I have a patient that has this fairly severely right now. I too thought SP qi deficiency with LR qi stagnation at first - similar presentation, overweight, high stress, fatigue, chronic alternating constipation and loose stools - puffy tongue with slight red on tip/sides, wiry pulse. LR/SP disharmony. Xiao yao wan produced cramping. A deeper look shows yang deficiency signs…coldness before menses, cold feet/hands with the granulomas concentrating on the extremities, recent history of prolapsed colon. BM every other day, but on those days it takes 2 hours to complete, and they are loose with undigested food. Recently she’s had a cortisone shot and steroid creams with no effect. I only see this patient once/month, which is definitely not enough, but its what she can do. I’m thinking along the lines of this yang deficiency, with yin blood being relatively replete, and not moving as the lesions are much more purple and raised now, so blood stasis. Using LI4/LR3 to promote circulation, R12,6, ST25,36 to harmonize the bowels, SP9, 8 & 6 to boost the spleen, clear dampness and resolve stasis. Also moxa on Ren 6 & ST36 as well as on one lesion, which I’ve surrounded with needles and am using as a “test lesion” to see what the moxa & surrounding does. I’d appreciate herb suggestions, I think the chai hu doesn’t agree with her, but not sure which herb in Xiao yao wan it is really, but it causes cramping & gas after a couple days of use. Does my diagnosis sound on track?
If she has more signs of deficiency, xiao yao wan can be too moving and lead to some of the symptoms you are describing. Assuming you are dealing with patents you could use xiao yao wan with bao he wan for example to better buffer and lightly strengthen the spleen, or xiao yao wan with a small amount of gui pi wan. Diagnosis wise you are in the ballpark, but you could clarify it a bit. For example, while I have no doubt she has tapped her reserves, I don’t think she is really yang deficient (cold hands/feet are stagnation generally, deep internal cold is more yang deficiency) and you have offered limited signs of yin deficiency (no nightsweats, no palpitations, no strong heat signs, etc.).
Not knowing all the patient personally, I can only speculate, but I would probably do a week or three of a blood/stagnation mover like xue fu zhu yu wan if she tolerates it well maybe longer. Then perhaps try a combination of jia wei xiao yao wan w/gui pi wan and see how she does. Points wise I would try to work in some shu points such as the hui meeting of the blood - UB 17, UB 18 (liver), and UB 19 (GB and blood w/UB 17). Perhaps also UB 40 and/or SP 10. Move the moxa to SP 9 and ST 36 (or 40).