Ayurvedic management of alopecia areata: A case report

Abstract

Índralupta is a disease characterized by patches of hair loss spread throughout the body and scalp. It can be considered alopecia areata according to conventional medical care. The present case report is on the effectiveness of shodhana (treatment in which aggravated doshas are expelled from the body) and shamana (treatment that pacifies the aggravated doshas) in the patient of índralupta. A patient 25 years old, had hair loss patches on the scalp and many other areas of the body. The patient took conventional modern medicine as well as ayurveda treatment but didn’t get a satisfactory result. The patient was hospitalized and treated with vamana (medicated emesis), virechana (medicated purgation), basti (administration of medicine through procto-colonic route), raktamokshana (blood-letting), and nasya (medicine administered through nasal route) along with shamana treatment for more than 6 weeks. The hair eruption started from many patches of the scalp and whole body. In this case, regrowth of hair from hair follicles was evident within 15 days of treatment. The collected data of this study suggest that shodhana and shamana treatment can provide noteworthy relief in índralupta.

1. Introduction

Hair contributes to one’s personality and reflects overall identity. In ladies, hair symbolizes femineity and nature gifted ornament. Men typically associate a full head with youth and vigor. It is a crowning glory to one’s personality and the center of attraction. So, each one is extra conscious about it and is in search of a better remedy for hair growth. Hair thinning, pattern baldness, hair fall, etc. are growing issues of the society which everyone is aware of but refrains to talk about it. Hence, hair is a sensitive issue for both genders. In today’s fast-moving world, it increases due to pollution, improper diet and regimen, stress and tension, increased industrialization and urbanization, and other intrinsic factors and genetic cause. Loss of hair in any form can cause issues with physical appearance and psychological problems. Ayurveda approach suggests, that diseases related to hair loss are described in various classical textbooks with different names i.e., indralupta, khalitya, and rujaya or ruhaya [[1], [2], [3]] (1. Ni 13/33–34, 2. Utt 23/24–25, 3. Chi 26/132). In Madhukosha tika (commentary) of Madhava nidana, it is commented that indralupta is the one that occurs on the mustache and beard, khalitya on the scalp, and rujaya/ruhaya on the entire body [4] (55/28–29) Hence, índralupta can be considered alopecia areata. According to ayurveda, vitiated pitta in association with vitiated vata causes the falling of hairs from the scalp. After that, vitiated rakta and kapha block the orifices of the hair follicles which restricts the growth of new hair. Thus, vata, pitta, and kapha dosha (three factors responsible for all physiological processes inside the body) and rakta dushya (one of the sites in the body where the disease occurs) are the main internal causative factors of índralupta. The shodhana chikitsa has been described as the first line of treatment followed by shamana chikitsa in this type of disorder [3] (Chi 26/262).

The present treatment available in modern medicine is divided into first-line, second-line, and third-line therapies. First-line therapy consists of intralesional corticosteroids, topical corticosteroids, minoxidil, anthralin, topical immunotherapy, prostaglandin analogs, topical retinoids, bexarotene, and capsaicin. Second-line therapy consists of sulfasalazine, photochemotherapy, excimer laser, and fractional photothermolysis laser. Third-line therapy consists of systemic corticosteroids, methotrexate, cyclosporine, azathioprine, and biologics. None of the agents available currently for treating this condition is curative or preventive completely [5,6]. There is a need for treatment that facilitates hair growth. In ayurveda, shodhana, and shamana both types of treatment are described for such patients. This case report describes the usefulness of ayurvedic management (shodhana and shamana chikitsa) in the treatment of alopecia areata.

2. Patient information

On 24th December 2020, a 25 years old patient, unmarried, previously working as an assistant professor in an animation academy, came to the OPD of kayachikitsa department of P D Patel Ayurveda Hospital. The patient had complained of patchy hair loss from all over the body for 5 years with associated complaints of hard, unsatisfactory defecation and flatulence for 2–3 years. The patient was relatively healthy before 5 years. The patient identified a small patch of hair loss on the scalp before 5 years. The patient visited a dermatologist in Anand where the diagnosis was done as alopecia areata and treated for the same. Eventually, he recovered from it but similar complaints reoccurred 3 years back in which small patches of hair loss developed on the scalp, hand, chest, and eyebrow. The patient again took medicine for the same, but only the patch on the scalp recovered, the others persisted. After 2 years, again similar patches of hair loss started appearing on the scalp, beard, and mustache. Around 1.5 years back, the patient consulted a dermatologist, where Inj. Triamcinolone single dose was given, and a few days later patient started experiencing severe patchy hair loss from all over the body after which the patient stopped the allopathic medication. The patient took ayurveda medicine from Anand for a brief period but had no visible relief. After this, the patient came to P. D. Patel Ayurveda Hospital for further treatment. No family history is observed. The patient has a history of dengue in 2018.

