Pemphigus Vulgaris - A pragmatic approach through Panchakarma

CASE REPORT July 2023 Journal of Ayurveda and Integrated Medical Sciences | July 2023 | Vol. 8 | Issue 7 204 Pemphigus Vulgaris - A pragmatic approach through Panchakarma Preeti Chaturvedi 1 , Nupur Namdeo 2 1 Reader, Dept. of Panchakarma, Pandit Khushilal Sharma Govt. Ayurvedic College and Hospital, Bhopal, Madhya Pradesh, India. 2 Post Graduate Scholar, Dept. of Panchakarma, Pandit Khushilal Sharma Govt. Ayurvedic College and Hospital, Bhopal, Madhya Pradesh, India. I NTRODUCTION The word Pemphigus is derived from the Greek word “Pemphix” which means blister or bubble [3] The Pemphigus vulgaris (PV) is a group of highly lethal autoimmune disease. In case of pemphigus, the immune system mistakenly produces antibodies against specific proteins in the skin called desmogleins [4] These proteins form the glue that keeps the skin cells attached and intact. When desmogleins Address for correspondence: Dr. Nupur Namdeo Post Graduate Scholar, Dept. of Panchakarma, Pandit Khushilal Sharma Govt. Ayurvedic College and Hospital, Bhopal, Madhya Pradesh, India. E-mail: drnupurnamdeo 1017@gmail.com Submission Date: 08/05/2023 Accepted Date: 15/06/2023 Access this article online Quick Response Code Website: www.jaims.in DOI: 10.21760/jaims.8.7.39 are attacked, skin cells separate from each other and fluids gets collect in-between the layers of skin forming infection and blisters that do not heal. These lesions may occupy a part of body or can spread in the entire body Charakacharya explains in Chikitsasthana as they are Sarvashareeragata (appear in the whole body), with burning sensation, associated with fever and thirst [5] Vagbhata explains about Visphotaka in Nidanasthana having Tanutvacha (thin skin at the wound site), with reddish discolouration [6] Sushruta in Nidanasthana explains about Visphotaka as, they are associated with Rakta and Pitta [7] , they look similar to the lesions of a burnt skin, associated with fever Madhava Nidana has explained a separate chapter named after it [8] He explains 6 types of Visphotaka namely, Vataja , Pittaja , Kaphaja , Dvandvaja , Sannipataja and Raktaja . A similar entity i.e., Agni Visarpa which is an extreme Atyayik Roga that can prove fatal if left untreated. It is said to be caused by the vitiation of the Tridoshas and shows specific variations in the manifestations depending on the Dosha predominance. The types of Visarpa stated in A B S T R A C T Blistering disorders are a group of diseases presenting with vesicles and bullae over skin and mucous membrane [1] Pemphigus describes a group of chronic bullous eruptions of the skin, where Pemphigus vulgaris is the commonest one [2] Which is a life threatening autoimmune mucocutaneous blistering disease with a mortality rate of 5-15%. In Ayurveda all the skin disorders are collectively named under the heading of Kushta . Ayurveda Acharyas have described all the Kushta are having the involvement of all the three Dosha ’s . But the signs, symptoms and the treatment depend on the predominance of the Dosha involved. Visphotaka and Agnivisarpa can be compared to Pemphigus vulgaris due to its resemblance in signs and symptoms. This disease needs early and proper treatment to prevent further morbidity or mortality. To control these diseases, generally physicians use corticosteroids and immunosuppressive drugs as adjuvants. Here, an attempt is made to study in detail about the disease Pemphigus vulgaris and its understanding through Ayurveda . Management of such diseases through Ayurveda is rarely reported. A case report of 32 yr old male patient presenting with the similar complaints treated with Vamana followed by Virechana Karma along with Shaman drugs is presented in this paper. Key words: Pemphigus vulgaris, Autoimmunity, Visarpa, Visphota.

