|Year : 2021 | Volume
| Issue : 1 | Page : 24-29
Ayurvedic management of vitiligo (Shvitra)
Meenakshi Sharma, Sisir Kumar Mandal
Pathology and Diagnostic Procedure, All India Institute of Ayurveda, New Delhi, India
|Date of Submission||12-Sep-2020|
|Date of Decision||20-Sep-2020|
|Date of Acceptance||26-Sep-2020|
|Date of Web Publication||26-Mar-2021|
Sisir Kumar Mandal
Pathology and Diagnostic Procedure, All India Institute of Ayurveda, New Delhi
Source of Support: None, Conflict of Interest: None
Introduction: Vitiligo is a common autoimmune disorder in which the destruction of melanocytes occurs, resulting in the formation of white spots on the skin. It has a major impact on the quality of life of patients, as they feel distressed and stigmatized by their condition. Treatment available in contemporary medicine has its own limitations and side effects. In Ayurveda, Shvitra is the term employed for the hypopigmentation disorders of the skin. Due to the holistic approach, Ayurveda has the vast potential to treat such autoimmune skin diseases. Here, a case study of chronic vitiligo treated successfully with ayurvedic interventions is reported. Main Clinical Finding: There were white patches measuring about 7x5 cm, 4x3 cm, 3x3 cm and 4x2 cm on right and left arm, neck, chest, forehead region respectively. There were multiple small patches on fingers of hand also. The spots and patches were asymmetric, well defined whitish-pink and without scaling and discharge. Diagnosis: The patches were spread on large area (bahala), colour of patches was white/whitish pink (tvaka vaivarnyata), no secretion from lesion (aparisravi) ,with no itching (kandu) and loss of hair (romavidhvamsha) on affected area, so the case was diagnosed as Shvitra kustha on the bases of observed sign and symptoms. Intervention: The management approach was personalized and holistic in nature incorporating Ahara,vihara and Aushadha. In Sanshamana chikitsa Pitta-kapha shamaka and Vyadhi pratyanika line of treatment including internal administration of Khadira sara, decotition of Amla and Udumbara Chhala and Shashilekha Vati with external application of Chakramarda beeja, Muli beeja and Vakuchi beeja lepa was incorporated. Outcome: After 3 months of interventions, skinny spots appeared between the white patches. After six months, patches of chest, neck and forehead almost disappeared and that of arms significantly decreased with no recurrence. No adverse effect was seen during treatment and in follow up period
Keywords: Ayurveda, Bakuchi, Shashilekha vati, Shvitra, Vitiligo, Kustha
|How to cite this article:|
Sharma M, Mandal SK. Ayurvedic management of vitiligo (Shvitra). J Ayurveda 2021;15:24-9
| Introduction|| |
Skin is our first line of defense, which guards us against invading pathogens and environmental hazards. The disease manifested by the skin has a significant impact on our quality of life, productivity, and mental health., Vitiligo is a common skin disease characterized by the presence of hypopigmented lesions, resulting from a reduction in the number and function of melanocytes that negatively affects patients' self-esteem and quality of life.,, The clinically characteristic symptoms of the vitiligo are pale or milk-white macules or patches due to the selective destruction of melanocytes. They occur on the skin in different parts of the body and sometimes also on the mucous membranes. The exact pathogenesis of vitiligo is not known. Multiple mechanisms, including metabolic abnormalities, oxidative stress, generation of inflammatory mediators, cell detachment, and autoimmune responses, may play a role in the pathogenesis of disease., The prevalence of vitiligo in India is reported between 0.25% and 4%. There is no cure for vitiligo. First-line therapy for re-pigmentation includes topical corticosteroids and ultraviolet (UV)-B phototherapy. Current treatment for vitiligo attempts to either increase or decrease pigmentation to increase the patient's self-esteem. Many of these topical and light therapies aid in re-pigmentation but require extensive treatment periods and carry unwanted side effects.,,
Vitiligo can be correlated to Shvitra in Ayurveda and untruthfulness, ungratitude, disrespect for gods, insult of preceptors, indulge in sinful acts, misdeeds of previous birth, and consumption of mutually contradictory food are its main etiological factors. In Ayurveda most of the skin diseases are described under the heading of kushta. Kushta is further divided into Mahakustha and Kshudrakustha. However, Shvitra is not described under any of these contexts. Acharya Sushruta has mentioned Shvitra as another form of kushta which is differentiated from it because of the absence of secretions and its confinement to the skin only and classified it as vataja, pittaja, and kaphaja. Acharya Charaka has given three stages of Shvitra, and according to its penetration in dhatus like if it is located in rakta dhatu, it appears red in color. If in mamsa dhatu, it appears coppery color, and if in meda dhatu, it appears white in color, as deep as the penetration more it is difficult to treat and also mentioned it under the rakta pradoshaja vikara based on the clinical symptoms.,
| Case Report|| |
A 42-year-homemaker visited skin outpatient department, presented with a history of white patches on the forehead, neck, chest, hands, elbow, legs, and foot with mild itching over affected area and gradual increment for 10 years [Figure 1]a,[Figure 1]b,[Figure 1]c. The disease was in the active stage, and new spots were increasing gradually. Family history in first-degree relation was negative. There was no past history of major illness. No history of trauma or surgery was found. Her menstrual cycle was regular. She had allopathic medication history for the last 5 years including corticosteroid orally and psoralen and UV A light therapy along with external applications. She had found some improvement in the starting phase of the treatment, but then, there was no progress in that condition for the last 2 years. Then, she visited Ayurvedic Government College for better treatment.
