I. Preface
1.Disease overview
Herpes zoster is an acute herpetic skin disease caused by varicella zoster virus. The disease is mostly acute in onset, with clinical manifestations of dense clusters of blisters distributed in a band along one peripheral nerve, preferably in the intercostal nerve distribution area, often accompanied by severe neuralgia and local lymph node swelling pain, and prone to post-neuralgia, and is rarely seen bilaterally, with few recurrences (recurrence rate of 0.2%). The disease can be classified according to its manifestations as: rashless, eruptive, maculopapular, hemorrhagic, gangrenous, or generalized herpes zoster. Herpes zoster can occur secondary to other diseases such as malignancy, organ transplantation, AIDS, and after major surgery, and can also cause diseases such as facial palsy, trigeminal neuralgia, visceral herpes zoster, and can even lead to serious clinical events such as blindness, deafness, and death. Postherpetic neuralgia (PHN) is defined as pain that persists for more than 1 month after clinical cure of herpes zoster. The incidence and duration of postherpetic neuralgia in the elderly has been clinically proven to be high.
The epidemiological findings at home and abroad suggest that the onset of herpes zoster is epidemic, with an annual prevalence of 10-20%, and that its prevalence and proportion of the total number of cases are roughly 15% for the head and face, 12% for the neck and collar, 55% for the chest and back, 14% for the lumbar abdomen, 3% for the sacrococcygeal region, and 1% for the whole body; the onset of herpes zoster can be seen at all ages, and the age of the patient is proportional to the incidence, pain level, and The incidence of herpes zoster can be seen at all ages, and the age of the patient is directly proportional to the incidence, pain level and latency period, with 70% of patients over 50 years of age and over 30% of those over 60 years of age, while the younger the age, the lower the incidence. The incidence of post-herpetic neuralgia in patients with shingles is about 20%.
The pathogenesis of herpes zoster is that the varicella-zoster virus enters the sensory nerve endings of the skin after infection, migrates along the nerve fibers and lurks in the neurons of the sensory ganglia of the spinal nerve or brain nerve. In the case of herpes zoster, the incubating virus becomes active again and spreads along the nerve fibers to the skin, causing a recurrent infection. The varicella-zoster virus is dermophilic and neurophilic, so neuralgia is one of the characteristics of the disease. The virus mainly attacks the intercostal and trigeminal nerves, and the degree of pain does not correlate significantly with cutaneous manifestations. Clinical studies have also confirmed that herpes zoster is a self-limiting disease with a natural course of approximately 2-3 weeks and an average of 16-17 days.
Herpes zoster has been observed and studied in Chinese medicine for more than a thousand years, and a clear and unified understanding of its etiology and pathogenesis has been formed. The diagnostic criteria include three types of herpes zoster, including liver heat, spleen deficiency and dampness, and qi stagnation and blood stasis.
Western medicine uses antiviral, immune enhancement, analgesic and symptomatic treatment as the main tools, such as acyclic guanosine, interferon, interleukin-2, diclofenac sodium, etc.; Chinese medicine uses draining the liver and clearing heat, strengthening the spleen and dampness, and regulating qi and activating blood stasis according to the results of identification. Based on the results of identification, Chinese medicine is mainly based on the treatment principles of draining the liver and clearing heat, strengthening the spleen, promoting dampness, regulating qi and activating blood circulation, and using non-pharmacological treatments such as Chinese herbal tonics for internal and external application or acupuncture, moxibustion and cupping, which have the advantages of rapid pain relief and shortening the duration of the disease and low incidence of post-neuralgia.
