Management of Childhood Shwitra in the purview of Vitiligo through Ayurveda Protocol: A Case Study

Introduction

According to Ayurveda, Kushtha is the umbrella term for all skin conditions. The classic Kushtha Roga Chikitsa mentions about Shwitra. The Sanskrit root Shwit, meaning white patch, is the root of the word Shwitra.[1] Thus, Shwitra is a condition in which the body develops white spots. In accordance with “Shweta Bhava Michanti Shwitram” from the Kashyapa Samhita.[2] It is also known as Shweta Kushta, Kilasa, Daruna, and Aruna. Chhaya and Prabha of Tvacha (skin) are prompted by Bhrajaka Pitta, which is found in the skin. [3] Skin conditions like Shwitra can be brought on by any disruption of the Bhrajaka Pitta, Vata and Kapha Doshas. Medhodhatu is where morbidity is found in Shwitra. Three different varieties of Kilasa are referenced in Dhatus based on color and Ashraya: red if found in Rakta, coppery if found in Mamsa and white if found in Medas.[4] This may be closely linked to vitiligo because of the similarities in how the two conditions present. Vitiligo is an acquired macular depigmentation disorder associated with the destruction of melanocytes.[5]. A localized loss of melanocytes causes hypopigmentation in certain areas. The disorder represents a clinical end-point resulting from a complex interaction of environmental, genetic and immunological factors. The hands, wrist, feet, knees, neck, and areas surrounding body orifices are all affected by generalized vitiligo, which is frequently symmetrical.[6] Although segmental vitiligo is limited to a single area of the body, it is not always a dermatome. The depigmentation spots are clearly visible.

As per National Institutes of Health (NIH)- 2019, the prevalence of vitiligo in India has been invariably reported between 0.25% and 4% of dermatology outpatients across studies from India and up to 8.8% in Gujarat and Rajasthan

Objective of the study

To determine the efficacy of Ayurvedic treatment in Shwitra, as mentioned in classical Ayurveda text.

Brief history of patient

Present case report is of a 10-year-old female child, that came with complaint of whitish discolored patches over bilateral upper eyelids, back of neck, right side of temporal region, hand and abdomen with no itching or burning sensation in the last 1 year. At first it was only one whitish patch over back of neck that spread all over the above regions in a year.

Developmental history

Patient’s development was appropriate as per the age in all the domains (eg. Gross motor, Fine motor, social and speech domain)

Immunization history– Patient was immunized as per the age as per the guidelines of National Immunization Schedule.

Past history– The patient has no significant past medical history, including autoimmune or dermatological conditions.

Family history– No significant familial predisposition or hereditary conditions identified.

Personal history–

• Appetite- Unaltered
• Diet- Vegetarian
• Bowel habits- Regular, with no abnormalities noted.
• Bladder habits- Regular, with no abnormalities noted.
• Sleep- Sound sleep, approximately 8–9 hours at night and 2–3 hours during the day.
• Allergy: None Reported
• Addiction: None Reported

Nidana

1. Aaharaja-

Viruddhahara- Milk with Fruits e.g., Mango and Banana

Adhyashana- Eating food before previous meal being digested.

1. Viharaja-

Diwasawapna

Baseline findings

The patient’s general condition was moderate with 30.5kg weight and height 128cm and 18.6 kg/m2 of body mass index. The patient’s vitals were 98.2°F temperature, 84 beats/min of pulse rate, 22 breaths/ min of respiratory rate, and 100/70mm Hg of blood pressure.

On systemic examination, the patient was conscious and well oriented; on auscultation of heart S1, S2 heard, the chest was clear with air entry to lungs bilaterally equal, and gastro-intestinal system examination showed that the abdomen was soft, non-tender with normal bowel sound.

Clinical findings

• Site of lesions- Bilateral Upper eyelids- oval and irregular (3x6cm)
  • Back of neck- multiple, small and oval and irregular (1x1cm) each
  • Right temporal region- round shaped (0.2x 0.5cm)
  • Hand- small coin like round shaped lesion (0.2x 0.2 cm)
  • Abdomen- very small round lesion (0.1x 0.1cm)
• Margins- non-elevated
• Character of lesion – Macules
• Color – White
• Itching- no
• Discharge- no

Clinical test

Wood’s lamp test- In dark room, the wood’s lamp emits ultraviolet light that makes affected areas of vitiligo affected skin glow a dull-off white light.

Aggravating factors– Spicy food, Rainy season.

Samprapti Ghataka

• Dosha – Tridosha [Vata Kapha dominance]
• Dushya – Rasa, Rakta, Mamsa, Meda
• Ama – Jathargni Janya Ama
• Agni – Jathargnimaandya, Dhatwagnimaandya
• Srotas – Rasavaha, Raktavaha, Mamsavaha & Medovaha
• Srotodusti Prakara – Sanga
• Rogamarga – Bahya
• Vyakta Sthana – Twacha
• Roga Swabhava – Chirakari
• Sadhyasadhyata – Yaapya

 Materials and Methods

Assessment criteria

Subjective Criteria- Patient was observed for improvement in number of Hypopigmented patches and improvement in general condition.

