Skin diseases in Integrative Medicine

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Diagnosis and Management of Skin diseases in Integrative medicine

This article is based on a lecture delivered by Dr. S. R. Narahari, MD (dermatology in biomedicine), Director, Institute of Applied Dermatology, Kasaragod, Kerala, India, in Prof.M.S.Baghel Memorial Lecture Series on Aug 09, 2021.The video lecture can be accessed on the link of facebook page.

Contributors
Section/Chapter/topic Concepts and Contemporary Practices -Nidana Chikitsa / Vyadhi / Skin Diseases
Author Dr. S.R. Narahari 1
Reviewer Basisht G.2
Editors Deole Y.S.2, Aneesh E.G.2,Basisht G.2
Affiliations

1Director, Institute of Applied Dermatology, Kasaragod, Kerala, India

2Charak Samhita Research, Training and Development Centre, I.T.& R.A., Jamnagar, Gujarat, India
Correspondence email: carakasamhita@gmail.com
Date of first publication: September 28, 2021
DOI Under process

Integrative Medicine

The use of interventions from traditional medicine alongside biomedical (Western medicine) treatments for a biomedical diagnosis is integrative medicine.[1] The assessments for improvement (clinical outcomes) are made using biomedical parameters. Integrative medicine mainly focuses on prevention, improvement in the quality of life and healing, and holistic treatment. The present article provides insights into integrative medicine practices in skin diseases with evidence from peer-reviewed publications.

Diagnosis through Integrative Medicine

In integrative medicine, a disease is diagnosed by contemporary medical science parameters and its comparable condition in alternative medicine. For example, in Psoriasis, annular, erythematous, xerosis lesions with an uneven surface are diagnosed as guttae psoriasis. The relative terms as explained in Ayurvedic classics in the context of Kushtha are listed in table 1. It shows that guttae psoriasis resembles mandala kushtha.

Fig 1: Guttate Psoriasis (Mandala kushtha)
Table 1: Guttate Psoriasis (Mandala Kushtha)
Symptom Relative terms in Ayurveda
Annular Mandala
Erythematous Rakta varna
Xerosis Ruksha/Parusha
Uneven surface Khara

Clinical examination in integrative medicine gives a mutual orientation with different medical systems.

Some general dermatological features and their Ayurvedic correlations in Lichen Planus[2] are given in table 2.

Fig 2: Lichen Planus
Table 2: General dermatological features of Lichen Planus
Symptom Relative terms in Ayurveda
Violaceous Shyava/ Asita
Elevated Utseda
Uneven surface Khara
Pruritic Kandu

Specific nomenclature resembling lichen planus is not observed in Ayurveda classics. However, in such cases, Ayurveda describes them based on pathophysiological features and still recommends treatments.

In table 3, symptoms of lymphedema and its relative biomedical terms are explained. Lymphoedema is known as Shleepada in Ayurveda[3]. The table contains essential clinical features of the disease.[4]

Fig 3: Lymphedema
Table 3: Features of lymphedema (known as Shleepada in Ayurveda)
Biomedical terms Relative terms in Ayurveda
Dependent oedema of foot Bahushopha pada
Black pigmentation Krishna
Pricking pain or pain without any cause Theevra Thoda or Arthi or Animitta rujam
History of fever Bahusho jwara
Discharge Samsrava
Soft Mrudu
Heaviness Gurutwa
Largely oedematous Adhika shopha
The warmth of the limb/ fever Jwara yukta
Oily/shiny Snigdha/Snigdha varna
With Nodules/ warty growth Bahukantakai parivrtam
Huge in size Sthoola
The feeling of heaviness[continuous] Guru Gurutwamanisham
Fig 4: Vitiligo
Table 4: Vitiligo (Swithra)
Symptom Comparable terms in Ayurveda
Absence of hair on lesioned skin in hairy areas (differentiate it from Leprosy) Roma vidhwamsa
Color of lotus petal Padmapatraprateekasha


The above examples show that the final diagnosis could be similar even though the nomenclatures are different in two different medical systems. In an integrated system, both systems learn from each other.

Local pathology (sthaneeya vikruti)

While examining a patient through Ayurveda, the vitiated doshas must be carefully examined and understood. Ayurveda selects an appropriate drug for a chosen patient, whereas modern medicine selects a patient for a chosen drug. The examination of the status of dosha in skin diseases can be done based on clinical features, as shown in the example (table 5).[5]

