Ayurvedic Management of Shwitra: A Case Study

Shwitra is a chronic illness. The lesions of shwitra being dry and also noninfectious thus differs from the kushtha in general. It is whitish discoloration of skin starting from child to old, rich to poor, irrespective of sex, religion, status, age. vitiligo can be co-related with Shwitra disease in Ayurveda due to the alike signs and symptoms which are; non exudative white, red or coppery-red colored patches, roughness, dryness, itching, burning sensation of the patches, loss and discoloration of the hair. Shwitra is caused by vitiation all the three doshas. Pracchanna karma is one of among the shastrakrita raktamokshana in which multiple small incisions are made to irrigate the impure blood. It is usually adopted as a sthanika chikitsa. In this study, Balyadi lepa is used externally for the management of shwitra, the result of which has been found encouraging.


INTRODUCTION
Shwitra is a chronic illness.The lesions of shwitra being dry and also non infectious thus differs from the kushtha in general.It has been described along with kushtha in the classic.It is whitish discoloration of skin starting from child to old, rich to poor, irrespective of sex, religion, status, age.It is common skin disorder, which is correlated with vitiligo to certain extent in contemporary system of medicine.Vitiligo is a non-contagious acquired pigmentation disorder characterized by sharply defined white patches of variable shape and dimensions, increasing in size and number with time.Vitiligo is the most common depigmenting skin disorder, with an Case Study estimated prevalence of 0.5-2% of the population in both adults and children worldwide [1].Males and females are equally affected, although women and girls often seek consultation more frequently, possibly due to the greater negative social impact than for men and boys [2].Vitiligo is a multifactorial disorder characterized by the loss of functional melanocytes [3].Multiple mechanisms have been proposed for melanocyte destruction in vitiligo.These include genetic, autoimmune responses, oxidative stress, generation of inflammatory mediators and melanocyte detachment mechanisms.It can be co-related with Shwitra disease in Ayurveda due to the alike signs and symptoms which are; non exudative white, red or coppery-red colored patches, roughness, dryness, itching, burning sensation of the patches, loss and discoloration of the hair [4].Shwitra is caused by vitiation all the three doshas.Shwitra is raktapradoshaja vikara and tvakagata roga [5].The main cause for the disease is believed to be Purva Janma Krita Paapa Phala [6].In the case of Shwitra, bhrajaka pitta gets imbalanced and causes depigmentation of skin.Ayurvedic medicine is the best option for balancing of bhrajaka pitta and samavastha of all three doshas without any side effect [7].
Prachanna karma is one of among the shastrakrita raktamokshana in which multiple small incisions are made to irrigate the impure blood.It is usually adopted as a sthanik Chikitsa.This case is there to show the effect of pracchanna karma followed by balyadi lepa application.

BRIEF CASE HISTORY
The patient is a 26-year-old boy who first started experiencing depigmentation at age 14 over skin of calf region laterally, and ankle region medially of right lower limb.There were 08 patches of white color and irregular margins, having mild itching occasionally on the patches since 07 years.The patient gave history of lesions that initially they were small in size than increase in size gradually.The size measuring up to 1×1 cm2, 1×1cm2, 1×0.8cm2, 5×3.8cm2, 4×3.8cm2, 2×2.5cm2, 1.8×1cm2, 4.5×3.3cm2.Sensation, temperature of the lesions was normal but hair color of the lesions was white.Patient had taken treatment for the vitiligo from their local hospital, topical creams and steroids were given but he didn't get any relief.Of note is the absence of any family history of vitiligo or autoimmune disorders.

Treatment Plan
After Proper analysis, (blood investigation , coagulopathy, any allergy, about serological ,)patient was planned for pracchanna karma once a week for one month with BALYADI LEPA application.

Procedure
Under all aseptic conditions, patient was made to lye down in suitable position, part preparation done.Local area clean with sprit.Pracchanna karma done with 11 number surgical blade, after vertical parallel superficial incisions were made, bloodletting done.Application of balyadi lepa was done for when it was came to dry then wiped out with sterile gauze pieces.Balyadi lepa application was done twice a daily for one month.And 2 follow up after 15 days in one month.

Assessment Criteria
Healing of shwitra was assessed on the basis of-1.Color 2. Itching 3. Size

OBSERVATION
Regular use of Balyadi lepa application with pracchanna karma minimized the size and shrinkage of patches.There was color change in patches from white to pink and then dark brown in the whole treatment schedule of 02-month study.And hair color of lesions was also in black color.

RESULTS
Out of 08 the lesions the smallest 4 lesions could acquire skin color after one month treatment whereas rest of the 4 of bigger size are shown positive inclination towards acquiring skin color in near future as they turn white to brown color after one month follow up.By this we can predict the total remission of the disease with either repeated procedure or long term follow up.In the whole study no internal medicine was done.

DISCUSSION
In this study, Balyadi lepa is used externally for the management of shwitra, the result of which has been found encouraging.Shwitra is caused by vitiation of Tridosha and Twacha, Rakta, Mamsa and Lasika as dushya's effecting the bahya roga marga by means of vimarg gaman type of sroto dushti prakara.The treatment protocol as per the classics for any kushtha is shodhan followed by lepa on the lesions [8].In this case study sthanik shodhana of shwitra lesion was achieved by prachanna karma, as one of the dushya involved in shwitra is rakta dhatu.Further in the context of lepa application Acharya sushrutas advocated application of lepa on shwitra should be done only after some lekhana.Hence the pracchanna was planned to achieve Bhuta shodhana and lekhana purpose.Followed by balyadi lepa, to clear the srota sanga and stimulates the melanin secretion by means increased blood circulation.Balyadi lepa consist of madhur, katu, tikta and Kashaya rasa .Laghu, ruksha, tikshna, mradu, guru and snighdha guna.Ushna and sheet virya, Madhur and katu vipaka, Kaphavatashamak, kaphapittahar, kaphapittashamak, vatapittashamak and pittavardhak.So in shwitra srotodushti is removed by pracchanna karma, as in this, the vitiated blood is irrigated out causing high blood circulation in that area and thus provide nutrition to the cells present there.

CONCLUSION
Based on the observation and results of this single case study it can be concluded that shwitra due to obstructive pathology by means of vitiated tridosha and dushyas like rakta mamsa lasika meda has got remedy in the ayurvedic classics specially with sthanic prachanna karma followed by balyadi lepa.Result may be achieved in less time duration and with high percentile, if the pracchanna karma and balyadi lepa advocated after classical vaman and virechana.The case demonstrates clinically promising results in re-pigmentation without any adverse effects.It is also worth noting that new areas of hypopigmentation also did not appear during the treatment.

CONSENT AND ETHICAL APPROVAL
As per international standard or university standard guideline patients consent and ethical approval has been collected and preserved by the authors.