A 45-year-old man with a five-year history of severe, recurrent oral ulcers triggered by alcohol was managed using a concise damp-heat clearing and fire-dispersing herbal strategy.

Case ID: CHC-0017

Case Summary

This case describes a 45-year-old man who presented with a five-year history of refractory, painful oral ulcers that worsened significantly following heavy alcohol consumption. The original report documented a conventional diagnosis of aphthous ulcers and a TCM assessment of Oral Sores driven by Damp-Heat. The patient was managed through a highly targeted, six-herb decoction designed to clear the stomach fire, drain dampness through urination, and disperse constrained heat.

Patient Presentation

• Patient: 45-year-old male.
• Main Complaint: Recurrent, painful ulcerations in the mouth and on the tongue for over five years, with a severe exacerbation over the past month.
• History: The patient reported that his oral ulcers were initially brought on by an episode of heavy drinking. Since then, the severe, painful sores would reliably flare up whenever he consumed alcohol or ate spicy foods. He had intermittently tried various Western and Chinese medications over the years, but the results were poor and the condition remained refractory. At the time of consultation, his bowel movements and urination were reported as normal.

Examination and Diagnosis

• Conventional Diagnosis: Oral ulcers (Aphthous stomatitis).
• TCM Tongue and Pulse: The tongue was red with a thin, yellow coating. The pulse was stringy and slippery (弦滑).

TCM Assessment

The original practitioner interpreted the presentation as Oral Sores driven by Damp-Heat syndrome (口疮 – 湿热证).

According to the principles of Yin and Yang Chinese Medicine, overindulgence in alcohol and spicy foods directly damages the Spleen and Stomach, impairing their ability to properly process and transform fluids. The original report noted that this dysfunction generated internal damp-heat. Over time, this stagnant damp-heat transformed into pathological Fire. Because Fire naturally travels upward, it steamed and scorched the meridians of the mouth and tongue, resulting in the recurrent, painful ulcerations. The red tongue, yellow coating, and slippery pulse provided objective confirmation of this internal damp-heat accumulation.

Treatment Approach

The primary treatment principle was to clear heat, dry dampness, facilitate urination, and stop pain (清热燥湿，清利止痛). The strategy aimed to clear the localized inflammation in the mouth while opening downward pathways to flush the pathological heat out of the body.

Herbal Formulas and Modifications

• Core Formula (Initial Visit – September 19, 2023): The practitioner prescribed a precise, 6-herb decoction to address the fire and dampness.
  • Clearing Fire: Huang Lian (Coptis, 10g) acted as the chief herb. Its extremely bitter and cold nature strongly clears heat and dries dampness, making it an essential classical herb for treating Heart and Spleen fire that manifests as mouth sores.
  • Draining Heat Downward: Dan Zhu Ye (Lophatherum, 10g) is sweet and bland, serving to guide the pathological heat downward and out of the body through the urine. Ze Xie (Alisma, 10g) and Zhi Ke (Aurantium, 10g) were added to move Qi, unblock the bowels, and further descend the turbid heat.
  • Dispersing Constrained Heat: Sheng Ma (Cimicifuga, 10g) has an ascending and dispersing nature. It was specifically utilized to vent and disperse the trapped fire from the upper body.
  • Cooling Blood and Stopping Pain: Chi Shao (Red Peony, 10g) was included because severe, trapped fire often scorches the local blood vessels and causes blood stasis. This herb slightly cools the blood and invigorates circulation to rapidly relieve the severe ulcer pain.

Follow-Up

• September 28, 2023 (Second Visit): After taking six doses of the daily decoction, the source reported highly successful results. The patient noted that no new oral ulcers had formed. The existing ulcerated lesions were nearly fully healed, and the pain was vastly reduced. The practitioner prescribed three additional doses of the identical formula to consolidate the therapeutic effect.

Why This Case Is Interesting (Clinical Reasoning)

The notable feature of this case is the practitioner’s application of the classical TCM principle: “Fire constraint requires dispersing” (火郁发之).

When treating severe oral ulcers, there is a common tendency to prescribe massive doses of heavy, cold, heat-clearing herbs. However, the original practitioner recognized that simply dumping cold herbs onto the system can sometimes trap the heat deeper inside. By intelligently combining descending/draining herbs (Dan Zhu Ye, Ze Xie) with an ascending/dispersing herb (Sheng Ma), the formula created a dynamic push-and-pull mechanism. This approach not only opened a lower exit pathway for the damp-heat but also actively vented the localized stagnation in the mouth, leading to rapid healing of a stubborn, five-year condition with only six doses of medicine.

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What This Case Can — and Cannot — Tell Us

This is an individual case report, not a controlled clinical trial. It documents the reasoning, treatment, and outcome reported for one patient and should not be interpreted as evidence that the same approach will produce the same result in another person.

Source

• Original source: Beijing University of Chinese Medicine Shenzhen Hospital (Longgang) / Guangdong Provincial Administration of Traditional Chinese Medicine
• Original title: 【以案说医】王进东：湿热侵口疮难愈，良方解困身自舒
• Practitioner: Professor Wang Jindong (王进东)
• Publication date: October 25, 2024
• Original language: Chinese
• Source link: View original page
• ChineseHerb.org version: English translation and editorial adaptation