Shingles Part II: TCM Differentiation and Treatment
[Caution for my readers: The information in this Shingles TCM differentiation post is intended for healthcare practitioners. Do not attempt to administer any of the suggested medicinals or supplements to yourself at the doses suggested here. Not all of the substances mentioned here are safe for every patient and they should only be prescribed by licensed practitioners.]
I have treated many cases of shingles since I started treating patients in 1998. Recently I actually broke out in shingles myself and my experience as a patient suffering from this condition taught me more about it than I ever wanted to know. Here is what I have been taught (and what I have learned) over the last 14 years about the treatment of shingles with Traditional Chinese Medicine.
The Three Most Important Things To Keep In Mind About Treating Shingles (Herpes Zoster)
- ACUPUNCTURE IS AMAZING AT RELIEVING THE ACUTE PAIN FROM SHINGLES. Everyone who is unfortunate enough to develop shingles should get acupuncture treatment as soon as possible. Not only does it alleviate the horrible pain, but acupuncture treatment during an acute shingles outbreak can significantly reduce the risk of post-herpetic neuralgia.
- Practitioners, YOU MUST NOT BE WUSSY when treating shingles. You must be assertive and you must treat quickly and frequently. Acupuncturists, please forget about that “once per week for 10 weeks” crap. You start herbs and acupuncture IMMEDIATELY upon diagnosis. If the patient can get to you within the first couple days of the rash, you treat every day for the first 5 – 7 days. Don’t make these patients wait, not even a day if you can help it. Treat even if they are also taking a pharmaceutical antiviral. Some patients may choose to let this self-limiting disease just burn itself out. That is fine, but realize there is increased risk of post-herpetic neuralgia and scarring. I always choose to treat in the elderly and for cranial nerve cases (affecting face and eye region).
- Acute attack of herpes zoster is always an excess (shi) condition. At least to some degree. There may be deficient conditions underlying the development of this illness (especially in the elderly and those with suppressed immune systems), but the acute attack is always excess and must be treated aggressively to spare the patient post-herpetic neuralgia and scarring of the skin (which is rare but is especially a concern when shingles appear on the face).
Acute pain from this condition is easy to treat and responds exceptionally well to acupuncture treatment, but post-herpetic neuralgia can be stubborn and sometimes does not respond to acupuncture treatment. So it is vital that you educate your patients about how to recognize shingles immediately so they can seek treatment as soon as possible. Patients should start antiviral therapy (western pharmaceutical or herbal) within 72 hours of the first signs of the rash erupting (FYI, Famvir is the best choice for pharmaceutical antiviral therapy against Herpes Zoster – it is more effective than Acyclovir or Valcyclovir/Valtrex). For many people, shingles will resolve with no problems even if they do not treat it. But I would not leave it up to such chance. And I would never let a case of shingles go untreated in a person over age 50 or in the case of ophthalmic zoster, regardless of patient age. Be aware that there is a version of shingles in which no lesions actually manifest on the skin. This is called zoster sine herpete and will present similar to the prodromal phase of herpes zoster without the visible rash ever coming out to the surface. It often gets misdiagnosed. Look for one-sided pain (along the rib cage, at the sternocostal joints of ribs, down one leg or one side of the face) that the patient reports as severe, burning, searing, disproportionately tender or sudden and intense, when they cannot recall any trauma or physical activity as a possible trigger.
TCM Differentiation and Herbal Treatment of Acute Herpes Zoster
Acute herpes zoster typically is either Liver & Gallbladder Damp Heat with Fire Toxin (the most common pattern), or Damp Heat in the Spleen with Fire Toxin. Either of these patterns can lead to Stagnation of Qi & Blood which is seen in post-herpetic neuralgia.
Liver & Gallbladder Damp Heat with Fire Toxin usually arises from emotional stress that caused Stagnant Liver Qi that then was constrained for a long period. This stagnant Qi develops into Heat that then “blazes” out from the channel to the skin. In all practicality, the differentiation of Liver & Gallbladder Damp Heat with Fire Toxin is not an indication that the symptoms are strictly confined to those channels alone. The patches of blisters most often will appear on the torso in the hypochondriac region (the flanks) or the lumbar region. They typically will show up first on the back just lateral to the spine or on lateral aspect of the torso and can progress along the dermatome to the anterior midline. Lumbar region vesicles can spread into the groin or even down the thigh (any aspect – anterior, lateral or posterior thigh). Sometimes the eruptions will begin on the shoulder blade or just lateral to the spine of the upper back. In cases of shingles involving the 5th cranial nerve, pain and vesicles will erupt right along the Gallbladder channel on the scalp and forehead. Know your dermatomes – this will help you predict the progression of the eruptions and “head them off at the pass” (via acupuncture, which will be discussed momentarily). In this syndrome, the vesicles usually are small and clumped close together (appearing very similar to poison ivy) in patches that form relatively linear trails and the pain from the shingles often has a burning quality to it.
