USE OF TRADITIONAL CHINESE ACUPUNCTURE FOR TREATMENT OF
PAIN AND SKIN RASH ASSOCIATED WITH SHINGLES IN A 67-YEAR-OLD
PATIENT: A CASE REPORT
Arkady Kotlyar* (PhD, CAc), Rina Brener (MD), Michael Lis (MD)
Pain Clinic, Kaplan Medical Center, Israel
*Corresponding author
Authors' Information
Arkady Kotlyar, PhD, CAc dr.kotlyar@chi-point.com
ABSTRACT
Introduction
There are several treatment options for pain associated with herpes zoster (HZ; shingles).
However, many patients, especially the elderly, experience side effects of medication.
Therefore, pain associated with the HZ infection remains a challenge for effective
management. Recently, the efficacy of acupuncture has been evaluated for pain therapy in
acute HZ. This case report describes the use of traditional Chinese acupuncture for the
treatment of pain and skin rash associated with HZ in a clinical setting.
Case Presentation
A 67-year-old Caucasian female with lower back pain (LBP) and lateral irradiation to the
left leg, accompanied by a skin rash in the lower back and pelvic area that was caused by
acute HZ, was observed at a Health Management Organization (HMO) clinic. The patient
was prescribed analgesic, antispasmodic, and antiviral medication. These medications
caused urinary retention, and the patient was directed to the Outpatient Pain Clinic of a
Medical Center for further treatment. At the Pain Clinic, the patient was prescribed an
urgent epidural steroid injection to prevent the suspected development of peripheral
neuropathy, a selective serotonin and norepinephrine reuptake inhibitor, and acupuncture.
The patient refused to receive pharmacological treatment and was treated with weekly 20minute sessions of Chinese acupuncture for five weeks.
Conclusions
The present case report describes a conceivable effect of acupuncture on acute pain caused
by HZ in a patient who could not be treated pharmacologically. Additional studies are
warranted to investigate the effect acupuncture in the management of acute and
neuropathic pain caused by HZ.
Introduction
Herpes zoster (HZ; shingles) is a viral disease caused by the varicella zoster virus (VZV),
which reactivates following primary infection with varicella (ie, chicken pox), usually
during childhood.(1) After the resolution of the original infection, the virus remains
dormant for years in the dorsal root ganglia of cranial or spinal nerves.(1) Acute HZ is
usually caused by re-activation of a latent VZV as a result of a decrease in cellular
immunity.(1) Re-activation can occur at any age; however, because it is primarily
associated with an age-related decline in cell-mediated immunity, it is more frequent in
older adults.(2,3) After re-activation, the virus is transported along peripheral nerves,
producing an acute neuritis.(1) Thus, the disease is characterized by a painful, unilateral
vesicular eruption, usually in a restricted dermatomal distribution.
Pain associated with the HZ infection is known as herpetic neuralgia. It is classified as
acute (pain preceding or accompanying the eruption of a rash that persists up to 30 days
from its onset), sub-acute (pain that persists beyond the healing of the rash but resolves
itself within four months after onset), or post-herpetic neuralgia (pain persisting for more
than four months from the initial onset of the rash).(4)
Post-herpetic neuralgia is a neuropathic pain syndrome (NPS), and is the most common
complication of HZ, mainly in patients aged 50 years and older.(3) Older age is also
associated with a greater likelihood of a more severe HZ rash.(4)
In immunocompetent patients, the primary goal of treatment for HZ is pain reduction.
Early intervention with antiviral medication can reduce the risk of complications, lower
rash severity, and accelerate its healing.(4,5) The addition of corticosteroids to antiviral
medication may further alleviate short-term HZ-related pain.(4,5)
However, pharmacological treatment can be associated with an increased risk of serious
adverse effects, especially among older adults.(5) If a patient does develop postherpetic
neuralgia, such medication as gabapentin, pregabalin, opioids, tricyclic antidepressants,
lidocaine, and capsaicin may be used for palliative treatment.(5) However, for individuals
with treatment-refractory postherpetic neuralgia, non-pharmacological approaches, which
are beneficial to patient well-being in general(4), may be considered as alternative or
intregrative treatment options, and a pain management specialist should be consulted.(5, 6)
Case Presentation
A 67-year-old Caucasian female suffering for a week from lower back pain (LBP) and
lateral irradiation to the left leg was observed at a Health Management Organization
(HMO) clinic. The patient was a heavy smoker, previously diagnosed with pneumonia and
moderate-to-severe chronic obstructive lung disease (COPD). Also, in the past, the patient
underwent ablation for atrial fibrillation and flutter.