3. Clinical findings

The patient had hair loss in patches from the scalp and the whole body for the past 5 years, hard, unsatisfactory defecation for the past 2–3 years, flatulence for the past 2–3 years, the general condition was good, all the vitals were normal and moderately built with no other systemic illness.

Ashtavidha pariksha

• 1.Nadi: Vata-kapha
• 2.Mutra: Normal out-put, no abnormality in urine
• 3.Mala: Hard stool, once in a day, not satisfied, sometimes foul smell
• 4.Jihva: Normal in size and shape and color, no coating or cracks on the surface, nirama
• 5.Shabda: No abnormal sound
• 6.Sparsha: Normal sparsha of the affected part
• 7.Drik: Normal
• 8.Akriti: Madhyama sharira (normosthenic), several patches of hair loss are seen on the scalp and whole body in an asymmetrical pattern

4. Timeline

The Table 1 represents the timeline of the occurrence of events in the present case study. It represents all the symptoms along with the previous treatment taken by the patient and the results obtained.

Table 1.

TIMELINE.

2015	Small patches of hair loss on the scalp, recovered fully after allopathic treatment.
2017	Small patches of hair loss on the scalp, hand, chest, and eyebrow. Patches on the scalp recovered fully after allopathic medicine, but that on the hand, chest, and eyebrow persisted.
2018–2019	Small patches of hair loss on the scalp reoccurred, with few on the beard and mustache, other patches persisted. Consulted a dermatologist, where a single dose of Inj. Triamcinolone was given. Only in a few days, severe patchy hair loss started from all over the body, after which the patient totally stopped his allopathic medication.
2020	Took panchakarma procedures- vamana and virechana, ayurveda medication from Anand for a brief period but had no satisfactory result.
24th December, 2020	The patient came to P D Patel Ayurveda Hospital with complaints of patchy hair loss from the scalp and the whole body for 5 years with hard, unsatisfactory defecation, and flatulence for 2–3 years.

5. Diagnostic findings

Several patches of hair loss are seen on the scalp and whole body in an asymmetrical pattern.

The patient was already pre-diagnosed with alopecia areata by well-known dermatologists of Anand. The routine laboratory investigations did not suggest any systemic or other illness.

• Hb – 12.6 gm%. The rest of the CBC was within normal limits.

• FBS – 95.6 mg/dl

• TSH – 0.532 mIU/ml

6. Treatment schedule

The patient was treated through shodhana (please see Table 2) and shamana treatment as follows.

• Shamana chikitsa

Table 2.

SHODHANA CHIKITSA.

Date	PROCEDURE/TREATMENT	OTHER DETAILS
24/12/20 to 27/12/20	Panchatiktaghruta Snehapana	40 ml twice daily with water in increasing dose (85 ml twice was the last dose given on 27/12/20) empty stomach in the morning and evening.
28/12/20–29/12/20	Sarvanga Abhyanga – Jatyadi Taila Sarvanga Bashpa Svedana- Nirgundi Patrena	On 28th Dec., morning, the patient had 3 frequencies of loose and slimy stool.
29/12/20	Vamana Karma Madanphala Churna −3.5 gm Madhu-as per required Yavani Dhuma Nasya	Vamana Karma is done in the morning.No lunch was given. Peya was given at 4 o’clock when the patient was hungry.
30/12/20–31/12/20	Sansarjana Karma	On 30th Dec., Lunch – Peya, Dinner – liquid khichdi. On 31st Dec., Lunch – liquid khichdi, Dinner - Khichdi
1/1/21 to 4/1/21	Panchatiktaghruta Snehapana	40 ml twice daily with water in increasing dose (85 ml twice was the last dose given on 4/1/21) empty stomach in the morning and evening.
5/1/21 to 7/1/21	Sarvanga Abhyanga – Jatyadi Taila Sarvanga Bashpa svedana- Nirgundi Patrena	On 4th Jan, night, the patient had 2 frequencies of loose and slimy stool. On 5th Jan, the morning the patient felt a lightness in the body.
7/1/21	Virechana Karma- - Eranda Sneha – 50 ml - Dindayala Churna – 5 gm	Virechana Karma done in the morning. Diet was the same as on 29th Dec.
8/1/21 - 9/1/21	Sansarjana Karma	Same like 30th Dec. and 31st Dec.
From 10/01/21 Daily	Sarvanga Abhyanga and Sarvanga Bashpa Svedana	30 days Abhyanga and Svedana
From 10/01/21 Daily	Prachanna Karma daily followed by Shirolepa with Nirgundi Patra + Japa Pushpa + Shrungi Bhasma (1 g)	30 days Prachanna daily before Lepa.
From 10/01/21 Alternate day	Niruha Basti (Dashmula Kvatha 320 ml)	Total 15 Niruha Basti. Empty stomach
From 10/01/21 Once a week	Raktamokshana by Siravedha	4 times

