E-ISSN:2456-3110

Case Report

Agnivisarpa

Journal of Ayurveda and Integrated Medical Sciences

2024 Volume 9 Number 3 March
Publisherwww.maharshicharaka.in

Understanding the treatment modalities of Pemphigus Vulgaris (Agnivisarpa) through the lens of Ayurveda - A Single Case Study

Singh H1*, Panwar G2, Vinay Vasudev Welankar V3
DOI:10.21760/jaims.9.3.40

1* Harpreet Singh, Post Graduate Scholar, Dept of Panchakarma, Uttrakhand Ayurveda University Rishikul Campus, Haridwar, Uttarakhand, India.

2 Gareema Panwar, Post Graduate Scholar, Dept of Panchakarma, Uttrakhand Ayurveda University Rishikul Campus, Haridwar, Uttarakhand, India.

3 Vaidya Vinay Vasudev Welankar, BAMS Aayurvedacharya CRAV Guru, Mumbai, Maharashtra, India.

Pemphigus is a disease that causes blisters and sore on the skin or mucous membrane. The blisters rupture easily, leaving open sores, which may ooze and become infected. Agnivisarpa can be compared to pemphigus vulgaris due to its resemblance in sign and symptoms. The disease needs early and proper treatment to prevent further morbidity and mortality. Being an autoimmune disorder physician generally use corticosteroids and immunosuppressive drugs here an attempt is made to study in detail about pemphigus vulgaris and its understanding though Ayurveda. A case report of 47year old male patient with clinical presentation of fluid filled blisters burning and pain along with hyperpigmentation received systemic medication in modern medicine without an adequate response. Samshodhan coupled with Samshamana medication are the cornerstones for Visarpa. Hence in this study, Virechana Karma once in a week for 2 month. After that Raktamokshana (After completion of 3 sitting of Virechana Karma) followed by 3 months of Samshamana medicine. At the conclusion of treatment, a skin lesion assessment was performed.

Keywords: Agnivisarpa, Pemphigus, Raktamokshana, Virechana Karma, Ayurveda.

Corresponding Author How to Cite this Article To Browse
Harpreet Singh, Post Graduate Scholar, Dept of Panchakarma, Uttrakhand Ayurveda University Rishikul Campus, Haridwar, Uttarakhand, India.
Email: 		Singh H, Panwar G, Vinay Vasudev Welankar V, Understanding the treatment modalities of Pemphigus Vulgaris (Agnivisarpa) through the lens of Ayurveda - A Single Case Study. J Ayu Int Med Sci. 2024;9(3):249-254.
Available From
https://jaims.in/jaims/article/view/3156

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2024-01-01 2024-01-10 2024-01-20 2024-01-30 2024-02-09
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
None Nil Yes 21.87

© 2024by Singh H, Panwar G, Vinay Vasudev Welankar Vand 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

Pemphigus vulgaris is a rare bullous disease of the skin and mucous membrane. It is clinically characterized by blisters and erosions of the mucus membrane and skin. It is characterized by the production of autoantibodies directed against desmosoal protein leading to acantholysis and thus formation of epidermal bullae.[1,2] Visarpa is a Pitta Nanatmaja Vyadhi Charakacharya explains in Chikitsa Sthana as they are Sarva Shariragata (appears in the whole body) with burning sensation along with fever and thirst.[3] It is said to be caused by the vitiation of the Tridoshas and shows specific variations in the manifestations depending on the Dosha predominance. The Vishesh Samprapti varies in accordance with the Doshas involved leading to variable manifestations. Pemphigus vulgaris bears a resemblance with to Agni Visarpa wherein vitiation of Vata and Pitta and in turn Rasa, Rakta, Twak, and Mamsa is the reason of Lakshanotpatti. Prakupit Pitta and Rakta cause Aaraktata, Shotha and Pidika. Agnidagdha Prakara Sphota is the main characteristic feature of Agnivisarpa and the fatality is more when compared to other skin diseases.

