Management of Hydradenitis Suppurativa by Apamarga Kshara Sutra - A Case Study

ISSN: 2456-3110 CASE REPORT Sep-Oct 2017 Journal of Ayurveda and Integrated Medical Sciences | Sep - Oct 2017 | Vol. 2 | Issue 5 194 Management of Hydradenitis Suppurativa by Apamarga Kshara Sutra - A Case Study Chiranth Kumar R, 1 Syeda Ather Fathima, 2 Kulkarni Sharad 3 1 Post Graduate Scholar, 2 Professor & HOD, Department of Post Graduate Studies in Shalya Tantra, Govt. Ayurvedic Medical College, Bengaluru, Karnataka, 3 Assistant Professor, Dept. of Prasuti Tantra & Stree Roga, Jain AGMAMC, Varur, Hubballi, Karnataka, India. I NTRODUCTION HS is a disease affecting the terminal follicular epithelium in the apocrine (Coiled glands which open into the hair follicles) [1] group of sweat glands. Sites of apocrine sweat gland include axilla, groin, areola, umbilicus, scalp, chest, and perineum. Most common site is axila [2] often bilateral. Clinical course of disease Address for correspondence: Dr. Chiranth Kumar R Post Graduate Scholar, Dept of Post Graduate Studies in Shalya Tantra, Govt. Ayurvedic Medical College, Bengaluru, India. E-mail: chiranth 2010@gmail.com Submission Date : 22/09/2017 Accepted Date: 28/10/2017 Access this article online Quick Response Code Website: www.jaims.in DOI: 10.21760/jaims.v 2 i 05.10278 is highly variable, mild cases may present as recurrent isolated nodules, while severe instances of the disease with chronic inflammation may leads to scaring, cicatrisation, contractures, keloids and rarely squamous cell carcinoma [3] Hormonal influence and secondary infection plays a major role in the disease expression. Clinically the disease presents with tender subcutaneous nodules beginning around puberty. The nodules may rupture spontaneously or coalesce, forming painful, deep dermal abscess. Modern line of management includes Antibiotics - cephalosporins, long acting penicillin. Aetiology 1 Hormonal changes 2 Poor local hygiene 3 Obesity, smoking. 4 Steroids A B S T R A C T Hydradenitis suppurativa (HS), also known as Acne Inversa, is a chronic disease characterized by recurrent, painful, deep-seated, rounded nodules and abscesses. Subsequent hypertrophic scarring and suppuration of apocrine gland bearing skin: axilla, groin, peri-anal and perineal regions are main features. Onset is usually after puberty. The disease tends to become chronic with subcutaneous extension leading to indurations, sinus and fistula having a profound impact on the quality of life. The exact aetiology remains unknown. The clinical features of HS can be compared with Naadivrana mentioned in classics. Treatment modalities of Naadivrana includes mainly Ksharataila Poorana and Ksharasutra application are adopted in the present case. A case report of patient suffering from HS since 4.5 years (c/o multiple pus discharging abscesses and hardened area in both axillary region) was treated by number of allopathic surgeons and physicians but there was minimal relief and recurrence (6-7 times) even after Incision and Drianage (I&D) and wide excision. The patient was under Ayurveda treatment for approximately 5 months and pus discharge, hardness reduced completely and is on followup since 8 months there is no recurrence, patient was treated internally with Gandakarasayana, Triphala Guggulu and Varunadi Kashaya. Apamarga Kshara Taila infiltration followed by Apamarga Kshara Sutra application to the intercommunicating sinuses, adviced to maintain local hygiene. Key words: Naadivrana, Kshara Taila, Kshara Sutra, Hydradenitis Suppurativa.

