Melasma is a widespread acquired symmetrical hypermelanosis characterised by irregularly shaped but clearly defined dark brownish maculae on photo-exposed areas, particularly the forehead, temples, nose, eyelids, chin, and upper lips. It is a major cosmetological issue that can also affect a person’s psychological well being. Melasma can be correlated with Vyanga in Ayurveda. Vyanga is one of many Kshudra Rogas and Raktapradoshaj Vikaras. According to modern medicine, local application of corticosteroids is preferred for the management of melasma. However, due to the relapse of the disease and the side effects of steroids, an Ayurvedic approach is beneficial. Ayurveda mentions Shaman Chikitsa in the form of Lepa, which has Vatapittahara, Varnya, Twachya, Kushthaghna, and Raktaprasadaka properties as the line of treatment. Hereby, the authors present a case report of a 46-year-old female who reported to the Outpatient Department (OPD) of Kayachikitsa, complained of brownish discolouration on her face for six months, which was diagnosed as Vyanga (melasma). Ayurvedic treatment was planned according to the classical principle of Shaman Chikitsa, with a local application of Lepa containing depigmenting and skin rejuvenating drugs, along with lifestyle modifications. Due to the recurring nature of the disease, a proficient treatment approach was required. Vyanganashak Lepa has skin resurfacing and revitalising properties that act efficiently on the disease. In present case, Vyanganashak Lepa was found to be highly effective and showed remarkable results with continuous usage in a short period.
Case Report
A 46-year-old female patient presented to the Outpatient Department (OPD) of Kayachikitsa with chief complaints of prominent, moderately dark brownish hyperpigmented lesions on her bilateral cheeks, nose, forehead, and chin for the past six months. The condition was associated with occasional itching at the sites. The patient was pre-menopausal and had experienced prolonged and irregular menstrual cycles. She was also a known case of hypertension for three years and was on regular medication. There was no family history of any skin disease. The lesions gradually increased in size and darkened in colour. She was stressed due to cosmetic concerns and therefore requested immediate intervention.
On dermatological examination, there were moderately dark brown lesions on the bilateral malar region, nose, forehead, and chin, which were symmetrically distributed, irregular in shape, but clearly defined, leading to the diagnosis of Vyanga (Melasma) [Table/Fig-1].
Moderate dark brown colour lesions over forehead, bilateral cheeks, nose, upper lip and chin (all over face).
The elements of pathogenesis (Samprapti Ghatak) that explain the manifestation of the disease are as follows:
Dosha: Vata (Udaana), Pitta (Bharajaka)
Dushya: Rasa, Rakta
Adhishthana: Mukhagata Twaka (bilateral cheeks, nose, forehead, and chin)
Vyadhi Marga: Bahya
Srotasa: Rasavaha, Raktavaha
Strotodushti: Vimargagamana
Doshagati: Tiryaka, Vriddhi
Agni: Vishamagni
Sadhya-Asadhyata: Sadhya
Swabhava: Chirkari
According to arbitrary grading on the symptom-Shyavata [Table/Fig-2] and assessment of grading and severity of lesions [Table/Fig-3], it was observed that the patient had a moderate dark brown lesion on the face with a score of 3 and Grade 3 (severe) [1].
Arbitrary grading on the symptom – Shyavata [1].
| Features | Score |
|---|
| Deep dark brown colour lesion over face | 4 |
| Moderate dark brown colour lesion over face | 3 |
| Light dark brown colour lesion over face | 2 |
| Faint dark brown colour lesion over face | 1 |
| Normal skin tone | 0 |
Assessment of grading and remarks on severity of lesions [1].
| Grade | Grade of point | Sign (degree) | Remark |
|---|
| G4 | 4 | ++++ | Very severe |
| G3 | 3 | +++ | Severe |
| G2 | 2 | ++ | Moderate |
| G1 | 1 | + | Mild |
| G0 | 0 | Nil | Normal |
The treatment was initiated by making a thick paste of Vyanganashak Lepa [Table/Fig-4]. This Lepa was applied locally to the face daily and scrubbed off with cold water after 20 minutes for 30 days. Along with this, lifestyle modifications and an exercise regimen were advised. Dietary modifications included restrictions on spicy foods, hot garlic, masalas, chillies, excessive salty and sour food items, pickles, fried items, fermented foods, and yogurt. The patient was advised to consume green gram khichdi, seasonal fruits, and foods with less oil and salt. In addition to the dietary changes, the patient was encouraged to practice Pranayama early in the morning.
