A case of oral lichen planus treated by clearing phlegm and heat

Yu-Shuo Liu,Ya-Tian Wu,Xiao-Xuan Duan,Yu-Hui Ma,Guo-Wei Zhang*,Bo Zhang

1College of Chinese Medicine,Hebei University,Baoding,Hebei,071002,P.R.China;2College of Traditional Chinese Medical,North China University of Science and Technology,Tangshan,063000,Hebei,P.R.China;3Baoding No.1 Hospital of TCM,Hebei,China.

Abstract Oral lichen planus(OLPS),a common oral mucosa disease,not only affects the patients’daily life,but also has a certain risk of cancerization.In traditional Chinese medicine,“phlegm”and“heat”can cause many various illnesses.Professor Bo Zhang holds the point that the pathogenesis of OLPS is related to phlegm-heat amassment.He treated the patient in the case report with traditional Chinese medicine which was based on the principle of clearing phlegm and heat,and got a good curative effect.He treats OLPS with his own unique experience,which is taking clearing phlegm-heat and coordinating spleen-stomach as the main method,taking strengthening vital Qi to eliminate pathogenic factor as the supplement,and applying Wendan Decoction flexiblly.In order to provide a reference and guidance for clinicians,we report the typical case of OLPS.

Keywords:Oral lichen planus,Clear phlegm-heat,Wendan Decoction,Chinese herbals.

Introduction

The etiology of oral lichen planus(OLPS)has remained undetermined until now,and the popular studies believe that it is related to autoimmunity.The clinical manifestation of OLPS is ulcers with dendritic or reticular silvery-white fine lines and small papules on the surface of oral mucosa,which are mostly symmetrical distribution and often accompanied by pain[1].What’s more,the female incidence is nearly twice as high as male incidence,and the women aged 50-60 are the most common[2].Taking the epidemiological survey in Baoshan District of Shanghai as an example,the incidence of OLPS is 1.23%[3].Moreover,OLPS has a certain risk of cancerization.In western medicine,anti-inflammatory,anti-infective and immunosuppressive method are often used to treat OLPS,resulting to the side effect of drug dependence and relapse for the short drug action duration[4].Glucocorticoid is the main first-line threpy,which is often unacceptable for patients due to the side effects.Traditional Chinese medicine has a significant effect in treating OLPS with little side effects,which can relieve the pain of patients.Nowadays,most traditional Chinese medicine doctors think that the cause of OLPS is intermingled deficiency and there is more deficiency syndrome,and we should treat the disease from some aspects like dampness-heat of spleen and stomach,Yin deficiency and endogenous dryness,deficiency of both Qi and blood and so on[5].

Professor Zhang Bo is a well-known Chinese medicine professor in Baoding City and he is also a visiting professor in Beijing University of Chinese Medicine.He learned from Zhizheng Lu,a master of traditional Chinese medicine,and became one of the inheritors of his academic thought and clinical experience.He doesn’t stick to the old methods when he treats OLPS,and holds the point that“phlegm”and“heat”are the main pathogenic factors of OLPS.Therefore,he puts forward that removing heat-phlegm is most effective to treat OLPS.According to the theory of traditional Chinese medicine,"phlegm"is the pathological product of water stagnation in human body,different from the ordinary phlegm that we are familiar with.The production of“phlegm”is affected by eating,emotion and physical constitution of human.The character of“phlegm”is viscous and can affect many viscera to generate diseases,which is not easy to recover and usually have a long course.“Heat”,just like what we say in daily,belongs to the syndrome differentiation of eight principles,which can make human body hyperactive.“Heat”can cause excessive Yang in the body or the consumption of Yin and fluid,resulting in the relevant diseases.Moreover,“Phlegm”and“heat”often combine together to cause disease that are not easy to heal.So professor Zhang Bo puts forward that the key to cure OLPS is to removing phlegm and heat.Now,we report one typical case of OLPS in our clinical practice,in order to provide a reference and guidance for other clinicians.

Case presentation

Case history

Ms.Li,a 60-year-old female,visited our department on 21 February 2019 at the first time.Her main complaint was“repeated tongue pain with multiple oral mucosal ulcers for more than three years”.Three years ago,she got tongue pain and discomfort without inducement.She was diagnosed as oral lichen planus at the local hospital according to the her condition and Intraoral Camera system results,and was given glucocorticoids(specific details are not known).Then the symptoms were alleviated after hormone treatment.Owing to the recurrence of disease,the patient visited many hospitals for traditional Chinese medicine treatment,but the symptoms did not improve significantly.In the meantime,she received intermittent treatment with metacortandracin,30 mg orally once daily.

