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Journal of Korean Medical Society of Acupotomology 2024; 8(1): 7-16
Published online June 30, 2024 https://doi.org/10.54461/JAcupotomy.2024.8.1.7
Copyright © Korean Medical Society of Acupotomology.
Garam Yang1 
, Hongmin Chu2 , Youn Sook Kim3 , Won Gun An1,*
Correspondence to:Won Gun An
School of Korean Medicine, Pusan National University, 49 Pusandaehak-ro, Mulgeum-eup, Yangsan 50612, Korea
Tel: +82-51-510-8455
Fax: +82-301-402-0172
E-mail: wgan@pusan.ac.kr
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 noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Objectives: Fungal infections are the leading cause of foot lesions in diabetics. However, oral and topical antifungal therapies require prolonged use and are often difficult to implement in polypharmacy situations due to the risk of drug interactions and poor patient compliance. This study presents the case of a diabetic patient treated for long-standing tinea pedis without the use of antifungal drugs. The treatment relied solely on herbal ointments and pharmacopuncture.
Methods: The patient used two kinds of herbal ointments daily, and acupuncture was performed on the affected area approximately every 10 days via home-visiting healthcare service.
Results: Approximately 1 month after treatment initiation, clearance of moccasin-type tinea pedis was observed. High patient satisfaction was reported, with decreased pain on walking and a half-point improvement in the Bates-Jensen wound assessment tool score.
Conclusion: Effective short-term treatment of tinea pedis in a diabetic patient was achieved using herbal topicals and acupuncture, without the use of antifungal medication.
KeywordsDiabetic foot, Pharmacopuncture, Herbal ointment, Tinea pedis, Bamboo salt
Type 2 diabetes mellitus (T2DM), characterized by hyperglycemia due to insulin resistance, accounts for 90-95% of all diabetes cases and clinically presents as metabolic syndrome. Globally, the prevalence of T2DM in adults has tripled over the last 20 years, increasing from 151 million in 2000 to 537 million in 20211). Diabetic foot (DF), defined as a foot with ulcers, infections, and deep tissue damage in a diabetic patient, is a common complication affecting at least 15% of diabetes patients during their lifetime2). DF lesions contribute significantly to healthcare costs and impede mobility, influencing the ability to perform daily and leisure activities. This results in a diminished quality of life and increased risk of depression3). Although educational programs have been developed for diabetes management in the elderly to prevent DF complications, studies have demonstrated that generic education may not be as effective as individualized, ongoing, and tailored programs4). Prolonged elevation of blood sugar levels in diabetes can lead to peripheral nerve damage, resulting in undetected infections and wounds. The combination of abnormal inflammatory responses, hypoxia, and neuropathy culminates in foot lesions. As abrasions and ulcers increase in size, they can become chronic and serve as entry points for bacteria, fungi, or other pathogens. This increases the risk of various diseases, necessitating partial lower limb amputation, and can even lead to death in severe cases. Diabetic patients are particularly vulnerable to fungal infections, with onychomycosis, the most common nail disease, affecting 46% of the diabetic patients5). It results in thickened, sharp, brittle nails that can penetrate the skin and damage the blood vessels by increasing the subungual pressure, thereby contributing to foot ulcers. These superficial infections not only pose cosmetic concerns but also increase the risk of secondary bacterial infections, such as lower extremity cellulitis6). Tinea pedis, another common fungal infection among diabetics, affects approximately 15-20% of the population, causing skin cracks on the soles of the feet or between the toes, which can progress to ulcers7). In both onychomycosis and tinea pedis, wounds create pathways for pathogens, promoting the development of secondary bacterial infections, ulcers, cellulitis, osteomyelitis, gangrene, and further complications, including lower extremity amputation8,9). Treatments for these fungal infections include individual and combination therapies involving lasers, topical ointments, and oral medications. However, polypharmacy in diabetics can complicate treatment due to potential medication interactions. In addition, peripheral neuropathy and elevated blood sugar levels can make it challenging to keep the foot clean and dry10). Therefore, prompt and aggressive treatment of fungal foot infections in diabetic patients, along with appropriate treatment protocols, is crucial to prevent secondary morbidity and improve quality of life.
In this paper, we present the case of a patient under long-term care who previously underwent toe amputation due to a DF lesion about 10 years previously and currently required rehabilitation. The patient developed chronic keratosis pilaris type tinea pedis that persisted for several years, and was effectively treated for approximately 1 month with herbal ointment and bamboo salt pharmacopuncture, without the use of antifungal drugs.
The patient was a 70-year-old male who had been under treatment and observation at our clinic for the complex condition of keratotic athlete’s foot combined with DF lesions. Treatment involved a combination of herbal topical medicines and acupuncture needles. The patient had been managing his glycemic control with medications for more than 20 years and had been self-administering insulin injections for more than a decade. In addition, the patient had underlying medical conditions, including hyperlipidemia and declining renal function, leading to limited mobility due to back stenosis and peripheral neuropathy. The patient was taking multiple medications for these conditions. Due to his mobility issues, the patient was receiving regular medical home visits as part of his long-term care. For the past 5 years, the patient had been self-administering NovoMix 30 Flexpen (insulin aspart 30%), but his postprandial blood glucose occasionally spiked to approximately 260 mg/dL despite insulin use. Although his glycated hemoglobin level was not very high at 6.8%, the patient experienced difficulty controlling his blood sugar levels, particularly in the early morning and on an empty stomach. Following a few episodes of hypoglycemic shock or dizziness, the patient became reluctant to venture far from home. The patient had poor kidney function, with a glomerular filtration rate of 35 mg/mmol and nocturnal urinary frequency of 2-4 times.
