TROPICAL ACNE - AETIOLOGY, PATHOLOGY and TREATMENT

This case history was originally published in the book: " Acupuncture in Practice " (Case history insights from the west - compiled by Ted Kaptchuk and Hugh MacPherson, Churchill Livingstone 1997). by Shmuel Halevi Ph.D

Medical History

Miss E. was 23 years old on January 1993 when she first presented herself at my clinic in Nahariya, Israel.

At first glance it was almost impossible to detect any health disturbance, major or minor, from her appearance. She was a lean, good looking young woman, who expressed herself fluently although somewhat shyly. Her story, nevertheless, was rather depressing and revealed a long-term illness.

At the age of 14.5 years Miss E. had her first menstruation, which was not quite normal. Her menses colour was brown and contained many clots. There had been plenty of discharge, and it lasted 7 days. Inflamed eruption of acne appeared on her face along with her first period, and since then her ship of troubles set sail. Her dermatologist first suggested antibiotics, along with regular visits to an experienced cosmetician.

The antibiotics were changed several times in the course of several months, due to their failure to bring about any relief at all. Presumably because of the antibiotics, as she herself suspected, the eruptions wandered from her face down to her upper chest and back.

At the age of 17, for no apparent reason, the acne suddenly disappeared both from her face and trunk, and she was clear of it until she was 19 years old. At this time Miss E. started taking contraceptives, and discovered, a few months later, that her old problem had reappeared, in a much more serious fashion, but only upon her upper trunk.

Again she was given various kinds of antibiotics, she changed her contraceptives, managed her diet and changed her dermatologist....all to no avail. The problem only seemed to worsen.

When I examined her, after listening to her story, I was astonished by the extent of the phenomenon. Her entire chest and upper back were covered with deep red large papules and pustules, some of them clustered together to form areas of inflamed lesions.

Her tongue had a normal colour except for the tip and sides which were redder. The left rim was scalloped, and the tongue coating was white, thin and slippery.

Palpating the pulse revealed that her left cun (heart) position was slightly tense and somewhat hard, and so was the right guan (spleen) position, which was also thin. Kidney pulse was absent on both wrists. Overall, her pulse was at a normal rate (72 beats), and soft.

Moving on to her trunk I was not surprised to discover that all her five Zang Mu points were very tender, especially So Jen-17 (AKA Ren, or CV-17) Tanzhong. Also SP-9 Yinlingquan was extremely tender.

These findings naturally gave rise to a series of questions which uncovered the following information. During her early teens Miss E. became very fond of a certain milk product, which was very sweet and flavoured by various fruit extracts. She used to consume this product cold and in excess. Since her first menstruation, which was described above, she suffered from excessive vaginal discharges, which were white in colour, thick, and with an offensive odour. She is usually quite irritable, and inclined to inner tension. She is fond of drinking water, has occasional bouts of excessive hunger , and dislikes hot weather.

Her periods are short, her menses scant, and before each menstruation she experiences low back pain.

Diagnosis

In Chinese medicine it is usually common to define the pattern of disharmony in skin diseases, by the shape and appearance of the affected skin lesions. 1 Dark red and inflamed eruptions which resemble pustules and are chronic, are usually attributed to stasis of Qi and Blood. The dark red colour is a sign of heat in the blood, and the white exudate is due to pathogenic Damp. The body area on which the affected skin lesions occur is also of significance. Usually the upper parts of the body are generally considered to be mostly affected by wind pathogen, while the lower parts of the body, by dampness. Sometimes the lesions appear in the course of body segments, such as Tai Yang or Shao Yang, and this also may help in the understanding of the root of the imbalance.

In our case, as stated above, the shape and appearance of the lesions, suggested a pattern of Heat and Damp stagnation. The root of this imbalance lay, of course, in the uterus, as indicated by the time of the onset of the problem. The consumption during puberty of too much cold and milky products, may be a cause for accumulation of Damp-Cold in the lower Jiao. This may later give rise to disturbances in the normal functioning of the uterus, such as dysmenorrhea, vaginal discharge and the like. At the age of 14, as in our case, when menstruation begins, the Chong and Ren channels are energetically activated, and then Damp Cold may turn into Heat, which will travel upward along the routes of these two channels. Ren May will thus carry Damp and Heat to the face, while Chong Mai might disperse this pathogen over the chest and upper back. 2 In western medicine too, the pathogenesis of acne is understood mainly in terms of an imbalance of hormones. 3 Acne begins at puberty when the increase of androgens causes a corresponding increase in the size and activity of the pilosebaceous glands. The pilosebaceous follicle becomes blocked and leads to the formation of the comedo acnes. These are composed of sebum, keratin and bacteria. Retention of the sebaceous secretions, and dilation of the follicle, may lead to cyst formation. Rupture of the follicle, and release of the contents into the surrounding tissues, induces an inflammatory reaction which is seen as the reddening, swelling and oozing of the affected lesions.

