AYURVEDIC THERAPIES AND MANAGEMENT
Introduction :
A disease in which the Immune system of the body attacks and destroys the normal cells of the body by producing ‘auto antibodies’ is termed as an ‘autoimmune disease’. Such diseases either occur singularly or as a syndrome or arise as an effect of another autoimmune disease. Currently, almost 80 such diseases have been identified and pose a threat to the health and longevity of an individual.
One such rare but very severe autoimmune disorder is Pemphigus vulgaris which is typically characterized by the outbreak of variable blisters on the buccal and other mucosa, skin and the genitals.
Prevalence and Pathogenesis:
Gender wise, no difference is noted in the occurrence of the disease. However, middle aged or elderly people are predominantly affected, while children are spared.
The epidermal cells bind to each other via proteins thus maintaining the skin continuity. In Pemphigus vulgaris, antibodies are formed by the immune system which destroy this proteinaceous binder. This results in the separation of the epidermal layer of the skin from the deeper layers causing peeling and blister formation.
Clinical Manifestations :
- Clear, soft blisters of variable size
- Peeling off of skin
- Raw, painful erosions/ulcers exposed
- Begin as oral blisters
- Convert into ulcers causing dysphagia
- Spread to throat, skin, genitals etc.
- Resemble burn injuries
- Rapid spread and exudation of fluid
- Chances of infection especially in exposed/eroded lesions
- Hyperpyrexia(on infection)
- Malaise
Diagnosis And Differential Diagnosis:
Skin biopsy is the most important diagnostic tool to identify the disease on the basis of the antibodies present and layers of skin involved.
Pemphigus vulgaris needs to be differentiated mainly from Bullous phemigoid. This too is a more frequently seen autoimmune disorder but is not as fatal. The clinical features are:
- Appearance of bullae or large, oedematous patches on the skin.
- Itching usually noted as a precursor sign
- No widespread skin peeling
- No oral blisters/ulcers
- Usually seen at joints eg. Groin, cubital /popliteal fossae, axilla etc.
Contemporary Management Of Pemphigus Vulgaris:
- Oral / Intravenous corticosteroids
- Dose is tapered off gradually on reduction of symptoms
- If recurrence in symptoms is noted then immunosuppressant are administered eg. Cyclophosphamide, Methotrexate etc.
- Low dose drug and / or steroidal therapy for long duration
- Plasmapheresis-a plasma exchange therapy for blood purification is used to control severe cases by filtration of the antibodies from the plasma
- Local wound care of erosions along with oral antibiotics if necessary
Limitations of Management:
The disease frequently shows no response to the above mentioned line of treatment and
5-15% deaths ensue. Widespread Pemphigus vulgaris is more fatal.
The limitations of the contemporary management of Pemphigus vulgaris give rise to the need of an alternative method of treatment.
Traditional Overview Of Twak Vikara (Skin Diseases) :
Ayurved is a traditional system of medicine stressing on the equilibrium of Dosha, Dhatu and Mala to maintain health and longevity. Any vitiation of one or more of these attributes causes ‘Vyadhi’ or ‘Gada’. Agni plays a key role in the process of health maintenance.
Samdoshaha samagnishcha samadhatu malakriya |
Prasannatmendriya manah swastha iti abhidheeyate ||
( Su.Su.15/41)
SAMPRAPTI OF TWAK VIKARA:
(Pathogenesis of Skin Diseases)
The Twak (skin) has been stated as a Gyanenendriya(sense organ) and the seat of Bhrajaka Pitta. Pitta has an Ashray-Ashrayi Sambandh(Shelter-sheltered relation) with Rakta, so any vitiation in either of the two results in vitiation of the other. The respective aetiological factors stated by the Acharyas are primarily responsible for vitiation of the doshas and dhatus.
Any disease involving the Twak has been indicated to occur due to apathyakara aahar vihar. This results in Agni-Vaishamya, Aamotpatti, Dosha dushti (vitiation) especially Pitta and Rakta. Ayurved has enlisted all Twak Rogas under the aegis of 18 Kushtha (Maha and Kshudra) and visarpa. Of these visarpa is characterized by clinical features similar to those of Pemphigus vulgaris. Besides, a Kshudra Kushtha by the name of Visphota also bears a striking resemblance.
Ayurvedic Correlation of Pemphigus Vulgaris:
Pemphigus vulgaris resembles Visarpa and Visphota as stated by Charaka and Vagbhata. Sushruta has named Visphota as Sthoolaruksha. The symptoms mimic those of the two vyadhis which has been explained earlier.
- Visarpa:
This is an extreme Atyayik Roga that can prove fatal if left untreated. It is said to be caused by the vitiation of the Tridoshas and shows specific variations in the manifestations depending on the Dosha predominance. The types of Visarpa stated in the classics are Vataja, Pittaja, Kaphaja, Sannipatika, Agni, Kardama and Granthi Visarpa.
SAMPRAPTI (PATHOGENESIS) OF VISARPA:
The samanya samprapti of Visarpa involves the vitiation of the Tridoshas by their respective aetiological factors. The vishesh samprapti varies in accordance with the Doshas involved leading to variable manifestations.
