Carbuncle is an acute suppurative condition of the skin involving several adjacent hair follicles and their sebaceous glands. It is most commonly seen on the nape and the back.
Etiology, Pathology and Clinical Manifestation
The carbuncle results when exogenous Wind-Heat or Dampness-Heat interacts with poisons in the visceral organs, and the mixed pathogenic evil and poisons accumulate in the superficies. In consequence, there is disharmony of the Defensive and the Nutritive Levels and stagnation of Qi and stasis of blood, which in turn lead to blockage of the meridians and channels. This is the strength type of carbuncle.
In a patient with deficiency, resistance to illness is compromised and carbuncles may develop. This is the deficiency type. Patients with diabetes are especially prone to develop carbuncles.
A carbuncle usually begins as a red swelling with a grain-sized pustule. It is hot and painful. It gradually enlarges, develops multiple pustules and takes on the appearance of a small honeycomb. Pain becomes strong. Suppuration then extends to the entire lesion, making it fluctuant. In the ulcerative stage, portions of the surface become necrotic and rupture, draining much pus and leaving an open wound. The wound slowly heals as new tissue grows. Before the rupture and drainage of pus the patient may have such systemic symptoms as chills and fever, headache and anorexia.
In most cases, the clinical course takes about a month. If the patient is very weak or has diabetes, the carbuncle is likely to develop more rapidly, is more serious and has a longer course.
Herbal Treatment
For proper treatment, it is important to determine whether the carbuncle is of the strength or deficiency type.
Internal Treatment
Strength Type: Early Stage
Main Symptoms. The lesion is red, swollen, hot and tender, with one or several pustules. The patient may have chills and fever. The tongue coating is white or yellow, and the pulse is taut, slippery rapid.
Therapeutic Principle. Cool Heat, detoxify poisons, mobilize blood and eliminate stasis.
Treatment. Qing Re Jie Du Yin (Heat-Clearing Poison-Detoxifying Drink). It has the following composition: jinyinhua (Lonicera) 30 g, pugongying (Taraxacum) 30 g, danggui (Angelica) 15 g, chishaoyao (Paeonia) 15 g, danshen (Salvia) 15 g, wild juhua (Chrysanthemum) 15 g, loulu (Rhaponticum uniflorum) 15 g, and gancao (Glycyrrhiza) 6 g.
If the swelling is particularly firm and painful, take Xing Xiao Wan (Waking-Dissipating Pill) with water, twice daily, 1.5-3 g each time. Xing Xiao Wan has the following composition: de-fatted ruxiang (Boswellia) 30 g, de-fatted moyao (Commiphora) 30 g, shexiang (Moschus) 4.5 g, and xionghuang (realgar)15 g. First grind ruxiang, moyao and xionghuang separately. Accurately weigh each. Mix them with shexiang and grind them together. Over-cook 30 g of unpolished rice until the grains become mash. Thoroughly mix in the ground powder of the herbs and form into granules. Dry in the sun; do not dry over heat.
If fever is high, with much thirst, add xuanshen (Scrophularia) 15 g, tianhuafen (Trichosanthes) 15 g and zhimu (Anemarrhena) 9g.
If Heat poisons are especially strong, add banlangen (Isatis) 15 g, huanglian (Coptis) 9 g and qiyeyizhihua (Paris polyphylla) 9 g.
Strength Type: Ulcerative Stage
Main Symptoms. The carbuncle has the appearance of a honeycomb, with much swelling and some rupture and drainage of pus. There is much pain. Accompanying symptoms include thirst and fever. The tongue coating is yellow, and the pulse is slippery and rapid or surging and rapid.
Therapeutic Principle. Purge Heat, detoxify poisons and drain pus.
Treatment. Qing Re Pai Du Tang (Decoction for Purging Heat and Poisons). It has the following composition: jinyinhua (Lonicera) 30 g, pugongying (Taraxacum) 30 g, raw huangqi (Astragalus) 30 g, banlangen (Isatis) 30 g, lianqiao (Forsythia) 15g, baijiangcao (Patrinia scabiosaefolia) 15 g, tianhuafen (Trichosanthes) 15 g, jiegeng (Platycodon) 10 g, baizhi (Angelica dahurica) 10 g, chuanxiong (Ligus-ticum) 10 g, chuanshanjia scales (Manis pentadactyla) 10 g and zaojiaoci (Gleditsia sinensis) 10 g.
