Article by Vd.A.Rangaprasad Bhat.
Alopecia or balding refers to loss of hairs from a part of the head or the body. Commonly the head is involved. The severity of hair loss can vary from a small area to the entire body.
Inflammation or scarring of hair follicle may or may not be present. In some people psychological distress causes the hair fall as in telogen effluvium, where in thinning of hair is the feature.
1. Male-pattern hair loss (khalitya),
2. Female-pattern hair loss,
3. Alopecia areata (indralupta) and
4. Telogen effluvium (kesha patana) are some of the common pattern of hair loss observed clinically.
The male-pattern hair loss (khalitya), female-pattern hair loss, alopecia areata (indralupta) and telogen effluvium (kesha patana) are some of the common pattern of hair loss observed clinically. A combination of genetics and male hormones results in male pattern hair loss, whereas in female pattern the cause is unclear. The allopecia areata is autoimmune related and the telogen effluvium is a common presentation in pregnancy.
(Reference:- निबन्धसङ्ग्रह व्याख्या (डल्हण कृत): रोमकूपानुगमित्यादि| खालित्यं पुंसामेव न तु योषिताम्| तथाच विदेहः- “अत्यन्तसुकुमाराङ्ग्यो रजो दुष्टं स्रवन्ति च| अव्यायामरता यस्मात्तस्मान्न खलितिः स्त्रियाः” इति||Commentary up on verse ३३-३४|| सुश्रुतसंहिता|| निदानस्थानम् – १३. क्षुद्ररोगनिदानम्)
Having said that, Ayurveda labels the hair loss as
Kesha patana – hair fall
Indralupta – alopecia areata
Khalitya – baldness depending upon the involvement of the doshas accumulating in the hair follicles.
Apart from above the other common causes of hair loss are the following –
pulling or plucking of hairs as seen in certain psychiatric cases (kehsAvapATanam),
HIV/AIDS etc attributes as a causative factor for non inflammatory and non scarring alopecia.
On the contrary the inflammatory and scarring pathology of hail loss is observed in fungal infections, lupus erythematosus, radiation therapy and sarcoidosis etc situations.
The attributed causes of hair loss in Ayurveda are –
1. pitta accumulation in hair follicle,
2. Tejo- AnilAdaya tridoshAs – increase of fire and air elements due to Tridosha imbalance
(Reference:- तेजोऽनिलाद्यैः सह केशभूमिं दग्ध्वाऽऽशु कुर्यात् खलतिं नरस्य| किञ्चित्तु दग्ध्वा पलितानि कुर्याद्धरिप्रभत्वं च शिरोरुहाणाम्||१३२|| |इति खालित्यरोगनिदानम्| चिकित्सास्थानम् – २६. त्रिमर्मीयचिकित्सितम् ||)
3.vAta & pitta in association with kapha & shonita, Pitruja bhAva vikruti,
(Reference:- केशश्मश्रुनखलोमदन्तास्थिसिरास्नायुधमन्यः शुक्रं चेति (पितृजानि)|| चरकसंहिता- शारीरस्थानम् – ३. खुड्डिकागर्भावक्रान्तिशारीरम् || ७||
4. asthi majjA dhatvagni vikara – Imbalance in Dhatu agni (formative factor) of bone, marrow tissues.
(Reference:- किट्टमन्नस्य विण्मूत्रं, रसस्य तु कफोऽसृजः| पित्तं, मांसस्य खमला, मलः स्वेदस्तु मेदसः||१८|| स्यात्किट्टं केशलोमास्थ्नो, मज्ज्ञः स्नेहोऽक्षिविट्त्वचाम्| प्रसादकिट्टे धातूनां पाकादेवंविधर्च्छतः||१९|| परस्परोपसंस्तब्धा |२०| चरकसंहिता- चिकित्सास्थानम् – १५. ग्रहणीदोषचिकित्सितम् ||)
5.KshAra ati upayoga – excess usage of Kshara medicines.