In Liver & Gallbladder Damp Heat with Fire Toxin, accompanying symptoms may include bitter taste in the mouth, constipation, darker or scanty urine, dizziness, restlessness, red eyes, red facial complexion, irritability or outright anger. But let’s be realistic…when the patient is experiencing this much pain (shingles is disproportionately painful to what you will see on the surface of the skin) and itching (the lesions can get crazy itchy!), it is near impossible to be anything but restless and irritable. So that is not really very helpful diagnostic criteria. The patient’s tongue will likely be red with a yellow sticky coating, but this may not be the case if there is much underlying deficiency. The pulse will likely be wiry and rapid, even if there is underlying deficiency, as this is an indication of the acute pain and inflammation.
The Treatment Principal for Liver & Gallbladder Damp Heat with Fire Toxin is to Clear Heat, Drain Damp, and Resolve Toxins (and Stop Pain). The chief formula to accomplish this is Long Dan Xie Gan Tang (Gentiana Decoction to Drain the Liver). In simple cases (younger patients, small area of skin affected, early diagnosis/treatment), patent formulations can be effective enough if you dose high and also prescribe a concurrent antiviral formula (Chuan Xin Lian formula from Mayway is my patent of choice for adjunct antiviral therapy for shingles). Have the patient take both formulas at full dose of each (which obviously depends on which brand of pills you choose). I advise using a custom formulation in the form of decoction or granules if the pain is severe, if there is significant inflammation, if a large area of skin is involved, if the patient is over age 50, if the patient has much underlying deficiency, or if the face (cranial nerve) is involved (this is a dangerous condition). If you are making a custom formula, use Long Dan Xie Gan Tang as the base and add Ban Lan Gen (15 – 18g) and Ma Chi Xian (30g) to further Clear Toxins and for their antiviral properties (they have specific antiviral effect against herpes zoster). You can also add herbs that Move Blood to Stop Pain such as Dan Shen, Ru Xiang, Mo Yao and/or Yan Hu Suo. If the skin rash is severe, add Da Qing Ye, Lian Qiao, Ye Ju Hua, and/or Jin Yin Hua. You may also consider modifying your formulation for other symptoms such as fever or constipation. Give the patient the maximum dose of the formula appropriate for their age/size/constitution and warn the patient how bitter this formula will be. If the patient is elderly and/or has much deficiency, adjust your formula accordingly. Long Dan Cao (the chief herb in Long Dan Xie Gan Wan) is very bitter. If you feel it may be too bitter for your patient, substitute Ban Lan Gen. Keep the main treatment principal to Clear Heat and Drain Liver Fire, but add a small amount of herbs to support their constitution (such as herbs to Nourish Liv Blood /Yin, like Dang Gui). As the vesicles begin to scab over, the itching can become intense. At this stage, add herbs such as Bai Xian Pi, Fang Feng, and/or Ku Shen to further reduce itching.
Damp Heat in the Spleen develops from underlying Spleen Qi Deficiency and is more difficult to treat than Liver & Gallbladder Damp Heat with Fire Toxin. When shingles erupts on the chest, upper trunk in/near armpit, or on the face, consider this syndrome for your differentiation. To generalize (which is not always a good thing to do), the individual vesicles from Damp Heat in the Spleen are typically larger than those seen in Liver & Gallbladder Damp Heat with Fire Toxin, have thinner walls and more fluid in them. These vesicles tend to ooze more and in serious cases (like on the face), necrosis and erosion can occur, leading to scars. Vesicles of this type form a soft crust that looks like cottage cheese or cauliflower (see photo to the left) that eventually forms a black scab and can leave an erosion when the scab finally falls off (scroll down to next photo). With Damp Heat in the Spleen, accompanying symptoms can include loose stools, bloating, fatigue (though most patients will be fatigued during the viral outbreak), and poor appetite. The patient’s tongue will be puffy or flabby (or really big) with greasy coating and possibly scalloped sides. The pulse will likely be soft or slippery, but can be wiry and rapid if there is much pain and inflammation.
