Purple Patch Wind, Zi Dian Feng: Lichen Planus Case Study

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One percent of the world suffers from a skin disease that has been recognized and treated by Chinese medicine (CM) for roughly 1000 Years. These patients lose their sleep and ability to concentrate on daily activities due to persistent, intense itching. Some lose confidence in public due to purple papules and plaques that develop on their body. Lichen planus, known in Chinese medicine as Zi Dian Feng (紫癫风), which means 'purple patch wind,’ has been recognized, categorized, and treated by Chinese medicine since the Song Dynasty (Al-Khafaji, 2020).

How many of the patients tossing in their beds tonight know that their condition has been long known to Chinese medicine? How many know this condition can be treated by traditional Chinese herbal medicine? How many of the practitioners reading this treat this condition or refer their patients to someone who can? Is it possible to quantify the amount of global pain that exists is from the incessant scratching of lichen planus? From how many other conditions do people suffer without knowing that other treatments exist?

Lichen planus is not the only known dermatological disease that has been categorized and treated by CM. By the end of the 17th century, Chinese medicine had categorized up to 360 skin diseases (Al-Khafaji, 2020). Diagnosis of Chinese medical dermatology diseases actually parallel Western medical diagnosis for the simple reason that skin disease presents the same visually, regardless of the observer's medical orientation. This is important in the case of a disease like lichen planus, as many patients have been offered treatments that only temporarily abate their symptoms. These patients look for other treatments, especially those deemed natural. Practitioners of CM dermatology can confidently offer treatments for Purple Patch Wind / Lichen planus and many other conditions.

Case Study Intro

This article will review the case of J.P, a 54 year old female. J.P sought treatment for lichen planus in October 2021 at the author’s clinic. The patient was treated consistently until January 2022. The author will use this patient's treatment as a medium to generally introduce lichen planus to the reader including its various types, causes, CM treatment principles involved in the treatment of lichen planus, and hopefully strike enough interest for the reader to pursue further studies in dermatology or to refer to those practitioners that specialize in this area.

Case History

In October 2021, the patient presented at the author's office for the first time and reported suffering from lichen planus for almost 8 months.

Treatments Prior To Chinese Medicine

J.P stated that she initially sought treatment with a conventional dermatologist eight months ago due to developing a "very itchy rash" with "itchy bumps". As per J.P, she was prescribed a topical steroid which the patient stated had "no effect". The patient reported that the dermatologist then prescribed topical clobetasol which had "some effect" in "flattening" the lesions and reducing itch temporarily. However, the patient reported that the clobetasol did not stop the development of newer and highly pruritic lesions elsewhere on the body, including on the soles of her feet. J.P also stated that she was left with "white spots" or hypopigmented skin in some areas where she used the topical steroid. The patient stated she would not mind this if the rash was not continuing to spread. Therefore, J.P decided to pursue a different treatment which eventually brought her to the author's office.

Information Found On Inquiry

The patient reported a long history of anxiety, successfully treated with daily medication for the last 10 years (see below).

The patient denied digestive issues and reported regular well-formed bowel movements on inquiry. The patient denied subjective feelings of cold or warmth. However, she reported a few years history of significant "hot flashes" which have subsided.

• Medications: citalopram 20 mg/day
• Vital Signs: Height: 5'5" Weight: 164 lbs HR: 68 BPM Temp: 98.3 F
• Pulse: Slightly choppy. Chi positions deep bilaterally.
• Tongue: Pink, dry, no coat, slightly scalloped edges, with a central crack starting approximately 1 inch from the tip, extending for 1.5 inches. Tongue is very stiff on protrusion.

Description of Presenting Skin Lesions

The patient presented with numerous scattered purple, polygonal, planar papules spread all over the body. Some lesions were excoriated, which is expected due to intense itching and scratching. The lesions were mostly small, usually 1 cm or less, approximately. One lesion on the back was approx 2 cm. The lesions were most numerous on the back. The patient also presented with numerous purple papules on her ankles and the dorsum of the feet, lower legs , thighs, wrists and arms. There were few scattered lesions on the soles of the feet. White waxy lines (Wickham's Striae) were slightly visible on the lesions on the dorsum of the foot near the ankle, on around lesions on the soles, and on the sides of the foot where no papules were present. Some lesions, though not many, were healed and flat with just purple hyperpigmentation remaining.

