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    • A STUDY ON AYURVEDIC PERSPECTIVE OF INFECTIOUS SKIN DISEASES WITH SPECIAL REFERENCE TO SUPERFICIAL MYCOSES Dissertation submitted to the Kannur University, Kerala, in partial fulfillment of the regulations for the award of the degree of DOCTOR OF MEDICINE (Ay) in Roganidana By Dr. Madhu P.M. B. A. M. S. Under the Supervision of Dr. R. Sreekumar M.D. (Ay) Professor & H.O.D., Department of Roganidana Govt. Ayurveda College Kannur DEPARTMENT OF POST GRADUATE STUDIES IN ROGANIDANA GOVERNMENT AYURVEDA COLLEGE, KANNUR – 670502 2005 www.ayurvedicmedicinalplants.com
    • CERTIFICATE This is to certify that this thesis envisages the outcome oforiginal thinking and observations made by Dr P.M.Madhu on “Astudy on ayurvedic perspective of infectious skin diseases withspecial reference to superficial mycoses” for the partial fulfillmentof the degree of Doctor of Medicine (Ayu.). This work has beencarried out under my direct guidance and supervision in thespeciality of Roganidana, Department of Roganidanam, Govt.Ayurveda College, Kannur. This thesis bears abundant evidence of original thoughts anddedicated work. It marks a distinct progress on scientific lines in thesubject. I strongly recommend and forward this thesis to be subjectedto the adjudicators.Forwarded: Guide:Dr B. Ambika, Dr.R.Sreekumar,Retired professor & H.O.D. Reader,Department of Roganidanam, Department of Roganidanam,Government Ayurveda College, Govt. Ayurveda college,Pariyaram, Kannur Pariyaram,Kannur www.ayurvedicmedicinalplants.com
    • Á uÉÉXèûç qÉå qÉlÉÍxÉ mÉëÌiÉÌ·iÉÉ qÉlÉÉå qÉå uÉÉÍcÉ mÉëÌiÉÌ·iÉqÉç AÉ uÉÏUÉ uÉÏqÉï LÍkÉ uÉåSxrÉ qÉ AÉhÉÏ xjÉÈ ´ÉÑiÉqÉ qÉå qÉÉ mÉëWûÉxÉÏÈ AlÉålÉÉkÉÏiÉålÉ AWûÉåUɧÉÉlÉç xÉlSkÉÉÍqÉçç HiÉqÉç uÉÌSwrÉÉÍqÉ xÉirÉqÉç uÉÌSwrÉÉÍqÉ iÉlqÉÉqÉuÉiÉÑ iÉiÉç uÉ£üÉUqÉuÉiÉÑ;AuÉiÉÑ qÉÉqÉç AuÉiÉÑ uÉ£üÉUqÉç, Á vÉÉÎliÉÈ vÉÉÎliÉÈ vÉÉÎliÉÈMy words may rest in mind, and the mind in my words. It appears to methat they are the two pins of my knowledge that holds its wheels. May whatI have learnt not forsake me. I join day and night with what I have learnt. Ishall speak of the real, I shall speak the truth. May this protect me and maythis protect the teacher. Let us pray for an auspicious future. [Eithereya Upanishad] www.ayurvedicmedicinalplants.com
    • We were the first batch of P.G.students in Kannur Ayueveda College. As anormal procedure for sample collection, we had published the informationabout the beginning of some special O.P.Ds in our hospital. For a largesample collection, this present subject was published as ‘skin diseases likeitching or discolouration.’ As a result, a large variety of patients sufferingfrom skin diseases came to our O.P. Senior doctors were broad mindedenough to give us the freedom for examination and selection of treatment.Thus we came to experience with a vast variety of dermatological cases bothas out patients and as inpatients. Most patients were economically poorvillage people. They came to us after a long run through many othermedicines. So it became our responsibility to heal the condition mosteffectively. Challenging cases made us to study about the scientific details.We were forced to discuss the problem among ourselves and among othersubject experts. Failures made us to reconstruct the pattern of treatment. Eachand every skin patients taught us new stories of Dermatology. Thus, slowlyand very slowly ….we started loving the branch of Dermatology verysincerely. …Hence, this thesis work is a humble dedication to varioussufferings of our patients, which really made us to think about our scopes andlimitations. www.ayurvedicmedicinalplants.com
    • ContentsAcknowledgementsAbbreviationsList of tablesList of pictures Part 1Introduction1.1 Need and significance of the study1.2 Relevance of Ayurvedic study1.3 Ayurveda and infectious skin diseases1.4 About this thesis work1.5 Outline of the thesis Part 2Review of Literature-Modern review2.1 Infection- basic concepts 2.1.1 The sources of infection 2.1.2 Pathogenicity of microorganisms 2.1.3 Microorganisms 2.1.4 Normal flora 2.1.5 Fungus 2.1.6 Cell biology of fungi 2.1.7 Fungal metabolism2.2 Fungal Infection 2.2.1 Superficial mycoses 2.2.2 What causes fungal infection? 2.2.3 Tinea corporis 2.2.4 Tinea cruris 2.2.5 Tinea versicolar www.ayurvedicmedicinalplants.com
    • 2.2.6 Tinea capitis 2.2.7 Tinea pedis 2.2.8 The ‘ID’reaction 2.2.9 Defense against fungi 2.2.10 Diagnosis 2.2.11 General treatment pattern 2.2.12 Prevention Part 3Skin and skin diseases3.1 The skin Anatomical and physiological aspects3.2 Twacha The Ayurvedic view 3.2.1. Role of various internal factors 3.2.2. Assessment of the health of skin3.3 Skin diseases and infectious skin diseases 3.3.1. Bacterial infection 3.3.2. Viral infection Part 4Review of Ayurvedic literature4.1. Vedic references 4.1.1 Krimiroga 4.1.2 General charecterestics 4.1.3 The effects of krimis4.2. Ayurvedic literature 4.2.1 Janapadodwamsa 4.2.2. Oupasargika 4.2.3 Graha 4.2.4. Krimi 4.2.5. Twak vikara and krimi 4.2.6. The Treatment principle www.ayurvedicmedicinalplants.com
    • 4.2.7. Kshethravada and Beeja vada4.3. Theory of infection-A critical analysis 4.3.1. The web of causation-An Ayurvedic perspective 4.3.2. The spectrum of infectious diseases4.4. Ayurvedic perspective of Superficial mycoses 4.4.1 Assessment of the disease 4.4.2 Nidana-Viprakrishta and Sannikrishta 4.4.3 Poorvaroopa 4.4.4 Roopa 4.4.5 Samprapthi 4.4.6 Upasaya Part 5 Clinical study 5.1 Methodlogy 5.2 Observations & Analysis Part 6 Discussion 6.1 Discussion on theoretical aspect 6.2 Discussion on clinical examination 6.3 Discussion on test response 6.4 Discussion on statistical analysis Part7 Conclusion 7.1 Conclusion 7.2 Limitations 7.3 suggestions Summary Bibliography www.ayurvedicmedicinalplants.com
    • Acknowledgement xÉuÉï ÌuÉZlÉWûUqÉç SåuÉqÉç xÉuÉï ÌuÉZlÉÌuÉuÉÎeÉïiÉqÉç xÉuÉï ÍxÉ̬ mÉëSÉiÉÉUqÉç uÉlSåWûqÉç aÉhÉlÉÉrÉMüqÉç At this unforgettable moment of successful fulfillment of an ambition, Ibow to my parents and to all my respectful teachers by whom I was able to thinkand work on such a divine medical science. I most sincerely convey thanks with best of my respects and gratitude to myhonorable Guide Dr. R Sreekumar. His guidance and valuable suggestions throughout the course of my study have helped in completing this thesis successfully. It gives me immense pleasure to express the heartfelt gratitude toDr.S.Rajeev, Associate Professor, Dept.of Dermatology, ACME Pariyaram, whohelped me a lot with valuable scientific guidance. I pay my sincere thanks to Dr.S.Jayadevan, Associate Professor, Dept.ofCommunity Medicine, ACME Pariyaram, who helped me a lot with valuableguidance on statistics. It is beyond the reach of my language to inscribe the profound gratitude, Ifeel for my department staff, colleagues and patients, who were always with me todiscuss various theoretical as well as practical issues confronted during the study. I would like to convey my heartfelt thanks to my beloved life companionand my little daughter, whose cooperation was always with me. I use this grateful event to convey my sincere thanks to all other teachers,friends and relatives, who have extended their direct or indirect co-operation formy dissertation. www.ayurvedicmedicinalplants.com
    • AbbreviationsA. H. Su. - Ashtanga Hridya Sutra SthanaA. H. Chi. - Ashtanga Hridya Chikitsa SthanaA. H. Ni. - Ashtanga Hridya Nidana SthanaA. H. Sa. - Ashtanga Hridya Sharira SthanaA. S. Ni. - Ashtanga Sangraha Nidana SthanaA. S. Sa. - Ashtanga Sangraha Sharira SthanaA. S. Su. - Ashtanga Sangraha Sutra SthanaA. V - Adharva VedaCh.S. - Charaka samhithaCh. Chi. - Charaka Samhita Chikitsa SthanaCh. Ni. - Charaka Samhita Nidana SthanaCh. Sa. - Charaka Samhita Sharira SthanaCh. Su. - Charaka Samhita Sutra SthanaCh. Vi. - Charaka Samhita Vimana SthanaChak. - ChakrapaniDal. - DalhanaHar. - Harita SamhitaKa. Su. - Kashyapa Samhita Sutra SthanaMa. Ni. - Madhava NidanaMa.M.K. - Madhava Nidana Madhukosa vyakhyaSu. S - Susrutha SamhithaSu. Chi. - Sushruta Samhita Chikitsa SthanaSu. Ni. - Sushruta Samhita Nidana SthanaSu. Sa. - Sushruta Samhita Sharira SthanaSu. Su. - Sushruta Samhita Sutra Sthana www.ayurvedicmedicinalplants.com
    • List of tables1. Layers of the skin2. Properties and functions of doshas3. Effects due to vitiated doshas4. Skin diseases due to Bacterial infection5. Skin diseases due to viral infection6. Sex wise distribution7. Age wise distribution8. Marital Status wise distribution9. Religion wise distribution10. Education wise distribution11. Occupation wise distribution12. Socio economical status wise distribution13. Habitat wise distribution14. Desatah wise distribution15. History of previous illness16. First choice of medication17. Dietary habit wise distribution18. Habit of excessive intake of some food item19. Appetite wise distribution20. Addiction wise distribution21. Bowel condition wise distribution22. Sleep pattern wise distribution23. Nature of cloth using24. Habit of using, soap, oil and powder25. Deha Prakriti wise distribution26. Sara wise distribution www.ayurvedicmedicinalplants.com
    • 27. Sanhanana wise distribution28. Sattva wise distribution29. Satmya wise distribution30. Abhyavarana Sakti wise distribution31. Jarana Sakti wise distribution32. Vyayama Sakti wise distribution33. Kostha wise distribution34. Condition of sweat35. Nature of the skin36. Chief complaints reported by 75 patients of superficial mycoses37. Distribution of the types of superficial mycoses were like this38. Onset wise distribution39. Duration wise distribution40. Causes of aggravation of symptoms41. Occupation Exposed to sunlight42. History of emergence of the disease on exposure to43. Involvement of different Srotas44. Initial data45. After treatment period46. One month after treatment47. Two months after treatment48. Variations in total score49. Variations in symptom score –A comparison between the groups during follow –up50. Comparison of total score through the follow-up periods51. One way ANOVA test for TOTAL SCORE-Initial stage52. One way ANOVA test for TOTAL SCORE-Final stage53. Paired t test –group A54. Paired t test –group B55. Paired t test –group C www.ayurvedicmedicinalplants.com
    • PART 1 Introduction ‘Infection’ is the most dreadful condition that the modern world has everseen. Many of the serious questions arisen by newly evolved infectious diseases,to the medical world remain unsolved even in this ultra scientific world. Now,each and every system of medicine is trying to evolve most effective method fortackling many infectious conditions. As research students of Ayurveda, it is ourduty to interpret the condition in the frame of Ayurveda and to evolve mostscientific and effective solutions after thorough observations and clinical trials.Attempting to give an Ayurvedic perspective on such an entity as ‘Infection’, onwhich the final word in modern research itself has not been out, is an arduous task.But, it is the utmost necessity of the present era. So, this work is a humblebeginning in this aspect.Considering various limitations of such a vast study, here ‘Infectious skindiseases’ form an example for infection, among which ‘superficial mycoses’ is thetypical sample for study. The cases are very common among our tropicalpopulation.1.1 Need and significance of the study One of the baffling problems of mankind since time immemorial is the skindisease, which manifest in variety of forms. Infectious diseases are the mostpredominant among them. About 10% of all the patients coming to a generalpractitioner consists infectious skin disease. To a dermatologist, nearly 40%consists of various types of infections (1). These are the figures from world widestatistical data.Considering the tropical condition, according to our hospital records, (Govt.Ayurveda college, Kannur O.P. Register 2003-2004) nearly 23% of all the cases www.ayurvedicmedicinalplants.com
    • are contributed by Skin diseases. Among this, many cases were of ringworminfection. Enquiry in to details of this condition will open a wide vista of facts.For millennia, yeasts and fungi have enjoyed relatively good relations withhumans. Despite their abundance—they appear on plant leaves and flowers, soil,salt water, baked goods and beer, as well as in our gastrointestinal tracts and skinsurfaces—very few yeasts and fungi trigger disease in healthy people. But thescenario has changed very much now. Bacteria, the most common pathogenicorganism became almost yieldable to various potent antibiotics. Corticosteroidsplay miraculous game in infectious conditions. But the major advances inmedicine and technology has created a suppressive effect on the patient’s immunesystem, subjecting human body to various types of mere or fatal other infections.An increased number of several fungal infections have been observed during thelast two decades. This alarming increase in the fungal infections is seemed due tonew potent antibiotics and corticosteroids and up to a certain extent owing toenvironmental pollution (2).A survey of literature reveals that several saprophytic or plant pathogenic fungi areknown to become opportunistic pathogen in immunocompromised/immunosuppressed patients (3). Unfortunately, some medical advances have alsogiven rise to new problems. Organ transplantation, invasive surgery, implantationof prosthetic devices, and the use of immunosuppressive therapies have prolongedsurvival from some diseases but also resulted in compromised immunity andrendered previously normal individuals susceptible to microbes formerlyconsidered to be pure saprophytes.In tropical regions of Kerala, increasing prevalence of fungal infection is said to bedue to the climatic peculiarities and due to unhygienic practices of people. In arecent survey conducted at a rural area of ‘Kumble’ (Kasargod district) showed11.16% patients with dermatological problems. Of these patients, 43.41% hadcutaneous infections and 57.07% had non-infectious dermatoses. Fungal infectionwas the commonest infection seen (22.92%) and eczemas took an upper hand in www.ayurvedicmedicinalplants.com
    • non-infectious group (32.19%) (4). According to laboratory of mycology and plantpathology, University of Rajasthan, Dermatophytoses poses a serious concern tothe sociologically backward and economically poor population of India. Fungicause both superficial and internal mycoses. The mycoses, normally not lethal, areunpleasant and difficult to cure, and cause considerable economic loss. Antibioticscan kill bacteria without much bad side effects, but as fungi contain cellularmachinery and proteins similar to our own, its hard to find agents to kill fungi thatdont have negative effects on us. By this fact, modern world find it more difficultthan Bacteria, to remove pathogenic fungi from our body (5).1.2 Relevance of Ayurvedic study Now, the ancient Indian medicine, ‘Ayurveda’ has become globallyacceptable with its unique concept of pure health. Many of the health seekersconsider it as their destiny of hope as it promise the holistic health. Living in a fastgoing and newly emerging world of modern science, the acceptance to Ayurvedais a surprising trend. So, by considering the significance of the situation, it is ourduty to present the concepts of Ayurveda in the frame of evidence based medicinewith clinical observations.According to the ‘General Guidelines for Methodologies on Research andEvaluation of Traditional Medicine’, published by WHO, there are various scopesfor unconventional medical fields, for research. Well established randomizedclinical trials provide the highest level of evidence for efficacy. Observationalstudies involving large number of patients may also be a very valuable tool for theevaluation of theories or efficacy of herbal medicines. According to the theoriesand concepts of traditional medicine, (as mentioned in Part1-section 1.3 of theguide line) the prevention, diagnosis, improvement and treatment of illness areoften based on the specific needs of the individual patient. So even a single casestudy itself is significant (6). www.ayurvedicmedicinalplants.com
    • 1.3 Ayurveda and Infectious Skin Diseases Many of our traditional healers have much experience with various types ofinfectious skin disorders. Fascinating stories of long lasting results after Ayurvedictreatment really attract us towards this field of medicine. Complete cure, absenceof side effects, rare chances of recurrence etc are the main benefits. Success withAyurvedic treatment after so many other trials really signifies its magnanimity.But as a medical science, it has to be under the ground of evidence based clinicaltrials and under the criteria of statistical analysis. Other wise, the world will notaccept our theories or findings.1.4 About this thesis work Experience and practice have strong theories behind. We have the historyof various experiences from the classical books of Ayurveda. Our duty is to findout the theory behind each practice and generalize it with clinical trials andobservations. The attempt in this work is to observe and to understand ‘Superficialmycoses’ through the theories and clinical studies based on Modern as well asAyurvedic principles. To do that, it was felt necessary to first have an overview onsuperficial fungal infection, including the latest trends of research. This type of acompilation can throw light to many facts pertaining to mycology. A criticalanalysis through these facts reveals the necessity of a true intervention in this field.The research-oriented analysis through the olden pages of Ayurveda has drivenmuch information about this concept. There was a visible concept of infection inthose pages. Cases like that of ‘superficial mycoses’ were described in those oldendays. Based on these concepts, a thorough observational clinical study wasconducted among the patients. This thesis work contains the details of theseobservations and clinical interpretations.1.5 Outline of the thesis This is an observational clinical study, in which patients of superficialmycoses were randomly selected and grouped in to three categories. A clear cutMethodology was formulated as a first step of the study. Patients were selected www.ayurvedicmedicinalplants.com
    • after thorough examination of their clinical symptoms and personal details.Diagnosis was purely based upon modern criteria. For the confirmation of fungi,scrapings were taken for microscopic study. First group was administered withExternal medicine, second group with Internal medicine and the third group withboth administrations. This is an ‘upasayathmaka’ study as the etiopathologicalaspects of the disease are still obscure. By comparative assessment of the degreeof symptomatic cure in all the three groups, here is an attempt to infer the degreeof pathological involvement. This thesis work tries to answer various questionsregarding the role of internal morbidity in the causation of infection.Follow up research works will really contribute for a concrete basis for the theoryof various infectious diseases in Ayurvedic perspective, which may lay morebeneficial milestones in the development of our science in modern scenario.References:1. Current science, vol.85, no1, 10 july2003, page302. Journal of investigative dermatology 116, 2, 313-318 (February, 2004)3. Journal of investigative dermatology 112, 3, 56-58 ( May, 2005) Mishra M, Mishra S, Singh PC, Mishra BC. Clinicomycological profile of superficial mycoses. Ind J Dermatol Venereol Leprol. 1998; 64:283-5. Huda MM, Chakraborty N, Sharma JN. Clinico-mycologicalStudy of superficial mycoses in upper Assam. Ind J Dermatol4. Pattern of skin diseases in an Indian village, Rao GS, Kumar SS, Sandhya Dermatology & Venereology Dept, KMC, Mangalore, Nov-20025. Current science, vol.85, no1, 10 july2003, page306. General Guidelines for Methodologies on Research and Evaluation of Traditional Medicine, Published by WHO, Geneva 2000. www.ayurvedicmedicinalplants.com
    • PART 2 Review of the literature Modern review To study the Ayurvedic perspective of a disease, on which many studieshave already done by modern scientists, it is essential to have an up to dateknowledge of the present subject. So this chapter comprises the most recentknowledge about the infection, microorganism, fungal infection, superficialmycoses, their diagnostic methods and modern treatment schemes.2.1 Infection-Basic concepts The word infection originates from the Latin term, ‘infectio’ whichindicates the process of the successful invasion, establishment and growth ofmicroorganisms in the tissues of the host. The fate of infection alters depending onthe organism and patient. If the circumstances are suitable, this invasion causes aninfectious disease in the host. They are capable of transmission from one person toanother.2.1.1 The sources of infection The source of an infection refers to the habitat or growth area in the humanor animal reservoir and vehicle refers to objects that are contaminated or colonizedby microorganisms. As per the source, infections may be viewed as Endogenousor ExogenousEndogenous: It is from within the same individual. There are certain organisms,which live on the external and internal surfaces of the body, without causingdisease; such ability is called commensalisms. At times these act as pathogens andcause disease whenever bodily resistance is lowered.Exogenous: These are derived from human beings, animals or the soil (inanimatenature). The human carriers could be healthy convalescent and chronic. www.ayurvedicmedicinalplants.com
    • 2.1.2 Pathogenisity of microorganisms The ability of certain microorganisms to establish an infective process isreferred to as pathogenesity. In practice, pathogenic mechanisms can besubdivided as follows1. Invasiveness: The ability to invade tissues.2. Evasiveness: the ability to evade host-defense mechanisms whilst invasion occurs.3. Virulence the ability of the micro organisms to produce tissue injuryDifferent microorganisms possess different pathogenicity. Depending on theirpathogenicity, the nature of disease also may have difference in presentation.Before explaining them, now we may go through the relevant aspects ofmicroorganisms.2.1.3 Microorganisms Universe is filled with a number of microorganisms. Earthly environmentalso harbours a variety of microorganisms. Each particular microorganismpossesses so many specific characters in their life cycle, transmission and inrelations. On the basis of their life-habits, organism may be classified assaprophytes or parasites.Saprophytism is the mode of life of free-living organisms, which obtain theirnourishment from soil and water. Saprophytes usually do not require a living host.Parasitism implies adaptation to life on or in the bodies of higher organisms. Theassociation may be of symbiosis, commensalisms or pathogenesis.2.1.4. Normal flora The normal skin of healthy persons contains so many classes ofmicroorganisms. Though there are a variety of microorganisms residing on humanskin, they remain harmless because of the relationship existing between the skinand its microflora. As the skin contains fats, proteins, nitrogeneous substances,minerals, by-products of keratinization and cutaneous appendages, they willprovide sufficient nutrition for the growth of microorganisms. The microbial flora www.ayurvedicmedicinalplants.com
    • of each region of the skin seems to differ in detail from other regions. Climaticconditions, sweating, body hygiene and of course, skin disease besides a host ofother factors influences the composition of the microflora.Basic pattern of colonization of healthy human skin is different from others. Dryskin supports a low level of colonization, while moist areas and those wellsupplied with sebaceous glands are heavily populated. Within the genusStaphylococcus, 10 different species have regularly been isolated from normalskin. The normal flora of the skin appears to have several functions, of which themost important is probably defense against bacterial infection through bacterialinterference. It is almost certainly responsible for the production of free fatty acidsfrom skin lipids.Pityrosporum ovale is part of the normal skin flora in adults, but is rare in prepubertal children; it is generally found in greatest density in the scalp andproximal flexures. The proportion of the normal scalp flora represented by P.ovale is increased in adults with seborrhoeic dermatitis.The normal flora of the skin includes a number of morphologically distinctlipophilic yeasts. Pityriasis versicolor in most cases represents a shift in therelationship between a human and his or her resident yeast flora. Factorscontributing to the change are probably multiple.Most attention has been devoted to environmental factors and individual hostsusceptibility.The skin provides a dry, mechanical barrier from which contaminating organismsare constantly being removed by desquamation. Investigators have spreadorganisms on the skin surface, studied their disappearance and attempted toelucidate the factors concerned. It seems that more than 20% of normal subjectscarry some skin bacteria that produce antibiotics capable of inhibiting othermicroorganisms. On nearly one in 10 of normal human skins, these antibioticproducers actually predominate, in which case they appear to be helpful inprotecting against staphylococcal wound infection after surgery. www.ayurvedicmedicinalplants.com
    • The normal human skin is colonized by huge numbers of bacteria that liveharmlessly as commensals on its surface and within its follicles. At times,overgrowth of some of these resident organisms may cause minor disease of theskin or its appendages. Apart from the arrival of these frankly pathogenicorganisms, a wide range of bacteria land more or less fortuitously on the skin, andlinger briefly in small numbers before disappearing, unable to multiply and thrivein this relatively inhospitable environment. Detailed quantitative studies ofpathogens and commensals, and investigations of epidermal replication and of theimmune capabilities of the host, are becoming feasible in a research setting. Thelessons they teach must be used to interpret the problems found in daily clinicalpractice, where such sophisticated methods are generally unavailable.Microorganisms of medical importance can be divided in to several large groups,including Bacteria, Virus, fungi and a number of organisms intermediate betweenthem. Study about these organisms became a serious subject of discussion,following the germ theory of disease causation. As our subject of discussion isabout Fungus, we may detail about that.2.1.5 Fungus All life on earth is divided into five kingdoms: Plants, Animals, Fungi,Protozoa, and Monera (bacteria). Fungi are neither plants nor animals; but are adifferent and more primitive kingdom whose differences provide the ability topoison the denizens of other kingdoms, including the species, Homosapiens.Fungi are the most widely distributed organisms on Earth. They are eukaryoticprotista. Many fungi are free-living in soil or water; others form parasitic orsymbiotic relationships with plants or animals, respectively. There are over200,000 fungal species and they make up a quarter of the biomass of the earth.There are 100,000 genera of the mold species, but only approximately 80 generaare known to cause illness. Their features can be classified on morphological,anatomical, ultra-structural, biochemical or based on sequences of nucleic acids. www.ayurvedicmedicinalplants.com
