By Eric Brand

Last week I talked on the phone with a customer who was inquiring about genital herpes and our external formula Jade Dew. As it says in our product guide, Blue Poppy’s Jade Dew formula is from the Zhong Yi Wai Ke Xue Jiang Yi ("Chinese Medicine External Medicine Teaching Materials"), a contemporary Chinese medical textbook on external conditions, including dermatology. Ma Chao-ying and Li Yuan-shi recommend it for the treatment of herpes simplex in Bing Du Xing Ji Bing De Zhong Yi Zhi Liao ("The Chinese Medical Treatment of Viral Diseases").

Over the course of my conversation with the caller, I realized that many practitioners didn’t get a really comprehensive overview of this particular condition while in school. There is a bit of a knee jerk reaction for students to associate genital herpes purely with Long Dan Xie Gan Tang, but ultimately it is important to remember to use pattern differentiation and an appropriate balance of supporting right and dispelling evil to match the case. I mentioned to the caller that Blue Poppy has a book called Fire in the Valley that covers the topic and the awesome book Treatment of Modern Western Medical Diseases with Chinese Medicine also has a chapter on it. Pubmed has some interesting research articles about herbs and herpes as well (I remember finding one study that said that extracts of Xia Ku Cao showed promise in topical applications).

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After the call, I sent the customer some of my teaching notes from the gynecology class that I used to teach at PCOM. When I was teaching at PCOM, I essentially created my class notes by translating the Chinese source texts that I used when preparing for the class. I figured that the notes might reach a broader audience if I put them on the blog, so here they are:

Definition

Chinese medicine did not have the specific disease definition that we now have for genital herpes until after the arrival of Western medicine. However, gynecology textbooks contain a basic TCM disease category for yin sores (genital sores). This disease category is far broader than genital herpes, and includes many more serious conditions, such as sores that would now be diagnosed as chancres from syphilis or cancerous lesions. Sores similar to genital herpes were described under the disease headings of huang shui chuang (“yellow-water sore”) and nong wo chuang (“purulent nest sore”), but neither of these disease descriptions precisely match our modern definition of genital herpes.

Genital herpes is usually caused by the HSV-II virus; genital lesions are also possible in patients with only the HSV-I virus, but such cases are less common. Approximately 22% of the US adult population is seropositive for HSV-II, and over 90% of US adults are positive for HSV-I. Most patients infected with the virus experience primarily mucocutaneous lesions; infections affecting the central nervous system, visceral organs, or neonates are rare, although such infections are also more severe. While most individuals suffer from relatively infrequent recurrences that are fairly mild, some patients have frequent recurrences that cause significant physical or psychological discomfort. Since herpes is incurable, many patients seek to reduce its impact upon their life through the use of complementary medicine. Thus, genital herpes is one of the most commonly seen illnesses in modern Chinese medical gynecology.

Pathomechanisms

The Chuang Yang Jing Yan Quan Shu (“The Empirical Compendium on Sores”) described “yellow-water sores” in the Song Dynasty. Although the disease differed from genital herpes in several important ways, it contains an early glimpse into the pathomechanisms involved in the generation of similar sores. For example, yellow-water sores are sores exuding yellow fluid. Yellow-water sores start with a red macule within which a millet-shaped vesicle develops that is painful and itchy. When the vesicle ruptures because of scratching, a yellow watery discharge escapes, after which the sore forms a scab and heals. It most commonly affects infants and children and occurs on the head, ears, and neck, easily spreading to other parts of the body.

The Chuang Yang Jing Yan Quan Shu stated that the eruption of these sores arise when the “qi of harsh summerheat-heat toxin enters the flesh.” This disease was associated with the invasion of seasonal summerheat-heat evil and toxin during the summer and autumn. When the qi dynamic is inhibited and there is a lack of the liver’s free coursing, the evil steams into the skin, producing the sore. The disease arises more easily after contact if the skin is broken or the body’s resistance is low. The text also provided clear evidence that the Chinese knew that this disease was contagious, as it states that: “During an eruption of this disease…[it may be transmitted to] the family.”

In addition, the traditional disease of “purulent nest sores” describes sores that have some similar features to herpetic lesions. However, like “yellow-water sores,” the location and surrounding characteristics of these sores are markedly different than the presentation of genital herpes.

