The Skin: A Mirror of Temperament and Inner Health

Farzollah Gholizadeh and Fariba Bayrami

Introduction

The skin is the body’s largest and most visible organ, and it shows many inner changes sooner than any other organ. Its colour, temperature, moisture, oiliness, thickness, sweat and smell, together with the hair and nails, are each a clue to a person’s temperament, the quality of the humours, the work of the stomach and liver, hormonal balance and, sometimes, a hidden internal disease.

The physicians of humoral (traditional Persian) medicine wrote detailed chapters on the skin, hair, nails and visible diseases of the body: Ibn Sina (Avicenna) in the Canon of Medicine, Razi in al-Hawi, Majusi Ahvazi in Kamil al-Sina’a, Jurjani in Zakhireh-ye Kharazmshahi, Aqili Khorasani in Kholasat al-Hekmah and Hakim Azam Khan in Exir-e Azam [1-9]. Modern medicine now explains the same patterns in the language of hormones, immunity, microbes and genetics [23-28].

This is the first of a two-part series. Here we learn how to read temperament from the skin, which skin signs point to internal disease, and how each skin condition is understood in humoral and modern medicine. Treatment is covered in part two, Treating Skin Diseases in Humoral and Modern Medicine.

A few notes on method

Linking a disease to a humour is the theoretical framework of humoral medicine; on its own it is not a firm diagnosis.
Many classical names, such as baras, bahaq, quba, sa’fa, shara and nar-e farsi, do not match modern names exactly. Where the match is uncertain, we say so.
No colour, mark or spot on its own shows which internal organ is unwell. A spot on the chin does not necessarily mean a problem with the womb, nor a spot on the forehead a problem with the bowel.
Not every skin disease has an inner root. Infection, contact allergy and sun damage have outside causes, and many internal diseases progress with no skin signs at all.
This article is educational and does not replace examination, tests or medical treatment.

1. The foundations: temperament and the skin

In humoral medicine, the four qualities of heat, cold, moisture and dryness combine to make the four main temperaments. Ibn Sina lists ten groups of signs for recognising temperament; four of them are read directly on the skin and its appendages: touch, flesh and fat, hair, and colour [1,5]. The rest (body shape, sleep, activity, the body’s wastes and state of mind) are weighed alongside these four.

The skin in each temperament

Sanguine (hot and moist): warm, soft, moist, rosy skin; full veins and open pores. The skin is fresh, but in youth it tends to red, congested spots and inflammation.
Bilious (hot and dry): warm, dry, thinner, sensitive skin with a yellowish or light wheat tone. It tends to burning, small sharp spots and hot itching.
Phlegmatic (cold and moist): cool, soft, moist, white or pale and fairly thick skin. It tends to puffiness, soft swelling, slow white spots and cold hands and feet.
Melancholic (cold and dry): dry, rough, dull, dark and inelastic skin. It tends to flaking, cracks, dark marks and chronic lesions.

Signs of temperament in touch, flesh and hair

Touch: skin that is warm and soft points to heat and moisture; cool, rough skin to cold and dryness. Ibn Sina takes the skin of the palm of a balanced person as the measure of balance [1].
Flesh and fat: firm, full flesh is a sign of heat and moisture; a lot of fat and slack flesh, of cold and moisture; leanness and dry flesh, of dryness.
Hair: in the classical texts, thick, coarse, black, fast-growing hair is a sign of heat, and sparse, soft, light, slow-growing hair a sign of cold. Curly hair is linked to heat and dryness, straight soft hair to moisture [1,5]. These signs also vary with ancestry, age and genetics and must be read with the others.

Three ideas not to confuse

A person’s basic temperament: the fairly stable quality they are born with.
A local dystemperament of the skin: a change of quality in one area or one lesion.
The matter of the lesion: the humour which, in humoral theory, produced the lesion.

Someone with a hot and moist basic temperament may develop a dry, melancholic lesion, and the reverse. The current state of the skin changes with food, season, age, sleep, stress and illness.

Simple and material dystemperament, and burnt humours

Simple dystemperament: only one quality, such as heat or dryness, has left balance; no matter is involved.
Material dystemperament: an excess or spoiled humour plays a part in the lesion.
Burnt humour: a humour made sharp and irritating by intense heat. The physicians held burnt yellow bile and burnt black bile responsible for severe, chronic skin diseases [1,2].
Salty phlegm: phlegm that has become salty and sharp; it is invoked in itchy, weeping lesions.

From this division come the three pillars of classical treatment: correcting the temperament, correcting food and lifestyle, and expelling the disease-causing matter. The details are in the treatment article.

2. Reading the skin: from temperament to internal disease

Every skin sign has two readings: the temperament reading of humoral medicine and the reading of modern medicine. The right reading puts both side by side and treats no single sign as a verdict [1,23,24].

