Ayurvedic management of life-threatening skin emergency erythroderma: A case study.

Erythroderma or generalized exfoliative dermatitis is a skin disorder that requires attention equivalent to medical emergencies. It is more prevalent in male population. It accounts for 35 cases/100,000 cases in dermatologic outpatient departments. In erythroderma even with proper management there are certain metabolic burdens and complications which make it more critical. The primary aim, in this case, was to treat the patient with Ayurvedic management. A 18-year-old patient, suffering from erythroderma, was treated on the line of Kapala Kushtha and Audumbera Kushtha. The patient had primarily suffered from psoriasis for 8 years. Erythroderma was developed due to abrupt self-medication with an unknown amount of intramuscular methylprednisolone several times in last month. Rasamanikya-125 mg, Arogyavardhini Vati-1 g, Kaishora Guggulu-1 g, Khadirarista-20 ml, and Panchatikta Ghrita-20 ml, all drugs twice a day with 3-4 times local application of Jatyadi Taila were administered. A decoction of Jwarhara Kashaya was also administered in the dose of 40 ml twice a day. The patient had relief from the acute phase after 20 days of treatment and complete remission after 3 months of treatment. This case study demonstrates that Ayurvedic management may be useful in erythroderma like acute and life-threatening condition.

Introduction

Erythroderma is an inflammatory skin disorder characterized by extensive erythema and scaling all over the body caused due to dysfunction of skin metabolism. The body surface involves in this condition accounts for more than 90%. Erythroderma even with proper management has metabolic burden and complications. It has multiple etiologies which makes its management more and more challenging. In the Indian subcontinent, the incidence is 35 cases/100,000 cases attended at dermatologic outpatient department. It is more prevalent in males with the male: female ratio ranging from 2:1 to 4:1, and the mean age between 40 and 60 years.[1] A pre existing dermatitis is the single most common cause of adult erythroderma. A number of dermatitis can progress to erythroderma, but the most common include psoriasis and eczema.[123] Uses of herbal medicines such as Aloe vera leaves and Yoruba agbo leaves are also demonstrated as a causative factor.[4]

Some clinical features of erythroderma are common to all patients. A patchy erythema may rapidly spread within 12–48 h and accompanied by pyrexia, malaise, and shivering.[5] Scaling appears 2–6 days later. At this stage, the skin is hot, red, dry, thickened, and indurated due to edema and lichenification.[6] The patient experiences irritation and tightness of the skin and feels cold. There may be copious and continuous exfoliation of scales. If erythroderma has been present for some weeks, scalp, and body hair is lost. The nails become thickened and may be shed.[7] Pigmentary changes are also prominent. In some patients sparing of the nose and paranasal areas is also found (nose sign)[8] This is described in Ayurveda as Nasabhanga due to spreading of skin disease up to bone and bone marrow level and involvement of Pitta Dosha.[910] Cardiac failure and hypothermia are especially found in the elderly patients. Edema and cutaneous or respiratory infection are also found in some patients. The pulse rate is always increased. The most common causes of death in patients with erythroderma are heart failure, pneumonia, and septicemia.[11] Initial studies reported death rate in the range of 4.6-64%. Laboratory findings are usually nonspecific. Common abnormalities are leukocytosis with eosinophilia, erythrocyte sedimentation rate, mild anemia, decreased serum albumin, abnormal serum protein electrophoresis, increased uric acid, and elevated IgE levels. The initial management of erythroderma included replacement of nutritional, fluid, and electrolyte losses. Local skin-care measures as well as wet dressings followed by the application of bland emollients and low-potency corticosteroids. Secondary infections are treated with antibiotics.

This case report is of a patient of erythroderma which was successfully managed according to the line of management of Kapala Kushtha and Audumbera Kushtha.

Case Report

A 18-year-old boy came to OPD of National Institute of Ayurveda, Jaipur, India on July 27, 2013, for a severe skin problem. The patient was suffering from pyrexia, malaise, shivering, edema, cracking of skin, erythema, shedding of skin from all over the body, severe itching, oozing, restlessness, and breathlessness [Figure 1]. This condition had appeared suddenly from last 5-6 days following intramuscular injection of methylprednisolone taken to relieve itching of the skin. First patient felt hot, red, dry, and thickened skin with irritation and tightness of the skin associated with severe shivering. The patient was suffering from psoriasis. The patient had taken medicine irregularly from many allopathic skin specialists. From last 6 months was on self-medication of intramuscular methylprednisolone about 4 times in a month but from last month frequency of self-medication with intramuscular prednisolone was increased. Family history was negative for similar conditions or skin disorders. Physical examination showed extensive non-uniform erythematous scaly patches involving the scalp, face, trunk, arms, legs, palms, and soles. There was severe sloughing of the epidermis from all over the body. The nails were thickened, had ridges, and shedding were also there in some nails. Other laboratory investigations and vital signs were also abnormal [Table 1]. This patient was treated in I.P.D. of National Institute of Ayurveda, Jaipur. The patient was treated on the line of management of Kapala Kushtha and Audumbera Kushtha. Rasmanikya-125 mg,[12] Arogyavardhini Vati-1 g,[13] Kaishora Guggulu-1 g,[14] Khadirarista-20 ml,[15] and Panchatikta Ghrita-20 ml,[16] twice a day with 3-4 times local application of Jatyadi Taila[17] was administered for treatment. A decoction of Jwarhara Kashaya [Table 2] was also administered in the dose of 40 ml twice a day for total 3 months. The patient had relief from the acute phase after 20 days and complete remission after 3 months of total treatment [Figure 2].

