Ayurvedic Management of Vicharchika vis-à-vis Atopic Dermatitis: A Case Report
Correspondence Address :
Dr. Vaibhavi Chitmulwar,
Postgraduate Scholar, Department of Kayachikitsa, Mahatma Gandhi Ayurved College, Hospital and Research Centre (DMIHER), Salod, Wardha-442005, Maharashtra, India.
E-mail: chitmulwarvaibhavi91@gmail.com
In this fast-paced developing world, regular day-to-day activities like diet and sleep are neglected, leading to various skin disorders (Kushtha). Kushtha is a generalised term used for all skin diseases in Ayurveda. It is mainly divided into two types: Maha kushtha and Kshudra kushtha. Vicharchika is a type of Kshudra kushtha characterised by symptoms like blackish discolouration (Shyava varnata), vesicles (Pidika), discharge (Strava), and itching (Kandu), which can be correlated to atopic dermatitis/eczema. There is no adequate treatment to cure the root cause in contemporary medicine other than topical steroids and antihistaminic agents. The main treatment protocol according to Ayurveda involves the use of both purification (Shodhana) and palliative treatment (Shaman chikitsa). A 21-year-old female patient presented with small blackish papules on both upper limbs, oosing, and itching on the lesions. She was given medication for both internal use and external application, resulting in significant improvement in symptoms. The patches resolved, and the discharge, itching, and vesicles disappeared.
Kshudra kushtha, Maha kushtha, Papule, Shodhana, Shyava varnata
A 21-year-old female patient presented in the Outpatient Department (OPD) of Kayachikitsa with complaints of small blackish papules oosing from both upper limbs (at the palmar aspect of the forearm) for the last six years. The condition was associated with itching at the site. During examination, she mentioned that the itching was more intense at night, leading to the oosing of clear fluid from the lesions. There was no history of any skin disorders in the family. The patient had been diagnosed with bronchial asthma 10 years ago and was on regular medications, including inhalation of Salbutamol respules once a day. Her bowel habits and urination were normal. She experienced loss of appetite and disturbed sleep due to excessive itching. The patient noted that consumption of oily, spicy, salty, and sour foods, sesame (Tila), black gram (Masha), jaggery (Guda), milk (Dugdha), garlic, indigestion, heavy physical exertion, and exposure to extreme heat worsened the symptoms. On examination, the lesions appeared grouped, circular, 3-4 cm in size, rough in texture, salmon pink in colour with crusts, itching marks, and no associated bleeding, while the surrounding skin was brownish-black. The presence of Pidika (papules), Shyavata (blackish discolouration), Kandu (itching), Bahustrava (copious oosing), and Rukshata (dryness) (Table/Fig 1) led to the diagnosis of Vicharchika (atopic dermatitis), and a treatment plan involving both Shodhana (purificatory management) and Shamana chikitsa (palliative management) was devised. All routine haematological investigations were within normal limits, and all vitals were stable (Table/Fig 2). A second follow-up was scheduled after one month.
Dermatological Examination
On the initial examination, the skin over the mouth, scalp, nails, trunk, and lower body appeared normal. However, lesions were discovered on both upper limbs (palmar aspect of the forearm) ranging between 3 to 4 centimeters in size. The lesions were salmon pink in colour, round in shape, grouped, symmetrically distributed, and had a crusty texture.
Systemic Examination
• system: Chest is bilaterally symmetrical, with no abnormal sounds heard.
• Cardiovascular system: S1S2 normal.
• Musculoskeletal system: Superficial and deep reflexes are intact.
• Gastrointestinal system: Soft, non tender, non palpable.
Samprapti Ghataka (Elements of pathogenesis)
Dosha- Tridosha (predominantly Kapha Pitta)
Dushya- Rasa, Rakta
Strotas- Rasavaha, Raktavaha
Strotodushti- Vimargagamana
Vyadhimarga- Bahya
Doshagati- Tiryaka, Vriddhi
Agni- Manda
Udbhavasthana- Aamashaya
Vyaktasthana- Twaka
Swabhava- Chirakari
Treatment Plan
When the patient first visited the OPD, she was not willing to undergo Shodhana Chikitsa (purificatory management). Therefore, only Shamana Chikitsa (palliative management) (Table/Fig 3) was planned.
During the first follow-up after 15 days, improvements were noted in the size and texture of the lesion, along with a reduction in itching. Consequently, the patient agreed to undergo Shodhana (purificatory management) (Table/Fig 4). A second follow-up was scheduled after Samsarjana Karma (dietary regimen) (Table/Fig 5). These medications are indicated in Kushtha (skin disorders) (Table/Fig 6) (1),(2),(3),(4),(5),(6).
