Treating Skin Diseases in Humoral and Modern Medicine

Farzollah Gholizadeh and Fariba Bayrami

Introduction

In humoral (traditional Persian) medicine, a skin disease is less a “disease of the skin” than the outward sign of a dystemperament or of excess and spoiled humours within. Lasting treatment therefore begins inside and works outwards. The order of treatment in this school is clear: first, managing the six essentials of life and food; then correcting the organs that make and filter the humours; then ripening (nuzj) and expelling (istifragh) the disease-causing matter; and alongside all of these, carefully chosen topical treatment matched to the stage of the disease [1,2,5,7,11].

This is the second of a two-part series. Recognising the temperament of the skin and diagnosing its diseases is covered in part one, The Skin: A Mirror of Temperament and Inner Health. Here we turn to natural and traditional treatment, and note where modern research supports a teaching of humoral medicine.

Doses of remedies and herbs are not given in this article, because the right amount depends on temperament, age, season, strength and other illnesses, and must be set by a practitioner.

1. Foundations: the skin in humoral medicine

The skin: site of the fourth digestion and a route of elimination

The physicians described digestion in four stages: the first in the stomach (making chyle), the second in the liver (making the four humours), the third in the vessels, and the fourth in the organs themselves, where each organ takes its food from the blood and makes it like itself [1,7]. The skin is fed in this fourth digestion; so if the blood reaching it is not clean and balanced, or the skin’s own strength is weak, waste stays in it.

The skin is also one of the body’s natural routes of elimination: sweat, skin grime, hair and nails are all wastes of the fourth digestion. When Nature (the body’s governing power) moves waste away from the vital organs, it pushes it towards the surface. So many spots, itches and scales are in fact Nature’s effort to expel matter; a treatment that only closes this route sends the matter back inside [1,2].

Three conditions for disease to settle in an organ

According to Ibn Sina, three things are needed for matter to settle in an organ: excess or spoiled matter, the strength of the organ that pushes it away, and the weakness of the organ that receives it [1]. Complete treatment addresses all three: it reduces and corrects the matter, treats the pathway and the sending organ (for example the liver or spleen), and strengthens the skin so that it does not receive the matter.

Simple and material dystemperament

A skin disease may come only from a change of quality, with no build-up of humour (simple dystemperament), such as dry skin from cold wind or redness from the sun. Or it may involve humoral matter (material dystemperament), such as pustular spots, melasma and weeping eczema. In the simple type, balancing the quality with its opposite is enough and no evacuation is needed; in the material type, the balance will not last until the matter has left [1,8].

Natural and burnt humours

All four humours (blood, phlegm, yellow bile and black bile) can cause disease in the skin. But in chronic, stubborn, scaly diseases such as scabies, quba, severe itching, psoriasis and leprosy, the physicians spoke mostly of “abnormal black bile”: black bile formed by the burning of blood, yellow bile or phlegm, which is sharp and corrosive [1,2,8]. The distinction matters greatly in treatment. Natural black bile is cold and dry, but burnt black bile carries leftover heat; treating it with very hot remedies is a mistake, and it calls instead for moistening, tempering the heat and gentle cleansing.

“Salty phlegm”, formed when yellow bile mixes with phlegm, is likewise counted among the common causes of itching, scabies and weeping lesions [1,2].

2. The basic rules of treatment in humoral medicine

• Treat with the opposite, in proportion: every dystemperament is treated with the opposite quality: heat with cold, dryness with moisture, and the reverse. But the strength of the remedy must match the strength of the disease; cooling too much creates a new dystemperament [1].
• From gentle to strong: as long as lifestyle and food can treat, do not turn to medicines; as long as a simple remedy is enough, do not use a compound one; and keep manual procedures such as venesection and cupping for where they are needed [1,7].
• Treat the cause before the symptom: if spots come from weak digestion or a congested liver, a topical remedy only calms the surface until that is corrected, and the matter is made again.
• Separate simple from material: simple dystemperament needs only balancing; material dystemperament needs ripening and expelling the matter first, then balancing.
• Ripen before expelling: thick, sticky matter must first be “ripened” and made ready to leave, then expelled. Thin matter, especially yellow bile, needs little ripening (section 5).
• Cleanse the whole body before the part: if the body is full of humour, the whole body is cleansed first and then the affected part; otherwise a topical remedy draws fresh matter to the part [1].
• Do not drive matter back inside: when Nature is pushing matter towards the skin (as at the start of a widespread eruption, or a rash after fever), it must not be driven back towards the vital organs with strong repellent remedies and intense cooling. Repellents are used only at the start of local swellings and after the body has been cleansed [1,2].
• By the nearest and most natural route: expel matter by the route nearest to it and to which Nature inclines. If matter is flowing into an organ, it is drawn in the opposite direction [1].
• Treat the partner organ: if the skin is ill because of another organ, such as the liver, spleen, stomach or womb, treating that organ is a central part of treating the skin (section 4).

The conditions for evacuation

Before any evacuation, Ibn Sina requires these to be weighed [1]:

• Fullness: is there really excess matter? Without it, evacuation weakens the body.
• Strength: a weak body cannot bear evacuation.
• Temperament: a very hot and dry, or very cold, temperament does not tolerate strong evacuation.
• Agreeing signs: the signs of dominance of that same humour should be present.
• Build: a lean, dry body tolerates less; a fleshy, moist body more.
• Age: childhood and old age are barriers or limits.
• Season and weather: intense heat and intense cold are not times for strong evacuation; spring and autumn are the usual seasons for cleansing.
• Place, occupation and habit: a person’s way of life and habit of evacuation set its type and strength.

These conditions show that evacuation in humoral medicine is a measured, individual act, not a general prescription.

3. Step one: the six essentials and diet

The physicians built prevention and treatment on six essentials: air; food and drink; bodily movement and rest; movement and rest of the mind; sleep and waking; and retention and evacuation [1,7]. Treatment of the skin begins with these six too.

