Fallberichte | Case Reports
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A. Kotlyar*, R. Brener, M. Lis
Use of Traditional Chinese Acupuncture for
Treatment of Pain and Skin Rash Associated with
Shingles in a 67-Year-Old Patient: A Case Report
Fallbericht: Klassische chinesische Akupunktur
als Therapie gegen Herpes-zoster-assoziierte
Schmerzen und Effloreszenzen bei einer
67-jährigen Patientin
Abstract
Introduction: There are several treatment options for
pain associated with herpes zoster (HZ; shingles). However,
many patients, especially the elderly, experience side ef-
fects of medication. Therefore, pain associated with the HZ
infection remains a challenge for effective management.
Recently, the efficacy of acupuncture has been evaluated
for pain therapy in acute HZ. This case report describes the
use of traditional Chinese acupuncture for the treatment of
pain and skin rash associated with HZ in a clinical setting.
Case Presentation: A 67-year-old Caucasian female with
lower back pain (LBP) and lateral irradiation to the left leg,
accompanied by a skin rash in the lower back and pelvic
area that was caused by acute HZ, was observed at a Health
Management Organization (HMO) clinic. The patient was
prescribed analgesic, antispasmodic, and antiviral medi-
cation. These medications caused urinary retention, and
the patient was directed to the Outpatient Pain Clinic of a
Medical Center for further treatment. At the Pain Clinic, the
patient was prescribed an urgent epidural steroid injection
to prevent the suspected development of peripheral neu-
ropathy, a selective serotonin and norepinephrine reuptake
inhibitor, and acupuncture. The patient refused to receive
pharmacological treatment and was treated with weekly
20-minute sessions of Chinese acupuncture for five weeks.
Conclusions: The present case report describes a conceiv-
able effect of acupuncture on acute pain caused by HZ
in a patient who could not be treated pharmacologically.
Additional studies are warranted to investigate the effect
acupuncture in the management of acute and neuropathic
pain caused by HZ.
Keywords
Herpes zoster, shingles, postherpetic neuralgia, acupunc-
ture, traditional Chinese medicine
A. Kotlyar Pain Clinic, Kaplan Medical Center, Israel
Arkady Kotlyar, PhD, CAc www.chi-point.com
dr.kotlyar@chi-point.com
* Corresponding author
Zusammenfassung
Einleitung: Es existieren verschiedene Optionen für eine
Schmerztherapie bei Herpes zoster (HZ, Gürtelrose). Viele Pa-
tienten, gerade die älteren, leiden jedoch unter deren Neben-
wirkungen. Daher bleibt das Schmerzmanagement bei einer
Herpes-zoster-Infektion eine besondere Herausforderung. Vor
Kurzem wurde die Wirksamkeit von Akupunktur im Rahmen
der Schmerztherapie bei akuten Herpes-zoster-Infektionen
evaluiert. Der vorliegende Fallbericht schildert die Anwen-
dung traditioneller chinesischer Akupunktur als Therapie ge-
gen Schmerzen und Hauteffloreszenzen bei Herpes zoster in
einem klinischen Setting.
Fallbeschreibung: Eine 67-jährige weiße Patientin stellte
sich in einer HMO-Praxis mit Schmerzen der LWS, lateral
ausstrahlend ins linke Bein sowie Hauteffloreszenzen im
LWS- und Hüftbereich vor, die auf eine akute Herpes-zos-
ter-Infektion zurückzuführen waren. Die Patientin erhielt
Analgetika, Spasmolytika und eine antivirale Medikation.
Darunter kam es zu einem Harnverhalt, und die Patientin
wurde zur weiteren Behandlung an die Schmerzambulanz
eines Klinikums überwiesen. Dort erhielt die Patientin bei
Verdacht auf eine sich entwickelnde periphere Neuropathie
notfallmäßig eine epidurale Steroidinjektion, sowie einen
selektiven Serotonin- und Noradrenalin-Reuptake-Inhibi-
tor und Akupunktur. Die Patientin verweigerte die phar-
makologische Therapie und erhielt stattdessen über fünf
Wochen einmal pro Woche eine 20-minütige Behandlung
mit klassischer chinesischer Akupunktur.
Schlussfolgerung: Der vorliegende Fallbericht beschreibt den
nicht zu übersehenden Effekt von Akupunktur auf den akuten
Schmerz im Rahmen einer Herpes-zoster-Infektion bei einer
Patientin, die nicht pharmakologisch behandelt werden konnte.
