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A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH”IN THE MANAGEMENT OF SWITRAM (VITILIGO), K.NAMRATA, Department of Kayachikitsa, PG unit Dr.BRKR Govt. Ayurvedic College, HYDERABAD

A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH”IN THE MANAGEMENT OF SWITRAM (VITILIGO), K.NAMRATA, Department of Kayachikitsa, PG unit Dr.BRKR Govt. Ayurvedic College, HYDERABAD

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  • 1. 1 INTRODUCTION  The aim of medicine is to safeguard and rescue men from the consequences of their vices. Since its inception Ayurveda emphasizes on maintenance of positive health and alleviation of the diseases pestering humankind, among which skin diseases are one. Switra is a dermatological disorder having its references cited in the Vedas. Theterm is derived from “Sweth Varne” meaning white colour. It is basically a diseaserelated to hypopigmentation. Switra is also known as “Sweta Kustam” or “Kilasam”. Switra emerges as a sequel to irregular dietary habits, life style changes, andgenetic predisposition. Constant use of chemicals, cosmetics, plastic, rubbers, andpollution may accelerate the attack of the disease. The disease involves the skin and doesnot cause pain, ulceration or any secretions. Switra inflates an inferiority complex in thepersons affected. Skin is the vital organ involved in this disease. Skin being the largest organ of thebody and on the surface is continually exposed to injury. The colour of the skin plays animportant role as high cosmetic value is attributed to it. Colouring, tattooing, adorningwith jewellery are all part of skin appeal. The general state of the health is reflected in the appearance and condition of theskin and the earliest signs of many systemic diseases may be observed by inspecting it.As the skin is on the surface and it is on display patient with skin diseases are always inpublic eye. The greatest handicap of all is to be unwelcome and isolation by thecommunity. The functions of the skin are impaired in skin diseases making those moreaffected, more vulnerable and less able to reconstitute themselves after damage. 20-30%of skin diseases require serious attention. (Davidson) The disease Switra is one amongthem, as it causes immense mental agony and social embarrassment. A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 2. 2 Based on the clinical features of switra, it can be correlated to vitiligo of the thmodern medicine. Vitiligo on the face is ranked 17 by WHO in world’s most Disablingdiseases. Vitiligo is also an ancient malady having references cited in Bible and othercontemporary Texts. It is defined as a common acquired discolouration of the skincharacterized by well circumscribed, ivory or chalky white macules which are flush on tothe surface. Sometimes systemic, Cutaneous, ocular associations may be present. Thehair over the patch may be white or normal. Vitiligo occurs world wide with an overall prevalence of 1%. The higherincidence of the condition has been recorded in India from Asia, followed by Mexico andJapan. The incidence is 6% in Calcutta, 4% in Vellore, 8% in Amaravati, 2.9% in Goa,8.8% in Delhi. The difference of its incidence may be due to higher reporting of vitiligoin a population where an apparent colour contrast and stigma attached to the conditionmay force them to seek early consultation. Both males and females are equally affectedwith no predilection of sex. The age of first onset is below 20 years and the lower limbsare generally the site of first onset. The imperatives of its epidemiology both in rural India and in global arereckoning and have been highlighted. In spite of the latest advancements made in modernmedicine the etiology of vitiligo remains unknown. It is expected to be of autoimmuneorigin as it is associated to some of the autoimmune disorders. Occasionally it may bepossible to identify the triggering factors. An effective panacea for the disease could not be found till date. Generally topicalcorticosteriod therapy, topical PUVA, Oral Psoralen Photo chemotherapy or oral PUVA,Surgical techniques like skingrafting, other techniques like tatooing, camouflage creamsare employed to manage vitiligo. But all the above mentioned methods are associatedwith high risk factors, are expensive, and unsuitable for people living in differentclimatic conditions and the success rate is not commendable. A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 3. 3 Ayurveda offers absolution to many diseases among which switra is one.Innumerable yogas have been described to combat the disease. One such comprehensive formula is “Dhatri- Khadira Kwath” from BhaishajyaRatnavali, contemporary text of 19 A.D. A total of 30 patients were taken for this study and all the patients received thetreatment for 45 days. The medicine was administered in kwath form, followed by honeyas anupana. The main aim was to assess the efficacy of the formula in causingpigmentation in the white patches of switra. And three Clinical parameters – colour of thepatch, number of patches and size of the patches were taken into consideration to assessthe result. Present study is divided into five parts. The first part deals with review ofliterature of the disease, second part deals with drug review, third part deals with clinicalstudy – observations and results, fourth part deals with discussion, conclusion, summaryand fifth part deals with references, bibliography and annexure. Thus a humble step has been made to probe into various aspects of switra and itsmanagement with the trial drug. A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 4. 4 HISTORICAL REVIEWSwitra is an ancient malady and a historical background will facilitate continuity withcurrent research .Many earliest references of switra dating back to Vedic kala are foundand the contribution of our ancestors in combating the disease is known.For convenience sake time period is divided into:1. PRACHEENA KALA (5000 BC- 7 A.D )2. MADHYAMA KALA ( 8 A.D –15 A.D )3. ADHUNIKA KALA (16 A.D ONWARDS )PRACHEENA KALA (5000 BC- 7 A.D):VEDIC PERIOD: includes description of the disease in Rig, Yajur, Sama &Atharvavedas.RIG VEDA: a) Old looking unmarried princess Ghosa, the daughter of Kaksivana was cured of kusta roga and was made young and beautiful, and was married .1 b) Sujava was cured of kusta and rejuvenated and was married to a good looking 2 girl . 3 c) Diseases like kilasa and Palithya were described . d) Application of Bringraj, Harida , Neelika , Indravaruni in kusta ,palitya rogas .Here Sayanu interprets kusta as Svetha kustam. 4YAJUR VEDA: There is a reference of moon being affected by the disease.5 A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 5. 5ATHARVA VEDA: a) There is a refernce in Atharva Veda that white coloured patches appear in a disease called Sweta kusta, and when it penetrates into deeper dhatus it is called Kilasa kusta .6 In this context “ASIKINI “and “RAJINI” are the drugs used which are veryimportant in the disease.SAMA VEDA : No references found in this veda.Aitheraya Aranyaka: Sage Bharadwaja mentioned twak, mamsa .rakta are derived frommother and in a stage all the three are affectedDuring Uanishad period Asvatayana mentioned maharogas .Narayana interprets Kusta 7as one among them.In Mahabharata (400 B.C) mentioning of many twag doshas are found but no specialreference of Switra is found.Puranas (500 B.C) were influenced by the medical concepts and description of manydiseases are found in them.Padmapurana mentions kusta and Switra as diseases caused due to the imbalance of the 8tridoshas.Markandeya purana mentioned two girls suffered with this disease and were eventuallycured 9It is regarded by this purana that all twag rogas are due to past life sins.Vayu purana regarded kusta and kilasa to have evolved due to faulty practice of yoga 10. A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 6. 6 11Vishnu purana mentioned a wide variety of skin diseases in sharirika rogas .Inanatomical chapters a detailed description of embryological development of organs isfound and seven layers of skin have been described in this context.Itihasa purana mentioned switra among several diseases caused due to derangement ofthe doshas .Sins or the papakarmas are considered to play a major role in causing the skindiseases in particular .12.Brahma vaivartha purana mentioned many skin diseases under the heading GALITHA 13VYADHIS among which switra is one.Agni purana mentioned kusta as a broad term to describe all the skin diseases includingswitra.In Yagnavalkya smriti skin or the twacha has been described having six layers and allthe diseases arise from these layers .14Manu smriti (200B.C-200 A.D) has clearly mentioned that a stealer of clothes suffersfrom switram .It is aquainted as hereditary disease and people suffering with this diseaseare not eligible for marriage . 15OTHER LITERATURE DURING VEDIC PERIOD:Other than the Indian literature, earliest references of the condition can be traced back tothe period of Aushooryan (2200 B.C) in the classic TARIKH –E-TIL-IRAN.16Pharaonic medicine in the ebers papyrus (1500B.C) described two types of diseasesaffecting the colour of the skin. a) With tremors probably leprosy b) with colour changeprobably Vitiligo .The latter was said to treatable . 17In Arabic medicine the terms “BOHAK “BAHAK” ‘BARAS’ are the terms mentioned todenote a similar condition like Vitiligo.18In Bible the term “ZORAAT”denotes Vitiligo.19 A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 7. 7In Japanese literature (1200BC) SHIRABITO is the term used for the condition like likeswitra . 20SAMHITA KALA:Charaka samhita: In this treatise switra is described in the kusta roga chapter .Adetailed description of the disease is found in this text.A special etiology is mentioned forswitram, types and treatment has been vividly described .21 thSushruta samhita: Has also described switra in a detailed fashion.In nidana Stan 5 22chapter description of the disease is found .Bhela samhita; Bhela included switra in eleven kshudra kustas and mentioned it as 23asadya roga .Harita samhita :did not give a detailed description of the disease but mentioned a stealerof clothes and money is prone to get this disease .And arista lakshanas of kusta rogas arementioned and said to be applicable to switra also. 24Kashyapa samhita: included switra in eleven types of kshudra kustas .Five types are 25mentioned but no names and clinical features are found .it is said to be a asadya vyadhi.SANGRAHA KALA;Astang Sangraha: switra as a bahya vikruti and in sutra Stan mentions that using a 26poisonous jalouka for rakta mokshanam shall cause the disease .Astang Hrudayam: describes switra as a separate disease .Etiology, types, clinicalfeatures, prognosis and treatment are clearly mentioned .Vagbatta has considered switrato a medical emergency as delayed medical intervention may lead to completedepigmentation. 27 A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 8. 8MADHYAMA KALA (8 A.D. - 15 A.D):Vangasena: a text book of 10 A.D describes about the etiological factors responsible forthe disease. Specially seven dietary factors are mentioned which cause kusta rogas.The 28etiology of kusta and switra are considered same .Madhava Nidan: a special text on etiology of different diseases describes switra in49thchapter .complete description of the disease is found vividly in this book.29Sharangdhara samhita :( 11-12 A.D) has mentioned the etiology of kusta and switra tobe same and mentioned three types of the disease based on the involvement of thedhatus . 30BhavaPrakash: written by Bhavmisra has given a detailed description about the diseasethe etiology, types ,clinical features ,prognosis and treatment have been in the text.31BUDDHIST LITERATURE:Tripitika literature is the oldest source to have a glimpse of Indian medicine inBuddhist tradition. It is mentioned that kusta, kilasa, ganda, sosa, apasmara, are fiveprevalent abadhas.Vinaya pitam mentioned the disease kilasa i.e spotted deer 32.Sardulakarnavadana: In this book Ayurveda is mentioned along with four vedas.Kushta and kilasa are mentioned seperately33.Lalithavistara: One among the nine important texts deals with the advent of LordBuddha and his teachings. In this context those diseases caused by vata, pitta, sleshmaand sannipata diasease of kushta and kilasa34Saddharmapundarika: Diseases like kusta and kilasa are mentioned seperately35JAIN TRADITION: 16 diseases are enumerated among which leprosy is one. thKalyanakaraka: By Vugraditycharya. 20 chapters are present. From 8 chapter onwardsdiseases are mentioned. Kusta is one among mahamayas. A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 9. 9OTHER NON-MEDICAL SOURCES: th ndPanini (7 B.C): Sutras were annotated by patanjali in 2 B.C. Kusta and Kilasa arementioned separately.Kautilya’s Arthasastra: (321-297 B.C) In a chapter on secret means, a number ofdiseases has been mentioned among which kusta is one. In this disease this physician’s 36certificate is honoured.Bana Bhatta (606-648 A.D): In Harsacharitra and Kadambari mentioned the concept ofhealth and described Switra separately. 37Amarakosha (600 A.D): Has mentioned switra separately and terms like “Padasphota”,“Twak pushpi” are mentioned in this context. 38ADHUNIKA KALA (16 A.D ONWARDS):Yogaratnakar: mentioned switra as kilasa and described it in kusta chapter.Bhaishajya Ratnavali: switra is described in kusta roga adhikar. Treatment of switra isdescribed with various formulations . 39RESEARCH WORKS DONE IN VARIOUS INSTITUTIONS :1. Dr.Sheela ratna M.V, Switra roga and its management Mysore 1979.2. Dr.Patil A.K, Survey of Switra in Jamnagar and Vicinity in reference to its nidana and Chikitsa .Jamnagar 1984.3. Dr.Upadhyaya R.K, Therapuetic assessment of some Ayurvedic drugs in treatment of Vitiligo.Varnasi 1985.4. Dr.Shankaran.K, Managament of Switra with special reference to Bakuchi Trivendrum 1986. A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 10. 105. Dr.Lahiri P.K, Clinical studies and management of Switra kusta (leucoderma) with Ayurvedic drugs, Calcutta 1987.6. Dr.PrithviRaj, Concept of switra and its management in Ayurveda, varnasi1988.7. Dr.ThakoreS.R, Switra mein Kakodumbara ka Prayogika Adhyayan. Ahmedabad1989.8. Dr.Srikanth Babu, Evolution of Kakodumbaradi yoga in management of Switra. Mysore 1992.9. Dr.Sharada C.L, Clinical study of Switra (leucoderma) and its management with kakodumbara and manahshiladi lepa.Jamnagar 1993.10. Dr.Kambale.S, Switra kustavar nidana parivarjana aushadhi (bavanchi) ani aharacha parinama.Nanded 1996.11. Dr.Prabhakar.Shinde, A Clinical study of the effect of Somarajyadi churnam (int) and Somarajyadi lepa (ext) in Switra .Hyderabad 1996.12. Dr Seeta Devi.P .A clinical study on the effect of lepa in Switra .Mysore 2003.13. Dr.Venugopal CH, A clinical study on the effect of kaseesabadda ras (int) with and without chitraka lepa in Switra (VITILIGO) Hyderabad 2003.14. Dr.Mahantesh P.M, A Comprehensive management of kilasa kusta Vitiligo).Hubli 2006. A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 11. 11 NIRUKTIThe term switra is derived from “swith” dhatu meaning white colour. Rak pratyaya isadded and letter “kha” is deleted.It belongs to napunsaka gender. Swith +ra = Switra40 Switra =Sweth varne switraThe term indicates a disease where white coloured patches appear on the skin. Switra is analogous to the disease vitiligo in the contemporary medicine .Theterm Vitiligo is derived from latin word “vitium” meaning defect .41 Documentation of 42the word is present in the book De-Meedicina by the Roman Physician Celsus . A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 12. 12 PARIBHASHAThe definition of Switra is given by all the ancient classics .The acharyas who havedefined switra primarily suggested that this is a disease related to impairment of colour.The term Switra is derived from “sweth varne switra” meaning white colour. 43Amarkosha defined switra as “Swetate twaganena Switram” meaning ‘white colourof the skin’.Shabda kalpa drumam defined it as “Swetate itihi” meaning white colour . 44Kashyapa samhita defined Switram as “Sweta bhavamicchanti switram” meaning 45reflection of white colour .Sushruta defined it as “Twagatam eva aparisravi “one which involves only the skin andhas no oozing tendency.46The essence of all the above mentioned, indicate Switra as a disease in whichhypopigmentation is a cardinal feature.Vitiligo is defined as a dermatological disorder characterized by milky white patchesdevoid of melanocytes .It bears resemblence in having a progressive tendency and 47genetic predisposition. A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 13. 13 SHAREERA RACHANAIntroduction: “Twak’ or the “Twacha” are the analogous names to identify the skin inAyurveda. It is one of the largest organs which cover the entire external surface area ofthe body. Twak is aptly defined as “Twach Samvarne” 48 meaning the one which covers. Itcovers the entire external surface of the body protecting the underlying rakta, mamsa, 49medo dhatus . The skin forms a self renewing, self repairing interface between the bodyand the environment.Embryonic Development of Twak:- A perfect combination of healthy sukra and 50sonitha leads to the formation of an healthy embryo . The pancha maha bhutas actaccordingly on the embryo leading to the formation of various anga – pratyangas.Amongst the five, Vayu helps in the division of the cells, and Tejo maha bhuta helps inthe maturation and specialization of the cells forming different layers of cells of differentorgans. Sushruta opined that as the cream is formed over the boiling milk, the variouslayers of the skin are also formed and deposited on the rapidly forming product of thecombination of sukra & sonitha.51 Vagbatta described that during the process of cooling (Processing) of the blood,the layers of twak are formed, and the purity of the skin lies in the purity of blood. 52Sushruta described seven layers of the skin, Charaka 53 and Vagbatta54 described sixlayers of skin. Twak is derived predominantly from vayu and akash mahabhutas and itsadhistana devata is vayu 55. Twak is one of the pancha gnanedriyas56 and its indriyartha isSparsha57, its indriya buddi is Sparshana58. 59 The entire body is a combination of three doshas, Sapta dhatus and three malas .Skin also being a part of this body is composed of vata, pitta and kapha. It is an upadhatuof mamsa dhatu. Sweda is excreted through the skin. A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 14. 14 The tridoshas have their respective role to play in the twak. The skin being the 60 51.seat of vata it does the sparsha grahana, pitta helps in imparting the colour and lusterKapha gives the mrudutwa and snigdatwa to the skin.62 In the process of formation of various dhatus, the mamsa dhatu is derived from 63 64rakta dhatu. The prasada bhagha of mamsa dhatu is subdivided into vasa & twak.These two are nourished by the mamsa dhatu. Apart from receiving nourishment from itsparent dhatu, twak is also nourished by numerous rasavahinis. Sometimes the rasa andtwak become analogous, twak Sara person is considered as rasa Sara also65. Twak is considered to be a rasaja bhava by the virtue of its property to reflect the 66varna.LAYERS OF THE SKIN: st 671 Layer: is named as “udakadhara” by charaka and is believed to contain waterysubstance such as rasa or lasika (body lymph). Sushruta named it as ‘avabhasini’ whichmeasures 1/18vreehi; this layer reflects the colour and complexion of the skin 68.Vagbhatta named it as “bhasini”. It is the site for manifestation of sidma andpadmakantakam. nd2 Layer: is named as ‘asrgdhara’ by charaka as it contains blood capillaries. Sushrutanamed it as “Lohita”. It measures 1/16 vreehi. Vagbhatta named it as “Lohini”.Cutaneous infections like Tilakalaka, Nyaccha, and Vyanga are manifested here. rd3 Layer: Unnamed by charaka, Sushruta named it as “sweta” it measures 1/12 vreehi.It is the site for manifestation of Charmadala, Ajagillika, and Mashaka.Charaka describedthis layer to be the seat for Sidma & Kilasa.4th Layer: Not named by charaka & Vagbhatta but explained it to be the site for all thvarieties of kusta and dadru. Sushruta named it as ‘Tamra’ measuring about 1/8 vreehiand seat for various types of kusta and kilasa. A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 15. 15 th5 Layer: Not named by Charaka and Vagbatta but explained diseases like alaji, and thvidradhi being manifested here. Sushruta named this layer “vedini” measuring about 1/6of vreehi. And diseases like kusta and visarpa are explained here.6th Layer: Not named by Charaka but Vagbhatta named it as “pranadhara” the supporterof life and seat for diseases like arumshi. Excision of which leads to tremors and enteringto darkness. Any manifestations are deep rooted here and difficult to treat. Sushrutanamed this layer as ‘Rohini’ which measures 1 vreehi. Grandhi, arbudas, apache, slipada,galaganda are manifested here. All muscular outgrowths are noted here. th7 Layer: Named by sushruta as “Mamsadhara”. The deepest layer, thickness is doublethe vreehi, and diseases like Bhagandara, Vidradhi are manifested here. All the diseasesinvolving mamsa and rakta dhathu are explained here. 69According to Charaka :Table -1S.No. Name of the Layer Function Diseases 1. Udaka dhara Protects the loss of body fluids - 2. Asragdhara Reservoir of blood - 3. Tritiya - Sidma, kilasa 4. Chaturtha - Dadru, Kusta 5. Panchami - Alaji, Vidradi 6. Shasti - Tremors and darkness before eyes. A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 16. 16According to Sushruta70:Table -2 S.No. Name of Thickness Function Diseases the layer1. Avabhasini 1/18 Vreehi Reflection of Sidma, Padma Kantakam colour & complexion2. Lohita 1/16 Vreehi - Tilakalaka, Nyaccha, Vyanga3. Swetha 1/12 Vreehi - Charmadala, Ajagallika, Mashaka4. Tamra 1/8 Vreehi - Kilasa & Kusta5. Vedini 1/6 Vreehi - Kusta & visarpa6. Rohini 1 Vreehi - Granthi, Apacchi, Arbuda, Galaganda, Sleepada7. Mamsadara 2 Vreehi - Bhagandara, Vidradi, ArsasAccording to Astangahrudaya 71:Table -3S.No. Name Function Diseases of the layer 1. Bhasini Expresses Colour and five - shades of complexion 2. Lohini - - 3. Swetha - - 4. Tamra - - 5. Vedini - - 6. Rohini - - 7. Mamsadhara - - A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 17. 17 ANATOMY OF THE SKIN Among the three primary germ layers of the embryo, the epidermis is derivedfrom the ectoderm-the outer most primary germ layers. At the beginning of the secondmonth the ectoderm consists of simple cuboidal epithelium. These cells flatten and areknown as Periderm. By the end of fourth month, all layers of the epidermis are formed and each layerassumes its characteristic structure. The dermis is derived from wandering mesodermal cells. The mesenchymebecomes arranged in a zone beneath the ectoderm and there undergoes changes in theconnective tissues that form the dermis. Nails develop during third month from ectoderm. Hairfollicles develop betweenthird & fourth month from the ectoderm. By the fifth and sixth month follicles producedelicate hair called lanugo which usually shed before birth. The secretory portions of sebaceous and sudoriferous glands are derived fromectoderm. The connecting tissues and blood vessels associated with the glands developfrom mesoderm.Microstructure of the Skin:Epidermis: is a compound tissue consisting mainly of continuously self replacingstratified keratinized squamous epithelium. The principle cells of which are calledKeratinocytes. Other Cellular elements of different developmental orgin within themature epidermis includes melanocytes or the pigment forming cells from embryonicneural crest. Langercells are immunocompetent antigen presenting cells derived frombone marrow. Other cells are Lymphocytes. These disparate cells are collectivelyknown as non-keratinocytes or epidermal immigrants. Neurally associated Merkel cellsare now thought to be modified Keratinocytes. A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 18. 18 Sensory nerve endings are also sparsely present within the epidermis. Eachcomponent has an individual primary function, but the fact of there intimate spatialassociations and of functional interactions has led to the concept of epidermal symbionts. The population of keratinocytes undergoes continuous renewal through out thelife a mitotic layer of cells at the base replacing those shed at the surface. As they moveaway from the base of the epidermis, the keratinocytes undergo progressive changes inshape and content full of protein keratin, a process known as keratinisation. It is usual to divide the epidermis into number of strata from deep to superficial asfollows, S.basale, S.spinosum, S.granulosum, S.lucidum and S.corneum. The first threeof these layers are metabolically active and often grouped together as the stratummalpighi. The more superficial strata of cells achieving terminal keratinazationconstitute the cornified zone.1. Stratum basale: This includes the deepest layer of cells adjacent to the dermis andappears to rest upon a continuous narrow ‘basement membrane’ which includes the basalplasma membrane of the cell, a basal lamina consisting of lamina lucida and laminadensa, and a dermal reticular lamina. This area is also known as epidermal – dermaljunction. The cytoplasm contains the common cellular organelles, melanosomes andmany cytoskeletal intermediate filaments. The plasma membranes of the opposed cellsare connected by desmosomes and the basal plasma membrane has hemidesmosomes.Melanocytes, Langerhans cells and Merkelcells are interspread among the basalkeratinocytes.2. Stratum spinosum (Prickle Cell Layer): This contains several layers of maturekeratinocytes packed closely and inter digitating by means of numerous projections andindentations of the cell membrane which are linked by many desmosomes giving thenspiny appearance, hence also called as Prickle cell layer. The cytoplasm contains thecommon organelles including some lysosomes and melanosomes. Langerhans cells and A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 19. 