Professor Liu Guobin used traditional Chinese medicine to cure a case of primary erythema limb pain

Shi-Meng Yan, Ren-Yan Huang, Wei-Jing Fan, Feng Xu, Guo-Bin Liu

Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine

Keywords:Primary erythema limb pain Traditional Chinese medicine Internal and external use Famous medical experience Guobin Liu

ABSTRACT Primary erythema limb pain is a very rare disease, and its pathogenesis is not clear. Usually, the pain symptoms of patients exist for a long time, which seriously affect the daily life of patients and increase the economic burden of patients. Professor Liu Guobin, who has been engaged in the diagnosis and treatment of peripheral vascular diseases for nearly 30 years, believes that heat-toxin and blood stasis collaterals are closely related to the disease, and emphasizes the principle of heat-toxin and evil qi causing the disease. It is emphasized that clearing heat and detoxification, promoting blood circulation and dispersing blood stasis are the main treatment principles. This paper selects a typical case to describe Professor Liu's clinical experience in the treatment of primary erythema limb pain by oral and external use of traditional Chinese medicine, so as to provide an effective method of traditional Chinese medicine for the treatment of primary erythema limb pain.?Corresponding author: Liu Guo-Bin, chief physician, doctoral supervisor, Ph.D.

Erythematous limb pain is a rare syndrome, which is typically characterized by paroxysmal swelling at the extremity of the limb, flushing skin color, elevated skin temperature and severe scorching pain [1].Legs and feet are the main affected objects, and the symptoms will worsen when the temperature is high, and can be obviously relieved when the temperature is low.In severe cases, symptoms persist and form a vicious circle.Clinically, it can be divided into primary and secondary types [2].The disease has a very high disability rate, clinical treatment is very challenging, severe cases face amputation risk [3].Current research shows that there is no specific drug for clinical treatment of this disease [4].

Liu Guobin, professor of Shanghai University of Traditional Chinese Medicine and tutor of doctoral students, chief physician of vascular surgery of traditional Chinese medicine in Shuguang Hospital affiliated to Shanghai University of Traditional Chinese Medicine, and deputy chief member of peripheral vascular branch of Chinese Traditional Medicine Association.Professor Liu has been engaged in the clinical diagnosis and treatment of peripheral vascular diseases for nearly 30 years, and has accumulated rich clinical experience in the treatment of vascular diseases of lower limbs. He believes that traditional Chinese medicine has great potential in the treatment of primary erythema limb pain and has definite curative effect.The experience of internal and external treatment of these drugs is introduced as follows.