Grading Assessment for Subjective Criteria-

 Objective criteria- Improvement calculated on basis of VETI (Vitiligo Extent Tensity Index) scoring method

VETI score formula: (Ph x Th) + (Pt x Tt) 4+ (Pu x Tu) 2+( Pl x Tl) 4+ (Pg x Tg) 0.1

(Percentage of head involvement x grade of tensity) + (Percentage of trunk involvement x grade of tensity) 4+ (Percentage of upper limbs involvement x grade of tensity) 2+ (Percentage of lower limbs involvement x grade of tensity) 4+ (Percentage of genitalia involvement x grade of tensity) 0.1

Treatment Plan-

 Avalgujadi Lepa- contains 1 part of Bakuchi churna and 4 parts of Shodhita Harataala mixed with cow’s urine. [7]

Pathya– pointed gourd, bitter gourd, Tila Taila, less spicy food

Apathya– Sarshapa Taila, spicy food

Follow-up – The patients was in follow-up up to 6 months, no recurrency of the symptoms reported during this time- period.

Results

VETI score before treatment

VETI: (Ph x Th) + (Pt x Tt) 4+ (Pu x Tu) 2+ (Pl x Tl) 4+ (Pg x Tg) 0.1

= (3 x 1) + (1 x 1) 4 + (1 x 1) 2 + (0 x 0) 4 + (0 x 0)0.1 = 9

VETI score after treatment

VETI: (Ph x Th) + (Pt x Tt) 4+ (Pu x Tu) 2+ (Pl x Tl) 4+ (Pg x Tg) 0.1

= (1x 1) + (0x 0) 4 + (0 x 0) 2 + (0 x 0) 4 + (0 x 0) 0.1 = 1

As per VETI scoring for vitiligo patient was observed with significant improvement of VETI scoring 9 before treatment to VETI scoring of 1 after treatment. The improvement was observed in subjective criteria with 80-85% filling of hypopigmented patches with normal skin tensity.

Discussion

In contemporary science vitiligo is being treated with potent topical steroids and narrow-band ultraviolet light B is the treatment of choice in patients with more extensive involvement. In all forms of vitiligo, response to therapy is slow, taking many months to years and spontaneous remission is seen in most of the cases.

Shwitra can be managed very well in Ayurveda by both Shodhana & Shamana Aushadis, if treatment can be initiated in early stages, we can observe satisfactory results. In this case patient presents with whitish discolored patches in bilateral upper eyelids, right side of temporal region, back of the neck, hands and abdomen, with 1^st Shodhana (Vamana) the patches started to fade and after 2 months of Shamana Aushadha, the patches around eyelids and temporal regions became smaller. With 2^nd Shodhana (Virechana) the patches around back of the neck became faded and after completion of 2 months of Shamana Aushadha the patches of back of neck, hands and abdomen diminished completely. The total improvement is evaluated as per VETI score.

Due to similarities between the related elements and Adhisthana and Dushya of the disease the principle of Kustha treatment has been used to treat Shwitra. Shwitra is a kind of Kilasa and has the prominent symptom of hypopigmentation that can be localised or generalized, the involvement of the Pitta, particularly the Bhrajaka pitta, is unquestionably present. Additionally, the Rakta, which circulates throughout the body, will become vitiated in all types of Kusthas. Propagating the disease with the inclusion of the seven Dushyas, such as Tridoshas and Dhatus like Rasa (Twak), Rakta, Mamsa, and Lasika, all Kustha are essentially Tridoshaja, which finally runs in a longer path and results in Chronicity. The clearance of metabolic waste, poisonous substances, and undigested antigenic materials from the cellular level, and consequently clearing the Dhatugata Ama, is the main prerequisite to achieving the Samprapati Vighatana when we analyse the pathology of Kustha or the Shwitra. The mainstay of treatment to achieve relief in Shwitra is the further regularisation and alteration of the cellular metabolism connected to phenylalanine by removing Sanga at the cellular enzymatic level to guarantee the normal generation of Melanin pigment by activating the critical hormonal axis.

Shodhana is essential in the management of Kustha Roga because without internal purification, external application may lead to the exacerbation of the disease.[8]

Chitrakadi Vati– It has Katu and Lavan Rasa along with Tiksna Guna which helps in Ama Pachan and Agni Deepana by stimulating Jathargni.

Mahatikta Ghrita- It is indicated in Kustha and it is Pittahara, it is having healing and improving lustre property which helps in early healing with good pigmentation.[9]

Vamana was done by Aakantha Dugdha Paana due to age of patient.

Virechana was done by Trivritadi Avaleha and Draksha Fanta which helps to pacify Pitta and Kapha Doshas and helps in easy purgation.

