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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 4  |  Issue : 2  |  Page : 64-67

Ayurvedic management of bullous pemphigoid (Visphota): A case report


1 Department of Rog Nidan Evum Vikriti Vigyan, All India Institute of Ayurveda, New Delhi, India
2 Department of Vikriti Vigyan, Faculty of Ayurveda, IMS, BHU, Varanasi, India
3 Department of Kaumarabhritya, All India Institute of Ayurveda, New Delhi, India

Date of Submission28-May-2020
Date of Acceptance17-May-2021
Date of Web Publication16-Aug-2021

Correspondence Address:
Dr. Sisir Kumar Mandal
Department of Vikriti Vigyan, Faculty of Ayurveda, IMS, BHU, Varanasi, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JACR.JACR_28_20

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  Abstract 


Bullous pemphigoid is a rare, potentially fatal autoimmune blistering disease in which the immune system produces antibodies to the fibers that connect the outer layer (epidermis) and next layer (dermis) of the skin. These antibodies trigger inflammation that produces the blisters and itching of bullous pemphigoid. It is uncommon in childhood. This manifestation has close resemblance with Visphota in Ayurveda. A case of five month-old female patient with chief complaints of multiple ruptured blisters or bullae and reddish black lesions over both upper and lower extremities, face, lower abdomen, lower back, and scalp for two months is presented here. Oral administration of Paripathadi kadha and Mahatikta ghrita to mother and local application of Rasonta (~decoction of Daruharidra) with milk and Jatyadi taila to patient simultaneously were prescribed. Complete recovery within a month with no signs of relapse after three months of follow-up was noticed.

Keywords: Autoimmune disease, bullous pemphigoid, mahatikta ghrita, paripathadi kadha, Visphota


How to cite this article:
Sharma M, Sharma B, Mandal SK, Mahapatra AK. Ayurvedic management of bullous pemphigoid (Visphota): A case report. J Ayurveda Case Rep 2021;4:64-7

How to cite this URL:
Sharma M, Sharma B, Mandal SK, Mahapatra AK. Ayurvedic management of bullous pemphigoid (Visphota): A case report. J Ayurveda Case Rep [serial online] 2021 [cited 2021 Oct 25];4:64-7. Available from: http://www.ayucare.org/text.asp?2021/4/2/64/323902




  Introduction Top


Bullous pemphigoid (~Visphota) belongs to a group of autoimmune sub-epidermic bullous disorders.[1],[2] It is a rare but potentially fatal group of skin diseases.[3] It is an autoimmune disorder presenting with sub-epidermal blistering. It features with circulating auto-antibodies against distinctive skin's basal membrane antigens and adjacent mucous membrane antigens.[4],[5],[6] It's clinical presentation shows vesicles and blisters of variable size, usually symmetrical and ungrouped on erythematous skin associated with pruriginous, erythematous papules, and plaques with irregular borders and polycyclic configurations.[5] It mostly affects the elderly and is considered uncommon during childhood and in infants.[6] Here are different clinical presentations depending on the age of affected children and most cases of childhood bullous pemphigoid occurred in small children under the age of 12 months.[7] Often affected areas are flexural areas of the limbs, trunk, abdomen, face, head, and neck.[8] The usual recovery time varies from nine weeks to 17 years (median treatment time, 25 months).[9] It is a chronic disease with unpredictable exacerbations with majority of relapses (i.e. up to 50% of patients) reported to occur within the first three months of treatment discontinuation.[10] The mean interval to relapse was 3.2 (3.3) months.[11] It is commonly managed with corticosteroids, antibiotics, and other anti-inflammatory drugs.[1],[12]

In Ayurveda, it has been described as the disease in which eruptions of burn like vesicles (~Agnidagdha sphota) appear all over the body or on any particular area, associated with fever is called Visphota.[13] The manifestations occur with vitiated Rakta and Pitta.[14] Sphota (~blisters) appears all over the body along with burning sensation, fever, and thirst are the symptoms of Visphoṭa.[15] It is also described as one of the types of Kshudra kushta with symptoms as Shveta arunavabhasa sphota (~whitish-red) and Tanu tvak (~skin over the rash will become thin),[16] that occurs due to vitiation of Pitta and Kapha dosha.[17] Above symptoms are similar to bullous pemphigoid. The present case diagnosed with bullous phemphigoid by allopathic physician managed with successful outcomes through Ayurveda treatment approach on the line of Visphota is described.


