VIRECHANA IN VITILIGO: A RAY OF HOPE.

Pretya Juyal 1 , Lalita Sharma 2 , K.K Sharma 3 , Alok Kumar Srivastava 4 and Parul Sharma 5 . 1. PG Scholar, Dept of Panchakarma, Rishikul Campus UAU, Haridwar. 2. PG Scholar, Dept of Panchakarma, Rishikul Campus UAU, Haridwar. 3. Head, Dept of Panchakarma, Rishikul Campus UAU, Haridwar. 4. Professor, Main Campus UAU, Dehradun. 5. Assistant Professor, Rishikul Campus UAU, Haridwar. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History Received: 12 July 2019 Final Accepted: 14 August 2019 Published: September 2019


Pathogenesis
The etiopathogenesis of Vitiligo is not clearly understood. The patchy loss of skin pigmentation in Vitiligo, may be due to immune attacks on melanocytes. Although there is no significant proof or evidence, many doctors believe that it can be caused by defects in many genes. Variations in genes that are part of the immune system or part of melanocytes have both been associated with Vitiligo. The immune system genes are associated with other autoimmune disorders. There are two basic mechanisms whereby the skin can become white 14 . Melanin is synthesized by melanocytes within melanosomes that are transferred into the surrounding keratinocytes. The keratinocytes transport the melanin and melanosomes from the basal layer of the epidermis to the stratum corneum where they are desquamated into the environment 15 .
There seem to be three major factors involved in the destruction of melanocytes in patients with vitiligo 16 . The first is that vitiligo patients inherit a set of three "vitiligo" genes which predisposes them to destruction of melanocytes 17 . There probably are many different sets of three genes that can cause vitiligo so that not every individual would necessarily inherit the same three. The second abnormality relates to the melanocytes themselves. Melanocytes from patients with vitiligo differ from those obtained from a person without vitiligo. For example, vitiligo melanocytes require different and more fastidious culture conditions than those from normal individuals 18 . Also, vitiligo melanocytes are much more sensitive to phenolic chemicals than normal melanocytes and readily undergo apoptosis when exposed to such agents 19 .The third factor is an environmental agent(s) that activates (or inhibits) the genes involved, thereby setting in motion the process of destruction of the susceptible melanocytes. The vitiligo genes activated (inhibited) by the environmental agents seem to cause an excessive immune reaction that induces melanocytes to undergo apoptosis 20 , and depigmentation of the skin results.

Clinical Features
It is characterized by the appearance of patchy discoloration evident in the form of typical chalky-white or milky macule(s). The size of the macules may vary from a few millimetres to several centimetres with the lesions affecting the skin or mucous membranes. Mostly, the lesions are asymptomatic and symmetrically distributed although in some patients itching or burning may precede or accompany the onset of the lesions 21 .
However, it is a slow and progressive disease but it may have remissions and exacerbations corelating with triggering factors. Although any part of the skin and / or mucous membranes is amenable to develop vitiligo, the disease has a predilection for normal hyperpigmented regions such as the face, groin, axillae, areolae and genitalia. Furthermore, the areas like the ankles, elbows, knees, which are subjected to repeated trauma / friction, may develop lesions.

Morphological variation may be there in the form of: Trichrome vitiligo:
It is recognized by the presence of a narrow to broad intermediate colour zone between a vitiligo macule and normal pigmented surrounding skin.

Quadri-chrome vitiligo:
It is a well-documented fourth colour in vitiligo lesions, usually seen in darker skin phenotypes. A macular perifollicular or marginal hyperpigmentation is its salient feature 22 .

Penta-chrome vitiligo:
black skinned individuals are more prone to have this disorder. It is an infrequently encountered variant in which there is a sequential display of white, tan, brown, blue-grey hyperpigmentation and the normal skin 23 .

