Part Two: Infectious Diseases, Chapter Six: Varicella Including Herpes Zoster

Part Two: Infectious Diseases, Chapter Six: Varicella (Including Herpes Zoster) I. Overview Varicella (Chickenpox) is an acute, eruptive infectious disease caused by the varicella-zoster virus. It presents with mild systemic symptoms and a phased appearance of macules, papules, vesicles, and crusts on the skin and mucous membranes. The lesions contain fluid, are clear and bright, and lack pus or cloudy vesicle contents. This disease is prevalent during winter and spring. After infection, most individuals develop lifelong immunity, though it can lead to herpes zoster (see below). The varicella-zoster virus belongs to the herpesvirus family and has very low resistance to external environments. It can be detected in the nasal passages, pharynx, secretions, blood, and vesicles of infected patients. The virus primarily enters through the respiratory tract, grows and multiplies on the mucous membranes, then enters the bloodstream and lymphatic system, reproduces a second time within reticular endothelial cells, causing viremia and systemic lesions. The primary sites of infection are the skin, though visceral involvement is occasionally seen. Rash appears on the first day of illness, and approximately 1–4 days later, as antibodies in the blood appear and viremia subsides, the rash gradually fades. Lesions mainly occur in the spinous layer and deeper layers of the epidermis, with cells exhibiting balloon-like changes, cellular edema, and degenerated cells surrounding the edema, forming vesicles filled with a large number of viruses. The fluid in the vesicles is initially transparent, but becomes turbid as epithelial cells shed and white blood cells infiltrate. Secondary infections may transform the vesicles into pustules. Because dermal inflammation is relatively mild, no scars remain after the crusts fall off. Similar vesicles can also appear on the oral, nasal, pharyngeal mucosa, or conjunctiva, and they are prone to ulceration. II. Diagnosis If a patient has a history of contact with a varicella patient during winter or spring, develops a fever for one day followed by a rash, particularly localized to the trunk and presenting in a “centripetal” distribution, the diagnosis of this disease can be considered. The rash appears in phases, and multiple stages of macules, papules, vesicles, and crusts can be observed simultaneously. However, it is important to differentiate this condition from other eruptive diseases.

1. Smallpox This condition is often seen in individuals who have never been vaccinated against smallpox, or who have not been vaccinated for many years, or who have never received vaccination. Mild cases of smallpox can be confused with severe cases of varicella, but smallpox typically presents with a rash that appears 3 days after fever onset, often distributed on the head, face, and limbs in a “peripheral” pattern. The rash is deeper, denser, and harder, leaving scars after crusting (known as “smallpox marks”). Smallpox has long since disappeared.
2. Herpes Zoster The rash is distributed along specific peripheral nerves, appearing as clustered vesicles that do not extend beyond the midline of the torso, with localized pain (burning, dullness, tingling).
3. Lichenoid rashes are common in infants and young children. The rash at the tip resembles vesicles, but is smaller and firmer than that of varicella, often appearing on the limbs and trunk, with red papules appearing in batches and causing itching. Many patients have a history of allergies or insect bites, or intestinal roundworm infections.
4. Pustular rashes are common in children, especially during hot seasons, frequently occurring around the nose, lips, or exposed areas of the limbs. Initially, they appear as vesicles, then turn into pustules; once ruptured, the pus can spread to surrounding skin, causing new pustules, but they do not appear on mucous membranes. III. Traditional Chinese Medicine Understanding and Treatment of Varicella (A) Historical Medical Views on Varicella

