The Treatment of Pompholyx Eczema by Chinese Herbal Medicine

Definition and nomenclature Pompholyx eczema is a very distinctive form of eczema, characterised initially by an eruption of very itchy vesicles on the sides of the fingers and palms of the hands and occasionally the soles of the feet and toes. The vesicles, which contain clear fluid, usually subside without rupturing, although in some cases they may become tense, burst and discharge. In either case, the vesicular stage, which usually lasts for one to two weeks is followed by a dry desquamating phase, by which time the itching is usually markedly reduced. This condition has been recognised and described in medical texts in China since at least the Ming dynasty. In the True Lineage of External Medicine, Chen Shi-gong uses the name River snail vesicle, giving a fair description of the disorder: "River snail vesicle mostly erupts on the hands and feet, suddenly it is as if the area was on fire; purple, white and yellow vesicles will appear next; this is wind damp attacking and pouring into the Spleen channel." Less than a century later, Gu Shi-deng the author of Collection of Treatments for Sores uses the alternative and more commonly used name of Ant nest to define it: "Ant nest …mostly erupts on the hands and feet, it's appearance is like the nest of an ant, just like the pricks of a needle, the itching is extreme and enters the Heart. On rupturing there is a watery exudation … it may also erupt on the back of the hands and wrists".

The name pompholyx is derived from the Greek word for the boss of a shield and by extension a bubble or blister, the characteristic lesion of this eczema. The alternative name dyshidrotic eczema refers to the common finding associated with this eczema of excessive sweating from the palms and occasionally the soles.

Lesions Vesicle is the characteristic lesion of pompholyx eczema. The smaller vesicles are commoner, although they may coalesce to form larger vesicles or bullae. Typically the deep-set vesicles develop rapidly, and are accompanied by intense itching. Due to the thickness of the epidermis of the palms and soles, the fluid inside often appears pearly white, and instead of rupturing and discharging, as it would more often do if it were found elsewhere on the body, it is usually reabsorbed without a break in the skin. Bullae may form as a result of several vesicles coalescing, and are more often seen on the feet. Occasionally they may grow to a size of several centimetres. In such cases pain and incapacity may be significant features. Crusting is formed only if the vesicles or bullae rupture and discharge. There will typically be a mixture of yellow or white crusting tinged with dry bloody scabs. Erosion occurs as a consequence of breakdown of a vesicle or bulla. The superficial layer of skin, the epidermis, is worn away exposing the lower layer of skin, the dermis. This is almost always associated with crusting. Desquamation, scales and fissures are seen at the end stages of a cycle of eruption. They may develop following re-absorption, or after break down, discharge and crusting of the vesicles and bullae. In some chronic cases, only the fissures are seen, with absence of any vesicles. Lichenification is most commonly seen in chronic cases, where typically the patient has suffered repeated attacks over many years, and vesicle formation is replaced by desquamation, fissuring and lichenification. Lichenification is often more readily observable when the eczema spreads to the dorsal aspect of the hands and fingers. Pustules are not infrequently seen when the area becomes infected.

Distribution Pompholyx eczema affects the hands and feet, either together or separately. By far the most common presentation, accounting for about 80% of cases is for the hands to be involved exclusively. The remaining 20% of cases will be equally divided amongst patients with involvement of either the feet alone, or the hands and feet together. Being an endogenous condition, the eruptions are almost always symmetrical. Although an asymmetrical presentation may occur, the possibility of a fungal infection or a contact sensitivity should always then be considered. The vesicles tend to erupt on the sides of the fingers and palms, and often on the dorsal aspect of the distal fingers, where the skin is anatomically similar to that of the palms (absence of hair follicles). In more severe attacks the eczema spreads to the dorsum of the hands. If the eruption is particularly virulent, the eczema may extend upwards to involve the arms, neck and even the face. In a minority of cases, a generalised eczema of the entire body may also occur. When the feet are involved, the same pattern will emerge as is seen on the fingers and palms, with an increased tendency for the vesicles to become confluent, and merge into bullae. As with the hands, in more persistent cases the eruption will affect the dorsal aspect of the feet, and may spread up the legs.

Natural history and clinical features Pompholyx eczema is most often seen in 20-40 year olds, and only rarely in the elderly or prepubescent. It occurs slightly more frequently in females, and accounts for up to 20% of eczema cases seen in the clinic. There are several factors that are regularly associated with initial eruptions, or subsequent relapses. Frequently the first attack is triggered by hot weather, appearing in late spring or summer; indeed a proportion of patients tend to get eruption only at these times, the eczema spontaneously subsiding once the weather turns cooler. Alternatively an initial attack, or exacerbation, may follow intense emotional upset, frustration, grief or unremitting stress. Commonly excessive hand washing in new mothers, or the use of detergents, or other chemicals without proper protection will be sufficient to irritate the hands and precipitate an attack. The symmetrical outbreak of vesicles may either start on the inner aspects of the fingers, on the palms themselves, or in both areas at once. In mild cases only the sides of the fingers may be affected. The patient usually reports a prickly, burning hot sensation before the appearance of the vesicles, followed rapidly by intense itching once the vesicles emerge. The palms and the area between the fingers typically glisten with sweat, drawing attention to the common finding of excessive sweating from affected areas. At the early stages, erythema is conspicuous by its absence, developing either only slightly as the condition develops, or more intensely only after it has progressed. Erythema is more likely to be present if, as can often happen, the vesicles spread up the sides of the fingers, to occupy the dorsal aspects of the fingers and hands. If the nail beds are affected repeatedly, a characteristic irregular transverse ridging, discoloration and pitting of the nails will also be evident.

