Eczema Behind the Knees: A 30-Month Photo Record of Fluctuating Improvement With TCM Herbal Therapy

Sequence of clinic photographs of the leg findings in a case of face, arm, and leg eczema, from Baseline through Month 30 of oral and topical TCM herbal therapy: widespread active eczema at Baseline, substantial improvement by Month 2, a relapse peaking around Month 11, and a mostly quiet state with residual pigmentation at Month 30, documented at 11 irregularly spaced visits.

 

A photograph at every visit

A woman in her twenties had lived with eczema for three years before coming to Tangs Clinical TCM. It affected her face, neck, arms, and legs; this article follows the leg findings specifically, through the photographs taken at every documented visit over 30 months. The skin behind her knees was thickened, itchy, and slow to settle — the kind of long-running flexural eczema that tends to respond in fits and starts rather than all at once.

She was otherwise healthy. As a child she had urticaria that settled with antihistamines, asthma, and one episode of mild Raynaud’s phenomenon that was investigated at the time with a normal ANA blood test. For roughly two years before starting herbal treatment, she had used a topical corticosteroid cream on her arms and legs, together with topical tacrolimus (Protopic) on her face whenever the eczema flared there.

Her case was assessed against the clinic’s own TCM pattern-differentiation framework for chronic eczema, set out in the table below, and oral and topical TCM herbal treatment was started. The topical corticosteroid and Protopic were stopped at the same time. On the legs — the area shown in the photographs above — the transition was not smooth: the rash reportedly increased in extent, with weeping and inflammation, before the gradual improvement in the photographs began. The early phase was topical steroid withdrawal (TSW): a reaction pattern described in the dermatology literature as typically emerging within days to a few months of stopping long-term topical corticosteroid use on the same skin. That’s the clinic’s clinical impression of this case, not a laboratory-confirmed diagnosis — and it’s part of the honest record either way, not left out of it.

Photographs were also taken of the face, neck, and arm involvement over the same period, and those areas went through a broadly similar course to the legs — a rough early phase, improvement, and a later relapse, rather than a straight recovery.

What the photographs show

The photographs above tell the rest of the story, and it is not a straight line. At Baseline, both knee creases show widespread active eczema — confluent redness reaching past the fold, numerous small raised bumps, and unevenly thickened skin. By Month 1 the colour and density of the rash had eased but were still clearly visible. By Month 2, the redness and bumps had substantially receded, leaving mild residual discoloration and some textural change in the skin folds. Months 4 and 5 were comparatively quiet, though some chronic thickening remained at the creases.

Then came a setback. Between Months 8 and 11, the eczema flared again — more redness, more noticeably thickened plaques — peaking around Month 11 without returning to how it looked at Baseline. It settled again by Months 14 and 15, leaving mostly redness-free skin with residual pigmentation and texture. There is then a long gap in the record: the patient’s next documented review was not until Month 29. This is a familiar pattern in long-term chronic skin disease — once symptoms feel clearly better, it’s common for a patient to space out follow-up on their own rather than keep to the review schedule originally set (here, roughly every one to two months). What her skin did in the 14 months in between was not photographed and is not known. Month 29 showed a mild fluctuation in colour and texture; Month 30 was relatively quiet again, with no widespread active plaques, weeping, crusting, or heavy scaling — the main findings by then were faint residual pigmentation and mild thickening in the creases. She did not return for further follow-up after that visit. Separately, over the course of treatment, she had two short flares of urticaria (hives), each of which settled with antihistamines and was managed independently of the eczema treatment.

What can honestly be said from this record: over the 30 months documented, without any corticosteroid or immunosuppressant used at any point, this patient’s leg eczema moved from widespread active disease to a quiet state — by a path with a real relapse in the middle of it and an early rough transition at the start, not a smooth recovery arc. What caused what cannot be proven from a single case like this one; the clinical appendix below sets out the alternative explanations and the limits of what this record can support. The record above ends at Month 30 because she did not return afterward, not because treatment was formally concluded.

How the clinic read this case, in TCM terms

Alongside the Western diagnosis of eczema, the clinic’s TCM assessment of this case set out a pathogenesis, a pattern, and a treatment method, reproduced below.