Overview Of Lichen Planus - Western/Eastern

The clinical presentation just described will make more sense with additional background information. Lichen planus is present in approximately one percent of the population. It is inflammatory in nature. There is no known cause, but it is known to be a reaction to medication for some, and viruses, particularly hepatitis C, in others (Ardell, 2022). Some consider lichen planus to be autoimmune in nature (Ardell, 2022). The disease is often self-limiting, running its course often over two years (Ardell, 2022). It can re-occur at any time. However, lichen planus can still present with extreme symptoms including erythroderma, which is when 90% of cutaneous regions are inflamed. Even in less extreme cases, the itch alone can cause significant distress due to its intensity and relentlessness.

Western medical treatment of lichen planus often focuses on management of symptoms and improving quality of life, typically offering topical steroids to reduce the surface activity and itching while the disease plays its course. However, treatment with JAK (Janus Kinase) inhibitors and anti-interleukin biologics (specifically anti IL-12/23 and anti IL-17) have started to be used by Western medicine practitioners to treat this condition as well (Bock, 2021).

In Chinese medicine, the etiology and pathological nature of the disease can manifest from both external and internal disharmonies. In many cases some combination of Wind, with both Heat and/or Damp, accumulate and bind in the skin causing stagnation of Qi and Blood. This leads to localized malnourishment of the skin that when combined with the lodged pathological factors leads to the development of disease. Some consider Toxin to develop from the obstruction of Qi and Blood as well. The Xu (2004) textbook is a worthwhile investment for any practitioner who is serious about specializing in dermatology. In that text, he quotes famous Chinese medicine dermatologist Zhu Renkang on lichen planus as follows:

Lichen planus falls into the category of zi dian feng (purple patch wind) in TCM. It is caused by the accumulation of Wind-Damp, which transforms into Toxins when retained for a prolonged period; these Toxins are obstructed in the skin and interstices (cou li) and lead to Qi stagnation and Blood Stasis. This disease should therefore be treated by arresting Wind, drying Dampness, clearing Heat, and relieving Toxicity. (Xu, 2004)

In other cases internal factors, such as Dampness, can predispose patients to attack by those from the exterior. Internal development of Damp Heat or internal Deficiency of Liver and Kidney Yin may directly result in the development of lesions in the mouth and/or genitals.

Stress is also considered a contributing factor. "My skin is as angry as I am" is what one lichen planus patient told the author almost a decade ago. In the author's experience, a high majority of the lichen planus cases treated occurred in patients with chronic or acute stress or anxiety, possibly with other negative emotions. (The author’s experience may be different from others.)

Lichen planus presents in numerous different subtypes that need to be distinguished. The subtypes of lichen planus are recognized by both Western and Chinese medicine. Further differentiation by Chinese medical pattern types are presented below.

The most common presentation of lichen planus is a localized papular form which presents with small scattered highly pruritic lesions in a symmetrical fashion on both sides of the body. While these lesions can present anywhere, they often present around the wrist, forearm, ankles, lower legs, sacrum and genitalia. Slightly larger papules can sometimes show Wickham's striae. Wickham's striae are milky-white lace like ridges which have a wax like appearance. Wickham’s striae are more likely to be seen clearly in the hypertrophic form or in oral lichen planus.

An important diagnostic feature of the localized papular form of lichen planus is that it presents with what is known as the “5Ps”: Pruritic, Purple, Polygonal, Planar, and Papular. The papules typically present with these five features. Dermnetnz.org is a great free reference material to familiarize oneself with the 5P's, every other feature of lichen planus, and many other dermatology diseases, https://dermnetnz.org/topics/lichen-planus.

Lichen planus also presents as a hypertrophic form. This involves large plaques often on the shins that can be purple, red or brown. The author has seen them hypopigmented as well, likely due to prolonged steroid usage. These plaques form from the coalescence of many papules. If the Wickham’s striae are not clearly visible, use of oil on these lesions can make Wickham’s striae more visible (Sachdeva, 2011).

Oral & genital lichen planus is also a common subtype. Often Wickham striae can be found along the sides of the tongue and cheeks. In some cases the whole tongue can be covered and it's important to be able to distinguish the Wickham's striae from thick tongue fur. The Wickham striae are not directly on the surface of the mucosa but deeper in the epidermis and will therefore present quite differently than tongue fur or even candida. It's important to check the mouth of the patient presenting with other forms of lichen planus as it often overlaps with the localized papular form and / or hypertrophic form. There is also a rare erosive form of oral and genital lichen planus which can destroy the local tissue that some believe is associated with increased chance of cancer.

