|Year : 2021 | Volume
| Issue : 3 | Page : 90-94
Management of Herpes Zoster (Visarpa) through Ayurvedic approach: A case report
Department of Indian Systems of Medicine, Government ISM Dispensary, Kadmal, Union Territory of Jammu and Kashmir, India
|Date of Submission||12-Feb-2021|
|Date of Acceptance||30-Sep-2021|
|Date of Web Publication||14-Dec-2021|
Dr. Arun Gupta
House No. 161, Bharat Nagar, Near J and K Bank, Rehari Colony, Jammu, Union Territory of Jammu and Kashmir
Source of Support: None, Conflict of Interest: None
Herpes zoster is a viral skin infection though uncommon in childhood can be caused by the reactivation of the varicella zoster virus due to lower immunity. This clinical entity can be compared with Visarpa (~vesicular or bullous eruptions). Visarpa is a clinical syndrome in which vitiated Vata-Pitta dosha along with vitiated Rakta (~blood plasma) cause progressive skin lesions, which are painful and look like scalds or burns, and require Pitta allaying internal and local treatment. An 8-year-old female child presented along with her father with the vesicular lesions on her left cheek associated with mild fever, itching, and pain on the local lesion. She was administered with 125 mg of Kamadudha rasa (plain) thrice a day before meals with milk and Pinda taila for local application on the facial lesions. The patient reported on the 5th day with significant relief in the size and shape of the facial lesions and other symptoms. The scars limited to minimal without any inflammatory signs by the 7th day of follow-up. Kamadudha rasa and Pinda taila are two readily available and cost-effective compound ayurvedic formulations, which can be used in the management of herpes zoster infection, especially in low-resource settings.
Keywords: Herpes zoster, Kamadudha rasa, Pinda taila, Visarpa
|How to cite this article:|
Gupta A. Management of Herpes Zoster (Visarpa) through Ayurvedic approach: A case report. J Ayurveda Case Rep 2021;4:90-4
| Introduction|| |
Herpes zoster, commonly known as shingles and primary varicella, is a viral skin disease of childhood. It is characterized by appearance of grouped vesicles in dermatomal patterns, which are associated with burning sensation and pain along the affected dermatome. On the basis of its characteristics, it resembles clinical picture of Agneya visarpa (~scald-like progressive vesiculobullous eruptions). Charaka samhita attributed Vata pitta vitiation (~endogenous dynamic and heat elements) to the eruption of scald-like Visphota (~vesicular lesions). Sushruta samhita classified Visarpa as a Kshudra kushtha (~minor skin ailments) caused by the vitiation of Twacha Dhatu (~integumentary tissue) and Rakta and Mamsa Dhatu (~fascio-muscular tissue), which make it rapidly progressive inflammation causing local and general symptoms. Acharya Vagbhata referred to Vata pitta-predominant Visarpa as painful, fast-moving Visphota like vesiculobullous lesions. Visphota is also defined as skin lesions of Nija Vrana (~endogenous lesions) caused by the Pitta predominance, characterized by burning sensation, pain, and bullous morphology. The main stay of treatment is to allay Pitta dosha (~vitiated fire element) through eliminatory therapies or by using Pitta-pacifying drugs. Acharya Sushruta also recommended Ropana karma (~promotion of wound healing) on the Pitta- and Rakta-predominant lesions. I In the context of Visphota, Ropana karma (~healing) is also indicated. Current clinical evidence demonstrate that skin ailments are common childhood maladies and almost 30% pediatrician visit involve skin issues. Herpes zoster is one of the blistering disorder or vesiculo-bullous disease of infective origin which prompt a health care facility visit. In hard to reach areas where these Ayush institutions are usually located, appropriate drugs are not readily available. Treatment of such skin lesions especially in a pediatric patient become a challenge due to lower pharmaceutics resources and special clinical considerations. Therefore it requires a rational approach of choice of drugs based on the principles of Ayurveda. In these circumstances, physician has to make a rational choice by clinically applying the fundamentals of Ayurveda. The case report demonstrates the efficacy and safety of two cost-effective remedies, which are available in the Government medicine supply in public Ayush institutions of Jammu and Kashmir. These drugs were found to be effective in the management of a Pitta-predominant disorder called Visarpa clinically identified as herpes zoster.