    • 2.1.6 Cell biology of the fungiFigure 1 Their basic cellular unit is described as a hypha. This is usually a tubularcell, which is surrounded by a rigid, chitin-containing cell wall. The hypha extendsby tip growth, and multiplies by branching, creating a fine network called amycelium. Hyphae contain nuclei, mitochondria, ribosomes, Golgi and membrane-bound vesicles within a plasma membrane bound cytoplasm. The sub-cellularstructures are supported and organized by micro-tubules and endoplasmicreticulumNot all fungi are multicellular; some are unicellular and are termed yeasts. Thesegrow by binary fission or budding, creating new individuals from the parent cell. www.ayurvedicmedicinalplants.com
    • 2.1.7. Fungal metabolism Fungi prefer moist habitats and they are largely mesophyllic, preferringtemperatures between 15°C and 35°C. The carbon needs of fungi for energymetabolism and biosynthesis has to be met heterotrophically by one of threelifestyles: -A) Parasitism of plants or animals (causing disease).B) Saprophytism, growing on dead animal, plant or microbial biomass.C) Symbiosis, growing together with algae, plants or insects.2.2 Fungal infections Fungal infections are caused by Fungi. Fungi may be contaminants,opportunistic invaders or pathogens. They can produce harmful effects because ofthe production of mycotoxins by evoking allergic reaction or by direct tissueinvasion. Fungal infections may be primary or superficial when it involves theskin and its appendages, or it may be deep mycosis with secondary manifestationson the skin. A third type of fungal infection is opportunistic infection, occurring inpatients with debilitating diseases.2.1.1 Superficial mycoses. Superficial mycoses are of two types-surface infections and cutaneousinfections. In the former, the fungi live exclusively on the dead layers of the skinand its appendages. They have no contact with living tissue and hence elicit noinflammatory response. The only changes produced are cosmetic effects. Tinea(pityriasis) versicolor, Tinea nigra and Piedra fall in to this group.In cutaneous infection, microorganism is generally confined to the cornified layerof the skin and its appendages but a variety of inflammatory and allergic responsesis induced in the host by the presence of the fungi and their metabolic products.The most important cutaneous infection is dermatophytosis caused by a group ofrelated fungi called the dermatophytes. Clinical surveys carried out in India haveshown ringworm as one of the most common infective organism. Their species www.ayurvedicmedicinalplants.com
    • consist, trichophyton, microsporon and epidermophyton. Generally they are calledas Ringworm fungi, which are of three types according to the place they reside:Anthropophilic -reside on humanGeophilic -resides in soilZoophilic -resides on animalsAnthropophilic infections are often episodic in nature. They transmit from humanto human either by direct contact or indirectly by fomites. A relatively non-inflammatory infection often located in the covered area of the body. ChronicT.rubrum infection is the commonest example of non-suppurative lesions causedby anthropophilic species. Once the host skin is inoculated with the fungi undersuitable conditions, various stages follow. These area) Period of incubation,b) Enlargement,c) Refractory period andd) Stage of involution.Once the infection is established in the stratum cornium, two factors are importantin determining the size and duration of the lesion.1) The fungal growth rate must equal or exceed the epidermal turnover rate or the organism will be shed quickly.2) The inflammatory response at the rim of the annular lesions stimulates an increased epidermal turnover in an effort to shed the organism.2.2.2. What causes fungal infections? Fungal infections occur because the mold, mildew or yeast spores aretouched or inhaled and develop into an overgrowth in or on the body. Dependingon the conditions, these infections can be superficial or serious. Under conditionsof moisture, warmth and irritation, these fungi grow rapidly and may cause seriousillness.Superficial fungal infections can be caused by an overgrowth of existing fungi orcan be the result of contact with an infected person or contaminated surfaces and www.ayurvedicmedicinalplants.com
    • objects. Fungal infections can be easily spread through bed sheets, towels andclothing. They can also spread from one part of the body to another by scratching.Systemic Fungal infections are often linked to the soil. Usually, they arecontracted when Fungi spores in the soil get inhaled when soil is dug up or blownaround in the air. They can be a chronic problem for people with suppressedimmune systems.Contact with a pathogen (fungal spore) alone will not be enough to cause a fungalskin infection. The fungal spore must be able to enter the skin (e.g. through minorskin lesions) in order for the fungal threads to multiply, and thus to bring about thetypical symptoms of reddening, itching, burning and flake formation on the skin.The sites most frequently affected in healthy people are the skin, hair and nails.Presumably infection is spread mainly a by air-borne spore. This is whyveterinarians do not want ringworm-infected animals to remain in their clinics orhospitals. If this is the case, all of us at one time must be exposed to infections byvarious ringworm fungi. Why is it then that few of us become infected? Why isinfection usually localized, e.g. ringworm of the scalp only occurs in part whilemost areas are not affected? Surely, there are enough spores produced that theentire scalp will be infected. Sometimes one person in a family, or animal in aherd, will get ringworm and it will not spread to others, whereas other times it ishighly contagious. There is a great deal to be learnedaboutringworm.Most people will be affected by a fungal infection, at least once during theirlifetimes. However, there are also some people whose risk of suffering a fungalskin infection is considerably higher. These high-risk groups include, for example, • People who are overweight (increased perspiration) • Sports persons (changing cubicles, showers) • People with metabolic disorders (diabetes mellitus) • People with weakened immune systems (AIDS) and with cancer • Pregnant women www.ayurvedicmedicinalplants.com
    • • Elderly people • Young children and drug addicts are also at a higher risk of fungal skin infection.In general, a reduction in the bodys defense mechanism and a deficiency in theskins protective acidic coating (hydrolipid film) contribute to an increase in thesusceptibility to fungal infectionsThe estimated lifetime risk of acquiring a dermatophyte infection is between 10and 20 percent. Recognition and appropriate treatment of these infections reducesboth morbidity and discomfort and lessens the possibility of transmission.Dermatophyte infections are classified according to the affected body site, such astinea capitis (scalp), tinea barbae (beard area), tinea corporis (skin other thanbearded area, scalp, groin, hands or feet), tinea cruris (groin, perineum andperineal areas), tinea pedis (feet), tinea manuum (hands) and tinea unguium(nails).2.2.3. Tinea corporis (Ringworm of the body)The key characteristic of Tinea corporis is that the fungus involves the glabrous(relatively hairless) skin. The infection is limited to the stratum corneum of theepidermis. Vellus hair (the fine hair present on glabrous skin) may be invaded, andthe hair follicle may serve as a reservoir for the fungus. Tinea pedis, Tineamanuum, and Tinea cruris refer to Tinea corporis that is limited to the foot, hand,and groin, respectively. There is otherwise little special about them.History lesson:The term tinea has an interesting origin. A worm of a moth would sometimes growon a woolen blanket. The resulting round holes were similar to the rounded lesionsseen on the skin of patients. The genus name for the moth was Tinea, and thus thisname was used as part of the Latin binomials naming these infections.Epidemiology:Transmission of tinea corporis may occur from direct contact with infectedanimals (especially cats and dogs), infected humans, or contaminated fomites such www.ayurvedicmedicinalplants.com
    • as furniture and clothing. Like many other fungal skin infections, warmth andhumidity favor the occurrence of this infection. Therefore, tropical and subtropicalregions have a higher incidence of tinea corporisClinical features:In hot humid climates, ringworm infection of the glabrous skin are much morecommon. Classically, the lesions are circinate and and this has lead to the termringworm .the lesion starts as an erythematous itchy papule which enlarges toform a ring. The centre is relatively normal and the borders are active, elevatedand may be vesciculopapular. The lesions may be single or multiple and eachlesion may enlarge up to 10 cm. Neighbouring lesions may become confluent.Aetiology and pathogenesis In India, T.rubrum accounts for the majority of cases of T.corporis.Theorganism invades the stratum corneum possibly aided by warm, moist, occlusiveconditions and resides in it. After about 1-3 weeks of incubation, it startsspreading centrifugally. The active advancing border has an increased epidermalturnover rate, presumably an attempt to shed the organism by exceeding the fungalgrowth rate. This defence mechanism is successful to a certain extent as there isrelative clearing of infection in the centre of the annular or polycyclic lesions.Temporary resistance to infection occurs in this area for a variable time; however,second waves in re-infection are commonly seen later. In addition to involvementof the stratum corneum, hair follicle involvement may also occur.2.2.4. Tinea cruris (Jock itch, ringworm of the groin) Tinea cruris is an acute or chronic infection of the groin, perineum, andperianal region.Epidemiology: This dermatophytoses is more commonly seen in men. According to Martinet al., the apparent reasons for this include:The temperature, humidity, and occlusion of the scrotum and groin area, especiallyrelated to the clothing, are ideal for the development of these fungi. www.ayurvedicmedicinalplants.com
    • Men suffer more frequently from other dermatophytoses, particularly tinea pedis,and cross infection between sites is very common.Both direct contact between infected individuals and indirect contact withnonliving contaminated objects (towels, clothing, bed linens, urinals, and bedpans) are ways of transmission. Tropical climates and summer months intemperate regions appear to promote higher rates of this infection.Clinical manifestations: Tinea cruris presents with sharply demarcated lesions with a raisederythematous margin and thin dry epidermal scaling. Papulovesicular lesions mayalso be present but pustules such as those caused by candida are very unusual.Lesions classically involve the genitocrural area and medial upper thigh in asymmetrical fashion, but asymmetrical involvement may occur. The scrotum isusually minimally affected, and this is a distinct contrast with infections of thisarea by Candida (‘Intertrigo’). Extension to the pubic area, lower abdomen,buttock, and perianal areas occurs rarely but can be seen, especially ifTrichophyton rubrum is the causative agent. Patients complain initially of intensepruritus, but the lesions will become painful if maceration and superinfectionoccur. In addition to candidiasis ("intertrigo"), the differential diagnosis alsoincludes lichen simplex and erythrasma.During summer months, the prevalenceincreases due to the chances of accumulation of sweat.The infection is highly contagious and is usually transmitted through contaminatedtowels or the floors of bathrooms, showers, or hotel rooms. In many cases, patientswho present with tinea cruris also have tinea pedis, both caused by the samefungal species. Severe maceration may lead to subsequent bacterial superinfection. If the penis or scrotum is involved, the infection is probably due tocandidiasis rather than tinea.2.2.5 Tinea versicolor Tinea versicolor is an infection of the stratum corneum epidermidis wheresebaceous glands are present. Caused by the lipophilic yeast M. furfur (previously www.ayurvedicmedicinalplants.com
    • called Pityrosporum orbiculare), it is not contagious and in most cases represents ashift in the relationship between a human and his or her resident yeast flora. Tineaversicolor commonly causes small round or oval macular areas ofhyperpigmentation or hypopigmentation. The back, chest, and shoulders areusually affected; facial involvement is particularly common in children. Hightemperature and humidity are predisposing factors involved with this condition.Patients most often have multiple, discrete macules or patches on the trunk thatmay coalesce into larger patches. The macule is characterized by fine, dustlikescaling with variations in skin color. The color of the macules ranges fromhyperpigmented in untanned white skin, to hypopigmented in tanned or dark skin.2.2.6 Tinea capitis Tinea capitis is the most common mycotic infection in children. Thepredominant age range affected is between 3 and 7 years. Initially, the areaaffected by tinea capitis is flat and scaly, but ultimately it becomes raised. Thecardinal clinical feature of this infection is the combination of inflammation withhair breakage and loss. Most patients who have any degree of inflammationultimately have retroauricular or posterior cervical lymphadenopathy2.2.7 Tinea pedis (Athletes foot, ringworm of the foot) Tinea pedis is a fungal infection of the feet, principally involving the toewebs and soles.Epidemiology: This infection is related to footwear and is considered to been a ‘new’dermatophytoses in that it began in association with use of footwear. Moreocclusive shoes are associated with higher chances of having tinea pedis. Contactwith bath or pool floors is another recognized risk factor and the rate of infectionincreases in relation with the number of people using the facilities. The infection ismore common during summer months and in tropical climates. www.ayurvedicmedicinalplants.com
    • Clinical manifestations: Tinea pedis may present in several ways, varying from mild chronic scalingto acute lesions that are exfoliative, pustular, or bullous. 1. Tinea pedis: this form typically affects the toe webs and subdigital areas producing chronic scaling, fissuring and maceration. The 4th to 5th and 3rd to 4th interdigital areas are the most commonly affected. Some studies have implicated the interaction of dermatophytes with the mixed skin flora characteristic of this area in the pathogenesis of this infection . 2. Tinea pedis with a papulosquamous pattern ("moccasin-like"): as the name suggests, this form affects the soles and lateral aspects of the feet in a pattern suggestive of the skin covered were one wearing a moccasin. Scaling is the main process while inflammation is minimal. This type is usually bilateral and interestingly may present with concomitant involvement of one hand in a pattern called "one hand, two feet". 3. Vesicular or vesiculobullous tinea pedis: this form involves the instep and the mid-anterior aspect of the sole. It causes small, confluent vesicles or vesiculopustules surrounded by scaling. Scales may extend to the toewebs. Occasionally, large bullae appear. 4. Ulcerative tinea pedis: this type causes a more acute and symptomatic picture characterized by maceration and ulceration of large areas of the soles. White hyperkeratosis and a strong heady odor are characteristic. Bacterial superinfection, usually with gram-negative organisms, is frequent and should be taken into account at the time of treating this condition.Despite the previously detailed characterizations, it is not unusual to see apresentation in which there is overlap of two and even three of these clinicalvarieties. A correlation between lower extremity erysipelas and tinea pedis hasalso been established www.ayurvedicmedicinalplants.com
    • Tinea pedis is regarded as a fungal infection of the feet that is caused bydermatophytes. In families, tinea pedis tends to spread throughout the household.It is communicable for as long as the infection is present. The differentialdiagnostic considerations include juvenile plantar dermatosis, dyshidrotic eczema,atopic and contact dermatitis, erythrasma (a superficial bacterial infection causedby Corynebacterium minutissimum), and other bacterial infections withstaphylococci, streptococci, or gram-negative organisms.The most common clinical form is an intertriginous dermatitis characterized bypeeling, fissures, itching, and maceration that affects the toe clefts. In T. rubruminfection, a squamous hyperkeratotic variety of tinea pedis may occur. Thisvariation is particularly chronic and resistant and affects the sole, heel, and side ofthe foot. Affected areas are pink and covered with fine, silvery white scales. If thefoot is extensively involved, the condition is called "moccasin foot"2.2.8. The ‘ID’ reaction Patients infected with a dermatophyte may show a lesion, often on thehands, from which no fungi can be recovered or demonstrated. It is believed thatthese lesions, which often occur on the dominant hand (i.e. right-handed or left-handed), are secondary to immunological sensitization to a primary (and oftenunnoticed) infection located somewhere else (e.g. feet). These secondary lesionswill not respond to topical treatment but will resolve if the primary infection issuccessfully treated2.2.9. Defense against fungi Defense against the fungi causing ringworm depends on both innate andacquired immune mechanisms, the latter requiring the intervention ofimmunological memory.Serum factors appear to be able to inhibit the growth of dermatophytes in vitro,and on cultured explants of skin. It is not entirely clear what is responsible for this,but unsaturated transferrin is one candidate, which inhibits the growth ofdermatophytes by binding to the hyphae. Its mode of action appears to be www.ayurvedicmedicinalplants.com
    • independent of iron-binding capacity. In experimental infections of skin graftedonto nu/nu mice, there is evidence of increased turnover of epidermis, whichoccurs in the absence of effective T-lymphocyte-mediated defense.A further, potentially important mode of defense is provided by the presence offatty acids from sebaceous glands, which inhibit dermatophyte growth in vitro.This activity appears to reside in saturated fatty acids with chain lengths of 7, 9, 11and 13 carbon residues. It has been postulated that their presence on the skin inpost pubertal children may account for the spontaneous resolution of tinea capitisafter this age, and the rarity of new infections in adults. Undecenoic acidderivatives are a practical example where fatty acids have been used for thetreatment of dermatophytos.A further potential factor is the ability of commensal Malassezia yeasts forlipolysis, which may increase the pool of fatty acids available for inhibitoryactivity. Whatever the influence of these factors, it is clear that in experimentallyinfected mice the initial inflammatory changes occur as early in the process as 4hafter infection. This suggests that endogenous mechanisms may attract leukocytes,and the role of inflammatory mediators such as the eicosanoids, in this respectneeds to be investigated.It has also been found that dermatophytes are chemotactic, and that they canactivate the alternative pathway of complement activation. This has beendemonstrated for T. rubrum,T. mentagrophytes and fungi causing endothrix scalpinfections, such as T. violaceum. The production of cytokines, such as interleukin1 (IL-1), by keratinocytes has not been investigated in the mobilization ofneutrophil defenses.It has been shown that neutrophils, and to a lesser extent monocytes, can killdermatophyte conidia. This activity depend both on intra- and extra cellularmechanisms, and the generation of the respiratory burst is an important stage inthis process. Dermatophytes produce catalase and superoxide dismutase, whichmay act as defenses against the phagocyte myeloperoxidase system. By contrast, www.ayurvedicmedicinalplants.com
    • there is little evidence that antibodies to dermatophytes are protective. Patientswith widespread infections, such as tinea imbricata, may have high antibody titers. The presence of elevated IgE in particular is associated with chronicity. Transferof specific serum containing a high titer of antibody to irradiated mice does notconfer immunity on recipients. It is still premature to rule out a role for antibody,as dermatophytes show some cytological changes when grown in the presence ofspecific antibody in vitro. There is, however, strong evidence that the developmentof cellular immunity via sensitized T-lymphocytes is a key factor inimmunological defense. Lymphocytes bearing T-helper phenotypic markers areresponsible for transferring immunity to infection to naïve recipient mice. Inhumans, the appearance of inflammation in ringworm correlates with thedevelopment of delayed-type skin reactivity to trichophytin.Chronic infections are associated with poor T-lymphocyte-mediated response tospecific fungal antigens, suggesting that depression of responses is responsible forthe poor clinical response. Other in vitro parameters of resistance, such asleukocyte-migration inhibition and leukocyte adherence, may also indicate that T-lymphocyte-mediated pathways are involved. Langerhans cells can act as antigen-presenting cells for dermatophyte antigens.The reasons for failure of immunity in persistent infections, and its relationshipwith chronicity, are still not well understood. There is an association between thepresence of atopy and chronic dermatophytosis, with a high proportion of thosewith persistent disease having atopy (usually asthma or hay fever) as well asimmediate-type hypersensitivity and raised IgE levels. It has been suggested thatmodulation of T-lymphocyte activity either locally or systemically may beresponsible.It has also been found that dermatophyte antigens, including those that containmannose residues, can reversibly suppress lymphocyte proliferation, but not theexpression of human leukocyte antigen (HLA)-DR Patients with persistentinfection have detectable levels of circulating antigen. Both are possible factors in www.ayurvedicmedicinalplants.com
    • the regulation of immunity in dermatophytosis. Patients with dermatophytosis areusually otherwise healthy. However, altered or chronic infections have been notedin a number of patient groups, such as those with chronic mucocutaneouscandidosis, AIDS and patients on corticosteroid therapy or with endogenousCushings syndrome. In addition to these, there is the raised incidence of atopy inthose with chronic infection, suggesting that host factors may well determine theclinical course.2.2.10 Diagnosis Clinical wisdom of the physician remains the most important factor indiagnosis of superficial fungal infections. Historical data and predisposing factorsare also crucial to elicit. To confirm a diagnosis, physicians have essentially threetest options.Potassium hydroxide preparation The potassium hydroxide (KOH) preparation is the most rapid, convenient,and sensitive test for diagnosis. A sample of scale, nail, or hair is obtained with ascalpel or cotton swab. The active border or edge of a suspicious lesion is best forobtaining a specimen. The material is placed on a glass slide, and 10% to 20%KOH is added with or without dimethyl sulfoxide. (If dimethyl sulfoxide isincluded, heating is generally not necessary.) The skin or hair sample is placed ona slide with potassium hydroxide (KOH) solution and gently heated. This solutionslowly dissolves the skin cells but not the fungus cells. The fungus cells can thenbe seen with a microscope. Color stains may be used so that the fungus is easier tosee. Findings of a KOH test may include the following.Normal: No fungi are present in the skin or hair samples. Other tests may be done to determine the cause of the skin infection.Abnormal: Fungi are present in the skin or hair samples. www.ayurvedicmedicinalplants.com
    • A positive KOH test shows numerous septate hyphae under microscopicexamination. Overall, the sensitivity of the KOH technique is 88%, but thesensitivity is less than 50% for tinea capitisWood’s light (Ultraviolet radiation) examination Examination under Wood’s lamp is used for the confirmation of thepresence of fungus. With ultraviolet light, Microsporum species, which causeabout 10% of tinea capitis, show a bluish green fluorescence under Woods light;the scaly lesions of pityriasis (tinea) versicolor fluoresce yellow to yellow-green.Fungal culture The standard fungal culture medium is Sabourauds dextrose agar.Appropriate agar choices include dermatophyte test medium and Mycosel andMyco-Biotic agars. Scale and affected nail or hair can be obtained by gentlyscraping a moistened area of involvement with a scalpel, cotton-tipped applicator,or toothbrush and placing the sample on the surface of the appropriate agar. Aphenol red indicator in the agar turns from yellow to red in the area surrounding adermatophyte colony. Malassezia furfur, the pathogen in tinea versicolor, grows invitro only with the addition of fatty acids to the medium and rarely needs to becultured. Fungal cultures are useful primarily in scalp and nail infections or whena diagnosis is in question, but the required incubation at room temperature for 2 or3 weeks is a disadvantage.2.3 General treatment options Modern treatment method against dermatophytes gives importance to thefungicidal action of medicines. For this purpose, they use both internal as well asexternal medications. Commonly used drugs are, Itraconazole, terbinafinehydrochloride, Ketoconazole, selenium sulfide and griseofulvin. Though theirpharmacokinetics slightly differs, all will cease the proliferation of fungus veryeffectively.Localized fungal infections, like tinea corporis, especially of recent origin,commonly responds to topical therapy applied twice daily, usually for about a www.ayurvedicmedicinalplants.com