1) Air and surroundings

• Hot, bilious skin is made worse by heat, strong sun and dry air; it needs mild, humid air and shade.
• Cold, phlegmatic skin grows heavier in cold, damp, sunless places; it needs mild air tending to warm and dry, and good ventilation.
• Melancholic, dry skin cracks in cold, dry air and needs moderate warmth and humidity.
• In scaly diseases such as psoriasis, the physicians advised avoiding intense heat and cold, which increase dryness [18].
• The change of seasons, especially spring (the surge of blood) and autumn (the rise of black bile), is when many skin diseases flare, and calls for preparation before the season.
• In pigmentation, melasma, rosacea, lupus and vitiligo, suitable covering and avoiding strong sun are essential.

2) Food and drink

The stomach and liver are the source of the humours, and correcting the diet is the first treatment for skin disease [1,15-17]. The test in humoral medicine is not whether a food is “good or bad” but whether it suits the person’s temperament, the season, the amount and the time of eating.

General rules:

• Eating before real hunger and before the previous meal is digested, and overeating, are the root of spoiled digestion.
• Incompatible foods in one meal (such as fish with milk, which the physicians held to predispose to baras and bahaq), and a lot of cold water with food, upset digestion.
• Stale, slow-to-digest and processed food produces bad humours.

Bilious pattern (hot red spots, burning itch, rosacea, red hives): cut down on spicy, fried, very sweet and very fatty foods, honey and dates; favour cold, moist, light foods such as courgette, lettuce, spinach, cucumber, plums, sweet-sour pomegranate, verjuice, mung beans and barley [15].

Sanguine pattern (congested, inflamed spots, scattered redness, boils): cut down on blood-building foods such as a lot of red meat, sweets, dates and grapes; favour mild sour foods such as sumac, verjuice and pomegranate, and cooling vegetables. In this pattern, eating less is itself the treatment.

Phlegmatic pattern (white puffy spots, cold swelling, white bahaq, oily dull skin): cut down on heavy dairy, a lot of white rice and bread, cold soft foods, too much watery fruit and cold water; favour warm, dry, light foods, mild spices such as ginger, cinnamon, cumin and ajwain, and more activity.

Melancholic pattern (melasma, psoriasis, dry eczema, chronic itching, warts): cut down on foods that generate black bile, such as beef and game, lentils, aubergine, cabbage, aged cheese, salted fish, tinned food and sausages, and a lot of pickles and vinegar; favour warm, moist, easily digested foods such as barley soup, broths, lamb and chicken, olive and almond oil, raisins, figs and jujube [17]. If the black bile is of the burnt kind (with burning, hot itching and thirst), food should be moist and tending to cool, not hot.

In modern medicine: in acne, a diet low in sugar and refined carbohydrate has helped in some trials, and high milk intake, especially skimmed milk, is associated with acne [30,31]. Weight loss helps psoriasis and acanthosis nigricans, and correcting deficiencies of iron, zinc, vitamin D and B12 helps hair loss and some skin conditions; but extra supplements do not improve the skin of someone who has no deficiency.

The gut–skin axis: modern medicine calls the link between digestion and skin the “gut–skin axis”: a disturbed gut flora can raise inflammation in the body and play a part in acne, eczema and psoriasis [33]. This is what the physicians explained as “spoiled digestion”. The evidence for probiotics is promising but still limited. The skin has its own microbiome too, which maintains its acid mantle and is harmed by too much washing with strong cleansers [32].

3) Movement and rest

Moderate exercise stirs the innate heat, disperses waste and improves blood flow to the skin. A phlegmatic person benefits most from activity; a bilious person, or someone with rosacea, should avoid heavy exercise in the heat; and a melancholic person does better with gentle exercise. The physicians advised exercise before food and after the bowels and bladder have emptied, not on a full stomach.

4) The mind and emotions

In humoral medicine, anger kindles heat and increases yellow bile; sorrow, worry and overthinking dry the body and increase black bile; and fear brings cold. Moderate joy strengthens the innate heat. In modern medicine too, stress, through cortisol and the nerves of the skin, triggers flares of acne, eczema, psoriasis, hives, alopecia areata and cold sores. Relaxation, deep breathing, prayer and remembrance, time in nature and, where needed, psychotherapy are part of treating the skin.

5) Sleep and waking

Too much wakefulness dries and heats the body and increases black bile and the burning of humours; too much sleep, especially in the daytime, increases moisture and phlegm [1]. So melancholic and bilious people particularly need enough sleep at night, and a phlegmatic person should avoid oversleeping and sleeping after meals. In modern medicine, lack of sleep slows skin repair and increases inflammation.

6) Retention and evacuation

Regular clearance of the natural wastes (bowel movements, urine, sweat and, in women, regular periods) is a condition of healthy skin. The physicians stress constipation especially in melasma, melancholic acne and psoriasis [17,18]. Enough water, fibre, plums, figs and raisins help. Therapeutic evacuations are covered in section 5.

4. Step two: correcting the organs that make and filter the humours

The physicians said that until the organ that makes a bad humour, or should filter it, is corrected, the skin disease returns after every treatment [1,15]. So these organs are attended to before, and along with, evacuation. The choice of remedy depends on the temperament of the organ itself, not just on the name of the disease.

The stomach: the first digestion

Weak stomach digestion makes raw chyle, and every humour made from it will be defective. A weak, cold, moist stomach is corrected with warming tonics such as ajwain, cumin, fennel, mastic and ginger; a hot, inflamed stomach with cool, astringent tonics such as rose, sandalwood, quince paste and plain sekanjabin (vinegar syrup).

The liver: the source of blood

A hot liver burns the blood and makes yellow bile and burnt black bile; a cold liver makes thin, phlegmatic blood; and a congested liver cannot filter the blood properly. For a hot, inflamed liver the texts commonly use cool, opening remedies such as chicory, jujube, barberry and verjuice; for a cold liver, warm opening remedies such as wormwood, agrimony and asarum; and to open obstruction, fumitory and rhubarb, according to temperament [9,12,14,15].

