MIAO Han-chi (缪函池), SHANG Hong-tao (商洪涛)

The Affiliated Hospital of Nanjing University of Chinese Medicine/Jiangsu Province Hospital of Chinese Medicine,Nanjing 210029, China

ABSTRACT Alopecia is a common but difficult miscellaneous disease in dermatology. Director SHANG Hong-tao believes that alopecia is often caused by exogenous cold or heat in daily life, internal damage of emotions and improper diet, leading to injury of spleen and stomach. So it can be treated with LI Dongyuan's Shengyang Sanhuo Decoction (升阳散火汤), which protects spleen and stomach. Here are 3 proved cases as evidence.

KEYWORDS Shengyang Sanhuo Decoction; Alopecia; Spleen deficiency; Experience of famous doctors

Alopecia is a common disease in dermatology.In traditional Chinese medicine (TCM), it is also called "You Feng (油风)", "Gui Ti Tou (鬼剃头)",Seborrheica Alopecia and so on[1], belonging to intractable diseases. Director SHANG Hongtao is an academic heir of a nationally renowned TCM expert in Ministry of Health. He learns from Professor LIU Shen-lin and has considerable experience in treating spleen and stomach diseases.He clinically applies Shengyang Sanhuo Decoction(升阳散火汤) and has treated dozens of patients with alopecia, with clear efficacy. The author of this paper has been learning from SHANG Hong-tao for more than a year, copying his prescriptions. SHANG Hong-tao's clinical experience in the flexible use of Shengyang Sanhuo Decoction in treating alopecia of spleen deficiency is introduced in this paper, aiming at exploring the application method of Shengyang Sanhuo Decoction in treating intractable diseases,so as to provide reference for peers. Three proved cases are as follows.

EXAMPLES OF PROVED CASES

Case 1: Mr. SHI, male, who was 39 years old,engaged in radiation related work all year round.First visit on June 5, 2018: The patient had alopecia for one year, almost lost all his hair. He slept well,with loose and sticky stools, and normal urination.The tongue was pale and fat with tooth marks, the coating was thin and white, and the pulse was stringy on the left and slow on the right. Diagnosis: Alopecia(spleen deficiency and dampness exuberance).Prescription:Rhizoma et Radix Notopterygii10 g,Radix Angelicae Pubescentis10 g, honeyRhizoma Cimicifugae10 g, vinegarRadix Bupleuri10 g,Herba Schizonepetae10 g,Radix Saposhnikoviae10 g,Radix Puerariae20 g,Radix Glycyrrhizae Praeparata5 g, stir-friedRhizoma Atractylodis15 g,Cacumen Platycladi10 g, black soybean skin 10 g,mulberry 10 g,Rhizoma Dioscoreae30 g, stir-friedBombyx Batryticatus10 g,Periostracum Cicadae10 g andRhizoma Curcumae Longae10 g. A total of 30 sets, one set per day, 2 times a day, and decocted in water for oral administration. Second visit on July 2, 2018: New black hair took up half,with loose stools but no more discomfort.Radix Puerariaein the original prescription was increased to 30 g, simmeredSemen Myristicae6 g andHerba Epimedii10 g were added. Another 30 sets were prescribed. Third visit on August 7, 2018: New black hair continued to increase compared to the status before, covering more than 3/4, with occasional loose stools but no more discomfort. RhizomaZingiberis Praeparata6 g was added to the original prescription and 30 sets were prescribed for oral administration. On a subsequent visit on September 10, 2018, the patient's head was covered with new black hair and his alopecia was cured.

