Xianhui Li

1. Class 11: Dermatological Diseases: uticaria, erysipelas, Herpes Zoster, boil, breast abscess, Goiter Xianhui Li

2. Herpes zoster (Shingles) • Herpes zoster (or shingles) is an acute infection of the nerves that supply certain areas of the skin. It is caused by reactivation of the varicella zoster virus that entered the cutaneous nerves in an earlier attack of chicken pox. The virus may be reactivated and migrate along the nerve at the skin to trigger an outbreak of herpes zoster when the immune system is depressed.

3. Clinical manifestations • Herpes zoster mainly affects people over 50 and the incidence rises with age. Younger people with weakened body conditions may also be affected. • Mild systemic symptoms are often observed prior to the development of the cutaneous lesions of herpes zoster, such as fatigue, poor appetite, headache, and fever. Pain, tingling and dysesthesia may precede the attack by days. • Herpes zoster starts with inflammatory erythema and papules, forming a band like distribution with clear interspaces between the patches. They evolve into vesicles of varying sizes usually filled with clear transparent fluid. In three or four days, the fluid inside the vesicles becomes turbid. Vesicles rupture and soon dry up leaving a crust. Crusts drop off in two to three weeks, leaving temporary pinkish marks or pigmentation locally, usually without scarring. • Post-herpetic neuralgia is rare in patients under 40 years, but is more common in the elderly. Pain can persist for months after an attack. • Although recurrence of the disease is not common, an attack of herpes zoster does not confer lifelong immunity and further episodes may take place.

4. Etiology and pathology • Failure of the transportation function of the spleen results in dampness. Internal dampness moves outward to the skin and water accumulates in the flesh, forming a dense distribution of pearl-like vesicles. • Qi depression of the liver and heart leads to the generation of heat. Heat retained over a prolonged period transforms into fire. Heat and fire congest in the skin and obstruct the channels and network vessels, resulting in such symptoms as erythema, papulovesicles and severe pain. • Residual toxins that become trapped in the channels and vessels impair the free circulation of qi and result in qi stagnation and blood stasis. Qi and blood cannot be diffused in the channels, often resulting in constant or stabbing pain.

5. Accumulation of damp heat • Clinical manifestations • The skin is slightly red in the diseased area and clusters of vesicles full of turbid fluid appear. Exudation or erosion may occur on rupture of the vesicles. Accompanying symptoms include pain, poor appetite and abdominal distension. The tongue body is pale red with a white or yellow greasy coating, the pulse is slippery. • Treatment principle • Clear and transform damp-heat, cool blood and relieve toxicity

6. Exuberant heat toxins • Clinical manifestations • The skin in the affected areas appears bright red. Papules, papulovesicles and tensely distended vesicles, sometimes blood-filled, are present in clusters or strips. Patients have subjective sensations of burning or stabbing pain, which makes it difficult to sleep. Dry throat, bitter taste in the mouth, yellow urine, constipation. Red tongue with yellow dry coat. Wiry and rapid pulse. • Treatment principle • Clear heat and drain fire, relieve toxicity and alleviate pain

7. Qi stagnation and Blood stasis • Clinical manifestations • Constant or stabbing pain. There can be severe pain after all the eruptions have subsided, which makes sleep difficult. Lack of appetite and irritability and restlessness. Red or dark red tongue with white coat, fine or wiry pulse. • Treatment principle • Regulate liver qi, remove blood stasis and alleviate pain • Acupuncture treatment: Local Ashi points, LI11, SP10, GB34, BL40, LIV3, HT7 • LI11 dispels wind and clears off heat • SP10 and BL40 eliminate heat in the blood • GB34 and LV3 reduce damp heat from the liver and gallbladder • HT7 calms the spirit • Blood letting therapy reduces the pathogenic toxin • Herbal treatment: xue fu zhu yu tang or long dan xie gan tang

8. Erysipelasdan du • Erysipelas is an acute contagious infectious skin disease characterized by sudden onset of chills, fever, local redness and swelling which may take place on any site of the body and rapidly extend.

