E-ISSN:2456-3110

Case Report

Leech therapy

Journal of Ayurveda and Integrated Medical Sciences

2024 Volume 9 Number 12 DECEMBER
Publisherwww.maharshicharaka.in

Role of Leech therapy in the management of Vyanga w.s.r. to Melasma - A Single Case Study

Bola S1*, Kumari S2
DOI:10.21760/jaims.9.12.41

1* Sunita Bola, Assistant Professor, Dept of Panchakarma, Shekhawati Ayurved Medical College and Hospital, Pilani, Rajasthan, India.

2 Sunita Kumari, Assistant Professor, Dept of Panchakarma, Shekhawati Ayurved Medical College and Hospital, Pilani, Rajasthan, India.

Vyanga is categorized under Kshudra Rogas and primarily occurs due to the vitiation of Vata, Pitta, and Rakta. It can be correlated with Melasma in terms of its signs and symptoms. A key feature of Vyanga is the presence of Niruja, Tanu, and Shyava Varnayukta Mandala (a type of pigmentation) on the facial area (Mukhapradesha). Melasma is an asymptomatic, acquired, and chronic condition characterized by hyperpigmented macules or patches that develop slowly and symmetrically on areas like the molar region, bridge of the nose, forehead, temples, and upper lips. These patches are typically dark, irregular, sometimes small, and well-demarcated. Brhajaka Pitta, which is responsible for skin coloration, is closely related to the complexion of the skin. Vitiated Pitta Dosha plays an important role in the development of Melasma. The management of this condition should focus on pacifying the aggravated Doshas and promoting Raktashodhana (blood purification or detoxification). Leech Therapy (Jalaukavacharana) is considered a key treatment modality, as it aids in blood purification, removes toxins, and eliminates the vitiated Doshas accumulated in the body. This case study presents a single patient suffering from Melasma, who was selected for the study at Shekhawati Ayurved Medical College & Hospital, Pilani. The efficacy of Leech Therapy was found to be significant, yielding positive results.

Keywords: Vyanga, Kshudraroga, Jalaukavacharana, Melasma, Leech Therapy

Corresponding Author How to Cite this Article To Browse
Sunita Bola, Assistant Professor, Dept of Panchakarma, Shekhawati Ayurved Medical College and Hospital, Pilani, Rajasthan, India.
Email: 		Bola S, Kumari S, Role of Leech therapy in the management of Vyanga w.s.r. to Melasma - A Single Case Study. J Ayu Int Med Sci. 2024;9(12):301-307.
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Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2024-11-09 2024-11-19 2024-11-29 2024-12-09 2024-12-20
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© 2024by Bola S, Kumari Sand 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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ResultsDiscussionConclusionReferences
Sunita B et al. Role of Leech therapy in the management of Vyanga w.s.r. to Melasma

Introduction

Melasma is a condition that diminishes the natural glow of the face and affects the skin, leading to cosmetic concerns. It significantly impacts a person’s quality of life, particularly their emotional well-being and social interactions.

This condition is more commonly observed in females than in males and holds considerable importance as a cosmetic disorder in society.

Vyanga, as mentioned by various Ayurvedic scholars, is classified under Kshudra Roga. Acharya Charaka describes it as a Raktadushtigata Vyadhi[1] (disease caused by impurity of blood) in the Trishotheeya Adhyaya.[2]

Acharya Vagbhata considers Vyanga as a manifestation of Rakta Vruddhi Lakshana,[3] and Acharya Sushruta categorizes it as a Raktaja Roga.[4] Additionally, a separate description of Vyanga is found in the Sushruta Samhita under the chapter of Kshudra Roga.

Krodhaayas Prakupito Vayuh Pitten Samyuktah: |
Sahasa Mukhamagatya Mandalam Visrajtyata:|
Nirujam Tanukam Syavam Mukhe Vyangam Tamadishet || (Su.Ni. 13/45-46)

Acharya Sushruta explains that due to the vitiation of Vata and Pitta arising from Krodha (anger) and Aayaasa (fatigue), the doshas reach the Mukha (face) and cause Vyanga, which is characterized by Niruja (painless), Tanu (thin), and Shyavavarna Mandalas[5] (bluish-black patches) on the face, due to the vitiation of Vata, Pitta, and subsequently Rakta Dosha.