Song · Qian Yi’s “Children’s Medicinal Evidence Directly Explained” includes a description of this disease: “The sores appear in five forms: the liver produces vesicles, with tears flowing like water, their color being green and small; the lungs produce pustules, with thick, turbid mucus, their color white and large; the heart produces spots, with blood in the heart being red and small, slightly smaller than the vesicles; the spleen produces rashes, smaller than the spots, and its primary function is to contain blood, hence red, blister-like rashes, with thick, turbid fluid.” According to Gu · Wang Ken Tang’s “Diagnostic and Therapeutic Guidelines for Children,” he distinguished between smallpox and varicella: “Children’s rashes differ between ‘regular’ smallpox and varicella… the skin is thin like a pool, and once broken…” Practical Internal Medicine Combining Traditional and Western Medicine When the rash breaks through, “clearing” — as mentioned by Zhan Qian et al. in “Medical Canon Golden Mirror ·” In “Rash Heart Method,” the causes and treatments of varicella were discussed: “Varicella is caused by damp-heat, and the external manifestations…”

The rash is round, with a slight tip containing clear fluid, easily swollen and blistered, not filled with pus or pus-like material. At the beginning, use Jing Fang Bai Du San, adding red beans to enhance the treatment; then continue with the formula. Qing · Chen Feixia’s “Young Children’s…”

She described the characteristics of varicella: “Varicella is similar to regular smallpox, with a red face and red lips, eyes like water, coughing and sneezing, thick, sticky mucus, and a fever lasting two or three days, but the rash is clear and as pure as a water bubble, shaped like small beans, with thin skin and crusts at the center, smaller circular rings, easy to break through and blister.” Qing · Hua Shu’s “Ma Ming” proposed: “All varicella is pink in color… clear, bright, with water bubbles… some are even reddish like rouge, also known as ‘red smallpox.’”

(B) Traditional Chinese Medicine’s Understanding of the Pathogenesis of Varicella

This disease is caused by external pathogenic factors, often entering through the mouth and nose, accumulating in the lungs and spleen. The lungs connect with the skin and hair, governing the descending function; when external pathogens invade the lungs, their ascending and descending functions become disrupted. Thus, in the early stages, pulmonary defense symptoms are common, such as fever, cough, and runny nose. If damp-heat accumulates in the stomach and intestines, or if the virus penetrates deeply, symptoms related to the Qi level may appear. The spleen governs the muscles; when pathogenic factors combine with internal dampness, they manifest externally on the skin, leading to the appearance of varicella. This disease is often classified as a mild case of wind-heat, and when the pathogenic factors are cleared, the condition resolves. Since the pathogenic factors in this disease…

Generally, they only affect the defensive qi and the Qi level, rarely penetrating into the yin and blood, so the condition is milder than smallpox or measles, with a good prognosis and fewer complications. A small number of children, however, experience severe heat toxicity, affecting the Qi and blood, and in severe cases, high fever, irritability, red face, dense, red or dark purple rashes may appear.

(C) Traditional Chinese Medicine’s Differentiation and Treatment Methods

1. Wind-Heat Type The main symptoms include no fever or only a mild fever, with rash appearing within 1–2 days. Small red papules appear first on the trunk and face, with a rosy, fresh color, clear vesicle fluid, and a red halo around the base that is not prominent; the rash is sparse, and may be accompanied by nasal congestion and runny nose, coughing and sneezing. The pulse is floating and rapid, the tongue is pale red, with a thin white coating. Treatment focuses on dispersing wind, opening the exterior, clearing heat and detoxifying, or assisting with dampness elimination. The formula uses Yin Qiao San with modifications: 15g of Jin Yin Hua, 15g of Lian Qiao, 12g of Burdock Seed, 10g of Mint, 10g of Ligusticum Chuanxiong, 6g of Jing Jie, 6g of Bamboo Leaves, 20g of Fresh Bamboo Roots, 15g of Purple Flowered Groundsel, 15g of Ban Lan Gen, 6g of Gan Cao. Take the decoction in water, one dose per day. If dampness is severe, add herbs like Talc or Mu Tong to promote water drainage and dampness elimination; if there is a red halo around the rash, add Paeonia Lactiflora or Red Peony; for severe skin itching, add Cicada Slough or Silkworm Moth.

2. Toxic-Heat Type The main symptoms include high fever, or prolonged, high fever, irritability, thirst, red face and red eyes, dense varicella rash, and dark purple skin tones.

