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\begin{document}


\def\RunningAuthor{Trupti Thakre and Sourabh Deshmukh}
\firstPage{4790}
\articleType{Case Report}
\receivedDate{26 Apr 2020}
\acceptedDate{13 Jun 2020}
\revisedDate{02 May 2020}
\journalVolume{2020, 11}
\journalIssue{3}
\journalDoi{ijrps.v11i3.2773}
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\title{\textbf{A Case Study to Evaluate the Treatment of \textit{Shwitra} with Ayurveda Modalities}}
\author{Trupti~Thakre\textsuperscript{*}\textsuperscript{1}, 
            Sourabh~Deshmukh\textsuperscript{2}~\\[5pt]{\textsuperscript{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 {\textendash} 442001}~\\{\textsuperscript{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 {\textendash} 442001}}

\begin{abstract}
In Ayurveda all the skin diseases are explained under the term Kushtha. The references of \textit{shwitra} are found in almost all the Samhitas like Bruhatrayees and Laghutrayees. In \textit{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 \textit{shwitra}. A female patient, aged 15 year suffering from white patch below the left eye since 3year was treated with both \textit{Shodhan} and \textit{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 \textit{shwitra.}
\end{abstract}\def\keywordstitle{Keywords}

\begin{keywords}Vitiligo,\newline Shodhan and Shaman,\newline Shwitra
\end{keywords}
\twocolumn[ \maketitle {\printKwdAbsBox}]
\makeatletter{\raggedright\textsuperscript{*}Corresponding Author\par Name:\ Trupti~Thakre~\\ Phone:\ +917020299894~\\  Email:\ truptithakre555@gmail.com
        \par}\vspace*{-11pt}\hrulefill\par{\fontsize{12}{14}\selectfont ISSN: 0975-7538}\par% 
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\section{\textbf{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. 


\begin{table*}[!htbp]
\caption{\boldmath {Showed internal medication with local ointmentin first sitting } }
\label{tw-8f79e9d74e78}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.0754\linewidth-2\tabcolsep}p{\dimexpr.2046\linewidth-2\tabcolsep}p{\dimexpr.14\linewidth-2\tabcolsep}p{\dimexpr.14\linewidth-2\tabcolsep}p{\dimexpr.14\linewidth-2\tabcolsep}p{\dimexpr.16509999999999998\linewidth-2\tabcolsep}p{\dimexpr.1349\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}S. No & Name of Medicine & Dose  & Route & Anupan  & Time & Duration\\
\tblmidrule 
1 &
  \textit{Ampachana vati } &
  250mg  &
  Oral &
  Lukewarm water &
  1 tab. Twice/day before meal  &
  5days\\
2 &
  \textit{Krimikuthar rasa } &
  250mg  &
  Oral &
  Lukewarm water &
  1 tab. Twice/day after meal &
  5days\\
3 &
  \textit{Bakuchighanvati } &
  250mg  &
  Oral &
  Lukewarm water &
  1 tab. Twice/day after meal &
  7days\\
4 &
  \textit{Lohasava } &
  20ml &
  Oral &
  Lukewarm water &
  Twice/day after meal &
  15days\\
5 &
  \textit{Khadhirarishta } &
  20ml &
  Oral &
  Lukewarm water &
  Twice/day after meal &
  15days\\
6 &
  \textit{Pigmento ointment} &
  q.s &
  LA &
   &
  Twice a day after bath &
  1month\\
7 &
  \textit{Kumariasava} &
  20ml &
  Oral &
  Lukewarm water &
  Twice/day after meal &
  15days\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}
As per the symptomatology of disease vitiligo, the clinical condition can be compared with disease \textit{shwitra} (white color patch). In Ayurveda the \textit{shwitra} is a disease explained in \textit{khshudrkushta}. It is also called as \textit{Kilas, Daruna, Aruna, Shwetakushta}\unskip~\citep{819008:19635635} etc. it explained in almost all the Brihatrayees and Laghutrayees. In Charak Samhita while explaining the \textit{Nidan } of\textit{ shwitra} Acharya Charak has explained \textit{virudha ahar vihar } (unbeneficial foods) and \textit{paap karmas } (bad deeds) are the main cause of \textit{shwitra}\ensuremath{^{}}\unskip~\citep{819008:19635637}. This produces the imbalance of \textit{Doshas} (body humours) like \textit{Vata, Kapha} and \textit{Pitta} specially \textit{Bhrajak Pitta} which helps in the formation and maintain the color of skin. These \textit{Doshas} are vitiated along with \textit{Rasa, Rakta,, Mamsa} and Meda Dhatus\unskip~\citep{819008:19635641} (body tissues).


