Abstract
A 57 years old male patient was admitted to an inpatient Naturopathy and Yoga (N&Y) hospital, diagnosed with pemphigus vulgaris (PV) for one year and co-morbid type 2 diabetes (T2DM) for 10 years, associated with poor quality of life (QoL). He was administered N&Y therapies for 10 days, along with conventional medicines. There was improved QoL and reduced dosage of insulin, along with reduction in body weight. These changes were sustained and improved further during the 60-day follow-up period. Although there was no improvement in the skin lesions, the improvement in QoL indicate a possible role of N&Y in management of PV and T2DM. This case report also warrants further studies for N&Y in the management of dermatological conditions as well as metabolic syndrome.
Keywords: Autoimmunity, Dermatology, Integrative medicine, Naturopathy, Pemphigus vulgaris, Yoga
1. Introduction
Pemphigus vulgaris (PV) is a chronic, intraepidermal bullous, autoimmune, life threatening disease characterized by erosions and blisters of skin and mucous membranes. PV is an uncommon disease with an incidence ranging from 0.076 to 5 per 100,000 person [1]. It affects all races and ethnicity with high incidence in Ashkenazi Jews and people with Mediterranean descent. In India, PV is the commonest variant among the pemphigus group of disorders [2]. PV is associated with IgG antibodies targeting several types of keratinocyte antigens and eliciting epidermal clefting (acantholysis) via intracellular signaling activating apoptotic enzymes (apoptolysis) [3]. PV is caused by circulating autoantibodies to the epithelial adhesion proteins desmoglein 1 and 3. These autoantibodies result in a failure of epidermal cells to adhere correctly to each other. This causes flaccid blisters and subsequently painful erosions in the skin and mucus membranes.
All types of skin diseases are significantly related to physical and psychological disturbances. PV affects the attitude and quality of life (QoL) of the patients as it covers the large surface area of the skin along with mucous membrane [4]. Patients suffering from PV have physical, emotional and psychological burden as there is no cure for it. Palliative management strategies are used to minimize the diseases progression, mostly thorough use of immunosuppression therapies [1].
Naturopathic medicine is a drugless, noninvasive, evidence-based medicine which provides the suitable environment for self-healing [5]. Yoga therapy is broadly used for psychological, and physical health. In India, Naturopathy and Yoga (N&Y) are used as a single system of medicine [6]. Although there is growing evidence for the role of N&Y to enhance QoL and management of symptoms in various disorders [7,8], there are no studies reporting their effect on PV. Thus, the current case study presents role of N&Y in improving the QoL and management of co-morbidities with PV.
2. Presenting concerns
A 57 years old male patient was admitted in a N&Y hospital with history of PV for 1 year. He was diagnosed with PV through histopathological study, when he approached a hospital for fluid filled lesions on chest and back region, which later spread all over of the body. The lesions ruptured, causing itching sensation over the area. He was taking Tab. Deflazacort 15 mg OD for managing the PV. He also had been diagnosed with type 2 diabetes (T2DM) for 10 years, managed with Human Mixtard Insulin injections (30 units/day), Tab. Glimepiride 2 mg OD and Tab. Metformin 500 mg OD.
3. Clinical findings
A detailed case history was taken when he was admitted to the hospital. The height of the patient was found to be 173 cm, weight was 72 kg and Body Mass Index (BMI) was calculated to be 24.06 kg/m2. His resting blood pressure was found to be 118/78 mmHg, pulse rate was 78 beats/m. On examination, maculopapular rashes were observed all over his chest, abdomen and back.
4. Diagnostic focus and assessments
Dermatology Life Quality Index (DLQI) is a simple and reliable tool (Chronbach's alpha ranging from 0.83 to 0.93) to assess QoL in patients with dermatological conditions, with a score ranging from 0 to 30. A higher score indicates poorer QoL [9]. DLQI scores were obtained on the day of admission (day 1) and on the day of discharge (day 10), and on follow up on 30th and 60th day from the day of admission. Fasting (FBG) and Post Prandial Blood Glucose (PPBG) levels were monitored using glucometer on day 1, 10, 30 and 60.
