Assessment of Quality of Life in Patients With Skin Disorders Undergoing Ayurvedic Panchakarma (Biopurification) as Management

Abstract

Background.

Chronic skin conditions can have a negative impact on one’s quality of life, affecting their physical, functional, and emotional well-being. Whereas biopurifactory measures (panchakarma) of Ayurveda claims to provide better quality of life after treatment. Hence current study is planned to provide evidence in patients with skin disorders, undergoing Ayurvedic treatment.

Methodology.

Sixty patients with skin disorder, who underwent purification therapies like therapeutic emesis and therapeutic purgation, were randomly placed in 2 groups to assess quality of life. Quality of life assessment was done with the help of Skindex-29 among the patients before and after Ayurvedic purification therapy. Thereafter, the quality of life assessment was done on the first follow-up.

Results.

A statistically significant improvement in the quality of life domains—emotions, functioning, and symptoms—after the Ayurvedic management was observed with P value <.001.

Conclusion.

Study concludes that there is improvement in quality of life among patients with skin disease after undergoing Ayurveda purification therapies.

Keywords

Ayurveda Panchakarma quality of life skin diseases

Skin diseases are a common health condition responsible for considerable disability.¹ Patients with skin disease may experience severe symptoms, such as itching, pain, and discomfort that can have a profound psychological impact. Furthermore, patients’ social and physical activities, including sports and work, may be adversely affected because of reluctance to allow others to see their skin disease. Some treatment modalities can situationally decrease quality of life due to the difficulties involved in using topical creams and ointments.² Although mortality rates are generally low, skin diseases have significant effects on quality of life.³

Diseases affect human life in a profound way. They cause premature death resulting in decreased “quantity” of life, but more often they cause structural and functional limitations that may seriously affect the “quality” of life. Measurement of quality of life in addition to measuring objective signs gives an added perspective to the assessment of new therapies. The use of information from a simple but formal validated quality of life measure may assist the clinician in making more appropriate clinical decisions, and may have the added advantage of documenting clear justification for the use of drugs that are expensive or have associated risks.⁴

Patients with eczema, vitiligo, or psoriasis face embarrassment, worry, and depression. A survey of patients with psoriasis revealed that many deliberately avoid swimming.⁵ In addition, few wear short sleeves, shorts, or skirts because they feel that people regard them as “untouchable” or “contagious.” Playing sport is a problem for psoriasis sufferers.⁶ Children with psoriasis are more likely to be bullied.⁷ Impairment of quality of life correlates poorly with severity of disease. A Polish survey found that disease severity was related to impact on employability and family finances.⁸ The poor correlation of quality of life with severity of disease and other demographic variables, such as gender and education, has also been reported.^9,10

Stress, either environmental or psoriasis induced, has important implications for the management of psoriasis. Depression and even suicide may occur. Cognitive behavioral therapy in vitiligo improved quality of life.¹¹ Childhood atopic eczema affects not just the child but the whole family and education may be of benefit to all.¹² It can affect sleep, schooling, development, and relationships within families. It can lead to unfair criticism of parents who may be deemed to be neglectful by those who may underestimate the severity of a child’s eczema. Ayurveda being the oldest system of medicine in the world adapts a unique holistic approach to the science of life, health, and cure.

Over the years, the number of patients opting for ayurvedic treatment has also increased dramatically due to less adverse effects and permanent curative methods.¹³ This has paved way for tremendous surge of ayurvedic medicine that has been increasingly made use of in treating acute and chronic skin disorders effectively. Panchakarma (biopurification methods) is one among the several mode of treating the disorders in ayurveda (alternative medicine). Such purification allows the biological system to return to haemostasis and to rejuvenate rapidly and also facilitates the desired pharmacotherapeutic effects of medicine. The elimination of waste products is known as shodhana (purification). Hence the current study was planned with the aim to assess the quality of life in patients with skin disorders undergoing ayurvedic management.

Materials and Methods

Sixty patients suffering from skin disorders irrespective of age, sex, and religion were taken for the study, from the Skin Outpatient and Inpatient Departments of our hospital, after obtaining permission from the Institutional Ethics Committee.

Study Plan

Thirty patients were randomly placed under 2 groups undergoing purification methods like therapeutic emesis and therapeutic purgation. In group 1 those patients were included who underwent vamana karma (therapeutic emesis) and group 2 included patients who were subjected to virechana karma (therapeutic purgation). Quality of life assessment was done with the help of Skindex-29 among the patients before commencement of treatment and also after the shodhana therapy (purification) as per inclusion criteria. Thereafter, the quality of life assessment was done on the first follow-up. The results were analyzed statistically.

