||Editor's Note: From time to time, we publish Chinese
medicine case studies. These case studies may include medical
information you are not familiar with. Trained acupuncturists
and herbalists may get more out of them than laypeople. But,
if you are a layperson, such cases can demonstrate Chinese
medicine's thoroughness, attention to detail, and how a case
is likely to proceed. Remember, every
person is different, and this particular eczema patient's patterns
of imbalance differ from other eczema patients. Nonetheless, the
"discussion" section at the end contains some basic
information about eczema from a Chinese medicine perspective.
Case: Male, 30 years old. Single. IT Consultant. Re-occurring
eczema, itching of the skin for 25 years. Initial consultation
23rd January 2003.
History of present illness: The affected areas are on
the popliteal fossa (behind the knee) and are symmetrical. They
are itchy, without sharp demarcation, no oozing of pus and leaves
no scaring after being scratched. The itching cannot be controlled
by the patient, affects his sleep, and he feels tired and fatigued.
The patient generally feels hot and is irritable and has numerous
colds and dislikes drafts. He feels a burning sensation in the
anus when defecating. The stools are sticky with a fetid odor,
whilst the urine is dark and scanty. The patient eats excessively
at irregular times, feels bloated for at least two hours afterwards,
and works excessively.
Past history: Asthma started at age 3 in the summer. Itching
(eczema) started at the age of 4, one year after the development
of asthma, but ceased at the age of 14 and then re-occurred at
the age of 28. Asthma ceased at the age of 18. The location of
the itching varied from the age of 14 at the antecubital fossa
(elbow crease) to the popliteal fossa (back of knee) at the age
of 28. Between the ages of 4-14, the patient's GP prescribed steroid
creams which helped the itching but the patient later chose not
to use them as he disliked steroids.
Pertinent physical examination and laboratory findings:
Red lichenified (thickened) areas with erythema located at the
popliteal fossa. Blood pressure was measured at 130/75 mmHg.
Tongue inspection: The tongue had a red tip whilst the
body was swollen with teeth marks around the edges. The coating
was thick yellow and greasy.
Pulse condition: The pulse was rapid and slippery on both
left and right sides.
Orthodox Diagnosis: Eczema (Atopic Dermatitis) for 25
TCM Diagnosis and syndrome differentiation: Damp-Heat obstructing
Wei Qi with a constitutional Lung Qi deficiency.
Principles of Treatment
1. Drain the damp, clear the Heat and stop the itching.
2. Tonify the Lung Qi (after principle 1 has been achieved).
Base Herbal Formula
1. Chu Shi Wei Ling Tang with Er Miao Tang plus Ku Shen and Bai
2. Shi Zhen San (atopically).
Prescription: Cang Zhu ~ 3g, Hou Po ~ 3g, Chen Pi ~ 3g,
Zhu Ling ~ 3g, Ze Xie ~3g, Chi Fu Ling ~ 3g, Chao Bai Zhu ~ 3g,
Hua Shi ~ 3g, Fang Feng ~ 3g, Zhi Zi ~ 3g, Rou Gui ~ 1g, Gan Cao
~ 1g, Deng Xin Cao ~ 3g, Huang Bai ~ 9g, Ku shen ~ 9g, Bai xian
pi ~ 6
To be decocted and taken once in the morning and once in the
evening after meals.
Huang Qin ~ 150g, Duan Shi Gao ~ 150g, Han Shui Shi ~ 250g, Wu
Bei Zi ~ 125g
Grind all the herbs together into a fine powder. Mix with vegetable
oil to form a paste, or sprinkle some of the powder directly on
the affected area. Apply once or twice daily.
Lifestyle Suggestions: Eat at regular times and not excessively.
Course of Treatment
2nd consultation: 06th February 2003. The itching was
a little less intense and the patient could sleep better. The
stools were still sticky and the burning sensation was still felt.
The tongue had a thick yellow coating with a red tip and teeth
marks, whilst the pulse was still rapid and slippery. The prescription
remained the same with Chu Shi Wei Ling Tang with Er Miao Tang
plus Ku Shen and Bai Xian Pi and Shi Zhen San.
3rd consultation: 20th February 2003. The itching was
less intense and is more controllable throughout the day and night.
The tongue body was less yellow whilst the thick coating was reduced.
