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ERYTHEMA(ERYTHEMA MULTIFORME, EXFOLIATIVE ERYTHEMA, EYRTHEMA NODOSUM, ERYTHEMA INDURATUM)

GENERAL

Clinical Manifestations	Erythema (from the Greek erythros, meaning red) is redness of the skin or mucous membranes, caused by hyperemia (increased blood flow) in superficial capillaries. It occurs with any skin injury, infection, or inflammation. Erythema nodosum is a type of skin inflammation that is located in a part of the fatty layer of skin. Erythema nodosum results in reddish, painful, tender lumps most commonly located in the front of the legs below the knees. The tender lumps, or nodules, of erythema nodosum range in size from a dime to a quarter. It usually occurs symmetrically on the lateral side of the lower legs and occasionally on the medial side of the lower legs and buttocks. The onset is usually abrupt. The course of the disease is usually about six weeks but may last several months. Erythema induratum is a panniculitis on the calves. It occurs mainly in women, but it is very rare now. Historically, when it has occurred, it has often been concomitant with cutaneous tuberculosis, and it was formerly thought to be always a reaction to the tuberculum bacillus. Erythema multiforme (EM) is a skin condition of unknown cause; it is a type of erythema possibly mediated by deposition of immune complexes (mostly IgM-bound complexes) in the superficial microvasculature of the skin and oral mucous membrane that usually follows an infection or drug exposure. It is an uncommon disorder, with peak incidence in the second and third decades of life. The disorder has various forms or presentations, which its name reflects (multiforme, "multiform"). Target lesions are a typical manifestation. Two types, one mild to moderate and one severe, are recognized (erythema multiforme minor and erythema multiforme major). The disease mostly affects females. The lesion often appears symmetrically on the dorsum of the hand, palms, finger edges,insteps, heels,face, neck, mucous membranes of the mouth and genitalia. The patient has a feeling of burning Heat and itching. The course is usually two to three weeks, but is liable to relapse.
Treatment Principle
Herb Formulas	Erythema Multiforme: Topical: For wheals, papules and blisters: Yu Hong Gao For erosion of the skin: Yu Huang Gao Qing Dai Gao For ulcers and erosion of the mouth: Qing Guo Shui Xi Ji followed by Yang Yin Sheng Ji San For dry skin: Topical: Run Ji Gao
Points

TAI YANG ZHONG FENG (ERYTHEMA MULTIFORME)

Clinical Manifestations	Pale red eruptions Worse on exposure to Cold or cold water Better with Heat Urticaria Eczema Generalized itching Aversion to Wind Aversion to Cold T: Normal C: Thin and white P: Superficial and slow
Treatment Principle	Dispel Wind-Cold Regulate the Ying and Wei Stop itching
Herb Formulas	Ma Gui Ge Ban Tang
Points

WIND-COLD (ERYTHEMA MULTIFORME)

Clinical Manifestations	The case relapses or grows more severe when it is Cold The case becomes mild or cures itself when it is warm Dark purple maculae The skin temperature is lower toward the end of the limbs The fingers and toes may be swollen Aversion to Cold Cold extremities Abdominal pain Loose stools T: Normal C: Thin and white P: Slow and soft
Treatment Principle	Expel Wind-Cold Invigorate the Blood Remove Blood Stasis
Herb Formulas	Dang Gui Si Ni Tang modified Topical: Er Hao Xi Yao
Points

WIND-HEAT WITH PRE-EXISTING DAMPNESS (ERYTHEMA MULTIFORME)

Clinical Manifestations	Red lesions Blisters Fever Sore throat Dry mouth Sore joints Dry stools T: Red tip C: Thin or sticky yellow P: Slippery and rapid
Treatment Principle	Scatter Wind Clear Heat Dry Dampness
Herb Formulas	Gui Dan Jiang Can Tang Li Xiao Tang With marked Damp-Heat: Qing Ji Shen Shi Tang
Points

WIND-HEAT WITH BLOOD DRYNESS

Clinical Manifestations	The lesions have a slightly erythematous base The scales are dry and powdery The scales may be very thick on the scalp or Hot toxic sores The lesions have defined margins They suddenly appear after contact Papules Erythema Water blisters Maybe necrosis Maybe severe itching Maybe severe burning Maybe pain in severe cases Fever Chills Anhidrosis Pain and stiffness of the head and neck Stuffy nose Blood shot eyes Sores that are red, swollen and painful Generalized body aches and pain Headache Swollen eyes Thirst or no thirst T: Normal C: Thin white
Treatment Principle	Clear Heat Transform Dampness Reduce Fire toxicity Activate the Blood Dispel Blood Stasis Alleviate pain Dissipate nodules Alleviate itching
Herb Formulas	Da Huang Bing Pian Fang
Points

