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Deficient And Damp Liver Skin Complaints In A Dog

by fdzenitsky - January 20, 2022 View Case Report

Hey Steve, Happy New Year!

Cookie, a now 7YO SF Am. Pit bull, first presented to me in 2019 with digestive and Damp skin issues including nailbed infection. All resolved with an unprocessed diet, so that was that. She has a history of nervousness outside her home, with new people, loud noises, slippery floor, and aggressive to dogs not in her pack.

In Spring 2020, she presented w/ a thin coat – dorsal head and tail, and caudal/medial hind legs with alopecia on ventral abdomen, skin normal. I wasn’t using TCM herbs yet, so started supporting her endocrine system. That Fall, her owner started her on the SWXFY I put another one of her dogs on and the coat started filling in. December, thin coat only on medial legs and 2 areas of comedones on ventral abdomen and medial thigh. ALP is mildly elevated (214 iU/L), was WNL in March. Her T is pale lavender and dry, P is deep, lifting. I conclude she is Blood Def. 2’ to Spln Qi Def. and continue the SWXFY.

In May 2021, her coat is beautiful, comedones persist. When weaned off the SWXFY, the alopecia returns and again improves when restarted, so I keep it up. In September, thin hair only over lateral thighs and liver enzymes elevated: AST (115), ALT (232), ALP (494), and occult blood and RBCs in her urine. The owner notes her stools are now bulky like kibble-fed, they used to be small like the raw-fed dog she is. T is pale, fleshy; P is wiry, fairly superficial to mid depth. Dx: Liver Blood Def., w/ Damp Heat and Blood Stasis in Bladder. I d/c the SWXFY and start BGT and PGZYT, also some digestive enzymes and fermented greens.

So after almost 3 months, I recheck her this week. Her coat has filled in, still thin ventral abdomen and medial thighs. There are discreet elliptical lesions – flat to slightly raised rash, dry, not pruritic – midline inguinal and at creases of inner thighs. Comedones cleared up. Stools still bulky. The liver enzymes more elevated: AST (162), ALT (393), ALP (1032), GGT (18) and still occult blood and RBCs in her urine. T is pink w/ lavender center, P is felt rel. superficial, stronger deeper and is wiry, full. Dx: I still see Liver Blood Def. w/ Damp Heat and Blood Stasis in Bladder and Liver.

I think I see why the SWXFY was not the best, I was tonifying an Excess I didn't see, correct?? Why, oh why Steve, did the current formulas make things worse and not at least resolve the hematuria? Is it for lack of Spleen support? I thought I really had something good going, but I see now there was no Spleen love. Are the bulky stools a sign of Spleen Qi def.? I am leaning towards DGSYS, but I really would like to get it right this time! Will this formula be expected to resolve everything, including hematuria? Is there a better choice and do I need 2 formulas to start with?

Other notable tests, BUN has always been lower than expected for a raw-fed dog, and CPK and TRI also persistently low. I don't know what to make of those last 2…the liver makes TRI, but not CPK. What’s the deal w/ low CPK and does low TRI go mean the same as low CHOL or LIP, i.e., Bld Def?

Thanks as always!
Franchesca

by naturevet

January 20, 2022

Hi Franchesca

It seems like you've helped the dog a lot, but just don't have the whole picture. Damp and Spleen deficiency are certainly on the table given the initial reaction to diet change and the bulky stools. The trace hematuria suggests Dang Gui Shao Yao San might be a fine way to start.

My only concern with that, though, is the steadily increasing liver enzymes on Blood tonics. That suggests you have an excess Liver disorder coupled with the Blood deficiency. Options are Si Miao San + added Dang Gui Shen (20g per 100g of SMS); and 60 g of Xiao Chai Hu Tang mixed with 40 g of Si Wu Tang. The latter helps a lot of Blood deficient skin cases but fits the strong pulse. It can also aid dysbiosis and colitis, which might conceivably make the stools bulky.

As for low CPK, is there low muscle mass present? If there is a bit of atrophy, then I've seen combined Spleen and Blood tonics help, such as Xiao Yao San

Hopefully one of those helps you out. Please let us know how things go!

Steve

by fdzenitsky

January 26, 2022

Thanks Steve!