Podiatric issues exacerbated the patient’s discomfort, causing numbness and tingling in the feet. However, his sensitivity to acupuncture or injection treatments was significantly dulled. During our examination, we observed thick dead skin, cracks, and recurrent wounds in the big toe area on the soles of both feet, occasionally leading to bleeding and staining of the socks. The severity of tinea pedis and keratinization was particularly pronounced on the right foot. Despite attempting self-care, the patient struggled to maintain cleanliness around bleeding wounds due to his diminished pain sensitivity. The patient had undergone amputation of the right second toe approximately 10 years previously due to a necrotic DF lesion, which subsequently weakened his muscles and facilitated the spread of infection. This led to foot deformity and compromised balance while walking.
This study was approved by the Institutional Review Board (IRB) of Wonkwang University, Iksan city, Korea (WKIRB-202401-BM-003).
The herbal topicals included an ointment formulated from a blend of Ilhwango and Jaungo, sourced from an extramural herbal dispensary facility in South Korea (Table 1). This facility has obtained good manufacturing practice (GMP) certification from the government. As an herbal medicine pharmaceutical company, it allows multiple medical institutions to collaborate in the manufacturing and procurement of herbal medicine products. Ilhwango is an ointment composed of 11 herbal medicines, including Borneolum, methylsulfonylmethane, burnt alum, and olive oil, while Jaungo is a topical agent traditionally used for moisturizing purposes.
Table 1 Herbal ointment Ilhwango ingredients
| Herb | Content (wt%) |
|---|---|
| 1.4 | |
| 2.9 | |
| 5.8 | |
| 11.6 | |
| 58.0 |
The process of making Ilhwango involves cold-soaking Dictamni Radicis Cortex, Houttuyniae Herba, Saururus-chinensis, and Ulmi Cortex in olive oil for 2 weeks, followed by filtration. Then crystal menthol, Borneolum, methylsulfonylmethane, and burnt alum are added to the filtered oil, stirred thoroughly for even distribution, and poured into containers for curing.
Jaungo is an herbal ointment widely used in Japan and Korea to aid the healing of various wounds including skin abrasions, burns, cuts, and frostbites. Its main ingredients are Lithospermi Radix and Angelica Sinensis. Lithospermi Radix is used in traditional medicine as an ingredient in various topical skin preparations11). Angelica Sinensis, an herb used for the treatment of anemia and ischemic disease, is currently undergoing investigation for its efficacy and mechanisms in animal and cellular experiments12). Several studies have explored the pharmacological effects of Lithospermi Radix, demonstrating its anti-inflammatory and antibacterial properties. In addition, studies have reported various physiological benefits, including anti-inflammatory and antitumor effects, of Shikonin, the principal active component of Lithospermi Radix13,14).
Pharmacopuncture uses bamboo salt obtained from the extramural herbal dispensary facility. Bamboo salt is traditionally prepared by filling bamboo with salt, covering it with soil, and roasting it over a fire. The high temperature allows absorption of the substances produced by the bamboo into the salt for oral or topical use. This process involves baking the salt using wood as a traditional fuel, and subsequently removing the bamboo and soil residue in the form of ash. Then the salt is crushed into pillars. This baking procedure is repeated eight times using bamboo and soil. Finally, the salt is melted at a temperature exceeding 1,300℃ using rosin as fuel, followed by drying and grinding to obtain the powdered form15).
Bamboo salt is a traditional Korean folk remedy considered particularly efficacious for promoting gum health. It is not only used as a food ingredient but is also frequently included in toothpaste formulations. Studies have reported its effectiveness in treating dental plaque and gingivitis16,17). In addition to its primary ingredient, sodium chloride (NaCl), bamboo salt also contains potassium, magnesium, calcium, and sulfate, with slight variation in composition depending on the salt source and processing method. For pharmacopuncture, bamboo salt is diluted in the appropriate amount (3.0 wt%) of sterilized distilled water, followed by sterilization, filtration, and packaging for subsequent use.
During the treatment, 1 cc bamboo salt pharmacopuncture was injected into three or four areas around the tinea versicolor lesion, with no more than 0.5 cc medicinal needle solution injected per area at a depth ≤1 cm. The acupuncture sessions were performed approximately 10 days apart, coinciding with each photographic observation. While most patients experience stabbing pain due to diffusion of the injection fluid, our patient, having had peripheral neuropathy, exhibited dulled pain sensation. Consequently, the acupuncture procedure caused relatively mild pain.
The ointment was applied in two steps. Initially, Ilhawango was applied for a duration of at least 10 min but not exceeding 20 min. Subsequently, the area was washed with soap, followed by Jaungo application. Then the treated area was dressed with parchment paper and left overnight. The patient was instructed to follow this regimen at least once daily in the evening.
The Bates-Jensen wound assessment tool (BWAT), which assesses trauma, wounds, and scars, was used to objectively assess the patient’s progress. Photographs of the patient’s foot were taken at each appointment to monitor recovery. The Visual Analog Scale was considered unreliable because of the patient’s advanced age. Therefore, post-treatment satisfaction and quality of life improvements were assessed through oral interviews.
After commencing treatment on November 20, 2023, photographs were taken approximately every 10 days for observation (Fig. 1). While the exact size of the lesion could not be determined, it was estimated to be around 15 cm2, measured as a square of 5 cm×3 cm, centered on an area of severe keratinization. After 10 days, the thickly keratinized skin began to slough off. Areas of epithelialization developed following granulation tissue formation at the exfoliation site, particularly in the big toe area. On day 21 of treatment, although there was no significant change in the wound itself, the thin crusts resulting from tinea pedis around the lesions had decreased. By day 33, most of the crusts and dead skin cells had been shed from the lesions, with complete epithelialization observed. The accelerated healing of skin tissue between days 21 and 33 could be attributed to the initial granulation tissue formation and subsequent epithelialization beneath the keratinized areas (Fig. 2).
Figure 1.Change of foot ulcer during treatment.