5. Methods
Following a detailed history, initial counseling and signed informed consent, the N&Y therapies were planned. The dosage of insulin and oral hypoglycemics was tapered while monitoring the blood glucose levels. He was admitted to the inpatient facility for 10 days. Later he was given a follow-up N&Y plan. The follow up data was obtained through email and telephonic feedback. The timeline of the case is depicted in Table 1.
Table 1.
Timeline of the case.
| Health Event | Time |
|---|---|
| Diagnaosis of Type 2 Diabetes | December 2007 |
| Initial Diagnosis of Pamphigus vulgaris | June 2016 |
| Admission to Yoga and Naturopathy Hospital | 18 July 2017 |
| Discharge | 28 July 2017 |
| First Follow up | 27 August 2017 |
| Second Follow up | 26 September 2017 |
6. Therapeutic focus and assessment
The patient was kept on a calorie restricted (estimated at about 800 Kcal/day), wholesome vegetarian diet consisting of seasonal fruits (water melon/papaya/pomegranate), salads (prepared from green gram sprouts/carrot/leafy vegetables) and boiled vegetables. The calorific value of the food was calculated by using the quantity of each food item and their estimated calorific value as suggested by the National Institute of Nutrition, Hyderabad [10]. The N&Y module was adapted from an earlier study on metabolic syndrome [6], with changes made based on the patient's response assessed in the daily visit of the physician. In addition, considering the skin ailment of the patient, topical application of neem oil, and turmeric paste in the red-rice paste was also added to the Naturopathy protocol. The Yoga therapy practices consisted of asana, pranayama, deep relaxation, suddhi-kriya and dhyana. The N&Y module is presented in Table 2a, Table 2bb.
Table 2a.
List of Naturopathy therapies administered during the patient's inpatient stay.
| Day | Morning Therapy (duration ~ 45 min) | Afternoon Therapy (duration ~ 20 min) |
|---|---|---|
| 1 | Rest | Gastro Hepatic Pack |
| 2 | Red rice paste with turmeric to whole body | Cold Hip Bath |
| 3 | Mud application to whole body | Gastro Hepatic Pack |
| 4 | Red rice paste with turmeric to whole body | Cold Hip Bath |
| 5 | Neem oil application to whole body | Whole body dry sauna |
| 6 | Mud application to whole body | Gastro Hepatic Pack |
| 7 | Red rice paste with turmeric to whole body | Cold Hip Bath |
| 8 | Mud application to whole body | Gastro Hepatic Pack |
| 9 | Red rice paste with turmeric to whole body | Whole body dry sauna |
| 10 |
Neem oil application to whole body |
Gastro Hepatic Pack |
| Name of the therapy |
Details of application |
|
| Red Rice Paste with Turmeric to whole body | Paste of red rice (approx. 500 gm) was mixed with freshly ground turmeric paste (about 250 gm) and applied over skin throughout the body. After the plastered paste dried, it was washed off using plain water | |
| Mud application to whole body | Non-contaminated, sun dried black soil, soaked in water overnight was applied over skin throughout the body and left to dry under sunlight. After the plastered mud is dried, it was washed off using plain water | |
| Neem Oil application to whole body | Oil extracted from Azadirachta indica fruits and seeds was applied over the body with gentle massage. Patient was advised not to use any chemical soaps for bath following therapies | |
| Gastro Hepatic Pack | The hot water bag (45 °C) was applied over the abdomen, covering the epigastric, left and right hypogastric, left and right lumbar and umbilical region. The ice bag covered the region of lumbar vertebrae L2, L3, L4 and L5. | |
| Cold Hip Bath | Patient was asked to sit in a specially designed tub immersing from mid-thigh to umbilical region in water (18–24 °C). | |
| Whole Body Dry Sauna | Patient was seated in a specially designed sauna cabin at a temperature of 50–55 °C. | |
Table 2b.
