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The syndrome of acne with macules (maculae) differs from that with papules (papulae). This is because papules are small, fragmented, and have distinct shapes, whereas macules form in patches without fixed shapes. When acne first erupts, if there are patches of red swelling resembling cotton fibers, or red halos flat against the skin surface with no sign of elevation, these are all syndromes of acne with macules. Macules arise from heat-toxin stagnating in the blood level (blood aspect) and floating between the muscles; this is governed by the Foot-Yangming Stomach Meridian. Alternatively, cold pathogen sinking into the Yangming meridian, stagnating and transforming into heat, can also cause macules. In all such cases, cooling the blood and resolving toxicity are appropriate. If the macules recede and the acne becomes visible, it is auspicious; otherwise, the skin may ulcerate with macules, the sores may itch easily, and the tender skin may break readily. Furthermore, if red macules form lumps with swollen, hard, and knotted flesh, it is named Danliu (red tumor/abscess). The toxin here is particularly severe, and the sores will ulcerate before maturing, which is incurable.

1. The method for treating macules generally involves using exterior-releasing and dispersing methods before the macules emerge, and using clearing and purging methods after suppuration. If the entire body is intensely red, the treatment is similar.

2. For mild cases of acne with macules, Shengma Gegen Tang (Cimicifugae et Puerariae Decoction) added with Shigao (Gypsum Fibrosum) and Xuanshen (Scrophulariae Radix) should be used. For severe cases, Renshen Baihu Tang (Ginseng White Tiger Decoction) combined with Liuwei Xiaodu Yin (Six-Ingredient Toxin-Resolving Drink) is suitable.

3. For cases caused by external wind-cold where the exterior pathogen has not been resolved and macules appear, Jingfang Baidu San (Schizonepeta and Saposhnikovia Powder to Rescue from Toxicity) is indicated, or one may add Shigao (Gypsum Fibrosum) and Xuanshen (Scrophulariae Radix).

4. If the macules are purple-red and accompanied by constipation, Sishun Qingliang Yin (Four-Obedience Clearing and Cooling Drink) should be used to promote bowel movement. Once the macules have receded, Si Jun Zi Tang (Four Gentlemen Decoction) or similar formulas should be used immediately to strengthen the spleen, thereby preventing the pathogen from sinking inward.

Master Cheng stated: In treating acne with macules, it is urgent to cool the blood and resolve toxicity. Use Qianghuo San (Notopterygii Rhizoma Decoction) added with Jiuchao Shaoyao (Wine-fried Paeoniae Radix), Zicao (Arnebiae seu Lithospermi Radix), Honghua (Carthami Flos), Chantui (Cicadae Periostracum), Mutong (Akebiae Caulis), Guangui (Cinnamomi Cortex), and Nuomi (Oryza Sativa Glutinosa), administered continuously for several doses. After the macules recede, Baoyuan Tang (Preserve the Origin Decoction) added with Muxiang (Aucklandiae Radix) and Doukou (Amomi Fructus Rotundus) should be decocted and taken to counteract the cold nature of Zicao (Arnebiae seu Lithospermi Radix) and prevent diarrhea. If acne is accompanied by papules, the treatment is the same; however, if delayed, it may transform into black macules, which become difficult to treat.

5. If macules appear after the acne has formed scabs, this indicates residual toxins boiling the blood level, inevitably leading to ulceration. Huanglian Jiedu Tang (Coptidis Decoction to Resolve Toxicity) added with Danggui (Angelicae Sinensis Radix), Shaoyao (Paeoniae Radix), Huangqin (Scutellariae Radix), and Shigao (Gypsum Fibrosum) is indicated. In severe cases, Da Lianqiao Yin (Large Forsythia Decoction) may be used. If internal heat-toxin steams and boils, resulting in foul-smelling pus and blood in the stool along with macules, this is a syndrome of stomach rot, which is incurable.

6. For macules that have ulcerated, Jiuku Mieban San (Bitter-Saving Scar-Removing Powder) should be applied externally.