Although warts are a common skin condition/disease that recurs in childhood, treatment completion is difficult owing to the pain associated with conventional therapies. In this case, Korean herbal medicine, Guijakjihwang-Tang, and indirect moxibustion was used to treat a recalcitrant cutaneous wart without pain and recurrence. A 7-year-old boy presented with recurrent cutaneous warts on his right hand and received cryotherapy 3 times in the previous year. The wart recurred during the course of cryotherapy treatment, and the patient did not want to suffer any more pain from the previous treatment. Therefore, parents sought an efficient and painless therapy. The patient was treated for 2 months using Guijakjihwang-Tang combined with indirect moxibustion. The prominent lesion separated in the 2nd month of treatment and completely recovered without adverse events in the 3rd month. There was no recurrence over 12 months of follow-up. This report provides meaningful insights into the use of Korean medicine as a safe, painless and efficient treatment for warts in pediatric patients.
©2021 Korean Acupuncture & Moxibustion Medicine Society. This is an open access article under the CC BY- NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Article history:
Submitted: July 06, 2021 Revised: July 21, 2021 Accepted: July 27, 2021 Keywords:
case report, herbal medicine, moxibustion, warts
https://doi.org/10.13045/jar.2021.00143 pISSN 2586-288X eISSN 2586-2898
J Acupunct Res 2021;38(3):233-235
Case Report
A Combination of Herbal Medicine and Moxibustion Treatment is Effective for a Recalcitrant Cutaneous Warts in a Pediatric Patient:
A Case Report
Ji-Yeon Lee 1, Sul-Ki Kim 2, Cheon-Hoo Jeon 2, Soo-Bo Shim 2, Hae In Ahn 3, NamKwen Kim 3, 4,*
1 Department of Sasang Constitutional Medicine, Kyung Hee University Hospital at Gangdong, Seoul, Korea 2 College of Korean Medicine, Daejeon University, Daejeon, Korea
3 Guideline Center for Korean Medicine, National Institute for Korean Medicine Development, Seoul, Korea 4 Pusan National University Graduate School of Korean Medicine, Yangsan, Korea
ABSTRACT
Journal of Acupuncture Research
Journal homepage: http://www.e-jar.org
Introduction
Warts are benign proliferations of the skin and mucous membranes resulting from human papillomavirus (HPV) infection [1]. The prevalence of warts is particularly higher in children (approximately 10.0-44.0%) than in adults (3.3-33.0%) [2-4].
Salicylic acid and cryotherapy are representative treatments for common warts [5]. However, treatment completion is difficult owing to the pain associated with these treatments, especially in children [6,7]. Korean medicine treatments for warts promote immune activation e.g., Guijakjihwang-Tang, a Korean herbal medicine, and indirect moxibustion. These treatments do not cause any pain and are therefore easy to administer in children. Herein, we present a case of successful painless treatment of a wart with a combination of Guijakjihwang-Tang, and moxibustion without recurrence for over 12 months in a pediatric patient.
Case Report
This report complied with the CARE case report guidelines, and was approved by the Daejeon Korean Medicine Hospital of Daejeon University Institutional Review Board (no.: DJDSKH- 20-E-23-1) as a retrospective case study. The patient’s caregiver was informed that photos of the wart area, a detailed process of the treatment, and the treatment history of the patient will be reported, and that the patient’s personal information will be protected. After detailed explanation, consent for academic publication of the case was obtained from the patient’s caregiver.
A 7-year-old boy presented at the Korean medicine clinic with a cutaneous wart on his right hand. The patient had recurrent warts (3 times) in the same region within 1 year of cryotherapy treatment and refused further treatment because of pain during treatment.
Black pinpoints on the lesions with hyper-keratinization suggested
*Corresponding author. NamKwen Kim
Guideline Center for Korean Medicine, National Institute for Korean Medicine Development, 173 Toegye-ro, Jung-gu, Seoul, Korea E-mail: [email protected]
ORCID: Ji-Yeon Lee https://orcid.org/ 0000-0001-7305-9087, Sul-Ki Kim https://orcid.org/ 0000-0001-5981-7849, Cheon-Hoo Jeon https://orcid.org/ 0000-0003-2474-412X, Soo-Bo Shim https://orcid.org/ 0000-0002-6684-0841, Hae In Ahn https://orcid.org/ 0000-0003-1584-2588, NamKwen Kim https://orcid.org/ 0000-0001-6969-1231
©2021 Korean Acupuncture & Moxibustion Medicine Society. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc- nd/4.0/).
J Acupunct Res 2021;38(3):233-235 234
common warts. A common wart measuring 8 × 8 × 6 mm (length
× width × height) was observed at the dorsum of his right hand.
The patient did not experience pain or discomfort, due to the skin lesion, whilst performing daily life activities (Fig. 1A).
The patient was prescribed Guijakjihwang-Tang which is a herbal medicine that mainly consists of Rehmannia glutinosa (Gaertn.) DC., Coix lacryma-jobi L., and Dioscorea japonica Thunb (Table 1), at a dose of 80 mL twice a day for 2 months.