病机 (Pathogenesis) 久病耗伤肝肾阴血，肌肤失养，血燥生风 — in TCM terms, years of chronic illness are understood to have worn down the body’s deeper reserves (Liver-Kidney yin and blood), leaving the skin under-nourished, dry, and prone to itching (“wind”).
证型 (Pattern) 肝肾阴虚、血燥生风、瘀阻肌肤证 — the clinic’s working pattern name for this presentation: depleted yin and blood, blood-dryness, and sluggish local circulation in the skin.
治法 (Treatment method) 滋补肝肾、养阴润燥、凉血活血 — the treatment strategy built to match that pattern — replenish what is seen as depleted, moisten what is seen as dry, and improve local circulation.

This is pattern-differentiation reasoning in TCM’s own idiom — the logic that guided which herbs were selected. It is not a biomedical mechanism, and it is not evidence that the treatment worked.

 

Frequently Asked Questions

What treatment did this patient receive?
Oral and topical TCM herbal medicine, prescribed according to the clinic’s TCM pattern-differentiation assessment of her case, set out above. Her prior topical corticosteroid cream (arms and legs) and topical tacrolimus (Protopic, face) were stopped when herbal treatment began, and no corticosteroid or immunosuppressant medication was used at any point during the 30 months documented here.
Did her skin get worse before it got better?
Yes, in two separate ways. On the legs, the early transition onto herbal treatment was reportedly rough — the rash increased in extent, with weeping and inflammation, before things began to turn around. The treating clinic read this as topical steroid withdrawal, a reaction pattern that can follow stopping long-term topical corticosteroid use, though it is not a lab-confirmed diagnosis and has no agreed diagnostic criteria in the medical literature. Later, after a period of improvement, the eczema flared again between Months 8 and 11 — so this second flare reads either as TWS 2nd wave or as the eczema’s own natural relapsing course. Both episodes are part of the honest record; a smoother-looking version of this case would not be an accurate one.
Did the eczema fully clear?
Not completely, by the last documented visit. At Month 30, there were no widespread active plaques, weeping, crusting, or heavy scaling — but faint residual discoloration and mild thickened skin remained in the knee creases. She did not return for further follow-up after that visit.
Does this prove the herbal treatment caused the improvement?
No. This is one uncontrolled case, assessed by photographs rather than a validated severity score. Eczema itself relapses and remits on its own, the prior topical corticosteroid and Protopic were stopped at the same time herbal treatment started (which read as triggering TSW-type flare), and follow-up was inconsistent. None of that can be fully separated out from a single case, so no cause-and-effect conclusion can honestly be drawn here.
What else could this be, besides eczema?
The eczema wasn’t confined to the legs — it also affected the face, neck, and arms, a combined flexural-and-facial pattern that is itself more typical of atopic dermatitis than of a localized reaction. For the leg findings specifically, allergic or irritant contact dermatitis and flexural (inverse) psoriasis were the realistic alternatives. No biopsy or patch testing is recorded for this case, so the diagnosis rests on the appearance, distribution, and course of the rash rather than on a confirmatory test.
Does this record cover the eczema on her face, neck, and arms too?
Photographs of those areas exist, but this article and its display use the leg series only. The face, neck, and arm involvement followed a broadly similar course to the legs over the same period.
Why is there such a long gap between some of the photographs?
The clinic intended reviews roughly every one to two months, but this patient did not keep to that schedule — only 11 visits were documented across the full 30 months, including a gap of around 14 months between Month 15 and Month 29. She also did not return for further follow-up after the Month 30 visit. This is a familiar pattern in long-term chronic skin disease: once symptoms feel clearly better, some patients understandably let follow-up slide. It also means the record has real blind spots — what her skin did during that gap, and how she has done since Month 30, are both unknown.
Will this treatment work for me, or for anyone with eczema?
No honest treatment can promise a particular result for a different person, and this single case cannot show that either. Eczema varies a great deal between individuals, and TCM treatment here was prescribed after an individual pattern-differentiation assessment rather than as a fixed formula for eczema in general.
When should someone with eczema like this see a doctor promptly?
If the skin becomes suddenly more painful, hot, swollen, or starts weeping pus (possible signs of infection); if fever develops alongside a worsening rash; if the rash spreads rapidly over a large area; or if the itch is significantly affecting sleep, daily function, or wellbeing — these warrant prompt medical review rather than waiting for a scheduled visit.
Why were the steroid cream and Protopic stopped?
They were stopped at the point herbal treatment began, in line with the clinic’s approach of not combining its herbal formulas with corticosteroids or immunosuppressants. This case does not show whether continuing them alongside herbal treatment would have changed the course — only what happened once they were withdrawn together with the change in treatment.
The patient also had a couple of urticaria (hives) flare-ups during treatment. Was that related to the eczema treatment?
It appears to be a separate, pre-existing tendency rather than a reaction to the herbal treatment: she had childhood urticaria before this course of treatment began, and both flare-ups during treatment settled with antihistamines, the same way her childhood episodes did.
What does it mean that this was a “TCM pattern”?
It is a diagnostic framework specific to TCM, distinct from the Western diagnosis of eczema. The table above sets out this patient’s pattern, in the clinic’s own words, alongside a plain-language explanation. It describes an internal imbalance in TCM terms, and it guided which herbs were chosen; it is not a biomedical explanation of the disease, and it is not, by itself, evidence that the treatment worked.
Clinical appendix: diagnosis, differential, confounders, evidence tiering & limitations