Preeti Chaturvedi et al. Pemphigus Vulgaris - A pragmatic approach through Panchakarma ISSN: 2456-3110 CASE REPORT July 2023 Journal of Ayurveda and Integrated Medical Sciences | July 2023 | Vol. 8 | Issue 7 205 the classics are Vataja , Pittaja, Kaphaja, Sannipatika, Agni, Kardama and Granthi Visarpa [9] The Vishesh Samprapti varies in accordance with the Doshas involved leading to variable manifestations. Pemphigus vulgaris bears a resemblance with to Agni Visarpa wherein vitiation of Vata and Pitta and in turn Rasa, Rakta, Twak , and Mamsa is the reason of Lakshanotpatti . Prakupit Pitta and Rakta cause Aaraktata, Shotha and Pidika . A IMS AND O BJECTIVES 1 To study the effect of Vamana Karma followed by Virechana Karma in the management of pemphigus vulgaris. 2 To find out the effective Ayurvedic management of Pemphigus vulgaris. M ATERIALS AND M ETHODS Selection and source of patient For this study, patient was registered from OPD of Panchakarma department and admitted in General IPD ward of Pt. Khushilal Govt. (Auto.) Ayurveda Hospital Bhopal. Plan of study: The drugs required for Vamana Karma and Virechana Karma were procured and prepared in Prakalpa of Panchakarma Theatre in Pt. KLS Govt. Ayurveda Hospital Bhopal. Duration of study: 40 days C ASE R EPORT A 32 yr old male patient came in the hospital (OPD no. 39858, IPD no. 20222863) with the complain of Mouth ulcer (blister), Pidakas (eruptions blister) over face and back region since 4 yrs. Associated complain joint pain. The Pidakas were Vedanayukta (painful) with Daha (burning) and there was some pus discharge and Raga (redness). Fluid filled bullae all over body were also present, which turned to crusting erosions after getting ruptured during course of healing. History of Present Illness Patient was apparently well 3 years back. One day he noticed recurrent episodes of mouth ulcers took some allopathic medicine and got temporary relief. Also, few blisters over face, trunk and back region so he consulted allopathic doctor he took treatment but there was no improvement in the presenting complain. Patient had tried other alternative medicines, but was not relieved. In February 2022 he went for skin biopsy and was diagnosed with pemphigus vulgaris. So, the Patient was admitted in our hospital to adopt ayurvedic treatment which was planned to go for classical Vamana followed by Virechana Karma in this autoimmune disease. Past history: No relevant past history was noted. Family history: Mother having psoriasis Personal History Dietary habits revealed intake of non veg and spicy food, Viruddha Ahara , irregular bowel habits. Sleepdisturbed Vihar - Diwaswapna Aahar - Virudha Aahar General examination Icterus - absent Cynosis - absent Clubbing - absent BP - 100/60 mmHg Pulse - 80/min Astavidha Pareeksha ▪ Nadi - 80 bpm ▪ Mala - Baddha Kostha ▪ Mutra - 7-8 times per day and one time at night ▪ Jihva - Aliptata ▪ Shabda - Prakruta ▪ Sparsha - Anushna Sheeta, ▪ Drika - Prakruta ▪ Shabda - Prakruta ▪ Aakruti - Madhyam

Preeti Chaturvedi et al. Pemphigus Vulgaris - A pragmatic approach through Panchakarma ISSN: 2456-3110 CASE REPORT July 2023 Journal of Ayurveda and Integrated Medical Sciences | July 2023 | Vol. 8 | Issue 7 206 Dashavidha Pariksha 1. Prakriti - Vata-Pittaja 2. Vikriti - Dosha-Dushya Samoocchana 3. Sara - Madhyama 4. Samhanana - Madhyama 5. Pramana - Madhyama 6. Satva - Madhyama 7. Saatmya - Madhyama 8. Ahara-Shakti - Aawara 9. Vyayaam Shakti - Aawara 10. Vaya - Madhyama Local Examination 1 Site of lesions - whole body mainly over face and back region 2 Nature - eruptive blister, painful 3 Shape - irregular 4 Colour - reddish 5 Itching - mild 6 Discharge - present with pus Investigation Skin biopsy (16/2/2022) - Skin biopsy was done which showed revealing features suggestive of Pemphigus vulgaris. 17/08/2022 Total cholesterol - 158 mg/dl Triglyceride - 99 mg/dl RBS - 93 mg/dl SGOT - 17 U/L SGPT - 20 U/L 26/09/2022 USG (whole abdomen) was done which showed rest and normal. ECG was normal, Chest x-ray (PA view) was done, which showed normal. Treatment regimen Treatment Dose Timing Duration Deepan Pachana with 1. Dhanyasunthi Churna 2 . Panchakola Phanta 5 gm 15 ml Bid Tid 3 days 3 days Snehpan with Dadimadya Ghrita , orally, empty stomach Start with 60 ml in increasing dose up to 400 ml till Samyak Lakshanas seen In the morning 8 days Sarvang Abhyanga with Amritadi Tail and Mridu Vashpa Swedan with Dashmool Kwatha Q.S In morning 2 day Vamana Karma Madanphala Churna Vacha Churna Saindav Lavan Madhu (honey) In the morning 10 gm 8 gm 6 gm Q.S Empty stomach after Abhyanga and Swedana Patient got 6 Vega ( Madhyam Shuddhi ) after that - Vairachanika Dhoompana done Samsansarjana Karma 5 days After 15 th day of Vaman again Snehapana For Virechana Snehpana with Dadimadya Ghrita orally, empty stomach Start with 35 ml in increasing dose up to 450 ml (till Samyak Lakshan seen In morning 5 days