Yin Deficiency with Strong Poisons
This occurs mainly in the weak or elderly, or in a patient with diabetes.
Main Symptoms. The lesion is flat and is dark purple in color. Ulceration and drainage develops slowly, and when they come about the pus is watery or bloody. Other symptoms include a dry mouth with thirst, a red tongue and a threadlike and rapid pulse.
Therapeutic Principle. Nourish Yin, generate fluids, cool Heat and remove poisons.
Treatment. Zhuye Huangqi Tang (Lophatherum-Astragalus Decoction). It has the following composition: renshen (Panax) 10 g, processed banxia (Pinellia) 10 g, maimendong (Ophiopogon) 10 g, baishaoyao (Paeonia) 10 g, chuanxiong (Ligus-ticum) 10 g, danggui (Angelica) 10 g, huangqin (Scutellaria) 10 g, raw huangqi (Astragalus) 30 g, shengdihuang (Rehmannia) 30 g, raw shigao (gypsum) 15 g, gan-cao (Glycyrrhiza) 6g, danzhuye (Lophatherum gracile) 6 g, dengxincao (Juncus effusus) 0.6 g, shengjiang (Zingiber) three slices, jinyinhua (Lonicera) 30 g and zaojiaoci (Gleditsia sinensis) 9 g.
Weak Constitution with Strong Poisons
Main Symptoms. The carbuncle is diffuse and slow festering, and it drains watery pus. The necrotic tissue formed after ulceration sloughs with difficulty. There are accompanying fever and weariness. The tongue coating is white and greasy or slightly yellow. The pulse is rapid but forceless.
Therapeutic Principle. Augment Qi, generate blood and remove poisons.
Treatment. Tuo Li Xiao Du San (interior-Supporting Poison-Detoxifying Powder). It has the following composition: dangshen (Codonopsis) 30 g, raw huangqi (Astragalus) 30 g, jinyinhua (Lonicera) 30 g, chuanxiong (Ligusticum) 9g, danggui (Angelica) 9g, baishaoyao (Paeonia) 15 g, baizhu (Atractylodes) 10 g, jiegeng (Platycodon) 10 g, baizhi (Angelica dahurica) 10 g, fuling (Poria) 10 g, zaojiaoci (Gleditsia sinensis) 10 g, and gancao (Glycyrrhiza) 6g.
If the lesion is slow to suppurate, increase the amount of huangqi to 45 g and add chuanshanjia scales (Manispentadactyla) 9 g.
If the drainage is very watery pus, increase the amount of dangshen to 45 g, baizhu to 15 g and fuling to 15 g.
If fever is high, increase the amount of jinyinhua to 45 g and add lianqiao (Forsythia) 15 g.
Deficiency of Both Qi and Blood
Main Symptoms. Following rupture the watery pus is clear and thin. The putrescent matter clears slowly, and new granulation tissue grows very slowly so that the wound heals with difficulty. There are such systemic symptoms as lassitude, weakness, lusterless complexion, a pale tongue and a depletive and feeble pulse.
Therapeutic Principle. Augment and restore Qi and blood.
Treatment. Shi Quan Da Bu Tang (Complete Major Restorative Decoction). It has the following composition: danggui (Angelica), chuanxiong (Ligusticum), baishaoyao (Paeonia), huangqi (Astragalus), rougui (Cinnamomum), renshen (Panax), shudihuang (Rehmannia), baizhu (Atractylodes), fuling (Poria), and gancao (Glycyrrhiza).
Topical Treatment
In the early stage, wash with warm Jie Du Xiji (Detoxifying Wash).
In the ulcerative stage, first wash the wound with Jie Du Xiji. Then cover with Dahuang You (Rhubarb Lotion) on gauze. Change the dressing as needed. If pus does not drain, it may be necessary to incise the carbuncle to facilitate drainage.