9. Etiology and Pathogenesis • Invasion of wind and toxic heat • Accumulation of damp heat from stomach and intestines into blood, skin and muscles

10. Pattern identification and treatment • Clinical manifestations • Rapid onset of a well demarcated patch of redness, hotness and burning pain, rapidly extending in size, change in color of the patch from bright red to dark red and then healing with desquamation. • Invasion of Wind heat • Chills and fever, acute headache, thin yellow coating and superficial rapid pulse. Delirium, convulsion • Accumulation of damp heat • Fever, irritability, thirst, stuffy sensation in the chest, poor appetite, constipation, dark urine. Red tongue, yellow sticky tongue coating and rapid pulse. • Treatment principle • Eliminate heat and relieve toxins • Acupuncture treatment: LI11, LI4, PC3 qu ze, BL40, SP10, Ashi points • Wind heat: GB20 • Damp heat: ST36, ST40, SP9 • Toxin in the interior: DU14, PC8 lao gong, Twelve Jing-well points • Constipation: SJ6 • Herbal treatment: pu ji xiao du yin or bi xie sheng shi tang

11. Urticariafeng zhen • Urticaria is an eruption of the skin characterized by transitory wheals. It is called ‘wind wheal’ in Chinese medicine.

12. Etiology and Pathogenesis • Accumulated heat in the stomach and intestines, Disharmony between stomach and spleen. • Attack of wind heat, or wind damp

13. Wind heat • Clinical manifestations • Abrupt onset with itching wheals of various sizes or with pimples rising one after another. Aggravated or lessened by the changing of weather. Red rashes with severe itching, rashes comes and goes quickly, superficial and rapid pulse. • Treatment principle • Disperse wind and eliminate heat in blood • Acupuncture treatment: LI11, LI4, BL40, SP10, SP6, DU14 • Wind rash is mainly caused by stagnation of the pathogenic wind, heat or damp in the skin and muscles or due to accumulated damp heat in the stomach and intestine. So LI11 and LI14 are used to disperse the pathogenic factors from the skin and muscles • SP10 and BL40 eliminate heat in the blood • SP6 tonifies spleen and drain dampness • DU14 reduces the heat • Herbal treatment: xiao feng san

14. Wind damp • Clinical manifestations • Abrupt onset with itching wheals of various sizes or with pimples rising one after another. White or light red rashes accompanied by heaviness of the body, superficial and soft or superficial and slow pulse, white and sticky tongue coating. • Treatment principle • Disperse wind damp and eliminate heat in blood • Acupuncture treatment: LI11, LI4, BL40, SP10, SP6, SP9 • Wind rash is mainly caused by stagnation of the pathogenic wind, heat or damp in the skin and muscles or due to accumulated damp heat in the stomach and intestine. So LI11 and LI14 are used to disperse the pathogenic factors from the skin and muscles • SP10 and BL40 eliminate heat in the blood • SP6 tonifies spleen and drain dampness • SP9 removes dampness • Herbal treatment: fang feng tong sheng san

15. Accumulation of heat in the stomach and intestines • Clinical manifestations • Abrupt onset with itching wheals of various sizes or with pimples rising one after another. Red itching rashes complicated by abdominal or epigastric pain, constipation or diarrhea, yellow coating and rapid pulse. • Treatment principle • Clear heat and stop itching • Acupuncture treatment: LI11, LI4, BL40, SP10, SP6, ST40, ST36, ST25 • Wind rash is mainly caused by stagnation of the pathogenic wind, heat or damp in the skin and muscles or due to accumulated damp heat in the stomach and intestine. So LI11 and LI14 are used to disperse the pathogenic factors from the skin and muscles • SP10 and BL40 eliminate heat in the blood • SP6 tonifies spleen and drain dampness • ST36 and ST25 clear heat from the stomach and intestiens • ST40 resolves dampness and phlegm • Herbal treatment: huang lian jie du tang or fang feng tong shen san

16. Boil • Clinical manifestations • Boil appears like a grain of millet in yellow or purple color. A blister or pustule with a hard base is formed. Later there is increased redness, swelling and pain with burning sensation. • Etiology and Pathogenesis • Endogenous toxicity • Invasion of the exogenous toxic factor • Treatment principle • Clear heat and eliminate toxics • Acupuncture treatment : DU10 ling tai, DU12 shen zhu, PC4 ximen, LI4, DU14, BL40 • DU10 is an empirical point for the treatment of boil • DU12 readjusts the qi of all the yang meridians in order to disperse heat. • PC4, xi cleft point of the pericardium meridian, is effective for eliminating heat in the blood and stopping pain • LI4 removes the exogenous pathogenic factors from the exterior of the body • BL40 is effective for clearing away toxin from the blood • DU14 clears heat • Herbal treatment: huang lian jie du tang

