Skin Lesions and Their Manifestations

Secondary Lesions

• Represent the evolution and subsequent manifestations of primary lesions.
• Can arise naturally or as a result of treatments.

Scale

• Shedding of the uppermost layer of skin (stratum corneum).
• Dry white scale on a red background suggests Extreme Heat generating Wind.
• Dry white scale with a pale or brownish background indicates Blood Xu with Wind or Blood Stasis with Wind.
• Greasy, larger, and yellow scale suggests Damp Heat with Wind or Fire toxin.

Erosion

• Partial break in the epidermis, no scarring after healing.
• Usually occurs after scratching off vesicles, bullae, or edematous lesions.
• Always shows Damp Heat.

Ulcer

• Loss of epidermis, with scarring after healing.
• Indicates Damp Heat with Fire Toxin, on a background of Qi Xu and Blood Stasis.

Crust

• Dried exudate that forms after clear, purulent or bloody discharge.
• Golden yellow crust suggests staphylococcus, damp heat with fire toxin.
• Bloody crust indicates blood heat.
• Purulent brown crust suggests damp heat, fire toxin.

Excoriations (Scratch Marks)

• Shallow excavation in the top layer of skin from scratching.
• Bloody excoriations on a red (erythematous) background suggest blood heat with wind, light fire toxin.
• Excoriations with no red background or pale red suggest blood xu with wind.
• Excoriations with lichenification (thickening of skin) suggest blood stasis, blood xu, with wind.
• Excoriations with edematous erythema and yellow-brown scabs suggest damp heat fire toxin.

Fissure

• Cracks in the epidermis extending into the dermis.
• Often due to extreme dryness caused by heat, blood xu, fire toxin.
• Can also be due to damp heat, if accompanied by vesicles or swelling (pomphoyx eczema).

Lichenification

• Thickening of the skin with accentuation of skin creases.
• Indicates blood xu, yin xu, blood stasis.

Atrophy

• Thinning and transparency of skin caused by diminution of the epidermis, dermis, and subcutaneous tissue.
• Presents as parchment-like skin with wrinkling and loss of skin markings.
• Skin becomes fragile, easily breaking and bruising.
• Can be caused by topical steroids and certain skin diseases (lichen sclerosis and atrophicus).
• Irreversible unless very superficial.

Hypo and Hyperpigmentation

• Usually a post-inflammatory process that leaves qi and blood not harmonized in the skin.
• Can also indicate qi, blood, kidney xu.
• Sun damage can also cause it.

Essential Points for Successful Derm Treatment

• Most dermatological diseases, regardless of their cause, present with strong excess/heat.
• Heat often combines with dampness, toxins, wind, or stasis to create more complex conditions.
• Determining the location of excess factors (wei level, qi level, organ level, blood level) is crucial.
• Even chronic dermatological diseases often present with excess pathogenic factors.
• Treatment must prioritize addressing the excess (branch) before attempting tonification.
• The order of treatment is to clear, vent, or drain, followed by harmonization, then tonification.
• Symptoms such as dryness or fissures are more commonly due to heat, damp, or stasis than blood or yin deficiency.
• Cold and bitter herbs and formulas are surprisingly well tolerated over long periods, if there is no pronounced spleen qi deficiency.
• Deficient Blood or Yin with Wind is a rare pattern in clinical dermatology practice.
• Tonics are less commonly used in dermatology treatment compared to herbs that address excess.
• Mastering the therapeutic actions of herbs that expel Wind Heat, Clear Qi Level Heat, Damp Heat, Toxic Heat, and Blood Heat is essential.

Precise Diagnosis

• Morphology of skin lesions and their TCM correspondence are crucial for diagnosis.
• Tongue diagnosis is helpful but not absolute, and is trumped by the skin presentation.
• Observing the skin in an untreated state is essential for accurate diagnosis.
• Any topical creams, balms, or oils patients use can alter the appearance of lesions and obstruct the diagnosis.
• Commonly used nutraceuticals and supplements can be harmful or ineffective when there are excess factors.
• Food sensitivities are rarely relevant and should only be suspected if digestion is significantly compromised.
• Pet and dander allergies are a concern for atopic or hand eczema sufferers.
• The pulse is not particularly diagnostic in dermatology treatment.

Explore the various types of secondary skin lesions, including scales, erosions, ulcers, and crusts. This quiz delves into their characteristics, causes, and implications for treatment. Understand how these lesions evolve and the underlying conditions they signify.