After 1 month of treatment, the patient showed a positive attitude toward the treatment and cooperated with further treatment.
Therefore, during the 2nd month of herbal medicine treatment, he was additionally treated with moxibustion to accelerate recovery (Fig. 1E).
In the 1st month of herbal medicine treatment, the wart became harder and cracks appeared (Fig. 1B). Indirect moxibustion (Ehwadang Company, Seoul, Korea) was applied on top of the wart for 3 minutes without changing moxibustion, with the maximum temperature controlled within 45-50°C, and this was performed once a week for 1 month. During the 2nd month of treatment, the wart became firmer, smaller, and separated earlier than expected (Fig. 1C). After the separation of the wart, moxibustion was no longer required, and skin recovery was observed. The skin recovered completely within 1 month (Fig. 1D), and the wart did not recur for over 12 months of follow-up, which was more than double the previous period of non-recurrence.
Discussion
Warts are benign proliferations of the skin and mucous membranes, and the conventional treatments for common warts are Salicylic acid, cryotherapy, bleomycin, and photodynamic therapy. However, some warts are resistant to these conventional treatments, thus, recurring warts are a persisting challenge for clinicians. At present, considering that the immune system controls the proliferation of warts [9], therapies that regulate the immune system such as intralesional immunotherapy, are used to treat warts [8]. In fact, effective cell-mediated immunity has been reported to eradicate HPV infection [10].
In this patient, Guijakjihwang-Tang was prescribed to promote effective immune activation. Guijakjihwang-Tang is a herbal
Fig. 1. Procedure of tretment. (A) January 30, 2020: White or skin-colored wart appeared on the back of the right hand. The wart was firm and clotted blood vessels were seen at the center of the lesion. (B) February 25, 2020: After administrating herbal medicine, the lesion seemed to have cracked. (C) March 30, 2020: After 3 courses of moxibustion treatment, the lesion became firmer and smaller, and was detached by accident. (D) April 13, 2020: The lesion recovered completely 2 weeks after separation. (E) Simple schematic of the entire treatment process.
(A) (B) (C) (D)
(E)
Scientific name Amount (g)
Rehmannia glutinosa (Gaertn.) DC. 12
Coix lacryma-jobi L. 12
Dioscorea septemloba Thunb. 6
Angelica gigas Nakai 6
Paeonia japonica (Makino) Miyabe & Takeda 6
Cornus officinalis Siebold & Zucc. 4
Paeonia suffruticosa Andrews 4
Alisma canaliculatum A. Braun & C.D. Bouche 4
Poria cocos 4
Cnidium officinale Makino 3
Table 1. Components of Guijakjihwang-Tang Taken Each Day.
Ji-Yeon Lee et al / Pediatric Treatment of Refractory Warts 235
medicine originating from Wai ke zheng zhi quan shu (外科證治 全書) [11], which is prescribed when a patient shows shortage of yin. The constituents of Guijakjihwang-Tang enhance the cellular and humoral immune system response by increasing the number of T cells and inducing the proliferation of spleen cells [12-14].
Even a single herb prescription of C. lacryma-jobi L., a constituent of Guijakjihwang-Tang, has been reported to lead to the complete treatment of warts [13].
Moxibustion, a type of thermotherapy, refers to the burning of herb moxa (Artemisiae Argyi Folium or mugwort) at a certain distance from the skin (Fig. 2) [15]. A case of complete treatment of warts using direct moxibustion has been reported [16].
However, considering that the patient in this case report had been afraid of pain caused by previous treatments, indirect moxibustion was prescribed. Local hyperthermia therapy at a temperature of approximately 42-45°C can promote the migration and maturation of immune cells, thereby activating cell-mediated immunity [17].
The present case report provides meaningful insights into the management and treatment of warts using Korean medicine in pediatric patients. In Korea, there are medical licenses for Western medicine doctors and Korean traditional medicine doctors.
Korean medicine doctors can treat recalcitrant and hardly curable conditions/diseases using Korean medicinal treatments, such as acupuncture, moxibustion, and herbal medicines. The combination of herbal medicine and indirect moxibustion prompted the patient to voluntarily cooperate to complete treatment. A gradual introduction of treatment has been reported to have an important implication for medical results in children because their fear of hospitals can lead to inappropriate treatment regimens [18].
Hence, herbal medicine followed by indirect moxibustion therapy could ensure high treatment compliance in children. In addition, no recurrence was observed for over 12 months of follow-up, indicating that combined therapy may be effective in clinical settings. Future studies are needed to support the safety and efficacy of combined therapy with herbal medicine and indirect moxibustion.
Conflicts of Interest
The authors declare no conflicts of interest.
Funding
This study was supported by research funds from the Ministry of Health & Welfare through the Korea Health Industry Development Institute (KHIDI) and by the Guideline Center for Korean Medicine of the National Institute of Korean Medicine Development (HI16C0275).
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Fig. 2. Aplication of indirect moxibustion. The hand does not belong to the patient in this study.