\begin{table*}[!htbp]
\caption{\boldmath {Showing Dose, Route, Kala and \textit{Anupan} of drugs used in \textit{Purvakarma }of \textit{Vaman }} }
\label{tw-ac2d7ba91918}
\def\arraystretch{1.1}
\ignorespaces 
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\tbltoprule \rowcolor{kwdboxcolor}S.No & Name of Medicine & Dose  & Route & Anupan & Time & Duration\\
\tblmidrule 
1 &
  \textit{Trikatu churna } &
  3gm  &
  Oral  &
  Lukewarm water &
  Before meal &
  3 days from 21/2/19 to 23/2/2019 \\
2 &
  \textit{Panchatikta Ghrita } &
  1\ensuremath{^{st }} day -30 ml \mbox{}\protect\newline 2\ensuremath{^{nd}} day -60 ml \mbox{}\protect\newline 3\ensuremath{^{rd}} day -90 ml \mbox{}\protect\newline 4\ensuremath{^{th }} day -120 ml \mbox{}\protect\newline 5\ensuremath{^{th}} day -160 ml \mbox{}\protect\newline 6\ensuremath{^{th }} day -180 ml &
  Oral  &
  Lukewarm water &
  Early morning at 7 am &
  24/2/19 to 1/3/19\\
3 &
  \textit{Sarvanga Abhyanga }with \textit{Marichadi tail } followed by\ensuremath{^{}} \mbox{}\protect\newline \textit{Sarvanga Swedan} &
  q.s &
  External Application &
   &
  A day before and on the day of \textit{Vamana}. &
  2/3/19 and 3/03/2019\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

    
\section{Material and Methods}
\textbf{Aim }

To study the case of \textit{Shwitra} through Ayurveda

\textbf{Objective }

1. To study the role of Ayurveda in management of \textit{Shwitra. }

2. To study the disease \textit{Shwitra} in detail. 

\textbf{ Case Report}

 A 15 Y/F patient came at OPD in our Ayurveda institution Maharashtra with the complaint of White coloured patch (\textit{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\ensuremath{^{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. 

\textbf{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.

\textbf{Personal History}

\textit{\textbf{Aharaja}} \textbf{\space }

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

\textit{\textbf{Viharaj}}

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

\textbf{Examination}

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

\textit{\textbf{Ashtavid pariksha}} \textbf{\space }

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

\textbf{Diagnosis}- \textit{Shwitra }

\textbf{Treatment protocol}

\textbf{Total duration }

5 months

\textbf{Treatment given}

Shaman Chikitsa \unskip~\citep{819008:19635648} and Shodhan Chikitsa (Vaman) \unskip~\citep{819008:19635655} was given.