Table 5: Local pathologies and dosha specific clinical features in lymphoedema
Vata dosha Pitta dosha Kapha dosha
Ayurvedic terms Relative biomedical terminologies Ayurvedic terms Relative biomedical terminologies Ayurvedic terms Relative biomedical terminologies
Ruksha Xerosis Daha Burning sensation Snigdha/snigdha varna Oily/ shiny
Bahushopha pada Dependent edema of foot Raktavarna Erythema/ redness Shwetabha Whitish
Sphutana Fissures Peeta varna Yellowish discoloration Drudham/ sthiram Organized
Krishna Black pigmentation Samsrava Discharge Bahukantakai parivrtam With nodules/ warty growth
Teevra toda/ arthi/ animittarujam Pain Mrudu Soft Sthoola Huge in size
Bahushajwara History of fever Gurutwa Heaviness Gurutwamanisham The feeling of heaviness (continuous)
Adhika shopha Largely edematous Sheetanvita Cold to touch
Jwara yukta The warmth of the limb/ fever Adhika shopha Largely edematous
'Fig 5: Vata Dominance Vitiligo
Table 6: Vata dosha specific features in vitiligo
Symptoms Allopathic terms
Ruksha Xerosis on inspection
Aruna Dusky red color
Mandala Annular
Parusha Xerosis on palpation
Paridhwamsi Galloping lesions with repigmentation or exploded
Krishna Dark repigmentation within the lesioned skin when examined for the first time

Clinical methods in Ayurveda

The core concept of integrative medicine is ‘adhere to the basics of each system of medicine being integrated. If another system cannot explain certain concepts of one medical system, it should not be rejected. Instead, it should be accepted and included. ‘Amsha-amsha kalpana’ of Ayurveda is similar to the system by system examination of biomedicine. Researchers have shown that ayurvedic clinical examination goes beyond the ten types of clinical examination (dashavidha pariksha; the classical Ayurveda teaching).[6] Clinical methods in Ayurveda can be categorized as shown in table 7.

Table 7: Methods of clinical examination in Ayurveda
Clinical methods in Ayurveda Comparable biomedical terminologies
Prakriti Biological constitution of the body
Dosha Primary life force
Dushya Deranged basic body tissues and excretions
Desha Habitat
Vaya Age
Pramana Body measurement
Sara Firmness or strength
Samhanana Acquired body build
Kala Seasonal and duration
Vyayama shakti Exercise capacity
Agni/Koshtha and Ahara Assessment of digestive process and dietary habits and disorders related to it
Sattva Behavior patterns
Satmya Compatible dietary habits
Bala Immunity of the patient
Roga avastha Stage of the disease
Bhaishajya Clinical pharmacology

The above details of patient information contribute to the Ayurvedic diagnosis and drug selection.

Dosha theories and personalized medicine are essential concepts of Ayurveda, meaning clinical presentation and its pathophysiology are of prime importance. In biomedicine, clinical presentations, diagnosis, and co-morbidities are also given prime importance. In addition, clinical methods and differential diagnosis are in greater detail than in Ayurveda.

Skin diseases in Ayurveda

In Ayurveda, seven major skin diseases (maha kushtha) and 11 minor skin diseases (kshudra kushtha) are explained. Mainly this classification is based on the dosha combination. The skin lesion is examined according to color, shape, appearance, sensation, spreading in the body, pain, and discharge. For example, the symptoms of Kapala kushtha and its attributes are given in Table 8.

Table 8: Clinical features of kapala kushtha
Symptom Biomedical description Attributes
Krishna Hyperpigmented Color
Kapalabha Dusky red Color
Ruksha Concave in shape like mud pot Shape
Parusha Dry on inspection Appearance
Tanu Atrophic lesions Appearance
Toda bahula Severe pricking pain Pain
Vishama Poor prognosis Prognosis

In modern dermatology, skin lesions are also categorized based on history, morphology, pattern of distribution, and others. Rather than disease, those 11 minor skin diseases need to be considered as lesioned skin morphology. In the Institute of Applied Dermatology, Kasargod, Kerala, Ayurveda doctors are asked to determine dosha vitiation of specific skin lesions. Dermatologists also examine the same patients to confirm the current diagnosis. Thus, the conditions are diagnosed and treated with an integrative approach.

Stages of disease

Fig 6: Stages of disease

Ayurveda describes different stages of the disease by different names. For example, fig 6 can be discussed below. Fig 6 (a) is Lichen rubour planus. Since it is erythematous (raga), annular (mandala) and papular (pidaka), this is considered as dadru as per Ayurveda. Fig 6(b) &6(c) are hypertrophic lichen planus. There is hypopigmentation observed in the middle, surrounded by violaceous color. The lesions are thickened (ghana), elevated (utseda) with rough edges (rukshambahi). All represent Kapha vata dosha dominance. It is essential to know the stage of disease (roga avastha) to guide specific and selective treatment options.

Fig 7: Lymphedema: Differential diagnosis (vyavachedhanidhana)

In both these conditions, erythema (rakta varna), discharge (srava) and papular lesions are present. Therefore, it is considered as pitta predominant condition. However, the same treatment fails in one patient but improves the condition in another. One patient developed more pain, which is considered as aggravation of vata. Biopsy of the patient in (b)revealed that the condition was lymphangiosarcoma arising from lymphoedema, while the patient who got relief by treatment is lymphoedema with lymphangiectasia and lymphorrhoea (a).

