OBSERVATION OF THE SKIN

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Chapter 21

imageOBSERVATION OF THE SKIN

INTRODUCTION

Observation of the skin is an important aspect of observational diagnosis. It includes observing the skin colour, skin texture, skin pores and the body hair as well as, of course, any abnormal manifestations on the skin such as various skin diseases, moles, warts or naevi.

Skin layers

Ancient Chinese medicine had its own conception of the skin as made up of different layers and muscles. This conception was similar to that of modern Western medicine. The various layers and muscles in the structure of the skin are:

Fu indicates the superficial layer of skin (i.e. the epidermis), which is influenced mostly by the Lungs. Ge indicates the deep layer of skin (i.e. the dermis), which is influenced by the Lungs, Liver and Kidneys. Ji, a word that is sometimes translated as “flesh”, indicates the subcutaneous muscles and this structure is influenced by the Spleen and Liver. Fen Rou indicates two structures, i.e. fat (influenced by the Spleen, Kidneys and Directing Vessel) and muscles near the bones (influenced by the Spleen and Liver). Cou Li (therefore, the space between skin and muscles) is influenced by the Lungs and Spleen.1 Xuan Fu are the pores (including the sebaceous glands) through which the sweat comes out and they are influenced by the Lungs and Spleen.

Box 21.1 summarizes the organs influencing each layer of the skin.

BOX 21.1   ORGANS INFLUENCING LAYERS OF THE SKIN

THE SKIN AND THE INTERNAL ORGANS

The skin and the Lungs

As a whole, the skin is influenced by the Lungs. Chapter 10 of the “Simple Questions” says: “The Lungs are connected to the skin and control the state of the body hair”.2 The Lungs also control the opening and closing of the pores and this function is related to the Lung’s diffusing of Defensive Qi to the skin. The pores were called “sweat holes” (Han Kong) and their function is to discharge turbid Qi and sweat. The Defensive Qi and, therefore, the Lung’s opening and closing of the pores, is a manifestation of the protective function of the Defensive Qi against the invasion of pathogenic factors. When the Defensive Qi is properly regulated, the pores are closed on exposure to a pathogenic factor and properly open during exercise or on exposure to hot weather. A weakness of Lung-Qi and of the Defensive Qi may lead to “flaccidity” of the pores and result in their being too open: this facilitates the invasion of pathogenic factors. In pathology, a weakness of Lung-Qi, and therefore of the Defensive Qi in the space between the skin and muscles, causes acute skin diseases due to invasion of external Wind such as urticaria.

The skin and the Stomach and Spleen

The Stomach and Spleen produce Qi and Blood and the turbid part of Qi forms the Defensive Qi while the clear part forms Nutritive Qi. The Defensive Qi, through the diffusing of Lung-Qi, reaches the skin, warming it and regulating the opening and closing of the pores. On the other hand, the Stomach fluids also reach the skin through the diffusing of Lung-Qi, moistening it. The Stomach is also one of the origins of Body Fluids, part of which go to the Lungs and part of which go to the Kidneys. Kidney-Yang warms the Body Fluids deriving from the Stomach; the turbid part is excreted as urine and the pure part goes to the skin via the Triple Burner and the Bladder channel in the back.

The Spleen also controls the muscles immediately below the skin as well as the adipose tissue located there. In pathology, a deficiency of the Spleen may affect these structures and cause diseases such as scleroderma. Of course, Dampness resulting from a deficiency of the Spleen is the cause of many common skin diseases such as eczema, herpes, acne, etc. A failure of Spleen-Qi in holding blood in the vessels may cause bleeding under the skin and therefore red maculae.

The skin and the Kidneys

The Kidneys also influence the skin in other ways. First of all, although the Lungs diffuse Defensive Qi, and the Stomach and Spleen contribute to Defensive Qi’s production, the Defensive Qi stems from the Lower Burner and from the Kidneys. Defensive Qi is Yang in nature and it is therefore influenced by Kidney-Yang and the Fire of the Gate of Life. The Kidneys also play an important role in the distribution of Defensive Qi to all other channels and parts of the body with the aid of the Triple Burner and the Bladder channel. The Back Transporting points where the Defensive Qi infuses to the Internal Organs are situated in the back along the Bladder channel. This is because the Defensive Qi emerges from the Kidneys, through the Triple Burner, and flows up along the Bladder channel. Moreover, when the Defensive Qi emerges in the morning after flowing in the Yin organs at night, it starts from the Kidney channel (Chapter 76 of the “Spiritual Axis”)3 (Fig. 21.2).

Therefore, when the Kidneys are deficient, the Defensive Qi may also be deficient. This deficiency in the skin gives rise to skin diseases. In particular, a deficiency of the Kidneys, with its consequent failure to irrigate the skin with Defensive Qi, is often at the root of complex, modern skin diseases such as lupus erythematosus or scleroderma.

Apart from a Kidney deficiency and impairment of the Defensive Qi circulation in the skin, these diseases are often associated with Yin Fire, that is, a pathological rise of the Minister Fire upwards stemming from a deficiency of the Original Qi (Yuan Qi). In such diseases, there are superficial manifestations on the skin but the root cause is a Kidney deficiency and a deficiency of the Original Qi; this also explains the often contradictory signs of a red rash on the skin of the face and a Pale tongue.

The Triple Burner also influences the skin and, in particular, the skin’s moisture, because it plays such an important role in the metabolism of fluids. One important aspect of the Triple Burner, in fact, is the diffusion of fluids in the Upper Burner, the separation and transformation of fluids in the Middle Burner and the excretion of fluids in the Lower Burner. As heat is needed to transform and excrete fluids, the Triple Burner relies on that derived from the Fire of the Gate of Life in between the Kidneys. From this point of view, the Triple Burner’s function of transporting and excreting fluids is inseparable from its location between the Kidneys where the Fire of the Gate of Life resides. For this reason, the Triple Burner is closely related to the Original Qi.

