E-ISSN:2456-3110

Case Report

Vitiligo

Journal of Ayurveda and Integrated Medical Sciences

2022 Volume 7 Number 5 June
Publisherwww.maharshicharaka.in

Ayurvedic management of Shwitra (vitiligo) - A Case Study

Patil S.1*, Ashwini S.2
DOI:

1* Sneha Patil, 3rd Year Post Graduate Scholar, Department of PG Studies in Kayachikitsa, A.L.N. Rao Memorial Ayurvedic Medical College & Hospital, Koppa, Karnataka, India.

2 S.G. Ashwini, Assistant Professor, Department of Kayachikitsa, A.L.N. Rao Memorial Ayurvedic Medical College & Hospital, Koppa, Karnataka, India.

Introduction: In Ayurveda all skin diseases are classified under heading Kushta Roga. Shwitra is one among them. Shwitra is a condition characterized by whitish discolored patches on the body, it is caused due to involvement of Sapta Dravyas i.e., Vata, Pitta, Kapha, Rasa, Rakta, Mamsa and Meda. The fourth layer of Twacha (Tamra) mainly considered as prime location of Shwitra. It can be can be correlated to Vitiligo. Vitiligo is a hypopigmentation dermatological disorder, affecting 1% of the population worldwide. Methodology: The present case report is of 63 years old male, came with complaints of whitish discolored patches over bilateral legs (shin aspect) with mild itching and no burning sensation; was effectively treated with Shamana Aushadis initially, followed by repeated Shodhana i.e., with Virechana and Jaloukacharana. Result: Patient showed encouraging result after Virechana, Jaloukacharana and followed by Shamana Aushadis, where subjective criteria evaluated using scoring method & objective criteria evaluated using VETI scoring method. Discussion: Patient was Initially treated with Shamana Aushadis, where white discolored patches turned to pinkish, later treated with repeated course of Virechana followed by Jaloukacharana in regular intervals, where subject was observed with 85% improvement in subjective criteria & VETI scoring improved from 12 to 4. Hence, the present case study highlights the importance of efficacy of Ayurvedic treatment in Shwitra, as mentioned in classics.

Keywords: Shwitra, Ayurveda, Vitiligo, Virechana, Jaloukacharana

Corresponding Author How to Cite this Article To Browse
Sneha Patil, 3rd Year Post Graduate Scholar, Department of PG Studies in Kayachikitsa, A.L.N. Rao Memorial Ayurvedic Medical College & Hospital, Koppa, Karnataka, India.
Email: 		Sneha Patil, S.G. Ashwini, Ayurvedic management of Shwitra (vitiligo) - A Case Study. J Ayu Int Med Sci. 2022;7(5):139-145.
Available From
https://jaims.in/jaims/article/view/1818

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2022-04-28 2022-04-30 2022-05-07 2022-05-14 2022-05-21
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
Nil Nil Yes 19%

© 2022by Sneha Patil, S.G. Ashwiniand Published by Maharshi Charaka Ayurveda Organization. This is an Open Access article licensed under a Creative Commons Attribution 4.0 International License https://creativecommons.org/licenses/by/4.0/ unported [CC BY 4.0].

Journal of Ayurveda and Integrated Medical Sciences 2022;7(5)139
Patil S et al: Ayurvedic management of Shwitra (vitiligo) A Case Study

Introduction

In Ayurveda all the skin diseases are categorized under the heading Kushta. Shwitra is mentioned in Kushta Roga Chikitsa in classics. The word Shwitra is derived from Sanskrit word Shweta, which means white patch.[1]

So, Shwitra is a disease where white patches appear on body. According to Kashyapa Samhita ‘Shweta Bhava Michanti Shwitram’.[2]

It is also called as Kilasa, Daruna, Aruna and Shweta Kushta. Bhrajaka Pitta which is situated in the skin is responsible for Chaya and Prabha of Twacha (skin).[3]

Any impairment of Bhrajaka Pitta and Vata Dosha can cause skin diseases like Shwitra.

In Shwitra morbidity is located in Medhodhatu. Depending on the colour and Ashraya in Dhatus 3 types of Shwitra are mentioned i.e., if located in Rakta (blood) it is red in colour, if in Mamsa (muscle tissue) it is of coppery colour, and if located in Medas it is white in colour.

Due to similarity in the manifestation of the disease this can be co-related to Vitiligo. Vitiligo is an acquired condition affecting 1% of the population worldwide.[4]

Focal loss of melanocytes results in the development of patches of hypopigmentation. It is thought to be the result of cell-mediated autoimmune destruction of melanocytes. Generalized vitiligo is often symmetrical and involves hands, wrist, feet, knees and neck, as well as areas around body orifices.[5]

Segmental vitiligo is restricted to one part of the body but not necessarily a dermatome. The patches of depigmentation are sharply defined.

