Ayurveda Understanding of Chronic Inflammation

Article by Dr Manasa S, B.A.M.S & Dr Raghuram Y.S. MD (Ay)  

Inflammation is a response of the body for an injury or infection. It is basically of two types – acute and chronic inflammation.

Acute Inflammation is the sudden response of the body to injury. It is marked by pain, tenderness, swelling, redness and flushing of skin.

Chronic inflammation is a condition wherein there is slow yet continuous and long standing inflammation which lasts for months to years. Joint pain or stiffness, body and muscle pain, chronic fatigue, insomnia, depression, anxiety, constipation, acid reflux, diarrhea, fever, skin rash, mouth sores and weight issues.  

Related Reading – Chronic Inflammation

Ayurveda Perspective of Chronic Inflammation

No single condition mentioned or explained in Ayurveda treatises can be compared to chronic inflammation. But going deep into the treatises we can get many fundamental principles and basics of doshas, diseases caused due to the aggravated doshas, description of symptoms and treatment principles  which denote ‘inflammation like conditions’ happening in the body. We can bring all these concepts under the umbrella of discussion of chronic inflammation.

Diseases are broadly of two types according to Ayurveda –

Nija Rogas – are caused due to aggravated doshas. Here there need not be injury or infection. The foods and lifestyle practices and emotional / mental disturbances will cause imbalance of doshas and these doshas cause diseases by damaging the tissues. Chronic inflammatory changes also happen inside, in the tissues and viscera and also on the surface of body due to aggravated pitta and vata. Modern texts too have explained similar conditions like arthritis, dermatitis, cellulitis, vasculitis, hepatitis, nephritis, pancreatitis etc. which are either acute or chronic in nature.

Agantuja Rogas – here injury / trauma and other afflictions occur due influence from external factors. Even in these conditions, tridoshas, mainly pitta and vata, get aggravated leading to inflammation. When not treated promptly, this can sum up into chronic inflammation.

To sum up – inflammation can be caused both due to intrinsic and extrinsic factors according to Ayurveda. Both these should be considered in the study and not just the inflammation caused by injury or infection.

Conditions explained in Ayurveda to be considered in studying chronic inflammation from Ayurveda perspective

Dosha involvement – Inflammation is the body’s response to infection or injury. Inflammation presents with five cardinal signs i.e. pain, heat, redness, swelling and loss of function, be it acute or chronic inflammation. In the initial phase of inflammation i.e. acute inflammation all these cardinal signs are present. From an Ayurveda perspective, all three doshas are involved in acute inflammation with predominance of pitta. Pain and loss of functions are predominantly caused by vata, heat and redness by pitta and swelling by kapha.

The Pitta connection – In acute inflammation it is pitta which will dominate the picture. As the inflammation becomes chronic, vata would get dominant as evident by the symptoms of chronic inflammation. Pitta symptoms are also seen during flare ups. Since the inflammation is an ongoing process in chronic inflammation, pitta is invariably involved at all times.

a. Pitta Prakopa – Paridaha – burning sensation is a symptom of pitta aggravation. Similarly reddish discoloration, increased body heat, paka – suggestive of inflammation and suppuration, excessive discharges / exudates, gangrenes, exhaustion, intoxication and stupor are also the symptoms of pitta aggravation – all these indicate inflammation. When these symptoms have a long run, they are suggestive of chronic inflammation. Suppuration, gangrenes, stupor and exhaustion are symptoms which occur after long term pitta aggravation. These are definitely suggestive of chronic inflammation.

b. Pitta Prasara – Osha – sensation of boiling, Chosha – sensation of squeezing, Paridaha – sensation of burning and Dhumayana – feeling as if smoke or fumes is being eliminated from the body surface or from the interior of the body are the symptoms of pathological spread of pitta in the body. All these symptoms show a chronic inflammation process which is spreading in the body from one place to the other.

Chronic inflammation is a high vata-pitta condition – Seeing the symptoms of chronic inflammation (see tab below) we can see that signs of aggravation of vata and pitta are present together. Chronic inflammation will thus have combined aggravation of vata and pitta with mild to moderate involvement of kapha.

Pittaja Disorders – Since chronic inflammation is a remnant inflammation which is progressive, all pitta disorders of chronic disorders can be considered as disorders involving chronic inflammation. Though agantuja (external factors) factors are mainly involved in causation of inflammation, nija pittaja rogas i.e. diseases caused due to intrinsic factors – mainly due to aggravation of pitta / pittaja subtypes of chronic diseases can be considered.

