“Ayurvedic Assessment and
Management of Skin Diseases”
Part-4
Prof. Muralidhara Sharma
based on the lecture available at
Ayurvedic Assessment and Management of Skin Diseases
Another variation is ‘Bahu kleda kandu krimini’, where the patient would have more of the discharge and itching or even the risk of Krimi. This is very typically seen in case of Pemphigus. Now, Pemphigus has mainly two varieties: Pemphigus vulgaris, which is an autoimmune disorder with a totally different prognosis, and Pemphigus of a secondary origin produced often due to drugs. Then there is another variation, Pemphigoid. These three are always confusing ones. The issue arises when a Pemphigus is produced due to an external agent, either a drug or at times food.
It is common that when a patient is administered a specific drug, within 3 or 4 days, the patient tends to develop these bullous lesions. It is not rashes, and characteristically, these Pemphigus-induced effects would not involve the mucosa itself. It is always in the keratinized area. Maximum it may come to the kerato-mucous junction at the lip, but not beyond that. Whereas, typical Pemphigus vulgaris has a higher chance of involving the oral mucosa.
So, that is one of the important issues. Otherwise, it may look similar, with bullous lesions occurring rapidly and it may even be a self-limiting disorder. Whereas, Pemphigus vulgaris has a poor prognosis.
Comparatively, the distribution of these drug-induced Pemphigus is also limited to a certain area of the body. It is not throughout the body. Whereas, typical Pemphigus vulgaris can spread throughout the body and produce a very ferocious presentation. We may discuss the Agni Rohini later. So, that difference has to be kept in mind.
So, that kind of a relatively minor variety of Pemphigus, there is no specific word in the textbook like a minor Pemphigus. I use that word. The major variety of Pemphigus which is often produced with drugs, and again the commonest drug which induces this kind of a complication is Penicillin. It is the commonest. When I say this, it is not only Penicillin, it could be many other drugs, but one of the common conditions is Penicillin. These can be comparatively easy to match.
The only important thing is to differentiate it from Pemphigus. Pemphigus has a very serious prognosis, whereas Pemphigus due to the drug-induced condition has a relatively easy treatment outcome. Many times, even without treatment, it may heal. But the critical point is to differentiate it from the other parts and identify the real cause of it. If you know that exact cause, I think the treatment is going to be simpler. It is not termed as allergy; it is termed as a hypersensitivity reaction. Though the phenomena are very much similar, again I will not go into the theoretical issues of that differentiation.
Another variation of the Kaphaja variety of the Kushtha is ‘Saktigaati samuthanbhedini’, where the lesions would not result in a complete disruption of the skin surface. It is limited to the deeper area of the skin. That word of Sushruta is very important: Saktigaati. The tracts of the lesions are covered and occasionally the tracts may rupture, that is typical of the subcutaneous mycosis, a comparatively rare condition. But you may have a few patients presenting with this feature, a variant of the mycetoma, a superficial fungal infection, where you will have multiple tracts opening and then the discharge will occur. Whereas in a subcutaneous mycosis, it is a single fungal lesion, but they do not rupture easily. The patient will not have severe pain, often dull pain, and the skin looks rough, irregular like at the area. Rarely, occasionally it may rupture and produce some ulcers. Ulcers could be quite prolonged, unlike that of mycetoma where you will have a small opening with multiple tracts. It may tend to result in a wider ulcer till that whole lesion is opened out, and the condition tends to be very chronic. Prognosis also is poor. The outcome is not definite and usually, again, one way or another, the patient would come for Ayurvedic treatment and so on because you do not have a satisfactory treatment anywhere. My preference would be the same as the mycetoma because from my point of view there is a Kaphaja of variety. The only thing is the prognosis is unpredictable. Some of the patients show some satisfactory response, some may not. So, it is very difficult to predict exactly what would be the outcome.
Then another typical picture of a Kaphaja kustha is a Parimandala, the circumscribed lesion. That is a very perfect word which is used in contemporary terminology as the ringworm, tinea corporis. That is a very similar issue, where the lesions are circumscribed, and characteristically you will have the lesions which are expanding towards the periphery. There is always a central zone of clearance; in the central area, there will be no lesions left over. I think that is again a very common condition. Patients tend to have this kind of symptoms quite frequently and a well-publicized disease like, almost if you go to any public toilet, you will have advertisements for certain lotions.