Note: The middle-aged male patient, who had engaged in radiation medical work for a long time,received a certain dose of radiation. In the long term,his essence was exhausted and injured, hurting the spleen and stomach. Also, because of his irritable personality, Yang Qi (阳气) stagnated internally and fire stagnated in the spleen, he was afraid of heat and prone to diarrhea. The prescription was consisted ofRadix Glycyrrhizae Praeparata,Radix Bupleuri, honeyRhizoma CimicifugaeandRadix Puerariaefor benefiting Qi (气), invigorating spleenstomach, elevating Yang (阳) and dispersing fire,combined withRadix Saposhnikoviae,Rhizoma et Radix NotopterygiiandRadix Angelicae Pubescentisfor astringing Yin (阴), purging fire, dispelling wind and resolving dampness. The black soybean skin was used for nourishing blood and dispelling wind,Rhizoma Curcumae Longaefor breaking blood and activating Qi,Periostracum Cicadaefor dispersing wind and dissipating heat, andRadix Puerariaefor elevating Yang and relieving diarrhea as well as promoting fluid production to quench thirst. During the second visit, the patient was still suffering from loose stools caused by deficient cold of spleen and stomach for a long time, soSemen Myristicaewas added to warm spleen and stomach for activating Qi, and astringe intestine for relieving diarrhea, andHerba Epimediiwas used to supplement kidney and strength yang, and consolidate body resistance and bank up the origin.

Case 2: Miss. ZHOU, female, 19 years old, and a student. First visit on March 27, 2018: The patient had dry stools, frequent onset of head and neck eczema, severe alopecia and greasy hair that had to be washed everyday, and acne with pus head was common on the top of her head. After a meal, she had abdominal distension, fear of cold, fatigue, bitter and dry mouth, preference for hot drinks, a pale tongue with tooth marks, and a deep thready pulse.Diagnosis: Alopecia (Qi deficiency and dampnessheat). Prescription:Rhizoma et Radix Notopterygii10 g,Radix Angelicae Pubescentis10 g,honeyRhizoma Cimicifugae10 g, vinegarRadix Bupleuri10 g,Herba Schizonepetae10 g,RadixSaposhnikoviae10 g,Radix Puerariae20 g,Radix Glycyrrhizae Praeparata5 g, stir-friedRhizoma Atractylodis15 g, slicedRhizoma Curcumae Longae10 g,Radix et Rhizoma Rhei5 g (decocted later),Rhizoma Smilacis Glabrae30 g,Cacumen Platycladi10 g, stir-friedBombyx Batryticatus10 g,Periostracum Cicadae10 g,Herba Lycopi10 g and honeyCortex Mori15 g. A total of 14 sets, one set per day, 2 times a day, and decocted in water for oral administration in the morning and evening.After taking it for half a month, the eczema was improved significantly, without new acne on the top of her head. Her alopecia was significantly relieved,and defecation was once a day, without abdominal distention. The original prescription continued to be taken for 14 days. The patient reported no obvious alopecia at the subsequent visit on May 5, 2018, no recurrence of eczema, and defecation was regular for once a day.

Note: The patient was a student at school,under high study pressure. Her syndrome belonged to primordial Qi (元气) deficiency and heart fire attacking upwards, which should be treated with benefiting Qi, invigorating spleen-stomach, and clearing heart fire. "Yin-fire (阴火) means heart fire."Blazing heart-fire led to bitter mouth and halitosis.Insufficient primordial Qi and dysfunction of spleen in transportation caused accumulation of dampness and production of heat. Dampness and heat were steaming up to the head and face, so acne on the top of her head and neck recurred frequently.Dampness-heat blocked hair follicles, causing alopecia. Combination ofBombyx BatryticatusandPeriostracum Cicadaewere used for elevating clear Yang (清阳) within Yang, strengthening the effects ofRadix Bupleuri,Radix PuerariaeandRhizoma Cimicifugaein Shengyang Sanhuo Decoction. The patient had constipation, soRadix et Rhizoma Rheiand slicedRhizoma Curcumae Longaewere added to descend turbidity and remove filth. Clear Yang was able to rise, so that turbid Yin (浊阴) fell by itself, then all symptoms of the patient got better,and alopecia was also healed.

