Ayurvedic visha hara (antitoxic) chikitsa in recurrent dyshidrotic eczema skin disease: A case report.

Dyshidrotic eczema is a chronic, enigmatic condition that usually affects the hands and feet that probably accounts for about 5%-20% of hand eczemas. In Ayurveda various skin manifestation are mentioned under different chapter & context like kushtha, visarpa, kshudra kushtha, vidradi, krimi roga, keeta visha (insect bite), Garavisha &Dooshi visha (latent toxicity).Visphota variety of kushtha is characterized by pustules which are either white or reddish in appearance. These pustules have a thin skin and it is pitta-kapha predominant. The ayurvedic diagnosis was made as "Dushivisha janya visaphota kushtha" and treatment was done basis on this. There was not a single cases on the internet treated on Ayurvedic line of management thus the present article was prepared to assess the role of Visha Hara and Rasayan Chikitsa in such emerging automimmune skin condition. Improvement in the skin lesion were observed after a period of 1 months of regular treatment and complete remission with no further attack after 2-month follow-up. The improvement was observable through the follow-up photograph.

Introduction

Dyshidrotic eczema is a chronic, enigmatic condition that usually affects the hands and feet and probably accounts for about 5%–20% of hand eczemas [1]. The peak age of onset is between 20 and 30 years of age [2]. It is characterized by recurrent pruritic and painful erythematous papules and vesicles followed by peeling, scaling, and fissuring of the skin [3]. In Ayurveda various skin manifestation are approached under different concepts like kushtha, visarpa, kshudra kushtha, vidradi(abscess), krimi roga(worms), keeta visha (insect bite), Gara visha (poison) and D. visha (latent toxicity). We report a case of dyshidrotic eczema treated successfully with pure Ayurvedic treatment with complete remission. Ayurvedic visha hara and long term rasayan chikitsa is found to be effective in treating emerging autoimmune skin conditions and need to be accessed further through big clinical studies.

Patient information

A female 21 year student was presented in hospital (7-9-2018) with 4 month history of an intensely itchy, vesicle rashes affected over palms of both hands on & off. Onset was acute and gradual. Clinical sign & symptoms like raga (redness), saphota (vesicles), pidika (small pastules), kandu (itching), paka (supparation), kleda (fluid filled secretion), anga patina (cracking of skin), utsedha (swelling/inflammation), ati swedana (hyper sweating), sheeta (coldness), snighdha (sliminess) were present. She had taken treatment from general physician but found no relief then she came here for further management.

Associated complaints

She had Agni mandya (low digestive fire), Ajirna, (indigestion), Chardi (nausea sensation in morning), Mala vibhanda (conspitation) and regular sleep pattern. She having habit of taking tea, Virudh ahaar (milk shakes, fish) and fast food as she living in college hostel.

Past history

No h/o DM/HTN/hypothyroidism or any other major medical or surgical history.

Family history

No history of same illness in any of the family members.

Psychological evaluation

She was in stresse due to unable to do the work and cosmetic consideration.

Examination

The detailed examination is enlisted in the Supplementary Table 1.

Local examination

Deep-seated “tapioca-like” vesicles and, less commonly bullae primarily at all over the palms and lateral surfaces of the fingers with few rupturing of vesicles (Fig. 1a & b).

Fig. 1

Ayurvedic Intervention (a & b) Deep seated “tapioca-like” vesicles of left hand and right hand respectively (c & d) - clinical changes after 1st follow up, reduction in itching & redness, mild reduction in size and erythema (e & f) changes during 2nd follow up, No itching, No redness, significant reduction in size and erythema (g & h) changes during 2nd follow up, No redness, No itching and new vesicles ( i & j) changes after 1 month follow up, smoothness of skin with complete reduction of lesions over both hands after follow up.

Based on clinical sign and symptoms with examination suggestive of Dyshidrotic Eczema or pompholyx eczema from modern science Due to some issue skin biopsy or tzanck smear investigation was not possible to confirm diagnosis.

