Volume 2, Number 2 | Summer 2007

Japanese Acupuncture - Current Research
Treatment of Tinea Unguium with Heat-sensing Moxibustion
Yuki Menjo
Sukoyaka Acupuncture Clinic

1. Introduction
The removal of warts is a well-known example of
the application of moxibustion for the treatment ofskin diseases, but in actual clinical practice thismodality is widely used for the treatment of atopic
dermatitis, postherpetic neuralgia, alopecia, eruptions,
incision wounds, pruritus and the like. Currently,internal application of antifungal agents is considered
to be an effective treatment for tinea unguium. Tinea
unguium is often refractory to treatment and if left
untreated almost never heals naturally, but it is alsodifficult to achieve improvements with therapy of
topical antifungal medications alone. Under certain
circumstances, pregnant women or people with
impaired liver or kidney function may not tolerate theinternal application of antifungal agents1). For
patients in whom oral administration of antifungal
agents is difficult, we thought about the possibility ofusing moxibustion for skin diseases and thus tried touse moxibustion for the treatment of trichophytosis
unguium.

2. Methods
Duration: from June 2000 to September 2004
Site: Nagoya University, Medical Faculty, ambulanceof the Department of Dermatology
Subjects: The study included 36 patients in whom
direct microscopic examination revealed trichophytia
and who were thus diagnosed with trichophytosis
unguium, presenting with opacities extending overmore than half of the nail area and in whom oral
administration of antifungal agents was difficult
either because of complications or by choice of thepatients. These patients were divided into the A group:comprising 8 patients treated continuously for morethan 24 weeks for trichophytosis with antifungal
agents for external use (3 men, 5 women, average age
62.4±12.9 years, average duration of the morbidity
with trichophytosis 4.5±4.3 years), and the B group: 28
patients who consented to be treated with a2

combination of antifungal agents for external use andmoxibustion (12 men, 16 women, average age
61.1±13.1 years, average duration of the morbidity
with trichophytosis 6.3±4.1 years) (Table 1).
Moxibustion treatment: Moxa ( 長 沙 乙 = Changsha,
Chinese product) was rolled by hand into half ricegrain-sized cones of approximately 2 mg (basediameter approximately 2 mm, height approximately 3mm) and placed on both sides of the posterior nail foldsof the affected toe (hallux) (at sites corresponding towell points) and directly on the opaque areas toperform heat-sensing moxibustion using one cone oneach point once a week. Heat-sensing moxibustion
refers to a technique, where the tip of the moxa cone it
lighted and removed by the practitioner, when thepatient feels the heat.
Study duration: 24 weeks from the first moxa
treatment.
Observation: Once a month pictures were taken fromthe affected nails in both group A and B. In group B in
addition to the pictures sketches of the condition of thenails from the first treatment were made after eachtreatment and the ratio of opacity from the end of thenail (opacity ratio) recorded as figures. Opacity ratio
refers here to the degree of opacity defined as "10",when it extends from the free margin to the posterior
nail fold, a distance divided into 10 equal sections, oras an opacity ratio of 3, when it extends only over three
sections (Figure 1).

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

Figure 1

Volume 2, Number 2 | Summer 2007

Figure 1:
Opacity ratio: The distance from the free margin to theposterior nail fold divided into 10 equal parts is used toexpress the opacity ratio. The figure shows an opacity
ratio of 3. The presence of fungi was evaluated bydirect microscopic examination. The black circles
indicate the sites of the moxibustion treatment
Evaluation of results: The 4-step evaluation defines areduction of the opacity ratio in the 24th week by 5-10,
as compared to the time of the first moxibustion
treatment, as "markedly effective", a reduction by 3-4
as "improvement", a reduction by 1-2 as "slight
improvement" and 0 or a negative value as "no change
and aggravation".

3. Results
Result 1:
In group A only "no change or aggravation" andnothing better than slight improvements wereobserved, but in group B slight improvement or better
results were observed in 86% of the cases (markedly
effective: 6 patients (21%), effective: 6 patients (21%),slight improvement 12 patients (43%) and no changes
or aggravation: 4 patients (14%) (Figure 2)

Figure 2:
B group: (combination therapy of antifungal agents forexternal use and moxibustion therapy: 28 cases)
Variations in the opacity ratio in intervals of 4 weeks.
Solid lines indicate the variations in intervals of 4
weeks for each patient. The dashed line indicates theaverage of the opacity ratio.