Chapter 66 of the “Classic of Difficulties” states:

The Motive Force (Dong Qi) that resides between the Kidneys below the umbilicus is the source of life (ming) and the root of the twelve channels and that is why it is called Original [Qi]. The Triple Burner is the emissary of the Original Qi.4 It penetrates through the three Burners and spreads to the five Yin and the six Yang organs. Original Qi is the honorary name for the Triple Burner and that is why the places where [the Qi of the Triple Burner] stops in turn are called Origin [Source] points. Therefore diseases of the five Yin and the six Yang organs can be reflected on the Origin [Source] points.5

As the Original Qi, which resides between the Kidneys, is the basis for the Triple Burner and transforms fluids that affect the skin, this is another way in which the Kidneys influence the skin (Fig. 21.3).

Chapter 47 of the “Spiritual Axis” illustrates the connection between the skin and the Kidneys and Triple Burner: “The Kidneys are connected with the Triple Burner and the Bladder which influence the pores and body hair”.6 Another passage from Chapter 64 of the “Simple Questions” also illustrates the relationship between the Kidneys and the skin: “When there is a pathogenic factor in the Kidneys, the skin is affected and there is a rash.”7

Therefore, if the Kidneys are healthy, the skin is moistened and has lustre. If the Kidneys are deficient (in particular Kidney-Yin), the fluids are deficient and the skin loses moisture and becomes dry and lustreless. The thickening and hardening of the skin seen in scleroderma may be caused by a deficiency of Kidney-Yin in chronic cases. If Kidney-Yang is deficient, the fluids accumulate in the space between the skin and muscles and cause oedema.

The skin and the Heart

The Heart influences the skin in a similar way to the Liver: Heart-Blood moistens and nourishes the skin just as Liver-Blood does. The influence of Heart-Blood in skin diseases, however, is seen especially on the face.

Box 21.2 summarizes the influences of the Internal Organs on the skin.

BOX 21.2   INFLUENCES OF THE INTERNAL ORGANS ON THE SKIN

Thus, from the diagnostic point of view, the skin reflects first of all the state of the Body Fluids, and therefore of the organs mentioned above, and also conditions of Heat or Cold, Fullness or Emptiness and of Yin or Yang.

The skin and the Connecting channels

The blood vessels (venules) visible on the surface of the skin are always a reflection of the Connecting channels. When they become visible, the blood vessels are an expression of the percolation of the Blood Connecting channels towards the surface of the skin (the Blood Connecting vessels at the deep level of the Connecting channels).

Chapter 17 of the “Spiritual Axis” says: “The Main channels are in the Interior, their branches are horizontal [or crosswise] forming the Luo channels: branching out from these are the Minute Luo. When these are Full with stagnant Blood they should be drained with bleeding with needle; when they are deficient, they should be tonified with herbs”.8 Chapter 10 of the same book says: “The Main channels are deep and hidden between the muscles and cannot be seen; only the Spleen channel can be seen as it emerges from above the internal malleolus and it has no place to hide. The Luo channels are superficial and can be seen.”9 The same chapter also says: “When the Luo channels are greenish-bluish it indicates Cold and pain; when they are red it indicates Heat.”10

Macules are a reflection of the Blood Connecting channels and red macules indicate Blood-Heat, while purple ones indicate Blood stasis. Bluish macules indicate pain and Blood stasis. Papules indicate Heat in the Connecting channels. Vesicles indicate Dampness in the space between skin and muscles and the Connecting channels. Pustules indicate Toxic Heat in the Connecting channels.

Apart from the blood vessels, the colour of the skin itself reflects the condition of the Connecting channels; red indicates Heat, green indicates pain, purple indicates Blood stasis, and bluish indicates Blood stasis and pain.

SKIN SIGNS

Skin colour

“Skin colour” refers to the colour of the body skin itself, as distinct from the complexion (discussed in Chapter 3). It does not refer to skin rashes, which will be discussed separately. The colours discussed are:

Of course, when observing body-skin colour one should take into account individual variations due to race and occupation. This has already been discussed in Chapter 3 dealing with observation of the complexion. For example, a body skin that might be described as “pale” in a Mediterranean person would be normal in a Swedish person. Generally speaking, the colours described below apply to any racial group: for example, the body skin of an African-American or an Indian may be pale in colour, like a Caucasian’s, although it will obviously look different.

The pathological colours described below may not necessarily appear all over the body, but may manifest in various localized places; the location of the pathological colour gives an indication of the organ and channel involved. If a large area is affected, this generally indicates that an organ is involved, whereas if the pathological colour appears along a definite line it indicates that the channel is involved. For example, if the epigastrium is generally very pale, it may indicate a condition of Yang deficiency of the Stomach, whereas if there is a redness appearing along the Lung channel it may indicate Heat in that particular channel rather than in the organ (although it would not exclude Heat in the organ as well).

Dark body skin

A dark body skin generally indicates severe Kidney deficiency. In Chinese medicine this particular colour was called “dark jaundice” (Hei Dan) although it has nothing to do with jaundice. The Kidney deficiency manifesting with this colour was attributed to excessive sexual activity in old times; for this reason, this colour was also called “women-fatigue jaundice” (Nu Lao Dan). In reality, this Kidney deficiency may be caused by other factors (such as overwork) besides excessive sexual activity.

A dark skin colour may also be caused by Blood stasis, in which case it will be dark without lustre and it will be associated with a purple colour of the lips and nails.

Box 21.3 summarizes the patterns underlying different skin colours.

BOX 21.3   SKIN COLOURS

Skin texture

Apart from the colour, other aspects of the skin should be considered:

Lustre

Lustre in relation to the skin has already been described in the chapter on Complexion (Chapter 3). A body skin with lustre indicates a good state of Body Fluids and of the Lungs, Stomach and Liver.