Weitere Studien sind notwendig, um den Effekt von Akupunk-
tur beim Management akuter und neuropathischer Schmerzen
im Rahmen von Herpes-zoster-Infektionen zu untersuchen.
Schlüsselwörter
Herpes zoster, Gürtelrose, postherpetische Neuralgie, Aku-
punktur, traditionelle chinesische Medizin

Fallberichte | Case Reports
Introduction
Herpes zoster (HZ; shingles) is a viral disease caused by
the varicella zoster virus (VZV), which reactivates fol-
lowing primary infection with varicella (i.e., chicken
pox), usually during childhood [1]. After the resolution
of the original infection, the virus remains dormant
for years in the dorsal root ganglia of cranial or spinal
nerves [1]. Acute HZ is usually caused by re-activation
of a latent VZV as a result of a decrease in cellular im-
munity [1]. Re-activation can occur at any age; however,
because it is primarily associated with an age-related
decline in cell-mediated immunity, it is more frequent
in older adults [2, 3]. After re-activation, the virus is
transported along peripheral nerves, producing an acute
neuritis [1]. Thus, the disease is characterized by a pain-
ful, unilateral vesicular eruption, usually in a restricted
dermatomal distribution.
Pain associated with the HZ infection is known as herpetic
neuralgia. It is classified as acute (pain preceding or accom-
panying the eruption of a rash that persists up to 30 days
from its onset), sub-acute (pain that persists beyond the heal-
ing of the rash but resolves itself within four months after
onset), or post-herpetic neuralgia (pain persisting for more
than four months from the initial onset of the rash) [4].
Post-herpetic neuralgia is a neuropathic pain syndrome (NPS),
and is the most common complication of HZ, mainly in pa-
tients aged 50 years and older [3]. Older age is also associated
with a greater likelihood of a more severe HZ rash [4].
In immunocompetent patients, the primary goal of treat-
ment for HZ is pain reduction. Early intervention with
antiviral medication can reduce the risk of complications,
lower rash severity, and accelerate its healing [4, 5]. The
addition of corticosteroids to antiviral medication may
further alleviate short-term HZ-related pain [4, 5].
However, pharmacological treatment can be associated
with an increased risk of serious adverse effects, espe-
cially among older adults [5]. If a patient does develop
postherpetic neuralgia, such medication as gabapentin,
pregabalin, opioids, tricyclic antidepressants, lidocaine,
and capsaicin may be used for palliative treatment [5].
However, for individuals with treatment-refractory post-
herpetic neuralgia, non-pharmacological approaches,
which are beneficial to patient well-being in general [4],
may be considered as alternative or intregrative treat-
ment options, and a pain management specialist should
be consulted [5, 6].
Case Presentation
A 67-year-old Caucasian female suffering for a week from
lower back pain (LBP) and lateral irradiation to the left leg
was observed at a Health Management Organization (HMO)
clinic. The patient was a heavy smoker, previously diag-
nosed with pneumonia and moderate-to-severe chronic ob-
structive lung disease (COPD). Also, in the past, the patient
underwent ablation for atrial fibrillation and flutter.
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During the first two weeks of observation at the HMO
clinic, the patient was symptomatically prescribed oral
Spasmalgin (Acetaminophen, Atropine SO4, Codeine PO4,
and Papaverine HCl) and thereafter Tramadex (Tramadol
Contramid). Both medications had no therapeutic effect
but caused urinary retention and dryness in the mouth.
Ten days post-onset of LBP, unilateral itching and a pain-
ful rash appeared in the lower back and pelvic area. About
three weeks post-onset of LBP, after the appearance of the
rash, the patient was diagnosed with acute HZ. The diag-
nosis was based on the anamnesis and the clinical picture.
Considering the symptoms and the patient’s age, no addi-
tional analyses were required to confirm the diagnosis [1–
4]. Therefore, the patient was prescribed daily oral Zovirax
(Acyclovir) for a week. During the treatment, the patient
began to experience severe pain in the abdominal area.
As a result, the treatment with Zovirax was discontinued
after three days. About four weeks post-onset of LBP, the
patient went through an abdominal computer tomography
(CT) examination that did not reveal any dysfunction. Be-
cause pharmacological treatment had no positive effect,
five weeks post-onset of LBP, the patient was prescribed
oral Optalgin (Dipyrone) and Bondormin (Thienodiazepine,
a Benzodiazepine analog), and directed to the Outpatient
Pain Clinic of a Medical Center for further treatment.