| Patient Information|| |
An 8-year-old girl presented to Government Ayurvedic Dispensary with her father having vesicular eruptions on the left cheek with itching, pain, burning sensation, and fever. According to the father of the patient, she was apparently alright three days back and noticed strange pain on the left cheek and ear, itching, and a small boil on the left cheek, on which they applied mustard oil. The redness on the cheek reportedly increased with cluster of similar eruptions. On the night preceding to her visit to AYUSH dispensary, she also developed fever with chills. The patient denied any complaints of stinging sensation. No history of such lesions in the past, prolonged illness, recurrent febrile illnesses, indigestion, delayed milestones, or any other symptoms significant to childhood was reported. Medical history, surgical history, and drug history were unremarkable. The patient is the third child in the family delivered per vaginally at home. There was no history of congenital skin lesions or eruptions. Childhood also remained uneventful. Vaccination history was also not clear. No history of any allergic disorders was noted. No such incidence of similar lesions in the family members and community living in the camp was noticed.
| Clinical Findings|| |
On examination, the face looked flushed possibly due to local inflammation associated with conjunctival congestion. On the local examination, 8.5 cm long and 4 cm wide patch of tense vesicular/fluid filled lesions were apparently seen on the left cheek [Figure 1]. Throat showed mild congestion with mild tonsillar inflammation. No preaural or auricular extensions were noted. No lymph nodes were palpable. Auscultation revealed no adventitious breath, heart, and bowel sounds. On the basis of the above clinical manifestation, a treatment plan based on the principles of Pitta shamana, Rakta pitta hara (~pacification of vitiated Pitta and Rakta), and Vrana Ropana (~wound healing) medicines through external application and internal administration along with dietary and life style counseling was planned.
Ashtavidha pariksha (~eight-fold examination)
Guru (~heaviness) with Teevra gati (~increased rate) was noted, Mala-mutra were normal, Jihva (~tongue) was coated, Sparsha (~touch) was warm, Drik (~eyes) was normal with conjunctival congestion, and Akruti was Visphot opchit twacha of Vama kapola with facial flushing (~bullous vesicular eruptions on left cheek).
| Diagnostic Assessment|| |
On the 1st day, temperature was 99.5°F, heart rate was 96 beats per minute while respiratory rate was 16 breaths per minute. The intensity of pain was recorded on a pictorial Visual Analog Scale (VAS) which was 7. On local examination, the patient had 6.5 cm long and 4 cm wide area of multiple vesicular fluid-filled lesions [Figure 1].
| Timeline|| |
A detailed systemic and local examination was carried out on alternate days for one week. Timeline of the events are depicted in [Table 1].
| Therapeutic Focus and Assessment|| |
On the basis of the clinical manifestation of the lesions, the patient was prescribed 125 mg of Kamadudha rasa (plain) thrice a day with milk, before meals, for seven days. Pinda taila (four times a day) was prescribed for topical application. The patient's father was also counseled about the life style changes. The patient was advised to take milk, ghee, sweet (Madhura rasa pradhana) diet, and Masura yusha (red lentils soup) and instructed to maintain local hygiene. The patient was advised to abstain from soap application on the lesion, exposure to high temperature, accumulation of dust and dirt, and consumption of yogurt, pickles, salted snacks, chutneys, spice, and sour fruits.
| Follow-up and Outcome|| |
The patient was followed up on the 3rd and 5th day during the course of treatment. On day three, the patient was afebrile, vitals were normal, and crusting was noted on some vesicles. On VAS, the pain score was 3. The patient was re-examined for the effect of therapy on the 5th day, where temperature was noted to be normal, heart rate was 84 beats per minute, and respiratory rate was 15 breaths per minute. VAS grading was reduced to 2. On local examination, the length of the lesion was reduced to 4 cm long and 2 cm wide with evidence of crusting and desquamation of the lesion. Number of vesicles also reduced considerably [Figure 2]. The inflammation of tonsils and congestion in the oral cavity also subsided. The patient was again telephonically followed up on 7th day and reportedly had no vesicular lesions; all the complaints of pain and itching subsided by then. On 15th day, the patient was followed up for any residual lesions or symptoms and was found to be free from any residual symptoms [Figure 3]. During her course, the patient never reported any adverse effect of the medication.