Ayurvedic intervention

A detailed therapeutic intervention undertaken is provided in Table 1.

Table 1

Therapeutic intervention.

Date	Treatment	Dose	Duration
7-9-2018	Aragwadhadi kashaya	Oral- 20 mL each twise a day before mealWith Equal amount of Warm water	10 days
	Patol katurohinyadi kashyaya
	Bilwadi vati	Oral – 2 tablet TID After meal.
	Triphla powder	External- Decoction for wash and lepa over both palms
20-9-2018	Guduchiyadi kashaya	Oral- 20 mL each twise a day before meal with Equal amount of Warm water	Next 15 days
	Patol katurohinyadi kshaya
6-10-2018	Kalyanaka ghrita	10 g early morning around 6 am after few exercise	Next 1 month

Pathya & apathya (do’s & don’t’s)

Patient was advised to follow strict Pathya –Apathya (Ayurvedic diet). light food like khichadi, eating more of moog daal, kerala, patol (tikta raasa), Hot water for drinking. Apathya-meat, milk, curd, mansa (non veg), virudha hara (incompatable food items), adhyasana (over eating), vidhaya food (which causes burning like – pickles, chillies), abhishyandi ahara, Avoid day sleep, ati amla rasa (sour food items). Soaps and detergents was completely avoided and advice to wear gloves during bath (Fig. 1a & b).

Follow-up and outcomes

The symptoms like mandala (vesicles), pidika, srava (secretion), kandu (itching), vedana (pain), paka (supparation), kleda (fluid filled secretion), anga sphutana (cracking of skin), utsedha (inflammation), were 60% reduced with in 8 day, no fresh vesicles seen (15-9-2018) (Fig. 1c & d) Weekly examination was done and after 15th day picture was taken with consent. After 60 day treatment, 95% the lesions were resolved and skin comes back to normal (30-10-2018) (Fig. 1e–j).

Discussion

Predispose factor

Most cases are idiopathic. Factors that may predispose to the development of dyshidrotic eczema in a susceptible individual include atopic, contact allergens, contact irritants, dermatophyte infection, allergy to metal (in particular, nickel and cobalt), hyperhidrosis, bacterial foci, or drug eruptions, prolonged use of protective gloves, intravenous immunoglobulin, psychological stress, and smoking [[4], [5], [6]]. Excessive sweating (hyperhidrosis), especially on the hands and feet, is considered to be in connection with the aetiology of the disease, sweating may become normal or may even decrease [7]. A gene locus on chromosome 18q22.1–18q22.3 was identified in a large Chinese family with 14 affected individuals through 4 generations [8].

Limitation of management

In contemporary science, topical and systemic corticosteroids are the mainstay of treatment but there are reports of cases that have been treated with botulinum toxin and calcineurin inhibitors [9]. Other immunosuppressants such as cyclosporine, azathioprine, and methrotrexate have occasionally be used for recalcitrant and severe cases unresponsive to the above measures, but with variable success, and typically not in children [10]. Oral antihistamines can provide symptomatic relief because of their sedative properties. Unfortunately, most of these attempts do not lead to long-term improvement and the majority of cases of dyshidrotic eczema relapse, persists for years, and still presents a therapeutic problem.

Role of Dooshivisha in kushtha chikitsa

Dooshivisha janya saphota kushtha was clinical condition diagnosed in the present case, which can be taken as toxic manifestation of skin due to visha (Dooshivisha-latent toxic) due to contact relation with chemicals, contact allergens, contact irritants, allergy to metal. Dooshivisha (cumulative poison); is a form of toxin that has not been completely eliminated or neutralized due to various reasons, remains in the body for some time and eventually gets manifested in the form of some disease [11]. Exposure to certain environmental factors or due to consumption of incompatible foods which act as visha and directly affects the rakta dhatu and rasa dhatu. when visha enter into the body it vitiates raktha first [12]. This is because the ingested toxins effect and disturb jataragni primarily and consequently bhoothagni and dhatwagni. Agni mandya leads to aam which vitiates rasa dhatu and rasavaha srotas. For Dooshivisha -habitat, season, food and day sleep are said to be the aggravating factors [13]. Due to Dooshivisha, many skin diseases are said to appear like mandal (vesicles/boils), kotha (round patches and rashes on the skin), kitibha kushtha [14] (various skin manifestation). When Dushivisha vitiates rasa dhatu [15], it will produces the rasa pradoshaja vikara (diseases) like-disinclination towards food, anorexia, indigestion, fatigue, anemia, obstruction of the srotas, etc [14, ch 28/9-10]. When dushivisha located in rakta dhatu, it will produces rakta proshaja vikara like-skin disorders, erysipelas, vesicles [16], etc which are very much evident in present case.

