The word Urticaria is derived from Latin word ‘urtica’ which means stinging nettle. A transient redness and swelling of skin with itching, causing wheals (localized intracutaneous oedema) in the dermis or large hypodermal swellings, is called Urticaria.
Individual hives can last as briefly as 30 minutes to as long as 36 hours. Their size can be small as a millimetre or 6–8 inches in diameter. Upon exerting pressure over the wheals they blanch, as the dilated blood vessels are compressed causing the pallor in the centre of the wheal.
The dilated blood vessels and increased permeability that characterize urticaria are present in the superficial dermis and involves the venular plexus in that location.
But, when the pathology lies a little bit deeper involving the dermis it manifests as angioedema, where in swelling is the major manifestation, and the overlying skin may either look normal or erythematous. The itching or pruritis is less due to involvement of fewer of type C nerve endings, but the pain & burning will be immense.
In Ayurveda the above such manifestation are classified as ShItapitta, Udarda, and KoTha depending upon the stages of the pathology.
The clinical features of shItapitta, udarda, koTha:
VaraTi damShTra samsthAna shotha1 – localised swelling resembling that of a nettle sting bite,
Jvara – fever,
KaNDu bahula2 – intense itching,
VidAha – burning sensation,
Toda bahula – pricking sensation,
Sa utsanga sa rAga – reddish coloured swelling,
MaNDala – wheal,
Chardi – vomiting,
KShaNikotpAda vinAsha3 – transient manifestation followed by its disappearance.
वरटीदष्टसङ्काशः1 कण्डूमांल्लोहितो2 ऽस्रकफपित्तात्| क्षणिकोत्पादविनाशः3 कोठ इति निगद्यते तज्ज्ञैः || – varaṭī daṣṭa saṅkāśaḥ kaṇḍūmāṃ llohito asra kapha pittāt| kṣaṇikotpāda vināśaḥ koṭha iti nigadyate tajjñaiḥ ||
The causes of urticaria & angioedema / shItapitta – udarda – koTha:
The causes of urticarial & angioedema are –
Frequent infections like cold, sore throat or influenza triggers the condition.
Antibiotics like penicillin
Painkillers like aspirin, ibuprofen
ACE inhibitors group of drugs used in treating high B.P.
Autoimmune antibodies
Physical factors like exposure to heat, cold, friction, water & pressure on skin.
In Ayurveda, the causes for shItapitta, udarda & koTha are –
Raktapradoshaja vikAras – blood vitiated disorders6 ,
PunarAvartaka Jvara –recurrent fever
SannipAtaja Jvara – fever caused by tridoShAs,
NAnAtmaja pittavikAra8 – intrinsic pitta diseases,
NAnAtmaja kaphavikAra9– intrinsic kapha diseases,
Santarpana janya vikAra – life style disorders due to over nutrition7,
Chardi nigrahaNa – controlling of the natural urge of vomiting,
DivAsvapna – sleeping at day time,
Contact with polluted water for bathing, tight clothing, artificial ornaments13 etc.
AmAshayagata viSha – endotoxin of stomach,
Intake of dUShiviSha (less potent toxic substances that which remain in a dormant state within the body for years) etc.