It is hard to accurately assess how long ago sexual transmission was recognized as a vector of disease in Chinese medicine. Many diseases that are now known to be caused by particular organisms or other vectors of disease were traditionally believed to be caused by the invasion of evil qi contracted from environmental factors. For example, malaria was not known to be caused by mosquitoes; it was classically attributed to contraction of summerheat during the hot season, contact with mountain forest miasma, or contraction of cold-damp. Similarly, sexually transmitted diseases were long thought to be due to contraction of external environmental evils. Genital herpes would be particularly difficult to conclusively link with sex due to its latency, potential transmission from asymptomatic carriers, and recurrences unrelated to sexual intercourse.

Zhang Zhong-Jing’s Shang Han Za Bing Lun (On Cold Damage and Miscellaneous Diseases) is the first text to describe disease transmission by sexual means, but it is not referring to sexually transmitted disease per se. Rather, it documents the observation that one could contract disease of the six excesses without environmental exposure, if one is in close contact with an individual afflicted by disease from the six excesses.

We can see more clear evidence that the Chinese knew of sexual transmission by 1264 CE, in the Southern Song Dynasty text Ren Zhai Zhi Zhi Fang Lun. This text states: “[After] great licentiousness, sores are formed on the penis...women also have sores at the jade gate, which are called genital erosion sores.” Although this text goes on to describe a disease that is more severe than genital herpes, it nonetheless suggests knowledge of sexual transmission.

By the Ming Dynasty, sexual transmission was indisputably recognized as a causative factor in syphilis (梅毒mei du). In 1624 CE, Zhang Jie-Bin (also known as Zhang Jing-Yue) described the pathomechanisms of syphilis in his text, the Jing Yue Quan Shu (“Jing-Yue’s Complete Compendium”). He states: “…most of these pathoconditions are engendered following the transmission of licentious (sexual) toxins. Following the discharge of essence, the qi of this foul licentious toxin follows the essence pathway, exploiting vacuity to penetrate directly into the life gate before pouring into the controlling (ren) vessel. It goes to all the places that the controlling (ren) vessel reaches, the skin and body hair in the outer body, and the bones and marrow in the inner body; there is no place that it does not reach.”

By definition, our understanding of genital herpes is inseparable from modern medical influence. Traditional disease categories fail to provide us with a time-tested understanding of its pathomechanisms. However, the prevalence of the disease has allowed many doctors to formulate theories based upon traditional pathomechanisms and pattern identification-based treatment.

Clinically, the first episodes of genital herpes generally present with damp-heat in the liver channel, and treatment consists of draining the liver, clearing heat, and disinhibiting dampness. Recurrences may occur repeatedly; over time, this wears on right qi. In such cases, supplementing vacuity becomes the primary therapy, and dispelling evils becomes an auxiliary aspect of treatment.

Treatment

Internal use of Chinese medicinals is the basis of treatment. The effect of treatment is best if both internal and external treatments are applied. In addition to the prescriptions below based on pattern identification, topical formulas may be used for all patterns. Examples of such formulas include jie du xiao pao ding tong xi ji (Wash Prescription for Resolving Toxin, Dispersing Herpes, and Relieving Pain) and pao zhen wai xi fang (External Wash Formula for Herpes).

Jie Du Xiao Pao Ding Tong Xi Ji (解毒消疱定痛洗剂Wash Prescription for Resolving Toxin, Dispersing Herpes, and Relieving Pain)

huang qin (黄芩 scutellaria, Scutellariae Radix)

guan zhong (贯众 aspidium, Aspidii Rhizoma)

jin yin hua (金银花 lonicera, Lonicerae Flos)

long dan (龙胆 gentian, Gentianae Radix)

huang bai (黄柏 phellodendron, Phellodendri Cortex)

bing pian (冰片 borneol, Borneolum)

When decocting this formula, direct the steam at the external genitals. After the decoction cools, it may be used as a sitz bath. Instruct the patient to sit in the decoction 1–2 times per day, for 10–15 minutes each time.

Pao Zhen Wai Xi Fang (疱疹外洗方External Wash Formula for Herpes)

hu zhang (虎杖 bushy knotweed, Polygoni Cuspidati Rhizoma) 30 g

da qing ye (大青叶 isatis leaf, Isatidis Folium) 30 g

zi cao (紫草 arnebia/lithospermum, Arnebiae/Lithospermi Radix) 30 g

da huang (大黄 rhubarb, Rhei Radix et Rhizoma) 20 g

xuan shen (玄参 scrophularia, Scrophulariae Radix) 30 g

ku fan (枯矾 calcined alum, Alumen Dehydratum) 15 g

ye ju hua (野菊花 wild chrysanthemum flower, Chrysanthemi Indici Flos) 20 g

Decoct the formula, then let it cool and use it as a sitz bath. Soak the affected area in the decoction once per day, for 20 minutes each time.

