The role of nervous system support in naturopathic treatment of skin disorders: A case study.
Besides its principal physiological roles, the skin can be an organ of emotional expression, functioning as an outlet for anxiety and psycho-emotional issues (1). At least one in three people presenting with skin diseases have associated psychosocial factors (1). Further, emotional and psychosocial stress has been linked to the first onset of certain chronic dermatologic conditions (2). Psychopathology may manifest on the skin in the absences of any identifiable skin disease (1), whilst emotional stress is also known to exacerbate existing primary skin disorders including psoriasis, atopic dermatitis and acne (2). Gupta and colleagues (3) present a more detailed hypothesis and discuss the link between emotional regulation and the skin, whereby the skin reacts to incidences of trauma and stress associated with an individual's compromised capacity to cope. States of chronic hyperarousal and acute psychological stress may have a direct effect on the skin, causing physical symptomatology (3).
The concept of a "brain-skin axis" has been described as "the interactions between psyche, immune system, and cutaneous inflammation" by Kleyn and colleagues (4), who discovered that concentrations of Langerhans' cells (LCs) (located in the epidermis and play a role in regulating cutaneous immune responses) were reduced after episodes of acute social stress. Further, Kim and colleagues (5) discuss the direct link between the skin and the nervous system where stress alters hypothalamic-pituitary-adrenal (HPA) axis hormones as well as cytokine profiles and the secretion of stress-related neuropeptides, illustrating the possibility of HPA axis hormones interacting with some cytokines and neuropeptides causing increased or exacerbated localised inflammation (5).
It is common place for patients to consult health care practitioners for physical symptoms, but to overlook their psychological associations, perhaps due to lack of awareness or due to the social stigma around mental and emotional health (1). A substantial proportion of people with psychopathology have reported feeling stigmatised as a significant barrier to seeking treatment for mental health conditions (6). Gordon-Elliott and Muskin (2) suggest the naturopathic practitioner may be one of the few health care providers who the client might trust, due to holistic principles of practice and capacity to integrate several aspects of an individual's physical, psychological and emotional health into the case analyses. Therefore, an essential component of effective naturopathic case management is being able to recognise and address the impact of psychosocial and emotional issues, within their case understanding, and within their scope of practice. Comprehensive and compassionate case taking could help identify key issues during naturopathic consultations. Psychological issues are not always what the patient directly complains about (7); however, it is essential to understand the impact of the client's psychology in order to rectify the presenting skin complaint.
The purpose of this case study is to highlight the complex interplay between the nervous system and the skin, providing insight into important considerations on which to base a treatment for people with skin conditions of unknown aetiology. We discuss the potential benefit of herbal medicine support for the nervous system, reducing anxiety, and regulating the physiological stress response in the treatment of non-specific skin disorders.
The case overview
'Kay' presented to the Wellnations student clinic on 7th March 2017 for treatment of a chronic skin condition. Kay is a 27-year-old female with a five-year history of a dry, bumpy rash on her chin and upper lip, treated with antibiotics and steroid cream with no lasting result. The rash was worse for touch, by eating too much sugar, or when Kay felt overly stressed or anxious.
Kay's bowel motions fluctuated between diarrhoea and constipation; however, her general pattern was 1-2 soft stools per day. She experienced bloating in the morning, eased by taking apple cider vinegar, and she reported diarrhoea after eating fatty foods in some instances.
Kay revealed that she was in an abusive relationship for three years, where she felt manipulated, criticised, insulted and isolated from her social networks. She reported that she had "moved past stressed to just feeling numb" and that she was having difficulty remembering anything. Kay had a history of abusive relationships. Further, she was grieving due to her grandmother's recent passing, with whom she lived for 22 years and who was a consistent support. She has experienced nightmares and disturbed sleep. Kay's fingernails were short, bitten and picked at.
Kay expressed that she generally consumed a wholefood diet, with limited processed foods, refined grains and sugar. Her meals often consisted of a lean protein source (for example, chicken) with a variety of fresh vegetables; however, her diet was lacking in fibre and nutrients from plant-based foods.
No pathological reports were available.
Rationale for the naturopathic treatment
The naturopathic treatment strategy in this case was based on the consideration of the skin being an organ of emotional expression (1), in the way that chronic stress may increase gut permeability (9), and that disorders of the skin may manifest and remit secondarily to digestive capacity and intestinal permeability (10). We identified a multi-directional link between Kay's nervous system, gastrointestinal system and integumentary system. Prolonged activation of the HPA axis and the sympathetic nervous system (SNS) was possibly suppressing secretion of digestive enzymes and potentially compromising digestive capacity (8). Chronic stress may also have been contributing to increased gastrointestinal permeability (9) and subsequently complicating an inflammatory skin condition, which may be an underlying expression of psychological stress and anxiety (1).
