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There are two types of cases where smallpox develops into maceration (skin erosion and ulceration). First, if the condition requires dispersing methods but they are not applied, the pathogenic toxin becomes stagnant within the chest and diaphragm, leading to panting, shortness of breath, and mental restlessness; or if the toxic qi rushes and breaks through the skin, this disease results. Second, if dispersing methods are forcibly applied when inappropriate, the couli (pores and interstices) open widely, causing a sudden leakage of Yang Qi, with heat toxins fully manifesting on the muscle surface, also resulting in this disease. Treatment should focus on protecting Spleen Earth and harmonizing Ying (Nutritive) Qi and Stomach Qi, so that the toxic qi will naturally resolve and the wet erosions will heal. Additionally, in infants under one year old, although the lesions may appear red and vibrant, if they are densely packed without gaps, the Blood and Qi cannot adequately support them, leading to maceration. This is likened to a small boat unable to bear a heavy load, inevitably sinking. If the infant can take milk and food, there are no contraindicated symptoms at the lesion sites, the complexion is lustrous, the throat is clear without swelling or pain, and no other diseases are attacking, survival is occasionally possible. Furthermore, if excessive dispersing leads to external maceration while the muscles become empty internally, and Yang Qi fails to remain secure, causing spontaneous diarrhea from the Zang-Fu organs, this situation urgently requires rescuing the interior. Muxiang San (Aucklandia Powder) is indicated, and for severe cases with cold limbs (Jue Ni), Yigong San (Yi Gong Powder) may be used.

The most desirable outcome for smallpox is that it remains firm, does not break, and forms round, clean scabs. Cases involving ulceration indicate an excess of Fire. The Classic states: "When Heat prevails, flesh decays." The function of Fire is fierce and violent; proximity causes dryness and itching, pressure causes burning pain, and scorching leads to erosion and sores. Thus, nothing destroys matter like Fire. However, Fire arises from emptiness and does not burn unless there is deficiency. When driven by Wind, its flames intensify. Therefore, smallpox ulceration occurs because the muscles are inherently deficient, allowing Evil Wind to invade. Wind is agile and changeable, traveling through the meridians and acupoints, and scattering between Ying and Wei (Defensive) Qi. Once the toxin erupts from the interior, Wind responds on the exterior. Wind and Fire fan each other, causing the muscles to swell and the skin to rupture, leading to the destruction of the sores. If pus forms and then ulcerates, the toxin has transformed; the only concern is that the discharge may stick to clothes and bedding, hindering healing. Externally, Baicao San (Decayed Grass Powder) can be used as a dressing. As Danxi stated, for damp sores, dampness must be removed; internally, Wind-dispersing herbs such as Bai Zhi (Angelicae Dahuricae Radix) and Fang Feng (Saposhnikoviae Radix) may be used, or diuretics to promote urination. If the pus has not formed and the toxin has not transformed, and scratching due to itching causes ulceration, the Wei Qi has suddenly leaked, and body fluids fail to nourish the tissues. This is like trees losing their bark, leading to withering and death. The Classic states: "Those rooted within are called Shen Ji (Spirit Mechanism); when Spirit departs, mechanism ceases. Those rooted externally are called Qi Li (Qi Establishment); when Qi stops, transformation ends." This refers to the aforementioned situation. If ulceration recurs after crusting, it is due to residual toxins failing to be cleared, remaining stagnant in the muscles. Treatment should focus on resolving toxicity and leaching out dampness. If smallpox ulcers have no pus, accompanied by incessant vomiting and diarrhea, blood in stool or urine, and inability to digest milk and food, these are all incurable.