Below are the results from group B
1) Marked effectiveness or improvements classified byhands and feet shows improvements in 66% of thefingernails and 36% of toenails.
2) Classification of "no change or aggravation" by
diseases showed for the fingernails one case ofgastritis and for the toenails one case of dermatitis,
one case of diabetes and one case of hypertension.
3) Depending on the number of years of morbidity theratio of improved cases was 67% for patients withmorbidity duration of less than one year, 40% formorbidity duration of 1 to 5 years, 33% for less than
5-10 years and 27% for morbidity duration of morethan 10 years.
Result 2:
On this occasion I add a report of observed
variations in the opacity ratio in all toes of one patient
treated over a period of one year and 8 months withmoxibustion from the first treatment on April 13 (final
treatment on December 6, 2006). The patient was a
75-year old woman, presenting with impaired liverfunction and leukemia. Due to difficulties associatedwith oral administration of the antifungal agents, thetopical application of butenafine hydrochloride wascombined with heat-sensing moxibustion. (Figure 3)

Figure 3
Age 50 years, female, 4th digit of right hand
About 4 months after moxibustion treatment,
improvement in opacity ratio from 5 to 1.
If the weekly interval of the moxibustion treatment
is spaced wider, the opacity ratio tends to deteriorate.
During the wet and hot season from April to August

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

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Volume 2, Number 2 | Summer 2007

the opacity ratio tends to deteriorate, while it rarely
deteriorates during the dry season from August to
March of the following year. Continued moxibustion
treatment resulted in a tendency towards facilitatedimprovement, even if a temporary aggravation occurs.
The opacity ratio for the 2nd, 3rd and 4th toes of both
feet tends to improve easily.

Figure 4:
Variations in the opacity ratio in intervals of 4 weeks
for a 75-year old woman (combination therapy of
antifungal agents for external use and moxibustion
therapy). The numbers in bracket indicate the numberof moxibustion treatments during that month. The
horizontal line below indicates the actual number ofyears/months (seasons).

4. Discussion
Improvement of the nails here does not refer toimprovements of the deformed or discolored portions of
the nails, but rather a faster growth of new nail at thenail matrix than the invasion of the nails by thefungus, so that the discolored portions are pushed
outwards and thereby end the infection. Nail growthfrom the posterior nail fold to the free margin in thefingers of healthy adults usually takes about 6 months
and in the toes somewhere between 12 and 18 months2).
The experimental observation period was with 6month too short, so that the result "no change"
observed in the 24th week for one affected toe hadchanged by the 48th week to "improved", suggestingthat long-term treatment and extended observation
periods are required. Classified by sites it was found,
not surprisingly, that improvements occurred moreeasily in the fingernails.

4Heat-sensing moxibustion has the advantage, thatit can be performed regardless of the presence ofimpaired liver or kidney function. Yet, with treatment
intervals longer than 1 week the results deteriorate,
indicating that regular moxibustion treatments ofmore than once a week are necessary. In our clinic I
instruct the patients under certain conditions also to
perform the moxibustion treatment at home, using
commercially available simplified moxa products.
However, in cases of sensory disturbances of theaffected finger of toe, poor skin condition or in case of
insufficient comprehension of the explanations, thishome treatment is not recommended.
On this occasion I did not examine the degree of
sensation of coldness of the feet, but after themoxibustion treatment the patients reported "my toes
are now feeling comfortably warm", suggesting thatthe moxibustion stimulation of the nails had promoted
peripheral blood circulation, raised the skintemperature, inhibited the growth of the trichophytia,
promoted the growth of the nails, improved the local
immunocompetence and thereby was considered toinfluence improvements in the onychomycosis.
In case other family members also suffer from
onychomycosis there is a high likelihood of contracting
the disease. Prolonged time spent in highly humid
environments, wearing shoes or similar environmental
factors too have a strong influence. It is therefore
necessary to communicate to the patients, that theyshould try to maintain cleanliness and keep theaffected areas dry during the treatment.
In the control group treated only with antifungal
agents for external use no improvements in theonychomycosis
wereobserved,butthroughcombination
withmoxibustion
treatment
improvements of the onychomycosis were observed
also in cases, in whom oral treatment with antifungal
agents was difficult. There are also clinical cases inwhich improvement of the onychomycosis had beenachieved by moxibustion therapy alone3), but thequestion, whether there are any significant differences
still remains unanswered. Application of antifungal
agents for external use tends to prevent trichophytia
infection of hands and feet and this effect is enhanced
through combination with moxibustion therapy,

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

Volume 2, Number 2 | Summer 2007

suggesting that the latter may have promoted
improvements in the onychomycosis.
Well points lie on both sides of the posterior nailfold. These well points are said to be "the site, wherethe vessel qi emerges, like from a spring, if likened to a
stream of water"4), so that stimulation withacupuncture and moxibustion is not limited to theparticular area, but is considered to influence theentire area of the affiliated meridian.

References
1) Harada T: Dermatomycoses. Shigeo Ikeda, Jiro
Arata, Takeji Nishikawa (editors) 㸬 Standard
Dermatology 5, Tokyo, Igaku Shoin, 1999: 393-418㸬
2) Hiruma S (Ed.): Tinea unguium treatment manual;
MD Derma, 111, Tokyo, All Japan Hospital
Publishing, 2006㸬
3) Kojo Y, Hayakawa R, Sugiura M: A patient withtinea unguium improved through moxibustion
treatment. Skin Science, 1(5): 335-337 (2001)

5. Conclusion
Moxibustion therapy may be a possible treatment
choice for cases in whom the oral administration of4) Shirota B: Basics of Acupuncture and Moxibustion
Therapy, 7, Yokosuka, Ido no Nihon Sha, 1983)

antifungal agents proves to be difficult. This indicatesthe role of acupuncture and moxibustion for cases

Key words: trichophytosis unguium, moxibustion

refractory to pharmacologic therapy.

therapy

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

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Volume 2, Number 2 | Summer 2007

Table 1

Patient backgroundA group: topical application of antifungal agents for external use only
No.