The space between skin and muscles (Cou Li)

The space between the skin and muscles, called Cou Li, is where the Defensive Qi flows and where sweat comes from.11 The state of the space can be deduced by observing the state of the pores, sweat and skin texture. One should differentiate between a state of openness or closure and one of looseness or tightness.

The state of openness or closure of the space between the skin and the muscles can be judged by the sweating: the presence of sweating indicates that the space between the skin and muscles is open (either through Heat or Yang deficiency); its absence indicates that the space is closed.

A state of excessive openness of the space between skin and muscles facilitates the invasion of external pathogenic factors, while a state of excessive closure renders the person prone to fever and generally Heat.

If the skin is tight and thick, it indicates that the space between skin and muscles is tight, which is caused by a Full condition of the Triple Burner and Bladder; if the skin is loose and thin, it indicates that the space between the skin and muscles is loose, which is caused by an Empty condition of the Triple Burner and Bladder.

Macules, papules, vesicles and pustules

Macules

A macule, called ban in Chinese, is a localized, flat area of colour change without elevation or infiltration of the skin: when a finger is passed over it, the macule does not stick out. A macule can be hypopigmented, as in vitiligo, pigmented, as in a freckle, or erythematous (red), as in a capillary haemangioma (the swollen and superficial capillaries seen frequently on the legs of the elderly).

Yang macules occur in diseases of external origin, have a sudden onset and appear first when the Heat reaches the Nutritive-Qi or Blood level. They generally appear on the chest first and are sparse and red in colour; then they gradually extend to the four limbs, becoming more dense and darker in colour as the patient grows feverish. A good prognosis is indicated by lightening of their colour, lessening of their concentration and receding from the limbs; a poor prognosis is indicated by darkening of their colour, increase in their density and spreading along the limbs.

Yin macules start gradually and are not associated with an external origin or a febrile disease: they are generally due either to chronic Blood-Heat or to Qi deficiency.

One should differentiate the shape, density and colour of the macules. The shape of a macule can be loose or tight: a loose macule looks like a wine stain and indicates a good prognosis; a “tight” macule looks like the tip of a knitting needle and indicates that Toxic Heat and Blood-Heat are severe and that the prognosis is poor.

The density of the macules is also important: the more dense they are, the more intense is the Blood-Heat.

As for the colour, one should differentiate the following colours of macules:

Red macules

Red macules always indicate Heat. In the course of a febrile disease, they appear at the Nutritive-Qi or Blood level and they should always be considered as a dangerous sign. Meningitis is an example of an acute febrile disease that manifests with macules when it reaches the Nutritive-Qi or Blood level. Macules can be differentiated from papules (see below) by pressing them: if they disappear on pressure they are papules, if not, they are macules. A good method is to use a glass: if the spot disappears when the side of a glass is pressed against it, it is a papule; if not, it is a macule. In the course of acute, febrile diseases, especially in children, it is vital to distinguish papules from macules because the latter indicate the progression of a disease to the Blood level, which is always a dangerous sign. For example, if a child falls ill with meningitis the appearance of macules is a dangerous sign which should always be taken seriously.

The darker the macules, the more intense is the Blood-Heat.

Remember: in the course of an acute, febrile disease, especially in children, it is vital to distinguish between papules and macules. Papules disappear when the side of a glass is pressed against them, macules do not.

Papules

A papule, in Chinese called Qiu Zhen, is a small, solid and usually well-demarcated elevation of the skin, generally defined as less than 5 mm in diameter. Papules may be flat-topped as in lichen planus or dome-shaped as in acne.

Red papules always indicate Heat. The Heat may be in any organ but the most frequent locations are the Lungs and Stomach. In terms of levels, the Heat manifested by papules may be at any level, that is, external Wind-Heat, Heat at the Qi level or Heat at the Blood level. Papules frequently reflect Heat combined with Dampness or Phlegm.

Dark-red or purple papules indicate Heat with Blood stasis. Chronic papular eruptions may be due to Spleen-Qi deficiency with Dampness. Papules with a crust indicate Blood or Yin deficiency.

A wheal, called Feng Tuan in Chinese, is a type of papule (although it may also be a plaque) characterized by a transitory, compressible elevation of skin with dermal oedema, red or white in colour. Urticaria is a typical example of skin eruptions with wheals. Pale wheals are caused by invasion of Wind-Cold or Yang deficiency; red wheals are caused by Heat or Empty-Heat; dark, purple wheals indicate Blood stasis. (See Plate 21.3 on p. P9).

A plaque, in Chinese called Ban, is a type of papule: it is a palpable, plateau-like elevation of skin, usu-ally more than 2 cm in diameter. Certain psoriasis lesions are typical examples of plaques. The clinical significance of plaques is the same as that of papules, that is, red plaques signify Heat while dark ones indicate Heat with Blood stasis. The fact that the Chinese name for plaques is the same as that for macule (Ban) should not induce us to infer that plaques indicate Blood-Heat (as do macules). (See Plate 21.4 on p. P9.)

Pustules

A pustule, in Chinese called Nong Pao, is a visible collection of free pus in a blister. Pustules may indicate infection (as in a furuncle or infected eczema) but not always, as the pustules seen in psoriasis, for example, are not infected.

Pustules usually indicate Toxic Heat or Damp-Heat mixed with Toxic Heat. The Heat is often related to the Lungs, Stomach or Spleen. (See Plate 21.6 on p. P10.)

Box 21.4 summarizes the patterns underlying these skin growths.

BOX 21.4   MACULES, PAPULES, VESICLES, PUSTULES

Dry skin

Symptoms and signs, Chapter 77

The most common cause of dry skin is Liver-Blood deficiency; this is especially common in women. Liver-Yin and Kidney-Yin deficiency are a common cause of dry skin in the elderly. In some cases, a dry skin may be due to Stomach-Yin deficiency.