YING STAGE HEAT ENTERING THE PERICARDIUM

Clinical Manifestations	Faint erythema and purpura High fever worse at night Thirst Insomnia Major mental problems Dramatic change of personality Delirium Speech difficulty Aphasia Poor memory Dizziness Maybe fainting Maybe coma Feverish extremities T: Deep red P: Thready and rapid
Treatment Principle	Clear Heat in Pericardium
Herb Formulas	An Gong Niu Huang Wan Zi Xue Dan Qing Ying Tang
Points	To Clear Heat from the Heart: HT-3, PC-8, Sifeng, bleed Shixuan For delirium: PC-7 To detoxify: LI-11 To Pacify Heart and calm the Shen: HT-5, HT-6, HT-7 To Nourish Yin: KI-3, SP-6

WIND-DAMPNESS WITH HEAT (ERYTHEMA NODOSUM)

Clinical Manifestations	Erythema Swollen painful joints (especially lower limbs) Joints are warm to the touch (may be burning and swollen) The pain is worse at night Reduced range of motion Chills Anhidrosis Weight loss Shortness of breath Muscular atrophy Difficulty walking and moving Thirst Hemiplegia Rigidity of the limbs Headache Dizziness Vertigo Nausea Vomiting Edema Emaciation Swollen feet Numbness of the extremities Paralysis Fatigue T: Normal C: White and greasy or Thin, yellow and greasy P: Wiry and slippery or Slippery and rapid
Treatment Principle	Unblock Yang Qi Promote the movement of Qi Dispel Wind Eliminate Dampness Clear Heat Unblock the channels and collaterals Stop pain
Herb Formulas	Gui Zhi Shao Yao Zhi Mu Tang Xin Zhi Jing Fang San Xuan Bi Tang Topical: Zhi Yi Xi Fang
Points

LIVER AND KIDNEY YIN DEFICIENCY WITH BLOOD STAGNATION

Clinical Manifestations	Palmar erythema A swollen, distended, hard abdomen Obvious dilated, blue-green veins radiating out from the umbilicus Hypochondriac and abdominal pain Pain that is fixed, stabbing and /or severe Pan is worse with pressure Dark, ashen, sallow or purplish complexion Fixed, palpable masses Bleeding with clots Purple lips and conjunctiva Dark rings under the eyes Purple nails Dry, scaly skin Blue, dark or purplish discoloration of skin in small or large areas Varicose and spider veins Cold hands and feet Tendency to hemorrhage dark blood or clots Black, tarry stools T: Purple, possible purple or red spots Red purple if there is Heat Blue purple if there is Cold C: White P: Choppy or Wiry and choppy
Treatment Principle	Nourish Yin Anchor Yang Invigorate s the Blood Break up Stasis Eliminate Dampness
Herb Formulas	Xiao Yu Tang
Points

QI AND YANG DEFICIENCY WITH BLOOD STAGNATION OBSTRUCTING THE CHANNELS (NODULAR ERTHEMA NODOSUM)

Clinical Manifestations	Nodular erythema Hemiplegia Paralysis Atrophy of the lower limbs Facial paralysis Slurred speech Drooling Dry stools Frequent urination Urinary incontinence Deviation of the eyes and mouth Excess salivation Cold extremities Asthenia T: Normal C: White P: Moderate
Treatment Principle	Tonify Qi Invigorate the Blood Unblock the channels Promote movement in the limbs
Herb Formulas	Bu Yang Huan Wu Tang
Points

QI AND BLOOD STAGNATION (ERYTHEMA NODOSUM, ERYTHEMA INDURATUM)

Clinical Manifestations	Pain that is fixed, stabbing and /or severe or Pains that move around Distention Depression Irritability Pan is worse with pressure Dark complexion Fixed, palpable masses Bleeding with clots Purple lips Purple nails Dry skin Blue, dark or purplish discoloration of skin in small or large areas, Varicose and spider veins Cold hands and feet Tendency to hemorrhage dark blood or clots T: Purple, possible purple or red spots C: White P: Choppy or Wiry and choppy
Treatment Principle	Invigorate the Blood Disperse Stasis Regulate Qi Unblock the Channels
Herb Formulas	Tao Hong Si Wu Tang modified
Points

QI AND BLOOD STAGNATION DUE TO BLOOD AND YIN DEICIENCY (ERYTHEMA INDURATUM)