  Patient Information Top


A five month-old female baby along with her mother visited the skin outpatient department (OPD) with chief complaints of multiple ruptured blisters and reddish black lesions over both upper and lower extremities, face, lower abdomen, lower back and scalp associated with fever, burning sensation, severe pain, and itching for two months. Her mother explained that the patient developed small multiple blisters initially on the lower back with low grade fever which later progressively spread to lower extremities. Then similar lesions appeared over both hands, face, lower abdomen and scalp, accompanied by papules and plaques associated with severe burning sensation, redness, pain, itching, oozing from lesions, decreased appetite, and disturbed sleep (due to continuous weeping). Fluid filled bullae or blisters after getting ruptured, turned the skin over affected area into crusting erosions during course of healing. She consulted an allopathic physician and was diagnosed with bullous skin disease and took allopathic medication for one month. No significant relief was noticed with the treatment. After one week, she came to skin OPD for further possible management.

There was no relevant family history. The patient was born at term with normal vaginal delivery, without complications and exclusively breastfed. The patient received their commended vaccines. On general examination, normal vital signs revealed. No icterus, pallor, clubbing, cyanosis, and lymphadenopathy were observed. The lesion type was multiple, asymmetric, widespread, ruptured blisters affecting areas of normal as well as erythematous skin. Lesions were located predominantly over upper and lower extremities, scalp, face, lower abdomen, and back. Texture was rough and dry. She presented with hemorrhagic crusts, papules, and urticarial erythematous plaques. Nails and mucosa were unaffected.


  Diagnostic Focus and Assessment Top


As the symptoms of Sphota were associated with Jvara (~fever), Daha (~burning sensation), Ruja (~pain), Srava (~watery or serous secretion), Paka (~fluid filled blisters or bullae), and Trishna (~thirst); the case was diagnosed with Visphota (Pitta dominant).[18]


  Therapeutic Focus and Assessment Top


Based on the involved Doshas and Samprapti (~pathogenesis), Pittashamaka (~Pitta pacifying) line of treatment was adopted. Samshamana chikitsa along with diet restriction [heavy food items, incompatible food, Tila (~sesame), Urad (~black gram), Kulatha (~horse gram), intake of excessive salty, sour and pungent and dry food items].


  Timeline Top


The timeline of internal and external medication is described in [Figure 1].
Figure 1: Timeline of internal and external medication

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  Follow-Up and Outcome Top


Patient was presented with hemorrhagic crusts, papules, and urticarial erythematous plaques [Figure 2]a and [Figure 2]b. After two weeks, the patient was examined and significant relief in redness, pain, and burning sensation was observed. Complete cessation of new bullae and marked healing in old lesions was noticed [Figure 3]a and [Figure 3]b. There was marked improvement in the sleep and appetite. After four weeks of treatment, there was complete healing of lesions with no signs of relapse. Itching and all other associated symptoms were also subsided [Figure 4]a and [Figure 4]b. Oral medication was continued for three more months and external application for one month. No adverse drug reaction was noticed during the treatment period nor during follow-up period.
Figure 2: (a) Lesions of face and (b) lower back and hip region before treatment

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Figure 3: (a) Lesions of face and (b) lower back and hip region after two weeks of treatment

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Figure 4: (a) Lesions of face and (b) lower back and hip region after four weeks of treatment

