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By the eighth to ninth day, or eleventh to twelfth day of smallpox (Dou Chuang), the pustules are filled with pus, and the purulent fluid gradually dries. The scabbing process begins first around the Renzhong point (GV26) above and below, and on both sides of the mouth and nose, extending down to the lower neck and forehead. The entire body and limbs begin to scab simultaneously; the scabs are thick and dark in color, falling off gradually. Normal diet, urination, and defecation indicate a favorable prognosis. If scabbing starts first on the forehead, it signifies "solitary yang cannot generate," and if it starts first on the feet, it signifies "solitary yin cannot grow"; both are ominous signs of severe deviation.

If the pus is not dense, the pustule tops are not full, facial swelling suddenly subsides, eyes that were closed suddenly open, the base of the lesions becomes moist, the color turns pale and dry/wrinkled, and the scabs are thin as paper, this indicates exhaustion of body fluids and blood deficiency with retained toxins. Urgently use Sijunzi Tang (Four Gentlemen Decoction) added with Maidong (Ophiopogonis Radix), Niubangzi (Arctii Fructus), Jingjie (Schizonepetae Herba), and Lianqiao (Forsythiae Fructus) to rescue the patient. Nowadays, people often mistake this condition for simple scabbing with no danger, leading to many untreatable cases due to delay.

In some cases, during the impending scabbing phase, fever persists and the pulse is slippery and rapid, indicating that the toxin has not been fully expelled. Use Tuoli Kuaiban Tang (Support Interior and Rapidly Expel Rash Decoction) to disperse it. After administration, secondary pustules (Zeng Dou) will erupt, and the fever will naturally subside. If secondary pustules appear within existing lesions just before scabbing, this is auspicious. However, if there is sufficient pus but difficulty in scabbing, and the color turns black, this is inauspicious. Cases where the patient can eat and remains clear-minded are treatable.

During scabbing, if cough and throat obstruction occur, this is due to residual fire in the Lung and Stomach not being cleared. Use Jiegeng Tang (Platycodon Decoction) added with Niubangzi, Lianqiao, and Heishen (Scrophulariae Radix). If the clear pus suddenly dries and turns black, it is called Daoye (Reverse Scabbing). If there is sufficient pus and scabbing proceeds sequentially, with thick, mature-colored scabs, but sudden shortness of breath and abdominal distension occur, this is caused by food stagnation. Use Baohe Wan (Preserve Harmony Pill) to digest and guide out stagnation. If scabbing occurs on schedule but the body is hot with panting and rebellious qi, this is due to external invasion of wind-cold. Treat according to severity with diaphoresis (sweating method).

Alternatively, during the scabbing period, if the body is hot, restless, irritable, accompanied by belching, abdominal distension, diarrhea, chills, and teeth grinding, urgently use Qian's Yigong San (Qian Yi's Five Gentlemen Powder) added with Muxiang (Aucklandiae Radix) and Danggui (Angelicae Sinensis Radix) to assist scabbing. If the eyes open, swelling subsides, but the color is pale and scabbing does not proceed, accompanied by abdominal distension, dry mouth/thirst, irritability, and belching, this is likely due to prior diarrhea or overuse of cooling medicines, resulting in Spleen-Stomach deficiency. Use Chen's Muxiang San (Chen's Aucklandia Powder); otherwise, Daoye may occur, endangering life.

Xue Ji stated: If hands and feet are cold, it belongs to Spleen-Stomach deficiency-cold; use Chen's Yigong San. If hands and feet are slightly cold, it belongs to Spleen-Stomach weakness; use Qian's Yigong San added with Muxiang. If hands and feet are hot, constipation, thirst with desire to drink, it belongs to Spleen-Stomach excess-heat; use Sishun Qingliang Yin (Four-Obedience Cooling Decoction) to nourish yin and suppress yang.

In cases where lesions ulcerate and weep profusely during scabbing, it is because the toxin should have been dispersed but was delayed, causing toxin accumulation in muscles; or if dispersed too early before the proper time, causing toxin to burst forth, damaging muscles, leading to burning and rotting, potentially causing internal qi deficiency, slippery diarrhea, irritability, groaning, and death. Urgently use Chen's Muxiang San or Qian's Baizhu San (Qian's Atractylodes Macrocephala Powder) to treat the interior, and Doukou Wan (Cardamom Pill) to stop diarrhea. Externally apply Bailuo San (White Conch Powder) or powder from decaying grass found on walls. Alternatively, burn yellow cow dung until charred but retaining its nature, add a little Shexiang (Musk), and apply. Or burn silkworm cocoons to ash, add a little Kunfan (Alumen), and apply. Alternatively, mix Tartary Buckwheat Flour (Qiaomai Mian) with Pig Bile to apply to ulcers, and place Tartary Buckwheat Flour under the body to absorb toxins. In midsummer heat, use Mangxiao (Natrii Sulfas) and Pig Bile mixed for application.

