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Fearfullness In A Dog And Damp Heat

by jenmercier - May 11, 2024 View Case Report

Nellie – 9 mo old FS Labrador Retriever, 65 pounds

Adopted at 8 mo intact and with poor socialization.
1/15/24 Initial exam: yeast otitis externa with malodor (yeast, rods, cocci), pododermatitis, perivulvar dermatitis and pruritus, obesity; labwork all normal

In general, she is excited and happy with other dogs if they are calm and gentle but has displayed aggression with the older dog in the house. Most of the time she is friendly but a few times she has attacked the older dog when she walks by, possibly over resources. She is very fearful of people, places, and noises and easily startles. She is comfortable in her crate at all times. One time since her adoption the owner forgot to put her in her crate when they left the house. They came home to find her in a panic with the windows covered in saliva.
During exams she becomes nervous, tail tucked, crouching, hypersalivating, and almost catatonic.
The owner reports vivid dreaming.
Appetite, thirst, stool, urination all normal.

3/1/24 exam revealed:
Spayed 1/30/24
Persistent/recurrent yeast otitis, perivulvar dermatitis, pododermatitis- improved but still active
New hot spot bacterial pyoderma- focal lesion at GB40 on left side
Pruritus – excoriations on her ventro-lateral thorax/abdomen (around GB24)
Tongue wet, full, ranging from light pink to normal pink
Pulse deep, slow, decreased tone, neither wide nor thin
Malodor reduced
Her body condition is improving with reduced calorie intake and exercise. She is working with a trainer.

Diet: Purina Pro Plan puppy; switching to RC HP puppy for now with recommendation to transition to fresh food

Medications:
Simparica trio
Topical ear medication- multiple treatments
Medicated baths
Cephalexin 2 weeks
Cytopoint
Zylkene

5/10/24: exam (1 yo now)
Si Miao San and Dang Gui Shao Yao San started ~4/1/24
- She is down to 65lbs
- Dosing Kan Essentials 4 tabs of each once daily
Started Omega Benefits fish oil a few weeks ago
Fully transitioned to The Farmer’s Dog fresh food. Variety of proteins.
Persistent perivulvar dermatitis- cocci and yeast with erythematous and lichenified regions dorsal and lateral folds
Small hot spot or start of lick granuloma on the right dorsal forelimb (along LI channel?)
Very slight pododermatitis but not really symptomatic
Ears look normal
Major concern for owner is her fearfulness. She is getting along much better with the older dog in the house but remains very fearful- going on walks, interacting with other dogs and people, noises, her harness, getting in the car
Tongue: full, wet, light pink to pale pink, drooling during appointment
Pulse: normal to relatively low rate, deep, toned, didn't feel forceful at all and didn't compress easily but was deep, not narrow or wide
mild heat around BL20/21

TCVM Dx:
Since starting herbs- tongue hasn’t really changed but the pulse has more tone
Spleen Qi deficiency with Damp heat
Shen Disturbance due to Liver Blood deficiency and Liver Qi Stagnation

Questions:
How do I adjust the herbs? Do I need different formulas or adjust the dosing of current herbs? I think we have made progress with the Damp heat but behavior is not changing much. I realize this may take time and training too.

by naturevet

May 13, 2024

Hi there,

I'm wondering if you should now switch to a Shao Yang disharmony approach to the skin, even though there has been a payoff in treating Dampness. Findings consistent with Shao Yang disharmony include:
- locations of lesions on the Shao Yang channels (most lick graulomas are on the Triple Burner channel)
- the pulse she currently has (deep, resistant to compression, not weak)
- the profound anxiety in the office and at home
The latter is consistent with a Metal excess and a Wood deficiency. Tonifying the Wood element with Blood tonics could help here, but given the pulse and the lesion locations, I'd be tempted to do so using a mix of Xiao Chai Hu Tang (Minor Bupleurum) and Si Wu Tang (Four Materials Decoction). You can obtain this pre-mixed from Gold Standard Herbs as Cessorex, or you can mix your own. Use two parts XCHT to 1 part SWT.

You could continue the other two formulas to guard against Dampness. Or you could increase the amount of Blood tonification in your current protocol by switching from Dang Gui Shao Yao San to Xiao Yao San. That will still support the Spleen.