I just wrapped up the Liver Disorder section of CIVT1006 and still don't have a clear understanding of interpreting the liver enzymes and applying either a Excess or Deficiency approach. I see now that Cookie has an excess disorder based her current pulse, skin lesions, and response to tonics. My thinking at the times I prescribed the SWXFY and BGT were, since ALP was first to rise back in Dec '20 and led led enzyme elevations since then, a congestive disorder needed more blood flow and that the congestion was causing (and trumped) the inflammation. NO? I have thought of ALP/GGT as congestive and ALT/AST as more inflammation. In an case of Excess, ALP can be higher than ALT and an ice pack is needed first? Then, as I understand now, LE elevations that worsen Oct-March (like Cookie's) mean under perfusion - chronic inflammation, shunts, degeneration and the need to tonify. But, her case needs an ice pack, not a hot tub, so more acute. So, any LE elevation, whether ALT or ALP/GGT must be taken in a seasonal context w/ circulation changes/signs and ALP>ALT doesn't necessarily mean decongest first? I don't think I would have made that connection of Liver Excess back in September. Did I miss something you would not have?

Moving forward for Cookie you suggest Si Miao San + Dang Gui Shen (20g per 100g of SMS); and 60 g of Xiao Chai Hu Tang + 40 g of Si Wu Tang. I'm assuming in tandem and both formulas BID for now, recheck in 1-2 months? Why did the PGZYT not resolve her hematuria and why do you think are we seeing it? Will your suggested protocol address it?

She does not have atrophy. I have several dogs w/ low CPK persistently, I cannot explain it, but think it should be meaningful!

by naturevet

January 28, 2022

Hi Franchesca

There are no hard and fast rules in an inductive logic system that always apply to every patient. They are characteristic of deductive logic systems. In inductive diagnostic systems, your goal is to find a story that makes sense of the findings you're seeing. If something is not happening that you think really should be, that is more a feature of deductive systems.

This leaves us with a set of interpretations that overall are accurate and commonly seen, but may not apply to every case. For example, when ALP and GGT are higher than ALT, the problem is one of hepatic congestion rather than underperfusion. But I have certainly seen high ALP levels respond to Blood tonics.

Similarly, as a rule, liver problems that worsen in the months that straddle the winter solstice are more likely to be due to under perfusion, but if they worsen despite use of a Blood tonic during that period, then it looks like they are not, at least for that particular case.

In short, what we work with here are probabilities, which means there are always going to be cases that fall outside of those.

The realities of your patient that we have to build a story around (while ignoring the things we are not seeing) are:

Improvement on a real food diet, which tends to suggest either Dampness or sometimes Blood deficiency

Hair growth on Blood tonics, signaling Blood deficiency

Worsening liver enzymes, due to continued use of a Blood tonic but also perhaps just the winter solstice. The first of these suggests a congestive problem. The second of these suggests continued but not completely addressed Blood deficiency and consequent Liver hypoperfusion. An element of that is Jue Yin excess

Mild hematuria is more 'deficient' a finding than full on cystitis, suggesting Wei Qi deficiency, mild Dampness, or perhaps Blood stasis as a cause. It calls for a tonic

Next I look for the thread that runs through your case - really, just the number of times that I make note of a particular diagnosis. The one that appears most often and consistently is still Blood deficiency, so it becomes the 'must treat' part of the case, or the 'hook' on which everything else must hang.

Once I have that hook, I can look through again and see if I can find a story that fits as many of the possible diagnoses I've written down as possible. One idea I have that I didn't mention is Bu Zhong Yi Qi Tang. It addresses all the possibilities except Dampness. It has Wei Qi tonics to address hematuria and astringe Blood loss (and any very low grade infections). It addresses escalating Liver enzymes over the winter solstice (since it addresses Jue Yin excess). It is a Blood tonic. It can support skin perfusion and control of cutaneous infections. It fits a wiry deeper pulse.

Runner ups would be formulas that address Blood deficiency and Damp, such as XYS and DGSYS.

The pulse is a little deep for SMS, so it's not as high on my list. If the pulse was very broad, I'd wonder about Xiao Chai Hu Tang.

How do I decide what to do? I definitely use a response to acupuncture to help guide me. Even if you don't do acupuncture, you can look up some point locations and use acupressure to help make decisions. For example, if GB 34 didn't moderate the deeper toned pulse, then XCHT is not likely to help. For BZYQT, acupressure at GV 20 should aid. For Damp, look for SP 9 to help the pulse. For pure Blood deficiency, ST 37 should help.