After completing Shodhana Chikitsa, a seven-day Samsarjana Karma (dietary regimen) was prescribed to normalise the appetite. Therefore, the second follow-up was conducted after 15 days.
Diet and Hygiene
Considering the Dosha predominance, the diet was tailored to pacify the primary vitiated Dosha. Foods such as hot and spicy items like chilies, garlic, and raw onions, excessive salt, fried food, sour fruits, fermented foods like curd, pickles, and yogurt, ice cream, cold drinks, nuts, and strong tea were restricted. The patient was advised to consume nutritious, easily digestible foods such as masoor dal, moong dal, khichadi, seasonal fruits, and so on. Additionally, maintaining proper hygiene was also emphasised.
The patient presented with Pidika (papules), Shyavata (blackish discolouration), Kandu (itching), Bahustrava (copious oosing), and Rukshata (dryness). These parameters were graded as 0, 1, 2, and 3 (Table/Fig 7). After 15 days, there was significant improvement in Kandu, Strava, and Rukshata, and the patient was able to sleep properly. By the end of Vaman Karma (1 month), marked improvement in the signs and symptoms was observed. During the third follow-up (Table/Fig 4), which was after three months of complete treatment, all symptoms had completely resolved (Table/Fig 8),(Table/Fig 9).
The skin, the largest organ of the body, serves as a vital barrier between the body and the external environment, protecting it from various physical, biological, and chemical threats. It is more than just a protective cover, as it encounters a high volume of pathogens at the interface between the torso and the surroundings (7). Skin disorders are prevalent worldwide due to increasing neglect of diet, sleep, and elevated stress levels resulting from work pressure. Dermatitis encompasses a broad spectrum, with erythematous rashes ranging from minor to severe forms (8),(9). Eczema is triggered by delayed hypersensitivity reactions from the adaptive immune system, which targets infected host cells, activating other immune cells to produce cytokines that cause an inflammatory response (10),(11). Eczema can manifest as acute or chronic, depending on the severity of the antigenic response (12).
When Vicharchika is analysed in terms of causative factors (Nidana), prodromal symptoms (Purvarupa), clinical features (Rupa), pathogenesis (Samprapti), and management (Chikitsa), it is undoubtedly correlated with atopic dermatitis. The Charak Samhita describes Vicharchika as pruritic, oosing, and black pimples (13), while the Sushruta Samhita characterises it as extremely painful and itchy (14). According to Ayurvedic classics, Vicharchika is a Kapha Pradhana Tridoshaja Vyadhi (15) that affects Rasa, Rakta, Mamsa, and Kleda in the form of Dushya as it progresses (16). Key features include Pidika, Shyavata, Kandu, Lichenification (Raji) (17), Pain (Ruja), Copious oosing (Bahustrava) (18), and excessive dryness (Rukshata). The fundamental cause of all disorders is a decrease in the metabolic process (Agnimandya) (19).
Vicharchika, as a Kaphaja condition according to Acharya Charak, involves Kapha aggravation and accumulation in the Annavaha Strotas, obstructing the Rasavaha and Raktavaha Strotas and eventually settling in the Mamsavaha Strotas, leading to itching, swelling, and exudation. Charakacharya categorises all skin disorders as Sannipataja, but the variation in clinical presentation depends on the dominance of a specific Dosha. Kushthas with similar causative factors have distinct presentations based on colour, symptoms, type of pain, name, effects, and treatment, determined by the association, variation, and location of Doshas (20). The initiation of Dosha accumulation and vitiation begins in Rasa Dhatu, progressing to Rakta Dhatu, which affects and enlarges the Rasa, Rakta, and Mamsa. The course of Vicharchika involves multiple Doshas and Dhatu involvement, making the process complex. Evidence indicates that Rakta Dushti is a major contributing factor to skin issues (21).
