Vamana And Virechana In The Treatment Of Kushta

By Dr Raghuram Y.S. MD (Ay) & Dr Manasa, B.A.M.S
Kushta is a term which includes many skin disorders. According to Ayurveda there are 18 types of kushta. All types of kushtas are caused due to aggravation of all three doshas. In spite of all three doshas being involved in the causation of kushtas one or the other doshas will be predominant. Due to severe aggravation of doshas in the pathogenesis of kushta, cleansing therapies should be administered frequently since there will be chances of recurrences. This is achieved by skillful administration of Panchakarma therapies depending on the predominance of doshas in the causation of the disease. Vamana is one among the five therapies of Panchakarma and is preferred in diseases caused by predominant aggravation of kapha. Vamana is also a preferred treatment in Kushtas caused by predominant vitiation of kapha.
Read – Maha Kushta: Major Skin Diseases, Symptoms, Prognosis

Table of Contents

Vamana In The Treatment of Kushta

a. In kapha predominant kushta, therapeutic emesis shall be administered as the first line of treatment. It is the best therapy for morbid kapha as well as curative of kapha predominant kushtas. The formulations for emesis as mentioned and explained in Kalpa Sthana section of Charaka Samhita shall be chose for emesis therapy.

b. In case of Kushtas manifesting in the upper parts of the body, when there is aggravation of doshas mainly kapha in the chest, emesis should be administered using shita rasa (cold decoction / juice) or pakva rasa (processed / hot decoction) of the below mentioned herbs mixed with the juice of neem –

Kutajaphala / Indrayava – fruit or seeds of Holarrhena antidysenterica
Madanaphala – fruits of Randia dumetorum
Licorice – Glycyrrhiza glabra
Patola – Trichosanthes dioica

Honey and Licorice are also used as effective emetics in this condition.

Vamana in Kapha predominant Kushta
Vamana i.e. therapeutic emesis has been said to be the treatment of choice in the skin disorders caused by vitiated kapha. Broadly two conditions are explained pertaining to administration of vamana in Kushta by Master Charaka.

1. In kapha predominant kushta
As a rule vamana – therapeutic emesis shall be administered as the first line of treatment in kapha predominant kushtas. It is the best therapy for kapha predominant kushtas. Repeated emesis therapy will also prevent the recurrence of kapha predominant kushta and provide immunity against the disease. Therefore, precise diagnosis of kapha predominant kushtas by recognizing the symptoms manifested therein is very important from physician’s perspective.

Where to get the formulations for emesis from?
Master Charaka tells that the formulations for emesis as mentioned and explained in Kalpa Sthana section (of Charaka Samhita) shall be chosen for emesis therapy. Though there are 6 chapters dedicated for emesis therapies and formulations in Kalpa Sthana section there are only finger count formulations in which ‘kushta’ has been mentioned as an indication. They are as below mentioned.

a. Use of Ikshvaku – Lagenaria siceraria
The pulp of Iksvaku is mixed with whey and taken by the patient suffering from obstinate skin diseases including leprosy. The same formulation is also advised for patients of anemia and toxicities.
Read – Leprosy Awareness: Early Detection Is Important

b. Use of Krtavedhana – Luffa acutangula
Krtavedhana is exceedingly pungent, sharp and hot in nature. It is useful in deep seated diseases, mainly kushta vis-à-vis obstinate skin diseases including leprosy. Krtavedhana is also effectively used in the treatment of diseases including anemia, splenic disorders, edema, phantom tumors and toxicosis.

