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A CLINICAL STUDY TO EVALUATE THE EFFECT OF SHODHANA AND SHAMANA IN THE MANAGEMENT OF VICHARCHIKA BY RANJIT PATIL DEPARTMENT OF POST GRADUATE STUDIES IN KAYACHIKITSA, S. D. M. COLLEGE OF AYURVEDA, ...

A CLINICAL STUDY TO EVALUATE THE EFFECT OF SHODHANA AND SHAMANA IN THE MANAGEMENT OF VICHARCHIKA BY RANJIT PATIL DEPARTMENT OF POST GRADUATE STUDIES IN KAYACHIKITSA, S. D. M. COLLEGE OF AYURVEDA, UDUPI

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    • A CLINICAL STUDY TO EVALUATE THE EFFECT OF SHODHANA AND SHAMANA IN THE MANAGEMENT OF VICHARCHIKA BY RANJIT PATIL, B.A.M.S. Dissertation submitted to the Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore In partial fulfillment of the requirements for the degree of DOCTOR OF MEDICINE (AYU) IN KAYACHIKITSA Under the Guidance of DR. G. SHRINIVASA ACHARYA., M.D.(AYU) H.O.D., S.D.M.C.A, Udupi Co-Guide DR. SHRILATHA KAMATH .T. M.D. (AYU) Lecturer, S.D.M.C.A, UdupiDEPARTMENT OF POST GRADUATE STUDIES IN KAYACHIKITSA S. D. M. COLLEGE OF AYURVEDA, UDUPI – 574 118 2006
    • RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES DECLARATION BY THE CANDIDATE I hereby declare that this dissertation entitled “A Clinical study to evaluate the effectof Shodhana and Shamana in the management of Vicharchika ” is an above-boardresearch work carried out by me under the guidance of Dr.G. Shrinivasa Acharya, M.D.(AYU) and co-guidance of Dr. Shrilatha kamath.T., M.D.(AYU). RANJIT PATIL B.A.M.S.Date:Place: Udupi
    • RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES CERTIFICATE BY THE GUIDE This is to certify that the dissertation entitled “A Clinical study to evaluate theeffect of Shodhana and Shamana in the management of Vicharchika” is an above-board research work done by Ranjit Patil in partial fulfillment of the requirement for thedegree of M.D. (AYU) Signature of the Guide: DR. G. SHRINIVASA ACHARYA., M.D.(AYU) H.O.D.,S.D.M.C.A.,Udupi. Signature of the Co-Guide:Date: DR. SHRILATHA KAMATH.T. M.D.(AYU)Place: Udupi Lecturer, S.D.M.C.A.,Udupi.
    • RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES ENDORSEMENT BY THE HOD, PRINCIPAL / HEAD OF THE INSTITUTION This is to certify that the dissertation entitled “A Clinical study to evaluate theeffect of Shodhana and Shamana in the management of Vicharchika” is an above-board research work done by Ranjit Patil, under the guidance of Dr.G. ShrinivasaAcharya.,M.D.,(Ayu) and co-guidance of Dr. Shrilatha Kamath.T.,M.D.(Ayu). Signature of the H.O.D. Signature of the Principal Dr. G.Shrinivasa Acharya, M.D. (Ayu) Dr. U.N. Prasad, M.D. (Ayu) Head of the Department PRINCIPALDepartment of P.G Studies in Kayachikitsa. S.D.M.C.A, UDUPI S.D.M.C.A, UDUPI.Date :Place : Udupi.
