Lecture Note: “Ayurvedic Assessment and Management of Skin Diseases” Part-3

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Ayurvedic Assessment and
Management of Skin Diseases

Part-3

 Prof. Muralidhara Sharma 

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

The one more variation in that particular variety, as per the text, is in addition to that ‘Tamrani tamra khar romaraji bhi avanbaddhani bahalani’, where there would be local oedema; that is exactly what we call as angioedema. Angioedema is again a hypersensitivity reaction. So, it can present with the angioedema. Angioedema comes in various degrees; many times, it could be very temporary, transient. Many people might have experienced, for example, if something stings, temporarily for 1 or 2 days, you may have swelling and then it subsides. At times, it may occur without specific causes. It may subside spontaneously or it may persist for a bit longer time; when the oedema involves the larynx, it can even be fatal. So, that angioedema is very difficult to predict; that word is not really sufficient to express the total outcome. It depends upon a vast assessment of the patient’s condition.

 Now, the important thing is that if the patient presents with angioedema, the most important thing is, we will have to rule out that laryngeal oedema. If there is any adventitious respiratory sound, it will be difficult to manage, so the patient needs acute observation. At times you may need ventilatory support also may be required, so that is a condition where you have to be very careful. If there is not much of that risk of laryngeal oedema, the rest of the conditions, of course, we can manage very well safely, so the most important part is to rule out that involvement of the respiratory tract, the laryngeal oedema has to be ruled out, once the patient has laryngeal oedema, then unless there is ventilatory support, it may be difficult to make the patient survive, it can go to that extent, where it can be fatal even.

If there are no such laryngeal oedema features, it can be definitely managed with the Laghu Sootashekhara, Punarnava mandoora, and Manjishtadi kwatha. Primarily it is a Sheetapitta ,kaphapittaja vyadhi and the treatment will be exactly the same line as we treat with the Sheeta Pitta.

In case of ‘bahu bahala puyalasika’, a Pittaja variety, may present without having reddish (tamra varna) coloured lesions; instead, the patient may present with pus discharge. Primarily, at the onset itself, there could be pus or the spread is wide throughout the body; that is typical of auto eczematisation, also called Id reaction, which is often again produced due to lots of causes. You will have plenty of patients presenting with sudden developing scratches and within a few days, you will have lots of rashes over the area, discharges also, itching, and burning sensation, both would be the presentation. The important point is that it is difficult to make out the diagnosis; the exact cause would be very difficult and many times you need to have an elaborate assessment. Conditions like autoimmune pathology and tubercular pathology, they may not respond very well to only our treatment. Autoimmune pathology becomes very chronic and once it is confirmed, so many times that histopathological diagnosis, the tissue study would be very critical. But once we have ruled out those serious conditions, moderate infectious conditions or simple contact irritation conditions, they can be managed very well with our treatment like Kaishora Guggulu, Gandhak Rasayana, and Khadirarishta. But the most important, the critical part is to rule out the other causes, when the patients come to having treatment done elsewhere, chronic long-term patients and then move from one to the other doctors, right, then you will have higher chances of having these complications either autoimmune or tubercular. Fresh cases, chances of having infectious or contact irritation are higher, but that is one area where your clinical assessment is very critical, if you miss that clinical assessment, many times the prognosis is unpredictable, so one of the danger areas.

The other is ‘Kandu kleda kotha daha pakavanti ashuagati Samuthana’. Even in the case of the Pittaja vyadhi, there could be Kandu as a clinical symptom, as well as Kleda, the discharge and necrosis would be more and the course of the disease is very rare; that is exactly the pyoderma gangrenosum. Pyoderma gangrenosum is again, though not very rare and very often it occurs in the patients who have other systemic illnesses like diabetes mellitus; they tend to develop these pyodermas as a complication. In that condition, the most important part is to rule out diabetes or any other immune suppressive disorders and usually because the course is rapid, I would always prefer to use an antibiotic course. Usually, my choice would be of lesser variety, the older variety of antibiotics; without that, it will be difficult to manage because the damage to the tissue would be very rapid. Within a few hours, it tends to extend; the necrosis will be quite a few, but once that is under control, the part of the healing, it can be better managed with the treatment like Kaishora Guggulu, Gandhak Rasayana, and Khadirarishta and Triphala Kawatha parisheka. The point is about the clinical assessment and the identification of the condition.

