Ayurveda management of oro-facial herpes: a case report.

Viral infections are one of the challenging health hazards of the present medical care. One among such viral infections is "Oro-facial Herpes", caused by the Varicella Zoster Virus (HSV-1). This case report shows the successful treatment of "Oro-facial herpes" and its complication only through Ayurveda. In which, there will be closed grouped vesicles on an erythematous base in the dermatomal pattern, with burning type of pain. The condition in Ayurveda can be co- related to 'Visarpa'. We present a case of 72-year, male, with sudden onset of edema over upper gums, with 3 to 4 vesicles over the left upper lip, left part of face within 2 days, along with reduced sensation to touch and temperature. The patient had redness, watering and burning sensation of left eye. Clinically the patient was diagnosed with "Oro- Facial Herpes". As pitta dosha and raktadhatu vitiation was noticed the case was managed by Nitya pitta rechaka (cholegogue), the dravy's with tikta, sheetaveerya and ruksha in nature. The patient showed improvement over 5 months of treatment from 10-Apr to 15-Aug-2018. The complaints of pain in the lesions reduced from 8 to 2, headache from 8 to 1 (VAS) and burning sensation reduced by 90%.

Introduction

Oro-facial herpes is a viral infection characterized by closely grouped vesicles on an erythematous base in the dermatome pattern associated with burning type of pain. The condition is caused by the varicella zoaster virus [1]. Herpes is epidemiological and of public interest. The incident rate of oro-facial Herpes is 16.2% within the age group of 14–49 years. The antiviral agents are effective in the management of the Oro facial Herpes, but these agents also have shown the evidence of the transient renal insufficiency [2] and some have shown the resistant. In Ayurveda, this condition is termed as ‘Visarpa’ and is defined by Acharya Charaka as ‘sarvato visarpanaad visarpa’ (that which manifests and spreads in the body rapidly) [3]. In which there will be vitiation of rakta dhatu and pitta dosha. The predisposing factors for the origin of Oro-facial Herpes are old age, underlying HIV infection, immunosuppressive conditions such as Hodking’s lymphoma and leukemia (Table 1) [4].

Table 1

Pathogenesis of Visarpa (Oro-facial herpes).

Sr. No	Literature of Visarpa	Literature on Oro-facial Herpes	Clinical Manifestation
1	Visapra is the spread of blisters and swelling in all directions (vividham sarpatiti urdhvam, adha and tiryakk prasarati, sphotat, shophat)	Skin lesions or blisters in the dermatome pattern	Vesicles ruptured and spread to the left maxillary region, left nasal ala, left lateral part of nose and below left eyelid
2	Agni nasha, anna dwesha, sarpsha agynana, jwara, daha, anga sadana, ek desha grahi, shirogurutva, Nidra, tandra, moha, annadweshi, pralapa, dourbalya, asthibheda, moorcha, pipasa, Indriya jadyat, snigda, mandavedana, swavathu, gambhirapaka, shigrakleda, kunapagandhi	Fever, malaise, myalgia, lesions on the lip, left cheek till left lower lid of the left eye.	Agni nasha, jwara, anna dwesha, sparsha agyanana, daha, anga sadana, ek desha grahi, snigdayukta.

Patient information

A 72-year-old male patient, known hypertensive, approached the OPD of KLE Ayurveda Hospital, Medical Research Centre, Belagavi on 10 April 2018, presented with chief complaints of crests over the left side of the upper lip, left side of the face and lower eye lid was associated with redness, burning and watering from the left eye. The patient was unable to open left eye for two days. On history taking, the patient explained there was a sudden onset of edema of upper gums from 1st April 2018, for which he consulted the dentist and was prescribed Tab O2 (Ofloxacin 200 mg and Ornidazole 500 mg) one BD, Tab B complex OD and Dologel topical application over gums. Swelling in the gums reduced after two days of medication. From 3rd of April the patient noticed vesicles, three to four in number on the left half of upper lip, which ruptured and spread to the left maxillary region, left nasal ala, left lateral part of nose and below left eyelid within two days. The patient had raised body temperature of one episode on 8th April 2018. Above complaints were associated with reduced sensation to touch and temperature at the left maxillary region, left nasal ala, left lateral part of nose, left upper lip portion and below left eyelid (Fig. 1).

