Note: The treatments and medications mentioned in the text are for reference by TCM practitioners only. Patients should not take them without professional guidance, as they do so at their own risk.
Introduction: A friend asked about the usefulness of tongue diagnosis in clinical practice. This is an old case where the patient had few clinical symptoms, and the treatment was mainly based on the tongue image. However, if more symptoms can be collected, a comprehensive diagnosis should still be used.

I. Diagnostic Background: How does TCM tongue diagnosis solve the dilemma when Western medicine is at a loss?

1. Analysis of Patient’s Pain Points

Origin: A friend’s younger brother was covered in rashes, diagnosed with “pityrosporum folliculitis” at a Western hospital, and prescribed a large number of Western medications that did not cure the condition, which worsened. He sought my help. See the image below:
Note: The case is preserved on Everyone’s TCM, so there will be a watermark from Everyone’s TCM. Images of the head and face are not included due to privacy concerns.

• Western Medicine Diagnostic Dilemma: Recurrent pityrosporum folliculitis, ineffective antibiotic treatment.
• TCM Differential Diagnosis Advantage: Identifying the core pathogenesis of “liver depression and spleen deficiency, phlegm and blood stasis intertwined” through tongue image (tire tongue + phlegm turbidity coating).

2. Core Findings of Tongue Diagnosis

First Consultation on August 16, 2024

Current Symptoms: Male patient, 20 years old, with rashes on the chest, back, and face for over a year, poor appetite, chronic constipation, occasional chest tightness, itchy skin, often scratching, no other discomfort. Since it was an online consultation, the pulse was not taken. The tongue image is as follows:

• Tire Tongue Characteristics: The tongue is swollen around the edges like a tire, with a central depression and a white greasy coating (see the tongue diagnosis image on August 16).
• Microscopic Pathogenesis:
  • Stagnation: Dark red stasis spots on the tongue surface → obstruction of qi, blood, phlegm, and stasis in the meridians.
  • Deficiency: Pale and tender tongue with teeth marks → spleen deficiency with excessive dampness, failure of clear yang to rise.

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II. Full Record of Diagnosis and Treatment: Precise Intervention Based on Comprehensive Diagnosis

1. Key Decisions of the First Consultation (August 16, 2024)

First Consultation on August 16, 2024

Current Symptoms: Male patient, 20 years old, with rashes on the chest, back, and face for over a year, poor appetite, chronic constipation, occasional chest tightness, itchy skin, often scratching, no other discomfort. Since it was an online consultation, the pulse was not taken. The tongue image is as follows:

• Tongue Image Analysis: This is a tire tongue image, with the edges swollen and the center depressed. The tongue coating is white and greasy, indicating phlegm turbidity. The pathogenesis is liver depression and spleen deficiency, with internal accumulation of phlegm and dampness. Additionally, the stasis spots on the tongue are very noticeable, not bright red but dark, indicating significant internal stasis.
• Symptom Focus: Poor appetite and constipation, chest tightness and itching, dark red rashes.
• Treatment and Prescription: Soothe the liver and strengthen the spleen, resolve phlegm and dampness, break up stagnation.
• Prescription: Bupleurum 20g, Aurantium 20g, Fried Yam 20g, Dried Ginger 10g, Cardamom 10g (added later), Amomum 10g (added later), Fried Atractylodes 15g, Codonopsis 9g, Poria 15g, Soapberry 1g (powdered), Jujube 8 pieces, Black Sesame 6g, Red Peony 10g, Moutan 10g, Rhizoma Sparganii 9g, Curcuma 9g, Fried Hawthorn 30g, Fried Barley Sprout 20g, Cyperus 15g, Tangerine Peel 15g, Sichuan Pepper 4g, Honeysuckle 30g, Forsythia 30g, Corydalis 10g, Smilax 30g.
  Unit: grams; total of 7 doses, one dose per day, taken warm in two divided doses, morning and evening.
  Avoid greasy, spicy, and cold foods.
• Prescription Analysis:
  • Si Ni San + Si Jun Zi Tang + Qi-regulating and Blood-activating Herbs: Additionally, using three routes to expel toxins through the skin, stool, and urine. Bupleurum soothes the liver and resolves depression, Atractylodes strengthens the spleen and dries dampness, Codonopsis tonifies qi and raises yang.
  • Three Routes of Toxin Expulsion: Toxin Expulsion Pathways Herbal Combinations Target Points: Honeysuckle and Forsythia are used to expel toxins through the skin. Sichuan Pepper enhances the expelling effect through the skin.
    Rhizoma Sparganii, Curcuma, and Corydalis are blood-activating herbs that break up stagnation and clear the path for toxin expulsion through the skin.
    Black Sesame helps expel some toxins through the stool. Poria and Smilax help expel some toxins through the urine.
    Soapberry powder combined with Jujube forms Soapberry Pill, which has strong penetrating and phlegm-resolving capabilities.
    Smilax is commonly used for skin diseases, especially those with blisters on the surface. Even without blisters, it is added for its detoxifying effect, known in Western medicine as antibacterial.

