Man in his 20s, Atopic Tendency, and Nummular Eczema

An Exploration of the Skin's 'Gaps' and the Body's 'Tone'

Why Does Atopic Dermatitis Appear on the Calves, Not in Flexural Areas?

A man in his mid-20s. His atopic dermatitis, which began in elementary school with scratching the inner elbows, returned in adulthood after a long period of remission. But in recent months, the nature of the battle has changed. The battlefield has shifted. Instead of the relatively quiet inner elbows, red, coin-shaped lesions (plaques) 2-4 cm in diameter began to appear one by one on the firm anterior lower legs and flanks.

“It gets itchier only at night. If I scratch it, it starts to ooze thinly.”

This phenomenon, where flexural areas are unaffected but circular raised lesions appear only on the calves and flanks, is the first mystery we need to solve, as it's difficult to explain with the typical presentation of atopic dermatitis.

The Skin as a Levee: Where Water Collects Like Coins

To put it simply, this phenomenon is a collaboration of local 'gaps' and systemic 'tone.'

Imagine a huge levee. If the overall waterproofing function of the levee is weakened (a systemic atopic tendency), water does not seep out from the entire levee. Instead, water collects like coins only in the 'gaps' that are under the most pressure or are structurally vulnerable. The same applies to the skin.

His skin lacked ceramides and Natural Moisturizing Factors (NMFs), resulting in impaired basic barrier function. Furthermore, there were 'topographical weaknesses' like the anterior lower legs, which are prone to friction from clothing and dryness. He had a habit of showering with hot water for 15-20 minutes daily and moisturizing less than twice a week. As these irritations accumulated, moisture escaped through micro-fissures in the weakened areas, and the epidermal pH balance collapsed, leading to the establishment of well-demarcated, coin-shaped inflammatory lesions (plaques). In other words, the 'shape' and 'location' of eczema are determined by the 'topography' of the skin barrier.

Fungal Infections and Allergies: Eliminating Common Suspects

Of course, other possibilities must be checked. I always interrogate the most common suspects first. First, suspected fungal infection with long-term steroid use (Tinea incognito). However, KOH tests performed by scraping the lesion edges were negative both times. The fungal hypothesis was ruled out.

Second, contact dermatitis. It's a plausible hypothesis if symptoms started after exposure to a new detergent, perfume, or metal. But his lesions appeared fixed in specific areas, and it was difficult to find a clear temporal link between contact and symptom onset. Both suspects had alibis.

The Map of Traditional Korean Medicine: Reading the Body's 'Foundation' and Local 'Inflammation'

I unfolded another map: Traditional Korean Medicine. On this map, his condition is divided into two layers.

Gi (基): The Foundation

His body is close to a state of 'blood deficiency with wind-dryness' (혈허풍조, *Xue Xu Feng Zao*). Due to insufficient 'blood' (혈, *Xue*) to nourish the skin, it is generally dry, and as a result, the 'wind' (풍, *Feng*) of itching intensifies at night. The dry appearance of his tongue with little or no coating supports this hypothesis.

Biao (標): The Manifestation

The coin-shaped, oozing local lesions are an accumulation of 'wind-damp-heat' (풍습열, *Feng Shi Re*). It's a pattern where dampness and heat locally intertwine on dry ground, causing an inflammatory reaction. Modern medicine's 'impaired barrier function' precisely overlays with Traditional Korean Medicine's dry 'foundation (Gi),' and 'local inflammation' with 'damp-heat (Biao).' The two maps pointed to the same land.

A Traditional Korean Medicine Approach: Simultaneously Addressing Gaps, Itching, and Immunity

The integrated diagnosis is "a complex type, with nummular eczema superimposed on a foundation of dry atopic dermatitis." Therefore, treatment proceeds as filling the gaps in the levee, turning off unnecessary alarms (itching), and restoring the overall balance (immunity) of the levee.

First

Systemic inflammatory and immune responses are regulated with 'Hanbang herbal remedies.' This is the process of correcting the body's 'tone,' which is the root of the problem. To improve the dry foundation (blood deficiency with wind-dryness) and stabilize the immune system, herbal medicines from the Danggwieumja (당귀음자, *Angelica Sinensis Decoction*) family are used. To suppress local inflammatory reactions (wind-damp-heat), herbal medicines from the Sopungsan (소풍산, *Disperse Wind Powder*) family are used, aiming to restore the body's overall balance.

Second

'Acupuncture treatment' breaks the cycle of unbearable 'itching.' Itching is not a skin problem but a signal from hypersensitive nerves. By inserting needles into specific acupoints around skin lesions and throughout the body, it directly regulates and stabilizes the neural pathways that transmit itching signals to the brain, preventing secondary damage and the vicious cycle caused by 'scratching.'

Third

'Hanbang external preparations' fill the gaps in the compromised 'skin barrier.' Hanbang external preparations (herbal ointments) made from traditional Korean medicinal herbs that aid skin regeneration and moisturization, such as Seupjingo (습진고, eczema ointment), Jaungo (자운고, *Lithospermum erythrorhizon* ointment), and Cheongdaego (청대고, *Indigofera tinctoria* ointment), are consistently applied to the nummular eczema areas. This goes beyond simple moisturization; it directly nourishes the damaged skin barrier and forms a protective film, physically reinforcing the 'gaps' in the levee.

The compromised barrier and unfavorable topography create the 'shape' (of the lesions), while systemic imbalance determines 'how many times' that shape will recur. Ultimately, this protracted battle is not just about confronting visible skin inflammation but a process of redesigning the invisible topography and overall balance of my body. If you understand the map, it's time to set off on the journey.

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※ The cases presented in this content are based on actual clinical experience, but to comply with Article 56 of the Medical Service Act and the Personal Information Protection Act, patients' personal information (age, gender, medical history, etc.) has been partially modified and adapted.