19the occasional associated lymphocytes are the only non -keratinocytes present in thestratum spinosum.3. Stratum granulosum: In this stratum three to four layers of flattened cells withextensive changes in Keratinocyte structure occurs . The nuclei become pycnotic andbegan to disintegrate, the membraneous organelles such as mitocondria, golgi membranesand ribosomes degenerate, and keratin filament bundles become more compact andassociated with Keratohyalin granules. Small round granules with a lamellar internalstructure also appear in the cytoplasm. The lamellar granules are concentrated deep to theplasma membrane of the granular cell with which they fuse liberating their predominantlylipid content in to the intercellular space not only of this stratum, but also into the spacebetween it and the stratum corneum. They form an important component of thepermeability barrier of the epidermis, langerhans cells may occasionally be seen at lowerlevels of stratum granulosum.4. Stratum lucidum: Only found in thick glabrous palmo-plantar skin, this layerrepresents poorly understood stage in Keratinocyte differentiation. Ultrastructurallyresembles the transitional cell, an incompletely keratinized cell occasionally seen in theinnermost layer of the statum corneum of non-glabrous skin.5. Stratum corneum: This stratum is the final product of epidermal differentiation orKeratinazation. It consists of closely packed layers of flattened Polyhedral Corneocytes.These cells overlap at their lateral margins and interlock with cells of opposed layers byridges, grooves and microvilli. In this skin the statum may be only a few cells deep, but inthick skin it may be more than 50 cells deep. The interior of this corneocyte is devoid ofnucleus and membraneous organelles, consisting solely of a dense array of keratinfilaments embedded in an interfilmentous matrix partly composed of filaggrin derivedfrom keratohyalin granules. Desquamation of the outer layers of the stratum corneum involves a poorlyunderstood loosening of attachments (desmosomes and inter cellular substances) betweenthe cells, probably involving enzyme action and is normally imperceptible, when A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 20. 20execessive, it appears in hairy regions as dandruff and more massively in certain diseasesas peeling, scaling, and exfoliation. Langerhans cells are not present in the stratumcorneum and therefore are not desquamated.Melanophages are macrophages which have ingested performed melanin andmelanphores or dermal melanocytes, within which melanin can be rapidly aggregated ordispersed to change body colour in adaptation to environmental backgrounds. Embryonic precursors of melanocytes migrate from the neural crest to enter theepidermis as melanocytes from about eight gestational weeks. It is estimated that a singlemelanocyte may be in functional intact via its dendrites with up to 30 Keratinocytes toform an entity called the epidermal melanin unit. Melanocytes decrease significantlyin number in old age and are absent from grey hair. EPIDERMAL MELANOCYTES AND SKIN PIGMENTATION Melanocytes are melanin pigment forming cells derived from the neural crest andwidely distributed throughout the body in vertebrates. In humans they are present in theepidermis and its appendages, in oral epithelium, some mucous membranes, the uvealtract of the eyeball, parts of the middle and internal ear and in the leptomeninges at thebase of the brain. The cells of the retinal pigment epithelium, developed from the outerwall of the optic cup, also produce melanin, and neurons in different locations within thebrain stem synthesize a variety of melanin called neuromelanin. True melanins are complicated,high molecular weight polymers attached to astructural protein (to form melanoproteins) and in humans there are two classes, thebrown black eumelanin and redyellow Phaeomelanin both derived from tyrosinecatalysed by the enzyme tyrozinase . The dermis is for the survival of the epidermis andimportant morphogenetic signals are exchanged at the interface between the epidermal-dermal junction during development and postnatally. The dermis can be divided intosuperficial papillary layer, and a deeper reticular layer. A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 21. 21Dermis: The dermis is an irregular, moderately soft connective tissue, with a matrixcomposed of an inter woven collageneous and elastic network in an amorphous groundsubstance of glycosamino glycans, glycoproteins and bound water, which accommodatesnerves, blood vessels, lymphatics, epidermal appendages and a changing population ofcells. The dermis provides considerable strength to skin by virtue of the number andarrangement of its collagen fibres, which give it tensile strength and it has elastic recoil,because of its elastic fibres.Layers of dermis:1. Papillary Layer:- This is immediately deep to the epidermis and is specialized to provide mechanical anchorage, metabolic support and trophic maintainance to the overlying tissue as well as housing rich networks of sensory nerve endings and blood vessels. Its superficial surface is marked by numerous papillae which interdigitae with recesses in the base of the epidermis and form the dermal- epidermal junction at the interface. The papillae have round or blunt apices which may be divided into several cusps. In skin especially in regions with little mechanical stress and minimal sensitivity, papillae are few and very small, while in thick skin of the palm and sole of the foot, they are much larger, closely integrated, and arranged in curved parallel lines following the pattern of ridges and grooves typical of these surfaces. Lying under each epidermal ridge are two longitudinal rows of papillae or either side of epidermal retepegs through which the sweat ducts pass on the way to the surface. Each papilla contains dense collagen fibres, elastic fibrils, microfibrils, attached to the basal lamina. Also present in thick hairless skin meissner’s corpuscular nerve endings.2. Reticular Layer: This merges with the deep aspect of the papillary layer. Its bundles of collagen fibres are thick than those in the papillary layer and interlace with them and with each other form a strong yet deformable three dimensional lattice in which many fibres are parallel to each other and within which lies a variable number of elastic fibres. The Orientation of the collagenfibres may be related to the direction of action of the mechanical forces to which the dermis is subjected and may be involved in the development of the skin surface lines. A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 22. 22ULTRASTRUCTURE OF MELANOGENESIS: Melanocyte is a dendrite non-keratinocyte, lacking desmosomal contacts withapposed keratinocytes. The nucleus is large round and euchromatic. In the cytoplasm are intermediate filaments, a prominent golgi complex andvesicles, associated granular endoplasmic reticulum, mitochondria and coated vesiclestogether with a characteristic marker organelle, the melanosome. The melanosome is a membrane bound structure which undergoes a sequence offour developmental stages during which melanin is synthesized and deposited within it bythe tyrosine – tyrosinase reaction. Stage –I Stage I melanosome is spherical vacuole, derived probably from the rough endoplasmic reticulum, and containing filamento - amorphous structural protein and vesiculo globular bodies. Stage-II Stage II Eumelanosomes become spherical or ellipsoid and the inner matrix becomes organized into filamentous sheets exhibiting a 9nm periodicity. Stage-III At Stage III melanin begins to be deposited on the innersheets, gradually observing their arrangement, until densely pigmented. Stage-IV is reached, exhibiting no other internal structures apart from non- melanized vesiculo globular bodies. Phaeomelanosomes retain their spherical shape throughout all stages. A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 23. 23 In most active melanocytes, melanosomes of the four stages are present. Whenmature, stage IV melanosomes move into the dendrites along the surfaces ofmicrotubules and are transferred to keratinocytes by a special type of phagocytosis, withsubsequent liberation of melanosomes into the keratinocytes cytoplasm. Hence colour of the skin plays a vital role in protecting the humans from variousphysical, chemical agents and harmful effect of sunlight.APPENDAGES OF THE SKIN: Organs that develop from the embryonic epidermis – hair, sweat glands,sebaceous glands, nails ceruminous glands, have a host of important functions toperform. Hair and nails protect the body. The sweat glands help regulate bodytemperature. The sebaceous glands produce an oily substance the sebum and ceruminousglands provide waxy secretion in the ear canal. Skin along with its appendages forms theintegumentary system72-73. A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 24. 24 SHAREERA KRIYA Ayurveda defines “Shareera” as “Sheeryate iti Shareeram” means the one whichconstantly undergoes wear and tear. This applies to all the organs which constitute theshareera, particularly the skin. As defined by Shabdakalpadrumam. “Twachati Samvrunoti medo shonithadikamiti”74 Twak covers the underlying rakta, mamsa, medo dhatus. Twak not only covers theentire body area but also forms a strong physical barrier against microbial invasion. Itprotects the body against mechanical, chemical, thermal, osmotic and photo damage. It ismajor site of inter communication between the body and environment. Second vital function of the twak is to impart Varna or the colour to the body andits structures. It reflects the luster and brilliance present in it. The Varna of an individual is determined in the embryonic stage of life. It is arasaja bhava75. The tejomahabhuta is the main factor in determining the varna76. The kindof food taken during pregnancy also determines the colour. The four prakrut varnasformed by the combination of different mahabhutas.  Tejo+Jala = Gouravarna  Tejo+Prithvi = Krishna varna  Prithvi + Akash = Krishna – Shyama  Jala + Akash = Goura – Shyam Charaka has attributed the Varna aspect to the udana vata (one among 77panchavidha vatas). The vital functions of Pitta are mentioned as production of normaland abnormal temperature in the body as well as normal or abnormal colour of the 78.Skin Among the five types of Pitta, imparting colour to the skin is a specializedfunction of the Bhrajakapitta 79. As pitta is involved in the above said function, kaphabuilds the texture of the skin making it supple, shiny and strong.80 A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 25. 25 There are two major aspects of varna-(i) Prabha (brilliance of the skin) (ii) Chaya(Substratum of the colour) Prabha is of 7 types- rakta, Peeta, Sita, Syava, Harita,Pandura, Asita. Prabha specifies the colour of an individual. Chaya is of 5 types, 81according to the panchamahabutas . Nabhasi, Vayavi, Agneeyi, Ambasi, Parthivi and isthe substratum of the colour. Prabha is reflected to farther distance but chaya can beappreciated only from a close view. Prabha and chaya are inseparable aspects of Varnaand their reflection is the vital function of Prakrit pitta. In a deranged state, pitta exhibitsabnormal colours. Amongst the dhatus, twak is closely related to rasadhatu. It derives nutrition fromthe rasadhatu through its channels. The texture of the skin is depended on the quality of 82nutrition provided Sweda, which is a mala of medodhatu, is expelled out through skin. But in normalstate it acts like a dhatu. It is held in the skin, thereby moisturizing it83. Tridoshas have their own specific properties by the virtue of which they perform 84various functions. “Ushma” is the inherent property of pitta, which enables it performthermoregulation and helps in eliciting the lustre of the skin 85Applied aspect: 86 In ksheena avastha of pitta “Prabhahani” is noticed If pitta prahopakara diet is consumed it vitiates pitta causing digestion of the cells 87 producing colour to the hair leading to a condition called “Palityam” In a vitiated state vata, pitta and kapha exhibit black, yellow and white colour respectively. 88 A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 26. 26BHARAJAKA PITTA & ITS FUNCTIONS: It has been specified by sushruta that production of colour, exhibition of luster ofskin are the functions of Bhrajakapitta 89 The word Bhrajaka is derived from “Bhraj Dhatu meaning “Deepti” or “Kanti”‘Sushruta’ mentioned that Bhrajaka pitta resides in the skin. ‘Dalhana’ Commented that 90Bhrajakapitta resides in the bahyatwak i.e. avabhasini. Hence it is mentioned in thereference of avabhasini that its main function is reflection of colour & luster. Vagbatta also stated that Bhrajaka pitta is located in the skin and reflects the 91radiance of the skin. Arunadutta commented that Bhrajaka pitta performs functions like 92“deepana” “Pachana” of the substances used for abhyanga, lepa, Parisheka Chakrapani mentioned that variations in the body temperature and colour are the 93functions of bhrajaka pitta . Dalhana stated absorption and digestion of the substances used together with oilsand decoctions used for sprinkling over the body is also done by the Bhrajakapitta. Bhela Samhita has also described the function of Bhrajakapitta as providingushma and Prabha to the body94 .Hence it can be concluded that Bhrajaka pitta resides inthe avabhasini the first layer of twak and performs vital function like. Providing luster and brilliance to the skin. Helps in thermoregulation of the body. Capable fo presystemic metabolism of drugs and other substances applied topically through the process of “abhyanga” “parisheka” “avagahana” & “lepa”.Applied aspect: Any derangement in the Bhrajakapitta functions leads to alteration ofskin colour and impaired thermo regulation. In the present disease switram, pathology isnoted due to the impairment of this pitta. A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 27. 27 The third vital function of twak is thermo regulation. By the virtue of pitta(Bhrajaka) located in the skin this function is performed. “The Ushma” property of pittaaides in this function. Any derangement of pitta leads to “mandoanala” condition and“Sheetam” 95 abnormal cold sensation to the body. The fourth important function of twak is being a sensory organ. Twak is one 97 97among the pancha gyanendriyas . It is seat for the vata . And “Sparsha” or the tactilesensation is the inherent property of vata98 among the panchavidha vatas; the Pranavatacontrols all the indriyas99. All kinds of sensations like touch, temperature, pain, pleasureare perceived by the skin. The fifth function of the skin is excretion. It is the channel for the excretion ofsweda which is considered as a mala of the body. If sweda is not generated sufficiently itleads to bad odour, Cracks in the skin and hairfall. 100 Sixth function of the twak is to act like channel or marga. Twak is categorized 101under shakha along with other dhatus and shakha is classified under bahyarogamarga102 .This rogamarga help in manifestation of the diseases and prognosis can beknown. Certain shodhana procedures are done to transfer the dhoshas from shaka tokosta. Hence skin or twak also acts as a channel. It also lodges the nakha and smashruwhich are the malas of asthi. Hence, it can be said that the twak is a tridoshaja bhava in which vata acts as ainitiative principle pitta acts a metabolic principle and kapha is a preservative principle. A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 28. 28 PHYSIOLOGY OF THE SKIN The skin is the largest organ of the body, being on the surface and continuallyexposed to injury. It has to be both strong and supple to resist the wear and tear. It formsthe integumentary system along with its derivatives like hair, nails, sweat and sebaceousglands. It forms about 8% of the total body mass and its surface area varies with heightand weight.Functions of the skin:1. Protection: The skin covers the entire body. It forms self renewing and self repairing interface between the body and its environment it is major site of inter communication in both directions between the two. Within limits it forms an effective barrier against microbial invasion, and has properties which can protect against mechanical, chemical, osmotic, thermal and photo damage.2. Thermoregulation:- In response to high environmental temperature of strenuous exercise, the evaporation of the sweat from the skin surface lowers an elevated body temperature to normal. In response to low environmental temperature production of sweat is decreased, which helps to conserve heat. Apart from this, changes in the blood flow also regulate body temperature. The rich vasculature of the skin has a generous rescue to meet the requirements of wounding and repair, so common on surface. Dilatation can increase the flood flow 100 fold, assisting the thermo regulation.3. Sensation: Skin is a major sense organ, richly supplied by nerve terminals and specialized receptors for touch, temperature, pain, pleasure stimuli.4. Excretion: Besides removing heat and some water from the body, sweat is also a vehicle for excretion of small amounts of salts and several organic compounds. A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 29. 295. Synthesis of Vitamin D: It can be regarded as endocrine organ as it carries out many biochemical synthetic processes (Boyce 1994) including formation of vitamin D. It can synthesize vitamin D from calciferol in the presence of sunlight. Apart from synthesizing vitamin D it also helps in the synthesis of cytokines and growth factors. Cytokines include inter leukins, interferons.6. Immunity: It is an important site of immuno-surveillance against the entry of antigens and initiation of primary immune response.7. Frictional property: Skin has good frictional properties, assisting in locomotion and manipulation by its texture. It is elastic, and can be stretched and compressed within limits. It is capable of absorption and excretion and selectively and regionally permeable to a variety of chemical substances.8. Skin Colour: The colour of human skin derives from and varies with the amount of blood (and its degree of oxygenation) in the cutaneous circulation, the thickness of the stratum corneum and the certainty of specialized cells producing the pigment melanin. Melanin has protective role against ultraviolet radiation, and acts as a scavenger of harmful free radicals produced under this and other circumstances. Racial variations in the colour are mainly due to the differences in the amount, type, distribution of melanin and are genetically determined. The anterior pituitary gland or the adeno hypophysis secretes hormones thatregulate a wide range of bodily activities including skin pigmentation. Some cortiotrophsof remnants of pars intermedia secrete MSH – melanocytes stimulating hormone whicheffects the skin pigmentation. MSH increases skin pigmentation by stimulating thedispersion of melanin granules in melanocytes in amphibians. Its exact role in humans isunknown. Three pigments, melanin, carotene and haemoglobin give colour to the skin.Melanin is located mostly in the epidermis, carotene in dermis and haemoglobin in thered blood corpuscles. A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 30. 30 The amount of melanin varies the skin colour. Melanocytes are most plentiful inthe nucous membrane, penis, nipple of the breast, areola, face and he extremities. Thenumbers of melanocytes are same in all the races but the amount of melanin produceddecides the colour. Melanocytes synthesize melanin from the amino acid tyrosine, in the presence ofan enzyme tyrosinase in an organelle melanosome. Exposure to ultraviolet radiationincreases the enzymatic activity leading to the darkness of the skin which further protectsthe body from ultraviolet radiation. In this condition called VITILIGO there is partial or complete loss of melanocytesfrom patches of skin thereby producing hypopigmented spots. The colour of the hair isalso due to the substance melanin, absence of which causes white colour of the hair. Thecells melanocytes are scattered in the matrix of the bulb of the hair.TYROSINASE, AND SYNTHESIS OF MELANINS: Tyrosinase is a copper containing metallo enzyme, present in the form of several isozymes, which catalyses initial stages of the synthesis of tyrosine – melanin. It is formed by ribosomes on the granular endoplasmic reticulum, conveyed to the golgi complex, glycosylated and incorporated into coated vesicles which attach to the limiting membrane of the stage I melanosome, liberating active enzyme. A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 31. 31ILLUSTRATION-1: The first two steps include oxidation of tyrosine to DOPA OXIDATION TYROSINE DOPA TYROSINASE Oxidation of DOPA to Dopaquinone OXIDATION DOPA DOPAQUINONE TYROSINASE In eumelanin synthesis, dopachrome is formed converted into dihydroxyindoles and 5-6 dihydroxy indoles, 2-dicarboxylic acid. Dopaquinone Dopachrome Dopachrome Oxido Dopachrome tautomerase reductase 5-6 dihydroxy indoles and dihydroxyindole 2-dicarboxylic acid s The final stages in the pathway to melanin essentially involves complex polymerizations in which tyrosinase may again be involved. In phaeo melanin synthesis, the amino acid cysteine is added to dopaquinone to form 5-S cysteinyldopa. Most natural melanins are mixture of eumelanins and phaeomelanin A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 32. 32FUNCTIONS OF MELANINS: Melanin has biophysical and biochemical properties related to its functions in the skin. It protects against the damaging effects of the ultra violet radiation on DNA through its special absorptive electron-photon coupling and amorphous semiconductor properties, whereby it can absorb any different types of energy and dissipate them in the form of vibrational modes or heat. Its redox capacity makes it an efficient scavenger of damaging free radicals, however generated, and its ability to bind to a variety of metal ions and drugs suffest it can act as an anti toxic agent. However, if the energy input is too great, these properties can be expressed in the output of toxins activated, chemical species which can be damaging. Another disadvantage is that a high concentration of melanin in relation to incident solar UV may adversely affect synthesis of vitamin D.DETERMINATION AND CONTROL OF MELANIN PIGMENTATION: Melanin Pigmentation of human skin can be analysed in two bases (1) Constitutive (2) facultative Constitutive pigmentation is the intrinsic level, genetically determined. Facultative pigmentation comprises reversible changes induced by environmental agents eg: UV and X-radiation, chemicals and hormonal influences. Genetics: Specific genes can influence differentiation of neural crest cells into melanoblasts, and also melano blast migration to the skin, their differentiation with melanocytes and morphological features of these such as shape, size, and A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 33. 33 length of dendrites, which in turn determine the size of the pool of keratinocytes to which each cell transfers its melanosomes. Other genes acting primarily within the melanocyte control the synthesis of tyrosinase, its type and activity, the type of melanin synthesized the size, shape, protein structure and number of melanosomes, their degree of melanization and their rate of transfer to keratinocytes. Constitutive melanin pigmentation in man is probably under similar precise genetic control. Racial variations in pigmentation are due to differences in melanocyte morphology and activity of melanocytes than to numerical differences. In heavily pigmented skins the cells tend to be larger, more dendritic and to contain more and larger Stage III and IV melanosomes than melanocytes. Ultraviolet radiation: The response of the melanin pigmentary system to ultraviolet varies with genetic and constitutional factors. It includes immediate tanning, or pigment darkening, which can occur within few minutes due to photo oxidation of preexisting melanin. Delayed tanning occurs after about 48hrs and involves stimulation of new melanogenesis within the melanocytes, and transfer of additional melanosomes to keratinocytes. There may also be some increase in size of active melanocytes and their numbers. Lower frequency UV band induces synthesis of keratinocytes of b-FGF, as well as inter leukin I which induces them to produce  melanocyte stimulating  hormone a known stimulant of melanogenesis. Hormonal Influences: In amphibians MSH from the anterior lobe of the hypophysis and melatonin, a skin lightening hormone secreted by the pineal, are involved in pigmentary alterations. A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 34. 