|Year : 2021 | Volume
| Issue : 3 | Page : 105-110
Ayurvedic management of Alopecia areata (Indralupta) with surgical procedure Kuttanam and internal medications: A case report
G N Sree Deepthi1, C B Roopesh Kumar2, V Krishna Kumar1, Emy S Surendran3, D Sudhakar1, R V Binitha Raj4
1 National Ayurveda Research Institute for Panchakarma, Cheruthuruthy, Thrissur, Kerala, India
2 ESIC model and Super Speciality Hospital, Asramom, Kollam, Kerala, India
3 Regional Ayurveda Research Institute for Lifestyle Related Disorders, Thiruvananthapuram, Kerala, India
4 Drug Standardization Unit, Thiruvananthapuram, Kerala, India
|Date of Submission||18-Jan-2021|
|Date of Acceptance||16-Jul-2021|
|Date of Web Publication||14-Dec-2021|
G N Sree Deepthi
National Ayurveda Research Institute for Panchakarma, Cheruthuruthy, Thrissur, Kerala
Source of Support: None, Conflict of Interest: None
Alopecia areata is an autoimmune disorder characterized by transient, nonscarring hair loss, especially on the scalp ranging from well-defined patches to diffuse or total hair loss with hair follicle preservation. It affects approximately 2% of the general population. This condition is described as Indralupta (~alopecia) in Ayurveda. The current presentation is a case report of 36-year-old female patient who visited the outpatient department with patchy hair loss of scalp over the vertex and occipital region and generalized hair loss for two years with no associated symptoms. The treatment was determined giving significance to systemic effects of disease along with localized pathology in the skin caused by the vitiation of Tridoshas (~three body humors). She was treated on outpatient level with Ayurvedic internal medications, external applications and Kuttanam (~a minor operative procedure) for four months. The uniqueness of this case is that transition of hairs from gray to black occurred over the course of a single hair follicle growth cycle. The phenomenon of natural reversal of depigmentation of hair in a single hair follicle growth cycle is not found in any of the scientific databases. The patient showed remarkable improvement including regeneration of black hair at the site of hair loss. During the follow-up period of two years, no recurrence was observed. This case report shows that holistic approach of Ayurvedic treatment can produce clinically significant results in Indralupta and shows possibility of application of these principles in repigmentation of hairs.
Keywords: Alopecia areata, Indralupta, Kuttanam
|How to cite this article:|
Deepthi G N, Kumar C B, Kumar V K, Surendran ES, Sudhakar D, Raj R V. Ayurvedic management of Alopecia areata (Indralupta) with surgical procedure Kuttanam and internal medications: A case report. J Ayurveda Case Rep 2021;4:105-10
|How to cite this URL:|
Deepthi G N, Kumar C B, Kumar V K, Surendran ES, Sudhakar D, Raj R V. Ayurvedic management of Alopecia areata (Indralupta) with surgical procedure Kuttanam and internal medications: A case report. J Ayurveda Case Rep [serial online] 2021 [cited 2022 Jan 27];4:105-10. Available from: http://www.ayucare.org/text.asp?2021/4/3/105/332436
| Introduction|| |
Alopecia areata is an autoimmune condition described clinically as transient, nonscarring hair loss on the body, especially on the scalp preserving the hair follicle. Clinical presentation of hair loss can vary from loss in well-defined patches to diffuse or total hair loss termed as alopecia totalis or alopecia universalis, which can affect all hair-bearing sites. Graying of hair is one of the major complications because of the destruction of melanocyte associated proteins., The uniqueness of this case report is that transition of gray hair to black was observed within a short time period through Ayurvedic medication, so that the hair shaft remained gray at the distal end and transition to black occurred at the proximal end. Regenerated hairs formed at the site of hairloss were also black colored. The authors were not able to find any scientific literature in which complete transition of gray hair to black over the course of a single hair follicle growth cycle could happen naturally through Ayurvedic treatment. During the follow-up period of two years, no new patch of hair loss or graying was observed. Normally alopecia has got recurrence but after Ayurvedic treatment, no recurrence was observed during the follow-up. The management of Indralupta includes topical and oral corticosteroids and immunotherapy in the modern medicine. In most patients, continued treatment is needed to maintain hair growth and the response is usually insufficient to justify the adverse effects.