For sure, though, I think the Liver is the next organ to help, regardless which of these two strategies you use. Genital lesions are primarily due to Liver issues.

Hopefully this helps you out! Let us know how things go!

Steve

by jenmercier

August 28, 2024

Hi Steve,
This dog has made improvements but continues to have perivulvar dermatitis. We just treated a right ear infection as well but I think this was initiated by having to clean tar off her head. The owners have had workers on the property and she managed to get herself covered in tar!
She has been generally mildly itchy and the only skin lesions I am seeing are the perivulvar bacterial dermatitis and one paw has slight erythema and moist exudate in the ventral webbing.
She is doing great with her training. Fearfulness is slowly improving. She has had no dominance aggression at all.

Her tongue and pulse are much the same but perhaps the pulse is more toned that the previous two assessments:
Tongue light pink, somewhat full and moist
Pulse toned at all levels and strongest at the deeper level but I am not sure it is actually "deep".
Her body condition is now excellent

She is taking Si Miao San and Xiao Yao San granules at 1 tsp twice daily (she is now 59 pounds)
Eating a fresh food diet

As you have said before, genital lesions are primarily due to Liver issues. Liver Damp?
Do I need to reach for something like Long Dan Xie Gan?

Jen

by naturevet

September 11, 2024

Hi Jen,

That's great you're seeing progress, and it's comprehensive enough that we should continue in the Dampness theme, my previous reply notwithstanding. The pulse is deep enough, that I think what might be needed now is something more dispersing. Chu Shi Wei Ling Tang is a good follow up formula for dogs clearly responding to Si Miao San. That said, I know you're itching (pun intended!) to try Long Dan Xie Gan Tang, so I guess go with that first. If it doesn't work, remember CSWLT. And if suddenly the whole case changes on you, remember the Chai Hu Si Wu Tang I mentioned earlier.

Steve

P.S. The depth of the pulse is where you find it's maximum beat strength. Not where you first feel it or where you last feel it.

by jenmercier

September 11, 2024

Thank you! I am reading up on Chu Shi Wei Ling Tang and I think it fits maybe a bit better than the Long Dan Xie Gan for her current status. Presuming the ear infetion was truly from the whole tar incident.
I am thinking of going with CSWLT then. This would be used instead of SMS correct?
Would I also discontinue the Xiao Yao San?

by naturevet

September 11, 2024

I often use SMS and CSWLT at the same time, to start with. I'd just add in the third formula and then if things go well, see what can be reduced or removed

by jenmercier

November 1, 2024

Hi Steve,
Nellie has been taking SMS, XYS, and CSWLT now for at least a month or more. She continues to have waxing and waning perivulvar dermatitis. Right now it actually looks pretty good. Overall she is much more itchy and has been chewing at her paws. The dorsal aspect of the interdigital webbing is affected.

Tongue: lightly purple, somewhat dry, not thin, not much coating (tongue is dryer than the rest of her mouth which is normal wet)
Pulse: slow, NSA, moderate to superficial depth, vessel toned, pulse soft
Maybe a bit warm all over but it has been hot outside.
Behavior is much improved

Wind Damp Heat but maybe underlying she still has a Blood deficiency?
I feel like I haven't been very helpful with her pruritus and the Damp Heat continues to surface.
Time for Cessorex?

I look forward to your input!
Jen

by naturevet

November 3, 2024

Here's a thought. Skin lesions that persist or recur in the same location can indicate Blood Stasis. In terms of which Blood mover you might use to treat the dog, you could look at Xue Fu Zhu Yu Tang. Normally that is a formula to move Blood in the Upper Burner, but the Nan Jing described the Upper Burner as including the entire body periphery. For sure that includes the anal glands, so maybe it includes the perivulvar region, too. XFZYT harmonizes Metal and Wood, so it treats the Liver, and is a good formula for anxiety. So it's an overall good fit with your impressions of the dog and the owner's priorities.

Now, if the owner has completed the switch to real food, and there has been no improvement, then the way is clear to add in Chai Hu Si Wu Tang (2 parts XCHT and 1 part Si Wu Tang), while easing off on the Damp drainers. It has a lot in common with XFZYT, so you wouldn't need to do both. Just CHSWT should be enough. Dogs on real food diets that continue to itch are almost NEVER Damp, so a lack of benefit of that kind of diet signals we can likely simplify her protocol.