Inclusion Criteria

Patients with skin disorders, older than 18 years of age, and who are willing to participate voluntarily in the study were included.

Exclusion Criteria

Patient with systemic disorders and who were contraindicated for vamana and virechana therapies were excluded.

Skindex

This questionnaire was specifically designed to assess quality of life in patients with dermatological conditions. Skindex-29 was previously tested and validated and its English language version, used in the current study, was also previously validated. Permission to use the Skindex-29 in this study was obtained from the original Skindex-29 author, Mary-Margaret Chren, MD, and also from the MAPI Research Trust.

Each question in the survey had a 5-point answer scale, ranging from “never” (0) to “all the time” (5); the lower the score (range 0-100) the better the patient’s overall quality of life. The overall quality of life score can be further divided into 3 domains: the patient’s emotional state, symptom severity, and functioning state.

Skindex-29 is a disease-specific questionnaire that comprehensively assesses the effects of skin diseases on patient’s quality of life. It was specifically developed to detect changes throughout the time, as well as differences among patients with different skin diseases. The questionnaire covers areas considered crucial in an instrument designed to evaluate quality of life, such as, degree of symptoms, psychosocial functioning, and emotional status. The 29-item version is a refinement of a previous 16-item version, and combines the advantage of an easier administration with improved psychometric properties.

Observations

In the study, majority of the subjects were between 18 and 30 years of age (48.33%), 30% were between 31 and 40 years of age, 16.6% were between 41 and 50 years of age, and only 5% were between 51 and 60 years of age. The study cmprised 40 (66.7%) males and 20 (33.3%) females. Hindus were 56 (93.3%) and only 4 (6.7%) were Muslim. Majority of the subjects were married (34, 56.7%) and 26 (43.3%) were unmarried. Majority of the subjects were undergraduates (26, 43.3%), 15 (25.0%) had higher secondary education, 12 (20.0%) had primary education, 5 (8.3%) were postgraduates, and only 2 (3.3%) had nursery education. Majority of the subjects were of middle-class background (33, 55.0%), 12 (20.0%) were poor, 9 (15.0%) were lower middle class, 5 (8.3%) were upper middle class, and only 1 person (1.7%) belonged to the rich class. Forty (66.7%) subjects had anxiety, 26 (43.3%) had stress, and 4 (6.7%) were found to have depression under emotional domain. Majority of the subjects were diagnosed with psoriasis (35, 58.3%), 10 (16.7%) with eczema, 5 (8.3%) with vitiligo, 5 (8.3%) with acne, 4 (6.7%) with urticaria, and only 1 (1.7%) was diagnosed with herpes zoster.

Statistical Analysis

Statistical Package for Social Sciences version 20 was used for data analysis. Friedman’s test was used to analyze the significance of change in subjective parameters. Wilcoxon signed rank test is done on parameters which show significance in Friedman’s test, to interpret the time of significant change. The obtained results were interpreted as

Not significant: P > .05

Significant: P < .05 or P < .01

Highly significant: P ≤ .001

Results

In the present study, 3 domains were analyzed to evaluate the quality of life and the results are summarized in Table 1.

Table 1.

Summarized Assessment of Quality of Life in Patients With Skin Disorders Undergoing Ayurvedic (Alternative Medicine) Management.

	Domain	Z	P	Significance
Within the groups
Vamana	Skindex Emotions	−4.792	.000	HS
(AT-BT)	Skindex Functioning	−4.071	.000	HS
	Skindex Symptoms	−4.715	.000	HS
Virechana	Skindex Emotions	−4.391	.000	HS
(AT-BT)	Skindex Functioning	−4.624	.000	HS
	Skindex Symptoms	−4.651	.000	HS
Follow-up		Domain	n	Mean	Std Dev	Mean Rank	Chi-Square	P	Interpretation
Emotions doman	Vamana	ED BT	30	71	17.52	3	60	.000	HS
		ED AT	30	54.16	22.45	2
		ED FW	30	37.41	18.18	1
	Virechana	ED BT	30	77.83	17.4	2.93	52.261	.000	HS
		ED AT	30	61	15.77	3
		ED FW	30	40.91	14.59	1.07
Functioning domain	Vamana	FD BT	30	60.23	20.14	2.88	52.362	.000	HS
		FD AT	30	46.66	22.89	2.07
		FD FW	30	30.69	15.58	1.05
	Virechana	FD BT	30	70.2	16.93	2.93	52.267	.000	HS
		FD AT	30	54.44	15.03	2
		FD FW	30	35.34	12.76	1.07
Symptoms domain	Vamana	SD BT	30	58.92	21.7	2.97	53.896	.000	HS
		SD AT	30	40.83	17.81	1.92
		SD FW	30	25.83	13.28	1.12
	Virechana	SD BT	30	61.9	11.42	2.9	50.276	.000	HS
		SD AT	30	47.02	9.56	2
		SD FW	30	29.28	9.85	1.1

Abbreviations: AT, After therapy; BT, Before therapy; FW, Follow up; ED, Emotions domain; FD, Functioning domain; HS, highly significant; SD, Symptoms domain; Std Dev, standard deviation.