1.Case data

The patient is a 65-year-old woman.On December 14, 2017, he went to Shuguang Hospital affiliated to Shanghai University of Traditional Chinese Medicine due to erythema of both feet with swelling and pain for 1 month.Chief complaint: erythema of both feet with swelling and pain for 1 month, aggravated for 1 week.Development and diagnosis and treatment process: The patient had redness of the back and sole of both feet with slight pruritus before January without obvious inducement, pain, skin temperature rise, self-complaint with burning sensation, and slight relief after immersion in cold water.Ten days later, erythema, pain and swelling appeared on the back of both feet, walking activity was limited, and the pain of the elevated affected limb was relieved. The patient reported that the pain was severe when heated and relieved when cooled.He went to the local hospital and was diagnosed as "erysipelas". He was treated with penicillin for antiinflammation, Nuoxinkang for promoting blood circulation and removing blood stasis, Astragalus membranaceus for invigorating qi and strengthening body resistance. The pain slightly improved, but erythema and swelling did not significantly improve.After visiting our hospital, the internal medicine department of traditional Chinese medicine diagnosed it as: swelling and pain of lower limbs to be investigated (cutaneous vasculitis?Moderate seronegative symmetrical synovitis with sunken edema syndrome?). Auxiliary examination: erythrocyte sedimentation rate, thyroid function, blood routine, electrolyte of liver and kidney function, fecal routine +OB, urine routine, cellular immunity, ANA, ENA and ANCA are all normal. Color Doppler ultrasound of veins of both lower limbs: deep veins of both lower limbs are normal.Double full dorsum MRI: edema of soft tissue on dorsum of foot, please combine with clinic.Kaishi improved microcirculation, adenosine cobalamin nutrition nerve, no obvious improvement, pain, redness and swelling increased, then transferred to our department.Inscription: Edematous erythema accompanied by pain, limited movement, reddish skin, anorexia, poor sleep, dark red tongue, thin, yellow and greasy coating, and pulse number can be seen on both feet.Physical examination: body temperature 36.5℃, heart rate 70 times/min, respiration 19 times/min, blood pressure 125/80mmHg.The dorsalis pedis artery throbs obviously, the extremity nerve feels normal, the Achilles tendon reflex and knee reflex are normal, and Babinski sign is negative.No abnormality is found in the blood flow diagram of both lower limbs.Specialized examination: swelling of both lower limbs, edematous erythema with pain on both feet, tenderness (+), high skin temperature.Combined with clinical symptoms, the diagnosis was: primary erythema limb pain.Syndrome Differentiation of Traditional Chinese Medicine: Accumulation of Heat Poison and Stagnation of Collaterals.Treatment principle: clearing heat and toxic materials, promoting blood circulation and removing blood stasis.Simiao Yongan Decoction plus Shaoyao Dihuang Decoction, honeysuckle 15 g, figwort 15g, angelica 15g, dandelion 30g, radix paeoniae rubra 15g, cortex moutan 15g, rehmannia 30g, frankincense 9g, myrrh 9g, viola yedoensis 15g, scorpion 3g, panax pseudo-ginseng 2g, licorice 9g, decocted with water, one dose daily.At the same time, Jin Huang San (composed of rhubarb, turmeric, phellodendron bark, magnolia bark, atractylodes rhizome, tangerine peel, Rhizoma arisaematis, dahurian angelica root and trichosanthin licorice root) is externall y applied, and the dressing is changed once a day for use in relieving pain (compound paracetamol tablet (ii)) and when the pain is severe.After taking the medicine for 2 days, the patient complained that the pain improved, and after 4 days, the pain in the back of the foot was obviously relieved, the redness and swelling subsided, and the pain of relieving pain was stopped.After persisting in taking the medicine for 10 days with external application of Jinhuang Powder, the pain of the affected part of the patient disappeared, erythema basically subsided, light-colored silt spots around the big toe of the foot disappeared, the patient walked freely, and recovered and was discharged from the hospital.The discharged patients took 14 doses of traditional Chinese medicine orally for consolidation treatment, and were followed up on June 21, 2018. The complaint was stable and did not recur.

According to: Primary erythema limb pain is a severe disabling syndrome with high morbidity, mortality and suicide rates.The main manifestations are triad of limb pain, redness and temperature rise, with an incidence rate of 1.3 parts per million per year [5].This kind of disease may be related to extreme burning pain at the extremities. The typical symptom is that the feet are more symmetrical than the hands, accompanied by paroxysmal symptoms, and the persistence is rare. Diagnosis is based on a detailed clinical history and physical examination. Complications are mostly caused by changes in skin barrier function, ischemia and skin nerve damage [3].The main clinical symptoms of this patient are skin erythema, severe pain, skin temperature rise, etc. No other drugs were taken before the onset of the disease, and there was no history of trauma, surgery or other diseases. Combined with platelets in the normal range, it is considered to be primary erythema limb pain. From the point of view of traditional Chinese medicine, insufficient endowment of patients leads to deficiency of vital qi in the body, deficiency of qi leads to failure of transportation and transformation, lack of power in blood circulation, resulting in obstruction of veins and blood stasis, combined with invasion of external pathogens into the body, stagnation and heat, burning blood vessels, resulting in red swelling and hot pain of feet. Heat evil competes with blood gas, forcing blood to move in disorder, spilling out of the pulse and infiltrating under the skin, resulting in erythema on the affected foot. Therefore, in the treatment, traditional Chinese medicine is given to clear away heat and toxic materials, promote blood circulation and remove blood stasis, and local application of traditional Chinese medicine ointment for clearing heat and reducing swelling is used to strengthen the overall curative effect.