Colour

Redness: in humoral medicine, a sign of blood and heat. In modern medicine it comes from increased blood flow, inflammation, fever, rosacea or high blood pressure.
Yellowness: in humoral medicine, a sign of yellow bile. New yellowing of the skin and the whites of the eyes (jaundice) means raised bilirubin and calls for checking the liver, gallbladder and blood. Yellow palms without yellow eyes may simply come from eating a lot of carrots and pumpkin.
Pallor: in humoral medicine, a sign of cold and phlegm. Pale palms, nail beds and inner lower eyelids can mean anaemia.
Darkness and dullness: in humoral medicine, a sign of black bile. General, sudden darkening of the skin, especially in the palm creases, gums and old scars, may come from adrenal insufficiency (Addison’s disease), liver disease or certain medicines.
Blue lips and tongue: a lack of oxygen in the blood; with breathlessness it is an emergency.

Temperature, moisture, oil and texture

Warmth and cold: local warmth with redness, pain and swelling means inflammation or infection. Sudden coldness, pallor and pain in a limb means blocked blood flow and is urgent. Permanently cold hands and feet do not on their own prove a cold temperament or heart disease.
Moisture and dryness: dry skin mostly comes from a damaged skin barrier: hot water, strong cleansers, cold air, age, eczema. Severe dryness with tiredness, constipation, feeling cold and hair loss calls for a thyroid check.
Oiliness: weighed in humoral medicine as heat and moisture; in modern medicine it is sebum produced under the influence of male hormones. A lot of oil with stubborn acne, excess hair and irregular periods calls for hormone tests.
Texture: thin, easily bruised skin is seen in old age or after long use of steroids. Thick, tight, shiny skin may be scleroderma.

Sweat and smell

The physicians treated the amount, smell and quality of sweat as signs of moisture, heat and the power of elimination, and wrote separately about foul sweat and underarm odour [2,5]. In modern medicine:

Heavy sweating goes with heat, anxiety, an overactive thyroid, low blood sugar, menopause, infection and some medicines. Repeated night sweats with fever and weight loss need investigation.
A fruity or acetone smell of the breath and body is seen in uncontrolled diabetes, a urine-like smell in kidney failure, and a fishy smell in a rare metabolic disorder called trimethylaminuria.
Sweating is not in itself “detox”; the liver and kidneys do the main work of elimination.

Skin signs of internal disease

Some signs are recognised clues to internal disease in modern medicine [23-25,28]:

Liver: jaundice, widespread itching, spider veins on the chest and face, red palms, white nail beds.
Diabetes and insulin resistance: velvety darkening of the neck and armpits (acanthosis nigricans), small skin tags on the neck and armpits, slow-healing foot ulcers, repeated fungal infections, light-brown patches on the shins.
High blood fats: soft yellow plaques on the eyelids (xanthelasma).
Thyroid: underactive, with dry cold skin, brittle hair and puffy eyes; overactive, with warm moist skin, sweating and hair loss.
Kidney: chronic itching, a yellow-grey skin tone, swelling around the eyes.
Bowel: red, painful lumps on the shins (erythema nodosum) and deep ulcers (pyoderma gangrenosum) in inflammatory bowel disease; very itchy blisters on the elbows and knees (dermatitis herpetiformis) in coeliac disease.
Autoimmune diseases: a butterfly rash on the cheeks and nose that worsens in the sun (lupus); purple-red eyelids and bumps over the knuckles with muscle weakness (dermatomyositis).
Nutritional deficiencies: dark, cracked skin on sun-exposed areas with diarrhoea (pellagra, from niacin deficiency); bleeding gums and bruising around hairs (vitamin C deficiency); lesions around the mouth and slow-healing wounds (zinc deficiency).
Heart and lungs: clubbing of the fingers, blue lips and nails.
Blood and cancers: tiny bleeding spots under the skin, stubborn unexplained itching, sudden widespread darkening of the skin folds in adulthood.

None of these signs is a diagnosis on its own; each is a reason to see a doctor and be tested.

3. Spots and eruptions: from humours to hormones

The exact word “acne” does not appear in humoral texts. Spots are discussed under “swellings and eruptions” (awram wa buthur), and Ibn Sina called the small milky spots of the face “milk eruptions” (buthur labaniyya) [2,10]. The physicians saw spots as the result of the body failing to clear waste by its natural routes and pushing it towards the skin, and they looked to the stomach and liver for the root [10,11].

Modern medicine attributes acne to four factors: excess oil under the influence of male hormones, blockage of the hair follicle opening, growth of the bacterium Cutibacterium acnes, and the inflammatory response [23,24].

Bilious spots

Appearance: small, pointed, red or yellow-headed, burning spots that come up quickly, mostly on the forehead, between the eyebrows and on the upper chest and back. With thirst, a bitter mouth and irritability.
Humoral reading: the heat and sharpness of yellow bile reaching the skin from the liver. Spicy food and stale fried food make it worse.
Modern view: superficial inflammatory acne. The yellow head is usually pus, not necessarily bile.