In my experience, the administration of antibiotics in cases of inflamed skin lesions (acne, boils, abscessess, etc.), which are the result of an internal systemic process, usually produces an aggravation of the problem, and/or diversion or peripatation to other sites in the body. This was exactly the case with Miss E. The ample use of various antibiotics banished the disease from the Ren domain to the Chong Mai domain.

Two years later, because of her use of contraceptives , she had a decrease of her kidney Qi (evidenced by low back pain, scant menses and profuse vaginal discharge), and a consequent restagnation of Chong Mai. As a result the acne appeared again on her chest and back.

Aetiology & pathology diagram

Summary of Clinical Manifestations

Very serious acne upon the upper parts of the chest and back, deep red and inflamed pustules and comedones, filled with white pus. Thirst, dislike of warm weather, bouts of hunger. Short periods, scant menses, profuse white vaginal discharge, low back pain before menstruation. Tongue : red tip and sides; scalloped left side; white and slippery coating. Pulse : heart position tense and hard, spleen position tense and thin, kidney position unpalpable, overall quality - soft. Mu points : all major Mu points tender, especially Jen-17 Tanzhong. Eyelids : left eyelid very red.

Evidence for the Patterns of Disharmony

Kidney Qi Xu with dampness pouring down, is, as described above, the basic disharmony, as shown by the absence of the Chi pulse, plus a general soft pulse quality. The tongue has a white and slippery coating, and in addition symptoms such as low back pain, scant menses and vaginl discharge, all confirm this basic imbalance. Imbalance between Ren and Chong Mai is suggested due to: The onset of the disease right on first mensturation when these two vessels begin to flourish. 4

The second appearance of the disease after contraceptives (hormones) were taken. Hormone consumptiongreatly affect the Chong and Ren Mai that originate in the uterus.

The location of the disease, i.e. where Chong and Ren disperse. Imbalance between spleen and stomach, which is usually the result of excess Damp that weakens and clogs the spleen, thus creating Heat within its related organ, the stomach. Symptoms of thirst, bouts of hunger etc. mark this Heat, while the pulse on right Guan position affirms it. Also the tongue, which was scalloped only on the left side and reddish on both sides, suggests a weak spleen and the presence of Heat. A tendency of the heat to rise to the upper parts of the body is seen mostly on the left side (due to an overriding Yang Qi). A red inner left eyelid is one sign. Another, is a scalloped and red left edge of the tongue. Heat in the blood, is shown by the nature and appearance of the skin disease, as well as by the close relationship between the stomach organ, the Chong Mai, and the blood. Thus, Heat penetrating the Chong Mai from the uterus, will easily find its way both to the stomach and blood. Heat generated in the stomach due to Damp stagnation of its Zang - the spleen - may penetrate the blood and the Chong Mai.

Treatment Procedure

After understanding the various components of this diagnosis, I felt it was essential to treat the acute symptoms in first place, and put less emphasis on the precipitating factors. Usually in chronic cases, the opposite approach would be more appropriate. However in this case there had been too much occurring of an acute nature, despite its chronicity, that made me take this approach.

I therefore decided to choose points that cool the blood, cool the stomach, and resolve excess dampness. In addition, I instructed the patient to omit heating and damp producing foods from her diet (such as: dairy products, coffee, chocolate, spices, alcohol etc.) and to eat more cooling foods (such as: celery, fruit, greens and the like).

My prescription for the first set of treatments was composed of two groups of points which were used alternately:

Group A

P-7 DALING,

P-3 QUZE,

LI-11-QUCHI,

REN-17 TANZHONG

ST-30 QICHONG,

SP-10 XUEHAI,

ST-44 NEITING

Group B

SP-6 SANYINJIAO,

SP-9 YINLINGQUAN,

DU-14 DAZHUI

B-16 DUSHU,

B-17 GESHU,

B-40 WEIZHONG

Group A - This group was composed of points capable of cooling the blood, mainly via the stomach and pericardium systems.

P-7 DALING, P-3 QUZE and CV-17 TANZHONG are situated, and/or having effect on the pericardium. (REN-17 TANZHONG being the MU point of the pericardium). The pericardium is related both to the heart (being its protector) and to the liver (being its companion in the segment of JUEYIN). Both organs, the heart and the liver, are closely related to the blood.

