Clinical Experience in the Treatment of Vitiligo by the Method of Invigorating Qi, Promoting Blood Circulation and Detoxification

Shuiqing LIU, Xi CHEN, Xiaoxiao ZHANG, Shengjuan HU, Fengchuan ZHANG, Guomei XU, Nan LI*

1. Beijing University of Chinese Medicine, Beijing 100029, China; 2. Department of Dermatology and Venereology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing 101012, China; 3. Department of Dermatology and Venereology, Dongfang Hospital, Beijing University of Chinese Medicine, Beijing 100078, China; 4. Department of Dermatology and Venereology, The Third Affiliated Hospital of Beijing University of Chinese Medicine, Beijing 100029, China

Abstract Studies have shown that traditional Chinese medicines have clear curative effects in the treatment of vitiligo with few side effects. Through literature research and clinical observation, the study summarized the etiology and pathogenesis of vitiligo in traditional Chinese medicine as "deficiency, toxin, and stasis", formulated the method of invigorating qi, promoting blood circulation and detoxification, and prescribed Fuse Hexue Jiawei Decoction for the treatment of vitiligo.

Key words Vitiligo, Toxin, Qi-boosting and toxin-resolving, Activating blood and removing stasis, Milli fire needle

1 Introduction

Vitiligo is an acquired depigmentation disease, and it is attributed to the decline of melanocyte function in skin and hair follicles caused by various reasons. The typical clinical manifestations are skin white patches of different sizes, shapes and numbers, and the affected skin is smooth, without desquamation, atrophy,etc., generally without subjective symptoms. But because of the influence on the appearance and long course of disease, the disease often brings patients greater psychological distress. The pathogenesis of this disease is not clear, and there is no clinical cure. Traditional Chinese medicines have unique advantages in the treatment of vitiligo due to obvious curative effects, small side effects and constitutional regulation. Based on medical literatures and the location of the disease, common concomitant symptoms and related biological indicators, the study tried to summarize the etiology and pathogenesis of vitiligo in traditional Chinese medicine, and explored the effect of the method of invigorating qi, promoting blood circulation and detoxification on the treatment of vitiligo, so as to provide new ideas for clinical practice.

2 Etiology and pathogenesis

From the perspective of traditional Chinese medicine, the disease location of vitiligo lies in striae of the skin. It is always caused by external infection of six exogenous pathogenic factors, internal injury due to seven emotions, dysfunction of viscera, and qi-blood disharmony[1]. The discussion on the etiology of vitiligo by doctors of different periods is mainly divided into the following categories. (i) Pathogenic wind attacking the superficies, qi-blood disharmony.GujinYitongDaquan(Medical Complete Book, Ancient and Modern) said, "Vitiligo is caused by qi-blood disharmony, and the pathogenic wind attacks the superficial layer of the muscles";ShengjiZonglu(General Medical Collection of Royal Benevolence) recorded, "Vitiligo is caused by pathogenic wind attacking muscular striae and deficiency of both lung and spleen"[2]. Meantime, pathogenic wind is often accompanied by cold, wet and heat evil, which attacks muscular striae and combines with damp heat evil, accumulates and damages skin, and further develops into white patch; or combines with cold evil, closes striae, and further develops into vitiligo of the skin due to disharmony between ying and wei. (ii) Heat congestion of lung and spleen, exogenous pathogenic wind.TaipingShenghuiFang(Peaceful Holy Benevolent Prescriptions) said, "There is heat congestion in the lung, and wind qi injures the muscles"[3]; Gu Shicheng proposed inYangyiDaquanthat vitiligo is "lung and spleen heat, with complex infection of exogenous pathogenic factors". (iii) Qi-stagnation and blood stasis.WaikeXinfaYaojue(The Surgical Mental Cultivation Methods) said, "Tinea versicolor has no itching pain, which appears white due to qi stagnation and purple hemagglutination"[3]; Wang Qingren put forward that "Vitiligo is caused by blood stasis in the skin", which should be treated with orifice-freeing blood-quickening decoction. (iv) Spleen-stomach weakness, blood deficiency and dystrophy.ZhenjiuFengyuan(The Source of Acupuncture and Moxibustion) recorded, "Tinea versicolor is caused by blood deficiency that can not fill the meridians and collaterals and pathogenic toxin damaging qi". The spleen and stomach are the sources of qi and blood formation, while spleen-stomach weakness will easily lead to deficiency of both qi and blood, and failure to nourish skin and muscle, resulting in easy occurrence of white patch. (v) Emotion-induced diseases, depression of liver qi. Professor Zhang Fengchuan found from clinical observation that patients with vitiligo often had a variety of emotional abnormalities before the onset of disease, such as emotional depression, anxiety and panic, insomnia and dreaminess, anxiety and irritability,etc.Therefore, it is believed that abnormal emotion and stagnation of liver qi are the main causes of vitiligo[4]. (vi) Deficiency of liver and kidney, failure of nourishing skin and muscle.SurgeryofChineseMedicineput forward that "Deficiency of liver and kidney will lead to dystrophy of striae of the skin, resulting in white patch". Zhang Zuozhou, a dermatologist, suggested that gloomy and bright skin color depends not only on the nourishing of liver and kidney essence and blood, but also on warming kidney qi and orderly liver qi, so nourishing liver and kidney is the basis for the treatment of vitiligo[5]. Combined with doctor’s discussion and clinical observation, the main causes of vitiligo were summarized as "deficiency, toxin, and stasis".

