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基本資料
病人資料：冼某，女/67歲。已婚，兼職文員。
過往史：否認藥物、食物敏感。否認長期病患史。
現病史：
蛇串瘡3周，後遺痛症1周。
訴於1.5.2021起感左側頭頸刺痛。於3.5.2021西醫診為頭痛，與止痛藥，不效。 6.5.2021另覓他醫再診，醫生見疼痛部位現水泡瘡瘍，斷為帶狀皰疹，處方7日特效藥。藥後皰疹退，患部呈褐色皮痂，濕潤無流滋，無發新瘡。唯治後，患側剌痛不減，如針刺、如火灼，入夜尤甚，痛不能眠，狀甚痛苦，再求診西醫，稱此為瘡後遺留神經痛，持續時間可以年計，亦不可再服前述特效藥，只與止痛藥。因劇痛未能緩解，故於19.5.2021前來就診。
治療
19.5.2021 初診
診時皰疹已退，在左後項、左頦下，左耳項交接處及左側顳部遺留若干大小不一的褐色皮痂， 濕潤無流滋，無發新瘡。現患部痛甚(其痛十之八九)，晚上尤為明顯，難以入睡。
神略疲。語速常，聲清。體形適中膚黑。眠素差，病後尤難入睡，要以收音機相伴始得眠1-2小時。納可，無脾胃不適症狀。無胸脅苦滿，口和，無頭痛頭暈，心情因病煩悶。大便日1行，成形。小便調，夜尿1-2次。汗出如常。無夜汗盜汗。無腰腿酸軟，無耳鳴/耳聾。舌暗紅，苔少色白。脈弦細略數。
診斷：蛇串瘡後遺神經痛：肝陰不足，血氣鬱滯。治以滋陰活血行滯止痛。
治療：
內服一貫煎及瓜蔞紅花甘草湯加減(生地黃、北沙參、當歸尾、枸杞子、麥冬、柴胡、瓜蔞、紅花、甘草、大黃、麥芽)，共3劑，分早晚服。
火針：以3毫米火針圍繞頦下及後項(無頭髮處)之瘡口，隔0.5-1厘米淺刺。左顳側有頭髮處以毫針圍刺。另以毫針刺雙側內庭、合谷、中渚、外關、丘墟及阿是穴，平補平瀉，留針15分鐘。另於耳尖及龍眼穴點刺出血3ml。
23.5.2021 二診
報患部刺痛及灼痛度由8減到5，痛減故眠改善，能眠2-3小時以上。瘡部焦痂脫落明顯，只餘火針淺刺留下的烙印，耳項交接處瘡口亦收小變干。頭部仍見麻緊，肩部及項部肌肉繃緊，壓痛明顯，按壓痛及同側耳朵。餘證同前。舌暗紅，苔薄，微黃，有少齒痕。脈弦細，稍數。
診斷：同上。治以活血行滯止痛，兼以安眠。
治療：
內服歸脾湯及瓜蔞紅花甘草湯加減(歸脾湯、瓜蔞、紅花、甘草、柴胡、黃芩、大黃)，共5劑。(因上次藥後未有作瀉，故加重大黃及瓜蔞之用量，亦囑咐患者若早晚分服仍不作瀉，可於晚上兩劑合服。)
針刺：以毫針刺雙側內庭、合谷、中渚、外關、丘墟、照海、翳風、肩井及阿是穴，平補平瀉，留針15分鐘。另於耳尖點刺出血。因瘡面已脫痂，故去火針。
30.5.2021 三診
疼痛基本已除(十餘不足一二)，瘡面已癒，火針淺刺烙印亦去，只留色素沉著。另肩部及項部肌肉繃緊依舊，仍見壓痛。神清，眠續改善。納可，口渴多飲。報藥改兩劑合服後得大便爛，日2-3行。納可，小便調。舌暗紅，苔少，有少齒痕。脈弦細。
診斷：同上。治以舒筋通絡止痛，兼以安眠。
治療：
內服歸脾湯及瓜蔞紅花甘草湯加減(歸脾湯、瓜蔞、紅花、甘草、合歡皮、香附、葛根、雞血藤)，共5劑。
刮沙及拔罐：在左側肩頸行刮沙及拔罐，留罐10分鐘。
病理概要
蛇串瘡(帶狀皰疹)以患處皮膚有灼熱感或神經痛(閃電、針刺)等前驅症狀、或兼見輕度發熱、倦怠、食慾不振。常於1至3天後患處出現不規則的紅疹(亦可在沒有前驅症狀下發疹)。繼而出現多發並成簇的粟粒至綠豆大小的丘皰疹，再速變為水皰，聚集一處或數處，排列成帶狀。初期皰液透明，5至7天後，轉為渾濁，或部分破潰、糜爛和滲液，最後乾燥結痂，再經數日，痂皮脫落而癒部分患者在皮疹完全消退後會留有後遺症，如神經疼痛可持續數月或更久，發在頭面者更可能影響視覺及聽覺。
其病因病機有因情志過極引致肝氣鬱結，氣鬱化火；或因飲食不節，過食性味過偏之物；或因憂思傷脾，濕濁內停，久鬱化生濕熱等。 簡言之，蛇串瘡總以“濕熱火毒外溢膚表，經絡氣血受阻不通，不通則痛”為主要病機。蛇串瘡的中醫辨證主要可分為肝膽火旺、脾虚濕盛和氣滯血瘀三種證型。中醫治療可配合內服外洗、濕敷、外塗、針灸等。
思路及體會
一診時，皰疹瘡面濕潤而不流滋，基本上已受控制，只留明顯的遺留神經痛，因此如何減低痛楚便成了主要的治療目標。此證辨為肝陰不足，內熱循肝膽經上犯，觸動濕熱火毒外溢膚表為患，使經絡氣血受阻不通，不通則痛。因此以滋陰瀉火清熱，行滯通痹為主要治則。方用一貫煎滋肝陰，配以瓜蔞紅花甘草湯散瘀通便，即以紅花散瘀解鬱，甘草補氣調和諸藥及瓜蔞瀉肝肺火，通大便，因此要務使患者腹瀉或大便次數增多；另以火針取“火鬱發之”之效，以祛濕熱毒邪，並在遠近兩端取龍眼穴及耳尖點刺出血。內外合治使邪有出路，經脈得通。
