms and soles, dry mouth and red lips, constipation and scanty, dark urine. The tongue is red and dry, and the pulse is rapid and floating.
Wei qiis derived from the post-heaven qi produced by the Spleen and Stomach, and thus CU oftenappears against a background of Stomach and Spleen qi deficiency and dampness (see Maciocia, 2005; p.185), which has itself usually been caused by improper diet. Wind in the skin can also be the result of blood deficiency or blood-heat, which manifests as large bright-red wheals with intense itching and sensations of heat. The clinical picture may also be complicated by blood stasis, which exhibits as large purple wheals which persist for up to 24 hours.
A 30-year old female sought acupuncture treatment in the summer of 2009 for daily attacks of urticaria. Her health problems had started in December 2004 when she had experienced a viral-like illness in which she developed fever, swollen glands, loss of voice and physical weakness. Her GP advised her to rest in bed and eat a healthy diet, and within a week she began to feel better. Despite improvements in some of her symptoms, however, she continued to feel tired and lethargic, with a recurrent sore throat. She worked full-time as a teacher in a college which involved an intense working programme and little time for rest. She found her job extremely stressful and she had to work at weekends and in the evenings to keep up with an ever-increasing workload. She began to feel increasingly tired at work, struggling to concentrate and experiencing a type of fatigue that she had never felt before. She took a week off work to rest, but her condition continued to deteriorate, and by the end of that week she could no longer walk without getting tired. She went to her GP who diagnosed post-viral fatigue syndrome.
She was advised to rest and was off work for three months. For two months she felt too weak to stand up and was unable to perform daily tasks such as washing and dressing. Lifting any heavy object became a formidable task and she even had difficulty holding a telephone. She began to lose weight and felt that the muscles in her arms and legs were decreasing in size. By the end of the third month of rest she began to improve once again and gradually increased her activity (some days managing to walk slowly to her local shop). On returning to work (with reduced hours and workload), however, she developed another virus and subsequently handed in her notice in April 2005. At this point she still complained of fatigue following minimal exertion and appeared drained and continuously tired.
In June 2005 patches of dry, red skin began to appear across her face, particularly around both eyes. She was prescribed hydrocortisone cream, which did not help, and more patches began to appear on her upper lip and across the rest of her face. Despite the use of various emollients the rash spread to her upper limbs, with increasing symptoms of itching and irritation.
In September 2005 she was well enough to start a new job four days a week, despite the worsening rashes across her face, upper limbs and trunk. She was referred to a dermatologist in November 2006, who diagnosed her with CU and advised her to avoid using facial cosmetics. She was prescribed various ointments of which one (propaderm ointment – a potent corticosteroid) was effective when the rash flared up. On her next visit to the dermatologist in March 2007 she mentioned that her rash tended to flare up when she consumed chocolate. On this basis the dermatologist referred her to a dietician who advised her to eliminate red meat, sugary food, fatty food and dairy products from her diet. Despite the dietician’s advice, however, she continued to suffer from frequent attacks of CU.
When she presented at the authors’ clinic, of she was experiencing at least two episodes of urticaria daily, in the morning and the evening. She noticed no relationship with exposure to heat, cold, dust, physical friction or drugs and there were no seasonal variations in the severity of the attacks. A routine examination of blood, urine and stools by her GP revealed no abnormalities. The patient did not drink or smoke and her family history was negative for connective tissue disease. She did not use any other medications on a regular basis and there were no known allergies, depite the worsening of her symptoms with chocolate. On examination, the patient demonstrated red urticarial wheals of an oedematous appearance on the skin of her face, arms and hands. She was also experiencing anxiety, sensations of heat, tremor, generalised weakness and palpitations
Our Chinese medicine diagnosis was wind-heat type CU. The patient was advised to exclude specific foods from her diet, including cheese, grapes, bananas, melons, dried fruit and any product high in sugar, in order to avoid the creation of dampness, phlegm or heat.
Acupuncture treatment involved a combination of manual and electro-acupuncture, lasting between 30 minutes and one hour and given twice weekly for 10 weeks. Disposable, sterile needles were used of 0.5 to one inch in length and between 25 and 30 gauge. To reinforce points mild manual stimulation was applied using a needle rotation of 60 to 90 degrees, whilst to reduce points strong manual stimulation was applied for 10 minutes with a needle rotation of 90 to 180 degrees. Electrical stimulation was carried out for 10 minutes after manual needle stimulation with the electrodes applied between Xuehai SP-10 and Sanyinjiao SP-6, and Shenmen HE-7 and Neiguan P-6, using a battery-operated electro-stimulator set at six hertz and the intensity just below the patient’s pain threshold.