Ayurvedic diagnosis

The clinical signs like shweta (whiteness-skin color), sheeta (coldness), kandu(itching), stherya (steadiness), shotha (swelling), utseda (elevated), kleda (stickiness) suggested the features of Kapha dominancy [14, ch 5/10]. Raga (redness), parisrava (excudation), ati sweda (sweating). Paka (inflammation), kleda (serus exudation), ang shputana (cracking in skin) suggested the feature of aggravated pitta dominant kushtha [14, ch 5/10]. On the basis of symptomatology, the present disease can be equated with Kapha-pitta doshic kushtha.

The variety of etiology (Nidanam) of Kushtha are explained in which due to visha (Dushivisha –latent poison) is very much suitable in present era as we all indulge in toxins environment knowingly and unknowingly. Patient has habitual taking virudh ahar (fruit milk shakes) & fast food. Visaphota variety of kushtha is characterized by pustules which are either white or reddish in appearance [14, ch 7/26]. The pustules have a thin skin and it is pitta-kapha predominant [14, ch 7//30]. Here sphota type of kushtha variety resembles with dyshidrotic eczema. Visha being the one important nidana (etiology), the final diagnosis was made as "Dushivisha janya visaphota kushtha".

All variety of kushtha results from imbalance of tridosha, hence at the time of treatment should be decided after determining the varying degree of each dosha by its specific features [15, ch 7/32]. The principle of management of kushtha in the different stages of the kushtha (skin diseases) and dushivisha (anti poisonous therapy) includes pancha karma (eliminative procedures-therapeutic emesis, purgation, etc.), vein puncture, local applications, and internal administration of drugs [14, ch 9/22-39; ch 23/63].

Selection of drug

The drugs with kapha pittaghna (Doshahara), ruksha guna, teekta rasa properties, primarly vishaharam, kushthaghna, krimihara along with aamhara, kandughna, deepana, pachana, rakta Shodhaka (blood purifier), Shotha hara(anti-inflammatory), Vrana shodhana, Ropanam, Vata anulomana and pitta rechak were chosen and prescribed at different stages in the case. First course of medication was selected (Table 1). No adverse drug reaction was noticed during the course of treatment. After 1 month, Aragwadhi Kshaya was stopped and Guduchiyadi kashaya was added with patolkaturohinyadi kashaya. Next, rasayan chikitsa started with kalyanaka ghruta for next 1 month and two month follow up was taken and now patient was completely relived and normal.

Selection of rasayan

K. ghrita is ghrita preparation and it contains 28 ingredients [18]. Ingredients are predominantly thikta kashaya rasa, laghu rooksha guna, ushna vērya, katu vipāka and pitta-kapha samaka in action. Kalyanaka ghrita as mentioned does good to mankind. Its been indicated for visha (poison) conditions and various mental disorders so it helps in reducing the mental tension in patient as stress is also one of the major factors for disease manifestation.

Addition to that, ghruta mentioned as a visha hara and good dēpana dravya. It can promote the digestive power in all the agni level. Ghrita is one of the best rasayan and vishaghna dravya as it is having all the qualities exactly opposite to that of visha. It is having brimhana, snehana, yogavaahi, daahaprashamana and medhya property. Snēhaguna property oleate the tissue, make proper arrangement of dhathu and do dridhēkaranam of body. Thus the body acquires bala, varna, lustier, firmness, and ability to encounter disease. Due to its manda guna, its action lasts longer. Medicines of the rasayana group are supposed to repair and rejuvenate damaged cells and having balancing and rejuvenating effects on the three constitutional elements that sustain human life (Table 2).