Ayurvedic view
In Ayurveda majority of skin ailments are considered under Kshudra Kushtha. But as in vitiligo (Shvitra), in spite of manifestation of disease over the skin, there may be systemic involvement. It is considered different from Kushtha on the basis of some factors like "Aparisravi" (Non discharging), non-infectious, peculiarity of causative factors, prognosis, chronicity and hereditary history. Acharya Sushrut opines that Twak gata Kushtha is Kilasa, In Shvitra colour of the skin is changed to Aruna, Tamra or Shveta Varna. As per Ayurveda, it has same causative factors as kushtha i.e., leprosy. Acharya Charaka has described some special causes for vitiligo e.g. telling lie, not believing God, not apologizing someone"s good deeds, performing sins, deeds of pervious life (Poorvakarma) etc 24 . These causes point to the inheriting nature of the disease in some cases and towards mal or abnormal thinking by the brain (Pragyaaparadha) as a major cause. The different causes have been given in the science but Viruddha aahar 25 is the unique concept of Ayurveda, is attributed as one of the cause responsible for Shvitra. The Nidana under the heading of "Ahara" like excessive intake of incompatible diets, intake of mutually contradictory food, drinks which are liquid, and heavy, Transgression of the prescribed order of the intake of food may alter the GIT environment, which leads to faulty digestion, malabsorption and improper distribution of nutrients to cells. Disturbance of any of them may lead to deficiency of required nutrients, which are extremely necessary for the pathway of melanin synthesis. It is different from Leprosy (Kushtha) in the respect that it is non-contagious, non-bacterial, it doesn"t destroy body tissues, doesn"t have any discharge (Vyadhiswabhava). It is without discharge, vitiated with three doshas i.e., Vata, Pitta, Kapha doshas.
In Ayurveda, it is classified according to Dosha dominanace as Vataja, Pittaja, and Kaphaja. Vataja Shvitra is dry (ruksha) and of Red-black (arun) in colour. Pittaja is coppery or lotus-like in colour and associated with inflammation (daha) and loss of hair. Kaphaja Shvitra is hard, heavy with white coloured and associated with itching. Dushya associated with Shvitra are Rakta (blood), Mamsa (Muscle tissue) and Meda (lipid) dhatus 26 . Additionally, Charaka has named synonyms of Shvitra (Kilasa) as Darun, Charun and Shvitra when the Doshas are seated in Rakta, Mansa and Medo Dhatus respectively. In fact, Dhatu's are not practically affected, but their initiation is expressed by dermis (twak).
Madhavnidan classified Shvitra on the basis of the causative factors viz., Doshaja and vranaj 27 . Madhavanidana described that Vitiligo (Shvitra) in which hairs are black, in a small percentage, with ununited spots, new (<1 year) is curable. Others including developed due to burns, in genitals, hands, and feet, lips, with a history of inheritance are non-curable or difficult for a cure 28 .
Acharya Charaka and Sushruta are of the opinion that disease of recent origin can be cured 29 .

Management
Since long ago, the treatment of vitiligo is a challenge to the medical fraternity. Due to its chronicity, long term treatment, lack of uniform effective therapy and unpredictable course of disease it is very demoralizing for patients and creates a very bad social stigma for the victim. In allopathic system no satisfactory and permanent cure is available. Treatment is steroid based, systemic psoralens with exposure to long wave UV radiation. Topical potent corticosteroids are used. Other treatment options are Cosmetic make up, Cryosurgery, Depigmentation, Dermabrasion Use of sun protective devices, Intra-lesion therapy, Depigmentation therapy, Laser treatment Punch grafting, Chemical peeling off.
Skin grafting is practiced but again it has its own limitations and side effects 30 .
In modern science PUVA (Psoralen + Ultra Violet A ray"s exposure) therapy are mainly used for treatment of disease but these therapies have so many harmful side effects. Everyone is expecting some beneficial and useful remedies. So, it is really needed to find a safe, easier, less complicating, cost effective and fruitful approach for the management of disease, and Treatment needs a holistic approach. There is an imbalance of regulating hormones for melanin synthesis. For homeostasis of hormones and detoxifying body with Ayurvedic body purification treatment i.e., Panchakarma is very useful. In fact, in Ayurveda, it is described as powerful purificatory treatment and it should be done before commencing any specific medical treatment for the disease. In Ayurveda internal medications (Abhyantara Chikitsa), Local application (Lepachikitsa), sun UV ray"s exposure (Aatapsevan), Body purification i.e., Panchakarma treatment-Therapeutic Emesis (Vamana), Purgation (Virechana), Basti-purification method for Vata, Bloodletting (Raktamokshan), etc., advised in texts. Treatment is long-term and should be continued from months to years