The spleen: the seat of black bile

In humoral medicine the spleen draws natural black bile from the blood and stores it. If the spleen is weak or congested, black bile stays in the blood and reaches the skin, causing melasma, dark marks, dark bahaq, quba and chronic itching [1,12,13]. Correcting the spleen, with remedies such as caper root bark, wormwood, lavender and seed sekanjabin, according to temperament, has a central place in treating melancholic skin diseases.

The gallbladder

The gallbladder takes excess yellow bile from the blood and pours it into the bowel. If this fails, bile stays in the blood and causes burning itch, jaundice and hot spots. Tempering the heat of the liver, opening the ducts and mild bile-clearing laxatives are used.

The womb and periods in women

The physicians counted retained or scanty periods among the important causes of melasma, spots on the chin and face, and sometimes excess hair [12,13,17]. Regulating periods, by lifestyle and remedies and under a physician’s care, is part of treating these conditions. In modern medicine too, many of them are linked to hormones and polycystic ovaries.

In modern medicine

Treating constipation, reflux and gastritis, fatty liver, diabetes and an underactive thyroid affects many skin diseases. Some researchers in humoral medicine stress the role of digestive disorders in melasma [38]. The link between itching and diseases of the liver and bile ducts, and between marks and dry skin and an underactive thyroid, is well established today.

5. Step three: ripening and evacuation

Ripening: preparing the matter

Thick, sticky or dry matter will not come out with a purgative until it is “ripened”; giving a purgative before ripening drains strength and scatters the matter further into the organs [1,8,11]. Ripening means bringing the matter to a consistency that is easy to expel: thinning what is thick, loosening what is sticky and softening what is dry. So the ripening agent differs for each humour:

• Yellow bile: natural yellow bile is thin and needs “tempering” (cooling and moistening) more than ripening. Only thick bile, or bile mixed with other matter, needs ripening, with remedies such as jujube, sebesten, prunes, tamarind, chicory and fumitory, and plain sekanjabin [9,11].
• Phlegm: with warm, thinning, opening remedies such as fennel seed, anise, celery and fennel root, maidenhair fern, hyssop, liquorice, figs and raisins, with honey sekanjabin [8,11].
• Black bile: with softening, moistening remedies such as borage flower, lemon balm, lavender, fumitory, maidenhair fern, jujube and seeded raisins. Whey (ma’ al-jubn) is the classic vehicle and moistener for ripening and clearing black bile in skin diseases such as scabies, itching, quba and melasma [8,11,13]. In burnt black bile the ripening agent should be more moistening and moderate than hot.

Evacuation: expelling the matter

“Istifragh” in humoral medicine means expelling excess matter by any route, not only vomiting. The choice of route depends on the humour, where it is in the body and the conditions in section 2:

• Purging: through the bowel, the main route in skin diseases. Mild purgatives of yellow bile include manna, tamarind, plums and yellow myrobalan; of phlegm, turpeth and chebulic myrobalan; of black bile, dodder (aftimun), polypody, senna and black myrobalan [9,11]. Black bile is thick and slow to leave, so the physicians cleared it with a mild purgative over several sessions, not with one strong one.
• Enema: washing the bowel from below, for someone who cannot tolerate an oral purgative or when the matter is in the lower bowel.
• Emesis: for phlegm and bile gathered in the stomach and upper body. Ibn Sina found vomiting easier in hot weather and purging in cold [1]; spring, when the humours stir, is the usual season of cleansing, especially for phlegmatic people. Emesis is not suitable for people with a weak chest or throat, weak eyes, high blood pressure or a hernia.
• Urine and sweat: expelling thin matter through the kidneys and skin, with suitable drinks, bathing and exercise.
• Venesection, cupping and leeches: evacuation through the blood (section 6).

After every evacuation the physicians strengthened the stomach and liver and balanced the temperament so that new humour was not formed.

Important warnings

• Do not take purgatives or enemas on your own or repeatedly; they harm the gut lining and its beneficial bacteria. They are forbidden or tightly restricted in pregnancy, breastfeeding, childhood, old age, weakness, heart and kidney disease, inflammatory bowel disease and dehydration.
• Long-term use of senna and other stimulant laxatives can lower potassium and make the bowel lazy.
• The very strong purgatives of the old texts (such as scammony, hellebore and Armenian stone) are not used today because they are too dangerous.
• Some herbs interact with blood thinners and with medicines for blood sugar, blood pressure, the thyroid and immunity (section 10).
• The choice of ripening agent and purgative, and its amount, duration and repetition, belong to a qualified practitioner.

6. Venesection, cupping and leeches

These three methods expel matter through the blood, but each works differently [1,6,7]:

• Venesection (fasd): from larger veins, for fullness of blood in the whole body or in one part. The vein was chosen according to the affected part: the cephalic for the head and face, the basilic for the lower body and liver, the median for the whole body, and the saphenous for diseases of the legs [1].
• Wet cupping (hijama): from the small vessels between skin and flesh. Ibn Sina considers cupping more suitable than venesection for cleansing blood near the surface, and recommends it in the second half of the lunar month, in the middle hours of the day, with the stomach neither full nor very empty [1]. Cupping between the shoulder blades has a general effect, cupping at the sides of the neck was used for the head and face, and cupping on the calf for the lower body and retained periods.
• Leeches: to draw thick, melancholic blood from local lesions and from places where cupping is not possible [1,24].

The texts forbid cupping before cleansing the body in general fullness, and venesection and cupping in childhood and old age.

Uses in skin disease, according to the texts

• Acne: after correcting the diet and medical treatment, the physicians proposed venesection, leeches and wet cupping as a third step for stubborn spots, scars and marks [15].
• Psoriasis: cupping, venesection and leeches are mentioned, alongside changes in lifestyle and diet, as ways of expelling spoiled matter [18].
• Quba and eczema, hair loss and boils: Ibn Sina recommended leeches for some skin diseases, including quba-type lesions, alopecia areata and boils. Leech saliva contains anticoagulant and vessel-widening substances [24].
• Melasma, dark marks, sanguine spots, erysipelas and some hives: where blood or black bile dominates.
• Cutaneous leishmaniasis: cupping, leeches and cautery are mentioned alongside topical remedies [22].