2.1 Deficiency"Deficiency" means vacuity of vital qi.Neijing(Internal Canon of Medicine) said, "When there is sufficient vital qi inside, the pathogenic qi have no way to invade the body." The prerequisite for any disease is the loss of vital qi in human body. If the vital qi is weak, the qi and blood can not run smoothly in the body, resulting in the accumulation of internal pathogenic factors and the invasion of external pathogenic factors, and the occurrence of various diseases. First, in case of vacuity of defensive qi, abnormality of body bioelectricity and weakened defensive qi, the six pathogenic factors and external toxin factors will easily invade striae of the skin, resulting in qi-blood disharmony in superficial layer of the muscles and developing into white patches. Second, in case of deficiency of qi in the zang-fu organs and abnormality of zang-fu function, the qi and blood can not operate normally, resulting in failure to nourish the skin and muscle and developing into white patches. The heart regulates the flow of blood and the liver stores blood. Heart-liver blood deficiency will result in failure to nourish the skin and muscle. The spleen and stomach are the sources for the production and transformation of qi and blood. The weakness of the spleen and the stomach and the lack of sources for the production and transformation of qi and blood will result in failure to nourish the skin and muscle. The kidney stores the essence of life, and deficiency of kidney essence and kidney qi will also result in failure to nourish the skin and muscle, and white patch is developed correspondingly.

On the other hand, deficiency leads to stagnation. Weak qi in the body is unable to promote the smooth operation of body fluid, so water, qi, blood and body fluid will accumulate in the body, stagnate for a long time and transform into endotoxin, which will further block the operation of qi and blood, and hinder the normal physiological functions of viscera and bowels, resulting in qi-blood disharmony and formation of vitiligo.

2.2 ToxinThe "toxin" here does not specifically refer to toxic substances, but also refers to pathogenic factors that damage the body. According to the source, it is divided into endotoxin and exotoxin. The endotoxin is stagnation of pathological products of viscera and bowels, such as impaired depurative descending of lung qi and heat accumulation in pulmonary lobe will transform into heat toxin after accumulation for a long time; emotional disorder and liver qi depression turn into toxin; due to improper diet and dysfunction of spleen and stomach, phlegm dampness will concentrate and turn into toxin; qi stagnation and blood stasis will become toxin over time. There are three pathogenic characteristics of the endogenous pathogenic toxin. The first is latent onset and watching for the proper moment for action, namely toxins are accumulated in the body, which generally do not break out immediately, but will activate when the body is weak with declined immunity. The second is lingering and hard to heal. Since qi, blood and body fluid are stagnated in the accumulation place of pathogenic toxin, and most of them are complex onsets of various pathogenic factors, the course of the disease is lingering and stubborn. The third is concealed consumption of qi and blood. The stagnation of endotoxin impedes the operation of qi and blood, and hinders the normal function of viscera and bowels, so the vital qi is consumed over time. Asthenic healthy qi with pathogen lingering makes it more difficult to heal. Studies have shown that the biological basis of endotoxin includes histocyte dysfunction, namely the products of the body in the pathological process, such as oxygen free radicals, inflammatory mediators, miocrothrombus, metabolic toxins,etc., and when the excessive production of physiological substances needed by the human body, such as cytotoxic T lymphocytes, endotoxins, leukotrienes, oxygen free radicals and lipid peroxidation products, exceeds the body’s own scavenging capacity, they can also be counted into the category of endotoxin[6]. According to modern medicine, stress, accumulation of toxic compounds, spread of infection, changes in cellular environment and impaired migration of melanocytes can lead to the occurrence of vitiligo[7], and its pathogenesis is related to immune dysfunction, abnormal secretion of anti-inflammatory cytokines (IL-10, IL-17A), changes in CD8+T cells, Treg cells, interleukin-17A (IL-17A) levels, mitochondrial structure and function damage, oxidative stress damage,etc.[8]. This provides a new research direction reference for the pathogenic path of "endotoxin" causing vitiligo.