Patient Profile

Name: xxxx

Age/Sex: 47yr

OPD No.: ग-266

Occupation: Doctor

Religion: Hindu

Address: Mumbai

Case Report

A 47year old male patient was consulted in OPD of Vd. Vinay Vasudeo Welankar Clinic (OPD No- ग-266) at Dombivli MS with complaints of Small fluid filled blisters on the face, upper trunk, and back, Pus along with blood discharge through blisters, Burning sensation, Pain, Inflammation, Hyperpigmentation of the affected area and Decreased appetite since 9 month. The patient also consulted to allopathic hospitals and took allopathic medications for 5 months but didn’t get any satisfactory relief. Then for further line of management he came to Dirghayu Panchakarma Chikitsalaya, Dombivli East (MS)

Past History - No. H/O HTN, Thyroid, H/O- D.M Since 2 month

Treatment History - The patient took some Ayurvedic medicines on and off

Allopathic medications

1. Tab Prednisolone 40mg
2. Tab Azoran 50mg

Family History - Not Specific

Personal History

Appetite: Reduced

Thirst: Normal

Bowel: clear

Micturition: Normal

Sleep: Disturbed

Diet: Vegetarian

General Examination

Pallor: Absent

Icterus: Absent

Clubbing: Absent

Cyanosis: Absent

Lymphadenopathy: Absent

Edema: Present

Vital Examination

Blood Pressure: 136/86mmHg

Pulse rate: 72/min

Respiratory rate: 18/min

Weight: 78kg

Temperature: 98.6°F

Ashtavidha Pariksha

1.NadiPitta Pradhan Kapha Anubandhi
2.MalaNiyamit (Regular)
3.MutraSamanya (4-5 Times a day, No burning sensation)
4.JivhaAlpa Samta (white coated)
5.ShabdaGambhir (Deep)
6.SparshaRuksha (Dry), Alpa Ushna (warm)
7.DrikaPittabh Shweta (Yellowish White)
8.AakritiMadhyam

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jaims_3156_01.JPG
Before Treatment (25 May 2021)

jaims_3156_02.JPG
After Treatment (10 July 2021)

Dashvidha Pariksha

1.PrakritiPitta Vatta
2.VikritiPitta Rakta
3.SaraMamsa Sara
4.SamhananaMadhyam
5.PramanaMadhyam
6.SatvaPravar
7.SatmyaSarvarasa Satmya
8.Ahara ShaktiMadhyam
9.Vyayama ShaktiAvara
10.VayaYuva

jaims_3156_03.JPG
Before Treatment (25 May 2021)

jaims_3156_04.JPG
After Treatment (10 July 2021)


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Raktamokshana (Siravedha)

Systemic Examination

Gastro-intestinal system: Soft, Non- tender

Respiratory system: Bilateral chest clear

Cardiovascular system: S1 and S2 heard normal

Central nervous system: Conscious, well oriented to time and place and person.

Skin Examination:

Site of eruption - Back, Chest, Face, Bilateral Axilla region.

Distribution - Asymmetrical

Margin - Irregular and diffuse

Colour - Blackish red

Samprapti Ghataka

NidanaVirudha Ahara, Dadhi Sevana, Atya Ambu Paan, Alpa Vyaayam, Krodha, Chinta,
DoshaPitta, Rakta
DushyaTwaka, Rakta, Mamsa, Lasika
SrotasRaktvaha Srotas
AdhisthanaTwaka
RogamargaBahya-Marga

Vyadhi Vinishchay (Provisional Diagnosis) - Agni Visarpa (A type of skin disorder)

Treatment

1. Samshamana Chiktisa
2. Shodhana Chiktisa

Table 1: Treatment Plan

Samshaman ChikitsaSansodhan Chikitsa
1.  Rasapachaka Vati (750mg) - TDS
2.  Raktapachaka Vati (500mg) - TDS
3.  Haridra Guduchi Ghan Vati(750mg) - TDS
4.  Laghu Manjisthtaadi Kasyam (20ml) - BD
5.  Krimikudharaadi Rasa (500mg) - TDS
6.  Chopacheeni Churna (500mg) - BD
7.  Vyadhiharan Rasayana		1.  Langhana/Rukshana
2.  Nitya Virechana with Trivutta Avleha (15-20gms) once in a week for 2 months.
3.  Raktamokshana (Sira Vedha) - After completion of 3 sitting of Virechana Karma.