    • COPYRIGHT DECLARATION BY THE CANDIDATEI here by declare that the Rajiv Gandhi University of health Sciences, Karnataka shallhave the rights to preserve, use and disseminate this dissertation/thesis in print orelectronic format for academic / research purpose. RANJIT PATIL B.A.M.S.Date:Place: Udupi. © Rajiv Gandhi University of Health Sciences, Karnataka
    • ACKNOWLEDGEMENTWith a bowed Head, to the Goddess Ambabai. I would like to express my profound reverence to Dharmaguru, Padmashri Dr. D.Virendra Heggade in giving me an opportunity to be a Student of such a prestigious andillustrious institution. I wish to offer my sincere thanks to Dr. U. N. Prasad, Principal and Dr. K. R.Ramchandra, the Vice-Principal, S.D.M. College of Ayurveda, for their encouragementand support. I express my deep sense of gratitude to my Teacher and Guide and Head,Department of Kayachikitsa Dr. G. Shrinivasa Acharya for the magnitude of his dynamicand untiresome guidance throughout the study, who has not only guided me to completemy research work, but has always been a source of inspiration and encouragement in allstages of my tenure of Post Graduate education. His great patience and fortitude hashelped me immensely. I am ever grateful to my Co-Guide Dr. Shrilatha Kamath T., Lecturer ofKayachikitsa department S.D.M. College of Ayurveda for her encouragement, supportand helpful suggestions. My gratitude due to Dr. Y. Narayana Shetty, Superintendent and Dr.Deepak S. M., Deputy Superintendent of the S.D.M. Ayurveda Hospital, Udupi for theirvaluable support and encouragement. I acknowledge the contributions of Teachers Dr. Jonah S ,Dr. Lavanya, Dr.Veerakumara K, Dr. Rajlakshmi, Dr. Nagaraj and Dr. Prasanna Mogasale. I am grateful to Mr. Harish Bhat, Librarian, for providing me with all the books Ineeded. My special thanks to Mr. Shivajirao Deshmukh (President, M.L.C.), PrithvirajChavan (Minister for State in the PMO), my Father Mr. Prataprao Patil, Mother Mrs.
    • Anitadevi Patil, and my brother Mr. Manish Patil & my Bhabhi, Mrs. Rajkunwar Patil,my sister Mrs. Vijaya Desai, and all my relatives who gave me support throughout mystudies. I am very much thankful to all my Batchmates Dr. Deepti , Dr. Shobha, Dr.Ramesh, Dr. Magan, Dr. Kuldeep and my junior friend Dr. Kotresh who have helped meduring difficulties throughout my study. I consider them to be the backbone of the work. I would like to extend my thanks to my Seniors Dr. Sunil Jain, Dr. Atanu Bairagi,Dr. Bhimsen Deshpande. I am ever grateful to Dr. Anilkumar Rai, Dr. Prasanna Rao, Dr. Ramesh Yadav(C.C.I.M Member), Dr. N.S. Shettar, Dr. Rajashekhar Pandey, Dr. Renjal, Dr. RavindraAngadi, Dr. Shrikant .P.,Dr. Muralidhar Ballal, Mr. Jaya Devadiga, Mr. K. D. Pudnekar,Janaki Amma, for their encouragement, support and helpful suggestions. My special thanks to Mr. Ganesh Kamath M/s Ananth Connections for hisexcellent formatting in bringing out quality copies, Mr. Shrinivasa of Sampark Xerox andAnand Graphics for beautiful photo editing. RANJIT PATIL