    • month. Topical terbinafine often works in a shorter time (e.g. 2 weeks). Oralantifungal medications may be required to treat dermatophyte infections in caseswhere the patient resists topical therapy (Noble SL, Forbes RC, Stamm PL.Diagnosis and management of common tinea infections. Am Fam Physician1998;58(1):163-781). Griseofulvin has been used successfully for treatment ofsuperficial dermatophyte infections for more than 30 years. It is best absorbedwhen taken with a fatty meal. In more widespread infections of recent onset, oralterbinafine or itraconazole will generally be preferred, and may be expected toclear the condition in about 2-3 weeks depending on the dose used. Withgriseofulvin, much longer-term treatment is needed, for up to several months withextensive infections.Modern treatment method against dermatophytes gives importance to thefungicidal action of medicines. For this purpose, they use both internal as well asexternal medications. Commonly used drugs are, Itraconazole, terbinafinehydrochloride, Ketoconazole, selenium sulfide and griseofulvin. Though theirpharmacokinetics slightly differs, all will cease the proliferation of fungus veryeffectively.Localized fungal infections, like tinea corporis, especially of recent origin,commonly responds to topical therapy applied twice daily, usually for about amonth. Topical terbinafine often works in a shorter time (e.g. 2 weeks). Oralantifungal medications may be required to treat dermatophyte infections in caseswhere the patient resists topical therapy (Noble SL, Forbes RC, Stamm PL.Diagnosis and management of common tinea infections. Am Fam Physician1998;58 (1):163-781). Griseofulvin has been used successfully for treatment ofsuperficial dermatophyte infections for more than 30 years. It is best absorbedwhen taken with a fatty meal. In more widespread infections of recent onset, oralterbinafine or itraconazole will generally be preferred, and may be expected toclear the condition in about 2-3 weeks depending on the dose used. With www.ayurvedicmedicinalplants.com
    • griseofulvin, much longer-term treatment is needed, for up to several months withextensive infections.2.4. Prevention Several important steps can be taken to prevent fungal infections. Practicegood personal hygiene, skin should be kept clean and dry. Household sources offungus such; as showers, bathtubs, floors should be maintained by cleaningregularly with warm water and a disinfectant.If a member of the household has a superficial infection, be sure to keep sheets,towels and clothing separate and clean. Contact with a pathogen (fungal spore)alone will not be enough to cause a fungal skin infection. The fungal spore mustbe able to enter the skin (e.g. through minor skin lesions) in order for the fungalthreads to multiply, and thus to bring about the typical symptoms of reddening,itching, burning and flake formation on the skin. The sites most frequentlyaffected in healthy people are the skin, hair and nails.Fungal infections should be treated as soon as possible, in order to prevent anyfurther spread of the cause of the disease. For example, a fungal infection of thefoot that is not taken to be seen by a doctor in good time is allowed to develop intoa fungal infection of the nail. The treatment for this is much more difficult andtakes much longer. Fungal infections of the hand and feet usually need about 2 to5 weeks treatment (with complete re-growth of the new skin tissue in about 28days). Equally important: Even if the symptoms of the fungal infection havedisappeared (itching, reddening, burning, flaking, etc.), medical treatment must becontinued for another 1-2 weeks until healing is complete, in order to avoid therisk of the fungal skin infection flaring up again.Fungal skin infections love the damp and the warmth, so please follow these rulesof conduct to minimise the risk of repeated fungal infection: www.ayurvedicmedicinalplants.com
    • • Do not wear clothes that prevent air circulation (synthetics). Do not wear trainers or rubber shoes for too long. • Wherever possible, wear clothes that can be boil washed (many fungal spores can easily withstand being washed at 60 degrees!). • Change your underwear every day, and especially after you have perspired heavily. • Do not walk barefoot in "risky" areas (changing cubicles, swimming pools, gymnasiums etc.). • Use a disinfectant foot bath as often as possible in public baths and showers. • Use mild skin cleansing substances rather than alkaline soaps. • Dry thoroughly after washing. Strengthen your immune system in general and keep your circulationworking wellReference:1 Text Book of Microbiology, Ananthanarayan & paniker, 7th edn.2. Text Book of Preventive and Social Medicine, K. Park, 14th Edn.3. Text book of Dermatology, edited by R.H.Champion,Cambridge.4. Textbook of Dermato-Epidemiology, Strachan D,Williams HC.5. Microbiology of Human Skin, Noble WC. London 1981.6. Medical Mycology, Chung KJ, Bennett JE. Philadelphia: 1992.7. Dermatology, Samuel L Moschella, Harry J Hurley. www.ayurvedicmedicinalplants.com
    • PART 3 Skin and Skin diseases Before entering in to the details of Ayurvedic enquiry of the subject, it willbe better if we have an over all idea about the structure upon which the disease getmanifested. The basic structural and functional aspects of skin in modern as wellas in Ayurvedic perspective are discussed in this chapter.The SkinHuman skin is a biological marvel. Skin is the largest organ in the body. It formsthe outermost protective covering of our body. In Latin, skin means, the covering.The skin is composed of a superficial epithelial layer ‘the Epidermis’ & theunderlying connective tissue layers ‘The Dermis or corium’. Beneath the coriumthere is another connective tissue layer, rather loose in texture ‘The Hypodermis’or subcutaneous layer.The free surface of the epidermis is marked by a network of linear furrows &ridges of various sizes. In different body parts, the epidermal arrangement showswide variety.Epidermis:The epidermis, composed of epithelial cells is formed from the ectoderm of thefertilized ovum. It consists of 5 layers devoid of blood vessels, which from thebasal to the superficial are as follows – 1. Stratum basale or germinativum- Forms the lowest layer & consists of single row of columnar cells & is capable of continued cell division. As these cells multiply, they push up towards the surface & becomes part of the upper layers. The appendages of the skin are also products of this layer of cells. www.ayurvedicmedicinalplants.com
    • 2. Stratum spinosum or malphigi -This prickle cell layer lies upon the basal layer & has 5 to 10 rows of polyhedral cells that fit close together. This layer involves most of the pathological conditions of the skin. 3. Stratum granulosum -It consists of about three rows of flattened rhombic granular cells. The granules vary in size & are highly reflectable. They consist of semisolid substance known as keratohyalin, which helps to form keratin. 4. Stratum lucidum -This layer is a thin clear strip of glistening, translucent, flattened cells without granules or nuclei. 5. Stratum corneum -The horny layer consists of several rows of flattened completely cornified horn cells containing a fatty & waxy material but no nucleus. The surface row of the cells appears as thin dry scales. This layer is thickest on the palms & the soles & thinnest on the eyelids & prepuce.Dermis: The dermis chiefly consists of white fibrous tissue, elastic fibers & nonstriped muscles & contains blood vessels, nerves, hair, sweat gland & sebaceousglands & nerve corpuscles. Finger like processes known as papillae projectupwards into the overlying epidermis followed by the reticular layer, which isformed of coarse, dense, interlining collegen fibres, a few reticular fibres &numerous classic fibres.The subcutaneous tissue or hypoderm resembles in its upper portion, the reticularlayer of the corium from which there is no distinct line of demarcation.Blood supply: There are two horizontal & parallel systems of plexuses which supply theskin. The plexus or network of blood vessels exists between the dermis & thesubcutaneous tissue. Its exact position can never be accurately described. Eacharteriole supplies an area of skin & each venous plexus associated with it drainsthe same area. www.ayurvedicmedicinalplants.com
    • Nerve supply: The nerve supply of the skin is very complicated, & the pathway for themediation of sensations through the various nerves is very much under debate. Thevaried sensations arising from skin are derived from a diverse population ofcutaneous nerve endings or receptors. Thus tactile, temperature & pain sensationare each sub served by different groups of receptors.Lymphatic drainage of the skin:Numerous blind-ending lymphatic vessels terminate in the dermis near the base ofthe epidermis & drain deeply first into a dermal network in the papillary layer,then into another network at the junction of the dermis & superficial fascia. Deepto this zone, the lymph flows through wider channels provided with valves, intothe main lymphatic drainage of the area. The lymphatic drainage of the skin isquite profuse & free anastomosis appears to occur between vessels at all levels sothat there is free interchange of lymph between areas of the skin which areadjacent to each other.Function of the skin:1. Maintains thermoregulation2. Protects against mechanical injury3. Prevents entry of noxious chemical & micro-organisms4. Screens & reduces penetration of radiation5. Prevents loss of body contents6. Provides a frictional surface for grip7. Discourages microbial growth8. Restricts electrical conductivity9. Serves as the outpost of the sensory nervous system10. Serves as the outpost of the immune system11. Signal emotions via the autonomic nervous system12. Synthesises vitamin ‘D’ www.ayurvedicmedicinalplants.com
    • 3.2 Thwacha -The Ayurvedic View Acharya Sushruta has given the simile of development of cream, whileexplaining the origin of Tvacha. As, a layer of cream develops over the boiledmilk; in a similar fashion a layer Tvacha is thought to develop after thefertilization of ovum. (1)According to Charaka, the six layers of the Tvak are formed from the MamsaDhatu (2).Whereas, Vagbhata holds the opinion that the Tvak is formed from the Rakta.After the Paka of Rakta by its Dhatwagni, it gets dried up to form the skin, like thedeposition of cream on the surface of boiling milk. (3) There are six Bhavas(factors) which have been considered responsible in the formation of Garbha.Tvak is formed & nourished by Matrija Bhava.Acharya Vagbhata has stated 7 layers of skin. Formation of layers is due toParipaka of Rakta Dhatu by Ushma. Sharangdhara has also named the layersfollowing the Sushruta except the 7th layer. He has named this layer as ‘Sthula’,the site of Vidradhi. (4).Acharya Gangadhara (5) clarifies the difference of opinion between AcharyaCharaka & Sushruta that the third layer told by Charaka has two parts, superficial& deep. The superficial part is the third layer (sweta), while the deep part is thefourth layer (Tamra) as told by Sushruta. Thus fundamentally there is nodifference in the number of layers told by both Acharyas, Charaka & Sushruta.Acharya Vagbhata has stated seven layers of skin Arundatta & Hemadri havenamed them in compliance to Sushruta in their commentary (6).Tvacha & Mahabhuta Tvacha, though Panchbhautic, has Pruthvi Mahabhutadhikya (7). Tvacha isthe Indriya Adhisthana of Sparshanendriya which has Vayu Mahabhutadhikya (8) www.ayurvedicmedicinalplants.com
    • Sparsha: Perception of tactile sensation is the function of Vata Dosha. Tvachaworks as a sensory organ (being Adhisthana of Sparshanendriya, Vata Dosha isthe main Dosha situated in Tvacha. (9) & is responsible for maintaining lusture ofthe skin. (10)Mala: Sweda is one of the Trimalas which maintains lusture & turgidity of theskin. (11)Layers of Skin: Acharya Sushruta has described seven layers of Tvak. Description of layersfrom above downwards is as follows –Name Thickness DiseasesAvabhasini 1/18th Vrihi Sidhma & PadmakantakaLohita 1/16th Vrihi Tilakalaka, Nyachcha & VyangaSweta 1/12th Vrihi Charmadala, Ajagallika & MashakaTamra 1/8th Vrihi Kilasa & KusthaVedini 1/5th Vrihi Kustha & VisarpaRohini 1 Vrihi Granthi, Arbuda, Galaganda, Apachi, SleepadaMansadhara 2 Vrihi Bhagandara, Vidradhi, ArshaDescription of skin according to Charaka – (12). No. Name Diseases take place 1 Udakadhara Contains Udaka means watery substance or lymph 2 Ashrukdhara Contains blood capillaries 3 3rd layer Manifestation of Sidhma & Kilas 4 4th layer Manifestation of Dadru & Kustha 5 5th layer Manifestation of Alaji & Vidradhi 6 6th layer Manifestation of Arunshi www.ayurvedicmedicinalplants.com
    • 3.2.1 Role of various internal factors in maintaining the health of the skin: According to Ayurveda, functional activity of any part of the body ismaintained by different forms of Doshas, dooshyas malas and ojus. (13). Skin isnot an exemption from this. Let us analyze the role of each factor, in the integrityof normal skin.Doshas: By a broader generalization, functions of the body are three, viz. motion,transformation and growth including maintenance. ‘Motion’ connotes, apart fromthe external voluntary movements, all the kinetic processes taking place in everycell. This function is attributed to vata. ‘Transformation’ includes separation ofdifferent portions of nutrition and formation of the structure. This also causesgeneration of heat. These are related to pitta. Functions of kapha are more relatedto stability and repair of the compact structure of body parts. Ref-(14)The table given below explains this principleVata: Generally vatha dosha controls all the kinetics in dermal physiology. Eachsingle action will have the involvement of different properties in different degrees.Properties Possible functions in skinRuksha Keeping the necessary dryness (Soshana)Sita Keeping the necessary limits (Sthambhana)Laghu Keeping the Lightness (Langhana)Khara Keeping the Roughness& hardnessSukshma Spread of factors through srotusChala Motion of various factorsVisada Lack of flexibility of structural forms www.ayurvedicmedicinalplants.com
    • Pitta: Generally pithadosha controls all the transformation processes inside thedermal system.Properties Possible functions in skinSasneha Keeping the normal moistureTikshna Penetration through minute channelsUshna Keeping the temperature, in normal levelLaghu Keeping the LightnessVisra Maintaining a smell to skinSara Flow of materialsDrava Discharging the enzymes and hormones at proper spots.Kapha: Generally kaphadosha controls all the nutritive and strengthening functionsin skin.Properties Possible functions in skinSnigdha Keeping the normal moisture (kledana)Sita Keeping the necessary limits (Sthambhana)Guru Providing the nutritive functions.Manda Necessary slowness in actionSlakshna Slimy discharges from various spots.Mritsna Slimy discharges.Stira Keeping the essential strength in the interconnections between the layers and among the components.Generally vitiation of Doshas will create some objective as well as somesubjective symptoms in the body. They are described by the following reference-Dosha vikrithi avastha (vitiated states) Effects due to the vitiated doshas (15) www.ayurvedicmedicinalplants.com
    • Vatha Pitha Kapha1.Loosness (sramsa) 1.Burning sensation (daha) 1.Coldness (saithya)2.Dislocation (Bhramsa) 2.Heat (oushnya) 2. Whitish (Swaithya )3.Dilation (Vyasa) 3.Suppuration (paka) 3,Itching (kandu)4.Obstruction(sanga) 4.Perspiration (sweda) 4.Heaviness (gouravam)5.Seperation (bheda) 5.Softening (kleda) 5.Stability (sthairryam)6.exhaustion (sada) 6.Putrifaction (kodha) 6.Fixation (bandha)7.Excitation (Harsha) 7.Itching (kandu) 7.Rigidity (sthaimithya)8.Thirst (trisha) 8.Redness (ragam) 8.Hardness (kaadinya)9.Tremour (kampa) 9.Discharge (sravam) 9.Oedema (sopha)10.Round masses (vartha) 10.Fainting (moorcha) 10.Numbness (supthi)11.Pulsation (chala) 11.Intoxicated (mada) 11.Indigestion (apakthi)12.Pricking (toda) 12.Weakness (sadam) 12.Unctuousness (sneha)13.Aching (vyadha) 13.Pungent/sour tastes 13.Softening/exudation14.convulsions (cheshta) (katu/amla) (kleda )15.Tightness (veshtanam)16.Harshness (prusha)17.Non sliminess (visada)18.Porousness (sushira)19.Dusky redness (aruna )20.Dark (syamavarnatha)21.Astringenttaste(kashaya)22.Wasting (sosha)23.Piercing pain (soola)24.Numbness (supthi)25.Contraction (sancocha)26.Rigidity (sthambhana)27.Lameness (ghanjattha) www.ayurvedicmedicinalplants.com
    • In the case of skin disease, Doshic predominance is assessed by some selectedfeatures from the above i.e. as far as Ayurveda is concerned, in the process ofdiagnosis, naming of the condition is not at all relevant than the doshapredominance of the stage. So assessment of the state of doshas should be givenprime importance in the process of diagnosis.Doshic predominance Any skin manifestation should be assessed on the basis of the doshapredominance.Vathika Syava,aruna, thanu, visarpini,thoda bheda,swapayuktha (Blackish,Reddish,Smooth,Spreading,Pain with numbness)Paithika Raga,osha, chosha, paridaha, dhoomayana, sweda, khshiprodhana, prapakabheditwa,krimijanma Kleda,sruthi.kodha (Reddish, Throbbing pain, Burning, hotness, sweating, sudden manifestation,spreading, origin of organisms, moisture,discharge, putrifaction)Kaphaja Uthsannatha, parimandalatha, kandu, chirothana,snigda, kadina, sopha (Rised,circular, Itching, longlasting, oily, hard,swelling)Dooshyas: As doshas are the Principal units of body functions, dooshyas are theSubunits. Each dooshya has a significant role in maintaining the structuralintegrity of the skin. We can elaborate this principle in this way-Rasa dhathu - Main part of the structure of skin,Raktha dhathu - Provides colour, nutrition and resistanceMamsa dhathu - Forms a slimy coatingMedo dhathu - Maintains an oily and balanced equilibrium www.ayurvedicmedicinalplants.com
    • Asthi dhathu - Maintains the general firmness and formMajja dhathu - Forms the main source of unctuousness to the skinSukla dhathu - Forms the hereditary factor for skin (Ref-16)Mala: Among the malas, Sweada and Moothra are the main factors related withthe Skin. They can control the moisture content of the body which in turn cancontrol the moistness of the skin. In each membrane of the skin, moistness is veryessential for various transformations. So, vitiation of sweada causes effects onskin.(17 )Sweada is the form of excretion through the skin. So any obstruction in thisexcretion will cause malasanchaya at various levels of skin.Ojus: The principle of Ojus provides efficacy needed for all the processes ofdhathus. So, for the proper nutrition, resistance power and health of the skin, goodojus is essential. Diseases like AIDS, in which the status of ojus is reduced verymuch, various pathogenic organisms may invade in to the skin, causing variousinfectious skin diseases.3.2.2 Assessment of the health of skin (18) According to Ayurveda, ‘Sara’ is the principle, which forms the criteria forassessment of the health of different entities in body. By external appearance ofcertain parts, we can assess the health of associated organs. For the assessment ofthe health of skin and associated organs, we should take the criteria of ‘Twak sara’1. Snigdatha (Unctuousness)2. Slakshnatha (Smoothness)3. Mriduthwa (Softness)4. Prasannatha (Fairness)5. Sookshma, Alpa, Gambheera, Sukumara loma (minute, small, deep rooted andfair hairs) www.ayurvedicmedicinalplants.com
    • 6. Saprabha (Lustrous)These are the assessment criterion. Optimum presence of all these factors incombination indicates good health of the skin. If any factor found in excess or indeficient, that indicate the reduction in skin health.Interpretation: According to Ayurvedic principles, formation of Twak (skin) is from theRakta. After the Paka of Rakta by its Dhatwagni, it gets dried up to form the skin,like the deposition of cream on the surface of boiling milk (19).So it has manyrelations with the organs of Rakthavahasrothas. Alterations in the functions of anyof these organs may precipitate deficient skin health.Yakrith (Liver) and Pleeha (Spleen) are the two main parts of Rakthavaha srothas.Liver maintains the major functions of detoxification and metabolism. Spleen isconcerned with the life of red blood cells. According to Ayurvedic principles, roleof these organs in dhathu parinama is very critical. The enzymes concerned withtheir functions can be correlated with the fractions of dhathwagni. Biochemicalaspects of these enzymes will prove their importance in maintaining many bodyfunctions. Lack or deficiency in these enzymes may block or alter certainmetabolic transformations, creating many abnormalities. In many skinmanifestations, this concept is very relevant. So, assessment of the health of skin,in other terms gives ideas about the health of internal organs of RakthavahaSrothas.In many contexts, we may notice the abnormalities in dhathwagni,leading toillhealth of the skin. For eg; medodhathwagnidushti happening in prameha leads tothe ill health of skin (20) resulting in prameha pidaka. (Carbuncles in Diabetes).Here a correlation with modern concepts proves the incidence of streptococcalbacterial invasion in to the skin due to the decrease in resistance power of skin.Actually, the abnormality happened inside the body makes the nest suitable forforeign microbial, and thus they enter in to the body. www.ayurvedicmedicinalplants.com
    • 3.3 Skin Diseases Skin is the first organ of the body interacting with the environmentalagents like physical, chemical & biological agents. Variations in theenvironmental stimuli & natural ability of body to deal with these factors result inspontaneous remissions & relapses. Interaction with these factors results inspecific reaction pattern producing characteristic skin lesions in different parts ofthe body. Large community prevalence studies have demonstrated that between20-30% of the population have various skin problems requiring attention.(Davidson 18th Ed.) Skin is a mirror that reflects internal & external pathology &thus helps in diagnosis of diseases. In Dermatology, we can observe a wide arrayof skin manifestations with different names. In present day science, it is observedthat there are over 2000 skin disorders. Depending upon the etiology, they can beclassified into various groups such as, Genetic, Autoimmune, Allergic, Infectious,Traumatic, Developmental, Occupational Climatic etc. Skin diseases affect theindividual in 4 ways .i.e. Discomfort, Disfigurement, Disability and Death.Among the infectious diseases, include mainly Bacterial, Viral and Fungal skindiseases.3.3.1 Bacterial infection The normal human skin is colonized by huge numbers of bacteria that liveharmlessly as commensals on its surface and within its follicles. At times,overgrowth of some of these resident organisms may cause minor disease of theskin or its appendages. On other occasions, bacteria not normally found there maycolonize the epidermis and lead rapidly to disease. Major bacterial diseases of theskin- www.ayurvedicmedicinalplants.com
    • Organism DiseaseCommensals Erythrasma,Pittedkeratolysis,Tricho mycosis axillarisStaphylococcal Erysipelas,Ecthyma,Folliculitis,Streptococcal Erysipelas,Cellulitis,Impetigo,EcthymaMycobacterial LupusvulgarisSpirochaetal syphilisThe normal human skin is colonized by huge numbers of bacteria that liveharmlessly as commensals on its surface and within its follicles. At times,overgrowth of some of these resident organisms may cause minor disease of theskin or its appendages. On other occasions, bacteria not normally found there maycolonize the epidermis and lead rapidly to disease. Apart from the arrival of thesefrankly pathogenic organisms, a wide range of bacteria land more or lessfortuitously on the skin, and linger briefly in small numbers before disappearing,unable to multiply and thrive in this relatively inhospitable environment.Bacteriological sampling will reveal the presence of these otherwise unsuspectedtransients. Organisms not normally considered as resident members of the skinflora may sometimes colonize and become established in modest numbers forrelatively long periods. Bacteria of this intermediate category have been labelledtemporary residents. Furthermore, certain sites such as the skin of the face may berepeatedly contaminated from the nostrils or mouth by Staphylococcus aureus orhaemolytic streptococci, giving the false impression that these organisms aremembers of the normal facial flora.3.3.2. Viral infection Normally, human skin contains no virus. For a virus to produce infection,it must gain entry into a susceptible cell within an appropriate host. Many viruses,in particular those producing systemic infection, enter the body via mucousmembranes after inhalation, ingestion or contact. The skin can act as a portal of www.ayurvedicmedicinalplants.com
    • entry, but this usually depends on some break of the barrier function of theintegument, for instance a scratch or fissure, or by direct inoculation. Attachmentto the cell surface by means of a receptor is followed by entry of the virion into thecell, by pinocytosis or phagocytosis.About fungal infection, detailed discussion is done afterwards.Major viral diseases of the skin:Organism DiseaseHerpes virus hominis Herpes simplexVaricella zoster Herpes zosterHuman papilloma virus Viral wartsDNA pox virus Molluscum contagiosumPathogenesis of viral disease: For a virus to produce infection, it must gain entry into a susceptible cellwithin an appropriate host. Many viruses, in particular those producing systemicinfection, enter the body via mucous membranes after inhalation, ingestion orcontact. The skin can act as a portal of entry, but this usually depends on somebreach of the barrier function of the integument, for instance a scratch or fissure,or by direct inoculation. Attachment to the cell surface by means of a receptor isfollowed by entry of the virion into the cell, by pinocytosis or phagocytosis.Viruses differ in the range and type of cells which they can infect; host specificityand tissue tropism are hallmarks of viral infections. Poliovirus, for example, caninfect neurones and is called a neurotropic virus, and human papillomaviruses(HPV) have a tropism for epithelial cells. A cell in which a particular virus canreplicate is described as permissive for that virus. After entry into the cell, pre-existing cell enzymes remove or damage the capsid sufficiently for the nucleicacid to emerge. The next stage depends on the nature of the virus. In relativelysimple ones, like enteroviruses, the RNA acts as a messenger, is infectious on itsown and is immediately translatable by host ribosomes into viral proteins. More www.ayurvedicmedicinalplants.com
