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\title{A Critical Review on Shvitra (Vitiligo) \& their Management}
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             \author[1]{O.P.  Vyas}

             \author[2]{Abhilasha  Sahu}

             \author[3]{Muraree  Girare}

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\date{\small \em Received: 10 December 2019 Accepted: 5 January 2020 Published: 15 January 2020}

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\begin{abstract}
        


Vitiligo is an acquired depigmentation of the skin. It affects 1% of the world population. It is a pigmentary disorder characterized by circumscribed loss of melanin pigment secondary to melanocyte attrition. It is an acquired, sometimes familial condition, an autoimmune disease in the majority. Vitiligo is associated with other autoimmune diseases such as thyroid disease, diabetes mellitus, Addison?s disease, and pernicious anemia. In Ayurveda, Shvitra is correlated by vitiligo.Shvitra is caused by the vitiation of all three Doshas but sometimes it manifest by either single or three or two Doshas. In modern medicine, steroids and corticosteroids are used in the treatment of vitiligo, which has so many side effects. In Shvitra, Samshodhana (purificatory therapies) for the entire body should be administered at the beginning of treatment of Shvitra after that applied Samshamana therapy.

\end{abstract}


\keywords{vitiligo, skin, shvitra.}

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\let\tabcellsep& 	 	 		 
\section[{Introduction}]{Introduction}\par
kin is one of the most important body organs because it protects the internal organ from the deleterious environmental influences \hyperref[b0]{1} . The major pigment of the skin is called melanin. It is produced inside special cells called melanocytes, which are located along with the basal cells in the epidermis and contain small granules called melanosomes \hyperref[b1]{2} . Vitiligo is an acquired condition affecting 1\% of the population worldwide  {\ref 3} . Vitiligo is skin depigmentationin which the melanocytes in localized areas of the body stop producing melanin. Clinically it manifests as macular areas of depigmentation. Occasionally, the skin in certain areas may only be hypopigmented. There is no other change in the skin. In some lesions the hairs may also become depigmented. This is called leucotrichia. The lesions very in shape and size and may appear on any part of the skin and mucous membranes 2 .The border is often convex, a feature that differentiates it from many other conditions of depigmentation. Sometimes at the margin of an active patch, three colors are seen from inside outwards, a depigmented zone, a hypopigmented zone, a normal-looking skin. This is known as 'trichrome vitiligo'. A treated patch often shows an additional perifollicular hyperpigmented zone, Author ?: M.D. Ph.D. Professor \& HOD, Dept. of Kayachikitsa, Govt. Dhanavantari ayurveda college \& hospital Ujjain, M.P., India. e-mail: opvyas24@gmail.com Author ? ?: M.D. Scholar, Dept. of Kayachikitsa, Govt. Dhanavantari ayurveda college \& hospital Ujjain, M.P., India. e-mails: abhilasha0392@gmail.com, giraremuraree@gmail.com and this is known as 'quadrichrome vitiligo' \hyperref[b3]{4} . Vitiligo is correlated with Shvitra in Ayurveda. Shvitra, also known as Kilasa and Daruna, is pointed to similar to Kustha, is nonexudative and arising from the three Doshas and three Dhatus (Rakta. Mamsa and Medas) \hyperref[b4]{5} . At the beginning of treatment of the Shvitra, Samshodhana therapy should be administered. After that, Samshmana therapy should be applied \hyperref[b5]{6} . a) Epidemiology \hyperref[b3]{4} The onset is most common in young adults, onset of disease is before the age of 20 years in approximately 50\% of the patients, with a quarter of the patients having onset by 15 years of age. Rarely disease is present at birth and is then known as congenital vitiligo.\par
b) Etiology \hyperref[b6]{7} In vitiligo, there are focal areas of melanocyte loss, which is considered to be due to cell-mediated autoimmune attack. Some patients have antibodies to melanin. It may be associated with other autoimmune disease such as diabetes, Addison's disease, and pernicious anamia.\par
Genetic factors may play a role; 20 to 30\% of patients may have family history of vitiligo.\par
Extrinsic factors also may play a role. Trauma, certain chemicals, and sunburn may precipitate the appearance of vitiligo. d) Clinical features \hyperref[b6]{7} Lesions may start at any age, but generally in early adolescence or adult life. Segmental vitiligo is restricted to one part of the body.\par
Generalized vitiligo is characterized by many widespread macules, often symmetrical, and frequently involves the hands, wrist, knees, and neck as well as the area around the body orifices.\par
The patches of depigmentation are sharply demarcated.\par
Sensation in the depigmented patches is normal, unlike leprosy.\par
The Course is static or slowly progressive. Some patients may experience spontaneous repigmentation.  
\section[{In Ayurveda}]{In Ayurveda}\par
Shvitrais also known as Kilasa and Aruna, is said to be produced by the same causes which produce Kustha, is nonexudative and arising from the three Doshas and three Dhatus 9 . 
\section[{Nidana}]{Nidana}\par
Untruthfulness, ungratefulness, disrespect for the gods, insult of the preceptors, sinful acts, misdeeds of past lives, and intake of mutually contradictory foods are causative factors of Shvitra \hyperref[b9]{10} . 
