Peripheral facial palsy results from damaged unilateral facial nerve pathway. Idiopathic facial palsy, called Bell’s palsy, is the most common type of facial palsy. Major symptoms include abrupt paralysis or weakness of the facial muscles within 48 h, hemifacial hypoesthesia, noise sensitivity, dryness of the eye and mouth, and loss of the sense of taste. Some patients experience headaches and ear pain¹⁾. Data from the Korea Health Insurance Review and Assessment Service show that the prevalence rate was 95 per 100,000 in 2018, and the 40s were the age group with the highest occurrence²⁾.

In the acute phase, steroid use is recommended within 3∼4 days of onset³⁾, and it is known that active acupuncture treatment is effective from the beginning of onset⁴⁾. Generally, 60∼70% of patients recover completely within 1 month; however, some patients may remain with sequelae such as full-blown post-paralytic facial syndrome, which complaints of synkinesis, gustatory sweating, hemifacial spasm, and dysesthesia⁵⁾. In addition, the average recurrence rate has been 6.5%⁶⁾. Diabetes, hypertension, old age, and pregnancy are risk factors^1,7). Recently, facial reanimation and nerve decompression have been considered to alleviate sequelae; however, their effectiveness remains unveiled⁸⁾.

Since the symptoms of facial palsy appear on the face, patients might choose high-risk and unproven therapies to minimise sequelae according to individual needs. Folk remedies for facial palsy are used in the form of attaching a toxic, natural substance to the face or arms. These methods are mostly invasive and associated with the risk of secondary infection. In addition, there is a safety issue because unqualified practitioners perform these therapies.

This case report shows the therapeutic effect of Korean Medicine in patients with peripheral facial palsy who experienced skin damage caused by folk patch therapy performed by an unqualified practitioner. This study aimed to determine the risk of uncontrolled, herbal patch therapy.

1. History taking

A 61-year-old female housewife receiving amlodipine for hypertension suddenly felt the right corner of her lip drooping after overwork on 13 October 2014. Brain computed tomography performed in the emergency room showed no abnormalities. She was diagnosed with peripheral facial palsy and was prescribed steroids. The following day, she received herbal patch therapy by a neighbour to her right cheek following the recommendation of an acquaintance. She said that the name of the herb attached to her face was Celery-leaved buttercup (Ranunculus sceleratus). After 24 h, a red, blistered crust developed on the right side of the cheek. Persistent paralysis of the right side of the face and aggravated skin lesions necessitated her visitation to our hospital. In January 2017, after she experienced a severe cold, she suddenly developed left facial numbness and immediately visited the hospital. After the second discharge, she applied an unknown herb to the inside of both forearms to prevent the recurrence of facial palsy (Fig. 1).

Fig. 1. Patient timeline.

Informed consent was obtained from the patient for the publication of images and medical records. This study was approved by the institutional review board of Pusan National University Korean Medical Hospital (PNUKHIRB 2022-10-011).

1) Yanagihara grading system (Y-system): The Y-system was used to measure the degree of facial palsy in 10 categories (at rest, wrinkled forehead, wrinkled nasal root, lightly closed eye, tightly closed eye, closed eye on the involved side only, whistle, grin, and depressed lower lip). Each category ranged from 0∼4 (4=normal, 3=slight, 2=moderate, 1=severe, and 0=complete paralysis)⁹⁾. The total score on the Y-system was 40. It was assessed daily by a practitioner during the hospitalisation period and was measured at each outpatient visit.

2) House-Brackmann facial nerve grading system (HB-system): The HB-system is a gross evaluation of the degree of facial palsy, ranging from I to VI (I=normal, II=mild dysfunction, III=moderate dysfunction, IV=moderately severe dysfunction, V=severe dysfunction, VI=no movement)¹⁰⁾. It was evaluated daily during hospitalisation and was measured at each outpatient visit.

3) Accompanying symptoms: Any symptoms that might accompany facial palsy (hypoesthesia, dryness of eyes, eye pain, lacrimation, ear pain, dizziness, noise sensitivity, dry mouth, leakage of food when eating, residue in the mouth after meals, leakage of water when brushing teeth, and loss of the sense of taste) were recorded and observed for changes.

4) Evaluation of skin lesions: During hospitalisation, the skin lesion of the right cheek was visually observed and recorded by an evaluator. Skin conditions were photographed to confirm the changes.