Once the vesicles have reached their height, there are two possible outcomes. They may grow tense and rupture, in which case there is discharge of fluid, erosion and eventually the formation of yellow and white, often blood tinged crusts. This situation is more often associated with infection and the formation of pustules, in which case lymphangitis and lymphadenopathy may complicate the picture. Alternatively and more commonly the vesicles become dry, shrink and are reabsorbed without a break in the skin.

Whatever the outcome of the vesicular stage, which typically lasts 7-12 days, it is superseded by dry, scaling or fissured skin. The itching is characteristically replaced by soreness and pain. Once the "attack" has reached the end of its cycle, it is either replaced by another eruption, or the lesions will subside, and the skin return to normal. The cyclic nature of this condition is sometimes a striking feature, with regular eruptions occurring at an almost predictable rate; the vesicular phase being followed closely by the dry, desquamating phase in wave-like oscillations. In other cases the two phases intertwine, vesicles are superimposed on dry, scaly skin, so that there is no clear-cut pattern. In a minority, when reoccurring attacks have continued for years, the vesicular phase disappears for the most part, and is replaced by chronic dry, scaly, lichenified eczema, with a greater or lesser degree of erythema, and fissures of the palms and finger flexures. This form is also often accompanied by eczematous changes of the dorsal aspect of the hands or feet

A remarkable attribute of this disorder is the excessive sweating (hyperhidrosis) that often occurs on the palms, fingers, soles and toes of sufferers. Over the years many clinicians postulated that the vesicles form as a consequence of the sweat being trapped under the skin. This has now been shown not to be the case, although it is interesting to note in regard to the excessive sweating that the distribution of a typical eruption of pompholyx eczema significantly corresponds to the distribution of the emotionally activated sweat glands of the palms and soles. At least one study1 has shown that when patients were trained to control excessive sweating by biofeedback, there was improvement in their condition. This confirms the common finding in practice, of attacks being triggered by emotionally stressful situations.

Pompholyx eczema can lead to significant morbidity. Due to denudation of the fingers and palms, regular eruptions on the hands can make the simplest tasks such as cutting vegetables, peeling fruit or handling paper a major problem, whereas pronounced eruptions on the feet can lead to incapacity and even inability to walk.

Diagnosis Pompholyx eczema is a straightforward condition to diagnose, and tends not to be mimicked by other conditions. However care should be taken not to confuse it with the following common conditions: Fungal infection. Fungal infection is much more common on the feet than on the hands. In the early stages it is almost always asymmetrical in its distribution (affecting mostly the spaces between the 3rd and 4th and the 4th and 5th toes, with a circumscribed area of vesiculation and scaling. A scraping of skin examined under the microscope will easily confirm the presence of mycelium. Although very uncommon, it is worth mentioning here the so-called "Id reaction". Fungal infection elsewhere on the body, most commonly on the feet, may provoke an eruption of pompholyx on the hands. Confirmation of this link depends on disappearance of the eczema when the fungal infection is eradicated. In such instances successful treatment will only require resolution of the fungal infection. Contact dermatitis. Contact dermatitis (allergic or irritant) may also present with asymmetrical lesions, although it tends to affect the dorsae of the hands and feet and the sides of the fingers or toes where the epidermis is thinner and therefore more susceptible to irritants or allergens than the thicker epidermis of the palms and soles. Pustular psoriasis. Yellow pustules on an erythematous background is the common presentation of this stubborn disease. The pustules typically resolve within 5-8 days, leaving characteristic brown patches and desquamation. Although clear vesicles may initially appear, they tend to rapidly become cloudy with purulent fluid. Itching can also occur with pustular psoriasis, but in contrast to pompholyx eczema this is not so common nor as severe, with soreness and pain being a much more frequent complaint. Occasionally with infected pompholyx eczema, pustules may emerge that superficially mimic the pustules of this type of psoriasis, however a correct diagnosis should be possible if a clear history is taken and it is noted that the pustules do not resolve into brown patches.

