A Case Study to Evaluate the Treatment of Shwitra with Ayurveda Modalities

Trupti Thakre; Sourabh Deshmukh

doi:https://doi.org/10.26452/ijrps.v11i3.2773

**A Case Study to Evaluate the Treatment of Shwitra with Ayurveda Modalities**

1 Department of Kaumarabhritya, Mahatma Gandhi Ayurved College, Hospital & Research Centre, Constituent College of Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha, Maharashtra, India – 442001, +917020299894

2 Department of Kayachikitsa Mahatma Gandhi Ayurved College, Hospital & Research Centre, Constituent College of Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha, Maharashtra, India – 442001

Abstract

In Ayurveda all the skin diseases are explained under the term Kushtha. The references of shwitra are found in almost all the Samhitas like Bruhatrayees and Laghutrayees. In shwitra disease the white patch is seen and considering these symptom it can be compared to vitiligo. Vitiligo is characterized clinically by the development of areas of depigmentation. These are often symmetrical and occur mainly on extensor surfaces. This hypopigmentation results due to destruction of melanocytes, which may be unknown in origin or due to autoimmune endocrinopathies selective IgA deficiency. In contemporary science treatment of vitiligo is not very effective. Potent topical steroids and tacrolimus is used which produces harm to skin on continuous use. So the effective medicines are expected from Alternative sciences. To evaluates the role of Ayurveda treatment modalities in shwitra. A female patient, aged 15 year suffering from white patch below the left eye since 3year was treated with both Shodhan and Shaman Chikitsa for a period to 5 months with follow up at every 15 days in between, Relief from the complaints was assessed by noting the changes in the size of patch. After 5 months of treatment the size of patch was reduced. The present case study revealed the efficacy of Ayurveda therapy both internal and external for duration of 5 months in the management of shwitra.

Keywords

Vitiligo, Shodhan and Shaman, Shwitra

Introduction

Vitiligo, a specific type of acquired leukoderma, is an idiopathic, patterned, circumscribed hypomelanosis or dipigmentation of the skin and hair. These are often symmetrical and occur mainly on extensor surfaces. The basis for this destruction is unknown, but immunologically mediated damage is likely and vitiligo sometimes occurs in individuals with autoimmune endocrinopathies, selective IgA deficiency. The incidence of vitiligo is 1 to 8.8%. The age of onset varies widely from infancy to old age, with a peak incidence in the 10 to 30 years age group. The reported female predominance may be spurious, especially in India where vitiligo can be a considerable disfigurement and can affect eligibility for marriage because vitiligo mimics leprosy. The etiology is unknown. There is a positive family history in 30% of patients. An immune process is the most probable mechanism of destruction of melanocytes, as there are several autoimmune disorders that occur with vitiligo. Clinically the white spots usually gradually appear and remain for life.

Table 1: Showed internal medication with local ointmentin first sitting

S. No	Name of Medicine	Dose	Route	Anupan	Time	Duration
1	Ampachana vati	250mg	Oral	Lukewarm water	1 tab. Twice/day before meal	5days
2	Krimikuthar rasa	250mg	Oral	Lukewarm water	1 tab. Twice/day after meal	5days
3	Bakuchighanvati	250mg	Oral	Lukewarm water	1 tab. Twice/day after meal	7days
4	Lohasava	20ml	Oral	Lukewarm water	Twice/day after meal	15days
5	Khadhirarishta	20ml	Oral	Lukewarm water	Twice/day after meal	15days
6	Pigmento ointment	q.s	LA		Twice a day after bath	1month
7	Kumariasava	20ml	Oral	Lukewarm water	Twice/day after meal	15days

As per the symptomatology of disease vitiligo, the clinical condition can be compared with disease shwitra (white color patch). In Ayurveda the shwitra is a disease explained in khshudrkushta. It is also called as Kilas, Daruna, Aruna, Shwetakushta (Shukla & Tripathi, 2009) etc. it explained in almost all the Brihatrayees and Laghutrayees. In Charak Samhita while explaining the Nidan of shwitra Acharya Charak has explained virudha ahar vihar (unbeneficial foods) and paap karmas (bad deeds) are the main cause of shwitra (Shukla & Tripathi, 2009). This produces the imbalance of Doshas (body humours) like Vata, Kapha and Pitta specially Bhrajak Pitta which helps in the formation and maintain the color of skin. These Doshas are vitiated along with Rasa, Rakta,, Mamsa and Meda Dhatus (Shukla & Tripathi, 2009) (body tissues).