Can other herbs mentioned in Kalpa Sthana also be used in treatment of Kushta?
Other herbs can also be used though kushta has only been mentioned in the context of Ikshvaku and Krtavedhana. Since emesis is administered in kapha predominant kushta all emetics mentioned in Kalpa Sthana section will be useful and the physician shall use them as per the need and in absence of availability of ikshvaku or krtavedhana.
Read – Vamanopaga Gana: Emesis Aiding Herbs: Review, Benefits, Formulations

2. In Kushtas manifesting in upper parts of the body
In case of Kushtas manifesting in the upper parts of the body, when there is aggravation of doshas mainly kapha in the chest, emesis should be administered using shitarasa (cold decoction / juice) or pakvarasa (processed / hot decoction) of the below mentioned herbs mixed with the juice of neem –

Kutajaphala / Indrayava – fruit or seeds of Holarrhena antidysenterica
Madanaphala – fruits of Randia dumetorum
Madhuka – Glycyrrhiza glabra
Patola – Trichosanthes dioica

Honey and Licorice are also used as effective emetics in this condition.
Read – Rules For Vamana and Virechana Treatment- Charak Samhita Sutrasthan 15

Kapha predominant Kushtas

1. Kushtas caused by only kapha vitiation
Kapha is predominantly vitiated in the below mentioned Kushtas –

Mandala Kushta – Maha Kushta (major skin disease)
Vicharchika – Kshudra Kushta (minor skin disease)

2. Kushtas caused by association of kapha with other doshas –
In these conditions emesis is given only if kapha is more dominant in comparison to the other associated dosha and if the condition reflects the need of emesis and if the patient is eligible to undergo the same. Though this has not been mentioned in the classics, here we have mentioned this to give an expanded vision and field of usage of emesis in the treatment of kapha predominant kushtas. The choice to administer emesis or not is totally left out to the skillful decision of the physician treating these conditions.

Kapha-Pittaja Kushtas – Kapha associated with pitta in –

Sl No	Name of Kushta	Type of Kushta
1	Pundarika	Maha Kushta
2	Pama	Kshudra Kushta
3	Shataru	Kshudra Kushta
4	Visphota	Kshudra Kushta
5	Dadru	Kshudra Kushta
6	Charmadala	Kshudra Kushta

Vata-Kaphaja Kushtas – Kapha vitiated with vata in –

Sl No	Name of Kushta	Type of Kushta
1	Sidhma	Maha Kushta
2	Charma Kushta	Kshudra Kushta
3	Eka Kushta	Kshudra Kushta
4	Kitibha	Kshudra Kushta
5	Vipadika	Kshudra Kushta
6	Alasaka	Kshudra Kushta

Sanskrit Verses

Virechana In The Treatment Of Kushta

Vamana or virechana – therapeutic purgation or a combo of both are administered to eliminate the morbid doshas and treat the kushtas comprehensively. Virechana is preferred in the diseases caused by predominant aggravation of pitta. Purgation is also a preferred treatment in skin diseases caused by predominant vitiation of pitta.
Read – Virechana Therapy – Right Method, Side Effects, Management

Virechana in Pitta predominant Kushta

As a rule virechana – therapeutic purgation shall be administered as the first line of treatment in pitta predominant kushtas. Purgation is the best therapy for morbid pitta as well as curative of pitta predominant kushtas. Recurrence of pitta predominant kushta can be prevented by repeated administration of purgation therapy. It also would provide immunity against the disease. Therefore, precise diagnosis of pitta predominant kushtas by recognizing the symptoms manifested therein is very important from the physician’s perspective. Apart from virechana, raktamokshana is also mentioned as one of the treatment choices in the treatment of pitta predominant kushtas. Therefore purgation and bloodletting are the best treatments for pitta predominant kushtas and shall be selectively administered.

Where to get the formulations for purgation from?
Master Charaka tells that the formulations for purgation (and also emesis) as mentioned and explained in Kalpa Sthana section (of Charaka Samhita) shall be chosen for purgation therapy. There are 6 chapters dedicated for purgation therapies and related formulations in Kalpa Sthana section, there are only few formulations in which ‘kushta’ has been mentioned as an indication. They are as below mentioned.

Trivrt – Operculina turpethum
Trivrt is one of the ingredients of Kalyanaka Guda, a formulation explained in chapter 7 of Kalpa Sthana of Charaka Samhita. This formulation has been indicated as a purgative in many disorders. Among the indications Kushta – skin disorders has also been mentioned.