Exotoxin refers to external toxin factors that can invade the human body. In addition to the six exogenous pathogenic factors of "wind", "cold", "summer-heat", "dampness", "dryness" and "fire", it also include man-made chemical, physical and other pathogenic factors, such as air pollution, light pollution, noise pollution, various additives, daily chemicals, drug poisons and radiation[9]. The fleshy exterior is located in the outermost layer of the human body. If the fleshy exterior has inadequate meridians and weakened defensive qi, it is the most susceptible to exotoxins, resulting in disharmony between ying (nutrient) and wei (defense), and disorder of qi and blood, thereby inducing vitiligo.

2.3 Stasis"Stasis" refers to blood stasis and collaterals obstruction, and moistened skin depends on blood nourishment. If the skin’s collaterals are stagnant, and qi and blood are blocked, the skin and muscle will fail to be nourished and decolor[10]. On the one hand, weakened body resistance, emotional stagnation and external injury can damage qi and blood, resulting in stasis. Moreover, nutrient and defense are connected with body surface, while meridians and collaterals are connected with visceral qi. Both endotoxin and exotoxin can invade from outside to inside, and from qi to blood, resulting in qi stagnation, blood stasis, obstruction of collaterals, blocking and dystrophy of striae, and further leading to skin white patch. On the other hand, according to the theory of collateral disease, chronic diseases will transform into collaterals. Vitiligo has a long course of disease, and blood stasis syndrome often appears in the middle and late stage. Modern studies have also found that the microcirculation of vitiligo patients often shows reduced number of capillary loops and slowed flow rate of blood[11].

The three pathogenic factors "deficiency, toxin and stasis" do not appear alone, but have related association and mutual correlation. Weakened body resistance may lead to invasion of toxin and blood stasis, while stagnation of toxin can further consume qi and blood, resulting in qi stagnation and blood stasis. Over time, it becomes a vicious circle; toxins are accumulated and vital qi is damaged till toxins and blood stasis hinder collaterals and disorder qi and blood, leading to refractory vitiligo. Therefore, for the etiology of "deficiency, toxin and stasis" of vitiligo, the treatment of traditional Chinese medicine can be established, that is, the method of invigorating qi, promoting blood circulation and detoxification.

3 The method of invigorating qi, promoting blood circulation and detoxification

3.1 Invigorating qi and strengthening body resistanceFrom the perspective of the cause of the disease,Neijingrecorded that "When there is sufficient healthy qi inside, the pathogenic qi have no way to invade the body"; "Where pathogenic factors accumulate, the parts of the body must be deficient in vital qi". Pathogenic factors will invade and make the human body sick only when the human body has a deficiency of vital qi. The vital qi of vitiligo patients is often damaged due to congenital deficiency, or emotional depression, fatigue, and diet disorder, and qi deficiency will promote fatigue, resulting in stagnation of pathological products, qi-blood disharmony, failure of nourishing skin and muscle, and the occurrence of white patches. Therefore, in the treatment of vitiligo, the deficiency and reality of the patient’s disease should be first identified. If the patient has the symptoms of blood heat, spleen stagnation and liver depression, without obvious signs of tongue and pulse deficiency syndrome, the dosage of tonic products can be reduced. If the patient has a history of strain and obvious deficiency syndrome, the use ratio of tonic drugs should be increased. It should be noted that over administration of drugs will lead to deficiency of vital qi and can not replenish muscular striae, while too much invigoration will lead to qi stagnation and collateral obstruction, and lingering of toxins. Therefore, we should pay attention to the "degree" when using drugs, so that counteracting toxins will not hurt the body resistance, and invigoration will not retain pathogenic factors, in order to harmonize qi and blood, and nourish the skin.

From the relationship between qi and blood, qi and blood can be transformed into each other; where there is qi, there is blood. The deficiency of qi and blood can lead to failure of nourishing and moisturizing skin, resulting in skin diseases. If vitiligo patients are accompanied with pale complexion and onyx, dry skin, dizziness, palpitations, hypomenorrhea of woman and other blood deficiency symptoms, Radix Astragali, Radix Salviae Miltiorrhizae, Radix Angelicae Sinensis, longan and Chinese-date can be used to replenish qi and enrich the blood. Qi is the commander of blood, and qi flow promotes blood circulation. Only when qi and blood run smoothly can nourish the skin of the whole body. The drugs such as Rhizoma Chuanxiong, Rhizoma Cyperi and Radix Aucklandiae can be used flexibly.