Otherwise, I just start, and evaluate responses as I go, staying in close touch with the owner until I think I've got the thread of it, as evidenced by broad-based improvements in everything in my story that supported my choice

Hopefully this gives you a bit more clarity on how to figure out cases and decide how to proceed

Steve

by fdzenitsky

February 1, 2022

Oh Steve, I so appreciate your explanation and logic stream. Let us also not forget the form of scientific reasoning that diverges from inductive and deductive reasoning. Abductive reasoning usually starts with an obviously incomplete set of observations (the best info available) and proceeds to the likeliest possible explanation for the data. I often make an educated guess after observing a phenomenon for which there is no clear explanation in my evolving, but imperfect mind! Alright, I'm going in, will let you know how it goes, thanks.

by naturevet

February 1, 2022

Abductive! That's a new one on me! Sounds like we need to use an Amber Alert when we fall into that habit?

S

by fdzenitsky

February 1, 2022

Sounds about right!
Hey, while I have your ear, how can I ask questions of a case I posted last year thinking I was asking for help, but used wrong format? I don't see that option. Do I need to ask a case question and have you link it, and is that true all the time? The patient is Jhett Jensen, yes, Cookie's housemate. I updated his saga yesterday.

by naturevet

February 1, 2022

Oh, yes. Just ask the question and I will link it on the back end to your case

S

by fdzenitsky

February 23, 2022

Hey Steve!

Cookie's skin is so far improving on BZYQT over the last 2 weeks, but she also needed a cone for a few days to not lick her abdomen. Over the weekend she suffered a partial CCL tear that we are going to try and manage conservatively with herbs and PT. Will rolling in both XHLD and XCHT be compatible with the BZYQT and her skin and ^ liver enzymes and are the 3 formulas too much here? I'm leaning towards just the XCHT/SWT (+ QJ) given her ventral skin lesions along the GB channel and that combo was a runner-up in our discussion last month, keeping up the BZYQT for now, and perhaps rolling in XHLD a bit later after herbal NSAIDs. Of course, Ruta 30C. Her owner does not want any Rx meds given her ^ LE. Does this protocol feel sound to you all things considered? What is the effect of XHLD on the liver, a hot tub?

Thanks!
Franchesca

by fdzenitsky

February 23, 2022

I questioned her owner and Cookie sleeps under the covers, so fond of warmth. Would that indicate use of XHLD instead of or in addition to XCHT to begin with? I still gravitate to the XCHT given her other concerns... Thanks again!

by naturevet

February 25, 2022

Hi there,

I think adding in XCHT or Chai Hu Si Wu Tang is the best option. Generally, when we have cruciate ligament issues, the Shao Yang is always a problem. It plays well with BZYQT, however, and there is a natural synergy between the two. You could even just try XCHT alone at first with BZYQT, as there is a possibility the Huang Qin in there can eliminate Stomach channel Heat, manifesting as abdominal itchiness. Many Shao Yang dogs are chilly, since the Shao Yang controls peripheral circulation (or lack thereof).

Hope that helps!

Steve

Xiao Chai Hu Tang

by fdzenitsky

April 19, 2022

Hey Steve,

So Cookie has been on the BZYQT since early February, added in XCHJQJT late Feb. for the CCL injury. I rechecked her last week. She is happy, energetic, not bothered by her skin, no urination issues. The CCL is healing nicely. Her coat is still thin on ventral abdomen and medial thighs, now also bilateral patches of thinning coat on lateral mid-trunk, no dander anywhere. The discreet elliptical lesions – flat to slightly raised rings of rash, dry, and NOT pruritic – midline inguinal and at creases of inner thighs -- are unchanged. Stools still bulky. The liver enzymes: more elevated (spiked) are ALP (1253) and GGT (23), but AST (90) and ALT (279) while still elevated are down some. She still occult blood (3+) and RBCs (21-50/HPF) in her urine, no change in that whatsoever. T is pale, P is felt rel. superficial, but is stronger and finger-lifting deeper.

I still see mostly Liver Blood Def. w/ Stasis and a little Damp Heat in Liver and I think her skin and coat are textbook Blood Deficiency, as may be the CCL injury. You mention above that mild hematuria is more 'deficient' a finding than full on cystitis, suggesting Wei Qi deficiency, mild Dampness, or perhaps Blood stasis as a cause. It calls for a tonic. My questions:

1) What is your take on the effects of the 2 herbal formulas on this dog's liver enzyme changes - reduced hepatocellular injury and increased cholestasis? I expected or hoped the combination would be both hepatoprotective and tonifying in tandem. In my lecture notes you mention that Blood tonics overwhelm XCHT benefits when XCHT is rolled in as an icepack while on tonics, but it appears here that there was more of an icepack than tonifying effect.