During the first two weeks of observation at the HMO clinic, the patient was
symptomatically prescribed oral Spasmalgin (Acetaminophen, Atropine SO4, Codeine PO4,
and Papaverine HCl) and thereafter Tramadex (Tramadol Contramid). Both medications
had no therapeutic effect but caused urinary retention and dryness in the mouth. Ten days
post-onset of LBP, unilateral itching and a painful rash appeared in the lower back and
pelvic area. About three weeks post-onset of LBP, after the appearance of the rash, the
patient was diagnosed with acute HZ. The diagnosis was based on the anamnesis and the
clinical picture. Considering the symptoms and the patient’s age, no additional analyses
were required to confirm the diagnosis.(1-4) Therefore, the patient was prescribed daily oral
Zovirax (Acyclovir) for a week. During the treatment, the patient began to experience
severe pain in the abdominal area. As a result, the treatment with Zovirax was discontinued
after three days. About four weeks post-onset of LBP, the patient went through an
abdominal computer tomography (CT) examination that did not reveal any dysfunction.
Because pharmacological treatment had no positive effect, five weeks post-onset of LBP,
the patient was prescribed oral Optalgin (Dipyrone) and Bondormin (Thienodiazepine, a
Benzodiazepine analog), and directed to the Outpatient Pain Clinic of a Medical Center for
further treatment.
Six weeks post-onset of LBP, the patient presented herself at the Outpatient Pain Clinic.
Considering the duration of the disease, and to prevent the suspected development of
postherpetic neuralgia and peripheral neuropathy, the patient was prescribed an urgent
epidural steroid injection (ESI) and treatment with Cymbalta (Duloxetine HCl). In
addition, acupuncture was recommended. The patient refused to receive pharmacological
treatment and started the acupuncture treatment on the same day. The patient was treated
with two 20-minute sessions of Chinese acupuncture per week for the first two weeks and
thereafter, with three additional weekly 20-minute sessions.
Acupuncture Treatment
Pain
Severe deep and distending pain originated in the left-side lower back area and worsened at
night. The pain irradiated laterally through the pelvic area, along the route of the
Gallbladder (GB) meridian, particularly through the GB 30 (Huantiao) point to the right
foot.
Rash
The observed rash was manifested by clusters of brownish crusted grain-sized vesicles
categorized in Chinese medicine as snake string sores (she chuan chuang). The rash was
distributed along a dermatome innervated by certain peripheral nerves.
Pulse Diagnosis
The pulse was Floating (fumai). On the left hand, in the Guan and Chi positions,
Gallbladder (GB) and Pericardium (PC) excess (shi), respectively, was detected. On the
right hand, in the Cun and Chi positions, Lung (LU) and Kidney (KI) deficiency (xu),
respectively, was detected.
Tongue Diagnosis
The tongue was slightly red, without coating. Red points (dian) were located between the
center and the tip of the tongue (chest area).
Treatment Protocol
The following acupuncture points were used:
1st session – GB41 (Zulinqi) left, SP6 (Sanyinjiao) bilaterally, ST36 (Zusanli) bilaterally,
LI4 (Hegu) bilaterally, LU10 (Shousanli) bilaterally, LI11 (Quchi) bilaterally, KI27
(Shufu) bilaterally, KI3 (Taixi) bilaterally;
2nd session – LV3 (Taichong) bilaterally, KI3 (Taixi) bilaterally, LU9 (Taiyuan) bilaterally,
LU10 (Shousanli) bilaterally, M-HN3 (Yintang), KI27 (Shufu) bilaterally;
3rd session – GB41 (Zulinqi) left, ST36 (Zusanli) left, KI 3 (Taixi) bilaterally, LU10
(Shousanli) left, LU7 (Lieque) left, TH5 (Waiguan) right, LI11 (Quchi) bilaterally;
4th session – LV3 (Taichong) left, SP3 (Taibai) left, KI3 (Taixi) bilaterally, LU7 (Lieque)
bilaterally, PC6 (Neiguan) right, M-HN3 (Yintang);
5th session – LV3 (Taichong) bilaterally, SP3 (Taibai) bilaterally, SP6 (Sanyinjiao)
bilaterally, PC6 (Neiguan) bilaterally, M-HN54 (Anmian) bilaterally, M-HN3 (Yintang);
After the fifth session, the patient no longer felt any pain and discontinued the treatment.