3.2 Promoting blood circulation and removing blood stasis

3.2.1Promoting blood circulation can dispel wind. Blood stasis and disharmony between qi and blood will generate endogenous wind, failure of nourishing the skin and depigmentation of skin, resulting in occurrence of vitiligo.Yizongbidu(Essential Readings for Medical Professionals) said, "treating blood before treating wind, self-eliminating of wind after blood circulating", that is, normal circulation of qi and blood is realized through nourishing blood and activating blood, and various pathogenic factors and pathological products (especially pathogenic wind) can be eliminated with the circulation of blood, playing the role of eliminating exogenous pathogenic factors. Nourishing blood and activating blood not only play the role of securing the exterior, dispelling the wind and dissipating pathogenic wind, and resist and treat the exogenous pathogenic wind, but also remove blood stasis for promoting tissue regeneration and inhibit endogenous pathogenic wind.

3.2.2Activating blood circulation can dredge collaterals. According to the theory of collateral disease, collaterals must be treated for enduring illness, and long illness will lead to unsmooth circulation of qi and blood, so there will be stasis in the blood collateral. The course of vitiligo is more lingering. Therefore, in the treatment of this disease, drugs that promote blood circulation and remove collaterals are often added, such as Radix Salviae Miltiorrhizae, Radix Angelicae Sinensis, Rhizoma Chuanxiong, and Radix Paeoniae Rubra. Besides, drugs that expel wind to remove blood stasis and dredge collateral can be used, such as lumbricus, hirudo, zaocys dhumnade,etc.Modern studies have also shown that patients with vitiligo often have microcirculation disorders[12], and the use of traditional Chinese medicine for promoting blood circulation and removing blood stasis can promote local vasodilatation, improve microcirculation and local metabolism, thereby activating the activity of tyrosinase and promoting the recovery of melanocyte function.

3.3 Detoxification of endotoxin and exotoxin

3.3.1Detoxification of exotoxin. The disease caused by six exogenous pathogenic factors, especially pathogenic wind, will easily mix with other pathogenic factors, inducing the occurrence of vitiligo. In addition, environmental pollution, daily chemicals, ultraviolet light,etc., will also affect the human immune system, damage the skin barrier, and induce the occurrence and development of vitiligo. Therefore, detoxification of exotoxin should be treated with the method of dispelling the wind, dispersing pathogenic factors, and clearing muscular striae. Drugs that can dispel the wind and relieve exterior syndrome can be used to directly act on illness station, such as Herba Spirodelae, Radix Saposhnikoviae, Schizonepetae Herba, Fructus Tribuli,etc.

3.3.2Detoxification of endotoxin. Endotoxin refers to the stagnation of pathological products caused by the disorder of zang-fu organs and the imbalance of qi and blood. Impuissante promotion of weakened body resistance and disorder of qi activity will lead to stagnation of qi, water and blood, which will slowly accumulate to endotoxin, such as qi-stagnation and blood stasis, phlegm-damp accumulation, internal heat stagnation,etc.Although the pathogenic toxin of vitiligo is lingering, it is not fierce, so the method of "detoxification" rather than "challenge" is adopted. The method of clearing away heat and toxic materials, promoting blood circulation and cooling blood, dispersing stagnated liver qi to relieve depression, strengthening the spleen and drying dampness is adopted to remove endotoxin, relieve liver qi, transport spleen qi and purify lung qi, thereby achieving the effect of treating diseases and regulating physical fitness.

4 Inference of prescription based on the patient’s condition, diagnosis and treatment based on an overall analysis of the illness and the patient’s condition

4.1 Fuse Hexue Jiawei DecoctionAccording to the etiology and pathogenesis of vitiligo, the treatment method of invigorating qi, promoting blood circulation and detoxification is formulated, and Fuse Hexue Jiawei Decoction is prescribed. The prescription is composed of 30 g of Radix Salviae Miltiorrhizae, 30 g of Raw Radix Astragalis, 10 g of Radix Angelicae Sinensis, 10 g of Rhizoma Chuanxiong, 10 g of lumbricus, 10 g of Rhizoma Cyperi, 9 g of Radix Curcumae, 15 g of Cortex Albiziae, 15 g of Fructus Ligustri Lucidi, 15 g of Herba Ecliptae, 10 g of Herba Spirodelae, 9 g of Fructus Tribuli, 9 g of Radix Scutellariae, 15 g of Herba Scutellariae Barbatae, and 15 g of Herba Hedyotidis.

