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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 5  |  Issue : 3  |  Page : 102-107

Ayurvedic management of recurrent pesticide-induced bilateral palmar contact dermatitis: A case report


1 Department of Agada Tantra Evum Vyavhara Ayurveda, Babe ke Ayurvedic Medical College, Daudhar, Punjab, India
2 Sushrutha Ayurvedic Medical College and Hospital, Bengaluru, Karnataka, India

Date of Submission09-Dec-2021
Date of Acceptance27-Aug-2022
Date of Web Publication03-Oct-2022

Correspondence Address:
Dr. Swathi Sharma
Department of Agada Tantra Evum Vyavhara Ayurveda, Sushrutha Ayurvedic Medical College and Hospital, Bengaluru - 560 105, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jacr.jacr_105_21

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  Abstract 


Allergic responses are found a major reason for occupational contact dermatitis and have a prevalence of 30% of reported cases. Those exposed to pesticide spraying have been more prevalent of being affected with occupational contact dermatitis. A 46-year-old female, working in agriculture fields, presented to the hospital with chief complaints of intense fissuring, painful cuts, scaly, and itchy lesions affected over the palms of both hands and sides of fingers for the four months. She frequently come across the pesticides while mixing them, spraying on crops, sowing pesticide-preserved seeds, and harvesting previously treated crops that recurred every season mainly during the rainy season. The present case of palmar dermatitis was treated with the principles of Gara visha chikitsa. The major symptoms such as Kandu (~itching), Twak paka (~inflammation), Vedana (~pain), Sphutana (~cracking of skin), and Rukshata (~roughness) were reduced within 20 days of treatment; major lesions healed within one month of treatment. After 90 days, lesions were completely healed, and no fresh symptoms were noticed even during the follow-up period of one month. The present observation and approach endorse a step toward the practice of Ayurvedic intervention in pesticide-induced hand dermatitis.

Keywords: Eczema, Gara visha, Irritant contact dermatitis, Kustha, Vipadika


How to cite this article:
Dhaliya R, Sharma S, Babu H. Ayurvedic management of recurrent pesticide-induced bilateral palmar contact dermatitis: A case report. J Ayurveda Case Rep 2022;5:102-7

How to cite this URL:
Dhaliya R, Sharma S, Babu H. Ayurvedic management of recurrent pesticide-induced bilateral palmar contact dermatitis: A case report. J Ayurveda Case Rep [serial online] 2022 [cited 2022 Dec 9];5:102-7. Available from: http://www.ayucare.org/text.asp?2022/5/3/102/357790




  Introduction Top


Occupational contact dermatitis creates up to 30% of reported occupational diseases. Irritants cause as much as 80% of cases of contact dermatitis. Irritant contact dermatitis manifests with exposure to chemical or physical substances that are capable of damaging the skin directly. Pesticides are perhaps underreported as a cause of occupational dermatitis. The exact prevalence of pesticide dermatitis in India is not known, but 26.7%–36.6% of farmers with dermatitis had a positive pesticide patch test.[1],[2] Workers of agricultural fields are exposed to pesticides while mixing the pesticides, spraying crops, sowing pesticide-preserved seeds, and harvesting of previously treated crops. Contact dermatitis is an eczematous symptom occurring as an outcome of skin exposure to an irritant or sensitizing agent. Contact dermatitis is generally categorized as allergic and irritant contact dermatitis. Allergic contact dermatitis is an immune-mediated inflammatory reaction, while irritant contact dermatitis is a nonallergic inflammatory reaction causing direct cell damage, resulting in skin dryness, redness, or even burns.[3]

National data and reporting systems are usually incomplete because of underdiagnosis and underreporting of occupational contact dermatitis, and it has been estimated that the incidence of occupational skin diseases, mainly pesticide-induced, is being grossly underestimated and mild cases are not included or unreported even. The prognosis of occupational contact dermatitis is often poor. Changes in work practice or occupation favor the prognosis, but many patients continue to have skin problems, especially hand eczema.

In Ayurvedic literature, all skin disorders come under one umbrella called “Kustha,” and different symptoms have been explained under the Dooshi and Gara visha lakshana.[4] Gara visha (~acute toxicity) comes to be such context. Various methods through which combinations of substances or chemicals can be administered to generate poisonous symptoms have been explained here. Pani visha (~hand wear poisons), Paduka visha (~footwear poisons), Abhyanga visha (~poisonous applications), and Abharana visha (toxic ornaments), etc., lead to dermatitis-like conditions. In the present case, pesticide-induced contact hand dermatitis has been diagnosed in Ayurvedic terms as Gara janya twak roga (~artificial poison-induced skin disease), and the principle management was followed as per Kustha chikitsa and Visha chikitsa simultaneously to manage the condition.


