Atopic Eczema: Wind Of The Four Crooks

She was the last patient of the day, and although I can always muster an interest in a new case, it had been a gruelling day and I was keen to finish and head off home. No question about it, it was her eyes that made me wake up and pay attention. I felt a shudder run down my spine. I had seen them, or something very similar many years ago. They had haunted me ever since, and although the passage of time had faded the impact, it all came flooding back this evening. Sixteen years ago a young woman in her early twenties had walked into my practice with severe and widespread eczema. The eczema was so intense that the unfortunate woman could not sleep at night nor rest in the day. Not only had the years of incessant itching worn her down and convinced her of her hopeless plight, but the stigma of having dry scaly red skin condemned her to a lonely existence. Instead of leaping into the delights of adult life, her teenage years had been a nightmare as she became increasingly isolated and unable to socialise with her contemporaries. She had struggled for almost her entire life and her grip was slipping. I could see that her eyes, when she mustered the courage to look at me, were empty and lacked that indefinable glint, betraying years of desperate and anonymous suffering. This lack of a sparkle, which I have ever since associates with motivation, fulfilment, and the will to live was utterly absent. Having taken a full case history and written the prescription, I ushered her to the door, my heart heavy, determined I would do all in my power to get her better. I don’t recall her exact words, but as she walked out of the door she mumbled something about nothing being worth it. A week later her inconsolable mother called to tell me that she had taken her own life. Mercifully it is rare that I see such eyes, but when Anna walked in at the end of my day, there they were again. She was 31 years old with widespread atopic eczema. Almost her entire face and neck were covered with a dry scaly erythema, punctuated by eroded, excoriated lesions where she had dug her nails deep into her skin in an attempt to quell the unrelenting itch. Around her ears I could clearly see yellow crusts that betrayed recent exudation of serous fluid, clearly indicating localised infection. Around her desperate empty eyes there was darkening of the skin that was thickened and swollen from the constant rub- bing and scratching that continued even in her fitful sleep. The oedema around her eyes was accentuated further by two deep lines that ran from just below the inner canthi around the lower border of the eyes; both these features so characteristic of the more severe cases of this form of eczema. The few areas of her face that were not livid red with inflammation, were unnaturally pale, once again a clear sign of atopy. Embarrassed and ashamed of her skin, she was initially reluctant to remove her clothes to show me the rest of her eczema. Both inner and outer aspects of her arms were also covered with red macular papuler lesions, with the telltale excoriated scratch marks. Scattered across the outer aspect of her forearms I noted pustular lesions, and as with the area around her ears, discreet yellow crusted lesions could be seen scattered around her wrists and on the dorsum of her hands. Between most of her fingers a multitude of vesicles could be seen, surrounded by a halo of erythema and yellow crusts. Around the inner aspects of here wrists and anti-cubital fossa, I was glad to see the skin was elephant like, thickened so that the skin markings were more pronounced into what is termed lichenification. I say I was glad, because after almost two decades of see- ing 20-30 atopic eczema patients a week, I have learned to fear the lack of lichenification in severe eczema more than any other single sign as an indicator of a poor prognosis. Lichenification occurs most commonly around the inner aspects of wrists and ankles, behind the knees, anti-cubital fossa and the neck. Most atopics are particularly prone to this. There are some however, who despite constant scratch- ing will continue to have smooth, all be it red skin. It is such patients, who account for probably no more than 5-10% of cases that are the most recalcitrant to treatment. Why this should be I can not say, but that it is so is indisputable. The skin on her back and upper chest was similarly covered with inflamed red patches, erosion and occasional yellow crusting. Her nipples, a common site of eczema in women who are atopic, was also encrusted with yellow exudation that had dried hard, all but obliterating the area below. As anyone who regularly treats dermatological disease knows, the skin is like an open book, the vast majority of information is there to be deciphered by those who can read the language. By closely observing the morphology, a formula will almost write itself. So what information had been gleaned so far? The erythema is a clear indication of heat rampaging on the blood level; the fact that it was intense in colour and covered half her body simply signi- fied the intensity. The excoriation left by her scratching is clearly indicative of the itch that she experienced. Intense heat as we know generates wind, and one important sign of the presence of wind in dermatology is excoriated scratch marks. However it is not only wind that leads to itching, and when reflecting on the source of the itch in atopic eczema, dampness and heat need to