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Tx for itching?


#1

Could use some input on a patient.

Male age 37. CC: Itching.
Started 2.5 years ago. Started in inguinal region. Now, can be anywhere and moves around: forearms, legs, anus, penis, scalp are most common areas. There is no rash associated with the itching, but sometimes scratching will produce discrete red dots on the skin. Sometimes itching will be in just one area, sometimes multiple areas. It is somewhat worse after showering. Otherwise, no obvious climactic factor influences it and it does not change with the seasons.

Patients states that he was fairly stressed when the itching began and that stress can be a problem for him. Has been to various doctors and has seen no relief. Dermatologist referred him for acupuncture.

-Tends to run cold.
-No abnormal sweating.
-Bowel movement-3x days, sometimes loose. Experiences gas and bloating and fullness after eating.
-Urination: Wakes 3x/night to urinate
-Diet: English is patient’s second language and I was pressed for time so didn’t get much detail-I think it’s a typical Mexican diet, though he states he doesn’t eat a lot of cheese.
-Lifestyle: Construction worker. In the past worked exclusively outdoors, but in last few years has more indoor work.
-Experiences pollen/seasonal allergies. At first visit was quite congested with phlegm and watery/itchy eyes. Moved to area in 1992 but allergies didn’t start until 2007

Pulse:
Lung: all positions slippery
SP: Tight (slightly slippery, but moreso tight or just present-which I found curious)
KD yin and yang: nothing remarkable, maybe a little weak

HT: Slippery
LR: tight

Tongue:
Pale, quivering, swollen, scalloped, thick white coat

On the first treatment I was honestly completely mystified as to why the itching was happening. Clearly, there is a wind component, but as to WHY the wind exists-I have no idea. I chose to needle with the principle of regulating LU/SP and to treat the existing phlegm/allergy symptoms. Clearly, there is damp accumulation and SP qi xu-but I don’t know how or even if that connects to the itching.

Points: LU-5, SP-9. LI-4, LU-7. SP-6. Baichongwo

Herbs:
Principles: Drain damp, support spleen, relieve itching/expel wind,
Cang zhu 9
Ku shen 9
fu ling 12
zhi mu 9
dang gui 9
chuan xiong 6
fang feng 9
jing jie 9
cang er zi 9

On next visit: Patient took herbs for 4 days (though I gave him a weeks worth.) He reported no change in the itching in that time, so decided upon recommendation of a friend to take an antihistamine. The antihistamine stopped the itching! (he said he’s never taken one before).

However, patient reports that his digestion symptoms are all noticably better, with less gas and bloating and nightime urination is reduced to 1x/night. His tongue has a less thick coat and is a bit less swollen. The less thick coat reveals stomach cracks that were not previously visible (or I just missed the first time) Pulse is fairly similar to first visit. I did the following points:
LI-11, St-40, baichongwo
LU-5, SP-9, Ren-12
ST-42 & SP-3 w/ moxa
Du-20,

And gave him a liu jun zi wan patent. (at least I know I can help the digestion!!)

Finally
I know this is really long and I appreciate anyone taking the time to read. My questions are as follows:

-Where is this wind coming from??? Patient’s most obvious disharmonies lie in taiyin-qi regulation and the excess damp. I do not know if/how that can create wind. I don’t believe he is blood deficient-so that is not creating the wind.

-A possibility that was suggested to me was that the wind is due to fluid deficiency. This seems an interesting idea. His skin is somewhat dry and there are stomach cracks on the tongue. Could this dryness (which coexists with pathological fluids-dampness) give rise to wind? If so, would simply nourising ST yin be able to anchor the wind? What are strategies to treat coexisting dryness and dampness?

Any thoughts are greatly appreciated.


#2

I wouldn’t over think those concepts, as we all know wind is a nebulous concept at best within Chinese Medicine. But I do agree in general with what you are hinting at by seeking a discussion about wind - and that is that there needs to be more of a release initially. It’s always hard to say what construction workers get into and/or react with as they are in contact with so many undesirable substances and in weather extremes along with depleting physical work - it’s a tough mix for the body to content with. But wind can arise from heat, damp-heat, and from depletion. If you think of the natural course of life for a construction worker - many start young and strong, work a lot, eat debatable diets, get older and more tired - so they start with excess heat and tap out to varying degrees over time. The dryness could be part of it as well, many workers do not hydrate well or have sugary drinks with caffeine to keep working. One of the more recent cases like this that I had it turned out after talking more he was drinking 10-12 sodas a day. We stopped that and all of his symptoms were improved almost immediately, then we fine tuned some things after that to avoid future trouble. He’d been to 5 or 6 doctors before that including a trip to Vanderbilt and nobody looked at the simple things.

Since the antihistamine worked he could just stay on that for a few months (can’t imagine no one had him try that before) - work out his other symptoms/issues and then walk him off the antihistamine and he might stay well.

If it were me, I would probably start by doing some extensive cupping, more blood heat clearing points (SP 10, UB 40, huatuo at T7, etc.), use a formula possibly like xiao feng wan (similar to what you tried, but give it a little longer), or maybe even xiao chai hu tang - to have a more clearing and outward movement the first treatment or two. Then see how the itching is and possibly then work on strengthening the system from there to avoid future problems.


