Ayurvedic Management of Refractory Atopic Dermatitis - Case Report

Shreya Bhatia¹, Gunvant H. Yeola², Abhijeet Sarjerao Shirkande³, Shweta Kodre⁴,

Snehal Pansare⁵, Aqsa Zarin Khan⁶, Mohini Niware⁷

¹Post Graduate Scholar, Dr. D. Y. Patil College of Ayurved and Research Centre, Pimpri,

Pune of Dr. D. Y. Patil Vidyapeeth, Pune (Deemed to be University), India.

²Professor and Head of Department of Kayachikitsa, Dr. D. Y. Patil College of Ayurved and Research Centre, Pimpri, Pune of Dr. D. Y. Patil Vidyapeeth, Pune (Deemed to be University), India.

³Associate Professor, Department of Dravyaguna Vigyan, Dr. D. Y. Patil College of Ayurved and Research Centre, Pimpri, Pune of Dr. D. Y. Patil Vidyapeeth, Pune (Deemed to be University), India.

⁴Post Graduate Scholar, Dr. D. Y. Patil College of Ayurved and Research Centre, Pimpri,

Pune of Dr. D. Y. Patil Vidyapeeth, Pune (Deemed to be University), India.

⁵Post Graduate Scholar, Dr. D. Y. Patil College of Ayurved and Research Centre, Pimpri,

Pune of Dr. D. Y. Patil Vidyapeeth, Pune (Deemed to be University), India.

⁶Post Graduate Scholar, Dr. D. Y. Patil College of Ayurved and Research Centre,

Pimpri, Pune of Dr. D. Y. Patil Vidyapeeth, Pune (Deemed to be University), India.

⁷Post Graduate Scholar, Dr. D. Y. Patil College of Ayurved and Research Centre,

Pimpri, Pune of Dr. D. Y. Patil Vidyapeeth, Pune (Deemed to be University), India.

*Corresponding Author E-mail: shreyabhatia235@gmail.com, gunvantayurved@gmail.com, drabhijitshirkande@gmail.com, shwetakodre608@gmail.com, snehaldpansare5@gmail.com, draqsakhan5@gmail.com, mohininoware@gmail.com

ABSTRACT:

The term 'eczema' refers to inflammation of the skin and makes the skin irritated. Most common type is atopic dermatitis or atopic eczema. Vicharchika (skin disease with excessive exudation) in ayurveda can be compared to atopic dermatitis (AD). It manifests as erythema, vesiculation and oozing in the acute stage, scaling, and crusting in the subacute stage and lichenification (hyperpigmentation, accentuation of skin markings and thickening of the skin) in the chronic stage. The current condition known as atopic dermatitis leads to eager, aroused skin. Most often, it takes the form of patches on the face, neck, trunk, or extremities. This article presents a case study of a child who is having signs and symptoms of vicharchika. According to ayurvedic etiopathogenesis (samprapti) patient was diagnosed with vicharchika and is treated accordingly by internal and external therapies. Assessment was conducted using subjective as well as objective criteria. Oral ayurvedic medications along with udvartanachurna for local applications as part of the treatment was given. This case was successfully treated using the chikitsasiddhanta of vicharchika. After treatment, there was noticeable improvement in both signs and symptoms. The course of treatment revealed no complications. The study's goals and objectives were to assess the efficacy of simple ayurvedic formulations for the treatment. This single case report highlights thatthis ayurvedic intervention generated beneficial results and raised the quality of life of the patient.

KEYWORDS: Atopic dermatitis, Atopic eczema, Vicharchika, Samshamanaaushadi, Bahirparimarjanachikitsa.

INTRODUCTION:

Skin diseases are a major health problem affecting a high proportion of the population in India. The incidence has grown significantly to around 15 to 20 percent of school-age children in developed countries and 3 percent of adults worldwide. The World Health Organization (WHO) has listed skin infection under the most generally known non-transferable diseases in India, which further emphasises the severity of having skin ailments in India¹. Skin diseases can placean emotional and psychological burden on patients that may be far worse than the physical impact. People with the disease tend to have dry, itchy skin that is prone to infection. Eczema is commonly known as the "itch that rashes" due to dry skin that leads to a rash because of scratching or rubbing. Atopic dermatitis is common, chronic, skin disease characterised by pruritus and repeated remissions and relapses². It is associated with other atopic disorders, including asthma and allergic rhino conjunctivitis. Recent reports demonstrated that indoor air pollution, outdoor exposure to allergens, and environmental tobacco smoke are considered to be some of the environmental factors^3-4. In ayurvedic texts all skin diseases are included under the kushtharogas (dermatological disorders). Kushtharogasare divided into two categories: mahakushtha and khudrakushtha. Vicharchika is a type of kshudrakushtha with symptoms resembling to those of eczema, including kanduta (_~itching), pidika, shayavata (_~discoloration), bahusrava (_~discharge), rajyo (_~scratches), ruja (_~pain), and rukshata (_~dryness). Vicharchika, like all kushtha, has tridoshaja origin which means it combines three doshas with kaphadominant balance. Various acharyas have stated that raktadushti is also present despite its tridoshaja origin. Kapha is responsible for kandu, pitta is responsible for srava, and vata is responsible for shayavata. It is a kshurdakushtha though it runs a chronic course and has a tendency of flare-ups. According to current research, no single treatment can cure eczema; only a few medications provide clinical relief.