A day earlier,the patient suffered tongue pain again after emotional agitation,and white papules appeared in the oral mucosa with symmetry distribution.The pain got aggravated when she eat spicy food.The oral lesions were concentrated in the back and the periphery of the tongue,with multiple aphtha which increased the pain when eating,accompanied by dry mouth,bitterness and appetite decrease.White spots of varying sizes were scattered on both sides of oral mucosa,and the scope of skin lesions can be up to 2 cm2.The patient was in emotional restlessness,anxiety and poor sleep.There was no history of fever,cough and pharyngalgia.So she came to Director Zhang Bo’s outpatient clinic for treatment.

Past medical history:the patient has been in good health.She has never hadhypertension,diabetes or coronary heart disease.

Physical examination and auxiliary examination

There was no abnormal skin and mucosa,no rash and no subcutaneous hemorrhage.White spots of varying sizes were scattered on both sides of oral mucosa,symmetric distribution,serious buccal teeth occlusion,and mucosal hyperemia around ulcer.The patient has no swelling of superficial lymph nodes.There was no edema in both lower limbs.TCM inspection and inquiry:gloomy face,poor spirit,thin shape,poor appetite,dry mouth and eructation sometimes,abdomen distends after eating little food,sleep disorder,over thinking,normal urination,sticky defecate and shapeless with three times a day,red tongue with yellow,thick and greasy fur,stringy and slippery pulse.The results of intraoral Camera system(2018-10-5)are shown in Figure 1.

Figure 1 Intraoral camera system results of the patient on 05 October 2018

Diagonosis and treatment

According to the patient’s condition and examination results,and referring to the diagnostic criteria of OLPS established by Chinese Stomatological Association in 2012,we can give the diagnosis of western medicine:lightly to moderately erosive oral lichen planus.Diagnosis of TCM:aphtha,syndrome of phlegm-heat amassment and spleen-stomach incoordination.Method of treatment:removing heat-phlegm,invigorating the spleen,harmonizing the stomach and drying dampness.The patient refused western medicine,especially hormone drugs.So she only received TCM treatment in our department.

First visit(2019-2-21).Medical prescription:Zhuru(Bamboo Shavings)10g,Huangqin(Baical Skullcap)10g,Qingbanxia(Alum Processed Pinellia)15g,Chenpi(Dried Tangerine Peel)10g,Fuling(Poria cocos)20g,Caodoukou(Cardamom cardamom)12g,Rougui(Cassia Bark)5g,Paojiang(Ginger-processed Officinal Magnolia Bark)12g,Xuanfuhua(Inula Flower)10g,Shigao(Gypsum)30g,Lianzixin(Lotus Plumule)12g,Danzhuye(Lophatherum Herb)30g,Taizishen(Radix Pseudostellariae)30g.One dose of herbal medicine was obtained in pre-compounded form by prescription and administered to patients orally twice a day,30 min after breakfast and dinner.Each course of treatment consisted of one oral dose per day in decoction form for 7 days.

Second visit(2019-2-27).The patient said that the pain of tongue was less than that of initial diagnosis.Abdominal distension and eructation almost disappeared,and the appetite restored.But her mouth felt dry and she could not sleep well.The range of speckles on both sides of oral mucosa was smaller than that before.The congestion was reduced,tongue quality was red with yellowish fur,and stringy and slippery pulse.The patient was given another 14 doses of the same formula plus Zhizi(Cape Jasmine Fruit)10g,Dandouchi(Fermented Soybean)12g and Zisugeng(Perilla Stem)30g.

Third visit(2019-3-13).The patient said that the tongue pain occurred occasionally.Symptoms of epigastric discomfort disappeared,and the patient felt relieved and slept well.The number of spots at lesions on both cheeks was decreased,and there was no obvious congestion.The edge and tip of the tongue were red with thin and white fur,the pulse is stringy and slippery.Adjusted decoction was as follow:removed Rougui(Cassia Bark)5g,added Baizhu(Rhizome pinelliae)20g,Chuanniuxi(Medicinal Cyathula Root)12g,Chishizhi(Hematite)10g,taking the top 14 doses continuedly with the same taking methods as above.

Fourth visit(2019-03-27).The patient said that the tongue pain almost disappeared.Spots in the lesions of both cheeks disappeared.Pink tongue,white and thin fur,stringy and slippery pulse.The photo are shown in Figure 2.7 doses of prescription were given to the patient,which is as the same as the last prescription.

Fllow-up.The patient visited clinic and took TCM regularly with stable condition.At present,the patient have stopped taking medicine.

