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AYURVEDIC THERAPY IN THE MANAGEMENT VARICOSE ECZEMA-A CASE REPORT

Published by : dr saurabh on:12-05-18 11:57 AM

 



ABSTRACT



Varicose
eczema is the condition usually present secondary to varicosity of superficial
veins . There is no successful surgery as well as medical remedy is available
for the complete cure of this condition.  Contemporary treatment includes combination
of locally applied topical steroids and the use of emollients either applied
directly or via emulsifying oils in bath water with the  treatment for varicose veins which  includes ligation, ligation with stripping
surgical treatments etc. But these treatments can cause re-occurrence of this
disease. We here by report a case of a 38 year old male with complaints of pain
,burning and discharges in the medial side of left lower limb near  ankle joint associated with dilated and
tortuous veins in the anterior aspect of lower leg with discolouration. He  was treated with virechana karma(therapeutic purgation therapy), internal
medication, external treatments and siravyadha
(venesection). During the treatment all the signs and symptoms of varicose
eczema as well as varicosity reduced to a very high extend.



Keywords: varicose eczema varicose vein, virechana karma  , siravyadha,internal  medication



INTRODUCTION



Varicose  eczema(also known as “congestion eczema,”
“gravitational dermatitis,” “stasis dermatitis,” stasis eczema” and
“gravitational eczema” 1 refers to the skin changes that occur in
the leg as result of stasis of/or pooling of blood by gravitational collection
of blood from insufficient venous return; the name of varicose eczema comes from
a common cause of this being varicose veins. 
Insufficient venous return results in increased pressure in the
capillaries with the result that both fluid and cells may “leak” out of the
capillaries. This results in red cells breaking down, with iron containing
hemosiderin possibly contributing to the pathology of this entity 2.The
most common physical signs of venous insufficiency are those attributed to the
progressive syndromes of chronic venous stasis and chronic venous hypertension.
These signs include the following: Edema Hyperpigmentation, Venous dermatitis,
chronic cellulitis, cutaneous infarction (atrophie Blanche)
lipodermatosclerosis and lichenification of the skin of that particular limb
and Ulceration.



Management was
planned based on principle that chronic diseases  requires some form of Shodhana(systemic purification). Virechana along with local care, Shamana Aushadhi and
raktamokshna
 have shown remarkable
healing response in this patient. In charak samhita, shonit sravan
(raktamokshan)
is described as one of the treatments for raktaj vikaras.3.
It is stated that when rakta flows out of the body, at the beginning
only dushta rakta flows out and after that only, shuddha rakta comes
out of the body. Raktamokshan or bloodletting is known to reduce
inflammation. It removes the inflammatory mediators such as tumor necrosis
factor-α, interleukin-1β, interleukin-6, and interleu-kin-22, etc. From the
blood stream and thus can control eczematous reactions  effectively.



 



CASE
REPORT-



A
38 years old patient  reported to shalyatantra opd SDM College of Ayurveda and hospital Udupi Karnataka
with the complaints of pain,mild itching ,burning and discharges from the
medial side of left lower limb near 
ankle joint  since 2 months
associated with dilated and tortuous veins in the anterior aspect of both lower
limb with discolouration since 10years.



 



HISTORY OF PRESENT ILLNESS



The
patient was apparently normal 10 years back . Gradually he noticed slight
bulging of veins in the both lower limbs below knee joint .which he ignored for
3 years later he developed discolouration near ankle and foot ,associated with
itching and burning sensation .He had undergone for allopathic treatment for 3
years but got only temporary relief later he advised for Doppler study of veins
and diagnosed as sephano-femoral incompetence and  advised surgery but he was reluctant. Since
last two months the pain aggravating on long standing especially in the
evenings and night hours accompanied with slight swelling , itching and some
serous discharges   at the left ankle
region.



 



On
examination, there was pain, swelling and dilated tortuous veins present in the
foreleg as well as in the calf region. There was swelling, and exfoliation of
skin with serous discharges seen in the left ankle region, blackish bluish
discolouration was evident.



Personal
History:



Bowel
: Regular



Appetite
: Good



Micturition
: Normal



Sleep
: Disturbed due to pain.



Habits
: H/o.Smoking.



Family
History:



Father
also had varicosity of lower limbs .



Physical
Examination:



B.P:
130/90 mm of Hg.



P.R
: 72/min.



Lab
Investigations
:



T.C
-8200/Cu.mm



D.C:
Neutrophils  : 66%



Lymphocytes:30%



Eosinophils
:4%



ESR:10mm/hr



H.B:-15
gm%



FBS:-78
mg/dl



PPBS:-140
mg/dl



Total
Cholestrol: 180 mg%



HDL
Cholestrol: 46mg%



LDL
Cholestrol: 110mg%



VLDL
Cholestrol: 30mg%



Triglycerides
: 150mg%



General
Survey:



Appearance
: Normosthaenic



Facies
: Normal



Attitude
: Conscious.