PATIENTINFORMATION:

A 7-year-old girl, vata-pittajaprakriti was having chief complaints of skin lesion, severe itching, dryness, and thickening of the skin with hyper pigmentation i.e., reddish white discoloration of palmer side of both feet and palmer side of left hand. She had vishamaagni (irregular appetite) also her bowel movements were not proper. The recurrence of extensive eczematous dermatitis along with a chronic course which started behind her knees since she was 4 years old. She was having ruja (_~pain) over both hands and feet, and daha(_~burning sensation) on the affected areas/parts. There was mild bleeding after she had itching. The patient got allopathic treatment and took medications for two years, but she experienced no improvement and was dissatisfied with the treatment, hence they opted ayurvedic management. Lesions were initially involved on knees and on one foot with a single spot asthe first symptom which started in June 2019 and kept on increasing on the feet and hands which in turn steadily worsened and expanded to the popliteal, antecubital fossae, and arm region. Although, there was a local increase in temperature, whereas nothing was prominent in terms of odour. The patient was bought by her parents approached to Kayachikitsa O.P.D. in Dr. D. Y. Patil College of Ayurved and Research Centre, Pimpri, Pune.

PAST MEDICAL HISTORY:

The patient had a history of recurring cough, cold, and fever, for which she took medicines likeFevago drops, Nasivion mini drops, Sinarest drops, Kufril LS drops, SypMeftal P, Sypsatrogyl O and other syrups at different ages.

SURGICAL HISTORY:

Patient had no surgical history.

FAMILY HISTORY:

Grandmother and uncle from the paternal family have allergies to dust and sand.

PERSONAL HISTORY:

EIGHT-FOLD EXAMINATION

SYSTEMIC EXAMINATION:

Systemic examination and all vital signs were normal.

LOCAL EXAMINATION

· Dry

· Macular patch

· Itching ++

· Erythematous

· Crusted

· Generalised cracks

· Scaling

Table 3a: Before treatment

Body region	Erythema	Oedema/Papulation	Excoriation	Lichenification	Area score	Multiplier	Score
Head/ neck	0	0	0	0	0	0	0
Trunk	0	0	0	0	0	0	0
Upper extremities	3	2	3	3	3	0.2	6.6
Lower extremities	3	3	3	3	3	0.3	10.4
The final EASI score is the sum of 4 region scores (0-72)							17.4

Moderate:17.4

According to the EASI assessment and calculations, the before treatment score of the patient was moderate which is 17.4.

Table 3b: After treatment

Body region	Erythema	Oedema/ Papulation	Excoriation	Lichenification	Area score	Multiplier	Score
Head/ neck	0	0	0	0	0	0	0
Trunk	0	0	0	0	0	0	0
Upper extremities	3	2	1	0	1	0.2	0.2
Lower extremities	3	3	1	3	2	0.3	0.6
The final EASI score is the sum of 4 region scores (0-72)							0.8

DISCUSSION:

Differentiating between various skin diseases can be challenging as they often share similar characteristics. Nevertheless, there have been certain times, when erythematous-squamous disease like psoriasis, seborrheic dermatitis, lichen planus, pityriasis rosea, chronic dermatitis and pityriasis rubra pilaris are difficult to differentiate^10-11. In the present study the patient got relief from itching and scaling was reduced.

Mode of action of oral medicines:

1) Raktashodhakvati (Sudhatatva pharmacy)

The contents of raktashodhakvati are arjuna (Terminalia arjuna), haridra (Curcuma longa), kutaki (Picrorhiza kurrooa), manjishtha (Rubia cordifolia), nimba (Azadirachta indica), and sariva (Hemidesmus indicus). Since, it has already been mentioned that the vitiation of the kapha, vata dosha, along with raktadhatudushti causes this condition, the ingredients of raktashodhakvati has kaphavatahara and raktadhatu purification impact. The raktashodhakvati owns several properties, including raktashodhana, vranashodhana, dahaprashamana, vranaropana, vedanasthapana, shothaghna, varnaprashadana, srotoshodhana, and satambhana. Additionally, it has analgesic, antioxidant, and antibacterial qualities. The medication was therefore successful in treating vicharchika¹².