Figure 2.BWAT score change during treatment.
The patient’s BWAT was assessed three times, revealing a score of 31 at baseline, 27 after 10 days, and 14 at the completion of the 33-day treatment. In BWAT interpretation, a score of 1 indicates healthy tissue, a score ≤13 indicates ongoing wound repair and regeneration, and a score of 60 indicates wound deterioration and degeneration. The evaluation indicated a gradual improvement in the patient’s wound, nearly to a state of tissue regeneration.
The patient self-reported that he had been experiencing pain while walking for several years due to skin cracking at the lesion site. The bleeding led to discomfort, resulting in soiled socks and skin adherence, but these issues showed significant improvements. There was a significant increase in aesthetic satisfaction, prompting the patient to be more proactive about his health. Previously, he did not engage in daily foot hygiene but started cleaning his feet at least once daily and moisturizing with Jaungo after the treatment. The improvement in his lesions increased his health awareness, leading him to actively pursue hospital visits, blood tests, and self-glycemic tests.
In tinea pedis treatment, emphasis was placed on the patient’s self-care practices, using only pharmacopuncture and ointments based on the principles of traditional and herbal medicine. Antifungal drugs or ointments were not used. To the best of our knowledge, this is the first documented case using Jaungo, bamboo salt pharmacopuncture, and Ilhwango, an ointment containing burnt alum and Borneolum, for the treatment of tinea pedis.
The fundamental principles of skin wound healing involve identifying infection, removing dead tissue through debridement, and protecting and moisturizing the wound with dressings. In traditional medicine, ulcers on the toes are referred to as Taljeo (脫疽), and when they occur in individuals with diabetes, they are classified as DF lesions. In the traditional Korean medicine text Donguibogam (東醫寶鑑) by Dr. Heo Jun, published in 1613, the initial step involves dispersing and removing pus, known as sanjongnaesek (散腫內消). When the lesion progresses to an ulcer, pus is discharged and toxins are drained using the drainage method known as Baenongyumdok (排膿斂毒). Subsequently, decayed tissue is removed through the method of Geobunaesaek (去腐內塞), followed by promoting the growth of new tissue and skin rejuvenation, referred to as Saengibuga (生肌付痂)18). Similarly, modern medicine prioritizes the removal of necrotic tissue and the promotion of new tissue growth. This process is similar to the traditional Botakbub (補托法). Traditional medicine also emphasizes the removal or sterilization of calluses after confirming infection, followed by treatment to improve nutritional conditions and create a moist environment in the affected area to facilitate new tissue growth, taking the patient’s health status and skin condition into consideration.
In this case, Ilhwango was primarily used to debride the rough skin and eliminate bacterial infection, utilizing its callus-removing effect and potent antibacterial properties. Among Ilhwango’s ingredients, Borneolum has traditionally been used in small quantities in combination with other medicines to enhance drug absorption into the body. Studies have demonstrated its ability to loosen the stratum corneum, thereby enhancing the permeability of topical agents to the skin and exhibiting robust antibacterial properties, which makes it suitable for the treatment of skin conditions19). To increase the transdermal penetration rate of the drug, 2% Borneolum is incorporated into many topical agents based on experiments demonstrating improved penetration rates20). Burnt alum, a dehydrated granule of roasted alum, has traditionally been used orally and topically for its anti-inflammatory properties. Its use in treating conditions, such as acute tonsillitis and cervical erosion, has previously been reported21). In addition, experiments have demonstrated that roasted alum exhibits stronger anti-inflammatory effects and diminished antioxidant properties compared to unroasted alum, explaining its clinical processing and use as burnt alum in the East. These properties, combined with its mineralized nature, make it a suitable choice for treating fungal infections. Sulfur, referred to as “the medicine of the heavens” in Donguibogam, has been used since ancient times for the treatment of various skin diseases. As a topical agent, it is effective for suppressing dermatological conditions caused by fungi, including athlete’s foot and dandruff, and is also used internally for heart conditions22). Several studies have documented its antibacterial and antifungal effects23). In addition, the antibacterial and anti-inflammatory properties of Angelica Dahuricae Radix, Dictamni Radicis Cortex, Houttuyniae Herba, Saururus-Chinensis, and Ulmi Cortex have been investigated. In particular, sulfur, Borneolum, and burnt alum, which are the predominant ingredients in this ointment, are used in solid form rather than extract, having greater effects compared to oil-extracted medicinal ingredients.
To eliminate athlete’s foot fungus and promote skin regeneration, it is important to use an external anti-inflammatory and moisturizing treatment. The use of ointments containing appropriate active ingredients can help maintain a moist environment and regulate inflammatory and painful factors2). In the present case, Jaungo was initially applied with parchment paper and left overnight with dressing to ensure constant skin hydration, which stimulated the expression of granulocytes and reduced the formation of dry keratin. Jaungo, composed of Lithospermi Radix and Angelica Sinensis with sesame oil as a solvent, has traditionally been used in various skin conditions, including atopic dermatitis, for its wound-healing and moisturizing effects. It has also been used to treat dermatitis resulting from radiation therapy in breast cancer patients24). While there are no reported cases of Jaungo being used to treat athlete’s foot, in the present case, its purpose was to support epithelialization through moisturization rather than its antifungal properties.