Case summary

Woman in her 20s, eczema affecting the face, neck, arms, and legs, of 3 years’ duration, diagnosed clinically and not stated as biopsy-confirmed; the photographic record and course described in this article cover the leg findings only, though photographs of the other sites were also taken. Personal history of atopy: childhood urticaria, antihistamine-responsive, and asthma. Childhood mild Raynaud’s phenomenon, investigated with a normal ANA. No family history recorded. Otherwise well.

Intervention

Oral and topical TCM herbal formula matched to the pattern set out in the TCM framework table above, started with concurrent discontinuation of a topical corticosteroid cream (arm and leg areas) and topical tacrolimus (Protopic, applied to the face during flares) that had been part of her regimen for roughly two years. No corticosteroid or immunosuppressant was used at any point across the 30-month period documented. Intercurrent fever or respiratory infections were treated symptomatically; two urticaria flares during the period were treated with antihistamine, independent of the eczema treatment. Assessment method: sequential clinical photography of the leg findings at each visit; no validated severity score, such as EASI or SCORAD, was recorded.

Course

Baseline — widespread active eczema, confluent erythema extending beyond the flexural creases, numerous small papules, unevenly thickened and lichenified skin. Month 1 — reduced inflammatory colour and lesion density, still clearly visible. Month 2 — first convincing major improvement, with diffuse erythema and papular activity substantially receded, leaving mild residual discoloration and flexural texture change. Months 4–5 — comparatively quiet, with focal chronic thickening persisting at the creases. Months 8–11 — a fluctuation, worst around Month 11, with renewed focal erythema and more conspicuous plaque-like thickening, not returning to Baseline extent. Months 14–15 — inflammation diminishes again, with less redness and predominantly residual pigmentation and texture. Month 29 — mild colour and textural fluctuation. Month 30, the last visit she attended — relatively quiet, with no widespread active plaques, exudation, crusting, or marked scaling; the dominant findings were faint post-inflammatory pigmentation and mild residual flexural thickening. She did not return for further review after this visit. Separately, on the legs, the early transition onto herbal treatment — concurrent with stopping the prior corticosteroid and Protopic — was reportedly rough, with the rash increasing in extent and showing weeping and inflammation before the improvement above began; the treating clinic read this as topical steroid withdrawal (TSW), not tied to a specific photographed timepoint in the record supplied for this article. Follow-up: only 11 visits were documented over 30 months against an intended one-to-two-month review interval; the patient did not attend on schedule, leaving the disease course unknown between documented visits, including a roughly 14-month gap between Month 15 and Month 29, and she was lost to follow-up after Month 30. Face, neck, and arm involvement was photographed separately over the same period and, followed a broadly similar course to the legs; those photographs are not included in this article.

Differential diagnosis

The eczema was not confined to the legs — it also affected the face, neck, and arms, a multi-site flexural-and-facial distribution that is itself more typical of atopic dermatitis than of a localized contact reaction. For the leg findings specifically, allergic or irritant contact dermatitis — given roughly two years of topical corticosteroid use over that same area — and flexural (inverse) psoriasis remained the realistic alternatives; no biopsy or patch testing is recorded, so the diagnosis rests on clinical morphology, distribution, and course rather than on a confirmatory test.