Chiranth Kumar R. et.al. Management of Hydradenitis Suppurativa by Apamarga Kshara Sutra - A Case Study ISSN: 2456-3110 CASE REPORT Sep-Oct 2017 Journal of Ayurveda and Integrated Medical Sciences | Sep - Oct 2017 | Vol. 2 | Issue 5 195 5 Diabetes mellitus. 6 Androgen dysfunction Diagnostic Criteria The diagnosis relies on the presence of: ▪ Typical lesions i.e. deep - seated painful nodules: “blind boils” in early lesions; abscesses, fistular, bridged scars and “tomb stone” open comedos in secondary lesions. ▪ Typical topography i.e axilla, groin, perianal region, infra mammary region. Chronicity and recurrences As the disease and its diagnostic criteria are frequently ignored, a lag time of several years between the first manifestation and a formal diagnostic of HS is commonly reported by patients. Severity grading / stages The classical 3 clinical stages are, 1 Stage 1: Single or multiple abscesses formation, without sinus tracts and cicatrisation. 2 Stage 2: Recurrent abscesses, with tract formation and cicatrisation. There may be single or multiple widely separated lesions. 3 Stage 3: Diffuse or near diffuse involvement or multiple interconnected tracts and abscesses are observed across the entire area. This classification is useful at least as a guide to choose between medical or limited surgical treatment (stage 1) and large excisional surgery (stage 3). Clinical Presentation ▪ Common in female 4:1 ▪ Most common site is axilla, often it is bilateral ▪ Onset is usually is insidious with earliest sign being erythema ▪ Comedo like follicular occlusion, chronic relapsing inflammation, muco-purulent discharge and progressive scarring ▪ Induration due to fibrosis ▪ May be associated with arthropathy symptoms such as poly-arthralgia or polyarthritis “ Sushrutha Samhita ” describes a condition called Nadivrana [4] with 8 subtypes, whose clinical features can be compared with hydradenitis suppurativa. In the present case, the features correspond to Vataja and Kaphaja subtypes. The treatment mentioned is also unique and effective which is minimal invasive technique namely Ksharasutra [5] and also Kshara Taila Poorana. Case Report A male patient aged about 25 yrs. presented with c/o multiple pus discharging abscesses with localised hardened area in both axillae since 2 months which was recurring since past 4.5 yrs in a interval of five to six months. (OPD-6, SJIIM Hospital Bengaluru) Clinical Examination Findings 1. General Examination ▪ Pallor - Absent ▪ Icterus - Absent ▪ Cyanosis - Absent ▪ Kylonychia - Absent ▪ Lymphadenopathy - Absent ▪ Oedema - Absent 2. Systemic Examination ▪ CVS - S 1 S 2 heard ,no any added sounds ▪ RS - normal vesicular breath sounds ▪ P/A - soft, BS+; No organomegaly. 3. Local Examination I) Right axilla A) Inspection ▪ Blackish discoloration of axilla ▪ Five -six small abscess of size <0.5 cms. ▪ Muco-purulent discharge from all the abscess ▪ previously operated scars

Chiranth Kumar R. et.al. Management of Hydradenitis Suppurativa by Apamarga Kshara Sutra - A Case Study ISSN: 2456-3110 CASE REPORT Sep-Oct 2017 Journal of Ayurveda and Integrated Medical Sciences | Sep - Oct 2017 | Vol. 2 | Issue 5 196 B) Palpation ▪ Raised temperature hydradenitis ▪ Tenderness + ▪ Four sinuses are inter-communicating to form threetracts, andis lined by dense fibrous tissue which was hindering the healing process. II) Left axilla A) Inspection ▪ Blackish discoloration of axilla ▪ Seven - nine small abscess of size <0.5 cms, in two sets upper and lower parts of axilla. ▪ Muco-purulent discharge from all the abscess ▪ previously operated scars ▪ Hypertrophied skin following a large excision and skin grafting. B) Palpation ▪ Raised temperature ▪ Tenderness + ▪ Three sinuses in upper part are interconnecting with each other and 5-6 abscess in lower part few are interconnected. ▪ There was a communicating tract between upper and lower sets of abscess. Management Lakshanas of both Kaphaja, Vataja Naadivrana are noted in the case i.e., Sashoola, Pichhila Sraava, Phenaanuviddha, Kathina Parusha Sukshma Mukhi Vrana . So the treatment adopted is of both Kaphaja and Vataja Naadivrana . Treatment plan and medications used in the present case, Internal medications ▪ Triphala Guggulu 1 Tid after food for 3 months. ▪ Gandaka Rasayana 1 Tid after food for 3 months. ▪ Varunaadi Kashaya 10 ml Tid for 1 month. ▪ Apamarga Kshara Taila Poorana done 7 days initially (to make the tract patent). ▪ Apamarga Kshara Sutra application done for inter-communicating sinus tracts for a period of five months. (Once a week Kshara Sutra changing is done). ▪ Advised to maintain the local hygiene by washing with Triphala Kashaya twice daily. DISCUSSION Sushruta has explained Prakshaalana, Kshara Taila Poorana, Shodhana, Kshara Sutra in the management of Naadivrana . As per Sushruta Karmukatha of Kshara is Lekhana, Dahana, Pachana, Tridoshagna. [6] Apamarga Kshara Taila used for Poorana helps in Lekhana, Shodana, Ropana . It is used for seven days Figure 1: Before treatment Figure 2: During treatment

