19 Skin Disease Case 1 Main complaints: Eczema—skin problems on chest and back of shoulders, but especially on the genitals (since age 10 months). History: Born 10 weeks premature. At the age of 2 she had double pneumonia, and at age 3, minor pneumonia—since then her lungs had generally been fine. Her father had a significant history of eczema. All other systems were normal. Diagnosis: Lung vacuity pattern (symptoms, abdomen, and pulse). Treatment: Tap with herabari LI-4, LI-10, LI-11, ST-36, BL-40, abdomen, chest, neck region, GV-20, GV-12, and on the back. Using a teishin, very light stroking was applied down the back and on the bladder channel on the legs, then supplementation was applied to right LU-5, SP-9, draining to left LR-8. Press-sphere: bilateral BL-25. Second visit—1 week later She had a problem with itching on the buttocks and upper thighs, but the vaginal itching was much better, the shoulders and chest better. Treatment: Tap with herabari LI-4, LI-10, LI-11, ST-36, BL-40, abdomen, occiput, neck region, GV-20, GV-12, and on the back. Using a teishin, very light stroking was applied down the back and on the bladder channel on the legs, then supplementation was applied to right LU-9, SP-3, with draining to left LR-3 and BL-58. Press-sphere: bilateral BL-25. Third visit—1 week later Overall improvement in her skin problems; some small spots remained on the buttocks, the vaginal region was much better. But she was slightly more irritable. Treatment: Tap with herabari LI-4, LI-11, LI-15, ST-36, BL-40, abdomen, occiput, neck region, GV-20, GV-12, and on the back. Using a teishin, supplementation was applied to right LU-9, SP-3, draining to left LR-4 and BL-58. Press-spheres were applied to right BL-18 and left BL-25. Fourth visit—15 days later She had some minor skin problems on the buttocks (small patches) but overall the eczema was much better. Treatment: Tapping with herabari LI-4, LI-10, LI-11, ST-36, BL-40, abdomen, occiput, neck region, GV-20, GV-12, and on the back. Using a teishin, very light stroking was applied down the back and on the bladder channel on the legs, then supplementation was applied to right LU-9, SP-5, draining to left LR-3. Press-spheres were left on left BL-18 and right BL-25. The mother said she wanted to take a break from treatment because Julie was much better, and it was difficult making the trip to the clinic on a regular basis due to scheduling difficulties and the long travel distances. She agreed to call for further treatment if the problem started worsening. Main complaints: Eczema over the whole body. Poor sleep. Congested nose with some coughing. History: Soon after birth he started developing red skin blotches, which soon gave rise to eczema over the whole body. The dermatologist immediately prescribed a cortisone cream, saying that it was a constitutional type of eczema. The parents used the cream, which helped, but the symptoms came back as soon as they stopped. They did not want to continue with the cortisone cream. The itching was very bad, causing him to wake five to seven times a night, so everyone became sleep deprived and tired. He had stopped breast feeding 1 month before and was eating relatively widely without a worsening of the symptoms. He became a bit phlegmy with a regularly congested nose and occasional mild cough. He had Vaseline applied regularly to keep the skin more moist and was bathed daily. Examination: The parents had not been advised by the dermatologist to examine whether there was a dietary problem that might be contributing to the eczema. He was a healthy-looking, largish child. His abdomen looked full and rounded. The skin over the abdomen was rough and a bit dry. The right deeper pulses were weaker than the left deeper pulses. Diagnosis: Lung vacuity pattern confirmed by the symptoms, abdominal findings, and pulse. Treatment: Using a teishin, a light stroking above the skin was applied quickly down the large intestine channels on the arms, the stomach channels on the abdomen and legs, down the bladder channel on the back, and down the neck and shoulders. Light stroking was applied using a silver enshin down the backs of the legs. Using the teishin, supplementation was applied to right LU-9, SP-3, left LR-3, yin tang, and GV-12. A gold-plated press-sphere was placed on CV-12. The parents were counseled about testing the effect of cow’s milk on the eczema. They were advised to try stopping the milk and milk products to see if there was any change in symptoms. Second treatment—7 days later He continued to be itchy and sprouted two teeth during the week. The stuffiness of the nose was better. Treatment: Using a teishin, a light stroking was applied quickly down the large intestine channels on the arms, the stomach channels on the abdomen and legs, down the bladder channel on the back, and down the neck and shoulders. Using a silver enshin, light stroking was applied down the backs of the legs. Using the