\textit{\textbf{Shodhan Chikitsa}} \textbf{\space }

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


\begin{table*}[!htbp]
\caption{\boldmath {Showing ingredients and properties of formulations used in \textit{Purvakarma} (\textit{Deepan, Pachan, Abhyanga \& Swedana})} }
\label{tw-dc74785b0b27}
\def\arraystretch{1.1}
\ignorespaces 
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\begin{tabulary}{\linewidth}{p{\dimexpr.1266\linewidth-2\tabcolsep}p{\dimexpr.2082\linewidth-2\tabcolsep}p{\dimexpr.37129999999999995\linewidth-2\tabcolsep}p{\dimexpr.2939\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}S.No & Name of medicine & Ingredients & Properties and Use\\
\tblmidrule 
1 &
  \textit{Panchatiktaghrita} \mbox{}\protect\newline \textit{(Snehapan)} &
  \textit{Nimba, Patola, Vyaghri, Guduchi, Vasa, Triphala {\textendash} Haritaki, Vibhitaki, Amla, Ghrita} &
  \textit{Dipana, Pachana, Amapachaka, Strotoshodhaka, Raktaprasadan, Raktashodhaka, Kandughna, Kushthaghna }and \textit{Varnya.}\\
2 &
  \textit{Marichadi tail} \mbox{}\protect\newline \textit{(Abhyanga)} &
  \textit{Krishna Marich, Haratala, Manshila, Musta, Arkadugdha, Ashwamara, Jatamansi, Nishotha, Gomayarasa, Indrayana, Kustha, Haridra, Daruharidra, Devadaru, Shwetachandan, Gomutra, Sarshptaila.} &
  \textit{Raktashodhak, Vranropak, Twachya, }useful in skin diseases\textit{. Dadru, Shwitra, Kushtha}\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Showing ingredients and properties of drugs used in \textit{Vamana Karma}} }
\label{tw-bd9f5a58afd5}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.1012\linewidth-2\tabcolsep}p{\dimexpr.30390000000000004\linewidth-2\tabcolsep}p{\dimexpr.2234\linewidth-2\tabcolsep}p{\dimexpr.1715\linewidth-2\tabcolsep}p{\dimexpr.20\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}S.No & Name of Ingredients & Latin name & Dose & Properties \\
\tblmidrule 
1 &
  \textit{Madanphala Churna} &
  Randia dumetorum &
  3gm &
  \textit{Vamanaopag}\\
2 &
  \textit{Vacha Churna} &
  Acorus Calamus &
  5gm  &
  \textit{Vamanaopag}\\
3 &
  \textit{Saindhav Lavan} &
  Rock Salt &
  5gm  &
  \textit{Abhishyandi, Shodhak}\\
4 &
  Honey &
   &
  25 ml &
  \textit{Abhishyandi, Yogavahi}\\
5 &
  Milk  &
   &
  2500 ml &
  \textit{Vamanaopag}\\
6 &
  \textit{Yashtimadhu phant} &
  Glycyrrhiza glabra &
  1000 ml &
  \textit{Vamanaopag}\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}
\textit{\textbf{Paschayat karma}}

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


\begin{table*}[!htbp]
\caption{\boldmath {After \textit{Shodhan} of body, \textit{Shaman Chikitsa} was given as follow} }
\label{tw-9cec6b934be4}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.08669999999999998\linewidth-2\tabcolsep}p{\dimexpr.23330000000000002\linewidth-2\tabcolsep}p{\dimexpr.16\linewidth-2\tabcolsep}p{\dimexpr.16\linewidth-2\tabcolsep}p{\dimexpr.16\linewidth-2\tabcolsep}p{\dimexpr.20\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}S. No & Name of Drug  & Dose & Anupan  & Time & Duration\\
\tblmidrule 
1 &
  \textit{Bakuchighanvati} &
  250mg &
  Lukewarm water &
  Twice a day after meal &
  2 months \\
2 &
  \textit{Lukoskin Ointment} &
  Q.S &
   &
  Twice a day after bath &
  2 months \\
3 &
  Syrup\textit{ Lukoskin } &
  2 ml &
  Lukewarm water &
  Twice a day after meal &
  2 months \\
4 &
  \textit{Lohasava} &
  20ml &
  Lukewarm water &
  Twice a day after meal &
  15days\\
5 &
  \textit{Tab. Pigmento } &
  250mg &
  Lukewarm water &
  Twice a day after meal &
  15days\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Assessment of \textit{Samyaka Vamana }} }
\label{tw-c23188d539ee}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.118\linewidth-2\tabcolsep}p{\dimexpr.282\linewidth-2\tabcolsep}p{\dimexpr.20\linewidth-2\tabcolsep}p{\dimexpr.20\linewidth-2\tabcolsep}p{\dimexpr.20\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}S.No & \textit{Mainiki} (measurement) \mbox{}\protect\newline Intake \& Output & Antiki (Procedural Inference) & Vegiki (No. of Vega) & Laingiki (Symptoms)\\
\tblmidrule 
\textit{Vamana} &
  2500 \mbox{}\protect\newline 3100 &
  \textit{Pittantak Vamana} &
  8 &
  \textit{Kaphachadrika} present in vomitus and no bleeding was seen\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Showing haematological parameters of patient} }
\label{tw-23a8a2460c5e}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.0995\linewidth-2\tabcolsep}p{\dimexpr.28369999999999997\linewidth-2\tabcolsep}p{\dimexpr.2168\linewidth-2\tabcolsep}p{\dimexpr.20\linewidth-2\tabcolsep}p{\dimexpr.20\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}S.No  & Haematological parameters & Before treatment (15/1/19) & \textbf{Before Vaman procedure} \mbox{}\protect\newline \textbf{(8/2/19)} & \textbf{After treatment} \mbox{}\protect\newline \textbf{(4/4/19)}\\
\tblmidrule 
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\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}
\textit{Bakuchi }is classified under tikta skandha \unskip~\citep{819008:19635643}  in Charaka Samhita, \textit{Katuk varga}\ensuremath{^{}}\unskip~\citep{819008:19635642} in Sushruta samhita, \textit{Shaka varga} in Ashtanga samgraha as \textit{Rasayana} in Ashtanga hridayam\ensuremath{^{}}\unskip~\citep{819008:19635640} \textit{Kushthaghna} (Leprosy destroyer\textit{), Jantughna} (Insecticidal), \textit{Deepana} (Appetizer\textit{), Pachana} (Digestive\textit{), Anulomana} (Laxative), \textit{Krimighna} (Germicidal), \textit{Yakridottejaka} (Choleretics), \textit{Kaphaghna} (Expectorant), \textit{Swedajanana} (Diaphoretics\textit{), Pandu} (Anaemia), \textit{Twaka roga} (In Skin Disorders) are the therapeutic properties of \textit{Bakuchi}\unskip~\citep{819008:19635652}.