Table 2: Showing Dose, Route, Kala and Anupan of drugs used in Purvakarma of Vaman

S.No

Name of Medicine

Dose

Route

Anupan

Time

Duration

Trikatu churna

3gm

Oral

Lukewarm water

Before meal

3 days from 21/2/19 to 23/2/2019

Panchatikta Ghrita

1^st day -30 ml

2^nd day -60 ml

3^rd day -90 ml

4^th day -120 ml

5^th day -160 ml

6^th day -180 ml

Oral

Lukewarm water

Early morning at 7 am

24/2/19 to 1/3/19

Sarvanga Abhyanga with Marichadi tail followed by

Sarvanga Swedan

q.s

External Application

A day before and on the day of Vamana.

2/3/19 and 3/03/2019

Material and Methods

Aim

To study the case of Shwitra through Ayurveda

Objective

1. To study the role of Ayurveda in management of Shwitra.

2. To study the disease Shwitra in detail.

Case Report

A 15 Y/F patient came at OPD in our Ayurveda institution Maharashtra with the complaint of White coloured patch (Twak Shwetata) on below the left eye along with general weakness and irregular menses. The patch was white, without dryness and scaling. Her family history was negative in first degree relation. Her father’s education is upto M.Com and currently working in bank, while mother’s education is upto 12^th and she is housewife. Socio-economic status was middle. There were no personal history of autoimmune disorders like psoriasis; asthma etc. there was no history of trauma or surgery.

History of present illness

Patient was apparently normal (means she is not aware about the disease) before 5 years. Her mother noticed that she having a white patch over left eye which is gradually increase in size. She visited to dermatologists for the same, where she undergone haematological investigation which showed low hb%, she advised some internal medicines along with topical steroids for white patch. She took treatment for more than 3 years, and then she stopped medicines by herself as improvement was not noticed. So, she approached to Ayurveda consultancy for the same.

Personal History

Aharaja

Taking vegetarian diet and having habit of eating outside food like panipuri, wadapav etc

Viharaj

patient get more exposure to sun for classes as she is student of 10^th standard. She has habit of sleeping at evening and study at night. She sleeps 3-4hrs/night and 2hrs/evening.

Examination

vitals are within normal limit. Systemic examination was normal, prakriti was pittavataj and weight was 37kg with 148cm height.

Ashtavid pariksha

Nadi was Pittavatja, no complaint regarding Mala (once a day with soft consistancy) and Mutra(5-6 time/day),Jivha was Niraam, Shabda was Spashta, Sparsha was Unushnasheeta and Drik was normal but conjunctiva was pallor as her haemoglobin was low and Akriti was Madhyam.

Diagnosis- Shwitra

Treatment protocol

Total duration

5 months

Treatment given

Shaman Chikitsa (Shukla & Tripathi, 2009) and Shodhan Chikitsa (Vaman) (Shukla & Tripathi, 2009) was given.

Shodhan Chikitsa

In second sitting after all examination and investigations ,patient underwent for Shodhan Chikitsa in which Vamana procedure was done (Month of March. 2019) in sequence of Purva Karma, Pradhan Karma and Paschayat Karma.

Table 3: Showing ingredients and properties of formulations used in Purvakarma (Deepan, Pachan, Abhyanga & Swedana)

S.No

Name of medicine

Ingredients

Properties and Use

Panchatiktaghrita

(Snehapan)

Nimba, Patola, Vyaghri, Guduchi, Vasa, Triphala – Haritaki, Vibhitaki, Amla, Ghrita

Dipana, Pachana, Amapachaka, Strotoshodhaka, Raktaprasadan, Raktashodhaka, Kandughna, Kushthaghna and Varnya.

Marichadi tail

(Abhyanga)

Krishna Marich, Haratala, Manshila, Musta, Arkadugdha, Ashwamara, Jatamansi, Nishotha, Gomayarasa, Indrayana, Kustha, Haridra, Daruharidra, Devadaru, Shwetachandan, Gomutra, Sarshptaila.

