Lecture Note: “Ayurvedic Assessment and Management of Skin Diseases” Part-2

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Ayurvedic Assessment and
Management of Skin Diseases

Part-2

 Prof. Muralidhara Sharma 

based on the lecture available at
Ayurvedic Assessment and Management of Skin Diseases

Cutaneous  lupus erythematosus:

Those conditions having similar features, like Ruksha, Aruna, Parusha, tend to spread haphazardly, and at the same time, have an irregular surface—either it could be raised centrally, or the peripheral area is thin. That’s the important issue. The description of the lesion is much more than what we say as a Macule or papule. In the case of a macule or papule, it gives only changes over the surface. But Sushruta goes to that level where the surface character, like the central area being raised in the middle, and so on, can be perceived after palpating the lesion. This type of feature is often observed in cutaneous lupus erythematosus, and the lesions tend to be symmetrical. So, the distribution of lesions could be haphazard or symmetrical. It is a chronic condition, and it is not an allergic or autoimmune pathology. Very often, the condition would be very chronic, and you may see incidences in the family. And, of course, the outcome would be poor. One day or another, the patient will come to an Ayurveda Physician due to the absence of a definitive solution in contemporary medicine.

It is only suppressive therapy in the form of glucocorticoids. But one of the major risks in these situations is that all these cutaneous erythematosus may also have a tendency to involve other organs, such as renal pathology and cardiac pathology, leading to a worse prognosis. If you have only cutaneous erythematosus and no other systemic involvement, we can manage somewhat with the extra, with Kamdugha, Sarivadyasava considering it as pittaja type, and Kaishor Guggulu is also a choice of drug. Better not to withdraw glucocorticoids if the patient is already on glucocorticoids. But we can taper down the dose of glucocorticoid, and very rarely we may even stop the glucocorticoids. Sudden withdrawal of glucocorticoids can lead to the exacerbation of pathology.

I would like to manage the patient with glucocorticoids, maybe for a long duration, and the duration of treatment could be years or it could be for the whole life. You do not have a definite target for the course of treatment, and there is always a potential risk of involvement of the other systems, and that makes the prognosis poor, hence the need to have an assessment of both functions regularly. Cutaneous manifestations can be managed satisfactorily with these prescriptions.

ततोऽनन्तरं कुष्ठान्यभिनिर्वर्तन्ते, तेषामिदं वेदनावर्णसंस्थानप्रभावनामविशेषविज्ञानं भवति;
तद्यथा- रूक्षारुणपरुषाणि विषमविसृतानि खरपर्यन्तानि तनून्युद्वृत्तबहिस्तनूनि सुप्तवत्सुप्तानि  हृषितलोमाचितानि निस्तोदबहुला
Ch. Ni 5/8

 In the above shloka, apart from appearance and palpation, textual description suggests clinical examination of sensation. When the lesions are presented with numbness or impaired sensation or a constant feeling of pain, that’s often seen in mycobacterial tuberculosis. Occasionally, lepromatous lesions can also show similar features. Either you may have lesions that are small, scattered, haphazard, or there could be an accumulation of lesions in some areas. Now, the characteristic feature is there is no itching, pain is almost not there. But the conditions will persist for a long time, many times discharge is absent, and the role of histopathological or biochemical investigations would be quite useful to confirm the diagnosis. Simple skin scratch and histopathological studies have to be done. Biochemical study to rule out tubercular nature has to be done. But interestingly, in simple cutaneous tuberculosis, you don’t need anti-tubercular treatment. With Kaishor Guggulu, Gandhak Rasayan, Khadirarishta, maybe you may have to have Vamana or Virechana repeatedly, and they can be effectively managed. The condition can be effectively managed. The only point is the duration of treatment is a minimum of a year, quite a long time. Virechana also has to be repeated, but we can effectively manage. So even though there is confirmed tubercular pathology, there is no need for anti-tubercular treatment as long as the lesion is limited only to the skin. Lepromatous lesions also can be effectively managed with a similar treatment. It’s exactly like the Kaphaja  or Kaphapittaja variety.

निस्तोदबहुलान्यल्पकण्डूदाहपूयलसीका
Ch. Ni5/7

You’ll have a relatively lesser amount of discharge; otherwise, the lesion looks similar. You will have local tuberculoid localized lesions, but in typical tuberculosis, there may not be much discharge, and it looks like a shining lesion. However, when the same undergoes necrotic changes, referred to as papulo-necrotic tuberculosis, it is also named as tuberculoid, and there may not be a positive tuberculin test. Confirmation requires the same biochemical tests. Occasionally, the tuberculosis organism can also be seen, and usually, the Mantoux test will be highly positive in this condition, while in the previous condition, the Mantoux test is often negative.