Preeti Chaturvedi et al. Pemphigus Vulgaris - A pragmatic approach through Panchakarma ISSN: 2456-3110 CASE REPORT July 2023 Journal of Ayurveda and Integrated Medical Sciences | July 2023 | Vol. 8 | Issue 7 207 Sarvang Abhyanga with Amritadi Tail and Vaspa Swedan with Dashmool Kwatha Q.S In morning 3 days Virechana Karma Haritaki Kwath Churna, Trivarat Kwath Churna, Amaltas Kwath Churna, Kutki Kwath Churna , Draksha each 50 gm 300 ml Virechan Kwath + 100 ml Nimba Amratadi Eranda Tail morning 10 ‘o’ clock Patient got 15 Vega ( Madhyam Shuddhi ) Samsarjana Karma 5 days DISCUSSION Pemphigus vulgaris is the common type of pemphigus. It is an acute spreading and fatal skin manifestation. It simulates with the Lakshanas of Visarpa explained in our classics. Dushya such as Rakta, Mamsa, Lasika and Twak are mainly involved in this condition which leads to production of Anunnata Aashu Shopha that has Sarpana Prakruti along with Daaha and Vedana . Agnidagdha Prakara Sphota is the main characteristic feature of Agnivisarpa and the fatality is more when compared to other skin diseases. Person suffers from severe burning sensation and become restless. To be specific the manifestations of pemphigus vulgaris more matches with the clinical presentations of Agnivisarpa . Visphota is also having a similar manifestation. But it is not as much fatal as that of pemphigus vulgaris. CONCLUSION As per the general principle of treatment for this disease, repeated application of Shodana Karma , Shaman Karma as well is beneficial. The present case study shows that Vamana Karma followed by Virechana Karma works effectively and can break the pathogenesis of pemphigus vulgaris. This Ayurvedic modality helps to prevent the progression of disease with subside in presenting complaint. The case reported here shows significant regression in the condition in short span of time. Repeated Shodhana is needed according to the patient condition to stop the uses of modern antihistamines and corticosteroids. REFERENCES 1 KV Krishnadas, Textbook of Medicine. New Delhi: Jaypee Brothers Medical Publishers (P) Ltd, 2008; 5: 1374. 2 Vinay Kumar, Abul K. Abbas, Nelson Fausto, Robbins and Cotran Pathologic Basis of Disease. Philadelphia: Saunders an Imprint of Elsevier, 2008; 7: 1260 3 KV Krishnadas, Textbook of Medicine. New Delhi: Jaypee Brothers Medical Publishers (P) Ltd, 2008; 5: 1375. 4 DM Thappa, Essentials in Dermatology. New Delhi: Jaypee Brothers Medical Publishers (P) Ltd, 2009; 2: 116. 5 Sastri K., Kushtha Chikitsa. Pandeya G. (ed.), Charak Samhita, Vidhyotinitika vol. 2, Chaukhambha Sanskrit, Varanasi, 2009; 7/21-25: 243. 6 Tripathi B., kushtha-Svitra-Krimi Nidanam. Astanga Hridayam, Nirmala hindi commentary. Chaukhambha Sanskrit Pratishan, 2009; 14/20-26: 531. 7 Acharya JT, editor. Sushruta Samhita of Sushruta, NidanaSthana. Ch. 13., Ver. 18. Varanasi: Chaukhambha Orientalia; 2014. p. 320. 8 Upadhyaya YN, editor. Madhava Nidana of Madhavakara, Visphota Nidana. Part 2, Ch. 53., Ver. 5. Varanasi: Chaukhamba Prakashan; 2014. p. 214 9 R.K.Sharma, Bhagwan Dash, Charaka Samhita of Agnivesha Based on Chakrapani Datta`s Ayurveda Dipika, Vol 4,Varanasi,Chowkhambha Sanskrit Series Office, 2005,Chikitsasthana Chapter 21,sloka, page no. 259 -278 ************************************* How to cite this article: Preeti Chaturvedi, Nupur Namdeo. Pemphigus Vulgaris - A pragmatic approach through Panchakarma. J Ayurveda Integr Med Sci 2023;07:204-207. http://dx.doi.org/10.21760/jaims.8.7.39 Source of Support: Nil, Conflict of Interest: None declared.

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Sushruta-samhita, Prakriti, Mamsa, Rakta, Panchakarma, Visphotaka, Agnivisarpa, Madhavanidana, Twak, Burning sensation, Immune system, Ayurvedic treatment, Treatment regimen, Ayurvedic College, Autoimmune disease, Vamana Karma, Shodhana Karma, Virechana Karma, Case report, Ayurvedic Management, Local examination, Dosha predominance, Irregular bowel habit, Doshadushya, Skin Biopsy, Mucous membrane, Samyak Lakshana, Skin disorder, Shaman drug, Pemphigus vulgaris, Mouth Ulcer, Blistering disorders, Presenting complaint, Skin cell, Digital object identifier.