Bamboo extract contains polyphenols, including catechin, chlorogenic acid, caffeic acid, 3-hydroxybenzoic acid, as well as aluminum, chromium, copper, manganese, nickel, and zinc. Medicinally, it exhibits antioxidant, tyrosinase inhibitory, SOD-like, and ACE inhibitory properties. The safety of bamboo salt has been confirmed through inductively coupled plasma mass spectrometry analysis at each stage of the baking process, showing minimal or negligible levels of harmful heavy metals25,26). Animal studies have demonstrated its pharmacological effects in relieving gastritis due to its antioxidant properties27). Studies on its anti-inflammatory effects have demonstrated inhibition of inflammatory cytokine secretion and protein expression in human mast cells stimulated with phorbol12-myristate 13-acetate compared to NaCl28). An animal model study used bamboo pharmacopuncture to improve cisplatin-induced hearing loss in the HEI-OC1 cell line29). In another study of skin diseases, including numismatic eczema, erythema, and pruritus, bamboo salt pharmacopuncture was found to have significant effects30). While the antifungal activity of bamboo salt is yet to be fully elucidated, bamboo oil, a major component of bamboo salts, shows concentration-dependent antimicrobial effects against athlete’s foot fungi, including Trichophyton mentagrophytes, Epidermophyton floccusum, and Trichophyton rubrun31). These findings indicate that its antibacterial and anti-inflammatory properties were effective for preventing secondary wound infections and eliminating the contagious fungus in this case. In addition, the 3 wt% bamboo salt pharmacopuncture used in this case, being at a higher concentration than normal saline, may have induced localized cell death through the osmotic effect of its main components, Na+ and Cl–, thereby promoting granulation tissue formation. The treatment approach, based on the principles of traditional and herbal medicine, relied solely on pharmacopuncture and ointments, without the use of antifungal medications or ointments, and was tailored to the patient’s self-care behavior. To the best of our knowledge, this is the first reported case of Jaungo, bamboo salt pharmacopuncture, and Ilhwango (containing Borneolum and burnt alum) being used for the treatment of tinea pedis.
An essential aspect of the treatment in this case was its suitability for self-administration by the patient, facilitated by the use of easy-to-apply ointments, eliminating the need for frequent visits to a medical facility. Furthermore, pharmacopuncture has been proven to be effective for patients with limited mobility, as it can be administered during medical visits, which makes it particularly suitable for long-term care or elderly individuals with mobility constraints. However, as this was a retrospective study, detailed assessments of the amount of ointment applied or the dressing method were not possible. Furthermore, the efficacy of ointments and bamboo salt pharmacopuncture, as well as the optimal treatment frequency, require standardization in future trials using various methods and protocols. Therefore, it is anticipated that systematic treatment protocols may be developed through the application of these methods to a larger number of cases.
In the treatment of foot mycosis, topical antifungal agents must penetrate the crust and persist within the lesion until the fungus is completely eradicated to exert their antifungal effects. However, topical antifungal agents alone may not suffice, necessitating the use of oral antifungal agents. Nonetheless, long-term treatment often leads to high dropout rates32). A Cochrane review has validated the efficacy of itraconazole, terbinafine, and griseofulvin for oral treatment33). Daily topical application of antifungal medications for a year, including cyclopyroxolamine and butenafine, has also shown effectiveness34). However, in diabetic patients, itraconazole may potentially interact with certain oral antidiabetic medications, including sulfonylureas, leading to hypoglycemia35). Consequently, tinea pedis and onychomycosis treatment in diabetic patients presents challenges, as standard methods may not be directly applicable despite the need for aggressive treatment. Therefore, there is a need to develop proactive and rapid treatment approaches for DF lesions. In the present case, oral medications were not administered to treat tinea pedis in a diabetic patient with polypharmacy. Instead, small quantities of purely herbal ointments and medications were used, minimizing the risk of interactions. This approach can also serve as a topical intervention before resorting to oral medication. However, the use of this treatment protocol in diabetic patients requires a thorough assessment to ensure compatibility with their existing medications.
In contrast to other types of herbal pharmacopuncture commonly used in Chinese medicine, bee venom may cause itching or allergic reactions, potentially leading to anaphylactic shock or immune antagonism. Moreover, the production of herbal acupuncture needles derived from processed raw herbs can be logistically challenging and expensive due to the volatility of herb prices and the utilization of numerous ingredients. However, bamboo salt pharmacopuncture has no reported side effects in clinical settings unless administered in excess. In addition, the raw material costs are relatively low, which makes it economically viable for production, thus reducing the healthcare cost. Consequently, a systematic analysis of healthcare costs compared to conventional antifungals is required.
A patient with tinea pedis resulting from a DF lesion and peripheral neuropathy was successfully treated for chronic moccasin-type tinea pedis through conventional methods without resorting to antifungal medications for approximately 1 month. The treatment approach involved the use of topical agents and bamboo salt acupuncture. The topical regimen included Ilhwango, applied initially to remove thickened dead skin cells and provide antimicrobial action, followed by Jaungo to maintain moisture and promote the growth of granulocytes while softening the dry skin cells. Bamboo salt pharmacopuncture, administered every 10 days, was used for its antibacterial and anti-inflammatory properties, thereby preventing secondary wound infections.
Fungal foot infections are more prevalent in T2DM patients than in nondiabetic individuals. Severe infections significantly increase the risk of lower limb amputation or mortality, and require prompt and aggressive treatment. However, many diabetic patients use multiple medications, which makes the use of antifungal drugs problematic due to potential interactions with existing medications. Meanwhile, traditional topical treatments often require prolonged use over several months to a year, leading to poor patient compliance. In the present case, the treatment approach utilized medicated pharmacopuncture and ointments, which were not associated with any serious side effects and provided rapid and effective results for the treatment of tinea pedis. However, this was a retrospective report of a single case and had several limitations, including the lack of systematic blood tests and imaging examinations, as well as a lack of a standardized treatment protocol. Future research on the use of herbal preparations for the treatment of active tinea pedis and mycosis may enhance patient health and quality of life.
This research was supported by Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education, grant number NRF-2021R1I1A1A01058697.
The authors declare no conflict of interest.
Journal of Korean Medical Society of Acupotomology 2024; 8(1): 7-16
Published online June 30, 2024 https://doi.org/10.54461/JAcupotomy.2024.8.1.7
Copyright © Korean Medical Society of Acupotomology.
