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Table of Contents
ORIGINAL ARTICLE
Year : 2020  |  Volume : 8  |  Issue : 3  |  Page : 185-192

Clinical evaluation of the effectiveness of Switra Nashak Churna and Lepa in the management of Switra (vitiligo): A pilot study


1 Ayurveda Hospital, North Eastern Institute of Ayurveda and Homoeopathy, Shillong, Meghalaya, India
2 Department of Panchakarma, North Eastern Institute of Ayurveda and Homoeopathy, Shillong, Meghalaya, India
3 Department of Samhita and Siddhanata, Govt. Ayurvedic College, Guwahati, Assam, India

Date of Submission01-Sep-2020
Date of Decision19-Sep-2020
Date of Acceptance07-Oct-2020
Date of Web Publication11-Nov-2020

Correspondence Address:
Dr. Abhishek Bhattacharjee
Department of Panchakarma, North Eastern Institute of Ayurveda and Homoeopathy, Shillong, Meghalaya.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JISM.JISM_81_20

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  Abstract 

Background: All the skin diseases in Ayurveda have been described under the heading of Kushtha. Pigmentation disorder Switra is also considered under Kushtha, as it fulfills the general criteria of Kustha, by causing cosmetic problems. The description of Switra found in Ayurveda texts is very much similar to that of vitiligo mentioned in modern contemporary medicine. According to modern medical science, vitiligo is the most common pigmentation disorder that is characterized by a progressive loss of melanocytes from the epidermis; it manifests as white macules and/ or patches on the skin and/ or mucosa with or without whitening of hair. Though many treatment modalities are available in the modern contemporary system of medicine, most of those treatment modalities are expensive, having serious adverse effects; apart from this, many a time, the output of the treatment is not satisfactory. In Ayurveda, many formulations for internal as well as external use have been mentioned for this condition. So to achieve an effective, safe, and affordable treatment, this study was planned with the drugs that are considered the best in the treatment of Switra. Objective: The objective of the study was to evaluate the effectiveness of Switra Nashak Churna and Lepa in the management of Switra (vitiligo). Materials and Methods: In this clinical study, 25 patients suffering from Switra were given Switra Nashak Churna (Bakuchi beeja and Khadir sara) with Haridra swaras anupana and Switra Nashak Lepa (Bakuchi beeja, Mulaka beeja, and Gomutra) as external application followed by a sun exposer. Out of the 25 patients, 20 completed the treatment for 60 days. Assessment was done before starting the treatment and on the 60th day based on the size and number of depigmented skin lesions. Result: Statistically significant improvement was observed in the patients in terms of the size and number of the skin lesions. Conclusion: It can be concluded that Switra Nashak Churna and Switra Nashak Lepa have been found to be effective in the management of vitiligo. After the assessment on the 60th day, the improvement was found to be significant.

Keywords: Swita Nashak Churna, Switra, Switra Nashak Lepa


How to cite this article:
Malakar S, Bhattacharjee A, Barman N. Clinical evaluation of the effectiveness of Switra Nashak Churna and Lepa in the management of Switra (vitiligo): A pilot study. J Indian Sys Medicine 2020;8:185-92

How to cite this URL:
Malakar S, Bhattacharjee A, Barman N. Clinical evaluation of the effectiveness of Switra Nashak Churna and Lepa in the management of Switra (vitiligo): A pilot study. J Indian Sys Medicine [serial online] 2020 [cited 2020 Dec 3];8:185-92. Available from: https://www.joinsysmed.com/text.asp?2020/8/3/185/300499




  Introduction Top


Evolutionary studies indicated that skin pigmentation was the result of adaptive responses to the environment (UV radiation) after the loss of hair coat in humans.[1],[2] Pigmentation provides photoprotection and participates in skin barrier function and antimicrobial defenses of the skin; hence, it is essential for maintaining body homeostasis.[3]

In Ayurveda, skin has been considered as Sparshanendriya Adhisthana and is said to be the site of Vata[4],[5] and Bhrajaka Pitta. Bhrajaka Pitta[6] is considered to be responsible for the color and complexion of the skin.[6] While describing the anatomy of the skin, Sushruta mentioned about seven layers of the skin along with the occurrence of diseases in those layers.[7]

All the skin diseases in Ayurveda have been described under the heading of Kushtha. According to Charaka, the numbers of skin manifestations are innumerable. Depending on the severity and prognosis, Kustha has been broadly classified into Maha-kushtha and Kshudra-kushtha.[8] Pigmentation disorder Switra is also mentioned under the heading of Kushtha, as it fulfills the general criteria of Kustha, by causing cosmetic problem (by making the body ugly) and it has been even considered more capable of causing cosmetic problem,[9] though it is not counted under seven Maha-kushtha and eleven Kshudra-kushta.[10]Switra differs from other varieties of Kushtha due to its nonsecretary and noninfectious nature, peculiarity of Nidana (causative factors), Lakshana (symptomatology), Sadhya-Asadhyata (prognosis), etc.[10],[11]