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Input: Purulent or cloudy fluid in the vesicles; or accompanied by sores on the mouth and tongue, swollen and painful gums, constipation, short yellow urine, a pulse that is rapid and numbing or deep and solid, a red or purplish tongue with a yellow, dry coating and little saliva. Treatment should focus on clearing heat and detoxifying, cooling the blood and nourishing yin. The formula should be a modified Qingying Decoction combined with Qingwei Powder; use 10g of Water Buffalo Horn, 15g of Rehmannia Root, 10g of Salvia Miltiorrhiza, 10g of Scrophularia Ningpoana, 12g of Ophiopogon japonicus, 6g of Coptis chinensis, 15g of Honeysuckle Flower, 12g of Forsythia Suspensa, 12g of Angelica sinensis, 15g of Paeonia lactiflora. Brew the herbs in water and take one dose per day. If the rash appears a deep red color, add Purple Flowered Groundsel, Purple Herb, or Gardenia to clear heat and cool the blood; if yin and liquid are severely depleted and the mouth is dry, add Pollen, Ophiopogon japonicus, and Reed Rhizome to nourish yin and generate fluids; for those with swollen and painful gums, sores on the mouth and tongue, and dry stools, also take Niuhuang Powder or Rheum officinale, Citrus Aurantium Fructus Immaturus, and other herbs to clear fire and promote bowel movements.

(4) Traditional Chinese Medicine Resources on the Diagnosis and Treatment of This Disease

Wang Junhua conducted a literature review on traditional Chinese medicine formulas, patent medicines, and integrated Chinese-Western medicine treatments for varicella between 2003 and 2006 as follows:

1. Compound Formulas Traditional Chinese Medicine views varicella as an external infection caused by harmful external factors affecting the lungs and spleen, leading to dampness and heat accumulation, which then manifest on the skin. Treatment should focus on clearing heat, cooling the blood, and detoxifying. Since patients are often children—whose bodies are still developing and whose constitutions are delicate—there is a high risk of yin and liquid depletion during the course of the disease; therefore, it is crucial to strengthen the body’s vital energy and consolidate its foundation. Compound herbal formulas follow the principles of TCM diagnosis based on syndrome differentiation and individualized medication adjustments, ensuring that each prescription is tailored to the specific condition of the patient. Yang Longsheng treated 20 cases of varicella based on Yin-Qiao San, all of whom experienced fever resolution, rash regression, skin lesion recovery, and elimination of complications such as infections, with overall health improving significantly. Zhang Hua and others used a self-prepared disinfectant decoction for internal administration and a topical decoction for external washing, treating 57 adult cases of varicella, achieving a cure rate of 1% within 10 days. Zhao Ping et al. used a modified Dabai Mei Jie Du Tang in combination with intramuscular injections of Acyclovir or intravenous infusions, finding that the treatment group showed significantly better efficacy than the control group. Yang Jingbo et al. administered Yinhuang Jie Du Tong He Ji Formula internally, while Ma Yinglong applied Longzhu Soft Paste to apply directly to the lesions, treating 21 cases of varicella, with 18 cases cured, resulting in an effective rate of 95.24%. Yang Xia et al. developed a silver-stone mixture for treating varicella in children, with an average treatment duration of 4 days, and no significant adverse reactions were observed. Zheng Dunfa compared a Qingre Jie Du Tang formula with a control group receiving intravenous acyclovir infusion; the treatment group achieved 35 cures, with a total effective rate of 100%, outperforming the control group (94.67%).

