A Case Study to Evaluate the Treatment of Shwitra with Ayurveda Modalities

In Ayurveda all the skin diseases are explained under the term Kushtha. The references of shwitra are found in almost all the Samhitas like Bruhatrayees and Laghutrayees. In shwitra disease the white patch is seen and considering these symptom it can be compared to vitiligo. Vitiligo is characterized clinically by the development of areas of depigmentation. These are often symmetrical and occur mainly on extensor surfaces. This hypopigmentation results due to destruction of melanocytes, which may be unknown in origin or due to autoimmune endocrinopathies selective IgA de(cid:977)iciency. In contemporary science treatment of vitiligo is not very effective. Potent topical steroids and tacrolimus is used which produces harm to skin on continuous use. So the effective medicines are expected from Alternative sciences. To evaluates the role of Ayurveda treatment modalities in shwitra . A female patient, aged 15 year suffering from white patch below the left eye since 3year was treated with both Shodhan and Shaman Chikitsa for a period to 5 months with follow up at every 15 days in between, Relief from the complaints was assessed by noting the changes in the size of patch. After 5 months of treatment the size of patch was reduced. The present case study revealed the ef(cid:977)icacy of Ayurveda ther-apy both internal and external for duration of 5 months in the management of shwitra.


INTRODUCTION
Vitiligo, a speci ic type of acquired leukoderma, is an idiopathic, patterned, circumscribed hypome-lanosis or dipigmentation of the skin and hair. These are often symmetrical and occur mainly on extensor surfaces. The basis for this destruction is unknown, but immunologically mediated damage is likely and vitiligo sometimes occurs in individuals with autoimmune endocrinopathies, selective IgA de iciency .The incidence of vitiligo is 1 to 8.8%. The age of onset varies widely from infancy to old age, with a peak incidence in the 10 to 30 years age group. The reported female predominance may be spurious, especially in India where vitiligo can be a considerable dis igurement and can affect eligibility for marriage because vitiligo mimics leprosy. The etiology is unknown. There is a positive family history in 30% of patients. An immune process is the most probable mechanism of destruction of melanocytes, as there are several autoimmune disorders that occur with vitiligo. Clinically the white spots usually gradually appear and remain for life.
As per the symptomatology of disease vitiligo, the clinical condition can be compared with disease shwitra (white color patch). In Ayurveda the shwitra is a disease explained in khshudrkushta. It is also called as Kilas, Daruna, Aruna, Shwetakushta (Shukla and Tripathi, 2009b) etc. it explained in almost all the Brihatrayees and Laghutrayees. In Charak Samhita while explaining the Nidan of shwitra Acharya Charak has explained virudha ahar vihar (unbene icial foods) and paap karmas (bad deeds) are the main cause of shwitra (Shukla and Tripathi, 2009d). This produces the imbalance of Doshas (body humours) like Vata, Kapha and Pitta specially Bhrajak Pitta which helps in the formation and maintain the color of skin. These Doshas are vitiated along with Rasa, Rakta" Mamsa and Meda Dhatus (Shukla and Tripathi, 2009c) (body tissues).

Aim
To study the case of Shwitra through Ayurveda Objective 1. To study the role of Ayurveda in management of Shwitra.
2. To study the disease Shwitra in detail.

Case Report
A 15 Y/F patient came at OPD in our Ayurveda institution Maharashtra with the complaint of White coloured patch (Twak Shwetata) on below the left eye along with general weakness and irregular menses. The patch was white, without dryness and scaling. Her family history was negative in irst degree relation. Her father's education is upto M.Com and currently working in bank, while mother's education is upto 12 th and she is housewife. Socio-economic status was middle. There were no personal history of autoimmune disorders like psoriasis; asthma etc. there was no history of trauma or surgery.

History of present illness
Patient was apparently normal (means she is not aware about the disease) before 5 years. Her mother noticed that she having a white patch over left eye which is gradually increase in size. She visited to dermatologists for the same, where she undergone haematological investigation which showed low hb%, she advised some internal medicines along with topical steroids for white patch. She took treatment for more than 3 years, and then she stopped medicines by herself as improvement was not noticed. So, she approached to Ayurveda consultancy for the same.

Aharaja
Taking vegetarian diet and having habit of eating outside food like panipuri, wadapav etc Viharaj patient get more exposure to sun for classes as she is student of 10 th standard. She has habit of sleeping at evening and study at night. She sleeps 3-4hrs/night and 2hrs/evening. Examination vitals are within normal limit. Systemic examination was normal, prakriti was pittavataj and weight was 37kg with 148cm height.

Ashtavid pariksha
Nadi was Pittavatja, no complaint regarding Mala (once a day with soft consistancy) and Mutra(5-6 time/day),Jivha was Niraam, Shabda was Spashta, Sparsha was Unushnasheeta and Drik was normal but conjunctiva was pallor as her haemoglobin was low and Akriti was Madhyam.