If the pulse responded to GB points like GB 34, then I would go the CHSWT route. If the pulse responded to BL 18 or LV 3, then I would go the XFZYT route.

I have also used Qing Ying Tang for Blood Stasis skin lesions, but it is pretty aggressively cooling, so I'd only try it instead of these other formulas it if the itch was pretty intense. Qing Ying Tang does work well with CHSWT if itch persists even as the anxiety and skin lesions improve on CHSWT.

Hopefully that helps you out!

Steve

by jenmercier

January 16, 2025

Hi Steve,
I have an update for Nellie. I switched her from SMS and XYS to Cessorex right around mid November 2024. It took awhile but the perivulvar dermatitis/pruritus has settled down. At the moment, her ears and paws are good too but she has a light papular dermatitis on her ventral abdomen so the ever shifting skin issues continue. The biggest concern for the owner is last week she started back up with some behavioral issues. Snapped at the owner when he reached down to pet her in her crate and also attacked the other old dog in the house (Lexi who I just sent an update on as well). She is docile and happy to see me and did great at the hospital. She used to drool and become almost catatonic in the hospital setting.

I just did labs on her and everything is normal. She is eating The Farmer's Dog and we restricted it to just the pork to limit variety for the moment. She has been on a fresh food diet for months now. Her BCS is perfect.
Her tongue is light pink, full, and moist/wet. Her pulse is soft and wide with little tone. It feels the same at all depths, rate is relatively slow.

I am wondering if I need to tonify Qi and Heart Blood? Her tongue and pulse seem to fit best with Qi deficiency now. I am not sure how to interpret her behavioral issues. She has improved greatly but the recent set back is confusing. Is this related to Liver Qi Stagnation (I don't get much of that on her PE) or related to the heart element responsible for housing the Shen?

I am thinking about Dr. Xie's Heart Qi tonic vs Gui Pi Tang vs other. If this is still Liver related, would I go back to XYS? And then I don't know how these are related to the persistent skin issues unless she actually does have food or environmental allergies which I am considering.

I see her and Lexi often so I can try some point/pulse evaluation as well.

As you can see, I need your guidance !!!!
Jen

by naturevet

January 20, 2025

Hi Jen,

I would wonder if the pulse meant low Wei Qi, which can be a component of the pathology in dogs that benefit from Cessorex. Using Bu Zhong Yi Qi Tang will address that, often helps get rid of ventral abdominal rashes, and relieves (fear) anxiety in many dogs.

I think BZYQT is a better call than Gui Pi Tang as it addresses Leaky Gut, which we know is an issue given the success of Cessorex. GPT doesn't have that benefit.

The other option, if you're sure of the Dampness diagnosis, is to use a Damp draining formula like Wu Ling San. The Fu Ling in the formula will have a calming influence and draining Damp should promote mental clarity. If you think the dog is very Hot, then you can try Long Dan Xie Gan Tang instead.

If you go that draining route first and the dog worsens, then you'll know for sure you need to instead raise Qi using something like BZYQT.

Hopefully this helps and you continue to see benefits! Please keep us posted!

Steve

by jenmercier

January 20, 2025

Thank you! I assume I can and should keep her on the cessorex and add the BZYQT?

by naturevet

January 20, 2025

Yes, that is correct!

S

by jenmercier

August 26, 2025

Hi Steve,
Nellie has had a few developments. Her behavior is perfect, no more episodes of aggression. However, she continued to struggle with perivulvar dermatitis. She was taking Cessorex with BZYQT. After a few urinary accidents in the house, I discovered that she is actually having urinary incontinence. Dribbling when she is laying down. Sometimes a large puddle. I began to wonder if that has been an underlying cause for licking that perpetuated the dermatitis. I started her in Incurin and she is now down to a dose every 3rd day and no incontinence.
Also, she continued with low to mid grade pruritus. Biting at her thighs and legs. No otitis or pododermatitis. I stopped the herbs since I really wasn't seeing what I wanted.
We ended up doing allergy blood testing and she is quite allergic to dust and storage mites, malassezia, and some grasses/trees. Dermatology formulated immunotherapy and she has is building up her injections now. Since moving on to the second bottle of higher concentration, she is having a nasty flare up. Severe bacterial otitis, moderate bacterial pododermatitis, some axillary erythema.