Switra is a skin disease that is very distressing for both the patient and physician. It mainly creates cosmetic problem, where depigmentation of the skin takes place and this disturbs a patient’s personal, familial, and social life. On the other hand, for the physician, Switra is troublesome because there is a lack of any specific remedy for radical cure and its poor prognosis. The description of Switra found in Ayurveda texts is very much similar to that of vitiligo mentioned in modern contemporary medicine.[12]

According to Ayurveda, both Kustha and Switra are considered as Raktaja Vikara (diseases arising due to the vitiation of blood).[8],[9] Again, Rakta and Pitta are related with Ashraya-Ashrayi Bhava.[13] So, Pitta, mainly the Bhrajaka pitta, which is located in the skin and responsible for normal skin color, gets vitiated in this disease, leading to patchy depigmentation of the skin.[14] In Ayurveda, a number of causative factors are mentioned but mainly Viruddha Ahar-Vihar (incompatible diet and activity) and Papa Karma (unrighteous deeds) are mentioned as the prime causative factors of Kustha as well as Switra.[8],[15]

According to modern medical science, vitiligo is the most common pigmentation disorder that is characterized by a progressive loss of melanocytes from the epidermis and that manifests as white macules and/ or patches on the skin and/ or mucosa with or without whitening of hair.[16] Clinically characteristic symptoms of vitiligo are pale or milk-white macules or patches due to the selective destruction of melanocytes.[17] According to modern contemporary medical science the exact etiology of the disease is still not clear. Some hypothesis such as involvement of genetic factors, oxidative stress, and environmental factors are mentioned as the probable cause of the disease.[18] In the modern system of medicine, the use of topical corticosteroids (mometasone 0.1% or clobetasol 0.05%), calcineurin inhibitors (tacrolimus 0.1% or pimecrolimus 1.0%), systemic corticosteroids, combination of Ultra Violet A (UVA) and Psoralen (PUVA) therapy, monochromatic excimer light (MEL) laser therapy, erbium laser-assisted dermabrasion, surgical transplantation (needling, split thickness grafting, suction blister grafting, melanocyte keratinocyte transplant (MKTP)) etc. are the treatment of choice.[19] These types of treatment modalities may cause harmful side effects such as skin-burn, erythema with pain,[20] nausea, central nervous system side effects (such as headache, dizziness, depression, insomnia, and hyperactivity),[21] photo-onycholysis,[21],[22] melanonychia,[23] friction blister and ankle edema,[24] hypertrichosis,[25] increased risk of cutaneous squamous cell carcinoma,[26],[27],[28] dermatoheliosis, that is ultraviolet-induced aging of skin[29] etc; the outcome of the treatment even is not very satisfactory in many of the cases. In such circumstances, the need of some therapy that is effective, safe for long-term use, and cost-effective is the need of the hour. In ancient Ayurveda texts, many such herbs and formulations were mentioned that are said to be effective in Switra (vitiligo). In the current study, as the oral medication Bakuchi (Psoralia corylifolia seed) has been considered the best medicine for Switra and Khadira (Acacia catechu heartwood) and the best drug for Kustha, it is used in Churna (powder) form. For external application, Lepa (paste for external use) prepared from Bakuchi (Psoralia corylifolia seed) beeja churna (seed powder), Mulaka (Raphanus sativus) beeja churna (seed powder), and gomutra (cow’s urine) was used followed by a sun exposer.


  Materials and Methods Top


Materials

Oral medicine

Switra Nashak Churna: Khadira Sara Churna (heartwood powder), 1 part

Bakuchi Beeja Churna (seed powder), 1 part

Dose: 6 gm twice daily after food

Anupana: Haridra Swarasa (juice), 10ml and Ushna Jala (warm water) [Table 1].
Table 1: Ingredients of Switra Nashak Churna

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External application

Switra Nashak Lepa: The paste is to be prepared with Bakuchi Beeja Churna and Moolaka Beeja Churna in equal quantity, mixing with Gomutra (cow’s urine)[30] [Table 2].
Table 2: Ingredients of Switra Nashak Lepa[30]

Click here to view


Process of administration: Patients were advised to apply Switra Nashak Lepa over the hypopigmented/ depigmented patches in the morning and they were advised to expose the affected skin lesions to the sun between 8 AM and 10 AM for 20 to 30min.