Insect bites like louse4, red ant5, bedbug, mosquito and dog louse – यूकाः4, पिपीलिकाश्च5; प्रभावः- कण्डूजननं, कोठपिडकाभिनिर्वर्तनं च – yūkāḥ, pipīlikāśca; prabhāvaḥ- kaṇḍūjananaṃ, koṭhapiḍakābhinirvartanaṃ ca ||
.ततः शोणितजा रोगाः6 प्रजायन्ते पृथग्विधाः| कण्ड्वरुःकोठपिडकाकुष्ठचर्मदलादयः|| च.सू.२४/१६| – tataḥ śoṇitajā rogāḥ prajāyante pṛthagvidhāḥ| kaṇḍvaruḥkoṭhapiḍakākuṣṭhacarmadalādayaḥ || ca.sū.24/16|
रोगास्तस्योपजायन्ते सन्तर्पणनिमित्तजाः7। प्रमेहपिडकाकोठकण्डूपाण्ड्वामयज्वराः॥५॥ rogāstasyopajāyante santarpaṇanimittajāḥ| pramehapiḍakākoṭhakaṇḍūpāṇḍvāmayajvarāḥ|| ca.sū.23/5||
पित्तविकारां8 श्चत्वारिंशतमत ऊर्ध्वमनुव्याख्यास्यामः ओषश्च,प्लोषश्च,…………….. रक्तकोठश्च, रक्तविस्फोटश्च, रक्तपित्तं च | च.सू.२०/१४ | – pittavikārāṃścatvāriṃśatamata ūrdhvamanuvyākhyāsyāmaḥ oṣaśca,ploṣaśca,…………….. raktakoṭhaśca, raktavisphoṭaśca, raktapittaṃ ca | ca.sū.20/14 |
श्लेष्मविकारांश्च 9 विंशतिमत ऊर्ध्वं व्याख्यास्यामः; तद्यथा- तृप्तिश्च, तन्द्रा च,…… उदर्दश्च, श्वेतावभासता च…। च.सू.२०/१७। – śleṣmavikārāṃśca viṃśatimata ūrdhvaṃ vyākhyāsyāmaḥ; tadyathā- tṛptiśca, tandrā ca,…… Udardaśca, śvetāvabhāsatā ca…| ca.sū.20/17|
Types of urticaria:-
Dermographism – The itchy wheals occur in areas of friction over skin, and appears a lines at the sites of scratching. They usually last for less than an hour period.
Cold urticaria – is caused upon exposure to cold weather15, rain, cold water in swimming pool10.
Solar urticaria – is caused by getting exposed to sunrays17.
Delayed pressure urticaria – In areas of pressure caused over skin by tight clothings11 or by holding the tools / instruments for a longer period, painful and several hours lasting wheals occur. स्नानाभ्यङ्गोत्सादनवस्त्रालङ्कारवर्णकैर्दुष्टैः| कण्ड्वर्तिकोठपिडकारोमोद्गमचिमिचिमा शोथाः||११८|| च.चि. २३.११८ – snāna10 abhyaṅgotsādana vastra11 alaṅkāra13 varṇakaih12 duṣṭaiḥ| kaṇḍu arti koṭha piḍakā romodgama cimicimā śothāḥ||118|| ca.ci.23.118 ||
Cholinergic urticaria – The factors which cause sweating like exertion, emotional stress, heat16 and eating spicy food items results in small bumps usually in upper torso of the body within minutes of exposure.
Contact urticaria – Contact of allergens14 from the skin with animals like dog, cats / animal products, certain plants like poison ivy; oak; sumac , certain food like eggs; pea nuts; citrus fruits; fish; crab; tomatoes; soy; wheat & milk, various chemicals like latex and those in soaps, detergents, shampoos, hair dyes, cosmetics12 etc., cause this variety of urticaria. यदुक्तं सुश्रुते- “जीर्णं विषघ्नौषधिभिर्हतं वा दावाग्निवातातपशोषितं वा| इहापि दूषीविषाः कीटा हीनवीर्यविषा वक्तव्याः| – yaduktaṃ suśrute- “jīrṇaṃ viṣaghnauṣadhibhirhataṃ vā dāva agni16 vātātapa15 śoṣitaṃ17 vā| ihāpi dūṣīviṣāḥ kīṭā14 hīnavīryaviṣā vaktavyāḥ ||
Angioedema without wheals – occurs due to allergic reaction18 caused by certain medicines like aspirin, penicillin, ACE inhibitors etc. – दूषीविषं18 तु शोणितदुष्ट्यारुःकिटिमकोठलिङ्गं च| विषमेकैकं दोषं सन्दूष्य हरत्यसूनेवम्||३१|| च.चि २३.११८ – dūṣīviṣaṃ tu śoṇitaduṣṭyāruḥ kiṭima koṭha liṅgaṃ ca| viṣamekaikaṃ doṣaṃ sandūṣya haratyasūnevam||31|| ca.ci 23.118
Urticarial vasculitis19 – occurs due to the inflammation of the blood vessels, on rare occasions. It usually lasts longer than a day presenting with a feeling of uneasiness, joint pains, and stomach pain in association with tender spots resembling a bruise. – पित्तविकारांश्चत्वारिंशतमत ऊर्ध्वमनुव्याख्यास्यामः ओषश्च,प्लोषश्च,…………….. रक्तकोठश्च19, रक्तविस्फोटश्च, रक्तपित्तं च | च.सू.२०/१४ | – pittavikārāṃścatvāriṃśatamata ūrdhvamanuvyākhyāsyāmaḥ oṣaśca,ploṣaśca,…………….. raktakoṭhaśca19, raktavisphoṭaśca, raktapittaṃ ca | ca.sū.20/14 |
Pathogenesis as per Modern science:
Urticaria results from an immediate hypersensitivity reaction after exposure to an allergen or an antigen. The skin mast cell releases the mediator histamine, through whose influence on the histamine1 (H1) receptors, the capillaries get dilated.