Raktashodhak, Vranropak, Twachya, useful in skin diseases. Dadru, Shwitra, Kushtha

Table 4: Showing ingredients and properties of drugs used in Vamana Karma

S.No	Name of Ingredients	Latin name	Dose	Properties
1	Madanphala Churna	Randia dumetorum	3gm	Vamanaopag
2	Vacha Churna	Acorus Calamus	5gm	Vamanaopag
3	Saindhav Lavan	Rock Salt	5gm	Abhishyandi, Shodhak
4	Honey		25 ml	Abhishyandi, Yogavahi
5	Milk		2500 ml	Vamanaopag
6	Yashtimadhu phant	Glycyrrhiza glabra	1000 ml	Vamanaopag

Paschayat karma

After obtaining Samyaka Vamana Lakshana Dhoomapan was given with stick made of Aguru for 5 minutes by each nostril. Then patient was advised to follow the Sansarjana Karma for five days. Sansarjana Karma was given in the form of Peya, Vilepi, Akrita Mudga Yusha, Krita Mudga Yusha for 5 days.

Table 5: After Shodhan of body, Shaman Chikitsa was given as follow

S. No	Name of Drug	Dose	Anupan	Time	Duration
1	Bakuchighanvati	250mg	Lukewarm water	Twice a day after meal	2 months
2	Lukoskin Ointment	Q.S		Twice a day after bath	2 months
3	Syrup Lukoskin	2 ml	Lukewarm water	Twice a day after meal	2 months
4	Lohasava	20ml	Lukewarm water	Twice a day after meal	15days
5	Tab. Pigmento	250mg	Lukewarm water	Twice a day after meal	15days

Table 6: Assessment of Samyaka Vamana

S.No

Mainiki (measurement)

Intake & Output

Antiki (Procedural Inference)

Vegiki (No. of Vega)

Laingiki (Symptoms)

Vamana

2500

3100

Pittantak Vamana

Kaphachadrika present in vomitus and no bleeding was seen

Table 7: Showing haematological parameters of patient

S.No	Haematological parameters	Before treatment (15/1/19)	Before Vaman procedure (8/2/19)	After treatment (4/4/19)
1	Haemoglobin	8.4gm%,	9.1gm%,	9.8 gm%,
2	MCV	64 cub.micron,	62 cub.micron,	66 cub.micron,
3	MCH	18.1 pico-gm	18.5 pico-gm	19.2 pico-gm
4	MCHC	28.2%,	28.0%,	29.1%,
5	RBC	4.65millions/cu.mm	4.75millions/cu.mm	5.10millions/cu.mm
6	WBC	5900/cu.mm	6200/cu.mm	6600/cu.mm
7	Platelets	3.83 lacs/cu.mm	4.1 lacs/cu.mm	3.63 lacs/cu.mm

Bakuchi is classified under tikta skandha (Shukla & Tripathi, 2009) in Charaka Samhita, Katuk varga (Sharma, 2004) in Sushruta samhita, Shaka varga in Ashtanga samgraha as Rasayana in Ashtanga hridayam (Murthy, 2006) Kushthaghna (Leprosy destroyer), Jantughna (Insecticidal), Deepana (Appetizer), Pachana (Digestive), Anulomana (Laxative), Krimighna (Germicidal), Yakridottejaka (Choleretics), Kaphaghna (Expectorant), Swedajanana (Diaphoretics), Pandu (Anaemia), Twaka roga (In Skin Disorders) are the therapeutic properties of Bakuchi (Sharma & Sharma, 2006).

Table 8: Showing Ingredients of Khadirarishta

S. No	Ingredients	Botnical Name
1	Khadira	Acacia catechu
2	Devadaru	Cedrus deodara
3	Bakuchi	Psoralea corylifolia
4	D¡rv¢	Berberis aristata
5	Triphala (Haritaki, Bhibitaki and Amalaki)	Terminalia chebula, Terminalia belerica, Emblica officinalis
6	Makshika	Honey
7	Sharkara	Sugar cane

