1.     Introduction

Alopecia aerata is an autoimmune disease characterized by hair loss on body especially on scalp without any clinical inflammatory signs. Its prevalence in general population was estimated at 0.1-0.2% with a lifetime risk of 1.7%¹. Male was reported to be more affected with the disease in comparison to children and women and causes more emotional problems in woman and children due to cosmetic concern². Its main treatment in modern science is corticosteroids which is having harmful side effects so not advisable for long term use³. Therefore world is expecting some remedies from alternative medical sciences. Ayurveda offers different effective treatment modalities for the management of different autoimmune diseases like psoriasis, eczema, etc⁴. Alopecia areata can be correlated with indralupta disease described in ayurveda. Acharya charaka mentions that pitta by involving vatadidosha when reaches the scalp, it results in khalitya (indralupta)⁵. According to acharya sushruta, pitta along with vata localize at the roots of hair (romakoopa) causes fall of hair and thereafter kapha along with rakta obstructs the channel of romakoopa leading to the stoppage of the regeneration of hair and this condition is known as indralupta or khalitya⁶. Thus vata, pitta and kapha dosha and rakta dushya are the main internal causative factors of indralupta (figure 1).

2.     Case
An 18 yrs old unmarried female which was referred to the ayurvedic hospital by her doctor sister for ayurvedic management, was presented in shalya department of tu ayurveda teaching hospital kirtipur opd no. 7901265 with following chief complaints.

2.1  Chief complaints
A patchy hair loss for 3 weeks on the scalp associated with mild itching.

History of present illness: according to patient she was asymptomatic 3 weeks ago then she develops patchy hair loss on scalp, with mild itching over affected area and gradual increment since 3 weeks which was gradual in onset and progressive in nature without any pain. There was patchy hair loss measuring about 4x4 cm on the mid scalp region. Patient didn’t notice any exaggerating or relieving factors.

History of past illness: there was no history of similar illness in past and no history of autoimmune disorders (like atopic dermatitis, psoriasis, vitiligo, asthma, urticaria, rheumatoid arthritis, thyroiditis), no history of drug intake, and no history of any systemic illness.

Family history: - no any significant family history i.e. No member of the family had history of such illness.

Menstrual history: - regular with normal duration without any dysmenorrhea and clots.

Personal history

Astavidha pariksha (eight folds of examinations)

 
General examinations

Dasvidha pariksha (ten folds of examinations)

Disease specific examinations

Examination showed patchy hair loss measuring about 4x4 cm on mid scalp region and mild dryness over patch, no scarring or cicatrization, nor any other skin lesion over scalp, no tumor in localized area and abnormalities of hair in adjacent area. Length of hair of adjacent scalp was uniform and was not broken off. The patient was clinically diagnosed as case of indralupta (alopecia areata) and advised for leech therapy.

Systemic examination
On examination, patient was found to be conscious and well oriented to time, place and person. Assessment of central nervous system, cardiovascular system, respiratory system and musculoskeletal system of patient was found within normal limits clinically. No clinical abnormality was detected on per abdomen examination.

Blood investigation
Blood investigations hb, tlc, dlc, esr, blood sugar values were within normal limit.

Treatment planned
The treatment was planned according to the basic principles narrated in the context of indralupta disease.

Primary management of indra lupta (alopecia areata patchy) is shodhan therapy (detoxification). As per ayurvedic literature application of jalauka (leeches) on diseased area is a type of raktamokshan (blood-letting) under panchakarma chikitsa. Blood vitiated by pitta should be removed from the body (diseased part) by using jalauka. Leech therapy (jalauka) was done once a week along with internal and local medications up to 2 month.

(tables 1, 2). Application of jalauka (leech) was done as per methodology described by ayurved text with all aseptic precautions. The follow up was taken once in a week.

Table1. Leech therapy (jalauka)

Table 2. Medicines

Advices

3.     Observations and results

Before treatment: there was patchy hair loss, no hair roots, slight dryness at the site was present.

During treatment: there was no any blister formation, etching or any adverse reaction at site or all over body.

Follow up: after 15 days of treatment small whitish grey hairs grew on the lesion. Length and density increased; hair fall decreased. No further complications were observed.

