Ayurveda Management of Post Herpetic Ulcer (Visarpa) - A Case Study

According to the report, skin diseases contribute around 1.79% to the global burden of diseases.

Although PHI has been reported to affect up to 58% of patients with shingles ^1. According to a study conducted in India, higher incidence of Visarpa observed in younger age group (21-40 years of age). Recent studies have revealed that the incidence of skin problem and skin diseases caused by virus are increasing. It is characterized by the localized painful spread of skin rashes and blisters. Ayurveda mention that Visarpa spreads like a snake and thus it is considered as Pradhan Vyadhi ². Many skin diseases are mentioned in Ayurveda classics on the basis of their origin. Most of the skin diseases are caused due to Vata, Pitta and Kapha Dosha aggravation. Some are Raktaja Vyadhi and some are caused by Agantuja (foreign agents). It is an Aashukarvyadhi (acute disease) of skin whose complications such as post therapeutic neuralgia can affect till many years. Postherpetic neuralgia (PHN) represents a type of peripheral neuropathic pruritus that occurs after an episode of shingles and is characterized by localized pain, paresthesia, and itch, termed postherpetic itch (PHI); all may simultaneously exist within the same dermatomal distribution ^3, is characterized by localized painful spread skin rashes and blisters. Herpes is correlated in Ayurveda with Visarpa based on its symptomatology. It is an Aashukari Vyadhi (acute disease) characterized by Aashu Anunnata Shopha, Daha, Jwara, Vedana and Pidika and it is described as Agnidagdhavat.⁴ Visarpa has given simile of Aashivisha or Sarpa Visha due to its rapid nature of spreading.⁵

CASE REPORT

A 77 years old male patient visited Agadatantra OPD-10, presented with a chief complaint of non- healing pustular ulcer over nape of neck associated with severe itching (kandu), pain (toda) and pus discharge (srava) which is continuous in nature for 15 days; Patient had a history of herpes zoster infection past 1 month

The patient is a known case of Diabetes Mellitus-II under oral medication since 5 years; patient took folk medicine for past 15 days, but didn’t found result

Past  surgical  history:  No  relevant  surgical

history.

Family  History:  No  similar  complaints have been reported among family members.

Psychosocial  Status:  The  patient  appears anxious and irritable.

 Personal History:

· Bowel  Habits:  Once  daily  with hard stools

· Appetite:  Irregular,  often accompanied by abdominal bloating

· Diet:  Mixed  (includes  both vegetarian  and  non-vegetarian foods)

· Micturition:  2–3  times  during  the day and 1–2 times at night

· Sleep:  Disturbed,  primarily  due  to pain

· Allergies: None reported

Past surgical history:  No relevant surgical history.

Family History:  No similar complaints have been reported among family members.

Psychosocial Status:  The patient appears anxious and irritable.

 Personal History:

1. Bowel Habits:  Once daily with hard stools.
2. Appetite:  Irregular.
3. Diet: Mixed (includes both vegetarian and non-vegetarian foods).
4. Micturition:  2–3 times during the day and 1–2 times at night.
5. Sleep:  Disturbed, primarily due to pain.
6. Allergies: None reported.

General Examination

On Examination

Temperature - 98.6°F

Pulse rate - 92/min

BP - 130/80 mmhg

RS – NVBS heard

CVS - S1S2 heard

CNS - Conscious and oriented

P/A - Soft and non-tender

Local examination

1. Inspection:

• Number of lesions: Single lesion over nape of neck.
• Lesion: Irregular ulcero proliferative/inflammatory lesion present.
• Size: Appears approximately 4–6 cm in greatest dimension.
• Surface: Covered with yellowish slough.
• Margins: Ill-defined, irregular, and inflamed.
• Discharge: Purulent/sloughy exudate seen.
• Surrounding skin: Hyperpigmented, edematous, and inflamed with matted hair.
• Tenderness: Likely tender on palpation.
• Bleeding: No obvious active bleeding seen.
• Sinus/Openings: Multiple small pits/openings may be present.

MANAGEMENT

Treatment given.

1. Aragwadadi Kashaya for Vrana prakshalana (Wound wash) twice a day morning and evening
2. Ropana gritha for external application twice a day
3. Nimbadi guggulu 2 tid after food with Luke warm water.
4. Dashanga lepa for external application at noon for 30 min, followed by vrana prakshalana with Aragwadadi kashaya
5. Nimbadi Kashaya 10 ml bid with equal amount of Luke warm water before food.
6. Jaloukavacharana over ulcer for one sitting on 3rd day of treatment course.

Advice on discharge

1. Nimbadi guggulu 2 tid after food with Luke warm water for 15 days.
2. Tab Mehabaya 2 bid after food with Luke warm water for 15 days.
3. Cap Grab 1 bid before food with warm water for 15 days.
4. Nimbadi Kashaya 10ml tid with equal amount of Luke warm water before food for 15 days.

Follow up medicine advice after 15 days

1. Tab Mehabaya 2 bid after food with warm water
2. Cap Grab,1 bid before food with warm water
3. Dooshivishari Gulika 1 bid after food with warm water
4. Jathyadhi thaila for external application before bath at morning.
5. Dashanga lepa extermal application with luke warm water for 30 min at morning.
6. Pancha v. Qwatha churna for wound wash at morning after lepa.
7. Nimbadi guggulu 2 tid after food with warm water

Fig 1: Before treatment

Fig 2: During treatment

Fig 3: After treatment (at the time of discharge)

Fig 4: 1^st follow up after 15 days.

DISCUSSION

Visarpa is caused due to the involvement of all the three Doshas where Pitta is predominant ⁶. The vitiation of the Doshas is due to both Nija and Agantu Nidanas. Etiological factors such as Aharaja -diet and Viharaja- life style related, injury, poisons, toxins, burns etc. some of these Nidana causes vitiations of the Dosha and Khavaigunya (disease prone condition) in Dhatu and some cause direct vitiation of Dosha and Dhatu leading to Visarpa. It shows that favorable condition for disease phenomenon or infection occurs first. The Nija Hetus are intake of Lavana, Amla, Katu, Ushna, Dadhi, Amla, Raga, Shadava, Shukla, Sura, Souveera etc ^7. These etiological factors cause vitiation of Pitta and Rakta immediately leading to Visarpa ⁸. Aragwadadi Kashaya with the properties of Kapha-Vatahara, Ushna veerya, Katu Vipaka. It is indicated in skin diseases mostly visha, prameha etc. disorders as this drug consists of antimicrobial, anti-inflammatory, antihyperlipidemic etc. properties in it ⁹. Ropana gritha is Pitta Shamaka and helps in healing wound by accelerating wound healing and works as anti-septic and cleansing action ^10. Dashanga Lepa is one such an Ayurvedic formulation clinically used as an anti-inflammatory agent and widely recommended for treating of skin disorders including herpes wounds, eczema and inflammation¹¹. Nimbadi kashaya is mentioned has actions like kapha pitha hara, rakta prasadhana, lekhana etc. Most of the ingredients in this formulation have an anti-inflammatory action, hence can be considered to have rakta prasada property and is effective in reducing   the   symptoms associated with increased kapha and pitha dosha. Being a tikta rasa pradhana formulation if helps in the Shoshana of kleda and hence removes the ama in dosha and dhatus there by clearing the corresponding srotas¹².

CONCLUSION

Visarpa Roga needs to be approached with Pitta Pradhana Tridoshahara Chikitsa. In-spite of chronicity and severity of the disease, Ayurvedic Shodhana and Shamana measures showed significant symptomatic improvement in this case of Visarpa (herpes) and its complication.

REFERENCES

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