Discussion
Pain is the most common complication of HZ that significantly reduces the quality of life
of the affected individual.(1,7) Recently, the efficacy of acupuncture therapy for herpetic
pain has been evaluated in controlled clinical trials.(7,8,9) According to a review by the
World Health Organization, the use of acupuncture in HZ therapy is classified in the
category “Diseases, symptoms or conditions for which the therapeutic effect of
acupuncture has been shown but for which further proof is needed”.(9)
In the present case, considering the adverse reactions to pharmacological treatment and the
patient’s refusal to receive ESI or any additional pharmacological treatment, not many
treatment options were available. On the other hand, considering the age of the patient, a
high risk of postherpetic neuralgia and peripheral neuropathy was a concern.(3) Therefore,
acupuncture was suggested as preferred treatment and started at the acute to sub-acute
phase of HZ.
Pain and Rash Symptoms
The localization of the pain indicated that an external pathogen invaded the nerve ganglia
along the affected segment of the corresponding dermatome. The character of the pain was
interpreted as a sign of Qi stagnation and Blood stasis.(10,11)
Usually, skin rash appears in the initial phases of HZ, a couple of days post-onset of the
pain.(12) In the present case, the rash appeared 10 days post-onset of the pain. Considering
that the patient had COPD and cardiac problems in the past, the severity of the pain and the
delay in the appearance of the skin rash can be explained by a deficiency of the Defensive
(Wei) Qi and Blood stasis.(13) Thus, the invasion of the external pathogen increased the
existing internal imbalances of Qi and Blood.(13,14)
The rash was itching and painful and corresponded to Wind-Heat when it first appeared.
However, by the time that the patient presented herself at the Outpatient Pain Clinic, the
rash became crusted and did not itch, although it remained painful. This changed character
of the rash indicated Damp-Heat. The changes in the character of the rash were interpreted
as an invasion of Toxic Wind that was challenged by Qi and Blood circulation.(10)
Conceivably, the increase of Qi and Blood circulation, which was already imbalanced,
obstructed the channels and vessels, and augmented the pain.
Pulse and Tongue Diagnosis
Pulse diagnosis corresponded to Wind-Heat shi, and LU and KI xu. The color and shape of
the tongue represented Heat. Lack of coating represented empty Heat derived from Yin xu,
while dian in the chest area represented Heat in the lungs.(15,16) According to Five
Elements, the clinical manifestations corresponded to the pattern of Fire insulting
Water.(13)
Treatment principle
Point selection was based on the patient’s complaints, conventional diagnosis, and the
findings obtained in the pulse and tongue diagnostics prior and during each acupuncture
session. To alleviate pain and heal the rash, the treatment rationale was to expel Wind-Heat
and fortify LU and KI.(Error! Reference source not found.18,18) The acupuncture points were selected
to achieve the following:









LU7 (Lieque), LU9 (Taiyuan) to pacify Wind and tonify the Lung;
LU10 (Shousanli) to clear Lung Heat;
LI4 (Hegu), LI11 (Quchi), GB41 (Zulinqi), TH5 (Waiguan) to expel Wind Heat;
ST36 (Zusanli), SP3 (Taibai), SP6 (Sanyinjiao) to tonify Qi, nourish blood and
Yin, calm the spirit, and alleviate pain;
SP10 (Xuehai) to cool blood and benefit the skin;
KI3 (Taixi) to tonify Kidney Yang, anchor the Qi, benefit the Lung, and alleviate
pain;
KI27 (Shufu), PC6 (Neiguan) LV3 (Taichong) to clear Heat, calm the spirit, unbind
the chest, and regulate Qi;
M-HN3 (Yintang) to pacify Wind, calm the spirit, and alleviate pain;
M-HN54 (Anmian) to calm the spirit;
After the first session, the skin rash turned pale, and the patient felt a significant decrease
in the severity of the pain. The reduction in pain severity continued throughout the course
of treatment. After the fifth session, the patient no longer felt any pain and discontinued
treatment.
