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Pompholyx eczema in 79yo

This patient is suffering so much; Thanks for taking time to read this and giving feedback!

79yo female

Chief complaint: pompholyx eczema on first on feet, then hands. History of dry/cracked heels, worsened in autumn 2019, correlated with aftermath of a course of antibiotics for bronchitis. Started in feet, now affecting hands.

Skin Appearance: see attached photos. The brown discoloration is Dermatology-M Da Huang Gao.



Bilateral soles of feet fissured, dry, with weeping of serous fluid. Use of Da Huang Gao and gauze covering, plus tight socks and sensible shoes, allow her to be able to walk, otherwise very painful. Intense itch when removing bandages, needs to scratch, which irritates the skin further.

Bilateral palms have the same fissuring, dryness, some weeping, itch, and pain. If doesn’t use Da Huang Gao and gauze, the fissuring and subsequent dryness pull on the palms so much that the fingers curl inward.

Different herbal iterations gave limited improvement: initially, formulas to treat damp heat and fire toxin healed fissuring a lot, but also induced urgent diarrhea. I’ve tried both powdered and vacuum-decoctions; the limitation with herbs is always diarrhea. (even herbs that support spleen and gently clear damp)

She was making slow but positive progress until June, when danger of potential business closure really increased stress. Since then, the fissuring and all pompholyx symptoms intensified. The inflamed area has spread to the ankles, L>R: redness, swelling, pitting edema, warm to touch, and itchy red macular lesions up lower legs, worst on SP line.

Appearance: small stature, thin physique with soft belly, thin arms and legs; fingers deformed by arthritis; bright eyes 9+, symmetry 7+, grooming 10+; rosy cheeks 2+; warm soft midline 8+; dry cracked medial heels 10+; many varicosities esp KD 3-6 area; LU10 deflated 1+; overall thin, dry skin 5+

Affect: Polite 9+, clear, witty, and direct communicator. Chatty 6+. Controlling 8+ (“fix me by next week” – humorous and also commanding). Recently feels depressed, doesn’t want to get out of bed, “I have no vim and vigor”, “what’s the point of dieting?”.

Lifestyle: owns and runs high-end interior design firm that’s been in business for 40 years, but now, like so many businesses, is in danger of closing. Does not want to retire. Drives shiny red volvo SUV. Divorced and seems content living alone. Has a son and grandkids whom she only visits with sometimes in the driveway now; she doesn’t seem too bothered by this. Rarely talks about her grandkids.

GI: eats reasonably but then snacks on chocolate and popcorn after dinner; reflux and stomach pain if overeats (often does, out of boredom). With herbs, has loose stools – urgent diarrhea. Without herbs, bm ~formed, but sticky.

Thirst, temp, sweat, urine – normal

Msk: arthritis in neck, hands, knees; often stiff, achy. R hand can be numb upon waking or with too much computer work, attributes that to neck arthritis.

Sleep: long history of taking Benadryl most nights to help with sleep. Recently poor sleep d/t stress of business.

EMO: depression, “what’s the point?” typically a firecracker, but now often doesn’t want to get out of bed. Feels manipulated by employees.

GYN: no history taken; has one child

Tongue: dusky, swollen, little/no white coat; midline crack lung area
Pulse: slippery

Saam Conformations (Excess unless noted)
LV:
SJ: bright eyes 9+, polite 9+, notices details, pink cheeks 2+, controlling 8+

HT: warm soft midline, talker 6+, lesions ht 8; erythema; skin needs moistening and cooling; neck pain

UB: not gaga about grandkids; lesions ht 8; neck pain

PC: concave lesions/fissures; lesions P8; Feels manipulated by employees.

GB: lesions P8; sudden extreme itch when removes bandages

SP: soft abdomen, diarrhea, eats carbs out of boredom, swollen L ankle, L SP line most affected, pitting edema; weepy lesions

LI: thin limbs, typically busy/productive, dry fissured skin; L SP line most affected

LU: well resourced; dry fissured skin

ST: thin limbs, swollen L ankle

KD: grooming 10+; volvo; still working at age 79; many varicosities; kd 1 area lesions

SI: Depressed. No vim and vigor. Dry cracked medial heels 10+; kd 1 area lesions

Saam treatments performed:
settled well, was v relaxed from most of these treatments
R SI+ neck pain improved
R LI+ L ankle swelling and redness decreased by end of session
R UB+ L ankle less swollen
R KD+ (“I’ve got no vim and vigor; what’s the point of dieting?”) - calm, rosy face
Bi LI+ ankle swelling and redness reduced

Despite her positive calming response and clear reduction of ankle swelling while on the table, the eczema is deteriorating.

The grossest thing in the room is the fissured skin, swollen red ankle with pitting edema.
I have no clarity on how to think about the damp/dry, interior/exterior issues.
Is this a clear Concave presentation? Does GB+ seem like a good idea?

Please send ideas and suggestions. Thank you!

Hi Fang,

Those are some serious fissures- poor lady!
My Saam miracle cure case of pompholyx was much more straightforward in terms of damp and dry. She had deep fissures, bleeding, intense itching in her hands but no weeping. She also had an inflated chest, big voice and was well resourced- ST+ was the ticket (along with UB+, P+).
This case is way more complicated.

It sounds like no Saam treatment has made a significant shift for her yet.

Since you have tried my top treatment choices for her without success, I would next focus on this part of her presentation. I am most curious about Stomach excess. The weeping is a damp exterior, her thin body is a dry interior. The pitting edema says fluid is accumulating from deficiency and could be seen as fluid on the surface. The threat to her business is a loss of resources, as well as her resistance to retiring at 79 yo! Her belly is soft- with Lung excess I would want to see an inflated belly.

From your analysis, it sounds like your impression of concave is from the fissures and feeling manipulated by employees. With the weeping and edema mixed with dryness, I don’t see the fissures as a caving in. The emotional/relationship piece might be making you wonder if she needs the convexity of GB. Instead of concave, both the physical and emotional aspects of her picture make me wonder if she is deflated. With St/Lung, I ask myself if the patient is overinflated or deflated. This is my idea but I find it really helpful.

A Lung+ would bring the dryness of metal to firm her surface while lifting and plumping her up qi. A really dramatic case of Lung+ doing just that can be found here: Slow Healing Wound Healed in 1 Treatment

It helped that the wound was on the Stomach channel but this woman’s skin was soooo dry but puffy as well.

Please let us know what you think and what happens.

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Hi Kristin, thanks for the helpful guidance, especially

I’m having a very hard time discerning ST/LU. the interior/exterior boundary seems so fluid. Last week I chose incorrectly a couple times and luckily could fix the mistake. I’ll apply this “inflation” perspective and see if that helps provide more clarity.

That slow healing wound case offers great insight. I need to noodle on all that. Will report back after seeing my patient again. thanks!