Sagun Tiwari, B.N.Y.S. Junior Resident a,
Apar Avinash Saoji, B.N.Y.S., Ph.D. Associate Professor b, *,
Kshamashree Madle, B.N.Y.S., M.Sc. Assistant Professor b,
Namrata Sapkota, B.N.Y.S. Junior Resident a,
H.C. Shashikiran, B.N.Y.S., M.D. Assistant Professor a,
Prashanth Shetty, B.N.Y.S., M.Sc., Ph.D. Principal a

 

a Sri Dharmasthala Manjunatheswara College of Naturopathy and Yogic Sciences, Ujire, India
b The School of Yoga and Naturopathic Medicine, Division of Yoga and Life Sciences, Swami Vivekananda Yoga Anusnadhana Samthana, Bangalore, India

 

abstract

A 57 years old male patient was admitted to an inpatient Naturopathy and Yoga (N&Y) hospital, diagnosed with pemphigus vulgaris (PV) for one year and co-morbid type 2 diabetes (T2DM) for 10 years, associated with poor quality of life (QoL). He was administered N&Y therapies for 10 days, along with conventional medicines. There was improved QoL and reduced dosage of insulin, along with reduction in body weight. These changes were sustained and improved further during the 60-day follow-up period. Although there was no improvement in the skin lesions, the improvement in QoL indicate a possible role of N&Y in management of PV and T2DM. This case report also warrants further studies for N&Y in the management of dermatological conditions as well as metabolic syndrome. © 2020 The Authors. Published by Elsevier B.V. on behalf of Institute of Transdisciplinary Health Sciences and Technology and World Ayurveda Foundation. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

 

1. Introduction

Pemphigus vulgaris (PV) is a chronic, intraepidermal bullous, autoimmune, life threatening disease characterized by erosions and blisters of skin and mucous membranes. PV is an uncommon disease with an incidence ranging from 0.076 to 5 per 100,000 person [1]. It affects all races and ethnicity with high incidence in Ashkenazi Jews and people with Mediterranean descent. In India, PV is the commonest variant among the pemphigus group of disorders [2]. PV is associated with IgG antibodies targeting several types of keratinocyte antigens and eliciting epidermal clefting (acantholysis) via intracellular signaling activating apoptotic enzymes (apoptolysis) [3]. PV is caused by circulating autoantibodies to the epithelial adhesion proteins desmoglein 1 and 3. These autoantibodies result in a failure of epidermal cells to adhere correctly to each other. This causes flaccid blisters and subsequently painful erosions in the skin and mucus membranes. All types of skin diseases are significantly related to physical and psychological disturbances. PV affects the attitude and quality of life (QoL) of the patients as it covers the large surface area of the skin along with mucous membrane [4]. Patients suffering from PV have physical, emotional and psychological burden as there is no cure for it. Palliative management strategies are used to minimize the diseases progression, mostly thorough use of immunosuppression therapies [1]. Naturopathic medicine is a drugless, noninvasive, evidencebased medicine which provides the suitable environment for selfhealing [5]. Yoga therapy is broadly used for psychological, andphysical health. In India, Naturopathy and Yoga (N&Y) are used as a single system of medicine [6]. Although there is growing evidence for the role of N&Y to enhance QoL and management of symptoms in various disorders [7,8], there are no studies reporting their effect on PV. Thus, the current case study presents role of N&Y in improving the QoL and management of co-morbidities with PV.

 

2. Presenting concerns

A 57 years old male patient was admitted in a N&Y hospital with history of PV for 1 year. He was diagnosed with PV through histopathological study, when he approached a hospital for fluid filled lesions on chest and back region, which later spread all over of the body. The lesions ruptured, causing itching sensation over the area. He was taking Tab. Deflazacort 15 mg OD for managing the PV. He also had been diagnosed with type 2 diabetes (T2DM) for 10 years, managed with Human Mixtard Insulin injections (30 units/day), Tab. Glimepiride 2 mg OD and Tab. Metformin 500 mg OD.