Table 9: Ingredients of Lohasava

S.No	Ingredients	Botnical Name
1	Loha	Iron dust
2	Trikatu (sunthi, maricha, pipali)	Zingiber officinale , Piper nigrum , Piper longum
3	Triphala (Haritaki, Bhibitaki and Amalaki)	Terminalia chebula, Terminalia belerica, Emblica officinalis
4	Makshika	Honey
5	Vidanga	Embelia ribes
6	Musta	Cyperus rotundus Rz.
7	Chitrak	Ricinus communis
8	Dhatki	Woodfordia fruticosa
9	Guda	Jaggery

Table 10: Showing Ingredients of Kumariasava

S.No	Ingredients	Botnical Name
1	Kumari Rasa	Aloe barbadensis
2	Madhu	Honey
3	Jatipatra	Myristica fragrans
4	Karkatshringi	Pistacia integerrima
5	Pushkarmoola	Inula racemosa
6	Lavanga	Syzygium aromaticum
7	Dhatki	Woodfordia fructicosa
8	Bhibitaki	Terminalia belerica
9	Kankola	Piper cubeba
10	Jatamasi	Nardostachys jatamansi
11	Tamra bhasma and Tamra Loha	Calcined Tamra and Calcined Lauha
12	Kababaka	Piper cubeba
13	Chitrak	Ricinus communis
14	Cavya	Piper retrofractum

Table 11: Showing Ingredients of Tab Pigmento

S. No	Ingredients	Botnical Name
1	Abrak Bhasma	Mica calx
2	Loha bhasma	Iron calx
3	Tamra bhasma	Copper calx
4	Hingula	Cinnabar
5	Shilajatu	Asphaltum
6	Kajjali	-
7	Triphala (Haritaki, Bhibitaki and Amalaki)	Terminalia chebula, Terminalia belerica, Emblica officinalis
8	Chitrak	Plumbago zeylancia
9	Latakaranja	Caesalpinia bonduc
10	Ritha	Sapindus mukorossis
11	Kasmarda	Cassia occidentails
12	Yavakshara	Hordeum valgare
13	Yashada bhasma	Zinc calx
14	Trayamana	Gentian kurroo

Table 12: Showing Ingredients of Syrup Lukoskin

S. No	Ingredients	Botnical Name
1	Vatsanabha	Aconitum Ferox
2	Bakuchi	Psoralya Corifolia
3	Kaunch	Mucuna Preurinis
4	Mandukparni	Cantilla Aciatica
5	Krishn Tulsi	Ocimum Americanum

Table 13: Showing Ingredients of Lukoskin ointment

S. No	Ingredients	Botnical Name
1	Bala Mool	Sida cordifolia
2	Bakuchi	Psoralya corifolia
3	Vatsanabha	Aconitum ferox
4	Ark	Calotropis gigantean
5	Kumari	Aloe vera
6	Chameli Tail	Jasminum officinale olie
7	Til Tail	Sesamum indicum olie
8	Petroleum Jelly/ Cream Base	q.s
9	Babchi Ash	Psoralya corifolia
10	Vish Naag Ash	Aconitum ferox

Table 14: Showing Ingredients of Pigmento ointment

S. No	Ingredients	Botnical Name
1	Aritha Beej	Sapindus muKorossi
2	Bavchi Beej	Psoralya corifolia
3	Tulsi Beej	Ossimum scantum
4	Kale Jeerak	Cuminum cyminum
5	Chitrak Mool	Plumbago zeylancia
6	Khair Chhal	Ascasia catecu
7	Neem Beej	Azadirachta indica
8	Erand Beej	Castor seed
9	Sonageru	-
10	Gandhak Shuddha	Purified sulphar
11	Chakra Marda	Cassia torra linn
12	Bavchi Tel	-
13	Butylated Hydroxy Toluene Ip	-
14	Kaolin Light Ip	-

Table 15: Showingthe Ingredients of Marichyadi Tail used for Bahya Snehana

S.No	Name of Drug	Latin Name
1	Marich	Piper nigrum
2	Nagarmotha	Cyperus rotundus
3	Arkadugdha	Calotrpis procera
4	Kanera Mula Twak	Nerium indicum
5	Nishoth	Operculina turpethum
6	Indrayanamula	Citrullus colocynthis
7	Kushtha	Saussurea lappa
8	Haridra	Curcuma longa
9	Daruharidra	Berberisaristata
10	Devdaru	Cedrus deodara
11	Raktachandana	Pterocarpus santalinus
12	Vatsanabha	Aconitum ferox
13	Sarshaptail	Brassica alba