Methods

Source of data

The patients suffering from Switra (Vitiligo) attending the OPD of Govt. Ayurvedic College Hospital, Guwahati were screened and allocated to the study. Overall, 25 patients were included into the study after them fulfilling the inclusion and exclusion criteria and after them providing written consent. Institutional ethical committee clearance was also obtained.

A detailed history taking and physical examination were carried out in these patients. The clinical data along with the elaborated assessment of the condition were recorded in the specially designed case proforma.

Among the 25 patients, 20 completed the treatment for 60 days. 3 patients did not complete the whole treatment due to an unknown cause, and 2 patients developed a burning sensation with erythema, itching, and blister formation after external application and a sun exposer. So, their treatment was discontinued.

Inclusion Criteria

  • Patients suffering from Switra (Vitiligo),


  • Duration of the disease being less than one year,


  • Age between 16 and 60 years, and


  • Patients who are willing to participate in the study.


  • Exclusion Criteria

  • Hypopigmentation due to scar formation as a result of burns or other injuries (Vranaja Switra),


  • Patients with any other hypopigmentation disorder of the skin other than vitiligo, and


  • Patients with any chronic disease that needs regular medication.


  • Investigations

    Hemogram, fasting and postprandial blood sugar, glycosylated hemoglobin, renal function test, liver function test, and routine examination of urine were carried out before treatment to exclude other conditions.

    Intervention

    Switra Nashak Churna 6 gm was given twice daily after food with 10ml of Haridra Swaras and luke warm water for 60 days to all the patients.

    Patients were advised to apply Switra Nashak Lepa over the hypopigmented/ depigmented patches in the morning and they were advised to expose the affected skin lesions after half an hour to the sun between 8 AM and 10 AM for 15 to 30min.

    Assessment Criteria

    Patients were observed for 60 days. Assessment was done initially on “0” day, that is, before the medical interventions. Then, patients were followed up on the 15th day, 30th day, and 45th day. Finally, assessment was done at the end, that is, on the 60th day. Assessment was done based on the size and number of the lesions.

    Statistical Analysis

    After completion of the treatment obtained, results were statistically analyzed and various parameters such as mean score, standard deviation (SD), standard error (SE), paired t test, and p value at various levels were calculated.

    Criteria for Overall Assessment

    The total effect of the therapy on 20 patients of Switra was calculated by taking the mean of percentage of improvement.

    The final overall effect was graded as cured, marked improvement, moderate improvement, mild improvement, and no improvement [Table 3].
    Table 3: Criteria for overall assessment of the intervention

    Click here to view



      Result Top


    The assessment of results was made by adopting the standard scoring methods related to vitiligo, which include the size and number of hypopigmented/ depigmented patches.

    1. Effect of treatment on the size of patches: Reduction of size of the patches was found to be significant at the end of the treatment [Table 4] and [Figure 1].


    2. Effect of treatment on the number of patches: The numbers of patches was significantly reduced after the end of the treatment [Table 5] and [Figure 2].


    3. Effect of treatment on the basis of Vitiligo Extent Tensity Index (VETI) Score: The combined assessment of the extensiveness and pigmentation status was analyzed both before and after the treatment by using the VETI Score. Significant improvement was observed in the patients in terms of this criterion [Table 6].
    Table 4: Effect of treatment on the size of patches

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    Figure 1: Effect of treatment on size of patches

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    Table 5: Effect of treatment on the number of patches

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    Figure 2: Effect of treatment on number of patches

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    Table 6: Effect of treatment on the basis of VETI Score

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    Considering the overall effect of the intervention, 50% of the patients had marked improvement, 25% of the patients were noted to have moderate improvement, 10% of the patients were noted to have mild improvement, and 15% of the patients had no improvement [Table 7] and [Figure 3].
    Table 7: Overall assessment of the intervention

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    Figure 3: Overall effect of the treatment

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    Thus, the overall outcome of this study was significant, indicating that the trial drugs as per reference of the Ayurveda text have an effective role in the treatment of Switra.


      Discussion Top


    Switra is considered as a variety of Kustha (skin diseases) that is caused mainly due to Kapha Pradhan Tridosha and Meda Dhatu Dusti. If we analyze the pharmacodynamics of the components of Switra Nashak Churna and Lepa from the Ayurveda point of view, it could be observed that most of the drugs have Laghu, Ruksha and Tikshna Guna, Katu, Tikta and Kashaya Rasa, Katu Vipaka, Ushna Virya, Kushtha/Switra Nashak Prabhava and most of the drugs have the Kapha Shamaka property and play a role in the management of Kustha and Switra/ Kilasa [Table 8].
    Table 8: Pharmacodynamics of the drugs used in Swita Nashak Churna and Lepa