Garam Yang1 , Hongmin Chu2 , Youn Sook Kim3 , Won Gun An1,*
1School of Korean Medicine, Pusan National University, Yangsan, 2Department of Internal Medicine, Wonkwang University Gwangju Medical Center, Gwangju, 3Research Institute for Longevity and Well-Being, Pusan National University, Busan, Korea
Correspondence to:Won Gun An
School of Korean Medicine, Pusan National University, 49 Pusandaehak-ro, Mulgeum-eup, Yangsan 50612, Korea
Tel: +82-51-510-8455
Fax: +82-301-402-0172
E-mail: wgan@pusan.ac.kr
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 noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Objectives: Fungal infections are the leading cause of foot lesions in diabetics. However, oral and topical antifungal therapies require prolonged use and are often difficult to implement in polypharmacy situations due to the risk of drug interactions and poor patient compliance. This study presents the case of a diabetic patient treated for long-standing tinea pedis without the use of antifungal drugs. The treatment relied solely on herbal ointments and pharmacopuncture.
Methods: The patient used two kinds of herbal ointments daily, and acupuncture was performed on the affected area approximately every 10 days via home-visiting healthcare service.
Results: Approximately 1 month after treatment initiation, clearance of moccasin-type tinea pedis was observed. High patient satisfaction was reported, with decreased pain on walking and a half-point improvement in the Bates-Jensen wound assessment tool score.
Conclusion: Effective short-term treatment of tinea pedis in a diabetic patient was achieved using herbal topicals and acupuncture, without the use of antifungal medication.
Keywords: Diabetic foot, Pharmacopuncture, Herbal ointment, Tinea pedis, Bamboo salt
Type 2 diabetes mellitus (T2DM), characterized by hyperglycemia due to insulin resistance, accounts for 90-95% of all diabetes cases and clinically presents as metabolic syndrome. Globally, the prevalence of T2DM in adults has tripled over the last 20 years, increasing from 151 million in 2000 to 537 million in 20211). Diabetic foot (DF), defined as a foot with ulcers, infections, and deep tissue damage in a diabetic patient, is a common complication affecting at least 15% of diabetes patients during their lifetime2). DF lesions contribute significantly to healthcare costs and impede mobility, influencing the ability to perform daily and leisure activities. This results in a diminished quality of life and increased risk of depression3). Although educational programs have been developed for diabetes management in the elderly to prevent DF complications, studies have demonstrated that generic education may not be as effective as individualized, ongoing, and tailored programs4). Prolonged elevation of blood sugar levels in diabetes can lead to peripheral nerve damage, resulting in undetected infections and wounds. The combination of abnormal inflammatory responses, hypoxia, and neuropathy culminates in foot lesions. As abrasions and ulcers increase in size, they can become chronic and serve as entry points for bacteria, fungi, or other pathogens. This increases the risk of various diseases, necessitating partial lower limb amputation, and can even lead to death in severe cases. Diabetic patients are particularly vulnerable to fungal infections, with onychomycosis, the most common nail disease, affecting 46% of the diabetic patients5). It results in thickened, sharp, brittle nails that can penetrate the skin and damage the blood vessels by increasing the subungual pressure, thereby contributing to foot ulcers. These superficial infections not only pose cosmetic concerns but also increase the risk of secondary bacterial infections, such as lower extremity cellulitis6). Tinea pedis, another common fungal infection among diabetics, affects approximately 15-20% of the population, causing skin cracks on the soles of the feet or between the toes, which can progress to ulcers7). In both onychomycosis and tinea pedis, wounds create pathways for pathogens, promoting the development of secondary bacterial infections, ulcers, cellulitis, osteomyelitis, gangrene, and further complications, including lower extremity amputation8,9). Treatments for these fungal infections include individual and combination therapies involving lasers, topical ointments, and oral medications. However, polypharmacy in diabetics can complicate treatment due to potential medication interactions. In addition, peripheral neuropathy and elevated blood sugar levels can make it challenging to keep the foot clean and dry10). Therefore, prompt and aggressive treatment of fungal foot infections in diabetic patients, along with appropriate treatment protocols, is crucial to prevent secondary morbidity and improve quality of life.
In this paper, we present the case of a patient under long-term care who previously underwent toe amputation due to a DF lesion about 10 years previously and currently required rehabilitation. The patient developed chronic keratosis pilaris type tinea pedis that persisted for several years, and was effectively treated for approximately 1 month with herbal ointment and bamboo salt pharmacopuncture, without the use of antifungal drugs.
The patient was a 70-year-old male who had been under treatment and observation at our clinic for the complex condition of keratotic athlete’s foot combined with DF lesions. Treatment involved a combination of herbal topical medicines and acupuncture needles. The patient had been managing his glycemic control with medications for more than 20 years and had been self-administering insulin injections for more than a decade. In addition, the patient had underlying medical conditions, including hyperlipidemia and declining renal function, leading to limited mobility due to back stenosis and peripheral neuropathy. The patient was taking multiple medications for these conditions. Due to his mobility issues, the patient was receiving regular medical home visits as part of his long-term care. For the past 5 years, the patient had been self-administering NovoMix 30 Flexpen (insulin aspart 30%), but his postprandial blood glucose occasionally spiked to approximately 260 mg/dL despite insulin use. Although his glycated hemoglobin level was not very high at 6.8%, the patient experienced difficulty controlling his blood sugar levels, particularly in the early morning and on an empty stomach. Following a few episodes of hypoglycemic shock or dizziness, the patient became reluctant to venture far from home. The patient had poor kidney function, with a glomerular filtration rate of 35 mg/mmol and nocturnal urinary frequency of 2-4 times.