Differentiation and treatment Generally speaking pompholyx eczema is not a difficult disorder to differentiate and treat successfully. However it is a dynamic condition that undergoes striking and dramatic changes as it progresses. In order to achieve the best results it is vital to assess the relative proportion of each of the primary lesions, and reflect this in the construction of the formula. Pompholyx eczema is fundamentally a shi pattern characterised by dampness and heat with a propensity to generate fire-toxin. Thus even in the dry desquamating phase, it is wise not to totally abandon the damp-heat clearing and fire-toxin resolving medicines that form the core of treatment. This may seem contradictory, but bear in mind the common clinical finding that extreme damp in the superficial layers of the body frequently leads to dryness due to obstruction at the skin level that prevents correct nourishment. A vesicle, the primary lesion, is a clear indicator for the presence of dampness. The more numerous the vesicles, the more intense is the dampness, and the more likely it is that heat and fire-toxin is present. This is even more relevant if bullae are formed as a consequence of coalescing of vesicles. At this stage it is crucial to use strong medicines to drain damp-heat, and resolve fire-toxin. As the condition progresses, and the vesicles are increasingly replaced by dryness and fissuring, the proportion of bitter damp-heat draining ingredients such as Long Dan Cao (Radix Gentianae Scabrae) and Huang Qin (Radix Scutellariae Baicalensis) can be reduced or removed entirely. In the same way the ingredients that deal with fire-toxin should also be adjusted, so that the "heavier" fire-toxin resolving ingredients should also be reduced, and the balanced tipped in favour of the "lighter" fire-toxin resolving and transforming herbs. So what does lighter and heavier fire-toxin resolving mean? It is useful to think of the fire-toxin medicines as being arranged on a spectrum. At one end sit the heavier and deeper acting ingredients such as Pu Gong Ying (Herba Taraxaci Mongolici cum Radice) and Zi Hua Di Ding (Herba Violae cum Radice) which are most appropriate for intense fire-toxin with a fulminant nature. At the other end reside the lighter acting ingredients such as Jin Yin Hua (Flos Lonicerae Japonicae) and Lian Qiao (Fructus Forsythiae Suspensae) (often also used for expelling wind-heat from the surface of the body, reflecting their lighter nature) which are more appropriate for resolving relatively superficial fire-toxin in the skin. In practice when resolving fire-toxin in pompholyx eczema, the differentiation into lighter and heavier resolving medicines is less critical than in some dermatological diseases (where inappropriate use of such ingredients can be associated with a clear worsening of the condition). Nonetheless if the ingredients are matched closely with the condition, a more rapid and complete cure is more readily achieved. The fire-toxin in pompholyx eczema lends itself well to being removed from the body by clearing at all depths, thus ensuring a complete eradication, and a speedy reinstatement of stability. So ingredients for both resolving the fire-toxin internally, and transforming and scattering it externally should be used. However as treatment progresses and the eruptions become less vesicular, and erosion, crusting and desquamation dominate the picture, it becomes increasingly appropriate to emphasis the more superficial acting fire-toxin resolving herbs. Wind-scattering ingredients also become more relevant as the condition becomes drier and less vesicular. Bai Ji Li (Fructus Tribuli Terrestris) is a particularly valuable ingredient for treating pompholyx eczema. It can and should be used at all stage of eruption, although a larger dose (up to 30g per day) is indicated when the vesicles are replaced by dry desquamation. Bai Xian Pi (Cortex Dictamni Dasycarpi Radicis) is its natural partner, enhancing its wind-scattering and anti-pruritic qualities. Erythema is an almost universal finding with the majority of acute eczemas. As mentioned above though, pompholyx eczema is exceptional for the fact that erythema is often absent, particularly in the initial stages, and this lack of erythema is a useful indicator in differentiating this disorder from others that affect the palms or soles. This is not to say that erythema may not appear as the condition to the feet, and exhibit typical manifestations of pompholyx progresses, indeed in a proportion of cases it may be a eczema. dominant feature, but in many cases it is insignificant and Tongue and pulse: In many cases a red tongue body with therefore blood cooling herbs tend to play a small part in the yellow greasy coating, and a wiry pulse is seen. However construction of the formula. There are however two com it should be noted that in practice a tongue and pulse mon presentations that are encountered in practice where picture that betrays no association with dampness and heat erythema is more likely to be observed; the first is where it of the Liver is not infrequently encountered. appears as a background to the vesicles on the palms, soles and sides of the digits; the second is when the eczema is Vesicles emerging disseminating and moves to the dorsum of the fingers and Long Dan Cao (Radix Gentianae Scabrae) 9g hands. In both instances, it is imperative to incorporate Huang Qin (Radix Scutellariae Baicalensis) 9g ingredients that remove heat from the blood. In practice this Zhi Zi (Fructus Gardeniae Jasminoidis) 9g is done not only by using ingredients such as Sheng Di Pu Gong Ying (Herba Taraxaci Mongolici cum Radice) 15g Huang (Radix Rehmanniae Glutinosae), Mu Dan Pi (Cortex Zi Hua Di Ding (Herba Violae cum Radice) 15g Moutan Radicis) and Chi Shao (Radix Paeoniae Rubrae), Lian Qiao (Fructus Forsythiae Suspensae) 12g but most importantly by also using lighter fire-toxin resolv- Bai Xian Pi (Cortex Dictamni Dasycarpi Radicis) 12g ing herbs such as Jin Yin Hua (Flos Lonicerae Japonicae), Bai Ji Li (Fructus Tribuli Terrestris) 15g Lian Qiao (Fructus Forsythiae Suspensae) and Da Qing Ye Ze Xie (Rhizoma Alismatis Plantago-aquaticae) 9g (Folium Daqingye). Chi Fu Ling (Sclerotium Poriae Cocos Rubrae) 12g A common and understandable mistake that is frequently Che Qian Zi (Semen Plantaginis) 9g made by those unaccustomed to treating dermatological Gan Cao (Radix Glycyrrhizae Uralensis) 4g disease, is the desire to use blood and yin nourishing ingredients for the dry phase of this disease. This should be Modifications resisted. As mentioned above, the dryness is the product of

• Erythema: add Da Qing Ye (Folium Daqingye) 12g, Mu obstruction by dampness and fire-toxin, and using tonic

Dan Pi (Cortex Moutan Radicis) 9g. medicines will compound the problem by as it were 'add ¥ Yellow pustules: add Ye Ju Hua (Flos Chrysanthemi ing oil to the fire'. The only exception to this rule is in

Indici) 12g, increase the dose of Zi Hua Di Ding and Pu chronic and refractory cases, where a long history of Gong Ying and use external soak (see below). reoccurring attacks has led to a situation of unrelenting

• Much exudation: add Ma Chi Xian (Herba Portulacae dryness and fissuring. In such instances a strategy of nour-

Oleraceae) 12-15g and Fu Ling Pi (Cortex Poriae Cocos) 12g. ishing yin and blood, and possibly supplementing the ¥ If the condition is particularly virulent, with many vesi-Kidney and Liver is frequently the only pathway to a cure.

cles, or bullae, add Huang Lian (Rhizoma Coptidis) 9g, Jin Yin Hua (Flos Lonicerae Japonicae) 12g, Hu Zhang (Radix
1. Liver damp-heat complicated with fire-toxin and wind et Rhizoma Polygoni Cuspidati) 12g and Long Kui (Sola-This is by far the most common form, accounting for 70% or num Nigrum) 9g. so of cases encountered in practice. Many cases, though not • Intense itching: add Fang Feng (Radix Ledebouriellae all, will report emotional upset as an initial trigger. Sesloidis) 9g and Ku Shen (Radix Sophorae Flavescentis) 9g Eruptions are more likely to affect the palms as opposed and use external soak (see below).