Pitta Nanatmaja Rogas – These are the specific diseases caused by pitta alone. They are 40 in number. Some of them indicate inflammation and chronic inflammation in the body. They are –

–         Osha – Severe burning sensation and restlessness in the whole body
–         Plosha – burning sensation and pain as if trapped in fire
–         Daaha – burning sensation
–         Davathu – burning sensation in the sense organs
–         Dhoomaka – feeling as if the smoke is being eliminated from the mouth / face
–         Amlaka – sour belching – inflammation in the stomach
–         Vidaaha – burning in different parts of the body
–         Antardaaha – burning sensation in the viscera – inflammation in different organs
–         Amsa daaha – burning sensation in the region of shoulder blades
–         Ooshma adhikya – excessive temperature of the body
–         Anga avadaarana – splitting pain in the body parts – pain is also a part of chronic inflammation
–         Shonita kleda – dilution of blood – inflammation in blood vessels
–         Mamsa kleda – decaying of flesh / muscles – inflammation in muscles
–         Twak daaha and avadaarana – burning sensation of skin and cracks and fissures in the skin – skin inflammation
–         Rakta kotha, visphota and mandala – red eruptions, blisters and red patches all over the body – inflammation in blood vessels
–         Kakshaa – sores or ulcers in the armpits
–         Aasya vipaaka – mouth sores – inflammation in the oral cavity, stomatitis
–         Paka of Gala, akshi, guda, medhra – ulcers / sores in the throat, eyes, anal region, penis – indicating inflammation and suppuration in these regions

These diseases indicate chronic inflammation in several regions, tissues and viscera of the body.

Vata involvement – Pain and loss of movements may be initially caused due to pitta but sooner or later there will be involvement of vata as well. Vata is predominant in chronic inflammation as against pitta in acute inflammation. Abhighata – injury is one of the main causes for vata increase. So vata will get aggravated immediately after injury. In a way we can tell that both vata and pitta are jointly involved in inflammatory swellings. Kapha may be predominantly involved in non-inflammatory swellings or oedema. Abhishanga – infections usually disturb the tridoshas.

Other considerations

Vrana Shotha – Vrana Shotha is compared to inflammation. The swelling present before formation of ulcer is called as vrana shotha (agantuja shotha is exempted). Inflammation and abscess should be formed before formation of vrana i.e. ulcer. These are six in number and will have ama – unripe, pachyamana – ripening and pakva – ripened stages. Ripened stage of vrana shotha can be considered as chronic inflammation.

Pittaja Shotha – Swelling / inflammatory swelling caused by aggravated pitta will be smooth, black, yellow (infected, pus) or red in color, will have burning sensation, will have clear intense pain, will suppurate and associated with giddiness, fever (raised heat), sweating, thirst and intoxication. There is no mention of injury or infection here but these would indicate the symptoms which manifest after injury or infection. In abhighataja shotha we find symptoms similar to pittaja shotha. When acute inflammation of pittaja shotha is not properly treated it can cause chronic inflammation in due course of time.

Abhighataja Shotha – In the context of shotha we come across a subtype called abhighataja shotha, swelling which is caused by injury / trauma. Many types of injury, exposure to snow (frostbite) breeze, and contact with fruits of Bhallataka and Kapikachchu etc are mentioned among the causes. Its symptoms are said to be similar to pittaja shotha. This explanation establishes the relationship between injury and pitta and inflammation. When abhighataja shotha is incompletely treated or neglected it can lead to chronic inflammation.

Vishaja Shotha – This kind of shotha – inflammation is caused by effect and contact with poisons of various kinds. It is caused due to sting, bite etc of poisonous insects and animals and contact with breeze flowing through poisonous trees and plants. Pain and burning sensation are common in these types of swelling.

Dosha involvement in symptoms of chronic inflammation

Causes of chronic inflammation

Since pitta is the main dosha causing inflammation, all pitta aggravating foods and activities are the causes of chronic inflammation occurring anywhere in the body.

Causes for Pitta Prakopa:

Pitta aggravating qualities – ushna (hot), vidaahi (corrosive), teekshna (irritant)

Pitta aggravating tastes – pungent, sour and salt

Pitta aggravating foods – pungent and corrosive foods, chilly, spices, condiments, fried foods, sesame, sour foods and curds, alcohols and fermented foods and drinks,

 Pitta aggravating activities – excessive exposure to sun or fire, anger, starving, excessive indulgence in sex

Natural causes – during digestion of food, mid-day, autumn season and middle part of the night

These are the causes for chronic inflammation occurring deep inside the body at the tissue and visceral level. They can also be triggers for intrinsic or extrinsic chronic inflammation.

Treatment of Chronic Inflammation

Treatment Principles

Nidana Parivarjana – The best and simplest way of treating chronic inflammation and the first step which needs to be taken is nidana parivarjana – i.e. keeping away from all the causative factors and triggers which are causal for initiation and ongoing process of inflammation. Along with proper treatment plan, identification and isolation of etiological factors will help in quick recovery of the condition and also would prevent in recurrence of the same.