34 Their importance as normal regulatory factors in man is unclear. In pregnancy, higher levels of circulating Oestrogens and progesterone are responsible for the increased melanization of the face, abdominal and genital skin and the nipple and areola. A number of other factors operating within the epidermis such as interleukins, arachidonic acid, prostaglandins and various cytokines, also affect melanogenesis. Level of pigmentation at anytime represents a balance between a large number of competing influences between constitutive and facultative, and these must be taken into account in the analysis and diagnosis of hypo and hyperpigmentary disorders103. A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 35. 35 NIDANA Nidana is defined as the etiological factors responsible for causing the disease104All the diseases affecting the skin in particular are described under one heading “kustarogas”. As switra also affects the skin it is described in this chapter. All the acharyas have mentioned a common nidana for kusta and switra. 105Acharya charaka has mentioned a vishesha nidana for switra.106 The etiological factor can be sub divided intoa. Aharaja nidanab. Viharaja nidanc. Chikista sambandhid. Anyajaa. Aharaja nidan: Vagbatta mentioned, a pregnant women consuming excessive kaphakara ahara, the baby shall be affected with switra.107 Viruddha ahara Mithyahara Asatmya bhojana Ahita bhojana Adhika matra Bhojana Ajeerna anantara bhojanam Vidhi viruddha ahara sevanam Kuvidhi of langhana Sheetala – ushna ahara sevanam Drava, snigdha, guru padarthas Gramya, anupa, jaleeyamamsa sevanam, anantharam dugda sevanam Navanna, dadhi, matsya, lavana, amla, masha, mulaka, pisti, tila, ksheera, Guda sevanam A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 36. 36 Tila, guda, dudga sevanam 108. Chilachima variety of fish 109Seven dietery factors (7) specially mentioned by vangasenaTila, Taila, Kulatthi, Valmika roga, Lingaroga, Mahisha dadhi, Vruntakam.b. Viharaja Nidan Chardi, Mala-mutradi vegadharana Ati vyayamam Ati Santapasevanam Vyayamam in ajeernaavastha Mithya vihara Diva swapnam Garma srama, Bhayarthanam sheethambu sevanam.c. Chikista sambandhi Nidana: Vagbatta mentioned usage of savisha jalouka in rakta mokshana leads to switra at 110 that site 111 Snehapana anantaram doing vyayamama,or vyavayam leads to skin diseases Suppression of vamana vegas or doing vyayamam or maithuna after vamana leads 112 to skin diseases . Panchakarma apacharas specifically produces skin diseases 113 Taking apakwa Vajra, Vaikrantha, Nag, Loha, Hingula, Rasakarpur, Tutha leads to skin diseases 114. Apakwa Hartal bhasma and Vanga bhasma leads to switra specifically. 115Vaidya Nimittija: Snehapan after attaining samyak snigdha lakshnas causes sneha vyapat which 116 leads to kustarogas . 117 Doing dushita rakta stambana leads to kilasa and kusta A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 37. 37d. Anya nidana: In adibala pravrutti Sukra – shonitha beeja doshas leads to kusta rogas in the progeny118 Manasika causes like bhaya, krodha leads to skin diseases 119 Dadga and kshatas produce switra 120 Bhoja mentioned vrana and parasparsha to be the cause for switra121 Manu smriti described stealing of clothes and wealth leads to switra 122 Harita samhita mentioned stealing of silver leads to switra123 Kashyapa mentions abstinence from yagnas, yagas, Homas, Bali, Improper athidi sevana leads to switra.124 Papakarmas of previous births Brahmana, Stri, Sajjana, go hatya Disrespecting parents, insulting Gods Having died of skin disease in the previous birth 125Vishesha Nidana specially mentioned by charaka 126 Viruddha annapana sevana Vacham asatyam Papakarmas Krutagna bhavas Ninda suranam Guru garshanam Poorva kruta karmas A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 38. 38Aharaja Nidana:Table – 4S.No. Nidana C.S. S.S A.H M.Ni B.P Va.S 1. Garbhini consuming excessive - - + - - - kaphakara ahara 2. Virudha ahara + + + + + + 3. Mithyahara - + + - - + 4. Asatmya Bhojan - + - - - - 5. Ahita Bhojan - + - - - - 6. Adhika matra Bhojan - - - + - + 7. Ajeernam anantara Bhojanam - + - + + + 8. Vidhi virudha ahara sevana - - - - + - 9. Kuvidhi of Langana - - - - - + 10. Sheetala – Ushna Ahara Sevanam - - - + + + 11. Drava – Snigdha – Guru padartha - + - + + + 12. Tila guda – dugda sevanam - - - + + + 13. Chilachima variety of fish + - - - - - 14. Gramya, anupa, jaleeyamamsa - + - - - - sevanam, Anantaram dugda sevanam 15. Navanna, dadhi, Matsya Lavana, Amla, - - - + + + Masha, Mulaka, Pisti, tila, Ksheera, Gud sevanam.Viharaja Nidana:Table - 5S.No. Nidana C.S. S.S A.H M.Ni B.P Va.S 1. Chardi, Mala-mutradi vegadharana - + - + + + 2. Ati vyayayam - - - - - + 3. Ati santapasevanam - - - + + + 4. Vyavayam in ajeernavastha - - - - + + 5. Mithya vihara - - + - - - 6. Diva swapnam - - - + + + 7. Garma, Srama, Bhayarthanam - + - + + + sheethambu sevanam A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 39. 39Chikitsa Sambandhi Nidan:Table - 6S.No. Nidana C.S. S.S A.H M.Ni B.P Va.S 1. Savisha Jalouka Prayog - - + + - - 2. Snehapana anantaravyayamam or - + - - - - maithun 3. Suppression of vamanadi vegas - - - + - + 4. Doing vyayama or maithun after - + - - - - vamana 5. Panchakarma apacharas - - - + + - 6. Snehapana after attaining samyak + - - - - - snigdha lakshanas 7. Dushitha raktha stambhana + - - - - -Anya Nidan:Table - 7S.No. Nidana C.S. S.S A.H M.N B.P Va.S M.S B.J Ka 1. Sukra shonitha beeja - + - - - - - - - doshas 2. Bhaya, Krodha - - - + + - - - - 3. Kshata, Dagda - - + - - - - - - 4. Vranas - - - - - - - + - 5. Para sparsha - - - - - - - + - 6. Stealing of clothes & - - - - - - + - - Wealth 7. Abstinence from - - - - - - - - + yagna, homa, bali 8. Papakarmas of + + + - - - - - - previous births 9. Brahmana, Stri, - + + + - - - - - Sajjana go Hatya 10. Vipra guru garshana + - - - + + - - - 11. Vacham asatyam + - - - - - - - - 12. Ninda suranam + - + - - - - - - 13. Having died of skin - + - - - - - - - diseases in previous birth A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 40. 40 ETIOLOGY The etiology of vitiligo is unknown but triggering / precipitating factors areidentified.Triggering / Precipitating factors: It is difficult to precisely define the triggering factors for vitiligo. Neverthless itis essential to elicit the details of history of emotional stress, drug intake, infections, 127trauma / injury (Koebner’s phenomenon) existant prior to the development of vitiligolesions .128-130 It is believed that major oxidative stress occurs in vitiligo skin, which is 131-132evidenced by low catalase levels and cellular vacuolization in the epidermis .several factors may contribute to the oxidative stress, thus leading to the accumulation ofepidermal hydrogen peroxide. The presence of the hydrogen peroxide can bedemonstrated invivo by using non-invasive Fourier transform Raman Spectro 133-134ScopyILLUSTRATION-2: VITILIGO TRIGGERING / PRECIPITATING FACTORS , THEIR ROLE IN PATHOGENESIS135-138Triggering Molecular level Genetic factors Factors Changes1. Nutritional Deficiency2. Emotional stress Biochemical changes Normal Skin3. Drugs4. Infections Enzymatic Disturbances Previtiligo5. Focal sepsis and toxins Auto Immunity and Vitiligo Immune dysfunction6. Exposure to chemical7. Oxidative stress Epidermal hydrogen peroxide VITILIGO accumulation A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 41. 41 POORVARUPAS Poorvarupas are defined as the prodromal symptoms of a disease to bemanifested. Madhukosh commentary defined poorvarupas as Bhavi Vyadhi Prabodhakas 139Generally the poorvarupas are only indicators of a particular disease to be manifested. Some times they are avyaktam not present at all and at times they are minimally 140exhibited. . The disease switram does not exhibit any poorvarupas, but as it has thesame causative factors like that of kusta 141, the poorva rupas exhibited by kusta rogas canbe considered for switram occasionally.Kusta Poorvarupas: 142 Sparsha Agnanam Atiswedam Aswedam Vivarnyam Loma harsha Kharatwam Kandu Toda Srama143 Klama Shula in vrana Sheegrautpatti Chira Stithiti Daha Suptata Ruksham Pipasa A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 42. 42 Gouravam Doubalyam Vepathu Pidaka Arunshi Ativedana Kota utpatti Ati bhrama Ati kopanam 144 Asruja Karshanyam A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 43. 43 RUPA Rupa can be defined as the clinical features of the manifested disease. They arethe subjective evidences of a disease. They are exhibited only after the completemanifestation of a disease. In the Shatkriyakalas the rupas are exhibited in the 145vyaktavasta . Dalhana commented that the rupas are exhibited after the completion ofDosha – dushya samurchana and the pratyatmaka lingam or the cardinal symptom is firstexhibited. 146 Eswarasena’s commentary on Madhava nidan defined rupam “Vyadhi hi Swarupam……. Tad Vyaktam Tadrupam. Madhukosh defined rupam as 147 “Utpanna vyadhi bodhakameva lingam rupam” 148 In switram, according to definition of kashyapa expressions of white colourpatches on the body is the Pratyatmaka linga of switram. Sushruta defined the rupas as “Twagtam eva aparisravi” 149. The patch involvesthe skin and has no oozing tendencyVishista dosha lakshanas: According to classical texts the vataja, pittaja, sleshmaja types of switram havebeen mentioned. The tridoshas invade rakta, mamsa, and medodhatus respectively andproduce lakshanas accordingly. A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 44. 44Vataja: Mandala Aruna varnam or rakta varnam Ruksham Sparsha katinatvam Parusham Keshanashanam Paridwamsi (Romapatrari)Pittaja Tamra Varnam Kamala Patravat Daham Roma VidwamsamSleshmaja Swetavarnam Snigdam Stulam Kandu yuktam Guru GhanamCharaka mentioned three varieties of the disease by the virtue of involvement of 150dhatus . 151 Daruna: When rakta dhatu is invaded by vata dosha it exhibits raktavarna Aruna: Mamsadhatu invaded by Pitta dosha it exhibits tamravarna Switra: Medodhatu invaded by kapha dosha it exhibits swethavarna A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 45. 45Rupas:Table -8 S.No. Lakshanas C.S S.S152 A.H 153 M.Ni154 Sha.Sha B.PVataja 1. Mandalam - + - + - - 2. Arunavarnam - + + + - - 3. Raktavarnam + - - - - + 4. Rooksham - - + - - + 5. Sparsha katinatvam - + - + - - 6. Parusham - + - + - - 7. Keshanashanam - + - + - - 8. Paridwamsi - + - + - -Pittaja 1. Tamravarnam + - + - - + 2. Kamalapatravat - + + + - + 3. Daham - + + + - + 4. Romavidvamsam - - + - - +Sleshmaja 1. Swetavarnam + + + + - + 2. Snigdam - + - + - - 3. Stulam - + - + - - 4. Kandu yuktam - + + + - + 5. Guru - - + - - + 6. Ghanam - - + - - + A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 46. 46 CLINICAL FEATURESEPIDEMIOLOGY: Vitiligo occurs world wide with an overall prevalence of 1%. However, its 155-161incidence ranges from 0.1 >to 8.8% . The highest incidence of the condition hasbeen recorded in India followed by Mexico & Japan. Behl et.al 162-163 had organized camps in rural areas and industrial pockets in Indiato evaluate the status of vitiligo. Its incidence was found to be higher in villagers livingnear dyeing, printing, carpet industries. A higher incidence of vitiligo in such areas maybe due to inclusion of cases with chemically induced depigmentation by industrialphenols, quinone’s which might have a completely different pathomechanism. Itsincidence however was relatively low amongst those residing adjoining copper mines.SEX INCIDENCE: Adults and children of both sexes are equally affected although the greaternumber of reports among females is probably due to the greater social consequences to 164-171women and girls affected by this conditionAGE INCIDENCE: Almost half the patients present before the age of 20 years and nearly 70-80% 172-176before the age of 30 years.FAMILY HISTORY: The proportion of patients with positive family history varies from one part of theworld to another. In India, in particular, it ranges from 6.25-18%. In some studies it is ashigh as 40%. The mode of transmission of vitiligo is quite complex. It is probablypolygenic with a variable penetrance177-181 A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 47. 47PERCENTAGE OF INCIDENCE: 1947 - Calcutta / India - 6% 1958 - Vellore / India - 4% 1969 - Amaravati/ India - 8% 1972 - Delhi / India - 8.8% 1974 - Goa / India - 2.9% 1988 - Delhi / India - 1.25%The difference in its incidence may be due to higher reporting of vitiligo in populationwhere apparent colour contrast may force them to seek an early consultation.CLINICAL FEATURES: Vitiligo is characterized by the appearance of patchy discolouration evident in theform of typical chalky – white or milky white macules. The macules are round and oval in shape with scalloped margins 182-183 The size of the macules may vary from few mm to several cms with the lesionsaffecting the skin and or mucous membrances. The lesions are asymptomatic although itching, burning may precede or 184-185accompany the onset of lesions in few patients . Vitiligo is a slow and progressive disease and may have remissions andexacerbations correlating with trigerring events 186-187 Occassionally the lesions of vitiligo may begin to form around a pigmentednaevus 188(Sutton’s nevus, Leucoderma aquisitum centrifugum) and then go on to affect 189distant regions . A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 48. 48 Although any part of the skin or mucous membrane is amenable to developvitiligo, the disease has a predilection for normal hyperpigmented regions such as theface, groin, axillae, areola, and genitalia. Furthermore lesions may develop in areas like, ankles, elbows, knees, which aresubjected to repeated trauma / friction, an outcome of koebner’s phenomenon 190. 191-193 In the event of extensive disease the lesions are symmetrically distributedwith an exclusive dermatomal distribution or mucous membrane involvement 194-196 Lip-tip syndrome, another variant of vitiligo is characterized by depigmentationfo the terminal phalanges and the lips.CLINICAL VARIANTS:1. Trichrome Vitiligo: Recognized by the presence of a narrow to broad intermediate colour zone between vitiligo macule and normal pigmented surrounding skin. It is a variant of unstable vitiligo 197.2. Quadrichrome Vitiligo: It is well documented fourth colour in vitiligo lesions, usually seen in darker skin types. A macular perifollicular or marginal hyper pigmentation is its salient feature and denotes a repigmentating disease.3. Penta chrome vitiligo: Infrequently encountered variant in which there is a sequential display of white, tan, brown, blue-gray hyperpigmentation and normal 198 skin. Black Skinned individual are predisposed to have this disorder4. Blue vitiligo: It usually corresponds to vitiligo macules occurring at the site of post inflammatory hypermelanosis 199.5. Inflammatory Vitiligo: It is an entity which may reveal an erythematous, raised border in a vitiligo macule with frequent itching / oozing. These can be induced by aggressive therapy200-202. A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 49. 49CLINICAL FEATURES OF VARIOUS TYPES OF VITILIGO:1. Localized: Focal: One or more macules in one area, but not clearly as in segmental or Zosteriform distribution. Segmental: One or more macules in quasidermatomal pattern. Mucosal: Involvement of mucosal membranes alone.2. Generalized Acrofacial: Involvement of distal extremities and face. Vulgaris: Scattered macules over the body. Mixed: Acrofacial and vulgaris involvement or segmental and acrofacial.3. Universal: Complete or nearly complete depigmentation.According to progression and prognosisSegmental: Has an early onset in life, spreads rapidly in affected area. The cause may arrest and depigmented patches can persist unchanged for the life. Vitiligo Zosteriformis: Macules distributed along a dermatome or lines of body cleavage.Non Segmental:Shows poor prognosis. Includes all types of vitiligo, except segmental type. Vitiligo _areata: 1 or 2 macules (Focal, Localized or partial). Vitiligo acrofacialis : Macules affecting face and tips of hands and feet. Vitiligo vulgaris: Scattered macules over the body. Vitiligo mucosal: Involvement of mucosal membranes alone. A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 50. 50According to clinical stages: Progressive Vitiligo: Developing new lesions . Increasing old lesions Ill defined border of lesion Quiescent stage: No appearance of new lesions Stationary old lesions Well defined, hyperpigmented bordersASSOCIATIONS OF VITILIGO: 203-210Cutaneous associations Premature graying of hair Leucotricha Halo nevus Lichen planus Alopecia areata Occasionally other skin disorders like Dermatitis herpetiformis, Giant congenitalmelanocytic nevus, Chronic urticaria, Malignant melanoma have been seen in associationwith vitiligo. Other interesting autoimmune associations include Morphea, and Hashimoto’s 211thyrioditis . While presenting strong direct and indirect evidence of auto immune etiology of 212alopecia areata, Hordinsky and Ericson stressed its association with vitiligo in manypatients. A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 51. 51Occular associations: Vogt-Koyanagi-Harada syndrome213-218 refers to full constellation of vitiligo,Poliosis and Alopecia with pan uvetis and auditory and neurological manifestations. However iris, retinal pigmentary abnormalities may be present as isolated 219-221findings in vitiligo patients. Choroidal abnormalities and irites may also be presentSystemic associations: Hypo / hyper thyroidism, Diabetes mellitus, Addisions disease, Perniciousanaemia, Lymphoma, Leukemia, HIV, Autoimmune poly endocrinopathy ,Candidiasis,Ectodermal dystrophy.CHILDHOOD VITILIGO: Morphological characteristics in childhood vitiligo are more or less identical tothose of adult onset vitiligo. Interestingly there has been steady increase in the evidenceof child hood vitiligo during past two decades222.CONTACT VITILIGO: Contact vitiligo is an acquired leucoderma as a result of repeated topical orsystemic exposure to variety of chemicals223. These chemicals are mainly alley phenols,catechols used in manufacturing plastics, resins, synthetics, rubber, paints, petroleum,deodorants, germicides, insectides, photographic chemicals, varnishes etc., Thesechemicals are also present in certain objects like footware, plastic watch strap andbindis.224-225 A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 52. 52 SAMPRAPTI Samprapti is defined as the phenomenon of dosha-dushya samurcchana226. Thecomplete process of manifestation of a disease is explained in this context. 227 The nidana and samprapti for kusta and switra are similar . The whole process 228of samprapti can be understood through shatkriyakalas Sanchaya Prakopa Dosha Prakopa avastha Prasara Stanasamshryam Dosha – dusya samurcchana Vyakti Vyadhi utpatti avastha Bheda The knowledge of samprapti is essential to break the chain of pathogenesis toprevent further progression of the disease and to implement specific treatment at differentstages of pathogenesis 229. 2301. SANCHAYAM: is the accumulation of vitiated doshas in their respective places .The doshas remain in equilibrium, unless disturbed by external causes. Viruddha ahara-vihara, Manasika karanas like Bhaya, krodha, papakarnas, sadvrut apacharas are the endogenous causes. Kshata, dagda, vranas, Savishajaloukaprayoga are the exogenous causes. The exogenous and endogenous causes are responsible for the vitiation of doshas. Viruddha ahara produces amavisha which is antagonistic to the dhatus, there by 231 leads to various disease. Adhika amla, lavana, ushna, teekshana dravyas cause pitta prakopa leading to rakta dusti 232 A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 53. 53 233 Virudha vihara, diwaswapnam, atisantapasevanam causes pitta prakopa Suppression of natural urges causes vitiation of apanavata and it travels in pratilomagati disturbs samanavata which in turn disturbs udana vata (responsible for Varna). Bhaya, kroda increase rajogunam in the body, which in turn causes vata-pitta prakopa Papakarmas, sadvrut apacharas leads to psycho-somatic disturbances, leads to vitiation of vata pitta doshas 234. In agantuja karanas, directly twakdusti occurs and lakshanas are exhibited, later 235 on the doshas are vitiated.2. PRAKOPA: Prakopa the next stage of sanchaya. The accumulation of vitiated doshascontinues and the doshas are ready to rise above their respective stanas236. Nidana Factors Sanchaya Prakopa Are continued3. PRASARA: This is the stage where the vitiated doshas get dislodged from theirrespective places and start spreading all over the body through siras or channels. Inswitra, the vitiated vata, pitta, kapha spread in the body through “Tiryagata Siras” 237 238which implies urdwa, adho, tiryak Siras. The doshas spread in all the directions .4. STANA SAMSHRAYAM: The most important phase of shatkriyakalas where themajor event “Samprapti” occurs239. Dosha – dushya samurcchana and vyadhi purvarupasare exhibited in this stage A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 54. 54 Doshas implies the vitiated vata, pitta, kapha and dushyas are twak, rakta, mamsa,and lasika in kusta, and rakta, mamsa, medo dhatus in switra. Switra is considered as “Tridhatu Samshrayam”240 which means involvementof tridoshas and tridhatus (rakta, mamsa, and medodhatus) in the pathogenesis of thedisease241. The vitiated doshas while moving in the body reach particular dhatus, by thevirtue of obstruction of that particular srotas. They get lodged in that dhatus.242. The doshas cause “Shithilatwam” of rakta, mamsa, medodhatus and areexpressed out on to the surface i.e. twak. The term “Bahirnischarantou” (bahya desha 243prasarantou) is used to denote the mechanism of outward movement of vitiated doshas.Charaka mentioned “doshopaghata”244 (being affected by the vitiated doshas) in thiscontext. The doshas reach “Twak” where they get settled. The twak becomes the placefor stanasamshrayam. The fourth layer “Tamra” is the site for switra roga. 245 No purva rupas are mentioned but as nidana is same for kusta and switra, somepurvarupas of kusta may occasionally appear.5. VYAKTAVASTHA: The stage of exhibiting the lakshanas of the manifested 246disease . “Mandalas” and “Twak vivarnyam” are seen at the site of manifestation ofvitiated doshas in the skin. In switra “Sweta Varnam” of twak is seen as a pratyatmaka lingam247. Switra Produces discolouration of skin only, it does not cause destruction,putrifaction of dhatus or exudation hence it is “aparisravi” and this feature differentiatesit from Kusta.248 In agantuja karanas like dagdas, kshata, vrana, directly twak dusti occurs causing“Twak Vaivarnyam” and after that doshas get vitiated. A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 55. 556. BHEDAVASTHA: The stage of complications or upadravas. If timely intervention isnot done leads to complete depigmentation of the body. Vagbhatta considered switra asmedical emergency as, if not treated on time spreads all over the body and makes itasadya249. The disease may go beyond medodhatu, and makes it asadya if not treated 250timely. Three types of switra are present due to particular dosha predominance and 251produce their respective colour on the patch Vataja Involves raktadhatu Raktavarnam Pittaja Involves mamsadhatu Tamra varnam Sleshmaja Involves medodhatu Sweta VarnamTypes of Samprapti Sankhya - 3 Vikalpa - Though sannipatika vyadhi, Ekadoshaja bhedas are also mentioned Pradhanya - Switra is a swatantravyadhi Bala - Depending upon the state of nidana, dosha, dushyas in each case Kala - Vyadhi kala not mentioned A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 56. 56 SAMPRAPTI GHATAKAS Doshas : Pittapradhana tridosha Dushya : Rakta, mamsa, medo dhatus Agni : Jataragni, dhatwagni Ama : Agnimandyam, dhatwagni mandyam Udbhavastan : Amapakwashyam Sanchara : Tiryakgata siras Srotas : Rasa, rakta, mamsa, medo Srotodusti : Sanga Adhistana : 4th Layer of twak “Tamra” Vyaktastana : Twak Rogamarga : Bahya Vyadhi Swabhava : Chirakari A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 57. 57ILLUSTRATION-3: FLOW CHART NIDANABEEJADOSHAS AHARAJA VIHARAJA MANSIKA PAPAKARMAS VRANA DAGDA KSHATASBEEJA BHAJA AGNIMANDYAMAFFECTED AMA UTPATTI DOSHA DUSTI VATA, PITTA, KAPHABEEJA BHAGAAVAYAVA TIRYAKGATA SIRAS RAKTA, MAMSA, MEDO DHATUS BAHYAMARGA GAMANTOU STANASAMSHRAYAM TWAK DUSTI BHRAJAKA PITTA DUSTI SWETA VARNAM SWITRAM A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 58. 