2.Therapy introduction
Fire acupuncture plus cupping technique for acute herpes zoster (fire acupuncture and Zanjian method) is a comprehensive method that brings together the advantages of traditional acupuncture methods such as fire acupuncture, blood pricking therapy, fire cupping therapy and Zanjian acupuncture method, and is a comprehensive method refined by Guang’anmen Hospital of the Chinese Academy of Traditional Chinese Medicine for the treatment of acute herpes zoster. The method uses fire needles and fire cupping as the main instruments. By burning the tip of the fire needle red to white, the high temperature of the needle burns the local lesion, and with the thick body of the fire needle and the shallow stabbing of the Zanshin needle method, it can cause the herpes lesion to be completely open, and with the strong adsorption effect of the fire can, the local poison and bad blood are carried out, and the damaged area is fully moistened by new blood to achieve pain relief and healing. Basic research has confirmed that the treatment of acute herpes zoster can effectively kill herpes local viruses, promote blood circulation, reduce local inflammation and nerve damage, thus relieving the symptoms of severe pain, and give full play to the anti-inflammatory and analgesic effects of acupuncture, while accelerating the repair of damaged nerve tissues by enhancing the body’s immune system, so that the disease can recover quickly. The results of the clinical study on the application of fire acupuncture and zanzhi method in the treatment of acute herpes zoster by our group suggest that the healing rate within 9 days of treatment with fire acupuncture and zanzhi method is as high as 90.9%, while the healing rate of the control group on the 9th day of oral valacyclovir treatment is 38.9%, which is consistent with the clinical evaluation of the efficacy of the new drug of valacyclovir (the literature reports that the healing rate of oral valacyclovir on the 9th day is 38.9%). This result is consistent with the clinical evaluation of the efficacy of the new drug (33.3%-38% of the healing rate on the 9th day of oral vaxilovir was reported in the literature), which proves that this therapy has better efficacy in treating acute herpes zoster.
3. Prospects for application
Fire acupuncture and cupping therapy for herpes zoster are widely used around the world, and clinicians have accumulated some experience in the application of fire acupuncture for herpes zoster, but there is a need to unify and improve the clinical operation methods and the standardization of the instruments used. The clinical evaluation study on the treatment of acute herpes zoster with fire acupuncture and cupping was completed through a project funded by the State Administration of Traditional Chinese Medicine, and the results showed that the method has good efficacy (high cure rate), fast onset of action, short course of treatment, low incidence of post-pain, good safety, relatively low cost, and high patient satisfaction with the treatment effect, while the study collated and formed the technical operation specification to solve the Therefore, this technical achievement has good application and promotion prospects.
Diagnostic criteria for diseases
1.Western medical standard
Refer to Modern Dermatology (edited by Yang Guoliang, etc.). Shanghai Medical University Press. 1996. 293-297) and “Diagnostic Routine” (Xie Lixin, ed. People’s Health Publishing House. 1997).
In typical cases, the diagnosis is made on the basis of unilateral rash, clusters of blisters arranged in bands along the peripheral nerves and neuralgia.
The disease sometimes needs to be differentiated from herpes simplex, which occurs at the junction of the skin and mucous membranes, with irregular distribution, small, easily broken blisters, and little pain, mostly in the course of fever (especially high fever), and often recurrent.
Occasionally it is confused with contact dermatitis, but in the latter case there is a history of contact, the rash is not related to the distribution of nerves, and there is self-conscious burning and severe itching without neuralgia.
In the prodromal phase of herpes zoster and herpes zoster without rash, those with significant neuralgia are easily misdiagnosed as intercostal neuralgia, pleurisy and acute abdominal conditions such as acute appendicitis, and need to be noted.
2.Chinese medicine standard
The Chinese medicine industry standard of the People’s Republic of China, “Diagnostic Efficacy Criteria for Chinese Medicine” (ZY/T 001.8-94), was adopted. “Serpentine sores” are caused by dampness and heat in the liver and spleen, as well as by the presence of evil toxins. It is a skin disease characterized by clusters of blisters distributed in a band along one side of the body, arranged like a snake’s line, and severe pain, which is equivalent to herpes zoster.
2.1 Diagnostic criteria for snake sores
(1) The lesions are mostly green bean-sized blisters in clusters, with tense walls and red bases, often distributed unilaterally and arranged in bands. In severe cases, the lesions may be hemorrhagic or gangrenous. If the lesions occur on the head and face, the disease is often more severe.
(2) The rash is often preceded by a tingling or burning sensation in the skin and may be accompanied by mild discomfort and fever in the periphery.
3）Self-perceived pain is obvious, and there may be unbearable severe pain or pain that remains after the rash subsides.
