"Psoriatic Arthritis Case Study" By Barbara Ferrero

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By Barbara Ferrero

 

History

The Chief Complaint (CC):
50 year old female with a chief complaint of Psoriatic arthritis (PA). Psoriasis is present mainly on the elbows, with some patches on the knees and at the base of the head (this area is variable). The joint pain depends upon changes in the weather, and occurs only on the distal small joints (fingers and toes).

History of Present Illness (HPI)
It started during the late 1970s, with joint pain in the fingers. Her doctor said it was arthritis, and a couple of years later, the skin lesions appeared and were diagnosed as psoriasis.
Twelve years ago, she had a big flare up episode with pain progressing to the large joints, such as the hips. Psoriasis remained the same, only in the areas reported above.
During the flare up, the patient had several tests done, including blood panel, stool sample, x-rays, and MRI that confirmed the diagnosis of arthritis.

The joint pain moves around significantly; on a given flare up, it could be in the thumb, or the 3rd toe, and it is aggravated by weather changes, usually before rain (a few days). Sunshine makes the skin better.

Past Medical History (PMH):
Around 1989, the patient felt excessively tired, gained some weight that she describes as “feeling puffy”, and got constipated – matching a classic presentation of thyroid dysfunction. Her pulse was 39 bpm, The development was Insidious, and the above signs and symptoms presented over a period of 6-9 months, maybe even a year, before she went to the doctor. Upon waking up in the middle of the night with no sensation in one arm that would not return to normal for a long while, she consulted her doctor to rule out stroke (especially because the arm that fell asleep was not the one she was lying on)

Her doctor diagnosed her with hypothyroidism and prescribed thyroxin. After 6 days she was feeling great, had lost the puffy weight and went back to her normal lifestyle.

14 years ago, while living in Sweden, the patient had acupuncture treatments for psoriasis with great results, almost complete remission. Now living in the US, she does not see an acupuncturist, so she receives no OM treatment.

Medications (MEDS):
Prescription cream for Psoriasis dovanex as needed (everyday)
Thyroxin, every day

Patient takes over the counter (OTC) naproxen sodium for joint pain and has had two cortisone shots – just 2, a year apart – and reports that “it feels amazing”.

Allergies/Reactions (All/RXNs):
None reported

Social History:
Minimal alcohol intake, does not smoke at present, although did smoke lightly for a few years and quit about 25 years ago.
No drug use.
Patient is married with 1 child, male, who is now 16 years old and has no signs or symptoms of PA

She loves art and traveling; has two pets, a dog and a parrot, and has an active social life.

Work History:
The patient owns a massage clinic and also works there as a therapist. An average week consists of 2-5 hours of massage and 30 hours at the front desk.
During flare ups, she does not perform massages or limits them to a bare minimum.

Family History:
There are 17 cousins in her family, and only 3 have a chronic skin disorder, including the patient. Of the other two, one has eczema and the other, psoriasis.

Obstetrical History (where appropriate):
Delivery was by c section.

Current Health Status
Annual check up: OK
Vegetarian, eats soy burgers, but mostly cooked vegetables and grains. She looks healthy and energetic.
She exercises daily, usually walking for 30 minutes and also practices Yoga sporadically, although she states that she would like to do it more often.


Review of Systems (ROS):
· Temperature: normal, although she tends towards cold, and feels that if she gets chilly, it takes her a long time to warm                      back up
· Sweat: Excessive as described by the patient.
· Appetite: normal
· Thirst: normal
· Taste: nothing unusual
· Urination: relative to fluid intake, normal color and smell. No pain or difficulty
· Bowel movement: Once a day in the morning, very regular, well formed.
· Pain: only the one reported above (joints)
· Sleep: patient gets about 7-9 hours a night, often wakes up 1-2 times to urinate (she drinks a lot of tea after dinner). She sometimes will have trouble falling asleep, when stressed out by work. No dreams
· Menses: LMP 1 year ago. She was taking hormone replacement therapy daily. Now she only takes it when needed usually 2x/wk

Physical Exam:
The patient is a 5’4”, 140lb woman that looks healthy with clear skin and calm shen.
She is well groomed and wearing pleasant clothing that looks comfortable.
Her demeanor is calm, yet lively. 
Vital Signs: Pulse: 65bpm
Blood pressure: 110/60
Respiration rate: 15/min
Her skin is at normal temperature and her hands are clammy.


OM Tongue and Pulse
T: Healthy pink, slightly trembly, with cracks in the front portion and slightly puffy. It is raised and smooth along the edges and rougher in the center. The coat is thin, white, and even

P: overall wiry and strong, middle depth. Stronger in the middle position. In the first position, the Left pulse is stronger. In the middle, it’s overall forceful with the right side being stronger.
The third position is stronger on the right, and faint on the left.

Skin & Lymph nodes
Skin tone is even, no edema. Lymph nodes are not swollen or tender
The skin of the hands is slightly redder, but not in the fingers (where the pain is)
The skin of the elbows and knees is red, shiny, and slightly raised in the areas affected by psoriasis.