58 PATHOGENESIS OF VITILIGO There are several diseases marked by lack of pigment in the skin that is grosslyreferred to as leucoderma. Some are caused by an inability of melanocytes to producemelanin, while others are caused by melanocytes either not being present or beingdestroyed. The latter are the pathology for the disease VITILIGO. Vitiligo is a progressive disease in which the melanocytes are gradually destroyedcausing unpigmented areas on the skin. The exact etiology of vitiligo is unknown, butfour main theories exist to explain the pathogenesis of it. a. Autoimmune hypothesis b. The neural hypothesis c. The self destruct hypothesis d. The growth factor defect hypothesis It is believed that vitiligo is a polygenic trait and that a convergence theory,combining elements of different theories is the most accurate etiology. Vitiligo is not a physically damaging disease. But effects are social andpsychological especially for dark skinned racesa. Auto - immune theory: There is great anecdotal evidence that an auto immunedisorder cause the destruction of melanocytes, and this is accepted as the common causeof vitiligo Vitiligo appears in conjunction with several other auto immune disorders, such asJuvenile diabetes, Addisions disease, Pernicious anaemia and additionally organ specificantibodies. If the immune system raises antibodies or cytotoxic T-cells to damagemelanocytes, the mode of action the cells take against the melanocytes could be apoptosisinduction directly against melanocytes or Ig induced Compliment. A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 59. 59 There is histological evidence in vitiligo patients that apoptosis is occurring inunpigmented skin lesions. There is damage to melanocytes and keratinocytes. Melanocytes exhibit nuclear shrinking, vacuolization, loss of dendrites, anddetachment.b. Neural Theory: The Peripheral nerve endings may secrete substance that is cytotoxicto melanocytes and cause their destruction. This is supported by segmental variety of vitiligo which occurs in specificdermatomes, indicating the skin is possibly affected by nerves of specific dermatomes. Vitiligo appears with certain neurological disorders such as encephalitis, traumathat cause peripheral nerve damage. Nerve endings in depigmented areas were seen to produce abnormal neuropeptides, nerve growth factors, and displayed axonal degeneration, these abnormalchemicals may be toxic to melanocytes. Depigmented areas showed some abnormal autonomic functions, such asincreased adrenergic toxins, increased norepinepherine, and an increased concentration ofcatecholamines. These data then suggested that neurotransmitter release could, have anaffect on melanocyte destruction and depigmentation.c. Self destruct theory: It is known that some of the intracellular pre-melanogenesismetabolites are toxic to melanocytes such as dopa, and dopachrome. Normallymelanocytes possess cellular measures to counteract these toxic substances and aredestroyed by leakage of metabolites into the cytoplasm and eventually cell lysis. There is evidence, that certain hydroquinone derivatives that are similar to theseintra cellular metabolites cause leucoderma. A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 60. 60d. Growth factor Defect hypothesis : It was noted that growth defects of melanocyteswere partially corrected by adding a growth factors to their culture suggesting that growthdefects may be part of pathology of vitiligo.e. Genetic Influences: There does appear to be a strong genetic influence in vitiligo. Apositive family history has been reported in about 20% of patients. It does not progress via simple Mendelian pattern but more likely is codedpolygenically. There is some evidence both proving and disproving involvement of HLA systemin occurrence of vitiligo. Hence, it is believed that genetic factors play a key role in the pathogenesis ofvitiligo.f. Convergence Theory: Researchers have begun to lean towards multifaceted etiology,for vilitigo. This theory states that genetic influences have a role in causing vitiligo inaddition to other elements, such as stress, accumulation of toxic compounds, infection,auto immunity, mutations, impaired melanocytes proliferation. A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 61. 61 SWITRA – BHEDAS The classification of switra gives the information about of the types of the disease.It is an attribute of Sankhya samprapti. Classifications are based on different criteria likeNidan Doshas, Ashraya dhatus and Sadya – asadyata.I. Based on Nidan: 252 Bhoja classified switra into two types.1. Doshaja: (endogenous Origin) again sub divided intoa. Atmajab. Paraja2. Vranaja (Exogenous Origin) 253II. Based on Doshas:1. Vataja2. Pittaja3. Sleshmaja 254III. Based on Ashraya Dhatus: 2551. Accroding to charaka Baluki tantra Rakta ashrita Daruna Daruna Mamsa ashrita Aruna Varuna Medo ashrita switra switraIV. Based on Sadhya – asadhyata: 2561. Sadhya-Curable2. Asadhya-incurableKashyapa257 mentioned 5 types of switra but has not mentioned names or clinicalfeatures. Bhela 258 has mentioned switra to be one among eleven kshudra kustas. A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 62. 62Switra Bhedas:Table -9S.No. Types C.S. S.S A.H M.Ni Sa.s B.P B.J Ka.S B.S Bh 3 3 3 3 3 3 2 5 - 3 1. Doshaja - - - - - - + - - - 2. Vranaja - - - - - - + - - - 3. Vataja - + + + + + - - - - 4. Pittaja - + + + + + - - - - 5. Sleshmaja - + + + + + - - - - 6. Raktashrita + - - - - - - - - + 7. Mamsashrita + - - - - - - - - + 8. Midho asshrita + - - - - - - - - + 9. Sadya + + + + + + - - - - 10. Asadya + + + + + + - - - - A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 63. 63 CLASSIFICATION OF VITILIGO The classification system is important because of special significance assigned toeach type of vitiligoI. Based on distribution:1. Localised259: a) focal b) Segmental c) Mucosal2. Generalized: a) Acrofacial b) Vulgaris c) Mixed3. UniversalII.Based on Progression and prognosis: 2601. Segmental: a) Vitiligo zosteriformis2. Non Segmental: a) Vitiligo areata b)Vitiligo acrofacialis c) Vitiligo Vulgaris d) Vitiligo mucosalIII. Based on Clinical Stages: 2611. Progressive Vitiligo2. Quiescent Vitiligo A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 64. 64 SAPEKSHA NIDAN Sapeksha nidan, otherwise called has vyadhi vyavacchedaka nidan is thedifferential diagnosis aspect of the disease. The knowledge is essiential to diagnose adisease and to implement specific treatment. In all the classics, the nidana of switra and kusta rogas are mentioned to besame,262 but they differ in the symptomatic aspect. Arunadutta specified that, the vitiated doshas affects the dhatus, eats up the hair,skin, ligaments and cartilages in the kustarogas but these sequential events do not takeplace in switra263. Switra has to be differentiated from sidma kusta which is one of the mahakusta264because of its close resemblance with the former.Sapeksha Nidana:Table - 10S.No. Features Switra Sidma1. Classified into Independent Mahakustas 265` 2662. Doshas involved Vata, Pitta, Kapha Vata-kapha3. Dhatus affected Rakta, mamsa, medo dhatus Twak, rakta, Mamsa, lasika th st4. Skin layer involved 4 layer Tamra 1 layer avabhasini5. Poorvarupas Not present Present6. Roopas (Clinical features White colour patches White, reddish brown patches(Alabu-Pushpaa. Colour 267 varnamb. Areas involved Anywhere through out the Mainly found on chest body and backc. Extent of layers involved “Twagatam only the Dermis is involved superficial epidermis is involvedd. Appearance Centrally hypopigmented External margins are with hyperpigmented border thin, fissured with A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 65. 65 reddish brown or white colour centrallye. Elevation Patch at the skin level, not Mildly elevated margins elevatedf. Scales Not present When rubbed produce a dust like material (Rajo Grushtam)g. Pain Not present Mild pain present on rubbingh. Itching Not present Present when in contact with sweati. Hair involved The hair of the patch may Hair not involved turn white (Leucotrichia)j. Oozing tendency “Aparisravi” no oozing Little purulent tendency. discharges present in chronic stagesk. External causes May be Produced by dagda, Not due to these factors vrana, kshatas alsol. Symmetry Symmetrical and Mostly asymmetrical asymmetrical patches patches present presentm. Sensation Not altered Sensation may be alteredn. Prognosis The deeper the dhatu Sadya roga268 involved, the disease becomes incurable A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 66. 66 DIFFERENTIAL DIAGNOSIS OF VITILIGOGeneralised vitiligo must be distinguished from Piebaldism, Waarden burg’ssyndrome, Woolf’s syndrome and Ziprokowski-margolis syndrome.Piebaldism: Is congenital Stable and spares the dorsal spine Hyperpigmented macules are present in white patches A white forlock is also present on forehead Characteristic distribution patternWaarden burg’s syndrome: Autosomal disorder Includes hearing defects Has characteristic eye features, fundi may be hypopigmented Along with white forelock, premature graying of scalp, hair, eyebrows, cilia and a dappled appearance of the skin is seen. Forehead, neck, chest, abdomen, anterior knees, arms, dorsa of hands are commonly involvedWoolf’s syndrome: Piebalism DeafnessZiprokowski-margolis syndrome: Rare congenital syndrome Occurs in males only Deaf – mutism Heterochromic irides Piebald like hypomelanosis of skin A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 67. 67 Round, oval or geographic hypopigmented macules Occurs mainly on extremities and trunkSegmental vitiligo must be distinguished from Nevus depigmentosus, Tuberoussclerosis, Hypomelanosis of Ito.Nevus depigmentosus: Rare, congenital, non familial Stable quasidermatomal leucoderma Unilateral macules of varied size Lesions are white to tan colour with regular or serrated margins Lesions mostly on trunk, lower abdomen, proximal extremities but may involve face and neck Quasinevoid macules with irregular, serrated, feathered marginsTuberous sclerosis: Uncommon neurocutaneous syndrome Appears during early life Classical triad – adenoma sebaceum, seizures, mental retardation preceded by the appearance of white macules White macules, polygonal and lance ovate in shape. White macules appear on trunk, lower extremities upper extremities, head and neck. CNS, heart, kidney, liver, thyroid, testes and gastrointestinal systems involvedHypomelanosis of Ito: Bilateral irregularly shaped leucoderma Mainly on trunk and extremities Randomly distributed with whorled or streaked configuration Margins are serrated and blurred Hypopigmentation may be progressive A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 68. 68A solitary vitiligo lesion must be distinguished from, Tinea versicolor, Pitryriasis alba,Idiopathic guttate hypomelanosis, Post inflammatory hypomelanosis, Chemicaldepigmentation, Vagabond leucoderma, Vogt-koyanagi-Harada syndrome,Scleroderma1. Tinea versicolor: Occurrence on the upper chest, not amelanotic, scaling positive for fungi. Lesions raised with hyperpigmented borders.2. Pitryriasis alba: Not amelanotic, faint margins, erythema and scaling.3. Idiopathic guttate hypomelanosis: Small, sharp margins, usually on arms, legs4. Post inflammatory hypomelanosis: History of presence of characteristic rash5. Chemical depigmentation: History of industrial exposure and small white macules at the site of contact6. Vagabond leucoderma: Is a leucoderma of older ill-kept men with history of poor hygiene, poor diet and chronic alcohol abuse. Depigmented patches are found in diffuse, light brown hypopigmented patches around waist and groin. The arms, legs, face are less involved Attributed to multiple ectoparasitic infections. A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 69. 697. Vogt-koyanagi-Harada syndrome: Rare multi system disease Characterised by uveites, alopecia, poliosis The first stage is the meningo encephalitic phase Second is the ophthalmic stage Third stage is vitiligo, poliosis, alopecia which marks the convalescent stage8. Scleroderma: A vitiligo like hypomelanosis Lesions primarly on the upper trunk and distal extremities Lesions amelanotic, with perfollicular spearing which resembles repigmenting 269 vitiligo A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 70. 70 SADHYA –ASADHYATA Sadhya – asadhyata is the prognostic aspect of a disease. They are the prabhava 270bheda of a roga . Prognosis is determined by the lakshnas of the disease exhibited bythe patient. Switra involves rakta mamsa and medhodatus. The deeper the involvement ofthe dhatus the prognosis becomes worse. In this context, Acharya vagbatta has specifiedthe sadhya - asadhyata based on the colour of the patch. Rakta Varna or Aruna Varna aresadhya, Tamra Varna becomes kasta sadhya and Sweta Varna becomes atishaya asadhya. 271As the disease penetrates the deeper dhatus it becomes asadhya. Charaka mentioned a person who has followed vamana – virechana, raktamokshana regime completely, who takes sattu regularly and whose papakarmas are over, 272such case is sadhya. Kashyapa273 and Bhela 274 have mentioned switra to be asadhya vyadhi.Sadhya lakshnas: Nutana or recent onset (less than one year) 275 Hair not dis coloured into Rakta varna Patch which is very superficial – Tanu White in colour or panduvarna 276 Mild elevation in the centre of the patch 277 If the disease is still present in the twak, rakta and mamsa 278 Patch small in size Less in number Patches not adjoining each other 279 Hair not turned into white colour A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 71. 71Asadhya lakshnas: If the disease is present for more than one year280 Hair discoloured into rakta varna, sweta varna Patches large in size Numerous patches all over the body Patches adjoining each other If the disease enters beyond medodhatu 281 If guhyastan i.e. genitals involved, palms and soles, osta ie lips involved If the patch is due to dagda, vranas, kshata 282Sadhya lakshnas:Table -11 S.No. Lakshnas C.S. S.S A.H M.Ni B.P 1. Nutana or recent onset (less than one year) + - + + + 2. Hair not dis coloured into Rakta varna + - + - - 3. Patch which is very superficial – Tanu + - + - + 4. White in colour or panduvarna + - - - - 5. Mild elevation in the centre of the patch + - - - - 6. If the disease is still present in the twak, rakta and - + - - - mamsa 7. Patch small in size - - + - - 8. Less in number - - + + - 9. Patches not adjoining each other - - + + + 10. Hair not turned into white colour - - + + + A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 72. 72Asadhya lakshnas:Table -12 S.No. Lakshnas C.S S.S A.H M.Ni B.P . 1. If the disease is present for more than one year + - - + - 2. Hair discoloured into rakta varna, sweta varna + - - - - 3. Patches large in size + - - + - 4. Numerous patches all over the body + - - + - 5. Patches adjoining each other + - - + - 6. If the disease enters beyond medodhatu - + - - - 7. If guhyastan i.e. genitals involved, palms and soles, - - + + + osta ie lips involved 8. If the patch is due to dagda, vranas, kshata - - - + + A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 73. 73 PROGNOSISa. Positive family history: A positive family history is associated with progression andshows poor signs of prognosis.b. Mucosal involvement: The site affected most commonly on the limbs and mucosae.The next affected sites are face and trunk. Bad prognosis was observed in patients havingmucosal involvement. In mucosal involvement lip involvement is very high. The order ofoccurance in lips, genetalia, nipple, buccal mucosa, gingivae, alveolar margins. It isworth while to state that mucosal vitiligo is of poor prognostic value.c. Koebner’s phenomenon: A trauma leading to hypopigmented patch defines this term.Subjects with Isomorphic Koebner’s phenomenon showed poor prognosis.d. Non - Segmental vitiligo: Among this, vitiligo vulgaris is the commonest typefollowed by acro-facial and mucosal. The non-segmental type of vitiligo is considered tobe of autoimmune origin. Hence this type is a poor prognostic indicator that portendsdisease progression. Amongst all forms V. Vulgaris is more predominant.e.Trichrome sign: Has an intermediate zone of hypochromia, located between theachromic centre and peripheral unaffected skin. Shows poor prognosis.f. Leucotrichia: leucotrichia may indicate poor prognosis in regard to repigmentation. There has been good prognosis in segmental type of vitiligo. The age atpresentation does not have much significance. But the mean age of presentation is around 28326-30 years. It may also start at young age in subjects with strong family history. A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 74. 74 CHIKISTA Chikista is defined as roga nidana pratikara charya 284. It is vyadhi harana kriya285.The Phenomenon which restores the normalcy in the equilibrium among the doshas, 286dhatus and malas . The primary step, in treatment of a disease is the prevention or abstinence fromthe etiological factors 287. The nidana of switra suggests viruddha ahara – vihara,papakarmas, and misconduct to be the vital causes for the manifestation of disease. The treatment aspect includes three types of therapies to combat the disease288 1. Daiva Vyapashray chikista – spiritual therapy 2. Yukti vyapashray chikista - rational therapy 3. Satvavajaya chikista – psychological therapy Vagbhatta mentioned switra to be a medical emergency due to its bheebhatsanature and tendency to turn asadya at the earliest, hence timely medical intervention is 289necessary.1. Daiva Vyapashray chikista – spiritual therapy:  The spiritual therapy consists of recitation of mantras, wearing roots and gems 290  Performing auspicious acts, offering gifts, oblations to the fire God.  Following religious precepts, atonement, fastings, invoke blessings, falling on the feet of Gods, pilgrimages.  Spiritual therapies have empirical powers to eradicate diseases instanteously. Such therapies are related to the blessings and influence of the Gods.  All the items enumerated under the spiritual therapy are effective in eradication of diseases only the to divine influences A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 75. 752. Yukti vyapashray chikista - rational therapy: consists of wise administration ofdiet and drugs. This is sub – divided intoa. Antah parimarjan chikista:  The drugs or diet taken internally to alleviate the disease.  In switra roga, a person is made to undergo all the shodhana procedures first.  After patient is fully evacuated, samsrama karma is done as primary step of treatment by giving malapu ras (Kakodumbara) along with gudam291.  The mixture should be given according to the balam of the rogi. After that he should be exposed to the sun. This procedure to be continued for 3 days.  During this event if patient feels thirsty, peya is given to quench his thirst .292  By doing the above patient develops blisters on the patches all over the body. The blisters should be pricked with kantakam to release the fluid in it.  After all the blisters are opened, a kwath prepared from bark of kakodumbara, priyangu, asan, and shatapushpa should be given early in the mornings for 15 days 293  Otherwise, Phanitham prepared from palasa kshara can also be given 294  All the yogas beneficial in kusta rogaas, are recommended in switra also  Sprinkling khadira kwatha externally on the body or taking it internally or even drinking khadira udaka is very beneficial in switra295  A person should be exposed to sun continuously for 1 week after taking Bakuchi churnam internally, pathya being dugda sevanam296 A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 76. 76  Gomutram is very useful in switra roga. Trikatu, Chitraka, madhu added in gomutram and stored in a jar of ghee for 15 days and then taking it is very 297 beneficialb. Bahirparimarjana chikista: Applications over the body are included in this category  Manahsilaadi lepam298  Burnt bone of as mixed with kadali kshara, cow’s blood and applied as a 299 paste  Kshara of Jati (Malathi) flowers mixed with elephant’s ichor, applied externally300  Nilotpala, kusta, saindhavalavana mixed in elephant’s urine  Seeds of Bakuchi and mulaka grounded in ‘Cow’s urine  Kakodumbara, bakuchi, chitraka, powdered with cow’s urine 301  Manashila powdered with peacock’s bile makes an effective paste in switra  The seeds of bakuchi, cow’s bile, loha bhasma, rasanjana, souveeranjana, 302 pippali, together made into paste and applied externally c. shastra pranidhan: all the surgical therapies are included here  Doing rakta mokshana is one therapy advised in switra  3. Satvavajaya chikista – psychological therapy: The satwavajaya chikista includes virteous conduct of a person. The psychological therapy is restraint of mind from the ahita or unwholesome objects.  Normally the mind, including the sensefaculties remains undisturbed. A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 77. 77  In order to retain this condition one should make efforts to maintain a healthy mind. This is achieved invariably by examining with intellect, not deviating from the generally approved principles, not breaking the code of conduct or sadrut 303  Respecting Gods,, Brahmins, preceptors, elderly people  Offering oblation to fire  Performing sandhya twice  Observing personal hygiene  Having faith and devotion towards teachers, gurus, and those who have accomplished spiritual knowledge or perfection.  Be friendly to all creatures  Reconcile the angry  Controller of intolerance  Be of peaceful disposition  Conquer the roots of attachment All the above acts help to maintain the psycho – somatic equilibrium, thus giving 304health to a person . The importance of these therapies is evident by the statement “aperson who has undergone shodhana procedures by vamana, virechana, raktamokshana,who has been taking sattu as his regular diet, whose body is roughened and whosepapakarmas are decreasing by following the spiritual and virteous conduct, the diseasegets cured in such person305 A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 78. 78 TREATMENT The main goal of treating vitiligo is to improve appearance. Therapy for vitiligotakes a long time; it is usually continued for 6 to 18 months. The choice of therapydepends on the number of white patches, their size, and location and how widespreadthey are. Each patient responds differently to therapy and a particular treatment may notwork for everyone.Current treatment options for vitiligo include:1. Medical2. Surgical3. Adjuvant therapies1. Medical therapies: Include most of which are applied topicallya) Topical Steroid therapy: Steroid creams are helpful in repigmentation, particularly ifthey are applied in the initial stages of the disease. Cortico steroids are a group of drugssimilar to hormones which are produced by adrenal glands. Mild topical steroid creams are prescribed for children under 10 years andstronger for adults. They should be applied for 3 months to expect results and this issimplest and safest treatment for vitiligo but not as effective as Psoralenphotochemotherapy. There are side effects like skin shrinkage and skin striae in areas particularlywhere skin is thin. They can be minimized by using weaker formulations of steroidcreams in these areas.b. Psoralen Photochemotherapy: also known as Psoralen and ultraviolet A Therapy orPUVA therapy. A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 79. 79 The most effective treatment for vitiligo available. The goal of PUVA is torepigment the white patches. Though time consuming yields better results but care mustbe taken to avoid side effects which some times can be severe. Psoralen is a drug that contains chemical that react with ultraviolet light to causedarkening of the skin. The treatment involves taking Psoralen by mouth (Oral) or by applying it on theskin (topically) this is followed by carefully timed exposure to sunlight.Topical Psoralen therapy: is used for small number of patches affecting a limited partof the body, it is also used for children 2 yrs old or older who have localized patches ofvitiligo.Oral Psoralen therapy: used for people with extensive vitiligo and for people who donot respond to topical PUVA treatment. Advised for children above 10 years as youngchildren have the risk of developing cataracts.c. Depigmentation: This treatment involves fading the rest of the skin on the body tomatch the areas that are already white. For more than 50% involvement depigmentation isthe best treatment options. Patients apply the drug monobenzyl ether of hydroquinone twice a day topigmented areas until they match the already depigmented areas.2. Surgical therapies: All surgical therapies are considered only after proper medicaltherapy is provided. These therapies are time consuming and expensive. They areappropriate only for carefully selected patients.a. Autologous skin Grafts: The doctor removes skin from one area of your body andattaches it to another area. This type of skin grafting is useful for small patches.Treatment with grafting takes time, and is costly. A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 80. 