Effect of a multimodality Ayurveda treatment in a case of Visphota kushta.

Visphota kushta (blistering skin disease) is characterized by transparent blisters with thin skin covering. Management of Visphota Kushta in Ayurveda is rarely reported. The case reported here showed significant regression in the condition in short span of time and could completely stop the use of anti histamines and corticosteroids. A 32 year old female, presented with complaints of blisters over both upper and lower extremities associated with edema, burning sensation, pain, severe itching and oozing since three months. The treatments were given after ascertaining the involved dosha and the samprapti (pathogenesis). The involved dosha were and Pitta (metabolic factor) and Kapha (binding factor) dosha. Pitta - kapha dosha hara line of treatment was adopted in terms of mitigating and purificatory therapy. It helped in arresting the progression of the condition and a complete healing of blisters. Photographs were taken during and after the treatment for records. The blister completely resolved and the skin was normal as before. The patient was back to her normal routine with no signs of relapse. The outcome was a combined effect of both shamana and shodhana chikitsa along with pathya sevana.

Introduction

Visphota kushta (blistering skin disease) is characterized by transparent blisters with thin skin covering [1]. It can be considered under the broad spectrum of vesiculobullous diseases which are characterized by vesicles and bullae. The condition varies from dermatitis to autoimmune blistering disorders. Ayurvedic management of such diseases is rarely reported. The case reported here with the informed consent of the patient showed significant regression in the condition with no signs of relapse. The patient showed a good response in short span of time and could completely stop the use of antihistamines and corticosteroids. The scope of Ayurvedic approach to address such vesiculobullous diseases is discussed in this paper. The employed treatments were non-invasive and cost-effective, purely based on the principles of Ayurveda.

Case presentation

A 32-year- old female nursery teacher, presented with chief concerns of blisters over both upper and lower extremities along with oedema since 3 months. It was associated with severe burning sensation, pain, itching and oozing.

It started with a small nodular skin lesion on the ventral aspect of the left hand above the wrist. Then similar lesions appeared on either hand which increased in size day by day for which she took allopathic medication and found relief. But the condition relapsed on discontinuing the medications. Gradually blisters developed over both upper and lower extremities along with oedema. It was associated with severe burning sensation, pain, itching and oozing. The symptoms aggravated on contact with water and she was unable to do her daily chores. There was no relevant history of any past illness or relevant family history. The personal history of the patient reveals regular intake of fish, curd, and excessive intake of sour and spicy food which may have attributed to the condition. No other specific causative factor was found relevant in the present condition.

Clinical findings

The lesion type was vesicle and bullae with oval, dome-shaped configuration. The lesions were transparent and fluid filled with smooth texture. It was distributed over upper and lower extremities mostly in hands and foot along with swelling. Nails and mucosa were unaffected.

Diagnostic assessment

Investigations

Blood routine and liver function test were within the normal limits. Other skin investigations were not done due to financial constraints of the patient.

Diagnosis: Visphota kushta

Based on the manifested symptoms and clinical findings the case was diagnosed as Visphota Kushta which is characterized by transparent blisters with thin skin covering. The lesions were limited to the extremities and it helped to rule out other blistering disorders associated with systemic illnesses.

Therapeutic intervention

The interventions were done after ascertaining the dosha involved. The involved dosha were Pitta (metabolic factor) and Kapha (binding factor). It was elicited based on the presenting complaints like severe burning sensation, itching and the nature of the skin lesion. The mentioned causative factors also suggest the vitiation of Pitta and Kapha dosha. The treatment was accomplished in two phases- Shamana Cikitsa (treatments aimed at mitigating the dosha) administered as outpatient and Shodhana Cikitsa (treatments for eliminating excessive morbid dosha) was performed as inpatient.

First phase of management – Shamana cikitsa

The internal and external medications given are listed in Table 1. The patient was advised to avoid curd, fish, black gram, brinjal, ladies finger, sour, spicy food, fried items, etc in the diet.

Table 1

First Phase of Management (Shamana Chikitsa) - as outpatient.

Sl No.	Formulation	Dose	Adjuvant	Duration
1	Patolamooladi kashaya[2](Decoction prepared out of herbs)	10 mL of each kashaya together twice daily on an empty stomach	60 mL of boiled then cooled water	0th–14th day
2	Guducyadi kashayam[3](Decoction prepared out of herbs)
3	Manibhadra gulam[4](Jaggery based herbal preparation)	1 tablespoon at bedtime	–	0th–14th day
4	Dushivishari gulika[5](Tablet)	1-0-1 tab	Rice washed water	0th–14th day
5	Nimbaharidradi churna[6](Herbal Powder)	Decoction for washing the lesion	–	0th–14th day
6	Herbal Paste	External application	–	0th–7th day
7	Mahatiktaka ghrta[7](Medicated ghee)	External application	–	0th–14th day

Second phase of management – Shodhana cikitsa

Virecana (Purgation therapy) was planned for the purification of the body. As a part of preoperative procedure pacana (carminative therapy) using kashaya dhara (pouring of medicated decoction over the body), oleation therapy (both internal and external) and sudation therapy were performed as listed in Table 2.