| Discussion|| |
Kamadudha rasa is one of the most commonly prescribed herbomineral compound preparations for the management of the Pitta-predominant disorders. Kamadudha rasa contains Amalaki swarasa (~fresh juice of fruits of Phyllanthus emblica Linn.), Guduchi satva [~starchy extract of Tinospora cordifolia (Thunb.) Miers], and Swarna gairika (processed hematite, Fe2O3) treated with cow's ghee. On the basis of its composition, Kamadudha rasa is a safe Kharaliya rasayana (~compound medicinal preparation made in pestle and mortar). Kamadudha rasa is a widely used Ayurveda formulation for the management of Pitta vikriti. A variety of hydrolysable tannins present in Amalaki have demonstrated its antimicrobial, anti-inflammatory, and immune-regulating activities in In vitro and in animal studies. An in vitro study demonstrated the free radical scavenging activities of Amla extract for the cellular defense which explains its antimicrobial and antiviral activities. Phytoconstituents such as saponins, alkaloids, phytosterols, and triterpeoids present in Guduchi extract demonstrate virucidal effects and explain its antiherpetic properties. Swarna gairika is clinically reported as metabolism modulator and antioxidant and can act as an iron supplement. Hence, Kamadudha rasa by virtue of its versatile pharmacological effects, i.e., immunomodulator, antioxidant, and antiviral effects, can be used internally in the management of herpes zoster infection, especially in children. In addition to this, Kamadudha rasa owing to its Pitta hara properties also helps in controlling the systemic effects such as fever, malaise, and pain in the patients.
Pinda taila is a classical medicated oil preparation highly recommended for external application, especially in pain associated with Rakta disorders. It is made up of Tila taila (oil of Sesamum indicum L.) processed with the water extracts of Manjistha (Rubia cordifolia L.), Sariva (Hemidesmus indicus L.), Sarjarasa (gum resin of Vateria indica L.), and Madhuchishta (bee wax). Anthraquinones and tannins present in Manjistha roots show wound-healing action. Phytoconstituents present in Manjistha roots cause increased cellular proliferation, improved tissue regeneration and granular tissue formation, and epithelialization by attracting inflammatory cells to the site of wounds, thereby leading to dermal and epidermal healing. Sariva root extract has established antiviral activities against herpes viruses, which by reducing the infectivity of viral progeny and by preventing the virus attachment to the host cell surface. Aromatic aldehydes, and their derivatives, phenolics, triterpenoids, and many other compounds, present in root extracts of Sariva have been attributed to antiulcerogenic, anti-inflammatory, antioxidant, and antimicrobial properties. Due to the presence of various alkaloids, flavonoids, phenol, tannins, steroids, glycosides, saponins, and diterpenes in the aqueous extract of Sarjarasa, it exerts anti-inflammatory effects by affecting on albumin denaturation, proteinase activity, and stabilization of the red blood cells membrane.
Madhuchishta (bee wax) is in use since ages in the dermatological disorders and wound healing. Aliphatic alcohols purified from bee wax have demonstrable anti-inflammatory and analgesic activities. In combination with other substances, bee wax shows a synergistic effect and prevents secondary infection of the wound. In the available scientific literature there is a great paucity of the clinical evidence favoring use of Pinda taila in viral skin infections like herpes zoster, yet on the basis of its composition which comprise of herbs demonstrating anti-inflammatory and wound healing properties Pinda taila can be used for quick healing of the skin lesions caused by Herpes zoster infection and prevents the secondary infection of the scald like lesions of shingles. There is also a great dearth of studies, which show effects of individual constituents of Pinda taila in the management of bullovesicular skin lesions or herpetic lesions. During the study period, the patient did not demonstrate any untoward effect to the drugs used in the treatment which vouch for the safety. It is also pertinent to know that there are no pharmacovigilance reports, demonstrating any adverse effect of these two preparations in pediatric population.
| Conclusion|| |
Ayurveda always encourage the rational use of medicine by the physician. Versatility of action of ayurvedic compounds also helps in reducing the cost of treatment, and synergy of action of the chemical entities present in these compounds also contributes in reducing healing time. In the low resource clinical settings, these two compound preparations, which are readily available, cost effective and apparently safe for use in pediatric patients. These compound pharmaceutical preparations are easy to administer in pediatric patients as one preparation is a palatable pill and other is a topical preparation, patients show high compliance yielding good clinical results. Thus, Kamadudha rasa and Pinda taila can be used to support management of skin manifestations such as herpes zoster infection (Visarpa).
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.
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