Chiranth Kumar R. et.al. Management of Hydradenitis Suppurativa by Apamarga Kshara Sutra - A Case Study ISSN: 2456-3110 CASE REPORT Sep-Oct 2017 Journal of Ayurveda and Integrated Medical Sciences | Sep - Oct 2017 | Vol. 2 | Issue 5 197 Figure 3: After treatment helped in making the unpatent tract to become patent Snuhi Ksheera based Apamarga Kshara Sutra applied for inter communicating helped in draining of pus from the abscesses along with Lekhana of fibrous tissue and promoted the healthy granulation so that there will be cutting of the tract along with healing Triphala Guggulu helped in reducing local inflammation and pain Gandaka Rasayana acts as an antibiotic drug to control the infection Varunaadi Kashaya mentioned in managent of Aabhyantara Vidradi helps to reduce the pus and local inflammation Post-operative tissue damage and scarring are very minimal. No recurrence is seen since 9.5 months after the treatment CONCLUSION Hydradenitis suppurativa can be included under the Naadi Vrana according to its features, hence adopting Shodana and Ropana treatment is beneficial along with improving the general immunity of patient and local hygiene. Usage of Kshara in the form of Taila and Sutra is very effective, as there are no complications noted during the course of treatment and also patient was engaged in all his routine works. Therapy adopted is cost effective and given better relief to the patient. REFERENCES 1 Bhat S R M, SRB’s manual of Surgery, 4 th ed, New Delhi, Jaypee Brothers Medical Publishers(P)Ltd, 2009;p.46 2 Bhat S R M, SRB’s manual of Surgery, 4 th ed, New Delhi, Jaypee Brothers Medical Publishers(P) Ltd, 2009;p.47. 3 Revuz J. Hidradenitis suppurativa. Orphanet Encyclopedia. March 2004. http://www.orpha.net/data/photo/GB/ukhidradenitis-suppurativa.pdf. 4 P.V.Sharma, Sushrutha, Sushrutha Samhitha - Text with English translation and Dalhana’s commentary along with critical notes. Varanasi, Chaukambha Vishvabharathi, 2005;p.695. 5 Indradeva Tripati. editor; prof.Ramanath Dwivedy. Chakradatta. Sri Chakrapanidatta, text with hindi commentary vaidyaprabha, Chaukhamba Sanskrit Sansthan, Varanasi, 2005;p.268. 6 Prof.K.R.Shrikantha Murthy, Sushrutha. Sushruta Samhitha, Text with English translation. Varanasi, Chaukambha Orientalia, 2014:1.p.63. ******************************* How to cite this article: Chiranth Kumar R, Syeda Ather Fathima, Kulkarni Sharad. Management of Hydradenitis Suppurativa by Apamarga Kshara Sutra - A Case Study. J Ayurveda Integr Med Sci 2017;5:194- 197. http://dx.doi.org/10.21760/jaims.v 2 i 05.10278 Source of Support: Nil, Conflict of Interest: None declared.

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Ksharasutra, Sushruta, Ksharataila, Triphalaguggulu, Chronic disease, Clinical feature, Internal medication, Ayurveda treatment, Diagnostic criteria, Local examination, Systemic examination, Clinical presentation, Apamarga Kshara Taila, Clinical stage, Apamarga kshara sutra, Local hygiene, Acne inversa, Sushrutha Samhita, Clinical examination findings, Fibrous tissue, Post Graduate Scholar, Naadivrana, Hormonal change, Apocrine Gland, Abscesses, Govt Ayurvedic Medical, Hypertrophic scarring.