Modern evidence

A large systematic review found that wet cupping, alone or with other treatments, gave positive results in acne, but most of the trials were of low quality [26]. The same review includes reports on shingles. Even so, in viral skin diseases (shingles, cold sores, warts and molluscum) the main treatment is medical care, with antiviral medicine when needed. Cupping and leeches are not done on or near an active viral lesion, because of the risk of spreading the virus and of secondary infection. There are also reports in chronic hives and psoriasis.

In some eczema, cupping may do more harm than good, and in psoriasis skin injury can produce a new plaque at the site (the Koebner phenomenon). These methods are complements, not substitutes for proven treatment.

Who should not have these procedures

• People with anaemia, low blood pressure or severe weakness, and frail older people.
• People with clotting disorders, or taking blood thinners such as warfarin and aspirin.
• Pregnant women; and, for venesection and leeches, children.
• People with uncontrolled diabetes or weak immunity, or taking immunosuppressants.
• Where there is active infection, a wound or an active lesion at the site; an active viral lesion (cold sore, shingles, wart, molluscum) at or near the site; or active psoriasis or eczema at the cupping site.
• People with a history of keloids or raised scars.

Safety principles

• Only by a trained, licensed person.
• Sterile, single-use instruments, to prevent the spread of infections.
• Farmed medicinal leeches, used once for one person only; the bite site must be watched for infection.
• After cupping or leeches, keep the site clean and covered and watch for signs of infection (spreading redness, pus, fever).
• Repeating these procedures too often leads to iron-deficiency anaemia.

7. Topical treatment in humoral medicine

In humoral medicine a topical remedy is chosen on two grounds: the quality of the lesion (hot or cold, moist or dry) and the stage of the disease. The right remedy at the wrong stage does harm [1,2].

The stages of a swelling or boil

• Onset: matter is just starting to flow into the part. A repellent remedy is used, provided the body has already been cleansed and the matter is not of the kind Nature has driven out from the vital organs.
• Increase: a repellent with a little resolvent.
• Peak: resolvent and ripening remedies in equal measure.
• Decline: resolvent alone; and if a boil has come to a head, a ripening remedy and then opening by a physician.

Topical forms

• Tila: a thin preparation painted onto the skin; for marks, bahaq, melasma and spots.
• Poultice (zimad): a thick herbal paste applied and bound on; for swellings, boils and deeper lesions.
• Latukh: a thicker application than tila; for itching and scaling.
• Ointment and cerate: a greasy preparation of oil and wax; for cracks, wounds, burns and dryness.
• Oil (duhn): plain oil or oil in which a herb has been cooked; for dryness, stiffness and cracks (section 8).
• Wash (ghasul): a decoction or herbal water for washing the lesion.
• Pouring (natul): slowly pouring a lukewarm decoction over the part.
• Sitz or immersion bath (abzan): sitting in, or immersing the part in, a herbal decoction; for widespread itching, dryness and cracks.
• Dusting powder (zarur): a dry powder sprinkled on a wound or weeping lesion.
• Compress: warm or cold.

What topical remedies do

The physicians classified remedies by their action [1,2]:

• Cooling remedies for hot inflammation; warming remedies for cold lesions.
• Moistening (softening) remedies for dryness; drying remedies for weeping lesions.
• Repellents to stop matter flowing into a part at the start of a swelling; resolvents for swellings and thick matter.
• Ripening remedies to bring a boil to a head; cleansing remedies for wounds; flesh-growing and healing remedies to grow new tissue and close wounds.
• Clearing (jali) remedies to brighten the skin and remove marks; reddening (rubefacient) remedies to draw blood to colourless patches and to hair loss; and hair-growing remedies.

Substances most used for the skin in the texts

• Vinegar, honey, olive oil, fumitory, rose and salt: the most used substances for eczema-like lesions in Ibn Sina’s Canon [20].
• Frankincense, aloe, myrtle, henna, oak gall, pomegranate peel and rose: astringent, healing and cleansing in wounds.
• Sidr, marshmallow, chamomile, melilot, fenugreek, flaxseed and psyllium: softening and gently resolvent; widely used for spots and swellings [16].
• Sandalwood, camphor, rose water and chicory water: cooling in hot itching, hives and redness.
• Sulphur: in scabies and quba; sulphur is still used today in some scabies and acne products.

Laboratory research has shown anti-inflammatory, antimicrobial, antioxidant and wound-healing effects for many of these plants [16,23], but most still lack adequate human trials.

Litharge and white lead in traditional medicine

In the old texts, litharge (murdasang) and white lead (sefidab) were used on the skin to reduce sweating and body odour, dry weeping sores, soothe inflammation and itching, and whiten the face and remove marks. Both are lead compounds and can cause gradual poisoning, damage to the brain, nerves, liver and kidneys, and blood disorders; using them on the skin is not recommended. For similar purposes, use standard products free of heavy metals.

Alum and verdigris (copper compounds) in traditional medicine

In the old texts, alum, especially white alum, was used on the skin to reduce sweating and odour, tighten and dry wounds, stop surface bleeding and reduce discharge. Verdigris (compounds formed from copper) also appears in some old prescriptions for cleaning wounds, treating certain skin lesions and fighting local infection. However, verdigris can be irritant and toxic, and misuse of copper compounds causes inflammation, burns and skin damage. Topical use of these substances, verdigris especially, calls for great caution.

Do not use any topical product whose composition is unclear. Test a new substance on a small area of the inner forearm and wait 24 to 48 hours. “Herbal” does not mean “harmless”.

8. Bathing, soaking, oiling, massage, nureh, henna and the exfoliating mitt

Bathing and soaking

In humoral medicine the bath was used both for prevention and for treatment [1,25]. Its effect has two parts: the hot air of the bath warms, opens the pores and disperses moisture through sweating; but lukewarm fresh water moistens and softens the body. So the physicians counted soaking and lukewarm baths among the best measures for dry skin and a lean, melancholic body [1,18].