In the prescription, Radix Salviae Miltiorrhizae is used as the principal drug, and Radix Astragalis and Radix Angelicae Sinensis are as the adjuvant drugs, to achieve the effects of qi-boosting and toxin-resolving, blood nourishing, and complementing without stagnation; Rhizoma Chuanxiong and Radix Curcumae play the role of promoting blood and qi circulation, and circulating qi and blood; Rhizoma Cyperi and Cortex Albiziae play the role of dredging liver qi and reconciling mind, and simultaneous use of Rhizoma Cyperi and Cortex Albiziae can nourish yin and blood and invigorate the circulation of blood; Lumbricus is used to calm endogenous wind and dredge meridians and collaterals; the sweet taste and cold nature of Fructus Ligustri Lucidi and Herba Ecliptae can clear and nourish the liver, and boost kidney, playing the role of tonifying without being greasy; Radix Scutellariae, Herba Scutellariae Barbatae and Herba Hedyotidis are added to remove heat and dampness, cool blood and detoxify; Herba Spirodelae and Fructus Tribuli are used to induce drugs to the disease site, dispel the wind and disperse pathogenic factors. The whole prescription not only clear and nourish qi, detoxify, nourish yin and blood by using moistening and tonifying products, but also dredges the liver and regulates qi, relaxes collaterals and circulates blood with spicy taste. The drugs that can clear away heat and toxic materials, expel the wind and detoxify, remove pathogenic heat from the blood and toxic material from the body, eliminate dampness and heat are added. The combination of frigotherapy and pyretotherapy, and tonification and purgation not only remove the stagnation of pathological products, but also adjust qi and blood, yin and yang. The complex use of various drugs has the effects of removing stagnation and harmonizing qi and blood.

Radix Salviae Miltiorrhizae is bitter in taste and mildly cold in nature, and enters the heart and the liver meridian, and can both promote blood circulation and cool blood.BencaoGangmu(Compendium of Materia Medica) said, "Radix Salviae Miltiorrhizae can break stagnated blood and replenish new blood". Modern pharmacological studies have found that Radix Salviae Miltiorrhizae has anti-inflammatory, antioxidant and immunomodulatory effects, and Danshensu has inhibitory effects on macrophage secretion and leukocyte migration and chemotaxis. Salvia miltiorrhiza polysaccharide can down-regulate the mRNA expression of cytokine IL-1β, human leukocyte interferon α and inducible nitric oxide synthase, thereby exerting immune regulatory activity[13].

Raw Radix Astragalis is sweet in taste and flat in qi, enters lung and stomach meridian and invigorates qi, and it can circulate in channels and collaterals to benefit nutrient-blood. Raw Radix Astragalis not only benefits qi and blood, but also is good at reaching skin striae and connecting fleshy exterior[14].ChangshaYaojie(Changsha Drug Analysis) noted that "Raw Radix Astragalis can clear vacuity and reconcile, specifically circulate in channels and collaterals and benefit defensive qi; it is an essential medicine for harmonizing defensive qi, that is, the top grade of reconciling nutrient-blood." Pharmacological studies have found that Raw Radix Astragalis can increase the levels of immunoglobulin, immune cell subsets and white blood cells, and enhance the expression of various antioxidant enzymes such as superoxide dismutase (SOD) and glutathione S-transferase (GST), with the effect of anti-oxidative stress[15].

Radix Angelicae Sinensis is sweet and pungent in taste, mildly warm in nature, and enters the heart and the liver meridian, and can nourish blood and tonify liver, clam the wind and moisten wood qi.ChangshaYaojienoted that "Radix Angelicae Sinensis is nutritious and smooth, which can better calm the wind and nourish blood; and the nature of pungent in flavor and warm in property is appropriate with wood qi…It is most suitable for depression of liver wood and wind syndrome." Modern pharmacology found that Angelica sinensis polysaccharide can promote the differentiation and proliferation of hematopoietic cells, playing the role of "enriching the blood"; flavonoids and phthalides in Radix Angelicae Sinensis have antioxidant effects[16]. In addition, Radix Angelicae Sinensis also has the pharmacological effect of protecting liver and strengthening kidney.

Rhizoma Chuanxiong is pungent in taste and warm in nature, and enters liver, gallbladder and heart meridian for promoting blood and qi circulation, expelling the wind and alleviating pain.MedicineOriginsaid, "Rhizoma Chuanxiong has the effects of replenishing blood, searching liver qi, tonifying liver blood, moistening liver dryness, tonifying wind deficiency." Modern pharmacology has shown that Rhizoma Chuanxiong can exert anti-inflammatory effects through various signaling pathways. The ethanol extract of Rhizoma Chuanxiong has strong antioxidant activity[17]. With prolonged activated partial thromboplastin time (APTT) as an indicator, some researchers found that the total extract of Rhizoma Chuanxiong had significant anticoagulant activity[18].

Lumbricus is salty in taste and cold in nature, and has the effects of calming the wind and dredging collaterals. Modern pharmacology has found that the extract of lumbricus can increase the level of nitric oxide secreted by macrophages and antagonize the inhibitory effect of dexamethasone on nitric oxide secreted by macrophages; on the other hand, lumbricus can significantly increase the activation rate of macrophages, antagonize cyclophosphamide, and regulate immune function to a certain extent[19]. Some studies have found that the extract from the regeneration stage of broken lumbricus can promote the proliferation of fibroblasts and play a role in promoting wound repair[20].