The planopilaris form of lichen planus occurs on the scalp. This form involves perifollicular plugging which presents as pinpoint projections from a hair follicle or pore. Itching, scalp tenderness, and hair loss are present. The loss of hair can be permanent if scarring forms in the wake of the lesions. It is important to check the scalp of patients presenting with lichen planus elsewhere, as this form can co-exist.

The author has only seen the previous forms of lichen planus described in the clinic thus far, which only means that the author would like to clarify that he cannot corroborate textbook descriptions with clinical experience for the subtypes described in the remainder of this paragraph. For example, there is also a linear form of lichen planus, which presents as purple papules presenting in lines that often correlate with acupuncture channels, and also a pigmented/hyperpigmented form that presents without visual lesions, and only with hyperpigmentation in their wake that is very recalcitrant. There is a palmar and plantar form that may present without purple papules, appearing as hyperkeratotic growths along the edges of the fingers. These lesions can be extremely pruritic.

Chinese medicine further categorizes the presentation of lichen planus by Chinese Medicine Pattern Type. Common patterns include Binding of Wind-Heat, Accumulation and Binding of Wind Dampness, Blood Stasis in the Channels and Vessels, Damp Heat due to Spleen Deficiency, and Yin Deficiency of the Liver and Kidneys. The Damp Heat and Liver Yin Deficiency patterns often correlate with the oral and genital subtypes, however not exclusively.

Important Notes On Lichen Planus

While treating papular lesions, it is important for them to become flat before focusing the treatments on any hyperpigmentation that might have started to develop on healing lesions. Another important point is that lichen planus presents with some differences between skin colors. In some cases, Wickham striae are not as visible on darker skin (Sachdeva, 2011). However, it seems that oral lesions can appear equally across all skin types. Hyperpigmentation is known to be more recalcitrant and severe in people of color with lichen planus. The pigmented form described above, while rare, is still more common in people of color.

Differential Diagnosis

• Dx: Purple Patch Wind (lichen planus); rule out lichen simplex and rule out psoriasis.

J.P presented with the 5 Ps making confirmation of the diagnosis rather straightforward. However, for the sake of this exercise, we should compare the papular eruption seen to what might be found in lichen simplex or psoriasis.

A condition such as lichen simplex may develop at the ankles just as lichen planus. However the papules present in its early stages fail to typically be purple, planar, or polygonal. Also, the inflamed lichenified skin with accentuated skin creases that is typically seen as lichen simplex progresses is absent in lichen planus, and as such it is absent in this case.

While psoriasis can present as erythematous, itchy, papules with white scaling, the presentation and distribution is typically different than lichen planus. Psoriasis tends to start on the extensors of the extremities. While small papules can be present, especially in guttate psoriasis, they again fail to be as planar, polygonal, and even purple. The white scaling of psoriasis is different than Wickham’s Striae as well. Psoriasis scales are present at the top layer of the epidermis, the stratum corneum. Whereas Wickham Striae develop deeper in the epidermis, some say in the basal layer others in the granular layer. Covering the lesions with oil helps show the lace like white striations of Wickham striae. Psoriasis scales can often be picked at and possibly taken off leading to pinpoint bleeding. This won't occur with Wickham striae.

Chinese Medicine Pattern Diagnosis

Confirmation of the correct disease diagnosis is possibly more important or as important than pattern diagnosis in CM dermatology. However, both are actually essential to properly treat the patient.

The patterns J.P presented with included Wind Heat/ Damp Obstructing and some underlying Yin and Fluid Deficiency. The Yin and Fluid deficiency is reflected in the dry tongue with no coat with a deep central crack, as well as the history of hot flashes.

Treatment Principles & Plan for Lichen Planus with Wind Heat & Damp Obstructing The Skin

While this outbreak was almost 8 months old, due to its continued new activity, it was still treated mainly as a somewhat acute breakout with a pattern of Wind Heat and Damp Binding The Exterior. Both the overarching treatment principles employed in this case and the specific treatment principles guiding herb selection are derived from Mazin Al-Khafaji's Dermatology Diploma Course. Any errors in application are due to the author.

The primary CM Treatment Principles employed in this case (and most skin diseases I treat) are to:

1. "Drain" Pathogens (Acute Phase)
2. Harmonize (Middle Phase)
3. Tonify (Consolidation/Prevention Phase)

Specifically, in this opening phase where the lichen planus is still very active, "draining" actually will take place by venting, scattering, dispersing and generally pushing Wind, Heat, Damp, and Toxin out via the skin. Deeper Toxicity and Heat in the blood are also addressed and cleared. Important in treating lichen planus, the Luo channels need to be activated and Wind Damp expelled from the now open Luo collaterals.