Vicharchika occurs due to an adulterated lifestyle and dietary habits that lead to afflicted digestion and the aggravation of Kapha Dosha (22). Similarly, allergic conditions are one of the leading causes of Atopic Dermatitis. In present case study, the contents of Arogyavardhini vati act as Vata-reducing agents (Vata shamaka) and Kapha-reducing agents (Kaphaghna) that help reduce symptoms like Kandu, Shyavata, and Rukshata. This herbomineral formulation decreases the symptoms of Kushtha (Kushthaghna) but also acts as Deepaka, Pachaka, and Malashodhaka. It is hence, accountable for Agnideepana, Kushthaghna, Shodhana, and Dosha Shamana. Takzema cream is a non steroidal, herbal topical remedy for eczema. Its contents have inflammatory and immunomodulatory properties which reduce symptoms like Rukshata, Kandu, and scratching of skin. It exhibits antimicrobial properties that help in wound healing and prevent infections. It is also an antioxidant that protects skin cells and strengthens skin barrier functions. Its antibacterial and antifungal properties make it an effective microbial agent (22),(23). A 777 oil has moisturising ability that helps reduce dryness, keratinocytes, irritation, and softens the skin. Shodhana has been given great importance in the treatment of Kushtha. So, for purgation (Nitya Virechana), to attain purification of the GIT (Koshtha Shuddhi), Haritaki churna was administered for seven days. Panchtikta ghrita has contents that are spicy (Katu), bitter (Tikta), astringent (Kashaya), sweet (Madhur), light (Laghu), cool (Sheeta), dry (Ruksha), oily (Snigdha), and hot in potency (Ushna Virya) that help in Tridosha Shamana. The pacification of Vata Dosha helps in reducing Rukshata and Shyavata. Pacified Pitta Dosha decreases Pidika and Strava. The reduced Kapha Dosha helps in decreasing Kandu. Marichyadi taila contains drugs that calm the Vata Kaphaja conditions, which include Vrana, Kushtha, Vicharchika, among others (23).
Taila (Sneha) is considered one of the best for Vata Kaphaghna Twak Vikara due to its cleansing and wound-healing (Vrana Shodhaka) properties, according to the treatment protocol (Chikitsasutra) of Kushtha. It is a wonderful antioxidant (Rasayana), antiseptic (Vishghna), cleanser (Shoshaka), and antihelminthic (Krimighna), making it highly in demand for Vicharchika. Cutis cream, a herbal preparation, contains mostly antifungal content, thereby acting as a broad-spectrum agent against bacteria and fungi. P-sora powder contains drugs possessing properties like Kanduhara, healer (Ropana), and Kushthahara. Hence, when used with Gomutra Arka, it yielded marvelous results in reducing symptoms like Kandu, Rukshata, and scratching of the skin (22),(23). Gomutra is termed as a medicine in almost all classical texts. According to Bhavaprakash, it is Vishghna and Rasayana, rejuvenating the old, purifying the blood (Rakta Shodhaka), and curing all skin issues. The contents of Patolakaturohinyadi Kashaya, being Rakta Shodhaka and containing Tikta Rasa, aid in Rakta Dhatu formation. It is also Kushthahara, making it ideal for use in most skin disorders, as in present case. Vamana karma was also performed, as it is utilised in all skin disorders. Vamana yoga, consisting of Vacha churna, Pippali churna, Madanaphala churna, Saindhava, and Madhu, is also used in dermatological conditions. Vamana, which induces emesis, helps in detoxifying the body, aiding in reducing the symptoms of Vicharchika in present case study. The Poorva karmas or oleation (Snehana) and steaming (Swedana) provided a Samshodhana effect. The Vamana yoga helped reduce the Kapha Dosha, progressively eliminating the disease. This expulsion of toxins purified the Dushyas of Vicharchika. The therapy contents possessed Krimighna, Kushthaghna, Kaphaghna, and Amapachana properties that reduced the symptoms. The process cleared all the channels (Strotas), improving the nourishment process by clearing the external channels (Bahya Rogamarga) and elevating the sensory effect (Indriya Bala of Twacha), thus eliminating the severity of the disease (23).
There have been many cases (24),(25) reported on the management of Vicharchika, with most of them emphasising Shamana Chikitsa or palliative management. However, as the root cause has not been addressed, the chances of its recurrence are always present. Acknowledging all these factors, a treatment protocol needs to be designed that would eliminate the cause and reduce the chances of recurrence. In the present case study, a detailed dermatological examination of the patient was conducted to identify the Nidana (causative factor), Dosha, and Dhatus involved in the pathogenesis. Since breaking the pathogenesis would eliminate the disease, Shodhana (purificatory procedures) was performed along with internal medications. In the past, most case studies and case series have been published in which the treatment for Vicharchika was given with only internal medication. However, in the present case, the patient was treated with both Shamana and Shodhana Chikitsa to remove the root cause.
Vicharchika, a complex disorder, greatly impacts the quality of life of those affected. Based on the results of present case report, it can be concluded that ayurvedic formulations can help cure such severe dermatological conditions if, drugs are selected wisely, providing a dignified life to patients. Therefore, it can be inferred that internal medicines as per the classical texts of Ayurveda prove to be effective in managing Vicharchika compared to atopic dermatitis.
DOI: 10.7860/JCDR/2024/67529.19194
Date of Submission: Sep 14, 2023
Date of Peer Review: Nov 21, 2023
Date of Acceptance: Dec 26, 2023
Date of Publishing: Mar 01, 2024
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes
PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Sep 15, 2023
• Manual Googling: Nov 29, 2023
• iThenticate Software: Dec 22, 2023 (1%)
ETYMOLOGY: Author Origin
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