Kava Physiology Kava Dermopathy

Kava Dermopathy
(My personal trial and its results are at the bottom)​

Overview

Kava Dermopathy is a condition theorized to be caused by over consumption, long term use and/or possibly consuming too much root material. Kava Dermopathy has been well documented among Pacific Islanders [1] and is a reversible condition characterized by dry scaly yellow skin covering the palms of the hands, soles of the feet, and back [2]. Kava Dermopathy can present first at: the lips, hands, armpits or other parts of the body although these seem to be the most common based on anecdotal reports. Usually, the dermopathy starts with dry skin (without any peeling or other dermatological symptoms) and progresses to ichthyosis (a scaly appearing rash that peels).​

Causes

Anecdotal reports indicate that the "toss and wash" method of consuming raw root is very likely to cause the dermopathy to occur although it can also occur in traditional types of preparation, although it seems this method is safer from a dermatological respect. Many theories exist as to the cause from a biological level, including but not limited to:

1. interference with cholesterol metabolism[3]
2. the presence of an alpha-methylene-butyrolactone group which enables lactones to attach to skin proteins and forming antigens which eventually lead to a state of allergy [4]
3. reduction in glandular secretions
4. accumulation of plant flavopigments or kavalactones
5. chronic allergic dermatitis
6. a pellagra-like dermatosis,
7. dehydration [5-10]
8. niacin deficiency [11].

Niacin deficiency is the only theory that has been tested, and was found to be ineffective at controlling dermopathy [12]. Other theories have been untested to date.​

Prevention

Because Kava is a diuretic, one hypothesized way to prevent dermopathy is to consume significant amounts of water during and/or after kava consumption. Kava dermopathy seems to be most common in heavy and/or long-term users and therefore, decreasing the amount of kava consumed should be effective. Another possible preventative measure is to keep consumption of raw root to a minimum (ie. finely straining, avoiding "toss and wash").
​

Treatment

Because the dermopathy is reversible, cessation of kava consumption can heal the dermopathy. Some anecdotal reports reveal that the dermopathy can be manageable with moisturizing lotion, multivitamins and/or Vitamin E applied topically without cessation of kava consumption. However, individuals might not respond well and would have to cease consumption for the condition to resolve.​

-Multivitamins are almost never contraindicated, and it is certainly possible that they help in the recovery, however there is no evidence to show how or why.​

-Anti-histamines- Because dermopathy might be due to accumulation of antigens from skin proteins, and therefor an allergic response, 1st generation anti-histamines might have some efficacy. These include the most popular Diphenhydramine (found in Benadryl) and others such as Hydroxyzine (Atarax).​

-Keratolytics are substances that have the "capability of decreasing cell-to-cell cohesion in the stratum corneum and, therefore, promoting the physiologic shedding process" [13][14]. Because of the accelerate sloughing involved with this, it is possible that keratolytics help to remove 'damaged' skin cells in the dermis which could be the cause of the local reaction associated with dermopathy. Among keratolytics, the two most common are Alpha hydroxy acids (AHA) and Beta hydroxy acids (BHA).

• BHAs include the common Salicylic Acid which is commonly found in aspirin, but also many "cleansing" or "exfoliating" wipes, lotions and other preparations. BHAs are not as strong as AHAs, but are lipophilic unlike AHAs and can therefore penetrate through the sebum and oil in the skin and its pores.
• AHAs include lactic, citric, tartaric, malic and glycolic acids. The two most common seem to be glycolic and lactic acid. Glycolic acids are the smallest on a molecular level and are more bioavailable, possibly leading to it being the most common. However, lactic acid has been shown to work exceptionally well for some people with ichthyosis.

​

Prognosis

The dermopathy is benign and not dangerous. However, if care is not taken, it can become severe enough to cause the skin to split and bleed. Other ulcerous type lesions can also occur.

The dermopathy takes anywhere from 2 or 3 days to 3-4 weeks depending on the individual, how much and how long kava was consumed among other factors. Mild reactions will take less time to heal compared to more severe reactions.

Usually, the rash seems to start at one part of the body and then spreads. After the rash has spread, it will the exfoliate in the same order that it presented. It is not uncommon for the rash to get worse after cessation of kava consumption.

Because the dermopathy is reversible, it is not a chronic condition (unless it the etiology is an allergy, in which case it can be expected to occur whenever kava consumption is resumed).​

Citations

1. S. A. Norton and P. Ruze, “Kava dermopathy,” Journal of the American Academy of Dermatology, vol. 31, no. 1, pp. 89–97, 1994.

2. C. Ulbricht, E. Basch, H. Boon et al., “Safety review of kava (Piper methysticum) by the Natural Standard Research Collaboration,” Expert Opinion on Drug Safety, vol. 4, no. 4, pp. 779–794, 2005.

3. Benzera and Dupuis 1983

4. Norton, Scott A., and Patricia Ruze. "Kava dermopathy." Journal of the American Academy of Dermatology 31.1 (1994): 89-97.