Sanguine spots

Appearance: large, deep, bright red or purplish spots with throbbing pain, full of pus and slow to heal; with red cheeks and lips.
Humoral reading: excess blood and fullness of the vessels (imtila). A big appetite and fatty, sweet food increase it.
Modern view: nodular and moderate-to-severe inflammatory acne, which scars sooner than the others.

Phlegmatic spots

Appearance: white or skin-coloured, painless, soft or cystic spots with white, sticky contents; the surrounding skin is cool and moist. Mostly on the chin, jaw and neck. “Milk eruptions” are close to this group.
Humoral reading: weak digestion, a cold liver and build-up of raw phlegm. Too much dairy, cold heavy food and inactivity increase it.
Modern view: closed whiteheads and low-inflammation cysts.

Melancholic spots

Appearance: small, hard, dark or blackheaded, dry spots with little inflammation, with flaking, dull skin, and marks and scars after healing. Mostly on the cheeks, jawline and back.
Humoral reading: thick or burnt black bile settling in the skin; linked to chronic stress, lack of sleep, constipation, sorrow and heavy, slow-to-digest foods.
Modern view: chronic acne with blackheads and post-inflammatory darkening.

Other eruptions that look like spots

Prickly heat (hasaf): tiny red itchy bumps that appear in heat and after heavy sweating. Ibn Sina attributed it to sharp vapours carried with sweat [2]. Modern medicine calls it miliaria; it comes from blocked sweat ducts.
Folliculitis: small pus-filled spots around hairs, especially after shaving, sweating or swimming pools. Caused by bacteria or fungi.
Milia: very small, hard white bumps around the eyes; harmless, non-inflammatory keratin cysts.
Drug-induced spots: steroids, lithium, some anticonvulsants and bodybuilding supplements can cause sudden, uniform spots.

The role of hormones

Male hormones (androgens): the oil glands are sensitive to them. A rise in these hormones, or in receptor sensitivity, multiplies skin oil; this is the main root of teenage acne. In traditional terms it is close to the heat and moisture of youth.
Polycystic ovaries and insulin resistance: stubborn spots on the chin, jaw and neck, with oily skin, excess hair, male-pattern scalp hair loss and irregular periods, is the classic picture. High insulin raises free male hormone. In traditional terms it is read as a phlegmatic and melancholic pattern (moisture, thickness and delayed periods).
Cortisol (the stress hormone): chronic stress and lack of sleep raise it, stimulating the oil glands and slowing skin repair. This agrees with the traditional teaching that sorrow and sleeplessness generate black bile.
Oestrogen and progesterone: their changes before periods, in pregnancy and with hormonal pills make spots and pigmentation worse or better.
Thyroid: both under- and overactivity affect oil, sweat, hair and nails.

Important: where a spot is does not on its own show which organ is unwell. But stubborn acne with excess hair, hair loss and irregular periods calls for tests of hormones, blood sugar and insulin. Cystic, painful or scarring acne should be shown to a doctor early.

4. Marks and changes in skin colour

In humoral medicine, dark marks are mostly attributed to black bile or burnt yellow bile and white marks to phlegm. But the physicians did not assign a single cause to every mark; they looked at colour, depth, dryness, spread and accompanying signs [2,5]. Modern medicine sees marks as too much or too little melanin pigment, changes in blood vessels, or deposits in the skin.

Dark marks

Melasma (kalaf): symmetrical brown patches on the cheeks, forehead and upper lip, mostly in women aged 30 to 55. The physicians linked it to stopped or scanty periods, a weak liver, poor stomach digestion and black bile; some researchers in humoral medicine stress the role of the stomach and digestion [12,13]. In modern medicine, sun, pregnancy, hormonal pills, thyroid disorders and genetics make it worse. It is chronic and recurs.
Freckles (namash): small light-brown spots on fair skin that darken in the sun. Traditionally attributed to heat and yellow bile; in modern medicine, genetic and harmless.
Sun spots and age spots (lentigo): broad brown patches on the face and backs of the hands in later life, from years of sun. A spot that changes shape or colour must be distinguished from melanoma.
Marks after spots or inflammation: in traditional terms, the red stage is read as heat and the lingering darkness as dryness and black bile. In modern medicine it is increased melanin after inflammation; it fades with control of inflammation, sunscreen and patience.
Velvety darkening of the folds (acanthosis nigricans): thick, velvety, dark skin on the neck, armpits and groin. It is not in the classical texts under this name, and linking it to thick black bile is a modern interpretation. It is the most important skin sign of insulin resistance and pre-diabetes; a sudden, widespread onset in adulthood needs prompt investigation.
Dark circles around the eyes: from genetics, thin skin, lack of sleep, allergy and rubbing the eyes. Traditionally weighed as black bile or weak digestion, but not in itself a sign of disease.
Darkening from medicines and internal disease: some medicines, heavy metals (including arsenic), adrenal insufficiency and liver disease cause widespread darkening [30].