Figure 1

Before treatment

Table 1

Laboratory investigations and vital signs of patient before and after treatment

Table 2

Content of Jwarhara Kashaya

Figure 2

After treatment

Discussion

Erythroderma is a secondary disorder for several primary skin diseases. In the first stage of erythroderma patchy erythema, pyrexia, malaise, shivering, hot, red, dry indurated, thickened skin, and lichenification are found. These have the resemblance with the manifestation of Kapala kushtha that are erythematic and blackish discoloration of skin, dryness of skin, hardness of skin, thinning of epidermis and pricking such as itching sensation of skin and irregular spreading.[1819] In second stage of erythroderma oozing, shedding of skin from whole body, edema, cardiac failure, cutaneous or respiratory infection, pneumonia, septicemia, pigmentary changes in hair and sparing of nose, and paranasal areas, etc., complication are found. These have the resemblance with the manifestation of Audumbera Kushtha that are burning sensation, severe itching, pain, erythema of whole skin, discoloration of hair, edema and oozing from skin and rapidly cracking of skin and infection.[2021] Kapala Kushtha is a Vata Dosha dominant skin disease, and Audumbera Kushtha is a Pitta dominant skin disease. The line of Ayurvedic management of Kapala Kushtha and Audumbera Kushtha is the application of medicated Ghrita and Virechana (purgation).[22] Treatment was planned according to these principles. In this case study, patient reported in complication phase. In Ayurvedic point of view, this phase was the Audumbera Kushtha. So at this phase mild purgation was given with Arogyavardhini Vati and Jwarhara Kashaya. Due to shedding of epidermal skin barrier was lost and the body was prone for infection. So Jatyadi Taila was applied 3-4 times a day on the whole body surface. For oozing of skin (which is considered as Kleda in Ayurveda), Khadirarista was administered as Khadira has Kledashoshaka (controlling the oozing from skin) property due to its Khara Guna (roughness property). Jwarhara Kashaya was given which alleviate the shivering, pyrexia, and itching due to its Pittahara properties (suppression and elimination of deranged Pitta Dosha). Due to which after 8–9 days of treatment patient had relief. But erythema, itching, and feeling of tightness of skin were present. Some new sterile pinhead-sized pustules were also appeared. Panchatikta Ghrita was added to the treatment as it is the line of treatment of Kapala Kushtha. Within next 10 days, the patient got relief from acute stage of this disorder. There was some improvement in ridging of nails and shedding of nails. Administration of Panchatikta Ghrita was continued up to 3 months. After 3 months of total treatment nails had got luster back and there were no pitting and ridges on nails. Involvement of nails in skin disease in Ayurveda is considered under Asthigata Kushtha and for which treatment with Panchatikta Ghrita is necessary. Panchatikta Ghrita is a combination of drugs having Tikta Rasa (bitter taste) dominance. Tikta Rasa is used as a vehicle to deliver medicine up to bone Dhatu level. In Ayurveda, nails are considered as a byproduct of Asthi Dhatu (bone) metabolism. Rasamanikya, Kaishora Guggulu, Arogyavardhini Vati, and Jatyadi Taila are effective in Galita Kushtha (skin diseases with suppuration) Sphuthit Kushtha, Vatarakta, Vishphota, and Mandala Kushtha, etc.,(various skin disorders). Combined effects of these drugs are helpful in breaking of immunological reaction, removal of a toxic substance from the body, relieving from pain, inflammation, infection, and to improve general body condition. The combination of these drugs has the capabilities to address all the manifestations of erythroderma. In erythroderma mainly steroid is administered systematically and locally but in this case erythroderma was developed after more and abrupt uses of steroid. This case was successfully treated with Ayurvedic medicine on the line of management of Kapala and Audumbera Kushtha.

Conclusion

Various stages of clinical manifestation of erythroderma have close resemblance with Kapala Kushtha and Audumbera Kushtha. This case of erythroderma was successfully managed in the lines of management of Kapala Kushtha and Audumbera Kushtha. This case study demonstrates that Ayurvedic management may be useful in acute and life-threatening conditions such as erythroderma.

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Conflicts of interest

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