E-ISSN:2456-3110

Case Report

Ayurvedic management of Shwitra

Journal of Ayurveda and Integrated Medical Sciences

2023 Volume 8 Number 11 November
Publisherwww.maharshicharaka.in

Ayurvedic management of Shwitra (Vitiligo) with special reference to Twak Sharir - A Case Study

Sharma G1, Karnwal S2*, Sokiya G3
DOI:10.21760/jaims.8.11.32

1 Sharma G, Assistant Professor, Department of Rachna Sharir, Patanjali Bhartiya Ayurvigyan Evam Anusandhan Sansthan, Haridwar, Uttarakhand, India.

2* Shivani Karnwal, Final Year Post Graduate Scholar, Department Of Kayachikitsa, Patanjali Bhartiya Ayurvigyan Evam Anusandhan Sansthan, Haridwar, Uttarakhand, India.

3 Sokiya G, Assistant Professor, Department of Kayachikitsa, Patanjali Bhartiya Ayurvigyan Evam Anusandhan Sansthan, Haridwar, Uttarakhand, India.

Introduction: In Ayurveda, 'Twacha' or 'Charma' refers to the skin, and skin-related disorders fall under the broad category of 'Kushtha.' Among these conditions, 'Shwitra' stands out, marked by whitish discolorations on the skin. Shwitra's origins lie in the intricate interplay of seven essential bodily constituents, known as Sapta Dravyas: Vata, Pitta, Kapha, Rasa, Rakta, Mamsa, and Meda. Remarkably, Shwitra primarily manifests its enigmatic presence within the innermost stratum of the skin, known as 'Tamra.' This inner sanctum of the epidermis is held in high regard as the principal locus of Shwitra's affliction. It bears an intriguing resemblance to the more widely recognized condition known as Vitiligo, a dermatological anomaly characterized by hypopigmentation. This puzzling condition, Vitiligo, afflicts approximately 1% of the global population, adding a layer of complexity to our understanding of the intricate workings of the human integumentary system. Methodology: In this clinical case, a 43-year-old male presented with de-pigmented patches in the left buccal region, characterized by mild pruritus but the absence of any burning sensation. The therapeutic approach commenced with the administration of Shamana Aushadis, specifically targeted at symptom alleviation. The primary objective was to address the root pathology and facilitate the patient's overall recovery and well-being. Result: The patient responded well to Shamana Aushadis. Progress was assessed using subjective and objective criteria, employing a comprehensive approach to evaluate the treatment's effectiveness.

Keywords: Ayurveda, Shwitra, Vitiligo, Shaman Aushadi

Corresponding Author How to Cite this Article To Browse
Shivani Karnwal, Final Year Post Graduate Scholar, Department Of Kayachikitsa, Patanjali Bhartiya Ayurvigyan Evam Anusandhan Sansthan, Haridwar, Uttarakhand, India.
Email: 		Sharma G, Karnwal S, Sokiya G, Ayurvedic management of Shwitra (Vitiligo) with special reference to Twak Sharir - A Case Study. J Ayu Int Med Sci. 2023;8(11):199-205.
Available From
https://jaims.in/jaims/article/view/2779

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2023-09-13 2023-09-25 2023-10-05 2023-10-16 2023-10-24
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
None declared Nil Yes 18.66

© 2023by Sharma G, Karnwal S, Sokiya Gand 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].

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Introduction

The skin, body's largest organ, acts as a vital protective shield against external threats while providing a tangible reflection of one's emotional and physiological well-being. This interface between the inner and outer worlds plays a key role in both preserving beauty and defining individual identity within society. Changes in skin coloration often signal disruptions in the body's equilibrium, influenced by a web of interconnected factors including nutrition, hygiene, circulation, age, immunity, genetics, mental health, and medication usage. Vitiligo, referred to as "Shwitra" in Ayurveda, has been described in Vedic literature, employing terms like "Shweta Kushtha," "Kilasa," "Palita," which signify the transformation of normal skin colour into white. Vitiligo is a chronic skin disorder characterized by the absence of melanin pigments, resulting in de-pigmented skin patches with well-defined borders.[1] Approximately 1% of the global population is affected by Vitiligo, with the highest incidence in India and Mexico. It is estimated to affect 3-4% of the Indian population, and even higher rates, up to 8.8%, have been reported, particularly among dark-skinned individuals.[2] The aetiology of Vitiligo remains unclear despite its evident multifactorial clinical expression. The localized absence of melanocytes leads to the formation of hypopigmented patches, a condition believed to stem from cell-mediated autoimmune melanocyte destruction. Generalized vitiligo typically exhibits symmetric distribution and affects regions such as the hands, wrists, feet, knees, neck, and areas around body openings. In contrast, segmental Vitiligo is confined to a specific body region, albeit not strictly following dermatomal patterns. De-pigmented patches in segmental Vitiligo are characterized by sharp demarcation. Given this context, it becomes imperative to delve into the study of the skin, known as "Twak" in Ayurveda.