A particular type of dry skin is that due to chronic Blood stasis; due to the interaction and mutual exchange between Blood and Body Fluids, stagnant Blood may impair the circulation of Body Fluids and this may cause the skin to become dry. Dry skin from Blood stasis occurs only in chronic cases when the Blood stasis is severe and it is more common in the elderly. It is fairly easy to distinguish between dry skin due to Blood stasis and that due to Yin or Blood deficiency because in the former the skin is also dark and lacks lustre and the nails are often dark or purple and dry and withered. Apart from that, there will be some general symptoms and signs of Blood stasis.

Box 21.5 summarizes the patterns underlying dry skin.

BOX 21.5   DRY SKIN

Swelling of the skin

Observation, Chapter 18; Interrogation, Chapter 39; Symptoms and Signs, Chapter 64

Swelling of the skin may be due to accumulation of fluids under the skin as in oedema, stagnation of Qi or Dampness. Excluding the swelling due to Dampness, there are two main types of oedema: “Water oedema” (Shui Zhong) and “Qi Oedema” (Qi Zhong).

Water oedema is due to accumulation of fluids in the space between the skin and muscles usually from a dysfunction of the Lungs (not diffusing fluids), Spleen (not transforming fluids) and Kidneys (not transforming and excreting fluids). With Water oedema, there is pitting. Usually a distinction is made between Yang Water oedema, which has an acute onset, is of external origin and affects the top part of the body (usually with involvement of the Lungs), and Yin Water oedema, which has a slow onset, is of internal origin and affects the middle and lower parts of the body (usually with involvement of the Spleen and Kidneys).

Qi oedema is due to Qi stagnation in the space between the skin and muscles and there is no pitting on pressure. It may also be due to Dampness or Phlegm obstructing the space between the skin and muscles and impairing the Spleen’s transformation and transportation of fluids, in which case there may be pitting.

There is a third, less common, type of skin swelling due to Blood stasis; this is called Blood oedema. In this case, the skin is swollen, dark, purple and without lustre. This swelling is often associated with joint pain.

Box 21.6 summarizes the patterns underlying skin oedema.

BOX 21.6   OEDEMA

Scales

A scale, called Lin Xiao in Chinese, is an accumulation of thickened, horny-layer keratin in the form of readily detached fragments. Scales usually indicate an inflammatory change and thickening of the epidermis. They may be fine, as in pityriasis, white and silvery, as in psoriasis, or large and resembling fish scales, as in ichthyosis. (See Plate 21.7 on p. P10.)

In chronic skin diseases, dry scales are usually due to deficient and dry Blood giving rise to Wind; it should be noted here that “Wind” in the context of skin diseases is different from external Wind or Internal Wind. In acute or subacute skin diseases, scales may be due to Heat and will therefore also appear in Damp-Heat. One should not assume that scales cannot appear when there is Dampness: eczema is a typical example of this situation. Oily scales are due to accumulation of Damp-Heat.

Erosion of the skin

Skin erosion is a superficial break in the epidermis, not extending into the dermis, which heals without scarring. Erosion is often seen after the appearance of vesicles or pustules.

Red erosion with oozing of a yellow fluid indicates Damp-Heat. Erosion with exudate of thick yellow fluid indicates Damp-Heat with Toxic Heat. Erosion with oozing of thin-watery fluids indicates Dampness with underlying Spleen deficiency.

Box 21.7 summarizes the patterns underlying scales and erosion.

BOX 21.7   SCALES AND EROSION

Rashes

A rash, called Zhen in Chinese, is a redness of the skin caused by vasodilatation. The Western medical name is erythema. The main rashes to be differentiated are measles, German measles, chickenpox and urticaria.

Measles (morbillus), called “Hemp Rash” (Ma Zhen) in Chinese, once a common childhood infection, is now rare in developed countries but in developing countries is still common and still a major cause of child mortality.

German measles (rubella), called “Wind Rash” (Feng Zhen) in Chinese, is a common childhood infection with a benign course.

Chickenpox (varicella), called “Water Pox” (Shui Dou) in Chinese, is a common childhood infection characterized by Dampness.

The differentiation of the rash in these three diseases is made in Table 21.3.

Skin ulcers

Chinese pathology and diagnosis

In Chinese medicine two types of ulcers are differentiated: Yang ulcers have edges that protrude clearly, are clearly defined and are shaped like a basin; Yin ulcers do not have protruding edges, they are shallower, their edges are not clearly defined and there is more oozing. Yang ulcers are predominantly caused by a Full condition and have a better prognosis than Yin ulcers, which are characterized by a mixture of Deficiency and Excess.

The main patterns giving rise to ulcers are accumulation of Damp-Heat, Spleen-Qi deficiency with Dampness, Qi stagnation and Blood stasis and Liver- and Kidney-Yin deficiency.

Ulcers caused by Damp-Heat are characterized by hardened and rounded edges and oozing of a thick yellow fluid.

Ulcers caused by Spleen-Qi deficiency with Dampness are characterized by a greyish-white tissue inside the ulcer and oozing of a clear fluid.

Ulcers caused by Qi stagnation and Blood stasis are characterized by surrounding skin swelling with a purple colour, pain and varicosities.

Ulcers caused by Liver- and Kidney-Yin deficiency are characterized by deep-red surrounding skin and absence of pain.

Box 21.8 summarizes the patterns underlying ulcers.

BOX 21.8   SKIN ULCERS

SKIN DISEASES

Eczema

Symptoms and Signs, Chapters 77, 89

Western pathology and diagnosis

Eczema is the commonest skin disease seen in practice. In the UK, eczema and acne make up the highest proportion of skin diseases while, in general practice, eczema accounts for 30% of patients presenting with a skin problem. A complete discussion of the aetiology and pathology of eczema (both from a Western and a Chinese point of view) is beyond the scope of this book and I will concentrate on the diagnostic aspects, that is, how to recognize eczema and differentiate between it and other skin diseases. This is not a simple task since there are very many different types of eczema presenting in many different ways. In Western medicine, the term “dermatitis” is generally now preferred to that of “eczema”.

