Effective management Alopecia totalis by Ayurveda – A case report

Abstract

Alopecia areata (AA) is a T-cell-mediated autoimmune illness characterized by intermittent, non-scarring hair loss, Alopecia totalis(AT) is a type of AA characterized by total hair loss on the face and scalp. Unfortunately, it is projected that 10–15 % of people with AA will advance to total hair loss on the scalp (AT) or hair loss on the scalp and body Alopecia Universalis (AU) only 10 % of patients with AT/AU recover completely. Treatment for severe AA is often unsatisfactory. The most popular AT/AU therapy techniques were topical steroid application and oral steroid administration. We present a case of Alopecia totalis that was treated with cupping therapy and ayurvedic treatments such as Punarnava Mandoor, manjistadi Kashaya, asanadi gana Kashaya, purnachandrodaya rasa, a churna combo, and Malatyadi and Dhurdhurapatradi taila for external application over scalp. The treatment's effectiveness is due to the synergistic action of all the herbs and the immunostimulant activity of cupping.

1. Introduction

Alopecia areata (AA) is a T-cell-mediated autoimmune illness characterized by intermittent, non-scarring hair loss and follicle preservation that mainly affects anagen hair follicles. Localized circumscribed patches of non-scarring hair loss are the most common clinical presentation of AA in humans [1]. The American Hair Loss Association acknowledges that individuals who suffer from hair loss are psychologically sensitive since it is such a very distressing condition [2].

There are two types of AA: Alopecia totalis (AT) and Alopecia Universalis (AU). AT is defined by the total hair loss on the face and scalp; AU is the other kind of AA, which is characterized by global hair loss. The prognosis for AT and AU is often worse than for AA [3]. Both men and women are at risk for AA, which may strike at any age. Alopecia areata affects around 2 % of the general population at some time in their life [4]. One to three per cent of people who frequent dermatological clinics fall into this category [5]. Unfortunately, it is projected that 10–15 % of people with AA will advance to total hair loss on the scalp (AT) or hair loss on the scalp and body (AU), and only 10 % of patients with AT/AU recover completely [5]. Other autoimmune illnesses, atopic dermatitis, and thyroid abnormalities are common comorbidities [5,6].

Treatment for severe AA is often unsatisfactory. The most popular AT/AU therapy techniques were topical steroid application and oral steroid administration [1]. No treatment has been shown to change the course of the illness or provide a substantial long-term benefit [3]. Acne aggravation is another recognized side effect of corticosteroid treatment, according to Alharthi S et al. [7].

In Ayurveda, Acharya Sushruta described the ailment as Indralupta (Hair Loss) in the context of Kshudraroga and recommended Pracchanna karma (local bloodletting) and application of Manashila (Arsenic Disulphide), Kasisa (Iron sulphate), Tuttha (Copper sulphate), and Maricha (Piper Nigrum), or devadaru (Cedrus Deodara). Gunja kalka is often used locally (Paste of Abrus precatorius) [8].

We outline an instance of alopecia totalis that responded well to Ayurvedic treatment.

2. Patient information and clinical findings

A female patient, aged 56 and working as a homemaker, visited our outpatient department (OPD) with concerns regarding her recent hair loss over the past six months. Initially, she noticed the presence of white hair covering approximately 50 % of her scalp (Image 1). Furthermore, she experienced patchy hair loss in specific areas of the scalp. However, over time, the condition worsened, leading to complete hair loss across the entire scalp (Images 2 and 3). The patient had previously sought treatment from various dermatologists who prescribed steroids, but unfortunately, her hair loss could not be controlled, resulting in the complete loss of all her hair. Dissatisfied with the previous outcomes, she sought assistance from our hospital.

2.1. Clinical findings

Upon examining the patient's scalp, it was observed that approximately 80 % of her scalp had white hair, accompanied by patches that appeared shiny, smooth, and caused irritation. Other than the scalp-related symptoms, the patient exhibited a healthy appetite, a clear tongue, and regular bowel movements, and did not present any additional symptoms. The condition was diagnosed as Indralupta, or alopecia totalis (AT). The therapeutic intervention, observation and results are listed in Table 1.

Table 1.

Treatment Schedule, observations and results.