Shodhan Chikitsa
In second sitting after all examination and investigations ,patient underwent for Shodhan Chikitsa in which Vamana procedure was done (Month of March. 2019) in sequence of Purva Karma, Pradhan Karma and Paschayat Karma.

Paschayat karma
After obtaining Samyaka Vamana Lakshana Dhoomapan was given with stick made of Aguru for 5 minutes by each nostril. Then patient was advised to follow the Sansarjana Karma for ive days. Sansarjana Karma was given in the form of Peya, Vilepi, Akrita Mudga Yusha, Krita Mudga Yusha for 5 days.

RESULTS AND DISCUSSION
In Ayurveda Shodhan is the method of eliminating the Dosha from body to pacify the disease. This Shodhan when done by unctuous and Tikshna (strong) drugs, it cleanses the body. So in the present study, the patient irst treated with the medicines including Dipan, Pachan, and the drugs  Yashtimadhu phant Glycyrrhiza glabra 1000 ml Vamanaopag         Chameli Tail Jasminum of icinale olie 7 Til Tail  Sesamum indicum olie  8 Petroleum Jelly/ Cream Base q.s 9 Babchi Ash Psoralya corifolia 10 Vish Naag Ash Aconitum ferox  Then Bakuchighan Vati (Rajput et al., 2014) and Khadirarishta was advised which is most popular formulation for Kushta which contains a single drug Bakuchi belongs to Fabaceae family and Khadira, Devdaru, Triphala etc respectively are depicted in Table 8, (Ayurvedic Pharmacopoeia of India, 2003a). These are the main herbs in traditional Indian herbal medicine for the treatment of skin disorders. It has Tikta and Madhura Rasa which mitigates the Pitta Dosha and Ushna Virya alleviates the Kapha and Vata Dosha. Along with the above drugs poly herbal ointment (ointment Pigmento) was advised which having the main drugs Arishtak (Sharma and Vijnana, 2013) and Bakuchi along with Chitrak, Gandhak, Eranda (Table 14). These drugs having the properities of Kushtaghna, Krimighna, Kapha -Vata Hara and Pandurog Hara.
After routine investigation when we came to know about the low hb% which is one of the causes of irregular menses, the formulation like Lohasava (Tripathi, 2004) was advised which contain Loha and other ingredients which are depicted in Table 9. (Ayurvedic Pharmacopoeia of India, 2003b) and Kumariasava ( Ayurvedic Pharmacopoeia of India, 2003) contains Kumari as the main drug, the detail of herbal constitution of Kumariasava has been presented in Table 10 in addition with this drugs having Appetizer, Digestive and Carminative properties. The drugs like Amalaki and Pipali acts as a Rasayan and also having Panduroghara properities. Amalaki possess antioxidant activity and contain vitamin C which helps for the proper absorption of iron from the gut. Also the Lohasava is directly indicated in the treatment to Panduroga, Agnimandya, Krimi and Kushta. Likewise the Kumariasava is indicated in Agnimandya and bleeding disorders. This formulation showed excellent result in patient's haematological parameters (Table 7).
After that, for Shodhan of body Snehanpan was given by Panchatikta Ghrita contains (  (Shukla and Tripathi, 2009a). Ghrita used in formulation has lipophilic action which helps in carrying drugs to a target organ. This lipophilic nature of Ghrita facilitates entry of drugs into the cell and its delivery to mitochondria and nuclear membrane; it also helps in restoring the normal texture of skin (Shukla and Tripathi, 2009i).
Marichyadi Tail (Mishra, 2006) is used for external application which contains the drugs (Table 15) (Tables 12 and 13) and the drugs of Tablet pigmento which contains Abrak Bhasma ,Loha Bhasma , Chitrak, Triphala etc ingredients are depicted in Table 11 (selfgrowth.com t/t of lecoderma) all the drugs of this poly herbal products having the properities like Depan, Pachan , Anulomana which improves the function of GIT system, also the drugs having special property of Kushtaghna and Krimighna which were helps to reduce the symptoms of disease like Shwitra as shown in Figure 1 .

CONCLUSIONS
The lesion or white patch which was present below the left eye of 15 year old female patient was fully recovered after 5 months of treatment and also her menses becomes regular and the hb% was increased by 1.4 gm% by Ayurveda modalities like Shodhan and Shaman Chikitsa.
ACKNOWLEDGEMENT I acknowledge the full cooperation and encouragement of my husband Dr. Sourabh G. Deshmukh HOD & Associate Professor, Department of Kayachikitsa, MGAC for sparing his precious time. The endless support he has bestowed upon me has been the guiding force behind me. His dedication to work and amazing foresight made this study a success and it will always inspire me in all my future endeavors.

Funding Support
This study did not receive any speci ic grant from funding agencies in the public, commercial, or notfor-pro it sectors.