Table 2

Second Phase of Management - Shodhana Chikitsa – as inpatient.

Sl No.	Procedure	Formulation	Dose	Duration
1	Kashaya dhara (Pouring of medicated decoction over the body)	Triphala kashaya[8](Decoction)	Aprox. 5L/day	0th–4th day
2	Snehapana (Internal administration of medicated ghee in increasing dose)	Tiktaka ghrta[9](Medicated ghee)	Starting with 30 mL on the first day and increased up to 140 ml on the fifth day (final day)	5th–9th day
3	Abhyanga (Whole body oil massage) and steam fomentation	Eladi kera[10](Medicated oil)	120 mL/day	10th–12th day
4	Virecana (Purgation therapy)	Manibhadra gulam (Jaggery based herbal preparation)	60 g with hot water	12th day

Ingredients of medicine

The ingredients of the medicines used are given in Table 3.

Table 3

Ingredients of medicine.

Sl No.	Formulation	Ingredients
1	Patolamooladi kashaya (Decoction prepared out of herbs)	1. Trichosanthes dioica Roxb.2. Emblica officinalis Gaertn.3. Terminalia chebula Retz.4. Terminalia belerica Roxb.5. Citrullus colocynthis Schrad.6. Bacopa monnieri (Linn.) Pennell7. Picrorhiza kurroa Royle ex Benth.8. Zingiber officinale Roxb.
2	Guducyadi kashayam (Decoction prepared out of herbs)	1. Tinospora cordifolia (Willd.) Miers.2. Prunus cerasoides D. Don3. Azadirachta indica A. Juss.4. Coriandrum sativum Linn.5. Pterocarpus santalinus Linn.
3	Manibhadra gulam (Jaggery based herbal preparation)	1. Embelia ribes Burm.f.2. Emblica officinalis Gaertn.3. Terminalia chebula Retz.4. Operculina turpethum (Linn.) Silva Manso5. Jaggery
4	Dushivishari gulika (Tablet)	1. Piper longum Linn.2. Scindapsus officinalis (Roxb.) Schott3. Cymbopogon martini (Roxb.) Wats4. Nardostachys jatamansi DC.5. Symplocos racemosa Roxb.6. Elettaria cardamomum (Linn.) Maton.7. Tribulus terrestris Linn.8. Oroxylum indicum Vent.9. Valeriana wallichii DC.10. Saussurea lappa C.B.Clarke.11. Glycyrrhiza glabra Linn.12. Santalum album Linn.13. Red ochre
5	Nimbaharidradi churna (Herbal Powder)	1. Azadirachta indica A. Juss.2. Curcuma longa Linn.3. Berberis aristata DC.4. Ocimum sanctum Linn.5. Trichosanthes dioica Roxb.6. Saussurea lappa C.B.Clarke7. Withania somnifera Dunal.8. Cedrus deodara (Roxb.) Loud.9. Moringa oleifera Lam.10. Brassica campestris Linn.11. Zanthoxylum armatum DC12. Coriandrum sativum Linn.13. Chrysopogon aciculatus Trin.
6	Herbal Paste	1. Moringa oleifera Lam.2. Boerhavia diffusa Linn.3. Curcuma longa Linn.4. Acorus calamus Linn.5. Pterocarpus santalinus Linn.6. Cissampelos pareira Linn.7. Hemidesmus indicus (Linn.) R. Br.8. Aristolochia indica Linn.
7	Mahatiktaka ghrta (Medicated ghee)	1. Juice of Emblica officinalis Gaertn.2. Cassia fistula Linn.3. Alstonia scholaris (Linn.) R. Br.4. Picrorhiza kurroa Royle ex Benth.5. Acorus calamus Linn.6. Aconitum heterophyllum Wall. Ex Royle7. Cissampelos pareira Linn.8. Cyperus rotundus Linn.9. Vetiveria zizanioides (Linn.) Nash10. Emblica officinalis Gaertn.11. Terminalia chebula Retz.12. Terminalia belerica Roxb.13. Trichosanthes dioica Roxb.14. Azadirachta indica A. Juss.15. C urcuma longa Linn.16. Fumaria indica Pugsley17. Piper longum Linn.18. Piper chaba Hunter19. Santalum album Linn.20. Prunus puddum (Wall.) Roxb. ex Brandis21. Berberis aristata DC.22. Citrullus colocynthis Schrad.23. Asparagus racemosus Willd.24. Hemidesmus indicus (Linn.) R. Br.25. Holarrhena antidysenterica (Roth.) A. DC.26. Adhatoda vasica Nees.27. Marsdenia tenacissima (Roxb.) Moon28. Tinospora cordifolia (Willd.) Miers.29. Swertia chirata Buch. Ham.30. Glycyrrhiza glabra Linn.31. Gentiana kurroo Royle.32. Ghee
8	Triphala kashaya (Decoction prepared out of herbs)	1. Emblica officinalis GAERTN.2. Terminalia chebula RETZ. & WILLD.3. Terminalia bellerica ROXB.
9	Tiktaka ghrta (Medicated ghee)	1. Trichosanthes dioica Roxb.2. Azadirachta indica A. Juss.3. Picrorhiza kurroa Royle ex Benth.4. Berberis aristata DC.5. Cissampelos pareira Linn.6. Alhagi pseudalhagi (Bieb.) Desv.7. Fumaria indica Pugsley8. Gentiana kurroo Royle.9. Cyperus rotundus Linn.10. Andrographis paniculata (Burm.f.)Wallich ex Nees.11. Holarrhena antidysenterica (Roth.) A. DC.12. Piper longum Linn.13. Ghee
10	Eladi kera (Medicated oil)	1. Elettaria cardamomum (Linn.) Maton2. Hydnocarpus laurifolia (Dennst.) Steum.3. Saussurea lappa C.B.Clarke4. Callicarpa macrophylla Vahl.,etc5. Oil of Cocos nucifera Linn.