  Patient Information Top


A 46-year-old female, nondiabetic, nonhypertensive presented to the hospital on September 10, 2019, with a four month history of intense fissuring, painful cuts, scaly, and itchy lesions affected over the palms of both hands and sides of fingers [Figure 1]. She had a history of exposure to pesticides while mixing the pesticide, spraying crops, sowing pesticide-preserved seeds, and harvesting previously treated crops. Further inquiry revealed a history of self-treatment (with unidentified liquid) to clean her wound for one week and did not seek any medical advice before the current visit. She had similar skin presentations previously that reduce when she neither had exposure to pesticides nor use of topical ointments. This complaint recurred every season mainly during the rainy season, irrespective of exposure to chemicals or pesticides.
Figure 1: Intensely fissuring, cuts, scaly, and itchy lesions affected over palms of both hands

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  Clinical Findings Top


The patient presented with Agni mandya (~low digestive fire) and Ajeerna (~indigestion) along with the chief complaints mentioned above. She has no history of diabetes mellitus, hypertension, and hypothyroidism or any other major medical or surgical history. Family history was taken, and no other members had similar complaints. The patient was under extreme stress due to cosmetic considerations and hindrance in routine work because of the symptoms.


  Diagnostic Focus and Assessment Top


Onset was seen gradually after exposure to pesticides and agriculture work. Clinical signs and symptoms such as severe Kandu (~itching), Vedana (~pain), Twak paka (~inflammation, erythema), Sphutana (~cracking of skin), Kharatva (~roughness), Stabdhata (~stiffness), and Rukshta (~dryness) in both palms were present. Dryness and cracks at the tips of fingers were observed. It is suggested that pesticide patch test should be done for all pesticide-induced contact dermatitis workers; however, as the patient had a strong history of daily use and her poor economic status, it was not done. General examination revealed normal physiological findings [Table 1].
Table 1: General examination

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Pathya and Apathya (~wholesome and unwholesome)

The patient was advised to follow a strict Pathya and Apathya (~wholesome and unwholesome diet) such as light food as Khichadi, eating more of Mudga (~Green gram dal), Karela (Mimordica charantia L.), curry leaves, Patola (Trichosanthes dioica Roxb.), and lukewarm water for drinking.

The patient was advised to avoid milk, meat, Virudha ahara (~incompatible food items), Adhyashana (~over eating), Vidahi food (~which causes burning such as pickles and chilies), and Abhishyandi ahara such as curd, banana, cold water, avoidance of day sleep, Ati amla rasa (~sour food items), and sauces. Soaps and detergents along with other chemicals were also advised to be avoided as they were causing irritation to the patient. The patient was advised to wear gloves during the use of any detergents or chemicals during household work.


  Timelines and therapeutic intervention Top
]

A detailed timeline of therapeutic intervention undertaken is provided in [Table 2].
Table 2: Timelines and therapeutic intervention

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  Follow-up and outcomes Top


The major symptoms such as Kandu, Twak paka, Vedana, Sphutana (~cracking of skin), and Rukshata (~roughness) were reduced within 20 days of treatment. Cracks and fissuring were healed by considerably, and no fresh cracks were noticed on the second and third visits [Figure 2] and [Figure 3]. After 90 days of treatment, lesions were completely healed, and no fresh symptoms were noticed during the follow-up period of one month [Figure 4].
Figure 2: Reduced symptoms after a month

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Figure 3: After two months

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Figure 4: After treatment

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  Discussion Top


Allergic responses are found as a major reason for occupational contact dermatitis and have a prevalence of 30% of reported diseases. Those exposed to pesticide spraying have been more prevalent of being affected by this condition. Irritant contact dermatitis is a condition that occurs when chemicals or physical agents damage the surface of the skin faster than the skin can repair the damage. Irritant substances remove oils and moisture (natural moisturizing factor) from its outer layer, allowing the chemical irritants to penetrate more deeply and cause further damage by triggering inflammation. Pesticides frequently identified in causing contact dermatitis are dithiocarbamates, propargite, benomyl, sulfur, captan, chlorothalonil, pyrethroids, and chlorophenoxy and organophosphorus compounds.[5] Females are more commonly affected than males (2:1) possibly because of increased exposure to wet work in house and household chemicals.[6]