The dilation of the capillaries results in vascular permeability. The arteriolar dilatation resulting through the nerve reflex causes the typical flaring of the extravasations of fluid, thereby causing the wheals.
Histamine causes the pruritus too. Other products of mast cells, act as chemotactic factor in attracting eosinophils.
Urticaria results not only from sensitivity to antigens, but also from physical factors such as cold, heat, sunlight, water, pressure and vibration. The underlying mechanisms are not well understood, but the final common pathway is believed to involve release of mediators by activated mast cells and basophilic leukocytes. These mediators increase vascular permeability, and plasma leaks into the dermis, resulting in Urticarial wheals.
Pathogenesis in Ayurveda:
DoShAs involved: TridoShAs
Status of agni: Manda
Movement of doShAs: Vriddhi, Tiryak.
ShAkha VyAdhimarga (location of pathology): BAhya
DUShya (tissue elements involved): Rasa, Rakta
Srotas (system affected): Rasavaha, Raktavaha
Srotodushti prakAra (type of pathology): VimArga Gamana
Udbhava SthAna (site of origin): AmAshaya
Vyakti SthAna (site of manifestation): Tvak
SvabhAva (Onset of disease): AshukAri
The Vata and Kapha, upon getting vitiated and aggravated by the influence of ShIta, MAruta, kRumi, duShitaviSha etc., triggering causative factors, in confluence with Pitta, spreads over the epidermis and hypodermis of the skin to clinically manifest as shItapitta, udarda, koTha.
Treatment of Urticaria / shItapitta, udarda, koTha:
Depending upon the predominance of the doSha, and its gati at the time of clinical examination, after due consideration of the status of agni and dUShyas involved, suitable shodhana karma is to be done. In case of pitta dominance virecana / purgation and for kapha predominance the vamana / emesis therapy gets selected.
Post shodhana, the shamana chikitsa / internal medications are prescribed with herbal or herbomineral combinations capable of reducing the concentration of the aggravated tridoshas, as per the percentage of the doshic vitiation observed through clinical signs and symptoms and through pulse reading.
Along with shaman chikitsa, bahir parimarjana / external application over the site of lesions in the form of taila / powder / ointments are adviced.
The selection of medicine differs from one patient to another, depending upon the various factors explained in the Ayurvedic pathogenesis.
A few of the external and internal medications of Ayurveda pharmacopeia, used in conditions of sItapitta, udarda, koTha are enlisted for educative purpose.
Mustadi Churna
Eladi Gana
Trikatu Sharkara
Katu Taila
Yavani-Vyosha-Yavakshara
Ardraka-Puranaguda
Yavani-Guda
Nimbapatra-Ghrita-Amalaki
Ardrakakhanda
Vardhamanapippali yoga
Vardhamanalashuna prayoga.
Dietary:
Food items suitable for consuming:-
Rice, Soup of green gram dhal, soup of horse gram, hot water, radish soup, pomegranate, leaves of bitter gourd; drumstick; radish; pazhupAgarkaay ilai (Momordica dioica) , Indian gooseberry to mention a few.
Food items to avoid :-
Fish, crab, oysters, wheat, milk products, tomato, citric fruits, brinjal, peanuts, chocolates, soya beans to name a few.