    • complex RNA viruses, such as influenza, have non-infectious RNA, sometimescalled negative-strand RNA, which has to be transcribed into messenger RNA(mRNA) by a polymerase enzyme carried in the virus itself. RNA tumour virusescontain a reverse transcriptase enzyme which synthesizes DNA from the viralRNA template. DNA viruses are generally more complex and are able totranscribe mRNA from their DNA using either cell polymerase, for exampleadenoviruses, or viral polymerase, for example vaccinia. At the same time,replication of the viral nucleic acid also occurs. A variety of proteins, regulatory,enzymic and structural, are produced and these, together with the products of celldamage, probably contribute to the local and general response to the infection. Thetime required for new virus production in acute infections is measured in hoursand the number of new virions in thousands per cell. Newly produced virions caninvade adjacent cells or be carried via the bloodstream and so the infectionspreads. During this process the cell itself may be destroyed by a virus infection,for example enterovirus and herpes simplex, or damaged transiently, for examplemyxovirus. With time, an immune response develops against the virus particlesand processed viral proteins, which can lead to containment and clearance of theinfection. Not all virus infections end in this fashion. Some viruses infect cellswhich apparently remain normal and may multiply while virus replicationcontinues within, i.e. persistent infections. When persistently infected cellsproduce no infectious because the replication cycle is arrested, the virus is said tobe latent. From time to time, a latent virus can become active-reactivation, newvirions are produced and other cells are infected. This process can result in clinicalsigns and symptoms as in the case of cold sores (reactivated herpes simplex) andshingles (reactivated varicella-zoster). Other viruses cause cell proliferation, forexample poxviruses and human papillomaviruses. Viruses can also be implicatedin the process of carcinogenesis as in the development of cervical cancer andhepatoma. www.ayurvedicmedicinalplants.com
    • A detailed compilation of the infectious skin diseases will be beyond the scope ofour study. So just after touching through the basic factors of these conditions, wemay move to the subject proper. About fungal infection, detailed discussion isdone afterwards.Analysis of these infectious conditions proves the following facts; • Depending upon the infective organism and its virulence, the signs and symptoms may have different forms • Underlying the pathogenesis of each clinical symptom, there are various complicated processes in side the body.In Ayurveda, descriptions about skin manifestations are seen mainly in thefollowing contexts-Kushtam, Dushtavranam, Visarpam, Swithram, Kshudraroga, Krimi,Seethapitham Romanthika, Udarddam, Vidradhi, Kodam, Grandhi, Masoorika,Vatharaktham etc.A clinical correlation between the similar conditions described in Modernmedicine will prove that many of the above diseases are infectious conditions. Butthere are no ample descriptions about the role of microorganisms in theseconditions. It may be because of the lack of deeper knowledge aboutmicroorganisms in those instrumentally insufficient olden days or because of theirway of approach i.e. giving more relevance to the platform and body factors whichare vitiated in the process of disease. This concept is detailed later. www.ayurvedicmedicinalplants.com
    • Reference: 1 Su. Sha. 4/14 2 Ch. Chi. 15/16-17 3 A. H. Sha. 3/8 4 Sha. Pu. 5/22 5 Ch. Sha. 7/3 Gangadhara Tika 6 A. H. Sha. 3/8 7 Ch.Sha. 7/16 8 Ch. Su. 8/14 9 A.H. Su. 12/9 10 A.H. Su. 12/14 11 Su.Su. 15/17 12 Ch. Sha. 7/4 13. A.san.su19 14 A.san.su19 15. C.S-20/12, 15, 17 16. A.San.su.20; A.San.Sa 17. Ch.vi.5 18. A.San.Sa.6-15 19. A. H. Sha. 3/8 20. Ch.Ni.4 www.ayurvedicmedicinalplants.com
    • PART 4 Review of Ayurvedic Literature Ayurveda contains so many declarative statements based on thecrystallization of accumulated experience and observation of natural phenomena.The conclusive statements made years ago could be the end result of theexperiments conducted by our ancestors. But the methods of derivation employedto arrive at the conclusion remain largely unclear and unknown to the latergenerations. Sincere research works are needed to explore the scientific background of many of these principles. As a basic step in this effort, collection of allthe ayurvedic references related with the subject is necessary.Infection –The Ancient Indian perspective4.1. Vedic references: Vedās, the ancient most written treatise of knowledge are having plenty ofreferences regarding the different aspects of the present context. AncientAyurvedic scholars had the sense of understanding of the concept of infection andits role in causing disease. This, we can observe at various portions of our classics.But these descriptions seem very vague and are filled with theistic ideas. Whilereading the classics of science, we should understand them with respect to theperiod in which they had written. They had made these observations during theperiod, when they had no microscopes or other sophisticated instruments. It is theneed of the time to interpret these concepts in terms of modern findings.There are ample descriptions pertaining to infectious disease and krimis orpathogenic micro organisms in Vedas and other ancient Indian literature such asRigveda, Adharvaveda, Sathapadhabhrahmana, thaithireeya, Aranyaka,ChandogyaUpanishad, Vishnupurana, Bhagvath purana, Mahabharatha, www.ayurvedicmedicinalplants.com
    • Kamasoothra etc. Among these, Adharva Veda, which laid foundations forAyurveda contains much informations on.Basing on the descriptions available in the above ancient works, it appears thatduring Vedic period itself the ancient Hindus were well aware about the infectiousdisease innumerable varieties of pathogenic krimis (microorganisms) andcausation of disorders due to them, the clinical features and management ofinfectious diseases. In Vedas, much importance was given to Krimis (pathogenicorganisms) than in Ayurvedic texts. Krimi pisachas were regarded as one of thethree main aetiological factors of the diseases, the other two beings the toxicsubstances produced within the body and vatha, pitha and kapha. (1)4.1.1 Krimiroga From the days of Adharvaveda itself, there were discussions aboutmicroorganisms. In Vedas, many words were used to denote micro organisms. Theimportant among them are as follows: • KRIMI- Means which resides and nourish on raw flesh or which nourish on flesh and other tissues of the body. (2) • RAKSHASA- That which consumes the body; hence the body must be protected from these organisms. (3) • PISACHA- Means that which consumes raw flesh (4) • ASURA- Is that which causes death (5) • YAATHU- Spread in body and harm (6) • APSARA- Grow in water (7)Various types of Krimis are also described.4.1.2 General characteristics of Krimis or Microorganisms: In Vedic period itself, there were descriptions about the pathogenic andharmless varieties of micro organisms. Pathogenic Krimis are known as durnamaand the other one as sunama (commensals). Some cause Santhapa (Febrile) and www.ayurvedicmedicinalplants.com
    • others cause Asanthapa (Afebrile). Some are sista (good for health) and the othersare asishta (pathogenic) (8)There are descriptions about the colours, shapes, mode of movements and otherfeatures of these micro organisms. Krimis invade through air, water, food, drinks,milk and through bed cloths (9).they may enter in to the body through openwounds (10)They fly similar to bird and enter in to the host causing janayaya(tuberculosis) or other diseases (11)The bites of insects, cause diseases.(12)4.1.3 The effects of krimis on host The krimis vitiate raktha and mamsa (13), drink blood (14) consume rawflesh, embryo, impair growth (15), settles in the chest, head, yoni, prushta, uru,and in intestines(16). Various methods employed for destroying the krimis are alsodescribed. Manthras, physical techniques and medicines etc, were there. (17)Bhoothas, grahas, rakshasas, gamdharvas and pisachas were described in postvedic literatures like epics, puranas and classics. Diseases due to these organismsseemed very difficult to cure.4.2. Ayurvedic references Vedic references of the micro organisms may seem scattered, but reachingat the Ayurvedic parlance, we can see some what grouped and classifieddescriptions about the organisms. Ayurveda, based on further observations ofscientific truths, described in Vedas, systematized and recorded probably in 5thcentury B.C. Charaka has made many important observations pertaining toinfectious diseases in the context of Janapadodhwamsa, Vyadhikshamathwaheenatha, Krimi, Bhootha, Pisacha etc. Susrutha described the modes oftransmission of infectious diseases in very scientific manner. Bhela made someimportant observations pertaining to pattern of geographical distribution ofinfectious diseases. Hareetha described suchimukha krimi which is similar toEntamoeba histolytica. Sargadhara described snayuka krimi. Bhavamisradescribed phiranga; a new disease imported from French and transmits mainly bysexual contact. www.ayurvedicmedicinalplants.com
    • With reference to the description of krimis, certain groups simulate the parasites,some are of the creatures including insects too, and some as that of absolutemicroorganisms like bacteria, virus, fungus etc. In this thesis itself, concept ofKrimi is detailed later.4.2.1. Janapadodhwamsa Roga In the context of Janapadodhwamsa (18), vitiation of water, air, place andseason are described as the main causes of some natural calamities and epidemicdiseases. A variety of diseases may prevail in the community destructing the lifeof human mass. Polluted places, water and Air may create an atmosphere for theproliferation of pathogenic organisms. Altered qualities of these factors itselfmake many common diseases. Abnormal climatic variations make the earthlyconditions difficult to live. These descriptions resemble more with the spreadingof communicable diseases.4.2.2. Oupasargika Roga In the context of Oupasargika Roga (19), descriptions of transmittingdiseases are there. Disease that can be transmitted from one person to other isincluded under Oupasargika roga in Ayurveda. Vridha vagbhata observed that allthe diseases are communicable or infectious in general with reference specialreference to disorders of eye and skin. (20)Various ways through which the transmissions take place are described as • Prasanga (sexual contact) • Gathrasamsparsa (touch) • Niswasa(through expirated air) • Sahabhojana (sharing the food) • Sahasayya,Sahaasana (lying or sitting together) • Vasthramalayanulepana (sharing the dresses, ornaments and cosmetics) www.ayurvedicmedicinalplants.com
    • The Main oupasargika rogaas are, Kushta (skin diseases), Jwara (pyrexia), Sosha(emaciating diseases), Nethrabhishyanda (conjunctivitis), Masoorika (chickenpox), Romanthika (small pox), Grandhivisarpa (plague), Upadamsa (softchanchre), Kandu (pruritus). In many other diseases also, the chances oftransmission is described as: “Sparsaikaharasayyadisevanathprayaso gada Sarvve sancharinonethra twagvikaraa viseshatha”This is up to which the concept of disease transmission is described in ayurveda.What may be the factor transferring from one person to another? It is nothing otherthan the infective organisms. In such conditions, the relevant etiological factor iscalled as the vyadhihethu.4.2.3. Graha Rogas About the context of Graha rogas (21), a general analysis show thedescription of microscopic morphology, innumerable number, survival inunhygienic atmosphere and blood medium as positive culture, damaging thevictim’s immunity, more sustenance in darkness and low temperature etc. Theseresemble more with the characters of micro organisms like virus and bacteria.Grahavesa (invasion of microbs) is for Himsa, Rathi or Bali.Himsa is a type of pathogenesis in which the invaded creature tortures the host bycreating various diseases. In Rathi, the organism takes whatever needed for theirnourishment and enjoyment, from the host. This is a type of parasitism. Bali is theritual in which both the parties get benefit. This may be a type of Commensalism.About the pathogenesis, Susrutha opines that Grahas invade the body invisibly ashow the shadows enter the mirror, sunrays enter the lens and Athma enters thebody as well. These indicate the obscurity pertained in finding out the mode ofpathogenisity in olden days.4.2.4. Concept of Krimi Though many infectious diseases are described in detail in Ayurvedic texts,the descriptions of causative organisms and communicability are not given due www.ayurvedicmedicinalplants.com
    • importance as in modern medicine. In clinical features and all, they may seemidentical. But among the pathological factors, Ayurveda gives little relevance toorganisms in many situations. More over the krimis as causative factors of diseasehave not been given as much importance as in Vedas in Ayurvedic literature.It appears that the Acharyas of Ayurveda, keeping the knowledge of krimis ormicroorganisms and their effects on the body may have identified much morerelevant factors inside the body. They described diseases in terms of Doshas andDooshyas. In diseases which may appear as virulent infections in modern view,Ayurvedic treatments aim at correction of the doshas and dooshyas. i.e. Ayurvedagives much importance to the platform or field which become as morbid for thegrowth of microorganisms. Acharyas may have made many further experimentsbased on Vedic knowledge and finally came in to conclusion that unless thedoshas are imbalanced no disease occurs even though the individual is exposed topathologic microorganisms. Hence they had described more elaborately about thedoshas and only secondary importance was given to the association of krimis.Dalhana,the commentator on Susrutha samhitha had analysed this concept in verynice manner:According to basic concepts of Ayurveda, Thridoshas are the aetiological factorsresponsible for all nija disorders. When a burn is caused due to the heat situated inghee (i.e. hot ghee) It is routinely said that the burn is caused due to the gheeinstead of the fact that the heat itself is responsible for the burn. In the same waythe krimis are also produced due to the vitiation of doshas. However the diseaseprodused due to the vitiated doshas (through krimis) are termed as krimijadisorders.However some disorders have been recognized by Acharyas as associated withkrimis or caused by krimis. There are vast numbers of references pertaining tokrimis, microorganisms. Communicability of diseases etc;in Ayurveda. Thoughthere are many descriptions about external organisms similar to modern www.ayurvedicmedicinalplants.com
    • descriptions, I am not compiling all these descriptions. Portions which are helpfulfor the expansion of the subject under discussion are collected purposefully.As we have seen earlier, Krimi represents a wide variety of parasites living inhuman body. Generally, Krimis are four in type. Bahya krimi, Rakthaja krimi,Sleshmaja krimi and Pureeshaja krimi .Under each type, various forms are alsoseen.4.2.5. Twak Vikara and KrimiAmong the four types of krimis, clinical features pertaining to twak are seenmainly due to rakthaja krimi and bahya krimi. (22)Rakthaja KrimiCausative factors - Similar to causative factors of KushtaLocation - Blood circulatory pathwaysStructure - Minute, rounded, with numerous limbsColour - CopperyForms - Kesada, Lomada, Lomadweepa, Sourasa, Oudumbara, JanthumatharaEffects - (Superficially)-destruction of hairs and nails of various parts (In wounds) -horipilation, Itching, pain, Spreading (In Chronic) -destruction of skin, blood vessels, tendons, muscles and cartilages,Bahya krimiCausative factors: Absence of cleanlinessLocation: Hairs and cloths.Structure: minute, rounded with numerous limbsColour: Black or whiteForms: Yooka, PipeelikaEffects: Itching, formation of skin rashes www.ayurvedicmedicinalplants.com
    • In the view of Susrutha samhitha, Ashtanga sangraha, Bhela samhitha, Sargadharasamhitha and Madhava nidana also we can observe the role of krimi in producingthe skin diseases.According to Susrutha, in every forms of Kushta, there is the role of Krimi. (23)4.2.6. Treatment Principle In the context of treatment against the parasitic organisms (Krimis) in ourbody, Ayurveda put forward a distinctive treatment principle (24). Other than forinfectious conditions, we can utilize this principle for various other contexts alsoas it is an ideal principle, dealing with the alleviation from all the different aspectsof causation, pathogenesis and complications of a disease.In the process of healing, we should consider the following aspects-1. Vitiated factors/ potent microorganisms2. Changes happened due to pathogenesis3. Circumstances that again can introduce some vitiating effectsSo, in the process of healing, intervention is essential in all these three levels.Depending upon the nature and stage of the disease, certain particular aspect mayrequire more concentration. As these are very important factors in Samprapthi(etiopathogenesis), thorough ‘samprapthi vighatana’(Repairing the pathologicalchanges)can happen only through consideration of all these aspects. So, thetreatment principle consists of -1. Apakarshana- (deduction of vitiated factors/microorganisms)2. Prakrithi Vighatha- (normalization of the internal atmosphere)3. Nidana Varjjanam- (avoiding the external causative factors)Apakarshana: This is the deduction theory, which can be broadly classified in to two. i.e.Bahyapakarshana (removal from external surface) and Antharapakarshana(removal from internal atmosphere)If the organism is occupied on external surface, we can remove them by usingsome instrument or some antimicrobial medicines. If they are occupied internally, www.ayurvedicmedicinalplants.com
    • we should use appropriate purification therapy such as sirovirechana, vamana,virechana or vasthi. In the case of aggravated internal morbidity also, we can usethis principle of internal deduction.Prakrithi Vighatha: This is the principle of normalization of the internal atmosphere. Morbidityof the internal atmosphere makes the circumstances suitable for the pathogenesis.In the case of infective diseases, invasion and proliferation of microorganismrequire an adaptable field in the body. This is known by the technical term,‘Prakrithi’ in Ayurveda, here in this particular context. In order to alleviate fromthis morbid condition, microbial adaptations should be destroyed from the body.The organisms will not be able to proliferate in healthy atmosphere. For thispurpose, we use various drugs and combinations.Nidanavarjanam: Until we move away from the situations that again can introduce thechances of disease, complete healing cannot be acquired. For e.g. Itching on footcaused by walking in putrid water can only be cured by ceasing the habit ofwalking in putrid water. Improper food habits and life style are said to be the maincauses of many disorders in Ayurveda. Though the disease may get reduced bymedicines, if the patient indulges with the causative factors that may again subjecthim to the disease process. In the case of infective diseases, situations whichfavour microbial growth should be avoided. In short, avoidance from the causativefactors is very essential4.2.7. Kshethravada and Beejavada Though many infectious diseases are described in detail in Ayurvedic texts,the descriptions of causative organisms and communicability are not given dueimportance as in modern medicine. In clinical features and all, they may seemidentical. But among the pathological factors, Ayurveda gives little relevance toorganisms in many situations. More over the krimis as causative factors of diseasehave not been given as much importance as in Vedas in Ayurvedic literature. www.ayurvedicmedicinalplants.com
    • It appears that the Acharyas of Ayurveda, keeping the knowledge of krimis ormicroorganisms and their effects on the body may have identified much morerelevant factors inside the body. They had a strong belief in the theory ofKshethravada over and above the beejavada-(25). The opinion that if the body isfully conditioned, no amount of Aganthuja bhootha or microorganisms can harmthe host. In Manusmrithi, there is a saying that “Akshethre beejamuthsrishtamanthreva vinasyathi”, means that the seeds put in an unsuitable land will spoilthere itself.They described diseases in terms of Doshas and Dooshyas. In diseases which mayappear as virulent infections in modern view, Ayurvedic treatments aim atcorrection of the doshas and dooshyas. Ayurveda gives much importance to theplatform or field which become as morbid for the growth of microorganisms.Acharyas may have made many further experiments based on Vedic knowledgeand finally came in to conclusion that unless the doshas are imbalanced no diseaseoccurs even though the individual is exposed to pathologic microorganisms.Hence they had described more elaborately about the doshas and only secondaryimportance was given to the association of krimis. Accordingly a number ofmeasures are formulated like rasayana, sodhana etc to keep up the body in a fullygeared up conditioned state, so as to face the invading microbes. Once the body isconditioned, the immune system plays an active and vigilant role in defensemechanism.4.2.8. Diseases due to Krimis or Doshas? In many conditions, we attribute the causative factors as krimis, though thealteration had happened in doshas. Dalhana, the commentator on Susruthasamhitha had analysed this concept in very nice manner:According to basic concepts of Ayurveda, Thridoshas are the aetiological factorsresponsible for all nija disorders. When a burn is caused due to the heat situated inghee (i.e. hot ghee) It is routinely said that the burn is caused due to the gheeinstead of the fact that the heat itself is responsible for the burn. In the same way www.ayurvedicmedicinalplants.com
    • the krimis are also produced due to the vitiation of doshas. However the diseaseproduced due to the vitiated doshas (through krimis) are termed as krimijadisorders. However some disorders have been recognized by Acharyas asassociated with krimis or caused by krimis. There are vast numbers of referencespertaining to microorganisms, communicability of diseases etc; in Ayurveda.Though there are many descriptions about external organisms similar to moderndescriptions, this work is not intended to compile all these descriptions. Portionswhich are helpful for the expansion of the subject under discussion are collectedpurposefully.4.3 Theory of infection-A critical analysis The theory of infection is so celebrated in modern medicine that after theevolution of this theory, tremendous advance has taken place in the field ofmedical science. The theory of causation has achieved new horizons following thistheory. The concept which reveal that the factor of causation is an organism andthe treatment should aim at destroying the organism, gained the appreciation ofmedical world. Research workers in the field of microbiology identified manyminute organisms, which can initiate disease processes in side the body. Theyhave taken them for culturing in different Medias to study their individual natureand the field of microbiology also developed very fast. Seeking assistance frommany allied branches of science, modern medicine has gathered variousarmaments for the battle against the organisms. Actually, this was a big leap in thefield of medical science which made the Allopathic science far ahead from othermedical branches.Though this theory had achieved wide acceptance in the 19th and 20th centuries,later it is proved that this theory has so many limitations. It is well known that notevery one exposed to a particular organism will develop the same disease in sameintensity. Some times disease may not happen. There are other factors relating tothe host and environment which are equally important to determine whether ornot. www.ayurvedicmedicinalplants.com
    • Then, the theory of multi factorial causation or ‘web of causation’ came forserious discussion. This was a reasonable solution for many questions aroused byprevious theory. According to this theory, there are so many factors participatingin the causation of a single disease. When all these circumstances become suitablefor the causation, the disease starts. This theory admits the importance of hostimmunity, virulence of the microorganism, the environment, vectors etc, in theprocess of causation. By analyzing various diseases, it is observed that infectiousdiseases are produced due to the reduced defense power of the patient, and orincreased virulence of the organism.The invation and pathogenesis of microorganisms in to the body require so manyinterconnecting linkages or factors. An occasion in which all the factors in the webare suitable for the invasion and proliferation of microorganisms, the process ofdisease may get its anchor. In the progress of disease, pathogens may furthervitiate the living atmosphere.4.3.1 The Web of Causation-an Ayurvedic Perspective In the aspect of infectious diseases as we know, the concept - ‘web ofcausation’ is very relevant. The web of causation considers all the predisposingfactors of any type and their complex interrelationship with each other. Causationof a particular disease is the net effect of so many complex intra and extrareactions between the factors in the web. Similar theory had been postulated byour ancient seers of Ayurveda, years back in the Ayurvedic classics. According tothis perspective, these factors can broadly be classified as below; • Hethuvisesha • Dosha visesha • Dooshyavisesha www.ayurvedicmedicinalplants.com