White marks

In the classical texts, “bahaq” and “baras” were not always used in the same way. To tell them apart the physicians looked at colour, the depth of the change, whether the hair in the area turned white, and whether blood appeared when the patch was pricked with a needle [2,5,15].

White bahaq: a superficial white or light patch, attributed in some commentaries to phlegm. Modern researchers consider it the closest equivalent of vitiligo [14].
Dark bahaq: a superficial dark patch attributed to black bile.
Baras: a more chronic, deeper disease that also whitens the hair in the area. Its cause was given as thick phlegm, severe cold or sometimes obstructing black bile. Researchers warn that “baras” in the classical texts is not only vitiligo but covers several chronic whitening diseases [15].
Vitiligo in modern medicine: a chronic autoimmune disease that destroys pigment cells and produces completely white, sharply bordered patches. It affects about one per cent of people and is not contagious. It may accompany thyroid disease, type 1 diabetes, patchy hair loss and pernicious anaemia, so checking the thyroid and blood sugar is recommended [24,28].
Pityriasis alba: pale, slightly scaly patches on children’s faces; it goes with dryness and mild eczema and improves by itself.
Pityriasis versicolor (a superficial fungus): white, pink or brown patches with fine scale on the chest and back, mostly in summer and with sweating. The cause is the yeast Malassezia. In traditional comparisons it has sometimes been matched with bahaq.
White marks after inflammation, burns or aggressive treatments.
A white patch with reduced or no feeling: must be checked for leprosy.

General rule: never assign a mark to one humour or one definite disease by its colour. White patches are diagnosed by examination and sometimes a special light (Wood’s lamp).

5. Scaly, inflammatory and autoimmune diseases

Many modern names do not appear in the classical texts. Researchers have compared them, by similarity of signs, with headings such as quba, sa’fa, peeling of the skin, black baras and fissures. These matches are approximate [16-18].

Psoriasis

Humoral reading: there is no disease called psoriasis in the texts, but its signs resemble black baras, dry sa’fa and quba. In all three, excess black bile, yellow bile and salty phlegm in the skin produce a dry dystemperament [16]. Thickness and chronicity point to black bile, and active redness to heat.
Modern view: a chronic immune disease with thick, raised, sharply bordered plaques with silvery scale, mostly on the elbows, knees, scalp and lower back. It affects about 2 to 3 per cent of people [16]. It may involve the nails (tiny pits, lifting of the nail) and the joints, and is associated with obesity, diabetes, high blood pressure and heart disease. Stress, smoking, alcohol, throat infections and some medicines trigger flares.

Eczema and atopic dermatitis

Humoral reading: the physicians divided itchy lesions into moist and dry types and linked them to the liver [17,18]. The dry, cracked, scaly form is attributed to black bile, the weeping, crusted form to salty phlegm, and the red, burning form to yellow bile or blood.
Modern view: chronic inflammation of the skin with dryness, intense itching, redness and sometimes tiny blisters and weeping. A genetic weakness of the skin barrier and immune sensitivity play a part, and it often goes with asthma and hay fever. In children it affects the face and body, in adults the elbow creases and backs of the knees.
Difference from psoriasis: eczema itches more, has blurred edges and favours the folds; psoriasis has clear edges, thick plaques and silvery scale.

Other kinds of dermatitis

Contact dermatitis: redness, itching or burning where the skin touched a substance (nickel, perfume, hair dye, detergent, a plant or black henna). It may be irritant or allergic.
Hand eczema: dryness, cracks and tiny blisters on the palms and fingers, mostly in people who work a lot with water and detergents [17].
Discoid and varicose eczema: itchy coin-shaped plaques, and darkening and itching of the lower legs in venous insufficiency.
Seborrhoeic dermatitis (dandruff): greasy yellow scale on the scalp, eyebrows, sides of the nose and behind the ears. The classical texts attributed scalp scaling to salty phlegm or thick vapours [2]. In modern medicine, skin oil, the yeast Malassezia and inflammation are involved. Dry and oily dandruff should be told apart.

Quba and sa’fa

Quba: used in the texts for scaly, itchy, spreading and sometimes ring-shaped lesions. Ibn Sina distinguishes quba from thick melancholic matter and quba from sharp bilious matter [2]. Today it is sometimes matched with ringworm or eczema, but it has no fixed equivalent.
Sa’fa: scaly, crusted lesions of the scalp and face, sometimes weeping. Some compare it with favus and scalp ringworm, others with eczema and seborrhoeic dermatitis.

Rosacea and facial redness

Persistent redness of the centre of the face, flushing, fine blood vessels and spots without blackheads, sometimes with burning eyes. In traditional terms it is close to heat (blood and yellow bile). In modern medicine it is an inflammatory vascular condition made worse by heat, hot baths, hot drinks, alcohol, spicy food, sun and stress. In advanced stages the nose may thicken.