The Treatment Principal for Damp Heat in the Spleen is to Clear Heat and Drain Damp (and Stop Pain). The chief formula to accomplish this is Chu Shi Wei Ling Tang(Eliminate Dampness Decoction by Combining Calm the Stomach and Five-Ingredient Powder with Poria, original formula found on p. 182 Benskey). My version has a few modifications:Cang Zhu 9gChen Pi 12gZe Xie 12gChi Fu Ling 15gBai Zhu 12gFang Feng 9gZhi Zi 9gMu Tong 9gChe Qian Zi, 12gGan Cao 6g
Add Ban Lan Gen (15g) and Ma Chi Xian (30g) for their specific antiviral properties, and Da Qing Ye (12 – 15g) and/or Zi Cao (12 – 15g) to address the Heat Toxins in the skin. If there is a lot of oozing, I add Yi Yi Ren (15 – 30g). For itching, Di Fu Zi (12g) is my herb of choice here. For lesions in/around eyes add Ju Hua (9g). In the elderly or those with very weak constitution, add Huang Qi (30g) – don’t be afraid of the big dose…it needs to be big to help push out Toxins.
When the internal nerve pain caused by the herpes zoster infection becomes severe and intense, we have to consider that there is obviously Qi & Blood Stagnation. In my practice I have never seen a case of acute shingles that was purely Qi & Blood Stagnation, so I just add to the above formulas to address the Qi & Blood Stagnation accordingly. If you don’t want to make custom formulas, Evergreen Herbs makes a granule formula (available in capsules) specifically for herpes zoster. It is called Dermatrol HZ and I think it is a good formula regardless of TCM differentiation. For patients with very weak constitutions, amend your formulas with a small amount of tonics (Dang Shen or Huang Qi for general Qi Xu, Dang Gui for Blood Xu, Gou Qi Zi for Yin Xu). A decent patent formula for viral infections in a patient with a weak immune system is Astra Isatis by Health Concerns. Keep this on hand if you tend to treat many elderly or immune-compromised patients. This is also a good patent formula choice for chronic herpes zoster.
Having difficulty differentiating? You are not alone. In my case, I originally diagnosed my shingles as Fire in the Liver and Gallbladder channels because the eruptions and pain were right along the GB channel on my head, I had sudden constipation (when typically my stools tend toward loose), I was incredibly irritable and I was dealing with high stress levels (I have underlying Liv Qi Stagnation). In hindsight, I think I misdiagnosed myself. I think it was actually Damp Heat in the Spleen (underlying Spleen Qi Xu with Dampness that turned to Heat with the help of stagnation). I did not treat the Dampness enough once the scabs started to form since there was not much fluid in the vesicles…but then there was necrosis and erosion and now I have a pitted scar above my eyebrow – son of a bitch! (I’ll address how to treat that kind of scar in an upcoming post). So if your patient’s lesions begin forming that cauliflower-looking yellow crust, treat that as Damp Heat even if there hadn’t been much fluid in the original vesicle.
Acupuncture Treatment of Acute Herpes Zoster
Acupuncture is possibly the most effective method of reducing the acute nerve pain associated with shingles. You must start acupuncture treatment as soon as possible when treating shingles if you hope to reduce the likelihood of post-herpetic neuralgia. Patients should receive treatment EVERY day for the first 7 to 10 days. For patients with severe pain, twice daily acupuncture may be necessary. Wear gloves when performing acupuncture on shingles patients with acute eruptions (the vesicles may contain active virus). Patients will be far more needle-sensitive than they typically are. Do not underestimate the sensitivity of their skin and do not underestimate the severity of the internal nerve pain – it is so grossly disproportional to what you will see on the surface.
To properly choose where to needle, you must be clear which dermatomes are involved. If eruptions are on the trunk, needle the Jia Ji points associated with the affected dermatome as well as the adjacent dermatomes. I also recommend needling the points along the Kidney channel at the anterior aspect of the affected dermatome(s). Do circle needling (“surrounding the dragon”) around the patches of the vesicles. If there are many clumps of vesicles, choose the largest clumps and/or the ones that look “angriest”. Imagine that you are using your needles to corral the vesicles, to prevent them from spreading further along the nerve dermatome. Also needle LIV 14, GB 24, and SP 21. Needle points that help clear the affected channels (Shu-Stream points) and if your differentiation is Fire in the Liv & GB Channels, be sure to also needle GB 34, LIV 5, LIV 2, GB 43 and GB 44. You also can needle the Jing-Well points of affected channels or bleed them if the patient will tolerate it to help Clear Heat. General acupoints to choose from include LI 11 and LI 4 to Clear Heat; Sp 6 and Sp 10 to Move Blood; LIV 3 for pain; TW 5 to Dispel Wind from the skin if there is itching; or TW 5 + GB 41 to Move Qi along the sides of the body. For the nerve pain, needle directly into Ah Shi points. It will be quite painful to the patient, but the pain relief it can achieve will be worth it.
