Phonexay Lala Simon EAMP LAc MSAOM
December 2013

OVERVIEW

45-year-old male presents with psoriasis for 5 years, possible psoriatic arthritis for 2 years, and idiopathic neck pain and stiffness for 2 months. After 17 treatments of acupuncture and herbs, he has regained full range-of-motion, has less pain in his neck, his rashes are less painful and itchy, and he has more movement in his fingers and toes due to a decrease in swelling.

Subjective

45-year-old male presents with lesions on his scalp, back and limbs that began about 5 years ago. When his condition began, the patient was in Qatar working with construction and plaster. The lesions subsided upon his return to Nepal, and completely resolved within a year of being back. He continued to work in Kathmandu with plaster and construction. 2 years ago, he noticed the lesions returning. When the lesions erupted again, they began on his scalp, and continued to spread down his back. From there, the lesions spread to his abdomen and legs. Patient reports moderately achy and sometimes burning pain, with moderate itchiness that can be a nuisance at night. He finds them to be most bothersome during the day, and especially when he first wakes up, because it is the first thing that he notices. The patient reports that when he scratches the lesions, they are "weepy with water," and bleed. He has seen 1 other doctor in Kathmandu who gave him some creams and medication, but the patient does not recall what they were. They were not helpful. The rash does not subside with soap, or cold or hot water, and is actually irritated by most of the soaps that are available. As a result, the patient has stopped using soap entirely. Other than soap, the patient does not know if there are triggers that aggravate his condition, and he denies being emotionally or physically stressed.

The patient reports swelling with stiffness in the joints that began about 2 years ago, and has gotten progressively worse. Swelling occurs in the small metatarsals of his right foot, and his thumb, index and middle metacarpals on his left hand. He experiences moderate pain in his wrists and shoulders. He reports that his fingers are hard to move and bend, are usually moderately painful, and occasionally feel hot and burning. They are sometimes aggravated by cold. His brother also suffers from the same type of lesions, and swelling.

The patient presents with neck and shoulder pain that began about 2 months ago. The onset was idiopathic, sudden, and he cannot recall any possible causes. He reports the pain to be very severe and achy, with no sharpness. He says he can feel an electric sensation running downwards to his fingers when he coughs. Occasionally, the pain radiates up to his temporal area, or down to his wrists and hands. However, he denies numbness and tingling, or loss of strength in his arms and hands. Patient has severe pain and stiffness when resting, and he currently takes Paracetemol (acetaminophen- dosage unknown) to provide about 12-13 hours of pain relief.

Currently, the patient is not working due to his conditions, and he is supported and cared for by his son and daughter.

Objective

The lesions on the patient's body range from a large diamond-shaped patch on his lower back, that is about 5" wide and 8" long (his largest lesion), to multiple smaller ones ranging from .5" to 2" in diameter that stagger throughout his upper back, abdomen, elbows and legs. The lesions are discrete plaques that have a pink and tender appearance, as well as shiny, silvery white "scales." There are multiple breaks in the skin with some blood and weeping, possibly due to scratching. There is flaking and dryness on his scalp.

He has some obvious swellings on his toes and fingers. Most noticeably, his right second metatarsal, left thumb and third metacarpal are swollen to double the size of the same joints on the opposite hand and foot. He has limited range-of-motion in his right hand and can only clench his left hand 50% of normal, making a "C" shape.

The range-of-motion in his neck is 15 degrees flexion (normal 50 degrees), 30 degrees extension (normal 60 degrees), and lateral flexion of only 20-25 degrees bilaterally (normal 45 degrees). Most limited ROM is the lateral rotation of 10-15 degrees bilaterally (normal 80 degrees), and the patient has to move his entire torso to compensate for the lack of rotation. He reports moderate to severe pain in all movements past these ranges, and his face indicates that he is uncomfortable.

His labs are positive for elevated rheumatoid factor. This can be indicative of rheumatoid arthritis, but can also indicate other kinds of autoimmune disorders, such as psoriasis and psoriatic arthritis.

The patient seems in good spirits and looks healthy for his age and environment. He smiles during the whole interview, even when he is doing something that is uncomfortable. He makes eye contact during conversation. When rising from the chair to go to the massage table to undress, he rises very slowly, deliberately and is gentle with his motions.

