Deconstruct the peeled tongue, stagnation and yin deficiency, and the spleen’s failure to ascend clear qi as the main pathological mechanisms, followed by commonly used drug pairs for generating tongue coating.

I. Redefining the Peeled Tongue: From “Dry Soil” to “Blocked Water Channels” in Traditional Chinese Medicine

1. Breaking Through Traditional Theory

Let’s first look at the discussion on peeled tongue in the ninth edition of the textbook “Traditional Chinese Medicine Diagnostics”:

I don’t know why, but when I look at the textbook, I feel very sad.
It’s like a field that’s dry and can’t grow crops, and they just say the water tank is empty. We common folks know to check if the irrigation channel is blocked, or if the water pump’s pressure is too low to draw water.

Regarding the issue of tongue coating, we can take a look at this previously written article: The Principle of Tongue Coating Formation. Technique Article | Deconstructing the Principle of Tongue Coating Formation in Tongue Diagnosis
If we follow this analysis, I would say that all five viscera and six bowels are related to the formation of tongue coating, including peeled tongue. The operation of spleen qi, the warming of kidney yang, the propulsion of liver qi, and the diffusion and descending of lung qi.

So, with this in mind, it feels clear in my head, but when I actually use it, it’s a mess, unclear and confusing. So, let’s switch to a minimalist approach to look at the problem. It’s like acupuncture; you can treat diseases from the perspective of meridians, or from the perspective of image thinking, and using the five transport points and the five elements’ generation and restraint is also effective. For example, if you’re showering upstairs and suddenly the showerhead stops working, we can consider it from three aspects.
First, the water tank might be empty. Second, the water pipe might be clogged somewhere by hair or fabric. Third, the pressure pump might not have enough pressure to push the water up.
From this perspective, corresponding to our principle of peeled tongue formation, I summarize it as: stagnation, yin deficiency, and spleen’s failure to ascend clear qi.

Summarizing it this way, stagnation, yin deficiency, and spleen’s failure to ascend clear qi (three ascents) are simple to remember, comprehensive, and comfortable to use.

• ​Textbook Definition: Peeled tongue = deficiency of stomach qi/damage to stomach yin, but clinically it is found that:
  • Patients with peeled tongue often have a pale and tender tongue (insufficient yang qi) rather than a swollen and large tongue (excessive phlegm-dampness).
  • New coating particles can be seen at the peeled areas (a sign of yang qi wanting to ascend).
• ​Modern Verification: Tongue microbiome testing shows reduced microbial diversity in peeled areas (data from Nature Microbiology in 2023).

2. Three-Element Model of Peeled Tongue Formation

① Stagnation (qi, blood, phlegm, cold, heat) → Blocked water channels  
② Yin deficiency (insufficient transformation from spleen and stomach) → Impoverished soil  
③ Spleen's failure to ascend clear qi (lack of propulsion from liver and kidney yang) → Water pump failure  

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​II. Analysis and Treatment Plans for 12 Tongue Image Charts

1. Typical Peeled Tongue Classification

Let’s now look at the tongue image analysis:

2. Medication Logic

​Tongue Image Features	​Core Pathological Mechanism	​Recommended Formula
Front peeled tongue with teeth marks	Spleen deficiency and qi sinking	Bu Zhong Yi Qi Tang + Raw Barley Sprout 15g
Root peeled tongue with white greasy coating	Kidney yang deficiency and water-dampness not transforming	Zhen Wu Tang + Amomum 6g
Flower peeled tongue with dark tongue body	Liver depression and blood stasis	Xiao Yao San + Peach Kernel and Safflower Decoction
Mirror tongue with cracks	Deficiency of both qi and yin	Sheng Mai San + Dendrobium 15g

3. Key Points of Tongue Coating Generating Pill Formula

• ​Core Combination: Stir-fried Yam (nourishes spleen yin) + Raw Barley Sprout (raises liver qi) → Strengthens spleen, raises clear qi, breaks stagnation, and generates coating
  These two herbs, one strengthens the spleen and stomach, nourishes qi and yin, addressing the root problem. The other, Raw Barley Sprout, has an ascending nature, soothing liver qi, assisting the liver wood to ascend, and also helping the spleen to raise clear qi. The pathological mechanism of peeled tongue, stagnation, yin deficiency, and spleen’s failure to ascend clear qi, is all included.
• ​Mnemonic Rhyme:
  “Peeled tongue, three ascents to adjust, Yam and Barley Sprout together with Xiao Yao;
  Disperse stagnation, generate yin fluid, the tongue surface generates coating like spring seedlings.”

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​III. Common Misconceptions and Solutions for Modern People

The rigid and fixed content in textbooks cannot be fully applied to clinical practice. It’s like a line from “Ne Zha 2: The Brain of the Demon Child”: “Break it for me!” We need to constantly break down the solidified things.

This era has changed; it’s an era for the new generation of young Chinese medicine practitioners. We need to have confidence; our love for Chinese medicine will continuously give us the strength to move forward, making us shine in this era.

The last sentence: Inheriting the medical path, every person who loves Chinese medicine has a responsibility, not seeking to promote, but only to inherit the essence.

The road ahead is long and arduous, but I will seek and strive.

1. Three Fatal Misconceptions

• ​Misconception 1: Using yin-nourishing drugs upon seeing peeled tongue
  • ​Correct Approach: Pale and tender peeled tongue → Spleen yang deficiency, needs Li Zhong Tang + Amomum
• ​Misconception 2: Red peeled tongue = Yin deficiency and fire excess
  • ​Correct Approach: Red tongue with little coating and fear of cold → Upper heat and lower cold, needs Jiao Tai Wan + Cinnamon
• ​Misconception 3: Peeled tongue = Stomach yin damage
  • ​Correct Approach: Peeled tongue with abdominal distension → Spleen deficiency and qi stagnation, needs Xiang Sha Liu Jun Zi Tang

2. Treatment Cycle Planning

• ​Stagnation-Breaking Phase (1-2 weeks): Xiao Yao San as the base, add Cyperus and Lindera to soothe the liver
• ​Coating-Generating Phase (3-4 weeks): Shen Ling Bai Zhu San + Raw Barley Sprout, strengthen spleen and raise clear qi
• ​Foundation-Strengthening Phase (5-6 weeks): Gui Lu Er Xian Jiao to strengthen the foundation, with a small amount of Cinnamon Twig to promote yang