Fig. 1

Before Treatment: Please note that the skin lesions with crests reddish discoloration of the eye.

Clinical findings and diagnostic assessments

The patient’s detail history was noted and on general examination, there was no pallor, cyanosis and change in the nail, lymphadenopathy and edema. On local examination, the skin lesion morphologically appeared to be vesicles with ill-defined margins, extending from midline part of the upper lip to left maxillary region, left part of nasal ala and lower part of left eye. The color was red, with few black discolored crests. Sensation was reduced at the lesions site. Touch to cotton was absent. Patient was not able to recognize the two point discrimination. The motor examination of trigeminal nerve revealed no difficulty in chewing, biting and swallowing of the food, there was no wasting at the muscles of the left face and the forceful closure of mouth was normal. The sensory examination of trigeminal nerve revealed, reduced sensation to the soft cotton wool over maxillary, left part of nose, left part of upper lip and left cheek. Corneal reflex was normal. All other cranial nerve examination was intact. The examination findings were analyzed at different intervals such as 1st, 6th, 10th, 20th, 44th day.

Therapeutic intervention

Based on the history, detailed clinical examination, the patient was diagnosed to be suffering from Oro-facial herpes vis-à-vis Visarpa. The pathological staging was pitta and kapha dosha abnormality along with vata dosha and shonita dusti. The management of Visarpa is Rakta mokshana (therapeutic bloodletting) and other Panchakarma (bio-purificatory therapies) along with oral medications. Application of all these is according to stages of the disease and strength of the patient. Based on classical guidelines of Ayurveda the following treatment was adopted in this patient. Daily cleaning of the affected part with panchavalkala decoction of vata (Ficus benghalensis), udumbara (Ficu sglomerata Roxb), plaksha (Ficuslacor Buch), paarisha (Thespesia populnea), ashwatha (Ficus religiosa Linn) for 10 days from 10-Apr-2018 [4]. After complete drying of the affected part, the patient was educated and advised topical application of mahatiktaka ghrita ointment [5].Virocil syp ARAR pharmaceuticals consists of Guduchi (Tinospora cordifolia Willd),Punarnava (Boerhaavia diffusa Linn.), Bhringaraja (Eclipta alba Hassk.), Katuki (Picrorhiza kurroa Royle), and Tulasi (Ocimum sanctum Linn.),15 mL t.i.d, the powder of Guduchi (T. cordifolia Willd), Nimba (Azadirachta indica A.Juss), Sariva (Hemidesmus indicus Linn.), Vasa (Adhatoda vasica Nees), and Amalaki (Emblica officinalis Gaertn.) 4 gm thrice a day, Tab Sootashekara with gold 1 tablet b.i.d [6], Tab Nirocil proprietary medicine containing Bhumyamlaki (Phyllanthus niruri), one tablet t.i.d [7] and Avipattikara powder,10 gm at bed time were prescribed to the patient. Avipattikara powder acts as pitta rechaka (cholegogue) [8]. On 16-Apr-2018, the patient did not complain of any pain or burning sensations and lesions were healed. The same medicines were continued and Nimbaamrutadi Eranda Taila [9] 10 mL at bed time for three days was added after completing the dose of Avipattikara churna for dosha anulomana (setting dosha’s in their natural direction) and mridu samshodhana (bio-purificatory therapy). The patient complained of three episodes of headache, persisting for 5 min on the third visit on 20-Apr-2018. The patient was prescribed with Pathyadi Kadha 15mlb.i.d [10] for his headache. The lesion cleansing was continued till 20-Apr-2018. The patient visited OPD on 30-Apr-2018 with complaints of left sided headache which was continuous and burning in nature in the maxillary region from last 3 days. The crests had peeled off. The oral medicines were revised with Guloochyadi kashaya [11] three tsf b.i.d, Tablet Briht Vata Chinatamani (Swarnamukta) [12] b.i.d, Mahatiktaka Ghrita ointment topical application and to continue the Pathyadi Khada 15 ml b.i.d after food (Table 2). On patient’s fourth follow up on 14-May-2018, the previous complaints of pain in the lesions reduced from VAS scale 8 to 2, burning sensation reduced to 90% and headache reduced from VAS scale 10 to 2. The patient was advised to continue medicines for 15 more days and then stop completely. On last visit on 14-Aug-2018, patient had complete relief of all the complaints and was symptom free (Fig. 2).

