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Introduction

Ayurveda has described hair problems under Kshudra Roga, Shiroroga as Khalitya, Palitya, Indralupta etc.[1] Indralupta is a specific condition characterized by hair loss in form of patches in some scalp areas by the vitiation of Tridosha and Rakta Dhatu. Pitta associated with Vata gets lodged in Romak?pa and causes hair fall, later on Kaphadosha associated with Rakta causes obstruction to the hair roots and restricted the regrowth. [2]  Indralupta is one among the Kapalagata Roga and Kshudraroga by Vagbhata which is characterized by loss of hair. [3]  There are a many types of alopecia depending upon the pattern of hair loss. Alopecia areata is a disorder in which there is loss of hair causing patches of  baldness but no scarring of the affected area. It can affect the entire scalp. Modern lifestyle, avoidance of head bath, usages of harmful shampoos, allergic manifestations, reduced body resistance, hormonal imbalance, and malnutrition leads to poor hygiene of scalp. [4] Currently, medicines for Alopecia areata are Topical corticosteroids e.g.  Flucinolone acetonide cream, Intralesional corticosteroids e.g. Hydrocortisone acetate, Minoxidil, Topical immunetherapy eg. DNCB (Dinitrochlorobenzene). These medicines  have certain adverse effects like pruritus, skin rash, pain, atrophy etc. Ayurveda

suggests surgical procedures like Sriaveda, Pracchanna, Lekhana and para surgical procedure like Jalookavacharana in Indralupta. Large numbers of drugs for external application in the form of herbal, mineral and single drugs are also described. Many curative and preventive measures like nasya, Rasayana, moordha taila (Abhyanga, Pichu, Shirodhara, Shirobasti), pathya sevana, apathya nisheda are also mentioned.

Synonyms Of Indralupta

Ancient Acharya had adopted a method of defining a disease with various synonyms. Various synonyms of Indralupta are found in Ayurvedic as well as other texts of Sanskrit literature, which are as follows –

According to Ayurvedic Texts –

1. Indralupta - Sushruta, Bhoja

2.  Keshaghna - Harita

3.  Khalitya - Charaka, Sushruta

4.  Ruhya - Sushruta, Bhoja

5.  Rujya - Ashtanga Samgraha

6.  Khalati - Charaka, Ashtanga Samgraha, Ashtanga Hridaya

7.  Chacha - Ashtanga Hridaya

Acharya Susrutha considers ‘Khalathi’ as the synonym for Indraluptha. Videha and Bhoja consider Khalithyam and Khalli as the synonyms of indralutha respectively. But Acharyas like Vagbhata and Hareetha considers Khalathi as a separate disease. According to Madhukosavyakhyana, Indraluptha is a disease of beard and moustache, Khalathi is a disease of head and ruhya is the disease affecting the whole body. The commentator correlates Indralutha with Alopecia areata, Khalathi with simple Alopecia and Ruhya with alopecia areata, Khalathi with simple Alopecia and Ruhya with alopecia universails. According to Chakrapani, Khalathi is a disease occurring predominantlty in males. Acharya Videha had given a possible explanation to this. In females, Pradustarakta is expelled from the body rajas. Further due to the absence of strenuous works, vathapitta pradosha doesnot occurs and hence hairfall doesnot occur. Even if hairfall occurs, new one grows in its place, due to the absence of srotorodha by raktha. [5]

Nidana Panchaka of Indralupta

The examination of a diseased person should be done by Darshana, Sparshana and Prashna, whereas that of the disease by Nidana (etiological factors) Purvarupa (premonitory signs and symptoms), Rupa (Signs and symptoms), Upashaya and Samprapti (pathogenesis). Thus, to understand the disease Khalitya above five factors would be described.