The conditions which will present with ‘Sasantap krimi’, the severe pus and even chances of maggot formation, this also is a pyoderma. In the pyoderma, you may have that kind of situation where the patient may even have maggot formation. Very often, maggot formation with pyoderma could be due to underlying leprosy; leprosy patients tend to develop this as a complication. So, we have to rule out all that and in all that condition, once the patient has maggots, there is not much reason to worry too much about that. Maggots are the cleaners; they are better than any surgeon as they debride the wound and they are more efficient than any skilled surgeon. So, the only thing is you have to control, you have to see that the maggots do not proliferate to that extent where they produce significant damage and the usual treatment for maggots is turpentine and so on; the maintenance of hygiene is the most important part. Once you have maintained hygiene and the wounds tend to get a cleaner appearance, then the treatment is not much difficult; it has to be the treatment of any other vrana or if the patient has a lesion like leprosy, then you may need to have the same approach, whether it is anti-leprosy treatment drug or not is the next part, but otherwise a maggot-induced condition in the skin, they are also common, though not very rare; they are common and another important part is about hygiene. Patients who do not maintain hygiene also tend to develop maggots. With maggots, we need not worry too much; the only thing is they need to be controlled.

Another variant of the Pittaja variety is ‘Pakva Udumbara Phala Varnaani, oudumbar kushthani’; these are the varieties of the Pittaja Lakshanas, these are very obviously the cutaneous abscesses. Cutaneous abscesses, very often people use the common word like Romukari, which is a common word used in the local language, is a variation of folliculitis. Folliculitis usually presents as a papillomatous eruption, whereas when it has become a septic focus, it becomes somewhat pus-like, with pus and quite painful. And the treatment would be as in any other vrana; it is the same treatment. Dashanga lepa may be required in the initial stages, if the patient has come in the initial stages; later it is the same, Triphala Kwath Parisheka, Triphala Guggulu, Gandhaka Rasayana. Asanadi Kwatha if necessary, internally or may be locally. And many times, these also are the effect of other unhygienic practices or may be systemic disorders, like diabetes mellitus, also need to be ruled out. So, once you have these kinds of septic focus it needs to be ruled out and the outcome is comparatively easier, there is not much of a very significant issue about that; it can be managed somewhat better.

Kaphaja  Kushtha

The Kaphaja variety of the Kushtha, thet is the ‘Snigdhani Guruni Utsedhvanti’ It is the exact feature of cutaneous calcinosis, where there could be calcinosis, calcium tissue deposited in the skin and many patients, they do not have any symptoms as such, except a palpable rough or harder nodular lesion over the area. When it occurs in the hands or some other sensitive areas of the body, then the patient may be worried about that, otherwise generally does not require any treatment. Causes, of course, once a patient has calcinosis, it may be at times, it could be evidence of systemic malignancy. Now, one of the issues which I will discuss at the end would be the systemic disorders presenting with the local clinical symptoms, calcinosis also can be a sign of malignancy, paraneoplastic syndromes and that the only thing which has to be ruled out, of course, the incidence of that would be less common. If you have ruled out, naturally calcinosis does not require any specific treatment, if it is in a sensitive area like the tip of the fingers, it may require surgical removal, but surgical removal also has some risks as such, so better not to intervene, best of the treatment, I would not suggest any treatment for the calcinosis, I advise the patient just leave it as such, if it is in a sensitive area like the tip of the finger, which can affect the day to day function, surgical treatment is one of the options, but in the fingers if you do the surgery also, there is a possibility of a hypersensitive tip at the end, so it could be often more troublesome than having the calcinosis, so choice is depend, it is a very difficult, say like exact what should be the line of the treatment, the best of the option is not to intervene, that would be best of the option as such.