二診時，焦痂脫落。主要疼痛點減輕，反使次要疼痛部位肩頸繃緊痛成為關注。考此痛與長期(逾3星期)劇痛引起的肩頸肌肉緊張牽拉及失眠有著密切及互為因果的關係，故相信改善睡眠質素，亦可有助肌肉放鬆，改善疼痛及減輕其影響，所以方改用歸脾湯，養心益脾安眠。又因在一診時藥後沒有作瀉，故醫師在加大瓜蔞及大黃的用量外，亦囑咐患者若早晚分服不效，可於睡前合劑而服，以確定邪有去路。又瘡斂焦痂去，示濕熱邪毒已去八九，故停火針，亦不再在遠端龍眼穴出血。
三診遺留神經痛續改善，痛去八九，眠亦續安。合劑後大便果日2-3行，質爛。仍以歸脾湯養心益脾助眠，在去大黃減瓜蔞量，續以瓜蔞紅花甘草湯散瘀通便，輔以刮沙及拔罐去疏通經脈，以行氣血。
6.6.2021患者陪同丈夫前來復診濕疹。問及其病情，回曰神經痛已除，左顳部只留一點麻緊感但已不影響生活，所以沒掛號就診。醫囑其多按摩麻緊部位及鬆弛肩頸肌肉，以促進氣血流行。
在整個治療過程中，在方藥變換及不同手法交替運用方面都能得到患者充分的信任及配合，使得治療產生令人滿意的效果。當中最為深刻的莫過於在治療過程中，如何在外治及內治兩者配合中都力求體現“給邪有出路”這一治療原則的重要性。
Basic Information
Patient Information
Ms. Xian, female, 67 years old. Married, working part-time as a clerk.
Past Medical History
Denies medication or food allergies. Denies a history of chronic illness.
Present Medical History
Having Herpes Zoster for 3 weeks, followed by post-herpetic neuralgia for 1 week.
Complains of stabbing pain on the left side of the head and neck since May 1, 2021. Consulted a Western doctor on May 3, 2021, diagnosed with headache, prescribed painkillers, no effect. On May 6, 2021, sought another doctor, where the pain area presented with water blister ulcers, diagnosed as herpes zoster, prescribed a 7-day special medication. After medication, the blisters receded, leaving brown scabs on the affected area, moist without oozing, no new sores appeared. However, the pain on the affected side did not decrease after treatment, feeling like needles or burning, especially worse at night, causing sleeplessness and extreme discomfort. Revisited a Western doctor, diagnosed with post-herpetic neuralgia, expected to last for years, advised not to take the aforementioned special medication anymore, only given painkillers. Due to the severe pain not being relieved, came for consultation on May 19, 2021.