Patent medicines offer stable quality and convenient use, and the emergence of new dosage forms has expanded the range of delivery methods. Zhao Heying used Shuanghuanglian powder injections diluted to 0.8% for intravenous drip therapy; she also applied a 3% concentration solution topically to treat varicella, with 18 cases showing marked improvement and 4 cases showing effectiveness. He Guodong treated 46 cases of varicella using Banlan Gen decoction, all of whom were cured, with an average treatment time ranging from 2 to 5 days, up to 8 days in some cases. Cao Ning et al. used Fishyingcao Injection for treating varicella in children, comparing intramuscular or intravenous injection groups with Vitamin B₂ injections, intramuscular injections of Acyclovir, or intravenous infusions of Acyclovir. The results showed that the treatment group had highly significant differences in average fever reduction time, time to stop new rashes, and time for complete rash crusting compared to the control group (p<0.01). None of the treatment group experienced secondary rash development, and no adverse reactions occurred. Xiao Zhaowei soaked the compound Gua Zi Jin Ke Granules (Jin Hong Sheng) in warm water for oral administration, treating 43 cases of varicella, with 22 cases cured, 17 cases showing marked improvement, and a total effective rate of 97.7%, surpassing the oral formulation of Lìbā.

Part Two: Infectious Diseases

Wei Lin’s group reported a cure rate of 89.3%.

3. Integrated Chinese and Western Medicine Deng Hua used Qingkai Ling Injection, Fishyingcao Injection, and Huangqi Injection in conjunction with Western medicine Acyclovir for intravenous infusion, while simultaneously administering the traditional Chinese medicine Wu Wei Xiu Dan Decoction combined with anti-inflammatory and anti-itch medications. After treatment with these combinations of Chinese and Western medicines, along with Acyclovir intravenous infusions, 46 patients were treated as follows:

8 hours¹ 2 cases; rash regression took 2–3 days¹ 2 cases, 4–5 days 25 cases, 6–7 days 9 cases; the entire treatment process lasted a minimum of 3 hours¹ 2 cases, 6 hours² 4 cases,

the children’s mental state was relatively good, with no particular discomfort. Tang Yu used Acyclovir intravenous infusion combined with Fishyingcao Injection for intramuscular injections, and the treatment period was shorter compared to the control group, with faster fever reduction, earlier onset of new rashes, and quicker relief of itching, as well as more rapid skin crust formation—all of which were statistically significant compared to the control group (p<0.01). No cases of secondary rash development were observed, and no adverse reactions occurred. Xiao Zhaowei prepared compound Gua Zi Jin Ke Granules (Jin Hong Sheng) by soaking them in warm water for oral administration, treating 43 cases of varicella, with 22 cases cured, 17 cases showing marked improvement, and a total effective rate of 97.7%, surpassing the oral formulation of Lìbā.

4. Topical application of traditional Chinese medicine, whether through ointments or washes, is typically used as an adjunctive treatment for varicella. However, Huang Junyong treated 66 children with varicella using a self-prepared Yinchuan External Wash Solution, achieving a cure rate of 46 cases, with 13 cases showing marked improvement and 7 cases remaining unresponsive, resulting in a total effective rate of 89.4% (Tianjin Pharmacy, August 2006).

Zhao Rong randomly divided 76 children diagnosed with varicella into a treatment group of 42 cases and a control group of 24 cases. Based on standard treatment protocols, the treatment group received the traditional Chinese medicine Yinqiao Jie Du Tang (composition: Mulberry Leaves, Forsythia, Honeysuckle Flower, Coptis Chinensis, Banlan Gen, Purple Flowered Groundsel, Cicada Ear, Red Peony, Woodtongue, Wild Chrysanthemum, Coix Seed, Woodtongue, Licorice, etc.) for treatment, while the control group received intramuscular injections of recombinant human interferon alpha-2b, oral Acyclovir tablets, and external applications of Calamine Lotion. Compared to the control group, there were no statistically significant differences in the cure rate, total effective rate, time to relieve itching, or time for complete crust formation (p>0.05). However, the treatment group’s fever duration was significantly shorter than that of the control group (p<0.01), indicating that Yinqiao Jie Du Tang can help restore normal body temperature more quickly, thereby alleviating the discomfort experienced by children (Pediatric Pharmacy Journal, June 2007).