Case 3: Mr. HUANG, male, 80 years old. First visit on July 24, 2018: The patient's hair was whitish and sparse. He had poor appetite, tastelessness,defecation for every few days, a pale tongue with a thin coating, and a deep thready pulse. Diagnosis:Alopecia (deficiency of spleen and stomach).Prescription:Rhizoma et Radix Notopterygii10 g,Radix Angelicae Pubescentis10 g, honeyRhizoma Cimicifugae10 g, vinegarRadix Bupleuri10 g,Herba Schizonepetae10 g,Radix Saposhnikoviae10 g,Radix Puerariae20 g,Radix Glycyrrhizae Praeparata5 g, stir-friedRhizoma Atractylodis15 g,Caulis Spatholobi30 g,Herba Pogostemonis10 g andHerba Eupatorii6g. A total of 14 sets,one set per daily, twice a day, decocted in water for oral administration. Second visit on August 11,2018: Increased appetite after medication, with dry stools. Based on the original prescription,Rhizoma Atractylodis Macrocephalae30 g,Semen Pruni15 g andHerba Cistanches15 g were added,and stir-friedRhizoma Atractylodiswas removed.Another 14 sets were prescribed. During the subsequent visit on September 1, 2018, he had some new black hair on the top of his head and had smooth bowel movements.

Note: The patient was an octogenarian male.His liver and kidney Qi was weak, and his teeth and hair were lost. Since the liver and kidney were deficient, the spleen and stomach were also becoming weaker, leading to failure in receiving food as well as transportation and transformation, so he had difficulty moving bowels, and pooped every few days. On the basis of regulating spleen and stomach, SHANG Hong-tao addedCaulis Spatholobifor nourishing liver and kidney to cultivate the origin and consolidate the source.Herba Pogostemonisfor eliminating turbid pathogen with aromatics to support transportation and transformation.Herba Cistanchesfor supplementing kidney and moistening intestine to relax bowels, andSemen Prunifor promoting digestion and moistening intestine, thereby warming spleen and kidney Yang and eliminating Yin turbidity. During the subsequent visit,Rhizoma Atractylodis Macrocephalaewas prescribed for invigorating spleen, harmonizing spleen-stomach and benefiting Qi,Semen PruniandHerba Cistanchesfor moistening intestine to relax bowels, so as to purge Yin-fire. Therefore, transportation and transformation of spleen and stomach were gradually recovered, so that clear Yang was able to distribute food essence to the head to nourish the scalp for generating new hair.

IDEAS ON PRESCRIPTION

Etiology and pathogenesis of alopecia are not yet clear. Western medicine believes that it is often related to hormone metabolism mechanisms,immune mechanisms, immune factors, neural emergency mechanisms, genetic expression mechanisms, etc.. When treating alopecia from dysfunction of the secretion-immune-nervous system, side effects of drugs are difficult to avoid and the recurrence rate is high[2]. Finasteride and minoxidil are drugs approved by the US FDA.Although their clinical efficacy is significant, adverse reactions such as impaired sexual function and skin allergies cannot be ignored[3]. According to the TCM concept of Zang-Fu (脏腑), The heart, liver, spleen and kidney are the disease location, deficiency of viscera is the basis, and a comprehensive treatment takes into account internal wind, phlegm-dampness,blood stasis and other excessive pathogens. In the treatment, oral administration is often combined with external treatment such as acupuncture and moxibustion, external application, fumigation and washing and so on, highlighting TCM characteristics, in order to achieve better clinical efficacy. In the above-mentioned 3 cases, the patients had been sick for a long time, the spleen and stomach were weak, and spleen Yang failed to rise. The spleen-stomach injury was aggravated due to hard work, improper diet or anxiety, resulting in repeated attacks. Therefore, the treatment was based on the spleen and stomach to correct the root cause.

Etiology and Pathogenesis of Alopecia

Alopecia is recorded as "Mao Ba (毛拔)" and"Mao Zhui (毛坠)" inInner Canon of Huangdi(《黄帝内经》), "Mao Luo (毛落)" inClassic of Questioning(《难经》), "Gui Tian Tou (鬼舔头)" inGeneral Treatise on Causes and Manifestations of All Diseases(《诸病源侯论》), "Fa Zhu Tuo Fa", which refers to seborrheic alopecia inLife-saving Manual of Diagnosis and Treatment of External Diseases(《外科证治全生集》), "Zhu Fa Xuan (蛀发癣)" in XU Ke-chang'sComplete Treatise on Patterns and Treatment in External Medicine(《外科证治全书》),and "You Feng" inOrthodox Manual of ExternalDiseases(《外科正宗》), which is still in use today.