REN-17 TANZHONG served also as a local point for the affeccted chest region. All points were reduced by quick withdrawing maneouvers, and slow insertions. P-3 QUZE was occassionaly bled with a thick filiform needle.

LI-11 QUCHI, ST-30 QICHONG, ST-44 NEITING, are all situated on the YANG MING hand and leg channel. This channel is related to the stomach, and all of these points are renowned for their cooling ability. LI-11 QUCHI is even a specialized point for skin diseases. ST-30 QICHONG is the hinge, or barrier point, of the Chong-Mai - where the deeper Qi of the channel ascends to the surface.. It is usually used to balance the stomach with this extraordinary vessel, and, due to its location has a harmonizing effect on the uterus.

SP-10 XUEHAI is also a specialized point for blood disorders, especially for cooling the blood. It makes an age-old and well-known combination with LI-11 QUCHI to treat skin diseases. These points, too, were reduced.

Group B- SP-6 SANYINJIAO and SP-9 YINLIGQUAN, make a very good 06? formula to regulate both spleen and kidney, water metabolism in general, and damp accumulation in the lower jiao in particular. Thus, this pair was selected in order to resolve the vaginal discharge, promote uterus function, and regain hormonal balance. These points were evenly manipulated.

DU-14 DAZHU along with B-16 DUSHU the SHU point of the Du channel, have a cooling and harmonizing effect on the Du channel. DU MAI, being the collecting channel of all the YANG QI of the body, was thus sedated, which assists in lowering the heat level in general.

B-17 GESHU - the SHU point of the blood and B-40 WEIZHONG, both have the ability to cool the blood and treat inflamed skin lesions.

This procedure was carried out for five weeks, three sessions per week. During this period there was quite a reduction both of the amount of the acne already existing, and of newly formed lesions. The chest area was quite dramatically cleaned up, while the back seemed to be more stubborn.

At this stage I decided to obtain a more radical blood cleansing effect with diet therapy. I asked Miss E. to quit eating solid food for a whole week, and prescribed to her different juices instead. She was to drink a glass of carrot juice mixed with a small quantity of celery juice twice a day, water as much as she pleased, and a glass of almond extract once a day. All acupuncture treatments for this period were suspended. Two days after she embarked on this fasting program, she had a sudden raise of body temperature with perspiration, and general malaise. Even though I considered this a good sign (a release of long captured internal heat), I instructed her to stop fasting, and start eating gradually. A week later she resumed her fasting, this time without any side effects, for one complete week. At the end of this week , and a total of seven weeks since she came to my clinic, we were happy to discover that her condition had improved by 80 percent.

Now we resumed our treatments at a rate of two sessions per week. It is worthwhile mentioning here, that by this time Miss E. had no more vaginal discharge, no irritability, and no bouts of sudden hunger. Also her last periods had changed for the better.

In the remaining three weeks of treatment, I usually used points from both groups, chosen at random, and administered two special techniques to resolve the few remaining , or newly formed, acne.

The first technique works wonders in treating large boils, abscesses (whether hot or cold), and evidently, also big or tight clusters of acne pustules and comedones. The abscess or pustule is surrounded by 4-6 needles (usually gauge 30, length 1.5 inch), inserted shallowly beneath the bottom of the abscess, in a horizontal angle, forming a "blossom" of needles, and pointing to the center. This is left in situ for approximately 30 minutes. Where cold boils, or chronic QI XU type boils or abscesses exist (which is not the case here), it is also recommended to administer moxa. This is done either by a moxa roll above the boil, or by warm needling of one or two of the needles in the needle-blossom.

The second technique, which was also applied in our case, consists of shallow tapping of the pustules (especially those with pus), with the seven-star (plum-blossom) needle. This is done until slight bleeding and pus exudes. Right afterwards , a cup is laid over the wound for 20 minutes until an amount of blood is sucked out. The wound should afterwards be cleaned and sterilized.

Both of these techniques gave prompt results, and within the next 2-3 days the treated wounds usueally diminished and disappeared.

After 10 weeks of treatment we achieved the result of a virtually complete cure, and during follow-up over a year there has been no significant recurrence or relapse.

References:

The Journal of Traditionl Chinese Medicine Vol 13, No. 1. P.69-71

The Journal of Chinese Medicine NO. 43 , P. 28-29.

The Merck Manual Edition - 14th edition p. 2048

Su Wen-Ch.1