Shamana chikitsa was started from the next day of completion of sansarjana krama after the virechana. The following treatment was given. Daily shirobasti with bhringraja taila in the afternoon (30 shiro basti). Matra basti (bala taila 40 ml) on alternate days in the evening after dinner. Basti (1st with niruha) was started on the 10th of January. Total 15 niruha and 15 matra basti were given. Shatavri kshirpaka 100 ml twice empty stomach.

Sanshamani vati 2 tabs (500 mg each) twice before a meal with water. Dhatri rasayana 3 gm twice empty stomach with water.

Bhringraja churna 2 gm twice before a meal with water. Nasya karma with anu taila (6 drops) every day in the evening empty stomach (done for 30 days). The patient was allowed an ordinary diet that contains rice, chapati, veggies, and legumes for the period of shamana chikitsa.

7. Outcomes and follow-up

In the shodhana treatment, vamana and virechana were completed without any complications and no complications were observed post the procedures. The vamana karma got completed with pittanta sudhi, 6 bouts, and virechana karma got completed with kaphanta sudhi and 16 vegas.

The change in symptoms were as follows: As per the Fig. 1, Fig. 2, Fig. 3, Fig. 4, Fig. 5, Fig. 6, there was no visible hair or hair roots at various places on the scalp before treatment. After 15 days of treatment, there was visible hair eruption at many places on the scalp. There was a change in the condition of the patient after 30 days of treatment and the marginal area of the patches had considerably reduced. The images were taken 15–15 days apart and regrowth of hair was seen after the treatment.

Fig. 1.

Top view of scalp shows patches of hair loss before treatment, after 15 days of treatment, after 30 days of treatment, and after 5 months of treatment.

Fig. 2.

Right side view of scalp shows patches of hair loss before treatment, after 15 days of treatment, after 30 days of treatment, and after 5 months of treatment.

Fig. 3.

Back view of scalp shows patches of hair loss before treatment, after 15 days of treatment, after 30 days of treatment, and after 5 months of treatment.

Fig. 4.

Left side view of scalp shows patches of hair loss before treatment, after 15 days of treatment, after 30 days of treatment, and after 5 months of treatment.

Fig. 5.

Hands show patches of hair loss before treatment, after 15 days of treatment, after 30 days of treatment, and after 5 months of treatment.

Fig. 6.

Legs show patches of hair loss before treatment, after 15 days of treatment, and after 30 days of treatment.

After discharge from the hospital, the patient was instructed to continue the oral shamana treatment and lepana karma (local application of ayurveda medicine) along with pathya (wholesome diet regimen). Thereafter, the patient regularly came to the hospital for follow-up and continued the treatment. During follow-up, more improvement was recorded which is highlighted in the figures.

8. Discussion

Ayurveda approach suggests, that all tridosha, and rakta dushya are the main responsible factors of the internal body for the development of índralupta. In this case, the patient had a history of irregular food habits, untimely munching of snacks, consumption of junk food, irregular sleeping patterns, and changing different cities for studies. These factors are known to vitiate the doshas and dushyas which can be termed responsible for the occurrence of disease.

The patient took ayurveda treatment from another hospital where shodhana like vamana and virechana were done on an OPD basis which might be the cause of the non-attainment of the results. Pathya-apathya were not followed properly. Also, prachanna and raktamokshana were not done to remove local doshas.

The shodhana chikitsa-vamana and virechana done here balanced out the imbalanced doshas. In between the two consecutive shodhana, the agnibala was prakrut and proper samayak snehana lakshana were obtained after the snehpana. The vamana helped in eliminating the obstructed kapha [[2], [3]] (2. Su 13/4, 3. Si 2/13) from the hair follicles of the whole body, virechana helped in pitta shamana [[2], [3]] (2. Su 13/4, 3. Si 2/13). These shodhana karmas did desha shodhana and balanced all the three doshas which in turn helped in the proper digestion of the ahara (food), leading to the formation of proper ahara rasa and rasadi dhatus.