When the titre level is high, it will be papulo-necrotic tuberculosis. Characteristically, the lesion will be painless, with the presence of thick discharge that doesn’t get squeezed out but continuously oozes out. The patient’s clothes get spoiled with discharge, but after trying to squeeze, there will be no discharge. These conditions may require antitubercular treatment. It is the same tuberculosis, but when it is present with ‘toda Bahula’ or ‘Alpa kandu Daha puya lasika,’ it makes the prognosis difficult. Therefore, without antitubercular treatment, it is challenging to manage. Patients with tuberculosis of the skin from ayurvedic point of view  will  have  two sets of prognoses: in one set, we can manage it without the support of tubercular treatment; in another condition, it may be required. Patient  may  requires antitubercular treatment; otherwise, lesions may continue to extend.

Keratosis  Pilaris

Now, in addition to these lakshanas, you will have features of Dushita loma when there is involvement of the skin with discoloration, and the surface may be raised. At the same time, there is an involvement of the hairs. Now, this exactly the same description can be seen in Keratosis Pilaris, which is a non-infective pathology, often a genetic disorder, and very often seen in young age and children. They will have thick, scaly skin, something different from ichthyosis. Hairs tend to be broken, and the number of hairs will be lesser, and virtually, there will be no curative treatment anywhere. Kumkumadi lepa often helps in reducing visible deformity, and the patient’s skin may look somewhat better with Kumkumadi lepa; otherwise, I don’t prescribe any specific medicine. There will be no other symptoms; very occasionally, the patient may have hypersensitivity to sunlight. After exposure to sunlight, the patient may have more scratching lesions, and even discharge could occur. Visibly, that produces a significant deformity.

A lesion that is Ruksha, Arun, Parush, and the course is very rapid, and the surface becomes irregular is a typical feature that can be seen in acute contact dermatitis with lichen. It is similar to erythema multiforme in the initial stage, but patients often apply medicine over the skin, and most of the time, the application of substances over the primary erythema turns into lichen formation. Even without applying anything, lichen formation can occur. Actually, it is an extension of the primary erythema; lichen formation starts with thickening, then the formation of thick plaques, getting separated, and some discharges may be there, and it becomes chronic. At that time, virtually there is no curative treatment in contemporary medicine. The application of Malahar followed by improper washing of Malahar, or casual cleaning of Malahar can turn into lichen formation. After a few months of such application, you will have a concrete type of layer. In such conditions, Kamadugha or Manjishthadi can help because of Pittaja lakshna, i.e., paka lakshna comprising Ashu paka and Ashu bheda. It has a tendency for sepsis; in that condition, we can modify the treatment. In such  condition Triphala kwath parisheka is the first choice of treatment. I generally don’t advise any ointment over there. It is only cleaning with kwatha that responds very well to the treatment. The duration of the treatment is unpredictable, but usually, the patient responds very well within 2 to 3 months. It is observed that the application of cosmetics can precipitate the lichen formation. I have seen a patient with a history of repeated application of lactocalamine and developing lichen formation. After stopping applying lactocalamine, the patient got significant relief.

रूक्षारुणपरुषाणि विषमविसृतानि खरपर्यन्तानि तनून्युद्वृत्तबहिस्तनूनि सुप्तवत्सुप्तानि हृषितलोमाचितानि निस्तोदबहुलान्यल्पकण्डूदाहपूयलसीकान्याशुगतिसमुत्थानान्याशुभेदीनि जन्तुमन्ति कृष्णारुणकपालवर्णानि च कपाल
Ch. Ni 5/7

The lesion, which is Ruksha, Arun, Parusha, and additionally presents symptoms of blackish color, the area becomes a plaque that lichen and cutaneous plaques. It is also not a disease of specific origin; most of the time, it is secondary to infective lesions or hypersensitive reactions. The exact causes are not known. The prognosis is poor. Patients may not bother unless the lesion becomes extensive. This condition can have a significant clinical impact with Kaishor Guggulu, Khadirarishta, and Gandhak Rasayana, considering it as a Kaphaja Kushtha variety.  Repeated Virechana  is also advised.

Pittaja Kushtha lakshnas

ताम्राणि ताम्रखररोमराजीभिर

  When the color is reddish and there is a tendency to have brittle reddish hairs, it is a feature of purpura. Purpura lesions can have varied reasons, which could include leukemia, idiopathic thrombocytic purpura, etc., where the prognosis is poor. In cases where there is no thrombocytopenia with a normal platelet count, and still the patient has purpura, that is idiopathic purpura. In the case of thrombocytopenic purpura, the treatment will not be on the line of simply Kushtha. Many times, treatment can be complex. Even in non-thrombocytic purpura, although causes like renal disease or consuming drugs have to be ruled out, if the onset of purpura is after consuming some particular drug, then management becomes easier. Dapsone, which is a very commonly prescribed drug for leprosy, can produce purpura. After starting Dapsone, patients tend to develop acute lepromatous crisis or purpura as a complication. Naturally, this produces some confusion in the patient, and the patient can migrate from one physician to another. One variety of purpura is Henoch-Schonlein purpura, which is a vascular phenomenon and autoimmune disease where we can manage better. Management would include Kaishor Guggulu, Kamdugha, Manjisthadi kwath.

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