HEENT: Seldom, the patient gets migraines related to atmospheric pressure changes.
Abdomen: Not examined/No complaints

Musculoskeletal: the hands appear slightly swollen, although there are no obvious signs of edema or slow blood return.

Neurologic: not applicable


Lab Results, Radiologic Studies, EKG Interpretation, Etc.: not required, since the patient has already been diagnosed by a physician using lab tests. However, for consistency and completeness of charting, it would be desirable to have a copy of those reports.
Assessment:
Traditional Chinese Medicine (TCM) disease category: This presentation belongs to the category of Bi Syndrome (painful obstruction). External evils invade the body and lodge in the joints impeding the normal flow of qi, and causing pain and stagnation. Depending on the nature of the evil, the signs and symptoms will vary from hot, throbbing to cold, stabbing pain; moving or fixed, uni or bilateral, mono or polyarticular.
If wind evils lodge in the skin and blood is dry and unable to construct and nourish the skin, then it may become dry, lichenified and scaly. If the skin dries out so much that it cracks, there may be bleeding and pain. Because of the wind and dryness, there is itching. The accompanying arthritis is a type of impediment condition: due to the evils of wind, dampness, heat, and cold, the four types of evil qi which may cause impediment conditions resulting in joint pain. If loss of free flow endures for a long time, eventually there will also be blood stasis engendered in the network vessels. Because static blood hinders the engenderment of new or fresh blood, this development creates a self reinforcing loop, making this condition difficult to heal. (Sionneau & Flaws, 2005)

TCM working diagnosis: Wind Damp Bi in the joints and skin. The patient exhibits a classic pattern of Bi syndrome of the fingers, with the predominant signs of migrating pain, swelling and restricted range of motion (difficulty with flexion and extension) during flare ups. She also presents with a skin disorder related to the Wind-Cold-Damp blockage. This condition improves with direct exposure to sunlight and is aggravated by cold-damp weather as well. She has a slight accumulation of dampness in her body overall, and that may be evidenced by the ease of sweating (described by the patient as excessive). The joints affected are mostly the small joints, especially fingers and toes.

TCM differential diagnosis: According to Sionneau and Flaws, 2005, Psoriatic arthritis in Chinese Medicine can be classified as:
    •    Yin Vacuity with concomitant wind damp heat impediment
    •    Liver Spleen Disharmony with Damp Heat Stasis
    •    Damp Heat toxins damaging Yin Fluids

None of the above patterns match the signs and symptoms of the patient in a way that could justify the choice of either one of them.
 
In Dermatology in Chinese Medicine, Xu Yihou discusses several other patterns of Bi with skin lesions that make a better fit for the present case:

    •    Disharmony of the Chong and Ren Vessels: lesions related to menses, pregnancy and childbirth. Usually aggravated before menstruation and during postpartum, although could appear after menstruation. Bright or pale red lesions that are widely distributed and covered by silvery white scales. Other signs and symptoms include: irritability, dry mouth, dizziness, itching, low back pain, malaise. Tongue is unremarkable, pulse is slippery and rapid or deep and thready. This pattern is not applicable to the patient because her flare up periods are not related (or ever were) to her menstrual or reproductive cycles.
    •    Insufficiency of Liver and Kidneys: chronic, persistent and recurrent condition that develops into psoriatic arthritis. The psoriatic lesions are accompanied by arthralgia that gradually worsens, with deformity of the joints. Aching and pain of the lower back and knees, pale or dark red tongue with scanty or no coat, deep and slippery pulse (or thready and weak). This pattern matches the case at the onset, but is not the best fit.
    •    Damp Heat toxin accumulation: Pustular psoriasis. Acute onset of large erythematous patches spreading rapidly throughout the body, plus signs and symptoms of damp heat toxin. This pattern does not match the s/s or characteristics of the lesions.
    •    Blood Heat and Wind Dryness due to blood deficiency. These patterns do not match the presentation of the case in the overall signs and symptoms or the characteristics of the lesions.


Etiology and Pathomechanims: External contraction of Wind Damp. Evils lodge in the joints and obstruct the free flow of qi, resulting in pain and restricted ROM. Due to the nature of Wind, the pain moves in a random pattern and affects different joints each time. Understanding the path of the evils is key to determining a treatment plan. For example, internal heat can affect different organs and channels, and the method of treatment will vary greatly depending on whether the evil needs to be vented out from the skin, cleared out of the Lungs or purged out of the middle jiao. Likewise, the wrong treatment method can worsen the condition, by aggravating the pattern or driving the pathogen further into the body.


Biomedical differential diagnosis:
The patient has already been diagnosed by her physician with psoriatic arthritis, based on: presenting signs and symptoms, lab findings, x rays of the joints and differential diagnosis.
The diagnosis appears accurate, as does the treatment the patient is currently following.

In Biomedicine, there are different types of psoriatic arthritis: symmetric, oligoarticular, distal interphalangeal, spondylitis (primarily affects the low back), and arthritis mutilans (affects mainly the small joints of the hands and feet). The patient seems to have a form of oligoarticular psoriatic arthritis that is mild and episodic.
Her treatment is palliative and addresses the symptoms as they occur.
Treatment Principle: Dispel Dampness, dissipate Wind, relieve toxicity and free the network vessels. Even though the tongue and pulse do no evidence systemic heat, the skin lesions are a sign of heat trapped in the cutaneous layer. Given this, part of the treatment principle is to relieve that toxicity.

