Wind Of The Four Crooks – An Atopic Eczema Case Study

By Mazin Al-Khafaji

She was the last patient of the day, and although I can always muster an interest in a new case, it had been a grueling day and I was keen to finish and head 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 again. 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 her dry red scaly skin had also condemned her to a lonely existence. Instead of leaping into 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, lacking that indefinable glint, instead betraying years of desperate and anonymous suffering. This lack of a sparkle, which I have ever since associated with motivation, fulfillment, 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 to do all in my power to get her better. I don’t recall her exact words, but as she walked out 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.

The Tragic Outcome of Untreated Eczema

Mercifully, it is rare that I see such eyes, but when Anne walked in at the end of my day, there they were again. She was 31 years old and suffered from 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 pointed to recent exudation of serous fluid, indicating localised infection. Around her desperate, empty eyes, her skin was darkened, thick and swollen from the constant rubbing and scratching that continued even in her 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 her eyes, the so called Dennie-Morgan lines, so characteristic of more severe cases of atopic eczema. The few areas of her face that were not livid red with inflammation were unnaturally pale, so called white dermographism, again a strong feature of atopy. Both inner and outer aspects of her arms were also covered with red maculopapular 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 spread around her wrists and on the dorsum of her hands. Between most of her fingers a multitude of vesicles were apparent, surrounded by a halo of erythema and yellow crusts. Around her wrists and anti-cubital fossa, I was glad to see the skin was thickened, so that the skin markings were more pronounced into what is termed lichenification.

Detailed Dermatological Examination and Diagnosis

I say I was glad, because after almost two decades of seeing 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, anticubital fossa, and the neck. Most atopics are particularly prone to this. There are some, however, who, despite constant scratching, will continue to have smooth albeit 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 cannot 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, were 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?

Diagnosis and Initial Treatment Plan

The erythema is a clear indication of heat rampaging on the blood level; the fact that it was pronounced in colour and covered half her body simply signified 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 generate itching. Neither is it just an academic question; to decide that the itch is predominately created by wind will necessitate the use of wind scattering herbs, while on the other hand, if dampness predominates, then 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 primarily suffers with wind type itching, the dampness will be drawn inwards instead of venting 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 however by the presence of the erosion and yellow crusting that was so pronounced.  Yellow crusting indicates exudation of fluid from 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 well with the other signs I had observed, fire toxin often being present in more severe and intense cases.

While when treating dermatological disease the primary source of information is available to you by observing the patients skin, other symptoms and signs are of course also of great importance when weaving a picture of the pathology.

Anne told me that she had lived with eczema since she was three months old. This early onset is typical of at least 50% of cases and, counterintuitively, is a favourable sign. Unlike allergic asthma (a related condition), early onset is associated with a better chance of improvement. A late onset (eczema developed after age one) often correlates with a poorer prognosis. Although she did not have a history of asthma, she suffered from 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 exposure to dust or certain animals such as cats or horses.

Itching invariably disturbed her sleep. This is an indication of heat in the blood 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 from 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 from 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 formula seen to the right.

This is of course based on long dan xie gan tang with modifications. Sheng Di Huang (Rehmanniae Radix) is almost always the chief ingredient in treating eczema. It has an unparalleled ability to cool the blood without injuring it. I often use a larger dose (30-45g or even 60g), but in Anna’s case I did not, because of the presence of substantial dampness. Mu Dan Pi (Moutan Cortex) is second to none at plumbing the depths to reach and drain the hidden heat, so characteristic of atopic eczema. I use a larger dose (up to 30g) when the eczema is accompanied by allergic 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 rhinitis, the nature of the heat that leads to the eczema, responds particularly well by using a large dose of Mu Dan Pi (Moutan Cortex) when draining heat form the blood. Chi Shao (Paeoniae Radix rubra) will act synergistically with Sheng Di and Mu Dan Pi (Moutan Cortex), accentuating their action. Of equal importance in this recipe is Long Dan Cao (Radix Gentianae), bitter, cold and fiercely drying, and outstanding at clearing damp heat from the skin. Although unpleasantly bitter, it is an excellent herb to use in cases where dampness presents so obviously. Huang Qin (Scutellariae Radix) and Zhi Zi (Gardeniae Fructus) act as its helper, aiding its action.