Follow-up

The follow-up was carried after 1 month to rule out progression of disease and adverse reaction.

Table 2: Treatment protocol

DateChikitsa
25 May 20211.  Rasapachaka Vati (750mg) - TDS
2.  Raktapachaka Vati (500mg) - TDS
3.  Haridra Guduchi Ghan Vati(750mg) - TDS
4.  Laghu Manjisthtaadi Kasyam (20ml) BD
5.  Trivrutta Avleha for Virechana once in a week.
17 June 20211.  Rasapachaka Vati (750mg) - TDS
2.  Raktapachaka Vati (500mg) - TDS
3.  Haridra Guduchi Ghan Vati(750mg) - TDS
4. Aragvadhadi Kashayam (20ml) BD
5. Siravedha Raktamokshana (Amount 100-120ml)
10 July 20211.  Haridra Guduchi Ghan Vati(750mg) - TDS.
2.  Krimikudharaadi Rasa (500mg) - TDS
3.  Chopacheeni Churna (500mg) - BD
4.  Vyadhiharan Rasayana
5.  Virechana + Raktamokshana

Table 3: Changes in Sign and Symptoms

Sign and symptomsBefore treatmentAfter treatment
Daha (Burning Sensation)PresentAbsent
Pidika (Blisters)PresentAbsent
Shyava (Blackish discoloration)PresentReduced
Sarava (Discharge)PresentAbsent

Result

Significant relief has been observed in symptoms like Daha, Pidika, Shyava, Sarava. Significant improvement has also been observed in Appetite and bowel habits.

Discussion

Ayurveda have classified Visarpa based on Adhishtana and Doshabheda. To be specific, the signs and symptoms of pemphigus vulgaris matches more with the manifestations of Agnivisarpa.[4]

It is called Visarpa because it spreads in different directions and it is also called Parisarpa because it spreads all over the body.[5] Acharya Susruta


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describes the Pratyaatma Lakshana for pemphigus as Sarvaanga Saarina i.e., spreading.[6] To be specific, the clinical features of Pemphigus vulgaris simulate with symptoms of Agni Visarpa explained in our classics. Understanding of Dosha, Dushya, Agni, Ama and Srotas are the base of diagnosis and treatment as per Ayurveda. Rakta and Pittahar Chiktisa Raktamoksahan (Raktmokshana is the main treatment of Visarpa by Acharya Charaka. They have explained as other all Chikitsa on one side and Raktmokshana on one side in Visarpa.[7] and Virechana along with Prashamana Aushadha and Aharaa can be given as a treatment approach.

Nitya Virechana was given once in a week to break the pathogenesis of Visarpa. As Agni Visarpa have dominance of Pitta Dosha.Trivrutta Avleha used for Nitya Virechana Trivrutta Avaleha helps in correcting Jatharagni and Dhatuagni which further eliminates the Ama and Dushit Doshas with its Rechan property.

Before starting the treatment the patient was kept or fasting for one day. Then the Shamana Aushadi were given along with Rukshana. No oleation therapy was given because as per Acharya Vagbhatta.[8] So Sadhyo Virechana is given.

