Skin diseases in Integrative Medicine

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
Reviewers	Basisht G.2 Jamdade Yogita 3
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 3 Department of Ayurveda Samhita Siddhanta, PDEA'S College of Ayurveda and Research Centre, Nigdi, Pune, Maharashtra, India
Correspondence email:	carakasamhita@gmail.com
Publisher	Charak Samhita Research, Training and Development Centre, I.T.R.A., Jamnagar, India
Date of first publication:	September 28, 2021
DOI	10.47468/CSNE.2021.e01.s09.074

Integrative Medicine

The use of interventions from traditional medicine alongside biomedical (Western medicine) treatments for a biomedical diagnosis is integrative medicine. 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 from an integrative medicine treatment clinic; Institute of Applied Dermatology.

Diagnosis through Integrative Medicine

In integrative medicine, a disease is diagnosed in contemporary medical science and its comparable condition in ayurveda following the patient examination together. The patient examination is done by the multisystem doctors’ team separately based on their health system’s guidelines. This approach allows a clinician to understand the patient’s condition and helps identify the requirements, which is essential in the treatment using drugs from more than one system of medicine simultaneously. The findings of all the systems are documented to compare clinical features, prognosis, method of drug selection, and possible action of the drug in a specific disease condition. This process follows each therapeutic system’s guidelines strictly. After examining multiple patients, a sthaneeya vikruti table was developed by collating all patients’ information. The information that contradicts the certain well-known facts of allopathy was excluded through mutual discussion. For example, the coppery red colour (thamra varna) of pitta dominant shwitra was excluded since it is a classical feature of lepromatous leprosy. The international experts reviewed the integrative medicine protocol and upgraded it whenever the multisystem doctor’s team needed improvement. For example, in Psoriasis, annular, erythematous, xerosis lesions with an uneven surface are diagnosed as guttae psoriasis. The sthaneeya vikruti table lists the comparable clinical 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: Sthaneeya Vikruti of Guttate Psoriasis (Mandala Kushtha)

Biomedical description	comparable terms in Ayurveda
Annular	Mandala
Erythematous / Hypopigmented	Rakta / Shweta varna
Coalescing lesions	Anyonya samsaktham
Oily in appearance	Snigdha varna
Elevated	Utsanna
Uneven surface	Khara

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

Dermatological features and their Ayurvedic correlations in Lichen Planus are given in table 2.

Fig 2: Lichen Planus

Table 2: Dermatological clinical features of Lichen Planus

Biomedical description	Comparable 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 in ayurveda and biomedicine are listed. For example, lymphedema is known as Shleepada in Ayurveda..

Fig 3: Lymphedema

Table 3: Features of lymphedema (known as Shleepada in Ayurveda)

Biomedical description	Comparable terms in Ayurveda
Dependent oedema of foota	Bahushopha pada
Black pigmentationa	Krishna
Pricking pain or pain without any causea	Theevra Thoda or Arthi or Animitta rujam
History of fevera	Bahusho jwara
Dischargeb	Samsrava
Softb	Mrudu
Heavinessb	Gurutwa
Largely oedematousb	Adhika shopha
The warmth of the limb/feverb	Jwara yukta
Oily/shinyc	Snigdha/Snigdha varna
With Nodules/ warty growthc	Bahukantakai parivrtam
Huge in sizec	Sthoola
The feeling of heaviness[continuous]c	Guru Gurutwamanisham

a :Features of vata dosha dominant shleepada, b :Features of pitta dosha dominant shleepada, c:Features of kapha dosha dominant shleepada

Fig 4: Vitiligo

Table 4: Clinical features of pitta dominant Vitiligo (Swithra)

Biomedical description	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 in Ayurveda, the vitiated dosha must be carefully elicited through clinical examination. 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).

Table 5: Local pathologies and dosha specific clinical features in lymphoedema

Vata dosha		Pitta dosha		Kapha dosha
Ayurvedic terms	Comparable biomedical terminologies	Ayurvedic terms	Comparable biomedical terminologies	Ayurvedic terms	Comparable 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 comparable 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). 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 individualized 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

Ayurvedic term	Biomedical description	Attributes
Krishna	Hyperpigmented	Color
Kapalabha	Dusky red and concave in shape like mud pot	Color and shape
Ruksha	Xerosis on inspection	Appearance
Parusha	Dry on inspection	Appearance
Tanu	Atrophic lesions	Appearance
Toda bahula	Severe pricking pain	Pain
Vishama visruthani	irregularly shaped	Appearance

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 biomedical 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 in 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 Fig 7, both limbs exhibit erythema (rakta varna), discharge (srava) and papular lesions. Therefore, it is considered as pitta predominant condition. However, the same treatment fails in one patient (7B) but improves the condition in another (7A). The 7B patient developed more pain, which is considered as aggravation of vata. Biopsy of the patient in (Fig 7B)revealed that the condition was lymphangiosarcoma arising from lymphoedema, while the patient who got relief by treatment is lymphoedema with lymphangiectasia and lymphorrhoea (Fig 7A).

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 8. 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	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. Yoga and asana bring mobility, joint and muscle pump activation and dermal stretch. It is hypothesized that Yoga may induce drainage of lymph.

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. For example, 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.

Conclusion

Integrative medicine bridges the gap between biomedicine and Ayurveda. It allows the re-purposing of drugs within Ayurveda. Integrative medicine helps Ayurveda to 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. 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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