#3

In my own understanding chronic damp can diffuse into the blood. As an analogy, think of carbonated water, the water is the blood and the bubbles are the qi. Dampness is like sticking a greasy finger in the water…which forces the bubbles out. When the qi is pushed out of the blood, it can create tingling, or itching. That the itching tends to move around might not reflect wind per se. Again assuming the damp resides in the blood, it can move around with the blood, and like debris in a pipe it can accumulate into clusters then disperse and accumulate again down the line.

Within the context of being a construction worker, the work itself, exposure to various toxins, and general lifestyle tend to burn off the yin. It is the yin aspect of the blood that holds the qi, which is yang, in place. The dry skin suggest lung yin deficiency, which again in the context of his work he’s very likely inhaled all kinds of dust and debris which can directly damage the lung yin. Since the lung system governs the skin, and since lack of yin can cause the yang to expand outward the itching could be the result of the lung yin deficiency.

I definitely agree that cupping would be a good idea, I’d suggest moving cupping along the whole back UB line. My own take is don’t worry about trying to expel wind per se, use points to tonify the lung yin (LU 7, KD 6), strengthen the spleen (SP 3, ST 36 - I’d hold off on SP 6 due to excessive damp…), and clear damp (SP 9, ST 40, R 12). I’m not sure I saw any heat signs per se but I might have just missed something. If you do see signs of heat I’d add SJ 5, LI 11 and SP 10. I personally would not use moxa in this case.


#4

Chad, Stephen thanks very much for the responses.

-I definitely intend to do cupping. I just haven’t had time for it in these first two visits.

Chad: Being a student it’s difficult to not over think everything! I don’t have enough clinical experience/results to fall back on, so it’s easy to lack confidence if I feel I don’t understand etiology. Your point is well taken though.

Re; antihistamine. I too was surprised that he said he’s never taken an antihistamine. Doctors have given him various “pills,” so maybe it was just a language/communication barrier or misunderstanding.

After this last treatment, I had him stop taking the antihistamine, just to see what results the tx would have. Perhaps next visit I’ll advise him to start taking it again and continue a course of acupuncture treatments. Xioa feng wan sounds like a good idea too.

Stephen:
That physiological explanation is illuminating. Thank you. And I had only been thinking of ST yin; I will take into account the Lung yin (which, in retrospect seems obvious considering the Lung/skin relationship).

There aren’t many heat signs except: He reported that after 1st tx and the herbs that he was less hungry (ST heat?) and would feel sated with less food and less discomfort. Also, upon 2nd visit the edges (in front of tongue and about halfway back) of the tongue did appear a bit red in the scalloped areas.

Can you clarify why you advise to refrain from SP-6 b/c of dampness? I was thinking of it more as a moving point in this context-and I wanted to address the LR pulse tightness without using LR/GB channels in order to keep the treatment focused. Just curious about your rationale-there are definitely more appropriate points for him.


#5

My own take is SP 6 strongly nourishes the yin, since damp is yin in nature I’ve mostly avoided using that point when I see a lot of damp signs. Of course some practitioners think of it more as a moving point, which is probably fine. This gets into the art aspect of our practice, there are many different clinical interpretations as to how to use the various points. With regards to keeping the treatment more focused, again that’s a huge variable across practitioners. Some try to limit the channels, others use nearly every point (which tends to be terribly ineffective)…others still might not concern themselves with addressing multiple channels but still try to use as few points as possible. In my own practice I’ve never tried to limit myself to particular channels, its not something I even consider. In some cases I’ve probably used a point from nearly every channel and achieved good clinical results.

On another note, confidence is important. Every single one of my teachers emphasized that over and over again. ‘Better to fail confidently than succeed meekly’ was one of there favorite sayings. Its takes time to get really good, there is no shortcut, so don’t worry. Patience and persistence is the secret!


#6

Hi all, thanks for a very interesting case study and discussion. Chad and Stephen, your characterisations of the lifestyle and environment of construction workers is indeed illuminating and much appreciated! I, too am a student and I am following along with what you are all saying for the most part however I’m unclear on the cupping aspect of the suggested treatments. I’d like to understand why cupping would be beneficial to this client. We have touched on it in my course although some time back and I am due to revise. From memory cupping is good for excess conditions and opens the channels (so good for expelling wind cond’s) and is it right that it is then good for stagnation and heat symptoms? Stephen, you comment about not necessarily seeing heat symptoms and nor to focus on expelling wind, so I am unclear on the recommendation for cupping. Finally, we were also taught to take care with cupping where deficient conditions are present.
Many thanks in advance for any explanations! Jen


#7

As far as deficiency with cupping goes, you do have to keep that in mind. However, most skin conditions are there because the body is having a hard time expelling something internal. Accordingly, aiding that is most often the right approach. You can keep the cupping on the lighter side, both in pressure, but also in frequency and get good results with deficient patients. If you think of it as the patient doesn’t have the strength to clear the pathogen, it seems more viable.


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