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Discussion
Pityriasis lichenodes (PL) is a rare idiopathic skin condi5on that commonly affects gene5cally suscep5ble male children (19%-‐38%), with peak incidences at the age of 5 and age of 10. Under the umbrella term of PL, there are various subtypes of the disorder: acute (PLA), chronic (PLC), and the febrile disorder, Mucha-‐Habermanns disease.1 The acute form is characterized as erup5ons of small 2-‐3 mm reddish-‐brown clusters of papules on the skin, which fill with pus and blood and cause itching and burning; and in severe cases begin to ulcerate. PLC will oSen appear with small scaling papules that upon resolu5on will leave hypopigmenta5on. Simultaneous systemic symptoms like fever, lymphadenopathy and necro5zing papules will occur in Mucha-‐Habermanns disease.2 Diagnosis is oSen difficult because of the lack of clinical guidelines and its some5mes-‐similar presenta5on to atopic derma55s. Currently, diagnosis relies on clinical presenta5on, ruling out of other disorders and histological examina5on. Although the e5ology and pathology of PL remains unknown, it is hypothesized that PL is a atypical immune response triggered by an infec5ous agent because the symptoms and papules generally improve aSer an5bio5c therapy.3 Current standard of treatment of a pa5ent with PL is oral an5bio5c (tetracycline or erythromycin), topical cor5costeroid, and light therapy. The results have varying degrees of success and occasionally resolve on its own aSer several weeks to months.4
Background
Classic Chinese Herbal Formulas for the Treatment of Pityriasis Lichenodes: A Case Study of a 7 Year Old Boy Judith Miller, MAOM (c)
San Hong Hwang, MD (Taiwan), OMD
A 7 year-‐old boy with a mild form of PL was brought to the SCU Health System in Whi[er, CA in September 2013. The boy is a Caucasian of Moroccan and Cuban descent. The onset of the skin rash began during a family vaca5on to Hawaii in June 2013. The small, red, itchy papules ini5ally arose on his stomach and then progressed to his limbs and face. From June to August the pa5ent was ini5ally diagnosed with a viral infec5on, insect bites and scabies. During this 5me he was prescribed 200mg of liquid-‐oral erythromycin, which did not alleviate his symptoms or improve the skin condi5on. He was eventually diagnosed with PL aSer a histological exam in September 2013. He has no prior history of any skin condi5ons, but his mother and other immediate family members have a history of psoriasis and eczema.
Case presenta3on
Diagnosis and Treatment At the 5me of presenta5on, the pa5ent had several 2-‐3mm bright red, non-‐ulcera5ng papules covering his en5re body and face associated with severe itching at night. No history of any discharge was reported. His vitals and other physical exam findings were within normal limits. His mother reported that the boy started his second course of erythromycin at the same 5me when he reported to our clinic. His tongue was found to be red with prickles with a greasy white coat, and his pulse was slightly slippery. His TCM diagnosis was determined as an invasion of wind-‐damp and fire-‐toxin. He was prescribed: Huáng Lián Jiě Du Tāng (Cop4s Decoc4on to Resolve Toxicity) and Xiāo Fēng Sān (Eliminate Wind Powder from Orthodox Lineage) in granule form made by TCM Zone®. He was given 700mg BID. Yù Píng Fēng Săn (Jade Windscreen Powder) was subs5tuted for Xiao Feng San (Eliminate Wind Powder from Orthodox Lineage) aSer two weeks based on his improved skin condi5on.
Ini3al Visit
Visit 3: 2 Weeks A>er Ini3al Visit Visit 5: 4 Weeks A>er Ini3al Visit
Herbal Formulas Used Huáng Lián Jiě Du Tāng
Cop4s Decoc4on to Resolve Toxicity Xiāo Fēng Sān
Eliminate Wind Powder from Orthodox Lineage Yù Píng Fēng Săn
Jade Windscreen Powder 1. Huáng Lián (Cop5dis Rhizoma) 2. Huáng Qín (Scutellariae Radix) 3. Huáng Băi (Phellodendri Cortex) 4. Zhī Zĭ (Gardeniae Fructus)
1. Jīng Jiè (Schizonepetae Herba) 2. Fáng Fēng (Saposhnikoviae Radix) 3. Niú Bàng Zĭ (Arc5i Fructus) 4. Chán Tuì (Cicadae Periostracum) 5. Kŭ Shēn (Sophorae flavescen4s Radix) 6. Cāng Zhú (Atractylodis Rhizoma) 7. Mù Tōng (Akebiae Caulis) 8. Shí Gāo (Gypsum fibrosum) 9. Zhī Mŭ (Anemarrhenae Rhizoma) 10. Shēng Dì Huáng (Rehmanniae Radix) 11. Dāng Guī (Angelicase sinensis Radix) 12. Hēi Zhī Má (Sesami Semen nigrum) 13. Gān Căo (Glycyrrhizae Radix)
1. Huáng Qĭ (Astragali Radix) 2. Bái Zhú (Atractylodis
macrocephalae Rhizoma) 3. Fáng Fēng (Saposhnikoviae
Radix)
• Dose: 700mg BID • Taken from Ini3al Visit through Week 4
• Dose: 700mg Packet BID • Taken from Ini3al Visit through Week 2
• Dose: 700mg Packet BID • Taken from Week 3 through
Week 4
ASer 2 weeks of herbal treatment, the itching was less severe and limited to the right hip region. The papules began to change from red to white (hypopigmenta5on) and mostly disappeared, except around his elbows and knees. There were very few papules on chest, abdomen, back, and limbs. ASer 4 weeks of taking the herbs, majority of the boy’s papules healed and only slight hypopigmenta5on around the elbows and knees remained. His mother reported that he had 2 addi5onal flares of red papules with itching 2 months and 6 months later. Both Huáng Lián Jiě Du Tāng (Cop4s Decoc4on to Resolve Toxicity) and Xiāo Fēng Sān (Eliminate Wind Powder from Orthodox Lineage) were used to manage the exacerba5on of symptoms. No adverse effects were reported by the mother or boy during the en5re course of treatment.
The TCM diagnosis for this case is common for atopic derma55s, ur5caria, psoriasis and eczema. Xiāo Fēng Sān (XFS) is the most used formula for the treatment of these dermatologic condi5ons5 because of its strong an5pruri5c effect and ability to reduce hypersensi5vity responses.6,7 Huáng Lián Jiě Du Tāng (HLJDT) was the key formula used to treat the PL because the nature of the rash and its chronicity indicated that the use of only XFS would not be sufficient. Addi5onally, HLJDT has shown to be useful for systemic inflammatory condi5ons in laboratory and clinical studies7, and is considered an herbal an5bio5c. ASer 2 weeks the number of papules on the skin reduced, the color began to transform from red to white (hypopigmenta5on), and itchiness subsided; thus indica5ng XFS was no longer needed. Now the milder formula, Yù Píng Fēng Săn could be used because it can enhance the immune system and inhibit allergic inflamma5on.9 Overall, the posi5ve outcome in this case demonstrates that Chinese herbal medicine may be useful for PL. However, it is important to note that the pa5ent was simultaneously taking erythromycin while taking the herbs and it is unknown how this could have affected the outcome. Secondly, it has been reported that PL may resolve on its own without treatment as well. The obscurity and lack of clinical guidelines in treatment of PL can oSen lead pa5ents to prolonged use of medica5ons and without successful management of the condi5on. The current case may provide insight to an alterna5ve and natural approach to treatment of PLEVA by using Chinese herbal medicine to reduce the symptoms and severity of the papules, which warrant further inves5ga5on in rigorous trials.
Conclusion
References
Results
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