2.2 Diagnostic criteria for the typology of snake sores
(1) Liver meridian heat: bright red skin lesions, tense herpetic walls, burning and stinging pain, bitter mouth and dry throat, irritability, dry stools or yellow urine. The tongue is red, the tongue coating is yellow or yellow-thick, and the pulse is smooth and slippery.
2) Spleen deficiency with dampness: lighter color, loose herpes wall, no thirst, little food and abdominal distension, loose stools, light tongue, white or white greasy tongue coating, sluggish or slippery pulse.
3) Qi stagnation and blood stasis: local pain persists after the rash subsides. The tongue is dark, with white coating and thin pulse.
III. Indications
Acute phase of herpes zoster (duration of illness less than or equal to 7 days).
The appropriate age range is from 8 to 85 years old.
It is suitable for all types of herpes zoster in the acute phase.
IV. Contraindications
This method is safe for the treatment of herpes zoster, but the doctor needs to be careful when treating patients with the following conditions and to develop an appropriate treatment plan in conjunction with the patient’s specific situation.
1. contraindicated in patients with hemophilia and in patients with other bleeding tendency diseases
2. Contraindicated in women who are pregnant.
3, contraindicated in combined cardiovascular, cerebrovascular, diabetic, malignant tumor, liver, kidney and other serious primary diseases or systemic failure.
4, long-term application of corticosteroids or immunosuppressive agents is contraindicated.
5. Contraindicated for those with scarring.
6, facial and perineal herpes zoster is contraindicated.
7.Caution for breastfeeding women and infants.
8.Patients with mental illness who cannot cooperate with the treatment should be used with caution.
V. Technical operation method
1.Apparatus preparation
1.1, the fire needle needle: puncture special fire needle, made of tungsten steel as raw material. Specifications: medium fire needle diameter of 0.75mm, thick fire needle diameter of 1.2mm.
1.2, fire cans: 1-5 general glass fire cans.
1.3, medical degreasing cotton balls, hemostatic forceps, 95% alcohol.
1.4, matches or lighter
1.5, the acquisition of fire needles difficult or in emergency situations, you can specifications for 0.30 × 25mm standard acupuncture needles instead of fire needles, but limited to burning needles 10 times.
2.Detailed operation steps
2.1, patient position
Sitting or lying position according to the site of herpes zoster lesion, in order to make the patient feel comfortable, facilitate relaxation, and facilitate the doctor’s operation.
2.2. Point selection, treatment sequence and disinfection
Select the treatment sites at the ends and in the middle of the rash, first at the earliest part of the rash, i.e. the beginning of the rash – “snake head”, then at the middle of the later rash – “snake waist” and “tail”. The treatment will be applied to the middle part of the rash – the “snake’s waist” and the end of the rash – the “snake’s tail”. If the lesions are large and the number of localized herpes is large, treatment can be done in batches.
The skin is disinfected with 75% alcohol, and if the lesions are broken, the skin is disinfected with iodine to relieve the patient’s pain.
2.3.Fire needling
Number of needling.
According to the size of the herpes cluster to determine the number of needles, the number of herpes in the cluster of 1/3 to 1/2 is appropriate.
Fire needle burning needles.
The left hand holds a hemostatic forceps to hold a medical skimmed cotton ball soaked in 95% alcohol and ignite it so that the flame is close to the patient’s lesion and about 10-15 cm from the previously selected needle site, taking care to prevent the flame or burning alcohol from dripping down and burning the patient. The right hand holds the needle in a pencil grip, and the needle tip and body are probed into the outer flame of the flame and burned red or until they turn white.
Fire needle zanzhi.
After burning the needle to herpes clusters as a unit in a “zigzag” puncture. The time required is within one second, and the needle tip is still red when it is decisively and quickly pierced into the herpes zoster lesion, straight in and straight out, without skewing or dragging. For blisters, papules or erythematous areas, use medium and coarse fire needles to puncture the herpes and reach the base of the herpes at the depth of the needle tip. For larger pustules or hemorrhagic blisters that are 0.5 cm or more in diameter, use coarse fire needles to puncture, and use sterilized skimmed cotton balls to squeeze out the herpes after the puncture.