 

3. Clinical findings

A detailed case history was taken when he was admitted to the hospital. The height of the patient was found to be 173 cm, weight was 72 kg and Body Mass Index (BMI) was calculated to be 24.06 kg/m2 . His resting blood pressure was found to be 118/ 78 mmHg, pulse rate was 78 beats/m. On examination, maculopapular rashes were observed all over his chest, abdomen and back.

 

4. Diagnostic focus and assessments

Dermatology Life Quality Index (DLQI) is a simple and reliable tool (Chronbach's alpha ranging from 0.83 to 0.93) to assess QoL in patients with dermatological conditions, with a score ranging from 0 to 30. A higher score indicates poorer QoL [9]. DLQI scores were obtained on the day of admission (day 1) and on the day of discharge (day 10), and on follow up on 30th and 60th day from the day of admission. Fasting (FBG) and Post Prandial Blood Glucose (PPBG) levels were monitored using glucometer on day 1, 10, 30 and 60.

 

5. Methods

Following a detailed history, initial counseling and signed informed consent, the N&Y therapies were planned. The dosage of insulin and oral hypoglycemics was tapered while monitoring the blood glucose levels. He was admitted to the inpatient facility for 10 days. Later he was given a follow-up N&Y plan. The follow up data was obtained through email and telephonic feedback. The timeline of the case is depicted in Table 1.

 

6. Therapeutic focus and assessment

The patient was kept on a calorie restricted (estimated at about 800 Kcal/day), wholesome vegetarian diet consisting of seasonal fruits (water melon/papaya/pomegranate), salads (prepared from green gram sprouts/carrot/leafy vegetables) and boiled vegetables. The calorific value of the food was calculated by using the quantity of each food item and their estimated calorific value as suggested by the National Institute of Nutrition, Hyderabad [10]. The N&Y module was adapted from an earlier study on metabolic syndrome [6], with changes made based on the patient's response assessed in the daily visit of the physician. In addition, considering the skin ailment of the patient, topical application of neem oil, and turmeric paste in the red-rice paste was also added to the Naturopathy protocol. The Yoga therapy practices consisted of asana, pranayama, deep relaxation, suddhi-kriya and dhyana. The N&Y module is presented in Tables 2a & 2b.

 

7. Follow-up

Following the completion of the 10-day inpatient stay at the hospital, the patient was advised to continue calorie restricted vegetarian diet (approx. 1200e1500 Kcal/day), and yoga practices for 1 h/day. He was also advised to continue using the red rice paste with turmeric at least twice a week. The Patient reported to have good compliance with the follow-up advice using the periodic telephone calls. Data on day 30 and day 60 was collected (weight, FBG, PPBG and DLQI) thourgh telephone call.

 

8. Outcomes

The changes from the day of admission to day 10 and follow up days 30 and 60 are depicted in Table 3. The DLQI scores reduced from 21 on day of admission to 18 on day of discharge and further reduced to 15 on day 60 of follow-up, demonstrating better QoL. The body weight reduced from 72 Kg on admission to 70.5 Kg on day 10, which further reduced to 69 on day 60, with a corresponding reduction in the BMI (24.32, 23.82 and 23.32 kg/m2 on day of admission, day 10 and day 60 respectively). There was a better glycemic control depicted through the FBG (123, 112 and 108 mg/dl on day of admission, day 10 and day 60 respectively) and PPBG (180, 160 and 158 mg/dl on day of admission, day 10 and day 60 respectively) requiring lesser quantity of insulin (from 30 units/ day to 10 units/day on day 10 which was constant thereafter through the follow-up period). The dosage of oral hypoglycemics was maintained thorughout the follow-up period.

 

9. Discussion

A ten-days N&Y protocol was administered to a 57-year-old male patient suffering from PV and T2DM, followed up for next 60 days. The DLQI scores reduced, which are indicative of better QoL. There was also reduction in the dosage of insulin required to keep the blood glucose in normal range, along with reduction in body weight and BMI. The patient self-reported the N&Y protocol to be easy to adapt and continued to follow the advice given to him on discharge. Although, no much difference was observed in the skin lesions of PV, there was about 28.5% reduction in the DLQI scores, which is a reliable tool to assess the QoL in patients with dermatological conditions. This is the first study reporting changes in the QoL in patients with PV using N&Y. Earlier reports of use of N&Y are for metabolic syndrome [6], rheumatoid arthritis [11] and urinary incontinence [12].

