Featured Case

MODERN DIAGNOSIS: Vitiligo

ABOUT THE DISEASE:

Vitiligo is a disease that causes loss of skin color in patches. This is also called as Leucoderma. The discolored areas usually get bigger with time. The condition can affect the skin on any part of the body. It can also affect hair and the inside of the mouth.

Normally, the color of hair and skin is determined by melanin. Vitiligo occurs when cells that produce melanin die or stop functioning. Vitiligo affects people of all skin types, but it may be more noticeable in people with brown or Black skin. The condition is not life-threatening or contagious. It can be stressful or make you feel bad about yourself.

Causes: Vitiligo occurs when pigment-producing cells (melanocytes) die or stop producing melanin — the pigment that gives your skin, hair and eyes color. The involved patches of skin become lighter or white. It's unclear exactly what causes these pigment cells to fail or die. It may be related to: 

• A disorder of the immune system (autoimmune condition) 
• Family history (heredity) 
• A trigger event, such as stress, severe sunburn or skin trauma, such as contact with a chemical

In this case report, an 8-year-old male patient presented with white patches on the chest region, right side armpit and right side of the waist since 6 months. In spite of taking standard of care for 2 months, the condition persisted. His parents opted for Ayurvedic treatment for further management and approached Dr Partap Chauhan.  Based on the clinical examination, the biomedical diagnosis was vitiligo and Ayurvedic diagnosis was made as shvitra. 

Symptoms: These include

• Patchy loss of skin color, which usually first appears on the hands, face, and areas around body openings and the genitals
• Premature whitening or graying of the hair on your scalp, eyelashes, eyebrows or beard
• Loss of color in the tissues that line the inside of the mouth and nose (mucous membranes)

Vitiligo can start at any age, but usually appears before age 30.

Depending on the type of vitiligo it may affect:

• Nearly all skin surfaces. With this type, called universal vitiligo, the discoloration affects nearly all skin surfaces.
• Many parts of the body. With this most common type, called generalized vitiligo, the discolored patches often progress similarly on corresponding body parts (symmetrically).
• Only one side or part of the body. This type, called segmental vitiligo, tends to occur at a younger age, progress for a year or two, then stop.
• One or only a few areas of the body. This type is called localized (focal) vitiligo.
• The face and hands. With this type, called acrofacial vitiligo, the affected skin is on the face and hands, and around body openings, such as the eyes, nose and ears.

Diagnosis: A physical examination and clinical evaluation are the primary diagnostic tools. If required, the blood tests and skin biopsy may be recommended.

Image 1. Photographs of the lesion at baseline dated 1.6.2023

Treatment & prognosis: The choice of treatment depends on your age, how much skin is involved and where, how quickly the disease is progressing, and how it's affecting your life. Medications and light-based therapies are available to help restore skin color or even out skin tone, though results vary and are unpredictable. And some treatments have serious side effects. So the health care provider might suggest that you first try changing the appearance of your skin by applying a self-tanning product or makeup. If you and your health care provider decide to treat your condition with a drug, surgery or therapy, the process may take many months to judge its effectiveness. And you may have to try more than one approach or a combination of approaches before you find the treatment that works best for you. Medications that control the inflammation and affect the immune system are normally resorted to. Some therapies done are Light, Psoralen and Depigmentation. Surgical options available are Skin and Blister grafting, and Cellular Suspension Transplant.

It's difficult to predict how this disease will progress. Sometimes the patches stop forming without treatment. In most cases, pigment loss spreads and eventually involves most of the skin. Occasionally, the skin gets its color back. But in this patient, inspite of taking conventional medicines for 2 months, there was no improvement at all. 

Reference

1. https://www.mayoclinic.org/diseases-conditions/vitiligo/diagnosis-treatment/drc-20355916

AYURVEDA DIAGNOSIS: Shvitra

ABOUT THE DISEASE:

Shvitra is correlated to Vitiligo in biomedicine bearing similarity in the presentation of symptoms. This is a common problem associated with an intense social stigma in the society.