\begin{table*}[!htbp]
\caption{\boldmath {Showing Ingredients of \textit{Khadirarishta }} }
\label{tw-4fad14a89a7b}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.1375\linewidth-2\tabcolsep}p{\dimexpr.4534\linewidth-2\tabcolsep}p{\dimexpr.4091\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}S. No & Ingredients  & Botnical Name\\
\tblmidrule 
1 &
  \textit{Khadira } &
  Acacia catechu\\
2 &
  \textit{Devadaru } &
  Cedrus deodara \\
3 &
  \textit{Bakuchi} &
  Psoralea corylifolia\\
4 &
  \textit{D\textexclamdown rv\textcent  } &
  Berberis aristata \\
5 &
  \textit{Triphala (Haritaki, Bhibitaki and Amalaki)} &
  Terminalia chebula, Terminalia belerica, Emblica officinalis\\
6 &
  \textit{Makshika } &
  Honey \\
7 &
  \textit{Sharkara } &
  Sugar cane\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Ingredients of Lohasava } }
\label{tw-9b04837bb174}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.15220000000000002\linewidth-2\tabcolsep}p{\dimexpr.5078\linewidth-2\tabcolsep}p{\dimexpr.34\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}S.No & Ingredients  & Botnical Name\\
\tblmidrule 
1 &
  \textit{Loha } &
  Iron dust\\
2 &
  \textit{Trikatu (sunthi, maricha, pipali)} &
  Zingiber officinale , Piper nigrum , Piper longum\\
3 &
  \textit{Triphala (Haritaki, Bhibitaki and Amalaki)} &
  Terminalia chebula, Terminalia belerica, Emblica officinalis\\
4 &
  \textit{Makshika } &
  Honey \\
5 &
  \textit{Vidanga } &
  Embelia ribes\\
6 &
  \textit{Musta } &
  Cyperus rotundus Rz.\\
7 &
  \textit{Chitrak } &
  Ricinus communis\\
8 &
  \textit{Dhatki} &
  Woodfordia fruticosa\\
9 &
  \textit{Guda } &
  Jaggery \\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Showing Ingredients of \textit{Kumariasava }} }
\label{tw-e4df8d2524cd}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.1438\linewidth-2\tabcolsep}p{\dimexpr.5162\linewidth-2\tabcolsep}p{\dimexpr.34\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}S.No & Ingredients & Botnical Name\\
\tblmidrule 
1 &
  \textit{Kumari Rasa } &
  Aloe barbadensis\\
2 &
  \textit{Madhu } &
  Honey \\
3 &
  \textit{Jatipatra } &
  Myristica fragrans\\
4 &
  \textit{Karkatshringi} &
  Pistacia integerrima\\
5 &
  \textit{Pushkarmoola } &
  Inula racemosa\\
6 &
  \textit{Lavanga } &
  Syzygium aromaticum\\
7 &
  \textit{Dhatki } &
  Woodfordia fructicosa\\
8 &
  \textit{Bhibitaki } &
  Terminalia belerica\\
9 &
  \textit{Kankola } &
  Piper cubeba\\
10 &
  \textit{Jatamasi } &
  Nardostachys jatamansi\\
11 &
  \textit{Tamra bhasma and Tamra Loha } &
  Calcined Tamra and Calcined Lauha\\
12 &
  \textit{Kababaka} &
  Piper cubeba\\
13 &
  \textit{Chitrak } &
  Ricinus communis\\
14 &
  \textit{Cavya } &
  Piper retrofractum\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Showing Ingredients of Tab Pigmento } }
\label{tw-4740550e9c9d}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.12079999999999998\linewidth-2\tabcolsep}p{\dimexpr.48480000000000004\linewidth-2\tabcolsep}p{\dimexpr.3944\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}S. No & Ingredients & Botnical Name\\
\tblmidrule 
1 &
  \textit{Abrak Bhasma } &
  Mica calx \\
2 &
  \textit{Loha bhasma } &
  Iron calx \\
3 &
  \textit{Tamra bhasma } &
  Copper calx \\
4 &
  \textit{Hingula } &
  Cinnabar \\
5 &
  \textit{Shilajatu } &
  Asphaltum \\
6 &
  \textit{Kajjali } &
  -\\
7 &
  \textit{Triphala (Haritaki, Bhibitaki and Amalaki)} &
  Terminalia chebula, Terminalia belerica, Emblica officinalis\\
8 &
  \textit{Chitrak } &
  Plumbago zeylancia \\
9 &
  \textit{Latakaranja } &
  Caesalpinia bonduc \\
10 &
  \textit{Ritha } &
  Sapindus mukorossis\\
11 &
  \textit{Kasmarda } &
  Cassia occidentails \\
12 &
  \textit{Yavakshara } &
  Hordeum valgare \\
13 &
  \textit{Yashada bhasma } &