Vesicles Bullae Crusting, weeping & Erythema Dryness and fissures erosion Damp, damp-heat & fire- As for vesicles but more Damp-heat not yet Hot blood/fire-toxin
1.Damp-heat still toxin

extreme resolved lingering
2. Deficiency of blood & yin The more intense and As for vesicles, although Drain dampness and heat Erythema as a Use lighter fire-toxin and concentrated, the more fire-toxin resolving herbs from the Liver or Spleen background to the wind scattering herbs. the dampness will be are usually needed in depending on condition. vesicles, or as a Draining damp accompanied by heat, larger numbers. consequence of spread to medicines should be and fire-toxin. the dorsum. reduced, but not stopped. Erythema surrounding a Use lighter fire-toxin In chronic cases vesicle is an indication of resolving and blood nourishing medicines heat in the blood with cooling ingredients. should be employed. fire-toxin. Use fire-toxin resolving herbs from all depths. • Constipation: choose from one or more of Yu Li Ren (Semen Pruni) 12-20g, Da Qing Ye (Folium Daqingye) 15g, Da Huang (Rhizoma Rhei) 9g (add at end). Dry phase following vesicular phase Sheng Di Huang (Radix Rehmanniae Glutinosae) 15g Bai Ji Li (Fructus Tribuli Terrestris) 20g Fang Feng (Radix Ledebouriellae Sesloidis) 9g Jin Yin Hua (Flos Lonicerae Japonicae) 12g Lian Qiao (Fructus Forsythiae Suspensae) 12g Zhi Zi (Fructus Gardeniae Jasminoidis) 9g Huang Qin (Radix Scutellariae Baicalensis) 9g Fu Ling (Sclerotium Poriae Cocos) 12g Gan Cao (Radix Glycyrrhizae Uralensis) 4g Modifications ¥ Much fissuring: increase the dose of Sheng Di Huang and Bai Ji Li, and add Xuan Shen (Radix Scrophulariae Ningpoensis) 15g, Huo Ma Ren (Semen Cannabis Sativae) 12g and Zhi Ke (Fructus Citri seu Ponciri) 9g. ¥ Itching: add Chan Tui (Periostracum Cicadae) 9g and Bai Xian Pi (Cortex Dictamni Dasycarpi Radicis) 12g. ¥ Much soreness: use a suitable external emollient. Soaks should not be used at this stage. ¥ Once the condition resolves, regulate the Liver.

2. Spleen channel damp-heat, with fire-toxin This pattern is mostly seen in pompholyx of the feet, or in cases where digestive symptoms dominate the picture. Typically the patient is prone to reoccurring bouts of foul-smelling diarrhoea, abdominal pain and bloating, and disrupted appetite. Pulse: slippery (hua) or soggy (ru) pulse. Tongue: greasy yellow coating, pale or red tongue body with teethmarks. Vesicles emerging Huang Bai (Cortex Phellodendri) 9g Bei Xie (Rhizoma Dioscoreae 12g Zhi Zi (Fructus Gardeniae Jasminoidis) 9g Huang Lian (Rhizoma Coptidis) 6g Chi Fu Ling (Sclerotium Poriae Cocos Rubrae) 12g Che Qian Zi (Semen Plantaginis) 12g Bai Xian Pi (Cortex Dictamni Dasycarpi Radicis) 12g Di Fu Zi (Fructus Kochiae Scopariae) 12g Bai Jiang Cao (Herba cum Radice Patriniae) 12g Zi Hua Di Ding (Herba Violae cum Radice) 12g Lian Qiao (Fructus Forsythiae Suspensae) 12g Huo Xiang (Herba Agastaches seu Pogostemi) 12g Hua Shi (Talcum) 12g Gan Cao (Radix Glycyrrhizae Uralensis) 6g Modifications • Diarrhoea with foul smell: add Chuan Xin Lian (Herba Andrographitis Paniculatae) 9g and increase Bai Jiang Cao to 15g or add Ge Gen (Radix Puerariae) 30g. ¥ Poor appetite with much bloating and abdominal discomfort: Sha Ren (Fructus seu Semen Amomi) 9g (crush and add at end), Chen Pi (Pericarpium Citri Reticulatae) 12g and Pei Lan (Herba Eupatorii Fortunei) 9g. ¥ Many blisters with exudation: Ma Chi Xian (Herba Portulacae Oleraceae) 12-15g, and use external soak. ¥ Erythema: Mu Dan Pi (Cortex Moutan Radicis) 9g, Chi Shao (Radix Paeoniae Rubrae) 9g and Jin Yin Hua (Flos Lonicerae Japonicae) 12g. ¥ Yellow pustules: add Ye Ju Hua (Flos Chrysanthemi Indici) 12g and Pu Gong Ying (Herba Taraxaci Mongolici cum Radice) 12g and use external soak. ¥ Involvement of the feet only: increase the dose of Che Qian Zi, Hua Shi and Huang Bai and add Chuan Niu Xi (Radix Cyathulae) 12g.

