A Case Series on Ayurvedic Management of Shwitra (Vitiligo/leukoderma)
Background: Vitiligo is a chronic and long-lasting disorder where white patches develop on skin. Vitiligo is a common autoimmune pigmentary disorder in which patches of skin loses their colour. The white patches appear on the skin owing to melanocyte deficit. Vitiligo is compared with Shwitra in Ayurveda. Ayurveda offers a lot of potential when it comes to treating autoimmune skin disorders. The Ayurvedic approach to autoimmune disease treatment focuses on restoring balance and boosting natural immunity. In addition to that a customized combination of panchakarma according to ones prakruti and combinations of various potential ingredients, diets and lifestyle recommendations work on the overall disease management. 14 and 15 years old two female patients were diagnosed with Vitiligo vulgaris with patches all over the body, specifically over both upper and lower extremities. On the basis of the patient’s condition, prakruti and sampraptighatak (pathological factors) a treatment protocol was designed which includes the shodhan and shamanachikitsa. The shodhanchikitsa (Biopurification) includes deepana pachan snehapana (pre-procedures to boost digestion) followed by vamana (Scientifically induced emesis) virechana (Scientifically induced purgation) and raktamokshana (bloodletting) along with the combination of shamanachikitsa (medicinal therapy) which includes Arogyavardhinivati with the local application of Bakuchitaila externally on white patches. Gandhakrasayana, Avalgujadilepaguti along with gomutra (cow’s urine) and the combination of various powdered herbs like Bakuchi, Kalamegh,Vidanga, Katuki were advised to both the patients with proper(dietary instructions and restrictions). The management strategy was efficacious in recovery of both the patients with the improvement in the repigmentation. This strategy could be useful in the future by including other drug combinations and therapeutic methods to get quick relief.
Vitiligo, Shwitra, Ayurveda, Shamana, Shodhanchikitsa, Pathyapathya, Prakriti
Vitiligo, also known as leukoderma is the most common depigmenting skin condition, affecting between 0.5 and 25% of the world's population in both adults and children. It is characterized by a selective loss of melanocytes in the afflicted areas of the skin, resulting in pigment dilution. The fully amelanotic, non-scaly white spots with distinct edges are the typical lesions. In Ayurved, this condition is known as Shwitra. It is characterized as an autoimmune disease caused by hereditary and environmental causes, as well as irregularities in metabolism, oxidative stress, and cell detachment. Shwitra is a form of kustharoga in Ayurveda that is induced by the vitiation of tridoshasas well as dhatus such as rasa, rakta, mamsa and meda. Skin diseases such as shwitra can be caused by any impairment of the bhrajaka Pitta, Vata, and kapha dosha .
The diagnosis was made based on Vitiligo's distinctive symptoms. Hypopigmentation was visible on the hands and legs, with a distinct boundary. The shodhana chikitsa was done to clear the strotas for the better efficacy of medication as initially doshas were in dominant phase. Over the course of three months, the following case was treated with shodhan karma and shaman treatment, with good results as evidenced by photographs. The results of these case studies would undoubtedly provide the optimum comfort to vitiligo patient’s by Ayurvedic management. The following is a case series of female patients who had chronic vitiligo and were treated with Ayurvedic medication, as well as sun exposure, proper diet and counselling .
The female patients of 14 and 15 years old resident of small town presented with the complaints of whitish discoloration over the hands and legs mainly over the ankle, wrist and legs. Both were from different families but same village. The lesions were varied in shape, no discharge or itch and poor pigmented patches observed. The spots were chronic and not disappearing in spite of regular treatment with modern medicines .Present history
Before 5 years, the both patients appeared to be in good health, but she gradually got some discoloration on her ankle region, which she ignored because the lesion was faint. After a few months, she noted that the size of the lesion was gradually rising, and she also observed patches on her ankles. In another case, the lesions were started on eyelids and posterior region of pinna. The both patients were taken to a skin specialty hospital in their hometown for treatment. They were diagnosed with Vitiligo there, and advised for allopathic medications, such as for local application and related oral medicines and multivitamin supplements. After a few months, they noticed that the sizes of the lesions were gradually rising, and also observed the spread of patches on their ankles, neck and back. She received treatment for eight months, but the patients did not get satisfactory relief. As they both were belonging from same town, they together came to our hospital for further treatment in order to be entirely relieved from this ugly disease .