Pemphigus vulgaris bears a resemblance particularly to Agni Visarpa wherein vitiation of Vata and Pitta and in turn Rasa, Rakta, Twak, and Mamsa is the reason of Lakshanotpatti. Prakupit Pitta and Rakta cause Aaraktata, Shotha and Pidika.
Lakshanas of Agni Visarpa:
- Spreads fast
- Blisters red in colour
- Burning pain
- Exudation of lasika(fluid)
- Hyperpyrexia
- Lakshan of Agnivaishmya like nausea, vomiting, abdominal discomfort etc.
- Bhrama, Trishna
- Restlessness
Though mild Shotha is noted in Visarpa it is Annunnata ( not easily defined ) in nature. This is similar to Pemphigus vulgaris wherein there may be mild swelling. This also differentiates it from Bullous phemigoid where oedematous bullae are seen as the preliminary symptoms.
- Visphota:
Vagbhatacharya and Charakacharya have stated this Tridoshaja type of Kshudra Kushtha which manifests as vesicles of red black colour with exudation seen all over the body.
Sphotaha shwetarunabhasa visphotaha syuhu……| (C.Ci.7/25)
However, fluid filled oedematous bullae is a symptom that does not simulate Pemphigus vulgaris. Considering the rest of the condition it can be correlated to it for appropriate traditional management that has been stated by Charaka as follows—
Klede prapatati cha angedahe visphotake sa charmadale |
Sheetaha pradeha seka vyadho vireko ghrutam tiktam ||( C.Ci.7/134)
However, visphota has been labeled as Sthoolaruksha by Sushruta and said to be Vata pradhan. Hence this cannot be said to be analogous with Pemphigus vulgaris.
Traditional Management of Visarpa:
Langhanam ullekhanam shaste tiktakam cha sevanam |
Kaphasthangate saame ruksha sheetaihi pralepayet pralepayet ||
(C.Chi.21/44)
- Aama Chikitsa:
Since Aama is the prime cause of vitiation of Doshas, it needs to be destroyed first. This is possible by following these procedures step by step.
- Langhana:
This therapy has a natural autoimmune power enhancing property eg. Manda, Peya etc. but may cause Vata Vriddhi. Hence care needs to be taken to maintain its balance.
- Tikta Sevana:
The best option hence is to use Tikta Rasatmaka Dravyas as these Dravyas also act as Aama Pachana, Pitta Shamana and Rakta Shodhana eg. Musta, Nimba, Guduchi, Katuka, Patola etc.
- Rukshana:
If the Vyadhi is recently formed and shows Saumya Lakshanas then Langhana and Rukshana may be employed eg. Trivrit, Musta, Patola, Amalaki, Shunthi, Lodhra etc.
- Snehapana:
Aamapachana must be followed by Snehapana in the form of Siddha Ghrita. Tikta Rasa Pradhan Dravyas are recommended to prepare the ghrit that help in Pitta-
Rakta Pachan and restore Twak, Mamsa swaroop. Eg. Trayamana Ghrita, Mahatiktaka Ghrita, Triphala Ghrita etc.
- Shodhana:
In case of severe Aamavastha, Shodhana or Doshavasechana is mandatory. This may be done by any one or more of the following methods.
- Vamana
*Nimba, Musta, Patola as per Charaka
*Patoladi Phanta as per Vagbhata
*Madan- Madhuka- Nimba Phanta
*Madan- Patola- Nimba Kwath
- Virechana
This is more useful in initial stages of the disease instead of Vamana. In severe cases should be given after Vamana as a Pitta Dosha Shodhanopkrama.eg.
*Trivrita Ghrita/Ksheer
*Trayamana Ksheer
Virechana Dravyas used in Visarpa are also Tikta Rasa Pradhan and thus act in alleviation of Pitta and its expulsion from the body. Similarly, Tikta Rasa and Virechan Karma both together aid in Shodhana and Pachana of the vitiated Rakta at the same time restoring Agni.
iii. Raktamokshana
Since the vitiation of Rakta is the main factor in samprapti, Raktasmokshana should be employed. Alabu, Shringa or Jalaukavacharan can be used as per Dosha predominance. In Tridosha Dushti, Siravedh can be employed. Like Langhana, Raktamokshana too aids in enhancement of the autoimmune system.
- Sthanik Shodhana:
Prakshalana with Triphala Kwath and regular Vranabandhana with Shatadhauta ghrita may be required in severe Pidika.
E.Shamana:
After Shodhana and Ama Pachana Chikitsa the remaining Doshas can be pacified by Shamana Chikitsa.
Mahatiktaka ghrita, Haridra Khanda Mahamanjishthadi Kwath, Paripathadi Kwath, Eladi Choorna etc. can be administered depending on the symptoms to be alleviated as also to prevent their recurrence or resurgence.
F.Lepa:
Shatadhauta Ghrita, Kasisadi Ghrita, Eladi Choorna may be used to reduce local symptoms and assist in Vrana Ropana amd Twak Prasadana.
G.Pathyakara aahar vihar:
Nidan parivarjan is an essential part of Ayurvedic treatment methodology. Hence consumption of pathyakara aahar and following pathyakara vihar is recommended.