(Reference:- क्षारः पुनरौष्ण्यतैक्ष्णयलाघवोपपन्नः क्लेदयत्यादौ पश्चाद्विशोषयति, स पचनदहनभेदनार्थमुपयुज्यते; सोऽतिप्रयुज्यमानः केशाक्षिहृदयपुंस्त्वोपघातकरः सम्पद्यते|…तस्मात् क्षारं नात्युपयुञ्जीत|| विमानस्थानम् – १. रसविमानम् / १७||)
6. medo nihsAra, shonithodbhava adrshya krimis like KesadA,lomAdA, lomadvipA: microbes arising due to blood and fat tissue vitiation (Reference:- Charaka Vimana 7th chapter)
Comparative Analysis Kesha & Asthi dhathu inter-relationship :-
1. Hair loss or known as alopecia is caused from the changing of hair follicle morphology and hair follicle cycling in an abnormal fashion. The cycles of hair follicles are that of growth, or anagen, regression or catagen, and rest or telogen. Genes such as Bone Morphogenic Protein 4 (BMP4) and Bone Morphogenic Protein 2 (BMP2) are both active within the precursors of the hair shaft, specifically BMP4 is found in the dermal papilla. BMP4 is part of the signaling network which controls the development of hair. It is needed for the induction of biochemical pathways and signaling for regulating the differentiation of the hair shaft in the anagen hair follicle. This is done through controlling the expression of the transcription factors which regulate hair differentiation. It is still unclear however where BMPs act within the genetic network. The signaling of bmp4 may potentially control expression of terminal differentiation molecules such as keratins. Other regulators have been shown to control hair follicle development as well.
2.When BMP4 is expressed ectopically, within transgenic mice the hair follicle outer root sheath (ORS) the proliferation of the cell matrix is inhibited. BMP4 also activates hair keratin gene expression noting that BMP4 is important in the differentiation of the hair shaft. Noggin, a known inhibitor of BMP4, is found within the matrix cells of the hair bulb. Other important factors to consider in the development of hair is the expression of Shh (sonic hedgehog), BMP7, BMP2, WNT (WNT is a lipid-modified signaling glycoproteins that are 350–400 amino acids in length), and β-catenin as these are required in early stage morphogenesis.
3 BMP4 is an important component of the biological pathways that involved regulating hair shaft differentiation within the anagen hair follicle. The strongest levels of expressed BMP4 are found within the medulla, hair shaft cells, distal hair matrix, and potential precursors of the cuticle.
The two main methods which BMP4 inhibit expression of hair is through restricting growth factor expression in the hair matrix and antagonism between growth and differentiation signaling.
4. Inhibition of the BMP4 signal (by chordin, noggin, or follistatin) causes the ectoderm to differentiate into the neural plate. If these cells also receive signals from FGF, they will differentiate into the spinal cord; in the absence of FGF the cells become brain tissue.
While over expression of BMP4 expression can lead to ventralization, inhibition with a dominant negative may result in complete dorsalization of the embryo or the formation of two axises.
It is important to note that mice in which BMP4 was inactivated usually died during gastrulation. It is thought that inactivation of human BMP4 would likely have the same effect. However, mutations which are subtle in humans could also have subtle effects phenotypically.
5. Protein structure: Yielding an active carboxy-terminal peptide of 116 residues, human bmp4 is initially synthesized as a forty percent residue preproprotein , which is cleaved post translationally.
BMP4 has seven residues which are conserved and glycosylated. The monomers are held with disulphide bridges and 3 pairs of cysteine amino acids. This conformation is called a “cystine knot”. BMP4 can form homodimers or heterodimers with similar BMPS. One example of this is BMP7. This ability to form homodimers or heterodimers gives the ability to have greater osteoinductive activity than just bmp4 alone. Not much is known yet about how BMPS interact with the extracellular matrix. As well little is known about the pathways which then degrade BMP4. (reference)
6. Fibroblast growth factor 5 (FGF5 gene) is a protein that in humans is encoded by the FGF5 gene.
The disruption of FGF5 expression in mammals increases the length of the anagen (growth) phase of the hair cycle, resulting in a phenotype of extremely long hair. This has been shown in many species, including cats, dogs, mice, rabbits, sheep and goats (the so-called angora mutation) and even elephants and mammoths. FGF5 also affects the hair cycle in humans; blocking FGF5 in the human scalp extends the hair cycle, resulting in less hair fall and increased hair growth. (reference)
By the above inputs from the research field of conventional medicine, the kesha as a byproduct getting mentioned by the granthas of Ayurveda as, “स्यात्किट्टं केशलोमास्थ्नो”. Could get further analyzed for a proper and better understanding of the inter relationship.
(Reference: स्यात्किट्टं केशलोमास्थ्नो, मज्ज्ञः स्नेहोऽक्षिविट्त्वचाम्| प्रसादकिट्टे धातूनां पाकादेवंविधर्च्छतः||१९||
परस्परोपसंस्तब्धा धातुस्नेहपरम्परा २०| || Charaka Chikitsa Sthana 15th chapter)
The asthi dhAtvagni during its process of metabolic conversion into majjA dhAtu produces prasAda bhAga to majjA dhAtu. During which process, it creates the residual product (aka kiTTabhAga) in the form of kesha, nakha & loma. It there by nourishes those structure too – “उक्तं च विविधाशितपीतीये- किट्टात् केशनखादयः पुष्यन्ति” (सू.अ.२८) इति ||
Many a times, the student community get confused to understand the prasad, kitta avstha of uttarottara dhathu utpatti. The doubt always gets revolving aroung which dhAtu’s prasada bhAga nourishes which one and the same doubt applies to the kitta bhaga too.