Confounders and competing explanations

The treating clinic’s own read of the early transition-phase worsening was topical steroid withdrawal (TSW), following roughly two years of continuous topical corticosteroid use on the arms and legs that was discontinued at the same time herbal treatment started. TSW is described in the dermatology literature as typically emerging within days to years of stopping long-term topical corticosteroid use, which fits the timing reported here, but the entity has no agreed diagnostic test or consensus criteria, and this case was not formally worked up against any published TSW criteria — the attribution is the treating clinic’s clinical impression, not a confirmed diagnosis. TSW as described in the literature may be expected to explain the separate relapse seen between Months 8 and 11, many months after the corticosteroid was stopped; that later fluctuation also may attributed to the naturally relapsing-remitting course of eczema itself, which fluctuates independent of any treatment. Two intercurrent urticaria flares were managed with antihistamine, a separate atopic process not attributable to the eczema treatment. Follow-up adherence was inconsistent and self-reported, with a roughly 14-month undocumented gap and loss to follow-up after Month 30. Photographic assessment was not standardized for lighting, angle, distance, or background across visits — variation is visible in the source images — and no validated severity score was used. Seasonal or environmental variation over the 30-month period was not controlled for.

TCM rationale note

The pattern-differentiation reasoning set out in the TCM framework table above — Liver-Kidney yin deficiency with blood-dryness generating wind and stasis obstructing the skin — is what guided herb selection for this case. It is TCM’s own diagnostic idiom, running alongside the Western diagnosis rather than translating it; it is not a biomedical mechanism, and its use here is not evidence that the treatment was effective.

Evidence tiering — how the herbal formulas may work

The oral formula used for this pattern, Tangs Derma-Zema, has a filled preclinical mechanism dossier, but no study has tested the formula itself; every entry concerns a single constituent herb, usually studied in mice or in cell culture, and different constituents point in different immunological directions. No single mechanism claim can honestly be made for the formula as a whole — the two entries below are each about one constituent only.

Radix Ophiopogon Japonicus (animal model, single compound) — in a mouse model of eczema-like skin disease, a compound from this constituent reduced skin thickening and inflammatory signalling in the laboratory; this is animal and single-compound work, not evidence in patients.

Radix Paeoniae Alba (animal model) — separately, in mice with dermatitis-like disease, an extract of this constituent lowered IgE and Th2-associated signals in the laboratory.

The evidence above is preclinical — laboratory or animal work on isolated constituents. It suggests how those constituents might act; it does not establish that the multi-herb formula is effective in people, and no conclusion about clinical benefit can be drawn from it. Herbal formulas are prescribed after individual assessment; they can interact with medicines and are not suitable for everyone. Do not self-prescribe.

Limitations

This is a single uncontrolled case. Assessment was photographic only, without a validated severity score, and lighting, angle, and background were not standardized between visits. Follow-up is limited to the 11 visits actually documented over 30 months, with a roughly 14-month gap in the middle of the record, and the patient did not return after Month 30, so her subsequent status is unknown. No conclusion about the effectiveness of any treatment — herbal or otherwise — can be drawn from one case.

Background references

The sources below concern conventional dermatology and disease background; none of them studied, or supports any claim about, the herbal formulas used in this case.

  • Hanifin, J. M., & Rajka, G. (1980). Diagnostic Features of Atopic Dermatitis. Acta Dermato-Venereologica, 60(92), 44–47.
  • Eichenfield LF, Tom WL, Berger TG, Krol A, Paller AS, Schwarzenberger K, Bergman JN, Chamlin SL, Cohen DE, Cooper KD, Cordoro KM, Davis DM, Feldman SR, Hanifin JM, Margolis DJ, Silverman RA, Simpson EL, Williams HC, Elmets CA, Block J, Harrod CG, Smith Begolka W, Sidbury R. Guidelines of care for the management of atopic dermatitis: section 2. Management and treatment of atopic dermatitis with topical therapies. J Am Acad Dermatol. 2014 Jul;71(1):116-32. doi: 10.1016/j.jaad.2014.03.023. Epub 2014 May 9. PMID: 24813302; PMCID: PMC4326095.
  • Hajar T, Leshem YA, Hanifin JM, Nedorost ST, Lio PA, Paller AS, Block J, Simpson EL; (the National Eczema Association Task Force). A systematic review of topical corticosteroid withdrawal (“steroid addiction”) in patients with atopic dermatitis and other dermatoses. J Am Acad Dermatol. 2015 Mar;72(3):541-549.e2. doi: 10.1016/j.jaad.2014.11.024. Epub 2015 Jan 13. PMID: 25592622