Chinese Herb Eczema Case Study by Attilio P. D'Alberto

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 years.

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 Xian Pi.
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.

Discussion

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 of eosinophils.

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.

References

• 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: Churchill Livingstone.
• 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.