JOURNAL OF CHINESE MEDICINE NUMBER 66 JUNE 2001


the feet than on the hands. In the early stages it is almost always asymmetrical in its distribution (affecting mostly the spaces between the 3rd


and 4th and the 4th and 5th toes,


with a circumscribed area of vesiculation and scaling. A scraping of skin examined under the microscope will easily confirm the presence of mycelium. Although very uncom- mon, it is worth mentioning here the so-called “Id reac- tion”. Fungal infection elsewhere on the body, most com- monly on the feet, may provoke an eruption of pompholyx on the hands. Confirmation of this link depends on disap- pearance of the eczema when the fungal infection is eradi- cated. In such instances successful treatment will only require resolution of the fungal infection. Contact dermatitis. Contact dermatitis (allergic or irritant) may also present with asymmetrical lesions, although it tends to affect the dorsae of the hands and feet and the sides of the fingers or toes where the epidermis is thinner and therefore more susceptible to irritants or allergens than the thicker epidermis of the palms and soles. Pustular psoriasis. Yellow pustules on an erythematous back- ground is the common presentation of this stubborn dis- ease. The pustules typically resolve within 5-8 days, leaving characteristic brown patches and desquamation. Although clear vesicles may initially appear, they tend to rapidly become cloudy with purulent fluid. Itching can also occur with pustular psoriasis, but in contrast to pompholyx ec- zema this is not so common nor as severe, with soreness and pain being a much more frequent complaint. Occasionally with infected pompholyx eczema, pustules may emerge that superficially mimic the pustules of this type of psoria- sis, however a correct diagnosis should be possible if a clear history is taken and it is noted that the pustules do not resolve into brown patches.


Differentiation and treatment


Generally speaking pompholyx eczema is not a difficult disorder to differentiate and treat successfully. However it is a dynamic condition that undergoes striking and dra- matic changes as it progresses. In order to achieve the best results it is vital to assess the relative proportion of each of the primary lesions, and reflect this in the construction of the formula. Pompholyx eczema is fundamentally a shi pattern characterised by dampness and heat with a propensity to generate fire-toxin. Thus even in the dry desquamating phase, it is wise not to totally abandon the damp-heat clearing and fire-toxin resolving medicines that form the core of treatment. This may seem contradictory, but bear in mind the common clinical finding that extreme damp in the superficial layers of the body frequently leads to dryness due to obstruction at the skin level that prevents correct nourishment. A vesicle, the primary lesion, is a clear indicator for the presence of dampness. The more numerous the vesicles, the more intense is the dampness, and the more likely it is that heat and fire-toxin is present. This is even more relevant if bullae are formed as a consequence of coalescing of vesicles.


At this stage it is crucial to use strong medicines to drain damp-heat, and resolve fire-toxin. As the condition progresses, and the vesicles are increasingly replaced by dryness and fissuring, the proportion of bitter damp-heat draining ingredients such as Long Dan Cao (Radix Gentianae Scabrae) and Huang Qin (Radix Scutellariae Baicalensis) can be reduced or removed entirely. In the same way the ingredients that deal with fire-toxin should also be ad- justed, so that the “heavier” fire-toxin resolving ingredients should also be reduced, and the balanced tipped in favour of the “lighter” fire-toxin resolving and transforming herbs. So what does lighter and heavier fire-toxin resolving


mean? It is useful to think of the fire-toxin medicines as being arranged on a spectrum. At one end sit the heavier and deeper acting ingredients such as Pu Gong Ying (Herba Taraxaci Mongolici cum Radice) and Zi Hua Di Ding (Herba Violae cum Radice) which are most appropriate for intense fire-toxin with a fulminant nature. At the other end reside the lighter acting ingredients such as Jin Yin Hua (Flos Lonicerae Japonicae) and Lian Qiao (Fructus Forsythiae Suspensae) (often also used for expelling wind-heat from the surface of the body, reflecting their lighter nature) which are more appropriate for resolving relatively super- ficial fire-toxin in the skin. In practice when resolving fire- toxin in pompholyx eczema, the differentiation into lighter and heavier resolving medicines is less critical than in some dermatological diseases (where inappropriate use of such ingredients can be associated with a clear worsening of the condition). Nonetheless if the ingredients are matched closely with the condition, a more rapid and complete cure is more readily achieved. The fire-toxin in pompholyx eczema lends itself well to


being removed from the body by clearing at all depths, thus ensuring a complete eradication, and a speedy reinstate- ment of stability. So ingredients for both resolving the fire- toxin internally, and transforming and scattering it exter- nally should be used. However as treatment progresses and the eruptions become less vesicular, and erosion, crusting and desquamation dominate the picture, it becomes in- creasingly appropriate to emphasis the more superficial acting fire-toxin resolving herbs. Wind-scattering ingredients also become more relevant


as the condition becomes drier and less vesicular. Bai Ji Li (Fructus Tribuli Terrestris) is a particularly valuable ingre- dient for treating pompholyx eczema. It can and should be used at all stage of eruption, although a larger dose (up to 30g per day) is indicated when the vesicles are replaced by dry desquamation. Bai Xian Pi (Cortex Dictamni Dasycarpi Radicis) is its natural partner, enhancing its wind-scatter- ing and anti-pruritic qualities. Erythema is an almost universal finding with the major-


ity of acute eczemas. As mentioned above though, pom- pholyx eczema is exceptional for the fact that erythema is often absent, particularly in the initial stages, and this lack of erythema is a useful indicator in differentiating this disorder from others that affect the palms or soles. This is


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