His pulse is soft, thin, slippery and empty in the deep Lung position. His tongue is pale pink, slightly puffy, with teethmarks and a white coat that is thin in the front, but thicker in the back with small, bilateral prickles.

Assessment:

TCM DX: Lung qi deficiency leading to wind-damp-heat, and qi and blood stagnation in the foot Shaoyang channel; Possible underlying blood deficiency

Lesions on the skin indicate involvement of the Lung organ system according to Chinese medicine, and the nature of resolving and recurring are indicative of a wind pathology with an underlying blood deficiency.

Western DX: Psoriasis with psoriatic arthritis

While rheumatoid arthritis is still a possibility, the history of a prolonged, severe psoriatic condition makes it more probable that it is psoriatic arthritis. However, both psoriatic and rheumatoid arthritis are treated similarly. His neck pain and stiffness are likely due to acute muscle strain and/or tendon sprain of the neck as a result of unidentified causes. It is a possibility that the arthritis is affecting the patient's neck, but physical examinations and presentation indicate a muscular source of his problem, rather than vertebral.

The pattern of lesions on the patient's skin most resembles a condition of psoriasis. Psoriasis is a dermatological inflammatory condition due to immune stimulation of epidermal cells (kerotinocytes). Although its exact cause is largely not understood, the result is erythematous lesions on the body. The presentation of lesions can be pustular, but the most prevalent and classic presentation is the discrete papules, or plaques, with thick, shiny, silvery scales. A family history is common, and there is a genetic susceptibility that can be triggered. Therefore, the condition can have episodes of spontaneous remission and recurrence, or triggered eruptions followed by remission when the trigger is removed.

Prognosis:

With regular use of both acupuncture and herbal treatments twice weekly, at least a 50% improvement in his severe neck pain and stiffness is expected within 13 treatments. The psoriasis is much more difficult to predict. Psoriasis is a difficult condition to completely understand and manage, even with good access to resources, unlike the situation the patient faces in Nepal, where resources are less accessible. Psoriasis is considered mild if less than 10% of the body is covered in lesions. Since the lesions cover about 20% of the patient’s body, his case is moderate. There are many important factors to consider, such as genetics, environment, lifestyle and psychoemotional triggers. Using acupuncture and herbs alone, a 25-50% improvement in the moderate pain, itching and size of the psoriatic plaque, and arthritis, is expected within 13 treatments.

Initial Plan:

Treat with acupuncture twice weekly for 13 treatments, in conjunction with Chinese herbal medicine, before reassessing. For the rash, focus on reducing moderate itch, and possibly the size of the psoriasis. In the joints, focus on reducing moderate pain and swelling. Reduce severe pain and increase range-of-motion in the neck. Use herbal medicine to reduce inflammation of the lesions and joints, then begin to tonify blood and strengthen Lung.

Typical points include wide Hua Tou Jia Ji points, inserted laterally towards the transverse processes, from C2 downwards, with SI14, GB20, SJ3 and SI3 to open the DU. Trigger points in the areas of the neck and shoulders are also indicated. To clear damp and heat, use LU5, ST40 and surround the largest lesion. To tonify and circulate, use ST36, UB13, UB17, LI4 and LV3.

Formulas to take internally are Xiao Feng San for clearing wind and itch. Add Dang Gui Yin Zi or Si Wu Tang to tonify blood once itching is reduced. Have patient take home moxa stick and 7 star needle, to try for 1 week, to see if it helps with the itchiness or size of the lesions.

Counsel patient to spend time in sunlight. UV therapy has been shown to be effective for psoriasis. Continue to guide patient on being emotionally aware, and to release negative emotions if possible. Psoriasis can be triggered or aggravated by emotions and stress. Educate patient on what psoriasis is, and what is going on in his body at a very basic level, and that the condition may come-and-go on its own. Try to identify possible environmental or lifestyle triggers so that he can take steps towards avoiding them, if possible.