  Zinc calx \\
14 &
  \textit{Trayamana } &
  Gentian kurroo\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Showing Ingredients of Syrup Lukoskin } }
\label{tw-5b3afacf8573}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.1647\linewidth-2\tabcolsep}p{\dimexpr.35940000000000005\linewidth-2\tabcolsep}p{\dimexpr.47589999999999996\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}S. No & Ingredients & Botnical Name\\
\tblmidrule 
1 &
  \textit{Vatsanabha } &
  \textit{Aconitum Ferox}\\
2 &
  \textit{Bakuchi } &
  \textit{Psoralya Corifolia }\\
3 &
  \textit{Kaunch } &
  \textit{Mucuna Preurinis }\\
4 &
  \textit{Mandukparni } &
  \textit{Cantilla Aciatica }\\
5 &
  \textit{Krishn Tulsi} &
  \textit{Ocimum Americanum}\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Showing Ingredients of Lukoskin ointment } }
\label{tw-bd56c02af342}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.1605\linewidth-2\tabcolsep}p{\dimexpr.4766\linewidth-2\tabcolsep}p{\dimexpr.36290000000000006\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}S. No & Ingredients & Botnical Name\\
\tblmidrule 
1 &
  \textit{Bala Mool} &
  Sida cordifolia\\
2 &
  \textit{Bakuchi } &
  Psoralya corifolia \\
3 &
  \textit{Vatsanabha } &
  Aconitum ferox\\
4 &
  \textit{Ark} &
  Calotropis gigantean\\
5 &
  \textit{Kumari } &
  Aloe vera\\
6 &
  \textit{Chameli Tail} &
  Jasminum officinale olie\\
7 &
  \textit{Til Tail } &
  Sesamum indicum olie\\
8 &
  \textit{Petroleum Jelly/ Cream Base} &
  q.s\\
9 &
  \textit{Babchi Ash} &
  Psoralya corifolia \\
10 &
  \textit{Vish Naag Ash} &
  Aconitum ferox\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Showing Ingredients of Pigmento ointment } }
\label{tw-fdd46576e1f8}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.14170000000000002\linewidth-2\tabcolsep}p{\dimexpr.5811\linewidth-2\tabcolsep}p{\dimexpr.2772\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}S. No & Ingredients & Botnical Name\\
\tblmidrule 
1 &
  \textit{Aritha Beej} &
  Sapindus muKorossi\\
2 &
  \textit{Bavchi Beej} &
  Psoralya corifolia\\
3 &
  \textit{Tulsi Beej} &
  Ossimum scantum\\
4 &
  \textit{Kale Jeerak} &
  Cuminum cyminum \\
5 &
  \textit{Chitrak Mool} &
  Plumbago zeylancia \\
6 &
  \textit{Khair Chhal} &
  Ascasia catecu\\
7 &
  \textit{Neem Beej} &
  Azadirachta indica\\
8 &
  \textit{Erand Beej} &
  Castor seed\\
9 &
  \textit{Sonageru} &
  -\\
10 &
  \textit{Gandhak Shuddha} &
  Purified sulphar\\
11 &
  \textit{Chakra Marda } &
  Cassia torra linn\\
12 &
  \textit{Bavchi Tel} &
  -\\
13 &
  \textit{Butylated Hydroxy Toluene Ip } &
  -\\
14 &
  \textit{Kaolin Light Ip } &
  -\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Showingthe Ingredients of \textit{Marichyadi Tail } used for \textit{Bahya Snehana}} }
\label{tw-f12d6f011364}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.14379999999999999\linewidth-2\tabcolsep}p{\dimexpr.512\linewidth-2\tabcolsep}p{\dimexpr.3442\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}S.No & Name of Drug & Latin Name\\
\tblmidrule 
1 &
  \textit{Marich} &
  Piper nigrum\\
2 &
  \textit{Nagarmotha} &
  Cyperus rotundus\\
3 &
  \textit{Arkadugdha} &
  Calotrpis procera\\
4 &
  \textit{Kanera Mula Twak} &
  Nerium indicum\\
5 &
  \textit{Nishoth} &
  Operculina turpethum\\
6 &
  \textit{Indrayanamula} &
  Citrullus \textit{colocynthis}\\
7 &
  \textit{Kushtha} &
  Saussurea lappa\\
8 &
  \textit{Haridra} &
  Curcuma longa\\
9 &
  \textit{Daruharidra} &
  Berberisaristata\\
10 &
  \textit{Devdaru} &
  Cedrus deodara\\
11 &
  \textit{Raktachandana} &
  Pterocarpus santalinus\\
12 &
  \textit{Vatsanabha} &
  Aconitum ferox\\
13 &
  \textit{Sarshaptail} &
  Brassica alba\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