Because that is the point where people will be aware of the lesion. As long as it is covered, they may not feel the itching. But once it is exposed and handled, they start itching there and then naturally that is the area where patients will remember that they have a lesion. Important is those conditions also, we will have to rule out the systemic pathology. Many times, it could be the underlying systemic pathology which causes it.
Hygienic conditions also are the other critical issues and the chance of the treatment would be again the same: Gandhaka Rasayana, Laghu sutashekhar, Khadirarishta. Maintenance of hygiene with Malahara is one of the critical issues. If we are sure about that, Karpooramalahar could be one of the drugs which could be used. Triphala kwatha can be used for cleaning purposes. Of course, lots of patent drugs are available in the market with the specific target of this ringworm treatment. Like most of those drugs would have a keratinolytic content like salicylic acid and they may produce relief temporarily. But in the long run, they are the reason for the lichenification. So better not to use so-called keratolytic substances. I am not suggesting any specific name as such, but in the market, it is very popular and very often it is a branded drug site targeted for ringworm. You have to have salicylic acid with content. Salicylic acid is primarily a keratolytic substance and which could be used in hyperkeratotic lesions but not in the lesions with the keratin tissue break off. So better, I would not give and many times the patients will be using those. I would advise them not to use that because temporarily the patient may have the relief. But in the long term, it will be like lichenification, the whole keratin tissue becomes thickened, hardened, and then it will be quite difficult to manage.
The other feature is ‘Parushani Arunavaranani’. That is exactly the point, like hyperkeratosis, hyperkeratosis is another very troublesome condition. It could be due to the same issue, like a keratolytic substance used regularly can be a cause for the hyperkeratosis or other causes such as friction over the area. It could be seborrheic; seborrheic is an inflammation of the sweat glands. Psoriasis also can present as hyperkeratosis and there could be plenty of other causes. So, differentiation of that would be the real cause of the hyperkeratosis itself is one of the troublesome conditions. Many times, the causes are more critical issues than really the treatment. Keratolytic ointments have been suggested as either a treatment or they could be many times the cause of that, so it is a very difficult issue. If there is a feeling like you can help in keratolysis, I would not use any of those so-called keratolytic ointments. Instead, a simple aspirin tablet, crushed with coconut oil applied over the area can be good in making those lesions softer. It should not be continued for a long duration, maximum one week. Once the lesion has become softer, then we treat with Arogyavardhini, Sarivadyasav or in children, I would prefer Aravindasawa as a choice of the treatment. With that, we can have a significant lesion, but the next important part is the identification of the causes of the hyperkeratosis. Hyperkeratosis also can have a variation in the presentation. The first hyperkeratosis which I have suggested is that the skin has become thickened at a smaller area and the location is very clearly seen, whereas a similar issue presented with the ‘Bahirant shyava’, where the colour is somewhat bluish and it tends to spread throughout the body and that is the typical lesion in the case of the variant of the hyperkeratosis, where the metabolic causes are the real causes. The causes are very difficult to identify, many times it comes as vitamin deficiency, many times it could be due to the abnormal synthesis of the keratin itself and that is the Figel’s disease where a metabolic pathology a complex issue.
Now, whatever the efforts you make to make the diagnosis, you make the name of, give the name of Figel’s disease, next there is nothing else to be done, so not much to be done as such. So, see such patients usually they get adjusted to that, they will have that thick skin, rough and moderate itching, and usually they are adjusted to medical treatment. I would not prefer more than any of these severe issues, occasionally I may suggest the patient to use simple tila taila regularly and which can help in lesions also.
A localized single lesion with hyperkeratosis could be angiokeratoma, a single lesion, when it is multiple throughout in Figel’s disease, virtually there is no medical treatment, whereas hyperkeratosis occurring due to angiokeratoma like it is usually congenital pathology, where there would be a blood vessel and then around that there will be keratin tissue, which is often confused with a wart unlike that of the wart, which is very hard and rough, Angio keratosis would be somewhat smoother and it will have a reddish or a bluish colour, suggestive of the vascular and in Angio keratosis, the simple treatment of excision is a better choice than any of the local treatment. Local treatment would never dissolve the condition and any local treatment can produce a disruption and complication of the sepsis, so better to have a total surgical excision than the other way.