Treatment
May 19, 2021 Initial Consultation
At the time of consultation, the herpes zoster had receded. Several uneven brown scabs of various sizes remained on the left occipital area, left below the chin, at the junction of the left ear and neck, and on the left temple, moist without oozing, no new sores. Severe pain in the affected area (pain score of eight or nine), especially pronounced at night, making it difficult to fall asleep.
Patient is mentally tired. Speech is normal, voice clear. Moderate physique, dark skin. Poor sleep quality, particularly difficult to fall asleep after illness, requires radio to accompany sleep for 1-2 hours. Appetite normal, no symptoms of spleen and stomach discomfort. No chest oppression, mouth is normal, no headaches or dizziness, feeling mentally distressed due to illness. Bowel movement once daily, well-formed. Urination normal, nocturia 1-2 times. Normal sweating, no night sweats. No lumbar and leg soreness or weakness, no tinnitus/hearing loss. Tongue is dark red, thin white coating. Pulse is wiry, slightly rapid.
Diagnosis: Post-herpetic neuralgia: Liver yin deficiency, blood stasis.
Treatment:
1) Oral administration –
Yi GuanJin and Gualou Honghua Gancao Tang with modifications (Sheng Di Huang, Bei Sha Shen, Dang Gui Wei, Gou Qi Zi, Mai Dong, Chai Hu, Gua Lou, Hong Hua, Gan Cao, Da Huang, Mai Ya), 3 doses, taken morning and evening.
2) FireNeedles Acupuncture –
Using 3 mm moxa sticks around the chin and back of the neck (hairless areas) at the sore sites, shallow needling at intervals of 0.5-1 cm. For the hairy area on the left temple, use fine needles for needling. Also, needle bilateral Neiguan, Hegu, Zhongzhu, Waiguan, Qiu Xu, and Ashi points, even supplementation and drainage, leaving the needles in place for 15 minutes.
3) Bleeding –
Additionally, bleed from the earlobe and Longyan points, 3 ml each.
May 23, 2021 Second Consultation
Reported reduction in stabbing and burning pain intensity from 8 to 5, improved sleep due to decreased pain, able to sleep for more than 2-3 hours. Noticeable shedding of scabs at the ulcer site, only leaving behind the marks from shallow moxibustion, with the ulcer at the junction of the ear and neck also drying up slightly. However, there are still tightness and tension in the head, neck, and shoulder muscles, obvious tenderness upon palpation, and tenderness on the same side ear. Other symptoms remain unchanged. Tongue is dark red with thin, slightly yellow coating and slight tooth marks. Pulse is wiry, slightly rapid.
Diagnosis: Same as above. Treatment focuses on promoting blood circulation to relieve stasis and aiding sleep.
Treatment:
1) Oral administration –
Guipi Tang and Gualou Honghua Gancao Tang with modifications (Guipi Tang, Gualou, Honghua, Gancao, Chai Hu, Huang Qin, Da Huang), 5 doses. (Due to lack of bowel movement after the previous medication, the dosage of Da Huang and Gualou is increased, and the patient is instructed to take two doses combined in the evening if divided doses do not induce bowel movements.)
2) Acupuncture –
Needle bilateral Neiguan, Hegu, Zhongzhu, Waiguan, Qiu Xu, Zhaohai, Yifeng, Jianjing, and Ashi points, even supplementation and drainage, leaving the needles in place for 15 minutes. Since the scabs have fallen off, fireneedle acupuncture is discontinued.
3) Bleed from the earlobe
May 30, 2021 Third Consultation
Pain has basically been relieved, the ulcer has healed, and only pigmentation remains where the moxibustion marks were. However, there is still tightness in the shoulder and neck muscles, with tenderness persisting. Patient is mentally clear, sleep continues to improve. Appetite is normal, thirsty and drinks a lot. After taking the combined doses, bowel movements have increased to 2-3 times a day, with a soft consistency. Normal urination. Tongue is dark red with little coating and slight tooth marks. Pulse is wiry.
Diagnosis: Same as above. Treatment focuses on soothing tendons, promoting meridian circulation, relieving pain, and aiding sleep.
Treatment:
Oral administration –
Guipi Tang and Gualou Honghua Gancao Tang with modifications (Guipi Tang, Gualou, Honghua, Gancao, Hehuan Pi, Xiang Fu, Ge Gen, Ji Xue Teng), 5 doses.
Gua Sha and cupping –
Perform Gua Sha and cupping on the left shoulder and neck to promote meridian circulation, leave the cups in place for 10 minutes.