    • “Sarva bhavanam bhavabhavou nantharena yogathiyogadeenvyavasyeth.Sarvesham punarvikaranamnidana dosha dooshya viseshebhyobhavabhava visesha bhavanthi.yada hyethe thrayo nidanadi viseshanannyonyamanubadhnandhyabala va na tada abhinirvarthanthe vyadhayaschirathva abhinirvarthanthe thanavo va bhavanthyasampoorna linga va.viparyaye thuvipareetha”. (26)There are three basic aetiological factors for the manifestation of any diseaseincluding infectious disease according to Ayurveda. In the context of infectiousdisease, Hethuvisesha include pathogenic organisms and associated externalfactors like diet, environmental factors etc.Doshavisesha includes the state of vatha, pitha and sleshma. These are basically,some qualities, the equilibrium of which is very essential for the normalfunctioning of the body. In this equilibrium, human body is a biomass of varioustypes of micro organisms. Imbalanced state of these factors causes theproliferation of some micro organisms in an uncontrolled manner while somegroups will come across an essential termination. Presence of certain microorganisms and their excreta can denature the dosha in certain places.Dooshya visesha includes saptha dhathus, upadhathus and malas.As an essence ofthese factors; we have to consider the concept of vyadhikshamathwa. Equilibriumin these factors also is very essential for a healthy life. Imbalance will make thebody susceptible to many organisms. If we analyze various infectious conditions,the pattern of affliction and affinity of the organism to different body parts mayexhibit various forms. These are due to the differences in degree of involvement ofdifferent srothases, dhathus, upadhathus, and malas.The first group of factors is regarded as Bahya karanas (external factors).Thesecond and third group of factors put together are regarded as Abhyantharakaranas (internal factors) of diseases. Depending on the degree of association andstrength of participation, a broad spectrum of clinical manifestations may present. www.ayurvedicmedicinalplants.com
    • 4.3.2. Spectrum of Infectious Diseases As we know, by the climatic variations, presence of certain creaturesbecome noticeable during certain seasons, changes in internal as well as inexternal atmosphere determines the life of the micro organisms in body. Normally,there is a unique equilibrium among the factors which control the residence ofmicroorganisms. The morbidity in doshas, dooshyas, malas and ojus may disturbthis equilibrium making the level of microorganisms altered. Alteredconcentration of microorganism undergoes many functional variations, secretingvarious toxic as well as non toxic byproducts in to the body, creating a spectrum ofinfectious conditions. Depending upon the nature of organism and itspathogenicity, the symptoms may have different grades. Superficial mycosis is onesuch.4.4 Ayurvedic perspective of superficial mycoses To frame an Ayurvedic perspective for the condition of superficialmycoses, it is essential to have an outlook about the disease through variouswindows based on Ayurvedic principles. As a first step in this aspect, we may gothrough various contexts in Ayurvedic classics, which have resemblances with theaetiopathogenesis and clinical features of the present disease.Normally, the clinical diagnosis of Tinea depends mainly on the History,inflammatory changes involved, itching sensation, discolourations and natureof aggravations. An attempt to find out some conditions described in Ayurveda,which simulate the above features will point towards the following conditions-Ahipoothana(27) Itching sensation due to excessive sweating or due to non cleanliness. Itching causes vesicles and discharge. Main doshas involved in this condition are, Kapha and Raktha.Alasam (28) Contact with putrid water on foot causes itchy intertriginous area with pain, burning sensation and maceration www.ayurvedicmedicinalplants.com
    • Vrishana kacchu (29) Itching sensation around the scrotum, due to the accumulation of dirt is known as Vrishana kacchu. Formation of sweat will aggravate the symptom. Itching causes the formation of vesicles, oozing and discolouration. The prominent doshas involved are, Kapha and Raktha This condition happens due to the absence of proper hygienic practices.Kacchu (30) severely itching minute vesicles on hand and gluteal region are known as Kacchu.Padminikandaka(31) Itchy circular whitish lesions with sharp papules are known as padmineekandakam. This is a kapha vathaja conditionDadru(32) Easy spreading itchy lesions with slightly elevated circular osy discolouration. Relapse and remissions are typical characters of this chronic lesion.Krimija vikaram (33) Itchy lesions on the skin with circumscribed circular patches. The condition is caused by the invasion of microorganisms (Bahyakrimi) due to the unhygienic practices of person. Among all these conditions, only a single condition cannot be correlatedwith all the types of superficial mycoses. For e.g. the condition of T.cruris hasmore resemblances with Vrishana kacchu while Alasam resembles more withT.pedis. The condition of T.corporis has more resemblance with Bahya krimijatwagvikara. Dadru may be correlated with T.versicolar. Among the Krimis, rakthjakrimis such as Kesada & Lomada can be correlated with T.capitis or T.barbae. An analysis through the treatment aspect of these conditions will showsome strong external medications which have antifungal property (34). Accordingto Ayurveda, treatment is the process of alleviation of the pathological changes. Sofrom this treatment principle, we can assess that our ancient acharyas were having www.ayurvedicmedicinalplants.com
    • the knowledge of the role of microorganisms in these causations. Theirobservation about the chronicity, sweating as an aggrevating factor, andunhygienic habits as etiological factors were also found very significant. In theseconditions, the ‘three fold treatment principle for Krimis’ were found veryeffective also.4.4.1. Assessment of the diseaseAccording to Ayurvedic principles, we have to assess any disease in terms of fivemajor criteriae- Nidana panchaka (35)1. Nidanam (Etiology)2. Poorvaroopam (Prodromal symptoms)3. Roopam (Signs &Symptoms)4. Samprapthi (pathology)5. Upasayam (Test response)We can make a general assessment of the disease through some relevant Ayrvedicprinciples.Nidana For the causation of a specific fungal infection over superficial skin,invasion and proliferation of the organism in to the epidermis is necessary. Thishappens as a result of an adaptable atmosphere created over the skin. Adaptableatmosphere for a saprophyte is a fetid field, created by external or internal causesof dirt accumulation (malasanchaya). This will not happen only by a single day.As a result of a long way of exposure to various etiological factors (Viprakrishtanidana) (36), the skin appendages become vulnerable to fungal growth.Twak Swabhava: (Nature of the skin)Sweada Swabhava: (Nature of the sweat)Mrijavarjjanam: (Unhygeinic practices)Malasanchaya kara Aharas: (Unwholesome foods that can precipitate redundantby-products)Ojakshayakaravikara: (Immunodepresent diseases) etc. can be www.ayurvedicmedicinalplants.com
    • considered as Viprakrishtanidanas in the causation of Superficial mycoses.Viprakrishtanidana (causes of longer duration)1. Twak Swabhava (Nature of the skin) According to ayurvedic principles, different Dehaprakrithis willhave different features in their skin (37). Vata prakrithi persons who have rooksha(dry) and sphutitha (cracked) skin, and in pitha prakrithi persons who have thanu(thin) and athimridu (very soft) skin, chances of microbial invasion are more as itrepresent less immune and microbe adaptable features. In between the numerousfurrows of the skin, chances of dirt accumulation are more and as the skin becomesoft, chances of entry point also more. In kapha prakrithi persons, hairs aredistributed abundantly and so chances of dirt accumulation is more. So, bydehaprakrithi itself, our skin has the chances of microbial growth. It is true in allthe cases of commensal growth also. But when the association happens with othercausative factors, the platform turns morbid.2. Sweada Swabhava (Nature of the sweat) According to Ayurvedic principles, sweada is a byproduct of metabolism ofmedodhathu (38).Though this is a mala bhava (excretory material), it is essentialin making the skin smooth. The Kleda or moist in the body is maintained byproper formation of sweada. Abnormality in sweada formation may create manyproblems including dermatological complaints (39).Depending upon the dehaprakrithi, sweat formation may vary. Pithaprakrithi isdescribed as ‘Sweadana’-having excessive sweating (40).In some pathologicalconditions also, excessive and foul smelling sweat is an important condition (41).3. Mrijavarjjanam (Unhygeinic practices) This is the technical term used in Ayurveda to represent unhygienicpractices (42).Habit of improper cleaning of the body parts precipitate dirt in thefolding of skin, making a suitable atmosphere for fungal growth. www.ayurvedicmedicinalplants.com
    • 4. Ojakshayakaravikara (Immunodepresent diseases) When the resistive power of the body is sufficiently strong, it can destroythe effects of causative factors. Ojus is considered as the factor of immunity in thebody. Diseases in which the principle of ojus gets depleted, body cannot resist theattack of microbes. This may result in various infectious diseases (43).Pointswhich are to be discussed in detail follows-Malasanchaya In our body, accumulation of waste materials (malasanchaya) may happenmainly in two forms, i.e, 1. Internal (Abhyanthara malasanchaya) and 2. External (Baahya malasanchaya).Abhyanthara malasanchaya We take a variety of items in our daily food habit. Some may undergoproper digestion and metabolism while some may subject to improper digestionand metabolism. This abnormality may happen due to various reasons. One andmost important among them is Agnimandya, in jadara level, bhootha level or indhathu level. To be exact; lack of any specific enzyme for the digestion of anyspecific item may create improper formation of that material. These improperlyabsorbed materials may precipitate inside the body or that may excrete outimproperly.To elaborate this concept, we may take the pathogenesis of Bromhidrosis. Lack ofcertain liver enymes for the metabolism of fat creates malformed sweat and thatwill be excreted out. Though this eccrine secretion is odourless, various substancesmay get excreted along with it. Skin surface containing this sweat may become afield of bacterial degeneration. This will emanate an excessive or offensive odourfrom the skin. Like this, various types of waste materials may create morbidconditions inside the body.Basically, this is due to the indigestion or altered metabolism in different levels.According to certain schools of ayurveda, internal accumulation of indigested or www.ayurvedicmedicinalplants.com
    • mal metabolized materials are termed ‘Aama’. This contributes for theintroduction of many abnormalities in side the body.Baahya malasanchaya Though there are various methods to keep our body clean externally, somepersons may not give much care for the hygienic practices. In many conditions,skin appendages may get afflicted by external mala. i.e. accumulation of decayedmaterials from outside the body. Nature of skin, which is suitable for theaccumulation of dirt, also makes the condition worse (more folded and illdefensive skin).This kind of an atmosphere pave for the microbial growth,especially for the saprophytic organisms. ‘Kleda’ is another principle concernedwith this discussion.Kleda: Kleda is one of the forms of moisture, produced in side the body as a resultof the normal metabolism. This provides normal moisture necessary for all thephysiological activities in side the body. According to Ayurveda, sweda andmoothra are the two forms of excretory materials, which help in maintenance ofkleda (44)Improper formation of Sweda (sweat) and Moothra (urine) is due to malformedkleda. Kleda can be considered as the form of moisture which contributes for theintercellular fluid. This has a fixed constitution in the normal body. Alteration Inthis constitution is due to the alteration in the permeability of the cells and due toaltered metabolism. This malformation of kleda is due to the abnormality in tissuemetabolism, which in turn will result in malformation of sweat and urine also.Altered kleda result in various pathogenesis in various systems. Depending on thenature of srothas, the clinical features may vary.In the case of many skin diseases, the clinical condition of hyperhydrosis andbromhidrosis may associate .Like this, moisture containing excreta may precipitateupon the skin in many conditions. The chance of moisture accumulation is more atthe folded parts in the body. This may create an atmosphere on the skin surface,for some organisms to harbour and to proliferate. In another aspect, all these www.ayurvedicmedicinalplants.com
    • factors will derange the homeostasis of Twak which is a structural form of Rasadhathu. Thus it becomes a Viguna srothas at which the microbial invasion is easy.Sannikrishta nidana (Recent causes) The immediate causative factor of the disease is called Sannikrishta hethu.Such hethus are mainly responsible for immediate aggravation of the disease.Generally, Sannikrishta hethus will act as triggering factors of already vitiatedinternal atmosphere, creating the specific symptoms of the disease. Exposure tofungus can be considered as the sannikrishta nidana, in the causation of superficialmycoses. Wearing of dirty or infected dress, Usage of contaminated closet, Closecontact with infected person, etc will precipitate the fungusPoorvaroopa Excessive sweating can be considered as a prodromal symptom of thedisease in many cases. This also triggers the accumulation of more and more dirton the skin, increasing the chances of infection.Roopa We have gone through various clinical features present in these conditions.Itching sensation (kandu), discolourations (vaivarnya), papules (pidaka), scaling(salka), erosions (vrana), discharge (srava) etc are the main morphological featuresof the condition.Samprapthi Knowledge of Samprapthi forms the essence of nidanapanchaka andvikrithivijnana. According to Vagbhata’s definition, knowledge of Samprapthishould give the idea about nature and manner of vitiation of doshas, associatedfactors, their spread and nature of lodgment.By all the causes of longer duration that already explained, the quality of skin getsdepleted. This may happen from inside or from outside. Deficient transformationpower in dhathu level (Dhathwagnimandya) may precipitate redundant materialsinside the internal atmosphere which may hamper the functions of Bhrajaka pitha.In healthy persons, Bhrajaka pitha is the main principle to maintain the functions www.ayurvedicmedicinalplants.com
    • of the skin. Improper actions of Bhrajakapitha may alter the structural firmness ofskin. As we know, skin is one of the structural forms of rasadhathu. So, this can beconsidered as a part of Rasavaha srothas. Causes of longer duration may destructthe structural firmness of skin in different degrees, creating the ‘Srothovaigunya’.Excess intake of food items which can vitiate the Kapha Paithika doshas form themain cause of the disease. Dhathwagni mandya may precipitate malaroopa kaphain excretory materials like sweat. Thus vitiated doshas and malabhavas may findlodgment upon the skin in due course, making the skin, deficient in resistance.Thus forms a nest over the skin for the fungus to reside.Invasion of microorganism may be due to the etiological reasons described first.Then the toxic materials secreted by these fungi derange the properties of doshaslocated on skin. Previously we have seen how the dosha factors are involved inmaintaining the structural entity of the skin. Derangements in the property ofdoshas disturb the structural equilibrium, initiating some manifestations. Behindeach symptom produced, there will be an altered dosha as precipitating factor.Analysis through the general symptoms of superficial fungal infection with thealtered functions of doshas will direct towards the following assumptions-1. Circumscribed itchy lesions with chronicity indicate the role of kaphadosha2. Erythematous itchy lesions with discharge and having the nature ofaggravation on sweating indicate the role of Pitha DoshaDepending on the stage of the disease, these symptoms may have different degreesof presentation. Predominance of dosha involvement should be assessed based onthis. But, in all the conditions described in Ayurveda, which simulate superficialmycoses, it is essential to consider the pathogenesis in terms of Bahyakrimi.Clinical experiences prove that in many of these conditions, the role of abahyakrimi is very significant www.ayurvedicmedicinalplants.com
    • Upasaya Upasaya is the assessment method by administering a test dose of medicine(or food or habit). Assessment about various factors involved in the process ofpathogenesis should be confirmed by Upasaya (45).In this sense, research studiesto formulate a clear picture about the disease form Upasayathmaka pareeksha.Whether the disease is involved only over the skin or whether it has any relationwith defects in internal atmosphere of the body? -is one of the major problems inrelation to superficial fungal infections. For the selection of appropriate treatmentmethods, the knowledge of the level of pathology is very essential. For theconfirmation of all the theoretical observations, Upasayathmaka pareekshabecomes an essential tool. To frame a hypothesis regarding the disease, testingwith medicines, food items and certain habits is necessary. Here, the intention ofstudent investigator is to search the level of pathogenesis or the factors involved inthe pathogenesis of superficial mycoses with an Upasayathmaka pareeksha. This isdescribed in the part of clinical study. www.ayurvedicmedicinalplants.com
    • Reference:1. A.V. IX 8.10 2. Niruktha 6/123 Niruktha 4/18,34 4 Niruktha 5/11,365 Niruktha 4/11,15 6 Niruktha 3/18,227 Niruktha 5/13,14 8. A.V.II.31,V.23VIII.679. A.V V-29 10. A.V.II.31.411. A.V.VIII.76.4 12. A.V.VII.58.2,313. A.V.II31.3 14. A.V29-1015. A.V.II.25.3 16. A.V.II.31.417. A.V II-32,1-4 R.V.X.162 18. Ref. Ka.sam.khi 13 Ch;Ch.Vi 3;Bh.soo.1319. Su.Ni.5ch 20. A.San.su.1421. Asht.san.uthara; Su. Vrana.chi; Ka. sam. Revatheekalpa22. Ch.Vi 7-10,11 23 Su.Ni.5-624. Ch.Vi.7-14 25. A.san.Ni.226. Ch.S.Ch 22 27. Su.Ni.1328 Su.Ni.13 29 Su.Ni.1330 Ma.Ni.7 31 Su.ni.1332. A.H.ni14-24 33. Ch.Vi.7-1034. Su.chi.20-18 35. A.H.Ni.11/236. M.N.1/5 37. Ch.Vi.8-86; Su.sa.4-72; A.sa.3-9638. A.S.Sa. 6-23 39. Ch.S.Vi 5-840. Su.Sa. 4-68 41. A.H.Ni.10-3842. Ch.Vi.7.10 43. Ch.Ni.8-344. A.H.Su.11-5 45. Ma.M.K-1 www.ayurvedicmedicinalplants.com
    • PART 5 (1) Clinical study Methodology Research is an attempt to gain solutions to the problems. It may be definedas properly planned, well disciplined study, by employing scientific methods andtools aiming at the growth of existing status of knowledge in the subject.Moreover, in the field of medicine, research has inherent dynamism as it involvesperpetual interaction with the living beings. Even though the pioneers of Ayurvedahave documented their observations as objectively as possible the penultimate aimof research in Ayurveda in today’s prospective is correct interpretation of itsprinciples. The need of the hour is proper mobilization of the concepts intofaultless practice to the absolute satisfaction of everyone, including the modern ness.Our great Acaryas also highlighted on this aspect of research i.e. method andimportance of practical application of the concepts. A theory becomes fixed onlywhen its hypothesis is tested, verified, retested and proved without any doubts bythe experts of that field (1).A hypothesis will never turn in to a theory/principlealways. It may be either approved or rejected depending on the results one gets. Itmust with stand the test of time to become a principle/theory. To test a hypothesis,many steps have to be followed. Similarly, if the theme of this work has to beproved then it has to overcome many steps.Here, this work is a humble effort to study the theory of infection in Ayurvedicperspective. For that we are taking the example of superficial fungal infection onskin. This is an observational study.Aims and objectives:1. To study the disease, ‘superficial mycoses’ textually & clinically.2. To assess the aetiopathological factors involved in the process of causation.3. To study the condition, having the same signs &symptoms, described in Ayurveda. www.ayurvedicmedicinalplants.com
    • 4. To assess the role of external as well as internal factors in the process ofcausation by upasayathmaka pareeksha and thus to frame an etiopathogenesis inAyurvedic aspect.Materials and Methods:Selection of Patients:For the present study the patients fulfilling the clinical criteria for diagnosis ofsuperficial mycosis were randomly selected irrespective of their sex, religion,occupation, etc. from O.P.D. & I.P.D. sections of Roganidana department, Govt.Ayurveda College, Kannur.Criteria for Diagnosis: Classical signs & symptoms of ‘superficial mycoses, according to textualbasis.A special Performa was prepared considering all the common causes of superficialmycoses and its clinical features. For the clinical assessment in Ayurvedicperspective, our examination methods also included. On the basis of this Performa,the entire patient’s of the present study were examined in detailScrapings from the skin lesions were collected and tested for fungus with 10%preparation of KOHGrouping and sampling: After diagnosis, the patients were randomly categorized into the following3 groups. 1st patient was included in Group-A, 2nd patient in Group B and 3rdpatient in Group C.Like this, every 4th, 7th, 10th…..patients were included in Group-A. Every 5th, 8th,11th…patients were included in Group-B. Every 6th, 9th, 12th…patients wereincluded in Group-C. Group-A: Subjecting to External application of medicine Group-B: Subjecting to Internal administration of medicine Group-C: Subjecting to both External as well as internal applications www.ayurvedicmedicinalplants.com
    • Drugs: Medicine for external application: Dadruvidravanamalahara (2) This ointment was given for local application for twice a day for one-month Medicine for internal administration: Patolakaturohinyadikashayam This kashayam was given 15 ml with 45 ml warm water twice daily beforefood for one month.Administration of drugs:Group-A In this group 30 patients were selected out of these 4 patientsdiscontinued & 26 patients had completed their course with applying‘Dadruvidravanamalahara’ externally for 1 month.Group-B In this group 30 patients were selected out of these 6 patientsdiscontinued & 24 patients had completed their course of in take of‘Patolakaturohinyadi kashayam’ for 1 month.Group-C In this group 30 patients were selected out of these 5 patientsdiscontinued & 25 patients had completed their course with internal as well asexternal administration of medicines.Pathyahara: Patients were advised to follow the pathyapathya available in Ayurvedicliterature on Kustha.Duration: The drug (Both internal &External) was administered continuously for onemonth in all groups.Criteria for Assessment (scoring criteria): All the patients were examined weekly during the treatment. Criteria ofassessment were done on the basis of relief in the signs and symptoms offungal infection. For this purpose, cardinal signs and symptoms were givenscores according to their severity and they were counted before and after thetreatment. Scoring method and pattern is mentioned below. www.ayurvedicmedicinalplants.com
    • 1. Itching (kandu) 0 - No itching 1 - Mild itching not disturbing normal activity 2 - Occasional itching disturbs normal activity 3 - Itching present continuously & even disturbing sleep2. Colour change (vaivarnya) 0 - No colour change 1 - Mild hyper pigmentation 2 - Moderate colour change 3 - Rigorous colour change3. Scaling (salka) 0 - No scaling 1 - Mild scaling on rubbing 2 - Moderate scaling 3 - Severe scaling always on itching4. Papules (pidaka) 0 - No papules 1 - Mild papules 2 - Moderate papules 3 - More papules5. Erosions (vrana) 0 - No erosions in the lesion 1 - Scanty eruptions in few lesions 2 - Scanty eruptions in at least half of the lesion 3 - All the lesions full of erosions6. Discharge (srava) 0 - No discharges in the lesion 1 - Scanty discharges in few lesions, occasionally 2 - Scanty discharges always 3 - Foul smelling thick discharge www.ayurvedicmedicinalplants.com
    • Criteria for the assessment of overall effect of the therapies:The total effect of the therapy was assessed considering to the over allimprovement in signs and symptoms. For this purpose, following categories weremaintained.Mild – Patients showing the symptoms, which have a total score between 1 and 6. (1-6)Moderate – Patients showing the symptoms, which have a total score between 7and 12 (7-12)Severe - Patients showing the symptoms, which have a total score between 13 and18 (13-18)Follow up study:All the patients under study were advised to follow-up through O.P, once in3weeks, after 1month (after stopping the medicines), for 3months.In each sitting,the changes in the skin were noted.Reference: 1. Cha.Vi. 8/37 2. Rasatharangini, Ashtamatharanga, 59 3. A.H.Su.15/15 www.ayurvedicmedicinalplants.com
    • PART- 5. (2) Observations & AnalysisOBSERVATIONS:Total 90 patients were registered, out of which 15 left against medical advice(LAMA). Hence their data are not included here. The data of remaining 75 arepresented in detail.Table No. 1: Sex wise distribution Group Percentage Sex Total A B C %M 17 10 13 40 53.3F 9 15 12 35 46.6Above table furnishes that maximum number of patients (53%) were male and 6%were female 18 16 14 12 10 Male number 8 Female 6 4 2 0 GroupA GroupB GroupCTable No. 2 : Age wise distribution. Group Percentage Age Total A B C %Youvana (16-25) 14 11 12 37 49.33Madhyama (25-45) 5 9 5 19 25.33Vridha (50-70) 6 5 8 19 25.33 www.ayurvedicmedicinalplants.com
    • The table shows that most of patients (49.33%) were of Youvana vaya. Remainingpatients (25.33%) were of Madhyama vaya and Vrddha Vaya. 14 12 10 8 Youvana 6 Madhyama 4 Vridha 2 0 GroupA GRUPB GroupCTable No. 3 : Marital Status wise distribution. Group Percentage Status Total A B C %Married 9 8 9 26 34.6Unmarried 16 17 16 49 65.3Above table shows that maximum numbers of individuals (65%) were unmarried.Remaining 34% were unmarried 20 15 number 10 Married Unmarried 5 0 GroupA GroupB GroupC www.ayurvedicmedicinalplants.com