5. Davidson C. Hawaiian Medicine. Medical Age 1899;25:373- 381. (Review)

6. Frater AS. Medical Aspects of Yaqona. Fiji Med J 1976;4:526-530. (Descriptive)

7. Lebot V, Cabalion P. Kavas of Vanuatu: Cultivars of Piper Methysticum Forst. Technical Paper No 195. Noumea, New Caledonia: South Pacific Commission 1988;3-53. (Descriptive)

8. Shulgin AT. The Narcotic Pepper: The Chemistry and Pharmacology of Piper Methysticum and Related Species. Bull Narc 1973;25:59-74. (Descriptive)

9. Siegel RK. Herbal Intoxication. JAMA 1976;236:473-476. (Review)

10. https://www.nakamalathome.com/kava-kava-information/side-effects-of-kava-kava.html

11. Ruze, P. "Kava-induced dermopathy: a niacin deficiency?." The Lancet335.8703 (1990): 1442-1445.

12. http://www.medscape.com/viewarticle/767932_9

13. Dorland."The Definition of Keratolytic". Elsevier. Retrieved 8 August 2012.
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My Personal Experience:
Backround

I had started consuming Kava for anxiety and insomnia problems 5 months ago. I had used it sporadically before, but not consistently enough to break through the reverse tolerance which happened 5 months ago.​

I mainly used Stone, although I would more rarely use others (2nd most common was Fu'u, next to Solomon's). I blend 5tbsps of Kava in a blender with soy lechtin, let it sit overnight, then blend for 2-4 mins. After that I would strain with a nylon stocking, then wring it out and drink.
​

Progression

I started to get the reddish stretch mark looking rash around my armpits at (8/9), and I stopped drinking kava for a week. As the days went on, I started to feel hot or sunburned mostly on the back of my neck and shoulders. The rash started to progress over a period of two days to my entire torso and even down to the tops of my thighs and up my neck. (see attached photo at bottom for image). I was applying moisturizing lotion to the affected areas once a day and taking a multi-vitamin.
​

Treatment

After reading as much as I could, I decided to try to try taking Diphenhydramine (Benadryl) and went out and got some along with more vitamins. I took 50mgs of the diphen. and the rash seemed to respond fairly quickly. It didn't cure it by any means, but I was getting desperate seeing as it was a week and still not better (and actually had gotten worse after ceasing kava intake). Now, the rash seems to be isolated to my armpits and the sides of my torso beneath them. I have taken a multi-vitamin as usual, but no lotion was applied today.
​

Questions/Hypotheticals/Comments

Is it possible that this is actually some sort of acute allergic reaction? I know that food allergies can occur at any time (ie. you could drink milk every day as a kid then have a glass one day and feel symptoms of lactose-intolerance) and I wonder if a dose-dependent allergic response is really what's happening here. The dermopathy really presented itself after I started to consume Fu'u which was incredibly finely ground. It seems that there is a general consensus that the more actual root (ie. sediment at bottom of bowl, toss and wash) you consume, the worse it will be. What is the best way to strain finely ground root? I have recently stumbled across something called a Chinois which is a very fine metal strainer, but this wouldn't allow the squeezing of the root fibers (which I believe to be important). So then, what is the best way to strain the very fine particulate found in all kavas, but mostly in finely ground ones like Fu'u?

Niacin has been proven to not help with dermopathy in Pacific natives.​

Here is the quote that led me to taking some diphen:

Trials

The dermopathy presented on 8/6, but since I didn't start my 'trial', I won't factor this into the tx timeline. (But you can always add 12 days to figure since the dermopathy presented). That being said, this is what I decided to do at that point (not part of my 'trial'):​

I decided to try to try taking a multivitamin and Diphenhydramine (Benadryl) and took 50mgs of the diphen. and the rash seemed to respond fairly quickly. It didn't cure it by any means, but I was getting desperate seeing as it was a week and still not better (and actually had gotten worse after ceasing kava intake). The rash seemed to be isolated to my armpits and the sides of my torso beneath them. I have taken a multi-vitamin as usual, but no lotion was applied that day. However, the rash continued to spread, regardless of continuation of Diphen. and this seemed to be a case of placebo...​

Here is what the Dermopathy looked like before the trial on the 17th:​

View attachment 25
Topical Treatment Trial

On 8/18 I started applying different topical treatments as well as 50mg of diphenhydramine every 6 hours and 1 multivitamin a day. For the sake of simplicity, I will call this (T-0).
[I didn't start applying #2 or #3 until late that evening which was only 4 hours after I started #1 and #4, so there's no photos for T-6hrs.]​

After one week, I consumed a few shells of Kava with no noticable difference in symptoms. I resumed Kava consumption on the 19th as normal, except for using 2 nylon stockings instead of one. I continued to take a multivitamin once a day, but only took 50mg diphen once a night. However, I only started to apply the AHA to my whole body on the 21st (meaning, a gap of 24 hours). What I found was quite interesting, and was noted below in "Conclusions".​