• Cold and moist (phlegmatic): a warmer bath with more sweating helps; less time soaking in water. Saunas, especially dry saunas, suit the phlegmatic temperament very well.
• Dry (melancholic and bilious): a short time in hot air and little sweating, but lukewarm water and soaking, followed by oiling. A long bath with heavy sweating dries the skin further and is unhelpful in psoriasis and dry lesions [18].
• Hot (bilious): lukewarm, not hot, water, and no long stays in the heat.
• The physicians forbade bathing on a full stomach or when very hungry, and held getting chilled or drinking cold water straight after a bath to be harmful [1].

In modern medicine there is no fixed frequency for everyone. Too much washing with hot water and strong cleansers strips the skin’s protective oil and its microbiome [32]. For dry skin, older people and those with eczema or psoriasis, a full bath a few times a week, with washing of sweaty areas on other days, is enough. Practical rules:

• Lukewarm, not hot, water, for about 5 to 10 minutes.
• A mild, fragrance-free, sulphate-free cleanser, only where needed. Gentle traditional cleansers such as sidr, marshmallow and bran suit sensitive skin.
• Moisturiser straight after the bath, on slightly damp skin.
• A herbal soak for widespread itching and dryness: sitting in lukewarm water with softening decoctions such as marshmallow, chamomile, barley or oatmeal.

Oiling according to temperament

The general principle: the quality of the oil should balance the quality that is in excess. An oil’s temperament is set both by the seed or plant and by the base oil [1,9]:

• Hot and dry: cold, moist oils such as violet oil, water-lily oil and pumpkin seed oil; and sweet almond oil, which is moderate and moist.
• Cold and dry: warm and moist, or moderate and moist, oils such as sweet almond oil, sesame oil and ripe olive oil.
• Cold and moist: a little warm, dry oil such as chamomile oil and black seed oil.
• Hot and moist: needs less oil; if needed, a little cool, light oil such as rose oil.

Safety: raw bitter almond oil may contain cyanide compounds; use only a refined, standard product. Plant oils, including black seed and chamomile, can cause contact allergy. Do not oil an open, infected or very inflamed lesion, and avoid heavy oils on an oily, acne-prone face.

Massage (dalk)

Ibn Sina sets out the effects of massage: firm massage makes a part firm and strong; soft massage makes it soft and relaxed; much, prolonged massage disperses and slims; and moderate massage makes a part full and fresh [1]. Rubbing with a rough cloth draws blood to the surface. In skin conditions, gentle, moderate massage with a suitable oil helps dryness, roughness, scars and cold phlegmatic skin. Do not massage active, infected or inflamed lesions.

Nureh (depilatory paste) in traditional medicine

What it is: nureh, or vajebi, is a mixture of lime and orpiment (arsenic sulphide) that was used in traditional bathhouses to remove unwanted hair. The physicians held its temperament to be very hot and dry and described it as resolvent, clearing and reddening.

Topical uses in the humoral texts: nureh and orpiment, alone or with substances such as sulphur, vinegar, mastic and honey, appear in topical prescriptions for some skin lesions, including bahaq, baras, quba, scabies, alopecia areata, warts and foul, purulent ulcers [2,9,39]. The logic in humoral medicine was to disperse moisture and thick phlegm, clear the surface of the skin and draw blood to the area.

Aftercare in the traditional sources: the physicians insisted on washing the whole body thoroughly after nureh and, to temper its dryness and heat, advised oiling with violet, pumpkin seed or olive oil and using rose water or henna. They considered it unsuitable for thin, sensitive, dry or broken skin and delicate areas, and stressed keeping the contact time short, especially in dry temperaments; left on longer, nureh burns the skin.

Today’s view: orpiment is an arsenic compound. Arsenic is a recognised human carcinogen (Group 1) and is absorbed through the skin, especially damaged skin; long-term exposure is linked to skin cancers [28,29]. The lime in nureh is a strong alkali and causes chemical burns. For these reasons arsenic-based nureh is not recommended today, either for hair removal or for treating skin disease. What is described here is a historical account, not instructions for use.

Henna

Henna (Lawsonia inermis) is a well-known plant in humoral medicine, held to be cold and dry in the second degree. Its leaves contain active compounds such as lawsone and tannins, which give it astringent, anti-inflammatory and antimicrobial properties.

The main skin properties and uses of henna:

• Antimicrobial and antifungal: used in traditional sources for some fungal and skin infections. Its compounds have also shown antibacterial and antifungal effects in laboratory studies.
• Healing: used as a poultice in some traditional prescriptions for grazes, superficial wounds and skin lesions.
• Reducing local inflammation and heat: used to soothe burning, inflammation and some skin irritation.
• Reducing sweat and body odour: because of its tannins and astringency, it was used to reduce sweating of the palms and soles and to relieve body odour.
• Controlling oil and spots: henna with suitable ingredients, such as rose water, was used in traditional masks for oily, acne-prone skin.

Combinations that can enhance henna’s effects:

• Henna and olive oil: to temper henna’s dryness and soften the skin.
• Henna and violet oil: to reduce dryness and keep the skin supple.
• Henna and sweet almond oil: for dry, sensitive skin.
• Henna and rose water: for mild, soothing masks.
• Henna and chamomile: to add chamomile’s calming, anti-inflammatory properties.
• Henna and aloe vera: for more moisture and less feeling of dryness.
• Henna and diluted vinegar: used in some traditional prescriptions for oily skin and skin lesions, though it may irritate sensitive skin.

A note from humoral medicine: because henna is cold and dry, combining it with gentle oils such as violet, sweet almond and olive oil can prevent it over-drying the skin. The combination should suit the temperament and skin type.

Caution: choose pure, natural henna and avoid “black henna” containing PPD. Do a patch test first, and do not apply it to open wounds or inflamed skin. Henna can cause haemolytic anaemia in newborns and in people with G6PD deficiency [27]. The combinations above are not proven treatments for infections or skin diseases.

Henna and nureh in traditional practice

In some traditional practices, henna powder and nureh were mixed and rubbed on the skin before bathing, for their effect on the skin rather than to remove hair. In humoral terms, nureh is very hot, dry and resolvent, and henna cold, dry, astringent and clearing; henna was thought to temper the harshness of nureh. Religious tradition also recommends applying henna after nureh and attributes protective properties to it.