2) The lack of any response to hematuria w/ the BZYQT, does that rule out Wei Qi def. and Blood stasis, and the need to address hematuria as mild Dampness?

3) I am considering DGSYS or XYS w/ the XCHT formula. I lean to DGSYS v the hematuria (the only Dampness sign I can find). I lean to XYS b/c there is more Deficiency than Damp, but will it be too cooling (she runs cold) or balanced by the XCHT - and can it help resolve the hematuria? Would you add a 3rd formula such as PGZYT or SFZYT - or not yet?

Thanks for your thoughts!
Franchesca

by fdzenitsky

May 2, 2022

Hi Steve, your thoughts on this case?
Thanks!

Franchesca

by naturevet

May 3, 2022

Hi Franchesca,

Sorry, I didn't get notified regarding your last post.

Increased ALP and GGT imply a congestive tendency within the liver that BZYQT didn't help, and may have aggravated. At the same time, it didn't help the hematuria. So, all in all, it's a bust, except you saw some skin improvements, which we have commonly encountered with Blood tonifying formulas. The stronger pulse implies we've over-tonified, though.

That leaves Damp Heat as an unexplored avenue. It's suggested as a possibility by the response to real food, but Damp Heat formulas are notoriously drying. Mildly Blood tonifying formulas like Dang Gui Shao Yao San may be the answer, as you've suggested. We can also look, though, at NPHC and Kan Essentials versions of Long Dan Xie Gan Tang. The latter would also conceivably help persistent hematuria (via its content of Dao Chi San), ventral skin rashes due to Damp Heat, hepatic congestion, yet Blood deficiency. Overall I like it more as our next go-to, since DGSYS is still enough of a tonic that it might aggravate the LEs further.

So, based on everything, I'd wonder about LDXGT next, as long as it's a relatively Blood tonifying version, which means the NPHC or Kan Essentials versions

Hope that helps!

Steve

Long Dan Xie Gan Tang

by fdzenitsky

May 4, 2022

Hi Steve,

I think you've thrown a curve ball! Mind if we confer on the mound for a moment? :)

I see that LDXGT addresses Damp Heat in the liver (marked by moderate to marked LE elevations) and its channels and that pulses will be forceful, as are Cookie's. But, I cannot reconcile any other aspect of this dog w/ Damp Heat, no severe skin lesions, the pulse is not toneless, tongue is pale, no heat intolerance or radiating Heat (in fact, she runs cold). The skin has not improved on the BZYQT (so it really was a bust!) and her pulse has not changed either, it remains full, wiry, felt rel. superficial, but stronger deeper, so Liver Excess, maybe SYD. But, the tongue is pale. She is acting, e/d normal and is unbothered by her skin, urinary tract, jacked-up liver. Isn't LDXGT more useful for acute hepatitis and cystitis and moist or ulcerating dermatitis, while this dog has more chronic hepatopathy and hematuria and what appears to be Deficiency skin lesions? I just feel I need to double check that this our next go-to all things considered, I've made so many bad choices w/ this dog and her housemate, Jhett (who is still a yeasty, itchy mess), I don't know why her person sticks it out with me!

Then, Cookie is still on XCHTJQJ for her CCL injury, so continue that or can it be aggravating her liver and urogenital tract, b/c sure, why not?! If to be d/c, I'll need to look at another of your picks for healing the ligament.

Thanks again!
Franchesca

by naturevet

May 6, 2022

Hi Franchesca,

Sorry to be muddying the waters for you. You can always blame me when the owner balks at yet another formula.

I hear you regarding this dog not looking like a fulminant heat case calling for LDXGT. Sometimes, though, they present as Blood deficient, yet excess somehow. That plus the 'canal congestion' implication of the high GGT and ALP made me recommend it. I agree, the pulse is more one of a Shao Yang disharmony, calling for something like XCHT, but she's already on it! Qing Ying Tang also fits that pulse and the skin complaints, but I've never tried it for elevated LEs

I thought as well of Xiao Yao San, but it's not as specific to the cystitis complaints. It does address well chronic active hepatitis and skin Blood deficiency complaints

Franchesca, do you do acupuncture? You could check points one by one, alternately tonifying and sedating, to see which points moderate the pulse. That will help me do a better job of supporting you. Meanwhile, I'm sure the owners appreciate your willingness to always try. Sometimes, too, owners stick with us because we have some important lesson to learn from a case. I guess use your intuition and see what it says to you about which of the above to try next

Steve

by fdzenitsky

June 8, 2022

Morning Steve,

I do not do acupuncture yet, but am starting an intro course this month :). I know that will greatly help you help me, and me, my patients!