Irritant contact dermatitis is found to be a cause of hand eczema in half of the cases, whereas acute contact dermatitis comprised 15% of cases.[6] Due to the high incidence and prevalence of this pathology, it has enormous socioeconomic consequences and a massive impact on patients' quality of life. Contact with pesticides may occur during sowing of previously sprayed crops or during spraying itself, especially when protective measures are not adequately followed. Sweating and the use of leaky spray equipment are additional risk factors. The present case was due to chronic exposure to agricultural chemicals, which was limited to hands only because of direct contact.

No universally accepted test exists for diagnosing irritant contact dermatitis. It is often diagnosed by excluding other types of dermatitis because of the clinical similarity between acute contact dermatitis & irritant contact dermatitis. It is important that patients undergo patch testing, which is positive in the former and negative in the latter.[1] In the present case, patch test was difficult to perform because of the poor economic condition of the patient.

Topical corticosteroids are the mainstay of acute contact dermatitis therapy; however, their use in irritant contact dermatitis is controversial. For mild or moderate localized dermatitis, topical corticosteroids are advised and are usually effective. However, frequent and prolonged use of topical corticosteroids in fold areas can cause atrophy, telangiectasia, or striae, and their use on the face can also cause steroid rosacea.[7] It has been noted that long-term use of topical steroids can enhance the production of the stratum corneum chymotryptic enzymes, which impairs the epidermal barrier function.[8] However, adverse effects profile of systemic steroids limit long-term use. Hence, it is necessary to come up with a steroid-sparing agent and natural products that provide a good response in the acute stage of the disease and have less rate of recurrence.

In the present case, the patient presented with skin lesions that were due to chronic exposure to agricultural chemicals limited to hands only. She complains of recurrence of skin lesions when there is a stoppage of the application of medicine. Considering this, the present case is much evident under Gara visha and presentation is being similar to Vipadika; hence, treatment was done under the principles of Gara visha and Vipadika Kustha.

Ayurveda broadly explains major skin disorders under one umbrella called “Kustha.” Kustha is a disease that causes deride or disgraceful situations.[9] Basically, in all Kustha roga, there is vitiation of Tridosha (~three humors), Twak (~skin), Rakta (~blood), Mamsa (~muscles), and Lasika (~lymph).[10] The main symptoms of Vipadika are cracks in the palms and soles, with severe pain[11] and others such as itching, inflammation, and eruptions.[12] Dark streaks, rough feel, itching, painfulness, cracking, and ulceration of skin look similar to Vipadika type of Kustha.[4],[13]

Pesticide is identical to Visha (~poison) that possesses properties such as Tikshna (~sharp), Ushna (~hot), and Ruksha (~dry) because of which it produces toxic symptoms such as redness of skin, blisters on the skin, and itching. Gara visha when introduced in the body either externally or internally results in various conditions based on the route of its application. When Visha applied externally to Pada (~feet), Pani (~hand), or Abharana (~ornaments) comes in contact with skin, the deeper layers may result in acute or chronic skin conditions similar to contact dermatitis. The present chemical-induced skin manifestations can be understood under Gara visha adhisthana[14] (~modes of poisoning) where Pani visha and Abhyanga visha seem to be correlated with modern diagnosis as “contact dermatitis.” The present case has been diagnosed as “Gara visha janya twak roga,” and hence, Gara visha chikitsa principles help in most of the Twak vikaras.[15] Thus, the principle management was followed as per Vata kapha kustha chikitsa and Gara visha chikitsa where Visha hara drugs were utilized simultaneously.

Such Visha when comes in contact with skin and deeper layers may result in acute or chronic skin conditions similar to contact dermatitis. The drugs were selected having Vata and Kapha hara, Snigdha guna (~unuctuous), Sheeta veerya (~cold potency), Tikta rasa (~bitter taste), Katu rasa (~spicy properties), Kushthaghna (~curing skin diseases), Krimihara (~relieves worm infestation), along with Kandughna (~anti-itching), Deepana (~assimilative), Pachana (~carminative), Rakta shodhaka (~blood purifier), Shotha hara (~anti-inflammatory), Vrana shodhana (~wound cleansing), Vrana ropana (~wound healing), Vata anulomana, Mala shodhana (~relieves constipation), and Pitta rechaka (~removes excess Pitta) properties[16],[17],[18],[19],[20] [Table 3]. The choice of formulations was also based on primarily having Visha haram (~antitoxic properties). No adverse drug reaction was noticed during the course of treatment.
Table 3: Rationale use of given medicine