The following points were selected, with the actions of the points based on the authors’ understanding of CU and theory from both Chinese and Western acupuncture texts.
- Specific point for allergy: Xuehai SP-10 (with strong reduction).
- Homeostatic point: Quchi L.I.-11.
- Immune-enhancing points: Dazhui DU-14, Zusanli ST-36, Sanyinjiao SP-6, Chize LU–5 and Weizhong BL-40.
- Sedative points: Sishencong (M-HN-1), Shenmen HE-7, Yinxi HE-6, Neiguan P-6, Ximen P-4, Xinshu BL-15 and Shenmai BL-62.
- Specific points for severe itching : Dushu BL-16 and Xuehai SP-10.
- Lung, Adrenal Gland, Endocrine and Shenmen.
Following her first two acupuncture sessions the patient began to notice considerable improvements in her energy levels. Within a month of treatment she was able to carry out physical tasks on her day off rather than using it as a day of rest. She described that the acupuncture sessions had left her feeling calm and restful after each session and improved her mood. She also noticed how the acupuncture would ease the dermatological symptoms of pain, redness and itching.
The patient’s skin lesions were cleared after twenty sessions of acupuncture. She responded well, with remarkable improvement in first three weeks of treatment and a full recovery after ten weeks. The patient was followed up at six months and had not experienced a single attack of urticaria.
No single Western medical treatment has been shown to be completely effective for all sufferers of CU and anti-histamine drugs are usually required to achieve partial relief of its signs and symptoms. There is some evidence that acupuncture is an effective intervention for treating the signs and symptoms of CU (Chung-Jen Chen, 1998; Watere, 2007, Wang & Wang, 1995; Kao, 1983). In one randomised, controlled, double-blind trial (Iraji et al., 2006), 40 patients with chronic idiopathic urticaria that had proved resistant to conventional treatment were randomly divided into two groups. The treatment group received manual acupuncture at Fengshi GB-31, Fengchi GB-20, Weizhong BL-40 and Hegu L.I.-4, and the control group received sham acupuncture (with non-inserted sham needles). After three weeks of treatment the mean number of episodes of urticaria was 4.81 in the control group and 3.62 in the acupuncture group (a 25 per cent reduction, P<0.01). The mean duration of urticarial episodes was 5.7 hours in the control group and 4.3 hours in the acupuncture group (a 25 per cent reduction, P<0.03). The study found that over the three weeks of treatment, the efficacy of acupuncture was greatest in the third week.
In general, the acupuncture mechanisms involved in the treatment of dermatological disease (including urticaria) are unclear (Tukmachi, 2001). Acupuncture can stimulate the release of β-endorphin which, coupled with the release of adrenocorticotrophic hormone (ACTH), acts on the adrenal cortex to stimulate the release of cortisol, producing an anti-inflammatory effect [Jubb et al., 2008, Tukmachi et al., 2004, Malizia et al., l979; Lee et al., 1982]. It has been suggested that acupuncture mechanisms in dermatological disease are mainly related to the stimulation of the hypothalamic-pituitary-adrenal axis, the autonomic nervous system and brain-derived neurotrophic factor (Chung-Jen Chen & Hsin-Su, 2003). Other clinical researchers have concluded that electro-acupuncture can stimulate the release of β-endorphin and corticotrophin (Malizia et al., l979), and that the hypothalamus-limbic system is distinctively activated by manual needling (Wu et al., 1999; Cho et al., 1998).
This preliminary case study supports the finding of Wang & Wang (1995) that acupuncture is an effective and safe treatment for CU, and thus offers a new treatment approach for dermatologists and a promising field of study for allergy researchers. The authors hope that it will lead to a better understanding and treatment of urticaria.
We would like to give special thanks to Professor Jack Moreland of the Mackay Institute of Communication and Neurosciencefor his valuable help, advice and suggestions with the manuscript.
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Dr. Emad Tukmachi MBChB DTM(Dublin) PhD(London) is a research associate (Hon) at the Department of Rheumatology Selly Oak Hospital Birmingham University. He has studied and researched traditional Chinese acupuncture in both London and China and since 1992 has practised acupuncture privately at North Staffordshire Wolverhampton and Derby Nuffield Health Hospitals. He can be contacted at firstname.lastname@example.org or see www.clinical-acupuncture.co.uk (01782 613 604/ 07814696437).