Twak Sharira

Formation: According to Acharya Sushruta, Twacha emerges as a result of the heat generated during the amalgamation of Shukra (reproductive tissue) and Shonita (blood) during the Garbhanirmaana Kala, the phase of embryogenesis.[3] Acharya Charaka posits that Twacha's development stems from the conjunction of Shukra

and Shonita and the subsequent formation of all seven Dhatu (bodily tissues).[4] Acharya Vagbhata suggests that Twacha's development occurs through the maturation (Paka) of Rakta Dhatu (blood tissue) by the action of Dhatvagni (tissue-specific metabolic fire).[5] Acharya Charak posited six skin layers, omitting thickness details. Two layers were named, while the rest were linked to diseases. Acharya Sushrut detailed seven skin layers, naming each and specifying thickness and associated diseases. Acharya Vagbhatta mirrored Sushrut's seven layers and emphasized the fourth layer, "Tamra," as the origin of all Kushtha ailments. Their insights enriched dermatological understanding significantly.

Layers of Skin according to Acharya Charaka

PrathamaUdakadhara - Bahya Twak
DwitiyaAsrugdhara
Tritiya Sidhma, Kilasa, Sambhaadhisthana
ChaturthiDadru, Kustha, Sambhavadhisthana
PanchamiAlaji, Vidradhi Sambhavadhisthana
Shashthi Injury - Kampa & Tamodarshana

Layers of Skin according to Acharya Sushruta

Avabhasini Sidhma, Padmakantaka
LohitaNyachcha
Shweta Charmadala, Mashaka, Ajagallika
TamraKilasa, Kustha
VediniKustha, Visarpa
RohiniGrahini, Arbuda, Apachi, Galaganda
MamsadharaBahgandara, Vidradhi

The aforementioned Acharyas have meticulously documented the localization of diseases within specific skin layers. However, a discrepancy arises concerning the classification of the "Shwitra" affliction. Acharya Charak attributes it to the third layer, whereas Acharya Sushrut situates it within the fourth layer of the integument.

Objective of study

To assess the effectiveness of Ayurvedic therapy for Shwitra, as delineated in classical Ayurvedic texts.

Brief History of the Subject

A 43-year-old male, presented at the outpatient department (OPD) of Patanjali Ayurved Hospital on June 15, 2023, complaining of a white hypo-pigmented patch on the left side of his face, specifically in the left buccal region. This condition had been persisting for duration of one year. Upon gathering a preliminary medical history, it was discovered that he had been in good health one year ago but had experienced a hyper-pigmented mark in the same facial area. In response, he had applied a depigmentation cream,


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which subsequently led to the appearance of a small white patch on the left side of his face. Initially, he did not pay much attention to it due to its small size. However, as time passed, he noticed its expansion, prompting him to seek medical intervention from a dermatologist at Banaras Hindu University (BHU). He underwent treatment for a period of one year, during which the patch exhibited partial resolution. Unfortunately, upon discontinuing the treatment, the hypopigmentation re-emerged, prompting his visit to Patanjali Ayurved Hospital for further and better management.

Past History: No H/O HTN, DM, COPD, Thyroid disorder.

Family History: No family history relevant to the case recorded.

Personal History

  • Occupation - Doctor Homeopathic
  • Marital Status - Married
  • Religion - Hindu
  • Diet - Vegetarian
  • Appetite - Good intake
  • Bowel - Regular
  • Micturition - Normal
  • Sleep - Sound
  • Allergies - Not Any
  • Addictions - Not Any

Clinical Findings

General Examination

  • Built - Medium
  • BP - 124/80 mm Hg
  • Pulse - 76 b/min
  • RR - 18/min

Systemic Examination

  • CNS - Patient is well oriented and alert to person, place and time. Muscle power, tone and reflexes - Normal
  • CVS - S1S2 Normal, Murmurs absent, Apex beat Normal
  • Respiratory - Chest B/L clear.
  • GIT - P/A soft, non-tender, organomegaly absent

Integumentary System

O/E of Skin

  • Site of Lesion - Over Left Buccal region
  • Lesion - Epidermal
  • Distribution - Unilateral
  • Character of lesion - Macule
  • of lesions - 1
  • Size - 1.5*2.5 cm
  • Colour - White
  • Itching - Mild
  • Discharge - Absent

