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Sun Simiao discussed: The *Suwen* (Basic Questions) states: When wind pathogen invades the muscles, the muscle exterior becomes deficient, and the true qi scatters outward. If it is then combated by cold at the skin level, causing the cou li (pores/skin texture) to open and the hair follicles to spread, the pathogenic qi acts recklessly, resulting in itching. Therefore, wind urticaria with itching arises from this cause. There are also red rashes that suddenly appear like mosquito bites; when irritation and itching are extreme, vigorous scratching causes the rash to rise, and areas scratched will subsequently erupt. There are also white rashes that present with chills; conversely, red rashes present with fever.

Wang Kentang stated: Wind urticaria occurs when pathogenic qi lodges in the skin and is further combated by wind-cold, forming urticaria. Red rashes arise when cold-dampness combats the interior of the muscles, and wind-heat combines to form red rashes. These worsen with heat and improve with cold. White rashes arise when wind qi combats the interior of the muscles, and wind-cold combines to form white rashes. These worsen with cold or exposure to wind, but improve with sunny weather or wearing warm clothing. The pulse is floating and surging; floating indicates wind, and surging indicates qi (pathogenic energy). The combination of wind and qi forms urticaria, leading to body itching. (*Zhunsheng*)

Zhu Danxi stated: Rashes belong to heat and phlegm in the Lung. Treatment should involve clearing Lung fire and descending phlegm, or resolving the exterior through sweating. In some cases, purgation may be applicable. (*Xinfa*)

Various treatises attribute the condition to dampness in the muscles. If cooled or heated improperly, unresolved heat forms red rashes; if affected by wind pathogen, wind-heat combination forms white rashes. Red rashes intensify with heat and subside with cold because heat is stagnant internally, thus disliking heat and favoring cold. White rashes worsen on rainy days and dissipate on sunny days because heat dissipates externally, thus disliking cold and favoring heat. Heat combats the Blood level; when pathogenic factors emerge to the exterior, they appear red. If wind-dampness combats the Qi level, Qi channels fail to circulate properly; when pathogenic factors emerge to the exterior, they appear white. Thus, treatment methods correspond accordingly: those with pathogenic heat dislike heat and prefer coolness; those with pathogenic dampness dislike rain and prefer sunshine. Treatises also mention "acne and prickly heat" (Cuo Fei), referred to in the *Neijing* as occurring when sweat meets dampness. It is also stated that labor sweat exposed to wind, with cold pressing against it causing stagnation, leads to acne and prickly heat; this belongs to the category of urticaria. All these refer to external pathogens stagnating heat in the muscle Xuanfu (pores). However, this differs from the *Neijing*'s description of Shaoyang and Shaoyin disorders where Ministerial Fire and Sovereign Fire pathogenic heat prevail, causing Danzhen (red rashes) to erupt externally, which is not mentioned in these treatises. Therefore, changes due to the stagnation and eruption of Sovereign and Ministerial Fire in human qi were likely omitted. This case represents one such variation. Thus, the stagnation and eruption of the two fires affecting the Qi and Blood at the exterior is no different from external pathogen stagnation. Furthermore, besides smallpox in children, a secondary outbreak of rashes often occurs, which is also due to fetal toxins not fully expelled by the eruption of Sovereign and Ministerial Fires.

It is also said: If urticaria enters the abdomen, it can be fatal. (It is advisable to wash with a strong decoction of Silkworm Sand.)

It is also said: If heat predominates in urticaria, the color is red; if wind predominates, the color is white. Severe cases involve both itching and pain, and scratching leads to ulceration.

Lin Shi asked: Why do macules and papules arise? Do they belong to Yin or Yang, deficiency or excess, exterior or interior? Can you explain in detail? He answered: The emergence of macules and papules can result from external contraction of wind-heat, excessive heat in the Stomach Fu organ, failure to purge in Cold Damage diseases, or failure to induce sweating in Yangming Channel patterns of Cold Damage, leading to epistaxis, parotitis, or if neither occurs, macules and papules. Generally, this belongs to extreme hyperactivity of wind-heat in the Yangming Stomach and Large Intestine. Unable to vent internally or express externally, it stagnates between the skin and cou li. Mild cases manifest as papules; severe cases as macules. This is akin to Fire overcoming Metal, where Metal is controlled by Fire. This constitutes Yang toxicity, belonging to the exterior and excess type of macules/papules. Other causes include Yin deficiency with blood heat, Yang deficiency with blood heat, and dual Qi-Blood deficiency with stagnant deficient heat. This rootless Fire of the Triple Burner exploits the deficiency of Qi and Blood to erupt upwards, stagnating within the skin and blood vessels. Unable to clear internally or scatter externally, it manifests as macules and papules. This is a Yin deficiency pattern belonging to the interior. (*Huo Ren Lu*)

He further asked: What distinguishes macules from papules? Since Yin and Yang differ, which is heavier and which is lighter? He answered: Macules appear in patches without distinct granules, resembling raised clouds. Pale red indicates mildness; purple-red indicates severity; black indicates peril. Mild cases itch; severe cases hurt. Papules resemble prickly heat or resemble marks from mosquitoes, fleas, or lice, but are not prominent. They fluctuate, appearing and disappearing throughout the day, faintly visible under the skin without significant elevation. Generally, Yang-type macules/papules are easy to diagnose and treat. Yin-type macules/papules arise with deficiency, making them difficult to diagnose and treat. Failure to examine carefully may lead to mistaking Yin for Yang, resulting in immediate danger. One must be cautious!