  Another variation of the Kaphaja variety is a ‘shlakshana sthir pitaparyant’ where the harder button-like lesion, but the surface is smooth and that tends to be having a thicker discharge, that is typical of the keratoacanthoma. Now again, a misleading condition, the patient may have this and you have a larger number of patients presenting with the type of lesion, but there could be some local swelling, which is persisting for years together, at times the patient may say that it is there since birth, at times it could be later and virtually does not produce much of a symptom, except repeated episodes of some discharge and the discharge should be hard, thick as of yellowish, they tend to subside many times, the whole thing gets closed, then again disrupts, so this may occur spontaneously and unless it is in the cosmetically visible area, many of the patients may not really report about that, they may not say anything about that, only when it is in the area like the face or so, they may be worried about, otherwise generally patients may try to conceal or some of the patients will be sensitive about that, the only important issue is when you palpate that, you will feel that borders are very clean, you can feel the borders very clearly, there will be no induration, the whole lesion can be somewhat easily moved as such and when you squeeze, you will have thick discharge and with a drop of blood, then it subsides and simple squeezing can temporarily produce a resolution, it looks like the whole thing has stopped, but it will not heal completely that tends to recur, it is typical of a keratoacanthoma, a benign tumour, but rarely  it could be a sign of malignant, so I would not suggest any medical treatment in that, the treatment would be simple excision, and histopathological study would be a safer option, though it may not be having a malignant every time, chances of having malignancy can also have to be considered, so I would not suggest any medical treatment in that condition, it is primarily a surgical condition.

Another variant of the Kaphaja variety, ‘shukla raktavbhasa’, where either the colour would be whitish or reddish, these are typical of the discoid lupus erythematosus. Now, lupus erythematosus can present with various clinical presentations, the classical clinical presentation if you read in the text is a butterfly wing shape discoloration, but it is not need not be only the butterfly, you will have many other creatures coming in. And the occasionally a discoid variant can present with the hardening of the skin and very often in the palmar area, thicker areas of the body, either palmar or the plantar area, where you will have circumscribed region with a thick elevated border, I think that feature is clearly seen in the image and the central area would be reddish in colour, but there will be no discard, scales are seen only in the periphery. So, these scales are very typical, a lupus scales are seen only in the borders, in the central area there will be no scales as such and that kind of a distribution is a very classical of course, when it comes to the Kshudra roga, Sushruta has used that word that is again we will come to that part also later, but I think I like to refer that issue also, Sushruta has used the word like ‘padma pushkara vata’, the description is compared to a pond of lotus flowers, pond of lotus where the lotus flowers would be seen in the new flowers would be seen in the periphery, the central area you will have old flowers which are just getting somewhat worn out or may be the area would be somewhat flatter ,that kind of an appearance which is expanding peripherally, that is the typical feature there and that is the typical feature of the discoid lupus .

In such conditions also, it is important that we have to rule out the systemic pathology. Renal function studies, cardiac function studies are important, if there is an involvement of them, naturally the skin lesion would be secondary, the primary target would be those functions. In the absence of those systemic pathologies, we can manage the patients with the typical the same Kaishor Guggulu, Laghu Sutashekhara, Khadirarishta. Virechana also can help in a large number of patients and it is the whole issue is from the clinical point of view, it is important to differentiate it from the psoriasis.
Psoriasis is another very common condition which presents with a similar issue, but in the psoriasis it may not be limited only to palmar or plantar area, whereas in discoid lupus erythematosus, these are limited to that hyper keratinized area, thickening area as such and the psoriasis lesions would not remain in the same area for a long time, there will be a distribution across, whereas the discoid lupus erythematosus, it limits to the same area for a quite a long duration that is about the clinical. Of course, at times you may need histopathological study to confirm that, histopathology can confirm or differentiate between a psoriasis where the vascular changes in the keratinase plane can be easily made out, so at times we may require the investigations to confirm the diagnosis, otherwise many times it can be a clinical diagnosis.