Discussion:-
Vitiligo is considered as one of the social evils from a very long time. Living with vitiligo can be a continuous struggle, this disease disturbs individuals psychologically, as it distorts the body image and causes extreme fear, anxiety and concern that is comparable to that experienced by a patient with any major illness, particularly in darkskinned victims. With the psychological characteristics of each individual determining their ability to adjust to and cope with disfigurement. The science has proved that it is only a deformity of the skin pigment and it is not of any infective or systemic disease, but it acts as a social stigma in the society. It results from an autoimmune process that damages melanocytes. The cause is multifactorial, may be genetic, autoimmunity, neurologic factors, toxic metabolites, and lack of melanocyte production or early degeneration of melanocytes. In Ayurveda all skin diseases are described under the common umbrella term Kushtha. It is named as a Rakta Pradoshaja vyadhi because vitiation of Rakta is found as a common pathology in this disorder 31 . The causative factors for skin diseases and Vitiligo are the same and affect the same basic body tissue levels. Shvitra differs from other skin disorders by the normal functioning of all but the 'skin tissue' resulting in discoloration of the skin), without discharge. Physical symptoms in vitiligo are usually mild, but the unpredictable nature of the disease and its tendency to progress in the majority of cases can be psychologically and cosmetically overwhelming. However, in Ayurveda the causes for the Shvitra are as untruthfulness, ungratefulness, disrespect for the god, and insult of the preceptors, sinful acts, misdeeds of past lives and intake of incompatible food 32 . No single theory is above to satisfactorily explain all the various types of vitiligo leading one to believe. Vitiligo is probably multifactorial in aetiology. The large majority of patients with this condition have only the cosmetic handicap, but there are others that may have systemic association as well. According to modern pathophysiology, in generalized vitiligo, melanocytes are not found in the affected skin. Melanocytes contain the pigment melanin which serves a protective action against the harmful effects of sunlight. Phenylalanine → Tyrosine → Dihydroxyphenylalanine (DOPA) → Melanin (adrenals) Melanin formation in the skin is augmented by the hormone Melanocyte Stimulating Hormone (MSH) or intermedion secreted by the par"s intermedia of the pituitary gland. ACTH by anterior pituitary has melanocyte stimulating activity similar to MSH although to a much lesser degree. 25% of cases are autoimmune 33 . The pathogenesis is thought to involve an autoimmune process targeted against melanocytes. Histologic studies showed an absence of melanocytes in the affected skin. As we know modern science fails to give a satisfactory treatment in Vitiligo. Unstable (spreading) vitiligo is controlled with systemic steroids. Once static, localized patches can be treated with topical steroids or topical PUVA and then residual areas surgically grafted whereas generalized lesions need systemic PUVA therapy for depigmentation. Oral psoralene may cause nausea and vomiting. Over exposure (phototoxicity) to UVA leads to erythema, oedema, vesiculation, pain and tenderness of the involved skin. Hyperpigmentation of the surrounding normal skin is the commonest side effect. But Ayurveda is still a hope in this modern world as it not only cures the disease but also have effect on other systemic diseases related to Vitiligo. Shodhan therapy in Panchakarma can prove a boon in Vitiligo. In shodhan specially Virechana can be implicated for Shvitra with following reason: 1. Acharya Charak enlisted Shvitra under Rakta Pradoshaja Vyadhi. 2. Pitta is a Mala of Rakta 3. Both Pitta and Rakta are interdependent 4. Both are involved in Shvitra Vata and bhrajaka pitta reside in the skin. As the skin covers the whole body, bhrajaka pitta should be maintained in a proper state, and it needs continuous care. Hence Virechana is line of treatment for Pittaja and Raktaja Vyadhi (due to Ashraye-Ahsrayee bhava) as involvement of Rakta and Pitta are very clear in Shvitra. So Virechana is most helpful in this disease. Only topical application cannot uproot the disease.

Mode Of Action Of Virechana
The mode of action in this case can be understood as: it Causes downward movement of doshas from koshta and i.e. the Virechana drug having the property like Ushna, tikshna, Sukshma, Vyavayi and Vikasi due to these property Aushadha reaches the Hrudaya and circulate through the vessel. Due to the Ushna property present in aushadhi they liquify the doshas located in the channel of entire body, thus doshas flow towards GIT, morbid doshas reaches the stomach carried by Udana vayu, due to the predominance of prithvi and jala mahabhuta in virechana dravya causes downward movement of doshas from koshta and leads to expulsion of unwanted toxin in the body

Conclusion:-
Though Shvitra is an auto immune disease Shodhana therapy is useful. The Curable kustha do not recur if pathological factors are expelled out by Shodhana. As Shvitra roga is difficult to treat in other System of medicine, it can be managed successfully with knowledge of our system of medicine by adopting Shodhana, by considering roga bala, dosha, dushya, prakriti etc thus Shodhana karma like Virechana will have good results.