Additionally, some Chinese hospitals use an injection formula containing jin yin hua (Lonicerae Flos), lian qiao (Forsythiae Fructus), and huang qin (Scutellariae Radix) that is administered regardless of pattern. This is an example of “disease identification as the basis for determining treatment” (辩病论治bian bing lun zhi), which is contrasted with “pattern identification as the basis for determining treatment” (辩证论治bian zheng lun zhi).

In a similar vein, some practitioners use modern formulas for internal use in the absence of pattern discrimination. Such formulas include pao zhen tang (Herpes Decoction), which is particularly suitable for presentations with heat and toxin.

Pao Zhen Tang (疱疹汤Herpes Decoction)

ban lan gen (板蓝根 isatis root, Isatidis Radix) 20 g

da qing ye (大青叶 isatis leaf, Isatidis Folium) 15 g

yi yi ren (薏苡仁 coix, Coicis Semen) 30 g

tu fu ling (土茯苓 smooth greenbrier, Smilacis Glabrae Rhizoma) 20 g

chai hu (柴胡 bupleurum, Bupleuri Radix) 10 g

bai hua she she cao (白花蛇舌草 oldenlandia, Oldenlandiae Diffusae Herba) 20 g

huang bai (黄柏 phellodendron, Phellodendri Cortex) 12 g

gan cao (甘草 licorice, Glycyrrhizae Radix) 9 g

Finally, it should be noted that some patients exhibit a prodrome to genital herpes that manifests with symptoms typical of an external contraction of wind-heat. In these cases, appropriate pattern-based treatment includes the selection of formulas such as yin qiao san (Lonicera and Forsythia Powder), possibly in combination with other formulas or medicinals tailored to the patient’s presentation.

Gynecology textbooks do not list acupuncture or moxibustion as an auxiliary treatment for this disease. However, integrative medical textbooks for sexually transmitted diseases sometimes list acupuncture as an adjuvant therapy. Typically, only one set of points is provided, regardless of pattern. One prominent text provides the following point prescription: Main points: GV 1 (chang qiang), CV 1 (hui yin), and CV 2 (qu gu). Auxiliary points: SP 6 (san yin jiao), ST 36 (zu san li), BL 23 (shen shu), and BL 20 (pi shu). Use supplementing technique for vacuity cases, and draining technique for repletion cases.

Liver Channel Damp-Heat

Treatment Method: Drain the liver, clear heat, and disinhibit dampness.

Medicinal Therapy: Use the formula long dan xie gan tang (Gentian Liver-Draining Decoction) from the Yi Zong Jin Jian (“The Golden Mirror of Orthodox Medicine”).

Long Dan Xie Gan Tang (龙胆泻肝汤 Gentian Liver-Draining Decoction)

long dan (龙胆 gentian, Gentianae Radix)

shan zhi zi (山栀子 gardenia, Gardeniae Fructus)

huang qin (黄芩 scutellaria, Scutellariae Radix)

sheng di huang (生地黄 dried rehmannia, Rehmanniae Radix Exsiccata)

che qian zi (车前子 plantago seed, Plantaginis Semen)

ze xie (泽泻 alisma, Alismatis Rhizoma)

dang gui (当归 Chinese angelica, Angelicae Sinensis Radix)

mu tong (木通 trifoliate akebia, Akebiae Trifoliatae Caulis)

chai hu (柴胡 bupleurum, Bupleuri Radix)

gan cao (甘草 licorice, Glycyrrhizae Radix)

Modifications: Some texts focused on sexually transmitted diseases modify this formula with the addition of 20 g each of ban lan gen (Isatidis Radix) and yi yi ren (Coicis Semen). For constipation, add 10 g of da huang (Rhei Radix et Rhizoma). If pain is pronounced, add 15 g of pu gong ying (Taraxaci Herba). For recurrences with less severe heat signs, add 15 g each of huang qi (Astragali Radix) and fu ling (Poria).

Acupuncture: Acupuncture treatment is not listed in core TCM gynecology textbooks as a supplementary treatment method for this condition. However, acupuncture treatments to clear damp-heat from the liver channel may be selected from diseases such as abnormal vaginal discharge. An exemplary protocol is the following: Base treatment mainly on ren mai (controlling vessel), du mai (governing vessel), spleen, and liver channels. Select the points GB 26 (dai mai), BL 30 (bai huan shu), CV 6 (qi hai), SP 6 (san yin jiao), CV 3 (zhong ji), LR 2 (xing jian), SP 9 (yin ling quan), and LR 3 (tai chong). Needle with drainage.

