A comparative analysis of variants of Sheetapitta and variantsof Urticaria with a supportive clinical trial

INTRODUCTION

Sheetapitta and udarda are vata and kaphadosha predominant conditions respectively. They usually develop after frequent exposure to sheetalavayu (cold breeze)3 . Both are characterized by varatidamshtravatshotha, kandu, daha, toda, jwaraand chardi4 butKota is kapha and pittapredominant condition caused due to chardivegadharanaor improper administration of vamana karma5 and the lesion of kota is transient in nature6 . Chakrapani in his commentry on Charaka Samhita visha chikitsa describes kotaasvaratidamshtravat shotha7 . As all these three conditions presents with similar type of lesions, they all can be considered as variants of sheetapitta.

Urticaria is a vascular reaction of the skin characterized by the appearance of wheals, generally surrounded by a red halo or flare and associated with severe itching, stinging, or pricking sensations8 . Episodes lasting longer than 6 weeks are regarded as chronic urticaria9 . Although persons in any age group may experience acute or chronic urticaria, with highest incidence of occurrence in their third decade of life10. The types of urticaria like angioedema, dermographic urticaria, eosinophilic urticaria and cholinergic urticaria, have different clinical presentation. Although, sheetapitta, udardaandkota have similarity in presentation of wheals, they differ in their doshic predominance11. Management of all three conditions by considering their dosha involved in pathogenesis should be the criteria for developing the management protocol.

Methods

Analysis between sheetapitta variants and urticarial variants Sheetapitta variants

vis-à-vis urticaria variants areanalyzed as given below,

1. Sheetapitta is avatapradhanatridosha javyadhi caused due to contact of sheetalavayu (cold breeze) and excessiveintake of aranala (kanji/ sour preparation), shukta (a kind of vinegar fermentation) andasurilavana (vidalavana/ kind of black salt)12. Thegeneral clinical features of sheetapittaarevaratidamshtravatshotha (wheals), kandu (itching), daha (burning sensation), toda (pricking pain), jwara (fever) and chardi(vomiting)13. Urticaria is mainly characterized by wheals and itching but Angioedema, the variant of urticaria is a condition wherein pain is predominant14. Even sheetapitta possess toda (pricking pain) as one of the symptom which is observed when vatadosha is predominant. Thusurticarial-angioedema can be compared to vatapradhanasheetapitta.

2. Udardais one more variant of sheetapitta which is also caused due to contact of sheetalavayu. Other specific causes mentioned for udarda are sheetalajalasparsha (contact of cold water) during sheetakala(cold season).Udarda is of kaphadosha predominant condition. Specific features mentioned for udarda are utseda(elevation), raagata(redness), kandu(itching) and mandala(lesions)15.According to Sushrutacharya, while describing shotha mentions that “without the involvement of kapha there will be no swelling”16. This statement potentiates the above condition. Among the urticarial variant, dermographism is the condition,wherein the skin is raised over the scratched area along with redness and itching. Thus, with the other symptoms, if the person has started to developdermographism, then such urticarial condition can be considered as udarda.

One more urticarial condition, where in itching is the predominant featurethan the presentation of wheals, is eosinophilic urticaria. This condition will mandatorilyhave excessive raised eosinophilic count17. Kaphadosha is responsible for kandu and is predominant in udarda. Understanding theamshaamshakalpana is the key factor in understanding the udarda as eosinophilic urticaria. Kapha in its prakrutaavastha is called as bala18 (strength/ immunity). Immunity is provided by the white blood cells. Eosinophil is one of the varieties of white blood cells, where in its proper quantity and quality, provides immunity against the pathogen entry and diseases. When there is increased count of eosinophils in the vasculature, it causes severe itching which is considered as vaikrutakapha. Thus, eosinophilic urticaria can also be compared to udarda.

3. Kota is kapha and pitta predominant condition caused by asamyakvamana (improper administration of emetic therapy)19. It is characterized by reddish lesions which are itchy and are many in number.Madhukosha in his commentary on Madhava Nidana mentions lesions of kotaare transient in nature20. Among urticarial variant, cholinergic urticaria have the characteristic features of minute, highly pruritic, punctate wheals or papules 1-3mm in diameter and surrounded by a distinct erythematous flare, lasts for 30-90 minutes followed by refractory period upto 24 hours. Cholinergic urticaria is caused due to increased sweating in the body by any physical exertion or mental stress21. Kota is caused due to improper evacuation of dosha during the emetic therapy. While mentioning vamanapradhurbhava (prodromal features of vamana) features swedapradurbhava (forehead sweating) is mentioned22. Sweda signifies that the doshais expected to evacuate but when there is no expelling of doshas especially kapha and pitta, leads to the development of papular lesions.Thus, clinical features and pathology involved in kotacan be correlated to cholinergic urticaria.

To understand this, supportive clinical trial is considered

An observational clinical trial was done with sample size of 33 subjects fulfilling the diagnostic criteria of sheetapitta vis-à-vis chronic urticaria. In the present trial, all the variants of sheetapitta visà-vis variants of chronic urticaria wereincluded. The diagnosis was based on classical features of sheetapitta vis-à-vis chronic urticaria. This clinical trial is retrospectively analyzed based on the results obtained among variants of urticaria.