Emotions Domain

The subjects who underwent vamana therapy (therapeutic emesis) found the improvement in quality of life after the treatment with Z = −4.792 and P = .000, which is statistically highly significant. While assessing the follow-up, improvement in quality of life with the mean ranks reduced gradually from Before therapy (BT) to Follow up (FW) with chi-square value 60.000 and P = .000, which is statistically highly significant. However, during assessment done after the virechana therapy, the improvement in quality of life after the treatment revealed Z = −4.391 and P = .000, at follow-up reducing gradually from BT to FW with chi-square value 52.261 and P = .000, which is statistically highly significant.

Functioning Domain

The subjects who underwent vamana therapy found the improvement in quality of life after the treatment with Z = −4.071 and P = .000. At follow-up, the values obtained were Z = −4.715 and P = .000, which is considered statistically highly significant. Virechana therapy found the improvement in quality of life after the treatment with Z = −4.624 and P = .000 and at follow up BT to FW with chi-square value 52.267 and P = .000 were obtained, which are statistically highly significant.

Symptoms Domain

The subjects who underwent vamana therapy found the improvement in quality of life after the treatment with Z = −4.715 and P = .000 and BT to FW with chi-square value 50.276 and P = .000, at follow-up which are statistically highly significant. However, virechana therapy found the improvement in quality of life after the treatment with Z = −4.651 and P = .000, which is statistically highly significant. The ranks reduced BT to FW with chi-square value 50.276 and P = .000 at follow up, which are statistically highly significant.

Discussion

Dermatologists and others caring for people with skin disease have probably always been aware of the potential for impairment of life quality caused by skin disease. This area has been described in dermatology literature many times over the past century. However, formal research, involving the creation and use of methodology to measure impact, is a relatively recent development.

Skin and Quality of Life

Quality of life can be difficult to define. The World Health Organization lists quality of life as “individual’s perception of their position in life, in the context of the cultural and value system in which they live and in relation to their goals, expectations, standards and concerns.”¹⁴ For patients with chronic skin diseases, quality of life can be as simple as wearing a pair of shorts or tank top without feeling ashamed. For health care as a whole and dermatology in particular, quality of life improvement is increasingly being seen as an important endpoint in clinical practice.¹⁵

Chronic skin conditions can have a negative impact on one’s quality of life, affecting their physical, functional, and emotional well-being. For example, patients with psoriasis report physical discomfort, stigmatization, loss of productivity, and low self-esteem, as well as limitations in daily activities, social contacts, and work.¹⁶ Many patients with vitiligo experience psychosocial distress and social stigmatization even though it is often considered a “cosmetic skin disorder” in the Western culture.^17
–19 A study conducted by Sprangers et al²⁰ showed that eczema and psoriasis have a negative impact on quality of life comparable to that of cardiovascular diseases. This is also supported by Rapp et al,²¹ who showed that the negative impact of psoriasis on quality of life is comparable to breast cancer, diabetes, heart disease, and major depressive disorder.

Skin diseases are among the common public health conditions responsible for considerable disability.¹ The associated limitations to normal daily activities pose serious socioeconomic problems. In tropical areas, where transmissible diseases are endemic, skin diseases are the dominant presentations and among the most common health problems seen in primary care settings.^22

–25 Although studies aimed at estimating the extent of the problems have been carried out in advanced societies, the quality of life of people with skin diseases in developing countries has continued to be a major problem, as issues relating to it have not been adequately addressed. Previous studies had only been focused on the prevalence and pattern of occurrences, and various rates ranging from 20% to 80% have been reported.^26,27

Emotions Domain

Skin disorders with emotional problems may develop a vicious cycle between anxiety/depression and dermatological symptoms. In one direction, anxiety and depression are frequent consequences of the skin disorder.