The most commonly seen eczema in practice is atopic eczema in children and babies. In babies, there is usually an exudative, vesicular rash on the face and hands. After 18 months, the pattern changes to the familiar involvement of the elbow and knee creases, neck, wrists and ankles. The face often shows erythema and infraorbital folds. Lichenification (from scratching), excoriation and dry skin are common and palmar markings are increased. Scratching and rubbing cause most of the clinical signs.

In adults, the commonest manifestation is hand dermatitis, exacerbated by irritants and with a past history of atopic eczema. A small number of adults have a chronic, severe form of generalized and lichenified atopic eczema. Exacerbations are often elicited by stress.

It should be remembered that many acute, sudden exacerbations are due to skin infection from Staphylococcus aureus rather than the eczema itself: skin infections in eczema are common as the skin is excoriated and therefore prone to invasion of bacteria. An acute infection is characterized by sudden aggravation of the eczema, papular or pustular rash and pronounced erythema. (See Plates 21.11–21.20 on pp. P11-P13 Plate 21.12 Plate 21.13 Plate 21.14 Plate 21.15 Plate 21.16 Plate 21.17 Plate 21.18 Plate 21.19 Plate 21.20.)

Chinese pathology and diagnosis

The modern Chinese name for eczema is “Damp Rash” (Shi Zhen) clearly indicating the idea that Dampness is always present in eczema.

Remember: in eczema, there is always Dampness, even if the skin is not oozing.

Acute eczema is characterized by intense itching, vesicles, erythema (redness), swelling of the skin. Chronic eczema is characterized by itching, erythema, swelling of the skin, crusting, scaling, lichenification (thickening of the skin with increased skin markings), excoriation, and erosion. Chronic eczema may be weeping or dry: weeping eczema indicates the predominance of Dampness, whereas dry eczema indicates the predominance of Heat. However, it should be remembered that in eczema there is always some Dampness as there are always fluid-filled vesicles under the epidermis (which causes the swelling of the skin); when these vesicles come to the surface, the eczema weeps. Furthermore, in atopic dermatitis the superficial stratum corneum of the skin is damaged so that the skin cannot hold moisture properly; this means that the skin becomes dry as a consequence rather than as a cause of the eczema.

The main pattern seen in atopic eczema is Damp-Heat with one or the other factor predominant (see above). In chronic eczema in adults, there is also Damp-Heat, but the the condition is characterized by Empty conditions as well and primarily a Spleen deficiency and a Blood deficiency and Dryness, with Blood failing to nourish the skin. Itching is caused by the Dampness or, in chronic cases, by the Wind generated by the Blood deficiency.

Wind also plays a role in chronic eczema in combination with Damp-Heat. Wind will manifest with the location of the rash on the upper part of the body and with intense itching. If the eczema is concentrated in the lower part of the body, this indicates the prevalance of Dampness. In chronic eczema in adults, Wind is also generated by the deficiency and Dryness of the Blood.

If the skin oozes a yellow fluid, it indicates the prevalence of Damp-Heat, while if it oozes a clear fluid, it indicates Dampness against a background of Spleen deficiency. If the skin oozes after scratching it also indicates Dampness, while if it bleeds after scratching, it indicates Blood-Heat. If the skin oozes a thick, sticky yellow fluid, it may indicate the possibility of a skin infection from S. aureus; this is a common complication of eczema.

Case history 21.1 illustrates a pattern underlying dry eczema.

Case history 21.1

A 29-year-old woman had been suffering from atopic eczema since she was a few months old. The manifestations were typical of atopic eczema manifesting with a dry red rash, scaliness, thickening of the skin and intense itching. The location of the eczema was confined to the top part of the body. The eczema became worse during a pregnancy and after childbirth. Her eczema was also aggravated with cyclical regularity every 7 years. Her tongue was slightly Red, with red points on the front part, a Stomach crack and not enough tongue coating. Her pulse was very Weak on the right Front position and Overflowing on the left at the middle level.

She was very thin and restless, tapping her fingers on the table as she talked.

Diagnosis: The immediate presenting pattern of the eczema is Empty-Heat in the Blood with Wind-Heat in the skin. The Empty-Heat in the Blood is manifested by the red, dry rash and the tongue being Red without enough coating; the Wind-Heat is manifested by the intense itching and the location of the eczema on the top part of the body. There is also a Yin deficiency of the Lungs and Stomach manifested by the Stomach crack and Weak pulse on the right Front position. The Yin deficiency is also manifested by the thin body and by her restless behaviour, tapping her fingers on the table as she talks.

Underlying this, there is also a deficiency of the Defensive-Qi systems of the Lungs and Kidneys and especially of the Lungs; this is manifested by the Weak pulse on the right Front position and by the aggravation of the eczema during pregnancy and after childbirth. An interesting feature of this case is the cyclical aggravation of the eczema every 7 years, which is in perfect accordance with the Chinese view on 7-year cycles in a woman’s life as described in the first chapter of the “Simple Questions”.

Box 21.9 summarizes the patterns underlying eczema.

BOX 21.9   ECZEMA

Acne

Observation, Chapter 5; Symptoms and Signs, Chapters 55 and 77

Western pathology and diagnosis

Acne is a chronic inflammation of the pilosebaceous units, producing comedones, then papules, pustules or cysts, and eventually possible scars. Acne has an equal sex incidence but tends to affect women earlier than men, although the peak age for clinical acne is 18 years in both sexes.

As for the clinical presentation, comedones are either open (blackheads, which are dilated pores with black plugs of melanin-containing keratin) or closed (whiteheads, which are small, cream-coloured, dome-shaped papules). They appear at about the age of 12 years and evolve into inflammatory papules, pustules or cysts. The sites of predilection (face, shoulders, back and upper chest) have many sebaceous glands. The severity of acne depends on its extent and the type of lesion, with cysts being the most destructive. Scars may follow healing especially of cysts. (See Plates 21.21–21.24 on pp. P13 and P14 Plate 21.22 Plate 21.23 Plate 21.24.)

