Differential Diagnosis of Acne in Chinese Medicine
Excerpts from an interview with Doctor Yu Feng Yau of Hong Kong, in Health & Wellness Magazine, edited by Laura Stropes, L.Ac. and Janet Borges, L.Ac.
In the clinic, acne may seem a less severe complaint when compared to conditions like arthritis, infertility, and digestive disorders, but acne can dramatically affect the life of patients of any age. This is particularly true in the age of social media, where acne can be a social impediment. Thus, it is useful for practitioners to review the differentiation of the causative patterns to effectively treat it.
Acne, medically referred to as acne simplex or acne vulgaris, is a chronic inflammatory skin disease of the hair follicles and sebaceous glands, with lesions arising after blockage of the follicles by sebum. Severe acne that impacts and forms boil-like pustules is known as cystic acne. From the age of about 6 or 7, the production of sebum by the sebaceous glands steadily increases, reaching an apex during puberty as boys and girls both experience a sudden rapid increase in male hormones/androgens. The excess of sebum combined with regularly shedding dead skin cells easily block pores and lead to blackheads (open comedones that trap dirt & debris), whiteheads (closed comedones), and pimples (acne). As the greatest concentrations of sebaceous glands are on the face, upper neck, chest and scalp, this is where most acne outbreaks occur.
Many diseases that refer to acne have been recorded over time in ancient Chinese medicine books, including “pulmonary wind acne” 肺风粉刺, acne 粉刺, “facial blisters” 面疱, white thorns 酒刺, cotton sores 棉疮. “Pulmonary wind acne” 肺风粉刺 appears frequently and describes common acne vugaris. It occurs primarily in adolescence with activation of the androgen hormones, and the basic symptoms are skin lesions such as scattered acne, papules, pustules, nodules and cysts, accompanied by seborrhea.
Clinically, Chinese medicine practitioners tend to view the etiology of common acne as inseparable from heat, as evidenced by the redness and papules. However, practitioners must differentiate whether it is "true heat" or "deficiency heat". The nature of true heat is "excess” with too much heat in the body. Specific conditions may include wind-heat, damp-heat, phlegm-heat, and stagnant heat. The nature of deficiency heat is “deficient,” due to Yin deficiency leading to excessive false Yang. It can also be due to weakness of the Spleen and Stomach leading to Yin deficiency, or when the entire body is in a state of extreme deficiency leading to the distancing of Yin and Yang. All of these patterns can lead to acne. But among these, Yin deficiency with internal heat is seen most commonly in the clinic. Practitioners should treat deficiency heat by tonifying the Yin to reduce fire, emphasizing nurturing the Yin, not through using herbs to clear heat. If excessively cold or cool herbs are used to treat deficiency heat with the goals of draining fire and removing toxins, the patient will become more deficient, which can impact their long-term health.
Teenagers are active, have lots of energy, and “vigorous Qi and Blood”. However, they tend to have less healthy eating habits, such as eating fried foods, fast food, high-carb and high-fat foods such as pizza, hamburgers, and other foods that can create heat. They can also be under considerable academic and social stress. Pimples in this situation would most likely be from true heat, including wind-heat and damp-heat, and the heat will be pronounced.
Adults in their 20s and 30s also have strong Qi and Blood so acne from true heat is common, but less frequent than for teenagers. They are entering the workforce, establishing marriages and careers, having children and raising a family, so they too have lots of pressures and stress. This leads to Liver Qi stagnation, which over time creates heat, resulting in acne due to stagnant heat.
In middle age, as the hormones begin to decline, the possibility of acne from true heat lessens, and conversely the possibility of Yin deficient heat, weak Spleen and Stomach, or Qi and Blood not flowing smoothly leading to acne increases.
Of course, it is possible that a younger person might be deficient, or an older person still have vigor, so it is important to make a differential Chinese medicine diagnosis.
Gender is a factor, as well, with men tending to Yang/fire, and women tending to Yin/water. In addition, women have menstrual cycles, pregnancy, childbirth and breastfeeding to contend with, all of which affect Yin and Yang, and thus their Qi and Blood can greatly wax and wane. When women of child-bearing age experience outbreaks of acne before their period, while pregnant or before giving birth, it is most likely due to excess, whereas acne outbreaks after their period and post-partum are usually due to deficiency heat. Therefore, when treating women in this age cohort for acne, the menstrual cycle can be another indicator of the correct diagnosis.
The area on the face where the acne appears sometimes reflects which organ is unbalanced. Chin = Kidney, left cheek = Liver, forehead = Heart, right cheek = Lung, nose = Spleen. But this should only be only one factor in our assessment.
Finally, taking into account the symptoms and characteristics of how the acne presents is vital to diagnosis. If pimples are primarily red, swollen, hot, painful, then it indicates true heat. If redness, swelling, heat and pain are less pronounced, then it is likely due to deficiency heat. Pronounced itchiness is likely due to wind, and pus is usually due to dampness. If pimples expel yellow pus, then it indicates damp-heat. If fresh blood comes out after a pimple bursts, it indicates heat in blood, which is forcing the blood out erratically. If pimples congeal and harden, particularly if they do not resolve for long periods of time, we must consider blocked Qi and stagnant Blood. However, we always need to consider the entire patient presentation, not just these symptoms.
In summary, to clearly define the correct diagnosis for acne, the practitioner needs to carefully observe not just whether the pimples are inflamed, but the level of redness, swelling, pain severity, itchiness, and whether there is pus, bleeding, hardened cysts, etc. The patient’s age, gender, health history, dietary habits, emotional status, etc. are crucial to a diagnosis. By close analysis of exactly how acne presents in our patients coupled by a constitutional diagnosis, we can reach a clear TCM diagnosis to best treat patients suffering with acne.