ChakrapANi while commenting up on verse 20 of ग्रहणीदोषचिकित्सितम्, explains –प्रसादभागोत्पादमभिधाय मलभागोत्पादमाह- किट्टमित्यादि| रसस्य कफ इति रसे पच्यमाने किट्टं कफो भवति, प्रसादश्च रक्तं; || Means, the kiTTa (residual by product) gets produced only after the prasAdabhAga (essential product) gets produced. Having said that, he further clarifies quoting an example with rasa dhAtu. That “Kapha is the kitta bhAga of rasa. It means that after completion of pacyamAnA stage of dhAtvagni pAka, the kapha as a residual byproduct get produced. In the meanwhile, the prasAda bhAga produced during the process of dhAtupacana nourishes the uttara dhAtu, the rakta.
Based upon this dhAtu utpatti tatva, enhancing or modulating the dhAtu pAka with dhAtupAchaka dravyas, especially that of the asthi & majja dhAtus helps in increasing both the prAsada bhAga (majjasya sneha amsha) & the kiTTa bhAga (kehsAdaya:) is one mode of chikitsa that helps in managing the rugnas complaining of kesha patana as a symptom. However, the samprApti and its ghatakas should fall in line over the involvement of the kshaya or vikrutAvastha of the mentioned two dhAtus to beget a clinical response with above chikitsa krama.
The author hereby makes it clear, that no claim of altering the BMP4 by the asthimajjApAcak dravyas is was mentioned, since a scientific study over the BMP4 factor has not been done yet, to claim so. However above chikitsa sutra sure does have an impact in the growth of hairs. A future research over the above lines when done, we will get a clearer picture regarding the pharmacodunamics of the asthimajjapAcak dravyas and their ability in causing the anagen cycle.
Chikitsa krama aka line of treatment (various) of Alopecia adopted in Ayurveda:
3. Lekhana as in indralupta.
4. Nasyam with Anu tailam or Maha Neeli tailam or vidarigandadi or Jeevaniya gana tailam or Prapoundarikadi tailam. Reference: Charaka Chikitsa Sthana 26/262 – 277
5. Shiropichu, shiro basti & Lepa (Reference:- सुश्रुतसंहिता|| चिकित्सास्थानम् – २०. क्षुद्ररोगचिकित्सितम् इन्द्रलुप्ते सिरां मूर्ध्नि स्निग्धस्विन्नस्य मोक्षयेत् |कल्कैः समरिचैर्दिह्याच्छिलाकासीसतुत्थकैः ||२४|| कुटन्नटदारुकल्कैर्लेपनं वा प्रशस्यते |प्रच्छयित्वाऽवगाढं वा गुञ्जाकल्कैर्मुहुर्मुहुः ||२५||लेपयेदुपशान्त्यर्थं कुर्याद्वाऽपि रसायनम् | मालतीकरवीराग्निनक्तमालविपाचितम् ||२६|| तैलमभ्यञ्जने शस्तमिन्द्रलुप्तापहं परम् |२७|
निबन्धसङ्ग्रह व्याख्या (डल्हण कृत): इन्द्रलुप्त इत्यादि| कुटन्नटेत्यादि कुटन्नटः तगरः| रसायनविधानोपदेशं कुर्वन्नेतज्ज्ञापयति- दुःसाध्योऽयं व्याधिर्न शक्यते रसायनमन्तरेणापनेतुं; रसायनमष्टादश दिव्यौषधयः सोमश्चौषधराजा| मालतीत्यादि स्नेहपाककल्पपरिभाषया जात्यादिकल्कसिद्धेन कटुतैलेन गोमूत्रचतुर्गुणेन शिरोऽभ्यञ्ज्यात्||२४-२६||
- Virechana – Purgation Panchakarma treatment
- Siravyadhana or rakta mokshana (Reference:- Same as point no 5)
- RasAyana Chiktsa krama (Reference:- Same as point no 5)
- Counseling regarding maintaining hygiene of hair.
Other useful remedies:-
Black sesame is snigdha and uSHNa in gunas with madhura and tikta taste. They are good for skin, hair growth and provide deha bala when consumed internally.
(Reference:- केशश्मश्रुनखादीनां कल्पनं सम्प्रसाधनम्||९९||- सम्प्रसाधनं मण्डनम्; एतच्च यथायोग्यतया योजनीयं; केशानां प्रसाधनं सम्यग्बन्धनादि; as per Chakrapani. || चरकसंहिता – सूत्रस्थानम्-५. मात्राशितीयोऽध्यायः
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