    Click here to view


    Among the ingredients of Switra Nashak Churna and Lepa, Bakuchi is the most important drug that has been extensively used by Ayurveda physicians in Switra (hypopigmentation) since ancient times with great success and hence it is also known as Kusthaghni.[31]Bakuchi seeds contain psoralens, which, on exposer to the sun, helps to stimulate melanocyte proliferation.[32] In Switra Nashak Churna, Khadira is another ingredient that has been said to be the best drug for Kustha (skin diseases) and also found as a common ingredient in most of the formulations used in Switra. The heartwood of Khadira exhibits anti-inflammatory,[33] immunomodulatory[34] functions. Catechins, rutin, and isorhamnetin, which are actively present in the heartwood of Khadira, exhibit antioxidant properties by scavenging free radicals.[35] Thus, when administered orally in the case of vitiligo, Khadira may help in the regression of the disease activity. Haridra Swaras was used as Anupana of Switra Nashak Churna. Curcumin, the principal component present in Haridra, has been found to be effective in vitiligo by protecting against disease progression via (1) an increase in MAPK/ ERK phosphorylation and inhibition of apoptosis; (2) an increase in total antioxidant capacity and a decrease in intracellular reactive oxygen species generation; and (3) an improvement in mitochondrial activity.[36] As the patients are also advised for a sun exposer after the application of Switra Nashak Lepa and due to which there is the possibility of allergic contact and photocontact dermatitis due to psoralens[37] present in Bakuchi beeja, so in such a condition also Haridra may even play a role to prevent such adverse effects due to its antiallergic activity.[38]Mulaka Beeja, the other ingredient of Switra Nashak Lepa, is used in different Vata-Kaphaja disorders and it has also been indicated in different skin conditions mainly due to Kapha.[39]Gomutra, which was used to prepare Lepa, acts as a chemical drug penetration enhancer and availability facilitator for bioactive molecules[40] and, thus, it may have a role in enhancing the activity and bioavailability of the drugs of Switra Nashak Lepa. Apart from this, all types of Mutra (including Gomutra ) are said to be effective in case of Kustha and Switra/Kilasa.[41],[42],[43]

    The treatment was tolerated well by most of the patients. However, a few adverse events were also reported during the study period. Three patients reported mild itching and a burning sensation with mild erythema over the affected skin after the first few applications. These patients were advised to apply coconut oil over the affected skin after removing the external application, which helped to resolve their complaints, and their treatment was continued. Two patients developed itching and a burning sensation with erythema and blister formation after external application and sun exposer, so their treatment was discontinued and they were advised to apply Shata Dhauta Ghrita.

    While analyzing the effectiveness of the therapy, it was observed that younger patients had better repigmentation than the elderly. The recently developed lesions improved better. Vitiligo lesions present over limbs, neck, and trunk responded well in comparison to the lesions present on the face and where palm and sole got involved. Better improvement was observed in the hairy areas of the body.[44][45][46][47]


      Conclusion Top


    Switra is a Tridoshaja Kriccha Sadhya (difficult to cure) disorder causing hypopigmentation/depigmentation of the skin. Various dietetic, behavioral, and psychological factors aggravate Kapha predominant Tridosha, which further vitiates the Medo Dhatu and results in whitish patchy discoloration of the skin. Switra can be correlated with vitiligo, the most common cause of depigmentation of the skin.

    A clinical trial with Switra Nashak Churna (containing Bakuchi Beeja and Khadira Sara) orally with Haridra Swaras Anupana and Switra Nashak Lepa (containing Bakuchi Beeja Churna, Mulaka Beeja Churna, and Gomutra) external application followed by a sun exposer has shown encouraging results in the repigmentation of the affected skin. Not much complications were observed in the patients at the end of the study. So this treatment protocol can be a good option for the management of Switra (Vitiligo). In the current study, as the sample size is very small and the follow-up period is short, to arrive at a conclusion about the effectiveness and safety of the treatment, a clinical trial with a big sample size and a long follow-up period will be needed.

    Declaration of Patient Consent

    The authors certify that they have obtained all appropriate patient consent forms. In the form/forms, the patient(s) has/ have given his/ her/ their consent for his/ her/ their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

    Financial Support and Sponsorship

    Nil.

    Conflicts of Interest

    There are no conflicts of interest.



     
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    Shastry JLN Illustrated Dravyaguna vijnana (Volume-II). Varanasi, India: Chaukhamba Orientalia; 2015. p. 513-8.  Back to cited text no. 46
        
    47.
    Shastry JLN Illustrated Dravyaguna vijnana (Volume-II). Varanasi, India: Chaukhamba Orientalia; 2015. p. 602-3.  Back to cited text no. 47
        


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