Dry phase following vesicular phase Sheng Di Huang (Radix Rehmanniae Glutinosae) 15g Fang Feng (Radix Ledebouriellae Sesloidis) 9g Niu Bang Zi (Fructus Arctii Lappae) 12g Bai Ji Li (Fructus Tribuli Terrestris) 15g Zhi Zi (Fructus Gardeniae Jasminoidis) 9g Huang Qin (Radix Scutellariae Baicalensis) 9g Lian Qiao (Fructus Forsythiae Suspensae) 12g Shan Yao (Radix Dioscoreae Oppositae) 15g Fu Ling (Sclerotium Poriae Cocos) 12g Cang Zhu (Rhizoma Atractylodis) 9g Huo Xiang (Herba Agastaches seu Pogostemi) 9g Gan Cao (Radix Glycyrrhizae Uralensis) 4g Modifications ¥ Poor response, with clear signs of qi deficiency: reduce fire-toxin resolving medicines, and use Bai Hua She She Cao (Herba Oldenlandiae Diffusae) 30g, Shan Yao (Radix Dioscoreae Oppositae) 15g and Huang Qi (Radix Astragali) 20g as the basis of the formula. ¥ Once the condition resolves, support the Spleen.

3. Qi and blood deficiency with fire-toxin and hot blood This pattern is seen in chronic cases with few or no vesicles and milder itching. The picture is dominated by fissures and dry and sore skin. Erythema is often present. This prescription may need to be alternated with more actively removing fire-toxin as in previous prescriptions, for example in cases of mixed patterns where vesicles become more pronounced in an otherwise dry pattern. Sheng Di Huang (Radix Rehmanniae Glutinosae) 15g Mu Dan Pi (Cortex Moutan Radicis) 9g Bai Ji Li (Fructus Tribuli Terrestris) 20 g Chan Tui (Periostracum Cicadae) 9 g Jin Yin Hua (Flos Lonicerae Japonicae) 12 g Ye Ju Hua (Flos Chrysanthemi Indici) 12 g Dang Gui (Radix Angelicae Sinensis) 9 g Bai Shao (Radix Paeoniae Lactiflorae) 15 g He Shou Wu (Radix Polygoni Multiflori) 12 g Huang Qi (Radix Astragali) 15g Bai Zhu (Rhizoma Atractylodis Macrocephalae) 12 g Gan Cao (Radix Glycyrrhizae Uralensis) 4g Modifications ¥ Much erythema: add Da Qing Ye (Folium Daqingye) 12g. ¥ Loose stools: remove Bai Zhu and He Shou Wu, and add Chao Bai Zhu (stir-fried Rhizoma Atractylodis Macrocephalae) 12g and Ge Gen (Radix Puerariae) 20g. ¥ Dry stools: add Sheng Bai Zhu (Rhizoma Atractylodis Macrocephalae) 30g, Huo Ma Ren (Semen Cannabis Sativae) 20g and Rou Cong Rong (Herba Cistanches) 12g. ¥ Much fatigue: add Dang Shen (Radix Codonopsis Pilosulae) 9g and increase the dose of Huang Qi to 30g. ¥ Much bloating: add Chen Pi (Pericarpium Citri Reticulatae), Sha Ren (Fructus seu Semen Amomi) and Mu Xiang (Radix Saussureae seu Vladimirae).

External treatment (soak) Use 2 litres of water per bag of herbs, cooking for 20-30 minutes. As the liquid cools the patient should initially steam then soak the affected part. This should be done 1015 minutes twice a day during the acute attack. Each bag can be used for two soaks.
1. Standard treatment Wang Bu Liu Xing (Semen Vaccariae Segetalis) 30g Ming Fan (Alum) 10g Ku Shen (Radix Sophorae Flavescentis) 15g • If blisters are particularly plentiful, add Peng Sha (Borax) 10g and Mang Xiao (Mirabilitum) 10g.
2. If dryness coexists with blisters Wang Bu Liu Xing (Semen Vaccariae Segetalis) 30g Tuo Gu Cao (Speranskia Tuberculata) 15g Ming Fan (Alum) 6g
3. In the dry phase, apply a suitable emollient ointment twice daily. Notes Pompholyx eczema is a satisfying disorder to treat, not only because it has simple and plain characteristics that are quite easily discernible, but also because, with attention to detail in prescribing, long term prognosis is excellent for an otherwise recalcitrant disease. All patients with pompholyx eczema should be given clear advice for the care of their hands and if necessary their feet. This involves the following points:

1. Wash hands as infrequently as possible. Ideally soap should be avoided and hands simply washed in lukewarm water. If soap is used, it should be used sparingly and soaps with perfume, tar or sulphur avoided. Hands should be dried carefully with a clean towel.

2. Shampooing, dyeing hair, applying hair lotion etc. should be done with plastic gloves or by someone else.

3. Avoid direct contact with household cleaners and

detergents. Wear cotton or plastic gloves when doing housework.

4. Avoid exposing hands to known irritants (e.g. handling fresh fruits, vegetables, fresh meat, wool etc.). Wear warm gloves in cold weather.

5. Use plastic rather than rubber gloves (rubber can further aggravate hand dermatitis). It is best to wear white cotton gloves under the plastic gloves. Several pairs of cotton gloves should be purchased so they can be changed frequently. Do not wear plastic gloves for more than 20 minutes at a time.