Because of the arsenic in orpiment, this mixture is not recommended today. Pure henna alone, or with the oils above, is the safer alternative.

The exfoliating mitt (kiseh)

Scrubbing with a kiseh in the traditional bath is a kind of rough massage that warms the skin and cleans its surface, and is considered more suitable for thick, cold skin. In modern terms it is mechanical exfoliation: it removes dead surface cells and may improve the look of thick skin, keratosis pilaris and dry dandruff, but it is not a treatment for acne, marks or freckles. Its benefits:

• Natural exfoliation: with controlled friction a woollen mitt removes dead cells, dirt and built-up oil without chemicals.
• Clearing the pores: with dead cells removed, blocked pores open.
• Better local circulation: the rubbing stimulates blood flow at the surface and freshens the skin.
• Why wool: wool is warm in nature, suits people with a cold temperament better than nylon mitts, and when wet glides more softly than synthetic fibres and does less damage.
• Preparing the skin for moisturiser: after scrubbing, the skin takes up oils and moisturisers better.

Important points:

• Do not scrub hard or every day. For most people once every one to two weeks, with gentle pressure on thoroughly wet skin, is enough to avoid damaging the skin barrier.
• Do not scrub wounds, inflamed spots, cracked skin, eczema, active psoriasis, rosacea, very dry or thin skin, or moles.

Roshur (traditional washing clay)

Because of its mineral salts and natural fat, roshur is considered warm and dry (or moderate tending to warm and dry) and is known as a traditional cleanser. Its main traditional benefits:

• Exfoliating and cleansing: by removing dead cells from the surface it helps open the pores.
• Increasing local circulation: its warm nature stimulates blood flow at the surface and freshens the skin.
• Brightening: regular use (especially with diluted natural vinegar or rose water) helps fade darkening of areas such as the elbows and knees.
• Softening: the animal fat (tallow) in roshur prevents the skin over-drying.
• Reducing body odour: clearing the pores with roshur and a mitt prevents build-up of oil and unpleasant smell.

Buy roshur from a reliable maker. In the past “sefidab” also meant white lead, which is toxic and must not be used.

9. Treatment, disease by disease

In humoral medicine a disease is not treated with one prescription: first the dominant humour and the stage of the disease are identified, and then the order of sections 3 to 8 is followed. What follows are the natural and traditional measures for each condition; the choice of remedy and its amount belong to the practitioner. The signs that call for urgent care or a doctor’s examination are listed in section 10.

Natural antimicrobials in the texts

To clean wounds and purulent, infected lesions, the physicians used substances whose antimicrobial effect laboratory research has now shown: garlic, pennyroyal, thyme, honey, myrtle, pomegranate peel, turmeric, frankincense and aloe [3,9,16,23]. They are useful in superficial, mild lesions as a wash, poultice or ointment, and garlic and thyme in food.

Propolis in black seed oil: propolis is a resinous substance bees make from tree buds and bark and use to disinfect the hive. Dissolving it in black seed oil puts two natural antimicrobials together; both being warm and dry, the mixture suits moist, phlegmatic and superficially infected lesions. The evidence for both is promising:

• Black seed oil has shown a concentration-dependent antibacterial effect in the laboratory against Staphylococcus aureus, including multi-drug-resistant strains isolated from diabetic wounds [41].
• Caution: propolis is one of the commonest causes of contact allergy among natural products; in Europe it has been part of the baseline patch-test series since 2019, and roughly 0.5 to 17 per cent of dermatitis patients react to it [42]. People allergic to honey, beeswax or bee stings, or with eczema or sensitive skin, should use it with care and only after a test on the forearm.
• Raw crushed garlic left directly on the skin for long causes chemical burns and blisters; use it diluted, briefly, and after a test on a small area.
• Pennyroyal oil and essence are poisonous if swallowed and damage the liver; they are forbidden in pregnancy. Apply essential oils to the skin only diluted in a carrier oil. Washing healthy skin with a weak pennyroyal infusion is fine.
• These substances do not replace medical treatment for an infection that is spreading, comes with fever or does not improve within a few days (section 10).

Acne

The physicians’ three steps: (1) correct the diet and the six essentials; (2) oral and topical remedies according to the dominant humour; (3) venesection, leeches or cupping for stubborn spots, scars and marks [15]. In the sanguine and bilious patterns: eating less, cooling food, and drinks such as jujube, chicory, fumitory and sekanjabin. In the phlegmatic pattern: less dairy and sweets, more activity, and ripening and purging of phlegm. In the melancholic pattern: treating constipation and the spleen, sleep, and ripening black bile with whey. In women, regulating periods. Topically: sidr, marshmallow, chamomile, psyllium and flaxseed as gentle masks, and honey on pustular spots [16].

Do not squeeze spots.

Facial redness (rosacea)

Usually from dominant heat and yellow bile or blood in the head and face, and a hot stomach and liver. Reduce heat: avoid hot baths, hot drinks, hot spices, sun and anger; temper the heat of the stomach and liver; and apply gentle rose water.

Scrubbing mitts, exfoliants and unknown creams make rosacea worse.

Melasma and dark marks

Mostly from black bile, rooted in a weak spleen, a hot congested liver, poor digestion and, in women, retained periods [12,13,17,38]. Avoid foods that generate black bile; correct digestion, the liver and the spleen; attend to constipation and periods; and ripen and gradually clear black bile. Topically: clearing (jali) applications; and covering and shade against the sun.

Lemon juice, strong vinegar, nureh and unlicensed whitening creams (which sometimes contain mercury or strong steroids) make marks worse.

Bahaq and baras (vitiligo)

The physicians distinguished bahaq from baras. White bahaq is superficial and comes from thin phlegm; baras is deeper, from thick phlegm that has disabled the skin’s digestive power, and is harder to treat. The distinguishing sign in the texts: if the patch is pricked with a needle and blood comes, it is bahaq; if white moisture comes, it is baras [1,2]. Dark bahaq comes from black bile. Treatment: correcting digestion; avoiding cold moist foods, heavy dairy and fish with milk; activity; and ripening and clearing phlegm under a physician. Topically: reddening remedies together with sunlight.