|Figure 1: (a) Patches of the forehead and neck before treatment. (b) Patches of the chest before treatment. (c) Patches of arms before treatment|
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The patient was having no addiction. Appetite and thirst was normal. His bowel was sometime constipated. The bladder was regular. Sleep was disturbed due to stress.
Atura Bala Pramana was assessed by Dasavidha Atura Pariksa. Prakriti of the patient was Pitta-Kaphaj and Vikriti was Pitta pradhana tridoshaja; Sara was Rakta; Samhana was Madhyam; Vyayama shakti was Avara; Ahara shakti and Jarana shakti was Madhyama; Satva was Avara; Satyama and Bala was Avara.
General physical examination
General condition of the patient was fair and afebrile. Vitals were normal. Pallor, icterus, clubbing, cyanosis, and lymphadenopathy were absent. On examination, cardiovascular, respiratory, urinary, and central nervous system revealed no abnormality.
There were white patches measuring about 7 cm × 5 cm, 4 cm × 3 cm, 3 cm × 3 cm and 4 cm × 2 cm on the right and left arm, neck, chest, and forehead region, respectively. There were multiple small patches on the fingers of the hand also. The spots and patches were asymmetric, well-defined whitish-pink, and without scaling and discharge.
As the patches were spreaded on the large area (bahala), color of patches was white/whitish pink (tvaka vaivarnyata), no secretion from the lesion (aparisravi), with no itching (kandu), and loss of hair (romavidhvamsha) on affected area, so it was diagnosed with Shvitra kustha on the bases of sign and symptoms.
In this diagnosed case of Shvitra kushta, based on the involved doshas and samprapti (pathogenesis) pitta-kapha shamaka line of treatment (according to doshas) along with Vyadhi pratyanika chikitsa was adopted. Samshamana chikitsa along with dietary restriction was suggested. The patient was taking snacks and milk regularly in the morning and evening and excessive salty, sour and spicy food, which was stopped during the treatment. The patient was having the habits of day sleep and night awakening. She was in continuous stress due to disease. Proper psychological counseling was done along with advice for yoga and meditation. The internal and external medications are listed in [Table 1].
Assessment was done before, during, and after treatment on the basis of symptoms mentioned in [Table 2],[Table 3],[Table 4],[Table 5],[Table 6],[Table 7].
The patient was taking corticosteroids orally that was completely withdrawn during treatment. After 3 months of treatment, skinny spots were found to appear between the white patches of arm, forehead, neck, and chest [Figure 2]a,[Figure 2]b,[Figure 2]c and [Table 8]. Same treatment was continued for the next 3 months. After 6 months, patches of the chest, neck, and forehead almost disappeared. Patches of arms significantly decreased to 4 cm × 3 cm [Figure 3]a,[Figure 3]b,[Figure 3]c and [Table 8]. The patient was followed for the next 6 months which showed complete regression of old patches with no recurrence.