Discussion

Figure 2 The manifestation of mouth mucosa and tongue in the patient on 13 March 2019

In ancient Chinese medical literature,OLPS falls into the category of“aphtha”and“mouth moss”[6].The oral cavity’s health is connected with spleen-stomach.Flourishing spleen makes a healthy mouth because spleen is in interlinked with mouth and mouth is the portal of the spleen-stomach.Spleen produces Qi-blood.Healthy spleen and stomach make body fluid transport and distribut normally.Patients with OLPS usually have improper diet and prefer to eat the food with too much fat.What’s more,they are in stressful and worried mood which is bad for spleen and stomach.So dampness-heat blocks the middle-jiao or induce the heart fire,which cause aphtha ultimately.We think that dampness-heat is the main reason of OLPS and is the cause of many secondary diseases as well.In recent years,some studies indicate that the incidence of OLPS is related to mental factors,especially anxiety and depression[7].Referring to the ideas that“phlegm-fire disturbing mind”,“spirit confused by phlegm”and“all diseases are caused by phlegm”,we can know that phlegm is one of the most important factors to the OLPS.The production of phlegm is related to imbalance of lung,spleen and kidney.In physiological situations,the essence of body fluid nourishes the viscera,limbs and muscles under the function of lung,spleen and kidney,without phlegm formed.If the function of lung,spleen and kidney is disordered,it may cause abnormal metabolism of body fluid transfusion and phlegm.Phlegm interrupts the Qi movement of viscera,resulting in wet-heat.Or when the mood is not good,the heat is turned into fire,which burns the body fluid into phlegm.As a result,phlegm and fire disturb the mind.On the other hand,too many worries are bad for spleen,and spleen deficiency can cause phlegm.“Phlegm is tangible fire,fire is invisible phlegm”,phlegm and fire knot each other,then the disease will appear.

In the case of our paper,we think that the patient has suffered OLPS and gastrointestinal discomfort for many years so the first treatment needed to do is to improve gastrointestinal tract.When the acquired basis is supplied,the Qi-blood will gradually be sufficient,then the disease will be healed.What’s more,the patient is thoughtful which can make fire inside,so it is important to pay attention to adjusting her mood and disperse the internal heat.But we should notice that when we clear the heat we cannot use the drug that is bitter and cold for stomach,which might be damaged.The patient lost her appetite because of dampness-heat which can burn fluid,so that she suffered a tongue pain.Phlegm and heat disturb the mind so that she suffered disordered sleep.According to tongue manifestation,the pulse and the symptoms,we can confirm that it is the syndrome of intermingled phlegm and heat,so Wendan decoction should be used to clear the phlegm-heat.

In the prescription,Alum Processed Pinellia,the sovereign drug,can eliminate dampness and phlegm;Bamboo Shavings,minister drug,can remove heat-phlegm;Dried Tangerine Peelcan regulate Qi-flowing for harmonizing stomach;Baical Skullcap can clear phlegm-heat in Shang Jiao,Poria cocoscan invigorate spleen for diuresis and tranquillize mind;Perilla Stemcan lessen fire and remove phlegm;Cardamom cardamomcan harmonize the stomach and dry dampness;Cassi Bark,directing fire to its source,can adjust ascending and descending of water and fire with heat-clearing drug.Inula Flowercan remove phlegm to adverse rising of stomach Qi;Gypsum,clearing the heat in Zhong Jiao with stomach damage,can clear the heart fire and heal the aphthous ulcer with the help ofLophatherum HerbandLotus Plumule,which are the components of Zhuye Shigao decoction.Radix Pseudostellariaecan invigorate Qi and spleen,which can strengthen and consolidate body resistance.Rhizome pinelliaeinvigorates spleen for removing dampness;Cape Jasmine Fruitcan clear the fire in San Jiao,and in the Zhizichi Decoction,it can clear stagnated heat withFermented Soybean;Hematiteis inducing astringency which can stop bleeding and detumescence to heal the aphthous ulcer.The whole prescription combines warm and cool drugs which have both dryness and dampness,regulate the rise and fall of Qi,clears phlegm and heat,and takes into account the spleen and stomach.

In conclusion,we find that it is easy to suffer aphtha when there are dampness-heat of spleen and stomach and intermingled phlegm-fire.Modified Wendan decoction can be used to treat OLPS owing to the principle that the spleen and stomach are regulated by removing phlegm and clearing heat.Here we present a case of OLPS to make clinicans to aware of the treatment of OLPS in TCM.It is common to treat OLPS with TCM,but it is the first time to recognize and treat OLPS from the aspects of phlegm and heat,opening up a new path in the clinical practice.From the point of view of phlegm-heat interaction,this paper puts forward the method of clearing phlegm-heat to treat OLPS,which provides a new idea for clinical work and is more conducive to the treatment of OLPS.

Abbreviations

OLPS,oral lichen planus;TCM,traditional Chinese medicine.

Acknowledgments

We thank the Professor Bo Zhang,for providing the case and sharing his experience.

Competing interests

The authors have no conflicts of interest to declare.

Statement of ethics

Consent for publication was obtained.The patient in this manuscript consent to publish these case details and photos.