Six weeks post-onset of LBP, the patient presented her-
self at the Outpatient Pain Clinic. Considering the duration
of the disease, and to prevent the suspected development
of postherpetic neuralgia and peripheral neuropathy, the
patient was prescribed an urgent epidural steroid injec-
tion (ESI) and treatment with Cymbalta (Duloxetine HCl).
In addition, acupuncture was recommended. The patient
refused to receive pharmacological treatment and started
the acupuncture treatment on the same day. The patient
was treated with two 20-minute sessions of Chinese acu-
puncture per week for the first two weeks and thereafter,
with three additional weekly 20-minute sessions.
Acupuncture Treatment
Pain
Severe deep and distending pain originated in the left-side
lower back area and worsened at night. The pain irradiated
laterally through the pelvic area, along the route of the
Gallbladder (GB) meridian, particularly through the GB 30
(Huantiao) point to the right foot.
Rash
The observed rash was manifested by clusters of brownish
crusted grain-sized vesicles categorized in Chinese medi-
cine as snake string sores (she chuan chuang). The rash
was distributed along a dermatome innervated by certain
peripheral nerves.

Pulse Diagnosis
The pulse was Floating (fumai). On the left hand, in the
Guan and Chi positions, Gallbladder (GB) excess (shi) and
Kidney (KI) deficiency (xu), respectively, were detected. On
the right hand, in the Cun and Chi positions, Lung (LU) xu
and Pericardium (PC) shi, respectively, were detected.
Tongue Diagnosis
The tongue was slightly red, without coating. Red points
(dian) were located between the center and the tip of the
tongue (chest area).
Treatment Protocol
The following acupuncture points were used:
1st session – GB41 (Zulinqi) left, SP6 (Sanyinjiao) bilater-
ally, ST36 (Zusanli) bilaterally, LI4 (Hegu) bilaterally, LI 10
(Shousanli) bilaterally, LI11 (Quchi) bilaterally, KI27 (Shu-
fu) bilaterally, KI3 (Taixi) bilaterally;
2nd session – LV3 (Taichong) bilaterally, KI3 (Taixi) bilater-
ally, LU9 (Taiyuan) bilaterally, Di 10 (Shousanli) bilater-
ally, M-HN3 (Yintang), KI27 (Shufu) bilaterally;
3rd session – GB41 (Zulinqi) left, ST36 (Zusanli) left, KI 3
(Taixi) bilaterally, LI 10 (Shousanli) left, LU7 (Lieque) left,
TH5 (Waiguan) right, LI11 (Quchi) bilaterally;
4th session – LV3 (Taichong) left, SP3 (Taibai) left, KI3
(Taixi) bilaterally, LU7 (Lieque) bilaterally, PC6 (Neiguan)
right, M-HN3 (Yintang);
5th session – LV3 (Taichong) bilaterally, SP3 (Taibai) bilat-
erally, SP6 (Sanyinjiao) bilaterally, PC6 (Neiguan) bilater-
ally, M-HN54 (Anmian) bilaterally, M-HN3 (Yintang);
After the fifth session, the patient no longer felt any pain
and discontinued the treatment.
Discussion
Pain is the most common complication of HZ that sig-
nificantly reduces the quality of life of the affected in-
dividual [1, 7]. Recently, the efficacy of acupuncture
therapy for herpetic pain has been evaluated in control-
led clinical trials [7–9]. According to a review by the
World Health Organization, the use of acupuncture in
HZ therapy is classified in the category “Diseases, symp-
toms or conditions for which the therapeutic effect of
acupuncture has been shown but for which further proof
is needed” [9].
In the present case, considering the adverse reactions to
pharmacological treatment and the patient’s refusal to
receive ESI or any additional pharmacological treatment,
not many treatment options were available. On the other
hand, considering the age of the patient, a high risk of
postherpetic neuralgia and peripheral neuropathy was
a concern [3]. Therefore, acupuncture was suggested as
preferred treatment and started at the acute to sub-acute
phase of HZ.
Fallberichte | Case Reports
Pain and Rash Symptoms
The localization of the pain indicated that an external
pathogen invaded the nerve ganglia along the affected
segment of the corresponding dermatome. The character
of the pain was interpreted as a sign of Qi stagnation and
Blood stasis [10, 11].