Objective of the Study

To determine the efficacy of Ayurvedic treatment in Shwitra, as mentioned in classical Ayurvedic treatises.

Brief history of patient

The present case report is of 63 years old male, not a known case of HTN/DM/Other systemic illness, came with complaints of whitish discolored patches over bilateral legs (shin aspect), associated with mild Itching, with no burning sensation since 1 year.

All these symptoms said to have aggravated in the past 1 month i.e., in the month of August 2021. Subject initially neglected these symptoms and did not take any medicines.

As patches started spreading gradually over the whole length of shin region bilaterally, hence, he consulted at ALN Rao Memorial Ayurvedic Medical College & Hospital for the treatment.

Past History

1. No history of above skin complaints before 1 year or trauma.

2. No history of HTN/DM/Thyroid/other systemic disorder.

Family History

Nothing significant all other family members are said to be healthy.

Personal history


  • Occupation - Farmer
  • Marital status - Married
  • Religion - Hindu
  • Diet - Mixed, predominantly non-veg (chicken & fish) weekly twice.
  • Appetite - Normal
  • Bowel - 1times/day
  • Micturition - 3 to 4 times/day, 1time/night
  • Sleep - Disturbed, 6 to 7hrs with day sleep of 1 to 2 hours.
  • Allergies to any medications/food - No
  • Addictions - No

Table 1: Nidana


Aharaja
Viruddha Ahara - Matsya with Dughda
Vishamashana - Intake of water after exposure to sun. Intake of Mamsa, Kulattha, Takra, Matsya and Mulika more frequently.
Adhyashana - intake of food before digestion of previous meal.
Viharaja
Diwaswapna Exposure to Sun for long hours. Sheeta-Vata Sevana (Exposure to cold) Working in mud for longer duration daily.[6]
Manasika
Chinta



Journal of Ayurveda and Integrated Medical Sciences 2022;7(5)140
Patil S et al: Ayurvedic management of Shwitra (vitiligo) A Case Study

Clinical findings

Integumentary system

O/E of Skin


  • Site of lesion - On both legs over shin aspect
  • Lesion - Epidermal
  • Distribution - Symmetrical
  • Character of lesion - Macules
  • No of lesions - Left-20, Right-14; Size-Left-1x0.5cm each, Right-0.25x0.25 cm each;
  • Color - White; Arrangement - Non-Segmental.
  • Itching - Mild present
  • Discharge - Absent

Superficial sensation on lesion


  • Pain - Absent
  • Swelling - Absent
  • Paresthesia - Absent

Aggravating factors

Rainy season, Mud area

Table 2: Samprapti

jaims_1818_01.JPG


Samprapti Ghatakas

Dosha - Tridosha

Dushya - Rasa, Rakta, Mamsa, Meda

Ama - Jatargni Janya Ama

Agni - Jatargnimandhya, Dhatwagnimandhya.

Srotas - Rasavaha, Raktavaha, Mamsavaha & Medovaha

Srotodusti Prakara - Sanga

Rogamarga - Bahya

Udbhava Sthana - Amashaya

Vyakta Sthana - Twacha

Roga swabhava - Chirakari

Sadhyasadhyata - Yapya

Materials and Methods

Assessment Criteria

Subjective Criteria

Patient was observed for improvement in Hypopigmented patches, itching and improvement in general condition.

Objective Criteria

Improvement calculated on basis of VETI scoring method.

Table 4: Grading Assessment for Subjective Criteria[7]

Score 0 1 2 3
Number of Patches depending on % of area involved Absent 1-29% 30-69% 70-100%
Colour Normal tensity >50% filling with normal tensity <50% of filling with pinkish discoloration White patches
Itching Absent Mild Moderate Severe
Hypopigmentation Patches Absent Solitary Segmental Generalized

Treatment Plan

  • Amapachana
  • Snehapana
  • Abhyanga and Swedana
  • Virechana
  • Jalokacharana

Journal of Ayurveda and Integrated Medical Sciences 2022;7(5)141
Patil S et al: Ayurvedic management of Shwitra (vitiligo) A Case Study