Chinese pathology and diagnosis

From the Chinese perspective, the main causes of acne are:

• Lung-Heat: this is characterized by papular whiteheads and blackheads usually on the forehead, around the nose and on the upper back and chest.

• Stomach-Heat: this is characterized by papular whiteheads and blackheads usually around the mouth and on the chest and upper back.

• Blood-Heat: this is characterized by red papules usually around the nose, mouth and eyebrows. This type of acne is often worse before and during menstruation.

• Toxic Heat: this is characterized by pustules which may be painful. It may also manifest with inflamed cysts. The most frequently affected sites are the upper back and chest.

• Damp-Heat with Toxic Heat and Blood stasis: this is characterized by deep, painful, inflamed nodules and pus-filled cysts. This type usually leaves pitting and scarring.

• Lung- and Spleen-Qi deficiency: this is often an underlying condition combined with Dampness and characterized by long-lasting papules which take a long time to resolve.

Box 21.10 summarizes the patterns underlying acne.

BOX 21.10   ACNE

Psoriasis

Symptoms and Signs, Chapter 77

Western pathology and diagnosis

Psoriasis is a chronic, non-infectious, inflammatory dermatosis characterized by well-demarcated erythematous plaques topped by silvery scales. The peak onset of psoriasis is in the second and third decades. It is unusual in children under 8 years of age.

About 35% of patients show a family history of the disease. There is a 25% probability that if one of a child’s parents has psoriasis the child will be similarly affected, but this increases to 60% if both parents have psoriasis.

Psoriasis’s appearance ranges from the typical chronic plaques involving the elbows to the acute, generalized pustular form. There are many different types of psoriasis:

• Localized: localized psoriasis may be seen on palms and soles, fingers and nails, scalp.

• Generalized pustular: this is a rare type of psoriasis characterized by pustules all over the body. Sheets of small, sterile, yellowish pustules develop on an erythematous background and may spread rapidly. The onset is often acute and the patient is unwell, with fever and malaise.

• Nails: thimble pitting is the commonest change in this type of psoriasis, followed by separation of the distal edge of the nail from the nail bed. There is subungual hyperkeratosis with a build-up of keratin beneath the distal edge of the nail, mostly affecting the toenails.

• Psoriatic arthritis: this is an autoimmune disease characterized by the simultaneous occurrence of psoriasis and arthritis which resembles rheumatoid arthritis.

Another diagnostic sign of psoriasis is the Auspitz’s sign – that is, scraping of the superficial scales will typically reveal tiny bleeding points.

As there are many types of psoriasis, other skin diseases may easily be wrongly diagnosed as psoriasis. Table 21.4 illustrates the differential diagnosis of the most common types of psoriasis (i.e. for each type of psoriasis, the table lists other skin diseases which may look like psoriasis). Although Chinese medicine treats skin diseases primarily according to the presenting pattern and not according to the type of skin disease, in the particular case of psoriasis it is important to differentiate it from other diseases because of its prognosis; psoriasis is usually more difficult to treat. (See Plates 21.25–21.31 on pp. P14-P16 Plate 21.26 Plate 21.27 Plate 21.28 Plate 21.29 Plate 21.30 Plate 21.31.)

Table 21.4

Differential diagnosis of various types of psoriasis

Type of psoriasis Differential diagnosis
Plaque psoriasis Psoriasiform drug eruption
Palmoplantar psoriasis Hyperkeratotic eczema, Reiter’s disease
Scalp psoriasis Seborrhoeic dermatitis
Guttate psoriasis Pityriasis rosea
Flexural psoriasis Candidiasis of the flexures
Nail psoriasis Fungal infection of the nails

Chinese pathology and diagnosis

The patterns causing psoriasis are:

• Blood-Heat: this is characterized by red macules or papules that increase and proliferate rapidly. Red scales pile up and are easily shed when scratched.

• Blood deficient and dry: this is characterized by pale and very dry plaques which are covered by a thin layer of white scales. The course of the disease is slow with new lesions appearing sporadically.

• Blood stasis: this is characterized by dark-purple plaques covered by thick scales. In chronic psoriasis only, lichenification may appear.

• Damp-Heat: this is characterized by dark-red macules or papules covered by greasy or thick, crust-like scales. The skin weeps. There may also be pustules. The sites affected are usually the palms, soles and skin flexures.

• Toxic Heat: this is characterized by erythematous or pustular lesions which develop and spread rapidly, often piling up together. There are red scales that shed easily and there is itching, burning and pain.

• Liver- and Kidney-Yin deficiency: this is characterized by pale-red macules covered by a thin layer of greyish-white scales. A chronic condition, it is usually seen in the elderly.

In addition to the above patterns, there is also nearly always Wind in psoriasis. Wind causes intense itching and also dryness: thus, it is important to remember that Dryness is not always a symptom of Blood deficiency.

Box 21.11 summarizes the patterns underlying psoriasis.

BOX 21.11   PSORIASIS

Urticaria

Symptoms and Signs, Chapter 77

Western pathology and diagnosis

Urticaria is a skin eruption characterized by transient, itchy wheals due to acute, dermal oedema. The cause is an allergic reaction. The lesions result when mast cells release histamine, which produces vasodilatation and the characteristic wheals.

Urticaria can be acute or chronic. Acute urticaria is typically due to an IgE-mediated type I reaction. The allergen is usually a food (e.g. shellfish or peanuts) or a drug. In some cases urticaria may also be due to insect stings or bites, desensitizing injections or inhalants such as pollen, moulds or animal dander. Some women develop urticaria during menstruation. Acute urticaria normally manifests with a sudden onset of red and very itchy wheals which rapidly spread all over the body. The lesions may be small or may enlarge to as much as 20 cm across. Chronic urticaria is characterized by pale-red or pink itchy wheals which typically last less than 24 hours and disappear without a trace. Often no allergen can be identified. Urticaria may also be caused by exposure to cold, heat or sun. (See Plates 21.32 and 21.33 on p. P16.)