Usually, skin rash appears in the initial phases of HZ,
a couple of days post-onset of the pain [12]. In the
present case, the rash appeared 10 days post-onset of
the pain. Considering that the patient had COPD and
cardiac problems in the past, the severity of the pain
and the delay in the appearance of the skin rash can
be explained by a deficiency of the Defensive (Wei) Qi
and Blood stasis [13]. Thus, the invasion of the external
pathogen increased the existing internal imbalances of
Qi and Blood [13, 14].
The rash was itching and painful and corresponded to
Wind-Heat when it first appeared. However, by the time
that the patient presented herself at the Outpatient Pain
Clinic, the rash became crusted and did not itch, although
it remained painful. This changed character of the rash
indicated Damp-Heat. The changes in the character of the
rash were interpreted as an invasion of Toxic Wind that
was challenged by Qi and Blood circulation [10]. Conceiv-
ably, the increase of Qi and Blood circulation, which was
already imbalanced, obstructed the channels and vessels,
and augmented the pain.
Pulse and Tongue Diagnosis
Pulse diagnosis corresponded to Wind-Heat shi, and LU
and KI xu. The color and shape of the tongue represented
Heat. Lack of coating represented empty Heat derived from
Yin xu, while dian in the chest area represented Heat in
the lungs [15, 16]. According to Five Elements, the clinical
manifestations corresponded to the pattern of Fire insult-
ing Water [13].
Treatment principle
Point selection was based on the patient’s complaints,
conventional diagnosis, and the findings obtained in the
pulse and tongue diagnostics prior and during each acu-
puncture session. To alleviate pain and heal the rash, the
treatment rationale was to expel Wind-Heat and fortify
LU and KI [18]. The acupuncture points were selected to
achieve the following:
• LU7 (Lieque), LU9 (Taiyuan) to pacify Wind and tonify
the Lung;
• LI 10 (Shousanli) to clear Lung Heat;
• LI4 (Hegu), LI11 (Quchi), GB41 (Zulinqi), TH5 (Waiguan)
to expel Wind Heat;
• ST36 (Zusanli), SP3 (Taibai), SP6 (Sanyinjiao) to tonify Qi,
nourish blood and Yin, calm the spirit, and alleviate pain;
• SP10 (Xuehai) to cool blood and benefit the skin;
• KI3 (Taixi) to tonify Kidney Yang, anchor the Qi, benefit
the Lung, and alleviate pain;
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Fallberichte | Case Reports
• KI27 (Shufu), PC6 (Neiguan), LV3 (Taichong) to clear
Heat, calm the spirit, unbind the chest, and regulate Qi;
• M-HN3 (Yintang) to pacify Wind, calm the spirit, and
alleviate pain;
• M-HN54 (Anmian) to calm the spirit;
After the first session, the skin rash turned pale, and the
patient felt a significant decrease in the severity of the
pain. The reduction in pain severity continued throughout
the course of treatment. After the fifth session, the patient
no longer felt any pain and discontinued treatment.
According to the classification of herpetic pain, prior to
acupuncture treatment, the patient was experiencing acute
to sub-acute pain [4]. Acupuncture affected the course of
the disease, and NPS did not develop. Taking into consid-
eration that in the absence of NPS, HZ is time-limited, it
is impossible to claim that acupuncture alone resolved the
disease. Additional studies are necessary to investigate the
effect of acupuncture on HZ-related pain and the develop-
ment of the disease.
Conclusions
The present case report describes a conceivable effect of
acupuncture on acute to subacute pain caused by HZ in a
patient who could not be treated pharmacologically. There-
fore, in the present case acupuncture was the available
treatment method. However, additional studies are war-
ranted to investigate the effect acupuncture in the man-
agement of acute and neuropathic pain caused by HZ.
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Autoreninformation – STRICTA requirements
Dr. Arkady Kotlyar has a background in medicine (Ki-
sinev State School of Medicine, Moldova) and holds a
PhD degree in Physiology and Pharmacology (Tel Aviv
University Israel). He has had 570 hours of training
in Chinese (Five Elements), Korean (Su-Jok), and au-
ricular acupuncture in a program accredited by the
Medical Society of Acupuncture of the Israeli Medical
Association and the International Association of Au-
ricular Medicine; one and a half years of acupunc-
ture training at the Center of Integrative Medicine
(SHIRAM) at the Assaf Harofe Medical Center, Israel;
and a number of continuing education courses. He
has six years of experience in drug development and
three years of acupuncture experience at the Clalit
HMO, Israel; the Outpatient Pain Clinic, Kaplan Medi-
cal Center, Israel; and his private clinic.