The initial formula employed the following Treatment Principles and Herbs:

• Light, acrid, warm herbs Jing jie and Fang feng were used to Scatter Qi on the Surface, Trigger a Mild Sweat, and Alleviate pruritus.
• Light & cool or cold herb Niu bang zi was used to Vent Heat and Toxin from the Surface and alleviate pruritus.
• Light & cold Lian qiao was used to Scatter Wind and to Scatter and Vent Heat and Toxin From the Surface.
• To Clear Wind and Dampness from the skin, warm and acrid Qiang huo was used. It is assisted by the previously listed herbs.
• To Activate the Luo Channels, Lu lu tong was used.
• To Clear Heat from the Blood level Sheng di huang, Zi cao, and Chi shao were used.
• To Clear Toxicity from all levels Bai hua she she cao was used.
• To further alleviate pruritus, cold, bitter, and damp draining Di fu zi was used to alleviate pruritis in the lower body. Warm, acrid Xu chang qing was used to generally alleviate pruritus and expel Wind Damp. Both are known for their antipruritic properties amongst other properties.
• To guide herbs to the extremities especially the ankles, bitter, cold Luo shi teng was employed, while also assisting to expel Wind-Damp.
• Due to the dry tongue with no coating, in order to balance the potentially drying effect of the other acrid herbs, Zhi mu assisted by nourishing Yin and Fluids along with Sheng di huang.
• Gan cao was used to harmonize all the herbs.

The herbs listed above were provided to the patient in granular extract form for 14 days. The patient was instructed to take 32g of the granules per day, split into two doses. Each dose was to be mixed with 10 to 12 oz of boiling water, mixed thoroughly, and then allowed to cool to a point where there is no was chance of burning oneself before drinking. The patient was instructed to drink the herbs in between meals.

Acupuncture was not provided. For topical treatment, in order to address the intense itch, the patient was advised to buy Chuan jiao (Szechuan pepper) at a local store and to add a handful to a boiling cup of water, remove heat, cover, let cool, then to apply to itchy areas with a wet cloth. The patient was advised to avoid alcohol and spicy foods.

Discussion Of Results

Visit Two

J.P reported a significant reduction in itch at the first follow up visit, 14 days later. The patient stopped topical steroids after our initial appointment. She was mostly compliant with the herbal regimen. The patient stated that the Chuan jiao decoction was helpful in reducing itch initially, but that she no longer needed to use it as the intensity of itch had reduced with time after drinking the herbal formula. J.P reported slightly looser stools which were tolerable.

Flattening and hyperpigmentation lesions were found on dorsum of the feet and soles of the feet. Some lesions had completely healed, meaning no papular lesion or hyperpigmentation was present. On the abdomen, papular lesions were still present but had a less violaceous hue and were more erythematous. The lesions on the back sides of the arms had an erythematous hue now as well.

Progress can be noted by the reduction in itch, the clearing of some lesions on the feet, and the reduction in pigment of others. However, due to the ongoing presence of lesions on the arms and abdomen the disease was still considered to be active and we continued to "Drain" pathogens. The same formula was repeated with minor changes. Chi shao was replaced with Qian cao gen. Lian qiao was replaced with Ban zhi lian. Zhi mu was replaced by Shi gao. All changes were to better Clear Heat and Toxicity and to reduce disease activity.

Visit Three

J.P was scheduled to be seen in 3 weeks but this was pushed back to almost 5 weeks due to contracting COVID-19. As per the patient, during the initial two weeks herbs were taken daily, however on some days J.P states she only took 16g of herbs in one dosage. J.P states she saw significant improvement in the first two weeks on the second formula which sustained after stopping the herbs due to catching COVID-19. J.P reported that she started herbs again before her third appointment, but that she took them sporadically in the last 10 days.

At the third appointment, approximately 7 weeks into treatment, J.P reported going "days without itching". She presented with many previous lesions completely healed and other mostly healed, flattened, and hyperpigmented.