Hetu (Etiological Factors)

In ancient Ayurveda texts, there is clear description of various factors which imbalance the state of equilibrium of Doshas. This ultimately leads to create suitable situation for various diseases. These factors are considered as Hetu (etiological factors). So far as disease Indralupta is concerned there is no clear description regarding the causative factors of Indralupta, but by analyzing the explanation of the pathogenesis of the disease and by collecting the scattered reference from Ayurvedic texts, an indirect knowledge of etiological factors may be acquired. Acharya Sushruta has encapsulated the pathogenesis in following way that Pitta along with Vata enters into the Romakoopa (hair roots) and produces Indralupta whereas the augmented Kapha along with Rakta obstructs the Romakoopa thus

preventing the production of new hair. [6]  Acharya Charaka has said that “Teja along with Vatadi Dosha, burn the Keshbhoomi to produce Khalitya (Indralupta)”. Chakrapani, while commenting on this, points out that Dehoshma is to be understood by the word Teja and Dehoshma is directly proportional to Pitta. [7] Thus observing the pathogenesis described by different Acharya, it can be said that the Vata, Pitta and Kapha Dosha and Rakta Dushya are the main internal causative factors of Indralupta. In addition to this, Acharya Charaka has mentioned various factors which vitiate Vatadi humors by which Shirogata Rakta also gets vitiated and gives rise to different Shiroroga. According to Vagbhatta, Khalitya comes under the roof of Shiroroga. So, the etiological factors mentioned by Acharya Charaka can be understood as that of disease Khalitya. [8]  Charaka in Vimanasthana, while describing the disorders occurring due to the over indulgence in Kshara, Lavana and Viruddha Ahara has mentioned the occurrence of Hair Loss as a consequence of it. It has been mentioned that the Viruddha Ahara like, simultaneous intake of Lavana (salt) with milk in the diet induces Indralupta, as observed in the people of Saurashtra and Bahlika. Thus, it can be said that a person habituated to excessive Lavana or Kshara intake and taking Viruddha Ahara in routine is prone to have Indralupta. [9] The Ashtanga Samgrahakara has enumerated Shiroroga under the caption of Urdhvajatrugata Roga and these are further subdivided into nine Kapala Vyadhi, Indralupta being one of them. [10]

Samprapthi:

Samprapti Ghadakas

• Dosha: Tridosha

• Dhatu: Rasa, Raktha, Asthi

• Upadhathu: Twak, Roma

• Srotas: Rasa, Raktha, Asthi, Sweda

• Adhishtana: Kapala

• Rogamargam: Bahyam

• Vyakthastanam: Kapalam

Samprapthi of Indraluptha can be explained in 2 stages.[11] Pachana is the function of pitta which leads to dhatu parinama. This helps in the nutrition of the body structures. Vata activates the functioning of pitta and regulates the nutritive function properly. Only when pitta functions properly with vata, roma with sthirathwa swabhava is formed.

1st stage: Pitta and Vata get vitiated due to the nidana factors. Vitiated pitta leads to defective pachana, which again leads to defective dhatu parinama. Vitiated vata leads to defective samvahana. Defective dhatu parinama and samvahana- together lead to defective nutrition and this leads to dhatukshya. When asthidhatu kshaya occurs, abrupt falling of hair occurs.

2nd stage: The hairfall results in empty romakopa. The vitiated kapharaktas get accumulated in the empty hair follicle and rodha of the romakoopa occurs. So regeneration of the hair from the follicle does not occur. Types of Indraluptha (Bhedam)

Types: 5 types of Indraluptha are mentioned in HareethaSamhitha43rd Chapter, ie,

Vathajam, pittajam, kaphajam, rakthajam and sannipatikamam.[12] The signs and symptoms described in Hareethasamhitha are represented in the table below:

Chikitsa

The line of treatment Indralupta mentioned by different Acharya is as under. Acharya Sushrut mentioned Samshodhana (snehan & shodhan) along with Nasya, Head massage of oil, Raktamokshan and Shirolepa. Acharya Charaka says that after adequate Samshodhana patient of Hair loss should be subjected to Nasya, massage of oil and Shirolepa.[13]  Therapeutic measure adopted by Ashtanga Samgrahakara coincides with that of Charaka and Sushruta. He advises to adopt regimens of Indralupta and Palitya in Khalitya along with administration of Samshodhana as per Doshas. He adds further that the Sira nearer the site of disease should be opened successively different Pralepa should be applied. He suggests another method for the Raktamokshana by scratching of the scalp either by Suchi, Kurchika or by rough leaves before application of Lepa. After Snehana, Swedana and Asravana, Acharya Vagbhatta advises to give Nasya.