Treatment of skin disorders

Importance of agni, ama

Fig 8: Importance of ama pachana in vitiligo

The assessment of agni (digestion and metabolism) and ama (accumulated undigested biological waste in the digestive tract) is vital for treating a skin disorder. The importance of treating ama is shown in figure 7. The ama aggravates by the treatment for vitiligo without ama pachana (digestion of ama). When ama is treated, the vitiligo also decreases. So if ama is present, treatment to remove it should be given at the beginning.

Integrative therapies should not compromise biomedical pathology, neither the principles of Ayurveda. Table 9 shows that mutual dialogue between the systems of medicine leads to the integrated treatment protocol

Table 9: Integrated Ayurveda and yoga treatment for lymphology guidelines
International Society of Lymphology consensus requirements[7] IntegratedAyurveda elements
Skincare to improve the barrier function of the skin Washing and soaking in hot infusion (phanta) to heal chronic wounds, care of bacterial entry lesions
Lymph drainage Udwartana (Indian manual lymph drainage) and Yoga
Breathing Yoga
Movements Yoga
Compression therapy Bandhana

The rotating ankle movements as a Yoga exercise (Gulpha chakrasana) are practiced for lymphoedema patients. An increase in radioisotope clearance from lymphatics of lower limbs with even small-amplitude ankle movements is reported by Prof Peter Mortimer.[8] Yoga and asana bring mobility, joint and muscle pump activation and dermal stretch. It is hypothesized that Yoga may induce drainage of lymph.[9]

Fig 9: The patient arrived for treatment on June 2 2017 (left), and returned for follow up on January 21 2018 (right)

The above approach to chronic disease care leads to better treatment not provided by a single system alone. Figure 9 below shows the response of Lymphatic Filariasis (lymphoedema) following integrative medicine treatment. A clinic to lab research-based developed from such studies might provide new treatments for chronic disease.[10]

Conclusion

Integrative medicine bridges the gap between biomedicine and Ayurveda. It allows the re-purposing of drugs within Ayurveda. Integrative medicine helps Ayurveda stage the disease; by adopting modern investigations, effectiveness of treatment can be improved. At the same time, intersectoral collaboration helps modern medicine to use evidence-based traditional medicines. Prakriti based studies will add more knowledge to pharmacodynamics. Especially in chronic conditions, integrating Ayurveda and Yoga could be an example for WHOs innovative care for chronic conditions.[11] In order to develop a treatment protocol of integrative medicine, a sound knowledge of applied and translational science is required.

Related chapters

Kushtha Nidana Adhyaya, Kushtha Chikitsa Adhyaya

Link to video lecture: https://fb.watch/8l9mKsmLtT/

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References

  1. Rees L, Weil A. Integrated medicine. BMJ. 2001 Jan 20;322(7279):119-20. doi: 10.1136/bmj.322.7279.119.
  2. Narahari SR, Prasanna KS, Sushma KV. Evidence based integrative dermatology. Indian J Dermatol 2013;58:127- 31.
  3. Narahari, S. R., Ryan, T. J.,Prasanna, K. S. and Aggithaya, G. M., Integrating modern dermatology and Ayurveda in the treatment of Vitiligo and lymphedema in India. International Journal of Dermatology, 2011;50: 310–334
  4. Narahari S. Treating lymphodema patients in Indian villages. J Lymphodema, 2011;6:87-90
  5. Narahari S.R, Ryan TJ, Aggithaya GM,Prasanna KS. Evidence based approaches for Ayurvedic traditional herbal formulations: Toward an Ayurvedic CONSORT model. Journal of Alternative and complementary medicine 2008;14: 769–776.
  6. Narahari SR, Aggithaya MG. Morrow SE and Ryan TJ. Developing an integrative medicine patient care protocol from the existing practice of Ayurveda dermatology. Current Science 2016:111:302-317.
  7. Executive Committee of the International Society of Lymphology. The diagnosis and treatment of peripheral lymphedema: 2020 Consensus Document of the International Society of Lymphology. Lymphology. 2020;53:3-19.
  8. Mortimer PS, Simmons R, Rezvani M. The measurement of skin lymph flow by isotope clearance –reliability, reproducibility, injection dynamics and the effect of massage. J Invest Dermatol 1990; 95: 677–682.
  9. Narahari SR, Ryan TJ, Aggithaya MG. How Does Yoga Work in Lymphedema? J Yoga Phys Ther 2013; 3:135. doi: 10.4172/2157-7595.1000135
  10. Karayi AK, Basavaraj V, Narahari SR, Aggithaya MG, Ryan TJ, Pilankatta R. Human skin fibrosis: up-regulation of collagen type III gene transcription in the fibrotic skin nodules of lower limb lymphoedema. Trop Med Int Health. 2020;25:319-327. doi:10.1111/tmi.13359
  11. Innovative Care for Chronic Conditions accessed from the WHO website https://www.who.int/chp/knowledge/publications/icccglobalreport.pdf on the 18th September 2019