teishin, supplementation was applied to right LU-9, SP-3, draining to left LR-3 and GB-37. Gold-plated press-spheres were placed on CV-12 and GV-12. Third treatment—7 days later Over the week his condition had improved, but the day before treatment it was not so good. The itchiness was less and the sleep was better. The skin looked clearer. It was discussed that the avoidance of milk products seemed to be helping and that the parents should continue having him avoid milk products. Treatment: Using the teishin, a light stroking was applied quickly down the large intestine channels on the arms, the stomach channels on the abdomen and legs, down the bladder channel on the back, and down the neck and shoulders. Stroking with a silver enshin was applied down the backs of the legs. Using the teishin, supplementation was applied to right LU-9, SP-3, draining to left LR-3 and right ST-40. Gold-plated press-spheres were placed on CV-12 and GV-12. Fourth treatment—7 days later He had sprouted two more new teeth, which disturbed his sleep again and left him with more nasal congestion. The skin was still itchy, but improved and looked better. Treatment: Using a teishin, a light stroking was applied quickly down the large intestine channels on the arms, the stomach channels on the abdomen and legs, down the bladder channel on the back, and down the neck and shoulders. Stroking with a silver enshin was applied down the backs of the legs. Using the teishin, supplementation was applied to right LU-9, SP-3, and left LR-3. Gold-plated press-spheres were placed on CV-12 and GV-12. It was recommended for the parents to briefly apply light stroking with a rounded silver instrument down the large intestine channels on the arms, the stomach channels on the abdomen and legs, the bladder channels on the back and the backs of the legs, and on the forehead around the nose. They were instructed to do this daily. Fifth treatment—7 days later He had had the best week in months. The skin was much less itchy, with an improved appearance, and his sleep was much better. It was discussed that this would be the last treatment until further intervention was needed. The parents could continue on a cow’s milk-free diet and continue the daily treatments, which they had been able to do every day over the last week. The parents agreed to call up and reschedule if the symptoms started recurring. Treatment: Using a teishin, a light stroking was applied quickly down the large intestine channels on the arms, the stomach channels on the abdomen and legs, down the bladder channel on the back, and down the neck and shoulders. Stroking with a silver enshin was applied down the backs of the legs. Using the teishin, supplementation was applied to right LU-9, SP-3, left LR-3, and right ST-36. Gold-plated press-spheres were placed on CV-12 and GV-12. Skin problems usually take time to improve, and sometimes cannot be changed much with treatment. Most children show some degree of responsiveness, but it can be a complicated problem to treat. In general, the pattern-based treatment is very important as it will allow you to start changing the underlying constitutional tendency of the child. The non-pattern-based treatment is more limited for eczema and skin problems in general, and tends to be only applied around the affected regions, which means it is not usually a “root” treatment per se. It is also more difficult deciding what or if home treatment can be applied. Sometimes you are unable to have the parents apply any home treatment, due to the nature and extensiveness of the symptoms. Thus, we need to place more emphasis on the pattern-based root treatment. There are a few symptomatic treatments for eczema (such as direct moxa), but they can be difficult to do on small children. Because of these typical complications, I recommend not making predictions about how many treatments before the problem is better, rather to suggest trying a certain number of treatments to see if what you do helps, then to continue or not as needed and based on response. The lung vacuity pattern is by far the most common, especially if the eczema problems began as an infant. If the eczema is associated with lung symptoms—as the skin improves the lungs worsen, as the lungs improve the skin worsens—this is also a clear sign of lung vacuity pattern. But, extensive use of steroid creams can gradually shift the patient from a lung to kidney vacuity pattern. To identify this, check the feet. If they are cold or tend to become cold, this is a sign of the kidney involvement. While on small children the pulse may remain difficult to read, the additional sign of cold feet can be taken as an indication to try the kidney pattern. Sometimes the skin problems show in relation to food allergies. The food allergies themselves can be a sign of spleen and/or liver involvement. It can depend on the manifestation of associated symptoms. If there is a history of food allergy reactions since infancy, with