Results and Discussion

In Ayurveda Shodhan is the method of eliminating the Dosha from body to pacify the disease. This Shodhan when done by unctuous and Tikshna (strong) drugs, it cleanses the body. So in the present study, the patient first treated with the medicines including Dipan, Pachan, and the drugs which increase the haemoglobin as well as improves the function of uterus was given (Table 1). Then after that Dipan, Pachan and Abhyanga should be done as Purvakarma (Table 2 ) of Shodhan (purification) procedure. In Shodhan, Vaman (Shukla & Tripathi, 2009) (expelling the impurities o.e vitiated dosha through the upper channel) procedure was done followed by Samsarjan Krma and then Shaman Chikitsa was given for 2 months with the follow up at every 15^th day in between.

Agni is said to be the accountable for Varna (complexion) and Sukhayu (healthy life). Mandagni (loss of function of Agni) is considered as root cause of all the diseases (Murthy, 2007). Mandagni cannot form enough Rasa Dhatu (nutrition) which provides nutrition for further Dhatus and the person gets easily diseased. In Ayurveda some medicines found which helps in maintaining the normal state of Agni like Ampachan Vati (Chetan, Bhalkar, Thakre, & Sheshagiri, 2018) which contains Katu drugs like Chitraka, Pipalimula, Ajvian, Shudh Javakhar, Sunth, Chavya, Sajikhar, Shudh Nosager, Kalimirch, Pipali, Samudra Namak, Hing, Saindhav in which Bhavana was given by Nimbu Swaras which is the best drugs for Dipan and Pachan. As Krumi is one of the cause of Raktadushti and produce disease like Pandu and Kushta, here Krimikuthar Rasa (Neha et al., 2017) was given which contains Karpoor, Kutaj, Trayamana, Alameda, Vidang, Shuddhga Hingul, Shudder Vatsanabha, Nagkeshar, Palashbeej in which Bhavana was given by Bhrungaraj Swarasa, Akhuparni Swarasa, Brahmi Swarasa which helps to rid out of disease. So, first Amapachana Vati and Krimikuthar rasa was given.

Then Bakuchighan Vati (Rajput, Meena, & Singh, 2014) and Khadirarishta was advised which is most popular formulation for Kushta which contains a single drug Bakuchi belongs to Fabaceae family and Khadira, Devdaru, Triphala etc respectively are depicted in Table 8, (Ayurvedic Pharmacopoeia of India, 2003). These are the main herbs in traditional Indian herbal medicine for the treatment of skin disorders. It has Tikta and Madhura Rasa which mitigates the Pitta Dosha and Ushna Virya alleviates the Kapha and Vata Dosha. Along with the above drugs poly herbal ointment (ointment Pigmento) was advised which having the main drugs Arishtak (Sharma & Vijnana, 2013) and Bakuchi along with Chitrak, Gandhak, Eranda (Table 14). These drugs having the properities of Kushtaghna, Krimighna, Kapha –Vata Hara and Pandurog Hara.

After routine investigation when we came to know about the low hb% which is one of the causes of irregular menses, the formulation like Lohasava (Tripathi, 2004) was advised which contain Loha and other ingredients which are depicted in Table 9. (Ayurvedic Pharmacopoeia of India, 2003) and Kumariasava (Ayurvedic Pharmacopoeia of India, 2003) contains Kumari as the main drug, the detail of herbal constitution of Kumariasava has been presented in Table 10 in addition with this drugs having Appetizer, Digestive and Carminative properties. The drugs like Amalaki and Pipali acts as a Rasayan and also having Panduroghara properities. Amalaki possess antioxidant activity and contain vitamin C which helps for the proper absorption of iron from the gut. Also the Lohasava is directly indicated in the treatment to Panduroga, Agnimandya, Krimi and Kushta. Likewise the Kumariasava is indicated in Agnimandya and bleeding disorders. This formulation showed excellent result in patient’s haematological parameters (Table 7).