After treatment: after 60 days length and density increased. Black hairs easily observed over the affected site.

figure 1. Before treatment

figure 2. After 15 days of treatment

Figure 3. After 45 days of treatment

Figure 4. After 60 days of treatment

1.     Discussion

As vata, pitta and kapha dosha and rakta dushya are the main internal causative factors of indralupta. In ayurveda, both shodhana (internal and external cleansing procedures) and shamana treatment (disease specific internal medications) are prescribed for indralupta. Charaka in vimanasthana, while describing the disorders occurring due to over indulgence in kshara, lavana and viruddha ahara has mentioned the occurrence of hair loss as a consequence. It has been mentioned that the viruddha ahara like, simultaneous intake of lavana (salt) with milk in the diet induces indralupta, as observed in the people of saurashtra and bahlika. Thus, it can be said that a person habituated to excessive lavana or kshara intake and taking viruddha ahara in routine is prone to have indralupta⁷. So nidana pariwarjana is advised here. Various localized treatment modalities like pracchan karma, lepa application, abhyanga⁸, swedanaa nd nasya⁹ along with rasayana therapy are advised in the context of indralupta. As vata, pitta and kapha dosha and rakta dushya are the main internal causative factors of indralupta. So the medications 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 hairs¹⁰. Amlaki is keshya, khalitya-palityahar, tridoshhar, deepan, pachan, rasayan which help in rejuvenation process. It promotes digestive fire, clears body channels for the nutrients to reach to the tissues, balances fats in the body and removes toxins by improving the digestive system. Hair zone spray which mainly contains plasha was topically used. According to bhavaprakash, palash is one of the drugs which are krimighana. Palash is katu, tikta, kashaya and katuvipaki, deepan, vrushya, snigdha, and used in krimi,varnadoshanashak, kapha-pitta, raktavikar, dahashamak and kusthaghna¹¹. It has also proven that butea monosperma inhibits degeneration of hair follicles, extends the anagen phase of hair growth cycle and enhances proliferation and maturation of precursor epithelial cells of the final hair strand. It prevents the massive apoptosis in the proximal hair bulb and stimulates the multiplication of hair fiber cells with the stimulation of anagenic phase, and reduce the catagenic and telogenic phase¹². In-vitro study of palasa (butea monosperma) seed oil also revealed considerable bactericidal and fungicidal effects¹³. In this way it acts and prevent further hair fall.

Raktamokashana in this case performed with jalauka avacharan (blood-letting in which leech is used) as, it is described as best method to pacify the vitiated pitta and rakta¹⁴. Leech sucks the blood and improves local blood circulation mainly by injecting histamine like substances that causes vasodilatation. After the evacuation of vitiated blood from the affected site, re-channelization of blood flow is stabilized. Many studies have confirmed that leeches have more than hundred bioactive substances in its saliva, which mainly have analgesic, anticoagulant and anti-inflammatory effects. This is the reason for selecting the combination of topical application, systemic medications and leech therapy for treating this particular case. The available treatment in modern medicine mainly based on steroid and minoxidil etc. Which have their own side effects. Leech therapy works similar to minoxidil as it improves the local blood circulation along with its anti- inflammatory action.

2.     Conclusion
From this case report, we can conclude that shodhana therapy along with internal and local medication helps in the management of indralupta. Nidanaparivarjana was also a necessary part of the treatment. The patient suffering from alopecia areata was successfully treated. This treatment protocol should be clinically evaluated on large number of patients to confirm the efficacy.

References

1.  Tan e, tay yk, goh cl, chin giam y. The pattern of alopecia areata in singapore - a study of 219 asians. Int j dermatol 2002;41(11):748-753.

2.  Al-mutairi n, eldin on. Clinical profile and impact on quality of life: seven years’ experience with patients of alopecia areata. Indian j dermatol venereol leprol 2011;77(4):489-493.

3.  Seetharam ka. Alopecia areata: an update. Indian j dermatol venereol leprol. 2013;79(5):563-575.

4.  Shingadiya rk, sapkota yr, bedarkar pb, patgiri bj, prajapati pk. Efficacy of ayurvedic classical and modified formulations on skin disorders. Rasamruta 2017;1-17.

5.  Trikamji ay. Sthana csc. Chaukhambha orientalia varanasi reprint edition. 2004.

6.  Trikamji ay, sthana ssn. Chaukhambha krishanadas academy varanasi reprint  edition. 2004.

7.  Trikamji ay, sthana csv. Chaukhambhaorientalia varanasi reprint edition. 2004;672.

8.  Acharya vyt, samhita s, nibandhasangraha d, sthana c,  adhyaya c. 2007.

9.  Gaur bl, charaka a, samhita c, sthana c, adhyaya tc.  2014; 327.

10.    Sharma rk, bhagwan d, caraka s. 2018.

11.    Brahmasankara ms, bhavaprakasa sb, sansthan cs 1990;535.

12.    Rawal r, kolhapure sa. Evaluation of the efficacyand safety of “hair loss cream (pcpb hair cream)” in the management of telogen effluvium. Indian j clin pract 2005;16(5):19-26.

13.    Shahavi vm, desai sk. Anti-inflammatory activity of butea monosperma flowers. Fitoterapia 2008;79(2):82-85.

14.    Srikantha murthy kr, astanga hrdayam of vagbhata. 2005.