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Ghrita (~clarified butter) is said to have the property of Visha hara (~antitoxic). The Rasa, Guna, and Veerya (~pharmacological properties) of Ghrita are opposite to Visha.[21] Mahatiktaka ghrita (~medicated ghee) is indicated in all kinds of Kustha, primarily in Vataja.[22] Visha hara karma (~antitoxic) medicated ghee allows nutrition to reach skin by improving the property of Rasa dhatu. Hence, Shamana sneha (~internal medicated ghee) with Mahatiktaka ghrita is found to be beneficial in the present case.

Topical application

Chandana (~Santalum album L.) Lepa with water was advised for 10 days which is Kandu hara, Sheeta, and Visha hara. External application of Nalpamaradi oil relieves Kandu, Kharatva, Stabdhata, and Ruksha. In the second stage, Mahatiktaka ghrita application was advised to pacify Twak paka (~inflammation), Sphutana (~cracking of skin), Kharatva (~roughness), and Ruksha (~dryness). Altered barrier function after disruption of stratum corneum in the feature in most of the cases, thus causing transepidermal water loss.[23] Mahatiktaka ghrita acts as moisturizers, which believed to increase hydration or prevent transepidermal water loss, thereby maintaining skin barrier function and also reducing further risk of contact dermatitis. Ghrita application improves the normal functioning of skin and helps subside Sthanika rukshata (~local dryness), Twak paka, Kharata, and Sphutana caused due to vitiated Vata and Pitta doshas by its virtue of Snigdha and Sheeta guna. Ghrita also has the property of Sandhana karma.

Precautions

Identification and elimination of the irritant or allergen and protection from further exposure are important in managing contact dermatitis of all causes and types. Patients must be educated about potential sources of exposure and cross-reacting allergens and irritants, and they must be provided with lists of potential irritants that can exaggerate the cause.

In the case of hand dermatitis, the patient must include protective measures as well as the use of topical lubrication. The use of vinyl gloves with cotton liners to avoid the accumulation of moisture that often occurs during activities involving exposure to household or other irritants and foods (e.g., peeling or chopping fruits or vegetables) may be helpful. Administrative measures include education and training regarding specific job hazards. Environmental measures include eliminating hazardous materials, or finding substitutes for them is equally important.


  Conclusion Top


Pesticides are a common cause of occupational skin disease in farm workers. The present observation and approach endorse a step toward the practice of Ayurvedic intervention in pesticide-induced dermatitis. The conventional medicines being used by the patient were withdrawn before the start of Ayurvedic interventions. Protective measures along with the stand-alone use of topical medicines, such as Mahatiktaka ghrita and other internal medicines, give a better outcome in such conditions, where avoidance of external exposure is impossible.

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Verma G, Sharma NL, Shanker V, Mahajan VK, Tegta GR. Pesticide contact dermatitis in fruit and vegetable farmers of Himachal Pradesh (India). Contact Dermatitis 2007;57:316-20.  Back to cited text no. 1
    
2.
Sharma VK, Kaur S. Contact sensitization by pesticides in farmers. Contact Dermatitis 1990;23:77-80.  Back to cited text no. 2
    
3.
Rycroft RJ, Menn ET, Frosch PJ, Lepoittevin JP, editors. Epidemiology, Textbook of Contact Dermatitis. 3rd ed. Germany: Springer; 2001. p. 189-314.  Back to cited text no. 3
    
4.
Acharya YT, editor. Commentary by Chakrapani on Charaka Samhita of Agnivesha. Chikitsa Sthana. Ch. 7, Ver. 29. Varanasi: Choukhambha Orientalia; Reprint 2009. p. 451.  Back to cited text no. 4
    
5.
Verma G, Sharma NL, Shanker V, Mahajan VK, Tegta GR. Pesticide Contact Dermatitis in Fruit and Vegetable Farmers of Himachal Pradesh (India). Contact Dermatitis 57.5 (2007): 316–320.https://doi.org/10.1111/j.1600-0536.2007.01229.x.  Back to cited text no. 5
    