No other family members had the same problem in both the families. There was uneventful history of chronic ailments like auto-immune disorders, metabolic or genetic diseases. The personal history was uneventful in both the cases. She had allopathic medication history for last five years including cortical-steroidal creams for local application, internal administration of multivitamins, minerals, PUVA and other symptomatic treatment. They had seen some improvement in the early stages of treatment, but there had been no advancement in that condition over the previous three years and unable to receive costly therapies and medicines. Their family members were worrying for future difficulty in their marriages. As a result, they had come for Ayurveda medication on the advice of her neighbours. All routine investigations of blood and urine were normal .
Past History No: history of HTN/ DM/ Thyroid disorder in both the cases.
- Personal History
- Appetite- low to average
- Bowel irregular bowel intermittently
- Bladder 5-6 times/day urination
- Sleep- disturbed to average
- Diet Vegetarian, though the patient preferred sweet and sour food.
- Habit tea/coffee once a day
Medicinal History: The patients had been on allopathic medications for eight months but had not found any relief; therefore, they came to our hospital for Ayurvedic treatment .
Menstrual history both of them attained menarche 2 and 3 years back, menstruation was scanty
Ashtavidha pariksha of both patients shown in table 1.
Table 1: Ashtavidha pariksha of both patients.
|Sr no.||Ashtavidh Pariksha||Case 1||Case 2|
|1||Nadi (pulse)||74/min||84 beats per minute Vishama (Vataja)|
|3||Mala (stool)||Irregular bowel||Samaunsatisfactory bowel|
|4||Jihva-tongue||Niram||No coating reddish|
|5||Shabda/speeh||Clear no stammering||Clear|
|6||Sparsha-touch||Normal temperature||Soft moist touch|
Dasavidha Pariksha: Both cases were having common aspects as shown in (Table 2).
Table 2: Dashvidha pariksha of case 1 and 2.
|S No.||Dashvidha Pariksha||Case 1||Case 2|
|b. Dushya||Rakta, Mamsa, Meda||Rakta, Mamsa, Meda|
|3||Sara||Twak, Rakta, Mansa, Meda Asarata while Asthi, Majja, Sarata||Rakta, Mansa, Asthi, Majja, Sarata|
After obtaining the patient's informed consent, the examination was carried out. On general examination, the patients appeared to be alert, cooperative, and well-oriented in terms of time, location, and person, as well as being relaxed and mentally stable. There were many white patches measuring about 4 × 4, 3 × 5 cm, 3 × 6 cm and 4×3 cm on right and left arm, on ankles anterior region, elbow posterior regions, on anterior of knee and shin regions respectively. Case-2 had more hypo-pigmentive spots on both eyelids and post-auricular region along with extremities. There were multiple small spots on hands and legs. The spots and patches were asymmetrical, well-defined, whitish-pale, and scale-free .Diagnostic assessment
On local examination we found the white patches on both the upper and lower extremities with no loss of sensation. There was tendency of symmetricity in both the cases in appearance of white spots. The patients were clinically diagnosed as case of Shwitra (Vitiligo/leucoderma)Therapeutic intervention
The treatment principle applied in shwitra chikitsa depends on the intensity of vitiated doshas, so the combination of appropriate treatment was selected. As the patients were in the active stage of vitiligo because the doshas were in prakopaavastha, we planned to give a combination of shodhan and shamanachikista along with a combination of effective drugs having strong action against the increasing patches across the body. Furthermore, if a shaman medication is used after a suitable course of shodhana, it provides good relief and thus, helps in eliminating the disease completely from its root. The management was divided in 3 sets of treatment protocol
- First common treatment protocol for both the cases: As both cases were having lack of appetite due to mild constipation history. Hence Deepana and Pachana drugs were advised to them (Tables 3 and 4).
Table 3: First common treatment protocol for both the cases.
|1||First Day||Trikatu and Triphalachurna||2.5 gm each=5 gm||Warm water|
|2||Second Day||Trikatu-Triphalachurna||5 gm||Warm water|
|3||Third Day||Trikatu-Triphalachurna||5 gm||Warm water|
Time of administration Received twice a day, before each meal, on an empty stomach with warm water.
Table 4: Medicines suggested after period of deepan and pachana.
|S.N.||Medicines||Dose||Time of administration|
|1||Arogyavardhini vati||2 Tab||After meal, twice a day|
|2||Gandhak Rasayana||2 Tab||After meal, twice a day|
|3||Aragvadh-kapilla vati||1 Tab||At bed time with warm water|
Snehapana (intake of ghee prior Vamankarma) was started with Panchtiktaghrit in increasing order for 5 days, once in the early morning with hot water. Breakfast was avoided and light warm diet was advised during Snehapana (Table 5).