    • Table No. 4: Religion wise distribution Group PercentageReligion Total A B C %Hindu 11 9 9 29 38.66Muslim 9 9 6 24 32Cristian 5 7 10 22 29.33The data pertaining to religion wise distribution reveals that majority of patients(38.66%) were Hindus. 32% were Muslims and 29.33% were Christians 12 10 8 number 6 Hindu 4 Muslim 2 Cristian 0 A B C GroupTable No. 5: Education wise distribution Group Percentage Education Total A B C %Uneducated - - - - 0Educated 17 18 23 58 77.33High Educated 8 7 2 17 22.66Above table shows that maximum number of patients i.e. 77.33% were educatedfollowed by 22.66%of patients were highly educated. www.ayurvedicmedicinalplants.com
    • Eucation wise distribution 25 20 15 Educated number 10 High Educated 5 0 A- B CTable No. 6: Occupation wise distribution Group Percentage Occupation Total A B C %Business 3 1 4 8 10.66Housewife 2 7 6 15 20Service 2 2 4 8 10.66Labour work 8 10 9 27 36Retire 1 0 2 03 4Student 9 5 0 14 18.66Maximum numbers of patients i.e. 36% were laborers followed by 18.66%patients were students.10.66% patients were Business men or service men. Occupation wise distribution Bussiness House wife Service Labour work Retired StudentTable No. 7 : Socio economical status wise distribution www.ayurvedicmedicinalplants.com
    • Group Percentage Status Total A B C %Lower class 16 10 14 40 53.33Middle class 6 13 9 28 37.33Rich class 3 2 2 7 9.33 16 14 12 10 Lower class number 8 Middle class 6 Rich class 4 2 0 groupA groupB groupCMost of the patients (53.33%) belonged to lower class followed by middle class(37.33%) and rich class (9.33%).Table No. 8: Habitat wise distribution. Group Percentage Habitat Total A B C %Rural 23 21 14 58 77.33Urban 2 4 11 17 22.66In this series77.33% patients were from Rural population and 22.66% patientswere belonging to urban areas. www.ayurvedicmedicinalplants.com
    • Habitat wise distribution % person Urban % person Rural 0 20 40 60 80Table No8.b: Desatah wise distribution. Group Percentage Desatah Total A B C %Jangala 8 6 11 25 33.33Anupa - 2 - 2 2.66Sadharana 17 17 14 48 64The table shows that maximum (64%) no. of patients were having habitat ofSadharanadesa, while 33.33% patients were in Jangala desa.2.66% belong toAanupa desa. 20 15 Jangala number 10 Anupa Sadharana 5 0 GroupA GroupB GroupC www.ayurvedicmedicinalplants.com
    • Table No. 9: History of previous illness Group Percentage Illness Total A B C %Diabetes 2 1 1 4 5.33Asthma - - 1 1 1.33Other skin - 2 1 3 4diseasesGI disorders 1 3 4 8 10.66Among the patients, 10.66% were having gastrointestinal tract disorders, while 4%were having the complaints of other skin diseases, mainly allergicdermatitis.5.33% were diabetic patients and 1.33% were asthmatic. 4 3.5 3 2.5 Diabetis number 2 Asthma 1.5 Other skin diseases 1 GI disorders 0.5 0 GroupA GroupB GroupCTable No. 10 : First choice of medication Group Percentage Medication Total A B C %Allopathy 9 17 13 39 52Ayurveda 13 7 10 30 40Homeopathy 3 1 2 6 8Among the patients,52%depended Allopathic as their first choice of treatment.40% depended on Ayurveda and only 8% depended Homeopathy. www.ayurvedicmedicinalplants.com
    • 18 16 14 12 10 Allopathy number 8 Ayurveda 6 Homeo 4 2 0 GroupA GroupB GroupCTable No. 11 : Dietary habit wise distribution. Group Percentage Habit Total A B C %Vegetarian 4 6 9 19 25.33Mixed 21 19 16 56 74.6625.33%of this series were vegetarians and 74.66% of patients were taking mixeddiet C Group B Vegetarian A Mixed 0 10 20 30 number www.ayurvedicmedicinalplants.com
    • Table No. 12: Habit of excessive intake of some food item Group PercentageFood items Total A B C %Fish 1 12 14 40 53.33Curd 5 2 3 10 13.33Masala 1 16 12 43 57.33Hot and spicy 1 13 11 35 46.66Fried items 1 13 13 40 53.33Meat 5 6 2 13 17.33Leafy 9 12 8 29 38.66vegetablesAmong the patients,57.33% were having the habit of excessive intake ofMsala.53.33%were having the over hot and spicy items.38.66% were included excess leafyvegetablesin their food habit. habit of excessive intake of Fish and Fried items.46% wereused to take over hot and spicy items.38.66% were included excess leafyvegetables in their foodhabit. 16 14 Fish 12 Curd 10 Masala 8 Hot&sicy 6 Fried item 4 Meat 2 Leafy veg 0 GroupA GroupB GroupC www.ayurvedicmedicinalplants.com
    • Table No. 13 : Appetite wise distribution. Group Percentage Appetite Total A B C %Poor 2 3 1 6 8Moderate 6 11 13 30 40Good 17 11 11 39 52Most of the patients were having good appetite (52%), followed by 40% ofpatients having moderate and 8% of patients having poor appetite.Table No. 14 : Addiction wise distribution. Group Percentage Addiction Total A B C %Addiction 8 3 10 21 28Non addiction 1 21 15 54 72In this series,28%patients were having addiction of one other type. While 72% ofpatientswere not having any type of addiction.Table No. 15: Bowel condition wise distribution. Group Percentage Bowel Total A B C %Regular 12 17 4 33 44Irregular 8 4 12 24 32Hard 4 4 7 15 20Loose 1 0 2 3 4The table shows that 40% of patients used to pass hard stool. While 4% of patientsused to pass loose one, 32%of patients were having irregular bowel, whileremaining other (44%) were having regular bowel. www.ayurvedicmedicinalplants.com
    • Table No. 16 : Sleep pattern wise distribution. Group Percentage Sleep Total A B C %Sound 19 15 21 57 76Disturbed 6 8 4 18 24Maximum numbers of patients (76%) were having sound sleep while 24% patientswere having disturbed sleepTable No. 17: Nature of cloth using Group Percentage Cloth Total A B C %Cotton 11 10 8 29 38.66Polyester 9 13 11 33 44Silk 3 2 5 10 13.33Nylon 2 - 1 3 4Among the cases, 44% were having the habit of wearing polyester dresses moreoftenly.38.66% were having the habit of wearing cotton dresses.13.33% used silkdresses and 4% nylon dresses. 14 12 10 Cotton 8 number Polyester 6 Silk 4 Nylon 2 0 GroupA GroupB GroupCNo.18: Regarding the use of under weares: (comments in discussion)No.19: Regarding the habit of bathing:(comments in discussion) www.ayurvedicmedicinalplants.com
    • Table No. 20: Habit of using, soap, oil and powder Group Percentage Habit of using Total A B C %Soap 23 20 23 66 88Oil 4 5 8 17 22.66Powder 23 22 21 66 88on skin. Only 22.66% were used to apply some oils on skin at least once in aweek. Above table shows that 88% patients were having the habit of using Soapand powder, while they were reluctant towards the daily oil application 25 20 15 Numbe r Soap 10 Oil 5 Powder 0 1 2 3 GroupsTable No. 23: Deha Prakriti wise distribution. Group Percentage Prakriti Total A B C %Vata Pitta 12 10 17 39 52Pitta Kapha 5 2 1 8 10.66Kapha Vata 8 13 7 28 37.33Maximum numbers of patients (52%) were having Vatha pitta prakrithi.37.33%were Kaphavata Prakrti while 10.66% patients were having pitta kapha prakrti. www.ayurvedicmedicinalplants.com
    • 18 16 14 12 10 Vatha pitha number 8 Kapha pitha 6 Kapha vatha 4 2 0 GroupA GroupB GroupCTable No. 24 : Sara wise distribution Group Percentage Sara Total A B C %Pravara 0 0 0 0 0Madhyama 21 22 23 66 88Avara 4 3 2 9 12It could be observed from the above table that no patient was having Pravara Sara.Maximum numbers of patients i.e. 88% were having Madhyama Sara. Followedby 12% patients were having Avara Sara.Table No. 25 : Sanhanana wise distribution Group Percentage Sanhanana Total A B C %Pravara 0 1 0 1 1.33Madhyama 25 23 25 73 97.33Avara 0 1 0 1 1.33Above table shows that maximum numbersof patients (97.33%) were havingMadhyama Sanhanana.1.33% patients were of Pravara and Avara Sanhanana. www.ayurvedicmedicinalplants.com
    • Table No. 26: Sattva wise distribution. Group Percentage Sattva Total A B C %Pravara 0 1 0 1 1.33Madhyama 23 23 23 69 92Avara 2 1 2 5 6.66Above table reveals that maximum numbers of patients (92%) were havingMadhyama Sattva followed by 6.66% patients and 1.33% patients were havingAvara and Pravara Sattva respectively.Table No. 27 : Satmya wise distribution Group Percentage Satmya Total A B C %Sarva Rasa 25 25 25 75 100Eka Rasa 0 0 0 0 0Above table shows that all patients (100%) were taking Sarva Rasa.Table No. 28 : Abhyavarana Sakti wise distribution Abhyavarana Group Percentage Total Shakti A B C %Pravara 4 1 3 8 10.66Madhyama 12 15 18 45 60Avara 9 9 4 22 29.33Maximum numbers of patients were having Madhyama abhyavaharana Sakti(60%) followed by 29.33% patients were Madhyama and 10.66% patients werewith Pravara Abhyavarana Sakti. www.ayurvedicmedicinalplants.com
    • Table No. 29 : Jarana Sakti wise distribution . Group Percentage Jarana Sakti Total A B C %Pravara 7 6 9 22 29.33Madhyama 11 15 14 40 53.33Avara 7 4 2 13 17.33Maximum numbers of patients were having Madhyama Jarana Sakti (53.33%),while 29.33% patients and 17.33% patients were having Pravara and Avara JaranaSakti respectively.Table No. 30 : Vyayama Sakti wise distribution. Group Percentage Vyayama Sakti Total A B C %Pravara 8 11 12 31 41.33Madhyama 16 14 11 41 54.66Avara 1 0 2 3 4Above table shows that 54.66% patients were having Madhyama Vyayama Saktifollowed by 41.33% patients of Pravara and 4% patients of Avara Vyayama Sakti.Table No. 31 : Kostha wise distribution. Group Percentage Kostha Total A B C %Mrudu 5 4 3 12 16Madhyama 14 13 14 41 54.66Krura 6 8 8 22 29.33 www.ayurvedicmedicinalplants.com
    • Maximum numbers of patients (54.66%) were having Madhyama Kostha by29.33% of patients having Krura koshta and remaining 16% of Mrudu Kostha. 25 20 15 Mrudu number madyama 10 Krura 5 0 GroupA GroupB GroupC.Table No. 32: Condition of sweat Group Percentage Sweat Total A B C %Less 3 2 3 8 10.66Moderate 8 3 4 15 20Excessive 12 11 12 35 46.66Profuse 3 8 6 17 22.6646.66% patients complained excessive sweat, while 22.66% were having thecomplaint of profuse sweat.20% were with Moderate sweat while10.66%werehaving less sweat www.ayurvedicmedicinalplants.com
    • 12 10 8 Less number 6 Moderate Excessve 4 Profuce 2 0 GroupA GroupB GroupCTable No. 33: Nature of the skin. Group Percentage Nature Total A B C %Vata Pitta 12 10 17 39 52Pitta Kapha 5 2 1 8 10.66Kapha Vata 8 13 7 28 37.33Maximum numbers of patients (52%) were having the skin of Vatha pittaprakrithi.37.33% wereKaphavata Prakrti skin while 10.66% patients were having the skin of pitta kaphaprakrti. 18 16 14 12 10 Vatha pitha number 8 Kapha pitha 6 Kapha vatha 4 2 0 GroupA GroupC www.ayurvedicmedicinalplants.com
    • Table No. 34 : Chief complaints reported by 75 patients of superficial mycoses Group Percentage Complaints Total A B C %Itching 24 22 23 69 92Colour change 26 24 23 73 97.33Scaling 11 10 11 32 42.66Papules 10 18 8 36 48Erosions 7 9 7 23 30.66Discharge 14 6 14 34 45.33Above table shows that most of the patients (69.33%) were having the symptom ofItching as their main complaint.68% complained of colour change.48% patientspresented with popular lesions, while 45.33% complained of discharge from thelesion.30.66% were having the complaint of erosions occasionally 30 25 Itching 20 Colour change number 15 Scalng Papules 10 Erosions 5 Discharge 0 GroupA GroupB GroupC www.ayurvedicmedicinalplants.com
    • Table No.35: distribution of the types of superficial mycoses were like this- Group Percentage Type Total A B C %T.corporis 12 10 9 31 41.33T.cruris 13 12 13 38 50.66T.versicolar 1 0 2 3 4T.pedis 2 1 1 4 5.33T.barbae 0 1 0 1 1.33 14 12 10 T.corporis 8 T.cruris number 6 T.versicolar 4 T.pedis 2 T.barbae 0 GroupA GroupB GroupCThe above table shows that 50.66% patients were having T.cruris among the studysample.41.33%were with T.corporis .5.33% consisted T.pedis and 1.33%withT.barbae.Table No. 36: Onset wise distribution Group Percentage Onset Total A B C %Sudden 1 1 3 5 6.66Gradual 24 24 21 69 92Insidious 0 0 1 1 1.33Maximum numbers of patients i.e. 92% were of gradual onset. Followed by 6.66%were of sudden, while1.33% patient had insidious onset. www.ayurvedicmedicinalplants.com
    • 25 20 15 Sudden number Gradual 10 Insidious 5 0 GroupA GroupB GroupCTable No. 37 : Duration wise distribution. Group Percentage Duration Total A B C %Acute 1 2 4 7 9.33Chronic 24 23 21 68 90.66Above table shows That maximum number of patients (90.66%) were havingchronic nature. While remaining 9.33% were having acute nature. 25 20 15 number Accute 10 Chronic 5 0 GroupA GroupB GroupCTable No. 38: Causes of aggravation of symptoms Group PercentageAggravating factors Total A B C %Sweat 18 21 19 58 77.33Hot climate 15 21 16 52 69.33Any food intake 1 - - 1 1.33 www.ayurvedicmedicinalplants.com
    • For 77.33%patients, sweat was a major aggravating factor.69.33% were havinghot climate as aggravating factor. Only one patient complained fish intake as amajor aggravating factor. 25 20 15 Sweat number 10 Hot climate Food 5 0 GroupA GroupC.Table No. 39 : Occupation Exposed to sunlight Group Percentage Occupation Total A B C %Yes 12 4 11 27 36No 13 21 14 48 64Maximum numbers of patients (64%) were having occupation not related to directsunlight. expossure to sunlight C Group B A No Yes 0 5 10 15 20 25 num ber www.ayurvedicmedicinalplants.com
    • Table No. 40: History of emergence of the disease on exposure to Group PercentageExposure to Total A B C %Unhygienic closet 4 1 2 7 9.33Dirty cloths 9 5 11 25 33.33Over sweating 6 3 10 19 25.33Infected person 1 - - 1 1.33Unknown 5 16 2 23 30.66Among the 75 patients, 33.33% patients remembered about the emergence of thedisease immediately after the use of dirty cloths.25.33% told about the emergenceafter over sweating. Use of Unhygienic closet at some camp site or generalhospital was the reason for emergence in 9.33 cases. In 30.66% of cases, causalreason was unknown. 16 14 12 Unhygeinic closet 10 dirty cloths 8 Over sweating 6 Infected person 4 Unknown 2 0 GroupA GroupB GroupCTable No 41: Involvement of different Srotas (% according to Charaka) No. Stotas No. Mean Percentage (%) 1 Pranavaha 3 4 2 Udakavaha 1 1.33 3 Annavaha 4 5.33 4 Rasavaha 12 16 www.ayurvedicmedicinalplants.com
    • 5 Raktavaha 75 100 6 Mansavaha 3 4 7 Medavaha 6 8 8 Asthivaha 1 1.33 9 Majjavaha 0 0 10 Sukravaha 0 0 11 Mutravaha 6 8 12 Purisavaha 2 2.66 13 Swedavaha 46 61.33Table shows that 100% patients were having symptoms of Rakthavahasrothodushti, followed by 61.33% were having symptoms of Sweadavaha.16% patients were having symptoms of Rasavaha, while 8% patients were havingsymptoms of Medavaha and Moothravaha,each. 4% patients were havingsymptoms of Pranavaha and Manovaha,each.Symptoms of Annavaha srothodushtiwas complained by 5.33% of patients. 2.66% were having pureeshavahasrothidushti, while1.33% were having Asthivaha srothodushtiObservation on Initial clinical complaints Among the initial complaints, itching was the main discomfort for thepatients. Discolouration, Papules and Scales followed this. Some patients haddischarge from the lesion and some others were associated with some erosions atthe region. This grading was done according to the standard score sheet preparedat the beginning of the study. ( Ref-Appendix 1) www.ayurvedicmedicinalplants.com
    • Average Itching 15% 23% Discolour 10% Scales papules 16% 21% Erotions 15% DischargeObservation on positive fungal scarping16 cases in group A, 19 cases in group B and 22 cases in group C have shownpositive results on microscopic analysis with marginal scrapings of infectiouslesionsGrouping Among these 75 patients,1st, 4th, 7th …..Patients were included in Group Aand advised to apply an external application of ‘Dadruvidravana malahara’ for 1month over the affected part. General hygienic practices and suitable food habitswere also advised.2nd, 5th, 7th …..patients were included in Group B and advised to in take ‘Patolakaturohinyadi kashaya’ for 1 month. General hygienic practices and suitable foodhabits were also advised.3rd, 6th, 9th …..patients were included in Group C and advised to use both the abovemedications in combination with general hygienic practices and suitable foodhabits.]Observations on test responseResponse to grade of symptomsAccording to the score, we have sorted the patients in to 3 catogories, i.e.; patientshaving mild symptoms, moderate symptoms and severe symptoms, on the basis ofthe following scale, www.ayurvedicmedicinalplants.com
    • Total score 1-6 Mild 7-12 Moderate 13-18 SevereInitial data MILD MODERATE SEVERE GROUP A 9 10 6 GROUP B 6 12 7 GROUP C 3 11 11After treatment period NIL MILD MODERATE SEVERE GROUP A 3 22 0 0 GROUP B 7 18 0 0 GROUP C 6 19 0 01 month after treatment NIL MILD MODERATE SEVERE GROUP A 0 8 17 0 GROUP B 0 23 2 0 GROUP C 7 18 0 02 months after treatment NIL MILD MODERATE SEVERE GROUP A 0 12 12 1 GROUP B 5 18 1 1 GROUP C 7 18 0 0Variations in total scoreFrom the initial score, we have observed some variations in 3 groups during thefollow-up period which may be because of the effect of the treatment. www.ayurvedicmedicinalplants.com
    • T1 Initial stageT2 After treatment periodT3 1 month after treatmentT4 2 month after treatmentOverall effect of treatment T1 T2 T3 T4 Total score 9.786667 1.546667 4.186667 4.04GroupA T1 T2 T3 T4 Av.Score 8.76 1.96 7.28 7.36GroupB T1 T2 T3 T4 Av.Score 9.68 1.28 4.08 3.32GroupC T1 T2 T3 T4 Av.Score 10.92 1.4 1.2 1.44Variations in symptom score –A comparison between the groups during follow –up1. Itching I(1) I(2) I(3) I(4) GROUP A 2.08 0.56 1.64 2.28 GROUP B 2.32 0.28 1 1.04 GROUP C 2.28 0.32 0.36 0.642. Discolouration D(1) D(2) D(3) D(4) GROUP A 1.96 1.2 1.76 1.8 GROUP B 1.84 0.88 1 1.04 GROUP C 2.4 0.96 0.16 0.36 www.ayurvedicmedicinalplants.com
    • 3. Scaling S(1) S(2) S(3) S(4) GROUP A 1.32 0 1.2 0.96 GROUP B 1.32 0 0.64 0.28 GROUP C 1.8 0 0 0.084. Papules P(1) P(2) P(3) P(4) GROUP A 1.24 0 0.32 0.2 GROUP B 1.76 0 0.56 0.32 GROUP C 1.72 0.08 0.2 05. Erosions E(1) E(2) E(3) E(4) GROUP A 0.76 0 0.32 0.2 GROUP B 1 0 0.12 0.08 GROUP C 1.16 0 0.08 06. Discharge D(1) D(2) D(3) D(4) GROUP A 1.4 0.24 1.4 1.28 GROUP B 1.44 0.12 0.76 0.56 GROUP C 1.56 0.04 0.4 0.36 www.ayurvedicmedicinalplants.com
    • Comparison of total score through the follow-up periods T1 T2 T3 T4 GROUP A 8.76 1.96 7.28 7.36 GROUP B 9.68 1.28 4.08 3.32 GROUP C 10.92 1.4 1.2 1.44 T1 T4 T1-T4 % of relief GROUP A 8.76 7.36 1.4 15.98 GROUP B 9.68 3.32 6.36 65.7 GROUP C 10.92 1.44 9.48 86.81Statistical AnalysisOne way ANOVA test for TOTAL SCORE (To check whether there is anysignificant difference between the initial condition of the three INITIAL STAGEgroups of patients).Group Mean Std Dev SEMA 8.76 5.101 1.02B 9.68 4.028 0.806C 10.92 3.73 0.746Power of performed test with alpha = 0.050: 0.135The power of the performed test (0.135) is below the desired power of 0.800.Source of Some of MeanVariation DF squares square F Sig(P)Between groups 2 58.747 29.373 1.569 0.215Within groups 72 1347.84 18.72Total 74 1406.59The differences in the mean values among the treatment groups are not greatenough to exclude the possibility that the difference is due to random samplingvariability; there is not a statistically significant difference (P = 0.215). www.ayurvedicmedicinalplants.com
    • One way ANOVA test for TOTAL SCORE Final Follow-Up Group Mean Std Dev SEM Group A 7.360 2.956 0.591 Group B 3.320 3.159 0.632 Group C 1.440 1.294 0.259 Power of performed test with alpha = 0.050: 1.000 Source of Some of Mean Variation DF squares square F Sig (P) Between groups 3 664.190 221.397 30.401 <0.001 Within groups 96 699.120 7.283 Total 99 1363.310 The differences in the mean values among the treatment groups are greater than would be expected by chance; there is a statistically significant difference (P = <0.001).Paired t testGROUP A Mean Std Dev SEM Initial 8.760 5.101 1.020 Final 7.360 2.956 0.591 Difference 1.400 3.775 0.755 t = 1.854 with 24 degrees of freedom. (P = 0.076) 95 percent confidence interval for difference of means: -0.158 to 2.958 The change that occurred with the treatment is not great enough to exclude the possibility that the difference is due to chance (P = 0.076) www.ayurvedicmedicinalplants.com
    • GROUP B Mean Std Dev SEMInitial 9.680 4.028 0.806Final 3.320 3.159 0.632Difference 6.360 3.763 0.753 t = 8.452 with 24 degrees of freedom. (p = <0.001) 95 percent confidence interval for difference of means: 4.807 to 7.913 the change that occurred with the treatment is greater than would be expected by chance; there is a statistically significant change (p = <0.001)GROUP C Mean Std Dev SEMInitial 10.920 3.730 0.746Final 1.440 1.294 0.259Difference 9.480 3.441 0.688 t = 13.773 with 24 degrees of freedom. (p = <0.001) 95 percent confidence interval for difference of means: 8.059 to 10.901 The change that occurred with the treatment is greater than would be expected by chance; there is a statistically significant change (p = <0.001) www.ayurvedicmedicinalplants.com
    • PART-6 Discussion Any hypothesis becomes principle only after thorough discussion from allthe angles (1).Discussion improves the knowledge and scientific conclaves amongexperts with Sastra and experience becomes the base of establishment of theconcept (2). Here, as a part of this thesis, discussion has been divided into twoparts viz. clinical part and test response part. Clinical part is based on theobservations made during clinical examination of the patient while test responsepart is based on the observations during the follow- up studies. Both are on 75patients, who came to our O.P. So, this may not be a representation of generalprinciples applicable to the disease.Superficial fungal infection on skin became one of the major disturbing conditionsamong infectious skin diseases. Prevalence of the disease increases day-by-daydue to various reasons. On one side, it may happen as an out come of thesuppression of immunity due to over use of Antibiotics and corticosteroids, on theother side, due to the unhygienic practices. According to our conceptual studies,we have seen that the composition of sweat is a critical factor in the causation ofthe disease. So internal atmosphere, which determine the composition of sweatmay play significant part in the pathogenesis. This study is an attempt to find outthe extent of internal as well as external involvement in superficial mycoses.1. (Ch. Vi. 8/37).2. (Ch. Su. 25/40).6.1 Discussion on theoretical aspects: Though there are so many theories to explain the causes of superficialfungal invasion on to the skin, the exact cause of this pathogenic process stillremains obscure. Present knowledge about the microbial infection meets variousquestions to be answered in front of the medical world. Even among highlyeducated hygienic people, the dermatophyte infection may make their presence. www.ayurvedicmedicinalplants.com
    • Among same family members, all individuals may not be affected with fungus. Allpersons who have profuse sweating may not be affected with fungus.According to some most recent research works, the root cause of the superficialfungal infection lies in the composition of sweat (1). According to this theory,eccrine sweat may create some predisposing influence in many superficialmicrobial invasions. Actually sweating is not a mechanism to excrete wasteproducts, but a mechanism to regulate temperature of the body by secreting waterycompound through sweat glands to the outer surface of the skin. The main contentof sweat is water. The remarkable qualities of water, nature’s ubiquitous liquid,are strikingly evident in the diverse mechanisms by which eccrine sweating maypredispose to a variety of skin disorders. Watery eccrine sweat may soften the skinto facilitate inoculation of microorganisms, act as a nutrient to increase themicroflora, function as a solvent to extract allergens or irritants from materials incontact with the skin, provide a surfactant action promoting the flow of sebum,soften and injure the skin by maceration and in a way not yet defined, damage thestratum corneum to initiate the abnormal focal keratinization which results insweat retention. Sweating, therefore, plays an important role in the pathogenesis oraggravation of bacterial folliculitis, bullous impetigo, ringworm infection,candidiasis, Tinea versicolor, warts, allergic and primary irritant contactdermatitis, acne, and intertrigo (2).Composition of sweat The composition of sweat can vary greatly between different people, and isinfluenced by emotional state, diet, exercise and a variety of hereditary factors.For example, you may have noticed an oniony or garlicky odor on your skin afterconsuming those foods. The composition of sweat is similar to that of plasmaexcept that sweat does not contain proteins. After secretion, the fluid movesthrough the sweat duct, where salt and water are reabsorbed. The exact mechanismof sweat secretion is not known. It appears that sweat is a filtrate of plasma thatcontains electrolytes (such as potassium, sodium, and chloride) and metabolic www.ayurvedicmedicinalplants.com
    • wastes (like urea and lactic acid). Because sweat resembles a filtrate of plasma,water-soluble chemicals, like some drugs and metal ions, are found in sweat.However, sweat is not a major route of excretion of chemicals.Pathology In some persons, a liver enzyme, trimethylamine oxidase will be deficient,which is an essential enzyme for the oxidation of trimethylamine. Followingingestion of choline and lecithin containing foods such as fish, garlic, egg, liver orkidney individuals with this condition are unable to completely degrade theabsorbed trimethylamine, which accumulates in the urine, breath, sweat andmucus(3).Enzymatic block may happen in some other persons, resulting in accumulation ofalpha-hydroxy butyric and phenyl piruvic acids as swell as methinine,phenylalanine and tyrosine in sweat. A syndrome designated ashypermethioninemia is productive of a strong fishy, foul odour in sweat. Thishappens due to a familial hepatic problem. The responsible metabolic defect- thedeficient enzymes in liver- is an autosomal dominant trait (4).Inappropriate metabolism or detoxification of various materials from liver mayprecipitate many non-degradable byproducts at various body parts. The aboveconditions are some of them. Then as we have seen earlier, the presence of fetidsweat on the surface of skin may act as a nutrient to increase the microflora likefungi. Thus susceptibility to infection appears to be closely linked, in a reversiblemanner, to the metabolic state. Let us discuss another good example also.Biochemical abnormalities engendered by uncontrolled diabetes may create anenvironment congenital for the activities of bacteria, thus creating infectiveconditions like carbuncles. According to the experiments carried out at theRockfeller institute and other research centers, in USA, susceptibility to microbialdisease can be caused by manipulation of metabolism(5).It would therefore appear that susceptibility to infection may not necessarily beinherent in the tissues or be dependent, upon the presence of antibodies. It is often www.ayurvedicmedicinalplants.com
