Journal of Ayurveda and Integrated Medical Sciences

Introduction

The term eczema refers to inflammation of the skin and is classified into endogenous and exogenous eczemas depending up on whether the causative factors are internal or external. Erythema, vesiculation, and oozing are the symptoms of acute eczema, followed by subacute scaling and crusting and chronic lichenification.^[1]

A widespread, chronic, inflammatory skin condition marked by pruritus and recurrent remissions and relapses, atopic eczema or dermatitis is one of the endogenous dermatitis. It has links to other atopic diseases such as allergic rhino conjunctivitis and asthma. Atopic dermatitis affects 15 to 20% of people worldwide. 50% of cases appear in the first year of life, the majority do so within five years, and the remainder do so by the age of 30. It can be divided into 3 stages based on this: Infantile AD (2 months to 2 years), childhood AD (2 years to 10 years) and Adult AD. The majority of the individuals with atopic dermatitis report having had it as children. After the age of 18, AD affects 6% to 14% of people. Adults with atopic dermatitis develop small, erythematous, scaly plaques. In the acute stage, the lesion may ooze; in chronic cases, it may become dry, scaly and lichenified. It is triggered by stress, anxiety and depression in adults. Severe pruritus is the main outcome of this condition.

Ayurveda explains skin diseases under the main domain Kushta. Kushta, the word suggest any discolouration in the skin is having the involvement of three Doshas and Tvak, Raktha, Mamsa, Lasika as the seven pathogenic substances. The continuous and simultaneous involvement of these seven fold factors for a prolonged period and which are deep seated are involved in the pathogenisity. The Doshas travel through the Tiryak Siras to the skin through Raktha, Lasika and causes discolouration in the skin. Again, after discolouration of the skin, it starts to afflict the succeeding Dhatus, so this disease is having the two dimensional pathogenicity from inside to outside and vice versa.^[2] So the treatment should be based on the involvement of Doshas at particular stage of the disease pathogenesis. Kushta is broadly classified into Mahakushta and Kshudra Kushta which is again classified into 7 and 11 respectively.^[3] So a total of 18 types of Kushta and the Dosha involvement for each one were explained in the

allergy-asthma, hyperthyroidism-since 8 yrs. under medication for both. She consulted many allopathic hospitals with only momentary relief. So, she approached our hospital.

Diagnosis and assessment

Based on the history of the present illness and clinical examination, the condition was diagnosed. Signs and symptoms like erythema and vesicles with secondary lesion of lichenification were present in flexures with severe itching and disturbed sleep. History of bronchial asthma present.

The assessment criteria’s used were pruritus NRS (numeric rating scale), EASI score (eczema area and severity index), ADSS (atopic dermatitis sleep score) and DLQI (Dermatology Life Quality Index). Pruritus was measured using pruritus NRS where patient was asked to rate their itching each day from 0 to 10 based on the severity of their itching which is recorded on each day and weekly mean scores are taken. EASI score was taken based on the body regions affected and severity of the redness, thickness, scratching and lichenification. ADSS was also assessed by the self report of the patient, the impact of itch on sleep including 2-point assessment of difficulty in falling asleep and number of night time awakenings. DLQI was assessed with the help of a 10-point questionnaire which measures how much the patients skin problem has affected her life over the last week.

Table 1: Pruritus numeric rating scale (NRS)

Figure 1: pruritus numeric rating scale

Table 5: Atopic Dermatitis Sleep Score (ADSS)

Table 6: Dermatology Life Quality Index (DLQI)

Figure 3: Dermatology Life Quality Index

Intervention

Table 7: Internal medications

flexures which are lichenified in most areas with severe itching which disturbs her sleep heavily can be correlated to Charmakushta which is Vatakaphaja predominant.^[12] Treatment principles adopted here is Samshodhana which should be Snehayuktha along with the Samana Aushadhas which are Kushtaghna.^[13] Here the condition is chronic and in atopic dermatitis filaggrin deficiency, poor epidermal Samshodhana Chikitsa lipid layer with increased transepidermal water loss and predisposition to bacterial and viral infections along with reduced itch threshold happens, so should be done with a proper Snehana given in Arohana Matra and Bahya Snehana is done in form of Abhyanga.

Patient is a known case of allergy and asthma with a hereditary predisposition of the same and was under medication for the same. So Punarnavadi Kashayam was started along with Aragwadhadi Kashayam as she had severe itching with disturbed sleep. Vilwadi Gulika was given along with that which will act as an antimicrobial and prevents infection and removes all kinds of Visha. Haridhra Khandam was prescribed to reduce the vicious cycle of allergies.

Snehapana was done with Aragwadhadi Mahathikthaka Ghritha for 8 days with the dose increasing upto 230 ml and Vamana was done after one day of Bahya Sneha and Sweda. Vamana was done with Yashtimadhu Kashaya, Ksheera, Lavanodakam and Nitya Virechana was done with Manibadra Gulam. Bahya Sneha was done frequently with Jeevanthyadi Yamakam which is having an antimicrobial action along with Kashaya Dhara with Aragwadhadi Gana Kashayam. Utkarshanam was done with Aragwadhadi Kashaya Choornam and Kashayam to reduce the thickness of the secondary lesion of lichenification.

The parameters like NRS (numeric rating scale), EASI score (eczema area and severity index), ADSS (atopic dermatitis sleep score) and DLQI (Dermatology Life Quality Index) were assessed for measuring pruritus, area or extent along with severity, Sleep disturbance and quality of life of the patient respectively. All these parameters were assessed before and after treatment and also after follow-up. DLQI of the patient was 66.6% before treatment which was reduced to 26.6% after treatment and 13.3% after follow up. NRS score has showed a 5-point decrease in the score and ADSS showed a complete decrease

12. Agnivesha, Charaka Samhita, Vidyotini Hindi commentary by Kashiram Shastri and Gorakhnath Chaturvedi, Chaukhambha Bharati Academy; Varanasi, Part II, reprint 2006, Chikitsa Sthana 7/30, pp. 253.

13. Sharma R K, Dash B, editors. Charaka Samhita, Chkitsasthana. 7/21.Varanasi: Chaukhambha Sanskrit Pratishthan, Delhi, 2012.p.324-5