Her pulse yesterday: softly toned, slow, hard to tell depth, slippery
Tongue light lavendar

Prior to the Damp Heat flare up, I was thinking about the urinary incontinence and how that fits with her history. I was thinking of trying Sang Piao Xiao San considering a Heart/Kidney disconnect leading to the UI. Thoughts there?
With the allergy immunotherapy, should I also consider putting her back on SMS?

Looking forward to your thoughts!
Thanks,
Jen

by naturevet

August 26, 2025

Hi Jen,

The flare up suggests a true allergy, which puts us in Shao Yang territory, so I would revisit Cessorex. For dogs with a suggestion of Dampness as well, I team it with Si Miao San.

Once you have resolved the severe inflammation (i.e., Excess), you could try something like Sang Piao Xiao San or HRUI Combination (Natural Path). I would hold off on using those tonics until you've substantially improved these new symptoms, though.

Hopefully, that helps!

Steve

by jenmercier

March 18, 2026

Hi Steve,
I've got an update on this girl. Struggling to make any progress on her allergies. She is stable right now but still has a low grade itch, and licks her vulva. She is on every 2 weeks allergy immunotherapy injections (owner is not really appreciating any change but the dermatologist wants her to continue for at least 12 months before quittng).
She is not having UI on a low dose of incurin. She was seen by a chiropractor who felt she definitely has hip and pelvic issues so we are working with PT and adjustments. She continues to have no mobility issues whatsoever thankfully.
She is eating The Farmer's Dog fresh food diet and has completely normal appetite and bowel movements. She has lost weight but is a good BCS. I am not sure if the weight loss is a trend because her last weight check was a year ago. But if it is, it is unintentional. Her diet hasn't changed and appetite the same.
She has periods of being cranky and irritable. I think this represents Liver Qi Stagnation, possibly from Liver Blood deficiency.
The most troubling for the owner and telling to me is she is aggressively eating stool now. This is brand new starting about a month or so ago. This is pointing me to Spleen Qi deficiency more clearly now.
Her tongue is pale pink, very wrinkled, and definitely not moist. Qi and Blood deficiency
Her pulse is deep and soft and slow. Qi deficiency
I have not heard that she is seeking heat or cool so may be neutral.

She has been taking XCHT and SMS.

So far, I have reduced the XCHT to 1/2 dose and switched from SMS to SRT. I thought the SMS may have been too aggressively cooling and anti-inflammatory at this point. The other dog in the house is taking SRT so it made sense but I don't think this is ultimately going to be the perfect fit.

I am struggling to select a formula/formulas for her to address Spleen Qi deficiency, Blood deficiency, and Liver Qi stagnation. She doesn't have the classic GI signs for many of the Spleen Qi deficiency GI formulas. Every formula I look at just seems to fit partially.
Dampness and Damp Heat are intermittently evident in her skin allergies but not her GI.

I am thinking of Bu Zhong Yi Qi and Xiao Yao San. She has been on BZYQ before along with Cessorex. The coprophagia was not happening at that time. But also, the combination did not alleviate her skin itching as we had thought it might. The other dog in the house, whose poop she is loving, is taking XCHT, BZYQ, and SRT.

I look forward to hearing from you!
Jen

by naturevet

March 22, 2026

Hi Jen,

I like your thinking in this case. Liver Blood deficiency along with Spleen deficiency seems a good fit. The latter fits with coprophagy and even the weight loss. The former fits with her irritability.

Since the dog is not eating kibble, Dampness may not be a huge concern. So, you could look at more purely tonifying treatments. Bu Zhong Yi Qi Tang seems a great choice given the history of incontinence. If she has it on hand, she could try it again. Otherwise, Xiao Yao San is also a good choice.

If you do decide you see Damp, then the coprophagy and chronic low grade skin issues would have me reaching for Chu Shi Wei Ling Tang next.

Hopefully, one of those options helps you out!

Steve

by jenmercier

March 23, 2026

Thank you!

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