    • TABLE OF CONTENTSLIST OF TABLESLIST OF FIGURESLIST OF ABBREVIATIONS Page No INTRODUCTION 1-3 OBJECTIVES 4PART – I: CONCEPTUAL PART Chapter I- Historical Review 5-6 Chapter II- Etymology of Kushta and Vicharchika 7-8 Chapter III- Skin – Ayurvedic and Modern 9-21 Chapter IV- Nidana 22-26 Chapter V - Samprapti and Bhedas 27-36 Chapter VI-Purvarupa 37-38 Chapter VII-Rupas 39-44 Chapter VIII- Eczema- Modern Review 45-62 Chapter IX - Upadrava 63-65 Chapter X -Chikitsa 66-67 Chapter XI -Pathya-Apathya 77PART – II: DRUG REVIEW 78-80PART – III: METHODOLOGY Materials & Methods 81-85 Observations and Results 86-114PART - IV: DISCUSSION 115-128PART V: CONCLUSION AND SUMMARY 129-132BIBLIOGRAPHY 133-152ANNEXURE – PROFORMA 153-161
    • LIST OF TABLES1. Panchabhautikta of Tvacha 102. Layers of skin – Charaka 113. Layers of skin – Sushruta 114. Layers of skin – Different Acharyas 125. Tvacha – Modern Corelation 136. Nidanas of Vicharchika 247. Types of Mahakushta 348. Types of Kshudrakushta 359. Purvarupas of Vicharchika 3710. Rupas of Vicharchika 3911. Hypersensitivity Reactions 5312. Sapeksha Nidanas of Vicharchika 6513. Incidence of Age 8614. Incidence of Sex 8715. Incidence of Occupation 8816. Incidence of Marital status 8917. Incidence of Religion 9018. Incidence of Socio-economic status 9119. Incidence of Education 9220. Incidence of Habitat-I 9321. Incidence of Habitat-II 9422. Incidence of Ahara 9523. Incidence of Vyasana 9624. Incidence of Prakruti 9725. Incidence of Sara 9826. Incidence of Samhanana 9927. Incidence of Satmya 10028. Incidence of Satva 10129. Incidence of Ahara-Abhyavaharana shakti 102
    • 30. Incidence of Ahara-Jarana shakti 10331. Incidence of Vyayama shakti 10432. Incidence of Vaya 10533. Incidence of Nidana 10634. Incidence of Symptomatology 10735. Effect on Kandu in Vicharchika 10836. Effect on Severity of Kandu in Vicharchika 10837. Effect on Pidaka in Vicharchika 10938. Effect on Severity of Pidaka in Vicharchika 10939. Effect on Vaivarnya in Vicharchika 11040. Effect on Severity of Vaivarnya in Vicharchika 11041. Effect on Severity of Bahusrava in Vicharchika 11142. Effect on Severity of Daha in Vicharchika 11243. Effect on Severity of Rukshata in Vicharchika 11344. Overall Effect of the Therapy 114 LIST OF FIGURES1. Cross-Section of Skin 142. Samprapti of Vicharchika 293. Shatkriyakala in Vicharchika 314. Phenomenon of Itch 405. Incidence of Age 866. Incidence of Sex 877. Incidence of Occupation 888. Incidence of Marital status 899. Incidence of Religion 9010. Incidence of Socio-economic status 9111. Incidence of Educational status 9212. Incidence of Habitat-I 93
    • 13. Incidence of Habitat-II 9414. Incidence of Ahara 9515. Incidence of Vyasana 9616. Incidence of Prakruti 9717. Incidence of Sara 9818. Incidence of Samhanana 9919. Incidence of Satmya 10020. Incidence of Satva 10121. Incidence of Ahara-Abhyavaharana shakti 10222. Incidence of Ahara-Jarana shakti 10323. Incidence of Vyayama shakti 10424. Incidence of Vaya 10525. Incidence of Nidana 10626. Incidence of Symptomatology 10727. Effect on Severity of Kandu in Vicharchika 10828. Effect on Severity of Pidaka in Vicharchika 10929. Effect on Severity of Vaivarnya in Vicharchika 11030. Effect on Severity of Bahusrava in Vicharchika 11131. Effect on Severity of Daha in Vicharchika 11232. Effect on Severity of Rukshata in Vicharchika 11333. Overall Effect of the Therapy 114