After that, for Shodhan of body Snehanpan was given by Panchatikta Ghrita contains (Table 3 ) Panchtiktagana dravays like Patol (Luffa acutangula), Neem (Azardirachta indica), Guduchi (Tinospora cordifolia), Vasa (Adhatoda vasica), Vyaghari (Solanum xanthocarpum) and ghee. All contents are having Tikta Rasa, Ruksha and Laghu Guna. It mainly acts on Kleda, Meda, Lasika, Rakta, Pitta and Shleshma which help in balancing and correcting vitiated Doshas and Dhatus. It has Dipana, Pachana, Stroto Shodhaka, Rakta Prasadan, Rakta Shodhaka, Kandughna, Kushthaghna and Varnya properties (Shukla & Tripathi, 2009). Ghrita used in formulation has lipophilic action which helps in carrying drugs to a target organ. This lipophilic nature of Ghrita facilitates entry of drugs into the cell and its delivery to mitochondria and nuclear membrane; it also helps in restoring the normal texture of skin (Shukla & Tripathi, 2009).

Marichyadi Tail (Mishra, 2006) is used for external application which contains the drugs (Table 15) having Katu, Tikta, Kashay Rasa and Ushna Virya causes Kaphavata shaman. It has Raktashodhaka, and Kushthaghna propertities.

Then Vamana procedure was done by Madanphala, Vacha, Saindhav etc. (Table 4) helps in eliminating aggravated Dosha mainly Kapha and Pitta from the Amashaya. The drugs used for Vamana possess Ushna, Tikshna, Sukshma, Vyavayi and Vikasi properties which help to enhance their absorption and reach to the Hriday. From Hriday they move through Dhamani to all Sthula (macro) and Sukhma (micro) Srotas (channels). Vamanaopag Dravyas acts on microcellular level and helps in eliminating the toxins from the body. It strengthens the immune system and helps in preventing relapse. Ushna property of Vamak Dravyas results in liquefication of accumulated Doshas, Teekshna Guna causes separation of adherent Doshas from Sthula and Sukshma Strotasa and brings these doshas to Aamashaya. Vamak drugs have predominance of Agni and Vayu Mahabhuta hence they have Urdhavbhaghara Prabhava which ultimately leads to migration of Doshas in upward direction and eliminated through mouth, an upper part of the body. This detoxification was assessed by Samyaka Vamana Lakshana (Table 6) which results in elimination of root cause of disease.

https://typeset-prod-media-server.s3.amazonaws.com/article_uploads/88ca8ee6-fe70-4e8e-aaf4-33fe8b312c51/image/4fd84db0-7818-4788-a938-4cfab26e13de-upicture1.png — **Figure 1: Effect of Ayurveda modalities on disease Shwitra (Before and after treatment)**

Shodhan procedure was followed by Samsarjan Karma and Shaman Chikitsa (Table 5) with continuation of some previous given medicines along with some poly herbal syrup (syrup Lukoskin) and polyherbal ointment (lukoskin ointment) which contains Vatsanabha as main drug having properities like Dipan, Pachan, Strotoshodhana, Raktashodhaka, Krimighna and Tridoshahara, being Laghu, Ushna and Tikta, Katu in Rasa it specially act as a Kapha-Vataghana. Along with Vatsabhabh, Bakuchi, Kumari etc (Table 13; Table 12) and the drugs of Tablet pigmento which contains Abrak Bhasma, Loha Bhasma, Chitrak, Triphala etc ingredients are depicted in Table 11 (selfgrowth.com t/t of lecoderma) all the drugs of this poly herbal products having the properities like Depan, Pachan, Anulomana which improves the function of GIT system, also the drugs having special property of Kushtaghna and Krimighna which were helps to reduce the symptoms of disease like Shwitra as shown in Figure 1 .

Conclusions

The lesion or white patch which was present below the left eye of 15 year old female patient was fully recovered after 5 months of treatment and also her menses becomes regular and the hb% was increased by 1.4 gm% by Ayurveda modalities like Shodhan and Shaman Chikitsa.

Acknowledgement

I acknowledge the full cooperation and encouragement of my husband Dr. Sourabh G. Deshmukh HOD & Associate Professor, Department of Kayachikitsa, MGAC for sparing his precious time. The endless support he has bestowed upon me has been the guiding force behind me. His dedication to work and amazing foresight made this study a success and it will always inspire me in all my future endeavors.

Funding Support

This study did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Conflict of Interest

Both authors declared no conflict of interest.

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