Rhizoma Cyperi is pungent, bitter and sweet in taste, and enters liver, spleen and triple energizer meridian, and can disperse stagnated liver qi to relieve depression, regulate the flow of qi and reconcile middle energizer obstruction.BencaoGangmusaid, "Rhizoma Cyperi benefits triple energizer and relieves six depressions." Studies have shown that the alcohol extract of Rhizoma Chuanxiong and Rhizoma Cyperi can affect the release of central neurotransmitters and vasoactive substances[21]. Nam, a foreign researcher, reported that sesquiterpenoids of Rhizoma Cyperi could reduce the content of endochrome in melanoma cells of mice irradiated with ultraviolet rays (UVB)[22].

Radix Curcumae is pungent and bitter in taste and cold in nature, returns to the liver, gallbladder and heart meridian.BencaoBeiyao(Essential of Materia Medica) recorded, "Radix Curcumae promotes the circulation of qi, resolves depression, dissipate blood stasis, cool heart heat, and scatter liver depression." This medicine has circulating effect on both qi and blood. In modern pharmacological studies, the aqueous decoction of Radix Curcumae can reduce the whole blood viscosity and inhibit a variety of skin fungi and bacteria, while the alcohol extract of Radix Curcumae has antioxidant stress activity[23].

Cortex Albiziae is sweet in taste and flat in nature, and enters heart, liver and lung meridian.BencaoHuiyanrecorded, "Cortex Albiziae is sweet-warm and mild reinforcing, with the magical effects of activating five spirits and eliminating five minds; it mainly plays the role of relaxing heart qi; gentle heart qi will lead to happiness without worry; it can invigorate heart and spleen and has the effect of generating blood and qi."BencaoYanyiBuyi(A Supplement to Augmented Materia Medica) recorded that Cortex Albiziae has the effects of tonifying yin, regenerating the muscle, and reuniting muscles and bones. The simultaneous use of Cortex Albiziae and Radix Salviae Miltiorrhizae can nourish blood and promote blood circulation, regulate qi and blood, and stabilize the mind. The medicine is mild and has no dry dampness and aroma.

Fructus Ligustri Lucidi is sweet and bitter in taste and cold in nature, and can nourish liver and kidney without being too greasy.BencaoBeiyaorecorded, "Fructus Ligustri Lucidi benefits the liver and kidney, settles five organs, strengthens waist and knee, improves visual and auditory acuity, blackens the beard and hair, tonifies wind deficiency, and eliminates all diseases." Modern pharmacology has found that Fructus Ligustri Lucidi contains a variety of chemical components that can delay aging, and its anti-aging effect is mainly realized by anti-oxidation, reducing inflammatory reaction, regulating apoptosis and other ways[24].

Herba Ecliptae is sweet and sour in taste and cold in nature. In addition to nourishing the liver and kidney, Herba Ecliptae can also cool the blood, remove dampness and relieve itching. Because of cold nature, it should be used with caution in patients with deficiency cold. Modern pharmacology has found that Herba Ecliptae can enhance the cellular immune function of the body, and its ethyl acetate extract (EAEEP) has a certain regulatory effect on the cellular immunity mediated by T lymphocytes. The water decoction of Herba Ecliptae has a certain protective effect on the damage of genetic material of the body, and has anti-mutagenesis activity[25].

Herba Spirodelae is pungent in taste and cold in nature, enters lung and bladder meridian. "Herba Spirodelae is the most light, so it promotes lung qi on the top, reaches fur on the outside, releases sweat and heat, and connects water pathways on the bottom"[26]. Therefore, it has the effect of inducing various drugs to reach the fleshy exterior. Modern pharmacology has found that the extracts of Herba Spirodelae and Radix Salviae Miltiorrhizae can directly promote the proliferation of melanocytes[27].

Fructus Tribuli is bitter in taste and warm in qi, and enters liver and lung meridian, and can dispel both internal and external wind.BencaoHuiyanrecorded, "Fructus Tribuli dispels the wind and depresses qi, and promotes stagnation of qi in the liver and spleen." In the treatment of pigmentotic diseases, studies have found that Fructus Tribuli has a bidirectional regulatory effect on melanocyte metabolism and tyrosinase activity, and low concentration administration can activate tyrosinase activity and promote the recovery of melanocyte function[28].