Table 5: Treatment Schedule

Course Shodhana Shamana Observation
7/08/21 – T. Arogyavadhini Vati 1-0-1 AF Bakuchi taila L/A Backuchi Churna L/A to apply with Taila Aragwadadi Kashaya 15ml BD BF White patches
18/08/21 – Bakuchi Churna L/A with Marichadi taila Bakuchi Churna ½ tsp BD with honey T. Gandhaka Rasayana 1-0-1 AF Asanadi ghana plus 15ml BD AF Patches turned Pinkish from white
31/08/21 to 03/09/21 Snehapana – Guggulutikta Gritha 30 ml on 31/08/21 60 ml on 01/09/21 90 ml 0n 02/09/21 Sarvanga Abhyanga – Yasti madhu taila + Manjistadi taila Sarvanga Naadi sweda Virechana with – Trivruth lehya 30gm + Vacha Churna 10 gm + Drakshadi Kashaya – 200ml Vegas – 10 Jaloukachrana Khadiradi vati 1-0-1 Gandhaka Rasayana 0-2-0 Khadirarista 15 ml TID AF Bakuchi Churna L/A with Gomutra Bakuchi Churna ½ tsp BD with honey Same as Above
5/10/21 Sadhyo Virechana – Gandharvahastadi Taila – 2 cap Vegas – 8       T. Arogyavardini vati 1-0-1 Khadirarista 15mi BD AF Raktamrita Kwatha 15ml OD Bakuchi Churna 0- ½ tsp-0 with honey Bakuchi churna with Gomutra L/A Marichadi taila L/A Dark patches over skin (L) present on the depigmented areas (R) depigmented patches clearing out c/o occasional itching over legs affected area.
09/11/21 Jalokacharana Sadhyo Virechana – Gandharva Hastadi Taila - 2 cap Vegas – 8 T. Kaishora Guggulu 1-0-0 Khadirarista 15ml BD AF Bakuchi churna 0-0-1/2tsp with honey Bakuchi churna L/A with Gomutra Yastimadhu taila + Marichadi taila L/A Dark pigmentation over prior whitish patches observed with 80-85% filling (Left) & 90% (Right) Lower limb.

Results

Results: VETI score calculation done as below[8]

VETI score formula: (Percentage of head involvement x grade of tensity) + (Percentage of trunk involvement x grade of tensity) 4+ (Percentage of upper limbs involvement x grade of tensity) 2+ (Percentage of lower limbs involvement x grade of tensity) 4+ (Percentage of genitalia involvement x grade of tensity) 0.1

Table 6: Percentage of Area effected

Percentage of involvement = Area Score
0 = 0%
1 = 1-9%
2 = 10-29%
3 = 30-49%
4 = 50-69%
5 = 70-89%
6 = 90-100%

Table 7: Tensity

Stage 0 Normal Skin
Stage 1 Hypopigmentation (including trichrome & homogeneous lighter pigmentation)
Stage 2 Complete depigmentation with black hair and with perifollicular pigmentation
Stage 3 Complete depigmentation with black hair and without perifollicular pigmentation
Stage 4 Complete depigmentation with compound of white and black hair with/without perifollicular pigmentation
Stage 5 Complete depigmentation plus significant hair whitening

VETI score before treatment

VETI: (Ph x Th) + (Pt x Tt) 4+ (Pu x Tu) 2+ (Pl x Tl) 4+ (Pg x Tg) 0.1

= (0 x 3) + (0 x 3) 4+ (0 x 3) 2+ (1 x 3) 4+ (0 x 3) 0.1

 = 12

VETI score After treatment

VETI: (Ph x Th) + (Pt x Tt) 4+ (Pu x Tu) 2+ (Pl x Tl) 4+ (Pg x Tg) 0.1

= (0 x 1) + (0 x 1) 4+ (0 x 1) 2+ (1 x 1) 4+ (0 x 1) 0.1

= 4



Journal of Ayurveda and Integrated Medical Sciences 2022;7(5)142
Patil S et al: Ayurvedic management of Shwitra (vitiligo) A Case Study

As per VETI scoring for vitiligo patient was observed with significant improvement of VETI scoring 12 before treatment to VETI scoring of 4 after treatment.

The improvement was observed in subjective criteria with 80-85% filling of hypopigmented patches with normal skin tensity in left lower limb & 90% filling in right lower limb.

