Bullous Pemphigoid – Ayurvedic Herbal Treatment

Bullous Pemphigoid (BP) is a rare, autoimmune disease featuring inflammatory blisters in the sub-epidermal part of the skin. It is chronic in nature and can persist for months or years, with a tendency to spontaneous remissions and exacerbations.

It is not to be confused with another similar sounding disease, Pemphigus vulgaris (PV). While both are autoimmune diseases targeting the skin, PV is comparatively more common, is limited to the upper epidermis, involves the mucous membrane more often, blisters rupture easily, and it has a higher fatality rate. In comparison, BP is located between the dermis and epidermis, the tense blisters do not break easily, mucous membrane involvement is much lesser, and it is more amenable to treatment, though it too can be fatal in the elderly or debilitated people. The diagnosis can be confirmed in both diseases using skin biopsy for Direct Immunoflourescence test (DIF) and Indirect Immunoflourescence test (IDIF) using serum. While autoantibodies desmoglein 1 and 3 denote PV disease, the presence of anti-BPA 1 and 2 confirm a diagnosis of BP.

The standard treatment of BP includes the use of anti-inflammatory drugs and immune suppressants, to reduce and heal blisters and erosions and to prevent recurrence with continued use of the minimum possible dosage of medicines. Anti-inflammatory drugs include corticosteroids, tetracycline and dapsone, while immune suppressant drugs include azathioprine, methotrexate, mycophenolate mofetil and cyclophosphamide. Doxycycline has been found to be more effective and with lesser adverse effects as compared to prednisone. Most patients experience long term remission with about 6-60 months of treatment.

Most of the mortality associated with BP is due to the adverse effects of long term use of drugs used for treatment. Steroids can aggravate hypertension, heart disease, diabetes, peptic ulcer, and bone thinning. Since BP primarily affects elderly people, most patients already have such diseases as comorbidities. Localized skin involvement can be treated using potent topical corticosteroid ointments along with anti-inflammatory medicines so as to avoid the side effects of oral steroid therapy. Refractory patients may benefit from biological treatment with Rituximab.

Ayurvedic herbal medicines have a definite role to play in the management of BP since the treatment is safe for long term use, and can effectively provide prolonged or permanent remission from the disease. While it has been discussed above that BP is completely different from PV, since the part of skin involvement is different in both diseases, the Ayurvedic treatment guidelines and protocol for both diseases is more or less the same. This is because, till date, there is no different treatment approach based upon the different layers of affected skin.

Ayurvedic herbal treatment for BP involves the use of herbal medicines which have a direct action on skin, subcutaneous tissue, capillaries, blood, and blood vessels. Since this is an autoimmune disorder, treatment is aimed at managing inflammation, allergy, chronic infection, detoxification, strengthening and rejuvenation of faulty or dysfunctional tissue, and gradual modulation of immunity. As the disease gradually moves into a remission phase, follow up treatment includes the use of generalized rejuvenation of the full body, also known as Rasayana therapy. For better prevention, those herbomineral formulations are used which not only activate healthy body metabolism, but also simultaneously provide control for inflammation, allergy, and help gradually build up true body immunity.

Patients who do not respond adequately to simple oral herbal therapy, or those with severe involvement at presentation, are subjected to systematic detoxification plans known in Ayurveda as Panchkarma. These may be given singly or in combination, as per the discretion of the attending physicians. Caution needs to be exercised while doing detoxification procedures, since BP is mainly found in the elderly population. For recurrent, localized skin involvement, simple blood-letting from a vein near the affected parts, or leech application in several sittings may provide dramatic results at almost no risk.

Local application of herbal ointments along with a few oral herbs may provide benefit to most patients affected with BP. Ayurvedic herbal treatment for about 6-8 months is usually sufficient in providing long term remission to most patients who approach physicians for Ayurvedic treatment. Severe autoimmune involvement may require aggressive treatment for nearly 18- 24 months. The presence of comorbidities may additionally prolong treatment. Most affected people with BP usually get significant relief and lasting remission with Ayurvedic herbal treatment.