On the basis of Fuse Hexue Jiawei Decoction, three traditional Chinese medicines, Radix Scutellariae, Herba Scutellariae Barbatae and Herba Hedyotidis, are added. The three flavors are heat-clearing antitoxin, with bitter taste and cold nature. Radix Scutellariae is good at clearing lung fire and dampness-heat of liver and gallbladder; Herba Scutellariae Barbatae can enter the blood and cool the blood; and Herba Hedyotidis can clear heat, remove dampness and detoxify. Modern pharmacological studies have found that traditional Chinese medicines for clearing heat and detoxifying have similar pharmacological effects, including bacteriostatic, antiviral, tumor suppression, immunity regulation and microcirculation improvement[29]. The pathogenesis of vitiligo is complex. In addition to clearing heat and detoxification, the compatibility of drugs with wind-dispelling and toxin-resolving, blood-cooling and toxin-resolving, dampness-removing and toxin-resolving and qi-boosting and toxin-resolving effects can be selected according to syndrome differentiation. There is no need to rigidly adhere to prescription and medication.

4.2 Milli fire needleIn the traditional Chinese medicine treatment of vitiligo, milli fire needle also has the effects of invigorating qi, promoting blood circulation and detoxification. In terms of the treatment mechanism, milli fire needle has the function of warming and heating, which can activate yang and reach collaterals, stimulate the qi of meridians and collaterals, and encourage the circulation of qi and blood. Acupuncture of the superficial collaterals will give an outlet to blood stasis, achieving the effect of removing blood stasis for promoting tissue regeneration. Flaring up of fire will disperse upward, and stabbing striae with fire needle to open a hole can achieve the effects of inducing pathogens out and purging fire for removing toxin. At the same time, acupuncture on fleshy exterior can stimulate tiny blood vessels of the skin, accelerate substance metabolism, help inflammation resolution, and promote the recovery of normal physiological function of myoepithelial cells[30-31].

The specific operation method of milli fire needle is that the doctor holds 3-5 fire needles as a bundle, burns the needle body and tip red, and acupunctures vertically into white patches of the skin, with quick and repeated operation. Compared with traditional fire needle, the advantages of milli fire needle are thin needle body, shallow piercing, weak pain in the treatment process, small damage to the skin after treatment, and patients are easier to accept. Therefore, in the traditional Chinese medicine treatment of vitiligo, the combination of oral medicine with milli fire needle has better curative effect.

5 Examples of medical records

The patient surnamed Jian, 71 years old, was first diagnosed in September 2019. He saw a doctor because white skin was found on the left cheek, in the hairline behind the left ear and on the left neck for a month. Special examination: scattered white patches were found on the left cheek, in the hairline behind the left ear, and on the left neck, distributed along the cutaneous ganglia, with irregular shape, clear boundary, smooth surface, no furfuration, no itching, and no pain. Wood’s lamp examination was performed in another hospital, and the disease was diagnosed as "segmental vitiligo". The patient complained of sticky stool and frequent night urination, and body examination showed that there was dark red tongue, thick and greasy tongue coating, soft and moderate pulse. Combined with the patient’s symptoms, tongue and pulse, the disease was diagnosed as vitiligo by traditional Chinese medicine, with liver and kidney deficiency and phlegm-damp stagnation. Fuse Hexue Decoction was prescribed, and the specific prescription was as follows: Herba Ecliptae 15 g, Radix Curcumae 9 g, Radix Angelicae Sinensis 10 g, Rhizoma Chuanxiong 10 g, Fructus Tribuli 9 g, Herba Spirodelae 10 g, Rhizoma Cyperi 10 g, Fructus Ligustri Lucidi 15 g, Radix Salviae Miltiorrhizae 30 g, lumbricus 10 g, Radix Astragalis 30 g, Cortex Albiziae 10 g, Amomi Fructus Rotundus 8 g, Fructus Aurantii 10 g, Armeniacae Semen Amarum 8 g, Semen Coicis 15 g, Fructus Mori 20 g, Radix Puerariae 10 g, Rhizoma Polygonati 12 g, Semen Astragali Complanati 15 g, Semen Cuscutae 30 g.

At the subsequent visit in March 2020, the patient had no progress in white patch, with punctate and compound color on the edge, improved stool viscosity, frequent night urination, dark tongue color, thin coating on the tongue, and occasionally poor food intake. Milli fire needle therapy was added. The white patches on the left cheek and neck were pricked with fire needle, once every 2 weeks, as a course of treatment. Chinese medicine prescription was also given: Radix Angelicae Sinensis 10 g, Rhizoma Cyperi 10 g, Radix Astragalis 30 g, Fructus Ligustri Lucidi 15 g, Rhizoma Chuanxiong 10 g, Herba Spirodelae 9 g, Radix Salviae Miltiorrhizae 30 g, Herba Ecliptae 15 g, lumbricus 10 g, Herba Epimedii 6 g, Rhizoma Curculiginis 10 g, Semen Astragali Complanati 15 g, Eucommiae Cortex 10 g, Semen Cuscutae 30 g, Os Draconis 15 g, Radix Morindae Officinalis 10 g, Carthami Flos 10 g, Pyritum 10 g, Fructus Aurantii 10 g, Semen Coicis 15 g, Radix Scutellariae 6 g, Talxilli Herba 15 g, Radix Curcumae 9 g, coking malt 10 g.