Superficial Sensation on lesion

  • Pain - Absent
  • Swelling - Absent
  • Paraesthesia - Absent

Hetu - External Application of a depigmentation cream

Samprapti

Upon the activation of causal factors (Hetu), all three Doshas became aggravated, leading to a wide dissemination of the Tridoshas throughout the body via lateral movement (Tiryak Gati). This pathogenic process, known as Sthansanshraya, manifested beneath the cutaneous layers within the left facial region, resulting in depigmentation of the skin at this specific location (Vyakti). Consequently, the patient displayed the manifestation of Shwitra Kushtha Abhivyakti. The patient exhibited several indicative factors in their pathogenesis (Samprapti Ghataka).

Samprapti Ghatak

  • Dosha - Tridosha
  • Dushya - Rasa, Rakta, Mamsa, Meda
  • Agni - Jathragni, Dhatwagni Mandya
  • Srotas - Rasavaha, Raktavaha, Mamsavaha, Medovaha,
  • Srotodushti - Sanga
  • Rogmarga - Bahya
  • Udhbhav Sthana - Amashaya
  • Vyakta Sthana - Twacha
  • Swabhav - Chirkari

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  • Sadhyasadhyta - Yapya

Materials and Methods

Assessment Criteria

  • Subjective Criteria - Patient was observed for improvement in hypo-pigmented patches and improvement in general condition.
  • Objective Criteria - Improvement calculated n basis of VETI scoring method.
Score0123
No. of patches depending on % of area involvedAbsent1-29%30-69%70-100%
ColourNormal>=50% filling with normal tensity<50% of filling with pinkish discolorationWhite patches
ItchingAbsentMildModerateSevere
PatchesAbsentSolitarySegmentalGeneralized

Chikitsa Vivaran - Shaman Chikitsa was given to patient for 3 months as follows.

SN Treatment Dose and Anupana Days
1.Praval Pishti Giloy SatRas ManikyaManjistha ChurnBakuchi Churn 10g10g3g100g50g(Mix all together and advised to take 1 tsf bd after meal with honey)30 days
2.Divya Melanogrit Gold Tab2 tab bd after meal with water30 days
3.Amalaki Rasayana 1 tsf to be soaked overnight and taken in the morning30 days
4.Mahamanjisthadi Kwath2tsf with equal water bd after meal30 days

Results

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

VETI score calculation done as below:

Before treatment

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

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

= 3

After treatment

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

= (0*0) + (0*0)4 + (0*0)2+ (0*0)4 + (0*0)0.1

=0

According to the Vitiligo Extent Tensity Index (VETI)

assessment, a marked enhancement in the patient's condition was noted, as the VETI score reduced from 3 prior to treatment to a score of 0 following treatment. This improvement was particularly evident in the subjective criteria, where a 90-95% re-pigmentation of the hypo-pigmented patch was observed, accompanied by a return to normal skin colour intensity in the left buccal (cheek) region.

Criteria Score
BTAT
Number of patches10
Colour30
Itching10
Hypo-pigmented patch10

Before treatment
Jaims_2779_01.JPG

After treatment
Jaims_2779_02.JPG

Discussion

Vitiligo, known as Shwitra in Ayurveda, can be effectively managed through Shamana Aushadis


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(medicinal treatments). Initiation of treatment during the early stages often yields satisfactory outcomes. In this particular case a patient presented with a whitish discoloured patch on the left buccal region (cheek), significant progress was observed within a month of administering Shamana Aushadis. The initially white patches transitioned to a pinkish hue. Subsequent follow-ups demonstrated a gradual improvement, with the de-pigmented area filling in gradually and exhibiting a normal skin tone after the first follow-up. By the second follow-up, there was a 50% improvement in the condition. Remarkably, after the third follow-up, dark pigmentation was observed over the previously white patches, showing a 90-95% filling in the left buccal region. The overall improvement was assessed according to the Vitiligo Extent Tensity Index (VETI) score.

Upon a thorough assessment of the patient's medical history, a treatment regimen was formulated. In the treatment of Vitiligo, there exist two primary objectives: firstly, to halt or prevent further depigmentation, and secondly, to stimulate the process of re-pigmentation.

For individuals presenting with Saama-Avastha (a state of vitiated Doshas with relatively mild symptoms), a therapeutic approach was initiated, involving Pachana (digestive enhancement), Deepana (appetite promotion), Klednashana (moisture-reducing), and Krumihar Chikitsa (parasite-alleviating treatment). This treatment was administered alongside a regimen of Haritaki Churna (powdered Terminalia chebula) on a daily basis as Samsrana (Nitya Virechana Dravya).