The red tip had almost disappeared but the teeth marks were still
visible. The eczema on the popliteal fossa is unchanged. The pulse
was slightly rapid and still slippery. The prescription remained
the same with Chu Shi Wei Ling Tang with Er Miao Tang plus Ku
Shen and Bai Xian Pi and Shi Zhen San.
4th consultation: 06th March 2003. The eczema on the popliteal
fossa is reducing slowly. The tongue coating had a slight yellow
coating whilst the coating was mainly concentrated at the root
and the teeth marks were still present. The bowels are still slightly
sticky but the burning feeling around the anus had gone. The pulse
was slightly slippery. The prescription remained the same with
Chu Shi Wei Ling Tang with Er Miao Tang plus Ku Shen and Bai Xian
Pi and Shi Zhen San.
5th consultation: 20th March 2003. The eczema on the popliteal
fossa had almost disappeared. The tongue coating had no yellow
coating but a thin white coating indicating a small amount of
damp is left and the teeth marks had gone. The bowels were less
sticky. The pulse was slightly slippery. The prescription remained
the same with Chu Shi Wei Ling Tang with Er Miao Tang plus Ku
Shen and Bai Xian Pi and Shi Zhen San.
Atopic dermatitis is known as Si Wan Feng, which means 'four
bends wind,' reflecting the four skin sites that are commonly
affected: the antecubital fossa and the popliteal fossa (Shen,
Wu and Wang 1995, p165). The pathological causes include the six
external evils, notably Wind, whilst Spleen dampness is the primary
internal cause (Liang 1993, p22). The Bian Zheng Lun Zhi of this
case is a combination of excess and deficiency. The excess is
the accumulation of Damp-Heat in the body with an underlying Spleen
and Lung Qi deficiency.
From a western perspective, the development of eczema with the
onset of asthma at the age of four points towards an allergic
IgE response. This is a genetically determined disorder that occurs
in association with asthma and hay fever. Symptoms usually include
erythematous, scaling and lichenified areas, which when active
show crusting but no vesicles. If a blood sample is taken, it
will most likely show an increase in IgE levels and a high number
From a TCM view, atopic eczema and asthma involve the connection
between the Lungs and the skin. These two symptoms are very clearly
related and often one will appear as the other improves. Often
eczema appears first at a very early age or even from birth, later
to be followed by asthma when the child is about 4 or 5 years
old. This pattern is more likely to occur if the eczema is suppressed
with the application of cortisone cream. The reverse may also
occur when asthma appears first and then apparently improves only
to be followed by eczema as seen here (Maciocia 1994, p129).
The onset of asthma at the age of 3 points towards a constitutional
Lung Qi deficiency. The Lung Qi deficiency along with a Spleen
Qi deficiency would of lead to a deficiency of Wei Qi as the Spleen
produces Wei Qi and the Lung controls Wei Qi (Maciocia 1989, p45).
This would of-allowed the subsequent invasion of an exogenous
pathogen, Wind-Heat. The eczema was therefore originally Wind-Heat
type up until the age of 14 and was located at the antecubital
fossa, the upper part of the body. The asthma ceased when the
patient was 18 as he matured and 'grew out' of the asthmatic condition.
From the age of 28, the eczema changed into Damp-Heat type and
sank downwards into the lower jiao, which would of caused the
eczema to migrate from the antecubital fossa to the popliteal
fossa. In addition, the eczema can pass easily from the greater
Yin meridian of the Lung which is Taiyin to the greater Yang meridian
of the Urinary bladder which is Taiyang respectively.
The Wind-Heat in the Lung at the age of 4 impaired the Lung Qi
leading to a deficiency. As no herbal medication was given, the
Heat then entered deeper into the interior of the body, indicated
by the patient's constant thirst. The Lung is unable to distribute
fluid normally and regulate the water metabolism in the upper
burner causing the retention of water and the formation of damp.
The damp would have lead to the Spleen and Stomach's transportive
and transformative mechanism being impaired as increased strain
is put on the middle burner to regulate the body's water metabolism
resulting in the accumulation of more damp. Now, the patient's
thirst indicates Heat whilst the greasy tongue coating and teeth
marks indicate Damp-Heat and a Spleen Qi deficiency. The excessive
eating especially at irregular times would further exuberate the
Spleen Qi deficiency and the feeling of tiredness and fatigue.