Table 2

Rationale use of given medicine.

S. no.	Formulations	Ingredients	Karmukta (Ayurvedic pharmacology)	Dosha hara	Rationale use of In this case
1	Aragwadhadi kashaya	Aragwada, indrayava, patali, kakatikta, nimba, Murva, pata, bhunimba, sahachara, patola, saptachaddha, chitraka, karavi, madhanaphala, sahachara, Pugavishesha, PutiKaranja, Bana – sharpunka	Visha vikara, Chardhi, Kushtha, Vishajwara, Kandu, Prameha, Dustavrana	Kapha –pitta hara	Neutralizes all kind of visha (poison), usefull in all kapha kushtha (skin diseases), eliminates kapha symptoms like itching (kandu), reduces srava (secretion), heals all kind of dusta vrana (non healing ulcers),
2	Patolkaturohinyadi kashyaya	Patola, Katukarohini, Chandana, Madhusrava, Guduchi, Paatha	Kushtha,Jwara, Visha, Aruchi, Kaamalam, Vamana	Kapha –pitta hara	Neutralizes all kind of visha (poisons), usefull in relieving Aam, agnimandhya (low digestive fire), induces the liver functioning
3	Guduchiyadi kashaya	Guduchi, Padmaka, Arista (nimba), Vanka (Dhanyaka), Raktachandana,	Jwara, chardi, daha, trishna, kandu and kushtha.	Pitta-kapha hara	All are kshaya rasa due to which it reduces Aam (toxins) and mala (waste) from dhatus.It helps in reducing itching (kandu).It is good pitta –kapha kushtha like saphotakushtha.Neutralizes all kind of visha (poisons)
4	Bilwadi vati	Bilwa, Surasa(tulsi), Karanja, Tagara, Devadaru, Triphla, Sunthi, Maricha, Pipplali, Haridra, Daruharidra, aja mutra (goats urine).	Sarpa visha, and many other jangama visha (animate poison), Ajirna, Gara visha, jvara, Bhutaghna (antimicrobial, antiviral).	Kapha -vata hara	It does aam pachana.Helps in removing Gara visha and agni mandhya.
5	Kalyanaka Ghruta [17]	Vidanga, triphla, Danti, Devadaru, Hareenu, Talisapatra, Manjishta, Nagakesara, Ulpalam, Padmakam, Dadimam, Malati pushpam, Haridra, Daruharidra, Sariva, Krishnasariva, Shalaparni, Prsniparni, Priyangu, Tagaram, Kushtam, Bruhati, Kantakari, Elavalukam, Chandanam, Gavakshi		Kapha-pitta hara	Neutralizes effect of Gara Visha.Because of Rasayana property it helps in rejuvenating and repairing the damage cells.Helps in reducing the stress factor.
6	Triphla powder	Vibhitaki, amalaki, haritaki.	Kushtha hara, vrana ropaka, visham jwara nashni, deepan, ruchikaraka, (bhava prakash, haritaki varg)	Kapha-pitta hara,	Usefull in reducing symptoms like itiching and srava, kleda. help in healing ulcers, act as very good antibacterial to reduce secondary infection.

Conclusion

Dyshidrotic eczema or pompholyx is a rare and difficult skin condition to cure. It is notorious for its recurrence nature. The present conventional drug do not lead to long-term improvement and the majority of cases of dyshidrotic eczema relapse, persist for years, and still present a therapeutic problem. Present observation and approach endorses a step toward the practice of Ayurvedic intervention in Dyshidrotic eczema. Present case definitely boost up the new researcher scholar to take these condition and do further studies.

Patient perspective

Patient was satisfied to get complete remission.

Informed consent

Written permission for publication of this case study had been obtained from the patient.

Source(s) of funding

None.

Conflict of interest

None.