Day of Visit	Medicines/procedure	Dose	Observations and results
1st week	Krimikuthara rasa	2 tablets (125 mg each) BD Before food	No changes were seen
	Vidangarista	3 tsp BD After food
	Arogyavardhini Rasa	2 tablets (125 mg each) BD Before food
	Malatyadi taila	External application over scalp
3rd week	Modified Alabu (cupping therapy) was performed	(Image 2)	No visible changes and the irritation was reduced. Hair continued to fall out.
	Punarnava Mandoor	2 tablets (125 mg each) BD Before food
	Poorna chandrodaya rasa	1 tablet (125 mg each) BD After food
	Narasimha Rasayana	1 tsp on empty stomach early in the morning along with milk
	Manjistadi Kashaya	3 tsp BD Before food
	Dhurdhurapatradi taila	External application over scalp
2nd month	Modified Alabu (Wet Hijama) was performed		Tiny white hairs were spotted and the irritation was reduced.
	Asanadi Gana Kashaya	3 tsp BD Before food
	Poorna Chandrodaya Rasa	1 tablet (125 mg each) BD After food
	Arogyavardhini Rasa	2 tablets (125 mg each) BD Before food
	Guduchi + Ashwagandha + Amalaki + Musta + Vidanga powder combination	1 tsp BD After food
	Tab. Narasimha Rasayana	2 tab (250 mg) BD
3rd month	Same medicines were repeated		Complete loss of hair observed. The scalp was shiny with little irritation. (Image 4)
5th month	Same medicines were repeated		Fine black hair emerged from her scalp. No further hair fall.
6th month	Tab Narasimha Rasayana	2 tab (250 mg) BD	Hair started growing all over the scalp, No further hair fall
	Guduchi + Ashwagandha + Amalaki + Musta + Vidanga powder combination	1 tsp BD After food
	Manjistadi Kashaya	3 tsp BD Before food
12th month	The same medicines were continued		Hair were black and completely grown covering the whole scalp, No further hair fall was noticed. (Images 5 & 6)

2.2. Diagnostic assessments

We requested her regular bloodwork and thyroid profile. The reports, however, were all within acceptable ranges.

3. Therapeutic interventions

The mainstay of treatment for this patient was modified Alabu Chikitsa (Cupping Therapy), Krimighna Chikitsa, Rakta prasadana, Keshya (Hair Nourishing) and coupled with Rasayana medications. Modified alabu (cupping therapy (CT)) was scheduled for the second week. Before CT, local lekhana karma (scraping) was carried out using parijata patra (leaves of Nyctanthes arbor-tristis). Then, Prachchana karma was performed on three sites (Image 4). The cups were kept at the sites, and vacuum was produced using the pump. It was kept at the site for 10–15 min until it began to loosen. After that, the area was cleansed with an antiseptic solution. The therapeutic intervention, observation and results are listed in Table 1.

4. Follow-ups and outcome

She experienced extensive hair loss on her scalp after the CT scan, even after the next follow-up. The medications were continued for a month and later changes began to occur. The detailed findings are listed in Table 1. There was an inconsistent patient follow-up. She missed 7–8 months of visits because of the lockdown due to the COVID pandemic. (Images 5 & 6).

Tiny hair started to grow in the areas after 15 days of this therapy. But after 4 weeks 100 % hair was lost. The scalp was shiny, and local irritation was there. Cupping therapy was performed again. The medications were continued as mentioned in Table 1. Three weeks later, hair began to emerge and gradually grow.

5. Discussion

According to Ayurveda, the Vata and pitta doshas aggravate and reach the roots of the hair and destroy them, causing hair loss. Following that, the Rakta and Kapha will block the pores and inhibit further hair growth. This disorder is known as Indralupta or Khalitya [[9], [10], [11]].

Excessive indulgence in the consumption of Kshara (Alkaline), Lavana (Salt), Katu (Spicy) and Viruddha Ahara (Unwholesome food) have been mentioned as etiological factors for hair loss by Acharya Charaka [12]. Mental tension, anxiety, anger, and shock can enhance Pitta and Vata Dosha. While Vata has an aggravation in its Ruksha, Khara, and Chala qualities, Pitta's Ushna and Tikshna properties are increased. An exacerbated Pitta (Bhrajaka Pitta) assisted by vitiated Dehoshma destroys the Keshabhoomi, while an enhanced Vata causes more frequent and protracted Sirasankocha via its Ruksha and Khara Guna. Normal Kapha Dosha's Snigdhatva and Pichchhilatva maintain the skin smooth and moist. By intensifying the Ushna, and Tikshna, properties of pitta the kapha at the scalp gets liquified and fills the roma kupa (pores). Ruksha, and Khara qualities of Vata Dosha, the Sneha and Pichchhilatva of the Kapha Dosha are dried up inside the pores of the scalp skin, preventing the formation of new hair and producing Indralupta [13].