If arms, buttocks, or groin areas, which are in long contact with bedding, become abraded and difficult to scab, or break into large patches, becoming scorched, dry, and dark like burns or scalds, these are also difficult to treat.

Again, during scabbing, if there is fever, aversion to cold, body pain, cyanotic complexion, and lesions fail to scab, this is due to wind-cold invasion causing body pain. Use Guizhi Tang (Cinnamon Twig Decoction) added with Jingjie, Fangfeng (Saposhnikoviae Radix), and Danshi (Fermented Soybean). For deficiency patterns, use Rensu Yin (Ginseng and Perilla Drink). If summer living quarters are too hot, causing heat and toxin to congeal and cause pain, use Yiyuan San (Benefit Origin Powder) added with Zhike (Aurantii Fructus), Chenpi (Citri Reticulatae Pericarpium), Lianqiao, and Baishao (Paeoniae Radix Alba). Once pain ceases and heat subsides, lesions will naturally scab. If Dou Ding (Smallpox Carbuncle) is neglected and not picked/drained, causing pain during scabbing, urgently pick and drain to release toxin.

Or if the pustule top breaks, pus flows out, and forms clumps resembling broken rosin, this is due to excessive use of warming and tonifying herbs, where pathogenic qi benefits from tonification and damages healthy qi. Urgently grind fresh Xijiao (Rhinocerotis Cornu) for water intake, use Yiyuan San to promote urination, and Danggui Wan (Angelica Pill) to guide bowel movements; scabbing will occur naturally. There are cases where pus is insufficient despite filling, preventing scabbing; use Xijiao Xiaodu Yin (Rhino Horn Detoxification Drink) to resolve toxin, allowing scabbing. There are also cases where cooling/detoxifying herbs and cold water consumption caused intestinal slipping, shortness of breath, fatigue, and failure to scab; use Weiling Tang (Gastrointestinal Regulation Decoction) to harmonize stomach and stabilize spleen, enabling scabbing.

If lesion heads have holes with pus or clear fluid leaking, or suddenly rupture with clear fluid turning black, this is named Lou Chuang (Leaking Ulcer), which is untreatable. If delayed for a long time, ulcerating and weeping, with skin shedding and foul odor: if pus formed first then ulcerated, and the patient can eat without other symptoms, harmonize spleen and stomach, avoid wind-cold, and frequently apply dried Huangtu (Yellow Earth) powder; recovery will occur naturally. If ulceration occurs without prior pus formation, it is untreatable.

If skin was initially thin and damaged, and excessive tonics were used, causing repeated pus formation with fever and failure to scab, this is because healthy qi was boosted to expel evil as pus, yet healthy qi is ultimately overcome by pathogen and cannot force scabbing. Use Shiquan Dabu Tang (Ten Complete Great Tonifying Decoction). In cases of heavy pus formation with pus/blood soaking face and eyes, use Jiawei Xiaodu Yin (Modified Detoxification Drink) with increased Xijiao taken frequently. If original qi is solid, cure is possible; if pus/blood continues and transforms into Gan Shi (Gangrenous Erosion), it is difficult to treat.

If scabs are dry and thick, but sudden shivering, dry retching, and irritability/thirst occur, this is because healthy qi is recovering but cannot sustain itself; use Shengmai San (Generate Pulse Powder). If the whole body scabs except head and feet, this is disharmony of qi and blood; use Siwu Tang (Four Substances Decoction) removing Dihuang, adding Shengma (Cimicifugae Rhizoma), Niuxi (Achyranthis Bidentatae Radix), Niubangzi, Honghua (Carthami Flos), and Jingjie.

Chen Wensu stated: After smallpox scabbing, if high fever persists all over the body for days without other symptoms, use Chaihu (Bupleuri Radix), Maidong, Renshen (Ginseng Radix), Gancao (Glycyrrhizae Radix), Heishen, and Dancao (Gentianae Radix). Weng Zhongren stated: When smallpox pus is full and heat-toxin resolved, but scabbing is delayed for several days, if the lesion color remains normal, this is harmless; it is due to exterior deficiency failing to consolidate. Use Bazhen Tang (Eight Treasures Decoction) added with Mutong (Akebiae Caulis) and Niubangzi to tonify spleen and promote water metabolism; scabbing will occur naturally. Zhu Jichuan said: Exterior deficiency makes eruption easy but scabbing difficult; exterior excess makes eruption difficult but scabbing easy. From this, one can discern the excess/deficiency of the exterior and interior.