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.)

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.

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 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. The table contains essential clinical features of the disease.

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 lesional 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 (sthaneeyavikruti)

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).

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
Teevrathoda/ 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 lesional skin when examined for the first time

Fig 5: Vata Dominance Vitiligo

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 (dashavidapariksha; 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/Kostha 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 (mahakushtha) and 11 minor skin diseases (kshudrakushtha) 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 Kapalakushtha and its attributes are given in Table 8.

Table 8: Clinical features of kapalakushtha

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 lesional 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

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 amapachana (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.

Fig 8: Importance of amapachanain vitiligo

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	Udwarthana (Indian manual lymph drainage ) and Yoga
Breathing	Yoga
Movements	Yoga
Compression therapy	Bandhana

The rotating ankle movements as a Yoga exercise (Gulphachakrasana) are practised 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. 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.

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

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. In order to develop a treatment protocol of integrative medicine, a sound knowledge of applied and translational science is required.

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