3. Treatment

1) facial palsy treatment

(1) Acupuncture: At the time of the first hospitalisation, acupuncture for facial palsy was performed twice a day without retention time at acupoints that were widely used for facial palsy using 0.25×40 mm needles¹¹⁾. In cases of second hospitalisation and outpatient visits, acupuncture treatment was administered with a retention time of 20 min using 0.40×60 mm stainless acupuncture needles at the same acupoints as the first inpatient treatment. The details of acupuncture treatment were described in Table 1.

(2) Herbal medicine: Modified Tonggyu-tang was administered three times daily during the admission period. Details of composition and daily doses were shown in Table 2.

(3) Steam therapy: Herbal steam therapy was applied to the posterior neck and face using a steamer (Healer Vivian, Eunhyae Trade, Korea) during inpatient and outpatient periods. The herbs used for the steam were Mentha canadensis, Artemisia argyi, and Agastache rugosa.

(4) Others: Interferential current therapy (ICT) (EF-150, OG GIKEN, Japan) was applied at the area of the posterior neck and silver spike point therapy (SSP) (SPRIA TM-6002, Nihon Medix, Japan) was applied to EX-HN5, GB14, ST2, SI19, CV24, and ST6.

2) Skin lesion treatment: Skin acupuncture¹²⁾ was applied at the margins of skin lesions for 20 min with 0.40×60 mm as shown in Fig. 2. The area around the skin lesion was disinfected with povidone and alcohol before and after treatment.

Fig. 2. Skin needling.

4. Clinical result

When hospitalised for right-sided facial palsy, movement of the facial muscles was rarely observed. After inpatient treatment, the Y-system score increased from 11 to 19 (Fig. 3A). Closing of the eye was possible, and movement of the forehead was observed. According to the patient’s statement, the symptoms of dryness and discomfort in the eye were relieved as the right side of the eye was completely closed. She said that noise sensitivity also disappeared on the 5th day of hospitalisation. After 3 months of outpatient treatment, the Y-system score reached 36 points, and the HB-system grade changed from VI to II compared to when treatment was started (Fig. 3A). The pain in the right ear, which had been reliant on analgesics, was relieved during hospitalisation and disappeared during outpatient treatment. Oral-related symptoms, excluding residue in the mouth after meals, did not change during inpatient treatment but improved during outpatient treatment (Table 3).

Fig. 3. Changes of Y-system and HB-system scores. (A) Rt. Facial palsy in 2014, (B) Lt. facial palsy in 2017.

During the first hospitalisation, crusting, oozing, and redness were observed on the right side of the facial lesion. On the fifth day of hospitalisation, the crusting was completely removed, and redness was reduced. At the end of outpatient treatment, only a pink scar was observed in the lesion area. When she visited the hospital for left facial palsy, the scar in the right facial region improved (Fig. 4).

Fig. 4. Images of the facial lesion.

In 2017, when she developed left facial palsy, the Y-system score was 12, and movement of the left facial region was greatly reduced. Based on experience in 2014, she said that immediately decided to visit our hospital. After the second inpatient treatment, the Y-system score was 17, which increased to 38 at the end of the outpatient treatment (Fig. 3B). Since the eyes could be closed from the onset, the discomfort related to the eyes was not severe, however, the patient complained of tears. Ear-related symptoms disappeared early during hospitalisation, and oral-related symptoms were eliminated through outpatient treatment (Table 3). The HB-system score improved from IV to II after the end of outpatient treatment. (Fig. 3B).

However, after the end of the second hospitalisation treatment, she visited the outpatient clinic with herbal patch therapy on the inner side of both forearms in order to prevent recurrent facial palsy. Korean Medicine treatment was performed for 4 months, and the affected areas were treated without infection, although small scars remained.

Peripheral facial palsy usually occurs unilaterally and intensifies within 48 h after onset. There are various causes of facial palsy, such as tumours, trauma, and viral infection. However, the most common cause is idiopathic. Symptoms progress in the order of prodromal, paralytic, aggravating, parallel, and recovery stages. According to the clinical practice guidelines of Korean Medicine for facial palsy, from the early stage of paralysis, active acupuncture treatment and the combination of acupuncture and steroid treatment were verified to be efficacious, with recommendation grade A²⁾. In addition, as a result of investigating the distribution of medical service for facial palsy, the number of patients who used only Korean medicine was 68.8%¹³⁾.