|Figure 2: (a) Patches of the forehead and neck after 3 months treatment. (b) Patches of the chest after 3 months treatment. (c) Patches of arms after 3 months treatment|
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|Figure 3: (a) Patches of the forehead and neck after 6 months treatment. (b) Patches of the chest after 6 months treatment. (c) Patches of arms after 6 months treatment|
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|Table 8: Evaluation of symptoms before and after 3 months and after 6 months of treatment|
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| Discussion|| |
The main causative factor in the manifestation of pathology of Shvitra kustha is pitta (Bhrajaka pitta) pradhana tridosha that vitiates Tvaka (Rasa dhatu), Rakta, Mamsa, Lasika (lymph), i.e., kustha dravya sangraha (seven fold pathogenic substance of kustha). Due to the consumption of nidana simultaneous vitiation of doshas and shaithilyata (looseness) in dhatus (tvaka, rakta, mamsa, lasika) occurs. Vitiated doshas gain momentum to vitiate shithila dhatus leading to manifestation of Shvitra., The nidana (causative factors) is intake of incompatible and contaminated food, suppression of natural urges, drinking cold water just after exposure to the sun or after doing physical work, excessive intake of salty or acidic food items, haphazard intake of food with hot and cold properties, improper administration of panchakarma therapies, sleep during day time or indulge in sinful acts. In present case, unwholesome dietary habit (taking incompatible food like milk for long time, excessive sour, spicy, and salty food), sleeping at day time, and suppression of natural urges contributed to the aggravation of doshas resulting in the pathogenesis of Shvitra.
Probable mode of action of formulation chosen
Acacia catechu Linn. f. possesses Tikta, kashaya rasa, and seeta virya, which alleviates Pitta-kapha. Acharya Charaka mentioned it as the best kushthaghna drug in Agreya prakarana. Acharya Bhava Mishra highlighted its kandughna, kusthaghna, krimighna, vranahara, shothahara, and shvitrahara properties. Kashaya rasa of khadira possesses twakprasadak and raktashodhak properties which ultimately leads to raktaprasadana and reduction of discoloration of the skin. Studies evidenced its antioxidant, anti-inflammatory, antimicrobial, and chemoprotective properties.,
Phyllanthus emblica Linn. has Guru, ruksha, sheeta guna, amla rasa, sheeta-virya, and madhura-vipaka and is tridosha shamaka due to above pharmacological properties. Its raktapittaghana and rasayana qualities are described in the classical text. Various studies suggested its antibacterial, antioxidant, antiulcerogenic, hepatoprotective, gastroprotective, chemopreventive, and skin photoprotective effect.,
Ficus racemosa Linn. has Kashaya rasa, guru, ruksha guna, sheeta virya, and katu vipaka. It is pitta-kapha shamaka. Its vranashodhana, vranaropana, bhagnasandhankara, and krimighna properties are mentioned in the classical text. Acharya Charaka specifically mentioned it in Shvitra chikitsa. It has anti-inflammatory, antibacterial, anti-oxidant, hepatoprotective, antiulcer, and wound-healing potential revealed by studies.,
It is a well-known formulation mentioned by Acharya Yogaratnakara in the management of shvitra. It contains Shuddha Parada, Suddha Gandhaka, Suddha Tamra, and Bakuchi kashaya, etc. Among these ingredients, Parada is yogavahi (catalyst), gandhaka is recommended as the most effective drug for skin ailments, it enters to srotas quickly due tikshna and sukshma guna and ushna virya, removes obstruction from srotas. Bakuchi (Psoralea corylifolia Linn.) has katu, tikta rasa, ruksha guna, katu vipaka, and ushna virya. It has antibacterial, antifungal, anti-inflammatory, antioxidant, and immunomodulatory activities.
Chakramarda, mooli, and vackuchi lepa
Local application of Chakramarda (Cassia tora Linn.), Mooli (Raphanus sativus L.), and Bakuchi (Psoralea corylifolia Linn.) in equal quantity with Takra at the morning followed by exposure to the sun for 30 min is effective for repigmentation in Shvitra. Mooli and bakuchi lepa is mentioned by Acharya Charaka in Shvitra chikitsa. Bakuchi is a renowned herb mentioned in the classical text for pigmentation. It stimulates melanocytes for the production of melanin. It contains psoralen that absorb long-wave UV radiations after exposure to the sunlight and becomes photoactive and produces favorable milieu for promoting the growth of melanocyte migration and stimulates proliferation. It does not only aid in the proliferation of melanocyte but also prevents the autoimmune activity of disease. Seeds of R. sativus have anti-inflammatory, antibacterial, and antioxidant properties. Here, its role is to protect the skin from the irritating effects of Bakuchi. Chakramarda (Cassia tora Linn.) drug has Lagu, ruksha guna, and Ushna virya. It reaches to the deeper tissues through siramukha and swedavahi srotas (microchannels), removes kleda pacifies kapha that results in srotoshodhana (clearance of channels), and due to Tikta rasa, laghu, ruksha guna, it pacifies pitta also. Kandughna and kusthaghna property of chakramarda is mentioned in the classical text. Various studies suggested its potent antifungal and antimicrobial action. A lepa (topical application) when rubbed in the upward or reverse direction of the hairs over the skin the drugs enter into the pores and get easily absorbed in the capillary network to minor veins and further into circulation which will pacify the doshas, and it leads to break the samprapti. Internal medication shows their effect through jatharagnipaka (digestive tract) and dhatwagni paka (tissue level digestion), whereas external applications skip the above and get absorbed by bhutagni paka and shows quicker action which depends on drug chosen.