The fact that skin disorders are so prevalent makes the negative impact on quality of life a significant social issue. One of the most common triggers for many inflammatory skin disorders is emotional stress.²⁸ Probably emotional stress is commonly accepted as an exacerbating factor in the disease state of inflammatory skin disorders. Many subjects have fear, anxiety, low self-esteem, stress, and a feeling of shame in social interactions.²⁹

Probably due to the emotional problems, there was impairment in quality of life before the treatment. After the treatment, and also during the follow-up, the emotional problems were reduced due to the improvement in skin health or the appearance. This may be attributed to the improvement in quality of life.

Symptoms Domain

Physical symptoms may include dryness, redness, swelling, flaking, blistering, cracking, burning, bleeding, and pain from the irritated skin; but most notably, intense itching further leads to emotional stress, irritability, and insomnia. The impact of skin disorders goes beyond physical appearance. Itching, burning, bleeding, and scratching show a high negative impact on the quality of life.

Water plays an important role in preventing skin infections through hand washing, bathing, and other personal hygienic measures.³⁰ Extensive studies of showering and bathing conducted since the 1960s demonstrated that these activities increase dispersal of skin bacteria into the air and ambient environment.^31
–33

Probably due to the physical problems there was a disturbed emotional quotient, which in turn had affected the subjects’ quality of life. After treatment and during the follow-up the physical problems reduced, which lead to an improvement in quality of life.

Functioning Domain

Functional aspects of human being include sleep, work, and involvement in hobbies, sports, and sexual activities. Skin disorders can have a negative impact on one’s quality of life affecting their physical, functional, and emotional well-being. Skin disorders can lead to negative visibility, decreased productivity at work, and limitations in daily activities and social outreach. Social and sporting activities can become difficult for people with skin conditions due to the fact that they worry about what other people think of their appearance. It was also demonstrated that skin diseases can cause anxiety, depression, anger, and embarrassment, which lead to social isolation and absenteeism at work and school.^2,16,34

Lifestyle restrictions in more severe cases can be significant, including limitations on dressing style, routine work, and socialization. The impairment of quality of life caused by childhood atopic dermatitis has been shown to be greater than or equal to that of asthma or diabetes.³⁵

The symptoms like itching, burning, and so on, impaired the sleep and routine activities, including hobbies, which affected the physical functioning. The abnormal appearance had an impact on the mental functioning and attitude of the subjects. After the treatment and also during the follow-up, the functioning problems were reduced so there was an improvement in quality of life.

Mode of Action of Biopurification Over Skin Disease

Morbid vata (wind is the impulse principle necessary to mobilize the function of the body), kapha (body fluid principle which relates to mucus, lubrication, and the carrier of nutrients), and pitta (bilious humour) play a major role in the manifestation of skin disesaes, that is, kustha. There is an Asraya Asraye (Depends on each other) relation between rakta and pitta. So the morbidity in the pitta is leading to raktha dushti, which in turn vitiates skin after associating with kapha. So biopurification plays a major role here to expel this complex morbidity.

Conclusion

Quality of life after the ayurvedic management was found to be statistically significant. Improvement in the overall quality of life score was observed from the day of arrival to the day of departure and further to follow-up. In the emotions, functioning, and symptoms domains, subjects found statistically significant improvement in the quality of life after the ayurvedic management with P < .001, which is statistically highly significant. Quality of life for patients with skin disease in developing countries has continued to be a major problem because related issues have not been adequately addressed. Skindex is an instrument that measures the effects of a skin disease on a patient’s quality of life. Hence it can be concluded that biopuricatory measures of ayurveda improves quality of life.

Footnotes

Acknowledgments

The authors sincerely thank Professor K. J. Girish, Dr Suhas Shetty, and Dr Shivakumar Harti for techical advice throughout the work.

Authors’ Note

Ayurvedic purification methods (Panchakarma) concerns the management of skin disorders hence this work gives evidence for clinical studies. The current research also extends the level for evaluation of biopurification therapies like vamana (emesis therapy) and virechana (purgation therapy).

Author Contributions

HD contributed toward concepts, design, definition of intellectual content, literature search, studies, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing, manuscript review, and agrees to act as a guarantor. SK contributed toward concepts, design, definition of intellectual content, studies, data acquisition, statistical analysis, manuscript editing, and manuscript review. MBK contributed toward concepts, design, definition of intellectual content, literature search, studies, data acquisition, statistical analysis, manuscript preparation, manuscript editing, manuscript review, TBT contributed toward concepts, design, definition of intellectual content, literature search, studies, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing, manuscript review and AC contributed toward concepts, design, definition of intellectual content, literature search, studies, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing, and manuscript review.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Ethical Approval

This study was conducted after obtaining the permission of Institutional Ethics Committee (SDMCAH/IEC/57/13-14).

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