Chronic inflammation can be treated on the principles of treating the below mentioned conditions –

–  Pitta Prakopa – aggravation of pitta
–  Vata prakopa – aggravation of vata
–  Vata-Pitta prakopa – aggravation of both vata and pitta
–  Sama Pitta – pitta associated with ama
–  Sama Vata – vata associated with ama
–  Amavata – systemic inflammatory disease caused by vicious combination of ama and vata – compared to rheumatoid arthritis
–  Pittaja shotha – inflammation caused by pitta aggravation
–  Agantuja shotha – inflammation caused by injury
–  Vishaja shotha – inflammation caused by contact of poisonous substances
–  Vrana shotha – inflammatory swellings
–  Vatarakta – a disease caused by combined aggravation of vata and rakta, injury is one of the causes here also, this condition is often compared to gouty arthritis
–  Visarpa – herpes

Treatments mentioned in Shashti Upakrama

Master Sushruta has explained 60 kinds of treatments under the heading Shashti Upakrama. Among them few treatments are considered for treatment of vranashotha i.e. inflammatory swellings and chronic inflammation. They are –

–  Apatarpana – fasting
–  Alepa – application of medicinal pastes
–  Parisheka – showering medicinal fluids
–  Abhyanga – oil massage
–  Sweda – sudation
–  Vimlapana – gentle pressing / cleansing
–  Visravana – drainage (if pus is formed)
–  Sneha – inducing oiliness
–  Vamana – emesis
–  Virechana – purgation
–  Upanaha – poultices
–  Pachana – helping the pus to form properly so that it can be drained out
–  Nirvapana – applying and showering cold potency medicines
–  Utkarika – application of warm semi-solid vata alleviating medicinal pastes to treat wound inflammation and necrosis of wounds
–  Kashaya – administering herbal decoctions
–  Kalka – herbal paste application
–  Sarpi – use of medicated ghee
–  Taila – use of medicated oils
–  Rasakriya – administration of semi solid medicinal extracts
–  Avachurnana – sprinkling of herbal powders
–  Vrana dhupana – fumigation of wounds
–  Vasti karma – enemas
–  Uttara vasti – enemas given through urinary and genital passages
–  Patradana – covering the wounds with leaves
–  Krimighna – disinfectants
–  Brmhana – bulk promoting and strengthening treatments
–  Vishagna – anti-toxins
–  Shiro virechana / Nasya – nasal instillation of medicines
–  Kavala dharana – rinsing of mouth with medicinal liquids
–  Dhooma – fumigation
–  Madhu sarpi – administration of honey and ghee
–  Ahara – dietetic regimen

Related Reading – Shashti Upakrama

Panchakarma in Chronic Inflammation

Virechana and Vasti are the best Panchakarma treatments useful in the treatment of chronic inflammation. While Virechana takes care of aggravated pitta and halts the process of inflammation and burnouts in the body, Vasti effectively combats aggravated vata and relieves symptoms caused by the same. Decoction and unctuous enemas with ghee and oil prepared with pitta alleviating herbs, given through anal, urethral or uterine routes combats chronic inflammation and inflammatory diseases in the colon, urinary and reproductive systems and also in the entire body.

Both these treatments will help in preventing recurrence of symptoms pertaining to chronic inflammation and also will break the chain of pathogenesis. Since the body is purified of its impurities after administering these therapies, maintenance from the point of cure will be the key to prevent recurrences of inflammatory episodes. The responsibility of the patient will be a huge one in this direction. Periodic checkups, maintenance of good health and lifestyle practices, keeping away the stress and any known triggers will be the main strategies. If the inflammation doesn’t heal up as expected, the physician may recommend you with additional and periodic panchakarma therapies. Important Ayurveda anti-inflammatory medicines and Rasayanas may be prescribed for long term use.

Vamana is required sometimes to throw away the morbid pitta and kapha from the stomach to cure chronic inflammation pertaining to the stomach as in gastritis, GERD etc.

External treatments

–         Abhyanga – Massages with pitta mitigating herbal oils 
–         Sarvanga dhara – showering or bathing the site of inflammation or the entire body with oil, ghee or milk prepared with pitta mitigating herbs
–         Shirodhara – showering of medicated oils, ghee and milk prepared with pitta alleviating herbs over the head
–         Dhanyamla Dhara – showering of body parts or entire body with sour fermented liquids – as in amavata
–         Sugandha, gandha, hara, mani hara – application of fragrances, scents and perfumes, garland of flowers, necklaces made up of pearls etc
–         Anulepa – regular and frequent application of pastes of camphor, sandalwood and other coolant herbs

Other treatments

Snehapana – intake of medicated ghee prepared with pitta mitigating herbs in metered doses until the body cells get saturated with the medicinal properties is called oleation. This is administered as individual therapy i.e. for daily consumption in small doses or as pre-treatment procedure for purgation. Ghrta is the best in combating pitta and inflammation caused by pitta. It is also good for vata conditions. Snehapana should be an integral part of treatment of chronic inflammation.