 

 

The changes observed in the QoL in the current study may be due to reduction in symptoms. This may also be due to stress ameliorating effect of yoga [13,14]. Also, calorie restriction performed in this case could help in reducing the body weight and BMI and thereby enhancing insulin sensitivity and concurrently reducing the need for insulin supplement. These observations are similar to an earlier study done on Metabolic syndrome [6]. N&Y could help though normalizing the autonomic functions through an enhanced vagal tone [15]. The other mechanism involved could be reduction in inflammation due to calorie restriction [16]. Also, the turmeric applied along with the red rice paste could act as a topical anti-inflammatory, which is found to be useful in various kinds ofarthritis [17]. However, the earlier trials used the extract of the curcumin administered internally, whereas we used turmeric paste as a topical application. Other therapies such as massage with neem oil may have also helped, since neem oil is considered to have immunomodulatory and anti-inflammatory effects [18]. Earlier studies using topical application of neem oil has found to induce dermatitis [19], however, our patient did not get any adverse reaction. Topical mud application also has been found to be beneficial in dermatological conditions due to the properties of mud [20]. Naturopathic therapies such as hip bath [21] and Gastro Hepatic pack [22] are found to help in management of T2DM.

 

10. Patient perspective

The patient self-reported feeling of wellness during and following the 10 day inpatient treatments. He found the therapies easy to adapt and follow. He felt comfortable with his body and that prompted him to continue to follow-up of N&Y.

 

11. Conclusion

The observations from the case study reinforce the utility of N&Y as a possible useful integrative treatment modality in the management of T2DM and as a possible tool to enhance the QoL in patients with PV. Further clinical trials are warrantied to assess the efficacy of N&Y in the management of PV.

 

Informed consent

An informed written consent was obtained from the patient for reporting this case.

 

Financial support and sponsorship

Nil.

 

Declaration of Competing Interest

The authors declare no conflict of interest. References

 

References
[1] Gupta VK, Kelbel TE, Nguyen D, Melonakos KC, Murrell DF, Xie Y, et al.A globally available internet-based patient survey of pemphigus vulgaris:epidemiology and disease characteristics. Dermatol Clin 2011;29:393e404.https://doi.org/10.1016/j.det.2011.03.016. viieiii.
[2] Kanwar A, De D. Pemphigus in India. Indian J dermatology. Venereol Leprol2011;77:439.

https://doi.org/10.4103/0378-6323.82396.
[3] Grando SA, Bystryn J-C, Chernyavsky AI, Frusi
c-Zlotkin M, Gniadecki R, Lotti R,et al. Apoptolysis: a novel mechanism of skin blistering in pemphigus vulgaris linking the apoptotic pathways to basal cell shrinkage and suprabasal acantholysis.Exp Dermatol 2009;18:764e70. https://doi.org/10.1111/j.1600-0625.2009.00934.x.

[4] Ghodsi SZ, Chams-Davatchi C, Daneshpazhooh M, Valikhani M, Esmaili N. Quality of life and psychological status of patients with pemphigus vulgaris using dermatology life quality Index and general health questionnaires. J Dermatol 2012;39:141e4. https://doi.org/10.1111/j.1346- 8138.2011.01382.x.

[5] Joseph B, Nair PM, Nanda A. Effects of naturopathy and yoga intervention on CD4 count of the individuals receiving antiretroviral therapy-report from a human immunodeficiency virus sanatorium. Pune. Int J Yoga 2015;8:122e7. https://doi.org/10.4103/0973-6131.158475.

[6] Gowda S, Mohanty S, Saoji AA, Nagarathna R. Integrated yoga and naturopathy module in management of metabolic syndrome: a case report. J Ayurveda Integr Med 2017;8:45e8. https://doi.org/10.1016/j.jaim.2016.10.006.

[7] Nalgirkar S, Vinchurkar S, Saoji A, Mohanty S. Yoga as a therapeutic intervention in the management of dysfunctional uterine bleeding: a controlled pilot study. J Midlife Health 2018;9:8e13. https://doi.org/10.4103/jmh.JMH_ 76_17.