2.4. Fire cupping and retention
According to the size of the herpes cluster, choose the appropriate type of fire cans in the fire needle puncture after the needle local suction cupping, to fire cans can cover the herpes cluster, so that the fire needle puncture point is included in the cans for the degree, if the herpes cluster area is too large, you can use multiple fire cans. If the herpes cluster is too large, multiple cans can be used. Leave the can for 5 to 10 minutes for mild local skin bruising, usually a small amount of blood or exudate can be extracted.
If localized blood blisters appear after starting the cupping, the fire needle can be used again to puncture.
After the treatment, wipe the local skin surface with sterile cotton balls, and if the skin surface is obviously broken, apply sterile gauze and keep the wound surface dry and clean.
3.Treatment time and course
The patient will be treated once a day for the first three days of the visit, and once every other day thereafter.
There is no fixed course of treatment and the number of treatments should be decided according to the patient’s condition and tolerance. The results of the study showed that the healing rate within 9 days of treatment with this method was as high as 90.9%, and no post-neuralgia occurred.
4.Key technical aspects
4.1.Fire needle pointing
Emphasize “red”, “fast” and “accurate”.
Red – burn the needle completely, to ensure that the tip of the needle enough temperature.
Fast – fire needling operation into the needle, needle out of the process of decisive and rapid, to avoid dragging, to reduce the patient’s pain.
Accurate – when needling with clear eyes, quiet heart and steady hands, accurately multi-needle puncture on the herpes, into the needle depth to puncture the herpes to reach its base.
4.2.Cupping
Using the flash fire method of cupping, depending on the size of the herpes cluster, choose a fire can of appropriate caliber, so that the mouth of the can can can cover the herpes cluster, so that the acupuncture point is incorporated into the can.
In order to improve the therapeutic effect and ensure the appropriate amount of bleeding, cupping should be added quickly after the fire needle puncture.
The duration of cupping can be adjusted according to the changes in skin color at the site of application, the patient’s physical condition and tolerance level, and the severity of the disease.
5. Precautions
5.1. Precautions for physicians
(1) strengthen training to improve clinical skills, such as the doctor himself afraid of fire needles, do not easily apply fire needle therapy.
(2) fire needles because of repeated heating and cauterization, prone to aging, that is, deformation, softening and affect the clinical operation, to use the brand fire needles and regularly check the quality of fire needles, the quality of fire needles should be replaced in a timely manner.
(3) fire needles need to pay attention to aseptic disinfection before needling, after disinfection to avoid local recontamination.
(4) fire needle needling and cupping to prevent flames or burning alcohol dripping down to burn the patient.
(5) joints, large blood vessels and important organs and organs around the cautious use of fire needles.
(6) The face and other muscle thin parts should be used fine fire needles to reduce the patient’s pain.
7) The doctor should carefully observe the color of the skin and the patient’s reaction during the treatment, and deal with any unexpected situations such as stagnant needles, severe pain, bleeding, dizziness, infection, etc. in a timely manner according to the response plan for unexpected situations.
5.2. Precautions for patients
1）Patients with hemophilia and other bleeding tendency diseases are prohibited from fire needling.
2）Patients with diabetes mellitus have low resistance and should use fire needling with caution.
(3) Excessive hunger, overexertion, mental overstrain and extreme fear of fire needling should not use fire needling for the time being.
(4) fire needling after local small redness and mild itching is normal, prohibit scratching to prevent infection.
(5) fire needle treatment within 24 hours after the needles can not wash local, to prevent infection.
6.Possible accidents and treatment plan
6.1.Stagnant needle
Performance: fire needle needling out of the needle body and local tissue adhesion, fire needle can not be pulled out or out of the needle is not smooth.
Cause analysis.
(1) the fire needle heating temperature is not enough, or fire needle after leaving the flame into the needle speed is too slow. So that the needle body becomes cold.
(2) patient tension, resulting in local muscle spasm, or needling too deep and stagnant needles.
(3) Needle body is too old, its sharpness is not enough.
(4) the doctor’s finger strength and wrist strength is not enough, or the first time users due to the operation of the elements of mastery is not skilled.
Treatment methods.
(1) the fire needle heating necessary to burn the needle to the needle body red and white. When the fire needle needle body left the flame to stab into the acupuncture point, the operation can be as close as possible to the flame stabbed parts, so that the doctor and the patient’s position suitable for operation, and can slow the fire needle cooling.