Clinical Manifestations	Appears mostly in young women A subcutaneous nodulation which connects with the skin and turns purple appears on the back of the calf It does not protrude, but feels solid with slight pain on pressure Alternating itching and pain It may resolve itself or become ripe and perforate which will be a deep irregular shaped ulceration Once perforated it produces a yellowish fluid because of a deep-rooted ulceration Associated with tuberculosis of the skin Soreness and pain It has a long course with a strong possibility of relapse
Treatment Principle	Replenish the Blood Enrich Yin
Herb Formulas	Liu Wei Di Huang Wan in a light salt solution Topical: For unperforated lesions: Chong He San For perforated lesions: Hua Hu Sheng Ji San
Points

JING AND YANG (CONSTITUTIONAL) DEFICIENCY (ERYTHEMA MULTIFORME)

Clinical Manifestations	Purple lesions Swelling of the fingers and toes A sensation of coldness of the skin Aversion to Cold Cold limbs Abdominal pain Unformed stools T: Pink or Pale C: Thin and white P: Soft
Treatment Principle	Harmonize the Ying Dispel Cold
Herb Formulas	Dang Gui Si Ni Tang modified Zhi Fu Tang
Points

BLOOD HEAT DUE TO BLOOD STAGNATION

Clinical Manifestations	Skin lesion in the center of the face from forehead to chin. especially in the nasal region Initially red spots which occur acutely and transiently May be followed by groups of papules and blisters Blisters may be suppurative Blisters vary in size Red spots lead to capillary dilation Tissues thicken causing hammer nose Erythema Nodulation
Treatment Principle	Cool the Blood Remove Stagnation
Herb Formulas	Liang Xue Si Wu Tang
Points

COLD-DAMP (ERYTHEMA NODOSUM)

Clinical Manifestations	Persistent purple colored nodules Arthralgia Symptoms are worse in Cold weather Edema of the legs (severe cases) T: Pale C: White and greasy P: Deep and weak or Slow
Treatment Principle	Expel pathogenic Cold Eliminate Dampness Unblock the Channels
Herb Formulas	Erythema Nodosum #1 Topical: Huo Xue Zhi Tong San Hui Yang Yu Long Gao
Points

DAMP-HEAT (ERYTHEMA MULTIFORME, ERYTHEMA NODOSUM)

Clinical Manifestations	Erythema Multiforme: Bright red maculae Vesicles which may have erosion or exudation A burning Heat sensation Itching Fever Aversion to Cold Restlessness Thirst Arthralgia Yellow urine Dry stools T: Red C: Yellow and sticky P: Slippery and rapid Erythema Nodosum: Abrupt onset Headache Sore throat Arthralgia Fever Red skin rash A burning sensation on the skin Swelling with pain Thirst Dry stools Yellow urine T: Red C: Yellow and greasy P: Slippery and rapid
Treatment Principle	Erythema Multiforme: Eliminate Heat Resolve Dampness Expel Wind Erythema Nodosum: Eliminate Heat Resolve Dampness Invigorate the Blood Unblock the Channels
Herb Formulas	Erythema Multiforme: Bei Xie Shen Shi Tang modified Qing Ji Shen Shi Tang Er Hao Shi Zhen He Ji Ying Er Shi Zhi Nei Fu Fang Yi Topical: San Shi Shui Qing Dai Gao Huang Bai San Zhi Yang Xi Yao With lesions of the mucous membranes of the mouth: Soak 15g Flos Chrysanthemi Ju Hua and 15g Flos Lonicerae Jin Yin Hua in 500 ml boiling water, let cool and rinse the mouth several times a day. Erythema Nodosum: Si Miao Yong An Tang modified Erythema Nodosum #2 Erythema Arthriticum: Jia Wei Xuan Bi Tang Erythema with Damp predominant: Chu Shi Zhi Yang Tang Topical: Fu Rong Gao Yu Lu San Qing Dai Gao Jie Du Xi Yao San Huang Xi Ji Wet Dressing Formula
Points

TOXIC HEAT OR FIRE (ERYTHEMA MULTIFORME)

Clinical Manifestations	Sudden onset Lesions may cover the whole body including the mucous membranes of the mouth and genitalia Lesions are a mixture of red papules and blisters and erosions that bleed and crust over Aversion to Cold High fever Headache Malaise Sore throat Chest pain Cough Nausea Vomiting Joint pain T: Red C: Yellow P: Slippery and rapid
Treatment Principle	Nourish Yin Clear Heat Cool the Blood Eliminate toxicity
Herb Formulas	Pu Ji Xiao Du Yin modified Cuo Chuang Jian Ji Qin Lian Jie Du Tang Ye Ju Bai Du Tang Due to an External Heat invasion which has lodged in the channels: Wu Wei Xiao Du Yin Topical: Ru Yi Jin Huang San Jia Jian San Huang Gao Topical #2 For Toxic Damp-Heat: Dermatitis Compress #3 For Toxic Blood Heat: Dermatitis Compress #2
Points