    • LIST OF ABBREVIATIONS C.S. – Charaka Samhita S.S. – Sushruta Samhita A.S. – Ashtanga Sangraha B.S. – Bhela Samhita H.S. – Harita Samhita Mm - Millimeter U.V.- Ultraviolet D.E.J. – Dermo-Epidermal Junction T. – ThymusC.D. – ChakradattaM.H.C. – Major Histocompatibility ComplexH.L.A. - Human Leucocyte AntigenICAM – Intercellular Adhesion MoleculesA.H.- Ashtanga HridayaB.P. - Bhava PrakashaM.N. - Madhava NidanaK.S. - Kashyapa SamhitaWBC – White Blood CorpusclesRBC – Red Blood CorpusclesICD - Irritant Contact DermatitisACD – Allergic Contact DermatitisIg - ImmunoglobulinTIM – Topical ImmunomodulatorsFDA – Food and Drug AdministrationIFN – InterferonAIDS- Acquired Immunodeficiency SyndromeYR – YogaratnakaraBR – Bhaishajya Ratnavali
    • Vang. – VangasenaG.N. – GadanigrahaC.D. – ChakradattaKalyan. – KalyanakarakaSha. S. – Sharangdhara SamhitaR.R.S. – RasaratnasamuchayaO.P.D - Out-patient DepartmentI.P.D - In-patient DepartmentS.D.M - Shri Dharmasthala ManjunatheshvaraHb – HaemoglobinTc – Total CountDC – Differential CountESR – Erythrocyte Sedimentation RateMg – MilligramTid – Thrice in a DayP - Probability‘t’-‘t’ testBT - Before TreatmentAT - After TreatmentS.D - Standard DeviationS.E.M - Standard Error of MeanNo. – NumberPO2 – Partial Pressure of Oxygen.RAV – Rashtriya Ayurveda Vidyapitha
    • ABSTRACT Vicharchika is a variety of kshudra kushta. Though all the three dosha areinvolved in the causation of this illness, predominant vitiation of vata and kapha dosha isincriminated. Vesicular eruption, Itching, discharge are the cardinal manifestations of thisillness. This is being compared to eczema in modern parlance. Both shodhana andshamana treatment is indicated in patients suffering from vicharchika. Jalaukavacharanaforms the shodhana treatment in localized lesions of vicharchika. Along with thisshodhana therapy oral as well as topical medication forms the comprehensive treatmentof vicharchika. Oral administration of udayabhaskara rasa and topical application ofarkadi taila is said to be very effective in the treatment of vicharchika. But no study iscarried out evaluating the effect of these medications. Hence this study is planned toevaluate the total effect of jalaukavacharana, udaya bhaskara rasa and arkadi taila.This is a single blind clinical study with pre-test and post-test design where in 20 patientssuffering from Vicharchika of either sex between the age group of 16 and 60 years weresubjected to the trial. These patients were subjected to jalaukavacharana in the beginningat the site of lesion. This was followed by oral administration of udayabhaskara rasa in adose of 250 mg tid for 30 days. During this period external application of arkadi taila wasalso carried out. Therapeutic effect of the treatment was assessed based on specificsubjective and objective parameters. Results obtained were analyzed for the statisticalsignificance by adapting paired‘t’ test.Marked remission of the symptoms of Vicharchika was observed in almost all thepatients. The assessment of the overall effect revealed that 25% of the patients hadcomplete remission of the symptoms, 10% had marked improvement, another 25% hadmoderate remission, 35% had mild improvement and the remaining 5% of patientsshowed unchanged response of the illness.Key words: Vicharchika; Jalaukavacharana; Udayabhaskara rasa; Arkadi taila; Eczema.