Based on the clinical presentation, this condition is compared to Indralupta in Ayurveda,,, a condition in which hair loss along with arresting of new hair formation is clinically presented. Its pathophysiology, treatment, and complications including gray hair formation are precisely explained in the Ayurvedic literature. In this article, a case diagnosed with Indralupta treated successfully by the Ayurvedic management is presented.
| Patient Information|| |
A 36-year-old female having lengthy hairs, reported the Outpatient Department (OPD) with patchy hair loss over the scalp with a generalized, excessive hair fall with no associated symptoms for two years. The response was very less even after one year of conservative treatment including topical injections. The details of medications were not available with the patient. Only few hairs were regrown after allopathic medication, of which majority were gray colored along with very few blackish gray and were easily highlighted. The patch of hair loss was big and was present at the vertex; hence, it was a matter of concern to the patient. The presence of noticeable gray hair and bare scalp contributed to mental distress and out of frustration she discontinued treatment. She visited the OPD on November 30, 2018, and then two areas of patchy hair loss were identified; first one circular with a maximum diameter of 7 cm [Figure 1] over the vertex with a duration of two years and the second one over the back of the head, which was noticed few days before the visit. There was no personal history of autoimmune disorders such as vitiligo, hashimoto's thyroiditis, lupus erythematosus; major psychological disorders, or family history suggestive of any of these disorders. There was no history of drug intake for any comorbidity.
General examination revealed medium built without any significant pathological presentation. On local examination, the scalp was clear with no dandruff, itching, inflammatory signs, or scarring. Majority of hairs were gray colored with a very few grayish black hairs.
| Diagnostic Assessment|| |
Thyroid dysfunction and anemia were ruled out through blood investigations [Table 1]. Scalp color was normal with no signs of vitiligo, fungal infection, or dandruff. The patient was clinically diagnosed as a case of Indralupta.
| Therapeutic Intervention|| |
Details of medications prescribed to the patient and procedures are given in [Table 2]. Along with the medication, healthy food and lifestyle modifications were adviced such as intake of freshly prepared and easily digestible food, fresh fruits; avoidance of junk food, food additives, black gram, fried items, curd and sesame, as these can cause vitiation of Kapha, Pitta and Vata (~three body humors). Instructions to do proper physical exercise and avoidance of stress were given.
| Timeline|| |
Timeline of the case is described in [Table 3].
| Follow-up and Outcome|| |
The patient came for the follow-up visit once in a week. After two weeks of management, black spots were noticed indicating hair growth. During the course of treatment, gray hairs transformed to black and the scalp was fully covered with black hairs after four months of treatment. She was under follow-up for two years without any recurrence or any kind of unusual hair loss. After treatment, as the hair shaft length increased, the hair remained gray at the tip and black over the proximal end.[Figure 2], [Figure 3], [Figure 4] Later, after 10 months, the entire scalp was covered with thick, healthy, and black hairs.[Figure 5] No new patch of hair loss was observed during the treatment or during the follow-up period till January 2021. No adverse effects were reported pertaining to the procedure or prescribed medication. Normally, alopecia has got recurrence but through Ayurvedic medication the recurrence was prevented.
| Discussion|| |
Indralupta is included under Kapalagata roga (~diseases of scalp) by Acharya Vagbhata and Kshudra roga (~minor ailments) by Acharya Sushruta. Currently, available treatments have its own limitations and the response rate in severe types remain low and usually insufficient to justify the adverse effects.
In the pathophysiology of Indralupta, vitiated Pitta along with Vata gets lodged at the site of Romakoopa (~hair follicles) resulting in the destruction of hairs. Later, Rakta (~blood) and Kapha causes obstruction resulting in hindering of hair growth.,, Biopsy of affected skin usually shows a lymphocytic infiltrate in and around the bulb or the lower part of the hair follicle in anagen (hair growth) phase. These lymphocytic infiltrates hindering the hair growth seems similar to the obstruction of hair follicles by Rakta and Kapha as mentioned in Ayurvedic literature. As Indralupta is an immune-mediated disease, here autoreactive cytotoxic T-cells are involved in recognizing melanocyte-associated proteins such as tyrosinase which influences melanin production. The production of melanin, which is a pigment responsible for the black color of hairs is hindered in this case as the new hairs were gray colored when the patient first visited the OPD. As per Ayurveda concepts, impaired melanin production and impairment in hair production can be compared to Dhatwagnimandya (~impaired metabolism) at Majja and Asthidhatu (~bone) level since Agni (~digestive fire) is responsible for the Dhatu (~tissue) transformation, formation of Kitta and Upadhatu (~supplimentary tissues). The main cause for Indralupta is autoimmunity, which is similar to impaired Dhatupaka avastha wherein the cells of one's body is destructed. Considering the basic pathology of disease as impaired Dhatwagni, efforts were made to correct Agni since the beginning of treatment. Ashta churna was administered to correct Jataragni which in turn might help in correcting the metabolism leading to proper functioning of Majja and Asthi.