Maha-Vrksha / Sudha – Euphorbia neriifolia
Sudha is one of the best purgative remedies and has been indicated in many diseases. It is said that if properly administered Sudha quickly eliminates the doshas even if they are excessively accumulated. Among the indications for the usage of Sudha, kushta – obstinate skin disorders including leprosy has been mentioned.

Saptala and Shankini – Euphorbia pilosa and Euphorbia dracanculoides
Kushta – skin disorders has been mentioned amongst the indications for administration of saptala and shankini as purgative.

Can other herbs mentioned in Kalpa Sthana (purgative herbs and formulations prepared from the same) also be used in treatment of Kushta?
The other herbs mentioned in Kalpa Sthana can also be used for administering purgation though kushta has only been mentioned in the context of Kalyanaka Gudam (Trivrt), Mahavrksha, Saptala and Shankini. Since purgation is administered in pitta predominant kushta all purgatives mentioned in Kalpa Sthana section is useful and the physician shall use them as per the need and in absence of availability of the mentioned herbs.

Pitta predominant Kushtas

1. Kushtas caused by only pitta vitiation
Pitta is predominantly vitiated in Audumbara / Udumbara Kushta – Maha Kushta (major skin disease)

2. Kushtas caused by association of pitta with other doshas
In these conditions virechana is given if pitta is predominant in comparison to the other associated dosha and if the condition reflects the need of purgation and if the patient is eligible to undergo the same. This has not been mentioned in the classics, here it is mentioned to give an expanded vision of usage of purgation in the treatment of pitta predominant kushtas.

Kapha-Pittaja Kushtas – Kapha associated with pitta in –

Sl No	Name of Kushta	Type of Kushta
1	Pundarika	Maha Kushta
2	Pama	Kshudra Kushta
3	Shataru	Kshudra Kushta
4	Visphota	Kshudra Kushta
5	Dadru	Kshudra Kushta
6	Charmadala	Kshudra Kushta

Vata-Pittaja Kushtas – Pitta vitiated with vata in –

Sl No	Name of Kushta	Type of Kushta
1	Rshyajihva	Maha Kushta

In pitta predominant kushta, therapeutic purgation shall be administered as the first line of treatment. Bloodletting is also the best treatment in pitta predominant kushta and shall be skillfully combined with purgation therapy. The below mentioned herbs are used for administering purgation in kushta –

Trivrt – Operculina turpethum
Roots of Baliospermum montanum
Triphala – fruits of Terminalia chebula, Terminalia bellirica and Emblica officinalis

The below mentioned are used as base liquids for mixing the purging recipes prepared with the above said herbs –

Sauviraka – sour gruel
Tushodaka – fermented bean-husk water
Asava – fermented biomedicine
Sidhu – spirituous liquor distilled from molasses / rum

After proper purgation, graduated diet should be given to the patient of kushta in accordance to the best, moderate or less purgation.

Repeated Shodhana in Kushta

All three doshas are involved in the causation of kushta, though there is predominance of one or two doshas in particular types of kushtas
The doshas involved in the causation of kushta are aggravated to great proportions
The disease has a tendency to recur because the doshas accumulate in spite of repeated cleansing especially in those who do not follow the restrictions applied to the diet and lifestyle practices
The disease tends to spread deep into the tissues and contaminate them on long run which might lead to compromise immunity and formation of many complications
The disease causes disfiguration and adds to the stress of the patient
The etiological factors of kushta are not identified many times
Read – Charak Samhita Kushta Chikitsa – 7th Chapter

Basti in Kushta

Sarpi, Vasti in Vata predominant Kushta

a. Sarpi Pana – The first line of treatment in Vata predominant Kushta is Sarpi Pana i.e. oral consumption of medicated ghee. Snehapana / sarpi pana doesn’t count in the Panchakarma therapies. It is actually a preparatory therapy for emesis and purgation therapies which fall under Panchakarma therapy. But oral administration of medicated ghee has been mentioned as the first treatment for vata predominant kushta. In the later context Master Charaka emphasizes on administering Vasti i.e. enema therapy. Both forms of Vasti i.e. Asthapana Vasti and Anuvasana Vasti – unctuous enemas are advised.
Read – Oleation – Snehakarma Dose, Benefits, Side Effects, Management

b. Asthapana Vasti – Though the conditions for administering decoction enemas have not been specified it is wise to understand that it shall be administered –

in Vata predominant kushta
when oral administration of medicated ghee has not yielded satisfactory results