80b. Skin grafts using blisters: In this procedure the doctor creates blisters on yourpigmented skin by using heat suction or freezing cold. The tops of the blisters are thencut out and transplanted to a depigmented skin area.c. Micropigmentation: (Tatooing) : This procedure involves implanting pigment intothe skin with a special surgical instrument. This works best for lip area.d. Autologous melanocyte transplants: In this procedure, the doctor takes a sample ofyour normal pigmented skin and places it in a laboratory dish containing a special cellculture solution to grow melanocytes. When the melanocytes in the culture solution havemultiplied, the doctor transplants them into depigmented areas.3. Adjuvant therapies: In addition to medical and surgical therapies, there are manythings you can do to minimize the appearance of white patches and cope with emotionalaspects of vitiligo.a. Sunscreens: People who have vitiligo, particularly those fair skinned should usesunscreens to protect from both UVA and UVB forms of ultraviolet light. Sunscreensalso minimize tanning which makes the contrast between normal and depigmented skinless noticeable.b. Cosmetics: Some patients cover the depigmented patches with stains, makeup,selftanning lotions. These cosmetic products are effective for people whose vitiligo islimited to exposed areas of the body. Self tanning lotions have an advantage over makeupin that the colour will last for several days and will not come off with washing.c. Counselling and support groups: many people with vitiligo find it helpful to getcounselling from a mental health professional. A mental health counselor can also offersupport and help in coping with vitiligo. A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 81. 81 PATHYA – APATHYA Pathya – apathyas are the list of indicative and preventive measures to befollowed by a person afflicted by a disease. Pathya – apathyas are of great importance tothe patient to stay healthy and avoid further progression of the disease. In the ayurvedicclassics, acharyas have mentioned pathya – apathya for all the diseases. As the nidana issame for kusta and switra, the pathya – apathyas also remain same.Pathya:1. Ahara: Shali rice (Oriza sativa) Shastik rice (Oriza sativa) Yava ( Barly) Godhuma (Wheat) Koradoosh ( Paspalum scrobiculatum) Shyamak (Echinochlova frumentacea) Uddalaka ( wild variety of Paspalum scrobiculatum The above mentioned grains should be one year old and matured Mudga (Phaseolus radiatus) Adaki arhar (Cajanus cajan) Soups to be prepared from the above two Flesh of Jangala animals devoid of fatty matter2. Vihara: To be sincere and to be dutiful to God, Teachers, Gurus, To offer prayers, perform yagna, homas, give donation to poor and needy.3. Aushadha: Nimba Bhalltaka A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 82. 82 Manduka parni (Centella asiatica) Avalaguja (Psorhalia Corylifolia) Adusa (Adathoda vasica) Flowers of Arka (Calotropis procera) Medicated oil prepared from sarshapa (Brassica nigra) Medicated ghee prepared from chakramarda (Cassia tora), Patola (Trichosanthes dioca) Body of the patient can be anoinated with vajraka taila, Khadira kashaya, 306 Argwadhadi group fo drugs, power or paste.Apathya:1. Ahara: Mamsa (Flesh of birds) Vasa (Oily part of flesh) Dugdha (Milk) Dadhi (Curd) Tila taila (Seasame oil) Kulatta (Dolichos biflorus) Masha (Phaseolus mungo) Nishpav (Dolichos lablab) Preparations of sugar and Jaggery Pisti Amla (Articles having sour taste) Viruddha ahara (incompatible food) Vidahi (Food which can cause obstruction to channels) 307 Vidagda (food which cause acidic eructations)Arundutta mentioned that prohibition from aetiological factors constitutes the actualtreatment of disease. Although meat of all kinds may be prohibited but meat if notincompatible may be permitted.308 A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 83. 832. Vihara: Adhika matra bhojanam Food taken during ajeernam Diva swapnam Vegadharana Ativyayamam Ativyavayam Abusing elders, gurus, teachers A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 84. 84 CRITERIA FOR DRUG SELECTION The present drug “Dhatri-Khadira Kwatham” has been taken from th 309“Kustarogadhikar” of “Bhaishajya Ratnavali”, a contemporary textbook of 19century A.D. The compound has two drugs – Khadira and Amlaki, Madhu as anupana. Both the above mentioned drugs are non-controversial, unadulterated, easilyavailable, and economical It is a simple combination and easy to prepare and use. Both are sheeta Virya dravyas hence best pitta shamakas, and indicated inkustarogas. 310 “Khadira” is mentioned as “Kustagnanam” . It is equally beneficial in swithraalso. The use of Khadira Kashaya or Khadira udaka internally and externally is highly 311recommended in swithra . Hence to know its action, on pigmentation in the presentdisease is the main purpose for the selection. Amlaki, the best rasayanam312, easy to use highly beneficial for the body torestore health and improve immunity. Apart from this, it has mild laxative effect which is very beneficial in thetreatment. Regular use of amlaki destroys diseases like Swithra and Prameha313 Ultimately the principle “Swasthasya Swasthya rakshanam, aturasya vikaraprashamanam” is achieved through these two drugs. Khadira helps in treating the disease, amlaki helps in restoring the health. A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 85. 85 DESCRIPTION OF INDIVIDUAL DRUGSKHADHIRA:Latin Name : Acacia catechuFamily : Leguminosae – Mimosaceae - (Vatadi Varga)Charaka : Kustagna, KashayaskandaSushruta : Salasaradi GanaVERNACULAR NAMES:English : Black Catechu, Cutch TreeHindi : Katha, Khair, Khair babulTelugu : Kasu, Khadiramu, Mallasandra, Podala Manu, Sandra,SundaraSanskrit : Bahushalya, Balapatra, Bala putra, Balatanaya, Dantadhavana, Gayatri, Homa, Hima Shalya, Khadira, Karkati, Kantaki, Kusthari, Kustarahita, Medya, Tiktasara, Saradruma, Sushalya, Pathidruma, Vakrantaka, Yagnanga, Yagnika, YapadruMorphology: A moderate sized tree of 9-12 mts hight. Bark is dark coloured, rough.Young shoots are dark brown or purple glaborous. Leaves 2-pinnate.Bark: The part used in the present study. The bark is bitter and acrid, cooling, astringentto the bowls, antihelmenthic, antidysentric, antipyretic, cures itching, sore throat,bronchitis, indigestion, heaviness, ulcers, boils, Psoriasis, inflammations, leprosy,anemia, Leucoderma, also given in elephantiasis, urinary discharges, strengthens teeth. A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 86. 86PROPERTIES:Rasa : Tikta, KashayaGuna : Laghu, RukshaVirya : SheetaVipaka : KatuKarma : Kapha-Pittahara, Medogna, Dipana, DantyaMAJOR CHEMICAL CONSTITUENTS:Heart wood : Catechani, Catechutannic acidWood : I-epicatchin, Afzelchin, Gossypetin, Procyanidin, taxifolinGum : L-Arabinose, D-galactose, D-RhamnoseRESEARCH WORK DONE ON ACACIA CATECHU:1. A Medicinal extract of Acacia Catechu and Scutelleria baicalensis at as a dual inhibitor of cyclooxygenase and 5-lipooxygenase to reduce inflammation Ref: Burnett BP JiaQ.ZhaoY.levy RM. J.Med Food 2007 Sep; 10 (3) 442-512. Medicinal Plant extra acts as anti-Escheria coli 0157: H7 agents and their effects on bacterial cell aggregation. Ref: Voravunthikunchai SP.Linsuwan S. J.Food Prot 2006 Oct; 69(10) : 2336-413. Determination of the predominant catechins in Acacia Catechu by liquid Chromatography / electrospray ionization – mass spectrometry. Ref: Shen.D. WuQ. Wang M. Yang Y. Lavoie E J. Simon JE J. Agric Food Chem 2006 May; 3 54(9): 3219 -244. Final report of the safety assessment of Acacia Catechu Gum. Ref: Int.J.Toxicol 2005; 24 suppl. 3:75-118. A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 87. 875. Effective Medicinal plants against enterohaemorrghic eschercia Coli.0157:H7. Ref: J.Ethnopharma col.2004 Sep; 94(1) 49-546. Antimicrobial Evaluation of some medicinal plants for their anti – enteric potential against multi – drug resistant salmonella typhi Ref: Rani P. Khullar N. Phytother Res 2004 Aug; 18(8) : 670-37. In vitro plantlet regeneration from seedling nodal explant of Acacia Catechu. Ref: Sahani.R.Guptha Sc.Indian J.Exp Biol 2002 Sep; 04(9):1050-58. Preliminary observations on leukemia specific agglutinoins from seeds. Ref: Agarwal S.Agarwal SS. Indian J. Med Res 1990 Feb; 92:38-429. Antifertility activity of traditional contraceptive pill comprising Acacia Catechu Ref: Azad Chowdhary A.K Indian J. Med Res 1984 Sep; 80:372-410. Hypotensive action of Acacia Catechu. Ref: J.S.K. Sham, K.W.Chiu, P.K.T.Pang, Planta Med 1984; 50:177-180 A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 88. 88AMLAKI:Latin Name : Emblica officinalisFamily : Euphobiaceae (Haritakyadi Varga)Charaka : Vayasthapana, VirechanopagaSushruta ; Triphala, ParushakadiVERNACULAR NAMES:English : Emblic myrobalan TreeHindi : Amlaki, Amla, AmlikaTelugu : Amlakamu, Amalaki, Usiri, Usirikaya, Nelli, PullayusirikaSanskrit : Adiphala, Akara, Amalaki, Amrita, Amrita Phala, Bahuphali, Dhatri, Dhatrika, Dhatriphala, Shriphala, Vayastha, Tishya, Sriphali, Vrishya, Rochani, Karshaphala, Kayastha.Morphology: A deciduous small or middle sized tree with crooked trunk and spreadingbranches, bark greenish grey, peeling off in Conchoidal flakes. Branchlets glaborousleaves sub-sessile.Fruit: The part used in the drug given in the present study. The fruit is acrid, sour, bitter,sweetish, cooling, carminative, alterative, laxative, tonic, antipyretic, and useful inburning sensations, urinary discharges, thirst, leprosy, piles, and anaemia.Properties:Rasa : Amlapradhana Pancharasas (except lavana)Guna : Guru, SnigdhaVirya : SheetaVipaka : MadhuraKarma : Tridoshahara, Vayasthapana, Rasayana, Chakushya, Vrusya, Keshya. A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 89. 89Major Chemical Constituents :Fruit: Vit-C, Phyllembin, Tinolic Acid, indole, acetic Acid, Phyllembic acids & Salts,Ellagic acid, Corilagin.RESEARCH WORK DONE ON EMBLICA OFFICINALIS:1. Hypolipidaemic effect and anti atherosclerotic effects of fruit juice of Emblica Officinalis in cholesterol fed rabbits. Ref: Ritu Mathur, Arti Sharma, Mira Varma J. Ethnopharmacology Vol 50 (2) 1996 pgs 61-682. Detoxifies the body, regulates digestion, helps to increase lean body mass & reduce fats. A natural source of vitamin C. Ref: Dr. Manish, Chakrapani Ayurvedic Clinic & Research Centre3. Antitumor activity of Emblica Officinalis Ref: Jeena K. Jose, Girija Kuttana nd Ramadasan Kuttan. J. Ethnopharmacology vol 75; issues 2-3, May 2001 Pg 65-694. Flavinoids from Emblica Officinalis and Mangifera Indica effectiveness for dyslipidemia Ref: L. Anila and N.R. Vijayalakshmi J. Ethnopharmacology vol 79 issue:1, Feb 2002 pg 81-87.5. Hepatoprotective activity of Emblica Officinalis Ref: Jeena K. Jose and Ramadasan Kuttan J. Ethnopharmacology vol.72 (1-2) Sep 2002 pg 135-1406. Cytoprotective and immuno modulating properties of Amla (Emblica Officinalis) on lymphocytes and in-vitro study. Ref: M. Saiam; D Neetu Yogesh B. Anju P. J. Ethnopharmacology vol.81 (1) June 2002 Pg 5-10 A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 90. 90MADHU: There are 8 types of Madhu - Makshika, Bhramara, Ksaudra, Pauthika chatra, Ardya, Audalaka, and Dalam. Best anupana, has good yogavahi natureProperties: Sheeta, Laghu, Swadu, Ruksha, Gnahi, Lekhana, Netrahitakara,Agnideepaka, Swarakara, Vrana Sodhana, Ropana, Srotoshodhaka, Varnya, Medhya,Vrishya, Visada, Ruchikara, Kusta-arsas, Raktapitta, Kapha, Prameha, Klama, Krimi,Medohara, Swasa, Kasa, Hikka, Malabaddahara, Alpavatakara,Rasa : Madhura Rasa, Kashaya anurasaGuna : Laghu, RukshaVeerya : Sheeta ViryaVipaka : Katu A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 91. 91 METHOD OF DRUG PREPARATION The present yogam is a combination of Khadira and Amlaki The bark of Khadira, fruits of Amlaki are used in the preparation Barks of Khadira, fruits of amlaki are collected, through the herb collector; they are dried under shade, to restore their medicinal properties. Khadira bark is pounded into coarse powder & weighed. Equal quantity of amlaki fruit is pounded and added to it. The powder is made into kwath churam. It is stored in a neat, dry container and packed accordingly. The Kwath form is administered to the patient.Dose : 30ml Tid Madhu as anupana A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 92. 92 METHODOLOGY The study was conducted in the Department of Kayachikitsa, Govt. Ayurvedic Hospital, Erragadda,Hyderabad between 6-3-07 to 31.1.08 Aim: To assess the efficacy of Dhatri – Khadira kwath in causing pigmentation in white patches of switra. Source of Data : Patients of either sex aged between 5-70 years diagnosed as switra were selected from OPD of Govt.Ayurvedic Hospital, Erragadda, Hyderabad. Sampling Method and Research Design: The study was conducted as an open trial study with randomized selection of 30 patients of either sex within age groups 5-70 years suffering from switra were included. Informed consent from all patients was obtained prior to the study. A complete history was taken through a special proforma including age of onset, duration, family history of switra, H/o consangnious marriage of parents, any personal or family history of systemic diseases. A thorough dermatological examination was conducted on the patients. Inclusion criteria:-  Patients of either sex with sweta varna mandalas (i.e. milky white patches, centrally hypopigmented with sharp circumscribed borders).  Patients aged between 5-70 years  Chronicity less than 6 years. Exclusion criteria: as per ICD-10, L00-L99 skin and sub-cutaneous diseases, L80-Vitiligo Patients below 5 years and above 70 years Certain conditions originating in the perinatal period (P00-P96) A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 93. 93 Certain infectious and parasitic diseases – (B00-B99) Complications of pregnancy and childbirth (O00-O99) Endocrinal, nutritional and metabolic diseases (E00-E90) Congenital malformations, deformities and chromosomal abnormalities (Q00-Q99) Neoplasms (C00-D48) Systemic connective tissue disorders (M30-M36) With other skin diseases like Psoriasis, Eczema which interfere with the treatment. With Psychiatric problems like Psychosis, mania, OCD, Schizophrenia Investigations: Following investigations were done prior to the study. CBP ESR RBS CUE Diagnostic Criteria: Swetavarna mandalas with or without other features of switra Intervention: Drug: Dhatri – Khadira kwath Dose: 30ml tid, followed by madhu as anupana Route: Oral Duration: 45 days Followup: 2 months Assessment criteria: The assessment was made on the colour, number and size of the mandalas which were observed before starting the treatment, during and after the treatment. Change in the colour of mandalas Change in number of mandalas Change in the size of mandalas To assess the improvement in the colour the following grading was given A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 94. 94 C0 – Normal skin colour C1 – Tanned brown C2 – Light brown C3 – Dark pink C4 – Light pink C5 – White colour The data obtained before and after treatment were analysed. The complete results of treatment were ascertained in terms of, I. Colour of the mandalas: 1-25% - Mild Response 26-50% - Moderate Response 51-75% - Marked Response 76-100% - Excellent Response 0 - No Response II. Number of Mandalas: 1-25% - Mild Response 26-50% - Moderate Response 51-75% - Marked Response 76-100% - Excellent Response 0 - No Response III. Size of Mandalas: 1-25% - Mild Response 26-50% - Moderate Response 51-75% - Marked Response 76-100% - Excellent Response 0 - No Response A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 95. 95 Overall effect of therapy was assessed based on the following groups 1-25% - Mild Response 26-50% - Moderate Response 51-75% - Marked Response 76-100% - Excellent Response 0 - No Response In this study subjects were classified into 5 groups mild, moderate, marked excellent and No response groups. If the symptoms of a patient decrease by 1-25% he is put in mild group, if the patient has decrease in symptoms by 26-50% he is placed in moderate group, subject with relief of symptoms by 51-75% he is placed in marked group. If patient has relief by more than 75% he is placed in excellent group. There are patients with no relief of symptoms who are placed in no response group. A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 96. 96 OBSERVATIONS ACCORDING TO THE INCIDENCESTable – 13 Showing incidence of age:Sl.No. Age(in years) No. of Patients % 1. 0-10 yrs 6 20% 2. 11-20 yrs 7 23.33% 3. 21-30 yrs 6 20% 4. 31-40 yrs 4 13.33% 5. 41-50 yrs 1 3.33% 6. 51-60 yrs 4 13.33% 7. 61-70 yrs 2 6.66% Among 30 patients taken for the study maximum number of patients fall under11-20 yrs group. Highest percentage of study population includes females 56.66%Table – 15 Incidence of Habitat:Sl.No. Habitat No. of Patients % 1. Rural 2 6.6% 2. Urban 23 76.6% 3. Town 5 16.66% Majority of the subjects came from urban areas 76.6% A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 97. 97 AGE OF THE PATIENT 7 7 6 6 6 5 4 4 4 NO OF PATIENTS 3 2 2 1 1 0 0 TO 10 11 TO 20 21 TO 30 31 TO 40 41 TO 50 51 TO 60 61 TO 70 YRS Series1 INCIDENCE OF SEX MALES 43% FEMALES 57% MALES FEMALES INCIDENCE OF HABITAT 25 23 20 15 NO OF PATIENTS Series1 10 5 5 2 0 RURAL URBAN TOWN HABITATA CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 98. 98Table – 16 Incidence of Religion:Sl.No. Religion No. of Patients % 1. Hindu 21 70% 2. Muslim 6 20% 3. Christian 3 10%Majority of the subjects belong to Hindu community 70%.Table – 17 Incidence of Marital Status:Sl.No. Marital Status No. of Patients % 1. Married 13 43.33% 2. Un-married 17 56.66%Most of the patients taken for clinical study were un-married 56.66%.Table – 18 Incidence of Diet:Sl.No. Diet No. of Patients % 1. Mixed 23 76.66% 2. Veg 7 23.33%Veg: Vegetarian dietMajority of the subjects had mixed diet 76.66%Table – 19 Incidence of Socio - Economic Status:Sl.No. Age(in years) No. of Patients % 1. LIG 13 43.33% 2. MIG 17 56.66% 3. HIG 0 0LIG: Low income group (below 10,000/-),MIG: Middle income group (10,000/- to 20,000/-),HIG: High income group (20,000/- and above)Majority of the subjects belong to middle income group A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 99. 99 INCIDENCE OF RELEGION 25 21 20 15 NO OF PATIENTS 10 6 3 5 0 HINDU MUSLIM CHRISTIAN RELEGION Series1 MARITAL STATUS MARRIED 43% UNMARRIED 57% MARRIED UNMARRIEDA CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 100. 100 INCIDENCE OF DIET VEG 23% MIXED 77% MIXED VEG SOCIO -ECONOMIC STATUS 17 18 16 13 14 12 10 Series1 NO OF PATIENTS 8 6 4 2 0 0 LIG MIG HIGA CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 101. 101Table – 20 Incidence of Occupation:Sl.No. Occupation No. of Patients % 1. Agriculture 1 3.33% 2. Private Employees 2 6.6% 3. Business 2 6.66% 4. Electrician 1 3.33% 5. Student 16 53.33% 6. Housewife 6 20.00% 7. Carpenter 1 3.33% 8. Watchman 1 3.33%Majority of the patients belonged to student community 53.33%Table – 21 Incidence of Colour of the patients:Sl.No. Colour of pt No. of Patients % 1. Fair 9 30% 2. Wheatish 14 46.66% 3. Black 7 23.33%Majority of the subjects were wheatish skinned people 46.66%.Table – 22 Incidence of Origin of the disease:Sl.No. Origin No. of Patients % 1. Doshaja 28 93.33% 2. Vranaja 2 6.66%The origin of the disease due to external causes were found in two subjects 6.66% and inmajority of subjects the cause was endogenous 93.33% A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 102. 102 INCIDENCE OF OCCUPATION 16 16 14 12 10 NO OF PATIENTS 8 Series1 6 6 4 2 2 2 1 1 1 1 0 AGRICULTURE BUSINESS STUDENT CARPENTER OCCUPATION COLOUR OF THE PATIENT 14 14 12 9 10 7 8 Series1 NO OF PATIENTS 6 4 2 0 FAIR WHEATISH BLACK ORIGIN OF DISEASE VRANAJA 7% DOSHAJA 93% DOSHAJA VRANAJAA CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 103. 103Table – 23 Incidence of Prakriti:Sl.No. Prakriti No. of Patients % 1. VP 9 30% 2. PK 5 16.66% 3. KV 1 3.33% 4. PV 9 30% 5. VK 3 10% 6. KP 3 10%VP= Vata pitta, PK= Pitta kapha, KV= Kapha vata, PV= Pitta vata, VK= Vata Kapha,KP= Kapha pitta.Among 30 patients, majority of them belonged to vatapitta and Pitta vata prakruti 30%.Table – 24 Incidence of Family History:Sl.No. Family History No. of Patients % 1. Present 1 3.33% 2. Absent 29 96.66%Majority of the patients did not present with a family history 96.66%.Table – 25 Incidence of Stress:Sl.No. Stress No. of Patients % 1. Present 7 23.33% 2. Absent 23 76.66%Majority of the patients did not present with history of stress 76.66%.Table – 26 Incidence of Consangnious Marriage of parents:Sl.No. Cong.Marriage No. of Patients % 1. Presnet 6 20% 2. Absent 24 80%Majority of patients did not present with history of consangious marriage of parents 80%. A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 104. 104 PRAKRUTI 9 9 9 8 7 6 5 5 NO OF PATIENTS 4 3 3 3 2 1 1 0 VP PK KV PV VK KP Series1 FAMILY HISTORY present 3% absent 97% present absent STRESS PRESENT 23% ABSENT 77% PRESENT ABSENTA CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 105. 105Table – 27 Incidence Chronicity:Sl.No. Chronicity No. of Patients % 1. 1month – 1 yr 20 66.66% 2. 2 -3 yrs 6 19.99% 3. 4-5 yrs 3 10% 4. 6-7 1 3.33%Majority of the patients taken for the study had chronicity of disease from 1 month to 1year 66.66%.Table – 28 Incidence of Old/New cases:Sl.No. Old/New cases: No. of Patients % 1. Old 15 50% 2. New 15 50%Among 30 cases taken for the study 15 patients were new and 15 patients were old whoalready received treatment else were.Table – 29 Incidence of age of first onset:Sl.No. Age(of first onset) No. of Patients % 1. 0-10 yrs 7 23.33% 2. 11-20 yrs 8 26.66% 3. 21-30 yrs 4 13.33% 4. 31-40 yrs 4 13.33% 5. 41-50 yrs 1 3.33% 6. 51-60 yrs 4 13.33% 7. 61-70 yrs 2 6.66%In majority of patients disease started before the age of 20 yrs 49.99% A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 106. 106 H/O CONSANGNIOUS MARRIAGE PRESENT 20% ABSENT 80% PRESENT ABSENT CHRONICITY OF THE DISEASE 20 20 18 16 14 12 NO OF PATIENTS 10 8 6 6 3 4 1 2 0 1MON-1YR 2YR-3YR 4YR-5YR 6YR-7YR Series1 OLD/NEW CASES NEW OLD 50% 50% OLD NEWA CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 107. 107Table – 30 Site of first onset:Sl.No. Site (of first onset) No. of Patients % 1. Scalp 0 0 2. Face 11 36.66% 3. Neck 0 0 4. Chest 1 3.33% 5. Abdomen 2 6.66% 6. Back 4 13.33% 7. Upper limbs 2 6.66% 8. Lower limbs 9 30% 9. Genitals 1 3.33%In majority of subjects face was the site of first onset 36.66% followed by lower limbs30%Table – 31 Nidanam:Sl.No. Ahara nidanam No. of % Patients 1. Adika ushna, teekshana ahara sevana 1 3.33% 2. Amla, lavana, katurasa sevana 5 16.66% 3. Madura rasa sevana 3 10% 4. Adhika dadhi 4 13.33% 5. Adika mamsa 5 16.66% 6. Dumrapana 1 3.33% 7. Masha and mulakas 1 3.33% 8. Dadi and mamsa 1 3.33% 9. Nothing particular 9 30%Among 30 subjects 9 patients did not have any particular eating habits in excessive 30%. A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 108. 108 AGE AT FIRST ONSET 8 8 7 7 6 5 4 4 4 NO OF PATIENTS 4 Series1 3 2 2 1 1 0 0 TO 10 11 TO 20 21 TO 30 31 TO 40 41 TO 50 51 TO 60 61 TO 70 AGE IN YEARS SITE OF FIRST ONSET 12 11 10 9 8 NO OF PATIENTS 6 Series1 4 4 2 2 2 1 1 0 0 0 SCALP NECK ABDOMEN UPP.LIMB GENITALS SITEA CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 109. 109Table – 32 Types:Sl.No. Types No. of Patients % 1. Localized 26 86.66% 2. Generalized 4 13.33% 3. Universal 0 0Among 30 subjects taken for the study 26 of them presented with localized type ofvitiligo 86.66%Table – 33 Nature of spread:Sl.No. Spread No. of Patients % 1. Gradual spread 29 96.66% 2. Sudden spread 1 3.33% 3. Stable 0 0Among 30 subjects 29 of them presented with gradual spread of the disease 96.66%.Table – 34 Symmetry of the patches:Sl.No. Symmetry No. of Patients % 1. Symmetrical 15 50% 2. A symmetrical 15 50%Among 30 subjects 15 patients presented with symmetrical patches and 15 presented withasymmetrical patches 50%Table – 35 Leucotrichia:Sl.No. Leucotrichia No. of Patients % 1. Present 5 16.66% 2. Absent 25 83.33%Among 30 subjects 25 of them did not have leucotrichia (hair not involved) 83.33% A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 110. 110 TYPES OF VITILIGO 30 26 25 20 NO OF 15PATIENTS 10 4 5 0 0 LOCALIZED GENERALIZED UNIVERSAL Series1 NATURE OF SPREAD 29 30 25 20 NO OF PATIENTS 15 Series1 10 5 1 0 0 GRADUAL SUDDEN STABLE NATURE OF SPREADA CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 111. 111Table – 36 Colour of the patches:Sl.No. Colour of the patches No. of Patients % 1. White colour (C5) 23 76.66% 2. Light Pink (C4) 5 16.66% 3. Dark pink (C3) 2 6.66% 4. Light Brown (C2) 0 0 5. Tanned brown (C1) 0 0Among 30 subjects 23 of them presented with white coloured patches 76.66%Table – 37 Number of patches:Sl.No. Number of patches No. of Patients % 1. 1-5 27 90% 2. 6-10 1 3.33% 3. Above 10 2 6.66%Among 30 subjects 27 of them had 1-5 number of patches on them 90%Table – 38 Size of patches (for 24 patients only):Sl.No. Size of patches No. of Patients % 1. 1-15cm 19 82.6% 2. 16-30cm 2 8.68% 3. 31-45cm 1 4.34% 4. 46-60cm 0 0 5. 61-75cm 1 4.34% 6. 76-90cm 0 0 7. Above 90cm 1 4.34%Among 30 subjects 19 of them presented with patches between 1-15cm size 82.60% A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 112. 112 COLOUR OF THE PATCHES 25 23 20 15 NO OF PATIENTS 10 5 5 2 0 0 0 C5 C4 C3 C2 C1 NO OF PATCHES 30 27 25 20 NO OF PATIENTS 15 10 5 2 1 0 1 TO 5 6 TO 10 ABOVE 10 NO OF PATCHES SIZE OF THE PATCHES 20 19 18 16 14 12 NO OF PATIENTS 10 8 6 4 2 2 1 1 1 0 0 0 1-15 cms 16-30 cms 31-45 cms 46-60cms 61-75 cms 76-90 cms above 90 cms SIZE IN CMS Series1A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 113. 