    
\section{\textbf{Results and Discussion}}
In Ayurveda \textit{Shodhan} is the method of eliminating the \textit{Dosha} from body to pacify the disease. This \textit{Shodhan} when done by unctuous and \textit{Tikshna} (strong) drugs, it cleanses the body. So in the present study, the patient first treated with the medicines including \textit{Dipan, Pachan}, and the drugs which increase the haemoglobin as well as improves the function of uterus was given (Table~\ref{tw-8f79e9d74e78}). Then after that \textit{Dipan, Pachan } and \textit{Abhyanga } should be done as \textit{Purvakarma } (Table~\ref{tw-ac2d7ba91918} \textbf{) } of \textit{Shodhan} (purification) procedure. In \textit{Shodhan,} Vaman \unskip~\citep{819008:19635639} (expelling the impurities o.e vitiated dosha through the upper channel) procedure was done followed by \textit{Samsarjan Krma } and then \textit{Shaman Chikit}sa was given for 2 months with the follow up at every 15\ensuremath{^{th}} day in between.

\textit{Agni} is said to be the accountable for \textit{Varna} (complexion) and \textit{Sukhayu} (healthy life). \textit{Mandagni }\textit{(loss of function of  Agni)} is considered as root cause of all the diseases \unskip~\citep{819008:19635644}. \textit{Mandagni} cannot form enough \textit{Rasa Dhatu} (nutrition) which provides nutrition for further \textit{Dhatus} and the person gets easily diseased. In Ayurveda some medicines found which helps in maintaining the normal state of \textit{Agni }\textit{like }Ampachan Vati \unskip~\citep{819008:19635656} which contains \textit{Katu} drugs like \textit{Chitraka, Pipalimula, Ajvian, Shudh Javakhar, Sunth, Chavya, Sajikhar, Shudh Nosager,}\textit{Kalimirch, Pipali, Samudra Namak, Hing, Saindhav} in which \textit{Bhavana} was given by \textit{Nimbu} \textit{Swara}s which is the best drugs for \textit{Dipan} and \textit{Pachan}. As \textit{Krumi} is one of the cause of \textit{Raktadushti } and produce disease like \textit{Pandu} and \textit{Kushta,} here \textit{Krimikuthar Rasa}\unskip~\citep{819008:19635645} was given which contains \textit{Karpoor, Kutaj, Trayamana, Alameda, Vidang, Shuddhga Hingul, Shudder Vatsanabha, Nagkeshar, Palashbeej }in which\textit{ Bhavana } was\textit{\space } given by\textit{ Bhrungaraj Swarasa, Akhuparni Swarasa, Brahmi Swarasa} which helps to rid out of disease. So, first \textit{Amapachana Vati }and \textit{Krimikuthar} rasa was given.