Summary of Pathology
Herpes zoster (shingles) is characterized by a burning sensation or neuralgia (lightning-like, stabbing pain) at the affected skin, with or without prodromal symptoms such as mild fever, fatigue, and loss of appetite. Typically, 1 to 3 days later, irregular red rash appears at the affected area (rash may also occur without prodromal symptoms). This is followed by the appearance of clusters of papules ranging from millet to mung bean size, which quickly turn into vesicles, aggregating in one or several places and arranged in a belt-like pattern. Initially, the vesicle fluid is transparent. After 5 to 7 days, it becomes turbid or partially ulcerates, becomes macerated, and exudes fluid. Finally, it dries and forms scabs. After several days, the scabs fall off. After the rash completely resolves, some patients may experience sequelae, such as persistent neuralgia for several months or longer, especially if it occurs on the face, which may affect vision and hearing.
The pathogenesis of herpes zoster involves emotional extremes leading to stagnation of liver qi, which transforms into fire; or irregular diet, excessive consumption of overly pungent or greasy foods; or overthinking injuring the spleen, leading to dampness accumulation, prolonged stagnation turning into damp-heat, etc. In short, the main pathogenesis of herpes zoster lies in “damp-heat toxic fire overflowing to the skin surface, causing obstruction in the meridians and stagnation of qi and blood flow, resulting in pain.” The traditional Chinese medicine differentiation of herpes zoster mainly includes three patterns: hyperactivity of liver and gallbladder fire, spleen deficiency with dampness, and qi stagnation with blood stasis. Traditional Chinese medicine treatment can be combined with internal administration, external washing, moist compress, topical application, acupuncture, etc.
Reflection and Insights
During the initial diagnosis, the herpetic rash was wet without exudation, indicating that it was basically under control, with only obvious residual neuralgia remaining. Therefore, reducing pain became the main treatment goal. The diagnosis was deficiency of liver yin, with internal heat attacking the liver and gallbladder meridians, triggering the overflow of damp-heat toxic fire to the skin surface, obstructing the meridians and causing pain. Therefore, the main treatment principle was to nourish yin, clear heat, and promote the circulation of blood stasis. The prescription consisted of a consistent decoction to nourish liver yin, combined with Gualou Honghua Gancao Tang to promote blood circulation and relieve constipation, mainly using Honghua to promote blood circulation and relieve depression, Gancao to replenish qi and harmonize various medicines, and Gualou to clear liver and lung fire and promote bowel movements, with the main goal of inducing diarrhea or increasing the frequency of bowel movements in patients. Additionally, fire needling was used to disperse the stagnant damp-heat and toxic pathogens, with bloodletting at the Longyan points and ear apexes. The combination of internal and external treatment allowed the pathogens to be expelled, and the meridians were unblocked.
During the second diagnosis, as the scabs fell off, the main pain points decreased, shifting attention to the secondary pain in the shoulder and neck area. Considering the close and reciprocal relationship between this pain and the long-term (over 3 weeks) severe pain, which caused tension and insomnia, it was believed that improving sleep quality could also help relax muscles, alleviate pain, and reduce its impact. Therefore, the prescription was changed to Guipi Tang to nourish the heart, benefit the spleen, and aid sleep. Furthermore, due to the lack of diarrhea after the first diagnosis, the dosage of Gualou and Da Huang was increased, and the patient was instructed to take the combined dose before bed if splitting the dose morning and evening was ineffective, to ensure the pathogens had an exit. Additionally, since the scabs had fallen and the damp-heat toxic pathogens had mostly dissipated, fire needling was discontinued, and bloodletting at the Longyan points was no longer performed.
During the third diagnosis, the residual neuralgia continued to improve, with pain decreasing by about eight to nine points, and sleep remained sound. After taking the combined dose, the patient had 2-3 bowel movements per day with loose stools. Guipi Tang was still used to nourish the heart, benefit the spleen, and aid sleep, with a reduction in the dosage of Da Huang and Gualou, and Gualou Honghua Gancao Tang was continued to promote blood circulation and relieve constipation, supplemented with scraping and cupping to promote meridian dredging and blood circulation.
On June 6, 2021, the patient accompanied her husband for a follow-up visit for eczema. When asked about her condition, she replied that the neuralgia had been eliminated, leaving only a slight tingling sensation on the left temple, which did not affect her daily life, so she did not register for consultation. The doctor advised her to massage the tingling area more and relax the muscles of the shoulders and neck to promote blood circulation.
Throughout the entire treatment process, the patient’s full trust and cooperation were obtained in terms of changing prescriptions and alternating different methods, resulting in satisfactory treatment outcomes. Among them, the most profound aspect was how to demonstrate the importance of the treatment principle of “giving the pathogens an exit” in the coordination of external and internal treatments.