Vyanga can be closely correlated with hyperpigmentation, especially in the case of Melasma. The patches of hyperpigmentation are predominantly found on the cheeks, nose, forehead, and chin. Melasma is a common acquired, symmetric form of hyper melanosis, characterized by light brown to dark brown macules[6] and patches, primarily in sun-exposed areas of the face.

Although several etiological factors[7] are associated with Melasma, such as pregnancy, hormonal disturbances, racial predisposition, photo-toxicity, and sensitivity to certain drugs and food, the primary aggravating factor remains the exposure to sunlight.[8]

Raktamokshana (bloodletting) is an important therapeutic procedure for Raktaja Rogas.[9] Among the various methods of Raktamokshana, such as Siravedha, Shringa, Alabu, and Jalaukavacharana, Leech Therapy (Jalaukavacharana) is considered the safest and most effective methods in Vyanga (Melesma). In conditions of Pitta predominance, Jalaukavacharana[10] is particularly beneficial, as the leech’s secretions have a Sheeta (Cooling) property and possess Madhura Rasa[11] (sweet taste), which helps to purify the blood (Raktashodhana), remove toxins, and alleviate the vitiated Doshas from the body. Therefore, Leech Therapy is highly recommended for managing diseases like Melasma, especially when localized to the affected sites.

Case Study

Present Complaints

A 35-year-old female patient presented to the Panchakarma Department OPD of Shekhawati Ayurved Medical College & Hospital, Pilani, Rajasthan. She began noticing dark brown patches appearing gradually on both cheeks and the forehead without any itching or burning sensations over the past 9 months. She received allopathic treatment, but there was no significant improvement. As a result, she sought further treatment at our hospital’s Panchakarma department.

Past History: No significant medical history.

Family History: No significant family history.

Menstrual History: Regular menstrual cycle.

Personal History

Pulse rate - 74/minute
Blood Pressure - 110/70 mm of Hg
Appetite - Normal
Bowel - Clear
Bladder - Clear
Sleep - Normal
O/E - Dark brown coloured patches on the face.

Astvidha Pariksha

Nadi - Vata - Pittaja (74/min)
Mutra - D-5/ N-2 Times
Mala - Nirama (1 time/day)
Jihva - Malavaritta
Shabda - Prakruta


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Sunita B et al. Role of Leech therapy in the management of Vyanga w.s.r. to Melasma

Sparsha - Ruksha (dry, rough)
Drik - Samanya
Akrati - Madhyama

Assessment Criteria

Melasma Area and Severity Index (MASI):[12]

The MASI is a commonly used system for assessing the severity of melasma, especially in clinical settings and research. It measures both the extent and intensity of pigmentation across different areas of the face. The evaluation criteria include:

  • Area of Involvement: This is expressed as a percentage of the total facial surface, ranging from 0% to 100%.
  • Severity of Pigmentation: The intensity of pigmentation is rated on a scale from 0 (no pigmentation) to 4 (severe pigmentation).
  • Homogeneity: This measures the uniformity of pigmentation within the affected areas, scored from 0 to 4.

MASI Score Calculation:

For each facial region, the MASI score is calculated as follows:
MASI = 0.3 × (DF​×HF​×AF​) + 0.3 × (DRM​×HRM​×ARM​) + 0.3 × (DLM​×HLM​×ALM)​ + 0.1 × (DC​×HC​×AC​)

Table 1: Assessment Criteria

ParameterFindingScore
Severity of PigmentationNo Visible Pigmentation0
Slight Pigmentation1
Mild Pigmentation2
Moderate Pigmentation3
Severe Pigmentation4
Area of InvolvementNo Involvement0
<10 % Involvement1
11-29% Involvement2
30-49% Involvement3
50-69% Involvement4
70-89% Involvement5
90-100 % Involvement6
HomogeneityAbsent0
Slight (Specks Involvement)1
Mild (Small Patchy area of involvement <1.5 cm diameter)2
Moderate (Patches involvement > 2cm diameter)3
Severe (Uniform skin involvement without any clear area)4

Where:
D = Darkness score
H = Homogeneity score
A = Area score
F = Forehead
RM = Right Malar (Right Cheek)
LM = Left Malar (Left Cheek)
C = Chin

Treatment Protocol

Procedure: Raktamokshana through Jalaukavacharana (Leech Therapy) was performed across three sessions. In first session, leeches were applied simultaneously to both cheeks and forehead. Subsequent sessions were conducted at 7-day intervals.