Follow up and outcomes

There was the arrest in the progression of blister and oedema during the first week followed by erosion and healing of blisters in the second week of outpatient level management. Following the rupture of bullae the affected area of skin started to peel off and was replaced by the normal skin without any scarring or hyper pigmentation but secondary milia formation was noticed. There was marked relief of pain, burning sensation but itching persisted. Itching reduced considerably after Triphala kashaya dhara. After virecana there was complete relief in itching and all other associated symptoms. Photographs were taken during and after the treatment for records.

Timeline of the case report is shown in Table 4.

Table 4

Timeline.

Dates	Events	Intervention
10 Mar 2017	Initial presentation: Small nodular skin lesion on the ventral aspect of the left hand above the wrist. Similar lesions appeared on either hand which increased in size	Took allopathic treatment and found temporary relief.
12 May 2017	Condition relapsed on stopping allopathic medications.	Consulted traditional ayurveda practitioner and took medicines but did not get any relief
17 May 2017	Current Illness: Blisters over both upper and lower extremities associated with pain, burning sensation, severe itching and oozing	Shamana cikitsa using internal and external medications along with strict diet restriction
24 May 2017	Follow up 1: Blisters dried up and crust formation noticed in hand, peeling off of skin, few blisters on leg present. Burning sensation and pain reduced, itching persists	Continued same internal and external medications
31 May 2017	Follow up 2: Secondary milia present on both hands, crust formation and peeling off of skin on legs, itching persists	Continued same internal and external medications
24 Jun 2017	Follow up 3: Secondary milia present on both hands, itching persists, pain in both legs	Hospitalization for Shodhana (purgation therapy)
10 Jul 2017	Follow up 4: Complete relief in itching and leg pain. No signs of any skin lesion in the body.	Resolved completely, back to normal routine.
10 May 2018	Follow up 5 (Telephonic conversation): No signs of relapse.	–

Result

The blister completely resolved and the skin was normal as before. The patient was back to her normal routine with no signs of relapse. The photographs taken during shamana cikitsa, after the shamana cikitsa and after the shodhana cikitsa are shown in Fig. 1, Fig. 2, Fig. 3, Fig. 4, Fig. 5, Fig. 6, Fig. 7, Fig. 8, Fig. 9. Follow up after a year reveals no signs of relapse.

Fig. 1

During shamana cikitsa.

Fig. 2

After shamana cikitsa.

Fig. 3

After shodhana cikitsa.

Fig. 4

During shamana cikitsa.

Fig. 5

After shamana cikitsa.

Fig. 6

After shodhana cikitsa.

Fig. 7

During shamana cikitsa.

Fig. 8

After shamana cikitsa.

Fig. 9

After shodhana cikitsa.

Discussion

The main causative factors in the manifestation of the pathology of Visphota kushta are pitta and kapha dosha associated with dhatu's like rasa and rakta. As mentioned in viruddhahara (incompatible food), regular intake of fish and curd becomes the cause of the manifestation of skin eruptions. Patient's diet especially sour and spicy food also contributed to this and caused the vitiation of above-mentioned dosha resulting in the presentation of Visphota kushta (pitta kapha dosha predominant kushta) [11] with blisters and other associated symptoms in the skin. Based on the dosha involved, pitta kapha hara (pitta and kapha dosha pacifying) line of treatment was adopted in terms of shamana and shodhana cikitsa.