Alopecia not only affects the external image of the patient, but most of the treatment cycle is lingering, and it is also closely related to emotions,which can easily cause severe psychological pressure on the patient. Types of alopecia are not the same, but most of them are related to the root cause of heart, liver, spleen and kidney deficiency,as well as excessive manifestations resulted from dampness, stasis, heat, etc., and the disease is often caused by combination of many Zang viscera or multiple pathogenic factors. TCM syndromes are often liver and kidney deficiency, spleen deficiency and dampness exuberance, Qi and blood deficiency,as well as Qi stagnation and blood stasis. This paper focuses on the proved prescription for treating alopecia with spleen deficiency.

Ancient Ideas on How to Preserve Natural Healthy Energy of Plain Questions(《素问•上古天真论篇》) records, "For a man, at the age of 8, his kidney Qi becomes prosperous. His hair grows and the teeth begin to change... At the age of 40, kidney Qi declines, his hair begins to drop and his teeth start to wither. At the age of 48, Yang Qi over the upper part of the body collapses, his face starts to wither and his hair begins to turn white... At the age of 64, his teeth and hair begin to lose[4]." The kidney is the congenital foundation and it stores essence,transforming and generating blood to nourish hair;the spleen is the acquired foundation, and it can also be regulated and supplemented to cultivate deficiency of the congenital foundation[5].Treatise on Spleen-stomach Exuberance and Debilitation of Treatise on Spleen and Stomach(《脾胃论•脾胃胜衰论》) also records, "The pulse in stomach diseases is moderate, while the pulse in spleen diseases is slow... Yang Qi declines and fails to grow hair... or the fur is withered and the hair falls off." The spleen governs transportation and transformation, and is the acquired foundation and the origin of producing Qi and blood. Growth and nutrient supply for hair must be provided by water and grain essence transported and transformed by the spleen. If the spleen is insufficient in transportation and transformation, the origin of producing Qi and blood will be deficient,and the hair lacks nourishment, leading to withering and falling off[6].

In modern society, people's work and life pressures are increasing day by day. Many people often have imbalances in their work and rest, eat improper diets, eat cold and spicy foods, so that their spleen Qi is deficient, failing to ascend the clear and descend the turbid. Internal depletion of essence and blood leads to generation of internal Yin fire. The Yin fire damages the ascending Qi of spleen and stomach, so various diseases will come into existence. It can be seen that deficiency of spleen and stomach is the root cause of many modern diseases. SHANG Hong-tao believes that in daily life, people often get attacked by exogenous cold and heat, and internally injured by drinking and eating irregularity, abnormal emotions, etc..In the long term, the spleen and stomach can be injured. Therefore, daily maintenance for spleen and stomach should be paid attention to, so as to achieve preventive treatment of disease.

Theoretical Basis of Shengyang Sanhuo Decoction in Treating Alopecia with Spleen Deficiency

The core content of the internal injury theory initiated by LI Dong-yuan is to emphasize the role of spleen and stomach health in occurrence and development of human diseases.Treatment Experience in Regulating Spleen and Stomach of Treatise on Spleen and Stomach(《脾胃论•调理脾胃治验》) records, "Shengyang Sanhuo Decoction can treat male and female fever in the limbs,muscle heat, sinew impediment and heat, bone marrow fever, drowsiness, heat like burning, and feeling hot when touching in men and women. The disease is mostly caused by blood deficiency, or stomach deficiency and overeating cold food, which suppresses Yang Qi in the spleen-soil, and fire stagnation leads to its onset." Shengyang Sanhuo Decoction is one of the representative prescriptions of LI Dong-yuan's school of nourishing-soil. The mechanism is spleen-stomach Qi deficiency causing stagnation and the stagnation transforming fever. It is mainly used for treating fire stagnation in middle-Jiao (中焦).