Other scaly conditions

Pityriasis rosea: one large pink patch followed by smaller oval patches on the trunk in a fir-tree pattern; it usually clears by itself in 6 to 8 weeks.
Lichen planus: purple, flat-topped, very itchy bumps on the wrists and shins, sometimes white lines inside the mouth. Purple colour alone is not proof of black bile. It is sometimes associated with hepatitis C.
Ichthyosis: very dry, scaly skin like fish skin, often inherited. The texts attribute peeling to dryness and black bile.
Keratosis pilaris (“chicken skin”): small rough bumps around hairs on the upper arms and thighs. Traditionally close to dryness and thickness; in modern medicine a harmless disorder of keratinisation.
Fissures (shuqaq): cracks of the hands, heels and lips. The physicians attributed them to dryness, cold and black bile [2]. Deep heel cracks are more common in diabetes and an underactive thyroid.
Calluses and corns: thickened skin at pressure points. A corn has a hard, painful core and must be told apart from a plantar wart.

Autoimmune and blistering diseases

Lupus: a butterfly rash on the cheeks, sun sensitivity, mouth ulcers, joint pain and tiredness. Skin lupus may produce scaly plaques and scars.
Dermatomyositis: purple-red eyelids, red bumps over the knuckles and weakness of the shoulder and thigh muscles. Sometimes associated with internal cancer.
Scleroderma: tight, thick, shiny skin of the fingers and face, with fingers turning white and blue in the cold. Traditionally close to black bile; it needs specialist assessment.
Pemphigus and pemphigoid: fragile or tense blisters on the skin and in the mouth that leave painful sores. Researchers consider the classical term “hot ulcers” close to pemphigus [22]. These diseases are dangerous and need urgent specialist treatment.
Chronic hives and angioedema: see section 7.

6. Infectious, parasitic and contagious skin diseases

These diseases have a specific microbial or parasitic cause. For each, the physicians described a temperament background and a dominant humour, which is still useful in managing the body as a whole.

Parasites

Scabies (jarab): very intense itching, especially at night, with bumps and fine lines between the fingers and on the wrists, waist, armpits and genitals; people in close contact itch too. The physicians attributed it to black bile, salty phlegm or burnt yellow bile [2,3]. The cause is the tiny Sarcoptes mite, passed on by close contact.
Lice: itching of the scalp or body with white eggs stuck to the hairs. The physicians put lice down to spoiled moisture and lack of cleanliness [2]. They spread by contact and shared items.
Cutaneous leishmaniasis (salak, “Balkh sore”): after a sandfly bite a small bump appears and slowly becomes a crusted, painless ulcer that lasts for months. The physicians described topical remedies, cautery and cupping for it [21]. In areas where it is common, any slow-healing sore on the face or hands should be tested.
Guinea worm: described in detail in the classical texts, but almost eradicated today.

Viruses

Warts: rough, hard growths on the hands, feet and face. The physicians attributed them to thick black bile [2]. The cause is the human papillomavirus, and they are contagious. Plantar warts must be told apart from corns. Genital warts need separate assessment.
Molluscum: small, shiny, dome-shaped bumps with a central dimple, mostly in children; viral, contagious and usually self-limiting.
Cold sores: small burning blisters around the lips or nose that recur with fever, stress, sun and periods. Traditionally attributed to heat and yellow bile. The cause is the herpes virus.
Shingles: one-sided burning pain followed a few days later by a band of blisters along the same nerve. Traditionally attributed to burnt yellow bile. The classical names are not used consistently here: “nar-e farsi” (Persian fire) has been read as shingles, erysipelas or eczema, and “namla” was used for spreading blistering lesions. Shingles is a reawakening of the chickenpox virus. Shingles near the eye, or in someone with weak immunity, is urgent.
Smallpox, measles and chickenpox: Razi, in his treatise On Smallpox and Measles, was the first to distinguish smallpox from measles precisely. Smallpox has been eradicated. Measles causes merging red spots with fever, cough and watery eyes. Chickenpox is a separate disease with itchy blisters at different stages. Measles and chickenpox are contagious and have vaccines.

Bacteria

Impetigo: sores or blisters with a honey-yellow crust, mostly around children’s noses and mouths; very contagious. Traditionally attributed to yellow bile or salty phlegm.
Boils and carbuncles: a warm, red, painful lump that forms pus; a carbuncle is several joined boils with several openings. Attributed in humoral medicine to blood and yellow bile [2]. Repeated boils call for a diabetes check.
Abscess: a collection of pus deep in the tissue.
Hidradenitis suppurativa: recurring boils and pus-filled tunnels in the armpits, groin and under the breasts; a chronic inflammatory disease, not simple acne.
Erysipelas and cellulitis: hot, painful, spreading redness, often on the lower leg, with fever and chills. The physicians attributed it to hot, bilious blood [2]. It needs urgent attention.
Paronychia: swelling, redness and pain beside the nail, sometimes with pus.
Leprosy: pale or red patches with reduced or lost feeling, with thickened nerves and weakness of the hands and feet. The physicians attributed it to burnt black bile and counted it among the hardest diseases [2,3]. The cause is Mycobacterium leprae.
Skin tuberculosis and scrofula: “khanazir” in the texts is swelling of the neck glands, today mostly matched with tuberculosis of the lymph nodes.
Syphilis: a painless first sore followed by red spots on the palms and soles; a sexually transmitted infection that needs a blood test.