Daruharidradi Kashaya Vasti – The decoction prepared with Daruharidra and other herbs mentioned below shall be mixed with pastes of Indrayava (seeds of Holarrhena antidysenterica) and Musta and ghee and oil shall be administered in the form of cleansing enema. The herbs used for preparing the decoction are –

Daruharidra – Berberis aristata
Brhati – Solanum indicum
Sevya – Vetiveria zizanioides
Pointed gourd – leaves of Trichosanthes dioica
Pichumarda – leaves of Azadirachta indica (neem)
Madana – fruits of Randia dumetorum
Krtamala / Aragwadha – pulp of fruits of Cassia fistula

c. Anuvasana Vasti – Unctuous enema with medicated oil / ghee should be administered, if needed to a patient suffering from vata predominant kushta who had been already administered with purgation therapy and decoction enema i.e. when these therapies have not yielded satisfactory results. It should also be administered to only those who are fit to undergo unctuous enema.
Read – Anuvasana Basti: Method, Benefits, Mode Of Action, Contra Indications

Madanaphaladi Sneha / Anuvasana Vasti – The oil / ghee prepared using the decoction and paste of the below mentioned herbs shall be used to administer unctuous enema –

Madanaphala – fruits of Randia dumetorum
Madhuka – Glycyrrhiza glabra
Neem – Azadirachta indica
Kutaja – bark of Holarrhena antidysenterica
Patola – leaves of Trichosanthes dioica

d. Virechana – Purgation has actually not been mentioned in the treatment principle of Kushta of vata origin. But the above-mentioned reference wherein it is said that anuvasana vasti shall be administered after purgation therapy and decoction enema therapy points out that virechana shall also be used optionally and conditionally in the treatment of vata predominant kushta. So, oral intake of medicated ghee, purgation, decoction enema and unctuous enema shall be conditionally administered in the treatment of vata predominant skin diseases.

Raktamokshana In Kushta (Bloodletting)

Rakta – blood is one of the elements involved in the pathogenesis of kushta. Therefore, contamination of blood and this blood afflicting the skin and body parts to a great extent is mandatory in the causation of skin disorders according to Ayurveda. From this perspective bloodletting becomes an important therapy in the treatment of kushta.

Indication for raktamokshan

Bloodletting and purgation are the most important therapies in the treatment of pittaja kushta – skin disorders caused by predominant vitiation of pitta. Therefore, these therapies shall be preferred when pitta predominant symptoms are seen in kushta.

Both purgation and bloodletting are useful in combination in the treatment of pittaja kushta or selectively administered i.e. either purgation or bloodletting as and when needed, depending on the decision of the physician.

Blood and pitta are having residence-resident relationship. Pitta is located in the blood. Vitiation of pitta might cause vitiation of blood and vice versa. This is also the reason for administering bloodletting in pitta predominant kushta. Apart from Vatarakta, Kushta is another condition wherein master Charaka has detailed the administration of bloodletting.
Read – Charak Samhita Kushta Chikitsa – 7th Chapter

Raktamokshanam in Kushta

Prachanna – In the presence of aggravation of doshas in small quantity in kushta or when the doshas are seated in superficial tissues prachanna i.e. scraping of the afflicted region should be done. Following this, bloodletting should be done using srnga – horn or alabu – gourd.
Sira vyadha – On the other hand, in the presence of aggravation of doshas in large quantity in kushta or when the doshas are deep seated in deeper tissues bloodletting should be done by venesection method.
Read – Blood Letting Therapy – Siravyadha – Astanga Hrudaya Sutrasthana 27

Method of Bloodletting in Kushta

In skin disorders wherein the lesions are fixed, hard and circular in shape, firstly sudation should be administered using prastara (stone slab) or nadi (tubular) forms of sudation. Following this, the afflicted region should be rubbed using an instrument called kurcha. Kurcha is a brush shaped instrument having sharp and pointed bristles used for rubbing.