When blood gets vitiated in the Shakhas bloodletting itself should be done first, because increase of Kleda in Twaka, Mamsa, Snayu and Rakta.[9]

Table 4: Shamshana Yoga

SNName of the medicineComponentKarma
1.Ras-Pachaka VatiKalingaka, patolpatra, KatukrohioniRaktadhatuprasadaka, Ras Dhatu Agnivardhak, Kleda Kirmi Nashak, Vranropaka
2.Rakta- Pachaka VatiPatola, Sariva, Musta, Patha, KatukrohiniRas Dhatu Agnivardhak, Raktagat Kleda Shoshak, Raktaprasadak, Pitta Shamaka,
3.Haridra Guduchi Ghan VatiHaridra, GuduchiRas Dhatu Agnivardhak, Raktaprasadaka, Krmighana, Kusthagna, Vranagat Puya, Kleda, Sarawa, Shoshaka.
4.Arogya Vardhini VatiKutki etc.Kusthagna, Pitta Virechana,
5.Kirmi Kuthar RasaKarpur, Ajmoda, Vidanga, palash, Nagkeshara etc.Kaphhara, Krimighana, Kusthagana
6.Vyadhiharan rasayana + Chopchini ChurnaParad, Gandhak, Hartal, ManhshillaRakta Shodhaka, Shothhar, due to Action on Twacha And Snayu
7.Laghu Manjisthadi KashayaManjistha, Trifala, Kutki, Devdaru, Haridra, Guduchi, Nimba TwakaRakta Shodhaka, Pitta shamaka
8.Aragvadhadi KashayaAragvadh, Kiratikta, Bhunimba, Karanja, etc.Rakta Shodhaka, Kandughana, Anulomaka, Mridu Virechaka.

Conclusion

The main theory of treating this ailment states that it is advantageous to apply Shodhana Karma and Shamana Karma repeatedly. The current case study demonstrates the efficaciousness of Virechana Karma followed by Raktamokshana Karma work effectively and can break the pathogenesis of pemphigus vulgaris. This Ayurvedic technique lessens the presenting complaint while also preventing the disease from progressing. The case study presented here demonstrates a notable decline in the condition during a brief period of time. Depending on the patient's condition, repeated Shodhana may be required to discontinue the use of corticosteroids and contemporary antihistamines.

References

1. Tsunoda, T. Ota, M. Saito et al., “Pathogenic relevance ofIgG and IgM antibodies against desmoglein 3 in blister for-mation in pemphigus vulgaris,” -e American Journal ofPathology, vol. 179, no. 2, pp. 795–806, 2011.

2. M. Hammers and J. R. Stanley, “Mechanisms of disease: pemphigus and bullous pemphigoid,” Annual Review of Pathology: Mechanisms of Disease, vol. 11, no. 1, pp.175–197,2016.

3. Sastri K., Kushtha Chikitsa. Pandeya G. (ed.), Charak Samhita, Vidhyotinitika vol.2, Chaukhambha Sanskrit, Varanasi, 2009;7/21-25:243.

4. Agnivesa, Caraka Samhita. Ayurveda Dipika Commentary of Cakrapanidatta, edited by Vaidya Jadavji Trikamji Acharya. Chikitsa Sthana; Chapter 21, Verse 36. Varanasi: Chaukamba Krishnadas Academy, 2010; 561: 21 – 36.

5. Agnivesa, Caraka Samhita. Ayurveda Dipika Commentary of Cakrapanidatta, edited by Vaidya Jadavji Trikamji Acharya. Chikitsa Sthana. Varanasi: Chaukamba Krishnadas Academy, 2010; 559: 21 – 11.

6. Susruta, Susruta Samhita. Nibandhasangraha commentary by Sri Dalhanacarya, edited by Vaidya Jadavji Trikamji Acharya. Nidana Sthana; Varanasi: Chaukamba Krishnadas Academy, 2013; 306: 10 – 3

7. Yadavji Trikamji, Charak Samhita, Published by


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Chowkhamba orientala, Varanasi, 2017 ed, Chikitsasthana, Chapter 21, Shloka 141, Page no. 566.

8. Vagbhata, Astanga Hrdayam English commentary volume 2 translated by Prof. K.R.Srikantha Murthy : Chowkhamba Krishnadas Academy Chiktisa Sthana chapter 18\1 page no.59

9. Vagbhata, Astanga Hrdayam English commentary volume 2 translated by Prof. K.R.Srikantha Murthy : Chowkhamba Krishnadas Academy Chiktisa Sthana chapter 18\8 page no.466


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