Fungi

Ringworm of the body, groin and feet: red ring-shaped plaques with a paler centre and a scaly edge; itchy. Worse with moisture and sweat in the groin and between the toes.
Scalp ringworm: scaling and patchy hair loss in children, sometimes with a pus-filled swelling.
Nail fungus: yellow, thick, brittle nails lifting from the nail bed.
Candida: shiny, moist redness in the folds, under the breasts, in the groin and the nappy area, with small satellite spots; more common in diabetes and after antibiotics.
Pityriasis versicolor: see the section on marks.

In the classical texts most of these fungal lesions are discussed under quba and sa’fa, with “moisture and putrefaction of salty phlegm” as the cause [2]. Keeping the skin dry, as the physicians advised, is still a principle of prevention.

Bites

Bites from mosquitoes, bedbugs, fleas and spiders cause itchy bumps, often in rows or clusters. A bite with widespread swelling, breathlessness or a spreading sore is urgent.

7. Itching, hives, swelling, bruising, wounds and injuries

Itching (hikka)

The physicians classified itching by the quality of the sensation and the accompanying lesion [2,3]:

Hot, burning itch: yellow bile or sharp vapours.
Dry, widespread, chronic itch with flaking: black bile or dryness.
Moist, weeping itch: salty phlegm.

In modern medicine itching mostly comes from dry skin, eczema, hives, bites, scabies and fungi. But widespread, persistent itching, especially with no visible rash, is sometimes a sign of internal disease: kidney failure, bile obstruction and liver disease, an under- or overactive thyroid, iron deficiency, diabetes, lymphoma and some medicines. Itching in older people is often from dry skin. Severe, long-lasting itching, or itching with jaundice, weight loss and night sweats, needs medical investigation.

Hives (shara) and angioedema (mashara)

In the texts “shara” means sudden, red, itchy weals and “mashara” deeper swellings. Comparative studies consider them close to hives and angioedema respectively; sudden itching at night and the role of heating factors are among the similarities [19]. The physicians attributed shara mostly to hot blood and yellow bile, and sometimes to phlegm.

In modern medicine, hives come from the release of histamine; causes include food or drug allergy, infection, heat, cold, pressure, stress and thyroid disease. Hives lasting more than 6 weeks are “chronic” and often have no obvious cause. Swelling of the lips, tongue or throat, or breathlessness, is an emergency.

Swelling (awram)

The physicians recognised swellings by heat, cold, pain, hardness and speed of onset [1,2]:

Hot swelling: red, hot and painful; from blood or yellow bile.
Cold, soft swelling: painless and pitting under the finger; from phlegm.
Hard swelling: firm and not very painful; from black bile. The physicians distinguished hard, growing swelling from cancer.
Windy swelling: soft and stretched, springing back after pressure.

In modern medicine, swelling of both legs may come from long standing, venous insufficiency, medicines, heart failure, kidney disease, liver disease, insulin resistance or an underactive thyroid. Swelling around the eyes comes from allergy, lack of sleep, kidney disease or thyroid disease. Sudden, painful swelling of one leg (a possible blood clot), or swelling with breathlessness, is urgent.

Lymphoedema and elephantiasis: firm, persistent swelling of an arm or leg from impaired lymph drainage; “da’ al-fil” in the classical texts meant severe thickening of the lower leg and foot.

Bruising and bleeding spots

Traditionally, bruising is attributed to fullness or laxity of the vessels and the quality of the blood. In modern medicine, unexplained or repeated bruising, and tiny red or purple spots that do not fade under pressure, call for checking platelets, clotting, blood-thinning medicines, vitamin C and K deficiency and liver disease. Bleeding spots with fever are urgent.

Wounds and ulcers (quruh)

The physicians classified ulcers by the quality of the matter, the nourishment of the part and its ability to “grow new flesh”: simple, purulent, foul, spreading and eroding, and chronic slow-healing ulcers [2,4]. In modern medicine:

Diabetic foot ulcer: with numbness, often on the sole; do not delay with home treatment.
Venous ulcer: on the lower leg, with swelling and darkened skin.
Arterial ulcer: painful, on the toes and heel, with cold skin and a weak pulse.
Pressure sore: at pressure points in immobile patients.
Gangrene: blackened tissue and a bad smell; urgent.

