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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 15  |  Issue : 4  |  Page : 322-328

Ayurvedic management of lichen planus pemphigoid (Kitibha)


1 Department of Rog Nidan Evum Vikariti Vigyan, All India Institute of Ayurveda, New Delhi, India
2 Department of Vikrirti Vigyan, Faculty of Ayurveda, Banaras Hindu University, Varanasi, Uttar Pradesh, India
3 Department of Translational Research Biostatician, All India Institute of Ayurveda, New Delhi, India

Date of Submission10-Mar-2021
Date of Decision08-Jun-2021
Date of Acceptance10-Aug-2021
Date of Web Publication16-Dec-2021

Correspondence Address:
Sisir Kumar Mandal
Professor, Department of Vikriti vigyan, Faculty of Ayurveda, Banaras Hindu University, Varanasi, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/joa.joa_68_21

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  Abstract 


Introduction: Lichen planus pemphigoides (LPP) is a rare autoimmune sub-epidermal blistering disease associated with lichenoid skin changes. Here, a 52 years female patient diagnosed with LPP for the last 1.5 years was on steroid therapy treated successfully with ayurvedic interventions is being reported. Main Clinical Findings: Dermatological examination revealed hypertrophic, black to purple colored, round-to-oval papular, flat-topped, well-circumscribed lesions (2–5 mm), symmetrically distributed over upper and lower limbs. Psoriasis Area Severity Index (PASI) score was 34. Diagnosis: Blackish/purple lesions with roughness, itching and scaling correlated to Kitibha in classics. Interventions: Internal administration of decoction of Punarnava and Sahijana with Arogyavardhini vati and Tab Sumanta and external application of Apamarga kshara, Karanjadi and Somraji taila was prescribed as baseline treatment. Outcome: After 2 months of treatment, cessation of new lesions and marked reduction in itching and elevation was found. PASI score decreased to 9.6. In next follow-up, the elevation of lesions and symptoms completely declined and the skin reversed back close to normal texture. PASI score was also found 0. Conclusion: Ayurvedic interventions have proven effective potential in treating rare autoimmune disease like LPP.

Keywords: Karanja tail, Kitibha, lichen planus, Punarnava, Somraji tail, Vatakaphashamaka


How to cite this article:
Sharma M, Mandal SK, Kumar A. Ayurvedic management of lichen planus pemphigoid (Kitibha). J Ayurveda 2021;15:322-8

How to cite this URL:
Sharma M, Mandal SK, Kumar A. Ayurvedic management of lichen planus pemphigoid (Kitibha). J Ayurveda [serial online] 2021 [cited 2022 Jan 27];15:322-8. Available from: http://www.journayu.in/text.asp?2021/15/4/322/332609




  Introduction Top


Lichen planus pemphigoides (LPP) is a rare cross-over syndrome between lichen planus (LP) and bullous pemphigoid.[1] It is characterized by flat-topped purplish skin rashes of varying size, from pinpoint to centimeters, with firm bumps. People affected by LPP subsequently develop blisters on both the LP skin lesions and on normal skin.[2]

Studies reveled that, 1.13% - 3.5% of LP cases has the tendency of developing Squamous cell carcinoma (SCC).[3] Although the exact underlying cause of LPP is currently unknown, it is observed that autoantigen XVII collagen (COL17) is associated with the development of the disease.[4] High potency topical corticosteroids constitute first-line treatment along with oral antihistamines.[5],[6] Corticosteroids has adverse psychological effects thus affecting the quality of life of patients.[7] Oral retinoids and immunosuppressants are used in severe cases. Although various treatments are employed for LP, complete resolution is difficult to achieve.[8] Kushta is the term employed for skin disorders. Kitibha is a type of Kshudra kushta described in Ayurvedic classics. It has symptoms like Shyava (blackish scaly lesion), kina, khara sparsha (hard), and parusha (rough to touch).[9] It has Vata kapha doshika predominance.[10] Acharya Vagbhata has incorporated kandu (itching) as one of its symptoms.[11] Acharya Sushruta explained sravi (exudation), Vritam (round- and coin-shaped lesions), Snigdha (unctuous), Ghanam (well-defined borders), and Krishnasam (black) as the clinical features of Kitibha.[12] Acharya Kashyapa has described Kitibha as skin lesions which are Aruna (reddish-brown), Vriddhimanti (spreading in nature), Guruni (large), Prashanti cha punarutpadyante (subsides and relapse).[13] Herein, details of a diagnosed case of LP who was on systemic steroid therapy effectively intervened with Ayurvedic multi-modal approach have been described. A substantial reduction in pruritis and elevation was observed after 2 months of regular treatment and complete regression of the symptoms without any sign of relapse was found after the next 4 months of treatment showing the efficacy of Ayurvedic treatment in addressing such autoimmune diseases.