    • a temporary expression of some physiological disturbances. The mechanismresponsible for natural resistance seem, in general, to be effective within a narrowrange of conditions which constitute the ‘normal environment’, the population hasevolved any shift from the normal is, there fore, likely to make the equilibriumunstable. Disturbances which usually up set this equilibrium in the context of thepresent are,-metabolic abnormalities, treatment with antimicrobial drugs,psychosocial stresses and so forth.From the previous observations and conclusions drawn from recent developmentsin the field of medicine and allied subjects emerge the following facts which havea bearing on and which may have to be read together with Ayurvedic concepts ofDhathwagnimandya, Malasanchaya and invasion of krimis, to furnish a completeand up to date picture of them. The following concepts are very significant in thisaspect.1. Bhrajaka pitha :‘Bhrajaka’ is one of the 5 types of pithas, whose function isstated to impart ‘bhrajana’ (luster) to twak. Actually, luster is the healthy outcomeof all the metabolic transformations needed for the formation and functions skin.So, according to charkapanidatha, bhrajakapitha should be considered as the majorfactor which can employ with various metabolic transformations needed forhealthy skin (6).2. Twak:If we discuss on the concept of formation and nutrition of skin in Ayurvedicaspect, it seems that the ‘Twak’ is formed embryologically from rasadhathusituated in Raktha dhathu (7). In gradual course it gets nutrition also from the‘Dhathu parinama’ of Mamsa. The accessory structures like hairs are formed asexcreta during the course of metabolism of Asthi. Sweat is formed as excreta afterthe metabolism of Medas. Sebaceous secretions are the excreta after themetabolism of Mamsa and Majja (8). www.ayurvedicmedicinalplants.com
    • 3. Dhathwagnimandya:Any abnormality in major forms of pitha may affect its fractional forms(Dhathwagnis and Bhoothagnis), distributed in various other parts (9). Thiscorresponds to the dhathwagnimandya in the level of mamsa or medas due toabnormality in Bhrajakapitha. This may precipitate nondegradable parts in swedaand in other excreta. Deficiency in dhathwagni may happen as a result ofcongenital defect or due to the heavy load with food materials of particular type.4. Malsanchaya and Invasion of krimisNon-degradable byproducts formed due to metabolic errors in dhathwagni levelmay precipitate fetid sweat over the surface of skin, creating a nutritional mediafor some particular saprophytic organisms (10). In the causation of superficial mycoses, the root pathology may be in theabnormality of Bhrajakapitha, created by so many causes of longer duration. Thiscreates dhatwagni mandya, which in turn produces non-degradable substances insweat. Thus the saprophytic organisms get their anchor on the skin. In this view, the Dosha-dhathu-Mala samyatha or stead state, which hasalready been impaired leading to acute disturbances, is not returned to itsnormalcy. These acute conditions tend to become sub acute and chronic andcontinue as such. In this state, the morbid factors or the byproducts due to theimpaired functioning of the doshas, dhathus and malas, which arise inconsequence, are not properly disposed off. They continue to be retained in thebody, impeding the restoration of the samyatha or normal-equilibrium of doshas,dhathus and malas, leading to various functional and organic disturbances.Superficial fungal infection is one such abnormality.Treatment principle:According to the above principles, a thorough correction in the process ofdhathuparinama, along with external hygienic practices is very essential to healsuperficial mycoses in a better way. As we have seen earlier, abnormalities in livermetabolism, which may be correlated with abnormalities in ‘dhatwagni vyapara’ www.ayurvedicmedicinalplants.com
    • should be corrected basically. But as this has a genetic background, it is not easyto correct this abnormality permanently. So for a temporary correction inenzymatic action of liver,we may use effective liver corrective drugs.In this juncture, if we analyze our traditional Ayurvedic drugs which arecommonly used in this clinical condition, amazingly we may see very effectiveliver corrective drugs such as ‘Katukurohini’ (Picroriza kurrova) in combinationwith other drugs. This may strengthen the strong scientific background of ourtraditional principles. Further studies are required in this aspect.6.2 Discussion on Clinical examination:These are the observations about patient’s details on the following factors-Sex, Age, Marital status, Religion, Domicile, Status of education, Occupation,Socioeconomic status, History of previous illness, treatment history, Food habits,Personal history, Various anatomical and physiological peculiarities, Nature of skin, andthe Nature of the disease.1. Sex distribution: More number of patients (53%) was male and 46% werefemale. Though this is not a significant difference, generally it is noticed thatfemales have the tendency to hide their skin problems especially, that on venerealparts. According to general survey reports, fungal infections affecting the groin arehigher among females. Most among them, in this region may not be included inthis sample study. According to modern survey, there is no remarkable differencein occurrence of superficial mycoses between male and female.2. Age: Most patients were (49.33%) between the ages of 16 and 25(Youvana).Remaining patients (25.33%) were between 25-45 and 50-70,each.Thisseems to be a significant finding. General surveys prove that many persons wereaffected with fungal infection during their younger age. According to Ayurveda,‘youvana’ is the period of natural aggravation of pitha dosha. This may aggravatethe formation of sweat, which may accumulate in between the flexural aspects orfissures of the skin, causing the skin susceptible to microbial growth. In old age www.ayurvedicmedicinalplants.com
    • and in immunosuppressant conditions, chances of opportunistic infection alsopersist.3. Marietal status: In this sample study, as seen above, we have seen thatunmarried young people are more affected. In 3 patients, sexual contact withinfected partner is told as a cause of infection.4. Religion: The data pertaining to religion wise distribution reveals that majorityof patients (38.66%) were Hindus. 32% were Muslims and 29.33% wereChristians. This data reveals no significant finding as the Hindus are more ingeneral population.5. Status of education: Among the sample, maximum number of patients i.e.77.33% were educated followed by 22.66%of patients were highly educated. Thisshows that the disease is not due to non education. Patients were well educated.6. Occupation: Maximum numbers of patients i.e. 36% were laborers followedby 18.66% patients were students.10.66% patients were Business men or servicemen. Many of the coolie workers around this area have revealed their habit ofwearing the same dress for three or four days without proper washing. Thisincreases the chance of fungal growth upon the skin.7. Socio economical status: Most of the patients (53.33%) belonged to lowerclass followed by middle class (37.33%) and rich class (9.33%).Chances ofunhygienic practices are more among economically backward people. Intake ofgood nourishing food also lack among them. Commonly their food items containmore sour and salt which may precipitate ill healthy skin.8. Domicile: In this series77.33% patients were from rural population and 22.66%patients were belonging to urban areas. Generally, superficial fungal infections aremore among rural population due to their unhygienic practices and due to moistclimate.8. b .The table shows that maximum (64%) no. of patients were having habitat ofSadharanadesa, while 33.33% patients were in Jangala desa.2.66% belong toAanupa desa. www.ayurvedicmedicinalplants.com
    • History of illness & Treatment9. History of previous illness: Among the patients, 10.66% were having gastrointestinaltract disorders, while 4% were having the complaints of other skin diseases, mainlyallergic dermatitis.5.33% were diabetic patients and 1.33% were asthmatic10. Choice of treatment: Among the patients, 52% depended Allopathic as theirfirst choice of treatment. 40% depended on Ayurveda and only 8% dependedHomeopathy.This indicates the emerging reacceptance to Ayurveda, among common people.Food habits11. Vegetarian& Non. veg: 25.33% of this Series were vegetarians and 74.66%of patients were taking mixed diet. According to recent researches, food items likefish, egg, liver etc (containing more choline and lecithin) may precipitate morenon-degradable substances in our body. Individuals with this condition are unableto completely degrade the absorbed trimethylamine, which may accumulate in theurine, breath, sweat and mucus. According to Ayurvedic principles also, improperintake of many nonvegetable items may vitiate the medodhathu, producing moreputrid sweat.12. Masala &Fried items: Among the patients, 57.33% were having the habit ofexcessive intake of Masala & Fried items.53.33% of patients were using the overhot and spicy items. 38.66% were included excess leafy vegetables in their foodhabit. Modern society gives much importance to the use of fast foods, thepreparations of many unsuitable combinations. These food additives are havingthe property of ‘vidahi’, which can vitiate pitha dosha as well as raktha dhathu.Personal history www.ayurvedicmedicinalplants.com
    • 13. Appetite: Most of the patients were having good appetite (52%), followed by40% of patients having moderate and 8% of patients having poor appetite.14. Addictions: In this series, 28%patients were having addiction of one or othertype. While 72% of patients were not having any type of addiction. Form ofaddiction was mainly beedi / sigarete.15. Bowel motion: The table shows that 40% of patients used to pass hard stool.While 4% of patients used to pass loose one, 32%of patients were havingirregular bowel, while remaining other (44%) were having regular bowel.16. Sleep: Maximum numbers of patients (76%) were having sound sleep while24% patients were having disturbed sleep.17.Dress: Among the cases, 44% were having the habit of wearing polyesterdresses more oftenly.38.66% were having the habit of wearing cottondresses.13.33% used silk dresses and 4%nylon dresses. Except the cotton dress, allwill inhibit the easy vapourization of sweat.18. Underwear: Among the T. cruris cases, cases, only 2 patients told their habitof using the same underwear for two or three days without washing.3 studentsrevealed their situation which compels them to wear improperly dried underwear.All others told their hygienic habit, highly proper. This may not be a correctfinding.19. Bathing: Except 6 patients, all told about their bathing habit in two times. Thisalso, not seems to be correct.20. Use of soap: 88% of patients were having the habit of using some kind ofbathing soap. Though this can remove dirt from external surface, excess andprolonged use may destruct the lysosomal barriers on the skin.21. Powder: 88% of patients were having the habit of using some kind of talcumpowders. Though it may give some fragrance to the body, it may precipitate morewaste materials upon the skin. www.ayurvedicmedicinalplants.com
    • 22. Oil application: Only 22.66% were having the habit of external oil applicationover the skin. Actually this (Abhyanga) is good for the health of skin. Infectioneven after this, prove more potent other etiological factors.Various anatomical and physiological peculiarities23. Deha prakrithi: Maximum numbers of patients (52%) were having Vathapitta prakrithi.37.33% were Kaphavata Prakrti while 10.66% patients were havingpitta kapha prakrti.24. Sara: It could be observed that no patient was having Pravara Sara. Maximumnumbers of patients i.e. 88% were having Madhyama Sara. Followed by 12%patients were having Avara Sara.25. Sanhanana: More numbers of patients (97.33%) were having MadhyamaSanhanana. 1.33% patients were of Pravara and Avara Sanhanana26. Sathwa: Above table reveals that maximum numbers of patients (92%) werehaving Madhyama Sattva followed by 6.66% patients and 1.33% patients werehaving Avara and Pravara Sattva respectively.27. Sathmya: All patients (100%) were taking Sarva Rasa.28. Abhyavaharanasakthi: Maximum numbers of patients were havingMadhyama abhyavaharana Sakti(60%) followed by 29.33% patients wereMadhyama and 10.66% patients were with Pravara Abhyavarana Sakti.29. Jaranasakthi: Maximum numbers of patients were having Madhyama JaranaSakti (53.33%),while 29.33% patients and 17.33% patients were having Pravaraand Avara Jarana Sakti respectively30.Vyayamasakthi: Above table shows that 54.66% patients were having MadhyamaVyayama Sakti followed by 41.33% patients of Pravara and 4% patients of AvaraVyayama Sakti.31. Nature of Koshta: Maximum numbers of patients (54.66%) were havingMadhyama Kosta. By 29.33% of patients having Krura koshta and remaining16% of Mrudu Kosta. www.ayurvedicmedicinalplants.com
    • 32. Nature of sweat: 46.66% patients complained excessive sweat, while 22.66%were having the complaint of profuse sweat.20% were with Moderate sweatwhile10.66%were having less sweat.33. Nature of skin: In 52% of patients nature of skin is noted as Vatha pittaprakrti. 37.33% were Kaphavata Prakrti while 10.66% patients were havingpitta kapha prakrtiNature of the disease 34. Presenting complaints: Most of the patients (97.33%) were having thesymptom of discolouration as their main complaint. 92% complained of Itching.48% patients presented with popular lesions, while 45.33% complained ofdischarge from the lesion. 30.66% were having the complaint of erosionsoccasionally35. Type of Fungi effected: In present sample, 50.66% patients were havingT.cruris clinically. 41.33% were with T.corporis. 5.33% were having T.pediswhile 4% consist T.versicolar. Only one patient came with clinical condition ofT.barbae.36. Nature of onset: 92% were having the history of gradual onset. Followed by.66% were of sudden, while1 .33% patient had insidious onset37. Duration of the complaint: Most of the patients (90.66%) were havingchronic nature. While remaining 9.33% were having acute nature38. Aggravating factor: For 77.33% patients, sweat was a major aggravatingfactor. 69.33% were having hot climate as aggravating factor. Only one patientcomplained fish intake as a major aggravating factor39. Exposure to sunlight: Maximum numbers of patients (64%) were havingoccupation not related to direct sunlight.40. Emerging nature: Among the 75 patients, 33.33% patients rememberedabout the emergence of the disease immediately after the use of dirty cloths.25.33% told about the emergence after over sweating. Use of Unhygienic closet at www.ayurvedicmedicinalplants.com
    • some camp site or general hospital was the reason for emergence in 9.33 cases. In30.66% of cases, causal reason was unknown.41. Involved Srothas: 100% patients were having symptoms of Rakthavahasrothodushti, followed by 61.33% were having symptoms of Sweadavaha.16% patients were having symptoms of Rasavaha, while 8% patients were havingsymptoms of Medavaha and Moothravaha each. 4% patients were havingsymptoms of Pranavaha and Manovaha each. Symptoms of Annavaha srothodushtiwas complained by 5.33% of patients. 2.66% were having pureeshavahasrothidushti, while1.33% were having Asthivaha srothodushti.6.3 Discussion on test response This is an observational study based on the criteria of upasaya(upasayathmaka study), because all the aspects of the disease were not well provedin Ayurvedic perspective. This study is to find out a possible etiopathology of thecondition. By assessing the response of the body to the medications, food habitsand life style, we are trying to find out the affected factors in this disease. Thisassessment is intended to find out the scientific basis of our traditional Ayurvedatreatments. In clinical conditions as that of superficial mycoses, our traditionaltreatment gives importance to external as well as internal interventions. Internaladministration of Patolakaturohinyadi kashaya and external application ofDadruvidravana malahara were considered as one of the ideal combinations, insuch conditions. The present study is an attempt to substantiate this approach withevidence based clinical trials.Grouping of the patientsGroup-A: 25patients: Subjecting to External application of medicineGroup-B: 25patients: Subjecting to Internal administration of medicineGroup-C: 25patients: Subjecting to both External as well as internalapplications www.ayurvedicmedicinalplants.com
    • Assessment of the scores of the symptoms directed towards the following points-Alterations in Grade of the Symptoms1) Initially, there were 9 mild cases in Group A, 10 moderate cases and 6 severecases. In Group B, 6 mild cases, 11 moderate cases and 11 severe cases. In GroupC, there were 3mild cases, 11 moderate cases and 11 severe cases.2) After the treatment period of 1 month, an extra category of people not havingany symptom also appeared. In Group A, they were3 in, in Group B, they were 7and in group C, they were 6.Mild cases were 22, 18, and 19 in Group A, Group Band in Group C respectively. No persons in study group appeared with moderateor severe symptoms3) 1month after the treatment period; i.e. after 1 month when patient followedonly food habits and hygienic practices, but no medicines, there were 8 mild casesin Group A, 18 moderate cases. In Group B, 23 mild cases, 2 moderate cases. InGroup C, there were 18mild cases4) 2month after the treatment period; i.e. after 2 month when patient followedonly food habits and hygienic practices, but no medicines, there were 12 mildcases in GroupA, 12 moderate cases and a single severe case. In Group B, 18 mildcases and 5 cases of complete relief. In GroupC,18 got mild degree and 7 personsin this group got complete reliefAlterations in Results of Fungal Scraping1) Initially, 16 cases in group A, 19 cases in group B and 22 cases in group Chave shown positive results on microscopic analysis with marginal scrapings ofinfectious lesions2) After the treatment period, no scrapings were found positive for fungus in anygroups.3) 1 month after the course of treatment, scraping found positive in 18 cases, ingroup A and in 2 cases in group B. They were moderate cases. www.ayurvedicmedicinalplants.com
    • 4) 2 months after the course of treatment, 13 positive results obtained for groupA. In other cases, scrapings have shown negative results.Alterations in Average Score Among The Three Groups1) At the initial stage, persons in Group A were having a total score of 8.76.Aftera course of treatment for 1month, it was reduced to 1.96.But after 1month,somesymptoms were aggravated and the score raised to 7.28.again after1 month, it wasraised to 7.362) Initially, persons in group B were having an average score of 9.68. After theinternal administration of medicine for 1month, it was reduced to 1.28. After onemonth, it became 1.28. At the last follow-up, it was 3.323) Initially, persons in group C were having an average score of 10.92.After theinternal and external administration of medicines for 1month,it was reduced to1.4.After 1month, it became 1.20.At the last follow-up, it was 1.44Alterations in Average Score of Each Symptom1 Itching: In Group A, average score of itching was 2.08 initially. Due to theexternal application of medicine, it was reduced to 0.56.For the next one monththey have used no medicines and their average score for itching aggravated to1.64.Again for the next 1 month also they have used no medicines. Itching hasincreased to 2.28. Actually, this is more than initial score. Alterations in othergroups also studied. This shows that the rate of recurrence is least in group C, inwhich patients had received both internal as well as external medicines.2 Discolouration: In Group A, average score of Discolouration was 1.96initially. Due to the external application of medicine, it was reduced to1.2.For thenext 1 month they have used no medicines and their average score forDiscolouration aggravated to 1.76.Again for the next 1 month also they have usedno medicines. Discolouration has increased to 1.8. Alterations in other groups alsostudied. This shows that the rate of cure is better in group C, in whichpatients had received both internal as well as external medicines www.ayurvedicmedicinalplants.com
    • 3 Scaling: In Group A, average score of scaling was 1.32 initially. Due to theexternal application of medicine, it was reduced to 0. For the next 1 month theyhave used no medicines and their average score for scaling aggravated to1.2.Again for the next 1 month also they have used no medicines. Scaling hasincreased to 0.96. Alterations in other groups also studied. This shows that therate of recurrence is least in group C, in which patients had received both internalas well as external medicines4 Papules: In Group A, average score of papules was 1.24 initially. Due to theexternal application of medicine, it was reduced to zero. For the next 1 month theyhave used no medicines and their average score for papules aggravated to0.32.Again for the next 1 month also they have used no medicines. Papules haspresented with 0.2.Alterations in other groups also studied. This shows that therate of recurrence is least in group C, in which patients had received both internalas well as external medicines5 Erosions: In Group A, average score of Erosions was 0.76 initially. Due to theexternal application of medicine, it was reduced to Nil. For the next 1 month theyhave used no medicines and their average score for erosions aggravated to0.32.Again for the next 1 month also they have used no medicines. In final follow-up, they have presented with a score of 0.2, in Erosions. Alterations in othergroups also studied. This shows that the rate of recurrence is least in group C, inwhich patients had received both internal as well as external medicines6 Discharge In Group A, average score of Discharge was 1.4 initially. Due to theexternal application of medicine, it was reduced to0.24.For the next 1 month theyhave used no medicines and their average score for discharge aggravated to1.4.Again for the next 1 month also they have used no medicines. Discharge hasincreased to 1.28.Alterations in other groups also studied. This shows that the rateof recurrence is least in group C, in which patients had received both internal aswell as external medicines. www.ayurvedicmedicinalplants.com
    • A comparison between these three groups of patients during the follow –upperiods may give you an idea about the upper role of a combined therapy (externaland internal administrations) in patients of superficial mycoses.Percentage of Relief In 3 Groups- A ComparisonAfter a course of treatment for 1 month1) 77.63% relief was noted at the end of 1month for the total score of symptomsby only external application of ‘Dadruvidravanamalahara’.2) 86.78% relief was noted at the end of 1month for the total score of symptomsby only internal administration of ‘Patola katurohinyadi kashaya’3) 87.18% relief was noted at the end of 1month for the total score of symptomsby internal and external administration of both the above drugs.1 month after the treatment period1) After 1month, when patient was not taking any medicines, percentage of relieffrom initial score was 16.9% for the group of patients who received only externalapplication.2) 57.852% relief was noted at the end of 1month after the course of treatment forthe patients receiving only internal medicine.3) 89.04 % relief was noted at the end of 1month after the course of treatment forthe patients receiving internal and external administrations in combination.2 months after the treatment period1) 15.982% relief was noted at the end of 2months after treatment period for thetotal score of symptoms by only external application of ‘Dadruvidravanamalahara’2) 65.71% relief was noted at the end of 2months after treatment period for thetotal score of symptoms by only internal administration of ‘Patola katurohinyadikashaya’3) 86.82% relief was noted for the total score of symptoms at the end of 2monthsafter treatment period for the patients receiving internal and externaladministrations in combination. www.ayurvedicmedicinalplants.com
    • 6.4 Discussion on Statistical analysis:Assessment of the initial sample:We had assessed each patient based on the intensity of their symptoms, withrespect to the scores. A comparison among the average scores of each group byone way ANOVA shows that the differences in the mean values among thetreatment groups are not great enough to exclude the possibility that the differenceis due to random sampling variability; there is not a statistically significantdifference. Hence we could assure that we are making a research intervention onsymptomatically homogenous samples.Assessment of the Final follow-up:Assessment of the average scores of the symptoms at the end of 2months afterstopping the medications, show that the differences in the mean values among thetreatment groups are greater than would be expected by chance; there is astatistically significant difference. Hence we could understand the significantdifference in the effect of medications among the patients. A correlation studyamong the groups may prove the supremacy of ayurvedic treatment principle.Comparative assessment among the groupsIn Group A, the change that occurred with the treatment is not great enough toexclude the possibility that the difference is due to chance, at 95 percentconfidence interval for difference of means. Hence, in the given sample, onlyexternal application of ‘dadruvidravana malahara’ was not enough to reduce thesymptoms to a statistically significant minimum level.In Group B, the change that occurred with the treatment is greater than would beexpected by chance; there is a statistically significant change, at 95 percentconfidence interval for difference of means. Hence, in the given sample, onlyinternal administration of Patolakaturohinyadi kashaya was enough to reduce thesymptoms to a statistically significant minimum level. www.ayurvedicmedicinalplants.com