For shingles on the face, your main goal is to protect the health of the eye. Needle Bl 1 and GB1 as well as BL 2 and Yu Yao. This will hurt if the nerve is inflamed in this area – warn your patient. But don’t skip these points – they are invaluable. Other important points for ophthalmic zoster include Tai Yang, GB 14, GB 13, GB 15, TW 23, BL 7, ST 8 and any Ah Shi points on the scalp. Be sure to also choose points that clear the Gallbladder channel (even if your differentiation is Damp Heat in the Spleen), Triple Warmer (esp. TW 2) and the Bladder channel as these channels are along the dermatome of the 5th cranial nerve. Distal points I would needle to Clear Heat from the eye area are BL 62, LIV 2, KID 6, BL 67, GB 44 (BL and GB channels start at corners of eye). Don’t leave out the Ruler of the Face and Mouth, LI 4. Include other systemic points listed above for pain, Heat and Wind as necessary.
I highly recommend doing Plum Blossom (7 star) for shingles on the scalp as they can get really itchy and the Plum Blossom works great to reduce the itch – just don’t be too aggressive. You can also do it for smaller vesicles on the body but I do not recommend it for the big, deep vesicles seen in Damp Heat in the Spleen or for vesicles on the face. Use the disposable Plum Blossom needles so you can send one home with the patient to use daily.
The treatment of shingles may be the only time we use moxibustion to treat a hot condition. But indirect moxa can be very helpful to speed the healing of the lesions (it makes them come out faster and accelerates the course of the rash so it finishes sooner). And even though there is inflammation, the heat from the moxibustion actually feels good to the patient. I find smoky moxa poles work better than smokeless moxa, but choose your tools according to your preferences. Colleagues of mine have recommended tiger warmers for use on the face. Moxibustion can be done for 20 minutes daily. I do not allow patients to do moxibustion on themselves near their face (if you have shingles near your eye, you have to close that eye when the moxa is near and that impairs your depth perception and burns can occur easily. It would suck to have shingles and singe off your eyebrow or eyelashes).
Topical Treatment of Acute Herpes Zoster
As much as I love using herbs topically, I don’t think topical treatment is necessary for shingles. But it can be quite helpful to reduce the discomfort (especially the itching) from the rash and may help the rash heal faster. For large vesicles with much fluid in them, do not use oil-based ointments as you want air to get to the lesions. Herbal compresses, soaks or pastes are a better choice. A simple paste can be made from equal parts Shi Gao, Hua Shi and oatmeal (which helps with the itching). Grind rolled oats in a coffee grinder (or buy oat flour) and add it to the Shi Gao and Hua Shi in a jar (shake it up to mix well). Put a scoop of the dry mixture in a small bowl and add a small amount of water to form a paste. Apply this to the lesions and cover with loose gauze to avoid a mess. Alternatively, you could add 2 to 4 cups of this mixture to a bath and soak in it. I prefer to make a paste from oatmeal, Shi Gao, Hua Shi, Ma Chi Xian, Ban Lan Gen and Huang Bai, but the simpler formula will work well enough. You can also apply fresh aloe vera gel (directly from the plant). Put the cut leaf in the refrigerator to cool and then squeeze the gel from it and apply to the lesions – the cold gel is such a relief.
Any of the internal herbal formulas above can be decocted and used as a wash/soak/compress by dipping gauze into them and then applying to the skin of the affected area. Cover lightly with a dry piece of gauze to contain the mess. Do not wring out and reuse the gauze if the vesicles are fluid-filled.
Once the vesicles have dried out and are forming crusts, ointments can be applied. But I am not a fan of applying ointment to the entire rash area. You want those scabs to stay on there as long as possible so the skin beneath it has enough time to heal properly. Ointments tend to soften the scab so it may fall off too soon. I find it is better to apply ointments just around the edges of scabs to keep the skin there supple and to prevent it from being pulled too much as the scab shrinks.
Additional Treatment Considerations for Acute Herpes Zoster
- Vitamin C: to bowel tolerance (about 2000 mg BID). Helps immune system fight virus and helps with wound healing. I enjoyed the Emergen-C drink because it was refreshing when I felt like total shit with the shingles. I drank 2 packets per day and that also helped with the constipation.