  Case Report Top


A 52-year-old homemaker, diagnosed with LP by a dermatologist visited the outpatient department (OPD) of All India Institute of Ayurveda (AIIA), Delhi, (OPD Regn. No. 463106), presented with the chief complaint of elevated lesions with secretion on bilateral lower limbs and upper limbs with itching. Her history revealed that initially, she developed 1–2 papular lesions on the left leg for which she consulted dermatologist. During the course of treatment, she developed symptoms such as anxiety, loss of sleep, irritability, depression and was diagnosed with steroid-induced psychosis [Table 1]. Her condition got worsened with lesion spread over both limbs. She got no relief despite treatment. Hence, she visited AlIA, for better management.
Table 1: Time line of the case

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History of past illness

She also had a history of hypothyroidism and was on allopathic medication for the same. No history of previous surgeries or other major illnesses was found.

Clinical finding

General examination: The general condition of the patient was fair. Vitals were stable. Her appetite, bowel, and bladder were normal. Her sleep was disturbed due to constant itching. Her prakriti was vata-kapha dominant and on psychological evaluation, she was in stress due to her illness.

Clinical examination

Atura bala pramana (strength of individual) was assessed by Dashavidha atura pariksha (ten-fold examination of patient).[14] Prakriti (constitution) of the patient was vata-kaphaja; Vaya (age), Sara (proper nourishment of tissue), Samhanana (body built), Pramana (body proportion), Ahara and Jarana shakti (digestive and metabolic capacity) were Madhyama (medium); Satva (psychological strength), Vyayama shakti (physical strength), and Satmya (compatibility) were Avara (low); Vikriti (morbidity) was Vata-kaphaja.

Skin examination

Dermatological examination revealed hypertrophic, black- to purple-colored, round-to-oval papular, flat-topped, well-circumscribed lesions (2–5 mm) with mild secretion, symmetrically distributed over the upper and lower limbs. On touch, the surface of the lesions was very rough and the skin was slightly warm. No local tenderness or bleeding was elicited. No sign of varicose vein was observed on any of the legs.

Diagnosis

The lesions were having features like Shyava to Aruna (blackish/purple) color with Khara sparsha (rough to touch) and Kandu (itching) and Twakavadarana (scaling) The shape of Vrana (lesions) was Vritakara (round) with Ghana paryantam (well-defined borders) and of Vriddhimantah (spreading) in nature. All the symptoms were corresponded to Kitibha in classics. A PASI Score of 34 was assessed.

Treatment and management

Since the patient was complaining that her problem has increased after taking steroids, she was advised to taper off corticosteroids and continue the medicines for hypothyroidism as per the direction of the allopathic physician. She was instructed to follow Ayurvedic interventions in dosage as prescribed. The detailed interventions are mentioned in [Figure 1]. The assessment of symptoms was done before treatment, after 2 months and 6 months of interventions to evaluate the efficacy of treatment based on Psoriasis Area Severity Index (PASI) and subjective assessment criteria[15] [Table 2].
Table 2: Assessment criteria

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Figure 1: Ayurvedic interventions used for treating Kitibh

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Follow up and outcome

Pictures of the affected area were taken at the time of initiation of treatment [Graph 1], [Graph 2] and [Figure 2]a, [Figure 2]b, [Figure 2]c and subsequently on every visit to assess improvement. PASI and subjective criteria were adopted for assessment of the severity of lesions and treatment efficacy on all the visits. The patient was followed up on every fortnight telephonically, due to Covid-19 regulations. After 2 months of interventions, the patient visited us and it was found that appearance of new lesions were completely stopped and the symptoms like itching, scaling and secretion found to be considerably reduced [Table 3] and [Graph 1], [Graph 2] and [Figure 3]a, [Figure 3]b, [Figure 3]c. The steroids were completely withdrawn on the advice of allopathic physician as she was feeling much better physically and psychologically. However, the elevation of the lesions still persisted. The patient again visited 4 months after the last visit, (6 months from the start of treatment), it was observed that symptoms were completely subsided including the elevation of the lesion and the skin set back close to its normal texture with no sign of relapse [Table 3] and [Graph 1], [Graph 2] and [Figure 4]a, [Figure 4]b, [Figure 4]c.
Table 3: Assessment on the basis of symptoms (subjective parameter)