Podiatric issues exacerbated the patient’s discomfort, causing numbness and tingling in the feet. However, his sensitivity to acupuncture or injection treatments was significantly dulled. During our examination, we observed thick dead skin, cracks, and recurrent wounds in the big toe area on the soles of both feet, occasionally leading to bleeding and staining of the socks. The severity of tinea pedis and keratinization was particularly pronounced on the right foot. Despite attempting self-care, the patient struggled to maintain cleanliness around bleeding wounds due to his diminished pain sensitivity. The patient had undergone amputation of the right second toe approximately 10 years previously due to a necrotic DF lesion, which subsequently weakened his muscles and facilitated the spread of infection. This led to foot deformity and compromised balance while walking.
This study was approved by the Institutional Review Board (IRB) of Wonkwang University, Iksan city, Korea (WKIRB-202401-BM-003).
The herbal topicals included an ointment formulated from a blend of Ilhwango and Jaungo, sourced from an extramural herbal dispensary facility in South Korea (Table 1). This facility has obtained good manufacturing practice (GMP) certification from the government. As an herbal medicine pharmaceutical company, it allows multiple medical institutions to collaborate in the manufacturing and procurement of herbal medicine products. Ilhwango is an ointment composed of 11 herbal medicines, including Borneolum, methylsulfonylmethane, burnt alum, and olive oil, while Jaungo is a topical agent traditionally used for moisturizing purposes.
Table 1 . Herbal ointment Ilhwango ingredients.
| Herb | Content (wt%) |
|---|---|
| 1.4 | |
| 2.9 | |
| 5.8 | |
| 11.6 | |
| 58.0 |
The process of making Ilhwango involves cold-soaking Dictamni Radicis Cortex, Houttuyniae Herba, Saururus-chinensis, and Ulmi Cortex in olive oil for 2 weeks, followed by filtration. Then crystal menthol, Borneolum, methylsulfonylmethane, and burnt alum are added to the filtered oil, stirred thoroughly for even distribution, and poured into containers for curing.
Jaungo is an herbal ointment widely used in Japan and Korea to aid the healing of various wounds including skin abrasions, burns, cuts, and frostbites. Its main ingredients are Lithospermi Radix and Angelica Sinensis. Lithospermi Radix is used in traditional medicine as an ingredient in various topical skin preparations11). Angelica Sinensis, an herb used for the treatment of anemia and ischemic disease, is currently undergoing investigation for its efficacy and mechanisms in animal and cellular experiments12). Several studies have explored the pharmacological effects of Lithospermi Radix, demonstrating its anti-inflammatory and antibacterial properties. In addition, studies have reported various physiological benefits, including anti-inflammatory and antitumor effects, of Shikonin, the principal active component of Lithospermi Radix13,14).
Pharmacopuncture uses bamboo salt obtained from the extramural herbal dispensary facility. Bamboo salt is traditionally prepared by filling bamboo with salt, covering it with soil, and roasting it over a fire. The high temperature allows absorption of the substances produced by the bamboo into the salt for oral or topical use. This process involves baking the salt using wood as a traditional fuel, and subsequently removing the bamboo and soil residue in the form of ash. Then the salt is crushed into pillars. This baking procedure is repeated eight times using bamboo and soil. Finally, the salt is melted at a temperature exceeding 1,300℃ using rosin as fuel, followed by drying and grinding to obtain the powdered form15).
Bamboo salt is a traditional Korean folk remedy considered particularly efficacious for promoting gum health. It is not only used as a food ingredient but is also frequently included in toothpaste formulations. Studies have reported its effectiveness in treating dental plaque and gingivitis16,17). In addition to its primary ingredient, sodium chloride (NaCl), bamboo salt also contains potassium, magnesium, calcium, and sulfate, with slight variation in composition depending on the salt source and processing method. For pharmacopuncture, bamboo salt is diluted in the appropriate amount (3.0 wt%) of sterilized distilled water, followed by sterilization, filtration, and packaging for subsequent use.
During the treatment, 1 cc bamboo salt pharmacopuncture was injected into three or four areas around the tinea versicolor lesion, with no more than 0.5 cc medicinal needle solution injected per area at a depth ≤1 cm. The acupuncture sessions were performed approximately 10 days apart, coinciding with each photographic observation. While most patients experience stabbing pain due to diffusion of the injection fluid, our patient, having had peripheral neuropathy, exhibited dulled pain sensation. Consequently, the acupuncture procedure caused relatively mild pain.
The ointment was applied in two steps. Initially, Ilhawango was applied for a duration of at least 10 min but not exceeding 20 min. Subsequently, the area was washed with soap, followed by Jaungo application. Then the treated area was dressed with parchment paper and left overnight. The patient was instructed to follow this regimen at least once daily in the evening.
The Bates-Jensen wound assessment tool (BWAT), which assesses trauma, wounds, and scars, was used to objectively assess the patient’s progress. Photographs of the patient’s foot were taken at each appointment to monitor recovery. The Visual Analog Scale was considered unreliable because of the patient’s advanced age. Therefore, post-treatment satisfaction and quality of life improvements were assessed through oral interviews.
After commencing treatment on November 20, 2023, photographs were taken approximately every 10 days for observation (Fig. 1). While the exact size of the lesion could not be determined, it was estimated to be around 15 cm2, measured as a square of 5 cm×3 cm, centered on an area of severe keratinization. After 10 days, the thickly keratinized skin began to slough off. Areas of epithelialization developed following granulation tissue formation at the exfoliation site, particularly in the big toe area. On day 21 of treatment, although there was no significant change in the wound itself, the thin crusts resulting from tinea pedis around the lesions had decreased. By day 33, most of the crusts and dead skin cells had been shed from the lesions, with complete epithelialization observed. The accelerated healing of skin tissue between days 21 and 33 could be attributed to the initial granulation tissue formation and subsequent epithelialization beneath the keratinized areas (Fig. 2).
Figure 1. Change of foot ulcer during treatment.