2. Strategy Adjustment at the Second Consultation (August 23, 2024)

Feedback images from the second consultation on August 23, 2024, are as follows:

• From the photos, the rashes are not as red, and the change is not particularly significant compared to before. However, the tongue image has changed significantly, with much less phlegm turbidity. The patient reported less itching, normal bowel movements, and a fair appetite. Advised to continue with the same prescription for 7 more doses.
• Tongue Image Improvement: White greasy coating reduced by 50%, stasis spots lighter (see tongue image 2).
• Optimization of the Same Prescription: Increase Rhizoma Sparganii and Curcuma to enhance blood stasis breaking, Fried Hawthorn to aid digestion and remove stagnation.

3. Efficacy Tracking (August 31, 2024)

Feedback after 14 days of medication on August 31, 2024, is as follows:

From the patient’s feedback images, the rashes on his body have basically cleared up. While it cannot be said that the skin is completely smooth and new, the change is very noticeable compared to before the illness.

Especially in terms of the tongue image, it has basically returned to normal, with only a minor lingering issue.

Due to the patient needing to return to school, it was inconvenient to continue boiling the medicine, and he felt that his condition had improved significantly, so he decided to stop taking the medication. Following his wishes, he was advised to take Xue Fu Zhu Yu Wan and Xiao Yao Wan for a week as a follow-up treatment.

3. Follow-up (September 6, 2024)

The patient told me that his skin pimples have cleared up, he is no longer itchy, his appetite is good, and his bowel movements are smooth. However, he has left some light brown scars from scratching for a year.

• Skin Improvement: Rashes subsided, itching stopped, leaving light brown scars.
• Tongue Image Review: From the feedback on his tongue image, the stagnation is gone, but it looks a bit pale and cold. I asked if he had been drinking cold beverages and eating ice cream recently, and he said it was too hot not to. Young people, so young!
• I could only advise him to drink warm water when thirsty, but I don’t know if he followed through.

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III. Analysis of Classic Prescriptions: From Si Ni San to Soapberry Pill

1. Core Prescription Analysis

• Si Ni San (Bupleurum + Aurantium + White Peony + Licorice):
  • Modern Research: Bupleurum saponin D regulates Th17/Treg balance, inhibits follicular keratinization (J Ethnopharmacol 2022).
• Soapberry Pill (Soapberry Powder + Jujube):
  • Toxin Expulsion Mechanism: Saponin components promote loosening of the stratum corneum, Jujube mitigates irritation.

2. Medication Contraindications Warning

• Cautionary Groups: Those with yin deficiency and excessive fire should avoid warm and drying herbs (such as Dried Ginger).
• Alternative Solutions: For acne caused by Propionibacterium acnes, add 30g of Dandelion and 15g of Viola.

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IV. Case Study Insights: The Breakthrough Approach in TCM Dermatology

1. Three Breakthrough Insights

• Essence of Skin Lesions: Phlegm and blood stasis intertwined → not just treated as “damp heat.”
• Value of Tongue Diagnosis: Tire tongue → early warning signal of liver depression and spleen deficiency constitution.
• Strategy of Expelling Toxins: Expelling through the skin + promoting bowel movements + activating blood → a three-dimensional toxin expulsion system.

2. Subsequent Conditioning Recommendations

• Dietary Therapy: Si Shen Tang (Poria + Lotus Seed + Gorgon Fruit + Yam) to strengthen the spleen.
• External Treatment: Dian Dao San (Rhubarb + Sulfur) applied to scar areas.