Table 5: Dosages of snehapana for vaman.
|6||Sarvanga Abhyanga with Manjisthadi taila and Nadisweda||_||Kapha vardhak ahar sevana|
- On 7th day Vamana was performed early in the morning with
- Madanphala pippali and vachachurna with rocksalt and honey mixed leha
- 2 liters of milk
- Yashtimadhukwath-3 liters
Utttamshuddhi with 7 vega was observed and Samasarjana karma was followed for 3 days. There after, following medication advised to patients (Table 6).
Table 6: Post vaman medication.
|S.N.||Medication||Dose||Time of administration|
|1||Bakuchitaila||Quantity sufficient||Applied on patches early morning and exposed to sunlight for 15 min|
|2||Bakuchighanvati||2 Tab||Twice a day After meal|
|3||Khadirarishta||10 ml BD||Twice a day After meal|
|4||Mahamanjisthadi kwatha||10 ml BD||Twice a day After meal|
After Medication 15 days gap was given and 2ndshodhasn procedure virechan karma advised (Table 7) to the patients.
Table 7: Schedule of Snehapana for Virechana karma.
|1||Trikatuchurna||5 gm||Warm water|
|2||Trikatuchurna||5 gm||Warm water|
|3||Trikatuchurna||5 gm||Warm water|
|4||Panchatiktaghrita||30 ml||Warm water|
|5||Panchatiktaghrita||50 ml||Warm water|
|6||Panchatiktaghrita||80 ml||Warm water|
|7||Panchatiktaghrita||120 ml||Warm water|
|8 and 9||Sarvanga Abhyanga with Manjisthaditaila and Nadisweda||_|
|10||After snehan-swedan, Virechana karma||Triphala kwatha 100 ml and Avipattikar churna 20 gm|
Madhyamshuddhi with 15 Vegas was observed and Samasarjana karma was followed for 3 days and then medication was started (Table 8)
Table 8: Medication after virechana karma.
|S.N.||Medication||Dose||Time of administration|
|1||Bakuchitaila||Quantity Sufficient||Apply over patches and allow sun exposure for 15 minutes, twice a day|
|2||AragvadhKapilavati||2 Tab||Twice a day After meal with warm water|
|3||Khadirarishta||10 mlbd||Twice a day After meal with warm water|
|4||Mahamanjishtadikwatha||10 mlbd||Twice a day After meal with warm water|
|5||Avalgujadilepaguti||Lepguti||Rubbed with gomutra and Apply over patches and allow sun exposure for 15 minutes, once a day|
|6||Bakuchyadivati||2 Tab||Twice a day After meal|
Follow up and Outcomes: During the shodhan and shaman chikitsa, the patients were monitored for 8 months to see if there were any changes in skin pigmentation. After 15 days, the depigmented areas were reddish and scratchy, indicating that the treatment was working with no new spots appeared since the start of treatment. The skin became scaly with increased redness and itching. Normal pigmented patches began to emerge in the affected areas after 4-5 months. Early on, pigmentation of the hands began, followed by pigmentation of the legs. Re-pigmentation persisted after 6 months of treatment, and alterations in the patches were noticed. Within eight months, the majority of the skin had returned to normal pigmentation . Their appearance of skin pigmentation is likely to begin in areas of skin with less thickness and progress to areas of greater thickness. Due to regular sun exposure as a treatment strategy, the non-affected skin surrounding the depigmented patches showed minor hyperpigmentation. Oral medicines were administered for a long time in this situation. Treatment was continued in both the cases for nearly one and half years to get complete relief with no recurrence. Both the cases have fantastic results with no new spots of hypo-pigmentation. External application of Bakuchi tail with sun exposure was going on for minor faint spots in some places for another few months. After a two-year follow-up, there has been no recurrence of pigmented areas (Figures 1 and 2).
Figure 1:After treatment third treatment protocol.
