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.
|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|
1Director, Institute of Applied Dermatology, Kasaragod, Kerala, India
2Charak Samhita Research, Training and Development Centre, I.T.& R.A., Jamnagar, Gujarat, India3 Department of Ayurveda Samhita Siddhanta, PDEA'S College of Ayurveda and Research Centre, Nigdi, Pune, Maharashtra, India
|Publisher||Charak Samhita Research, Training and Development Centre, I.T.R.A., Jamnagar, India|
|Date of first publication:||September 28, 2021|
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.
|Biomedical description||comparable terms in Ayurveda|
|Erythematous / Hypopigmented||Rakta / Shweta varna|
|Coalescing lesions||Anyonya samsaktham|
|Oily in appearance||Snigdha varna|
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.
|Biomedical description||Comparable terms in Ayurveda|
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..
|Biomedical description||Comparable terms in Ayurveda|
|Dependent oedema of foota||Bahushopha pada|
|Pricking pain or pain without any causea||Theevra Thoda or Arthi or Animitta rujam|
|History of fevera||Bahusho jwara|
|Largely oedematousb||Adhika shopha|
|The warmth of the limb/feverb||Jwara yukta|
|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
|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).
|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|
|Ruksha||Xerosis on inspection|
|Aruna||Dusky red color|
|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.
|Clinical methods in Ayurveda||Comparable biomedical terminologies|
|Prakriti||Biological constitution of the body|
|Dosha||Primary life force|
|Dushya||Deranged basic body tissues and excretions|
|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|
|Satmya||Compatible dietary habits|
|Bala||Immunity of the patient|
|Roga avastha||Stage of the disease|
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.
|Ayurvedic term||Biomedical description||Attributes|
|Kapalabha||Dusky red and concave in shape like mud pot||Color and shape|
|Ruksha||Xerosis on inspection||Appearance|
|Parusha||Dry on inspection||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
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.
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
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
|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|
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.
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.
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.
Kushtha Nidana Adhyaya, Kushtha Chikitsa Adhyaya
Link to video lecture: https://fb.watch/8l9mKsmLtT/
- ↑ Rees L, Weil A. Integrated medicine. BMJ. 2001 Jan 20;322(7279):119-20. doi: 10.1136/bmj.322.7279.119.
- ↑ 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
- ↑ Madhava. Madhava Nidana. Kushtha nidana. Varanasi: Chowkhamba Orientalia, 2001; verses 12–13.
- ↑ Narahari SR, Prasanna KS, Sushma KV. Evidence based integrative dermatology. Indian J Dermatol 2013;58:127- 31.
- ↑ Narahari SR, Ryan TJ. Mainstreaming of an Integrative Medicine Protocol for Morbidity Management and Disability Prevention of Lymphatic Filariasis: An opportunity for establishing AYUSH based National Health Programme. Annals of Ayurvedic Medicine, 2020; 9: 108-115.
- ↑ Narahari S. Treating lymphodema patients in Indian villages. J Lymphodema, 2011;6:87-90
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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
- ↑ 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
- ↑ Innovative Care for Chronic Conditions accessed from the WHO website https://www.who.int/chp/knowledge/publications/icccglobalreport.pdf on the 18th September 2019