Ayurvedic management of adverse drug reactions with Shvitrahara Varti.

Adverse drug reactions (ADR) are an expression that describes harm associated with the use of medications at therapeutic dose. Traditional medicines also can develop ADRs due to their improper use. Shvitrahara Varti, one of such medicines holds Bakuchi as a component and is to be used judiciously. Furanocoumarins like psoralen present in Bakuchi makes skin hypersensitive and causes phytophotodermatitis in few cases. Hence, one should be careful while using medicines that contain Bakuchi. One such case is observed, where extensive reactions with application of Shvitrahara Varti were noticed and managed with Ayurvedic treatment.

Introduction

Traditional systems of medicines, including herbal medicines are being used since centuries for health-care by people in countries of the South-East Asia Region as well as in other parts of the world. Traditional medicine continues to be a valuable source of remedies to the people around the world to secure their health.[1] Ayurvedic medical system, the traditional medicine of Indian Subcontinent has been in vogue since Vedic period or even earlier. It emphasizes on the maintenance, promotion of health and curing diseases through natural resources.[2] There is a belief prevailing in the society that these natural products are safe and are free from adverse effects, which is not always true. Majority of adverse events with the use of herbal medicines or products are attributable either to poor product quality or to improper use.[3] One such adverse event was observed with the use of Shvitrahara Varti[4] that has been reported here.

Vitiligo is a condition that causes de-pigmentation of sections of skin that occurs when melanocytes, die or are unable to function. The world-wide incidence is lesser than 1%.[5] Though the condition is rare and non-communicable; patients who are stigmatized for their condition may experience depression and similar mood disorders.[6] The modern medical system has treatment modalities including topical corticosteroids etc., but is also known for their greater adverse events.[7] Considering the inconveniencies and limitations of modern medical system, the suffering population is searching options through traditional systems of medicines.

In Ayurveda, this condition is comparable with Shvitra. Ayurveda has ample of drugs to treat this condition. Single drugs such as Kakodumbara (Ficus hispida Linn.),[8] Khadira (Acacia catechu Wild.),[9] Apamarga (Achyranthes aspera Linn.),[10] Bakuchi (Psoralea corylifolia Linn.)[11] etc., and compound formulation such as Shvitrahara Varti, Shvitrari Rasa,[12] Gomutrasava,[13] Shashilekha Vati,[14] etc., are useful in the management of Shvitra. Shvitrahara Varti, one of such preparations is successfully being practiced by Ayurvedic physicians.

Case Report

A 58-year-old, male patient visited the out-patient department (OPD) of Rasa Shastra and Bhaishajya Kalpana during the month of November, 2012 presenting with symptoms of non-segmental vitiligo spreading over elbow and knee joint. History revealed that patient is non-hypertensive, non-diabetic and did not have any symptoms of endocrinal or immunological disorders. He worked in brass industry for the last 5 years and retired recently. On analysis, his Prakriti is found to have Pitta dominance. The lesions were non-itchy without any discharge.

Patient was prescribed Shvitrahara Varti [Table 1] as a local applicant along with internal drugs [Table 2]. It is advised to convert Varti into a paste by levigating in the presence of Gomutra and apply as a thin layer over the affected area (elbow and knee) followed by exposure to sun rays in the morning.

Table 1

Formulation composition of Shvitrahara Varti

Table 2

Treatment provided

After three consecutive topical applications, patient started feeling a burning sensation over the parts affected. Burning sensation became intense followed by pain, blister formation and mild inflammation. He stopped application of Shvitrahara Varti from day 3. On consecutive days, the blisters became extensive, dark red in color with purple margins and the blisters bursted of their own with watery discharge. Patient attended the OPD for treatment on 7th day [Figure 1].

Figure 1

Reactions on Day-1 on both the elbow and knee joints

Management and Observations

All the medicines were stopped immediately. Patient was advised to irrigate the lesions with freshly prepared Panchavalkala Kwatha,[15] followed by local application of Sarjarasa Malahara [Table 3].[16] Internally, combination of Punarnavashtaka Kwatha,[17] Manjishtadi Kwatha[18] along with Kaishora Guggulu[19] was administered [Table 4]. Patient was advised to continue the application of Malahara as frequent as possible until complete remission is observed and visit the OPD at regular intervals of a week for follow-up.

Table 3

Formulation composition of Sarjarasa Malahara

Table 4

Treatment schedule after the formation of blisters

Discussion

Shvitrahara Varti is found to be beneficial in cases of Shvitra and is frequently being practiced by Ayurvedic fraternity. This formulation is acombination of fine powders of Bakuchi and Haratala, levigated in the presence of Gomutra. Bakuchi is the predominant component of the formulation. Its compounds are preferred in the management of Shvitra since ages.[20] Haratala is useful in different types of skin diseases.[21] Urine, in general is attributed with properties like Shodhana and beneficial in cases of Kushtha (skin diseases), Shopha (inflammation) etc.,[22] The combination of these three components are expected to work synergistically and bring back the normal complexion of the skin. At the same time, Bakuchi contains several chemical constituents including flavonoids, coumarins and meroterpenes, etc.,[23] that makes the skin sensitive and hence, the precautionary measures are to be taken while its use. Inappropriate application in higher doses or application in sensitive individuals may lead to the development of adverse effects.

The reactions observed in the current study can be compared with the type of augmented adverse reactions that are related to the main pharmacological effect of the drug (Type A). The lesions were extensive, appeared with severe pain leading to loss of function of the affected parts. The drugs were stopped immediately and medicines were prescribed to counter the condition. Panchavalkala Kwatha is beneficial in cases of Shopha and Vrana. Sarjarasa Malahara is beneficial in pacifying Daha (burning sensation) and Shoola (pain). The combination of Punarnavashtaka Kwatha possesses Pitta Shamaka property. Manjishtadi Kwatha acts as Rakta Shodhaka (blood purifier) and Kaishora Guggulu is beneficial in Kushtha (skin diseases) and Vrana (wounds). The combination of all the medicines prescribed in the current case helps to alleviate the adverse effects, check Rakta Dushti and pacify aggravated Pitta. Application of Sarjarasa Malahara locally will check the morbid Doshas.

Conclusion

Adverse drug reactions are the integral part of drug pharmacology. They are expected to occur with administration of any drug. Medicines from traditional systems of medicines are not exempted from this. Ayurveda has considered in detail about the possible ways by which untoward effects can occur and provided all the guidelines to avoid the occurrence of such incidences. In any eventuality, if untoward effects are noticed due to non-compliance code of conduct, treatment procedures for such conditions have also been prescribed. It implies that, there is always a chance of developing adverse effects by the utilization of drugs from traditional systems of medicines.

Blisters occurred because of the presence of psoralen in Varti, which is a natural phenomenon and positive sign in the management of Shvitra. But, the individual under the treatment in the current case may be idiosyncratic to the drug and hence, extensive lesions were developed. At the end of treatment; the lightened skin at the elbow and knee became dark with and showed signs of repigmentation [Figures 2–4].

Figure 2

Improvement by 7th day

Figure 4

Improvement by 21st day

Improvement by 14th day