be considered as well. Damp, by obstructing the circulation of qi and blood in the skin can and frequently does also generate itching. Neither is it simply an academic question, it has crucial clinical sig- nificance; to decide that the itch is predominately created by wind will necessitate the use of wind scattering herbs, on the other hand if dampness predominates, than damp draining herbs will need to be used. In many instances to use wind scattering herbs when dampness prevails will not only have little impact on the itching, but by virtue of its dispersing nature will frequently compound the eczema and encourage it to spread. Likewise if damp draining herbs were used in a patient who predominantly suffers with wind type itching, the dampness will be drawn inwards instead of venting it via the skin, and similarly may well exacerbate the eczema. There was clear evidence of both in Anna’s case. Lesions principally congregated on the face and upper body is a useful indicator of prevalence of wind. This observation has to be tempered by the presence of the erosion and yellow crusting that was found not only on her hands and wrists, but also on her nipples and around her ears. Yellow crusting indicates exudation of fluid form the skin that has subsequently dried, whilst erosion is a sign of retained dampness and heat. The profusion of vesicles also firmly points towards the existence of substantial amount of dampness and fire-toxin. The pustules found on her arms are an indication of either excessive application of unduly greasy emollients, or if that were not the case, then a sign of fire toxin. Anna used a light emollient, so I had to conclude that it was not an artefact, but a sign of fire toxin. This fitted in well with the other signs I had observed, fire toxin often being present in more severe and intense cases. Although when treating dermatological disease the pri- mary source of information is available to you by observing carefully the patients skin, other symptoms and signs are of great importance when weaving a clear picture of the pathology. Anna told me that she had suffered with eczema since she was 3 months old. This early onset is typical of at least 50% of cases, and counter intuitively is a favourable sign. Unlike allergic asthma (a related condition), early onset is associated with a better chance of improvement. A late onset (developing the eczema after age one) is often correlated with a poorer prognosis. Although she did not have a his- tory of asthma, she suffered with severe perennial allergic rhinitis, a common accompanying problem. This meant that she had almost continual nasal congestion and discharge, paroxysmal attacks of sneezing and a concomitant poor sense of smell and taste; all made much worse with expo- sure to dust or when in the presence of certain animals such as horses and cats. Her sleep was invariably disturbed by itching. This is a indication of heat at the blood level and is almost a universal finding in the moderate and more severe cases. Other than that she had a normal appetite and bowel function, and although her skin often became worse pre- menstrually, she had a normal menstrual cycle. She suffered no abnormal thirst, and aside form the burning sensation of her skin, she did not feel particularly hot. Her tongue was predictably dry and red, with red prickles on the tip, extending towards the sides. The coating was thin and white. Her pulse was wiry and slightly rapid. It is clear that she suffered with an underlying condition of heat in the blood with wind, complicated with dampness and fire toxin. In such instances a successful strategy can be found by first peeling, as it were the outer layer, before attempting to tackle the core problem. What I intended to do first was to drain the damp heat and clear the fire. I used the following formula Sheng di huang 24 Mu dan pi 24 Chi shao 9 Long dan cao 9 Huang qin 9 Zhi zi 9 Ma chi xian 15 Zi hua di ding 15 Bai xian pi 12 Xi xian cao 15 Hai tong pi 12 Fu ling 12 Ze xie 12 Gan cao 6 This is of course based on Long dan xie gan tang with modifica- tion. Sheng di always forms the spear head of the formula. It has an unparalleled ability to cool the blood without injuring it. I often use a larger dose (30-45g), although in Anna’s case I did not, because of the presence of substantial dampness. Mu dan pi is second to none at reaching and draining the hidden heat so characteristic of atopic eczema. I use a larger dose (up to 30g) when the eczema is accompanied by rhintis, having as it does a specific action in treating it. Although my focus is on treating the eczema, I have found that in patients who have allergic rhinitis, the nature of the heat that leads to the eczema, responds particularly well by using a large dose of Mu dan pi when draining the heat form the blood. Chi shao will act synergistically with Sheng di and Mu dan pi, accentuating their action. Equally important in this recipe is Long dan cao, fiercely drying, it is outstanding at clearing damp heat from the skin. Although unpleasantly bitter, it is an excellent herb to use in cases where damp- ness presents so obviously. Huang qin and zhi zi act as its helper, aiding its action. Ma chi xian is a specific ingredient for removing damp- ness and resolving fire toxin from the skin. It’s forte is the treatment of dampness when it manifests as frank weeping (dampness may not always lead to weeping skin). Zi hua di ding is used in tandem to strength its fire toxin resolving