Shengyang Sanhuo Decoction, as the name suggests, it focuses on dispersing.Compendium of Materia Medica(《本草纲目》) records, "light flavors belong to Yang within Yin." Shengyang Sanhuo Decoction consists ofRhizoma Cimicifugae,Radix Puerariae,Radix Bupleuri,Rhizoma et Radix Notopterygii,Radix Angelicae PubescentisandRadix Saposhnikoviaeto help the rising of Yang-Qi and relieve Yang-Qi stagnation.Radix Bupleuridisperses Shaoyang (少阳) fire,Rhizoma CimicifugaeandRadix Puerariaedisperse Yangming (阳明) fire,Rhizoma et Radix NotopterygiiandRadix Saposhnikoviaedisperse Taiyang (太阳) fire, andRadix Angelicae Pubescentisdisperses Shaoyang fire. So its intention is to disperse fire of various channels[7]. Plus, "wind can overcome dampness", various medicines for wind syndromes can also eliminate dampness and invigorate spleen. However, the cause of this disease lies in spleen-stomach deficiency, soRadix GinsengandRadix Glycyrrhizae Praeparataare used to warm spleen, stomach and primordial Qi, aiming at Qi deficiency failing to ascend.Radix Glycyrrhizaecan purge Yin-fire,Radix Paeoniae Albatastes sour and can descends, as a supplement for the ascending medicines for wind syndromes, and also a supplement for the tonifyingRadix Ginseng, It embodies LI's thought on treatment aiming at its root causes[8].

The spleen dominates transportation,transformation and absorption. Only the spleen's transportation and transformation is usual, Qi of clear Yang in the human body can rise to the brain,and body fluid can be prosperous to nourish hair to grow vigorously. If the spleen fails to transport and transform, and production of Qi and blood is insufficient, then there is no nutrient for hair, and it begins to wither and fall off. Therefore, injury in the spleen and stomach is important etiology and pathogenesis of syndromes treated by Shengyang Sanhuo Decoction. The patients often have clinical manifestations such as loss of appetite,abdominal distension, a pale fat tongue, fatigue and a deep thready pulse. DONG Li-li[9]applied Bailing Shengfa Decoction (柏苓生发汤) to treat alopecia from the perspective of spleen-stomach deficiency and upward steaming dampness-heat.After 3 months of the treatment, 38 patients had obvious improvement in hair oil, dandruff, hair loss, new growth, etc. The total effective rate was 89.47%. In addition, occurrence and development of alopecia are often related to emotional disorders,and emotional dissatisfaction is most likely to transform into fire.Discussion on the Elucidation of Five-Qi of Plain Questions(《素问•宣明五气篇》)records, "The storage of five Zang (五脏)... The spleen stores thinking." It means that emotional disorders like excessive worrying can also damage the spleen, affecting Qi-movement, transportation and transformation of the spleen, and normal growth and development of hair[10]. Shengyang Sanhuo Decoction has significant efficacy in treating fever,especially for muscle heat, stagnant heat on the head, face and five sense organs, and long-term low fever[5]. Therefore, all alopecia patients with spleen deficiency of "deficient spleen and stomach causing Yin-fire ascending" can be treated by the method of ascending clear Yang and dispersing Yin-fire.

CONCLUSION

Indications of Shengyang Sanhuo Decoction should not be limited to the disease names in western medicine. Anyone with deficient spleen and stomach and internal stagnation of fire or accompanied by dampness-heat can be treated with it after being modified based on the syndrome. After continuous development and supplementation by later generations of doctors, it has been widely used for various diseases in clinical practice, especially in treating intractable diseases, such as chronic fatigue syndrome, intractable low fever, aphtha,dizziness, diabetes, etc., with satisfying efficacy.Long-term clinical practice has shown that TCM has good efficacy in treating alopecia and is safe and reliable, with high clinical acceptance by patients and no commonly seen drug resistance of western medicine. Flexible modification of Shengyang Sanhuo Decoction in clinical practice provides theoretical support for TCM treating alopecia based on syndrome differentiation in modern society, and is of great significance to further promotion of clinical diagnosis and treatment.