skin problems showing up as part of that pattern, the child may need to be treated as a spleen vacuity pattern. But this is not always very clear. The spleen signs can be included within the lung vacuity pattern, and if you are unsure, because the pulse and abdominal reaction findings are unclear, it is better to approach the patient as a lung pattern until other symptoms and signs become clearer. If the skin problems show along with food allergies, remember to add moxa treatment of the extra point uranaitei as part of the symptomatic treatment. Generally with the pattern-based root treatment we use the treatment combinations outlined in Chapter 10; for lung pattern supplement LU-9 and SP-3 or SP-5, for kidney pattern supplement KI-7 and LU-8. But if the skin is very red and irritated and especially affects the upper parts of the body, such as around the neck and face, then it could be useful to try using the “he-sea” points instead. One of my teachers, Akihiro Takai, recommended the use of the he-sea points in such cases as they are indicated in Nan Jing (Classic of Difficulties) Chapter 68 as being good for counterflow qi, and one can see the heat in the upper parts and generally in the skin as a sign of counterflow. Sometimes such a simple shift of point selection can improve treatment outcome. Thus, for the lung pattern, use LU-5 and SP-9, for the kidney pattern KI-10 and LU-5. Overall, this can be difficult to apply on children with eczema. The general recommendation is to use tapping around the lesions and no stroking or rubbing methods. This is not usually thought to be a root treatment as it targets only the symptom areas themselves. If you are using this approach it is a very good idea to make sure to include treatment by the pattern-based approach. A method that can be used in order to perform a non-pattern-based root treatment comes from my teacher, Toshio Yanagishita. He described a modified way of applying the teishin, using it with a very light stroking method. Here, the teishin is held between the finger and thumb and just touching the skin very lightly. The teishin is then moved, almost in a gliding movement rather than stroking movement along the body surface relatively quickly. A simple pattern is to stroke down the large intestine channels on the arms, stomach channels on the abdomen and legs, and bladder channel on the back and legs (see Fig. 19.1a). I have found it often helpful as a light technique for applying the non-pattern-based root treatment when the usual methods of performing that treatment are not possible. Normally for eczema, rubbing cannot be used; however, this technique has such light contact to the skin that it does not cause the problems associated with rubbing. This is illustrated in the case histories in this chapter. The limitation of this method is that it is not so easy to teach to parents as home therapy. At least it offers you the possibility of using a shonishin-like root treatment approach. Sometimes the latter technique is also not sufficient when treating skin problems like eczema, or atopic dermatitis, in which cases I recommend the use of the tapping only method directed neither to the body surfaces, nor to the areas around the lesions, but instead to a number of specific acupoints that are good for skin problems. You can apply tapping to a selection of the following points: LI-4, LI-10, LI-11, LI-15, BL-40, SP-10, ST-36, CV-12, GV-12, GV-3 area. Some of these points are usually treated with moxa for skin problems and some are needled. Applying direct moxa regularly on older children can be possible and even applying moxa at home, but in general and especially on babies and small children, this is not really an option. Thus, we can apply tapping to a selection of the points (see Fig. 19.1b). Often, there are lesions on the backs of the knees so that we cannot treat BL-40, in which case use SP-10, ST-36 instead. Often there are lesions in the elbows, in which case you may not be able to include LI-11. GV-12 can affect the upper body manifestations, GV-3 the lower body manifestations. Fig. 19.1a, b (a) Gliding action with teishin: • Down the large intestine channel on the arms • Down stomach channel on the abdomen and legs • Down the bladder channel on back and legs (b) Tap around: • LI-4, LI-10, LI-11, LI-15 • GV-12, GV-3 (for affected lower limbs) • GV-20 • BL-40 or SP-10 + ST-36 • CV-12 • And if possible around affected areas It is generally recommended to use acupoints on the large intestine channel with moxa for eczema. Shiroda (1986), following Takeshi Sawada’s style of treatment (see Chapter 13 on moxa), recommends the following moxa treatment for allergic skin problems, eczema, sweat rash: moxa BL-12, GV-12, LI-15, LI-11, LI-10. My Toyohari instructors following this kind of idea recommend the following: palpate and select the most reactive points from among LI-4, LI-10, LI-11, and LI-15 and apply direct moxa to them. This can