Ingredients of Vyanganashak Lepa.
| Contents of Vyanganashak Lepa | Quantity |
|---|
| Masoor dal powder | 2 tsp |
| Manjishtha churna | 2 gm |
| Raktachandan churna | 2 gm |
| Yashtimadhu churna | 2 gm |
| Jatiphala churna | 2 gm |
| Kumkumadi tailam | 3-4 drops |
| Raw cow milk | Q.S |
| Rose water | Q.S |
After 15 days, during the first follow-up, the scoring reduced to two, with light dark brown lesions on the face and Grade 2 (moderate). After 30 days of treatment, the scoring decreased to one, with faint dark brown lesions on the face and Grade 1 (mild) [Table/Fig-5].
After 30 days of treatment, the severity of lesions reduced and showed faint dark brown colour that is mild pigmentation.
Discussion
Vyanga is one of many Kshudra Rogas and Raktapradoshaj Vikaras [2,3]. It is a significant cosmetological issue that can also affect a person’s psychological well being. Vyanga can be correlated with melasma in modern medicine. According to Ayurveda, Shoka (sadness), Krodha (anger), and Ayasa (fatigue) are the causative factors of Vyanga [4]. As per modern science, ultraviolet rays and stress lead to the majority of cases of melasma. Vagbhattacharya explained that vitiated Pitta and Vata generate Mandalas of Shyava Varna on the face, known as Vyanga [5]. Acharya Sushrut explained that Vyanga is a skin disease in which Vata and Pitta are aggravated by Shoka (sadness), Krodham (anger), and Ayasa (fatigue), which ultimately leads to sthanasamshraya (accumulation) in the Mukhapradesha (face) and produces patches that are Tanu, Shyava, and Niruj [6]. Melanocytes produce melanin, and the transfer of melanosomes to nearby keratinocytes results in cutaneous pigmentation [7]. Melanosomes differ in number and size in different individuals, while the number of melanocytes remains the same.
Melasma is a widespread acquired condition characterised by symmetrical hypermelanosis, presenting as irregularly shaped but clearly defined dark brownish macules on photo-exposed areas, particularly the forehead, temples, nose, eyelids, chin, and upper lips. The two types of treatments (Chikitsa) used in Ayurvedic treatment for Vyanga are Shodhana and Shamana. Various treatments such as Lepa (external application), Siravyadha (bloodletting), Abhyanga (oil massage), Nasya (nasal therapy), Pana (drinking), Vamana (emesis), Virechana (purgation), and Udwartana (powder massage) are mentioned [8].
Lepa is regarded as one of the easiest and most efficient methods among these treatments. Panigrahi M et al., conducted a study on Vyanga and provided Mukhakantivardhaka Lepa, which is already mentioned in the Sharangdhar Samhita [9]. Lekshmi AG et al., also highlighted the use of Lepa for the management of melasma, noting that its use is well-documented in classical texts. The incorporation of manjishtha in Lepa is well known due to its Twakprasadak (skin-enhancing) properties [10]. In present study, manjishtha churna is used in combination with other effective drugs to accelerate the results in such severe cases. Kumari D et al., mentioned the use of Jatiphala churna along with milk, which aligns with present study, as it possesses properties that help scrape away the rough, dark patches of melasma [11].
When multiple drugs with such remarkable properties are used together, significant changes can be observed in a short time span, as demonstrated in this case study.