The patient showed significant improvement. Therefore, as the signs and symptoms had changed, the goal was to move forward with the overarching treatment plan to the Harmonization phase. This phase involved continuing to address the underlying pathological factors of the lichen planus while supplementing what was deficient in the body and addressing some other underlying patterns. In this case, it meant Tonifying Qi, Regulating Blood, and Nourishing Yin and Fluids. Together, these helped harmonize Qi and Blood and helped with the resolution of post-inflammatory pigmentation. Hyperpigmentation that follows the resolution of pathological lesions, in all disease, is due to a localized disharmony of Qi and Blood. Dan shen played an important role in this phase. The patient was instructed to finish the previous batch of herbs and then to start the new formula. The patient was provided the following granular formula, 32g per day split in two doses:

• Huang qi, Mai men dong, Sheng di huang, Xuan shen, Dan shen, Hong hua, Fang feng, Bai ji Li, Lu lu tong, Niu bang zi, Ban zhi lian, Shan yao, and Gan cao.

Visit Four

This visit was one month following the third visit. The fourth visit was 11 weeks into treatment. J.P was very happy to report "zero itch". Aside from one papule on the back, all other papular lesions were healed completely or only some hyperpigmentation was left. As J.P was feeling better, she reported only partial compliance with the herb regimen. J.P still had a majority of the herbs provided at the previous visit left. Unrelated, the patient reported fatigue since COVID-19 infection. The patient was instructed to finish the previous herbs and to return in a month.

Visit Five

J.P returned in a month, week 15, for her fifth and final visit. J.P was very happy and still surprised at how everything turned around for her. J.P inquired about what else the author and Chinese medicine can do. She reported "zero itch", some lingering post-covid fatigue, and now felt on the colder side. The one remaining papule on the back was now almost flat and was hyperpigmented and healing. Treatment moved on to the Tonifying phase which also could address the patient's fatigue and sudden coldness. The pulse was thin, weak and the chi positions were deep. The following herbs were provided in granular extract form and the patient was instructed to take 20g per day, split into two doses, for 14 days:

• Huang qi, Bai zhu, Ren shen, Fu ling, Jiu chao (wine fried) Dang gui, Bai shao, Shu di Huang, Mai men dong, Dan shen, Chai hu, Fang feng, Rou gui, Wu wei zi, Gan cao. The patient was instructed to finish the herbs and to call in at the any point in the future at the first sign of any return of symptoms.

Closing Thoughts

How many other J.P's are out there, gradually getting worse when they could be gradually getting better? I assume there are many, and I do believe that Chinese medicine can help many of them.

Therefore, if you are looking to learn more about Chinese medicine dermatology, or seek to refer your dermatology patients to a practitioner trained in dermatology, I recommend visiting the International TCM Dermatology Association.

In the author's experience, Chinese medicine can provide reliable results in the treatment of dermatology, but there are numerous factors that practitioners are up against that one should be aware of. Skin diseases can move to the extremes, for instance leading to erythroderma. So don't take skin conditions lightly. Secondly, even mild looking cases can be very recalcitrant. When patients tell you they've been on light chemotherapy for their skin condition, we should consider taking time to reflect upon the ingrained and difficult nature that even innocuous seeming skin conditions can have. Lastly, patient expectations can be challenging. Everyone wants to do things naturally, but if they're used to using topical steroids and other medications, they may not know what that means. Patients may have never seen their condition fully express itself on the skin, nor have seen it heal naturally with the production hyper- or hypopigmentation. Therefore, the practitioner needs a textbook, photo, and clinical knowledge about all the different directions the progression of disease can take, what to expect, and what to do. Fortunately, Chinese medicine has been used to treat these conditions for centuries and even millennia, and the knowledge of what to do and how the conditions will play out exists. We just have to take the time to learn it. And this is most definitely a worthwhile pursuit.

References

• Al-Khafaji, M. 2020. Dermatology In Chinese Medicine - A Clinical Overview [Webinar]. Available from https://eu-mazin-al-khafaji.myshopify.com/products/webinar-dermatology-in-chinese-medicine-a-clinical-overview
• Boch, K., Langan, E. A., Kridin, K., Zillikens, D., Ludwig, R. J., & Bieber, K. (2021). Lichen Planus. Frontiers in Medicine, 8. https://doi.org/10.3389/fmed.2021.737813
• Sachdeva S, Sachdeva S, Kapoor P. Wickham striae: etiopathogenensis and clinical significance. Indian J Dermatol. 2011 Jul;56(4):442-3. doi: 10.4103/0019-5154.84739. PMID: 21965861; PMCID: PMC3179016.
• Xu, Y. (2004). Dermatology in Traditional Chinese Medicine. Donica Publishing.