| Conclusion|| |
It is concluded from the study that Ayurvedic protocol (Shamana chikitsa) is effective in treating Shvitra. It is a safe, cost-effective, and purely based on the Ayurvedic principle. However, the present study should be carried out in a large sample size to confirm its efficacy.
Written informed consent was obtained from the patient for the publication of this case report and accompanying images.
Declaration of patient consent
The authors certify that they had obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Hay RJ, Johns NE, Williams HC, Bolliger IW, Dellavalle RP, Margolis DJ, et al
. The global burden of skin disease in 2010: An analysis of the prevalence and impact of skin conditions. J Invest Dermatol 2014;134:1527-34.
Eckert L, Gupta S, Amand C, Gadkari A, Mahajan P, Gelfand JM. Impact of atopic dermatitis on health-related quality of life and productivity in adults in the United States: An analysis using the National Health and Wellness Survey. J Am Acad Dermatol 2017;77:274-9000.
Picardo M, Dell'Anna ML, Ezzedine K, Hamzavi I, Harris JE, Parsad D, et al
. Vitiligo. Nat Rev Dis Primers 2015;1:15011.
Ezzedine K, Eleftheriadou V, Whitton M, van Geel N. Vitiligo. Lancet 2015;386:74-84.
Dell'Anna ML, Hamzavi I, Harris J, Parsad D, Taieb A, Picardo M. Vitiligo. Nature Rev Dis Primers 2015;1:1-16.
Amerio P, Tracanna M, De Remigis P, Betterle C, Vianale L, Marra ME, et al
. Vitiligo associated with other autoimmune diseases: Polyglandular autoimmune syndrome types 3B+C and 4. Clin Exp Dermatol 2006;31:746-9.
Bystryn JC. Serum antibodies in vitiligo patients. Clin Dermatol 1989;7:136-45.
Krger C, Schallreuter KU. A review of the worldwide prevalence of vitiligo in children/adolescents and adults. Int J Dermatol 2012;51:1206-12.
Felsten LM, Alikhan A, Petronic-Rosic V. Vitiligo: A comprehensive overview Part II: Treatment options and approach to treatment. J Am Acad Dermatol 2011;65:493-514.
Mouzakis JA, Liu S, Cohen G. Rapid response of facial vitiligo to 308nm excimer laser and topical calcipotriene. J Clin Aesthet Dermatol 2011;4:41-4.
Trikamji VY, Acharya. Charak Samhita of Agnivesa Elaborated by Charaka and Dridhbala with the Ayurved Dipika Commentary by Chakrapani. Ch. 7. Varanasi: Chaukhamba Surbharti Prakashana; 2014.
Shastri Ambika Dutt Commentary on Sushruta Samhita of Maharishi Sushruta, Nidana Sthana. Ch. 5., Ver. 17. Kusthanidana. Varanasi: Chaukhambha Sanskrit Sansthan; 2007. p. 249.
Trikamji VY, Acharya. Charak Samhita of Agnivesa Elaborated by Charaka and Dridhbala with the Ayurved Dipika Commentary by Chakrapani. Ch. 7. Varanasi: Chaukhamba Surbharti Prakashana; 2014. p. 173-4.
Trikamji VY, Acharya. Charak Samhita of Agnivesa Elaborated by Charaka and Dridhbala with the Ayurved Dipika Commentary by Chakrapani. Varanasi: Chaukhamba Surbharti Prakashana; 2014. p. 28.
Nath P, Dwivedi RR, Mandal SK. Atura Bala Pramana Through Dasvidha Pariksha. Journal of Ayurveda 2009;3:35-54.
Trikamji VY, Acharya. Charak Samhita of Agnivesa Elaborated by Charaka and Dridhbala with the Ayurved Dipika Commentary by Chakrapani. Ch. 7. Varanasi: Chaukhamba Surbharti Prakashana; 2014. p. 9-10.
Trikamji VY, Acharya. Charak Samhita of Agnivesa Elaborated by Charaka and Dridhbala with the Ayurved Dipika Commentary by Chakrapani. Ch. 5. Varanasi: Chaukhamba Surbharti Prakashana; 2014. p. 3.