2)Gandhakrasayan (Sudhatatva pharmacy)

Gandhakrasayan tablets contain suddhagandhak, chaturjata decoction consisting of barks of dalchini (Cinnamomum Zeylanicum), seeds of elaichi (Elettaria Cardamomum), leaves of tejpatra (Cinnamomum tamala) and flowers of kesara (Mesua ferrea), guduchi (Tinospora cordifolia), amla, haritaki, vibhitaki, and bhringraja juice. Suddhagandhak is an antiviral component with antibacterial properties that can be used to treat a variety of skin disorders including atopic dermatitis. Gandhakrasayan tablet is pittashamaka (pitta-reducing) and hence functions as kushtaghna (antibacterial), as well as has rasayana (rejuvenating) properties¹³. Zingiber officinale increases antioxidant bioavailability. Tinospora cordifolia reduces the sensation of burning, itching, and redness. Gandhakrasayan tablet prevents itching and burning caused by pathological causes and can also treat the pain associated with eczema.

3) Panchatiktaghrita (Sudhatatva pharmacy)

Panchatiktaghrita is a combination of five drugs having tiktarasa (bitter taste) dominance. Herbs with tiktarasa (bitter taste) are used to treat eczema because they aid in rasadhatu and raktadhatuprasadana by calming vitiated kapha and pittadoshas¹⁴.

4) Patolakaturohinyadikashayam (Kottakkalpharmacy)

Patolakaturohinyadikashayam contains patol (Luffa acutangular), katurohini (Picrorhiza Kurroa), chandana (Santalum album), madhusrava (Marsdenia volubilis), guduchi (Tinospora cordifolia), and patha (Cissampelos pareira). This is useful for vitiatedpitta and kapha doshas. Patolakaturohinyadikashayam is raktaprasadaka, yakritgami, and has deepana properties. The statistical analysis revealed that patolkaturohinyadikashaya significantly reduces daha¹⁵, thus cures this skin disease.

5) Arogyavardhinivati (Sudhatatva pharmacy)

Arogyavardinivati aids in the formation of rasadhatu and agnideepana.In addition to being utilised forrasayana (rejuvenating) effects, it also possesses antibacterial activity, and is also used for malashodhana (laxative effect). Katuki corrects rakta and aids in the removal of dustapitta¹⁶. Kustha and yakritvikara (liver disorders), are indications for arogyavardhinivati. Triphala is astringent and is anti-inflammatory. Nimba is an antiseptic that facilitates skin scale shedding and prevents subsequent infections.

Mode of action of local application:

1) Udvartanachurna (Sudhatatva pharmacy)

Udvartana is a treatment in ayurveda in which specially prepared herbal powder is massaged over the body. Powder of the following dravyas were given for applying externally as udvartana.

· Nimba (AzadirachtaIndica)

· Sariva (HemidesmusIndicus)

· Manjistha (Rubia Cordifolia)

· Khadira (Acacia Catechu)

· Triphala

· Daruharidra (Berberis Aristate)

· Chandana (Santalum Album)

· Masoordalachurna

· Chanadalachurna

Nimbaeradicates several diseases particularly skin diseases. In kushtha, the panchangachurna of nimba (Azadirachta indica) is used for applying externally or taking bath. Tannins related studies have reported its ability to exhibit anti-viral, anti-bacterial¹⁷. Nimba acts on both gram positive and gram negative bacteria¹⁸. Sariva (Hemidesmus indicus) or Shweta sariva called as anantamoola is twakadoshahara, raktashodhaka, varnya, and dahaprashamana. In sariva, iron is most important minor element, which is central atom of haemoglobin, hence it plays a vital role in blood formation. Thus, it has been reported to be useful in treating blood diseases¹⁹. Manjistha (Rubia cordifolia) is a reputed blood purifier and is useful as antipyretic. The mula and sara of Khadira (Acacia catechu)are useful in kushtha. It is used as external application in patients suffering from skin disorders like vicharchika. Triphla includes harada, baheda and amla in equal amount. This inclusion minimizes thekapha and pitta, also leads to the termination of kushtha. The bark powder of daruharidra (Berberis aristate) is useful in twakadosha, reduces the kandu and pain. Its root contains a significant number of alkaloids, majorly, berberine which is having anti-inflammatory activities²⁰. Berberine, in Berberis aristate, possess beneficial pharmacological actions such as in the treatment of wound healing, inflammatory disorders, skin diseases, and microbial pathologies²¹.Chandana (Santalum album) is mixed with other dravyas and is applied externally in twakadosha and kandu. The powdered form of masoordala (lentils) is used in purana vrana.Churna (powder) of allthese dravyas were mixed together along with milk and malai, which is also given for external application.