Acupuncture treatment: All points needled bilaterally with neutral technique.
Retention: 15 minutes on each side.
Distal and systemic points:
Du 14: Eliminate wind and clear heat
SJ 6:  River point: regulates qi, expels wind heat, especially for skin manifestations of wind heat in the blood.
SP 6: Strengthen Yin
SP 9: transform dampness

Back shu points to address the chronicity of the condition:
UB 13: back shu of the Lung: support the Lung function of protecting and nourishing the skin
UB 23: back shu of the Kidney: strengthen the Yin/Yang pair of the Lung and root of essence, that ultimately determines the quality of all tissues.
UB 17: Nourish blood, remove stagnation, tonify blood and qi

Local points:
Ba feng and Ba Xie: local treatment of bi of the toes, clear heat, reduce swelling


Adjunctive therapies: Massage joints with Castor oil during flare ups.

Herbs: Du Huo Ji Sheng Tang Jia Jian
This is a modification of Du Huo Ji Sheng Tang: Pubescent Angelica Root and Mistletoe Decoction.
The formula looks perfectly balanced and addresses every aspect of the presenting pattern, thus requiring no further modification until after 2 weeks of daily intake (unless side effects or worsening of the condition occur)

Qiang Huo 10g
Du Huo 10g
Fang Feng 10g
Sang Ji Sheng 18g
Qin Jiao 10g
Bi Xie 12g
Xi Xian Cao 12g
Tou Gu Cao 12g
Jiang Can 12g
Luo Shi Teng 15g
Ban Zhi Lian 15g
Gui Jian Yu 15g
Wu Jia Pi 6g
Hai Tong Pi 6g


Qiang Huo, Du Huo, Fang Feng, Sang Ji Sheng and Qin Jiao dissipate wind and disperse swelling

Wu Jia Pi, Hai Tong Pi, Sang Ji Sheng, Tou Gu Cao and jiang Can dispel dampness and free bi syndrome

Xi Xian Cao, Bi Xie, and Luo Shi Teng drain dampness, dissipate cold, free the network vessels and alleviate pain.

Gui Jian Yu invigorates the blood and frees the network vessels

Decoct herbs in 5 cups of water over a rolling boil until 3 cups remain. Strain, reserve the liquid and cook the herbs again with 3 cups of water until 1 cup remains. Strain, wrap the herbs in a gauze pad and cover the psoriatic areas for 15 minutes.

Mix the liquids and take 2 cups a day for two days, mid morning and mid afternoon. Repeat.

This formula is contraindicated in case of severe damp heat excess, which is not present in this patient.


Lifestyle recommendations: Increase the practice of Yoga or another movement therapy to help move qi and resolve obstructions.
Eliminate tomatoes and all nightshades from the diet.

Prognosis:
Considering that the patient has had this condition for around 30 years and that a common estimation is roughly 1 treatment per each month the patient has had a chronic disease, it would be reasonable to expect improvement during the first month of treatment, and then continuous progress for a long term of weekly or even bi weekly treatments.

The patient is very compliant and her qi is strong. She has a good, positive disposition which can only impact results in a positive way. Provided she receives weekly care, it can be estimated that total resolution of the disorder would take no less than a year. The treatment should be reassessed every 4 visits or whenever there is a decline in the progress, whichever happens first.

Summary/conclusion: 50 year old female with a chief complaint of Psoriatic Arthritis. Psoriasis is present mainly on the elbows, with some patches on the knees and at the base of the head. The joint pain depends upon changes in the weather, and affects only on the distal small joints (fingers and toes). The case fits the pattern of Wind Damp Bi Syndrome and can be treated by dispelling dampness, dissipating wind, relieving toxicity and freeing the network vessels.
The points and herbs chosen address all aspects of the treatment principle.
The patient will be counseled to modify her diet to exclude foods known to aggravate the condition, as well as to include more physical exercise to help move qi and reduce dampness.

Biomedically, the case matches the presentation of psoriatic arthritis as supported by labwork ordered by her Medical Doctor when the condition was diagnosed. Due to the longstanding and chronic nature of the disease and considering the patient’s good disposition and commitment to the treatment, the prognosis is good, with an estimated duration of treatment of no less than 1 year of weekly acupuncture and daily herb therapy.


Bibliography
Bensky, D., Scheid, V., Ellis, A., & Barolet, R. (2009). Chinese Herbal Medicine Formulas and Strategies. Seattle, WA: Eastland Press.
Psoriatic Arthritis. (2010). Retrieved February 18, 2010, from National Psoriasis Foundation: http://www.psoriasis.org/netcommunity/psoriatic_arthritis
Sionneau, P., & Flaws, B. (2005). The treatment of Modern Western Diseases wth Chinese Medicine. Boulder, CO: Blue Poppy Press.
Yihou, X. (2004). Dermatology in Traditional Chinese Medicine. China: Donica Publishing.