Brief stimulation of the sympathetic nervous system in response to stress (real or perceived) elicits a stress response that is considered to be a healthy coping mechanism (11); however, long-term stimulation is more likely to result in a decline of health, which may eventually impact several body systems including the gastrointestinal (GI) tract and heart (11). The HPA axis can become dysregulated and when this occurs, it may have a negatively adaptive effect on the central nervous system (12), and sustained suppression of the parasympathetic nerves and follow-on dysfunction of the GI tract (13) and other serious health complications (11).
Medicinal plants traditionally known as 'adaptogens' may alter the body's stress response by regulation of the HPA axis (12). This may enhance resistance to physical, biological and mental stress. Asparagus racemosus (Shatavari) has been used historically as a tonic and adaptogenic herb (14) and antidepressant (15), anxiolytic (16) and adaptogenic (17) effects have been recently demonstrated in animal studies. Investigations exploring the mechanism of action of Shatavari have shown physiological modulation of the HPA axis and the sympathetic-noradrenergic system in animals (16). This mechanism of action aligns with its traditional application as an adaptogen.
Anxiolytics and nervine herbal medicines may also be prescribed to reduce physical and psychological manifestations of stress (18) and may work synergistically with adaptogens. Passiflora incarnata (Passionflower) has an extensive traditional use to improve sleep and reduce anxiety. Clinical trials including people with insomnia and in stressful circumstances have demonstrated passionflower's effectiveness for stress reduction and safety (19-21). Avena sativa (Oats green) is another traditional nervine tonic with anxiolytic and restorative effects in people with nervous exhaustion (22).
Naturopathic herbal formulations are often underpinned by bitter tonics used to promote digestive function and general health (23). Bitter taste receptors are found at the back of the tongue and throughout the gastrointestinal tissue (24). Bitter herbs (for example Gentiana lutea) may stimulate these receptors and activate parasympathetic vagal nerve fibres and stimulate secretions of the digestive system and promote healthy diversity and ecology of microflora (25). The vagal stimulation may thereby facilitate digestion, assimilation and absorption of essential nutrients and improve immune balance (25). Medium to long-term use (23) of herbal bitters may be beneficial to sustain optimal digestive capacity, and improve general health and well-being (Moorhead, 1915, cited by (25)).
Cynara scolymus (Globe artichoke) contains bitter constituents and has a bitter action (25) as well as a choleretic action (stimulates bile acid secretion). It has been used traditionally for beneficial effects in the digestive system, biliary tract, and liver (26) and for reducing dyspeptic symptoms (26). Significant benefits have been demonstrated in the treatment of people with irritable bowel syndrome (IBS) (27-28). In adults suffering dyspepsia with alternating constipation/diarrhoea, bowel patterns have been observed to shift towards normal after treatment with globe artichoke (29).
Similar to bitters, herbal medicines containing pungent, warming constituents such as those in Zingiber officinale may have a stimulatory and tonic effect on the gastrointestinal tissue (25).
Ulmus rubra (Slippery elm (SE)) is a herbal medicine which has localised anti-inflammatory activity and may also improve integrity of the digestive ecology and reduce gastrointestinal permeability (25).
The herbal prescription
We provided two herbal mixtures (tonics) for treatment of Kay's skin condition (Table 1). Herbal tonic one contained Avena sativa, Cynara scolymus, Passiflora incarnata and Asparagus racemosus aimed to address the deep underlying nervous system support. Herbal tonic two was a digestive herbal combination of Gentiana luteum and Zingiber officanale provided in combination with slippery elm separately with the aim of supporting and regulating gastrointestinal function.
Kay missed the two-week follow-up appointment. At follow-up on 4th April 2017, the rash on Kay's chin had cleared and was no longer visible. Kay reported a significant reduction in stress, which she noticed soon after starting the naturopathic treatment. She was feeling calmer and more aware of herself in her relationship and was at a "crossroads" and feeling more capable of considering her options and what she wanted. Kay reported a marked improvement in digestion, she was no longer feeling bloated. She reported constipation when she stopped taking SE powder; however, her water intake was low, which may have limited its efficacy in bowel function normalisation.
Her prescription was repeated for a further two weeks with the additional use of a meditation app for daily meditation and an Australian bush flower essence mix for emotional support.
Over a course of 10 weeks, Kay attended three follow-up appointments where she was in varying degrees of mental and physical health and well-being. The rash on her chin did not re-appear; however, her digestive and mental health varied depending on life circumstances and compliance to treatment. Better well-being apparently depended on good compliance with the naturopathic treatment. She gained increased awareness of the connections between periods of non-compliance and slipping back into old states of poor mental and physical health. This empowered Kay's understanding of the connections between her skin and physical manifestations and stress, and the ability to make better decisions about her life and relationships when she felt well.