Cookie update and in need of your advise. I did start her on the LDXGT first week of May, continuing also the XCHTJQJ. Within a few weeks, Cookie's rash got worse - much redder and dry, one generalized hot pink flush extending to entire inguinal, lower abdomen, and inner thighs w/ white scabby areas, she started licking (never bothered her before). Her hair is also thinning on her head like it did in the past. Before I could get to her, the owner took her to another clinic to get a cytopoint injection. Vet said it was past cytopoint (thank goodness!) so put her on pred and cephalexin. When I saw her 4 days later, the skin was pretty much normal - that was fast! The liver enzymes however: more elevated ALP (1393); and GGT (15), AST (81) and ALT (220) while still elevated are down a little. Platelets are now up (421) too. She still occult blood (2+) and RBCs (4-10/HPF) in her urine, that has improved somewhat. T is not as pale and has phlegm lines, P is felt best deeper, toned, broad w/ some lift.

To recap her Hx, ALP seemed to begin increasing while on SWXFY that was started to help her coat grow in and worked well for that. ALP increasing w/ ALT and AST beginning to go up and hematuria. I switched her to BGT and PGZYT and AST, ALT, ALP, and GGT all increased, still hematuria, and dry, non-pruritic skin lesions developed on inguinal and inner thigh. Then on to BZYQT w/ no change in skin, more elevated ALP & GGT and slightly improved ALT & AST. Testing the Blood Heat theory, I put her on LDXGT.

So, I'm assuming the LDXGT is responsible for the severe skin lesions developing and the thinning coat by pulling circulation away from the dermis and similarly affecting portal circulation in a Deficient case. Rapid response to prednisone and steroids also suggests Deficient. From my CIVT derm notes, if skin gets worse on LDXGT, either damaged Spleen or pulled pathogen internal with worsening itch, exacerbating Wind and Blood def. cases. Now, the Wind has calmed w/ the meds and I am back to considering DGSYS or XYS. I lean to DGSYS v the hematuria and to XYS b/c there is more Deficiency than Damp, but will it be too cooling (she runs cold) and can it help resolve the hematuria if an herb is added like San Qi? Then, do I ditch the XCHT since it hasn't been doing her liver any favors that I can tell? Very frustrating this liver case, thankful that Cookie is acting her normal happy self!

Thanks, your continued support and tutoring is my jam. ;)
Franchesca

by fdzenitsky

June 13, 2022

Morning Steve!

A few cookie updates: her belly rash has come back since backing her off to 5mg of prednisone and holding on what to do next. It is not as bad as it was but it is red again. I forgot to mention that her TBil is starting to creep up, first time for that. Also, she tore her meniscus, so I believe we'll take her to surgery. I mention this b/c of the XCHT I have had her on. If not helping heal her liver or stifle, I'm okay taking her off of it. What are your thoughts?

Thanks again!

by naturevet

June 14, 2022

Hi Franchesca

A summer solstice aggravation of biliary canal disease, knee inflammation and a red belly make me think of Si Miao San. I can't see you've tried it but I know you talked about it. If you haven't tried it yet, it's probably the next step.

If signs of Blood deficiency develop but it's otherwise helpful, then adding Dang Gui in (as you had wondered way back when) would be the next step

Hope that helps. Tough case!

Steve

Si Miao San

by fdzenitsky

June 14, 2022

Thanks Steve, I was just about to dispense XYS, more concerned w/ the liver than the hematuria and thought the XYS would help w/ the Blood deficiency rash. I do like the SMS, but T&P don't fit. Does that matter? Will the SMS have any action v hematuria? Throwing in some SAMe as well.

by naturevet

June 14, 2022

Hi again

SMS can fit a few different pulses. If the liver enzymes have been climbing into the summer, SMS can help with that, too. Generally Blood deficiency liver problems get better as the summer progresses, not worse. As for the hematuria, it is technically a symptom of Damp Heat, so it could fit.

I defer to your read of the situation. I guess keep SMS in mind if XYS fails to deliver

S

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