113Table – 39 Aggravating factors:Sl.No. Aggravating factors No. of % Patients 1. Exposure to sun 4 13.33% 2. Contact with chemicals 1 3.33% 3. Application of Cosmetics 0 0 4. Intake of milk 1 3.33% 5. Intake of curd 2 6.66% 6. Non-veg diet 2 6.66% 7. Nothing particular 20 66.66%Among 30 subjects 20 of them had no specific aggravating factors 66.66%Table – 40 History of Allergy:Sl.No. History of Allergy No. of % Patients 1. Food 1 3.33 2. Drugs 0 0 3. Dust 1 3.33 4. Nothing particular 28 93.33Among 30 subjects 28 of them had no specific History of Allergies 93.33% A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 114. 114 RESULTSTable – 41 Responded / Not responded:Sl.No. Parameter Responded % Not % responded 1. Colour 24 80% 6 20% 2. Number 3 10% 27 90% 3. Size (for24 Pts) 11 45.8% 13 54.1%Amont 30 subjects 24 patients responded in colour and 6 did not respond, 3 patientsresponded in number and 27 did not respond, out of 24 patients 11 responded in size and13 did not respond.Table – 42 Response in the Colour of Patches:Sl.No. Mild Moderate Marked Excellent No (26-50%) (51-75%) (76-100%) response (1-25%) 1. 11 6 7 0 6Among 30 subjects 11 showed mild response, 6 moderate, 7 marked and 0 excellentresponse in colour. 6 patients showed no response in colour.Table – 43 Response in the Number of Patches:Sl.No. Mild Moderate Marked Excellent No (26-50%) (51-75%) (76-100%) response (1-25%) 1. 0 2 1 0 27Among 30 subjects 0 showed mild response, 2 showed moderate response, 1 showedmarked improvement, 0 showed excellent response. 27 patients showed no response inthe number of patches A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 115. 115 RESPONSE IN COLOUR NOTRESPONDED 20% RESPONDED 80% RESPONDED NOTRESPONDED RESPONSE IN COLOUR 12 11 10 8 7 6 NO OF PATIENTS 6 4 2 0 0 1-25% 26-50% 51-75% 76-100% % RELIEF Series1A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 116. 116 RESPONSE IN NUMBER RESPONDED 10% A NOTRESPONDED 90% RESPONDED NOTRESPONDED RESPONSE IN NUMBER 2 2 1.8 1.6 1.4 1.2 1NO OF PATIENTS 1 0.8 0.6 0.4 0.2 0 0 0 1-25% 26-50% 51-75% 76-100% % RELIEF Series1 A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 117. 117 RESPONSE TO SIZE RESPONDED 46% NOT.RESPONDED 54% RESPONDED NOT.RESPONDED RESPONSE IN SIZE 6 6 5 4 3NO OF PATIENTS 3 2 1 1 1 0 1-25% 26-50% 51-75% 76-100% % RELIEF Series1 A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 118. 118Table – 44 Response in the Size of Patches (for 24 patients only):Sl.No. Mild Moderate Marked Excellent No (26-50%) (51-75%) (76-100%) response (1-25%) 1. 3 6 1 1 13Among 30 subjects 3 showed mild Response, 6 showed moderate Response, 1 showedmarked improvement, 1 showed excellent Response. 13 patients showed no Response inthe size of patchesTable – 45 Overall Results:Sl.No. Mild Moderate Marked Excellent No (26-50%) (51-75%) (76-100%) response (1-25%) 1. 18 4 2 0 6Among 30 subjects 18 showed mild response ,4 showed moderate response, 2 showedmarked improvement, 0 showed excellent response after the clinical study, and 6 patientsdid not respond to the treatment at all.Table – 46 Results: VARIABLE MALES FEMALES N=13 N=17Age (Mean Age) 27.1 yrs 28.58 yrsHabitat – Urban 76.92 % 76.47 %Habitat – Town 15.38 % 17.65 %Habitat – Rural 7.69 % 5.8%Diet – Vegetarian 38.46 % 11.26 %Diet - Mixed 61.54 % 88.24 %Types – Localized 92.31 % 82.35 %Generalized 7.69 % 17.65 % A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 119. 119 O ER LLR SU V A E LTS 18 18 16 14 12 10N FPA TS OO TIEN 8 6 6 4 4 2 2 0 0 1-25% 26-50% 51-75% 76-100% 0R PO SE ES N %RESPO SE N Series1 A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 120. 120Table – 47 Statistical Analysis of the Results : PARAMETER MEAN MEAN STD STD t p REMARKS DIFF. DEV ERR Value ValueCOLOUR BT 4.44 0.84 0.48 0.08 6.6 < 0.0001 SIGNIFICANTCOLOUR AT 3.6 1.1 0.2NUMBER BT 1.66 0.28 2.23 0.41 1.7 <0.35 NOT SIGNIFICANTNUMBER AT 1.38 1.94 0.36SIZE BT 12.36 0.02 24.4 4.45 2.05 <0.1 NOT SIGNIFICANTSIZE AT 12.34 24.3 4.2 A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 121. 121 DISCUSSIONAbout the Disease: Switra is an ancient malady due to its references being cited in theVedas. It is evident that people suffered from this disease from times unknown. A similarcondition like switra was prevalent in other civilizations across the globe. This is evidentfrom, the description of the disease available in their respective literature. It was called“Kilas” in Tibet, “Bohak” in Arabia “Zorak” in Jerusalem, “Shirabito” in Japan,Hence it can be said that this disease was prevalent across the globe not restricting toparticular country or race. Since ancient times attempts were made to combat the disease.Switra can be well correlated to VITILIGO in contemporary medicine. Switra and vitiligo have similar clinical features and presentation of the disease.Both the diseases are related to hypopigmentation. Vitiligo is the most commonly aquiredhypomelanosis. The prevalence of the disease is 1% World wide. In a society where attractiveness is positively related to expectations of furthersuccess, happiness and satisfaction in marital relationships, it is not surprising that anyvisible illness like switra can make the afflicted person experience high levels of selfconciousness and low self – esteem. The etiology of vitiligo remains unknown, only the Triggering / Precipitatingfactors are identified, among which nutritional deficiency, emotional stress infections,exposure to chemicals are included. The etiology of Switra is given as incompatible diet,misconduct, improper life style. The essence of both remains same i.e. misconduct,improper life style indirectly leads to stress which disturbs the harmony between the bodyand mind. Stress plays an important role in dermatological diseases. Incompatible dietleads to disturbances in the metabolism and causes accumulations of toxins in the body,in directly leads to nutritional deficiency. Vitiligo (Non - segmental type) is considered ofauto immune origin.. A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 122. 122 During this study no prodromal symptoms are mentioned for both switra andvitiligo and the same was noticed in the study. The pratyatmaka linga “Swetavarna mandalas” were clearly evident. Patientssought medical attention when they noticed white coloured patches on the skin. As perthe definition of Sushruta, 30 switra is “Twagatam” and “Aprasravi”accordingly insubjects the skin was only involved, no pain or secretions were noticed. Vitiligo is alsopresented as milky white patches, centrally hypopigmented with sharp circumscribedborders and mostly asymptomatic. The clinical features of vataja, pittaja, sleshmaja couldnot be found in the patients as described in the texts. The macules were found to be ofround, oval shape and some macules were irregular in shape. The size of macules mostlyvaried from 1-15cm. The mucous membranes were affected and lips were mostly amongthe affected mucosal surfaces. Although any part of the skin or mucous membrane isamenable to develop vitiligo the disease has a predilection for normal, hyperpigmentedregions such as face, groin, axillae, areola, and genitalia. The same was observed that theface was the first site of onset in many patients. Further, lesions may develop in areas like ankles, elbows, knees, which aresubjected to repeated trauma or friction according to texts and the same has beenobserved in the patients whose first site of onset were limbs the areas generally involvedwere the knees, or elbows or ankles. Lip – tip syndrome characterized by depigmentationof terminal phalanges was not encountered during the study. Clinical variants of vitiligo were not seen in subjects of the study. Among thevarious types of Vitiligo, maximum prevalent type was localized – focal and segmentalforms. The non - segmental form, which is a generalized type, was also seen in thepatients in less percentage. A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 123. 123Discussion on Drug Review: The drug taken for the clinical study is “Dhatri – KhadiraKwath” selected from Baishaijya Ratnavali. It basically contains Dhatri i.e. Amlaki andKhadira. The main aim for selecting the drug is to find a simple panaceae for a diseaselike switra. The form of administration is kwath form which has high efficacy. Both thedrugs are easily available, non-controversial, unadulterated and economical. The kwathchurnam was given to the patients sufficient for every 15 days for a total duration of 45days. The patients were advised to take 1 tsp (5grms) of honey each time after taking themedicine. Before starting the treatment patients were advised to take Triphala Churnamfor virechanam. Khadira is the best kustahara dravya. Many instances have quotedkhadira to be beneficial in switra also. Works on Bakuchi, Kakodumbara, Chitraka, andKaseesabaddaras have been conducted but efficacy of khadira in causing pigmentationhas not been studied. Moreover Amlaki is the best rasayana, pitta shamaka and improvesthe efficacy of the formulation.Probable mode of action: Khadira is the Sheeta Virya Dravya having tikta, Kashayarasas. Has best Pitta Shamaka and rakta shodaka property. As Rakta and pitta(Interlinked with each other) are both vitiated in switra Khadira acts best in this aspect. Amlaki also is sheeta virya dravya with pancharasas (Except Lavana). It is thebest source of vitamin C. Helps to build immunity, and may hinder the autoimmunereaction in the body. It is also best pitta shamaka. Generally the oxidants which are theoutcome of metabolic reactions are accumulated in the skin which can be shown throughFourier – Raman spectroscopy. These oxidants are responsible for the harmful changes inthe skin. Amlaki has the best anti - oxidant property which can counter the effects oftoxins in the skin.Discussion on Methodology: The study was conducted in the Dept of Kayachikitsa,Govt.Ayurvedic Hospital, Erragadda, Hyderabad. The main aim was to assess theefficacy of Dhatri- Khadira Kwatha in causing pigmentation in white patches of switra. A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 124. 124 A total of 34 patients were incorporated, 4 patients were dropouts, 30 patientscompleted the treatment schedule. The patients had to come for a review for every 15days. And the improvement in the condition was assessed accordingly. Patients of eithersex aged between 5-70 yrs were randomly selected into a group, and an open trial wasconducted. Prior to the trial an informed consent from all the patients was obtained. Athorough dermatological examination and a detailed history were taken through a specialcase sheet.Inclusion Criteria: Patients of either sex were included in the study to know theincidence of the disease among males and females. Patients aged 5yrs were the lowerlimitand 70 yrs the higher limit. To know the increase in the incidence of childhood vitiligothe lower limit was taken and higher limit to know the incidence of switra in elderlypeople. Chronicity less than 6 yrs was taken to assess the response of patches to thetreatment. Generally above 6yrs of chronicity the patches do not respond to the treatmentand in some cases there may be complete depigmentation.(Fitzpatrick)Exclusion criteria: The exclusion criteria were followed from ICD-10. L00-L99-Skinand sub-cutaneous disease. L80 vitiligo; shows the exclusion criteria for vitiligo. Patientsbelow 5yrs are too young to take the medicine and above 70yrs also may not be able totake the medicine. Other skin diseases like Psoriasis and Eczema interfere with the treatment hencethey are excluded. The psychiatric problems like psychosis etc makes the patient unfit forthis treatment.Investigations: There are no special laboratory investigations to diagnose switra. As apart of routine examination CBP, ESR, RBS, CUE were done prior to the study.Diagnostic Criteria: Swetavarna mandalas on the skin and mucosal surfaces with orwithout other features of switra. A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 125. 125Assessment criteria: The assessment was based on three clinical parameters, the colour,number and size of the mandalas, which was observed before, during and after thetreatment. To assess the improvement in the colour, grading was given. C0- Normal Skincolour, C 1-Tanned Brown Colour, C 2 – Light Brown Colour, C3- Dark Pink, C4 – LightPink, C 5 – White Colour. All the patients did not present with white coloured patches.Some had light pink, others had darkpink colour in the patches. During the treatment theimprovement was assessed like change of colour from white to light pink and so on. Thegrading was given to assess the stepwise changes in the colour. The complte results of the treatment were ascertained in terms of 5 groups. If thesymptoms of a patient decrease by 1-25% he is put in mild response group, if the patienthad decrease in symptoms by 26-50% he is placed in moderate response group, if thepatient had relief of symptoms by 51-75% he is placed in marked response group. If therelief is more than 75% he is placed in excellent response group. If no know relief ofsymptoms is seen they are placed in no response group.Discussion on observations: A total of 34 patients were incorporated among whom, 4were dropouts and 30 completed the treatment schedule. The following discussion onobservations is based on them.Age groups: Among 30 patients, 6 of them (20%) were below the age of 10 yrs. 7patients (23.33%) were below the age of 20yrs. From past two decades there is a sharprise in the incidence of childhood vitiligo (Behl) and the same was observed in this study.Sex: Both males and females were taken for the study. The disease affects both the sexesequally. But the percentage of female patients (56.66) in this study is higher than men. Itcan be attributed to the social stigma and embarrassment caused due to depigmentationand thus making female patients seek medical attention earlier than males.Religion: Higher percentage of the subjects 70% belonged to Hindu community.Generally in particular communities the dietary habits vary, which may be the cause forthe disease, to evaluate that, religion was taken into consideration. A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 126. 126Marital Status: Among 30 subjects, unmarried patients were more in number 17,(56.66%).Diet: The higher incidence of the disease was found in subjects with mixed diet 23patients (76.66%). Generally taking non - vegetarian diet may accelerate the onset of thedisease.Socio Economic Status: The subjects were classified into three groups depending ontheir income level. Less thanRs.10,000/- were grouped into Low income group,Rs.10,000-20,000/- Middle income group and aboutRs.20,000/- High income group.Majority of subjects 17 (56.66%) belonged to Middle income group.Habitat: Incidence of the disease is high in the rural population (Behl), among the 30subjects taken for the study; a high incidence is seen in the urban population -23 patients(76.6%) Rapid phenomenon of urbanisation which leads to life style changes and dietarydisorders might have resulted in the higher incidence in urban people.Occupation: Switra may be produced as one of the occupational hazard. Occupation hasa direct influence on the disease. Occupation which includes contact with chemicals, orprinters, dyers, have chance of acquiring switra. In the present study majority of themwere students 16 (53.33%).Colour of the patients: Generally vitiligo affects all the races equally, but the darkskinned people are more prone to display due to the colour contrast. India is a tropicalcountry where we find more of wheatish to dark coloured people. In the study theincidence of switra was found more in wheatish skinned people 14 (46.66 %.)Origin of the disease: Switra has a doshaja (Endogenous) origin and vranaja origin(Exogenous). Generally due to intake of incompatible diet and other factors disease maybe produced and due to external causes likes vranas due to accidents, burns, chemicalcontacts or trauma Switra may be produced. Among 30 patients 28 of them (93.33%) areof endogenous origin and 2 (6.66%) had exogenous origin. Among which 1 patient A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 127. 127acquired the disease due to burns with spirit and other due to trauma (Koebner’sphenomenon). The origin of the disease due to trauma also holds significance.Prakriti: among 30 patients, majority of the patients 9 (30%) with switra belonged toVata – Pitta prakriti followed by Pitta-Vata prakriti (30%) The incidence was more inpeople with vata and pitta features.Family History: The proportion of patients with positive family history varies from onepart of the world to another. In India, in particular it ranges from 6.25 – 18%. In somestudies it is as high as 40% (Behl). In the present study the incidence of family historywas 3.33% only. The absence was 96.66% it cannot be generalized, but the polygenic andvariable penetrance of the disease can be known.History of Consangnious marriage: Among 30 subjects only 6 of them (20%)presented with a history of consangnious marriage of parents, 24 of them (80%) had nohistory.Stress: Though stress is said to be one of the triggering factors for the disease(Srivastava), in the present study only 7 of them presented with history of stress (23.33%)Chronicity: Majority of the subjects, 20 of them (66.66%) had chronicity below 1 year.The higher the chronicity, it was observed that patients’ response to treatment decreased.The highest chronicity of the study was 6 yrs. But no severe depigmentation was noticed.,Old/New: Among 30 patients’ 15 patients were new cases, who started treatment withthe trial drug and 15 cases were old who previously took treatment elsewhere.Age of first onset: Almost half the patients presented before the age of 20yrs and nearly70-80% before the age of 30 yrs (Lerner and Nor Bend). In the present study , 50% of thepatients presented before the age of 20 yrs , 13.33% before the age 30yrs and 13.33%before 40yrs. It is seen in majority of the patients that the disease presented before thesecond decade of life and the incidence decreased in the subjects with age above 50yrs. A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 128. 128Nidanam: As per Ayurvedic texts the ahara – vihara nidana plays an important role inthe disease. Description about the cause of the disease due to adhika amla, lavana, dadhi,dugda, masha, pisti sevana is mentioned. In the present study majority of them 9 (30%)did not have any particular dietary habits as mentioned above. But 16.66% patients hadhistory of excessive consumption of meat and 16.66% had history of excessive curdintake.Site of first onset: The disease has a predilection for normal hyperpigmented regionssuch as face, groin, axillae, areola, and genetalia. Further lesions may develop in areaslike ankles, elbows, knees, which are subjected to repeated trauma or friction (Behl) andthe same was observed in the clinical study that about 11 patients 36.6% face was thefirst site of onset and 9 patients 30% had lowerlimbs as first site of onset. In patients withlowerlimbs were involved the patches developed at the site of knees, ankles andbonyprominences of medial malleolus. Very less patients 1 (3.33%) presented genitals asfirst site of onset.Types: There are three types of vitiligo, localized, generalized and universal. Thelocalized forms includes focal, segmental and mucosal, the generalised includes the non-segmental, universal where complete depigmentation occurs. In the present studymajority of patients 26 (86.66%) were of localized types 4 patients were of generalizedtype(13.33%).No patients with universal type were seen.Nature of spread : In 29 (96.66%) patients the lesions had gradual spread ,only onepatient had sudden spread of the patches immediately after attaining puberty. Lesionsstable for many years was not found in any patients.Symmetry of the patches: The shape of the patches was taken into account. Equalnumber of patients had symmetrical 50% and asymmetrical patches 50%. Mostly roundand oval were prevalent in symmetrical types. A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 129. 129Leucotrichia: Hair over the patch may or may not turn white (Behl) But if hair turnswhite indicates poor prognosis. In the present study only 5 patients presented withleucotrichia. Among whom only 2 patinets responded to the treatment.History of Allergy: H/o dust allergy was found in 1 patient 3.33%, 1 patient had foodallergy (particularly to bananas, Brinjalas) majority of them 28 (93.33%) had no H/oallergy.Aggravating factors: A couple of observations regarding the aggravating factors weremade during the clinical study. Majority of them 20pts (66.66%) did not have anyaggravating factors, but 4 pts observed redness of patch, burnings sensation whenexposed to sun. 2 pts (6.66%) observed intake of non-veg diet particularly chicken andfish resulted in increase in the size of the patch, 2 patients observed taking curd causedintense itching in the patches, the same was observed by 2pts, that taking milk causeditching in the patches.Colour of the patches: Among 30 patients 23 (76.6%) of them presented with whitecoloured patches. 5 pts presented with light pink coloured patches, 2 pts presented withdark pink coloured patches. Probably the application of topical creams might have lead tothe change in the colour. Old cases presented with the about two coloured patches.Number of patches: Among 30 patients 27 (90%) of them had patches between 1-5 innumber only 1 patient had between 6-10, and 2pts had patches above 10 in number.Size of the patches: The size measurement was possible for only 24 patients. 19patients (82.6%) had patches ranging between 1-15cms. 2 patients has patches between16-30 cm, 1 patient presented with patch size between 31-45 cms, 1 patient presentedwith 61-75cms, above 90cms – 1 patient. A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 130. 130Discussion on Results: The results were analysed statistically by paired‘t’ test from theobservations made during and after the clinical study. The mean age of the studypopulation is 28 yrs. Mean age of female population is 28.58yrs. Majority of the subjectshad mixed diet, more than females, males were vegetarians. Highest percentage of thestudy population came from urban areas. In females the disease was more of systemictype.Colour of the patches: Among 30 patients, 24 patients (80%) responded in colour, 6patients (20%) did not respond in the colour. The patients who have undergone completetreatment schedule showed marvelleous improvement in the colour of the patches. Thepatient came every 15 days for a review. Each time patient noticed marked changes in thecolour of patch. In the first 15 days the colour changed to light pink, in some it eventurned into darkpink. In patients who have already taken treatment elsewhere presentedwith light and darkpink patches initially. In those subjects after 30 days brownpigmentation spots were noticed .After 45 days the pigmentation improved noticeably. Two kinds of pigmentation changes were noticed during the study. In some casespigmentation started from periphery bringing about changes in the size, such is peripheralrepigmentation. In some case pigmentation spots were seen around the hair follicles inthe center of the patch, gradually growing in size and changing the symmetry of thepatch, such is perifollicular repigmentation. The statistical analysis shows P<0.0001which is significant. Among the 24 patients responded, 11 patients showed mild response, 6 showedmoderate response, 7 showed marked response, no patients showed excellent response.Number of patches: Among 30 patients majority of them, 27 presented with 1-5 no ontheir body. 1 patient had patches in between 6-10 and 2 patients had more than 10 patcheson the body. After the treatment schedule, the patients did not show much response in thenumber. But patients who responded showed moderate and marked response. A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 131. 131 Of 30 patients only 3 responded in number and 27 numbers did not show anyresponse in change of number of patches. Out of 3, 2 patients showed moderate response,1 patient showed marked response. No patient showed excellent response. The statistical analysis shows P<0.35 which is not – significant. There werechanges noticed in the patch but there was no change in the number of patches. Thepatients in whom the number decreased were of recent onset and small in size. Butamong few who responded in number, their response was remarkable.Size of the patches: Among 24 patients, 19 patients had patches of size in between 1-15cms, 2 patients had size in between 16-30 cms. 1 patient had 31-45cms, 1 patient hadpatch ranging between 61-75cms, and 1 patient above 90 cms. After completing the treatment schedule 11 patients (45.8%) responded in size, 13patients (54.1%) did not respond. Among the 11 patients 3 showed mild response, 6showed moderate response, 1 showed marked response, 1 patient showed excellentresponse. The change in the size of the patches was depended on the colour changes. Therepigmentation occurring in the white patches brough about the difference in size.Peripheral repigmentation caused Shrinkage in the size and perifollicular repigmentationbrought about changes in symmetry (shape) which automatically brought difference inthe size The statistical analysis shows P<0.1 which is not- significant. But the responseseen in the size of the patches in duration of 45 days is commendable. During the clinical study, in the first 15 days majority of them started showingchanges in the patches. The colour change was prominent, but there was no change in thenumber and size. A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 132. 