Byadgi PS. Kushtha. Parameswarappa's Ayurvediya Vikriti Vigyan and Roga Vigyan. 1st
ed., Vol. 2. Varanasi: Chaukhambha Sanskrit Sansthan; 2009. p. 268-98.
Trikamji VY, Acharya. Charak Samhita of Agnivesa Elaborated by Charaka and Dridhbala with the Ayurved Dipika Commentary by Chakrapani. Ch. 7. Varanasi: Chaukhamba Surbharti Prakashana; 2014. p. 4-8.
Sharma PV. Dravyagunna vijyana (Vegetable Drugs). 1st
ed. Vol. 2. Varanasi: Caukambha Bharati Acedemy; 2006. p. 159.
Sharma PV. Dravyagunna vijyana (Vegetable Drugs). 1st
ed. Vol. 2. Varanasi: Caukambha Bharati Acedemy; 2006. p. 162.
Stohs SJ, Bagchi D. Antioxidant, anti-inflammatory, and chemoprotective properties of acacia catechu heartwood extracts. Phytother Res 2015;29:818-24.
Ojha D, Singh G, Upadhyaya YN. Clinical evaluation of Acacia catechu, Willd. (Khadira) in the treatment of lepromatous leprosy. Int J Lepr Other Mycobact Dis 1969;37:302-7.
Sharma PV. Dravyagunna Vijyana (Vegetable Drugs). 1st
ed., Vol. 2. Varanasi: Caukambha Bharati Acedemy; 2006. p. 759-60.
Krishnaveni M1, Mirunalini S. Therapeutic potential of Phyllanthus emblica (amla): The ayurvedic wonder. J Basic Clin Physiol Pharmacol 2010;21:93-105.
Zanwar A, Pharm M, Saini R. Role of Emblica officinalis
in Prevention of Skin Disease; 2013.
Sharma PV. Dravyagunna vijyana (Vegetable Drugs). 1st
ed., Vol. 2. Varanasi: Caukambha Bharati Acedemy; 2006. p. 666-7.
Trikamji VY, Acharya. Charak Samhita of Agnivesa Elaborated by Charaka and Dridhbala with the Ayurved Dipika Commentary by Chakrapani. Ch. 7. Varanasi: Chaukhamba Surbharti Prakashana; 2014. p. 162.
Yadav RK, Nandy BC, Maity S, Sarkar S, Saha S. Phytochemistry, pharmacology, toxicology, and clinical trial of Ficus racemosa. Pharmacogn Rev 2015;9:73-80.
Murti K, Kumar U. Enhancement of wound healing with roots of Ficus racemosa
L. in albino rats. Asian Pac J Trop Biomed 2012;2:276-80.
Shastri B, Bramhashankar S, Yogaratnakara. Chaukambha Sanskrit Sansthan. 8th ed. Kusthachikitisa: Shvitrachikitsa; 2004. p. 234.
Khushboo PS, Jadhav VM, Kadam VJ, Sathe NS. Psoralea corylifolia Linn-“Kushtanashini. Pharmacogn Rev 2010;4:69-76.
Trikamji VY, Acharya. Charak Samhita of Agnivesa Elaborated by Charaka and Dridhbala with the Ayurved Dipika Commentary by Chakrapani. Varanasi: Chaukhamba Surbharti Prakashana; 2014. p. 169.
Latha PG, Panikkar KR. Inhibition of chemical carcinogenesis by Psoralea corylifolia seeds. J Ethnopharmacol 1999;68:295-8.
Wu CS, Lan CC, Wang LF, Chen GS, Wu CS, Yu HS. Effects of psoralen plus ultraviolet A irradiation on cultured epidermal cells in vitro and patients with vitiligo in vivo. Br J Dermatol. 2007;156:122-9. doi: 10.1111/j.1365-2133.2006.07584.x. PMID: 17199578.
Jan M, Badar A. Effect of crude extract of Raphanus sativus
roots on isolated trachea of albino rat. Pakistan J Physiol 2012;8:23-6.
Sharma PV. Dravyagunna Vijyana (Vegetable Drugs). 1st
ed., Vol. 2. Varanasi: Caukambha Bharati Acedemy; 2006. p. 187-8.
Pandya MP, Sameja KD, Patel DN, Bhatt KD. Antimicrobial activity and phytochemical analysis of medicinal plant cassia tora. Int J Pharmacy Chem 2017;3:56-61.
Gupta N. Concept of nutritional dynamics of tissue (Dhatuposhana)-an ayurvedic approach. Int Ayu Med J 2016;4:25-6.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]