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Figure 2: (a) Lesions of upper and lower limbs before treatment. (b) Lesion of lower limbs before treatment. (c) Lesions of upper limbs before treatment

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Figure 3: (a) Lesions of upper and lower limbs after 2 months of treatment. (b) Lesions of lower limbs after 2 months of treatment. (c) Lesions of upper limbs after 2 months of treatment

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Figure 4: (a) Lesions of upper and lower limbs after 6 months of treatment. (b) Lesions of lower limbs after 6 months of treatment. (c) Lesions of upper limbs after 6 months of treatment

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  Discussion Top


Case conceptualization

Ayurvedic perspective of this particular case presenting the verrucous lesion with itching and elevation can be established with clinical presentation. Itching, elevation, hyperkeratosis, secretion are the features of kapha dosha while hardness, roughness on touching, black color, spreading in nature are the features due to vata dosha. Based on symptomatology, the disease was equated with vatakaphaja kushta. Classics has explained consumption of Viruddha ahara (incompatible food), Vega dharana (suppression of natural urges), following Diva svapna (day sleep) and Papakarma (indulgence in sinful acts) as the Nidanas (causative factor) of Kushta. In the present case, the patient was taking incompatible food (excess dahi, tea and snacks, hot and cold items together,) and Divaswpna (day sleep) and excessive stress that leads to simultaneous vitiation of Doshas and Shaithilyata (derangement) in Dhatus (Tvak, Rakta, Mamsa, Lasika). Vitiated Doshas further affects Shithila dhatus leading to the manifestation of the disease. The exact mechanism of such pathogenesis in modern terms needs to be understood. As per prognostic criteria of Ayurveda, it comes under krichhasadhya (difficult to treat) disease as the doshas constituting the prakriti of the patient were congruent to doshas of disease.[16] Although Shodhana is the treatment of choice in kushta but due to subnormal psychological and physical strength, Shamana chikitsa was adopted. Considering the involvement of Dosha and Dushyas (pathognomic factors) and analysis of etiological factors (hetu) of the disease, the multimodal Ayurvedic approach consisting of Aushadha, Ahara and Vihara was adopted at OPD level [Figure 5]. Vyadhipratyanika and Doshashamaka (including vata-kaphaghna, Kushtaghna, Shothahara, Medhya, Rasayana, Raktashodaka drugs) line of treatment was chosen. Pathya and apathya (do and don'ts) were advised to her.
Figure 5: Ayurvedic multimodal treatment adopted for Kitibha

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Rationale of interventions

Punarnava (Boerhavia diffusa L.) has Madhura, Tikta, and Kashaya rasa (sweet, bitter, astringent taste), Laghu (light), Ruksha guna (light, dry properties), Ushna virya (hot potency) and Katu vipaka (pungent as end taste of digestion). It pacifies Vata dosha due to Madhura rasa (sweet taste) and Ushna virya and Kapha dosha due to Tikta and Kashaya rasa, Ushna virya, Katu vipaka and Laghu, ruksha guna. Punarnava is Shothahara (anti-inflammatory) and Vata kaphahara (pacify Vata and Kapha dosha).[17] Acharya Sushruta has explained Shothanashaka and Vatashamaka quality of green leaves of Punarnava.[18] Studies has revealed its immune-modulatory,[19] antioxidant, hepatoprotective,[20] anti-inflammatory,[21] and anti-proliferative effects.[22]

Manjistha (Rubia cordifolia L.) possess Tikta, Kashaya and Madhura rasa; Guru, Ruksha guna; Ushna virya and Katu vipaka. It is Kapha shamaka (~ pacify Kapha) due to Tikta, Kashaya rasa; Ushna virya and Katu-vipaka while Pitta shamaka due to Madhura, Tikta, Kashaya rasa; Guru and Ruksha guna.[23] Ayurvedic text enumerated Varnya (improves complexion), Kushtaghna (anti-leprotic), Rakta sodhaka (blood purifier), Krimighna (anti-microbial) Shothahara, Vedana sthapaka (analgesic), and Shonita sthapaka (anti-coagulant) qualities of Manjistha.[24] Clinical studies revealed analgesic, anti-inflammatory, anti-microbial, anti-oxidant, anti-cancer activities of Manjistha.[25],[26]