Classical prescriptions for bahaq and baras include washing the patch with vinegar or steaming it before the remedy, and applications of orpiment, sulphur, mastic, pitch, honey and vinegar; cautery of small patches is also mentioned [2,39]. Of these, sulphur, vinegar-honey syrup, honey and reddening herbs can still be used today. The physicians held arsenic-based nureh to be useful in baras and bahaq, but because of its arsenic it is not recommended today (section 8).

Plants containing psoralens, such as bishop’s weed (Ammi majus) and babchi, make the skin sensitive to light and, with sunlight, bring back colour; modern light therapy grew out of this tradition. But applying them and sunbathing on your own causes severe burns and blisters; only under a practitioner’s supervision.

Psoriasis

Mostly from burnt black bile and dryness, with leftover heat in it. So treatment rests on moistening and tempering, not heating: correcting diet and lifestyle, losing weight, avoiding intense heat and cold, sleep and moderate exercise, lukewarm soaks and oiling, ripening black bile with whey and clearing it gradually, and, where there is fullness, venesection or leeches under a physician [18].

Cupping and scrubbing over plaques may produce new lesions. If you already take a medicine, do not stop it on your own; stopping some medicines suddenly brings the disease back more severely.

Eczema, quba and atopic dermatitis

In the dry, scaly type: black bile and dryness; oily moisturisers, softening soaks with marshmallow or barley, moist foods and ripening of black bile. In the weeping type: salty phlegm; mild drying, astringent substances and clearing phlegm. In the hot, burning type: yellow bile; cooling substances and tempering the liver. Vinegar, honey, olive oil, fumitory, rose and salt were the most used substances in the Canon [19,20]; in hand eczema the physicians stressed correcting the liver [19]. Identifying and avoiding irritants and strong detergents is essential.

Vinegar and salt on cracked skin sting and cause damage.

Dandruff and seborrhoeic dermatitis

Mostly from phlegmatic vapours and wastes of the head, or dryness in the dry type. Cut down on heavy and sweet foods, correct digestion, wash the hair with sidr or marshmallow, use henna, and use light oils for dry dandruff.

Hives

The physicians described two kinds: red and burning, from yellow bile and blood; and white with less itching, from phlegm. In the hot kind: avoid heating, stimulating foods; take cooling drinks such as sekanjabin, pomegranate juice and jujube; and, where blood dominates, venesection. In the phlegmatic kind: clear phlegm and avoid cold, moist foods [21]. Finding the trigger (food, medicine, heat, cold, pressure) and avoiding it is the main part of treatment.

Swelling of the lips, tongue or throat, or breathlessness, is an emergency.

Chronic itching and lichen

Itching mostly comes from a salty humour or burnt black bile, and the kind of itch (hot and burning, dry, or moist) decides the treatment; cleansing the blood with whey and fumitory, lukewarm soaks and oiling are widely used in the texts. Chronic itching may be a sign of liver, kidney or thyroid disease or anaemia; if it does not improve with treatment, look for an internal cause.

Scabies and lice

Scabies was attributed to a salty humour and burnt black bile: cleansing the body, and topical sulphur remedies, which are still recognised scabies treatments today. Everyone in close contact should be treated at the same time, and clothes and bedding washed in hot water and dried in the sun. For lice: a fine-toothed comb, washing and topical oils.

Fungal infections

From moisture and putrefaction: keep the skin and folds dry, wear cotton, cut down on moist and sweet foods, avoid sharing personal items, and use drying, antiseptic poultices and washes such as myrtle, pomegranate peel, thyme and diluted vinegar on intact skin. Nail fungus and scalp ringworm are persistent; if they do not improve, see a doctor.

Warts and molluscum

From thick black bile: correct the black bile and strengthen the body. Molluscum often clears by itself. The corrosive topical remedies of the texts are not recommended today because of the risk of ulceration.

Do not cut or burn warts yourself or use corrosive substances; in the humoral view they are treated from within, by correcting abnormal black bile and phlegm.

Cold sores and shingles

From heat and yellow bile: reduce heat, eat cool light food, rest and stay calm, and apply cooling preparations such as rose water and sandalwood. Cupping and leeches are not done on an active lesion.

For cold sores, propolis applied from the first tingling or itching is among the most useful natural treatments backed by a clinical trial [40].

Shingles near the eye, and shingles in older people or those with weak immunity, is urgent and must be seen in the first days; antiviral medicine works best within the first three days.

Boils, carbuncles and impetigo

A boil comes from thick blood; management follows the stages of swelling (section 7): a repellent at the start after cleansing, then a ripening poultice (such as marshmallow, fenugreek and flaxseed) to bring it to a head, and drainage by a physician; and correcting the blood and bile. For superficial impetigo: washing with a natural antiseptic wash and medical honey. Repeated boils: check blood sugar.

Do not squeeze a boil on the face. Hot, spreading redness with fever is an emergency.

Cutaneous leishmaniasis

The physicians mention many oral and topical remedies, such as unripe grapes, barberry, sandalwood, camphor, mustard, saffron, honey and alum, as well as cautery, cupping and leeches [22]. Leishmaniasis is a transmissible parasitic disease and should be reported to, and treated at, a health centre.

Leprosy

The physicians attributed it to widespread burnt black bile. Leprosy is an infectious disease; the World Health Organization provides its treatment free, and it is completely curable [34]. A numb patch must always be examined.

Chronic ulcers

Strengthen nutrition and the blood; clean the ulcer with cleansing substances, then use flesh-growing substances such as frankincense, aloe and medical honey; keep the dressing clean and moist; and attend to blood sugar, circulation and pressure on the ulcer.

Do not delay with home treatment for a diabetic foot ulcer or a black or foul-smelling ulcer.

