Introduction

Skin disorders are very common and their burden on population is significant. People are really concern towards physical appearance; diseased appearance of skin can really affect patient’s psychological health and has profound impact on quality of life. Skin diseases are rarely fatal but due to chronicity of disease it causes considerable distress to patient.

Ayurveda has described various acute and chronic skin disorders under Kustha-Rogadhikara. In Ayurvedic context Kustha is described as one which causes discoloration of skin, one which causes deformity of skin and give ugly look.^[1]

Kustha is classified as 7 Maha Kustha and 11 Kshudra Kustha depending upon involvement of Dosha, Dhatus and severity of symptoms. Acharya Charaka Described Kitibha Kustha in context of Kshudra Kustha. The skin lesions in Kitibha Kustha are blackish [hyperpigmented], rough in touch like scar [hypertrophied], Dry & hard on touch. There is predominance of Vata-Kapha dosha in Kitibha Kustha.^[2] The clinical presentation of Kitibha Kustha is resembling with lichen simplex chronicus.

Eczema or dermatitis is a group of inflammatory skin diseases provoked by a wide variety of stimuli, i.e., direct injury from toxic chemicals, mechanical trauma and immunological reactions.^[3] Chronic Eczema is represented by severe itching, hyperkeratosis and lichenification. Lichen simplex chronicus one of the characteristic examples of chronic eczema. It is a skin condition characterized by chronic itching and scratching that leads to thickened [hypertrophied], hyperpigmented plaques with increased skin marking.^[4] Lichen simplex chronicus may represent the end stage of a variety of pruritic and eczematous disorders, including atopic dermatitis. This itch-scratch cycle can be triggered by various underlying factors like chronic skin irritation, insect bites, psychological factors [anxiety, stress] and Dry skin. The area’s most commonly involved are those that are conveniently reached like nape of the neck, ankles, legs, forearms, wrists, and genitalia.^[5]

Treatment of lichen simplex chronicus in modern medicine includes high potency topical glucocorticoids, Antihistamins, Tricyclic Antdepressant with antihistamin activity.

History of Present Illness:

Patient was apparently normal before 5 years, then she gradually developed itching over anterior aspects of bilateral foot, itching was so intense and constantly present throughout the years, that it had ultimately led to hypertrophied, hyperpigmented and ulcerated plaques over foot. Symptoms got aggravated day by day causing vicious cycle of itching and scratching.

Patients’ symptoms got aggravated after working in farm & soil. Patient consulted Dermatologist for said complaints, they prescribed Steroidal ointment, which gave temporary relief in symptoms, but there is relapse when patient discontinued steroids. Due to continuous itching & scratching over years patient developed ulcerated plaques over bilateral foot which got infected for which patient presented at Dhaneshwari Ayurved Hospital, Chh. Sambhajinagar

History of Past illness:

Patient is Known case of Hypertension since 5 yrs for which she is taking Tab. Amlo-5 mg OD.

No history of Asthma, Diabetes, Tuberculosis, Allergy.

Personal History:

Diet - Vegetarian
Addiction - Tobacco
Occupation - Farm-worker
Socioeconomic status - Lower middle class

Systemic Examination

CNS - Conscious oriented
CVS - Sinus Rhythm
RS - AEBL Clear

Ashtavidha Pariksha

Nadi - 80/Min
Mala - Sama
Mutra - Prakrut
Shabda - Prakrut
Sparsha - Khara
Druka - Prakruta
Akriti - Krisha

Local Examination

In the present case scenario following important signs and symptoms are assessed before and after treatment.

Results

Figure 1: Jalauka-Awacharan

Figure 2: Jalauka-Awacharan

Figure 3: Before treatment

Jalauka-Awacharan: In present case secondary vitiated Dosha is Kapha Dosha, also due to chronicity of disease Rakta Dosha is vitiated. Acharya Charaka advised Jalauka-Awacharan in Kaphaj Kushtha with limited number of skin lesions. Patient is having limited skin lesions [at bilateral ankle joins] that’s why blood-letting is done by Jalauka.^[11] Total 3 settings of Jalaukaawacharan done 7 days apart, each time 20 ml blood-letting done. Patient was advised to take Panchatikt-Ghrita in Madhyam Matra [20ml] before and after Jalauka-Awacharan. Leech when applied to skin it sucks the blood at superficial level i.e., from capillaries or extra cellular region which is more impure than other body parts, thus creates new cellular divisions which takes place by removing dead cells layer and result in reduction in local swelling and lichenification.^[12] Leeches while Blood-letting secretes saliva which contain various bioactive substances, including anticoagulants and vasodilators which leads to reduction of Interlukin-1 which is responsible for inflammation, probable ways of action of leach therapy are; normalization and improvement of capillary circulation, Anti-inflammatory effect, immune stimulation and immune modulating effect.

Lepan: External therapies [Bahiparimarjan Chikitsa] are one of the major modes of therapy in Kustha, as it has direct action over skin. Acharya Charaka stated that, Lepana gives Immediate relief along with internal medicines in Kustha. According to Acharya Sushruta when disease is located in Blood (Raktagata-Awastha) line of treatment planned is Sanshodhan, Lepan and Kashaypan, so after Raktamokshan by Jalauka, Lepa of Khadir Churna mixed with Jatyadi Taila is applied over affected area (Anterior aspects of both foot).^[13]

Mode of Action of Jatyadi Taila and Khardira Churna

Jatyadi Taila is classical ayurvedic formulation described in Sharangdhar Samhita. Jatyadi Taila is potent Vranaropak and Vranashodak when applied topically. Jatyadi Taila possess ingredients like Jati, Haridra, Nimba, Patol, Karanja, Yashtimadhu, Lodhra, Tutha, Sariva etc. most of the ingredients are Tikta, Kashaya and Katu Rasa dominant. Kashaya and Tikta Rasa are predominantly in Kustha as they reduces Kleda and act as Twaka-Prasadana i.e., promotes texture of skin.^[14]