Figure 2:After treatment third treatment protocol.The Probable mode of action of prescribed medicines may be as follows
Trikatuchurna Trikatuchurna has Kaphaghna, Vataghna, and Ama Doshanashaka properties and improves Agni and Aam digestion. And thus performsAgnideepana. Snehapana with PanchaTiktakaghrita As this Panchatiktaghrita is Tiktapradhana, Kaphahara, and is mentioned in Kushtavikara. Snehapana is performed to restore vitiated doshas to a proper state, i.e.Utklisthadoshaavastha, so that they can be easily evacuated. Ghrita softens and lubricates the Dosha, enhances digestive power, controls bowel movements, and enhances strength and complexion.Abhyanga Abhyanga with ManjisthadiTaila and YashtimadhuTaila, Pacify the vitiated Vata and give relief in itching and dryness. Swedana It brings the aggravated doshas in the koshtha.Vamana Karma It.
Laminates the Kaphadoshas from the body along with the pitta and amawhich has obstructed the Strotas. The aim of giving Vaman karma as the 1st therapy was to expel huge amount of morbid Doshas from the body and it clears Strotas which helps in proper acting of Samanaaushadhi on the white patches and hence eradicate disease from its roots Virechana Karma-VirechanaKarmaperforms pitta and RaktaShodhana (detoxifying effect) and pacifies Tridoshain TwakVikaras. Bakuchi churna it contains antioxidants such as psoralen, isopsorale, bakuchiol, bavchinin, bavachin, and corylin, which help in stimulating melanocytes for melanin formation, have an immunomodulatory action, and inhibit antigen-induced granulation.
GandhakaRasayana-Shuddha-Ghandhaka (Sulphur) is the main element of Gandhaka-Rasayana, and it has several potential uses for skin health. It is Raktashodhaka, Twachya, and beneficial to the skin (kushtaghna). Jaloukavacharana It activates and stimulates the body's response to the injurious section of the skin, as well as the pituitary gland, which is responsible for the secretion of melanocyte stimulating hormone, thereby augment the secretion of melanin and regulate the normal colour of skin. Khadiraristha It has been considered to have property of detoxification. It detoxifies the body and assists in excretion of accumulated toxins from the body which enhances liver functions and hence blood gets purified and melanin pigments get active to produce melanocytes. MahamanjisthadiKashaya It makes skin healthy by purifying blood and facilitating the healthy formation of Bhrajak pitta there by normalizes its function. Avalgujadilepavati It is an alkaline formation made up of 3 main ingredients Avalgujabeeja (psoralecoryfolia) Hartala (arsenic trisulphide) and Gomutra. The Vati is triturated in the Gomutra and is applied over the affected patches for half anhour. It helps in removing white patches and in regaining color of the skin by stimulating melanocytes function. Bakuchitaila It is applied over white patches and is exposed in early morning sunlight for 10-15 min. It stimulates pigmentation process and helps in regaining the normal pigmentation of the skin. Aragvadhakapilavati It is useful in worm infestation and constipation. It helps in detoxifying body by clearing the bowel which helps in proper production of Raktadhatu hence helps in curing vitiligo.
The cases of Vitiligo have been rise in recent years as a result of different dietary and behavioral variable. Shwitra is a disease which has a high impact on the body as well as the mind state of the person. Ayurvedic treatment has proved to be most effective in chronic diseases as it removes the diseases from its roots therefore, the chances of reoccurrence is also nil in this condition. By increasing the immune system and enhancing the quality of life, Ayurvedic treatment for this Skin condition has provided a pleasant life. Shodhana therapy assists in removing the disease's fundamental cause and preventing recurrence by removing exacerbated Doshas from the body The Shamanaushadhis also had a crucial part in easing the symptoms by reducing the number of lesions, their size, and restoring normal skin colour. Because the patient had great alleviation, Ayurved Shodhan-Shaman combined approach can be utilized to manage Shwitra permanently in less duration than modern medicines.
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2Department of Ayurveda, Datta Meghe Institute of Medical Sciences,Sawangi, Meghe,Wardha, India
3Department of Rasashastra and Bhaishajya Kalpana, Datta Meghe Institute of Medical Sciences,Sawangi, Meghe, Wardha, India
Citation: Renu Bharat Rathi, Devika Labsetwar, Bharat Rathi, Amit Gulhane, Garima Singh. A Study on “A case series on ayurvedic management of shwitra (vitiligo/leukoderma),” J Res Med Dent Sci, 2022;10 (5):192-197
Received: 21-Feb-2022, Manuscript No. JRMDS-22-42912; Accepted: 02-May-2022, Pre QC No. JRMDS-22-42912; Editor assigned: 23-Feb-2022, Pre QC No. JRMDS-22-42912; Reviewed: 09-Mar-2022, QC No. JRMDS-22-42912; Revised: 22-Apr-2022, Manuscript No. JRMDS-22-42912;