    • Introduction INTRODUCTIONSkin is the first organ of the body, which interacts with physical, chemical & biologicalenvironmental agents. Variations in the environmental stimuli & natural ability of bodyto deal with these factors result in spontaneous remissions & relapses. Interaction withthese factors results in specific reaction pattern producing characteristic skin lesion indifferent parts of the body. Large community prevalence studies have demonstrated thatbetween 20-30% of the population have various skin problems requiring attention.1 Skinis a mirror that reflects internal & external pathology & thus helps in diagnosis ofdiseases. Skin complaints affect all ages from the neonates to the elderly & cause harm ina number of ways, such as discomfort, disfigurement, disability, etc.Nature is always doing better for all live beings, but life of modern man is far removedfrom the rules of nature. In fact, there has been a drastic change in his day-to-dayactivities including life style, food habits, sexual life, medication, environmentalpollution and industrial and occupational hazards. Ultimately, these all factors decline thehuman immunity day by day and due to less protective power and adulterative nutrient,many diseases are born and become rigid. Vicharchika is one of the diseases mentionedin ancient science among the kushta. Vicharchika is categorized in different ways i.e.Kshudra kushta, kshudra roga and sadhya kushta. All kushtas are having tridoshajaorigin, hence vicharchika can be explained in similar manner i.e. Kapha is responsible forkandu, pitta is responsible for srava and shyava indicates the presence of vata.2Despite its tridosha origin, various acharyas have mentioned different dominancies invicharchika i.e. Kapha3 , pitta4, vata-pitta pradhana5, which also suggest specificsymptom complexes. As per the symptomatology and pathogenesis, vicharchika has beendirectly correlated with eczema (dermatitis) in modern science, i.e. Sakandu (excessiveitching), pidaka (papules, vesicles, pustules), shyava (erythema with discolouration),bahusrava (profuse discharge, oozing), raji (thickening, lichenification of skin), arti(pain), ruksha (dry lesion), etc. Dermatitis is being used as a synonym of eczema by mostof the dermatologists.6 In recent days; modern science has reached the top by greatadvances, particularly when dermatology topic is concerned and also in regards to 1
    • Introductionavailability of powerful antibiotics, antifungal, antihistaminic, steroids, etc. But bettermanagement could not be searched out till today. Few drugs are available forsymptomatic relief only. Their indiscriminate use is most undesirable. Skin diseases likeeczema get a suitable atmosphere especially in developing countries, because of fast lifestyle, industrial and occupational hazards, repeated use of chemical additives etc. Diseaseof skin makes a person handicap in society, everyone forbids him, which makes his lifestressful. There is a popular adage that “skin patients are never cured and never die” andhardly even constitute an emergency. The patient with skin disease is unemployable inany job in which he or she is in the public eye or involved in food preparation (catering).60% have a significant skin condition including psyche involvement. Nowadays, wholeworld is gradually turning towards ayurveda for safe and complete cure of diseases.Especially in the field of skin problems ayurveda can contribute remarkably. Fewsamples of the RCT carried out in this regard is shown below.A single blind comparative clinical study was carried out in 20 patients suffering fromvicharchika. The patients were subjected to virechana followed by oral medication withlaghusutashekhara vati manjishtadi kvatha in one group and only the oral medication inthe other group. This study showed better improvement in patients treated with bothvirechana and shamanaushadhi.In another single blind comparative clinical study the therapeutic effect of virechanakarma and oral medication with ekavimshati guggulu is compared to the effect ofjalaukavacharana and oral medication in 20 patients suffering from vicharchika.Statistically significant improvement was observed in both groups of patients treated withvirechana and raktamokshana.Other than these many more research works were carried out in different researchinstitutes and post graduate centres and are mostly related to the establishment oftherapeutic effect of shodhana or different shamana medications in patient’s sufferingfrom vicharchika. Also it is observed that there is no uniformity in the understanding ofvicharchika in modern paralance. Oral administration of Udayabhaskara rasa and topicalapplication of arkadi taila is said to be very effective in the treatment of vicharchika. Butno study is carried out evaluating the effect of these medications. Hence this study is 2