Quantity: Three leeches were used in each session, applied once a week to affected area.

Duration: Duration of therapy was three weeks with each session lasting for 25-30 minutes with an interval of 7 days.

Selection of Leeches: Yogya Jalauka (Nirvisha Jalaukas)[13] were chosen for therapy.

Storage of Leeches: Collected leeches were stored in a wide, new earthen pot filled with natural tank water containing lotus. Water was changed every 2-3 days, and food was added to pot. Earthen pot was replaced every seven days to maintain hygiene.

Preparation of Jalauka:[14] Leeches were coated with a paste of Haridra (turmeric) and then kept in clean water for one Muhurta (approximately 48 minutes). This process activated leeches and alleviated exhaustion.

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Leech Therapy

Application of Procedure: Patient’s face was thoroughly cleansed with cold water, and treatment area was dried. Patient was positioned in a supine position, and leeches were applied directly to cheeks and forehead.


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Once an adequate amount of blood was extracted, leeches detached naturally detached within approximately 25 to 30 minutes. They primarily consumed impure or vitiated blood from area.

Observations and Results

Table 2: Showing the Result of Improvement

ParameterBefore Treatment ScoreAfter Treatment Score
Severity of PigmentationForehead41
Right Cheek42
Left Cheek31
Chin00
Area of InvolvementForehead31
Right Cheek52
Left Cheek42
Chin00
HomogeneityForehead31
Right Cheek32
Left Cheek31
Chin00
MASI Score39.63.3

Right Cheek

jaims_3863_02.JPG
Before Treatment

jaims_3863_03.JPG
After First Session

jaims_3863_04.JPG
After Second Session

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After Treatment

Left Cheek

jaims_3863_06.JPG
Before Treatment

jaims_3863_07.JPG
After First Session


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jaims_3863_08.JPG
After Second Session

jaims_3863_09.JPG
After Treatment

Forehead

jaims_3863_10.JPG
Before Treatment

jaims_3863_11.JPG
After First Session

jaims_3863_12.JPG
After Second Session

jaims_3863_13.JPG
After Treatment

After the first Jalaukavacharana session, mild improvement was observed in hyperpigmentation over the cheeks and forehead. By the second session, the patches started lightening in Varna (colour), transitioning from Krishna Varna (dark brown) to Shyama Varna (brown). After the third session, only a few patches remained on the cheeks and forehead, and the colour of Patches had turned from brown to a light brown. Post three sessions of Jalaukavacharana, there was a significant reduction in the MASI (Melasma Area and Severity Index) score, indicating substantial improvement in Vyanga (Melesma). The skin’s Prakriti (complexion) and Sparsha (texture) also improved, becoming smoother. Importantly, no adverse effects were observed throughout the treatment course.

Discussion

Vyanga is classified as a Twakvikara (skin disorder). Twakvikaras typically involve the vitiation of Rasa and Rakta dhatus. According to Acharya Sushruta, Vyanga results from the vitiation of Vata and Pitta Doshas, along with Rakta Dosha. Acharya Charaka has recommended Virechana (therapeutic purgation) and Raktamokshana (bloodletting) for conditions with Pitta predominance. Among the four types of Raktamokshana - Siravedha (venesection), Shringa (horn application), Alabu (gourd application), and Jalaukavacharana (leech therapy).


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Jalaukavacharana is particularly effective for conditions with Pitta predominance. In the case of Vyanga, which involves Pitta Dosha vitiation and Raktadushti (impurities in blood), leech therapy (Jalaukavacharana) is highly beneficial. Leeches extract impure blood locally from the affected area, enhancing circulation and promoting healing. The removal of vitiated Rakta helps pacify Pitta Dosha, reducing discoloration and patches. Due to their Sheeta (cooling) nature and Madhura Rasa (sweet taste), leeches are especially effective for Pitta related disorders. Leech therapy targets superficial blood (Avagadha Rakta)[15] as leeches can easily access the superficial veins, removing stagnation and improving the flow of purified blood, thereby reducing local inflammation.