132 After 30 days, the colour grading improved; the change in the colour waseven more remarkable. Pigmentation spots in the centre of patch were seen in somepatients and in few, changes from periphery were noticed. No change in the numbernoticed.After completion of 45 days – changes in the colour was even more satisfactory. Sizedifferences in the patches were clearly evident. Small patches of 1-3 cms disappeared andsome faded due to the pigmentation. They were not as prominent as before. Change innumber but only in 3 patients was noticed. The improvements were noticed in patientswith less chronicity, fresh cases with small sized patches. And the type was more oflocalized type. In cases where the buccal mucosa was involved changes in colour wasremarkable. During the treatment patients noticed many factors that caused irritation, itching,burning sensation and increase in size. No blisters or oozing was noticed. Initiallypatients experienced nausea, while taking the medicine but after a week the feelingdisappeared. Patients were advised for followup of 2 months. Only 12 patients hadregular followup. The changes that took after completion of treatment schedule persistedafter 2 months also. No new findings took place. No patients were Diabetic,Hypertensive or Asthamatic hence no changes were recorded in those aspects. Overall, from the clinical study conducted on 30 patients for duration of 45 dayssatisfactorily with negligible side effects 18 patients showed mild response, 4 patientsshowed moderate response, 2 patients showed marked response, no patients showedexcellent response. 6 patients showed no response to treatment at all. The initial resultsare promising depending upon the response in colour, number and size. Some more timeis needed to establish the results.Limitations of the study: A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 133. 1331. As the study does not have a control group, any categorical statements about the success attribution to drug cannot be made.2. The duration of the study is very short, it would have been better if the duration was for a longer period to establish the results even more effectively.3. As the sample size is very small (30pts) any significant findings found in the study cannot be generalized to the population.Recommendations for the future study:1. Study to be conducted on larger samples.2. To do a comparative study between a control group and test group with medicine taken internally.3. To do a comparative study between a control group taking medicine internally and externally and test group taking medicine only internally.4. To take a longer duration of time for clinical study.5. To scientifically probe the action of Khadira on melanocytes. A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 134. 134 CONCLUSIONFrom the discussion based on this study, it becomes nearly conclusive that, Switra is a pittapradhana tridoshaja, twak vikara. Sweta Varna mandalas appear on the skin suggestive of the disease. It has historical background suggestive that many people suffered from this disease since times unknown. Based on the clinical features it can be well correlated to vitiligo of contemporary medicine. The prevalence of the disease is 1% world wide, affecting males and females equally, but incidence of females is higher due to the social stigma and embarrassment attached to the disease. The incidence of childhood vitiligo is rapidly increasing from past two decades. In the present study 20% of the patients were below 10 years. The age of first onset, is before 20yrs, face and lowerlimbs are the site of first appearance of the disease. Family history and H/o consangnious marriage of parents had little role to play in the etiology. Many of the patients had no specific incompatible dietary habits, in most of the cases etiology was unknown. Koebner’s Phenomenon was noticed in two patients as etiology. Leucotrichia also was not seen in majority of patients. Certain foods caused itching, increase in size of the patches, exposure to sun caused redness and burning sensations in the patches. A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 135. 135 Early detection and short duration of the disease, small sized patches, good prognosis is seen. The drug proved to be beneficial as promising results were noticed initially in response of colour and size. No much change in number was noticed. Out of 30 patients – 18 patients showed mild response, 4 patients moderate response, 2 marked response and 6 members did not respond to the treatment. Better results can be established with “Dhatri-Khadira Kwath” if study is conducted on larger samples, for a longer duration in a comparative fashion by enthusiastic scholars. A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 136. 136 SUMMARY A clinical study was undertaken to evaluate or assess the efficacy of ‘Dhatri-Khadira Kwath’ in the disease switra. As the colour of the skin plays an important role in the lives of people, any visiblechanges in the skin can make the afflicted person experience high levels of self –conciousness and low self esteem. Patients are subjected to social embarrassment, thereby leading to psychological disturbances. Hence disease switra which is related tohypopigmentation was selected for the study. Based on the clinical features it is wellcorrelated to vitiligo of contemporary science. The etiology of the disease remains unknown. It is expected to develop as asequel to irregular dietary habits and life style changes. Genetic predisposition may alsoaccount for the disease. A comprehensive formula “Dhatri-Khadira Kwath” selected from BhaishajyaRatnavali was used in the clinical study. A total of 30 patients fulfilling the inclusion andexclusion criteria were taken for the study for duration of 45 days. The present literary work is divided into five parts which gives a detailed pictureof the disease, and clinical study. Thte first part consists of review of literature where the literary aspect about thehistorical background, anatomy, physiology of the affected part, etiology, clinicalfeatures, differential diagnosis, prognosis, treatment and dietary restrictions areexplained. A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 137. 137 The second part contains the drug review which includes the criteria for theselection of drug, description of individual drugs and method of preparation has beenelaborated. The third parts comprises of methodology, observations of the study and results ofthe study. Fourth part is mainly the discussion, conclusion and summary aspect of the study. Fifth part relates to references, bibliography, annexure which includes, mastercharts and special casesheet of the study. The present study highlights the fact that, medicine taken orally could bebeneficial in the management of Switra. A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 138. 138 REFERENCESHistorical Review: 1. Ibid 1.117.7 2. Ibid 1.117.8,24 3. Ibid 1.23.1-4: 1.24.1-4 4. Sayana on AVS .1.24.2 5. Y.V – 30/21 6. A.V. Kanda – 1: 23-24 7. A.V.S.1.23. 8. Padmapurana 1.81.2 9. Markandeyapurana 16.14 10. 1.11.35-58 11. V.P.2.115, 95 12. I.P 10.33.40 13. B.V.P1.26.26 14. Yagna.Praya.84.91-103 15. Pg.No.42 History of Medicine in India – P.V. Sharma 16. Najamabadi, M.Tarikh-E-Tib-E-Iran. Volume 1, Shamshi Tehran: 1934 17. Ebbel.B.The Papyrus, Ebesscopenhagen.lewin and Meinksgard.1937 Pg.45 18. El. Mofty AM.Vitiligo and Psoralens. Pergamon Press: Oxyford; 1968 p.1147-95 19. Goldman L, Moraites RS, Kitz miller KW White spots in biblical times. A background for the dermatologist for participation in discussions of current revisions of the bible. Arch Dermatol 1966; 93:744 – 53 20. ITO.M.Vitiligo.Tohokee .J. Exp.Med.1952: 5 72-6 21. Cha.Chi 7/173 22. Su.Ni 5/17 23. B.S 6th / 35 24. H.S Dwitiya stan; 4 adhyaya A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 139. 139 25. Kashyapa samhita kusta chikitsa 26. A.S.Su 35/3 27. A.H.Ni 14/34 th 28. Vangasena Kustaroga adhikar/8 sloka 29. M.Ni 49/4 30. Sha.Sa madhyamakanda, kustaroga adhyay 31. B.P. 54/3 32. Srivasthava.G.Vitiligo – Introduction Asian Clinic, Dermatol 1994; 1:1 – 5 33. S.L.V 1-Chapter – 33 34. Lalitha vistara. P.L. Vaidya .Ed Mithila Institute Darbhanga 1960 35. Saddharma Pundarika PLvaidya Ed Mithila Institute Darbhanga 1960 36. K.A.S. (14.177.1) 37. Harsha Charitra – 88 , 399 38. Indian .J. Dermatol / Venerol / Leprol / May – June, 2007 Vol.73 issue 3 39. B.R. 54 Chapter Kustaroga adikar.Nirukti: 40. Sanskrit Shabdarda Koustubha, Pd. Taranish Jha, Late Sri Chaturvedi Dwarakaprasad Sharma. 2nd edition. 41. Carter RL, editor, A dictionary of Dermatologic terms 4 th edition, (1992) Williams and Wilkins: Battimore 42. Nair B.K. Vitiligo retroaspect. Int J. dermatol 1978; 17:755-7Paribhasha: 43. Amarkosha 44. Shabda Kalpa drumam, 5th vol. 45. Kashyapa samhita kusta roga adikar 46. Su.Ni 5/17 47. Dermatology in General Medicine A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 140. 140Shareera Rachana: nd 48. Shabda stoma mahanidhi, 2 edition by Taranath Tark, Vachaspathi Bhattacharyena. nd 49. Shabdakalpa drumam, 2 Vol. Raja Radhakanth deva 50. Su.Sha 5/3 51. Su.Sha 4/4 52. A.S.Sha 5/17 53. Cha.sha 7/4 54. A.H.Sha 3/8 55. Su.Sha 1/10 56. Su.Sha 1/7 57. Su.Sha 1/26 58. Cha.Sha 7/7 59. A.H. Su 11/1 60. A.H.Su 12/8 61. Su.Su 21/9 62. Cha.Su 1/61 63. Su.Su 14/10 64. Cha.Chi 15/7 65. Cha.Vi 8/103 66. Su.Sha 3/31 67. Cha.Sha 7/4 68. Su.Sha 4/4 69. Cha.Sha 7/7 70. Su.Sha 4/4 71. A.H.Sha 3/8 72. Anatomy and Physiology by Tortora 73. Gray’s Anatomy – Integumentary system A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 141. 141Shareera Kriya: 74. Shabdakalpa drumam, 2nd vol 75. Su.Sha 3/31 76. Su.Sha 2/37 77. A.H. Su.12/5 78. Cha.Su 12/11 79. Su.Su 21/10 80. A.H.Su1/3 81. Cha.Ind 7/16 82. Cha.Vi 8/103 83. A.H.Su 11/4 84. Cha.Chu 1/16 85. A.H.Su 11/12 86. A.H.Su 11/15 87. Su.I 13/7 – Dal. Commentay 88. A.H.Su 11/5-7 89. Su.Su 21/9-10 90. Su.Su 21/10 – Dal Commentay 91. A.H.Su 12/14 92. A.H.Su 12/14 – Arunadutta commentary 93. Cha.Su 12/11 – Chakrapani Commentary 94. Bhelasamhita.Shareera.Purushanischaya Shareer 95. A.H.Su 11/15 96. Su.Sha 1/6 97. Su.Sha 1/10 98. Su.Sha 1/26 99. A.H. Su 12/4 100. A.H. Su 11/22 101. Cha.Su 11/48 102. Cha.Su 11/49 103. Integumentary system – Gray’s Anatomy A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 142. 142Nidana: 104. Cha.Ni ½ - Chakrapani Commentary 105. A.H.Ni. 14/1 106. Cha.Chi 7/177 107. A.H.Sha ¼ 108. Cha.Su 26/83 109. Vangasena Kustaroga Adikar / 8 sloka 110. A.S.Su 35/3 111. Su.Ni 5/3 112. B.P. 54/4 113. M.Ni. 49/6 114. Anupan Darpan 8 chapter 115. R.T. 18/7 116. Cha.Su 13/76 117. Cha.Chi 4/26 118. Su.Su 24/6 119. Cha.Sha 1/18 120. A.H.Ni 14/1-2 121. Su.Ni 5/17-Bhoja Commentary 122. Manusmriti – History of Medicine in India P.V. Sharma 123. H.S 38/1-3 124. Kashyapa samhita, kusta rogadhikar 125. Su.Ni.5/39-40 – Dalhana Commentary 126. Cha.Chi 7/177 127. Pengun Js. Vitiligo Br.J. Dermatol 1996 : 134:373 128. Shwartz RA, Jannigar CK Vitiligo Cutes 1997; 60: 239-44 129. Behl PN, Agarwal A. Srirastava G. Vitiligo in Behl PN, Srivastava G editors’ practice of Dermatology 9 th edition CBS Publishers: New Delhi 2003. Pg 238-41 A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
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  • 146. 146181. Federman DG, Kravetz JD, Ruser CB, Judson PH, Kirsner Rs. Vogt - Koyanagi Harada syndrome and ulcerative colitis. South Med J. 2004; 97: 169-71182. Schwartz RA., Jannigar CK. Vitiligo Cutis 1997; 60:239-44183. Behl PN, Agarwal A, Srivastava G. Vitiligo. IN Behl PN, Srinvastava G. editor th Practice in Dermatology 9 edition CBS Publishers New Delhi, 2003.Pg 238- 41.184. Arata J, Abe – Mastassura Y. Generalized vitiligo preceded by a generalized figurate erythemato squamous eruption. J Dermatol 1994; 21:438-41185. Fisher AA Differential diagnosis of idiopathic vitiligo from contact leucoderma Part II leucoderma due to cosmetics and bleaching creams. Cutes 1994:53:232-4186. Adbel Naser MB, Ludwing WD, Goldrick H, Or fornos CE Non – segmental vitiligo decrease of the CD4 5RA T – Cell subset and evidence for peripheral T cell activating Int J. Dermatol 1992; 31: 321-6187. Goudi RB, Spence JC, Markie R. Vitiligo Pattens stimulating autoimmune and rheumatic disease lancet 1979; 2:393-5.188. Wayne DM, Hebig EB. Halo Nevi Cancer 1968; 22:69-90189. Handa S, Dogra S. Epidemiology childhood vitiligo A study of 625 patients from North India. Pediat Dermatol 2003; 20:207-10190. Pengum Js. Vitiligo Br J. Dermatol 1996; 134:373191. Wee TA. A case report of extensive vitiligo. Harvair Med J. 1997; 56:37-40192. Drake L, Dinchart SM, Farmer FR, Goltz RW, Graham GF, Hordinsky MK. Et.al Guidelines of care for vitiligo patients. J. Am Acad dermatol 1996; 35:620-6193. Hann SK, Chun WH, Park YK Clinical Characteristic of Progressive vitiligo Int.J. Dermatol 1997; 36:353-5194. Hartmann G, Panconesi E. Vitiligo: A psychologically influencing diseases. Clinic Dermatol 1997; 15:879-9195. Mathias CG, Maibach HI, Conant MA. Perioral leukoderma stimulating vitiligo from use of toothpaste containing cinnamic aldehyde. Arch Dermotol 1980: 116:1172-3 A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
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  • 148. 148209. Anstey A, Marks R. Co-locolization of lichen planus and vitiligo Br. J. Dermatol 1993; 128:103-4210. Kang JK, Hann SK. Vitiligo coexistent with nevus depigmentoses .J. Dermatol Tokyo 1996; 23:187-90211. Down’s AM; Lear JT. Dunnil MG. Polymorphic light eruption limited to areas of vitiligo. Clinic Exp.Dermatol 1999;24:379-81212. Malignant melanoma and vitiligo J. Invest Dermatol 1979; 73:491-4.213. Nordlund JJ, Albert D, Forget B, Lerner AB, Halo Nevi and Vogt Koyanagi Harada Syndrome – Manifestation of Vitiligo. Arch Dermatol 1980; 116: 690-2214. Kumakiri M, Kimura T, Miura Y, Tagana Y. Vitiligo with an inflammatory erythema in Vogt – Koyanagi Harada disease. Demonstration of fila mentous masses and amyloid deposits J. cutan pathol 1982; 9:258-66.215. Barnes L. Vitiligo and Vogt. Koyanagi – Haradasyndrome. Dermatol Clin 1988; 6:229-39.216. Egli F, Walter R, Images in Clinical Medicine Vitiligo and pernicious anaemia N. Engl J. Med 2004; 350-2698217. Okada T. Sakamoto T, Ishi Bashi T, Inomata H. Vitiligo in Vogt – Koyanagi Harada disease Immunohistological analysis of inflammatory site Gafes Arch clin Exp Ophthalmol.1996; 234:359-63.218. Tsurata D, Hamada T, Teramae H, Hito H, Ishii M Inflammatoy Vitiligo in Vogt – Koyanagi Harada disease J. Am Acad Dermotol 2001, 44:129-31219. Fournier GA, Albut DM, Wagnoner MD. Choroidal halo nevus occurring in a patient with vitiligo. Suru Ophthalmol 1984; 28:671-2.220. Fragnoli MC, Bolognia, JL. Pentachrome vitiligo. J. Am. Acad Dermatol 1995; 33:853-6221. Federman DG, Kavertz JD, Ruser CB, Judson PH, Kirsner RS. Vogt-Koyanagi Harada syndrome and Ulcerative Colitis. South Med J. 2004; 97: 169-71.222. Halder RM, Erimes PE, Cowan CA, Enterline JA, Chakrabarti CG. Kenney JA Jr. Childhood Vitiligo. J Am Acad Dermatol 1987; 16:948-54.223,224,225. Singh P, Singh J. Agarwal US, Bhagavan RK. Contact Vitiligo:Etiology and treatment. Indian J.Dermatol Venerol Leprosol. 2003; 69:27-9 A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 149. 149Samprapti: 226. A.H.Ni.1/8 227. A.H.Ni.14/2 228. Su.Su.21/36 229. Cha.Ni 5/22-23 230. A.H.Ni. 12/22 226. A.S.Su 9/7 227. Cha.Su 24/1-10 228. A.S. Su 9/26 229. Cha.Su 8/18 230. Cha.Su 11/45 231. A.H.Su. 12/23 232. Su.Ni.5/3 233. Su.Ni 5/3 Dalhana Commentary 234. Su.Su.21/23 235. A.H.Ni.14/37 236. A.H.Ni. 14-37 Arunadutta Commentary 237. Su.Su 24/10 238. A.H.Ni 14/1-3 239. Cha.Ni 5/3 240. Su.Sha 4/33 241. Su.Su 21/34 - Dalhana Commentary 242. Amarakosha 243. Su.Ni 5/17 244. A.H.Chi. 20/1 245. Su.Ni.5/28 246. Cha.Chi 7/177Bhedas: 247. M.Ni 49/37-39 248. Su.Ni 5/17 A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 150. 150 249. Cha.Chi 7/174 250. M.Ni 49/37-39 – Bhalukitantra 251. Cha.Chi 7/175-176 252. Kashyapa samhita Kusta Rogadikar th 253. Bhela samhita 6 Chapter 254. Fitzpatrick; Elsen; Wolf Dermatology in General Medicine, 255. Behl PN, Agarwal A, Srivastava G. Vitiligo In Behl PN Srivastava G editor, practice of Dermatology 9th edition Pg 238-41 256. Behl PN, Agarwal A, Srivastava G. Vitiligo In Behl PN Srivastava G editor, th practice of Dermatology 9 edition Pg 238-41Sapeksha Nidan: 257. M.Ni 49/37 258. A.H.Ni 14/5 – Arunadutta Commentary 259. Cha.Chi 7/13 260. Su.Ni 5/17 261. Cha.Chi 7/28 262. Cha.Chi 7/19 263. Cha.Chi 7/37 264. Fitz Patrick, Eisen, Klaus Disorders of Melanocytes – Dermatology in General rd Medicine 3 editionSadya-Asadyata: 265. Cha.Vi 6/3 266. A.H.Ni.14/39 267. Cha.Chi 7/172 268. Kashyapa Samhita Kusta chikitsa 269. Bhela Samhita 6/35 270. Cha.Chi 7/176 271. Cha.Chi 7/177 272. Su.Ni 5/28 A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 151. 151 273. A.H.Ni 14/40 274. M.Ni 49/40 275. Cha.Chi 7/175 276. Su.Ni.5/28 277. B.P. 54/47 278. Dermatology General Medicine Vol-1 3 rd editionChikitsa: 279. Vaidyata Shabda Sindu 280. B.P. Purvakanda, 54 th Chapter 281. Cha.Su 9/5 282. Su.utt 1/25 283. Cha.Su 11/54 284. A.H. Chi 20/1 285. Cha.Su 11/55 286. Cha.Chi 7/162 287. Cha.Chi 7/163 288. Cha.Chi 7/164 289. Cha.Chi 7/165 290. Cha.Chi 7/166 291. B.R. 54/56 292. A.H.Chi 20/7 293. Cha.Chi 1/167 294. Cha.Chi 1/168 295. Cha.Chi 1/169 296. Cha.Chi 1/170 297. Cha.Chi 1/171 298. Cha.Su 8/16 299. Cha.Su 8/18 300. Cha.Chi 7/172 A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 152. 152Patya – Apatyas: 306. Su.Ni 9/5 – Dalhana Commentary 307. Su.Chi 9/4 308. A.H.Chi 19/25 – Arunadutta CommentaryDrug Review: 309. B.R 54/53 310. Cha.Su 25/40 311. Cha.Chi 7/166 312. B.P. Nigantu Haritak Kyadi varga/39 sloka 313. Cha.Chi 6/48 A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
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  • 157. 15741. Kaviraj Ambika Dutt Sastry Sushruta Samhita (Hindi) 6th edition, published by Chaukamba Sanskrit Series. th42. Acharya P.V. Sharma Dravyaguna Vignana (Hindi) Vol.II 8 edition, Published by Chaukamba Bharathi Acadamy.43. Sri Vishwanath Diwedi Aushadi Vignan Sastra 3rd edition (1986) published by Shri Baidyanath Ayurved Bhavan Limited.44. Vd. Laxmipathi Sastri, Bhisagrathna Brahma Shankara Sastri, editor Yogaratnakar (Hindi) with Vidyotini Commentory 7th edition. Published by Chaukamba Sanskrit Series.45. Dr. Vidyadhar Sukla padarth vignan Darpan, 2nd edition (1989) Foreword by Ach. P.V. Sharma. Published by Chaukambha Surabharathi Prakashan.46. Vd. Yadavji, Trikamji editor Charaka Samhita by Agnivesa, Revised by th Charaka and Dridabhala of Chakrapani datta. 5 edition. Published by Chaukamba Sanskrit Series.47. Bhishagvachaspathi Pd. Durgadutta Sastry Sharangdhara Samhita (Hindi) with tatwa Dipika. (2002) Published by Chaukamba Vidya Bhavan.48. Kaviraj Ambika Dutt Sastry Bhaishajya Ratnavali (Hindi) editor by Rajeshwar th Dutta Sastry 16 edition (2002) published by Chaukamba Sanskrit Samsthan.49. Spring House Hand book of Signs and symptoms.50. Dr. Seetha Devi. P “A clinical study on the effect of Lepa in Switra”. Mysore 2003 A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 158. 15851. Dr. Mahantesh P.M. “A Comprehensive Management of Kilasa Kusta (Vitiligo) Hubli 2006.52. Dr. Prabhakar M. “A clinical Study on the effect of Bakuchi Processed in vibheetaki and kakodumbara Kashaya (internally) on switra (Vitiligo).53. Dr. Venugopal Ch. “A Clinical Study on the effect of Kaseesa Badda Ras (Internally) with and without chitrakalepa in switra (Vitiligo)54. Dr. Ratna Priyadarshini Y “ A clinical Study on the effect of Eladi kwath in the management of muthrashmari (Uro lithiasis)55. Agnivesa Charaka Samhita (Hindi) by Chaukamba Vidyabhavan.56. Behl P.N, Agarwal A. Srivastava G. Vitiligo In Behl PN, Srivastava. G editors practice of Dermatology 9th edition CBS publishers New Delhi 2003. A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 159. 159 POST GRADUATE DEPT. OF KAYACHIKITSA DR.B.R.K.GOVT.AYURVEDIC MEDICAL COLLEGE, HYD-038. “A CLINICAL STUDY ON THE EFFECT OF “DHATRI- KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO) SPECIAL CASE SHEETName : OP/IP No:Age : Pt.Code No. :Sex : Sp.Diagnosis:Address : Date of Research: Drug Given:Occupation : Contact No:Marital Status :Religion / Nationality : CASE HISTORY1. Chief Complaint with duration :2. Associated Symptoms :3. History of Present Illness :4. History of Past Illness a. Medical Past History : DM/HTN/Br. Asthma /Anaemia / Hypo or Hyper thyroidism /koch’s /Any other Skin Disorders. b. Surgical Past History :5. Treatment History a. Regarding Switram : b. Other Illness :6. Family History a. Noint / Nuclear b. No. of Family Members present : c. H/o consangnious marriage in the family. d. Any member suffering with similar complaint. e. Any Psychological disturbance associated with the family. A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 160. 1607. Personal History: a. Socio-economics Status : LIG/MIC/HIG b. Diet : Veg/Mixed Staple food: c. Nature of Job : Sedentery/Active/Labourious/Standing/Travelling d. Psychological Stress : Mid/Moderate/Severe e. Timings : Day/Night/Late Nights/Shift f. H/o.Allergy : Food/Drug/or Any other g. Habits : h. Addictions :8. Menstrual/Obestetric History: a. Menstrual Cycle : b. Marital Life : c. LCB : d. Any other disorders :Physical Examinations:a. Height f. RRb. Weight g. Heartc. PR h. Lungsd. BP i. Abde. TempDASAVIDHA PARIKSHA:a. Prakruti f. Satmyab. Vikruti g. Satwac. Saara h. Ahara Shakthi : i. Abhyaharanad. Samhananam ii. Jarana shakthie. Pramananam i. Vyayama Shakthi j. VayastahASHTASTANA PARIKSHA:a. Nadi e. Shabdab. Muthram f. Sparshac. Malam g. Drikd. Jihwa h. AkritiSROTO PARIKSHA: A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 161. 161 EXAMINATION OF THE SKINi. AGE AT ONSET :ii. DURATION :iii. ETIOLOGY : a. Positive family history b. Trauma ( Koebner’s Phenomenon ) c. Incompatible food d. Untimely sleeping habits e. Emotional disturbances f. Stress g. Exposure to hot and cold climates h. Consangnious marriage i. Any history of autoimmune disorder j. Drug allergyiv. NATURE OF SPREAD: a. Gradual b. Stable c. Suddenv. TYPE OF LESION : a. Symmetrical b. A symmetricalvi. ANY H/O itching/oozing/inflammation:vii. ANY AGGRAVATING/RELIEVING FACTORS:viii. SITE INVOLVED: a. Face b. Scalp c. Trunk i. Chest ii. Abdomen iii. Back d. Limbs i. bony prominences ii. Upper limbs iii. Lower limbsvi ORIGIN OF LESION:I. a. Doshaja (endogenous) b. Vranaja (exogenous) A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 162. 162II. VATAKA PITTAJA (mamsa) KAPHAJA (rakta dhatu ) (medo)1. Mandala 1. Kamala parravat 1. Ghana2. Ruksha 2. Daham 2. Guru3. Parusham 3. Roma Vidwamsam 3. Kanduyuktam4. Kesha Nashanam 4. Tamra Varnam 4. Swetavarnam5. Aruna varnamvii. TYPES OF DEVELOPMENT:I Localized a. Focal b. Segmental c. MucosalII. Generalized a. Non-Segmental b. UniversalINVESTIGATIONS: a. CBP B. ESR C. RBSTREATMENT SHEDULE:Drug : Dhatri Khadira Kwatham for 45 days (Ref BR)Dose : 30ml tid or 45 ml BD A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 163. 163 DURING THE TREATMENT SCHEDULE BEFORE TREATMENT LOCATION 15 days 30 days 45 days Colour Number Area Colour Number Area Colour Number Area Colour Number AreaFaceScalpTrunki. Chestii. Ab domeniii. Backb. Limbsi. Upperlimbsii. LowerlimbsASSESSMENT OF THE RESULT : RESPONDED/NOT RESPONDED Sign of the Guide Sign of Co-Guide Sign of PG Scholar A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 164. 164 CONSENT FORMI, Smt. / Sri.______________________________aged ___________ years have willinglyAccepted to take the medicine given as a drug trial as a part of research programmescheduled for 45 days. Hence I shall continue the medicine for above said tenure withfull acceptance. Signature of the Patient.________________________________________________________________________ NOTES A CLINICAL STUDY ON THE EFFECT OF “DHATRI - KHADIRA KWATH” IN THE MANAGEMENT OF SWITRAM (VITILIGO)
  • 165. A CLINICAL STUDY ON THE EFFECT OF “DHATRI-KHADIRA KWATH” IN THE MANAGEMENT OF “SWITHRAM” (VITILIGO) BY Dr.K.NAMRATA Guide & Supervisor Dr. Prakash Chander M.D (Ayu) Professor & H.O.D., P.G.Unit (K.C)
  • 166. Introduction Swithra is a dermatological disorder having its references cited in the Vedas. The term is derived from “Sweth Varne” meaning white colour, & is a disease related to hypopigmentation 20-30% of skin diseases require serious attention & Switra is one among them. Based on the clinical features, swithra can be correlated to Vitiligo. Vitiligo occurs world wide with an overall prevalence of 1%. Vitiligo on the face is ranked 17th by WHO in world’s most Disabling diseases.