Burns, frostbite and sun damage

Burns: the physicians classified burns by depth and blistering and wrote cooling treatments and special ointments for them. Large or deep burns, burns on the face, hands, genitals or joints, and chemical burns are emergencies.
Frostbite: numbness and whiteness, then redness and blistering of the fingers in severe cold.
Raynaud’s phenomenon: fingers turning white, blue and then red in cold or stress; sometimes a sign of autoimmune disease.
Sunburn and photoageing: redness and pain after sun; and in the long term wrinkles, marks and precancerous lesions.

8. Moles, lumps and skin cancers

In the classical texts, moles are called “khilan”, soft lumps under the skin “sila'”, and hard, growing swelling “saratan” (cancer). The physicians attributed darkness and hard lumps mostly to thick or burnt black bile; a research review of humoral texts also finds black bile to be the key term for skin malignancies [20].

Benign lumps

Ordinary mole: evenly brown, round, with a regular border, under 6 mm.
Skin tag: small hanging growths on the neck and armpits; sometimes associated with insulin resistance.
Seborrhoeic keratosis: brown or black “stuck-on” growths with a rough surface, in middle and old age; harmless.
Lipoma and cyst: a soft, mobile lump of fat, or a cyst with a small central opening.
Haemangioma and vascular marks: red patches or bumps made of blood vessels.
Keloid: a scar that grows larger and more raised than the original wound.

Precancerous lesions

Actinic keratosis: small rough, scaly patches on the face, ears and backs of the hands in older people after years of sun. Untreated, it sometimes turns into cancer.

Skin cancers

Basal cell carcinoma (BCC): the most common skin cancer; a pearly bump with fine vessels or a sore that does not heal. It grows slowly and rarely spreads.
Squamous cell carcinoma (SCC): a scaly, firm or ulcerated lesion on sun-exposed areas or old scars.
Melanoma: a new or changing mole; fewer than 5 per cent of skin cancers, but the cause of most skin-cancer deaths [30].

The ABCDE rule for moles

A (asymmetry): the two halves do not match.
B (border): the edge is irregular, notched or blurred.
C (colour): several colours or uneven colour.
D (diameter): larger than 6 mm, although smaller melanomas occur.
E (evolving): it changes in size, shape or colour, or starts to itch, bleed or ulcerate.

A mole that looks different from all the others on the body (the “ugly duckling”) should also be checked. This rule is a warning tool, not a diagnosis.

Risk factors

The most important is ultraviolet light from the sun and tanning devices. Fair skin, many moles, family history, weak immunity and sunburn in childhood raise the risk. Arsenic is also a recognised risk factor: the International Agency for Research on Cancer classes it as a definite human carcinogen (Group 1), and a 2025 meta-analysis linked arsenic exposure to a higher risk of skin cancer, especially non-melanoma cancers [30,31]. This matters when we discuss depilatory pastes (nureh) made with arsenic sulphide.

9. Hair, nails and sweat

In humoral medicine, hair and nails are “appendages” nourished by vapours from the digestion of the humours, so their quality reflects temperament, digestive strength and the body’s nourishment [1,2]. Modern medicine likewise sees hair and nails as tissues that renew constantly and are sensitive to blood supply, nutrients and hormones.

Hair disorders

Diffuse hair shedding: appears 2 to 3 months after fever, childbirth, surgery, crash dieting, severe stress or an underactive thyroid, and usually grows back. Iron and protein deficiency also play a part.
Alopecia areata (da’ al-tha’lab): round, completely smooth bald patches, sometimes in the beard and eyebrows. An autoimmune disease. The physicians disagreed about its cause, attributing it to a bad humour, phlegm or spoiled blood [2].
Da’ al-hayya: hair loss with scaling of the scalp “like a snake shedding its skin”; today sometimes compared with scalp ringworm or severe dermatitis.
Male- and female-pattern hair loss: thinning at the front and crown; genetic and hormonal. In women, with acne and excess hair, it suggests polycystic ovaries.
Hair loss from pulling: from tight hairstyles or the habit of pulling out hair.
Excess hair (hirsutism): coarse hair on the chin, upper lip, chest and abdomen in women; male hormones should be checked.
Early greying (shayb): the physicians saw it as a sign of dominant phlegm and cold and weak innate heat [1,2]. In modern medicine it is mostly genetic; vitamin B12 deficiency, thyroid disease and smoking also contribute.
Brittle hair and split ends: from dryness, excess heat, dyes and chemicals, iron deficiency and an underactive thyroid.

For more detail, see our article Hair: The Crown of the Head.

Nail signs

Pale nails: temperament reading: cold and weak blood. Modern medicine: anaemia.
Blue nails: modern medicine: lack of oxygen, cold.
Spoon-shaped nails: temperament reading: dryness. Modern medicine: iron deficiency.
Brittle, layered nails: temperament reading: dryness and black bile. Modern medicine: dryness, underactive thyroid, water and detergents.
Tiny pits in the nail surface: modern medicine: psoriasis, alopecia areata.
Yellow, thick nails: temperament reading: phlegm and moisture. Modern medicine: nail fungus, psoriasis.
Horizontal lines: modern medicine: illness or high fever in recent months.
A dark lengthwise band that is widening: temperament reading: black bile. Modern medicine: nail melanoma must be ruled out.
Fine blood streaks under the nail: modern medicine: injury; occasionally infection of a heart valve.
A mostly white nail bed: modern medicine: liver or kidney disease.
Clubbed fingertips: modern medicine: chronic lung or heart disease.