17. Breast AbscessRu Yong (Acute Mastitis ) • Acute mastitis and breast abscess broadly correspond to the Chinese breast carbuncle. This is characterized by redness swelling, heat and pain in breast, and by red nodules which after some days, rupture with discharge of sticky pus. • The initial stage: acute mastitis • The later stage: discharging pus

18. Etiology and Pathology • Liver stagnation and stomach heat • Pathogenic toxicity • Improper feeding and retracting milk

19. Differentiation and Treatment • Manifestation: • After delivery with symptoms of breast: redness, swelling, heat and pain in the breast, accompanied by red nodules which, after some days, rupture with the discharge of sticky pus, thirst. Red tongue, yellow coating, slippery pulse • Treatment principle • Clear heat, dissolve toxins, pacify liver, clear stomach heat and resolve pus • Acupuncture Treatment: GB21, Ren17, ST18, SI1, ST36, LIV3, GB41 • Since breast abscess is caused by pathogenic heat in the stomach and the stagnation of liver qi, LV3 is used to remove the stagnation, ST36 and ST18 are to lower the stomach fire in order to eliminate the accumulation of pathogenic factors in the yang ming meridians • Ren17 is to regulate the activity of qi and remove obstruction of lactation • Foot shaoyang meridian runs along the chest and hypochondriac regions,GB21 is used to adjust qi circulation and remove obstruction of qi in the chest and hypochondriac regions being an effective point in treating the breast abscess. • SI1 is an empirical point for the treatment of the breast abscess • Chills and fever: LI4, TE5, LI4 clears heat from yangming, TE5 connecting the yangwei meridian is used to treat chills and fever • Herbal treatment: gua lou niu bang tang

20. Goiter • Goiter denotes an enlargement of the thyroid gland, causing a swelling in the front part of the neck, which is not companied by pain, ulceration or skin discoloration.

21. Etiology and Pathology • Emotional disturbance leads to stagnation of qi and accumulation of phlegm. Insufficient intake of iodine. • Qi goiter: “grow and disappear with emotion” a is mostly caused by insufficient intake of iodine and qi stagnation. • Flesh goiter: “no change in skin color” is due to qi stagnation and blood stasis accompanied with Yin deficiency with empty heat

22. Differentiation • Manifestation: • Qi goiter is marked by diffusive swelling in the neck, soft, gradually increasing in size with unclear margins, normal color, absence of pain, in some cases big and drooping, accompanied with dyspnea and hoarseness of voice. The size of the goiter usually changes with emotions. • Flesh goiter, a few oval movable lumps on the thyroid gland with smooth surface and without pain, accompanied by exophthalmos, hot temper, irritability, emaciation, tremor of the hands, sweating, feverish sensation, stuffiness in the chest, palpitation, wiry slippery and rapid pulse, and irregular menstruation.

23. Treatment • Treatment principle • Promote Qi and Blood circulation and dissolve phlegm • Acupuncture Treatment: TE13 naohui, LI17 tianding, SI17 tianrong, Ren22 tiantu, LI4, ST36 • TE13 is a point of the TE of hand shao yang, SJ dominates the qi of the whole body. So TE13 is used to remove obstruction from the meridians in order to relieve qi stagnation and phlegm accumultation for the goiter • LI17, SI17 and Ren22 are located on the neck. Puncturing them is to regulate the local circulation of qi and blood, to remove blood stasis and disperse agglomeration. • LI4 and ST36 belong to hand and foot yangming which pass through the neck region. They have the action of promoting qi circulation in the yangming meridians and eliminating stagnation of qi and blood • Liver Qi stagnation: Ren17, LIV3 • Palpitations: PC6, HT7, luo point of PC and yuan point of HT, are effective for palpitation • Exophthalmos: TE23 si zhu kong, BL2 zan zhu, BL1 jing ming, GB20 feng chi, these four points are used together to readjust the circulation of qi and blood in the eye region so as to control exphthalmos • Anxiety and sweating: SP6, KI7, are used to reinforce yin and check yang in order to relieve irritability, boulimia and excessive perspiration • Herbal treatment: si hai shu yu wan or hai zao yu hu tang

24. Patterns • Lung heat • Stomach heat • Spleen deficiency with dampness • Liver qi stagnation and blood stasis

25. Hyperthyroidism and Hypothyroid • Hyperthyroidism (Simple goiter) • Qi and yin deficiency • emaciation • Hypothyroid • Children: mental retardation, dementia, runty (dwarf), ugly, • Adults: less sweat, aversion to cold, low energy, fatigue, lethargy, poor appetite, gain weighty, constipation, impotence, amenorrhea, irregular period • Qi and blood deficiency, Spleen and kidney deficiency

