In TCM skin conditions are understood in terms of this system’s unique interpretation of the clinical features of the lesions as they present in each case. Through differentiating the nature of the lesions and taking into account the other more general clinical features of the patient, the practitioner is able to deduce the underlying pathogenesis as well as formulate a treatment plan.
Skin lesions are analysed in terms of the presence of pathogenic factors, each of which tends to manifest with specific clinical features:
- WIND: Sudden onset, severe itching, lesions that come and go in different locations, lesions tend to be confined to the upper body.
- DAMP: Skin lesions that are puffy or swollen, fluid filled vesicles, lesions with serous exudation, erosions, enlarged sebaceous glands, lesions that tend to be confined to the lower body.
- COLD: Wheals or rashes that are pale, pink or dark purple, smooth skin that lacks elasticity, prolonged course of the disease.
- HEAT: Sudden onset, red lesions that feel hot, lesions mainly in the upper body (in the early stages), swelling, pain and pus formation. Often with systemic signs and symptoms
- DRYNESS: Dry skin lesions with desquamation, rhagades (linear fissures) and lichenification (thickening and hardening of the skin).
- TOXIN: (skin lesions due to drugs or medications, contaminated food, insect bites, poison ivy etc.). Intense signs and symptoms with a sudden onset, together with general malaise, tissue damage and history of contact with an allergen or toxin. The main symptoms and signs are: redness, swelling, purple macules, papules, vesicles, wheals, erosions, ulcers, epidermal tissue damage and exfoliation, accompanied by local sensation of heat, itching or pain.
- BLOOD STASIS: Increase of pigmentation, pigmented spots, petechiae, ecchymoses, red or purple spots, dark red nodules, subcutaneous nodules, thickened or hardened skin, distention of the capillaries, varicosities, veruccae, scar tissue, generally occurring in the subacute and chronic stages.
- DEFICIENCY OF THE LIVER AND KIDNEY: pigmented lesions (e.g. chloasma melanosis), disorders of the hair and nails, connective tissue diseases (e.g. SLE, scleroderma)
Furthermore, various areas of the skin are closely related to disturbances in the different internal organ systems (zang-fu) and their related channels, as follows:
Nose and cheeks: Lung- Colon
Mouth and tongue: Heart (or Fire pathogen)
Flanks, hypochondrial area and genitals: Liver-Gallbladder
Upper back: Lung
Middle back: Heart and Liver
Lower back: Kidney
It should be noted that the correlation of skin regions with internal organs should not be interpreted rigidly, but should always be considered in light of other pertinent signs and symptoms. As an example, a skin lesion that appears on the face may be due to a disorder of the Stomach, Lung or Colon. Alternatively, it may be due to invasion by exogenous Heat, which tends to affect the upper part of the body. Only by a careful analysis of the overall clinical picture can the nature and location of the underlying pathology be determined.
Once the pathogens have been identified, the practitioner assesses the degree of severity of each. Then, taking into account the overall clinical picture, the pathogenesis can be deduced and a treatment plan implemented.
To illustrate how this is done in clinic, the following three case histories are presented, dealing with acne, eczema and shingles (herpes zoster), from the case files of Dr Wang Shu. In these cases, Dr Wang achieved excellent clinical results in a very short time. This can be explained by his laser-like precision in diagnosis together with the application of very large doses of herbal medicines. In traditional Chinese herbal medicine, the daily dose of an individual herb can range from 3gm to 30gm and in some cases up to 60gm; the larger doses being used in very severe or acute conditions and usually only given for short periods of time (i.e. 1 to 3 weeks). For an experienced practitioner, who is confident in his/her diagnosis, large doses generally cause no problems and can achieve a swift, positive effect. However, until one reaches this level of clinical expertise, it is better to go cautiously, using lower dosages (e.g. 15 – 30 pills [or 4 – 8 capsules], three times daily), and expecting clinical results in a slightly longer time frame. The cases include brief commentaries by Dr Wang, together with explanatory notes by the author.
Case 1: SKN002 Male, 82, with Shingles
The clinical signs of Heat in this case include the rapid pulse and the red tongue body; while the thin tongue coat shows that the Heat had transformed to Fire and dried the body Fluids, attenuating the signs of Damp on the tongue (i.e. while there were tooth marks on the edges, indicating Spleen weakness and a tendency to retain Damp, the actual coat was not thick or greasy). The wiry pulse indicates both Heat and Liver involvement; while the signs of predominant Heat and Fire confirm that the Liver is the main internal organ involved in the pathogenesis of the patient’s condition.