The other variation of the Kaphaja variety, where you will have these lesions‘Nila peeta tamravabhasani ashugati samuthanani kandu kleda krimini’. In this variation, you will have a rapid course, and the total course of the disease would having a somewhat ferocious presentation with ulcerative lesions. Until you have Alpa kandu kleda krimini, this is again not a very rare condition. Often, the patients may present with relatively painless, milder symptoms,and either it can present as ulceration. The whole area of the ulcers looks very somewhat disturbed with a blackish, brownish color and the surface would be irregular. Though the surface is irregular and looks ferocious, the patient would not have much of pain. So, a relatively painless, ferocious-looking ulcer is always dangerous. You will have to be very careful. I am not saying that every ulcer of that sort is a Verrucous carcinoma, but when the ulcers are ranged at, when you have irregular surfaces, chances are that it is a Verrucous carcinoma. Histopathological study is mandatory for any of those ulcers. Rather, the rule is, if it is a painless ulcer, histopathological study is mandatory to confirm the diagnosis. The incidence of Verrucous carcinoma is more common in the oral area and it is locally malignant and produces large destruction of the tissues. Hence, early surgery is always a better option than prolonging the condition. I would suggest surgery as the better option. At times, when the surgery produces more deformity, you may have to have a reconstructive follow-up also. Plastic surgery may be required in that condition.
Another variation of the same condition is when the skin thickness hardens and the surface becomes rough, known as acne keratosis. Acne keratosis is comparatively rare, but it can often lead to misleading conditions. What you typically observe is some discoloration and roughness, which the patient can feel in the affected area, often in exposed parts like the head or forehead. Patients may mistakenly consider this as a sun rash, which we typically associate with severe sunlight exposure or prolonged exposure to sunlight during specific seasons like April and May. However, unlike typical sun rashes that are temporary and last for a few days or months, acne keratosis lesions persist regardless of exposure and are more prominent in exposed areas like the face and hands.
Actinic keratosis, a precancerous condition, shares similar characteristics but is difficult to manage. While there’s no curative treatment for actinic keratosis, identifying it early can help in reducing the course of the disease with chemotherapy, thus lessening the clinical burden. Therefore, I do not recommend curative treatment for actinic keratosis. When a patient presents with actinic keratosis, I typically refer them to an oncologist. Initially, the disease may seem manageable, but it can progress rapidly, leading to complications. Hence, it’s crucial to avoid the critical course of the disease. This is how I usually manage cases of actinic keratosis; I don’t suggest any specific management for acne keratosis.
‘Shuka Upahata Upamam Vedanani Utsannamadhyani’ refers to a condition where the patient experiences a sensation of pain resembling a moving worm over the area, and the lesion has a raised surface in the middle, typical of a bullous lesion. This description aligns with contemporary medicine’s characterization of bullous lesions. Among these, one type is epidermolysis bullosa, which presents with single lesions. It’s crucial to differentiate between different causes, locations, and presentations of bullous lesions.
Intraepidermal lesions typically have a relatively transparent surface, whereas deeper lesions like junctional epidermolysis bullosa may have a thicker, opaque surface. While there may be similarities in pathology, the prognosis can vary. For instance, junctional epidermolysis bullosa often presents with dystrophic syndromic symptoms, indicating a tendency for renal pathology involvement. Moreover, secondary infections are common complications, initially appearing manageable but flaring up suddenly due to secondary infection. The infective organisms can vary widely, and antibiotic therapy may be challenging due to resistance.
I don’t recommend any specific line of treatment due to the unpredictable outcome. Management often involves monitoring and adjusting treatments as needed. Response to treatment varies among patients. Epidermolysis bullosa cases occur frequently and patients often seek treatment from various healthcare providers, including dermatologists. Given the complexity of managing these conditions and the variable response to treatment, I refrain from suggesting a specific treatment approach for epidermolysis bullosa.