The therapeutic benefits of leech therapy include the removal of metabolic waste, enhanced microcirculation, and reduction of stagnant blood. The saliva of leeches contains numerous bioactive compounds with anti-inflammatory, analgesic, thrombolytic, antioxidant, vasodilatory, anticoagulant, and antibacterial properties. These constituents not only detoxify but also promote blood purification and tissue repair. Thus, leech therapy effectively pacifies Pitta Dosha, removes impure blood, and reduces hyperpigmentation, making it a valuable treatment for Vyanga.

Conclusion

Vyanga can be clinically compared with Melasma described in ayurvedic classics and Symp toms of Melasma is patches of hyper pigmentation are seen especially on cheeks, nose, forehead and chin of light brown to dark brown colour.

The Leech Therapy treatment given in three sessions with an interval of 7 days. This treatment is effective in the management of these disease. The main aim of treatment is to be pacify of Pitta Dosha.

Leech therapy given in this case of Vyanga can treat vitiated Vata and Pitta Dosha and Raktadushti. Following the treatment, the Scoring shows a reduction in all evaluated parameters such as severity of pigmentation, area of involvement and symmetry, highlighting significant improvement. The Case study conclude that Jalaukavacharan (Leech Therapy) is highly effective in the treatment of Vyanga.

References

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2. Sastri K, Chaturvedi GN, editors. Charaka Samhita of Agnivesha. Reprint ed. Vol. 1. Varanasi: Chaukhambha Bharati Academy; 2013. Sutra Sthana, Chapter 18, Shloka 25. p. 379.

3. Gupta KA, editor. Astanga Hridaya with the ‘Vidyotini’ Hindi Commentary. 2016 ed. Varanasi: Chaukhamba Pratishthan; 2016. Sutra Sthana, Chapter 11, Shloka 9. p. 115.

4. Trikamji Y, editor. Sushruta Samhita with Nibandhasangraha. 2013 ed. Varanasi: Chaukhamba Sanskrit Sansthan; 2013. Sutra Sthana, Chapter 9, Shloka 24. p. 112.

5. Shashtri KA, editor. Sushruta Samhita of Mahrishi Sushruta. Reprint ed. Varanasi: Chaukhamba Sanskrit Sansthan; 2009. Part 1, Nidansthan, Shloka 13/45-46. p. 373.

6. Dorling Kindersley, editor. Oxford Dictionary. 80th ed. Oxford: Oxford University Press; 2007. p. 188.

7. James W, editor. Andrew’s Diseases of the Skin: Clinical Dermatology. 11th ed. Chapter 36. p. 855.

8. Buxton PK. ABC of Dermatology. 4th ed. BMJ Publishing Group; 2003. p. 76.

9. Sharma AR, editor. Sushruta Samhita – ‘Sushruta Vimarshini’ Hindi Commentary. 7th ed. Vol. I. Varanasi: Chaukhamba Surbharati Prakashan; 2002. p. 560.

10. Murthi KPS, editor. Susruta Samhita – Illustrated Sushurt Samhita. Vol. I. Varanasi: Chaukhamba Orientalia; 2010. p. 82.

11. Shashtri KA, editor. Sushruta Samhita of Mahrishi Sushruta. Reprint ed. Varanasi: Chaukhamba Sanskrit Sansthan; 2009. Part 1, Sutrasthan, Shloka 13/6. p. 57.

12. Kimbrough-Green CK, et al. Journal of the American Academy of Dermatology (JAAD). 1994.

13. Shashtri KA, editor. Sushruta Samhita of Mahrishi Sushruta. Reprint ed. Varanasi: Chaukhamba Sanskrit Sansthan; 2009. Part 1, Sutrasthan, Shloka 13/13-15. p. 51.


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14. Shashtri KA, editor. Sushruta Samhita of Mahrishi Sushruta. Reprint ed. Varanasi: Chaukhamba Sanskrit Sansthan; 2009. Part 1, Sutrasthana, Shloka 13/19. p. 60.

15. Shashtri KA, editor. Sushruta Samhita of Mahrishi Sushruta. Reprint ed. Varanasi: Chaukhamba Sanskrit Sansthan; 2009. Part 1, Shareer Sthana, Shloka 8/25-26. p. 92.

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