Heat, Wind, and Fire

A private patient of mine has had psoriasis for the last ten years. I particularly like this patient, because although he's an organic chemist, and despite the fact that it was his job to make pharmaceuticals, he has a keen interest in herbs and actually studied Western herbalism for a number of years. Highly intelligent and open to other things, he didn't allow his Western science training to blunt his curiosity to and openness to other modalities. Which, of course, goes without saying, since he's my patient. He's also a long-time taijiquan practitioner, which is how I know him. We both attend the same push-hands club.
As I mentioned, he's had psoriasis for the last ten years, and with the application of herbal liniments, has managed to keep it in check for some time. However, it had been flaring up recently, and so he sought treatment from me.
During the intake, it became apparent that there was a lot going on. In the last few years, he's lost 25 lbs., having gone from 140 to about 115. Already thin, this made him look fairly gaunt. His sleep has been terrible, although with a mixture of Ambien and melatonin he was able to get some sleep. He had been using Valerian to help this, but it eventually lost its efficacy. More on sleep later.
Bowel movements are unremarkable, as he goes once a day. However, he does try to stay hydrated, and always has water on hand. Despite his remarkable weight loss, he's not particularly hungry. He merely grazes throughout the day. He did mention that he can't eat the same foods he used to eat and enjoy, a prime example being corn chips. He used to enjoy them, but now they produce an uncomfortable feeling in his stomach.
Memory has been poor, and his limbs easily fall asleep. Finger and toe-nails are dull, cracked and in some instances peeling away from the nail bed (this last is confined to the toes).
Most remarkable has been his pulse. It's flooding and forceful, with a floating quality, especially in the guan positions. It has also been extremely rapid: one time, topping out at 105 bpm. This is practically tachycardia, and is indicative of raging heat. While lying on the table, he even feels hot, with his skin practically radiating heat.
Given all that, you'd think his psoriasis would be out of control, but it's primarily confined to his left elbow, and a small patch on his low back. He is afraid that he may be getting psoriatic arthritis, and his joints do pop dramatically at times.
His tongue is almost normal, with a thin white coat, but with red, peeled edges and tip.
One of the first differential diagnoses I thought of was diabetes, but he doesn't truly exhibit the triad of polyphagia, polydypsia, or polyuria. Hyperthyroid is a distinct possibility, but currently, he's between jobs and doesn't have health insurance (Congressional Republicans, are you listening?). As a result, he hasn't been to the doctor in a year.
TCM pattern diagnosis was Liver Blood Deficiency leading to Wind in the skin. There is also Liver and Heart heat (if not outright Fire) which is leading to Yin deficiency (especially of the Stomach, which is why he's finding it difficult to eat). I've found the warnings of my teachers to be true: it's turning out to be a difficult case to treat.
My first concern was to drain Fire, and then to boost Blood. For points, I followed the protocol of Yan Wu:

• Qu Chi Large Intestine 11: Excellent for all heat conditions and especially good for skin conditions.
• Xue Hai Spleen 10: To invigorate the Blood. Also an excellent point for itch.
• San Yin Jiao Spleen 6: The meeting place of the three leg-yin channels, to help tonify Yin in general.
• Ge Shu Urinary Bladder 17: The Diaphragm Back-Shu point, and the Meeting Point of Blood. Crucial for any Blood pathology. I also add Dan Shu UB 19, to activate the "Four Flowers."
  
• Zu San Li Stomach 36. Pre-eminent point for building qi and Blood. I also like to add with this point Shou San Li Large Intestine 10, a favorite combo of one of my teachers.

These comprise basic points for my patient. Other points I've used have been:

• Tai Xi Kidney 3 and Qu Quan Liver 8: another good Blood building combo.
• Zu Lin Qi Gall Bladder 41, to move stagnant qi. Sometimes, I'll use this on one foot, and on the other Di Wu Hui GB 42 to clear GB channel heat.
• Xin Shu UB 15 to clear Heart Heat and calm the Spirit. This works well with Shen Dao Du 11.
• Da Zhui Du 14, to clear heat.

My patient has told me that he always feels better after a treatment. However, psoriasis is a very stubborn condition, and the needling alone is insufficient. Therefore, I've also prescribed herbs for him. In keeping with his pattern of Blood Deficiency with Wind, I prescribed Si Wu Xiao Feng Tang, Four Substances Eliminate Wind Decoction. This riff on the classical Xiao Feng San is specific for this pattern, eliminating Wind in the skin while nourishing Blood, simultaneously treating root and branch.
Initially, I followed the dosages of the individual herbs in this formula as given by Bensky in his Strategies and Formulas:

• Radix Rehmanniae Glutinosae (sheng di huang) 9g
• Radix Angelicae Sinensis (dang gui) 6g
• Hb. seu Flos Schizonepetae (jing jie) 4.5g
• Rx. Ledibouriella Saposhnikoviae (fang feng) 4.5g
• Rx. Paeoniae Rubrae (chuan xiong) 3g
• Rx. Ligustici (chuan xiong) 3g
• Cx. Dictamni Dasycarpi (bai xian pi) 3g
• Periosctracum Cicadae (chan tui) 3g
• Hb. Menthae Haplocalycis (bo he) 3g
• Rx. Angelicae Pubescentis (du huo) 2.1g
• Rx. Bupleuri (chai hu) 2.1g
• Fr. Zizyphi Jujubae (da zao) 2 pcs

To which I added:

• Cx. Moutan Radicis (mu dan pi) 6g
  
• Cx. Lycii (di gu pi) 6g

You'll notice that the doses are somewhat low, if not outright wimpy. Trusing in Bensky, I kept the doses as such for two weeks. Initially, he reported that for one hour after taking the herbs, he felt fantastic. He also slept better, feeling refreshed in the morning, but still waking once or twice during the night. However, the effect wouldn't last. So, at least it seemed that I was on the right track. After two weeks, I decided to get more aggressive with his dosages, and bumped everything up to nine grams, with the exception of Rx. Bupleuri (chai hu) which I raised to six grams, and the Rx. Rehmanniae Glutinosae (sheng di huang) which I raised to twelve grams. For help with his sleep, I also added the following:

• Concha Margarita (zhen zhu mu) 30g
• Fr. Schisandrae (wu wei zi) 6g
  
• Caulis Polygoni Multiflori (ye jiao teng) 30g

After using this combination, my patient reported an interesting occurrence. Normally, he takes 1 half an Ambien to help him sleep. After ingesting it, he knows he has 1 half-hour to prepare to sleep. With the new formula, after taking the half an Ambien, within 10 minutes he began to feel sleepy, and had to retire for the night. He slept very well.
On his last visit, I was elated to find that his pulse rate had dropped to 82 bpm, and that he had gained 2 lbs, both positive changes. Also, while away in Massachussetts, he cheated on his gluten-free diet, yet didn't suffer any ill effects, nor experience a psoriasis flare-up. Currently, he's still undergoing treatment and taking his herbs. We decided that when he doesn't have to be anywhere the next day, to leave off the Ambien and simply take the herbs, to see what happens. I look forward to seeing and noting any future progress.