6.Remember to follow the above instructions for 4-6 months after the hands have healed.
7. For pompholyx of the feet, attention to regular changes of cotton socks should be observed. Although internal medicines constitute the primary method of treatment, the use of external soaks is a very useful adjunctive therapy during acute attacks. Itching, and vesiculation can be reduced significantly after even one soak, however several days will be needed for an acute attack to subside totally. If there is marked dryness accompanying the vesicular stage, then soaks should be used sparingly or not at all, especially if the patient finds that the drying effect of the soak is too strong. In the majority of cases, 10-14 weeks of treatment are required to resolve the condition completely. To ensure compliance of the patient to treatment, I find it very useful to explain at the outset the commonest mode of resolution. This most often involves a continuation of the characteristic ebbing and flowing of the condition for several weeks as treatment progresses, although the severity and frequency of eruptions is often markedly reduced within 4-6 weeks of treatment. Eventually no eruptions are observed. Once satisfied that the condition has stabilised, it is wise for the patient to continue taking the medicine on half dose for a period of 2 or 3 weeks, before weaning off completely. Looking after the hands (as explained above) for several months after clearing is important and will ensure a good long term prognosis. Most rapid results are achieved in the following types:

1. Recent onset (up to 6 months).

2. Eruptions only in spring and summer.

3. Predictable oscillation of eruptions, with distinct vesicular and desquamating phases.

Slowest results are seen in the following types, although perseverance with treatment almost always yields good long term results:

1. Chronic disease (over 2 years).

2. Indistinct and overlapping vesicular and dry phases.

3. Widespread eruptions reaching the dorsum of the hands, and inner aspect of the arms and face.

4. A history of eruptions with much vesiculation, that have since been replaced by chronic dry, scaly, lichenified and fissured eczema.

Treatment by biomedicine is usually of only palliative value. The mainstay of treatment is the use of the most potent topical steroid with occlusion (covered with poly thene). It is necessary to use potent steroids because weaker ones don't penetrate the thick epidermis of the palms and soles sufficiently. The steroids that many patients end up relying upon for long periods have a very observable detrimental effect on the skin, thinning it and predisposing to further attacks. With infection, antibiotics are prescribed. In recalcitrant cases, internal steroids may be used, usually for short courses, and occasionally as a maintenance dose. Other treatment may include UV light and immunosuppressive therapy such as cyclosporin. Case Examples: Case 1. Women, age 33 Initially developed pompholyx eczema 18 months prior to her first visit, following emotional upheaval when she split up from her partner of several years. The eruptions were intense from the outset, both hands being affected. After several months of near constant activity, the eczema spread to the dorsum of the hands. She describes the eczema as a burning hot sensation, with intolerable itching. At it's peak (several times a month) she was unable to sleep because of the constant itching. Soon after the onset she visited her GP, who prescribed Dermovate (the most potent of topical steroids). Twice daily applications initially helped, but after several months, she found that not only the skin of her palms became very delicate, tearing and fissuring at the slightest trauma, but increasingly the steroids became less effective. This was further complicated by reoccurring infection, manifesting as pustules with yellow exudation. The infections were controlled by regular courses of antibiotics. Eventually, in desperation she discontinued all treatment. Tongue: Thin yellow slippery coating Pulse : Thready and wiry On examining it was clear that the eczema was fiercely active. There was, numerous small vesicles, yellow crusting indicating recent exudation, on a background of intense erythema. The dorsum of her hands were also affected. This is a typical case of stagnant heat generated by a constrained liver leading to liver and gall bladder damp heat and fire toxin.
1. Pu Gong Ying 20 Zi Hua Di Ding 15 Ye Ju Hua 12 Ma Chi Xian 12 Huang Qin 9 Huang Lian 6 Bai Xian Pi 12 Bai Ji Li 15 Long Dan Cao 9 Yin Chen Hao 9 Ze Xie 9 Che Qian Zi 12 Mu Dan Pi 9 Da Qing Ye 12 Mu Tong 9 Gan Cao 6 External Wang Bu Liu Xing 30 Ming Fan 10 Huang Bo 15 Ku Shen 15 The above constituted the basis of her treatment for the first 7 week. Soon after starting she found that the intensity of the itch, and the development of pustules were significantly reduced. The external soak was very soothing, and significantly reduced the itching and heat sensation of the palms. It also had the effect of drying any developing vesicles and pustules. After 3 weeks of twice daily use, external treatment was no longer required.
2. Jin Yin Hua 12 Lian Qiao 12 Da Qing Ye 12 Ye Ju Hua 12 Sheng Di Huang 15 Mu Dan Pi 9 Zhi Zi 9 Huang Qin 9 Bai Ji Li 15 Fu Ling 12 Ze Xie 9 Gan Cao 6 On week 7, the prescription was changed significantly to take into account the changed circumstance. She no longer suffered with any pustuler eruptions, and the vesicles were markedly reduced, not only in quantity, but in frequency of appearance. The eczema was significantly drier, with a propensity for fissuring. It is worth studying the above two formulas with care, since they are characteristic of the formulas that are often employed for managing pompholyx eczema in its various stages. The emphasis of the first formula was on strongly resolving fire-toxin, draining damp heat, subduing itch and to a lesser degree cooling blood. Pu gong ying, Zi Hua Di Ding, Ye Ju Hua, and Ma Chi Xian all strongly resolve fire toxin on the deep level, that is clearly required for such intensely active eczema. Ma Chi Xian is particularly suitable for weeping eczema. Huang Qin, Huang Lian, Long Dan Cao, Yin Chen Hao strongly drain damp heat from the Liver and the skin. The fire toxin resolving and damp heat draining medicines are always primary in treating the initial active phase of pompholyx eczema. Bai Ji Li and Bai Xian Pi subdue itching, drain damp heat, resolve fire toxin and scatter wind. Ze Xie, Che Qian Zi, and Mu Tong aid removal of damp and heat via the urine. Mu Dan Pi and Da Qing Ye cool the blood and resolve fire toxin in the superficial layers. This was necessary in this case because of the marked erythema of the palms, and the fact that the eczema had spread to the dorsum of the hands. Despite this it should be noted that at this stage, a relatively small number of ingredients are used for cooling blood, pride of place given to the fire toxin resolving and damp heat clearing ingredients. It is imperative to use strong treatment to gain control over the continues eruptions. Once that is achieved, the emphasis of the treatment needs to change. Lighter fire toxin resolving medicine are much more appropriate for the reduced vesicular formation and the lack of pustules and crusting. Therefore Pu Gong Ying and Zi Hua Di Ding are replaced with Jin Yin Hua and Lian Qian. Long Dan Cao, Huang Lian, Yin Chen Hao have all served their purpose, and are therefore removed. Huang Qin is retained, and Zhi Zi is added to continue to drain damp and heat all be it more moderately. Zhi Zi has a further action (along with Mu Dan Pi) of releasing stagnant heat generated by constrained of liver, a primary factor in the initial development of the condition. Cooling blood is often not a significant factor in treating pompholyx eczema, In this case however not only is the erythema very pronounced, but the eczema has spread to the dorsum, both clear indications for the need to cool blood. Mu dan pi is retained, as not only is it effective at plumbing the depths and cooling pertinacious and intractable heat on the blood level, but it is also very well tolerated over the long term. It is complemented and enhanced in this action by adding Sheng Di Huang which also initiates the repair to the desiccated blood that is an inevitable consequence of the intense heat that has raged unchecked over the previous year and a half. The second formula was taken for a total of 6 weeks, with only slight modification. Once all eruptions have been stemmed, the final 4 weeks of treatment (two weeks full dose, two weeks half dose) are devoted to regulating the liver, by moving qi, nourishing blood and dealing with stagnant heat.
3. Chai Hu 9 Bai Shao 15 Dang Gui 9 Fu Shou Gan 12 Jin Yin Hua 12 Bai Ji Li 15 Zhi Zi 9 Mu Dan Pi 9 Gan Cao 6