Chinese pathology and diagnosis

In Chinese medicine, urticaria is called Feng Yin Zhen, which means “Wind hidden rash”. In both acute and chronic urticaria, there is usually always an underlying pattern of Wind in the skin. A very common pattern, “Wind” in the skin, manifests primarily with intense itching, either all over the body or moving from place to place, and in chronic cases, such as psoriasis, with Dryness of the skin; just as wind, in nature, dries up the soil, Wind in the skin may dry up the skin in chronic cases. Wind in the skin is neither an external type of Wind (because it does not cause exterior symptoms, such as aversion to cold, or fever) nor an internal type of Wind (because it does not cause tremors or paralysis).

In acute urticaria, Wind, especially Wind-Heat, predominates. It causes intense itching with sudden onset, and red wheals spreading rapidly; the more intense the itching, the stronger the Wind. In chronic urticaria, Wind may be combined with a Stomach and Spleen deficiency and Dampness, which usually makes the patient prone to food allergies. In this case, the wheals may exude a clear fluid, the itching is less intense and the wheals come and go with a chronic course. In chronic cases, Wind in the skin frequently occurs as a result of deficiency and Dryness of Blood; in such cases, the wheals may be pale red and the itching is less intense than in acute urticaria. This condition is more common in women and may be associated with menstruation or arise after childbirth.

Both acute and chronic urticaria may be accompanied by Blood-Heat, in which case the wheals are very large and bright red and, besides itching, the patient has an intense feeling of heat and the skin is very hot to the touch. Finally, chronic urticaria may be complicated by Blood stasis, in which case the wheals are purple and may last a long time.

Box 21.12 summarizes the patterns underlying urticaria.

BOX 21.12   URTICARIA

Naevi

Symptoms and Signs, Chapter 77

Western pathology and diagnosis

A naevus is a benign proliferation of one or more of the normal constituent cells of the skin. Naevi may be present at birth or may develop later. The most common naevi are those containing a benign collection of melanocytic naevus cells, commonly known as moles.

A differentiation between moles and other types of skin lesions is given in Table 21.5. (See Plate 21.34 on p. P17.)

Table 21.5

Differentiation of naevi

Lesion Distinguishing features
Freckle Tan-coloured macules on sun-exposed sites
Lentigo Usually multiple with onset in later life
Seborrhoeic wart Stuck-on appearance, warty lesions, easily confused with moles
Haemangioma Vascular but may show pigmentation
Dermatofibroma On legs, firm and pigmented
Pigmented, basal cell carcinoma Often on face, pearly edge, increase in size, may ulcerate
Malignant melanoma Variable colour and outline, increase in size, may be inflamed or itchy

Malignant melanoma

Symptoms and Signs, Chapter 77

Western pathology and diagnosis

Malignant melanoma is a malignant tumour of melanocytes, usually arising in the epidermis. It is the most lethal of the main skin tumours and has increased in incidence over the last few years. It is particularly common in Australia, accounting for 40% of common dermatological disorders (compared with 7% in the UK).

There are four main variants of malignant melanoma.

Tinea

Symptoms and signs, Chapter 77

Western pathology and diagnosis

The most common fungal infection is tinea. Tinea presents with disc-like lesions consisting of a clearly defined round erythema expanding outwards and often clearing in the centre; there is itching and some scaling. There are many types of tinea, including the following:

• Tinea corporis (of the body): this is characterized by single or multiple plaques with scaling and erythema, especially at the edges. The lesions enlarge slowly with central clearing, leaving a ring pattern, hence the name ringworm. (See Plates 21.40 and 21.41 on p. P18.) It may also manifest with pustules or vesicles.

• Tinea manuum (of the hand): this is characterized by a unilateral, diffuse, powdery scaling of the palm. (See Plate 21.42 on p. P18.)

• Tinea capitis (of the head): this is characterized by an inflamed, pustular swelling of the scalp. (See Plate 21.43 on p. P19.)

• Tinea pedis (athlete’s foot): this is characterized by an itchy, interdigital maceration with vesicles. (See Plate 21.44 on p. P19.)

• Tinea cruris (of the groin): this is characterized by scaling and erythema in the groin area spreading to the upper thigh. (See Plate 21.45 on p. P19.)

• Tinea unguium (of the nails): this is characterized by separation of the nail from the nail bed, thickening and brittleness of the nail, which becomes yellow, and subungual hyperkeratosis.

Candida

Symptoms and Signs, Chapter 77

Western pathology and diagnosis

Candida albicans is a physiological fungus which is found in the mouth and gastrointestinal tract; when it multiplies too rapidly it can produce opportunistic infections.

Predisposing factors include:

Infections by Candida albicans may affect the following areas:

• Genitals: this is characterized by itchiness, soreness and redness of the vulva and vagina in women (“thrush”). White plaques adhere to inflamed mucous membranes and a white vaginal discharge may occur. Men develop similar changes on the penis. Thrush can be spread by sexual intercourse.

• Flexures: this is characterized by a moist, glazed and macerated appearance of the flexures under the breasts in women, axilla, groin or between the fingers or toes.

• Oral: this is characterized by white plaques adhering to an erythematous mouth mucosa. It is often caused by use of broad-spectrum antibiotics.

• Systemic: this is characterized by red nodules on the skin; it occurs in immunosuppressed patients such as those suffering from AIDS or those undergoing long-term corticosteroid therapy.

(See Plates 21.46 and 21.47 on p. P19.)

Herpes simplex

Symptoms and Signs, Chapter 77

Herpes is a viral infection, of which there are two types: herpes simplex, which is due to infection from herpesvirex hominis, and herpes zoster (shingles), which is due to infection from varicella zoster.