This patient visited our hospital at the early stage of facial paralysis onset, which occurred twice in 2014 and 2017. She complained of weakness and paralysis of the facial muscles and eye, ear, and oral-related discomfort. At the time of the first hospitalisation, the treatment focused on preventing infection of facial skin lesions and recovering facial paralysis. Skin needling, one of the nine needlings, which is used by shallowly puncturing the skin surface, was applied to activate blood circulation around skin lesion¹²⁾. When she visited the hospital for recurrent facial palsy, the paralysed muscles and branches of the facial nerve were stimulated. Since the facial palsy occurred after overwork and having a cold, modified-Tonggyutang used for wind-cold pattern was administered. ICT, SSP, and herbal steam therapy were performed to help recover facial muscles.

The Y-system scores were 11 and 12 at hospitalisation and improved to 36 and 38, respectively, after the end of Korean Medicine treatment. This patient was receiving medication for high blood pressure and had a family history of diabetes; therefore, the improvement rate was slower than that in general patients. In addition, the slower improvement rate of left facial palsy compared to right facial palsy is consistent with a study showing that the improvement of recurrent facial palsy is delayed¹⁴⁾. The skin lesions on the right side of the face and inside both forearms also recovered without infection, and only a light scar remained on the right side of the face.

Since most folk remedies for facial palsy have been passed down orally, few organized data remain. Also, it is difficult to investigate the actual use of folk remedies because most of them are implemented privately. According to folk remedies of Jeju Island¹⁵⁾, facial palsy is treated by attaching the comb of Gallus domesticus or the blood of Monopterus albus to the affected face.

Folk patch therapy, which was performed twice by a non-professional practitioner, is similar in method to blistering moxibustion of Korean Medicine. Blistering moxibustion is a method of inducing local hyperaemia by attaching toxic herbs to the skin. Dryobalanops aromatica, Sinapis alba, and Eclipta prostrata are widely used as herbs for blistering moxibustion¹²⁾. According to the Dongui Bogam, an ointment called Cheonseon-go, made by Arisaema amurense, Aconitum ciliare, Bletilla striata and Bombyx mori is applied to patients with facial palsy caused by a stroke. In addition, the Bulhwangeum-dan consisting of Mentha arvensis, Schizonepeta tenuifolia, Bombyx mori, Ledebouriella seseloide, Gastrodia elata var pallens, Aconitum carmichaeli, Aconitum koreanum, Buthus martensi, and Glycyrrhiza uralensis is a prescription administered to the face of patients with facial palsy¹⁶⁾. A recent study has shown that blistering moxibustion enhances immune ability by regulating the activities of dendritic cells and promoting the reversible structure of the skin cell membrane, helping to absorb active ingredients^17,18). Since strong irritation can cause severe pain and ulceration of the lesions, a suitable attachment time, accurate treatment location, and post-treatment disinfection process should be considered when performing blister moxibustion¹⁹⁾. However, studies on the mechanism and clinical safety of blistering moxibustion therapy for facial palsy remain insufficient. As the amount of damage through vesiculation should be controllable, blistering moxibustion should be implemented by qualified experts at a medical institution to prevent infection. It would be preferable to use Korean Medicine treatment, which has proven efficacy and safety, even rather than blistering moxibustion, which has possible to cause permanent skin lesions and infection. Moreover, folk remedies should not be considered.

This case study had some limitations. First, the Y-system and HB-system were not measured periodically during outpatient treatment. Second, other treatments were not controlled between outpatient treatments; therefore, it is difficult to judge whether this improvement is effective with Korean Medicine treatment alone. Third, the patient received folk patch therapy despite being educated about its risks of the folk patch therapy. This means that there is a strong belief in folk remedies and there is a lack of awareness about the treatment of facial palsy.

Despite several limitations, this study is the first case to report skin damage caused by folk remedies for facial palsy and showed the effectiveness of Korean medicine treatment twice in patients with facial palsy. The movement of the facial muscles was restored to enable normal life, and the symptoms accompanying facial palsy were alleviated. Moreover, the lesion area caused by folk patch therapy improved without infection. In the future, patients’ perceptions should be continuously improved by providing accurate information on the treatment of patients with peripheral facial palsy. In addition, blistering moxibustion should be performed by medical practitioners with a safe procedure in a hospital.

None.

This work was supported by clinical research grant from Pusan National University Hospital in 2022.

Data cannot be made publicly available because of IRB restrictions.

The authors have declared that no conflicts of interest exists.