Case 2. Woman, age 35 She has suffered from excessive sweating from the palms since late teens. Six years prior to her visit to the Skin clinic, during a hot summer she developed her first bout of pompholyx eczema. Initially it was fairly mild, and cleared of it's own accord by the start of autumn, but as the years went by, she developed more intense eruptions of eczema earlier in the season, that tended to last longer into autumn before finally clearing. Four years after the first attack, the eczema settled in, so that she had continual eruptions irrespective of the season. At this stage she visited her GP, who prescribed Betonvate. When that proved ineffective she was prescribed Dermovate, which subdued the eczema somewhat, although benefits were short lived and increasingly less effective. At the same time as the eczema became more severe, and perennial, she became increasingly prone to bouts of foul smelling diarrhoea, punctuated by loose bowels and bloated sensation of the abdomen on eating. She also complained of loose of appetite. Tongue: Thin yellow slippery (hua) coating. Pulse : Slippery (hua) The diagnosis was of accumulation of damp heat in the spleen, and as consequence, an aggregation and gathering of fire toxin in the skin.
1. Bai Jiang Cao 12 Ma Chi Xian 12 Zi Hua Di Ding 15 Ye Ju Hua 12 Huang Qin 9 Huang Lian 6 Bai Xian Pi 12 Bai Ji Li 15 Bi Xie 12 Chi Fu ling 12 Sheng Yi Ren 15 Che Qian Zi 12 Mu Tong 9 Gan Cao 9 External: Wang Bu Liu Xing 30 Ming Fan 10 Huang Bo 15 Ku Shen 15 After 3 weeks of the above formula, the intensity of eruptions subsided, although she continued to suffer with foul smelling diarrhoea and loose stools. Chuan Xin Lian 9g was added. The external soak was also discontinued by week 4. By week 5, her bowels regulated, both in frequency and consistency of stools. Chuan xin lian was replaced with Ge gen 30g , with the rest of the formula in essence remaining unchanged until week 9. By week 9 the skin of her palms was dry but otherwise free of active eruptions of eczema. The majority of the time she opened her bowels once a day, with normal well formed stools. Her appetite showed some improvement. The formal was changed to the following:
2. Cang Zhu 12 Bai Zhu 12 Sheng Yi Ren 15 Bi Xie 9 Fu Ling 12 Huang Lian 6 Ge Gen 20 Dang Shen 9 Chen Pi 9 Gan Cao 6 Although the eczema is confined to the hands, the lack of association with an emotional trigger, and the development of digestive problems strongly implies that a treatment based on draining damp heat from the spleen is indicated. The initial formula reflects this. A few points could be made here. Bai Jiang Cao along with Ma Chi Xian form the primary ingredients. Not only are they able to drain damp heat from the skin and bowels, they strongly resolve fire toxin from the skin. Pu Gong Ying is not included, due to its strong action of moving the bowels. Instead Zi Hua Di Ding and YeJu Hua are used to potentiate the action of the leading ingredients. Taken together they drain damp heat and act as heavy or deep fire toxin resolving medicine. Huan qin and huang lian drain damp and heat from the middle jiao. This action is aided by Bi Xie that separates the pure from impure. This action of Bi Xie combines well with Yi Yi Ren, and the two are particularly useful in situations where the spleen is obstructed by dampness, leading to overflowing of damp and heat onto the skin. Chi Fu Ling, Che Qian Zi and Mu Tong complete the formula, by emphasising yet another conduit where by removal of dampness is achieved. Chuan Xin Lian is an extremely bitter medicine and best avoided unless the circumstances demand it. Its action of draining damp heat from the intestines is very powerful, and can be used for the widest range of such patterns. This action coupled with it's substantial effect on resolving fire toxin from the skin makes it ideal if progress is slow, or as in this case diarrhoea persists despite treatment. Once the majority of the damp heat was drained, and the bowel function improved, Chuan Xin Lian is replaced by a large dose of Ge Gen. Ge Gen is ideal in situations where the picture of a necessarily weakened Spleen is complicated by damp and heat. Ge Gen is equally adept at treating diarrhoea from both these origins. By week 9 the damp heat and fire toxin were removed to the extent that they no longer manifested on the skin. In order to achieve a good long term prognosis, it is wise to continue treatment using less bitter medicines that remove heat, emphasising rather draining dampness and bolstering the spleens function. To this end the formula was changed, removing the majority of the harsh bitter medicines.