List of Yoga practices.
| Integrative Yoga Protocol for Everyday | ||
|---|---|---|
| Name of the Practices | Details | Duration |
| Loosening practices | Joint loosening practices for hand, leg, neck and trunk | 5 min |
| Suryanamaskara | 12 counts (3 rounds) | 5 min |
| Breathing practices | Hand in & out breathing, hand stretch breathing, straight leg raising with breathing, Salabhasana Breathing, tiger brathing | 10 min |
| Asana practices |
Ardha chakrasana, Ardhakati Chakrasana, Padahastasana Ardha Machendrasana, Vakrasana, Navasana, Parivrtta Trikonasana |
20 min |
| Pranayama |
Kapalabhati (60 strokes/min for ~2 min), Surya anuloma viloma (9 rounds ~1 min) Vibhagiya pranayama (9 rounds each ~3 min) Nadisuddhi (9 rounds ~2 min) Bhramari (9 rounds ~2 min) |
10 min |
| Relaxation | Deep Relaxation Technique (DRT) | 10 min |
| Total Duration | 60 min | |
| Dhyana | Cyclic Meditation | 30 min/session, Sessions on alternate days |
| Suddhi Kriya | Jala Neti, Sutra Neti, Vamana Dhouti | On alternate days |
7. Follow-up
Following the completion of the 10-day inpatient stay at the hospital, the patient was advised to continue calorie restricted vegetarian diet (approx. 1200–1500 Kcal/day), and yoga practices for 1 h/day. He was also advised to continue using the red rice paste with turmeric at least twice a week. The Patient reported to have good compliance with the follow-up advice using the periodic telephone calls. Data on day 30 and day 60 was collected (weight, FBG, PPBG and DLQI) thourgh telephone call.
8. Outcomes
The changes from the day of admission to day 10 and follow up days 30 and 60 are depicted in Table 3. The DLQI scores reduced from 21 on day of admission to 18 on day of discharge and further reduced to 15 on day 60 of follow-up, demonstrating better QoL. The body weight reduced from 72 Kg on admission to 70.5 Kg on day 10, which further reduced to 69 on day 60, with a corresponding reduction in the BMI (24.32, 23.82 and 23.32 kg/m2 on day of admission, day 10 and day 60 respectively). There was a better glycemic control depicted through the FBG (123, 112 and 108 mg/dl on day of admission, day 10 and day 60 respectively) and PPBG (180, 160 and 158 mg/dl on day of admission, day 10 and day 60 respectively) requiring lesser quantity of insulin (from 30 units/day to 10 units/day on day 10 which was constant thereafter through the follow-up period). The dosage of oral hypoglycemics was maintained thorughout the follow-up period.
Table 3.
Changes in the variables on the admission, discharge and follow up.
| Day 1 (admission) | Day 10 (discharge) | Day 30 (follow up) | Day 60 (follow up) | |
|---|---|---|---|---|
| Height (cm) | 172 | – | – | – |
| Weight (kg) | 72 | 70.5 | 70 | 69 |
| Body Mass Index (kg/m2) | 24.32 | 23.82 | 23.65 | 23.32 |
| Fasting Blood Glucose (mg/dl) | 123 | 112 | 102 | 108 |
| Post Prandial Blood Glucose (mg/dl) | 180 | 160 | 154 | 158 |
| Insulin Dosage (units) | 30 | 10 | 10 | 10 |
| Dermatology Life Quality index scores | 21 | 18 | 17 | 15 |
| Systolic Blood Pressure (mmHg) | 118 | 122 | – | – |
| Diastolic Blood Pressure (mmHg) | 78 | 72 | – | – |
9. Discussion
A ten-days N&Y protocol was administered to a 57-year-old male patient suffering from PV and T2DM, followed up for next 60 days. The DLQI scores reduced, which are indicative of better QoL. There was also reduction in the dosage of insulin required to keep the blood glucose in normal range, along with reduction in body weight and BMI. The patient self-reported the N&Y protocol to be easy to adapt and continued to follow the advice given to him on discharge.
Although, no much difference was observed in the skin lesions of PV, there was about 28.5% reduction in the DLQI scores, which is a reliable tool to assess the QoL in patients with dermatological conditions. This is the first study reporting changes in the QoL in patients with PV using N&Y. Earlier reports of use of N&Y are for metabolic syndrome [6], rheumatoid arthritis [11] and urinary incontinence [12].