At the follow-up visit in April 2020, the patient’s white patches on the cheek and neck were basically recolored, and the white patches in the hairline behind the left ear were reduced, without new white patches. The overall curative effect was satisfactory.

Note comment: At first diagnosis, the patient was more than 70 years old, with declining visceral qi, liver and kidney deficiency, unfavorable qi and blood operation, body fluid stagnation, resulting in phlegm dampness and blood stasis, qi and blood imbalance, failure of nourishing skin and muscle, and developing into white patches. This case was characterized by the etiology and pathogenesis of "deficiency, toxin and stasis", and the treatment was guided by the method of invigorating qi, promoting blood circulation and detoxification. Fuse Hexue Jiajian Decoction was prescribed; Radix Salviae Miltiorrhizae, Radix Astragalis and Radix Angelicae Sinensis were used to maintain vital qi and harmonize qi and blood; Radix Curcumae, Rhizoma Chuanxiong, Rhizoma Cyperi and Cortex Albiziae were added to regulate activities of qi; Lumbricus is used to dredge the meridian and promote the circulation of qi and blood; Fructus Ligustri Lucidi and Herba Ecliptae were used to nourish the liver and boost kidney; Herba Spirodelae and Fructus Tribuli were used to induce drugs to the disease site, dispel the wind and disperse pathogenic factors. Besides, the products of regulating spleen and stomach, drying dampness and resolving phlegm were added, playing a role of nourishing liver and kidney, dispelling phlegm and dampness, and regulating qi and blood. On the basis of the original prescription, Amomi Fructus Rotundus, Fructus Aurantii and Semen Coicis were added to promote the circulation of qi to remove dampness; Fructus Mori, Semen Astragali Complanati and Semen Cuscutae were used to tonify the liver and kidney; Radix Puerariae and Rhizoma Polygonati were added to promote production of body fluid and benefit qi, better targeting the constitutional characteristics of the old patient with insufficient liver and kidney, and phlegm-damp retention.

The revisited patient was old and had kidney qi deficiency, adverse functioning of bladder, renal dysfunction, and frequent night urination. Therefore, Rhizoma Curculiginis and Herba Epimedii were added to tonify kidney qi and nourish kidney yang, and Os Draconis was supplemented, playing the role of convergence and astringency. Dark tongue color suggested that there was still stasis in the body, and Carthami Flos and Pyritum were added to activate blood and remove stasis. The patient sometimes had poor appetite, so coking malt was included to promote digestion and relieve stasis, and invigorate the spleen and stomach.

6 Discussion

Huang Yuanyu, a physician in the Qing Dynasty, said that "People survive relying on one qi". The occurrence of disease must first have the deficiency of vital qi. Due to weak defensive qi, pathogenic factors have an opportunity. Deficiency of qi in the zang-fu organs, unsmooth qi movement, and stagnation of pathological products for a long time will lead to blood stasis. The disease vitiligo is located in fleshy exterior, which is externally related to defensive qi and meridian qi, and is internally related to the lung, spleen, liver and other viscera functions. Inadequate meridians and weakened defensive qi make six exogenous pathogenic factors and external toxin factors easily invade skin striae, resulting in disharmony between qi and the blood and the occurrence of white patch. The lung, spleen, liver and other viscera are closely related to the operation of qi and blood; the lung plays the role of activating the flow of qi, food essence and body fluid, clearing the inspired air and keeping it flowing downward and helping maintain normal water metabolism; the spleen located in the middle energizer is the hub of qi and the source of qi and blood formation; the liver governs qi movement and blood storage. The failures in these three easily lead to generation of endogenous toxin, qi-blood disharmony, failure of nourishing skin and muscle, and the occurrence of white patch. Therefore, in the process of treatment of vitiligo, further theoretical and practical exploration can be implemented with the method of invigorating qi, promoting blood circulation and detoxification as the idea, so as to provide beneficial reference for clinical treatment of vitiligo.

Finally, in addition to medical treatment, patients should also pay attention to self-maintenance in daily life and face the disease with a positive and scientific attitude. In terms of diet, if there is no allergic food, a healthy, nutritious diet is enough without special taboo. In terms of life, it is necessary to participate in appropriate physical exercise, alternate work with rest, and avoid sun exposure outdoors.