26. Acne • Acne is a common inflammatory disease of the hair follicle sebaceous gland, characterized by papules, pustules, nodules and possible scarring. • It is called lung wind white thorns (fei feng fen ci) or early spring granules (qing chun dou) in Chinese medicine. • Many factors are responsible for the development of acne, sebum excretion, androgenic hormones, occlusion of sebaceous gland pores, infection with propionibacterium acnes. The development of acne is also influenced by genetic factors, gastrointestinal function, environmental factors, cosmetics, and emotional factors. • Excessive activity of the sebaceous glands, which are most numerous in the skin of face, chest and back. During puberty, these glands grow rapidly and keratin may block the opening. • White heads: white fluid that exudes when lesions is squeezed. • Black heads

27. Clinical manifestations • Acne is common among adolescents. It may persist into adulthood. • Lesions generally appear on the face, chest, back. • At the initial stage, lesions manifest as blackheads or whiteheads. As the disease develops, lesions may evolve into inflammatory papules or pustules. • In a few cases, mostly in males, papules may develop into red or dark red nodules or cysts, which are located deeper in the skin than papules, but may still raise the skin slightly. Atrophic and pitted scarring may occur where lesions are deep. • Acne is often complicated by increased sebaceous activity on the face and scalp, manifesting as an oily complexion with enlarged follicles and a greasy scalp.

28. Lung heat • Clinical manifestations • Lesions are distributed over the cheeks, forehead and around the nose, manifesting as discrete pinpoint red or pale red papules. In severe cases, lesions may involve the chest and back. Pressure may produce excretion of a plug of greasy matter or thick, yellow purulent discharge. The skin looks oily and shiny. Accompanying symptoms include a dry mouth and nose, constipation, a red tongue body with a thin yellow coating, and a floating pulse. • Treatment principle • Clear away heat from the lungs • Acupuncture Treatment LI11, DU14, SP10, BL17, BL12, BL13, LI4 • LI11 and DU14 are chosen to clear heat • SP10 and BL17 are used to tonify the blood and clear heat from the blood • BL12, BL13 and LI4 are used to disperse the lung qi and relieve exterior • Herbal treatment: sang bai pi tang

29. Stomach heat • Clinical manifestations • Lesions are similar to those in the lung-heat pattern, except that they are mainly distributed around the mouth. Accompanying symptoms include bad breath, aversion to heat, thirst with a desire for cold drinks, constipation, and dark yellow urine. Red tongue thick greasy yellow tongue coating, slippery and rapid pulse. • Treatment principle • Clear away heat from the Yangming meridian • Acupuncture Treatment LI11, DU14, SP10, BL17, ST40, ST44, LI4 • LI11 and DU14 are chosen to clear heat • SP10 and BL17 are used to tonify the blood and clear heat from the blood • ST40, ST44 and LI4 are used to clear heat from yangming meridian • Herbal treatment: xie huang san

30. Spleen deficiency with dampness • Clinical manifestations • Affected skin lesions dark red in color with pus, nodules, cysts, pitted scars, accompanied with poor appetite, diarrhea, loose stool, yellow greasy tongue • Treatment principle • Strengthen spleen and resolve dampness • Acupuncture Treatment LI11, DU14, SP10, BL17, SP9, ST36, SP6, BL20 • LI11 and DU14 are chosen to clear heat • SP10 and BL17 are used to tonify the blood and clear heat from the blood • SP9, ST36, SP6 and BL20 are used to tonify the spleen and drain dampness • Herbal treatment: shen ling bai zhu san

31. Liver qi stagnation and blood stasis • Clinical manifestations • Lesions manifest as red or purple papules on the face, concentrated around the nose and mouth and between the eyebrows. For women, papules normally increase before or after menstruation. Hot temper or anxiety. Normal tongue with red sides or red tongue. Wiry pulse. • Treatment principle • Soothe liver and expel blood stasis • Acupuncture Treatment LI11, DU14, SP10, BL17, LIV3, GB34, SP6 • LI11 and DU14 are chosen to clear heat • SP10 and BL17 are used to tonify the blood and clear heat from the blood • LV3 and GB34 clear heat from the liver qi stagnation and also soothe the liver • SP6 tonidy the kidney • Herbal treatment: xue fu zhu yu tang

32. Auricular acupuncture • Points: lung, endocrine, stomach, uterus, liver