The changes observed in the QoL in the current study may be due to reduction in symptoms. This may also be due to stress ameliorating effect of yoga [13,14]. Also, calorie restriction performed in this case could help in reducing the body weight and BMI and thereby enhancing insulin sensitivity and concurrently reducing the need for insulin supplement. These observations are similar to an earlier study done on Metabolic syndrome [6]. N&Y could help though normalizing the autonomic functions through an enhanced vagal tone [15]. The other mechanism involved could be reduction in inflammation due to calorie restriction [16]. Also, the turmeric applied along with the red rice paste could act as a topical anti-inflammatory, which is found to be useful in various kinds of arthritis [17]. However, the earlier trials used the extract of the curcumin administered internally, whereas we used turmeric paste as a topical application.
Other therapies such as massage with neem oil may have also helped, since neem oil is considered to have immunomodulatory and anti-inflammatory effects [18]. Earlier studies using topical application of neem oil has found to induce dermatitis [19], however, our patient did not get any adverse reaction. Topical mud application also has been found to be beneficial in dermatological conditions due to the properties of mud [20]. Naturopathic therapies such as hip bath [21] and Gastro Hepatic pack [22] are found to help in management of T2DM.
10. Patient perspective
The patient self-reported feeling of wellness during and following the 10 day inpatient treatments. He found the therapies easy to adapt and follow. He felt comfortable with his body and that prompted him to continue to follow-up of N&Y.
11. Conclusion
The observations from the case study reinforce the utility of N&Y as a possible useful integrative treatment modality in the management of T2DM and as a possible tool to enhance the QoL in patients with PV. Further clinical trials are warrantied to assess the efficacy of N&Y in the management of PV.
Informed consent
An informed written consent was obtained from the patient for reporting this case.
Sources of funding
None.
Conflict of interest
None.
Footnotes
Peer review under responsibility of Transdisciplinary University, Bangalore.
References
- 1.Gupta V.K., Kelbel T.E., Nguyen D., Melonakos K.C., Murrell D.F., Xie Y. A globally available internet-based patient survey of pemphigus vulgaris: epidemiology and disease characteristics. Dermatol Clin. 2011;29:393–404. doi: 10.1016/j.det.2011.03.016. vii–iii. [DOI] [PubMed] [Google Scholar]
- 2.Kanwar A., De D. Pemphigus in India. Indian J dermatology. Venereol Leprol. 2011;77:439. doi: 10.4103/0378-6323.82396. [DOI] [PubMed] [Google Scholar]
- 3.Grando S.A., Bystryn J.-C., Chernyavsky A.I., Frusić-Zlotkin M., Gniadecki R., Lotti R. Apoptolysis: a novel mechanism of skin blistering in pemphigus vulgaris linking the apoptotic pathways to basal cell shrinkage and suprabasal acantholysis. Exp Dermatol. 2009;18:764–770. doi: 10.1111/j.1600-0625.2009.00934.x. [DOI] [PubMed] [Google Scholar]
- 4.Ghodsi S.Z., Chams-Davatchi C., Daneshpazhooh M., Valikhani M., Esmaili N. Quality of life and psychological status of patients with pemphigus vulgaris using dermatology life quality Index and general health questionnaires. J Dermatol. 2012;39:141–144. doi: 10.1111/j.1346-8138.2011.01382.x. [DOI] [PubMed] [Google Scholar]