2. Discussion

2.1 TCM Etiology and Pathogenesis of Primary Erythema Limb Pain

Primary erythema limb pain, which has no corresponding disease records in traditional Chinese medicine, should belong to the category of "heat arthralgia", also known as "heat pain", "damp heat fetter syndrome" and "burning pain foot" [6].The etiology and pathogenesis of primary erythema and limb pain are mostly recorded in ancient Chinese literature.For example, "Puji Fang" refers to this disease as "pain" according to its clinical characteristics. "Where pain usually occurs in limbs, its red pulse is like twining, acute pain and strong heat, pain and heat rise to whatever ..." The description is more similar to that of primary erythema limb pain, pointing out that its etiology is "all caused by excessive heat from long-term labor, damp and cool, and this disease is also caused by qi stagnation in the pulse". The disease is caused by excessive body deficiency and heat and cold and dampness."Suwen Taiyin Yangming Theory" says: "Those who are injured by dampness will receive it first.Clearly point out the relationship between damp pathogen and this disease.In addition, "Su Wen Ju Tong Lun" records: "Cold enters the collaterals and takes time, weeping but not doing it, while the guest outside the pulse has less blood, while the guest inside the pulse has no qi, so death but pain."Dampness and cold are combined, qi and blood stagnate in veins, veins are blocked and blocked, and blockage leads to pain, so limb pain is seen, and the symptoms worsen at night.It can be seen that the etiology and pathogenesis of this disease should be attributed to exogenous dampness and heat, and pain caused by obstruction of collaterals.

As the saying goes, "chronic diseases enter the collaterals and are prone to stagnation and addiction."The disease lasts for a long time and the blood stasis is blocked in the collaterals."The Secret Record of Feng's Brochure" Ceng Yun: "The ten toes of a woman's foot are fried in hot oil. This is due to the qi deficiency of Ying and Wei, the qi of dampness and toxin ... and the foot of Hong Kong. It is also due to the heat of cloud."It is pointed out that due to the deficiency of healthy qi in the body's camp and defense, yin decays and fire is extremely strong, the yang meridian of the foot three Yin San is damaged, and dampness, toxin and blood stasis stagnate in the meridians, thus causing disease [7].According to the theory of origin and syndrome of various diseases, "fu fever attacks the hands and feet, which is caused by the five zang-organs and six fu-organs of the human body. the poison gas comes from the zang-fu organs, follows the channels and collaterals, and attacks the hands and feet. therefore, the hands and feet are swollen, red and painful."Clearly point out the location and development of the disease.It is described in "The Complete Collection of Chosen Doctors, Department of Exotic Diseases" that "human feet are as red as fire and cannot fall to the ground .... The fire gathers in the center of the foot and does not disperse, so the menstrual period does not heal."Pointed out the stubborn characteristics of the disease.Chen Shiduo of the late Qing Dynasty recorded in the Secret Records of the Stone Chamber "red feet", "hand and foot pain" and "red as fire in human feet" and so on [8].Although the descriptions of this disease by doctors in past dynasties are different, they basically mentioned that damp-heat and toxic stasis are closely related to this disease, and emphasized the principle of pathogenic heat and toxic pathogens.

2.2 Western Medicine Pathogenesis of Primary Erythema Limb Pain

Primary erythema limb pain is usually caused by external contact factors, such as elevated ambient temperature, exposure to heating floor or physical activity. Therefore, the frequency of symptomatic attacks is different and often depends on exposure to these trigger factors [9].With the improvement of medical treatment level, Yang[10] et al. discovered two different point mutations of SCN9A gene for the first time. Studies have confirmed that the acquisition of functional mutation of SCN9A gene is the main cause of primary erythema limb pain. At present, more than 20 SCN9A mutations have been associated with hereditary erythema limb pain in affected families worldwide. Although closely related genetic heterogeneity has been found, the correlation between SCN9A genotype and clinical type is still puzzling. For a long time, the diagnosis and identification of related diseases mainly rely on detailed medical history inquiry and physical examination. The disease may be related to myeloproliferative diseases, connective tissue diseases and malignant tumors. Therefore, these diseases should always be excluded through comprehensive hematological examination [11].