Once the patient exhibited Nirama Lakshana (absence of disease-specific symptoms), a comprehensive treatment strategy was employed for a duration of three months, focusing on the reduction of Kapha and Pitta Doshas (biological elements), and addressing specific ailments associated with Vitiligo.

In light of Bakuchi's recognition as a Vyadhi Pratyanik (disease-specific) drug for Shwitra Kushtha (Vitiligo), it was initiated from the outset as an internal medication, forming an integral component of the treatment regimen. Bakuchi Churna contains constituents like psoralen, isopsorale, bakuchiol, bavchinin, and corylin, all of which possess antioxidant attributes.

These constituents not only stimulate melanocytes for the synthesis of melanin but also exert an immune-modulatory influence. It is administered in conjunction with a blend of therapeutic agents, such as blood-purifying (Raktashodhak), Kapha-Pitta alleviating (Kapha-Pittahar), and rejuvenating (Rasayana) drugs. This combination includes Praval Pishti, Giloy Sat, Ras Manikya, and Manjistha Churna.

Divya Melanogrit Gold Tablet represents a proprietary Ayurvedic formulation meticulously crafted by Divya Pharmacy. This formulation comprises a unique blend of therapeutic ingredients, including Swarna Bhasma, Rajat Bhasma, Mukta Bhasma, Rasmanikya, Tamra Bhasma, Shudh Bakuchi, Khadir, Manjistha, and Amaltas. It functions as a robust revitalizing agent, promoting blood purification (Raktashodhak), and offering antioxidant and immune-modulating properties. Furthermore, it demonstrates the capacity to mitigate inflammation and promote overall skin health. The unique composition of Melanogrit Gold initiates and augments a systemic response within the body. This response, in turn, activates the brain's activity directed towards the affected area of the skin. It also stimulates the pituitary gland, responsible for the production of melanocytes required for melanin synthesis. Consequently, this combination aids in the restoration of the skin's natural pigmentation.

Amalaki, characterized by its Alavana Pancha Rasa (five distinct tastes with a predominance of sour), Sita Virya (cooling potency), and Madhura Vipaka (sweet post-digestive effect), serves as a Tridoshahara agent by harmonizing the three Doshas. It’s Rasayana (rejuvenating) and Vayasthapana (age-sustaining) properties promote the development of Prasastha Dhatu, consequently retarding cellular degeneration while fostering the generation of new cells. Additionally, Amalaki exhibits Kushthagna properties, which are particularly relevant in the context of Vitiligo, an autoimmune disorder. Notably, the potent immune-modulatory characteristics of Amalaki, found in the Amalaki Rasayana counteract the autoimmune mechanism, including the presence of antibodies against melanin that have been isolated from the serum of Vitiligo patients.

Mahamanjisthadi Kwath contains herbs exhibiting a range of properties, including Varnya


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(improving complexion), Kapha Pittashamak (balancing Kapha and Pitta Doshas), Shothahar (reducing oedema), Kushtaghna (treating skin diseases), and Vranropak (wound healing). Most of these substances possess Tridoshaghna (alleviating all three Doshas) or Kapha Pittahara (mitigating Kapha and Pitta Doshas) characteristics due to their inherent qualities of having Tikta (bitter), Katu (pungent), Kashaya (astringent) taste, Laghu (light), Ruksha (rough) properties, and Ushna Veerya (hot potency), with a Katu Vipaka (pungent post-digestive effect).

These substances collectively exert their therapeutic pharmacological effects based on their inherent qualities encompassing taste (Rasa), properties (Guna), potency (Veerya), post-digestive effect (Vipaka), and specific properties (Prabhava). These actions align with the principles of Samprapti Vighatana Chikitsa Siddhanta, emphasizing the disruption of the disease process.

Conclusion

The findings of this case report illustrate the successful management of Vitiligo through Ayurvedic formulations, without the use of cleansing therapy (Shodhan Chikitsa), thus emphasizing the fundamental principles of Dhatu Siddhanta, which pertains to the theory of tissue formation in Ayurveda. However, it is imperative to conduct further extensive trials involving a larger sample size and an extended treatment duration, utilizing controlled medications. The patient's facial lesions and white patches, which had manifested, demonstrated a remarkable recovery after a three-month course of treatment with Ayurvedic medications and dietary modifications. Notably, this treatment approach exhibited a high degree of efficacy in addressing Shwitra (Vitiligo). Vyadhihara Rasayana, particularly Bakuchi, was well-tolerated in this study, even when administered in higher dosages.

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