Western pathology and diagnosis

Herpes simplex is a common, acute, vesicular eruption which is highly contagious. After the primary infection, the latent, non-replicating virus resides mainly within the dorsal root ganglia from where it can reactivate, invade the skin and cause recurrent lesions. There are two types of herpes simplex virus: type one is usually facial and type two usually genital. Type one infection manifests with vesicles on the lips and around the mouth; they quickly erode and are painful. The illness may be accompanied by fever, malaise and local lymphadenopathy. Type two infection usually occurs after sexual contact in young adults who develop acute vulvovaginitis, penile or perianal lesions.

Recurrent attacks are the hallmark of herpes simplex infection and they occur at a similar site each time, usually on the lips, face or genitals. (See Plates 21.48 and 21.49 on p. P20.) The outbreak of vesicles is often preceded by tingling or burning, crusts form within 48 hours and the infection fades after a week.

Chinese pathology and diagnosis

From the Chinese point of view, herpes simplex is nearly always characterized by Damp-Heat because vesicles by definition indicate Dampness. However, different types may be distinguished according to the manifestations and location of the lesions. Lesions occurring in the upper part of the body such as lips and mouth are due to a combination of Damp-Heat and Wind-Heat. Lesions which occur regularly and repeatedly around the mouth and on the lips may be due to Damp-Heat in the Stomach and Spleen, while genital lesions are due to Damp-Heat mostly in the Liver channel. In the elderly, recurrent herpes simplex infections often occur against a background of Yin deficiency and Empty-Heat so that there is an underlying Empty-Heat, which predisposes the person to recurrent infection and Damp-Heat in the acute stages. If the eruptions become pustular or papular and are very painful, they indicate the presence of Toxic Heat as well as Damp-Heat.

Box 21.16 summarizes the patterns underlying herpes simplex.

BOX 21.16   HERPES SIMPLEX

Herpes zoster

Symptoms and Signs, Chapter 77

Chinese pathology and diagnosis

From the Chinese point of view, herpes zoster is also always due to Damp-Heat because of its vesicular and erythematous eruption, but a further differentiation can be made according to the manifestations and location of the lesions. If the lesions are located in the thoracic or hypochondrial region, they are due to Damp-Heat in the Liver and Gall-Bladder channels. Generally speaking, in lesions occurring in the neck and ophthalmic region (which is common in the elderly), in addition to Damp-Heat there is also Wind-Heat. Wind-Heat is also indicated if itching is very intense. If the lesions are pustular, they indicate the presence of Toxic Heat; if they are dark and very painful, they indicate Blood stasis, which also is common in the elderly.

Box 21.17 summarizes the pattern underlying herpes zoster.

BOX 21.17   HERPES ZOSTER

Warts

Symptoms and signs, Chapter 77

Rosacea

Symptoms and Signs, Chapter 77

Chinese pathology and diagnosis

From the Chinese point of view, rosacea may be due to the following patterns:

Box 21.19 summarizes the pathology of rosacea.

BOX 21.19   ROSACEA

NOTES

1. Cou Li (image) is a difficult term to translate and one that is interpreted differently by modern Chinese doctors. Cou indicates ‘spaces’ or ‘interstices’ and it refers to all the spaces in the body, especially the small spaces (as opposed to large cavities such as the chest and abdomen) all over the body, including the space between skin and muscles, which is probably the most clinically relevant. Li means ‘texture’, ‘grain’ (as in the grain of wood) or ‘pattern’, and it indicates the texture of skin and the Internal Organs: it refers to the organized way in which the skin and organs are arranged, forming a ‘texture’ or ‘pattern’. The ‘Synopsis of Prescriptions from the Golden Cabinet’ says: ‘Cou is the place of the Triple Burner where the Original True [Essence] converges and Qi and Blood concentrate; Li is the texture of the skin and Internal Organs’ (He Ren 1981 A New Explanation of the Synopsis of Prescriptions from the Golden Cabinet Jin Gui Yao Lue Xin Jie image), Zhejiang Science Publishing House, Beijingp. 2). I translate Cou Li as ‘space between skin and muscles’. Although this is not strictly accurate, because there are other spaces and because it ignores the Li part of it, it is the most clinically relevant. In the context of skin, therefore, Cou Li is the space between skin and muscles

2. The Yellow Emperor’s Classic of Internal Medicine – Simple Questions (Huang Di Nei Jing Su Wen image). People’s Health Publishing House: Beijing, 1979:70 First published c. 100BC

3. Spiritual Axis (Ling Shu Jing image). People’s Health Publishing House: Beijing, 1981:129 para 139. First published c. 100BC

4. Clavey gives a different interpretation of the words bie shi (image), which are usually translated as ‘emissary’ or ‘special emissary’. According to him, the words should be translated as ‘makes separate’. In other words, if this interpretation is correct, the Triple Burner separates the undifferentiated Original Qi and directs it into different channels and organs to perform its various functions. I personally feel that this interpretation is probably more correct. (Clavey, S. 1995 Fluid Physiology and Pathology in Traditional Chinese Medicine, Churchill Livingstone, Edinburgh, p. 21. )

5. Nanjing College of Traditional Chinese Medicine. A Revised Explanation of the Classic of Difficulties (Nan Jing Jiao Shi image). People’s Health Publishing House: Beijing, 1979:144 First published c. AD100

6. Spiritual Axis, p. 92

7. Simple Questions, p. 353.

8. Spiritual Axis, p. 50

9. Spiritual Axis, p. 37

10. Spiritual Axis, p. 37

11. The term Cou Li actually indicates more complex structures of the body and it includes all ‘spaces’ between organs and between channels: functionally, the Cou Li is connected to the Triple Burner. In this context, I will again translate it as ‘space between skin and muscles’ but the reader should bear in mind that this is only one of the Cou Li ‘spaces’. Furthermore, while cou means ‘spaces’ or ‘interstices’, li means ‘pattern’ or ‘texture’ and it refers to the striae of the Internal Organs. I therefore translate Cou Li as ‘space between skin and muscles’ in the appropriate context, even though this is only one of the meanings of Cou Li. (See also Note 1 above. )

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