In the healing stage, Sheng Ji San (Tissue-Generating Powder) may be sprinkled on the wound. Sheng Ji San has the following composition: kufan (dried alum), binglang (Areca), huangdan (yellow lead oxide), xuejie (Daemonorops draco), qingfen (calomel), and mitouseng (lead oxide).
Case Study
The patient was an 85-year old woman who had a carbuncle on the nape of her neck, accompanied by chills and fever. A week earlier, she first noticed a grainsized papule. It gradually increased in size and became painful. The pain extended to the shoulders and upper back, and neck movement became difficult. She also began having chills and fever, and some dizziness and headache. She was treated with injections of penicillin for 3 days, without any benefit. The swelling and pain increased, disturbing her sleep.
Her temperature was 38.5°C (101.3°F). On the nape she had a 7 by 9 cm (2.75 by 3.5 in.) swollen mass topped by numerous pustules. The whole lesion had the appearance of a honeycomb. There was little drainage of pus. The surrounding tissues were indurated and hot to the touch. There was much tenderness, and she resisted palpation. Her tongue coating was thin and yellow, and her pulse threadlike and rapid. A white blood cell count was 18,000, with 84% neutrophils and 16% lymphocytes.
Diagnosis. Carbuncle on the nape of the neck.
Therapeutic Principle. Augment and harmonize Nutritive Qi, cool Heat and promote drainage of pus.
Treatment and Course. Modified Xian Fang Huo Ming Yin (Celestial Life-Saving Drink). The modified composition is as follows: huangqi (Astragalu) 9 g, danggui (Angelica) 9 g, chishaoyao (Paeonia) 9 g, fangfeng (Saposhnikovia) 6 g, chenpi (Citrus tangerina) 6 g, yuanzhi (Polygala) 9 g, baizhi (Angelica dahurica) 6 g, zaojiaoci (Gleditsia sinensis) 9 g, stir-baked chuanshanjia scales (Manis pentadactyla) 9 g, gancao (Glycyrrhiza) 4.5 g, and jinyinhua (Lonicera) 9 g. She was to take three daily doses.
Second Visit. She returned for follow-up in 3 days. The pain and swelling decreased progressively. There was rupture of the carbuncle with much drainage of pus. She still had dizziness with headache. Her tongue was pale, with a clean coating. Her pulse was threadlike and feeble. The same formula with added juhua (Chrysanthemum) 9 g was continued, for three daily doses.
Third Visit. She returned in 3 days. Pain and swelling had resolved. There was sloughing of necrotic tissue, and the base of the carbuncle now showed fresh granulation tissue. Her appetite improved. The tongue coating was thin, yellow and greasy. The pulse was taut and threadlike. The same formula with added gouteng (Uncaria) 9 g was continued for three daily doses.
Fourth Visit. She returned in 3 days. All necrotic tissue had sloughed and the swelling resolved. She still had a potential cavity between the granulation tissue and the overlying skin. The residual lesion was mildly tender. She still had a mild headache. The tongue and pulse were unchanged. The therapeutic principle was now changed to one of restoring Qi and blood and stimulating the growth of new tissue. The prescription had the following composition: huangqi (Astragalus) 12 g, chuanxiong (Ligusticum) 4.5 g, danggui (Angelica) 9g, chishaoyao (Paeonia) 9g, baizhi (Angelica dahurica) 9 g, juhua (Chrysanthemum) 9 g, shijueming (Haliotis) 12g, gouteng (Uncaria) 9g, jinyinhua (Lonicera) 9g, yuanzhi (Polygala) 9g, and gancao (Glycyrrhiza) 6 g. She was to take this prescription for three daily doses.
Fifth Visit. She returned in 3 days. The wound had shrunk and the potential cavity gone. The surrounding tissue was now pink. Her headache had resolved. A cooling and restorative formula was prescribed to consolidate the clinical gains. Its composition was as follows: huangqi (Astragalus) 12 g, danggui (Angelica) 9g, chuanxiong (Ligusticum) 4.5 g, chishaoyao (Paeonia) 9 g, jinyinhua (Lonicera) 9 g, juhua (Chrysanthemum) 9 g, and gancao (Glycyrrhiza) 4.5 g. After three daily doses, the wound healed.