2)Gandhakadimalhara²² (Sudhatatva pharmacy)

The content of malahara possess snigdha, tikshna, ruksha, sara, and tridoshahara properties. All the ingredients of malahara have pharmacologically antifungal, antimicrobial, and antioxidant action, hence, effectively reduces the infection and prevent its recurrence by improving the immunity of skin. Shudhagandhaka plays vital role in immunesystem helps in detoxification and alsohelps in tissue repair. Girisindhoorais tridoshashamaka which is indicated in various skin diseases including vicharchika.

Below are the pictures of patient before treatment (figure 1 – figure3) and after treatment (figure 4– figure 6)

BEFORE TREATMENT:

Figure 1 (16/04/2022)

Figure 1: Foot showing generalised cracks and discoloration.

Figure 2 (16/04/2022)

Figure 2: Lichenification of the foot.

Figure 3(16/04/2022)

Figure 3: Left hand showing dryness and scaling.

AFTER TREATMENT:

Figure 4 (23/10/2022)

Figure 4: Treated foot cracks.

Figure 5 (23/10/2022)

Figure 5: Treated foot lichenification.

Figure 6 (23/10/2022)

Figure 6: Treated left hand dryness and scaling.

CONCLUSION:

Atopic dermatitis can affect people of any age but is very common in kids. Different dietary practises and climatic conditions have been blamed for this relative rarity.Dairy products have been proven to worsen skin conditions, and according to ayurveda, they should be avoided while taking medication. Overuse of salt, meat, and a conflicting diet (viruddhaahara and vihara) are one of the major causes of kushtaroga and therefore should be avoided. It showed that pathyaapathya was important in the treatment of this illness. Therefore, pathyaapathya was given the appropriate weightage in addition to internal drugs. Dermatologistsuse symptomatic medications like steroids to treat eczema because there is no known cure for this condition. However, those medications have serious side effects that include nephrotoxicity, osteoporosis, skin cancer, and others. Comparing the management of vicharchikato allopathic anti-eczematous regimens, shamana (Internal medications) and bahirparimarjanachikitsa (external application) were used here which gave excellent results to the patient from symptoms like itching and discolouration of skin. Vitiated blood was a major reason for this dermatological problem and thus required blood-purifying treatments during this treatment process²³. Current evidence suggests that vicharchikacan be cured by ayurvedic management. On the basis of this case study, it can be concluded that shamanatreatment along with udvartanachurna is effective in the management of vicharchika. Nonetheless, additional research is required to prove the efficacy of ayurvedic principles and possible treatments.

PATIENT’S RELATIVE PERSPECTIVE:

Before we visited Dr. D.Y. Patil College of Ayurved, my child was experiencing B/L foot itching, scaling, and burning sensations over her hands and fingers since last three years. She was eventually identified as having atopic dermatitis. For three years, she received allopathic treatment from a dermatologist, but the relief was minimal. After her ayurvedic consultation, the doctor provided a comprehensive overview of the entire therapy regimen, specifying that she should begin with oral ayurvedic medications along with external applications as part of the prescribed treatment. We were not sure how the treatment would turn out at first, but as it progressed, her symptoms gradually subsided.She found it challenging to drink panchatiktaghrita, but the doctor advised me to add it into her diet to make it simpler for her to consume. All these attempts helped to improve her symptoms, and the itching, scaling, and burning in her feet dramatically decreased. She received the most alleviation possible from this ayurvedic treatment. She can perform her everyday tasks and activities without experiencing any significant problems thanks to the efforts of the specialists. She continues to follow the course of treatment.

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Received on 21.03.2023 Modified on 07.10.2023

Research J. Pharm. and Tech 2024; 17(4):1510-1516.

DOI: 10.52711/0974-360X.2024.00239

Sr. No.	Medicine	Dose	Time of Administration	*Medium (anupana)*	Duration
1.	Raktashodhakvati (250mg)	1 TDS	Before meal	Lukewarm water	1 month
2.	Arogyavardhinivati (250mg)	1 BD	Before meal	Lukewarm water	2 months
3.	Gandhakrasayan (250mg)	1 BD	Before meal	Lukewarm water	6 months
4.	Panchatiktaghrita	5ml BD	Before meal	Lukewarm water	6 months
5.	Patolakaturohinyadikashayam	15ml BD	Before meal	45ml of lukewarm water	6 months
6.	Udvartanachurna	L/A	Once a day	-	4 months
7.	Gandhakadimalhara	L/A	Once a day	-	6 months

	Score
Before treatment	3- Moderate
After treatment	1- Almost clear