Sex

Age

Number of years ofAffected

External preparation

Opacity ratio /Opacity ratio / 24

Evaluation / 24 weeks

Complicating conditions

1

M

69

0

Left leg 2

Butenafine hydrochloride

10:10

10:10

No change

At will

2

F

51

0.3

Right leg 1

Butenafine hydrochloride

10:10

10:10

No change

Liver cirrhosis

3

M

63

0.1

Left leg 1

Butenafine hydrochloride

10:10

10:10

No change

Rheumatism

4

M

78

3

Left leg 1

Butenafine hydrochloride

10:10

10:10

No change

Chronic nephritis

5

F

42

5

Left hand 1

Butenafine hydrochloride

10:10

10:10

No change

Dermatitis

6

F

51

8

Right leg 1

Butenafine hydrochloride

10:10

10:10

No change

At will

7

F

73

10

Right leg 1

Croconazole Hydrochloride

10:10

10:10

No change

Hypertension

8

F

72

10

Left leg 1

Butenafine hydrochloride

No change

Diabetes

62.4

4.55

Avg.
M: male

10:10

10:10

10:10

10:10

F: female

B group: combination therapy of antifungal agents for external use and moxibustion

1

F

72

0.5

Right hand 1

Butenafine hydrochloride

10:10

0:10

Markedly effective

Gastritis

2

F

59

1

Right hand 4

Butenafine hydrochloride

7:10

0:10

Markedly effective

Gastritis

3

F

36

1

Right hand 1

Butenafine hydrochloride

10:10

5:10

Effective

Atopy

4

F

75

0.25

Left hand 1

Butenafine hydrochloride

10:10

6:10

Effective

Gastritis

5

M

75

5

Right hand 1

Butenafine hydrochloride

10:10

8:10

Some improvement

Diabetes

6

M

65

20

Left hand 2

Butenafine hydrochloride

9:10

10:10

Aggravation

Gastritis

7

M

50

6

Right leg 2

Butenafine hydrochloride

10:10

0:10

Markedly effective

Dermatitis

8

M

70

3

Left leg 2

Butenafine hydrochloride

10:10

1:10

Markedly effective

Prurigo

9

F

25

1

Left leg 1

Butenafine hydrochloride

7:10

3:10

Effective

Gastritis

10

M

39

10

Right leg 1

Butenafine hydrochloride

10:10

3:10

Markedly effective

Impaired liver function

11

F

52

15

Right leg 1

Butenafine hydrochloride

8:10

4:10

Markedly effective

Gastritis

12

F

72

5

Right leg 1

Butenafine hydrochloride

10:10

7:10

Effective

Diabetes

13

F

63

3

Left leg 1

Butenafine hydrochloride

10:10

4:10

Effective

Diabetes

14

M

72

10

Right leg 1

Butenafine hydrochloride

10:10

7:10

Effective

Impaired liver function

15

M

58

5

Left leg 1

Butenafine hydrochloride

10:10

8:10

Some improvement

Drug eruption

16

F

62

10

Right leg 1

Butenafine hydrochloride

10:10

8:10

Some improvement

Gastritis

17

M

70

1

Left leg 1

Butenafine hydrochloride

10:10

10:10

No change

Dermatitis

18

F

57

11

Right leg 1

Butenafine hydrochloride

10:10

8:10

Some improvement

Cerebral hemorrhage

19

F

52

10

Right leg 1

Butenafine hydrochloride

10:10

8:10

Some improvement

Diabetes

20

M

51

10

Right leg 1

Butenafine hydrochloride

10:10

8:10

Some improvement

Gout

21

M

64

0

Right leg 1

Butenafine hydrochloride

10:10

10:10

No change

Hyperpiesia

22

F

50

10

Left leg 1

Butenafine hydrochloride

10:10

9:10

Some improvement

Eruptions

23

F

54

8

Right leg 1

Butenafine hydrochloride

9:10

8:10

Some improvement

Hyperpiesia

24

F

73

10

Left leg 1

Butenafine hydrochloride

5:10

4:10

Some improvement

Diabetes

25

M

75

10

Right leg 1

Butenafine hydrochloride

10:10

10:10

No change

Diabetes

26

F

79

6

Right leg 1

Butenafine hydrochloride

5:10

4:10

Some improvement

Hyperpiesia

27

M

72

1

Right leg 1

Butenafine hydrochloride

10:10

9:10

Some improvement

Diabetes

28

F

69

4

Left leg 1

Butenafine hydrochloride

10:10

9:10

Some improvement

Diabetes

61.1

6.31

9.29:10

6.11:10Avg.

6

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)