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Treatment of Peripheral Facial Palsy with Skin Damage Caused by Folk Remedies Using Korean Medicine: A Case Report
민간요법으로 피부손상을 동반한 말초성 안면마비에 대한 한의치료 증례 보고
Korean J Acupunct 2022;39:191-198
Published online December 27, 2022;  https://doi.org/10.14406/acu.2022.022
© 2022 Society for Meridian and Acupoint.

Yoona Oh1 , Yeonhak Kim1 , Jihun Kim1 , Eunseok Kim1 ,2, Byung Ryul Lee1 ,2, Gi Young Yang1 ,2
오유나1ㆍ김연학1ㆍ김지훈1ㆍ김은석1,2ㆍ이병렬1,2ㆍ양기영1,2

1Department of Acupuncture and Moxibustion Medicine, Pusan National University Korean Medicine Hospital,
2Division of Clinical Medicine, School of Korean Medicine, Pusan National University
1부산대학교한방병원 침구의학과, 2부산대학교 한의학전문대학원 한의학과 임상의학교실
Correspondence to: Gi Young Yang
Division of Clinical Medicine, School of Korean Medicine, Pusan National University, 20 Geumo-ro, Mulgeum-eup, Yangsan 50612, Korea
Tel: +82-55-360-5963, Fax: +82-55-360-5890, E-mail: ygy@pnu.edu
This work was supported by clinical research grant from Pusan National University Hospital in 2022.
Received October 28, 2022; Revised November 17, 2022; Accepted November 21, 2022.
This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
Peripheral facial palsy generally results from damage to the facial nerve. As facial asymmetry is observed, it accompanies not only functional problems but also psychological and social difficulties. Medical institutions treat most patients, however, there are still patients who rely on invasive methods by unqualified practitioners for fear of sequelae. This case describes a 61-year-old woman who experienced facial palsy twice. She visited our hospital with skin damage after folk patch therapy for her facial palsy. Combined Korean medicine treatment was administered during treatment period. After treatments, the symptoms of facial palsy and skin lesions improved. This case showed that Korean Medicine was efficacious in improving symptoms of facial palsy with damaged skin caused by folk patch therapy. Education and awareness of uncontrolled invasive treatments for facial palsy are needed.
Keywords: peripheral facial palsy, Korean medicine, folk remedies, blistering moxibustion, case report
Introduction

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 factors1,7). 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.

Case Report

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).

2. Measurement of symptoms

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.

Standards for Reporting Intervention in Clinical Trials of Acupuncture (STRICTA)

Contents
1.Acupuncture rationale 1a)Style of acupuncture Classic acupuncture theory (Confluence Points of the Eight Extraordinary Vessels)
1b)Reasoning for treatment provided Based on historical context and literature sources (e.g., The Textbook of Acupuncture and Moxibustion Medicine)
1c)Extent to which treatment was varied Semi-individualized selection; according to the patient’s symptoms and conditions
2.Details of needling 2a)Number of needle insertions per subject per session 10∼20 points; practitioner adjusted the number of needle insertions according to patient’s symptoms and conditions
2b)Names of points ST2, ST4, ST6, TE17, TE21, TE23, LI20, BL2, GB1, GB2, GB14, SI19, CV24, GV26 and marginal area of skin lesion
2c)Depth of insertion 5-20 mm (according to the expected tissue depth on acupuncture points)
2d)Response sought Subjective De-qi sensation
2e)Needle stimulation Manual stimulation of rotation, lifting and thrusting just after the insertion of needles
2f)Needle retention time 0∼20 minutes
2g)Needle type Dong-bang stainless-steel disposable acupuncture needle
0.25 (diameter)×40 (length) mm, 0.40x60 mm
3.Treatment regimen 3a)Number of treatment sessions Based on length of patient’s treatment period
2 session/Day (Admission treatment period), 1 session/Day (Outpatient treatment period)
3b)Frequency and duration of treatment sessions Admission treatment period: Twice daily until discharge
Outpatient treatment period: 1-3 times a week
4.Other components of treatment 4a)Details of other interventions administered to the acupuncture group Herbal decoction, steam therapy, ICT, SSP
5.Practitioner background Description of participating acupuncturists Two Korean Medicine doctors
1)Resident trainee in acupuncture and moxibustion medicine with 3 years of experience
2)Specialist of acupuncture and moxibustion medicine with more than 10 years of experience
6.Control or comparator interventions 6)Not applicable Not applicable

ICT : Interferential current therapy, SSP : Silver spike point.



(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.

Composition of herbal decoction

Herb Daily Dose (g) Herb Daily Dose (g)
Lonicera dasystyla 32 Pueraria thunbergiana 8
Forsythia koreana 32 Schizonepeta tenuifolia 8
Uncaria sinensis 24 Glycyrrhiza glabra 8
Angelica dahurica 16 Xanthium strumarium 8
Astragalus membranaceus 16 Zizyphus jujuba 8
Ulmus pumila 16 Crataegus pinnatifida 8
Atractylodes japonica 12 Amomum villosum 8
Platycodon grandiflorum 12 Cnidium officinale 6
Magnolia denudata 12 Ephedra sinica 4
Zingiber officinale 12 Asarum heterotropoides 4
Gleditsia japonica 12 Mentha arvensis 4
Ligusticum tenuissimum 8 Gardenia florida 4
Cimicifuga heracleifolia 8 Cervus elaphus 4
Aconitum coreanum 8


(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).

Symptoms Change of Treatment Period

Rt. facial palsy (2014) Lt. facial palsy (2017)


Admission Discharge Outpatient Admission Discharge Outpatient
Hypoesthesia + + mild + mild mild
Dryness of eyes + mild mild +
Eye pain + mild mild
Lacrimation mild mild + + mild
Ear pain + mild
Dizziness +
Noise sensitivity + +
Dry mouth + + + + mild mild
Leakage of food when eating + +
Residue in the mouth after meals + mild + +
Leakage of water when brushing teeth + + + +
Loss of the sense of taste + + mild + + mild


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.

Discussion

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 ingredients17,18). 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.

Acknowledgement

None.

Funding

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

Data availability

Data cannot be made publicly available because of IRB restrictions.

Conflicts of interest

The authors have declared that no conflicts of interest exists.

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