Additionally, general acupuncture methods to clear damp-heat may be used. A typical protocol suggests the following: Base treatment mainly on stomach, large intestine, and spleen channels. Main points: ST 36 (zu san li), LI 4 (he gu), SP 9 (yin ling quan), and SP 6 (san yin jiao); needle with drainage. Selection of points according to pattern: If dampness is predominant, add CV 12 (zhong wan) and BL 20 (pi shu). If heat is predominant, add GV 14 (da zhui). For liver channel damp-heat, add LR 2 (xing jian), GB 43 (xia xi), and GB 34 (yang ling quan).

Dual Vacuity of the Heart and Spleen

Treatment Method: Nourish the heart and fortify the spleen, boost qi and supplement blood.

Medicinal Therapy: Use the formula gui pi tang (Spleen-Returning Decoction) from the text Ji Sheng Fang (full name Yan Shi Ji Sheng Fang (“Yan’s Formulas for Saving Lives”), with modifications.

Gui Pi Tang (归脾汤 Spleen-Returning Decoction) (modified)

dang shen (党参 codonopsis, Codonopsis Radix)

bai zhu (白朮 white atractylodes, Atractylodis Macrocephalae Rhizoma)

huang qi (黄芪 astragalus, Astragali Radix)

dang gui (当归 Chinese angelica, Angelicae Sinensis Radix)

gan cao shao (甘草梢 fine licorice root, Glycyrrhizae Radix Tenuis)

fu ling (茯苓 poria, Poria)

yuan zhi (远志 polygala, Polygalae Radix)

mu xiang (木香 costusroot, Aucklandiae Radix)

yi yi ren (薏苡仁 coix, Coicis Semen)

lian zi xin (莲子心 lotus plumule, Nelumbinis Plumula)

Acupuncture: Acupuncture treatment is not listed in core gynecology textbooks as a supplementary treatment method for this pattern. However, you may incorporate general acupuncture treatments that treat dual vacuity of the heart and spleen. Base your treatment mainly on back transport points, and the heart, spleen, and ren (controlling vessel) channels. Select BL 15 (xin shu), BL 20 (pi shu), BL 17 (ge shu), CV 6 (qi hai), HT 7 (shen men), ST 36 (zu san li), SP 10 (xue hai), and SP 6 (san yin jiao); needle with supplementation.

Effulgent Yin Vacuity Fire

Treatment Method: Nourish yin, clear heat, and downbear fire.

Medicinal Therapy: Use the formula zhi bai di huang wan (Anemarrhena, Phellodendron, and Rehmannia Pill) from the text Zheng Yin Mai Zhi (“Pathoconditions: Causes, Pulses, and Treatments”), with modifications.

Zhi Bai Di Huang Wan (知柏地黄丸Anemarrhena, Phellodendron, and Rehmannia Pill) (modified)

zhi mu (知母 anemarrhena, Anemarrhenae Rhizoma)

huang bai (黄柏 phellodendron, Phellodendri Cortex)

gan di huang (干地黄 dried rehmannia, Rehmanniae Radix)

shan yao (山药 dioscorea, Dioscoreae Rhizoma)

shan zhu yu (山茱萸 cornus, Corni Fructus)

fu ling (茯苓 poria, Poria)

ze xie (泽泻 alisma, Alismatis Rhizoma)

mu dan pi (牡丹皮 moutan, Moutan Cortex)

ban lan gen (板蓝根 isatis root, Isatidis Radix)

tu fu ling (土茯苓 smooth greenbrier, Smilacis Glabrae Rhizoma)

zi cao (紫草 arnebia/lithospermum, Arnebiae/Lithospermi Radix)

Acupuncture: Acupuncture treatment is not listed in core gynecology textbooks as a supplementary treatment method for this pattern. A general treatment for effulgent yin vacuity fire is to needle with supplementation at BL 23 (shen shu), KI 3 (tai xi), and SP 6 (san yin jiao), and with drainage at KI 6 (zhao hai), KI 2 (ran gu), BL 17 (ge shu), ST 36 (zu san li), ST 44 (nei ting), and HT 7 (shen men). For effulgent fire, you may also prick HT 8 (shao fu) to bleed.