- 5.Joseph B., Nair P.M., Nanda A. Effects of naturopathy and yoga intervention on CD4 count of the individuals receiving antiretroviral therapy-report from a human immunodeficiency virus sanatorium. Pune. Int J Yoga. 2015;8:122–127. doi: 10.4103/0973-6131.158475. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Gowda S., Mohanty S., Saoji A.A., Nagarathna R. Integrated yoga and naturopathy module in management of metabolic syndrome: a case report. J Ayurveda Integr Med. 2017;8:45–48. doi: 10.1016/j.jaim.2016.10.006. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Nalgirkar S., Vinchurkar S., Saoji A., Mohanty S. Yoga as a therapeutic intervention in the management of dysfunctional uterine bleeding: a controlled pilot study. J Midlife Health. 2018;9:8–13. doi: 10.4103/jmh.JMH_76_17. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Raghavendra P., Shetty P., Shetty S., Manjunath N., Saoji A.A. Effect of high-frequency yoga breathing on pulmonary functions in patients with asthma: a randomized clinical trial. Ann Allergy Asthma Immunol. 2016;117:550–551. doi: 10.1016/j.anai.2016.08.009. [DOI] [PubMed] [Google Scholar]
- 9.Lewis V., Finlay A.Y. 10 Years experience of the dermatology life quality Index (DLQI) J Invest Dermatol Symp Proc. 2004;9:169–180. doi: 10.1111/j.1087-0024.2004.09113.x. [DOI] [PubMed] [Google Scholar]
- 10.Gopalan C., Rama Sastri B.V., Balasubramanian S.C. Hyderabad: National Institute of Nutrition, Indian Council of Medical Research; 2016. Nutritive value of Indian foods. [Google Scholar]
- 11.Shetty G.B., Mooventhan A., Anagha N. Effect of electro-acupuncture, massage, mud, and sauna therapies in patient with rheumatoid arthritis. J Ayurveda Integr Med. 2015;6:295–299. doi: 10.4103/0975-9476.172415. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Vinchurkar S.A., Arankalle D.V. Integrating yoga therapy in the management of urinary incontinence: a case report. J Evid Based Complementary Altern Med. 2015;20:154–156. doi: 10.1177/2156587214563311. [DOI] [PubMed] [Google Scholar]
- 13.Saoji A.A. Yoga: a strategy to cope up stress and enhance wellbeing among medical students. N Am J Med Sci. 2016;8:200–202. doi: 10.4103/1947-2714.179962. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Pascoe M.C., Thompson D.R., Ski C.F. Yoga, mindfulness-based stress reduction and stress-related physiological measures: a meta-analysis. Psychoneuroendocrinology. 2017;86:152–168. doi: 10.1016/j.psyneuen.2017.08.008. [DOI] [PubMed] [Google Scholar]
- 15.Saoji A.A., Raghavendra B.R., Manjunath N.K. Immediate effects of Yoga breathing with intermittent breath retention on the autonomic and cardiovascular variables amongst healthy volunteers. Indian J Physiol Pharmacol. 2018;62:41–50. [Google Scholar]
- 16.Ott B., Skurk T., Hastreiter L., Lagkouvardos I., Fischer S., Büttner J. Effect of caloric restriction on gut permeability, inflammation markers, and fecal microbiota in obese women. Sci Rep. 2017;7:11955. doi: 10.1038/s41598-017-12109-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Funk J.L., Frye J.B., Oyarzo J.N., Kuscuoglu N., Wilson J., McCaffrey G. Efficacy and mechanism of action of turmeric supplements in the treatment of experimental arthritis. Arthritis Rheum. 2006;54:3452–3464. doi: 10.1002/art.22180. [DOI] [PubMed] [Google Scholar]
- 18.Upadhyay S.N., Dhawan S., Garg S., Talwar G.P. Immunomodulatory effects of neem (Azadirachta indica) oil. Int J Immunopharm. 1992;14:1187–1193. doi: 10.1016/0192-0561(92)90054-O. [DOI] [PubMed] [Google Scholar]
- 19.Reutemann P., Ehrlich A. Neem oil: an herbal therapy for alopecia causes dermatitis. Dermat contact, atopic. Occup drug. 2008;19:E12–E15. http://www.ncbi.nlm.nih.gov/pubmed/18627678 Available at: [PubMed] [Google Scholar]
- 20.Matz H., Orion E., Wolf R. Balneotherapy in dermatology. Dermatol Ther. 2003;16:132–140. doi: 10.1046/j.1529-8019.2003.01622.x. http://www.ncbi.nlm.nih.gov/pubmed/12919115 Available at: [DOI] [PubMed] [Google Scholar]
- 21.Mooventhan A., Chaudhari S.S., Venugopal V. Effect of cold hip bath on blood glucose levels in patients with type 2 diabetes mellitus: a pilot study. Diabetes Metabol. 2019 doi: 10.1016/j.diabet.2019.04.003. In press. [DOI] [PubMed] [Google Scholar]
- 22.Mooventhan A., Venugopal V., Chaudhari S.S. Twenty minutes of gastro-hepatic pack reduces blood glucose levels in patients with type 2 diabetes mellitus: A pilot single group pre-post study. Adv Integr Med. 2020 doi: 10.1016/j.aimed.2020.01.002. In press. [DOI] [PubMed] [Google Scholar]