After rubbing, the contaminated blood shall be removed from those regions of kushta. Once the contaminated blood has been expelled from the region of kushta the complications get subsided. Following this, the afflicted areas are provided with sudation. For this, the meat of animals and birds living in the anupa (marshy regions) and audaka (aquatic) regions should be boiled, tied in a bolus and used for providing sudation over the kushta areas.

Following this, to remove the contaminated blood the areas should be scraped using sharp instruments. Alternatively when the physician learns that doshas are aggravated in lesser proportions and are located superficially, the kushta area should be scraped and the morbid blood removed using horn or gourd. When the doshas are aggravated in larger proportions and located in deeper tissues venesection should be preferred for bloodletting.
Read – Raktamokshana Benefits, Types, Procedure, Indications

Lepa after Raktamokshana

Master Charaka explains different kinds of lepa i.e. medicinal pastes which can be applied on the areas of the body afflicted by kushta immediately after raktamokshana. Master Charaka also provides us with rules for application of lepas. Lepas shall be applied after having cleansed the patient by administration of therapeutic emesis and purgation and also after removal of morbid blood through bloodletting. Only when the medicinal pastes are applied after the completion of these therapies, they would be highly effective in treating the skin disorders. This means that bloodletting is one of the mandatory therapies which need to be done before administration of medicinal pastes or use of anointments.

Other conditions for bloodletting in kushta
In kushta wherein there are fixed, hard and circular lesions, prastara or nadi sweda type of sudation is administered. Later the contaminated blood shall be removed from the afflicted sites by scrubbing them with an instrument called kurcha – a brush like instrument with sharp edged bristles. Once the contaminated blood is expelled the complications get pacified. These lesions then provided with sudation using boiled meat of animals living in marshy regions and aquatic animals in a bolus. Thereafter to remove the remaining contaminated blood a sharp instrument like a razor should be used for scraping the afflicted region. When the physician finds that the kushta is caused by lesser aggravated doshas, the lesions are scraped and bloodletting is administered using srnga – horn or alabu – instrument made up of gourd. Alternatively bloodletting shall be done using leech application.

Nasya – Kushta located in the head

Errhines shall be administered to destroy kushta, worms and kapha aggravation in the head.

Saindhavadi Churna Nasya – the powder of the below mentioned herbs shall be used for errhine to treat the above-mentioned conditions, especially the skin disorders located in the head. The ingredients of this powder are –

Rock salt
Roots of Baliospermum montanum
Black pepper
Seeds of holy Basil
Fruits of Pongamia pinnata
Vidanga – Embelia ribes

Medicines for Kushta from Sahasra Yoga Text Book
Kushtahara Kashaya
Sannipata vikarahara Kashaya
Masurikahara Kashaya
Hikkadihara Kashaya
Jirna Jwarahara Kashaya
Tiktaka Ghrita
Mahatiktaka Ghrita
Panchatiktaka Guggulu Ghrita
Dhanvantari Ghrita
Kalyanaka Ghrita
Maha Kalyanaka Ghrita
Guggulyadi Taila
Panchavalkadi Taila
Kushtantaka Taila
Tiphaladi Taila
Dinesavallyadi Taila
Kacchuradi Taila
Pathadi Choorna
Khandasama Choorna
Pridhu Nimba Panchaka Choorna
Hapushadi Choorna
Vyoshadi Choorna
Ayaskantadi Choorna
Guggulu Panchapala Choorna
Gandhaka Choorna
Narasimha Choorna
Dasamoolarishta
Khadirarishta
Dantyarishta
Duralabharishta
Manibhardra Guda
Danti Haritakyavaleha
Gandhaka Rasayana
Dasamooladi Lehya
Chitraka Guda
Brihat Madhusnuhi Rasayana
Khadiradi Rasayana
Kaisora Guggulu