According to Ayurveda, the skin is an essential sense organ. Basic energy principles like vata and one of the five heat-producing activities similar to metabolism (bhrajaka pitta) reside in the skin (called twak in sanskrit). As the skin covers the whole body bhrajaka pitta should be maintained in a proper state and it needs continuous care.

Shvitra and Kilasa are synonymous. But there are opinions that there are two subtypes. Sushruta explains that Kilasa is a variety that affects only the skin. Supporting his opinion, Madhava and Vagbhata view that Kilasa is nirdista as it remains at skin level (called the twakgata condition in Ayurveda). Caraka explains that Shvitra becomes firmly established when the dosha enters different levels of dhatu, indicated by a change in the colour of the lesions. When dosha enters dhatu, the disease shows a poor prognosis (asadhya). Bhoja identified more subcategories on the basis of nidana; originating from the dosha and from vrana. Sub-classifications in the doshaja variety are Daruna, Aruna, and Kilasa. Depending on the presentation of symptoms, shvitra can be classified as vata, pitta and kapha type. 

In this case report, an 8-year-old male patient presented with white patches on the chest region, right side armpit and right side of the waist since 6 months. In spite of taking standard of care for 2 months, the condition persisted. His parents opted for Ayurvedic treatment for further management and approached Dr Partap Chauhan.  Based on the clinical examination, the biomedical diagnosis was vitiligo and Ayurvedic diagnosis was made as shvitra. 

Etiology

The causative factors for Kusta and Shvitra are the same and affect the same dhatu. Shvitra differs from other skin disorders by the normal functioning of all but the twak resulting in discolouration of the skin (twak vaivarnyata), without discharge (aparisravi). The dietary factors are also discussed in the causation of vitiligo. Seventeen ways of dietary intake are labelled as virudha diet. Excessive consumption of food that takes a longer time to digest (guru) and non-vegetarian and spicy foods are also associated with etiology.

Sadhyasadhyata

Good prognosis (sadhya) patients have lesions of recent onset (nava), are not thickened (thanu), and show pigmented hairs (ashukla roma). Patients who are likely to have poor prognosis exhibit lesions on the external genitalia, lips, and tips of fingers (Anthejatam), coalescing (samslista), and/or covering large areas of the body (bahala) or those that appears like burn wounds (agnidagdhaja).

Treatment: Classical textbooks of Ayurveda recommend four steps of treatment. The first step is shodhana karma using Psoralia corylifolia (bakuci kwatha) and Eurphorbia nerifolia (snuhi). This medicine is expected to induce multiple bouts of purgation. In the next step oil massage is advocated. The next step is the exposure of lesions to the sun rays as long as the patient can tolerate them (Soorya pada santhapam. The patient receives peya for the following three days. If bullae arise after a sun bath they must be punctured using a sterile needle. On these days, diet regulations should be strictly followed.

Ayurveda recommends several medicines alone or in combination, following the four steps of initial therapy mentioned earlier.

The rationale of treatment:  The rationale of treatment as explained by the treating physician is tabulated below.

Table 1. The medicines prescribed and the rationale

Reference

1. Narahari SR, Aggithaya MG, Suraj KR. A protocol for systematic reviews of Ayurveda treatments. Int J Ayurveda Res. 2010 Oct;1(4):254-67. doi: 10.4103/0974-7788.76791. PMID: 21455455; PMCID: PMC3059450.

In this case report, an 8-year-old male patient presented with white patches on the chest region, right side armpit and right side of the waist since 6 months. In spite of taking standard of care for 2 months, the condition persisted. His parents opted for Ayurvedic treatment for further management and approached Dr Partap Chauhan.  Based on the clinical examination, the biomedical diagnosis was vitiligo and Ayurvedic diagnosis was made as shvitra. 

Assessment: Subjective and objective parameters were assessed to analyse the outcome of the treatment.

Subjective parameters: After 1 month of treatment, significant improvement was noted. No formation of new patches and the re-pigmentation of white patches started. With 2 and a half months of treatment, no white patches were noted over the chest, armpit and waist region. The colour of the skin became normal with the re-pigmentation.            

Objective parameters: Photographs were taken and documented 

Image 1.Photographs taken throughout treatment of the lesions