Skin inflammations are becoming increasingly common, with atopic dermatitis or eczema affecting 10–20% of all children and 1–3% of adults and psoriasis affecting between 2 and 2.6% of the US population.
The prevalence of atopic dermatitis prevalence has doubled or tripled in industrialized countries during the past three decades. The visible and often disfiguring nature of skin inflammations leads to far greater levels of distress and depression than would be experienced with a more severe but less disfiguring condition. Because a number of patients are suspicious of cortisone creams prescribed for them by their family practitioner or dermatologist, they may frequently present for Ayurvedic care as an alternative.
Skin and Ayurveda
According to Ayurveda, skin has seven layers, corresponding to the seven dhatus. Similarly, in modern physiology, skin has been found to have seven layers, stratum corneum, on the surface, stratum lucidum, stratum granulosum, stratum spinosum, stratum basale, the basement membrane and the dermis. (See this diagram of the seven layers of the skin.)
At the same time, the epidermis of the skin, as whole, is seen as an secondary (upadhatu) of plasma tissue (rasa dhatu), and the dermis as part of muscle tissue (mamsa dhatu). Skin belongs to bahya marga, the external pathway of disease, and as such is very vulnerable to toxins carried by plasma rasa) and blood (rakta dhatus) during the spreading (prasara) stage of disease, accounting for the relatively common nature of skin inflammations.
Dermatitis
Let us turn our attention first to atopic dermatitis (AD). Also called eczema, this condition is due to a hypersensitivity reaction in bahya marga, leading to long-term skin inflammation which creates itchy and scaly skin. Long-term irritation and scratching may cause the skin to thicken and develop a leathery texture. If the ear canal is affected there may be discharge from the ears (for pictures of atopic dermatitis, for atopic dermatitis on ankles, for atopic dermatitis on arms, for atopic dermatitis in infancy).
Atopic dermatitis is most common in infants, often clearing by the age of three, while in adults it becomes a yapya condition that persists or recurs throughout the lifetime. In infants, lesions of AD begin on the cheeks, elbows and knees, while in adults the lesions are more commonly found on the knees and elbows alone. Typically, AD occurs on the flexor surfaces (the parts of the skin that touch when a joint bends). It arises most often where there is a family history of atopic conditions such as hay fever, asthma and eczema. Because skin belongs to bahya marga, AD is typically the first condition in the atopic picture, later followed by asthma or allergic rhinitis as the atopic process moves from the prasara stage to localize in prana vaha srotas. (1)
A combination of genetic factors (adi bala pravrutta), doshic skin type (dosha bala pravrutta), exposure to environmental allergens (parya varana) and immunological reactivity (pittaja), come together to create the tendency to AD. (1) Vata skin is more prone to AD because of dryness and pitta skin because of its greater irritant response. Manasaja or psychogenic causes also play a part, as stress can trigger an outbreak of AD in both children and adults. Annaja or dietary causes are extremely important in AD, and so are agantu causes or infective agents. In one study, 56% of children with AD were found to have food allergies that could trigger the condition. (3) Major food allergens associated with AD are eggs, cow’s milk, wheat, soy and peanuts (1, 3). Most patients with AD are colonized with Staphylococcusaureus instead of healthy, normal skin flora (1). Hence secondary (anubandha) Staphylococcus aureus overgrowths or infections are typical and can create AD relapses (1, 4). Although AD is not in itself infectious, lesions infected with Staph. aureus can be passed on to others.
Dermatitis treatments
Because AD is a multi-factorial condition, it can only be addressed effectively in a holistic manner, taking into account emollients for doshic skin type, removal of environmental toxins, pacification of pitta and cleansing of pitta ama with a herbal blends such as Guduchi and Neem or Neem and Sarsaparilla, dietary modifications to address annaja causes and ointments to address infective agents. Neem or coconut oil will act as excellent pitta emollients and can be mixed with neem powder as an anti-infective agent. For psychogenic causes, counselling, stress management, yoga and meditation will be beneficial.
Case studies: Patient A
A thirteen year old pitta prakruti girl presented in great distress with AD that affected her arms and face. As a teenager, she found an assault on her appearance to be unbearable. Fortunately for the practitioner, her exasperation rendered her a highly compliant patient. She agreed to use Neem and Sesame oil and to take Triphala and an herbal formula containing Guduchi, Turmeric, Neem and Manjista with Aloe Vera as an carrier (anupan). She was even willing, in her desperation, to follow a one month exclusion diet, eliminating eggs, cow dairy products, wheat, soy and peanuts from her diet completely. We explained to her that exclusion diets are only effective if followed meticulously. “This is an experiment. You don’t have to eat this way for the rest of your life.” Within two weeks of the exclusion diet, her skin had cleared completely. She then began challenging the allergens, one allergen per week. The challenge process used was to eat a significant amount of the suspected item, wait two days and then eat it again. During this process, she learnt that dairy products were the trigger food for her unwanted symptoms. She thus became a staunch devotee of the casein-free diet. She continued her herbal regimen for three more months to ensure that pitta was pacified and pitta toxins removed, after which she remained symptom free by following her prescribed diet.
