Pemphigus vulgaris (PV) is a chronic autoimmune bullous dermatosis that is commonly seen in adults aged between 40 and 60 years of age. The pathogenesis of PV is mostly associated with the production of autoantibodies against desmogleins 1 and 3.1 This usually presents as blisters and oral mucosal erosion, followed by flaccid blisters all over the skin.1 PV exhibits a bi-directional relationship with chronic lifestyle disorders like cardiovascular, endocrine, and neuropsychiatric diseases.2 PV is reported to have 10% mortality, predominantly due to septicemia.

The common treatment options for PV are systemic corticosteroids and immunosuppressive drugs.1 However, the present approaches have not discussed the impact of lifestyle changes on the prognosis of PV. Yoga and naturopathy-based lifestyle intervention program that include diet modification, yoga therapy, massage, and hydrotherapy have been reported to be beneficial in the management of PV and related comorbidities.3 In this case report, we describe a patient diagnosed with PV who successfully managed her condition with yoga and naturopathy based lifestyle interventions (YNBLI) along with conventional care.

In 2019, a 58-year-old female presented to a yoga & naturopathy inpatient setting with a 1-year history of PV, associated with migraine for 15-20 years and type 2 diabetes mellitus for 6 months. She also reported having a full body ache and burning sensations all over her body. She also complained of itching over the areas where her lesions ruptured. Further, the patient complained of having malaise, indigestion, and severe anxiety for the past year owing to her skin condition.

She had been prescribed Methyl prednisolone 16 mg, Metformin 500 mg, Glimipride 2 mg Capsule Pan D (Pantoprazole 40 mg, Domperidone 30 mg) once daily, and Mycophenolate Mofetil 500 mg twice a day by her general practitioner before getting admitted to our facility. She was also using topical applications (Ointment) like Soframycin(Framycetin), Vitaderm-C (Allium Cepa, Arnica Montana, Pinus Longifolia, and Calendula Officinalis), Mupirocin, LLCOL (Luliconazole) and potassium permanganate solution.

On examination, her body mass index fell under the category of overweight and she had bulla all over the body, especially on the abdomen, breasts, back, and thighs. She also had fluid-filled lesions and blisters all over her body, primarily on her chest and back. A histopathological investigation through the enzyme-linked immunosorbent assay (ELISA) technique showed the levels of Desmoglein 1 and 3 as 3.26 and 3.5 respectively. On admission, her fasting blood sugar was 113 mg/dl and her postprandial sugar level was 185 mg/dl.

On admission, we evaluated the patient's dermatological quality of life using the Dermatology Life Quality Index (DLQI) on which the patient scored 29, which depicts very poor dermatological quality of life. Her pain score and itching/burning score on a visual analog scale were 95 and 85, respectively, which corresponds to high disease severity.

The patient approached our lifestyle center as she could not find any relief in PV with conventional therapy and was diagnosed with type 2 diabetes mellitus within 6 months of the initiation of Methyl prednisolone and Mycophenolate Mofetil. Yoga & naturopathy interventions are based on a holistic, patient-centered approach that aims to influence physical, mental, and social determinants of health. Yoga & naturopathy physicians reckon with the innate healing capacity of the body and use modalities like hydrotherapy, nutrition, manipulative therapies, herbs, yoga therapy, sun exposure, etc. to heal patients.4,5

In our setting, the patient initially underwent YNBLI for a period of 53 days in 2019, followed by 10 days in 2020, and 15 days in 2021. The treatments included body massage, cold water enema, aloevera-turmeric paste application, mud application, hydrotherapy, acupressure, herbal dusting, sun exposure, and yoga therapy. The frequency of therapies over a three-year period is detailed in the supplemental file. Apart from these therapies, the patient underwent a customized diet program that was intended to promote anti-inflammatory effects and promote healing. The diet included herbal drinks, fresh fruits, vegetables, cereals, and nuts. Additionally, we recommended maintaining low salt, low oil, and no refined products menu even at the patient's home. The diet plan varied across the three time points of the patient's stay from 2019–2021. The detailed diet plan is outlined in the supplemental file.

Owing to the improvement in her body lesions, she was taken off all the topical applications and Capsule Pan D by the end of her first inpatient stay in 2019. She was followed up continuously and was taking a similar diet advised during the hospital stay at her home as well. She continued with Methylprednisone, Mycophenolate Mofetil, and Tab. Gemer (Metformin Hydrochloride Prolonged-Release (500 mg) and Glimepiride (2 mg)) until the end of 2020. By the time of her third inpatient stay in our setting, she had been tapered off completely from all the medications. Currently, she continues with the diet program and home remedies like therapeutic fasting once a week (500 kcal), sun exposure (15 minutes per day), a vegetarian diet, and yoga therapy (45 minutes per day).

The patient was slowly improving over time with a consistent reduction in the body lesions, blood sugar levels, body ache, and itching. The levels of serum autoantibodies Desmoglein 1 and Desmoglein 3 reduced to 0.46 and 1.01, respectively, in 2020, and later became undetectable during the years 2021 and 2022. Similarly, the patient's blood sugar levels have improved significantly; her fasting blood sugar (FBS) was reduced from 112 mg/dL at admission in 2019 to 70 mg/dL at discharge and has remained at a normal level throughout the follow-up period until 2021. A similar trend was observed in the post-prandial blood sugar levels (PPBS), which decreased to 148 mg/dL at discharge compared to 151 mg/dL at baseline. Similar to FBS, PPBS also remained at a normal level throughout the follow-up period.

Further, the self reported DLQI, pain, and itching sensation scores of the patient were recorded as zero by the end of 2021-22, suggesting a better prognosis and complete healing. The detailed prognostic changes in the clinical markers measured are tabulated in Table 1. Figure 1 depicts the changes in the skin eruptions of the patient from 2019 through 2022. Presently, the patient is completely stable and has not required any inpatient admissions or medications since 2021.