This case highlights a multi-directional naturopathic approach linking the nervous system, GI system and integumentary system, and addressing underpinning emotional stress as a causative and complicating factor. The case presented here corroborates the naturopathic understanding that skin is an organ of expression for emotional unrest and psychological stress.
It has been suggested that pathogenic mechanisms of skin disease are due to systemic disruption such as dysbiosis or increased intestinal permeability, even where GI signs are absent (30). Psychological stress plays a pivotal role, and may alter intestinal secretions, microflora diversity and barrier functions (31). Chronic stress exposure may cause significant dysfunction of the intestinal barrier throughout the small and large bowel (32) and increased permeability between the digestive lining and blood and lymphatic circulatory systems. This may have ultimately manifested on the skin. Another possible pathogenic mechanism was a direct effect of sustained sympathetic nervous excitation, described as the "brain-skin" axis. This may be causing local inflammation by altering skin cell and cytokine profiles (4-5).
The naturopathic treatment approach was informed by the findings of Kim and colleagues (5) that HPA axis hormones may negatively interact with some cytokines and neuropeptides, leading to an association between acute stress and skin inflammatory symptoms. Evidence from a clinical trial that examined the effects of marital relationships on inflammatory cytokines found that hostile and abrasive behaviours increased the frequency and intensity of pro-inflammatory cytokines (33). These findings support the principle of the "brain-skin" axis concept (4-34). Although the mechanism behind this concept is not fully understood, the consideration of a "brainskin" axis may be important to successful management of inflammatory skin conditions.
The case provides insight into the naturopathic management of skin presentations by holistic treatment, incorporating strategies to improve nervous system and digestive function to treat a skin condition. It demonstrates the synergistic use of herbal medicines to restore the emotions and tonify the nervous system and GI system during times of acute and chronic stress, and improved health literacy and self-efficacy for the client to make positive self-help decisions.
One of the limitations to this case study is the difficulty in attributing the clinical changes to single components of the naturopathic treatment. Counselling is an incidental component of naturopathic consultations and this may have provided a therapeutic effect in itself. Naturopathic consultations are long by nature and there is opportunity for patients' self-reflection through the process of telling the 'story' of their health. This self-reflection may have contributed to the progress made by the client in this case. A further limitation of the case study is the issue of generalisability. As a single case study, it is not possible to estimate the probability of the benefits occurring in other people.
This study demonstrates the defining differences of naturopathic and herbal medicine practice from a methodologically, ideologically, humane perspective and how these practices uniquely meet the complex and holistic health needs and desires of patients. Overall, the case demonstrates the potential of naturopathy in holistic treatment of skin disorders where there is underlying emotional disturbance.
This case study demonstrated a direct interplay between the nervous system, the digestive tract and the skin. These links highlight the relevance of investigating emotional health when treating patients with skin disorders and that nervous system support as a component of naturopathic care with an individualised herbal medicine prescription have been an effective treatment strategy.
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Sophia Gerontakos (BHSc Naturopathy)
Endeavour College of Natural Health, Fortitude Valley, Brisbane, QLD 4006
David Oasteleijn (MHSc Herbal Medicine)
Endeavour College of Natural Health, Fortitude Valley Brisbane, QLD 4006
University of Technology Sydney, Faculty of Health, Australian Research Centre
in Complementary and Integrative
Medicine, Ultimo, NSW 2007
Sophia Gerontakos, Suite15c, Level 2, 40 Annerley Rd, Woolloongabba, QLD 4102
Table 1: Prescription Herb Dosage Herbal mix 1 weekly dose Avena sativa 1:2 (oats 20 mL green) Oynara soolymus 1:2 15 mL 7.5mL to be taken (globe artichoke) twice daily in a small amount of water Passiflora inoarnata 1:2 40 mL (passionflower) Asparagus raoemosus 30 mL 1:1 (Shatavari) 105 mL Herbal mix 2 6 drops to be taken equal parts Zingiber officinale in a small amount (Ginger) Gentiana luteum (Gentian) of water about 10 minutes before meals Ulmus rubra (Slippery elm) powder 1 heaped teaspoon to be mixed into a glass of water and taken daily away from meals by at least an hour
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|Title Annotation:||Case Study|
|Author:||Gerontakos, Sophia; Casteleijn, David|
|Publication:||Australian Journal of Herbal Medicine|
|Article Type:||Case study|
|Date:||Mar 1, 2018|
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