be done regularly in the clinical treatment and additionally as a form of home treatment, having the patient (if older) or parents to do the moxa regularly at home. However, this is not an easy treatment to do. If there are food allergies associated with the problem, moxa uranaitei on the foot. Needling can be applied to some of the main treatment points that are usually treated with moxa when it is very difficult to apply the moxa. Thus, needling, for example, LI-4 or LI-11 can be helpful. Choose the more reactive points for treatment. On some children the itching is very distressing and can disturb sleep, and so on such children it may be necessary to needle acupoints such as GV-20 (pal-pate for a reaction) and around GB-20 (palpate to see if the region is stiff). It can be helpful leaving some kind of treatment tool on acupoints, but it can also be very difficult. First, the skin overall can be very dry on some children, in which case the tape generally does not stick well. Second, parents are often using some kind of moisturizing or other cream or salve on the skin, in which case it can be difficult to get things to stick well or at all. Third, the skin of some children with eczema is overall more sensitive, they sometimes react to the tape, sometimes to the metal of the press-sphere or press-tack. If there are any signs of reaction, you usually have to stop using these treatment tools. In general, if you are able to leave something like the press-sphere or press-tack needle, have them left for less time and changed more often so as to reduce the risk of skin irritation. On children who show the lung vacuity pattern, acupoints like BL-13, BL-17, BL-20 can be palpated and treated. GV-12 is usually helpful to treat as well. For children who show more the kidney vacuity pattern, BL-23 can be treated. If the child has accompanying lung problems like croup or asthma, you will need to stimulate acupoints specifically for that problem and thus choose which acupoint combination is best for the child (for example, the asthma shu points with press-tack needles for the asthma and GV-12 with press-sphere). If the child has concurrent digestive problems, such as food allergies contributing to the eczema, it can be useful to treat acupoints like BL-20, CV-12. If the problem is one of concurrent constipation, it can be helpful to treat acupoints like BL-25 or ST-25, to try to get the bowels moving better.1 __________________ Cupping can be applied around the navel if there are any food allergies related to the eczema. Be careful to match the dose to the child and make sure it is not uncomfortable. Bloodletting can be helpful for some children. If you find vascular spiders on the upper torso, it can be worthwhile trying to bleed these. Use the stab and squeeze method rather than the cupping method, to ensure lower dose. Dietary issues need to be attended to. Eczema can be a reaction due to sensitivity or allergy to cow’s milk products, thus it can be important to test for this. If other allergies are found, it is not uncommon that the parent has figured this out themselves already, either by trying and testing different foods or asking their physician to test for different allergies. In some cases home treatment can be difficult due to the complexity and extent of the manifestations and various restrictions involved in treating patients with eczema. The basic techniques of stroking are prohibited or need to be significantly modified. It is difficult for parents to do this. Tapping can be applied, but then it is done more as part of the symptomatic treatment rather than root treatment. Often root treatment is only possible in the clinic. When having the parent apply some tapping treatment at home, it is usually over specific acupoints, the selection of which depends on the manifestations of the eczema. Tapping is not applied over a lesion, only on healthy skin regions. Thus, it can be applied around lesions on the backs of the knees or in the elbows. If patches occur, tapping can be applied around each. But when there are extensive lesions of eczema covering large parts of the body surface, such tapping is difficult to do. Instead and sometimes as well, apply tapping to a selection of the following acupoints: LI-4, LI-10, LI-11, LI-15, BL-40, SP-10, ST-36, GV-12, GV-3 area. If there are lesions on the backs of the knees, use SP-10, ST-36 instead. If there are lesions in the elbows, you may not be able to include LI-11. I have learned a simple folk remedy that sometimes is helpful for treatment of eczema. It uses raw eggs and brown rice vinegar. Place a clean raw egg in its shell in a bowl then put enough brown rice vinegar in the bowl to cover the egg. Leave the egg in the vinegar in the bowl for a number of days. Since the vinegar is acidic and the shell alkaline, the shell will slowly dissolve. After around 8 to 10 days, the shell will have dissolved so that one has a membranous egg in the vinegar. When