Systemic
Examination:



CVS: - S1,S2
heard ,no added sound



CNS:-- Higher
mental functions intact



RS :-- NVBS



ABDOMEN-Soft
,Nontender



Treatment –



Considering
the history and examination of the patient was planned  for the Virechana
karma , Triphala Kwatha Parisheka
  4
, dressing with Jatyadi taila 5
over local site .Later siravyadha  was done to remove vitiated and stagnated
blood . Patient was administered with  Chitrakadi Vati 2 tid 6
before food for  two  days as Deepana
- Pachana.
After two days patient have attained Samyaka Pachana Lakshana and later patient was posted for Snehapaana with Mahatiktaka Ghrita7for 5 consecutive days ( till Samyaka Snigdha Lakshana ) with initial dosage
of 30 ml then increased  to 60 ml, 100 ml
and 140 ml ,240ml on second, third , fourth and fifth  day respectively. After Snehapaana, patient was adviced for Sarwanga Abhyanga with Balaguduchyadi  Taila8 and Sarwanga Swedana for next 3 days. On the
3th day of Sarwanga Abhyanga and Swedana, patient was administered Trivruta Lehyam9  50 gms as a Virechana Aushadhi along with drakshayadi
kashyam
as Anupaana. Patient had
16 Vega with Kaphanta and attained Madhyama
Langiki Shudhi
. Patient was observed for complications whole day. Later
patient was adviced to follow the Samsarjana
Karma
for 5 days.



 



After
the samsarjana karma patient was
adviced for the raktamokshna in the
form of siravyadha to remove dushita
rakta .



Poorvakarma
(Pre operative procedure)for siravyadha: The
following materials were collected prior to the procedure, gauze piece, swabs,
and bandages, tourniquet, kidney trays, ounce glass, beaker, scalp vein
(no.20), spirit, chairs and dressing table. The leg to be punctured was flexed
and a torniquet was tied just above the calf region to visualize the veins
carefully after Abhyanga (localized oil massage) and  Swedana (fomentation).



 Pradhana karma (Main procedure): The
most tortuous vein was selected and punctured with no.20 Scalp vein set
(butterfly canula), carefully the blood was observed and let flow on to a
placed beaker. Later, the output was measured with the help of ounce glass.
During this procedure total 200 ml blood was drained out.



Paschat
karma
(Post-operative Procedure): After
completion of the procedure, the flow of the blood decreased and finally
ceased; after which the needle was withdrawn. The pricked part was cleaned up
with cotton swab and tight bandaging was done with yastimadhu ghrita. Later the
patient was advised rest by raising her legs using a pillow.



Internal medication



·        
Kaishor
guggulu10
1tid



·        
Gururasayana11
2tid



·        
Mahamanjistadi
quatha12
4tsp
bd



Follow
up advices



Ø  Advice
to review at every 15  days.



Ø  Avoidance
of prolonged standing.



Ø  Raise
limbs during sleep.



Ø  Calf
muscle strengthen exercise (bicycle riding in the air while lying on back)



Ø  Dietary
advice-Avoid oily and spicy food,sour items 
bakery items, curds, excessive sweets etc.



 



 



 



OBSERVATION



 



Table -1



 



 



 



 



 



 



 



 



 



 



DISCUSSION



By considering the Sign and Symptoms,
there is involvement of Pitta and Rakta dosha. The Patient had predominate
symptom’s like of pricking type pain (Vata
and Pitta) and dilated torturous vein
in both leg below knee (involvement of Sira
which is the upadhatu of Rakta), Skin changes(vata, Pitta ,Rakta and Mamsa) . Virechana karma is selected due to involvement of Pitta, Rakta and Vata in this particular case. Deepana
and Pachana Dravyas are administered
for the correction of Agni and the dosha must be balanced and metabolic
toxin must be eliminated from dhatus through
Panchakarma. MahaTikthaka Gritha is selected for Snehapana as it is indicated in Pitta
vikara, Ruk, Twak vikara
and Vrana.
In this condition Vrana and vatarakta line
of treatment is adopted i.e. Avasechana
as per Doshik involment , So Virechana karma selected for elimination
of Pitta and Rakta Dosha, Vata Anulomana
action.  Siravyadham (venesection),
is the treatment of choice prescribed by the classics for Siragata granthi (Varicose
Vein) by Acharya Vagbhatta (Vaidya
Harishastri
, 2011) and (Acharya
Sharangadhara Parashuram Sastri,
2006) considers Siravyadham (venesection)
as Ardhachikitsa (half treatment) of Shalya Tantra (Surgery) and
is said to provide immediate results . (Acharya YT, 2009). The accumulation of Rakta
(blood) and vitiation of vata in the Siras (veins) leads to
dilation of veins and tortuosity.  Siravyadham
(venesection) brings down the local Shotha (swelling) local
congestion. This promotes proper circulation where the stasis is cleared off.
During the treatment , Daha (burning sensation) which is one the feature
of Pitta is completely  relieved
by Siravyadham (venesection) procedure. This could have been due to the
reduced the localised intravascular pressure. Tortuosity was partially relieved
in this study may be due to the regaining of normal elasticity by external
punctures and the expulsion of static blood.