Ma Chi Xian (Herba Portulacae) is a specific ingredient for removing dampness and resolving fire toxin from the skin. Its forte is the treatment of dampness when it manifests as frank exudate (dampness may not always lead to weeping skin). Zi Hua Di Ding (Violae Herba) is used in tandem to strengthen its fire toxin resolving properties. Bai Xian Pi (Cortex Dictamni Dasycarpi Radicis), Xi Xian Cao (Herba Siegesbeckiae Orientalis) and Hai Tong Pi (Erythrinae Cortex) are all excellent herbs to alleviate itching from dampness when it coexists with wind. Herbs such as Fang Feng (Saposhnikoviae Radix) and Jing Jie (Schizonepetae Herba), though very effective at ameliorating itching, may well worsen the condition in cases like Anne’s since they have a scattering effect. Fu Ling (Poria) and Ze Xie (Alismatis Rhizoma) 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 cleared without activating urination”.

Observing Initial Treatment Progress and Adjustments

I saw her a week later, and already there was clear improvement in her skin. All weeping from her skin had stopped, with the exception of the nipples. The erythema was reduced and she had 30-40% reduction in itching. I re-prescribed the above formula with the addition of 12g of Yin Chen Hao (Artemisiae Scopariae Herba), a specific for damp eczema of the nipples.

When I saw her two weeks later, there was further and substantial improvement. Because the itching was reduced, she was disturbed less at night, which meant she was less exhausted in the day. I re-prescribed the formula for a further two weeks with the addition of Bai Ji Li (Tribuli Fructus) 15 to further quell the itching. I judged that Bai Ji Li (Tribuli Fructus), though predominantly a wind scattering herb, would be of benefit since much of the dampness had already been removed. When I saw her two weeks later (5 weeks since the start of treatment), it was clear that she was doing very well indeed. I could sense that, though she didn’t want to give herself 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 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 in acute exacerbation of the underlying hot blood, had been driven off, and it was time to alter the recipe to reflect the changed circumstance. With that in mind, I prescribed the formula seen to the left.

Final Stages of Treatment and Consolidation

Once the dampness has been significantly reduced, it becomes important to increase the dose of Sheng Di Huang (Rehmanniae Radix), 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 (Herba Portulacae) and Zi Hua Di Ding (Violae Herba) are no longer required, though it is prudent to retain a fire toxin resolving element in the form of Lian Qiao (Forsythiae Fructus). 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 it produces), which of course sets up a vicious cycle where the skin is constantly stimulated to further inflammation. Lian Qiao (Forsythiae Fructus) is very well tolerated and excellent at dealing with low grade infections that may otherwise gain a foothold. Tong Cao (Tetrapanacis Medulla) is a worthy substitute for the now banned Mu Tong (Caulis Mutong) in draining dampness and heat via urination when hot blood dominates.

Aside from a minor setback following excessive celebration on her birthday, Anne continued to show rapid improvement. By week 12 of the treatment, 95% of her eczema had cleared with, for her, the unexpected bonus of substantial improvement 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 post-inflammatory pigmentation that follows the clearing eczema was hardly discernable.

In Chinese medicine, the classic approach to consolidating the treatment for eczema is to nourish the skin via the blood and yin tonics. Though this is important to ensure a stable state upon 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 hidden heat, which in practice means that tonics such as Dang Gui (Angelicae sinensis radix) and He Shou Wu (Polygoni multiflori radix) should be used with caution. As such, I prescribed the formula seen to the right as her final formula, initially to be taken daily, but with instructions to wean herself off of them as she grew confident that the skin would not relapse.

Reflecting on Atopic Eczema in Modern Context

Anne has remained well since this treatment three years ago. In winter, she needs to make sure to apply emollients regularly to guard against skin, but in essence she leads a normal life, free of the agony of severe eczema. Although atopic eczema (known as si wan feng, 四灣風, ‘wind of the four crooks’ in traditional Chinese medicine) has probably existed for many centuries, it must have been extremely uncommon in previous centuries, and in fact has only reached the epidemic proportions we see today in modern industrialized nations. It is therefore a great tribute to Chinese medicine, and to the insights made by so many, that by carefully using the concepts that have been formulated over centuries, a “modern” disease like atopic eczema can be so successfully controlled and managed.

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