Burns

Cool at once under lukewarm-to-cool running water (not ice) for about 20 minutes, and cover with a clean dressing. For a small superficial burn: simple ointments, aloe gel and medical honey. Do not put oil, toothpaste or household substances on a burn. A large or deep burn, or a burn on the face or hands, is an emergency.

Fissures, calluses and keratosis pilaris

From dryness: soak in lukewarm water and use moistening ointments and oils such as almond oil and wax (cerate). Do not cut calluses yourself, especially in diabetes.

Hair loss

Diffuse shedding comes from poor nourishment of the hair or dryness; patchy loss from a bad humour at the hair root. Strengthen digestion and the blood, correct iron and protein deficiency, stay calm, oil the scalp with oils suited to your temperament, use henna, and in alopecia areata reddening substances and local leeches or cupping [2,24].

Neat onion and garlic juice may burn the scalp; diluted and used with a mild natural shampoo they are better tolerated.

Excess hair

In humoral medicine it is linked to regulating periods and correcting the womb; polycystic ovaries should be checked. For hair removal, use arsenic-free methods; nureh is not recommended.

Heavy sweating and body odour

From excess moisture and weakness of the retentive power: cut down on moist and spicy foods, wash with a decoction of myrtle and rose, and use astringent dusting powders.

Blistering and autoimmune diseases, and skin cancers

Pemphigus, pemphigoid, lupus, scleroderma and skin cancers are serious diseases that need diagnosis and follow-up by a specialist; the measures of humoral medicine have a place alongside that care [23]. Never treat a lesion suspected of being cancer with any poultice or corrosive substance.

10. Herbal safety and the limits of treatment

“Natural” does not mean “harmless”

• Sun sensitivity: babchi, bishop’s weed, the sap of fig leaves and unripe figs, celery and citrus oils on the skin cause burns and marks in the sun.
• Liver damage: some herbs, including germander (kalpureh), have been reported to damage the liver with long-term oral use.
• Blood pressure and potassium: long-term liquorice raises blood pressure and lowers potassium.
• Stimulant laxatives (senna, oral aloe): low potassium and a lazy bowel with long use.
• Pregnancy and breastfeeding: many purgatives and period-inducing herbs (such as rue) are forbidden, as are venesection and cupping.
• Children: henna in G6PD deficiency [27], and oils and sharp substances on a child’s thin skin, call for caution.
• Drug interactions: herbs interact with blood thinners and with medicines for blood sugar, blood pressure, the thyroid and immunity. Always tell your doctor which herbs you use.

Product quality

Herbal and traditional products should come from a reliable, licensed source. Some “herbal” creams and ointments on the market secretly contain strong steroids, mercury or hydroquinone, and some powders are contaminated with heavy metals. Hidden strong steroids thin the skin, cause rosacea and spots, and when stopped the disease returns more severely.

When to see a doctor or go to emergency care at once

• Sudden, painful swelling of one leg, or swelling with breathlessness.
• Hives with swelling of the lips, tongue or throat, or breathlessness.
• Hot, spreading redness with fever and chills.
• Widespread blisters and peeling skin, especially after a medicine, with sores in the mouth and eyes.
• Shingles near the eye.
• New jaundice with abdominal pain, fever or dark urine.
• Tiny bleeding spots under the skin with fever or feeling very unwell.
• Burns, blisters or severe pain after nureh, a depilatory or any topical product.
• A black, foul-smelling or spreading foot ulcer.

And sooner or later these need a specialist’s examination: a changing mole, a sore that will not heal, a numb patch, cystic and scarring acne, and any skin disease that does not improve with ordinary treatment.

Conclusion

In humoral medicine the skin is a mirror of what is within, and its treatment begins within: identifying the dominant humour and separating simple from material dystemperament; managing the six essentials; correcting the stomach, liver, spleen and womb; ripening and expelling matter with care for the conditions of evacuation; and topical treatment suited to the quality and stage of the disease. Many of these teachings, such as the role of digestion, sleep, stress and food, now have support in modern medicine too.

At the same time, spreading infections, autoimmune diseases and cancers need a doctor’s examination and follow-up; evacuating and invasive methods should be carried out only by a qualified person; and toxic products such as arsenic-based nureh and mercury ointments have no place in treatment today. The best results come from a thoughtful combination of the two bodies of knowledge.

Where does treating your skin begin?

As you have seen, food, oil, bathing and even the kind of ripening agent and purgative differ for hot and cold, dry and moist temperaments. So the first step is to know your temperament and adjust the six essentials of health to it.

If you face these problems (and have none of the emergency signs in section 10):

• Spots, marks or melasma that creams and ointments have not cleared, or that keep coming back
• Chronic eczema, psoriasis, itching or hives
• Dryness, cracks, excess oil or dull skin
• Hair loss, dandruff, or sweating and body odour

Take these five steps:

1. Take the free temperament test: 16 questions, about 2 minutes, with the result on screen straight away: Dr Kalan’s free tests. Then use the balance test to see which humour is dominant now; treating the skin starts here.
2. Get a nutrition guide for your temperament: the book İnsan Mizaçları ve Sağlıklı Beslenme (Human Temperaments and Healthy Nutrition, in Turkish): an eating plan that corrects digestion and the liver and reaches the skin from within. Order on WhatsApp.
3. See the related training: the online course “Signs of the Body” (in Turkish) on reading the signs of the body and temperament. Doctors and practitioners who want to learn temperament-based cupping and leech therapy properly can contact us about the specialist course.
4. Browse natural products suited to your temperament: natural oils, personal and skin care, herbal teas and the full Dr. Kalan Natural range: order page.
5. Ask for a consultation if you need one: for a personal plan, especially before any evacuating method such as purgatives, cupping or leeches: training and consultation or WhatsApp +90 552 852 10 00 (Ankara office, Türkiye).

To learn about recognising temperament and diagnosing skin diseases, read part one of this series, The Skin: A Mirror of Temperament and Inner Health.

References

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2. Ibn Sina (Avicenna). Al-Qanun fi al-Tibb. Book 4: swellings, eruptions, skin diseases and adornment. Beirut: Dar Ihya al-Turath al-Arabi; 2005.
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