2.3 Professor Liu's Traditional Chinese Medicine Thinking on Treating Primary Erythematosia and Limb Pain

Professor Liu believes that patients with primary erythema limb pain have insufficient endowment, yin and yang disharmony, irregular Ying and Wei, combined with exogenous heat toxin, internal burning of blood vessels, excessive blood heat, and blood stasis blocking the vena cava, thus causing red swelling and heat pain at the affected part.Heat toxin competes with blood gas, and heat evil forces blood to move in disorder, spilling out of the pulse and permeating under the skin. erythema is seen on the affected part. The traditional Chinese medicine syndromes are: accumulation of heat and toxin and stasis of collaterals. Therefore, Professor Liu adopts the principle of both internal and external treatment in treatment, and takes orally the principle of clearing away heat and toxic materials, promoting blood circulation and dispelling blood stasis.Externally apply the method of clearing away heat and toxic materials, promoting blood circulation and relieving swelling. The recipe consists of Simiao Yongan Decoction and Shaoyao Dihuang Decoction, modified and modified, combined with Jinhuang Powder for external application.In the formula, honeysuckle, dandelion, dried rehmannia root and figwort root have the effects of clearing away heat and toxic materials and cooling blood, red peony root, tree peony bark, notoginseng and the like have the effects of promoting blood circulation and removing blood stasis, angelica sinensis has the effects of enriching blood, scorpion detoxifies and resolving hard mass, unblocks collaterals and relieves pain, frankincense and myrrh have the effects of promoting blood circulation, promoting qi circulation and relieving pain, and liquorice reconcilesThe key points of syndrome differentiation are heat and blood stasis. Grasping the key points of syndrome differentiation has obvious effect.

Wu Shangxian in Qing Dynasty, focusing on the method of external treatment, Ceng Yun: "The principle of external treatment is the principle of internal treatment, and the medicine of external treatment is the medicine place of internal treatment."The other is Faer."Traditional Chinese medicine believes that the skin is the largest organ of the human body, and drugs can penetrate through the skin to reach the meridians and zang-fu organs, giving full play to the efficacy quickly, and the side effects are less when administered locally [12].Jin Huang San has the effects of promoting blood circulation, dispelling blood stasis, relieving swelling and pain, clearing heat and removing dampness. In the formula, rhubarb has the functions of clearing heat and toxic materials, promoting blood circulation and removing blood stasis.Curcuma longa can break blood, promote qi circulation, dredge channels and relieve pain. Cortex Phellodendri has effects of clearing heat, eliminating dampness, purging fire and detoxicating; Angelica dahurica has the effects of expelling wind and dampness, relieving swelling and pain. Trichosanthes root reduces swelling and expels pus. Arisaema star dries dampness and disperses stagnation; Pericarpium Citri Reticulatae and Cortex Magnolia Officinalis are vaporized and wetted; Glycyrrhiza uralensis and other herbs have better therapeutic effects [13].

3.Summary

Professor Liu believes that the primary erythema limb pain is caused by many factors such as heat accumulation in the body, resensation of wind, cold and dampness, and mutual beat and knot.In terms of treatment, it adheres to the academic thought of clearing away heat and toxic materials, promoting blood circulation and removing blood stasis, and adheres to the treatment method of combining oral administration and external application of traditional Chinese medicine. Starting from the etiology and pathogenesis, it has achieved better curative effect in clinical treatment.Patients with primary erythema limb pain mainly have the pathological characteristics of "heat" and "blood stasis". In treatment, the key pathogenesis should be grasped, accompanied by detoxification and blood cooling products.The classic records of traditional Chinese medicine state that "if the disease has a definite location, it can be applied between skin and bones and muscles, and the medicine can be wrapped and applied to block the qi, so that the medicine property can enter into the body of the patient from the pores and pass through the meridians, or be lifted out, or be dispersed with effort, thus teaching the medicine is particularly effective".The importance of external application of traditional Chinese medicine is emphasized. Its properties enter meridian points and reach the viscera along the meridian. It not only repels pathogenic factors and channels, but also regulates the viscera. Its effect is better than oral administration.

At present, a variety of local and systemic drugs have been proposed for primary erythema limb pain, but the evidence and effectiveness are very limited, and the individual reactions reported are also varied.Therefore, although there are many clinical treatments, it is not clear which single drug, drug group or non-drug intervention is generally effective [14].In short, primary erythema limb pain is rare and rarely understood. Although the latest progress has identified the genetic genes of some patients and hopes targeted therapy, there are few patients and effective experimental exploration cannot be carried out [15].In this case, this article has added literature of case nature, providing new clinical ideas for prospective study of primary erythromelalgia.(Instructor: Liu Guobin)