Treatment Legend=
- Salicylic Acid (BHA) 2% wipe as found in Stridex wipes (low right side of abdomen [#1])
- Salicyclic Acid (BHA)2% wipe followed by AmLactin 12% (AHA) (high right side of abdomen [#2])
- Vitamin E infused lotion (high left side of abdomen [#3])
- AmLactin (AHA) 12% (low left side of abdomen [#4])

Salicylic Acid- 6hrs after application [#1]
View attachment 26

Lactic Acid- 6 hrs after application [#4]
View attachment 28

Salicylic Acid- 24hrs after application [#1]
View attachment 29

Salicyclic Acid followed by Lactic Acid- 24 hours after application [#2]
View attachment 34

Vitamin E- 24 hours after application [#3] (sorry, file was corrupted and I only got the upper half but you can still see a reasonable sample)

View attachment 31

Lactic Acid- 24 hours after application [#4]
View attachment 37

On day 2, 48hrs after I started the trial, it became clear to me that Lactic Acid (AHA) was the best treatment. 5 days after starting the trial, I began to apply that to my whole body (where dermopathy was present) along with taking multivitamin and 50mg diphen at night.

T-7 days since first application- 2 days of application + original 2 days
View attachment 36

Conclusion/Analysis

AHAs and BHAs are both Keratolytics which work by loosening the outer layer of skin, causing it fall off. In addition, keratolytics soften keratin allowing the a greater potential for moisturization of the skin. What I found was that the BHA (Salicylic Acid) did well to 'clean' the skin, and using the abrasive nature of the pad, I was able to remove some skin. However, the AHA tested (Lactic Acid) seemed to do exceptionally well at not only accelerating the shedding of the dry and flaky skin, but also moisturized exceptionally. As mentioned above, I did not apply the AHA for 24 hours and I found that, during that gap, a significant amount of skin flaking was occurring in that isolated spot (where I had been testing the AHA). Not only was it much more flaky than the other untreated parts of my body, but the flakes were much looser and easier to remove. After I sloughed these off with a washcloth, the area has continued to be clear and supple (normal) to this day (the 26th, 8 days after starting the application).

I found that the AHA not only did well to accelerate the process of shedding and sloughing off of the dead skin, but once that skin was removed, the area remained clear and supple, even during the 24 hrs of non-treatment.
​

Thanks! I'm working on compiling the images and trying to make them homogenous.

Thanks, I forgot to do that. Glad I could help in some way.

The directions for AmLactin say to put it on twice a day "for best results'" but I found that even once daily applications can be beneficial. The main issue tended to be (for me) that applying it to flaky, dry skin would use up a lot more lotion than would normally be used for that amount of skin. Until the skin starts to loosen up, this can't really be avoided other than using a loofa or something to exfoliate. But as we all know, the sort of eruption caused by dermopathy is a sort of 'stubborn' flakiness that doesn't exfoliate easily. That's one of the main benefits of AHAs is that they help to loosen up the dry skin. After a few days, it should start to 'peel' off in rather large flakes fairly easily and it helps to try to exfoliate this skin before applying it further. Once you have clear skin, you might only need to apply it once every other day.

Awesome, let me know how it goes.

I found that applying the lotion twice a day (I usually would do it after a shower where I tried to scrub the skin off) was only necessary for the first two days. You might see it appear to get worse a day or two after 1st application (as in larger flakes), but these are easily removed and a sign of it's keratolytic nature (which seems desirable in treating this dermopathy). After that stage, it was all better for me. Good luck!

Strange, it never had that effect on me (but my skin wasn't cracked or anything really bad).

Oddly enough, even though LA is most effective at low pHs, they buffer it with Ammonium to bring it to neutral.

Glad it worked for you! Still surprised that it burned, due to the fact that the pH is buffered. Maybe it's still slightly acidic though.

Did you have 'cracked' kind of skin (ie. irritated looking, redness, etc) or just dry flaky skin?

Ah, well that's why.

If I had known that I would have warned you because, while it is buffered somewhat it might still be slightly acidic although I don't know for sure.

Do other lotions or creams burn/sting like that when you have the dermopathy?

Yeah, (this is just conjecture), but I find that after a shower and drying yourself off, I get a better effect due to *trapping the moisture in*

I would imagine that for those with cracked or severely damaged skin, the discomfort should subside within two applications or so due to how quickly it moisturizes. Not only does it have the keratolytic effect, but it also has the very important quality of very effective hydration of the skin. It's been two days since I've had any and my skin feels more supple than it's ever been. I wonder about its potential as a prevention technique... If the cause is due to dry skin (from lack of hydration or lack of glandular secretions) then this very well could be a preventative measure!

Got to confirm the burn. Some derompathy flared up around my neck and I put on the lotion right after shaving and wow, it definitely isn't pleasant. I only nicked myself once or twice too, yet it felt like my whole neck was on fire!

As a side note, the day it flared up, I started to apply some once a day and it's kept it completely clear.

I love this one.. Thanks