(2) when the patient is nervous, to do a good job of soothing. The operation should be light, grasp the depth of needling, do not operate blindly, so that needling too deep, resulting in patients due to tension and fear, increased pain, muscle spasms and stagnant needles.
(3) fire needles because of repeated heating and cauterization, very easy to aging, and should be timely inspection and replacement.
(4) the operation of the fire needle requires strong skills, the doctor must have a certain finger strength and wrist strength when operating to be comfortable. Therefore, it is necessary for doctors to exercise finger and wrist strength, for the first application of fire needling doctors, should be proficient in the basic rules of fire needle operation, do not operate recklessly.
6.2, fire needle needling failed to achieve the expected depth
Cause analysis.
(1) fire needle burning needle did not reach the predetermined high temperature, or needle body although heated to a predetermined high temperature, but after leaving the flame, the needle body cools too quickly, so that the needle body temperature is too low when entering the needle.
(2) the patient’s mood tension, resulting in local muscle spasm or the selected site or acupuncture point is not appropriate, such as needling when touching the bones, tendons, ligaments, etc.
(3) Needle body aging, the needle tip becomes rounded and blunt, and the resistance is high when operating.
(4) The doctor’s finger force is not enough, incorrect posture. Or because of the first operation, afraid to force deep stab.
Treatment methods.
(1) pay attention to the method of burning needles, until the needle body is red and white before entering the needle, and pay attention to burning needles as close as possible to the needling site, the direction of the needle tip should point to the site of the prick is appropriate.
(2) good preoperative preparation, eliminate the patient’s nervousness; doctor afraid of fire needles do not apply needles to people.
(3) when needling points in the skeletal, tendon, ligament areas, pay attention to the direction of needling, appropriate force.
(4) to pay attention to the needling posture. Do not throw your wrist into the needle. Needle, finger, wrist and forearm as one when entering the needle, take the elbow as the axis, flex and extend the forearm, lead the wrist, finger and needle line.
6.3, the patient pain is severe
Performance: fire needle needling should not have severe pain, generally a slight local burning pain after needling, soon disappear. If the pain is very painful when needling, the cause of the pain should be sought.
Cause analysis.
(1) fire needle burning needle temperature is not enough.
(2) needle tool selection is not appropriate.
(3) unskilled operation, slow action.
(4) out of the needle is not timely processing.
Treatment methods.
(1) burning needles (puncture fire needles) must be red and white, and then into the needle, such as not red is pain very. Note that burning needles in the periphery of the flame, first burn the needle body, and then burn the needle tip.
(2) into the needle as fast as possible, so the needle fire should be as close as possible to the affected area, the needle tip pointing into the needle site.
(3) Pay attention to the face, muscle thin part, should choose a fine fire needle.
(4) out of the needle to quickly use dry cotton balls, press the needle hole to reduce pain.
6.4, needle body bending or folding needles when needling
Cause analysis.
(1) into the needle posture is not correct, did not make the needle, finger, wrist integrated.
(2) The operator has a fear of needle mentality.
(3) needle body aging or not straight enough.
Treatment.
(1) correct the operating posture, pay attention to the tip of the needle, the needle body strength and needling parts as vertical as possible.
(2) fear of fire needles, do not apply needles to patients, otherwise the heart fear and hands soft, often difficult to enter the needle or bend the needle.
(3) Replace the needle with a new one, and try to avoid using a fire needle that has been bent.
6.5 Bleeding
Bleeding during fire needling is a common phenomenon.
Cause analysis.
(1) Fire needles have the effect of opening up the needle hole, and can often be used as an effective tool for bleeding and draining evil. The bleeding in this case is normal, do not stop, wait until the blood turns bright red, its self stop. Some lesions, due to internal obstruction of blood stasis, in which the pressure is high, when using fire needles to bleed out evil often see, the needle out and dark brown blood followed by the jet out of the phenomenon, do not stress to stop the bleeding, but also to wait for its out of the appropriate. Such as varicose veins in the lower extremities, some skin diseases rough and thick skin lesions can have this phenomenon.
(2) with cutting and branding fire needles, burning certain lesions, the operation is too fast, will cause bleeding.