Several Lepas, such as Varnya Gana Lepa mentioned in the Charak Samhita [12], Manjishthadi Lepa [13], and Jatiphala Churna Lepa [14], are referenced in classical texts, with many studies conducted on them. Some Lepas provide temporary relief. However, in present case, after addressing and understanding the foundations of Ayurvedic classics, a combination of new formulations was created to treat the underlying root causes and eliminate the recurrence of the disease.
The formulation includes easily available ingredients found at home, such as red lentils, which have significant results when used in a specific manner. Each ingredient has a contributing action towards treating pigmentation and revitalising the skin. By combining commonly available drugs with classically mentioned Varnya and Kushthaghna drugs, a beneficial outcome is achieved.
Along with the Lepa, lifestyle modifications were advised, including practicing Pranayama early in the morning, which reduced stress and simultaneously addressed the root cause of the disease. The patient was advised to follow a healthy diet regimen and to perform Pranayama and exercises [15]. The patient was instructed to apply the Lepa daily for 30 days. The ingredients of the Lepa (face pack) each possess different properties that have a combined effect on skin rejuvenation and depigmentation.
Masoor Dal (Red Lentils), being the main ingredient, has exfoliating properties and helps to remove blackheads. It has a bleaching effect that makes the skin lighter and more toned. Additionally, it removes tan, fine lines, blemishes, and dark spots [16]. Manjishtha (Rubia cordifolia) is known for its blood-purifying (Raktashodhak), anti-inflammatory (Shothahara), wound-healing (Vranaropaka), and skin disease-fighting (Kushtaghna) properties. It balances Kapha and Pitta shamaka, acts as an antihelminthic (Krimighna), and enhances metabolism (Deepana) and digestion (Pachana) [17].
Yashtimadhu (Glycyrrhiza glabra) acts as a heat pacifier, analgesic, and anti-inflammatory agent. It is also beautifying (Varnya), alleviates itching (Kandughna), rejuvenates, and balances skin doshas (Tvacha Doshahara). Due to its unctuous nature, it pacifies Vata, and because of its sweet and cooling properties (Madhura Sheeta Guna), it pacifies vitiated Pitta [18].
Rakta Chandan (Pterocarpus santalinus) has blood-purifying (Raktashodhaka), heat-pacifying (Dahashamaka), Kapha-pittashamaka balancing, anti-inflammatory (Shothahara), antihelminthic (Krimighna), beautifying (Varnya), and skin-dosh balancing (Twakdoshahara) properties [19]. Jatiphala Churna (Myristica fragrans) possesses exfoliating properties that help in the formation of new, fresh, healthy skin by removing unhealthy layers [20,21].
Kumkumadi Taila reduces pigmentation and brightens the skin. This oil contains compounds that modify immunological and melanocyte activity, leading to reduced hyperpigmentation. It works against inflammation, hyperpigmentation, and free radicals, likely reducing the amount of melanin pigment released [22].
Rose water balances Vata and Pitta doshas. It acts like an elixir by maintaining skin tone, cleansing and nourishing the skin, subduing blemishes and dark spots, and functioning as an exfoliant. It also has anti-aging and antioxidant properties [23].
A significant portion of the medications used in the Lepa (paste) have Vata-Pitta pacifying properties, which favour the effective treatment of the condition. The ingredients of the Lepa are recommended to be used with raw cow milk, which also helps calm vitiated Pitta and Vata. Local application and lifestyle modifications showed significant results after 30 days of treatment in this case. The patient was later followed-up for recurrence. After 30 days of treatment, local application of only Kumkumadi Taila was advised to avoid relapse and maintain the results.
Conclusion(s)
Vyanga is not only a cosmetic concern but also a physiological skin disease. Various treatment options are available for its management, but the recurring nature of the disease is notable. Therefore, if the root cause of the disease is not targeted, it may relapse. Vyanganashak Lepa has depigmenting and skin rejuvenating properties; hence, it is considered highly effective and has shown remarkable results with continuous use in a short period for the management of melasma.
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