Diet, lifestyle activities and exercises

–         Consumption of ghee / medicated ghee
–         Consumption of milk
–         foods which are cold and conducive to heart
–         Foods and medicines which have sweet, bitter and astringent taste should be consumed
–         One should avoid pungent, sour and salty foods, hot foods
–         Getting exposed to moonlight and cool breeze, hearing pleasant music, cold comforts,
–         One should avoid being anger, stressful and anxious
–         Indulging in likable and lovable activities
–         Wholesome and friendly talks with friends, relatives and kids
–         Company of loving wife who has adorned herself with coolant pastes of herbs, garlands and wet clothes
–         Spending time near sprinklers or fountains, staying in underground homes or rooms, walking in the gardens, walking on the sand on the banks of water

Preventive measures

All pitta (and vata) aggravating foods and lifestyle practices shall be avoided. Prompt treatment to address increased pitta should be planned and executed as and when signs of pitta increase depicting inflammation are seen. This will help in preventing pitta and vata from causing chronic inflammation. Similar strategies shall be followed for treating the pittaja disorders showing signs of inflammation. Treatments, diet and lifestyle changes advised above are also preventive measures.

Best herbs, vegetable, fruits and medicines for chronic inflammation

–         Amalaki – Emblica officinalis
–         Guduchi – Tinospora cordifolia
–         Ghrta – ghee
–         Butter
–         Drugs having sweet, bitter and astringent tastes
–         Shita – cold foods
–         Hridhya – lovable foods
–         Ripe jackfruit
–         Sugarcane
–         Pointed gourd
–         Dates
–         Lotus seeds and stalk, Rose
–         Grapes / raisins
–         Turmeric
–         Fennels, coriander
–         Cucumber
–         Coconut oil
–         Plums, prunes,
–         Sweet apples, guava, ripe sweet mangoes, papaya, watermelon
–         Asparagus
–         Cucumber
–         Pumpkin
–         Wheatgrass
–         Green beans
–         Carrot
–         Barley
–         Rice
–         Cheese
–         Black and kidney beans
–         Green grams
–         Asparagus etc.

Things to avoid in chronic inflammation

–         All pitta aggravating foods and activities
–         Foods rich in pungent, sour and salt tastes
–         Hot and spicy foods
–         Corrosive foods
–         Unripe mango and falsa fruit
–         Fenugreek
–         Cinnamon
–         Chillies
–         Pepper
–         Asafetida
–         Cumin, black caraway
–         Ajowan
–         Ajagandha – Gynandropsis gynandra
–         Amlavetasa – Garcinia pedunculata
–         Tila – sesame
–         Atasi – flax seeds
–         Dadhi – sour curds
–         Sura, shukta, aranala – fermented herbal drinks
–         Tulsi – holy basil
–         Mustard
–         Leaves and shoot of Chakramarda – Cassia tora
–         Fruit of Shami tree – Prosopis cineraria
–         Sour buttermilk
–         Sesame oil, mustard oil

Useful formulations for chronic inflammation

–         Avipattikara Churna
–         Amalaki Churna
–         Yashtimadhu Churna
–         Sukumaram Kashayam / Ghrtam
–         Gandharvahastadi Kashayam
–         Tiktakam Kashayam / Ghrtam
–         Mahatiktakam Kashayam / Ghrtam
–         Kamadugha Rasa

For doshaja inflammation / intrinsic – herbs and formulations explained in the context of those diseases having vata type shall be used. Example – Simhanada Guggulu in chronic inflammation related to arthritis, Phalatrikadi Kashayam or Pathyakshadhatryadi Kashayam in chronic inflammation of sinus and headaches, Punarnavadi Kashayam or Punarnavadi Mandura – in inflammatory swelling etc.

Important Yoga poses for chronic inflammation

–         Balasana – child pose
–         Prasarita Padottasana – Wide legged forward bend
–         Virabhadrasana II – Warrior II
–         Viparita Karani – Legs up the wall pose
–         Supta Matsyendrasana – Supine spinal twist
–         Ardha Matsyendrasana – Half Lord of the fishes pose
–         Adhomukha Svanasana – Downward facing dog pose
–         Marjariasana – Cat-cow pose
–         Sethubandhasana – Bridge pose
–         Trikonasana – Triangle Pose
–         Nadi Shodhana Pranayama
–         Shitali Pranayama
–         Bhujangasana – cobra pose
–         Marjari asana – cat stretch
–         Chandra Namaskara – moon salutation
–         Utkatasana – chair pose
–         Shavasana – corpse pose
–         Setubbandhasana – bridge pose
–         Ardha sarvangasana – half shoulder stand
–         Paschimottasana – seated forward bend

Related Reading – Chronic Inflammation