Where no temperament reading is given, the classical texts have no specific reading for that sign.

Sweat and body odour

Heavy sweating: the physicians saw it as a sign of moisture, heat or weakness [1,2]. In modern medicine, heavy sweating of the palms, soles and armpits (primary hyperhidrosis) usually starts in youth; new, widespread sweating calls for checking the thyroid, blood sugar, infection and medicines.
Reduced sweating: in some nerve and skin diseases and with some medicines; it raises the risk of heatstroke.
Body odour: from skin bacteria breaking down sweat; a sudden change in body smell may signal a metabolic disease (section 2).
Prickly heat: see section 3.

10. Warning signs and emergencies

Ten signs not to ignore

These are reasons to investigate, not diagnoses:

New yellowing of the skin and whites of the eyes: check the liver, bile ducts and blood.
Unusual pallor of the skin, palms and inner eyelids: check for anaemia.
Velvety darkening of the neck, armpits and groin: check blood sugar and insulin resistance.
Severe dryness with tiredness, constipation, feeling cold and hair loss: check the thyroid.
Stubborn acne with excess hair and irregular periods: check for polycystic ovaries and hormones.
Fingers turning white and blue in the cold: check for Raynaud’s phenomenon and autoimmune disease.
Severe, long-lasting itching with no obvious cause: check the liver, kidneys, thyroid and blood.
A changing mole or mark, or a sore that will not heal: see a dermatologist.
New swelling of the legs or around the eyes: check the heart, kidneys, liver, veins and medicines.
A numb patch or slow-healing foot ulcer: check for diabetes, circulation and leprosy.

Emergencies

In these situations do not look for a temperament diagnosis; go to emergency care at once:

Sudden, painful swelling of one leg, or swelling with breathlessness.
Sudden coldness, pallor and pain in an arm or leg.
Sudden blueness of the lips and tongue with breathlessness.
Hives with swelling of the lips, tongue or throat, or breathlessness.
Hot, spreading redness with fever and chills.
Tiny bleeding spots under the skin with fever or feeling very unwell.
Widespread blisters and peeling skin, especially after taking a medicine, with sores in the mouth and eyes.
Shingles near the eye.
New jaundice with abdominal pain, fever or dark urine.
A large or deep burn, or burns and blisters after a depilatory, nureh or any topical product.

Conclusion

In humoral medicine the skin is a mirror of temperament and the humours; in modern medicine it is a mirror of hormones, immunity and the health of the internal organs. The two views agree in many places: both stress the role of digestion and the liver, sleep, stress and food in skin health.

Reading the skin is an art completed by putting colour, temperature, moisture, texture, hair, nails and the person’s general condition together. No sign is a verdict on its own; warning signs must lead to examination and tests. Treatment of these conditions, by all the methods of humoral and modern medicine, is covered in part two.

What is your skin telling you? Your next step

Each person’s temperament is different, so a measure that helps one person may harm another. Before anything else, find out your temperament and adjust the six essentials of health (air, food and drink, movement and rest, sleep and waking, emotions, elimination and retention) to suit it.

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

Repeated or stubborn spots, marks and melasma, dry scaly skin, chronic itching
Very oily or very dry skin, dull or darkened skin, puffiness and swelling
Hair loss, dandruff, brittle nails, heavy sweating or body odour
Recurring eczema, psoriasis or hives

Take these five steps:

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 in your body right now.
Get a nutrition guide for your temperament: the book İnsan Mizaçları ve Sağlıklı Beslenme (Human Temperaments and Healthy Nutrition, in Turkish) shows which foods calm your skin and which unsettle it. Order on WhatsApp.
See the online course “Signs of the Body”: learn to read temperament and the state of the body from colour, temperature, moisture, hair, nails and pulse, with 20 videos, 2 live Q&A sessions and lifetime access (in Turkish): Bedenin İşaretleri Online Eğitimi.
Browse the natural products: natural oils, personal and skin care and the full Dr. Kalan Natural range: order page.
Ask for a consultation if you need one: for a careful assessment of your temperament and a personal plan: training and consultation or WhatsApp +90 552 852 10 00 (Ankara office, Türkiye).

To learn how skin diseases are treated, read part two of this series, Treating Skin Diseases in Humoral and Modern Medicine.

References

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Disclaimer

This article is for information only and is based on traditional medical sources and general health knowledge. It is not a medical diagnosis, treatment or prescription and does not replace an examination by a doctor. If you have a health complaint, take regular medication, are pregnant, or are considering this for a child, consult your doctor before applying anything. Herbal products can interact with medicines.