properties. Bai xian pi, Xi xian cao and Hai tong pi are all excellent herbs to alleviate itching from dampness when it coexists with wind. Herbs such as Fang feng and Jing jie, though very effective at ameliorating itching, may well worsen the condition in cases like Anna’s. Fu ling and Ze xie are of course utilised to conduct the heat and dampness out via urination. Though not considered amongst the primary ingredients in the formula, they are none the less essential in facilitating the removal of damp heat from the body. This is highlighted by the adage ”damp can not be drained without activating urination”. I saw her a week later, and already there was improvement in her skin. All weeping from her skin had stopped, with the exception of the nipples. The erythema was reduced and she had a 30% -40% reduction in itching. I re-prescribed the above formula with the addition of 12g of Yin chen hao, a specific for damp eczema of the nipples. When I saw her 2 weeks later, there was further and substantial improvement. Because the itching was reduced, she was distributed less at night, which meant she was less exhausted in the day. I re-prescribed the formula for a further 2 weeks with the addition of Bai ji li 15 to further quell the itching. I judged that Bai ji li, though predominantly a wind scattering herb, will be of benefit, since much of dampness had already been removed. When I saw her 2 weeks later (5 weeks since the start of treatment), it was clear that she was doing very well. I could sense that though she didn’t want to give her self false hopes, she was cautiously elated. Her guarded optimism was reflected in a more natural and sparkling gleam in her eyes. She could now muster a smile and a even a laugh. Her skin was a good 75% better, and each day brought further improvement. From my point of view the dampness and fire toxin, such clear factors of acute exacerbation of the underlying hot blood had been driven off, and it was time to alter the recipe to reflect the changed circumstance. I prescribed the following: Sheng di huang 30 Mu dan pi 24 Chi shao 9 Fang feng 9 Bai xian pi 12 Bai ji li 15 Xi xian cao 12 Lian qiao 12 Tong cao 4 Gan cao 4 Once the dampness has been significantly reduced, it becomes important to increase the dose of Sheng di, the primary ingredient from 24 to 30g. The only side effect of such a large dose is mild and transient loose bowels (which in fact is an indications that the correct dose has been reached, and should be elicited in hot blood type eczema as a matter of course). Ma chi xian and Zi hua di ding are no longer required, however it is prudent to retain a fire toxin resolv- ing element in the guise of Lian qiao. Many atopics who are prone to bacterial infection, develop an allergic reaction to the toxin from the commonest bacteria that affects the skin, staphylococcus aureus (aureus comes from the Latin for gold, named for the characteristic golden exudation that it produces) which of course sets up a viscous cycle where the skin is constantly stimulated to further inflammation. Lian qiao is very well tolerated, and excellent at dealing with any such infections that may otherwise gain a foot hold. Tong cao is a worthy substitute for Mu tong in draining dampness and heat via urination, when hot blood dominates. Aside form a minor set back following excessive celebra- tion on her birthday, Anna continued to show rapid improve- ment. By week 12 of the treatment 95% of her eczema had cleared, with, for her, the unexpected bonus of clearing of her allergic rhinitis. Now only minor erythema around her wrists and neck remained. The texture of her skin was all but normal, and even the hyperpigmentation following the resolution of the eczema was hardly discernable. In Chinese medicine, the classic approach to consolidating the treatment for eczema is by nourishing the skin by the use of blood and yin tonics. Though this is important to ensure a stable state when coming off the herbs, a word of caution when treating atopic eczema. To use the standard tonics will more often than not lead to fanning of the flames and exacerbation of the eczema. A large portion of the heat in atopics is known as hidden heat, which in practice means that tonics such as Dang gui and He shou wu are all but contraindicated. As such I prescribed the following as her final formula, initially to be taken daily, but with instruc- tions to wean herself off them, as she grew confident that the skin will not relapse. Sheng di huang 30 Mu dan pi 9 Dan shen 15 Xuan shen 15 Ji xue teng 15 Fang feng 9 Bai xian pi 12 Dan zhu ye 9 Tong cao 4 Gan cao 4 Anna has remained well since this treatment three years ago. In winter she needs to make sure to apply emollients to guard against dryness of skin, but in essence she leads a normal life, free of the agony of severe eczema. Although atopic eczema (known as “wind of the four crooks” (sì wän fëng in traditional Chinese medicine) has probably existed for many centuries, it must have been extremely rare, and has only reached the epidemic proportions we see today in modern industrialised nations. It is therefore a great tribute to Chinese medicine’s inherent flexibility, as well as the insights that have been made by so many, that by carefully utilising the concepts that have been formulated and honed over centuries, that a “modern” disease such as atopic eczema, can be so successfully controlled and managed in this way.

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