\section[{Rupa}]{Rupa}\par
It is classified into three subtypes, namely Daruna, Charuna, and Kilasa.\par
All of them are generally caused by the simultaneous vitiation of all the three Doshas. If located in Rakta dhatu,it is red color, if located in Mamsa dhatu(muscle tissue) it is coppery in color, and if located in Meda dhatu, it is white in color the subsequent ones are more serious than the previous ones \hyperref[b11]{11} .\par
Shvitra produced by Vata, the skin is dry andAruna (light red), in that produced by Pitta, it is coppery has burning sensation and destroys the hairs, in that produced by Kapha, the skin is white (Shveta), thick, heavy and itching \hyperref[b13]{12} . 
\section[{Sadhya-asadhyata}]{Sadhya-asadhyata}\par
Shvitrain which the hairs have not become white, the skin not become thick, the patches have not fused with one other and which is of recent origin, and that not due to burning by fire is curable, where as those of opposite varieties are incurable that which has arisen on the genital organs palm of the hands and lips, even though of recent origin are to be rejected by the physician \hyperref[b13]{12} . 
\section[{f) Management}]{f) Management}\par
In modern medicine \hyperref[b6]{7} Corticosteroids: Topical corticosteroids are the first choice for patients with limited disease. A topical preparation of fluticasone propionate or mometasone, once a day for four to six months has to be applied. 
\section[{Calcineurin inhibitors}]{Calcineurin inhibitors}\par
Ultraviolet light: Topicalor oral psoralens plus ultraviolet A radiation (PUVA), or ultraviolet B (UVB) radiation (phototherapy) is used in patients with extensive vitiligo.\par
Surgery: Split-skin grafts and blister roof grafts can be used to cover vitiligo patches.\par
Depigmentation therapy: If there is extensive vitiligo with only small areas of normal skin, these normal skin areas can be depigmented to make the ski look uniform. In Ayurveda Nidana Parivarjana is the first step of treatment.Chikitsa: 1) Shodhana Chikitsa 2) Shamana Chikitsa,\par
The patient of Shvitra should be purified by the administering of elimination therapies followed by the administration of pacification therapies.\par
The patient should, first of all, take oleation therapy as per once strength followed by intake of the juice of along with jaggery is an excellent tregimen cause Shamsana (a type of purgation). After the administration of this recipe, the patient should expose himself to the heat of the sun. This will induce purgation. After this purgation therapy, the patient will feel thirsty, for which the patient should be given Peya for three days \hyperref[b14]{13}   \hyperref[b15]{14} Pustular eruption over the patches of Shvitra should be punctured with the help of a thorn for removal of serous fluid from these pustules. After the exudation of the fluid, the patient should take every morning continuously for fifteen days, the decoction of Malapyu, Asana, Priyangu, and Satapushpa prepared by boiling with water. Alternatively, the Kshara of Palasa, along with Phanita, should be given an appropriate dose as per strength. 
\section[{External application 15 :}]{External application 15 :}\par
Nilotpala, Kustha, and Saindhava made to a paste by adding urine of elephant.\par
Seeds of Mulaka and Avalguja made to a paste by adding cow-urine. Kakodumbara, Avalguja, and Chitraka made to a paste by adding cow-urine.\par
Manhashila made to a paste by adding pea-cock bile.\par
In rare cases, patients of Shvitra, who are free from the effect of their sinful acts, get cured by the administration of elimination therapies, blood-letting, and intake of ununctuous food like Saktu. 
\section[{II.}]{II.} 
\section[{Conclusion}]{Conclusion}\par
Vitiligo is skin depigmentation due to the selective destruction of melenocytes. It is a common acquired idiopathic discoloration of the skin characterized by well-circumscribed, chalky white colored macules. Vitiligo is correlated with Shvitra in Ayurveda. Shvitra is caused by the vitiation of all three Doshas and three Dhatus (Rakta, Mamsa, and Medas). Generally, Shvitra has no harmful effect on the body, but the patient suffers a socially inferiority complex. Ayurvedic medicine \& purification therapy give better results than modern medicine, which has so many side effects. In Shvitra roga, Samshodhana (purificatory therapies) is the first line of treatment described by Acharya Charaka. After that, administered Samshamana therapy does dhatusamya. \begin{figure}[htbp]
\noindent\textbf{} \par 
\begin{longtable}{P{0.85\textwidth}}
Kashaya: Dose: 15ml-20 ml\\
Aragvadhadi Kashaya\\
Khadiradi Kashaya\\
Manjishthadi Kashaya\\
Ashva-Arishta:Dose: 15ml-30 ml; Anupana-: Sama\\
Bhaga Jala\\
Manjistharishta\\
Sarivadyaashva\\
Khadirarishta\\
Treatment of Pustular Eruption\\
Shamana chikitsa:\\
Rasa Aushadhi: Dose: 125 mg -250 mg\\
Gandhka Rasayana\\
Talkeshvara Rasa\\
Rasamanikya Rasa\\
Vati: Dose: 250mg-500mg\\
Kaishore Guggulu\\
Arogyavardhani Vati\\
Panchatiktagrita Guggulu\\
Churna: Dose: 3-6 gm\\
Bakuchi churna\\
Panchnimba Churna\\
Ghrita: Dose: 5-10 ml\\
Mahatiktaka Ghrita\\
Khadiradi Ghrita\\
Pachatikta Ghrita\\
Somaraji Ghrita\\
Taila: For local application\\
Somaraji taila\\
Bakuchi taila\\
Tuvarak taila\end{longtable} \par
 
\caption{\label{tab_0}}\end{figure}
 		 		\backmatter  			  				\begin{bibitemlist}{1}
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