Many scholars have reported that cupping therapy improves blood circulation and removes toxins and waste from microcirculation [14]. This can be done by enhancing microcirculation, stimulating capillary endothelial cell healing, speeding granulation and angiogenesis in localized tissues, and gradually relaxing the patient's muscles [15]. Cupping eliminates toxic elements from microcirculation and interstitial compartment, benefiting the patient [16].

Cupping tends to activate the complement system and modulate the cellular immune system [17]. It lowers aberrant immune system IgE, IL-2, and C3 levels [18]. It affects the immune system in three pathways. First, it provokes an artificial local inflammation, which infuriates the immune system. Second, triggers the complementary system. Third, amplifies immunological products like interferon and TNF. It also affects the thymus and promotes lymphatic flow [19]. Activation of the immune system by cupping may explain its diverse effects, including therapeutic results in individuals with autoimmune illnesses. Therefore, cupping may have been a significant factor in stimulating the immune system, which helped to facilitate hair eruptions.

Cupping therapy and Alabu Chikitsa share a similar concept of blood removal. In Alabu Chikitsa, a dried vegetable shell, particularly a bottle gourd, is used on the chosen area of the body. Small, shallow pricks are made on the site, and a vacuum is created inside the bottle gourd using Deepaka, such as a small lamp light or burning cotton. This vacuum draws out the air, resulting in the vitiated blood oozing out from the pricked site. In cupping therapy, the same principle is applied, but instead of using a bottle gourd, acrylic or glass cups are used. A pump is employed to create the vacuum inside the cups. Due to this modification, the therapy is referred to as Modified Alabu Chikitsa. The scraping (Lekhana karma) was carried out using parijata patra, which was selected due to its coarse leaves prior to the CT to remove or to scrap off the adherent dead tissue or debris. And it will also improve local blood circulation.

Krimighna therapy (Deworming) was used as the first course of therapy. Krimikuthar rasa, Vidangarista were chosen for the krimighna karma. The components of the Arogyavardhini compound, such as Tamra Bhasma, Triphala, Lasuna, Guggulu, which have Dipana and Pachana properties and remove Ama (the intermediate byproduct of digestion and metabolism), Triphala, Shilajita, and Kutaki, reduce Kleda (fluidity), and Meda and Guggulu, which remove Avarana of Vata and clear the srotas. Further Pharmacological actions and therapeutic indications of all the prescribed medicines are listed in Table 2. Punarnava Mandoor possesses pandughna, krimighna, and kustaghna actions. There is reported evidence that Punarnava Mandor (PM) has the potential to significantly increase iron levels in the body [21]. PM plays a vital role in supplying iron to the hair roots, thereby enhancing their strength and supporting their growth.

Table 2.

Medicines, pharmacological actions, and therapeutic indications [20].

Sl. No	Medications	Actions	Ayurvedic Therapeutic Indications
1.	Krimikuthara Rasa	Krimighna	Krimi (Worms)
2.	Vidangarista	Krimighna	Krimi (Worms)
3.	Arogya Vardhini Rasa [20]	Antioxidant, Antihyperlipidemic, Hepatoprotective Cholerectic Effect [36]	Jirna Jwara (Chronic Fever), Medodosha (Disorder Of Adipose Tissue), Kushtha (Diseases of Skin), Yakrutvikara (Disorder Of Liver)
4.	Punarnava Mandoor	Carminative, Hematinic	Pandu, Grahani, Sotha, Pleeha Roga, Vishamajwara, Arsha, Kusta, Krimi
5.	Poorna Chandrodaya Rasa	Rejuvenator, Aphrodisiac	Rasayana, Vrushya,
6.	Narasimha Rasayana	Hair Growth Promoter Rejuvenator, Aphrodisiac	Rasayana, Vrushya, Keshya, Balya
7.	Manjistadi Kashaya	Free Radical Scavenging, Antioxidant, Blood Purifier	Vartarakta, Pama, Kapalika, Kushtha, Medodosha, Raktamandala,
8.	Asanadi Gana Kashaya	Antidiabetic, Antihyperlipidemic [22]	Switra, Kusta, Kapha And Medo Dosha, Krimi, Pandu Prameha
9.	Guduchi [24] Tinospora Cordifolia (Willd.)	Immunomodulator, Antimicrobial, Analgesic, Antistress, Antiallergic, Antioxidant Activities.	Kushtha, Vatarakta, Jvara, Kamala, Pandu, Rasayana, krimi
	10. Ashwagandha [25,26] Withania Somnifera L.	Anti-Diabetic, Anti-Inflammatory, Anti-Microbial, Anti-Stress, Cardioprotective, Or Neuroprotective Enhanced Endothelial Function, Antioxidant, Modulates Mitochondrial Function, Thyroid Function, And Skin Diseases	Shotha, Kshyaya, Daurbalya, Vataroga, Klaibya. Rasayana, Balya, Vrishya.
	11. Amalaki [[27], [28], [29]] [[27], [28], [29]] [[27], [28], [29]] Emblica Officinalis Gaertn.	Immunostimulant Activity And Moderate Cytoprotective Antioxidant, Anti-Inflammatory, Anti-Microbial, Anti-Stress, Cardioprotective	Raktapitta, amlapitta, prameha, daha, keshya
	12. Musta [30] Cyperus Rotundus L.	Antioxidant, Anti-Inflammatory, Antimicrobial, Anticancer, Neuroprotective, Antidepressive, Antiarthritic, Antiobesity, Vasodilator, Spasmolytic, Bronchodilator, And Estrogenic	Agnimandya, atisara, shwasa, amavata, atisara, jvara, kasa, mutrakrichra, trishna, ajeerna, krimiroga, keshya
	13. Vidanga [37] Embelia Ribes Burm F.	Antioxidant Activity, Wound Healing, Antidiabetic, Central Nervous System (CNS)-Related Disease, Antiviral, Antiobesity, Cardioprotective, Antifungal, Antibacterial	Shula, Krimiroga, Udararoga, Adhmana
14.	Dhurdhurapatradi taila	Anti-dandruff	Darunaka
15.	Malatyadi Taila	Hair growth Promoting	Indralupta
16.	Poornachandrodaya Rasa	Rejuvenating	Rasayana