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  Discussion Top


The main causative factors in the manifestation of the pathology of Visphota are Pitta pradhana tridosha associated with Dhatu like Rakta, Mamsa, and Asthi. The Nidana (~cause of manifestation of the disease) is any sort of pungent, sour, spicy, alkaline, unctuous food in excess, eating before digestion of previous food, intake of food in indigestion condition, and avoiding seasonal regimen.[19] In the present case, unwholesome dietary habits of mother (especially unctous, pungent, sour, spicy food, and intake of food in indigestion condition) during pregnancy as well as lactating period has probably contributed to vitiation of Doshas (Pitta pradhana tridosha) that reached breast milk through Stanya vaha srotas[20] (~lactating channels) and manifested as Visphota in the patient due to Dushti of Rakta, Mamsa and Asthi dhatu.[19]

In Ksheerapa avastha (~up to one year), medicine should be given to Dhatri (~lactating mother) as well as infant.[21] As the formulation is unpalatable, it was solely given to lactating mother because infant is totally dependent upon mother for nourishment, hoping drug given to mother indirectly reaches infant through breast milk.

Paripatha [Cyclea peltata (Lam.) J. Hooker and Thoms.], a well-known substitute of Patha (Cissampelos pareira Linn.), is the main ingredient of Paripathadi kadha. For Stanya shodhana, Patha is the drug of choice.[22],[23] Clinical studies suggested potent antipyretic and analgesic action of Patha,[24] hence Paripathadi kadha was selected. Drug content of Paripathadi kadha has Tikta-katu rasa, Sheeta virya, and Katu vipaka which attributes toward its Pitta-rakta shamaka, Dahahara, Shothahara, Kushthahara, Krimighna, and Kandughna property.[25] Mahatikta ghrita was prescribed due to its Pitta shamaka guna and superior Kusthaghna property mentioned in the classical text.[26] The Vranaropaka property of Jatyadi taila is well documented.[27] Most of the ingredients of Jatyadi taila have Shothahara, Vedanasthapaka, and Ropana properties. Hence, for Vrana ropana purpose and to avoid secondary infections, Jatyadi taila was prescribed. Rasonta is a yellowish semisolid extract obtained by processing the decoction of Daruharidra (Berberis aristata DC.) with milk. Due to its Katu tikta rasa, Ushna virya and Chedana (~scrapping) Karma and Vranadoshahara quality, it heals chronic wounds, pacify swelling, and itching.[28]


  Conclusion Top


Clinical manifestation of bullous pemphigoid has close resemblance with Visphota and can be successfully managed with line of treatment of Visphota. The adopted treatment helped in significant regression in the short span of time with no signs of relapse proved Ayurvedic potential to address such autoimmune bullous disorders. As compared to contemporary management (corticosteroids, antibiotics, and antihistamines), the above treatment is cost effective, free from side effects and purely based on the principles of Ayurveda.

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Di Zenzo G, Della Torre R, Zambruno G, Borradori L. Bullous pemphigoid: From the clinic to the bench. Clin Dermatol 2012;30:3-16.  Back to cited text no. 8
    
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Ingen-Housz-Oro S, Plée J, Belmondo T, Maizières M, Pham BN, Hüe S, et al. Positive direct immunofluorescence is of better value than ELISA-BP180 and ELISA-BP230 values for the prediction of relapse after treatment cessation in bullous pemphigoid: A retrospective study of 97 patients. Dermatology 2015;231:50-5.  Back to cited text no. 10
    
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  [Full text]  
13.
Upadhyaya YN, editor. Madhava Nidana of Madhavakara, Visphota Nidana. Part 2, Ch. 53., Ver. 3. Varanasi: Chaukhamba Prakashan; 2014. p. 214.  Back to cited text no. 13
    
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16.
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18.
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20.
Acharya JT, editor. Charaka Samhita of Charaka, Chikitsa Sthana. Ch. 30., Ver. 236. Varanasi: Chaukhambha Orientalia; 2014. p. 644.  Back to cited text no. 20
    
21.
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22.
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23.
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24.
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25.
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27.
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28.
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Introduction
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