Then \textit{Bakuchighan Vati}\unskip~\citep{819008:19635653} and \textit{Khadirarishta } was advised which is most popular formulation for \textit{Kushta} which contains a single drug \textit{Bakuchi } belongs to Fabaceae family and \textit{Khadira, Devdaru, Triphala} etc respectively are depicted in Table~\ref{tw-4fad14a89a7b}, \unskip~\citep{819008:19635650}. These are the main herbs in traditional Indian herbal medicine for the treatment of skin disorders. It has \textit{Tikta } and \textit{Madhura Rasa } which mitigates the \textit{Pitta Dosha } and \textit{Ushna Virya } alleviates the \textit{Kapha} and \textit{Vata Dosha}. Along with the above drugs poly herbal ointment (ointment Pigmento) was advised which having the main drugs \textit{Arishtak}\unskip~\citep{819008:19635634} and \textit{Bakuch}i along with \textit{Chitrak, Gandhak, Eranda} (Table~\ref{tw-fdd46576e1f8}). These drugs having the properities of \textit{Kushtaghna, Krimighna, Kapha {\textendash}Vata Hara }and \textit{Pandurog Hara}.\textit{\space }

After routine investigation when we came to know about the low hb\% which is one of the causes of irregular menses, the formulation like \textit{Lohasava}\unskip~\citep{819008:19635636} was advised which contain \textit{Loha } and other ingredients which are depicted in Table~\ref{tw-9b04837bb174}. \unskip~\citep{819008:19635647} and \textit{Kumariasava}\unskip~\citep{819008:19635638} contains \textit{Kumari} as the main drug, the detail of herbal constitution of \textit{Kumariasava} has been presented in Table~\ref{tw-e4df8d2524cd} in addition with this drugs having Appetizer, Digestive and Carminative properties. The drugs like \textit{Amalaki} and \textit{Pipali } acts as a \textit{Rasayan} and also having \textit{Panduroghara} properities. \textit{Amalaki} possess antioxidant activity and contain vitamin C which helps for the proper absorption of iron from the gut. Also the \textit{Lohasava} is directly indicated in the treatment to \textit{Panduroga, Agnimandya, Krimi } and\textit{ Kushta}. Likewise the \textit{Kumariasava} is indicated in \textit{Agnimandya } and bleeding disorders. This formulation showed excellent result in patient's haematological parameters (Table~\ref{tw-23a8a2460c5e}).

After that, for \textit{Shodhan} of body S\textit{nehanpa}n was given by \textit{Panchatikta Ghrita} contains (Table~\ref{tw-dc74785b0b27} \textbf{)} \textit{Panchtiktagana dravays} like \textit{Patol } (\textit{Luffa acutangula}), \textit{Neem } (\textit{Azardirachta indica}), \textit{Guduchi} (\textit{Tinospora cordifolia}), \textit{Vasa} (\textit{Adhatoda vasica}), \textit{Vyaghari} (\textit{Solanum xanthocarpum}) and \textit{ghee}. All contents are having \textit{Tikta Rasa}, \textit{Ruksha} and \textit{Laghu Guna}. It mainly acts on \textit{Kleda}, \textit{Meda}, \textit{Lasika}, \textit{Rakta}, \textit{Pitta } and \textit{Shleshma} which help in balancing and correcting vitiated \textit{Doshas} and \textit{Dhatus}. It has \textit{Dipana}, \textit{Pachana}, \textit{Stroto Shodhaka}, \textit{Rakta Prasadan}, \textit{Rakta Shodhaka}, \textit{Kandughna}, \textit{Kushthaghna} and \textit{Varnya} properties \unskip~\citep{819008:19635649}.\textit{ Ghrita } used in formulation has lipophilic action which helps in carrying drugs to a target organ. This lipophilic nature of \textit{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 \unskip~\citep{819008:19635651}.