- Vitamin B12: 100 mg TID of a B Complex supplement or I.M. injection of hydroxycobalamin (if you do that sort of thing…I do not). Helps with nerve pain.
- Lysine: 2000 to 4000 mg/day. Inhibits the herpes virus. (If you think that seems like a lot, consider that the vet has my 6.2 lb cat on 1000mg/day for her herpes eye infection.)
- Vitamin E: internally 400 to 800 I.U. daily. Can also apply topically to the edges of scabs or to the entire lesion once scab falls off to prevent or reduce scarring.
- If ophthalmic zoster affects the eye (lesions on the eyeball, vision problems, pain in eyeball) or the ears (pain in ear or hearing loss), the patient should see an ophthalmologist (or ENT, respectively) immediately.
- Standard Process (nutritional supplements) protocol for acute viral infections:
- St. John’s Wort (from MediHerb) 6 – 8/day – weakens the protein shell of the virus (all herpes viruses are enveloped viruses that have protein shells) and alerts the immune system
- Cataplex C 12- 15/day
- Cataplex F 12 – 15/day
- Calcium Lactate 1 tblsp/day
- Immunplex 6 – 12/day
- Thymex 12/day
- Andrographis Complex 6 – 8/day (or can take Chuan Xin Lian pian from Plum Flower instead)
Length of Treatment
If you can start treating a patient when symptoms first arise, treat them daily for the first week. The rash should stop progressing after 7 days and should be fully scabbed over and healing by day 14. The rash should be fully healed (with the exception of any fresh scars) within 21 days. Scarring may require further treatment. The nerve pain should respond to acupuncture immediately, though it will return after each treatment during the progressive phase (first 7 days). Do your best to resolve all nerve pain by day 10. If nerve pain lingers beyond one month, post-herpetic neuralgia is likely. Keep patients on the appropriate base herbal formula (based on your original differentiation) but adjust individual herbs according to the evolution of symptoms. As the condition resolves, you can transition to formulas that treat underlying constitutional imbalances, but modify to continue treating any lingering pain or skin sensitivities due to lingering Toxins (I like Zi Cao, Ye Ju Hua, Lian Qiao and Jin Yin Hua for this). The skin may remain sensitive, itchy, or tender for 2 months or so, but this is not the same as the nerve pain and is not likely to result in long-term discomfort. Patients should keep the affected skin out of the sun to avoid hyper-pigmentation of the newly healed lesions. During the entire course of treatment, patients should avoid all alcohol and spicy/greasy/fried foods until the illness is completely resolved.
TCM Differentiation of Chronic Herpes Zoster
Shingles can become a chronic condition in some individuals. It may manifest as small patch of slightly red skin that is very tender or painful. Or it may manifest as post-herpetic neuralgia that lasts months or even years. This nerve pain can be quite disabling. If you start acupuncture or herbal treatment during this phase of the illness, do not make any promises on how much you can help because this pain does not always respond to TCM treatment. But do treat it because if you can make even minor improvement of this pain it can make a huge improvement in the patient’s quality of life.
The two most common TCM patterns seen in chronic shingles are Kidney Yin Xu and Qi & Blood Xu, both of which are often complicated by some degree of Qi & Blood Stagnation. Lesions that exist in this chronic phase should not be exposed to cold or damp as any accumulation of Damp will make the condition more difficult to treat.
If you are a health care practitioner and have additional treatment options for herpes zoster , please share in the comments section below. We’d love to hear what has worked for you and your patients.
[All photos in this post are Copyright © 2012 Elsevier Inc. and used with permission]
Publish Date: March 29, 2012 *Articles may include updates since original publishing.
About the Author (Author Profile)Diana Hermann is a licensed acupuncturist and board certified in Chinese Herbal Medicine. She received her Master Degree in Acupuncture and Oriental Medicine from the Oregon College of Oriental Medicine in Portland, OR and trained in China at the Nanjing University of Traditional Chinese Medicine. Diana treats patients in her Fort Collins, Colorado clinic and hand crafts herbal skin care products for her company Zi Zai Dermatology. In 2015, she completed the Diploma In Chinese Medicine Dermatology program from Avicenna in London, UK. She completed the program for a second time in 2019 in Chicago.
Sites That Link to this Post
- What Are the Treatments for Shingles With Acupuncture? | Health & Food - Popular Question & Answer | January 13, 2014
- Is Vaccination of Children Against Varicella Zoster Responsible for Increase … – PR Web (press release) | Shingles News Today | April 30, 2014