Drugs used in Virechana have properties like Ushna, Tikshna, Sukshma, Vyavayi, and Vikasi. These qualities help stimulate digestion, enhance the elimination of metabolic waste, and promote the release of Dosha from the body. Ushna boosts digestive fire, while Tikshna breaks down waste into water-soluble, non-toxic forms for removal. Vayavayi and Vikasi properties enable drug absorption at the cellular level. Snehana and Swedana aid in improving circulation and vasodilatation. Together, these actions allow the drug to spread through the body, facilitating Dosha removal and restoring balance. The above-mentioned qualities of the Virechana medication allow it to enter the Hridaya through its Virya, and after passing through the Dhamani, it permeates the entire body through the Sthula and Sukshma Srotas. It induces Vishyandana, or the seeping of the Dosha, due to its Agneya characteristics, and it can destroy the accumulated Doshas by its Tikshna properties. [10]

Khadirarista– main ingredient is Khadira extract (Acacia catechu). Khadira extract acts as an immune-modulatory, purify blood and antiphogistic.[11]

Arogyavardhini Vati is having Raktadhushtihara (blood purifier), Kushtahara (alleviates skin disease), Sroto Vishodhana (cleansing channels of body) and Pitta Doshahara (alleviates Pitta) properties. And it improves digestion and metabolic activities.[12]

Avalgujadi Lepa- contains Bakuchi Churna contain psoralen, isopsorale, bakuchiol, bavchinin & corylin which have antioxidant properties, stimulates melanocytes for Melanin synthesis and has immuno-modulatory effect.[13]

Triphala Churna has skin protective properties and natural anti-oxidants, it has protective effect on dermal fibroblasts. [14]

Action by eliminating Sanga of Tiryak Vaha Srotus

 The medications used have Ushana and Teekshna properties, Katu Rasa and Katu Vipaka

assist in the elimination of the local Sanga of the Kapha Dosha and the Ama. This facilitates Dhatu Poshana resulting in Dhatu Vridhi. There, melanocyte stimulation has been restored back by correcting cellular metabolism.

Action of Lepa

Ushna Virya and Katu Vipaka of the medicines when administered locally over affected patches of skin serve to change the local pH of the skin patches through a variety of methods, facilitating Mamsadhara Kala absorption of the medication. This probably acts by rising Twak Gata Agni, which in turn stimulates the melanocytes secreting cells, this also aids in enhancing the local Bhrajaka Pitta. Melanin is deposited on the skin and giving to normal color.

Drugs are Vidahi in nature, and when applied, it induces mild Shotha and Sphota in the affected area. This may also indicate an elevated Pitta dosha. This shows that an increase in local Pitta dosha promoted the Bhrajaka pitta which in turn, increasing the skin Varna. The drug ability to cause localised irritation is further reinforced Ushna–Teekshna characteristics promote Bhrajaka Pitta, which enhances melanogenesis.

Effect of sunlight to nourish Bhrajaka Pitta

As the pathology of Shwitra suggests there is defiencient Agni in the skin. As we know Ayurveda adheres to the Samanya Vishesha Siddhanta theory while treating disease. Pitta in the form of Agni that is found in the body. Bhrajaka variety of Pitta, which is present in the skin, is deficient in Shwitra. According to Samanya Vishesha Siddhanata by consuming

Samana Guna, Karma, and Dravyas can raise Agni or Pitta in the body. As a result, when patients were exposed to sunlight, which symbolizes the Tejo Mahabhuta, enhances Agni of body. Furthermore, studies have shown that UVA and NBUVB (Narrow-band UVB) are both effective melanocyte stimulants for depigmentation. Overexposure to sunlight with the full UV spectrum may result in marked pigmentation with diffuse skin darkening, depending on the intensity of UV light exposure. Additionally, UV light has an immunosuppressive impact on skin with vitiligo while at the same time increasing the number of remaining melanocytes.

Conclusion

According to Ayurvedic principles, it is crucial to identify and eradicate the multifactorial agents linked to vitiligo because its incidence is rising as a result of poor lifestyle choices. Most individuals can regain their pigmentation by adhering to the Ayurvedic therapy regimen outlined in Shwitra Chikitsa. Shwitra is a disease that causes cosmetic deformities and has a significant effect on both the body and the mind. By removing the body’s aggravated Doshas, Shodhana and Shamana Chikitsa help to eradicate the disease’s underlying cause and prevent its recurrence. This leads to an overall improvement in terms of the number and size of lesions as well as the restoration of normal skin pigmentation.

As this is a single case report, to apply of an large set of population with same reproducibility, more clinical trials should be done bigger population size to conclude on the results.

Declaration of patient consent

Obtained the parent’s consent form, on which the parent has granted permission for the case to be published in the journal along with the image and clinical data. The parent understands that although every effort will be made to keep the child’s identity anonymous, confidentiality cannot be ensured, the name and initials of their child will remain private.

ADR declaration

Throughout the course of treatment and the follow-up period, no adverse drug reactions were observed.

Conflicts of interest

There are no conflicts of interest.

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