Another variant of the Kaphaja lakshana, and there the features are the ‘shukla romaraji santanani’, where there would be a paler colour and there is an involvement of the hairs, it is not only the skin as well as the hair, which tend to involve and that is typical of Pityriasis alba, a very common condition, many patients would have this, usually the local word is shibba, and the same features are described in different names like kilasa, shwitra, these are the different names, that depends upon the course of the disease. If it is a simple Pityriasis alba, there could be the important feature there is no palpable sign, it is only the pale colour at the area, patient may have only the itching as a symptom, sensations are not altered, any patient with a pale patch, the most important part would be to assess the sensation, if the sensations are altered, you have to be very cautious, it could be the involvement of some of the other conditions like leprosy which is common, then other conditions have to be ruled out.

If it is not that, then the condition is going to be easy to be treated, outcome would be relatively good, I would prefer Kaishora Guggulu, Gandhak Rasayana, Khadirarishta, local applications of course, they do help like karpuramalahara does help, but the same issue, whether the patient can maintain the hygiene or not is the most important issue, I would not suggest as a standard line of the treatment, local applications, instead the internal medications would help. The other important part is to differentiate it from the usual deficiency disorder, which also can present in the patches, whitish patches, deficiency disorders very often produced due to worm infestations, patients having the worm infestations, they tend to develop these pale patches and the characteristic is that pale patches produced due to that deficiency disorder, they would not have itching as a symptom, there is only the pale patches and these pale patches, they tend to be migrating from one area to another, initially the pale patches will be seen in area, next day the patient may see in patches somewhere and so on, it may not be constantly at the same area. Whereas, in pityriasis alba the lesion would be constant, it may spread from one to the other, but the previous lesion would remain as it is not migrating sort of lesion and there is a tendency for the hairs to be more, either the hairs are lost or they are bigger, at times they could be discoloured, whereas in the deficiency disorder that is not seen and in the case of deficiency disorder induced that discolouration, treatment is, it is always better than anti-inflammatory, I would prefer a Krimi kuthara Rasa as the one, first course of the treatment, then it could be any Varnayam should be like Manjiasthadi, which would be useful, then it is not to be considered as a Kushta variety, but that is one of the important issues, which you have to rule out, for a patient it could be Shibba only, but we need to differentiate between those conditions. Of course, the other t theory in case of deficiency disorders, they are more common in the area, where the skin is exposed, like more common on the face or other areas, whereas Pityriasis alba, it can be spreading throughout, but more common in the areas, where the skin is covered, because of the collection of the sweat and so on, so many times it could be in the genital area, axilla, that the lesions are more focused in case of Pityriasis alba, whereas deficiency disorder often are seen in the face or hands and so on, that is how it can, it is another of the feature by which you can differentiate, but still in a patient with a pale face, that needs to be ruled out.

The similar lesions of Kaphaja variety, where patients could have pale scars and they tend to have ‘bahu bhahala shukla picchila sravi’, there is a tendency for thick and whitish discharge presenting over the area, that is very often seen as cutaneous mycetoma. These lesions are quite common now, these days the incidence is rapidly increasing and many times we consider this as a cause of unhygienic factors, but it happens in many of the patients who are on prolonged antibiotic therapy for any other reason. Irrespective of the causes, they may develop one of the complications, which is cutaneous mycetoma. Once there is a fungal infection, it tends to produce multiple openings throughout, many times we may have confusion with osteomyelitis. Otherwise, the appearance looks very often like an osteomyelitis lesion and the only difference is, unlike osteomyelitis, if you put a probe, the probe does not go in anywhere, the lesion is limited only to the subcutaneous plane and the condition tends to become very chronic. Now, some of the, of course, though the incidence is comparatively lesser in our area, the Madura foot we can in those areas where it is endemic, also can present with a similar presentation, only in that condition you will have that worm presented throughout in that wound as a steady worm, which can be seen, but comparatively in our it is rare, but once the lesion occurs, it tends to become chronic and virtually it is very difficult to manage, the disease tends to be chronic and none of the treatment will produce a complete resolution .There is no satisfactory treatment anywhere and from our point of view also, we can produce a satisfactory result, I do not say that the patient will be completely cured, but the patient would have a definitely better outcome, course of the disease can be easily controlled with a prolonged treatment of Kaishora Guggulu, Gandhak Rasayana, Khadirarishta. Virechana is another option, depending upon the patient’s fitness or other factors, repeated virechana also can produce a significant change in the outcome of the disease type.

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