Case of Post-herpetic neuralgia

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.

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.

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. 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.

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.

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.

Pathological Summary
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.