Shingles Part II: TCM Differentiation and Treatment
[Updated in 2024 to include new herbal treatment options]
I have treated many cases of shingles since I started treating patients in 1998. Recently (at the original time of writing this in 2012) 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 aggressive 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.
Acute attack of herpes zoster is always an excess (shi) condition. 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. SHINGLES NEAR THE EYE OR ON THE NOSE IS A MEDICAL EMERGENCY. REFER YOUR PATIENT TO URGENT CARE OR AN OPHTHAMOLOGIST IMMEDIATELY.
TCM Differentiation and Herbal Treatment of Acute Herpes Zoster
Acute herpes zoster typically is either Damp Heat in the Liver & Gallbladder Channels with Fire Toxin (the most common pattern), or Damp Heat with Fire Toxin in the Spleen. Either of these patterns can lead to Stagnation of Qi & Blood which is seen in post-herpetic neuralgia.
Shingles of the Body
From this photo alone, I would guess this was Damp Heat with Fire Toxin in Liv/GB Channels but Damp Heat in the Spleen is possible, too, since those are rather large vesicles with much fluid, and they extend into the axilla. In this case, the patient is young with strong vitality, so the Liver pattern is more likely than a pattern that has underlying Spleen weakness.
Damp Heat in the Liver & Gallbladder Channels with Fire Toxin is typically the TCM pattern that underlies shingles eruptions on the body (trunk, and limbs). It 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 Fire and Wind in the Liver & Gallbladder Channels 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 this pattern, 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.
Compare this to the photo below. This looks more like the pattern of Damp Heat in the Liver & Gallbladder Channels with Fire Toxin even though it appears on the face. The vesicles are small and tightly clumped with little fluid.
The Treatment Principal for the pattern of Damp Heat in the Liver & Gallbladder Channels with Fire Toxin is to Clear Heat, Drain Liver Fire, and Resolve Toxins (and Stop Pain). The chief classical formula to accomplish this is Long Dan Xie Gan Tang (Gentiana Decoction to Drain the Liver).. But to be effective for herpes zoster (shingles), the formula needs the addition of antiviral herbs and herbs to address vesicles. So we improved upon the classical formula in these ways and formulated Solution HZ: Body herbal supplement (a premade 5:1 concentrated granule formula). Give the patient a high enough daily dose (typically 10g or 12g twice per day) for this acute condition (adjusting for their age/size/constitution, of course). Warn your patient these herbs will be bitter and may trigger loose stools.
Shingles of the Head, Face, Upper Chest
Compare to photo above. I would diagnose this as Spleen Damp Heat with FIre Toxin. Note the larger vesicles and the facial edema around both eyes.
When shingles vesicles acutely erupt on the upper part of the body, this most commonly is Damp Heat with Fire Toxin in the Spleen. This pattern develops from underlying Spleen Qi Deficiency and is more difficult to treat than the previous pattern above. 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 Fire in the Liver & Gallbladder Channels, have thinner walls and more fluid in them (they are more flaccid). 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).
In this pattern, accompanying symptoms can include loose stools, bloating, fatigue (though most patients will be fatigued during the viral outbreak, regardless of which TCM pattern presents), 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 with Fire Toxin in the Spleen is to Clear Heat, Drain Damp, Resolve Toxins (and Stop Pain). The chief classical formula to accomplish this is Chu Shi Wei Ling Tang. However, there the classical formula does not address Fire Toxins and exudate and subsequent erosion of the vesicles enough. So we modified this base classical formula to make it much more targeted and effective for shingles. Our premade granule formula is called Solution HZ: Head herbal supplement. As with our formula to address shingles of the body, be sure your patient is taking a high enough dose to get therapeutic effect for such an acute case (typically 10g to 12g, twice per day unless it needs to be reduced for older or weaker patients).
Modify the Premade Formula for Pain if Necessary
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.
Each of the above mentioned CMD Skin Solutions premade granule formulas (herbal supplements) already contain a decent percentage of Yan Hu Suo to Move Blood for pain. But you could certainly add Hong Hua and Tao Ren. Chuan Xiong would be a good choice to add for intense pain of the head.
Acupuncture Treatment of Acute Herpes Zoster
In my personal (as a patient) and clinical experience, acupuncture offers possibly the most effective method of reducing the acute nerve pain associated with acute shingles outbreak. 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
Topcial herbal products 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. Good ol’ Calmine lotion is a common topical preparation to use. 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.
Once the vesicles/pustules have dried out and are forming crusts, ointments can be applied. For vesicles/pustules that have started to dry out, our Indigo Ointment is an excellent topical product to employ. It is modified from the original classical formula to include antiviral herbs for this exact use. You want those new 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. THIS IS A MEDICAL EMERGENCY.
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. This herb is already included in both of our premade herbal formulas for herpes zoster (the Solution HZ herbal supplements)
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 herbal formula (based on your original differentiation). The affected 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.
[All photos in this post are Copyright © 2012 Elsevier Inc. and used with permission]