He continued: Body heat without sweat, irritability, thirst, restlessness, pain or itching, appearance like clouds or brocade, abdominal pain, chest fullness, constipation of stool and urine, with pulses that are floating, surging, forceful, or floating-numerous and forceful, indicate wind-heat disease in the Hand-Yangming Large Intestine and Foot-Yangming Stomach channels, known as Yang Macules. Internal heat with spontaneous sweating, thirst without desire to drink, mental restlessness, weak Stomach and Spleen diarrhea, preference for dampness and aversion to heat, white and non-red color, itching without pain, with pulses that are slow, weak, or deficient-numerous and powerless, indicate internal hyperactivity of Yin Fire in the Hand-Taiyin Lung, Foot-Taiyin Spleen, Hand-Shaoyin Heart, and Foot-Shaoyin Kidney channels, known as Yin Macules. Although the shape of papules differs from macules, the etiology, involved Zang-Fu organs, and presenting pulse and symptoms are similar. Since macules have Yin and Yang types, so do papules. It is up to the physician to judge the Yin/Yang and deficiency/excess of the syndrome and the forcefulness of the pulse.

He stated: When two Yangs combine, Fire naturally thrives. Accompanied by food stagnation, accumulated heat is generated. Thus, the cause of macules and papules must be attributed to the Stomach and Large Intestine. Excessive Fire causes blood heat and scorches Metal. The Heart, being the Fire organ, governs blood vessels; the Lung, being the Metal organ, governs the skin and hair. Fire gathers in the chest, steaming the Lung, intensifying Heart Fire. Extreme heat may transform into wind, or external wind may stir internal Fire. The disease originates in the Heart and Lung channels, known as Yang Macules/Papules. Treatment must first clear and disperse wind-heat at the exterior and guide out accumulated heat internally, harmonizing interior and exterior to rescue from intense heat. If stool and urine are constipated, urgent purgation is needed. If Spleen-Kidney Yin deficiency leads to hyperactive Fire unable to return to its source and store properly, erupting upwards to burn the Heart and Lung, or if wind generates Fire or extreme heat generates wind, causing Yin Macules/Papules, initial treatment should also clear and resolve to promote eruption, soothe the chest and diaphragm, and relieve irritability. Subsequently, observe the size and deficiency/excess of the pulse, the fullness/emptiness of the Spleen and Stomach, and the constipation/looseness of stool, applying either clearing-tonification or warming-tonification.

He noted: Although both Yin and Yang types exist, Yang-type macules are more common and usually occur at the end of febrile diseases. Yin-type papules are more common at the beginning of diseases. Macules arise from accumulated heat and erupt slowly; papules involve wind-fire and erupt quickly. Quick eruption brings milder consequences; slow eruption brings deeper dangers, which is the inevitable trend of natural laws. Regarding seasonal epidemics causing rashes, wind-heat pathogen attacks the Lung channel, accompanied by nasal congestion, coarse breathing, and phlegmy cough. Residual heat lingers in the Yangming Large Intestine, combining with waste products to form damp-heat and stagnation, leading to spontaneous diarrhea. If heat stagnation transforms into Fire, whose nature is urgent, following Qi stagnation downward causing tenesmus,辛凉升散 (acrid-cool ascending-dispersing) formulas should be used to clear pathogenic heat, allowing trapped Qi to penetrate and resolve externally. This not only resolves macules/papules but also disperses damp-heat. If phlegmy cough persists, add herbs to clear Fire and Phlegm. If stagnation remains and damp-heat presses downward, add herbs to clarify turbidity and strengthen transportation/transformation, such as Aromatic Spice (Muxiang), Coptis (Huanglian), Hawthorn Seed (Shanzha), Fermented Wheat (Shenqu), Plantago Seed (Cheqian), and Alisma (Zexie). Use Magnolia Bark (Zhiqiao) to broaden the chest and open depression, lifting trapped pathogens.

If wind-dampness stagnates in the intestines and stomach, and wind-heat rebels at the muscle surface, damaging the Blood level, it causes aversion to cold with high fever, gastric discomfort, and abdominal pain. Damaging the Blood level results in red rashes; damaging the Qi level results in white rashes. Both cause incessant itching, appearing and disappearing three times a day. This is commonly known as "wind streak rash." First, avoid sesame oil, fresh seafood, wheat noodles, and sour/salty flavors. Ignoring these restrictions may lead to ulceration or frequent outbreaks, becoming a lifelong burden. Treatment should primarily focus on dispersing wind, clearing heat, and supporting the eruption of rashes.