Outcome:

After 13 treatments, the patient reported a significant decrease in the itchiness of his psoriatic lesions from moderate to mild, but no noticeable decrease in the size nor the amount of lesions. He wasn’t noticing the itchiness as much when he woke in the morning, nor during the day. He reported that the moderate pain in his fingers and toes had decreased to mild pain, and that it was easier for him to bend them. His left hand could close to about 75% of a completely closed fist. The most significant improvement was in the patient's neck. He reported that it was easier to move his neck, and the pain had decreased from severe to moderate pain. For the past few weeks, he needed his son or daughter to help him get up out of bed, but now he was able to rise from bed on his own. Range-of-motion tests showed that the patient could laterally rotate his neck, up to 55 degrees, without having to move his torso. His flexion improved slightly to about 25 degrees, or just half of full flexion. Extension was still around 30 degrees with minor pain in the front of his chest, and lateral flexion improved to almost full 45 degrees, but with moderate pain and stiffness.

Continued Plan:

Beginning at treatment 14, more emphasis was placed on recovering range-of-motion in his neck, rather than on surrounding the psoriasis lesions.

Continued Outcome:

On treatment 17, the patient had full lateral rotation to 80 degrees, and only with mild pain and stiffness. He could also manage full flexion, with only slight (very mild) pain in the back of his neck. Extension was much better, at 40 degrees, with very slight pain in his pectoral region. Lateral flexion had almost returned to a full 45 degrees, but he had to perform the motion slowly. He was able to lift his shoulders to 90 degrees more easily, which is not something he was able to do previous to the treatments, though it was not measured at the initial visit. Overall, there was about 80% improvement in the presentation of his acute neck pain.

The patient's movements became quicker and he no longer moved as gingerly as he had at the initial visit. He could also look up more comfortably during conversation. He enjoyed moving his neck to show the increased range-of-motion he was experiencing.

The patient's psoriasis condition improved slightly. There was a reduction in itching and pain. He said that the combination of acupuncture, herbs and the home moxa treatments had been incredibly helpful in decreasing the constant and moderate pain and itching from his lesions. He reported that the itching was no longer constant and the pain was more mild. Inspection of his lesions showed that many of the smaller ones had decreased scaling and appeared tender, but according to psoriatic progression, this was a small improvement. The largest lesion had less weeping and bleeding, possibly indicating that he had been scratching less. There was at least a 50% improvement in the moderate pain and itching of the lesions, though only a 10% (at most) improvement in the appearance and size of the lesions.

He reported that the swelling in his fingers and toes continued to improve. The moderate pain was mild and intermittent. The swelling had decreased to where the patient was able to close his left hand 90%, in comparison to the 50% from the first visit.

Discussion:

Psoriasis is an interesting condition because there are so many factors involved, therefore many therapies with which to try to manage. Western therapies include UV light therapy, vitamin D, immunosuppressants, corticosteroids and other anti-inflammatory drugs, along with education about possible environmental and emotional triggers that can be identified and possibly removed. Unfortunately, in Nepal, many drug therapies like Coal tar, Anthralin, and Calcineurin Inhibitors (anti-inflammatories) are not available. Also, it is difficult to educate the patient on how to use the drugs properly, and to monitor patients once they begin using potent drugs for a prolonged period of time. Therefore, drugs that tax the Liver and Kidneys such as Methotrexate or immunosuppressants like systemic corticosteroids are not viable options. More research needs to be done for viable therapies that are readily available to the patient, such as emollients (especially with salicylic acid), that can help to soften the lesions. Hydrocortisone is available in Nepal, but the large surface area of lesions makes it both contraindicated and expensive. Vitamin D3 analogs have been shown to be effective, and he can absorb it by UV (sun) therapy. The process of questioning, communicating and educating the patient about environmental, emotional and lifestyle triggers is also difficult, due to cultural and language barriers.
The acute neck pain and stiffness has been resolving nicely. Even though acute situations can resolve on their own, I believe that the treatments quickened healing, and helped him regain his range-of-motion. The patient has also begun mentioning pain "deep inside" his neck, so it may be worth considering if there is an arthritic cause to his neck pain, and if he may begin to develop chronic neck pain.

The most important part about this case, however, is that from the initial visit with the patient, I was focused on trying to help him with his psoriasis, due to my own interest and curiosity from a practitioner's standpoint. My perspective and perception about the case shifted at the reevaluation, when I realized how much the neck pain and stiffness was affecting his quality of life. At that point, I was able to focus more on making tangible gains in his mobility, and he was very responsive to the treatments. This shift in emphasis was vitally important to his daily well-being and a good outcome to this case.