[8] Raghavendra P, Shetty P, Shetty S, Manjunath N, Saoji AA. Effect of highfrequency yoga breathing on pulmonary functions in patients with asthma: a randomized clinical trial. Ann Allergy Asthma Immunol 2016;117:550e1. https://doi.org/10.1016/j.anai.2016.08.009.

[9] Lewis V, Finlay AY. 10 Years experience of the dermatology life quality Index (DLQI). J Invest Dermatol Symp Proc 2004;9:169e80. https://doi.org/10.1111/ j.1087-0024.2004.09113.x.

[10] Gopalan C, Rama Sastri BV, Balasubramanian SC. Nutritive value of Indian foods. Hyderabad: National Institute of Nutrition, Indian Council of Medical Research; 2016.

[11] Shetty GB, Mooventhan A, Anagha N. Effect of electro-acupuncture, massage, mud, and sauna therapies in patient with rheumatoid arthritis. J Ayurveda Integr Med 2015;6:295e9. https://doi.org/10.4103/0975- 9476.172415.

[12] Vinchurkar SA, Arankalle DV. Integrating yoga therapy in the management of urinary incontinence: a case report. J Evid Based Complementary Altern Med 2015;20:154e6. https://doi.org/10.1177/2156587214563311.

[13] Saoji AA. Yoga: a strategy to cope up stress and enhance wellbeing among medical students. N Am J Med Sci 2016;8:200e2. https://doi.org/10.4103/ 1947-2714.179962.

[14] Pascoe MC, Thompson DR, Ski CF. Yoga, mindfulness-based stress reduction and stress-related physiological measures: a meta-analysis. Psychoneuroendocrinology 2017;86:152e68. https://doi.org/10.1016/ j.psyneuen.2017.08.008.

[15] Saoji AA, Raghavendra BR, Manjunath NK. Immediate effects of Yoga breathing with intermittent breath retention on the autonomic and cardiovascular variables amongst healthy volunteers. Indian J Physiol Pharmacol 2018;62:41e50.

[16] Ott B, Skurk T, Hastreiter L, Lagkouvardos I, Fischer S, Büttner J, et al. Effect of caloric restriction on gut permeability, inflammation markers, and fecal microbiota in obese women. Sci Rep 2017;7:11955. https://doi.org/10.1038/ s41598-017-12109-9.

[17] Funk JL, Frye JB, Oyarzo JN, Kuscuoglu N, Wilson J, McCaffrey G, et al. Efficacy and mechanism of action of turmeric supplements in the treatment of experimental arthritis. Arthritis Rheum 2006;54:3452e64. https://doi.org/ 10.1002/art.22180.

[18] Upadhyay SN, Dhawan S, Garg S, Talwar GP. Immunomodulatory effects of neem (Azadirachta indica) oil. Int J Immunopharm 1992;14:1187e93. https:// doi.org/10.1016/0192-0561(92)90054-O.

[19] Reutemann P, Ehrlich A. Neem oil: an herbal therapy for alopecia causes dermatitis. Dermat contact, atopic. Occup drug 2008;19:E12e5. Available at: http://www.ncbi.nlm.nih.gov/pubmed/18627678.

[20] Matz H, Orion E, Wolf R. Balneotherapy in dermatology. Dermatol Ther 2003;16:132e40. Available at: http://www.ncbi.nlm.nih.gov/pubmed/ 12919115.

[21] Mooventhan A, Chaudhari SS, Venugopal V. Effect of cold hip bath on blood glucose levels in patients with type 2 diabetes mellitus: a pilot study. Diabetes Metabol 2019. https://doi.org/10.1016/j.diabet.2019.04.003. In press.

[22] Mooventhan A, Venugopal V, Chaudhari SS. Twenty minutes of gastro-hepatic pack reduces blood glucose levels in patients with type 2 diabetes mellitus: A pilot single group pre-post study. Adv Integr Med 2020. https://doi.org/ 10.1016/j.aimed.2020.01.002. In press.