The main treatment procedures of indraluptha are rakthamoksha and lepana.

Rakthamokashana: Rakthamokshana is described as one among 5 shodhana karma. For deep seated doshadusti in Sakha, it is very difficult to get them to koshta for shodhana and this therapy is indicated. When diseases are not cured by ushna or seetha application or snigadha or rooksha application then it is due to raktha vitiation, and it should be eliminated by rakthamoksha. Among rakthamoshaupayas  siravedha and pracchanna    are mentioned indraluptha. Pracchanna is selected due to simplicity of the procedure as well as comparatively less complications. Pracchanna is an aritificial process of blood letting

from a localized lision (pindithadosha or ekadesastham) Word Pracchanna is derived from the root ‘cchad’ which means a private door or loop hole or window. The literal meaning of pracchanna is to bleed by making incisions or cuts in the skin. Pracchanna is done when blood is pinditham (solidified) or ekadesastham (localized). It is done by making incisions in the skin with the help of sharp and pointed surgical instruments.

Lepana [14]: Here lepana is done to remove the kapha, producing rodha of the romakopa.

 Many lepas are prescribed in our classical text. Some of the examples are stated below-

 Application of the paste of

1. Gunjamoolam and Brihatiphala

2. Gokshura and thilapushpa with madhusarpis

3. Black cowurine and japapushpa

4. root and fruits of gunja

5. Langali root with milk

6. Kantakariswarasa with honey

7. putikaranjapatrawithsaidava

8. Tilapuspa and gokshurawith honey

Susruthacharya mentions      Rasayana prayoga [15] for Indraluptha.  Dalhana mentions ashtadosha somaraji rasayana.

Pathyapathyas

•       Avoidance of water in the affected site till growth starts.

•       Avoidance of amla, kadu and lavana rasa.

•       Avoidence of exposure to hot and dusty environment.

•       Pathyas of vrana can be adopted like jeernasalyoanam, snigdha alpa ushna bhoojanam with mudga, saindava etc. Avoid day sleep and over exposure to wind.

Discussion

Indralupta is a disease affecting kapala (Scalp). Tridoshas along with Raktha has major role in the manifestation of the disease. It is characterized by loss of hair with poor replacement. According to Ayurveda acharyas, Pitta associated with Vata gets localized in the romakupa and causes the hair fall, later Kapha dosha associated with raktha causes the obstruction to the hair roots and restricts hair re growth. The signs and symptoms described in the classics of Ayurveda for Indralupta and that of Alopecia areata mentioned in the modern science are almost identical. Hence Indralupta can be equated to Alopecia areata. Alopecia areata is an autoimmune disease mediated by T-lymphocytes directed against hair follicles. The natural history of Alopecia areata is not well known. Genetic predisposition and environmental factors may trigger the initiation of disease.

Ayurveda suggests surgical procedures like Siravyadha, Pracchanna, Lekhana and para surgical procedure like Jalaukavacharana in Indralupta. Large numbers of drugs for external application in the form of herbal, mineral and single drugs are also described. Many curative and preventive measures like Nasya, Rasayana, Moordha taila (Abhyanga, Pichu, Shirodhra, Shirobasti), Pathya sevana, Apathya nisheda are also mentioned. Lepana is mostly used because Lepana is a bahiparimarjana chikitsa. The drugs applied as lepana is absorbed by the action of twakasrita Brajakagni. The lepana which is applied over the scalp by the effect of its Rasa, Guna, Veerya, Vipaka, is absorbed by the hair follicles and which in turn causes the pores to open up and by the prabhava of the drug hair growth can be observed. Pracchanna drains out the vitiated blood from the Srotus and later when lepa is applied over the region it facilitates easy and faster absorption of the drug.

Conclusion

Indralupta is more common in young adults, even though it can occur in anyone irrespective of age and sex. on comparing the signs and symptoms, it can be co-related with Alopecia areata. In Pracchanna and jalaukaauchana is mostly used in the management of Indralupta followed by lepana karma which increases hair follicular growth.