Intervention

Amapachana was done with Ajamodadichurna23 15gms in three divided doses after food with warm water as anupana till niramalakshana were observed. Mahatiktaka ghruta24 was administered from the day of niramalakshana in arohana krama, starting with hrasiyasimatrauntilsamyaksnigdhalakshana were observed. Katu taila25 abhyangafollowed by ushnajala snana26 for 3 days in vishrama kala was given. Trivrut lehya27 was administered in the morning hours on empty stomach for the purpose of virechana. Dose varied between 40-70gms, depending upon the koshta of the subject. After aturanireekshana, samsarjana krama was advised according to shuddhiprakara. Ardraka khanda avalehya28 12 gms in two equally divided doses along with 40 ml of Amruta rajanyadi kashaya29 in two equally divided doses as anupanato ardraka khandafor the next 30 days was administered.

Results

The results were analysed based on the UrticariaActivity Scoring (UAS) system30.

The improvement was graded with following manner:

Marked improvement - 76-100% relief from reduction of signs and symptoms.

Moderate improvement- 51-75% relief from reduction of signs and symptoms.

Mild improvement- 26-50% relief from reduction of signs and symptoms.

No improvement- <25 % relief from reduction of signs and symptoms.

After the completion of the intervention, 10(31.31%) subjects had marked relief, 13(39.39%) subjects had moderate relief, 5(15.15%) subjects had mild relief and 5(15.15%) subjects had no relief.

After the completion of the intervention,out of 5 subjects possessing angioedema, 2 subjects got marked relief, 1 subject got moderate relief, 1 subject got mild relief and 1 subject had no relief. Out of 9 subjects possessing dermographism, 2 subjects got marked relief, 2 subjects got moderate relief, 4 subjects got mild relief and 1 subject had no relief. Out of 2 subjects possessing cholinergic urticaria, 1 subject had marked relief and 1 subject had mild relief.One subject of eosinophilic urticaria has got moderate relief.

Discussion

Sheetapitta, udarda and kota are three clinical conditions characterized by varatidamshtravatshotha. Though all three are having same kind of lesions, by their specific clinical features mentioned in different ayurvedic texts, they all can be understood as variants and can be compared to different urticaria varieties. The understanding of variants is mainly by its causative factors, pathology and clinical features. Sheetapitta being vatadoshapradhana can be compared to urticaria with angioedema which is pain predominant. Udarda being kaphadoshapradhana, itching, redness and swelling are its specific features can be compared to two urticarial conditions such as dermographic urticaria and eosinophilic urticaria.Kota is kapha and raktadosha predominant with transient papular wheals which can be compared to cholinergic urticaria. There are several other forms of urticaria that has similar clinical features by varied causative agents. They all can be considered grossly under urticaria or sheetapitta in general.

The results showed variations among 4 variants of urticaria. This may be because, the treatment opted was virechana karma. Virechanakarma helps in alleviating pittadosha in first order rather than kaphadosha. Hence,those having prabhuthakapha had mild to moderate relief from itching and swelling. Ardraka khanda is agnideepaka, kanduhara and rasayana. This yoga isvyadhipratyanika chikitsa. Amruta rajanyadikashaya are having tikta rasa pradhana and is acted as krimihara (anti-parasitic), kushta hara (reducing skin disease) and twakmamsasthirakaraka (maintiang the compactness of skin and muscle tissue). The combination of ardrakakhandavalehya and amrutarajanyadikashaya helped in counteracting all variants of sheetapitta vis-à-vis- variants of chronic urticaria in general.

In particular, Vamana karma helps in expelling out kaphadosha. In udarda, kaphadosha is predominant owing to swelling and itching. Hence, vamana karma followed by shamanachikitsa (alleviation therapy) could be the management protocol in udarda. Similarly, kota is kaphaandraktadosha predominant condition, where vamanakarma (emetic therapy) as well as virechana karma (purgation therapy) followed by shamana chikitsa (alleviation therapy) benefits the condition. Some texts mentioned the doshapredominancy of kotaas kapha and rakta. This can be understood as ashraya-ashrayi bhava of pitta with rakta. In this condition raktamokshana after the intake of mahatiktaghruta benefits the subject.

Not only shodhana chikitsa (purification therapy) varies according to doshas in these conditions but alsoshamana chikitsa (alleviation therapy) should be planned according to the dosha involved, strength of diseases and person, assessing the digestive capacity and assessing the satmya (conducive) of a person towards particular medications. Ardraka khanda which is employed in clinical trial is of ushnaveerya, where pittaja person cannot tolerate the effect of Ardraka khanda. In such persons, administration of Amruta-rajanyadikashaya alone can be administered or those having pitta doshapredominancy, sheetaveerya drugs with specific disease indicationcan be administered.

While planning pathya-apathya (diet) also it differs according to the condition. For those caused by pitta dosha, sheetalaannapana (food having cold nature /potency) should be given as pathyaeg., mudga rasa(green gram). Those caused by kaphadosha should be given ushnaannapana(food having hot nature/potency) as pathyaeg., kulattha(horse gram), ushnajala (hot water)31.

Thus, understanding the variants of sheetapitta according to dosha with respect to variants of urticaria helps to plan and adopt the appropriate line of management.