Case 2: SKN003 Female, 51, nurse with severe eczema
In this case, although the itching was severe and the lesions red (marking an acute type of presentation), there were signs suggesting that the disease process had moved on to the subacute or chronic stages. This was indicated by the following clinical features: brownish discoloration of the lesions, lichenification, absence of vesicles, and no exudation. From a TCM perspective, these are signs of Blood stasis and Heat Toxin, which generally develop over time, marking the subacute or chronic stage presentation. At this stage the best treatment strategy is to activate the Blood and dispel stasis, while also clearing Heat Toxin and nourishing the Yin to moisten Dryness. The formula Si Miao Yong An Wan covers these principles, while the formula Xiao Feng San was included as an adjunct to dispel Wind and alleviate itching while also reinforcing the principle of nourishing Yin to moisten Dryness.
Case 3: SKN004 Male, 16, high school student with severe acne and mouth ulcers
In TCM, facial acne relates to the following localised pathogens: Heat, Damp, Toxin and Phlegm. The main Internal organ systems that are affected include the Lung and Stomach, as their Channels connect to the face. From an understanding of TCM pathology, it often happens that Heat in the Liver-Gallbladder ‘invades’ or is transmitted to the Lung. Subsequently the pathogens rise to the face as it is the nature of Heat to
rise upwards in the body and, in this instance, to follow the Channel pathway of the Lung, taking the pathogens with it. Additionally, pathogenic Damp may be generated in the Spleen-Stomach, and subsequently develop Heat; in a similar manner the Damp-Heat pathogens rise up to affect the skin of the face. The Heat on its own, or Damp and Heat combined, may readily develop into Toxin (red, angry pustules) or Phlegm (more nodular lesions).
According to the significant clinical features, the main underlying imbalance in this case was Heat in the Liver-Gallbladder (red tongue, wiry-rapid pulse more apparent on the left side). Damp was not present to a significant degree, as evidenced by the absence of a thick tongue coat. The Heat had developed into Fire, shown by the mouth ulcers, redness of the lesions as well as redness of the face in general. Thus, the primary pathology is the Liver-Gallbladder Heat, which has developed into Fire, affecting the Lung and Stomach, and, following their respective Channel pathways, has risen to manifest in the skin of the face (location of the Channels of the Lung and Stomach). The pathogenic Heat has injured the body Fluids, which have ‘congealed’ to form Phlegm, which gives rise to the papules and pustules visible on the face. Additionally, the Fire has further developed into Toxin, manifesting as intensely inflamed lesions, and general malaise.
This case illustrates how treatment of the ben (root of the disorder) can achieve powerful clinical results in a short time. There are several ways a clinician could have approached this case, choosing to use one or more of the following: treating the biao, i.e. the manifest symptoms (the acne and the mouth ulcers) with topical and ingested herbs; treating the intermediate pathologies (focus on the Stomach and the Lung); treating the root (Liver-Gallbladder excess Heat). Taking such alternative approaches may have provided satisfactory results in this case. However, unless the root pathology is adequately addressed, the condition is highly likely to return.
In view of the young age of the patient and good general overall health and constitution, this approach (to focus on the root treatment) yielded a positive outcome in a short time. Also, in light of these same considerations, the tonification needed (for the Yin, Blood and body Fluids) could easily be provided through a return to normal nutrition (as eating was no longer hindered by pain from the mouth ulcers) and also through having sufficient sleep at night.
BIBLIOGRAPHY AND RESOURCES
Dermatology in Traditional Chinese Medicine. Xu Yihou, 2004., United Kingdom Donica Publishing Ltd., St. Albans, Herts, UK.
Manual of Dermatology in Chinese Medicine. Shen De-Hui, Wu Xiu-Fen, Nissi Wang,m 1995. Eastland Press, Seattle.
The English-Chinese Encyclopedia of Practical Traditional Chinese Medicine, Vol. 16: Dermatology. Xu Xiangcai, 1990. Higher Education Press, Beijing, China.
Diagnosis in Chinese Medicine – A Comprehensive Guide. G. Maciocia, 2004. Elsevier Linited, Edinburgh.
Chinese Herbal Formulas mentioned in the text are available from Sun Herbal Pty Ltd.