Guduchi (Tinospora cordifolia [Willd.] Hook. f. Thoms) has Tikta, Kashaya rasa; Laghu, Snigdha guna; Ushna virya and Madhura vipaka. It has Tridosha shamaka, Jvaraghna (anti-pyretic), Krimighna, Kushtaghna, Vishaghna (antidote), and Rasayana (rejuvenative) effect.[27] Studies demonstrated anti-inflammatory, immunosuppressive,[28] anti-leprotic,[29] anti-ulcer, anti-oxidant,[30] hepatoprotective, and immunomodulatory[31] properties of Guduchi.

Sahijana-Moringa oleifera L. possess Katu, tikta rasa, Laghu, ruksha and Tikshna guna; Katu vipaka and Ushna virya. It has kaphavata shamaka effect. It has Kusthaghna, vidhradhihara, sothaghna, kanduhara, and krimighna potential.[32] The immunomodulatory,[33] antimicrobial,[34] antioxidant[35] and anti-inflammatory,[36] antiproliferative,[37] and wound healing[38] properties of M. olifera extracts have been reported.

Arogyavardhini vati has Kutki as main ingredient that has anti-pruritic, antioxidant properties and acts as Dhatu Poshaka hence resolve any sort of impairment of Dhatus. As per the classics, it is Hridya, Deepani (digestive), Pachani and balances Tridoshas and indicated in Kushtha.[39]

Sumanta is a herbal combination of Brahmi (Bacopa monnieri L.), Ashwagandha (Withania somnifera L.), Jatamansi (Nardostachys jatamansi D. C.) and Tagara (Valeriana wallichii) has neuroprotective action. Most of the drugs in the formulation has antistress, antianxiety, antidepressant, brain tonic and immunostimulant effect.[40] As the patient was of Avara satva and on antipsychotic drugs, so the above formulation was given to improve her psychological strength.

Apamarga kshara tail has Apamarga (Achyranthes aspera L.) and Tila oil (Sesamun indicum L.). Apamarga has Katu and Tikta rasa, Ushna virya, katu vipaka. It pacifies kapha and vata doshas.[41] Acharya Sushruta has explained Chedana (excision), Bhedana (incision) and Lekhana (scrapping) effects of different Ksharas.[42] In this case, the scrapping effect of Kshara was utilized to reduce the elevation of the lesions.

Karanjadi tail: It is the formulation consisting of Tila tail (Sesamum indicum L.) processed with herbal drugs-Karanja (Pongamia pinnata L.), Saptachada (Alstonia scholaris L.), Arka (Calotropis procera Aiton), Langali (Gloriosa superba L.), Snuhi (Euphorbia nerifolia L.), Bringaraja (Eclipta alba L.), Nisha (Curcuma longa L.), Visha (Aconitum ferox Wall. ex Ser), Chitraka (Plumbago zeylanica L.). It is indicated in various skin diseases like Visarpa (erysipelas), kustha, visphota (Bullous pemphigoid) etc., in classical text.[43]

Somaraji tail: It contains Backuchi beeja (Psoralea corylifolia L.), Sarshapa (Brassica juncea L.) oil, Edagaja beeja (Cassia tora L.) processed with the kalka (herbal paste) of kushtaghna drugs like Kushta (Saussurea lappa Falc. Lipsch.), Khadira (Acacia catechu L.), Karanja (Pongamia pinnata L.), Neem patra (Azadirachta indica L.), etc. External application of this formulation alleviates all types of skin disorders especially Kitibha described in classics.[44]


  Conclusion Top


LP is a rare inflammatory skin disease which has tendency of recurrence and high possibility to develop into SCC. The conventional treatment options include steroid therapy which has serious side effect and negative impact on quality of life of patients. From the case study, it may be inferred that Ayurvedic interventions may be adopted in such types of autoimmune diseases where other science has limitations.

Declaration of patient consent

Authors certify that they have obtained patient consent form, where the patient/caregiver has given her consent for reporting the case along with the images and other clinical informations in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.





 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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Abstract
Introduction
Case Report
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