The general treatment for Indralupta comprises Shodhana (~cleansing procedures) and Shamana (~procedures other than cleansing) therapies in which internal medicines along with Pracchana (~a type of blood-letting therapy) through which the vitiated blood is removed from the site by making peripheral cut wounds and application of Lepana (~external application of various medicinal paste).,, In addition to this, a minor procedure namely “Kuttanam” is indicated in Kesasata (~hair fall) by Ashtanga Hridaya. Here multiple pricks are made on the skin using needle (a glucometer lancet was used in this patient) to produce mild capillary bleeding which can stimulate the hair follicles resulting in hair growth. Shamana therapy was selected as it was found suitable in this case after thorough assessment of the patient.
As per the management of Indralupta mentioned in Ayurvedic literature, Siravedha (~bloodletting therapy) is described as the most important treatment followed by Avagadha (~deep), Pracchana and Lepana of Teekshna (~potent) drugs such as Kasisa (~ferrous sulphate), Manahshila (~red arsenic), Tuttha (~copper sulphate), Maricha (~Piper nigrum L.), etc.,, Pracchana indicated in localized Rakta dushti (~vitiated blood) is Avagadha prachanna followed by Lepana with Teekshna drugs. This stimulates hair follicles facilitating hair growth.
An apprehension of classical literature along with Yukti (~logic) was applied in managing this case. Accordingly the medicines, administered were Aragwathanimba kashayam,, Avipatti churna, Navayasam tablet and Ashta churna internally. Malatyadi keram, Triphala churna, turmeric powder,, Indralupta masi and Neelibhringadi keram externally. The surgical procedure “Kuttanam” was carried out at regular intervals.
These medicines were selected after analyzing the pathophysiology. It is mentioned that doshas are vitiated in Twak (~skin) and here Rakta combines with Kapha and hinders the hair growth.,, Hence, Kushtahara (~acting on skin) and Kapha hara (~pacifies Kapha) drugs along with site specific action on the skin are needed to correct this pathology. Decoction of Aragwadha (Cassia fistula L.) and Nimba (Azadirachta indica A. Juss) which can act on the skin and correct the vitiated Kapha and Rakta were selected to achieve this.
Avipatti churna was selected as it is the best medicine for correcting vitiated Pitta, which is the main pathology in this disease. Navayasam tablet was selected because of its action on the skin.
Malatyadikera, a disease-specific drug, indicated by Acharya sushruta is advised for Shiroabhyanga (~oil application on the scalp), 15 min before bath and continued for 4 weeks to correct localized Dosha vitiation. During this time, Triphala churna with turmeric and luke warm water was advised for the external application over the affected area as Lepana before bath. Triphala churna has Shoshana (~having capacity to pacify Kapha) and Rookshana (~causing dryness) property, which is required for correcting Kapha and Pitta. Later, Triphala churna alone was advised for external application as Lepana, since prolonged use of turmeric may not be suitable for hair growth due to its Teekshna nature and Ushna veerya (~hot potency). Indralupta masi is an Ayurvedic medicine which is indicated in Indralupta for external application. This was applied along with Malatyadi keram over the scalp for first four weeks. Later onwards, it was applied along with Neelibhringadi keram and was continued for three months as it helps in enhancement of hair growth and its blackening. After four weeks, Neelibhringadi keram alone was advised for Shiroabhyanga, which was advised to continue as a routine practice.
Instead of Avagadha pracchana, Kuttanam was selected as treatment as it was found suitable for the patient. Further the pain while doing Kuttanam is very mild when compared to Pracchana, since only minor pricks are made on the scalp rather than making cut wounds as in Pracchana. This was done once in a week. This procedure stimulates the hair follicles and triggers hair growth. As a postoperative procedure, suitable medicated paste is usually applied. Murivenna with turmeric powder applied in this case as it is widely practiced by physicians of Kerala. This helps in proper healing of the skin and prevents any chance of infection. Now, till January 2021 (since two years), the patient is not suffering from any kind of unusual hair loss. Further this case report is an evidence of clinical application of basic principles of Ayurveda where Agni is given prime importance and its vitiation is considered the basic cause for all the diseases.
This case is unique as the transition of gray hairs to black happened in a short duration through Ayurvedic treatment. Without any adverse effects, disease was managed with cost-effective therapy.
| Conclusion|| |
The present case of Indralupta is successfully treated with Ayurvedic medications giving emphasis to systemic effects rather than localized pathology. This case report reveals the need of holistic approach in the management of diseases, especially in autoimmune diseases where Agni is given prime importance in the management, this in turn is a peculiarity of Ayurvedic science. This case report shows the possibility of natural repigmentation of gray hair through Ayurveda treatment.
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
Conflicts of interest
There are no conflicts of interest.
| References|| |
Pratt CH, King LE Jr., Messenger AG, Christiano AM, Sundberg JP. Alopecia areata. Nat Rev Dis Primers 2017;3:17011.