the shell has dissolved, carefully spoon the whole egg out of the vinegar, being careful not to break the membrane and spill its contents. Place the membranous egg in another bowl, without any additional vinegar. Break the membrane and empty the contents into the bowl. Remove the membranous part. Mix the contents. There will have been a chemical exchange across the membrane of the egg so that the egg becomes slightly “pickled.” For treatment smear some of the egg—vinegar mix over the affected skin regions. Leave the mix on the regions for about 20 minutes, then with warm soapy water wash the mix off. Repeat up to three times daily. The mix can sting when it is first applied, then after a while the stinging stops and it reduces the itching of the area. On some patients this can be a very effective simple treatment to help the eczema lesions. Do not use this on children with egg allergy. Do not use this on skin lesions where the skin has been scratched open or has cracked open. You may find that the stinging is too much for some children and they become upset or increasingly resistant to continued use. This method is simple and inexpensive; parents can try it at home. A few observations and comments are necessary. The egg in vinegar should be kept in a cooler cupboard, it should be covered, and not allowed to become warm or hot. Make sure that the egg is clean first. I have tried other vinegars when the brown rice vinegar is unavailable; it seems not to work as well. It is best to store the egg—vinegar mix in a covered bowl in the refrigerator with instructions “not to be eaten.” It usually takes 8 to 10 days for the shell to dissolve, but can take more time. The vinegar does not need to be thrown away, it can be used several times, thus as soon as one egg is ready, the next can be placed in the vinegar so as to keep a steady supply of egg—vinegar mix going. This technique is much easier to use on adults than children, but it can be worthwhile trying it. The following cases illustrate further modifications in the treatment of children with eczema. Main complaints: Eczema—itchy skin especially on the medial thighs, upper arms, and around the eyes (since birth). Used Vaseline and occasionally hormone cream. History: Born 10 weeks premature he was hospitalized for several weeks after birth. He had recurrent problems with bronchitis and some episodes of pneumonia. He caught cold easily. His lungs were an ongoing issue for him, a weak spot. He tended to get a stuffy nose very easily. His father had a significant history of eczema. All other systems were normal. Diagnosis: Lung vacuity pattern (the symptoms, abdomen and pulse). Treatment: Tap with herabari LI-4, LI-10, LI-11, ST-36, BL-40, neck region, GV-20, GV-12, and on the back. Using a teishin, very light stroking was applied down the back and on the bladder channel on the legs, then supplementation was applied to left LU-5, SP-9, and right GB-37. A press-sphere was applied to GV-12. Second visit—1 week later He was tired after the treatment. He had had a cold with fever on the weekend with coughing, but had recovered quite quickly. The skin appeared to be a little better. Treatment: Tap with herabari LI-4, LI-10, LI-11, ST-36, BL-40, abdomen, neck region, GV-20, GV-12, and on the back. Using a teishin, very light stroking was applied down the back and on the bladder channel on the legs, then supplementation was applied to left LU-9, SP-3, draining to right LR-3 and TB-5. A press-sphere was left on GV-12. Third visit—6 days later Skin itchiness was better overall—but with visible skin signs still. He was more moody and irritable. Treatment: Tap with herabari LI-4, LI-11, LI-15, ST-36, BL-40, abdomen, neck, neck region, GV-20, GV-12, and on the back. Using a teishin, supplementation was applied to left LU-9, SP-3, right LR-3, draining to right ST-40. Press-spheres were left on right BL-18 and GV-12. Fourth visit—15 days later Some itchiness of the upper arms and legs but overall he was much better. Treatment: Tap with herabari LI-4, LI-10, LI-11, ST-36, BL-40, abdomen, neck area, GV-20, GV-12, and on the back. Using a teishin, supplementation was applied to left LU-8, KI-7, draining to right SP-9, then supplementation to right TB-4. Press-spheres were left on GV-3 and GV-12. The next visit was cancelled since Paul’s condition had significantly improved and he had no more itchiness or skin lesions. They also had to travel more than an hour each way to get to the clinic. His mother promised to call if the symptoms worsened.
Eczema
Julie, Girl Age 5 Years
General Approach for Patients with Eczema
Most Likely Pattern-based Root Diagnosis
Typical Non-pattern-based Root Treatment
Recommendations for Symptomatic Treatment
Okyu—Direct Moxa
Needling
Press-spheres (Ryu), Press-tack Needles (Empishin), and Intra-dermal Needles (Hinaishin)
Cupping
Bloodletting
Other Considerations
Dietary
Home Treatment
Egg—Vinegar Folk Remedy
Further Case Histories