According to the classification of herpetic pain, prior to acupuncture treatment, the patient
was experiencing acute to sub-acute pain.(4) Acupuncture affected the course of the disease,
and NPS did not develop. Taking into consideration that in the absence of NPS, HZ is
time-limited, it is impossible to claim that acupuncture alone resolved the disease.
Additional studies are necessary to investigate the effect of acupuncture on HZ-related pain
and the development of the disease.
Conclusions
The present case report describes a conceivable effect of acupuncture on acute to subacute
pain caused by HZ in a patient who could not be treated pharmacologically. Therefore, in
the present case acupuncture was the available treatment method. However, additional
studies are warranted to investigate the effect acupuncture in the management of acute and
neuropathic pain caused by HZ.
References
1. Johnson RW. Herpes Zoster and Postherpetic Neuralgia. Expert Rev Vaccines.
2010;9(3s):21-26.
2. McElhaney JE. Herpes zoster: a common disease that can have a devastating impact on
patients' quality of life. Expert Rev Vaccines. 2010 Mar;9 (3 Suppl):27-30.
3. Sampathkumar P, Drage LA, Martin DP: Herpes zoster (shingles) and postherpetic
neuralgia. Mayo Clin Proc 2009, 84(3):274-280.
4. Schmader KE, Dworkin RH. Natural history and treatment of herpes zoster. J Pain.
2008 Jan;9(1 Suppl 1):S3-9.
5. Tyring SK. Management of herpes zoster and postherpetic neuralgia. J Am Acad
Dermatol 2007;57:S136-42.
6. Fleckenstein J, Kramer S, Hoffrogge P, et al. Acupuncture in acute herpes zoster pain
therapy (ACUZoster) – design and protocol of a randomized controlled trial. BMC
Complement Altern Med. 2009 Aug 12; 9:31.
7. Yawn BP, Saddier P, Wollan PC, et al. A population-based study of the incidence and
complication rates of herpes zoster before zoster vaccine introduction. Mayo Clin Proc
2007, 82(11):1341-1349.
8. Tan EK, Millington GWM, Levell NJ. Acupuncture in dermatology: an historical
perspective. Int J Dermatol 2009, 48,648 –652.
9. Acupuncture: review and analysis of controlled clinical trials. World Health Organization
2003.
10. Flaws B, Sionneau P. The Treatment of Modern Western Diseases with Chinese
Medicine: A Textbook & Clinical Manual. Blue Poppy Press 2001.
11. Maciocia G. Diagnosis in Chinese Medicine: A Comprehensive Guide. Churchill
Livingstone 2003.
12. Furuta Y, Ohtani F, Mesuda Y, Fukuda S, Inuyama Y. "Early diagnosis of zoster sine
herpete and antiviral therapy for the treatment of facial palsy". Neurology 2000; 55 (5):
708–10.
13. Maciocia G. The Foundations of Chinese Medicine. Churchill Livingstone 1989.
14. Liu Xiao-Juan. The Treatment of 58 Cases of Post-herpetic Neuralgia by
Acupuncturing the Paravertebral Points. Sichuan Chinese Medicine 5, 2008.
15. Kirschbaum. B. Atlas of Chinese Tongue Diagnosis, Vol. 1. Eastland Press 2000.
16. Maciocia G. Tongue Diagnosis in Chinese Medicine. Eastland Press 1995.
17. Maciocia G., Zhong Z. The Practice of Chinese Medicine: The Treatment of Diseases
with Acupuncture and Chinese Herbs. Churchill Livingstone 1994.
18. Deadman P. Al-Khafaji M. Baker K. A Manual of Acupuncture. The Journal of
Chinese Medicine 1998.