Figure 2. BWAT score change during treatment.
The patient’s BWAT was assessed three times, revealing a score of 31 at baseline, 27 after 10 days, and 14 at the completion of the 33-day treatment. In BWAT interpretation, a score of 1 indicates healthy tissue, a score ≤13 indicates ongoing wound repair and regeneration, and a score of 60 indicates wound deterioration and degeneration. The evaluation indicated a gradual improvement in the patient’s wound, nearly to a state of tissue regeneration.
The patient self-reported that he had been experiencing pain while walking for several years due to skin cracking at the lesion site. The bleeding led to discomfort, resulting in soiled socks and skin adherence, but these issues showed significant improvements. There was a significant increase in aesthetic satisfaction, prompting the patient to be more proactive about his health. Previously, he did not engage in daily foot hygiene but started cleaning his feet at least once daily and moisturizing with Jaungo after the treatment. The improvement in his lesions increased his health awareness, leading him to actively pursue hospital visits, blood tests, and self-glycemic tests.
In tinea pedis treatment, emphasis was placed on the patient’s self-care practices, using only pharmacopuncture and ointments based on the principles of traditional and herbal medicine. Antifungal drugs or ointments were not used. To the best of our knowledge, this is the first documented case using Jaungo, bamboo salt pharmacopuncture, and Ilhwango, an ointment containing burnt alum and Borneolum, for the treatment of tinea pedis.
The fundamental principles of skin wound healing involve identifying infection, removing dead tissue through debridement, and protecting and moisturizing the wound with dressings. In traditional medicine, ulcers on the toes are referred to as Taljeo (脫疽), and when they occur in individuals with diabetes, they are classified as DF lesions. In the traditional Korean medicine text Donguibogam (東醫寶鑑) by Dr. Heo Jun, published in 1613, the initial step involves dispersing and removing pus, known as sanjongnaesek (散腫內消). When the lesion progresses to an ulcer, pus is discharged and toxins are drained using the drainage method known as Baenongyumdok (排膿斂毒). Subsequently, decayed tissue is removed through the method of Geobunaesaek (去腐內塞), followed by promoting the growth of new tissue and skin rejuvenation, referred to as Saengibuga (生肌付痂)18). Similarly, modern medicine prioritizes the removal of necrotic tissue and the promotion of new tissue growth. This process is similar to the traditional Botakbub (補托法). Traditional medicine also emphasizes the removal or sterilization of calluses after confirming infection, followed by treatment to improve nutritional conditions and create a moist environment in the affected area to facilitate new tissue growth, taking the patient’s health status and skin condition into consideration.
In this case, Ilhwango was primarily used to debride the rough skin and eliminate bacterial infection, utilizing its callus-removing effect and potent antibacterial properties. Among Ilhwango’s ingredients, Borneolum has traditionally been used in small quantities in combination with other medicines to enhance drug absorption into the body. Studies have demonstrated its ability to loosen the stratum corneum, thereby enhancing the permeability of topical agents to the skin and exhibiting robust antibacterial properties, which makes it suitable for the treatment of skin conditions19). To increase the transdermal penetration rate of the drug, 2% Borneolum is incorporated into many topical agents based on experiments demonstrating improved penetration rates20). Burnt alum, a dehydrated granule of roasted alum, has traditionally been used orally and topically for its anti-inflammatory properties. Its use in treating conditions, such as acute tonsillitis and cervical erosion, has previously been reported21). In addition, experiments have demonstrated that roasted alum exhibits stronger anti-inflammatory effects and diminished antioxidant properties compared to unroasted alum, explaining its clinical processing and use as burnt alum in the East. These properties, combined with its mineralized nature, make it a suitable choice for treating fungal infections. Sulfur, referred to as “the medicine of the heavens” in Donguibogam, has been used since ancient times for the treatment of various skin diseases. As a topical agent, it is effective for suppressing dermatological conditions caused by fungi, including athlete’s foot and dandruff, and is also used internally for heart conditions22). Several studies have documented its antibacterial and antifungal effects23). In addition, the antibacterial and anti-inflammatory properties of Angelica Dahuricae Radix, Dictamni Radicis Cortex, Houttuyniae Herba, Saururus-Chinensis, and Ulmi Cortex have been investigated. In particular, sulfur, Borneolum, and burnt alum, which are the predominant ingredients in this ointment, are used in solid form rather than extract, having greater effects compared to oil-extracted medicinal ingredients.
To eliminate athlete’s foot fungus and promote skin regeneration, it is important to use an external anti-inflammatory and moisturizing treatment. The use of ointments containing appropriate active ingredients can help maintain a moist environment and regulate inflammatory and painful factors2). In the present case, Jaungo was initially applied with parchment paper and left overnight with dressing to ensure constant skin hydration, which stimulated the expression of granulocytes and reduced the formation of dry keratin. Jaungo, composed of Lithospermi Radix and Angelica Sinensis with sesame oil as a solvent, has traditionally been used in various skin conditions, including atopic dermatitis, for its wound-healing and moisturizing effects. It has also been used to treat dermatitis resulting from radiation therapy in breast cancer patients24). While there are no reported cases of Jaungo being used to treat athlete’s foot, in the present case, its purpose was to support epithelialization through moisturization rather than its antifungal properties.