The writer, Dr A A Mundewadi is available as an Ayurvedic Consultant at https://www.mundewadiayurvedicclinic.com and http://www.ayurvedaphysician.com

Pemphigus Vulgaris (PV) – Ayurvedic Herbal Treatment

Pemphigus vulgaris (PV) is a rare autoimmune disease involving the formation of blisters on the skin and mucous membranes. This disease is quite significant since it is potentially life-threatening, with a high mortality rate of 5-15%, even though affecting only the skin and mucous membranes. Circulating antibodies are directed against the keratinocyte cell surfaces in the skin; this causes a loss of cell-to-cell adhesion, resulting in a breach of the skin epidermis, thereby causing blisters. These blisters are of varying size, and may appear on normal or inflamed skin. The blisters are fragile and rupture easily; these are painful and heal slowly, usually without scarring. Almost all patients present with oral cavity involvement; other mucous membranes which may be involved include the conjunctiva, esophagus, labia, vagina, cervix, vulva, penis, urethra, nasal mucosa, and anus.

Diagnosis is usually made by skin biopsy from the edge of a blister; direct immunoflourescence (DIF) on normal-appearing skin surrounding the blister or plucked hair sheaths; and indirect immunoflourescence (IDIF) using the patient’s serum. ELISA tests can detect the presence of antibodies and these titers correlate well with disease activity. While antidesmoglein 3 antibodies are present in patients having only mucosal involvement, the course of the disease correlates well to antidesmoglein 1 antibody levels. Reversion of DIF test to negative can be used as an indicator of remission and for monitoring while tapering medicines.

Treatment of PV is mainly with corticosteroids to reduce and stop the inflammation process. Immune suppressing medicines are sometimes used early on in the course of the disease as steroid-sparing medication. Fatalities are more common in the first 5 years of the disease, and are related to susceptibility to infection, as well as fluid and electrolyte imbalance. Morbidity and mortality is related to the severity and extent of the disease, the dosage of steroids required to induce remission, as well as the presence of co-morbidities. Elderly patients and patients with extensive disease have a more serious prognosis. The long term use of steroids and immune suppressants also contributes to the overall morbidity and mortality. Rituximab, sulfasalazine, pentoxyphylline, methotrexate and dapsone have been used as steroid-sparing drugs. Intravenous immunoglobin therapy and plasmapheresis have been used with some degree of success in refractory patients.

Because of the high mortality of this disease as well as the contributing toxicity of steroids and immune suppressants drugs, Ayurvedic herbal medicines have a significant role to play in the overall long term treatment and management of PV. This being an autoimmune disorder, the treatment protocol includes a multipronged approach of detoxification, proper nutrition, rejuvenation of body systems, immune modulation, as well as specific treatment for the actual systems or organs affected.

Special attention is focused on strengthening the integrity of the skin and mucous membranes. This involves the use of medicines which act specifically on the skin and mucous membranes as well as on blood vessels. Herbal medicines which have immune modulating properties as well as act specifically on skin and mucous membranes are very useful in this scenario. Medicines also need to be given to help in healing of ulcers, and for the prevention of secondary infection in the sores.

Detoxification for each patient needs to be tailor-made according to the severity and chronicity of PV lesions. While some patients may require just a few additional medicines to boost kidney and liver function, yet others may require an elaborate detoxification plan for induced emesis, induced purgation, and blood-letting. Known in Ayurveda as Panch-karma, these procedures may be used as standalone or as combination-procedures. These detoxification procedures may provide rapid remission of PV symptoms; however, patients need to be selected carefully, since most affected with PV are old or have concurrent comorbid conditions.

Depending upon the severity of the condition as well as the response of patients to treatment, Ayurvedic herbal medicines may need to be given for periods ranging from about 6 to 10 months. With regular treatment, most patients affected with PV respond well to Ayurvedic herbal treatment and more than 80 % achieve full remission. Gradual tapering of medicines, as well as suitable modifications in diet and lifestyle, can help prevent recurrence of the condition. Aggravating factors like stress and certain medications also need to be avoided. A judicious utilization of Ayurvedic herbal treatment can thus bring about significant improvement in PV and considerably minimize the mortality due to this condition.

The writer Dr A A Mundewadi is available as an Ayurvedic Consultant at https://www.mundewadiayurvedicclinic.com and  www.ayurvedaphysician.com For Ayurvedic herbal treatment of PV, kindly click here