6.
Meding B, Swanbeck G. Consequences of having hand eczema. Contact Dermatitis 1990;23:6-14.  Back to cited text no. 6
    
7.
Coondoo A, Phiske M, Verma S, Lahiri K. Side-effects of topical steroids: A long overdue revisit. Indian Dermatol Online J 2014;5:416-25.  Back to cited text no. 7
  [Full text]  
8.
Lantinga H, Nater JP, Coenraads PJ. Prevalence, incidence and course of eczema on the hands and forearms in a sample of the general population. Contact Dermatitis 1984;10:135-9.  Back to cited text no. 8
    
9.
Bissonnette R, Diepgen TL, Elsner P, English J, Graham-Brown R, Homey B, et al. Redefining treatment options in chronic hand eczema (CHE). J Eur Acad Dermatol Venereol 2010;24 Suppl 3:1-20.  Back to cited text no. 9
    
10.
Bahadur RR, editor. Shadpakalpadruma. Part 2. 3rd ed. Varanasi: Choukhambha Sanskrit Granthamala; 1827. p. 61.  Back to cited text no. 10
    
11.
Acharya YT, editor. Commentary by Chakrapani on Charaka Samhita of Agnivesha. Nidana Sthana. Ch. 5, Ver. 3. Varanasi: Choukhambha Orientalia; Reprint 2009.  Back to cited text no. 11
    
12.
Acharya YT, editor. Commentary by Chakrapani on Charaka Samhita of Agnivesha. Chikitsa Sthana. Ch. 7, Ver. 22. Varanasi: Choukhambha Orientalia; Reprint 2009. p. 451.  Back to cited text no. 12
    
13.
Sundara S, editor. Astanga Hridaya of Vagbhata. Nidana Sthana. Ch. 14, Ver. 23. Varanasi: Krishnadas Academy; 1995. p. 526.  Back to cited text no. 13
    
14.
Acharya JT, editor. Commentary of Sri Dalhana and Chandrikapanjika of Sri Gayadasa Acharya on Sushruta Samhita of Sushruta; Nibandha Sangraha, Kalpa Sthana. Ch. 1, Ver. 25. Varanasi: Chaukamba Sanskrit Sansthan; 2015.  Back to cited text no. 14
    
15.
Maheshwari BH, Saswihalli SB. A literary review on Kritrima Visha Janya Twak Vikara. J Ayurveda Integr Med Sci 2020;4:378-81.  Back to cited text no. 15
    
16.
Murthy SK, editor. Ashtanga Hrudayam, Sutra Sthana. Ch. 15, Ver. 17. Varanasi: Chowkambha Press; Reprint 2007. p. 202.  Back to cited text no. 16
    
17.
Mishra SN, editor. Siddhiprada Hindi Commentary of Kaviraj Govind Das Sen on Bhaishajya Ratnavali, Vataraktadhikar. Varanasi: Chaukhamba Surbharati Prakashan; Reprint 2021. p. 582.  Back to cited text no. 17
    
18.
Murthy KR, editor. Astanga Hridaya of Vagbhata, Uttara Sthana. 6th ed., Ch. 35, Ver. 38. Varanasi: Chaukhamba Krishnadas Academy; 2012. p. 334.  Back to cited text no. 18
    
19.
Bramhanand Tripathi, editor, jiwanprada Hindi Commentary of Sharangdhara Samhita, Madhyam Khand. Ch. 9, Ver. 45 50. Varanasi: Chaukhamba Orientallia; Reprint 2007. p. 221.  Back to cited text no. 19
    
20.
Bhisagacharya HP, editor. Commentary Arunadatta and Hemadri on Ashtanga Hridayam, Uttarsthana. Ch. 28, Ver. 42. Varanasi: Chaukhambha Orientalia; 2005. p. 880.  Back to cited text no. 20
    
21.
Sundara S, editor. Astanga Hridaya of Vagbhata. Varanasi: Krishnadas Academy; 1995.  Back to cited text no. 21
    
22.
Shastry D, editor. Tattvadeepika Hindi Commentary of Durgadatta Shastry on Sharangadhara Samhita. Madhyama Khanda. Ch. 9, Ver. 45-50. Varanasi: Chaukhambha Vidhyabhavan; Reprint 2002. p. 36.  Back to cited text no. 22
    
23.
Harding CR. The stratum corneum: Structure and function in health and disease. Dermatol Ther 2004;17 Suppl 1:6-15.  Back to cited text no. 23
    


    Figures

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

  [Table 1], [Table 2], [Table 3]



 

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