Raktamokshana especially prachchanna (blood-letting in which scraping is mainly used) is good to eliminate the vitiated rakta if it is situated in a local part of the body [2] (Su 26/53) i.e., hair follicles and due to that reason, it was done before the application of lepa. Similarly, siravedhana (blood-letting through vein-puncture) was selected as the patches of hair loss were present on the entire body, and to eliminate the vitiated rakta spread in many parts of the body, siravedhana is preferable [[1], [2]] (1. Chi 20/24–25, 2. Su 26/53–54).

Basti is helpful to balance the vitiated vata of the body [[2], [3]] (2. Su 13/2–3, 3. Si 2/16, 3. Si 2/19). Ayurveda approach suggests that the kesha are kitta bhaga (waste product) of asthi dhatu [3] (Chi 15/19). Asthi dhatu and vata dosha have specific ashrayashrayi bhava (inversely interdependence relation) in which increased vata dosha results in asthi ksahaya [2] (Su 11/26). A combination of vatahara and brihmana basti will allow the vata dosha to do its normal functions and proper formation of asthi dhatu eventually leading to regrowth of the hair. Panchakarma, basti, tikta rasa ausadhi, kshira, and ghrita are mentioned for asthi dhatu chikitsa in ayurveda classics [3] (Su 28/27). Nasya is the gateway to shira and is used to treat urdhvajatrugata roga by balancing all the doshas [3] (Si 2/22). Nasya was done by anu taila as it has brihmana properties. Also, anu taila nasya was indicated in the management of the present clinical entity [3] (Chi 26/264).

The oral medicaments that balance out vata, pitta, kapha, and rakta and having action of keshaya (conducive to the growth of hair) and rasayana help promote the regrowth of hairs [3] (Chi 1/1/8). Panchatikta ghrit snehapana was used here for shodhanartha snehpana before shodhana karma. It is indicated for skin disorders hence; it may be beneficial in this disorder [7] (9/91–92). Jatyadi taila is useful in skin disorders and its ingredients are also mentioned as keshya. Japa and nirgundi are mentioned as keshya in bhavaprakasha nighantu.

The results obtained here can be explained based on the shodhana and shamana treatment. Many clinical studies were found on this clinical entity. These studies either highlighted the results of only shamana or some external applications with it or the use of only local procedures i.e., pracchhanna karma and jalaukavacharana. In this case, the use of all the karmas, vamana, virechana, niruha, and anuvasana basti, raktamokshana, and nasya along with shamana treatment performed can be credited for the results obtained.

Recurrence is a major issue in the treatment of alopecia. Here, in this case, recurrence was observed after complete relief by allopathic medication in 2015. No recurrence was observed during the twelve months of follow-up of ayurveda treatment done at P. D. Patel Ayurveda Hospital. The patient is regularly coming for the follow-up and following the diet and medicaments. Recent photos were taken (Fig. 7), where improvement in the patient’s condition and appearance of thick, smooth, soft quality hair in natural color is visible.

Fig. 7.

Regrowth of hair on the previous hair loss patches show effect of treatment in the current situation.

8.1. Patient perspective

When he came to this hospital, he had several patches of hair loss on his scalp, chest, hands, legs, etc. The changes were visible after vamana and virechana. Hair eruption had started on several patches that were present on the scalp, chest, hands, legs, etc. Also, after lepa and raktamokshana he had considerable changes.

8.2. Conclusion

We conclude that the ayurveda treatment used for this patient for one month was beneficial and the regrowth of hair started in several patches considerably in 15 days. The results obtained from this treatment show that further research can be undertaken based on this treatment plan for the ayurvedic management of alopecia areata (índralupta).

9. Patient perspective

The patient – “When I came to this hospital, I had several patches of hair loss on my scalp, chest, hands, legs, etc. The changes were visible after vamana and virechana. Hair eruption has started on several patches that were present on the scalp, chest, hands, legs, etc. Also, after lepa and raktamokshana I have considerable changes.”

10. Informed consent

Written permission for publication of this case study was obtained from the patient.

Funding source

The authors are thankful to the organization J. S. Ayurveda Mahavidyalaya where the research was carried out as they have funded the APC.

Declaration of competing interest

None.