Case 3. Woman age 29 Two years prior to her initial consultation, following severe and persistent emotional stress, she developed pompholyx eczema on the palms of her hands. Although she had almost continual eruptions, the vesicles were always reabsorbed without discharging. 3 months ago, associated with renewed emotional strain, the eczema flared and spread up the arms. The itching was most intense at night. This disrupted her sleep, compounding the problem. Otherwise her general health was okay. Pulse Wiry, Thready Tongue , Greasy yellow coating, red sides and tip.
1. Jin Yin Hua 15 Lian Qiao 12 Ye Ju Hua 12 Da Qing Ye 12 Huang Qin 9 Bai Xian Pi 12 Bai Ji Li 15 Mu Dan Pi 9 Chi Shao 9 Long Dan Cao 6 Zhi Zi 9 Che Qian Zi 12 Mu Tong 9 Gan Cao 9 Although clearly generated by damp and heat in the Liver and Gall Bladder, this is a much drier pattern than case number one. A close examination of the skin revealed, dry vesicles that were always reabsorbed. Erythema of both the palms and the anterior aspect of the arms was intense. Taken together this is clear indication for the need to emphasis the lighter fire toxin resolving medicine, along with medicines for cooling the blood. Although damp heat draining medicine is still used, it is of lesser significance. For the same reasons, external soaks were not prescribed. Jin Yin Hua and Lian Qiao together are said to transform as well as resolve fire toxin. This is more appropriate for fire toxin that as it were sits on the surface of the skin. To use heavy fire toxin resolving medicine will encourage drawing the fire toxin downwards to be assimilated and dealt with more deeply in the body. By contrast transforming fire toxin, allows it be vented more superficially and less complicatedly from the surface of the skin. The above formula formed the core of prescriptions used for the initial 9 weeks of treatment. By week 3 the majority of the eczema of the arms has declared. By week 9 the palms were clear, with only minor dryness and desquamation. To consolidate the improvement, the following formula was used for a further 4 weeks (2 weeks full dose, 2 weeks half dose). As can be seen it is centred around regulating the liver, and clearing stagnant heat. Lighter fire toxin medicines still feature.
2. Chai Hu 9 Bai Shao 15 Chi Shao 9 Mu Ddan Pi 9 Jin Yin Hua 12 Bai Ji Li 15 Huang Qin 9 Zhi Zi 9 Da Qing Ye 9 Gan Cao 6 Case 4. Woman age 34 She has suffered with pompholyx eczema of the palm since age 18. Initially attacks were confined to summer time, and associated with heat and sweating of the palms. In autumn and winter the eczema tended to clear. After 5 years or so of this pattern, she developed almost constant vesicular eruptions, intertwined with dry desqumating eczema, irrespective of the season. This continued for many years until the past 2 years, when it was replaced with a much dryer eczema confined to the medical aspects of the hands, little fingers, base of the ring finer and medical aspect of the dorsum of the hands. Close examination revealed lichenification and fissuring. Very little evidence of vesicular formation was recorded.

Her general health was okay, although she complained of sluggish bowels, and on occasions of fatigue. It is clear from the history and the morphology of the lesions, that the most suitable approach to treatment would be to nourish and supplement qi and tonify and cool the blood, scatter wind and regulate the bowels. Lighter fire toxin medicines are also used. Sheng Di 15 Mu Dan Pi 9 Bai Ji Li 20 Jin Yin Hua 12 Ye Ju Hua 12 Bai Hua She She Cao 15 Huo Ma Ren 20 Bai Zhu 20 Huang Qi 20 Dang Gui 9 Bai Shao 15 He Shou Wu 12 Gan cao 6 Sheng Di Huang has the dual action of nourishing dryness and cooling blood. Mu Dan Pi is able to penetrate deeply and seek out hidden heat from the blood. A large dose of Bai Ji Li is a very important ingredient on all cases of pompholyx eczema, but becomes essential for this subtype. Even in clearly deficient cases, it is wise to include lighter fire toxin clearing medicine. To this end Jin Yin Hua, Ye Ju Hua and Bai Hu She She Cao are used. Although Bai Hua She She Cao is bitter and cold in nature, it is also considered sweet and therefore well tolerated over the long term. It is suitable for cases of fire toxin co-exciting with deficiency. Huo ma ren along with a large dose of Bai Zhu is used to encourage better function of the bowels. Bai Zhu is generally thought of in cases of weakness of spleen with loose bowels or diarrhoea. A large dose however, is very effective for deficiency of spleen accompanied by constipation. Together with He Shou Wu, and Dang Gui, they also have the effect of moistening the skin, and supplementing dryness. Huang Qi, Dang Gui, Bai Shao and He Shou Wu, will nourish qi and blood systemically. The above formula with only minor variation was taken for a total of 16 weeks. The hands were clear of any eczema by week 10, but the treatment was continued for a further six weeks (the last 2 on half dose) to consolidate and anchor the improvement.
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Author Mazin Al-Khafaji
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