The reoccurrence of colds and aversion to drafts also indicates
a Wei Qi deficiency. Within the Five element theory, the Spleen
is Earth and generates the Lung which is Metal (figure 1). As
the Spleen, the Sea of Qi and Blood, becomes impaired by damp,
caused by overeating and excessive pensiveness, it cannot generate
Qi and Blood for the Lung and Wei Qi, allowing the invasion of
exogenous pathogens and Wei Qi's inability to defend the skin,
causing the aversion to drafts.
When dampness lingers in the interior, stagnation and turbidity
ensue. Damp turbidity severely interferes with the transporting
function of the Spleen, producing symptoms of epigastric and abdominal
distention, fullness and fatigue, which are seen in this patient.
The itching is caused by the Damp-Heat being trapped beneath the
skin and is also responsible for the raised white bumps. Damp-Heat
accumulates in the skin so that the Blood circulation is hindered
and Ying and Wei are disrupted. The sticky stools with the fetid
odour and the burning sensation when defecating and the dark scanty
urine, indicates that the Damp-Heat is sinking into the lower
Jiao. These symptoms require the use of aromatic herbs that cut
through the turbidity and revive the Spleen.
The relationship between the Lungs and skin is well known and
yet, when discussing the pathology of skin diseases, Chinese books
always seem to stress more the role of Blood (and Liver) in connection
with the skin. The irritability and anger caused by the itching
and lack of sleep leads to stagnation of the Liver Qi as indicated
by the poor Blood circulation. This further weakens the Spleen
as the stagnated Liver Qi invades the Spleen (figure 2).
The choice of Chu Shi Wei Ling Tang with Er Miao Tang plus Ku
Shen and Bai Xian Pi is primarily used to clear heat and dry dampness
in the lower burner, regulate Qi, and harmonise the middle burner
(Bensky and Barolet 1990, p183). However, this formula is modified
to include other herbs to relieve the itching. Cang Zhu dries
the dampness in the lower Jiao. Hou Po and Chen Pi both regulate
Qi and transform dampness. Zhu Ling and Ze Xie leech out dampness
and promote urination. Chi Fu Ling clears damp-heat, whilst Chao
Bai Zhu dries dampness. Hua Shi expels damp-heat through urination
and Fang Feng expels wind-damp. Zhi Zi clears heat, drains damp-heat
and eliminates irritability. Rou Gui leads fire back to the source
and encourages the generation of Blood. Gan Cao acts to protect
the middle Jiao and harmonise the formula. Deng Xin Cao clears
heat from the Heart channel and promotes urination. Huang Bai
treats the damp-heat in the lower Jiao, whilst Ku Shen clears
heat, dries dampness and relieves itching. Bai Xian Pi also clears
heat, eliminates dampness and relieves itching.
Shi Zhen San is used topically to clear the damp-heat. Huang
Qin clears damp-heat, whilst Duan Shi Gao clears heat. Han Shui
Shi drains fire and Wu Bei Zi relieves fire toxicity and absorbs
moisture (Bensky and Gamble 1986, p376).
The root of this disorder is deficient Qi which predisposes the
person to the development of damp-heat. Once the damp-heat has
been cleared, the second treatment principle can be employed to
tonify the Lung Qi, firstly by strengthening the Lung Qi and Wei
Qi with Bu Fei Tang, which augments the Qi and stabilises the
exterior (Bensky and Barolet 1990, p246). Once the Lung Qi is
strong and able to nourish the Wei Qi and stop the reoccurring
colds, then Spleen should be tonified in order to maintain a constant
supply of Qi and Blood for all the Zangfu organs.
- Bensky, D. & Gamble, A. (1986). Materia Medica. Seattle:
Eastland Press, Inc.
- Bensky, D. & Barolet, R. (1990). Formulas & Strategies.
Seattle: Eastland Press, Inc.
- Maciocia, G. (1989). The Foundations of Chinese Medicine.
Edinburgh: Churchill Livingstone.
- Maciocia, G. (1994). The Practice of Chinese Medicine. Edinburgh:
- Shen, D., Wu, X. & Wang, N. (1995). Manual of Dermatology
in Chinese Medicine. Seattle: Eastland Press, Inc.
- Zhang, T. & Flaws, B. (1993). A Handbook of Traditional
Chinese Dermatology. Boulder: Blue Poppy Press.