  • 167. CONT.. The higher incidence of the condition has been recorded in India from Asia The etiology of vitiligo remains unknown. It is expected to be of autoimmune origin. Dhatri-Khadira Kwath (B.R –kusta rogadikar)has been taken for the present study to assess the efficacy in causing pigmentation in white patches of swithra.
  • 168. SHAREERA RACHANA Twak is defined as “Twach Samvarne” meaning the one which covers. Sushruta mentioned seven layers of skin namely, Avabhasini, Lohitha, Swetha , Tamra, Vedini, Rohini, Mamsadhara. Tamra is the seat for Kilasa or Swithra. Charaka has mentioned 6 layers of skin namely, Udakadhara, Asragdhara, Tritiya, Chaturtha, Panchami, Shasti. Tritiya is the seat for Kilasa or Swithra.
  • 169. SHAREERA KRIYA Twak covers the underlying rakta, mamsa, medo dhatus Twak imparts varna to the body. Imparting varna to the body is a specialized function of the Bhrajakapitta. The third vital function of twak is thermo regulation by the virtue of pitta . Other functions include –being a sense organ,acting as a channel to excrete sweda. It belongs to bahya roga marga .
  • 170. NIDANAa. Aharaja nidan: Vagbatta mentioned, a pregnant women consuming excessive kaphakara ahara, the baby shall be affected with switra. Gramya, anupa, jaleeyamamsa sevanam, anantharam dugda sevanam, Navanna, dadhi, matsya, lavana, amla, masha, mulaka, pisti, tila, ksheera, Guda sevana. b. Viharaja Nidan Chardi, Mala-mutradi vegadharana ,Ati vyayamam , Ati Santapasevanam ,Vyayamam in ajeernaavastha Garma srama, Bhayarthanam sheethambu sevanam.
  • 171. CONT.. c. Chikista sambandhi Nidana: Vagbatta mentioned usage of savisha jalouka in rakta mokshana leads to switra at that site 110 Doing dushita rakta stambana leads to kilasa and kusta Vishesha Nidana specially mentioned by charaka Viruddha annapana sevana ,Vacham asatyam Papa karmas ,Krutagna bhavas Ninda suranam ,Guru garshanam Poorva kruta karmas
  • 172. RUPA Swetha Varna mandalas on the body is the pratyatmaka linga of switram. It is Twagtam and aparisravi . vataja, pittaja, sleshmaja types of switram have been described which invade rakta ,mamsa &medo dhatus If the doshas are present in rakta dhatu they produce rakta varna, when in mamsa dhatu produce tamra varna,and in medo dhatu produce swetha varna.
  • 173. SAMPRAPTI GHATAKAS Doshas : Pittapradhana tridosha Dushya : Rakta, mamsa, medo dhatus Agni : Jataragni, dhatwagni Ama : Agnimandyam, dhatwagni mandyam Udbhavastan : Amapakwashyam Sanchara : Tiryakgata siras Srotas : Rasa, rakta, mamsa, medo Srotodusti : Sanga Adhistana : 4th Layer of twak “Tamra” Vyaktastana : Twak Rogamarga : Bahya Vyadhi Swabhava : Chirakari
  • 174. SADHYA-ASADHYATA The deeper the involvement of the dhatus the prognosis becomes worse. Rakta Varna or Aruna Varna are sadhya, Tamra Varna becomes kasta sadhya and Sweta Varna becomes asadhya. Charaka mentioned a person who has followed vamana – virechana, rakta mokshana regime completely, who takes sattu regularly and whose papakarmas are over, such case is sadhya.
  • 175. CHIKITSA The treatment aspect includes three types of therapies to combat the disease Daiva Vyapashray chikista – spiritual therapy Yukti vyapashray chikista - rational therapy Satvavajaya chikista – psychological therapy CHIKITSA SUTRAM : In switra roga, a person is made to undergo all the shodhana procedures first. After patient is fully evacuated, samsrama karma is done as primarily by giving malapu ras (Kakodumbara) along with gudam.
  • 176. CONT…. After that he should be exposed to the sun for 3 days. If patient feels thirsty, peya is given to quench his thirst . patient develops blisters on the patches all over the body. The blisters should be pricked with kantakam to release the fluid in it. After all the blisters are opened, a kwath prepared from bark of kakodumbara, priyangu, asan, and shatapushpa should be given early in the mornings for 15 days Sprinkling khadira kwatha externally & taking it internally or drinking khadira udaka is very beneficial in switra. Gomutram is very useful in switra roga..
  • 177. DRUG REVIEW The present drug “Dhatri-Khadira Kwatham” has been taken from “Kustarogadhikar” of “Bhaishajya Ratnavali”, The compound has two drugs – Khadira and Amlaki, Madhu as anupana. The drugs are non-controversial, unadulterated, easily available, and economical It is a simple combination and easy to prepare and use. Khadira is mentioned as “Kustagnanam” The use of Khadira Kashaya or Khadira udaka internally and externally is highly recommended in swithra.
  • 178. CONT… Khadira is the Sheeta Viryadravya having tikta, Kashaya rasas.Tikta rasa has ama pachana &vishagna prop. Khadira has Pitta Shamaka and rakta shodaka property. As Rakta and pitta are both vitiated in switra Khadira acts best in this aspect. Amlaki also is sheeta virya dravya ,having best pitta shamaka effect. Amlaki, is the best rasayanam , for rasa and rakta dhatus Helps to build immunity, and may hinder the autoimmune reactions in the body. Amlaki has the best anti - oxidant property which can counter the effects of toxins in the skin
  • 179. CONT It has a mild laxative effect which is very beneficial in the treatment. Regular use of amlaki destroys diseases like Swithra and Prameha. The form of administration is kwatha which has high efficacy The bark of Khadira, fruits of Amlaki are used in the preparation Khadira bark is pounded into coarse powder & weighed. Equal quantity of amlaki fruit is pounded and added to it. The powder is made into kwath churam.
  • 180. KHADIRA BARK
  • 181. AMLAKI FRUITS
  • 182. DHATRI KHADIRA KWATH CHOORNAM
  • 183. CLINICAL STUDY-METHODOLOGY The study was conducted in the Department of Kayachikitsa, Govt. Ayurvedic Hospital, Erragadda,Hyderabad. Aim: To assess the efficacy of Dhatri – Khadira kwath in causing pigmentation in white patches of switra. Source of Data : Patients of either sex aged between 5-70 years diagnosed as switra were selected from OPD of Govt.Ayurvedic Hospital, Erragadda, Hyderabad. Sampling Method and Research Design: The study was conducted as an open trial study with randomized selection of patients . Informed consent from all patients was obtained prior to the study. A complete history was taken through a special proforma including age of onset, duration, family history of switra, H/o consangnious marriage of parents, any personal or family history of systemic diseases.
  • 184. INCUSION CRITERIA Patients of either sex with sweta varna mandalas (i.e. milky white patches, centrally hypopigmented with sharp circumscribed borders). Patients aged between 5-70 years Chronicity less than 6 years. Exclusion criteria: as per ICD-10, L00-L99 skin and sub-cutaneous diseases, L80-Vitiligo Patients below 5 years and above 70 years Certain conditions originating in the perinatal period (P00-P96) Certain infectious and parasitic diseases – (B00-B99) Complications of pregnancy and childbirth (O00-O99) Endocrinal, nutritional and metabolic diseases (E00-E90). Neoplasms (C00-D48)&Systemic connective tissue disorders (M30-M36)
  • 185. INVESTIGATIONS Following investigations were done prior to the study. CBP,ESR ,RBS ,CUE Diagnostic Criteria: Swetavarna mandalas with or without other features of switra Intervention: Drug: Dhatri – Khadira kwath Dose: 30ml tid, followed by madhu as anupana Route: Oral Duration: 45 days
  • 186. Assessment criteria The assessment was made on the COLOUR , NUMBER and SIZE of the mandalas which were observed before, during and after the treatment. To assess the improvement in the colour the following grading was given C0 – Normal skin colour C1 – Tanned brown C2 – Light brown C3 – Dark pink C4 – Light pink C5 – White colour The data obtained before and after treatment were analysed.
  • 187. CONT.. The complete results of treatment were ascertained in terms of, 1-25% - Mild Response 26-50% - Moderate Response 51-75% - Marked Response 76-100% - Excellent Response 0 - No Response If the symptoms of a patient decreased by 1-25% he is put in mild group, decrease in symptoms by 26-50% he is placed in moderate group, Relief of symptoms by 51-75% he is placed in marked group, relief by more than 75% he is placed in excellent group ,no relief of symptoms were placed in no response group.
  • 188. OBSERVATIONS INCIDENCE OF AGE: Maximum number of patients 7(23.3%)fall under 11-20 yrs group. INCIDENCE OF SEX : more of females 17(56.6%) INCIDENCE OF HABITAT: Majority of the subjects came from urban areas 23 (76.6%) INCIDENCE OF RELIGION: Majority of the subjects belong to Hindu community 21 (70%). INCIDENCE OF MARITAL STATUS: Most of the patients t were un- married17( 56.66%). INCIDENCE OF DIET: Majority of the subjects had mixed diet 23 ( 76.66%) INCIDENCE OF SOCIO-ECONOMIC STATUS: Majority of the subjects belong to middle income group,17( 56.6%). INCIDENCE OF OCC :Majority of the patients belonged to student community 16(53.33%)
  • 189. OBSERVATIONS ORIGIN OF THE DISEASE: The origin of the disease due to external causes were found in two subjects 6.66% and in majority of subjects the cause was endogenous 28(93.33%) COLOUR OF THE PT: Majority of the subjects were wheatish skinned people14( 46.66%) PRAKRITI: Majority of them belonged to vatapitta and Pitta vata prakruti 30%. FAMILY HISTORY: Majority of the patients did not present with a family history 29(96.66%) STRESS: Majority of the patients did not present with history of stress 25(76.66%). CONSANGNIOUS MARRIAGE OF PARENTS: Majority of patients did not present with history of consangious marriage of parents24( 80%).
  • 190. OBSERVATIONS CHRONICITY : Most had chronicity of disease from 1 month to 1 year 20(66.66%) Old/New cases: 15 patients were new and 15 patients were old who already received treatment else were. AGE OF ONSET: In majority of patients disease started before the age of 20 yrs 15(49.99%) SITE OF ONSET: In majority of subjects face was the site of first onset 11(36.66%) followed by lower limbs 9( 30%) Nature of spread: Among 30 subjects 29 of them presented with gradual spread of the disease 96.66% History of allergy: Among 30 subjects 28 of them had no specific history of Allergies 93.33%
  • 191. OBSERVATIONS Colour of the patches: Among 30 subjects 23 of them presented with white coloured patches 76.66% Number of patches: Among 30 subjects 27 of them had 1-5 number of patches on them 90% Size of Patches (for 24 patients only): 19 of them presented with patches between 1-15cm size 82.60%
  • 192. OBSERVATIONSBEFORE TREATMENT AFTER TREATMENT
  • 193. BEFORE TREATMENT AFTER TREATMENT
  • 194. BEFORE TREATMENT AFTER TREATMENT
  • 195. RESULTSResponded/Not responded Sl.No. Parameter Responde % Not % d responded 1. Colour 24 80% 6 20% 2. Number 3 10% 27 90% 3. Size (for24 11 45.8% 13 54.1% Pts)
  • 196. Response in the colour of the patches Sl.No. Mild Moderate Marked Excellent No (26-50%) (51-75%) (76-100%) response (1-25%) 1. 11 6 7 0 6
  • 197. Response in the number of patches Sl.No. Mild Moderate Marked Excellent No (26-50%) (51-75%) (76-100%) response (1-25%) 1. 0 2 1 0 27
  • 198. Response in the size of the patches Sl.No. Mild Moderate Marked Excellent No (26-50%) (51-75%) (76-100%) response (1-25%) 1. 3 6 1 1 13
  • 199. Overall Results Sl.No. Mild Moderate Marked Excellent No (26-50%) (51-75%) (76-100%) response (1-25%) 1. 18 4 2 0 6
  • 200. Statistical analysis of the resultsPARAME MEAN MEAN STD STD t p REMARK TER DIFF. DEV ERR Value Value SCOLOUR 4.44 0.84 0.48 0.08 6.6 < 0.0001 SIGNIFICBT ANTCOLOUR 3.6 1.1 0.2ATNUMBER 1.66 0.28 2.23 0.41 1.7 <0.35 NOT SIGNIFICBT ANTNUMBER 1.38 1.94 0.36ATSIZE BT 12.36 0.02 24.4 4.45 2.05 <0.1 NOT SIGNIFIC ANTSIZE AT 12.34 24.3 4.2
  • 201. DISCUSSION Switra is an ancient malady due to its references being cited in the Vedas. Switra can be well correlated to Vitiligo as both have similar clinical features and presentation of the disease. Both the diseases are related to hypopigmentation. The etiology of vitiligo remains unknown, only the Triggering / Precipitating factors are identified, among which nutritional deficiency, emotional stress ,infections, exposure to chemicals are included. The etiology of Switra is given as incompatible diet, misconduct, improper life style. No prodromal symptoms were seen. Swetavarna mandalas” were clearly evident,
  • 202. CONT… switra is “Twagatam” and “Aprasravi”accordingly in subjects the skin was only involved, no pain or secretions were noticed. The macules were found to be of round, oval and irregular in shape. Among the mucosal surfaces ,lips were commonly involved. There are no special laboratory investigations to diagnose switra. From past two decades there is a sharp rise in the incidence of childhood vitiligo (Behl) and the same was observed in this study. It was noticed that non –veg diet accelerated the disease progression. The origin of the disease due to trauma also holds significance. The higher the chronicity, it was observed that patients’ response to treatment decreased. pts observed redness of patch, burnings sensation when exposed to sun.
  • 203. COLOUR OF PATCH Two kinds of pigmentation changes were noticed during the study pigmentation started from periphery bringing about changes in the size, such is peripheral repigmentation. In some cases pigmentation spots were seen around the hair follicles in the center of the patch, gradually growing in size and changing the symmetry of the patch, such is perifollicular repigmentation. The statistical analysis shows P<0.0001 which is significant.
  • 204. NUMBER OF PATCHES  Among 30 patients , 27 presented with 1-5 no on their body. 1 patient had patches in between 6-10 and 2 patients had more than 10 patches on the body.  Out of 3, 2 patients showed moderate response, 1 patient showed marked response. No patient showed excellent response.  The statistical analysis shows P<0.35 which is not – significant.
  • 205. SIZE OF PATCHES The change in the size of the patches was depended on the colour changes. The repigmentation occurring in the white patches brough about the difference in size. Peripheral repigmentation caused Shrinkage in the size and perifollicular repigmentation brought about changes in symmetry (shape) which automatically brought difference in the size The statistical analysis shows P<0.1 which is not- significant. But the response seen in the size of the patches in duration of 45 days is commendable.
  • 206. CONT.. In the first 15 days majority of them started showing changes in the patches. The colour change was prominent, but there was no change in the number and size. After 30 days, the colour grading improved remarkably, but no change in the number was noticed. After completion of 45 days – changes in the colour was even more satisfactory. Size differences in the patches were evident. Small patches of 1-3 cms disappeared and some faded due to the pigmentation. The improvements were noticed in patients with less chronicity, fresh cases with small sized patches.
  • 207. LIMITATIONS OF THE STUDYAs the study does not have a control group, any categorical statements about the success attribution to drug cannot be made. The duration of the study was short, it would have been better if the duration was for a longer period to establish the results even more effectively. As the sample size is very small (30pts) any significant findings found in the study cannot be generalized to the population.
  • 208. RECOMMENDATIONSStudy to be conducted on larger samples. To do a comparative study between a control group and test group with medicine taken internally. To do a comparative study between a control group taking medicine internally and externally and test group taking medicine only internally. To take a longer duration of time for clinical study. To scientifically probe the action of Khadira on melanocytes.
  • 209. CONCLUSION Switra is a pittapradhana tridoshaja, twak vikara. Sweta Varna mandalas appear on the skin suggestive of the disease. Based on the clinical features it can be well correlated to vitiligo of contemporary medicine. The prevalence of the disease is 1% world wide, affecting males and females equally, but more commonly reported by females. The incidence of childhood vitiligo is rapidly increasing from past two decades. The age of first onset is before 20yrs, face and lowerlimbs are the site of first appearance of the disease. Family history and H/o consangnious marriage of parents had little role to play in the etiology.
  • 210. CONT… The drug proved to be beneficial as promising results were noticed initially in response of colour and size. No much change in number was noticed. Out of 30 patients – 18 patients showed mild response, 4 patients moderate response, 2 marked response and 6 members did not respond to the treatment. Better results can be established with “Dhatri-Khadira Kwath” if study is conducted on larger samples, for a longer duration in a comparative fashion by enthusiastic scholars.
  • 211. SUMMARY A clinical study was undertaken to assess the efficacy of ‘Dhatri- Khadira Kwath’ in the disease switra. Switra is related to hypopigmentation was selected for the study. 30 pts of either sex were taken for the study duration of 45 days fulfilling the inclusion and exclusion criteria Comprehensive formula “Dhatri-Khadira Kwath” selected from Bhaishajya Ratnavali was used in the clinical study Three parameters were taken to assess the improvement –colour ,number ,size of the mandalas. The work is divided into five parts which gives a detailed picture of the disease, and clinical study.
  • 212. THANK YOU
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