    • In Group C also, the change that occurred with the treatment is greater thanwould be expected by chance; there is a statistically significant change, at 95percent confidence interval for difference of means. Hence, in the given sample,both internal and external administration of the above drugs in combination waseffective to reduce the symptoms to a statistically significant minimum level.Further statistical representations showing the exact degree of reduction insymptoms may assist for the corroboration of our foremost hypothesis.Possible action of the medicinesExterna application with Dadruvidravana malahara and internal application ofPatola katurohinyadi kashaya were our trial drugs.Ingradients are the following:1.Dadruvidravana Malahara (Rasa Tharangini 8th Tharanga 59) 1. Siktha (Bee wax) 2. Thailam (sesemum oil) 3. Sudha gandhaka (Purified sulphur) 4. Tankana (Borax) 5. Chakramarda beejam (Seeds of Cassia tora) 6. Laksha (Lacifera lappa)Gandhaka, Tankana and Chakramarda beeja are having strong microbicidal action,while laksha is a repigmentery agent.Siktham and beewax are the effective media2. Patola katurohinyadi Kashayam (A.H.Su.15/15) 1. Patola (Trichosanthus dioica) 2. Katurohini (Picroriza kurova) 3. Chandana (Santalum album) 4. Madhusrava (Marsdenia tenocissima) 5. Guloochi (Tinospora cordifolia) 6. Pata (Cissampelos parcira)This combination is generally used as an effective medicine for many skin diseaseshaving the predominance of kapha and pitha.This may be because of its capacity toalleviate the toxic materials from blood and to normalize the properties of blood.Thismay happen by correcting the functions of Yakrith, which is the moola of rakthavaha www.ayurvedicmedicinalplants.com
    • srothas. Liver corrective action of ‘Katukurohini’ was scientifically proved withclinical evidence. All other drugs also can normalize kapha and pitha, which inturnmay correct the above mentioned liver abnormality.Correction in anormality ofBhrajaka pitha and dhatwagni will make the internal atmosphere References1. Boy’ds text book of pathology,vol.1,page 4862. Dermatology, Moschella &Hurley3. Dermatology, Moschella &Hurley4. Dermatology, Moschella &Hurley5. Reported from Rockfeller Institute, Byrn Maur College and U.S. Air Force School of Aviation medicine, (mentioned in ‘Introduction to Kayachikithsa’)6. Chakrapanidatha on Ch.Su.12/117. A.H.Sa.3/88. A.San.Sa.6/239. A.H.Su.11/3310. Ch.Vi.7-10 www.ayurvedicmedicinalplants.com
    • PART 7 Conclusion At the verge of completion of this study, the final conclusion can be drawnfrom the deductive reasoning of the relevant information and non-deceiving datacomprehended in the present study.1. A detailed study on modern concepts of superficial fungal infection on the skinshow that this clinical condition affecting the external skin appendages happen notmerely due to the unhygienic practices, but due to various peculiarities of the skin,its accessory structures and due to the composition of sweat.2. A critical look back at the Ayurvedic historical review shows that there wereample references regarding the infective skin disorders in our Ayurvedic classics.But our ancient Acharyas had never emphasized on the microorganisms for thecausation of infection, and they had treated such conditions by purifying the bodyas a whole. Hence it becomes clear that Ayurvedic science believes infection as anoutcome of internal morbidity3. It may not be true, if we correlate superficial mycoses with a single disease,described in Ayurvedic classics. There are many clinical conditions described inAyurveda, showing similarity with the features of superficial mycoses.4. Possible samprapthi (etiopathology) of this clinical condition may havecontributions from vitiated external as well as internal atmospheres. The nature ofBhrajaka pitha, which controls the health of skin, may have a basic abnormality todeplete the skin-health. Dhatwagni vyapara, which contributes for the compositionof accessory secretions on skin, may be abnormal, because of which improperlydecomposed materials are secreted along with sweda and kleda. This creates asuitable field on skin for the growth of Bahyakrimi (saprophytic fungi).Unhygienic practices may promote this pathology. www.ayurvedicmedicinalplants.com
    • 5. Modern findings about the skin health, role of liver enzymes in controlling skinhealth, formation of sweat, invasion of fungus etc; may help us to frame a betterpicture about the disease.6. Treatment is the process of alleviation of pathological changes. In this aspect,we may test the pharmacodynamics of our traditional Ayurvedic drugs, if we canframe an appropriate etiopathogenesis. In other sense, this may be used tosubstantiate the possible etiopathogenesis.7. An observational and comparative clinical study conducted among the patientsof superficial fungal infection may be used to substantiate the possibleetiopathogenesis that we have postulated.Observation on the sample shows that the disease is more prone tosocioeconomically lower or middle class rural population. Excess non-vegetarianand fast food habits may promote the chances. Over use of bathing soap and nonhabit of external oil application may reduce the skin health. Vatha pitha bodyconstitution (prakrithi) has more chances of the disease. Profuse or excessivesweating has found as major provoking factor for the causation.8. Combination of typical internal and external medicines found more effective inalleviating the clinical condition, which was used for such conditions traditionallyin Ayurvedic practice. As we can explain the scientific reason for this, it maysubstantiate the scientific background of many such Ayurvedic interventions.Internal administration of ‘Patolakaturohinyadi kashaya’ and external applicationof ‘Dadruvidravana malahara’, in combination was found more effective inreducing the dermatological symptoms of fungal infection, than their individualapplication-in a given sample.A clinical trial conducted on 3 groups of patients of superficial mycoses provedthat the combined therapy intended to purify internal as well as external body is70.83% more effective than single external therapy, and 21.11% more effectivethan single internal administration, among the sample. www.ayurvedicmedicinalplants.com
    • 9. Though this observational study was conducted on a few samples of aparticular infectious skin disease- superficial mycoses, this is an attempt tocontribute an Ayurvedic perspective for the theory of infection. As an outcome ofthe study, we have found out various factors involved in the process of infection,and their degree of involvement concerned with this subject. Clinical trials maycontribute for the confirmation of the hypothesis that the invasion ofmicroorganism is highly influenced by the internal morbidity.Limitations1. As the study was conducted on ‘superficial mycoses’-a comparatively lesssevere infectious condition on skin, we cannot generalize the observations andresults to all other infectious diseases of skin. Depending on the organism, itsvirulence and Pathogenecity, the nature and progression of the infection may havedifferent fates. So a detailed study on every infectious skin diseases is needed toframe Ayurvedic perspective for infectious skin diseases.2. The size of the sample was not adequate to draw generalized conclusions.3. The period of the study was limited.4. Longer follow up was not done.Suggestions1. As the superficial mycosis is a chronic infectious disease on skin, chances ofrecurrence are more even after a course of Ayurvedic therapy. So effectivetherapies for longer duration, such as ‘Rasayana’ may be tried on risk grouppatients, which can promote the health of skin (twak saratha) and accessorystructures.2. Dhatwagni samya (homeostasis of metabolic factors), which is an essentialrequirement for skin-health may be achieved by medicines which has the propertyto correct abnormalities in Rakthavaha srothas, especially in srothomoola-Yakrith(liver)3. Further studies on the theory of infection based on this thesis may impart moreconcrete information regarding various types and forms of infectious skin disease. www.ayurvedicmedicinalplants.com
    • 4. As the study was conducted over a small sample, a similar study performedover a large sample for a longer period would have procured much sharper andmore accurate results5. For a detailed and accurate analysis of the pathological states and the effect ofAyurvedic therapy, skin-biopsy will be an essential aid.6. Investigations on the level of typical liver enzymes and serum factors atdifferent stage of follow up may contribute for a better substantiation of role ofRakthavaha srothas and the effect of medicines on that, in the sample disease.7. Evidence based clinical trials on many other infectious skin diseases inayurvedic perspective will be really worth full as it may impart longstandingeffects on skin-health. xÉÉæwOèûuÉqÉç rÉiÉç ÌMüÎlcÉSÎxiÉ,iÉiÉç aÉÑUÉåUåuÉ qÉå lÉÌWû rÉS§ÉÉxÉÉæwOèûuÉqÉç ÌMüÎlcÉiÉç iÉiÉç qÉå aÉÑUÉålÉïÌWûAny Worthiness of this work is due to my respectfulTeachers; and any unworthiness, due to me. (Gurugeetha) www.ayurvedicmedicinalplants.com
    • Summary Summary is the replica of the thesis work. By reading the summary, oneshould get an idea about the subject dealt in the thesis. So the summary should bein such a way that it can represent the glimpses of a thesis subject. It is based uponthe "Uddesa Tantra Yukti". The subject which is described and discussed in anelaborative way in the thesis is summarised in the summary, it can be useful as ascientific material for Research paper.The present work entitled "A study on Ayurvedic perspective of Infectious Skindiseases with special reference to superficial mycoses" was taken up with anintention to frame an Ayurvedic out look for the concept of Infection. The studywas concentrated mainly upon ‘Superficial mycoses’ as it is a very commoninfectious condition in our region. The present work comprises 7 parts. Part 1 Introduction Part 2 Conceptual review on modern aspects Part 3 Skin and Skin diseases Part 4 Conceptual review on Ayurvedic aspects Part 5 Clinical study-Observation & Analysis Part 6 Discussion Part 7 Conclusion PART 1 The Introductory part deals with the relevance of the subject and thenecessity of an Ayurvedic research upon the subject. Infectious skin diseases arevery common among the regional population, among which superficial fungalinfections are very common. According to modern medical survey also, fungalinfections are becoming more threatening than others. Struggle against the www.ayurvedicmedicinalplants.com
    • organism become less effective in an atmosphere of more resistant organisms. Soapproach which imparts more relevance to the platform of microbial growthbecomes much significant. Ayurvedic approach is one such. This theory should behighlighted with all the important classical references and should be proved withclinical observations and with interventional studies. This is a necessary step in theworld of evidence based medicine. PART 2 As a first step in this effort, conceptual review on modern aspect wasdone, collecting all the details from modern parlance. ‘Infection’ is the mostdreadful condition that the modern world had ever seen. Regarding this subject,various new theories are emerging day by day. Literary review on the concept ofInfection, Microorganism, Pathogenecity, Host immunity, Normal flora, Fungus,Superficial fungal infections, different types, manifestations, treatment options etcare analyzed. Nature of external skin, which becomes putrid by the deposition ofmoisture, sweat and dirt, pave the fungal growth upon skin appendages. But in thebasic pathology, the diminution in skin defense must be considered with primeimportance. According to recent researches, loss of the defense power due to thedeficiency in the skin’s protective acidic coating (hydrolipid film) contributes toan increase in the susceptibility to fungal infections. According to anotherpostulate, deficiency or lack in some of the liver enzymes make abnormalities infat metabolism, imparting nondegradable materials in the sweat. Accumulation ofthis kind of putrid sweat along the foldings of the skin overlay microbial invasion,as it is so suitable for saprophytic growth. Modern treatment options give moreimportance to the elimination of these microbes by potent antimicrobials. Butbecause fungi contain cellular machinery and proteins similar to our own, its hardto find agents to kill fungi that dont have negative effects on us. By this fact,modern world find it more difficult than Bacteria, to remove pathogenic fungifrom our body. In this scenario, an alternative method which can remove the www.ayurvedicmedicinalplants.com
    • chances of fungal infection by improving the defence power of the body soundvery essential. Though we argue about experiences of this kind by Ayurvedictreatment, without any reported clinical evidence, it is not easy to present beforemedical world. PART 3 Before entering in to the Ayurvedic aspects of the disease, the most primarydetails of the Skin and skin diseases will really help in proceeding further studies.So such a compilation was done on modern as well as ayurvedic aspects of skinand skin diseases. As the subject is very vast, the most essential aspects of thetheme have taken. PART 4Literary review through Ayurvedic classics pointed towards various alliedaspects of the subject. Historical review, Concept of Krimi, Graha roga,Oupasargika roga, Janapadodhwamsa, Various related twakvikaras etc came underreview. The principle of treatment described for the diseases caused bymicroorganisms emphasize on threefold approach in the management. This givesimportance to deduction of vitiated factors/microorganisms, along withnormalization of the internal atmosphere and avoiding the external causativefactors. This treatment principle is to normalize our internal as well as externalatmospheres where the preparation for microbial growth had taken place. Thisprocedure is to clear the platform, where the chances of microbial growth persist.Hence it becomes clear that the pathogenesis involve the preparation in threedifferent levels. This theoretical fact should be proved with clinical evidence.Observation is the first step in this effort. We have given special reference tosuperficial mycoses as the sample collection is very easy in this tropical region. Atheoretical discussion has done on Ayurvedic perspective of superficial mycoses. www.ayurvedicmedicinalplants.com
    • For the assessment of the disease, an effort has done to find out theNidanapanchaka of the condition. Causes of longer duration (Viprakrishta nidana),which deplete the resistance power of skin by abnormalizing the functions ofRakthavahasrothas were discussed. Role of Yakrith, the moola sthana ofRakthavahasrothas found very critical in making the skin vulnerable to microbialinvasion. A correlational interpretation has done on abnormalities in secondarymetabolism of liver with Dhathwagnimandya, which can produce fetid sweat on tothe skin, making a suitable atmosphere for fungal growth. PART 5 This is an observational clinical study, in which patients of superficialmycoses were randomly selected and grouped in to three categories. A clear cutMethology was formulated as a first step of the study. Patients were selected afterthorough examination of their clinical symptoms and personal details. Diagnosiswas purely based upon modern criteria. For the confirmation of fungi, scrapingswere taken for microscopic study. First group was administered with Externalmedicine, second group with Internal medicine and the third group with bothadministrations. According to Ayurvedic principles, the third way is mostpreferable as it can correct the internal as well as external atmospheres. Sotraditionally we were using suitable internal and external administrations incombination. We have selected such most usual medicines for the study. Theclinical study consists observations and analysis. The general observations of 75patients, categorized in to 3 groups, pertaining to age, sex, occupation, etc aredescribed. The test response obtained also presented. PART 6The 6th part of the thesis deals with the discussion based on the clinical study andtest response of the present study. Critical discussion & comments have been www.ayurvedicmedicinalplants.com
    • offered to all the parameters of the clinical study & lastly the overall effect of thetherapy have been presented there. The present study is found throwing light on tothe scientific basis of our traditional Ayurvedic treatment in our subject ofdiscussion. PART 7Last part of the thesis concludes with the focal findings of the research work.According to the literary collection of Modern as well as Ayurvedic parts, anattempt has been done to understand the disease in detail. The role of internal aswell as external abnormalities in making the skin, infective to fungal flora waswell studied. According to the Upasayathmaka study, these levels of pathologywere substantiated. By this study, it is observed that in present sample, thoughsuperficial mycoses is confined to the upper layers of the skin, vulnerability tofungal infection was created both by internal as well as external causes.Abnormalities in the functions of Rakthavaha srothas were very significant.Upasayathmaka study conducted on 3 groups, who were receiving Internal,External, and both administrations respectively, has shown the difference inpercentage of cure in their symptoms. Correction in internal atmosphere was veryeffective in controlling the recurrence of the condition.This part ends with pointingout some limitatations of this study and with some positive suggestions for furtherstudies. www.ayurvedicmedicinalplants.com
    • Bibliography1. Astanga Sangraha, Vridha vagbhata, Sasilegha vyakhya, Vaidyabhooshanam K. Raghavan Thirumulpad, First edn.19822. Astanga-Hrdaya, Vagbhata,- Sarvangasundara vyakhya, by Arunadatha, Choukamba Orientalia,19893. Charaka Samhita-Ayurveda deepika vyakhya, Chakrapanidatha, edited by Vd. Yadavji Thrikumji, Munshiram publishers, fifth edn.19924. Susruta-Samhita-Nibandha sangraha vyakhya, Dalhanacharya, edited by Vd.YadavjiThrikumji, Krishnadas Academy,Choukamba Orientalia,19895. Kasyapa Samhita- Commentary Pt. Hemraja Sharma.6. Madhava Nidana, Madhava, with Madhukosa Commentary, Choukamba Orientalia,19897. Sidhantha nidana, Gananadh sen, Chowkamba Orientalia,19928. Thridosha theory,V.V.Subrahmanya sasthri,published by Kottakkal Arya VaidyaSala., 2002.9. Infectious diseases and Ayurvedic treatment, Dr. V. L. N. Sasthry, Hyderabad.Published by Kottakkal Aryavaidyasala, 1994.10. Digestion and Metabolism, C.Dwarakanadh11. Introduction to Kayachikithsa, C.Dwarakanadh12. Ayurvedic perspective of Communicable diseases. Published by Department of Swasthavritha, V.P.S.V. Ayurveda College. www.ayurvedicmedicinalplants.com
    • 13. Rasatharangini, SadanandaSarma, collectedby Kasinadhasasthri, MotilalBanarasidas, New Delhi, 1989 14. Doctrines of ‘Pathology in Ayurveda’, Prof. K.R.Srikantha murthy, Choukamba orientalia, Varanasi. 15. Ayurvedeey Kriya sareera, Vaidya Ranajith ray desay, Sreevaidyanadh Ayurveda bhavan. Modern Texts:16. Gray’s Anatomy, International Students Edition, 38th edition199617. Text book of Medical Physiology, Guyton &Hall, 9th Edn.18. Text Book of Microbiology, Ananthanarayan & paniker, 7th edn.19. Text Book of Preventive and Social Medicine, K. Park, 14th Edn.20. Text book of Dermatology, edited by R.H.Champion, Cambridge.21. Textbook of Dermato-Epidemiology, Strachan D, Williams HC.22. Microbiology of Human Skin, Noble WC. London 1981.23. Medical Mycology, Chung KJ, Bennett JE. Philadelphia: 1992.24. A dictionary of English and Sanskrit—Monier William25. General pathology, S.G. Deodhare, 5th edition,Popular prakasan,Bombay26. Medical laboratory technology, vol 1, Kanai L Mugharjee.27. Microbiology, David. t. Kings burgy28. Manual of skin diseases, Vijay K Jain, Anil Dashore, CBS publications29. Dermatology, Samuel L Moschella, Harry J Hurley.Publications30. Current Science, Vol85, No.1, 10 july2003.31. The Antiseptic, Vol.101, August 2004.32. Phytopharm, Vol.6, No.3, March 2005 www.ayurvedicmedicinalplants.com
    • Internet resources33. http/www.Mycology.com/34. http/www.Dermatology.org/35. http/www.controlled- trials.com/36. http/www.qmedin.com/medsites/37. http/www.doctorfungus.org/education/ www.ayurvedicmedicinalplants.com
    • CLINICAL STUDY APPENDIX-1 Initial data (symptoms according to the standard score)sl.no Itching Discolour Scales papules Erotions Discharge TOTAL 1 3 2 3 3 3 3 17 2 0 2 0 0 0 0 2 3 2 0 2 0 0 0 4 4 1 0 1 0 0 0 2 5 3 3 1 3 2 3 15 6 0 3 2 0 0 2 7 7 3 2 1 2 1 3 12 8 3 2 0 2 0 1 8 9 3 2 3 0 3 2 13 10 2 1 1 1 0 2 7 11 2 2 1 1 0 0 6 12 3 2 1 2 2 2 12 13 0 2 0 0 0 0 2 14 3 2 0 3 2 3 13 15 2 2 1 2 0 0 7 16 3 2 2 1 0 2 10 17 0 2 2 2 0 0 6 18 3 2 1 1 2 2 11 19 0 1 0 0 0 0 1 20 1 2 0 2 0 0 5 21 3 3 2 3 0 2 13 22 3 2 2 2 0 2 11 23 2 2 0 2 0 1 7 24 3 2 3 3 2 2 15 25 0 1 0 0 0 0 1 26 3 2 2 2 2 1 12 27 3 2 3 1 1 2 12 28 3 2 2 2 1 2 12 29 3 1 2 2 2 1 11 30 3 2 3 3 2 2 15 31 2 1 1 1 0 2 7 32 0 2 2 0 0 1 5 33 2 3 1 2 1 0 9 34 3 3 3 2 2 3 16 35 3 1 0 0 0 1 5 36 3 2 3 3 2 3 16 37 0 2 0 0 0 1 3 38 3 2 2 3 2 3 15 www.ayurvedicmedicinalplants.com
    • 39 3 2 0 1 1 0 7 40 3 2 2 2 2 2 13 41 3 1 2 2 0 1 9 42 3 3 2 3 1 2 14 43 0 2 1 1 0 2 6 44 3 2 0 2 2 1 10 45 1 2 1 2 1 0 7 46 3 2 2 2 0 1 10 47 3 1 1 2 0 2 9 48 3 3 2 1 1 3 13 49 2 1 1 1 0 1 6 50 3 2 3 3 3 3 17 51 3 3 1 2 1 2 12 52 3 3 1 1 2 2 12 53 3 1 3 2 0 1 10 54 3 2 2 2 3 2 14 55 1 2 0 0 0 0 3 56 2 2 1 2 0 1 8 57 3 3 2 2 3 3 16 58 3 3 2 3 3 2 16 59 3 2 3 2 2 3 15 60 3 3 2 2 3 3 16 61 3 3 2 1 0 0 9 62 2 2 1 2 1 1 9 63 1 2 1 1 0 0 5 64 3 3 1 0 0 1 8 65 3 2 3 2 3 2 15 66 2 3 2 2 0 2 11 67 3 2 2 3 2 2 14 68 2 2 1 0 0 2 7 69 0 3 1 1 0 0 5 70 3 3 2 3 3 2 16 71 3 2 2 2 3 3 15 72 1 3 2 2 0 2 10 73 2 2 1 0 0 0 5 74 2 2 1 1 1 1 8 75 1 3 2 2 0 1 9Average 2.226667 2.066667 1.48 1.573333 0.973333 1.466667 9.78 www.ayurvedicmedicinalplants.com
    • APPENDIX-2 Total score among the groups-Initial Sl .no. GroupA GroupB GroupC 1 17 2 4 2 2 15 7 3 12 8 13 4 7 6 12 5 2 13 7 6 10 6 11 7 1 5 13 8 11 7 15 9 1 12 12 10 12 11 15 11 7 5 9 12 16 5 16 13 3 15 7 14 13 9 14 15 6 10 7 16 10 9 13 17 6 17 12 18 12 10 14 19 3 8 16 20 16 15 16 21 9 9 5 22 8 15 11 23 14 7 5 24 16 15 10 25 5 8 9Average 8.76 9.68 10.92 APPENDIX-3 Data after the treatment periodsl.no Itching Discolour Scales papules Erotions Discharge TOTAL 1 1 1 0 0 0 1 3 2 0 0 0 0 0 0 0 3 0 0 0 0 0 0 0 4 1 0 0 0 0 0 1 5 1 2 0 0 0 1 4 6 0 0 0 0 0 0 0 7 0 1 0 0 0 1 2 www.ayurvedicmedicinalplants.com
    • 8 0 1 0 0 0 0 1 9 1 1 0 0 0 0 210 0 1 0 0 0 0 111 0 2 0 0 0 0 212 0 0 0 0 0 0 013 0 2 0 0 0 0 214 1 1 0 0 0 0 215 0 0 0 0 0 0 016 0 2 0 0 0 0 217 0 1 0 0 0 0 118 0 1 0 0 0 0 119 0 1 0 0 0 0 120 1 1 0 0 0 0 221 1 1 0 0 0 0 222 1 2 0 0 0 0 323 0 1 0 0 0 0 124 1 1 0 0 0 0 225 0 0 0 0 0 0 026 1 1 0 0 0 0 227 0 1 0 0 0 0 128 1 1 0 0 0 0 229 0 1 0 0 0 0 130 1 1 0 0 0 1 331 0 1 0 0 0 0 132 0 0 0 0 0 0 033 0 0 0 0 0 0 034 1 2 0 0 0 1 435 0 0 0 0 0 0 036 1 1 0 0 0 0 237 0 0 0 0 0 0 038 1 1 0 0 0 0 239 0 2 0 0 0 0 240 1 2 0 0 0 1 441 0 0 0 0 0 0 042 0 1 0 0 0 0 143 0 0 0 0 0 0 044 0 2 0 0 0 0 245 1 2 0 0 0 0 346 1 2 0 0 0 0 347 0 0 0 0 0 0 048 0 1 0 0 0 0 149 0 1 0 0 0 0 150 1 1 0 0 0 1 351 0 1 0 0 0 0 1 www.ayurvedicmedicinalplants.com
    • 52 0 2 0 0 0 0 2 53 0 1 0 0 0 0 1 54 0 2 0 0 0 0 2 55 1 0 0 0 0 0 1 56 0 1 0 0 0 0 1 57 0 1 0 0 0 0 1 58 1 2 0 0 0 1 4 59 0 0 0 0 0 0 0 60 0 2 0 0 0 0 2 61 1 1 0 0 0 0 2 62 0 1 0 0 0 0 1 63 0 2 0 0 0 0 2 64 1 2 0 0 0 0 3 65 1 2 0 0 0 1 4 66 0 2 0 0 0 0 2 67 1 1 0 0 0 0 2 68 0 1 0 0 0 0 1 69 0 0 0 0 0 0 0 70 1 2 0 0 0 1 4 71 0 1 0 0 0 0 1 72 1 1 0 0 0 0 2 73 0 1 0 0 0 0 1 74 0 0 0 0 0 0 0 75 1 0 0 2 0 0 3Average 0.373333 1.013333 0 0.026667 0 0.133333 1.546667 APPENDIX-4 Data ,1month after the treatment period Discolou Dischargsl.no Itching r Scales papules Erotions e TOTAL 1 2 2 2 1 1 2 10 2 0 1 0 0 0 0 1 3 0 0 0 0 0 0 0 4 1 0 1 0 0 1 3 5 2 2 1 2 1 1 9 6 0 1 0 0 0 0 1 7 2 2 1 1 1 3 10 8 1 0 0 1 0 1 3 9 1 0 0 0 0 0 1 10 2 1 1 1 0 2 7 www.ayurvedicmedicinalplants.com
    • 11 0 1 0 0 0 1 212 1 0 0 0 0 0 113 0 2 0 0 0 0 214 2 1 0 2 0 1 615 0 0 0 0 0 0 016 2 2 2 1 0 2 917 0 1 1 0 0 0 218 0 0 0 0 0 1 119 1 2 0 0 0 1 420 2 1 0 1 0 0 421 0 0 0 1 0 0 122 2 2 2 2 0 2 1023 1 1 0 1 0 1 424 1 0 0 0 0 0 125 0 1 0 0 0 1 226 2 1 0 0 0 1 427 0 0 0 0 0 0 028 2 2 2 1 1 2 1029 1 1 1 0 0 1 430 1 0 0 0 0 1 231 2 1 1 1 0 2 732 0 2 1 0 0 0 333 0 0 0 0 0 0 034 1 2 2 2 2 2 1135 2 1 0 0 0 1 436 1 0 0 1 1 2 537 1 2 0 0 0 1 438 0 2 0 0 0 0 239 0 0 0 0 0 0 040 2 2 1 0 0 2 741 1 1 1 0 0 1 442 1 0 0 0 0 0 143 1 2 1 1 0 2 744 1 1 0 0 0 1 345 0 0 0 0 0 0 046 3 2 2 2 0 1 1047 0 0 1 2 0 1 448 0 0 0 0 0 0 049 2 2 2 1 0 1 850 2 1 1 0 0 1 551 0 0 0 1 1 1 352 2 2 2 1 2 2 1153 2 1 2 0 0 1 654 1 0 0 0 0 1 2 www.ayurvedicmedicinalplants.com
    • 55 1 1 0 0 0 1 3 56 0 1 1 2 0 1 5 57 1 0 0 0 0 2 3 58 3 2 2 2 1 1 11 59 1 1 2 0 0 1 5 60 1 0 0 1 0 0 2 61 3 2 2 1 0 0 8 62 0 1 0 0 0 0 1 63 0 1 0 0 0 0 1 64 2 2 1 0 0 1 6 65 0 1 2 0 0 1 4 66 0 1 0 0 0 0 1 67 2 2 2 2 0 1 9 68 1 1 0 0 0 1 3 69 0 1 0 0 0 0 1 70 2 2 1 3 0 1 9 71 2 1 1 2 2 1 9 72 0 0 0 1 0 1 2 73 0 2 0 1 0 1 4 74 2 0 1 1 0 1 5 75 0 0 0 0 0 1 1Averag 0.61333 0.57333 0.17333 4.18666e 1 0.973333 3 3 3 0.853333 7 APPENDIX-5 Data ,2month after the treatment periodsl.no Itching Discolour Scales papules Erotions Discharge TOTAL 1 3 2 2 3 0 2 12 2 0 2 0 0 0 0 2 3 0 0 0 0 0 0 0 4 2 0 1 0 0 1 4 5 1 1 1 1 0 1 5 6 1 0 0 0 0 0 1 7 2 2 1 2 0 2 9 8 1 1 0 0 0 1 3 9 0 0 0 0 0 1 1 10 2 1 1 1 0 1 6 11 1 1 0 0 0 0 2 12 0 0 0 0 0 1 1 13 3 1 0 0 0 2 6 www.ayurvedicmedicinalplants.com
    • 14 1 1 0 0 0 1 315 1 0 0 0 0 0 116 2 2 0 0 0 1 517 0 0 0 0 0 0 018 1 0 0 0 0 1 219 2 1 0 0 0 2 520 1 2 0 0 0 0 321 1 1 0 0 0 2 422 2 2 2 2 0 2 1023 0 0 0 0 0 0 024 1 0 0 0 0 0 125 1 1 0 0 0 1 326 2 2 0 0 0 1 527 1 0 0 0 0 1 228 3 2 0 2 0 1 829 1 1 0 0 0 1 330 1 0 0 0 0 1 231 3 1 1 1 0 2 832 0 0 0 0 0 0 033 0 0 0 0 0 0 034 3 3 3 2 2 3 1635 1 1 0 0 0 1 336 1 1 0 0 0 0 237 2 2 0 0 0 1 538 3 2 2 3 2 3 1539 1 0 0 0 0 0 140 2 2 2 2 0 1 941 2 1 2 2 0 1 842 1 1 0 0 0 0 243 2 2 1 1 0 1 744 2 2 0 1 0 1 645 0 0 0 0 0 0 046 1 1 1 1 0 1 547 2 1 1 0 0 0 448 1 1 0 0 0 1 349 2 1 1 1 0 1 650 2 2 0 0 0 1 551 1 1 0 0 0 0 252 3 2 1 1 2 2 1153 1 1 0 0 0 0 254 0 0 0 0 0 0 055 2 2 0 0 0 2 656 0 0 0 0 0 0 057 1 1 0 0 0 0 2 www.ayurvedicmedicinalplants.com
    • 58 3 3 1 1 1 1 10 59 1 1 1 1 0 0 4 60 1 1 1 0 0 1 4 61 3 3 2 1 0 0 9 62 0 0 0 0 0 0 0 63 1 2 1 0 0 0 4 64 3 3 1 0 0 1 8 65 1 1 0 0 0 0 2 66 0 0 0 0 0 0 0 67 2 2 0 0 0 0 4 68 1 1 0 0 0 0 2 69 0 0 0 0 0 0 0 70 2 2 2 0 0 1 7 71 1 1 0 0 0 1 3 72 1 0 0 0 0 0 1 73 2 2 1 0 0 0 5 74 1 1 0 0 0 1 3 75 0 0 0 0 0 0 0Average 1.32 1.066667 0.44 0.386667 0.093333 0.733333 4.04 Appendix-6 Total score among the groups-last follow-upGroupA GroupB GroupC 12 2 0 4 5 1 9 3 1 6 2 1 6 3 1 5 0 2 5 3 4 10 0 1 3 5 2 8 3 2 8 0 0 16 3 2 5 15 1 9 8 2 7 6 0 5 4 3 6 5 2 11 2 0 6 0 2 10 4 4 www.ayurvedicmedicinalplants.com
    • 9 0 4 8 2 0 4 2 0 7 3 1 5 3 07.36 3.32 1.44 Dr. Abraham CN = Dr. Abraham, C = IN, O = www. ayurvedicmedicinalplants.com, OU = Ayurvedic Medicinal Plants I have reviewed this document Kannur, Kerala, India 2008.07.14 21:13:34 -0800 www.ayurvedicmedicinalplants.com