Asanadi gana Kashaya possesses Laghu, Ruksha and Sheeta guna; Tikta and Kashaya rasa and Katu Vipaka. They have shoshana and shodhana of kleda, meda, vasa, mutra & sweda, and rakta prasadana guna due to which mitigates raktagata and romakupa gata kleda and meda [22].The kleda have likely been alleviated by Asanadi Gana Kashaya, facilitating hair growth.

The Dhurdhurapatradi taila contains Datura (Dhatura metal), which has qualities such as Rookshana, Teekshana, Vyavayi, Vikasi, and Sukshma in addition to Kapha-Vata hara. It alleviates Abhishyanda, Sweda, Kleda & Vridhha Mala. Additionally, it possesses properties known as Kandughna (relieve itching) and Krimighna [23]. The Kandughna and Krimighna characteristics' cleaning of the hair roots may have aided in promoting hair growth.

The Guduchi, Ashwagandha, Amalaki, Musta, and Vidanga ingredients in the churna combination have all been demonstrated to have immunomodulatory, antioxidant, and antistress effects [[24], [25], [26], [27], [28], [29], [30]], all of which are essential for immune activation for hair regeneration. Guduchi, ashwagandha and amalaka are known for their Rasayana effect. Musta and amalaka are mentioned as Keshya. Vidanga is krimighna.

The Malatyadi Taila constituents (Malati [31], Karaveera [32], Karanja [33] and Chitraka [34]) have also been evaluated as a potential benefit in promoting hair growth. These contents are ushna, teexna and lekhana properties which facilitate avarana and medoharana. Malati (Jasmenium grandiflorum) has shown antioxidant, antiulcer, antimicrobial and wound healing properties [31]. Dey P et al. have demonstrated that Nerium Indicum (Karaveera) has demonstrated potent anti-inflammatory activity by inhibiting PGE2 expression in murine lymphocytes. This is possibly due to the suppression of NO, TNF-, and COX activity and an increase in IL-10 levels, as well as immunomodulatory activity by up-regulating IL-2, IFN-, and IL-10 expression and down-regulating IL-4, TNF-, in vitro [32,35].

6. Conclusion

Altogether, the synergetic immunomodulatory, antioxidant, antistress, and other effects of all the medicines along with the immunostimulant effect of cupping therapy might have had beneficiary actions in this patient. Large-scale clinical trials and more sophisticated assessment criteria are required to determine the overall efficacy of these medicines.

7. Patient perspective

The patient was happy with the treatment, and cooperative throughout the treatment. Her informed consent was obtained prior to the publication.

Sources of funding

Nil.

Author contribution details

Dr Shivanand P: Concepts, Design, Definition of intellectual content, Clinical studies, Experimental studies, Data acquisition, Data analysis, Manuscript preparation, Manuscript editing, Manuscript review. Dr Giramalla P: Literature search, Clinical studies, Experimental studies, Data analysis, Manuscript preparation. Dr Vijay P: Definition of intellectual content, Literature search, Data analysis, Manuscript editing.

Declaration of competing interest

None.

Appendix A. Supplementary data

The following are the Supplementary data to this article.

figs1.

figs2.