Table 2

Details of therapeutic interventions at different timelines viz Oro facial Herpes.

S.No	Duration of Intervention	Lakshana	Doshas	Dosha vrudhi/kshaya avastha	Chikitsa (Shodhana & Shamana)
01	1st to 10th day	Watering of eyes, burning of eyes, red lesions with few black crests, fever of one episode, loss of sensation at the left side of the chest.	Kapha pitta, and Rakta	Kapha and pitta vruddhi and shonita kleda vruddhi	1) Bahirparimarjana- vrana prakshalana with pancha valkala kashaya.After complete dry mahatiktaka Ghrita ointment application.2) Vatanulomana and mridu virechana - with Avipattikara churna for firsr 3 days followed by Nimbamrutadi Taila for next 3 day.3) Tab Nirocil BD4) Kashaya prepared out of guduchi, punarnava, bhringaraja, katuki and Tulasi.5) Guduchi, sariva, Nimba, vasa and amalaki 6 gms three times a day.6) Tab Sootashekar with gold once a day
02	10th to 44th day	Left sided headache, with severe burning sensation in the left maxillary region	Vata, pitta	Vata and pitta vruddhi	1) Pathyadi kadha 15 ml BD2) Briht vata chintamani with gold 1 BD3) Mahatiktaka Ghrita external application4) Guloochyad kashaya 15 ml BD

Fig. 2

After Treatment: Please note that the skin lesion color became almost to skin color.

Discussion

Visarpa is rakta (blood) pradoshaja disease and one of Pittaja disease manifesting in twacha (skin). Owing to its spreading nature it is termed visarpa and is classified into 8 subtypes viz., vataja, pittaja, kaphaja, sannipataja, agneya (vaatapittaja), kardama (kaphapittaja) and granthi (kaphavataja). Reported case had vitiation of pitta and kapha dosha and diagnosed with Kardama Visarpa. The treatment concentrated on lesion cleansing with panchavalkala decoction, which is kashaya rasa, sheeta veerya (cold potency), varnya (which imparts the normal color to the skin), vrana ropaka (wound healing property) and daha hara (pacifying the burning sensation) properties. The herbs in the Mahatiktaka Ghrita ointment possess tikta rasa, sheeta veerya (cooling), (laghu) light and (ruksha) drying in nature. The medicated decoction of Bhumyamalaki, Guduchi, Punarnava, Bhringara, Katuki, Tulasi is alleviates the kapha and pitta dosha. Punarnava due to its madhura, tikta and kashaya guna improves rakta dhatvagni, does shoshana of raktagata kleda. Bhumyamalakai does shoshana of vranagata kleda along with Guduchi possessing Tikta and kashaya rasa. As per the modern pharmacology, Bhumyamalaki acts as potent antiviral. In the above decoction, Punarnava, Bhringaraja and Guduchi act on Rajanaka Pitta. Sariva and Amalaki help in digestion of raktagata ama. Vasa and Nimba will ensure dosha pachana (digest morbid dosha) and pacify vitiated pitta and kapha dosha. The sootashekara rasa formulation digests the sama pitta in digestive tract thus promoting good quality rasa dhatu formation for dhatu poshana. The avipattikara churna and nimbamrutadi eranda taila helps in the expulsion of morbid pitta from the GI tract. In the later phase of the disease, Pathyadi kwatha, Brihat Vata Chintamaniand Gooluchyadi Kwatha were prescribed for the shirashoola (Post herpatic neuralgia) which mainly acts on vatakaphaja morbidity.

Conclusion

Abhishanga (viral infection) and pitta vitiation are main causative factors for visarpa. Ayurvedic management with Tikta rasa medicines internally and diet regimen along with anulomana variety of virechana and topical application of sheeta and ruksha lepa were beneficial for the patient for total period of 164 days. The patient was symptom free at the end of 164 days. The patient was treated with only ayurvedic line of treatment with no antiviral drugs. Results observed in this case were encouraging and emphasize the importance of ayurvedic intervention in the successful management of Oro-facial herpes.

Patient informed consent

Patient gave consent for publication of the article.

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Conflicts of Interest

None.