There was a gradual relief in the signs
and symptoms during this treatment course. The result obtained after the
external treatments and internal medication was encouraging. Pain, swelling,
burning sensation were reduced considerably. Dilated and tortuous veins in the
lower leg have reduced in size. Bluish discolouration which was present in the
dilated veins, reduced considerably.



 



CONCLUSION



Virechana
karma
, Siravyadham (venesection) along with
internal medication and local care of eczematous part  resulted the reduction of signs and symptoms
of  varicose eczema  as well as Siragranthi (varicose
veins) specially the symptoms like Shoola (pain), Daha (burning
sensation) and Vaivarnya (discolouration),exfloiations of skin.
During  the follow up period there was no
aggravation in the disease and varicose eczema was completely cured after a
period of 45 days. The treatments employed were purely based on the principles
of Ayurveda and was found to be very effective. The condition of the
patient improved remarkably.



REFERENCES
-



1. Rapini, Ronald P.; Bolognia, Jean L.;
Jorizzo, Joseph L. (2007). Dermatology: 2-Volume Set. St. Louis: Mosby; Chapter
14. ISBN 1-4160-2999-0.



2. “Gravitational eczemaand ulcers”.
United States National Institute of Health. Retrieved July 31, 2008.



3. Charak samhita volume i, hindi,
trans-lated by pandit kashinath pandey and dr. Gorakhnath chaturvedi, sutra
sthana, 24th chapter; verses 18, p-445, chaukhamba bha-rati academy, reprint
edition 2001.



4. Sushruta, Sushruta Samhita with
Nimandha Sangraha commentary of Sri Dalhanacharya, edited by Vaidya Yadavaji
Trikamji Acharya, Chau-khamba Surbharati Prakashan Varanasi 2012,
Chikitsasthana 1/17, p. 399.



5. Kaviraj Shri Govindadassen,
Bhaishajya Ratnavali,Ambikadatha Shasthri(edited), Chaukhamba Subharathi
Prakashana, 2010, Chapt.47:pp1312, pg.no.824.



6. Agnivesha, charaka Samhita, redacted
by Charaka and Dridhabala, Ayurve-dadipika commentary of Chakrapaan-idatta,
edited by Yadavjitrikamji, Va-ranasi Chaukhamba orientalia, Varana-si, U.P.
2011, p.622.



7. Vagbhata, Ashtanga Hrudayam, edited
with Nirmala Hindi commentary by Dr. Brahmanand Tripathi, Chaukham-ba Sanskrit
Pratishthan Delhi, Chikitsasthana 19/9-10, p.783



8. Sahasrayogam, by Dr. K. Nishteswar
and Dr. R. Vidyanath, Chaukhamba Sanskrit Series Office Varanasi 2008, Taila
Prakarana 11, p.116.



9. Agnivesha, charaka Samhita, redacted
by Charaka and Dridhabala, Ayurve-dadipika commentary of Chakrapaan-idatta,
edited by Yadavjitrikamji, Va-ranasi Chaukhamba orientalia, Varana-si, U.P.
2011, Chikitsasthana 29/158- 159 p. 421.



10. Bhaishajya Ratnavali, edited with
Sid-dhiprada Hindi commentary by Prof. Siddhi Nandan Mishra, Chaukhamba
Surbharati Prakashan Varanasi 2009, Vranashotha Chikitsa Adhikara 47/49, p.
824.



11. 
Agnivesha, charaka Samhita, redacted by Charaka and Dridhabala,
Ayurve-dadipika commentary of Chakrapaan-idatta, edited by Yadavjitrikamji,
Va-ranasi Chaukhamba orientalia, Varana-si, U.P. 2011, Chikitsasthana 29/158-
159 p.634



12. Sahasrayogam, by Dr. K. Nishteswar
and Dr. R. Vidyanath, Chaukhamba Sanskrit Series Office Varanasi 2008, Taila
Prakarana



 



TABLE -1



























Symptoms



Before treatment



After virechana 



After samsarjana



After siravyadha



Follow up (after 45 days)



Pain



+++



++



+



+



-



Tenderness



Grade 3



Grade 2



Grade 2



Grade 1



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