In the shamana chikitsa, both internal and external medications were included. The internal medicines helped in mrdu shodhana (mild purification) as well as helped in srotoshodhana (clearing the channels). The decoctions given were pitta kapha hara in nature and had a mild laxative as well as anti-inflammatory property. Trichosanthes dioica is known to have an anti ulcerous effect and proved useful in skin disorders [12]. Cucurbitacin B present in T. dioica has been shown to have antimicrobial and anti-inflammatory activity [13], [14]. Potential medicinal properties of Tinospora cordifolia reported by scientific research include antipyretic [15], anti-inflammatory [16], antioxidant, anti-allergic, anti-stress, anti-leprotic, hepato-protective and immuno-modulatory [17]. The ideal management of pitta dosha is virecana. This could be achieved on a daily basis by use of Manibhadra gulam that was indicated in conditions of skin. Dushivisha is the toxins thats get accumulated in due course of time and on exposure to some triggering factors, exhibits its symptoms including skin manifestations. The dietary habits of the patient, which are mentioned earlier like regular intake of fish and curd, etc, are considered as incompatible food and in due course of time, the toxins might have accumulated in the body acting as dushivisha. Dushivishari tablet is known for its antitoxic property and is reported to be beneficial in skin disorders.

The herbs given for external application like Curcuma longa [18], Azadirachta indica [19] were anti-inflammatory and mainly helped in the erosion of blisters which might have decreased the chance of wound progression by relieving pressure. The herbal paste, which includes Hemidesmus indicus [20], Moringa oleifera [21] are anti-inflammatory and anti microbial in action, helped in reducing oedema and preventing secondary infection in the wound. The aqueous extract of Boerhavia diffusa possesses anti-inflammatory properties [22] which can be attributed to its cell membrane stabilizing effect and inhibit the lysis and release of the proinflammatory mediators. Further, local application of medicated ghee processed with sheeta virya (cold potency) and tikta rasa (bitter taste) drugs helped in reducing the burning sensation and itching. Ghee has a special quality of nirvapana [23] (mitigating burning sensation) and also prevented excess drying up of the skin tissue. It prevents fluid loss from burn wound and also lubricates the surface of wound preventing hard eschar formation. It is having vranaropana (healing) and kantivardhana (improving luster) property which helps in early healing with good pigmentation.

As a part of shodhana cikitsa purgation therapy was planned. Prior to shodhana, Triphala kashaya was used for dhara. Triphala and its individual components showed an antibacterial effect on both gram-positive and gram-negative bacteria, which suggest the ingress of active phytochemicals through both the bacterial cells walls. The immuno-modulatory property of Triphala could be attributed to flavonoids, alkaloids, tannins, saponins, glycosides and phenolic compounds [24].

For the purpose of snehapana, Tiktaka ghrta was chosen, it is pitta hara (pacifying pitta dosha) in nature and indicated in skin diseases. It was suggested that the drugs present in the ghee may have some affinity towards the target organ [25]. Snehapana by virtue of its dosha utkleshana (increasing the dosha) separates toxins accumulated in the patient's body. The separated morbid dosha are eliminated by virecana. It helped in the removal of vitiated dosha out of the body along with toxins at cellular level. Even though avara shuddhi (minimal purification) was attained, there was a remarkable improvement in the patient. It is advised to perform repeated purification in minimal quantities in skin disorders to protect prana (life) as an excess elimination of dosha can aggravate vata dosha (factor responsible for neurological and cognitive responses in the body) and may further deteriorate the strength of the patient [26].

Throughout the shodhana procedures, the patient was advised to follow strict diet restrictions. Following wholesome food and regimens is also vital especially in conditions of skin. The diet restriction like avoiding curd, black gram, sour, spicy items was aimed to prevent further increase in kapha and pitta dosha. Moreover, curd and fish are considered as abhishyandi (secretive) and can cause srotorodha (obstruction to the channels). Incompatible and unwholesome food habits can further aggravate condition [27].

The outcome was a combined effect of both shamana and shodhana chikitsa along with pathya sevana.

Conclusion

In this diagnosed case of Visphota kushta, based on the samprapti (pathogenesis), pitta-kapha hara line of treatment was adopted. Both internal and external purification along with wholesome diet was found effective in doing the samprapti vighatana (breaking the samprapti). The patient showed a good response in short span of time and could completely stop the use of antihistamines and corticosteroids. The adopted treatment modalities helped in arresting the progression of the condition and complete healing of blisters. All other associated signs and symptoms resolved completely. Follow up after a year also revealed no signs of relapse.

Informed consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images.

Source of funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.