(3) deep needling fire needle, sometimes there will be subcutaneous or inter-tissue swelling, pain, or even affect the local tissue, nerve function, which is due to internal bleeding, failure to timely detection and treatment, and blood stasis subcutaneous or inter-tissue and become.
Treatment methods.
(1) Needling should avoid subcutaneous vessels as much as possible.
(2) after the needling to pay attention to observation, such as local swelling, should be promptly put on the needle hole with a cotton ball, with finger pressure on the local more than 10 minutes, do not rub, after the available cold towel external compress. 12 hours after the swelling of the local available hot towel hot compress. Swelling has become, then not dissipated generally need 7 days or more than 2 weeks to dissipate, but will not leave sequelae.
(3) Can also be used locally to stop bleeding with cotton balls or gauze compression.
(4) If the bleeding does not stop after the fire-needle acupuncture, most of them are hemophiliacs or those with clotting mechanism disorders. They should be treated promptly. Note that the above patients are prohibited from fire needling.
6.6. Infection
Fire needle therapy itself is a benign local mild burns, needling local will appear a small area of redness, there will be a slight scratching, and some people will have some systemic reactions, such as mild chills and fever. These are the results of the local sterile inflammatory reaction to the burn and are normal. However, in individual cases, the local is infected, and more serious redness, swelling, heat and pain occur, it is an unexpected situation of fire needle needling, which should be overcome.
Cause analysis.
(1) needle hole is not kept clean and dry, or shower within 1 day after the needle, etc.
(2) Local scratching infection.
(3) After needling, contaminated cotton balls were used to press the needle hole.
(4) The diabetic patient received fire needling and the skin disinfection before the needle was not strict enough.
Treatment.
(l) Local infection, redness, swelling and heat pain, use moxa mild moxibustion, or local acupuncture with fire needles.
(2) local use of four yellow cream topical. And can take oral anti-inflammatory drugs.
(3) diabetic patients, skin resistance is reduced, generally do not use fire acupuncture treatment, if used, it is necessary to local strict sterilization.
(4) fire needling must be strictly disinfected before needling. After needling local mild scratching, there is a small red swelling, do not scratch with your hands.
(5) Do not shower within 1 day after needling, do not contaminate the needle hole.
6.7.Sickness needle
Fire needling operation is fast and pain is not intense, so it is not uncommon for dizziness to occur in fire needling, and occasionally it can occur.
Cause analysis.
(1) the patient is afraid of fire needles, overly nervous, before treatment has not eaten, or sitting position to receive needles.
(2) into the needle slowly, the needle does not burn red enough, the pain is intense.
(3) a line of fire acupuncture points too much.
Treatment.
(1) occur after the needle acupuncture dizziness phenomenon, first help patients lying down, head low feet high, pay attention to keep warm. Can give the patient to drink sugar water, most ten minutes to recover.
(2) good preoperative preparation, eliminate the patient’s fear of psychology, and then accept the fire needle treatment. Needling can be done in the area away from the field of vision first, so that the patient gradually adapt. The first acupuncture with 1 to 2 points can be.
(3) The action should be agile, pay attention to the main points of operation, and pay attention to the cotton ball to press the needle hole after needling.
(4) People who are overworked, hungry, or timid should not receive acupuncture for the time being.
VI. Adverse reactions/events
There are few records of adverse reactions/events reported in clinical studies of fire acupuncture for herpes zoster. The group conducted a comprehensive search of the Chinese Hospital Digital Library (CHKD) database from 1994 to 2007 using the keywords “fire acupuncture, safety, adverse reactions, adverse events” and found no literature reporting adverse events with fire acupuncture therapy.
Similarly, no adverse events related to the treatment of herpes zoster with fire needling were recorded in this study, and the laboratory test results before and after treatment did not reveal any adverse effects on liver or kidney function. The study confirmed that if the patient is well soothed before needling, if the operating norms of sterilization and fire needle zanzhi therapy are strictly enforced during the procedure, and if the needle opening is cared for after needling and the patient is instructed to remember the various precautions to be taken, no adverse/event reactions generally occur.
In conclusion, this method is relatively safe for the treatment of herpes zoster.