Bamboo extract contains polyphenols, including catechin, chlorogenic acid, caffeic acid, 3-hydroxybenzoic acid, as well as aluminum, chromium, copper, manganese, nickel, and zinc. Medicinally, it exhibits antioxidant, tyrosinase inhibitory, SOD-like, and ACE inhibitory properties. The safety of bamboo salt has been confirmed through inductively coupled plasma mass spectrometry analysis at each stage of the baking process, showing minimal or negligible levels of harmful heavy metals25,26). Animal studies have demonstrated its pharmacological effects in relieving gastritis due to its antioxidant properties27). Studies on its anti-inflammatory effects have demonstrated inhibition of inflammatory cytokine secretion and protein expression in human mast cells stimulated with phorbol12-myristate 13-acetate compared to NaCl28). An animal model study used bamboo pharmacopuncture to improve cisplatin-induced hearing loss in the HEI-OC1 cell line29). In another study of skin diseases, including numismatic eczema, erythema, and pruritus, bamboo salt pharmacopuncture was found to have significant effects30). While the antifungal activity of bamboo salt is yet to be fully elucidated, bamboo oil, a major component of bamboo salts, shows concentration-dependent antimicrobial effects against athlete’s foot fungi, including Trichophyton mentagrophytes, Epidermophyton floccusum, and Trichophyton rubrun31). These findings indicate that its antibacterial and anti-inflammatory properties were effective for preventing secondary wound infections and eliminating the contagious fungus in this case. In addition, the 3 wt% bamboo salt pharmacopuncture used in this case, being at a higher concentration than normal saline, may have induced localized cell death through the osmotic effect of its main components, Na+ and Cl–, thereby promoting granulation tissue formation. The treatment approach, based on the principles of traditional and herbal medicine, relied solely on pharmacopuncture and ointments, without the use of antifungal medications or ointments, and was tailored to the patient’s self-care behavior. To the best of our knowledge, this is the first reported case of Jaungo, bamboo salt pharmacopuncture, and Ilhwango (containing Borneolum and burnt alum) being used for the treatment of tinea pedis.
An essential aspect of the treatment in this case was its suitability for self-administration by the patient, facilitated by the use of easy-to-apply ointments, eliminating the need for frequent visits to a medical facility. Furthermore, pharmacopuncture has been proven to be effective for patients with limited mobility, as it can be administered during medical visits, which makes it particularly suitable for long-term care or elderly individuals with mobility constraints. However, as this was a retrospective study, detailed assessments of the amount of ointment applied or the dressing method were not possible. Furthermore, the efficacy of ointments and bamboo salt pharmacopuncture, as well as the optimal treatment frequency, require standardization in future trials using various methods and protocols. Therefore, it is anticipated that systematic treatment protocols may be developed through the application of these methods to a larger number of cases.
In the treatment of foot mycosis, topical antifungal agents must penetrate the crust and persist within the lesion until the fungus is completely eradicated to exert their antifungal effects. However, topical antifungal agents alone may not suffice, necessitating the use of oral antifungal agents. Nonetheless, long-term treatment often leads to high dropout rates32). A Cochrane review has validated the efficacy of itraconazole, terbinafine, and griseofulvin for oral treatment33). Daily topical application of antifungal medications for a year, including cyclopyroxolamine and butenafine, has also shown effectiveness34). However, in diabetic patients, itraconazole may potentially interact with certain oral antidiabetic medications, including sulfonylureas, leading to hypoglycemia35). Consequently, tinea pedis and onychomycosis treatment in diabetic patients presents challenges, as standard methods may not be directly applicable despite the need for aggressive treatment. Therefore, there is a need to develop proactive and rapid treatment approaches for DF lesions. In the present case, oral medications were not administered to treat tinea pedis in a diabetic patient with polypharmacy. Instead, small quantities of purely herbal ointments and medications were used, minimizing the risk of interactions. This approach can also serve as a topical intervention before resorting to oral medication. However, the use of this treatment protocol in diabetic patients requires a thorough assessment to ensure compatibility with their existing medications.
In contrast to other types of herbal pharmacopuncture commonly used in Chinese medicine, bee venom may cause itching or allergic reactions, potentially leading to anaphylactic shock or immune antagonism. Moreover, the production of herbal acupuncture needles derived from processed raw herbs can be logistically challenging and expensive due to the volatility of herb prices and the utilization of numerous ingredients. However, bamboo salt pharmacopuncture has no reported side effects in clinical settings unless administered in excess. In addition, the raw material costs are relatively low, which makes it economically viable for production, thus reducing the healthcare cost. Consequently, a systematic analysis of healthcare costs compared to conventional antifungals is required.
A patient with tinea pedis resulting from a DF lesion and peripheral neuropathy was successfully treated for chronic moccasin-type tinea pedis through conventional methods without resorting to antifungal medications for approximately 1 month. The treatment approach involved the use of topical agents and bamboo salt acupuncture. The topical regimen included Ilhwango, applied initially to remove thickened dead skin cells and provide antimicrobial action, followed by Jaungo to maintain moisture and promote the growth of granulocytes while softening the dry skin cells. Bamboo salt pharmacopuncture, administered every 10 days, was used for its antibacterial and anti-inflammatory properties, thereby preventing secondary wound infections.
Fungal foot infections are more prevalent in T2DM patients than in nondiabetic individuals. Severe infections significantly increase the risk of lower limb amputation or mortality, and require prompt and aggressive treatment. However, many diabetic patients use multiple medications, which makes the use of antifungal drugs problematic due to potential interactions with existing medications. Meanwhile, traditional topical treatments often require prolonged use over several months to a year, leading to poor patient compliance. In the present case, the treatment approach utilized medicated pharmacopuncture and ointments, which were not associated with any serious side effects and provided rapid and effective results for the treatment of tinea pedis. However, this was a retrospective report of a single case and had several limitations, including the lack of systematic blood tests and imaging examinations, as well as a lack of a standardized treatment protocol. Future research on the use of herbal preparations for the treatment of active tinea pedis and mycosis may enhance patient health and quality of life.
This research was supported by Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education, grant number NRF-2021R1I1A1A01058697.
The authors declare no conflict of interest.
Table 1 Herbal ointment Ilhwango ingredients
| Herb | Content (wt%) |
|---|---|
| 1.4 | |
| 2.9 | |
| 5.8 | |
| 11.6 | |
| 58.0 |
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