Table 8: Results showing Subjective Criteria’s before and after treatment

Criteria’s Score
Before treatment After treatment
Number of Patches 1 1
Color 3 1
Itching 2 0
Hypopigmentation Patches 2 1


jaims_1818_02.JPG

Fig. 1: Before Treatment

jaims_1818_03.JPG

Fig. 2: After 1st Shodhana

jaims_1818_04.JPGFig. 3: After 2nd Shodhana

jaims_1818_05.JPGFig. 4: After 3rd Shodhana

Discussion

Shwitra can be managed very well in Ayurveda by both Shodhana & Shamana Aushadis, if treatment can be initiated in early stages, we can observe satisfactory results. In this case patient presents with whitish discolored patches in both lower limbs, after 10days of Shamana Aushadis white patches turned to pinkish. Gradual filling of depigmented area with normal skin tensity enhanced after 1st round of Shodhana. After 2nd round of Shodhana 50% improvement was observed. After 3rd round of Shodhana Dark pigmentation over prior whitish patches observed with 80-85% filling in left lower limb & 90% filling in right lower limb was observed. The total improvement is evaluated as per VETI score.[8]

Bakuchi Churna contain psoralen, isopsorale, bakuchiol, bavchinin & corylin which have antioxidant properties, stimulates melanocytes for Melanin synthesis and has immuno-modulatory effect.


Journal of Ayurveda and Integrated Medical Sciences 2022;7(5)143
Patil S et al: Ayurvedic management of Shwitra (vitiligo) A Case Study

Khadirarista main ingredient of Khadirarista are Khadira extract (Acasia catechu). Khadira extract is as an immune-modulatory, purify blood, bacterial refrigerant and antiphogistic.

Gandhaka Rasayana the main ingredient of Gandhaka Rasayana i.e., Bhavita Gandhaka (Sulphur) has several potential uses for skin. It is Raktashodhaka, Twachya and Kushtagna.

Arogyavardhini Vati is having Raktadhushtihara (blood purifier), Kushtahara (alleviates skin disease), Sroto Vishodhana (cleansing channels of body) and Pitta Doshahara (alleviates Pitta) properties. And it improves digestion and metabolic activities.

Raktamokshana activates and stimulates the reaction of body system, which further stimulates brain function towards the diseased part of skin, along with stimulation of the pituitary gland which is responsible for secretion of melanocytes for melanin formation. This helps to regain the normal color of skin.[9]

Conclusion

The incidence of vitiligo is increasing due to faulty life style, so identifying and eliminating multifactorial agents associated with the disease based on Ayurvedic principles is essential. Regaining of pigmentation can be achieved in most of patients by following Ayurvedic treatment protocol as mentioned in Shwitra Chikitsa. Shwitra is a disease having high impact on body and mind due to cosmetic disfigurement. Shodhana along with Shamana Chikitsa helps to remove the root cause of the disease and prevents the recurrence of the disease by eliminating aggravated dosha in the body, through resulting in overall improvement w.r.t. no of lesion, size of the lesions regaining of normal skin pigmentation.

Reference

1. Barman S, Switra and its treatment in veda, Ancient Science of life, 1995, XV (1), 71-74.

2. Tewari PV, Kshayapa Samhita, Chikitsastana, 9th chapter, Sloka 2, Choukhamba Visvabharati, Varanasi, reprint-2008.

3. Sushruta, Sushruta Samhita, Hindi commentary by Kaviraja Ambikdutta Shastri, Vol 1, Chaukhamba Sanskrit sansthan, Varanasi, reprint-2014, chapter 21, pg no-115.

4. Stuart H. Ralston, Ian D. Penman, Mark W. J. Strachan, Richard P. Hobson, Davidson’s Principles & Practice of Medicine, 23rd edition, 2018, page no-1257.

5. Stuart H. Ralston, Ian D. Penman, Mark W. J. Strachan, Richard P. Hobson, Davidson’s Principles & Practice of Medicine, 23rd edition, 2018, page no-1257.

6. Adil M, Khan IJ, Ahmad I, et al. Vitiligo and helminthiasis- a retrospective study to establish a causal relationship in patients treated with coded unani drug. J. Evolution Med. Dent. Sci. 2019;8(27):2209-2212, DOI:10.14260/jemds/2019/483.

7. Sunil, Gupta & Varsha, Saxena & Srivastava, Niraj. (2019). New hope in treatment of vitiligo (Switra) by ayurvedic medicines (A case study). 1283-1286.

8. Feily A, Vitiligo Extent Tensity Index (VETI) score: a new definition, assessment and treatment evaluation criteria in vitiligo. Dermatol Pract Concept. 2014;4(4):18. http://dx.doi.org/10.5826/dpc.0404a18

9. Salame, P. (2021). Ayurvedic Management of Shwitra: A Single case Study. Ayurlog: National Journal of Research in Ayurved Science, 9(04). Retrived from https://www.ayurlog.cpm/index.php/ayurlog/article/view/914.


Journal of Ayurveda and Integrated Medical Sciences 2022;7(5)144