Marichyadi Tail \unskip~\citep{819008:19635654} is used for external application which contains the drugs (Table~\ref{tw-f12d6f011364}) having \textit{Katu}, \textit{Tikta}, \textit{Kashay Rasa} and \textit{Ushna Virya} causes \textit{Kaphavata shaman}. It has \textit{Raktashodhaka}, and \textit{Kushthaghna} propertities.  

Then \textit{Vamana }procedure was done\textit{\space }by \textit{Madanphala, Vacha, Saindhav } etc. (Table~\ref{tw-bd9f5a58afd5}) helps in eliminating aggravated \textit{Dosha } mainly \textit{Kapha } and \textit{Pitta} from the \textit{Amashaya}. The drugs used for \textit{Vamana } possess \textit{Ushna}, \textit{Tikshna}, \textit{Sukshma}, \textit{Vyavayi } and \textit{Vikasi } properties which help to enhance their absorption and reach to the \textit{Hriday}. From \textit{Hriday } they move through \textit{Dhamani } to all \textit{Sthula } (macro) and \textit{Sukhma } (micro) \textit{Srotas } (channels). \textit{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. \textit{Ushna} property of \textit{Vamak Dravyas} results in liquefication of accumulated \textit{Doshas}, \textit{Teekshna Guna} causes separation of adherent \textit{Doshas} from \textit{Sthula} and \textit{Sukshma Strotasa} and brings these \textit{doshas} to \textit{Aamashaya}. \textit{Vamak} drugs have predominance of \textit{Agni} and \textit{Vayu Mahabhuta } hence they have \textit{Urdhavbhaghara Prabhava} which ultimately leads to migration of \textit{Doshas } in upward direction and eliminated through mouth, an upper part of the body. This detoxification was assessed by \textit{Samyaka Vamana Lakshana} (Table~\ref{tw-c23188d539ee}) which results in elimination of root cause of disease. 


\bgroup
\fixFloatSize{images/4fd84db0-7818-4788-a938-4cfab26e13de-upicture1.png}
\begin{figure*}[!htbp]
\centering \makeatletter\IfFileExists{images/4fd84db0-7818-4788-a938-4cfab26e13de-upicture1.png}{\includegraphics{images/4fd84db0-7818-4788-a938-4cfab26e13de-upicture1.png}}{}
\makeatother 
\caption{\boldmath {Effect of Ayurveda modalities on disease Shwitra (Before and after treatment)}}
\label{f-df59c21fdaed}
\end{figure*}
\egroup
\textit{Shodhan} procedure was followed by \textit{Samsarjan Karma} and \textit{Shaman Chikitsa} (Table~\ref{tw-9cec6b934be4}) with continuation of some previous given medicines along with some poly herbal syrup (syrup Lukoskin) and polyherbal ointment (lukoskin ointment) which contains \textit{Vatsanabha} as main drug having properities like \textit{Dipan, Pachan, Strotoshodhana, Raktashodhaka, Krimighna} and \textit{Tridoshahara,} being \textit{Laghu, Ushna} and \textit{Tikta,} \textit{Katu} in \textit{Rasa} it specially act as a \textit{Kapha-Vataghana}. Along with \textit{Vatsabhabh, Bakuchi, Kumari} etc (Tables~\ref{tw-5b3afacf8573} and~\ref{tw-bd56c02af342}) and the drugs of Tablet pigmento which contains \textit{Abrak Bhasma, Loha Bhasma}, \textit{Chitrak, Triphala }etc ingredients are depicted in Table~\ref{tw-4740550e9c9d} \textbf{(}selfgrowth.com t/t of lecoderma) all the drugs of this poly herbal products having the properities like \textit{Depan, Pachan, Anulomana }which improves the function of GIT system, also the drugs having special property of \textit{Kushtaghna} and \textit{Krimighna} which were helps to reduce the symptoms of disease like \textit{Shwitra } as shown in Figure~\ref{f-df59c21fdaed} \textit{.}
    
\section{\textbf{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 \textit{Shodhan } and \textit{Shaman Chikitsa.}
    
\section{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.

\textbf{Funding Support}

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

\textbf{Conflict of Interest}

Both authors declared no conflict of interest.
    

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