Case studies: Patient B
A forty two year old pitta woman presented with eczema localized to the fourth finger of her left hand. The symbolism of this location was not lost on us and we explored emotional causes in detail. She had a history of relationships with unavailable men and had remained unmarried as result. Currently, she was in her first promising relationship, with a man who wished to marry her and adopt a family. It is worth noting that her AD remained intractable when treated with a similar herbal regimen to the one which proved highly effective for patient A. In her case, emotional toxins were of more significance than physical ones. Accordingly, we started her on Brahmi tea to help move the emotional toxins. On her third follow up she had an epiphany, realizing that she feared intimacy and had created the eczema, “To make sure I can’t wear a wedding ring.” Following this realization, her eczema rapidly cleared. I last met her in the grocery store. She was proudly wearing a wedding ring and carrying her adopted son in her arms.
Psoriasis
Turning now to psoriasis; this is a condition opposite in many ways to AD. Psoriasis is a non-contagious, genetically based condition that typically appears as inflamed, oedematous skin lesions. The lesions are red and are covered with distinctive silvery white scales.
It is a lifelong illness for which there is no known cure, although it can be quite effectively managed Ayurvedically. Severe cases often move into asthi dhatu, presenting with pitted nails and painful joints. Unlike AD, psoriasis typically manifests on extensor surfaces, is not associated with atopy and does not result in frequent staphylococcal skin infections. It also begins in an older age group, with typical onset between the ages of ten and forty rather than in infancy. Although psoriasis is one of the most common skin conditions, affecting over 7 million Americans, its aetiology has long been poorly understood. It is now widely accepted as an auto-immune disorder sharing the same disease pathways as rheumatoid arthritis and inflammatory bowel disease (6, 7, 8).
In psoriasis, the journey of the keratinocytes from stratum basale to stratum corneum is shortened from 311 to 36 hours (5). The epidermal layer of the skin becomes thicker and cells are distributed abnormally. (5)
Psoriasis treatments
As an auto-immune condition, psoriasis requires a rather different treatment protocol than AD. It is not sufficient to clear pitta toxins and return pitta to its seat. In addition, anti-inflammatory herbs are needed, while pancha karma is necessary to reverse the disease pathways involved in auto-immunity.
Case studies: Patient C
A forty five year old pitta woman presented with psoriasis on her scalp and extensor surfaces. She was vata provoked and under great stress as she was conflicted in her marriage and currently involved in an extra-marital affair. She was given a medicated ghee containing Ashwagandha, Neem and Manjista to apply topically, and an herbal formula which also included Ashwagandha and Manjista, but not neem, on account of her vata provocation. It is important to note the value of Ashwagandha in dry, scaly skin conditions such as psoriasis, and also the role vata provocation may play in flaring up the condition. She took Brahmi tea to help her depression and stress and a formulation of Guduchi and Guggulu as an anti-inflammatory helpful in many auto-immune conditions. With this herbal regimen and a pitta-soothing diet, her psoriasis began to improve gradually. She then did seven days of pancha karma treatments using Refresh Pitta Massage Oil with a few drops of added cold pressed Neem Oil for therapeutic massage (abhyanga), Amalaki for its mild laxative effect (virechan) and decoctions of Dashamoola and Guduchi for basti. After this process, the psoriasis went into complete remission for the first time since its onset at the age of fifteen. She continued to maintain this level of improvement except for a small patch on her scalp, which would flare up whenever she stepped out of integrity with herself in terms of relationships. It was as if this remaining patch on her head acted as a kind of visible moral compass, calling her back to the journey of truth and compassion for self and others.
Both AD and psoriasis are quite prevalent inflammatory skin conditions which are very responsive to the holistic approach of Ayurveda. By combining topical and systemic herbs, appropriate diet and lifestyle, pancha karma therapies and emotional awareness, these conditions can be effectively cured or brought into remission.
References
- Donald Y.M. Leung, Mark Boguniewicz, et al, New insights into atopic dermatitis J. Clin. Invest. 113(5): 651-657 (2004).
- Gupta, Gupta (1998) Depression and suicidal ideation in dermatology patients with acne, alopecia areata, atopic dermatitis and psoriasis. British Journal of Dermatology 139 (5).
- Sampson HA, McCaskill CC. Food hypersensitivity and atopic dermatitis: evaluation of 113 patients J Pediatr. 1985 Nov;107(5):669-75.
- James J. Leyden11Department of Dermatology, School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, U.S.A., Richard R. Marples11Department of Dermatology, School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, U.S.A. and Albert M. KligmanStaphylococcus aureus in the lesions of atopic dermatitisBritish Journal of Dermatology Volume 90 Issue 5 Page 525-525, May 1974.
- Gerald D Weinstein, Jerry L McCullough and Priscilla A Ross Cell Kinetic Basis for Pathophysiology of Psoriasis Journal of Investigative Dermatology (1985) 85, 579–583; doi:10.1111/1523-1747.ep12283594.
- Davidson, A, Diamond, B: Autoimmune diseases. N Engl J Med 2001 345: 340–350.
- Frank O Nestle and Michel Gilliet, Defining Upstream Elements of Psoriasis Pathogenesis: An Emerging Role For Interferon Journal of Investigative Dermatology (2005) 125, xiv–xv; doi:10.1111/j.0022-202X.2005.23923.x.
- Joshi R. Immunopathogenesis of psoriasis. Indian J Dermatol Venereol Leprol [serial online] 2004 [cited 2008 Jun 15];70:10-2.