Jabbari A, Cerise JE, Chen JC, Mackay-Wiggan J, Duvic M, Price V, et al.
Molecular signatures define alopecia areata subtypes and transcriptional biomarkers. EBioMedicine 2016;7:240-7.
Ito T. Recent advances in the pathogenesis of autoimmune hair loss disease alopecia areata. Clin Dev Immunol 2013;2013:348546.
Harries MJ, Sun J, Paus R, King LE Jr. Management of alopecia areata. BMJ 2010;341:c3671.
Sharma SP, editor. Commentary on Shashilekha of Indu on Ashtanga Samgraha of Vagbhata, Uttara Sthana. 1st
ed., Ch. 27., Ver. 18-19. Varanasi: Chowkhamba Sanskrit Series Office; 2006. p. 764.
Paradakara HS, editor. Ashtangahrdaya of Vagbhata, Uttara Sthana. Ch. 23., Ver. 24-25. Varanasi: Chaukhambha Orientalia; 2005. p. 859.
Acharya NR, editor. Sushruta Samhita of Sushruta, Nidana Sthana. 8th
ed., Ch. 13., Ver. 33-34. Varanasi: Chaukhambha Orientalia; 2005. p. 322.
Acharya YT, editor. Charaka Samhita of Charaka, Chikitsa Sthana. Ch. 15., Ver. 18-19. Varanasi: Chaukhambha Orientalia; Reprint 2011. p. 515.
Paradakara HS, editor. Ashtangahrdaya of Vagbhata, Chikitsa Sthana. Ch. 14., Ver. 35. Varanasi: Chaukhambha Orientalia; 2005. p. 687.
Sharma SP, editor. Commentary on Shashilekha of Indu on Ashtanga Samgraha of Vagbhata, Uttara Sthana. 1st
ed., Ch. 27., Ver. 18-19. Varanasi: Chowkhamba Sanskrit Series Office; 2006. p. 769.
Paradakara HS, editor. Ashtangahrdaya of Vagbhata, Uttara Sthana. Ch. 24., Ver. 28-30. Varanasi: Chaukhambha Orientalia; 2005. p. 862.
Acharya NR, editor. Sushruta Samhita of Sushruta, Nidana Sthana. 8th
ed., Ch. 20., Ver. 24-26. Varanasi: Chaukhambha Orientalia; 2005. p. 479.
Paradakara HS, editor. Ashtangahrdaya of Vagbhata, Sutra Sthana. Ch. 26., Ver. 22. Varanasi: Chaukhambha Orientalia; 2005. p. 320-21.
Paradakara HS, editor. Ashtangahrdaya of Vagbhata, Sutra Sthana. Ch. 26., Ver. 51-52. Varanasi: Chaukhambha Orientalia; 2005. p. 324-5.
Tara Datt Panta Shastri, editor. Charaka Samhita of Charaka, Sutra Sthana. Ch. 4., Ver. 13. Varanasi: Chowkhamba Sanskrit Series Office; 2005. p. 21.
Pandey GS, editor. Bhavaprakasha Nighantu of Sri Bhavamisra. Varanasi: Chaukhambha Bharati Academy; 1998. p. 330.
Paradakara HS, editor. Ashtangahrdaya of Vagbhata, Kalpa Sthana. Ch. 2., Ver. 21-23. Varanasi: Chaukhambha Orientalia; 2005. p. 743.
Paradakara HS, editor. Ashtangahrdaya of Vagbhata, Chikitsa Sthana. Ch. 16., Ver. 14. Varanasi: Chaukhambha Orientalia; 2005. p. 702.
Paradakara HS, editor. Ashtangahrdaya of Vagbhata, Sutra Sthana. Ch. 6., Ver. 160. Varanasi: Chaukhambha Orientalia; 2005. p. 118.
Pandey GS, editor. Bhavaprakasha Nighantu of Sri Bhavamisra, Hareetakyadi Varga. Varanasi: Chaukhambha Bharati Academy; 1998. p. 114-6.
Proprietary Medicine, D/L No. 13/25D/76 Granted on 13-07-2000. Ashtavaidyan Thrissur: Thaikat Mooss' SNA Oushadhasala Pvt Ltd; 2000.
Krishnan Vaidyar KV, Gopalapilla S. Sahasrayogam, Tailayoga. Alappuzha: Vidyarambham printers; 2006. p. 290.
Ayurveda Formulary of India, Part III. Ministry of Health and Family Welfare, Government of India. 1st
ed. Delhi: The Controller of Publications; 2011. p. 203.
Murthy SK, editor. Ashatangahridaya, Nidana Sthana. 95th
ed., Ch. 12., Ver. 1. Varanasi: Chaukhamba Krishnadas Academy; 2003. p. 15.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3]