    • Introductionplanned to evaluate the total effect of jalaukavacharana, udaya bhaskara rasa and arkaditaila in this common chronic lingering skin disease vicharchikaThis dissertation is a sincere effort to study the nidana panchaka as well as chikitsa ofvicharchika. The combination of jalaukavacharana, oral medication with uduayabhaskararasa and topical use of arkadi taila is subjected to clinical trial in this study. Thisdissertation consists of: Conceptual Study. Clinical Study. Discussion. Conclusion and Summary. Conceptual study comprises of three chapters. The first chapter begins with thehistorical review of vicharchika. There after the definition, etymological derivation,anatomical understanding skin in ayurvedic and modern perspective, nidana panchakas,modern perpetuation of the disease vicharchika, chikitsa and pathyapathya in the secondchapter. Description of jalaukavacharana in general and the detail of drugs mentioned inudayabhaskara rasa and arkadi taila are mentioned in the third chapter of drug review. Clinical study starts with the materials and methods of the present work withcomplete description of the assessment criteria and descriptive statistical analysis of thesample taken for the study is methodically elaborated. Finally observations, results andtheir statistical analysis are presented in order along with tables and graphs. Discussion includes the critical conceptual analysis, observation and resultsobtained in the present study. The whole thesis work is summarized with conclusivepoints under the headings of Conclusion and Summary. 3
    • Objectives OBJECTIVES• To carry out a comprehensive literary study on Vicharchika with parlance of eczema.• To evaluate the total effect of jalaukavacharana, oral medication udayabhaskara Rasa and topical application of arkadi taila in Vicharchika. 4
    • Conceptual Study HISTORICAL REVIEWVedic period The history of kushta can be traced back since Vedic era. In Rigveda there areinstances, which depict that kushta was prevalent in that period also. For instance -LordIndra cured the charmaroga of Kapala.7Mahabharata In mahabharata, it has been mentioned that the person suffering from ‘tvakdosha’is not fit to be a king.Agnipurana There is a reference regarding the internal use of khadira & use of haratala &manahshila externally as an effective remedy to kushta.Samhitakala Ayurveda reached the zenith of knowledge regarding skin disease in the samhitaperiod.Charaka samhita Acharya charaka has divided 18 types of kushtas in two types-mahakushta andkshudrakushta. The term ‘vicharchika’ has been included under kshudra kushtas and itschikitsa is explained in 7th chapter .8 Sushruta is the first one to clearly describe the papakarma as causation of kushtaroga. He has also described krimi as a causative factor of kushta.9 In nidana sthana,sushruta explains the dhatugatatva & uttarottar dhatu pravesh of kushta.10 Sushruta hasexplained skin disorders in 2 chapters under the heading of kushta & maha kushta.Ashtanga sangraha Kushta has been mentioned to be of 7 types depending on the dosha involved &vicharchika has been defined as kapha pradhana kushta.11, It has been also mentioned asraktaja vikaraAshtanga hridaya Vagbhata has followed the classification of sushruta.12The disease vicharchika is dealt under the heading of kshudra kushta mainly as perdescription of charaka. Kandu, pidaka, kotha have also been mentioned as some of thelakshanas of kushta.13 5
    • Conceptual StudyBhela samhita In bhela samhita kushta has been described in sutra, nidana & chikitsa sthanawhere vicharchika is included in the category of sadhyakushta.14Harita samhita The description of kushta is available in 3rd sthana in harita samhita &‘vicharchika’ is mentioned as one of its varieties.15Kashyapa samhita Kushta is described in ‘kushta chikitsadhyaya’. Total 18 types of kushtas havebeen described under sadhya & asadhya categories. Vicharchika has been labeled assadhya kushta. In ‘rogadhyaya’ it has been termed as ‘raktaja roga’.16Madhava nidana Madhavakara in the chapter of kushta nidana described vicharchika in detailunder the heading of kshudra kushta. The description of vicharchika is mainly based oncharaka samhita.17Sharangdhara samhita There is explaination of kushta given in madhyama khanda along with itstreatment.18 The bhedas of kushta is also told in 7th chapter of purva khanda.19Vangasena Some special causes of kushta had been described including tila, kulatha, valmikaroga, vruntaka, etc.20Bhavaprakasha Bhavamishra has described kushta similar to charaka and Dhatugatatva &sadhyasadhyata in lines with sushruta. Arishta lakshana of kushta has also been described21 which were mentioned as asadhya lakshanas by sushruta .Bhaishajya ratnavali In the 54th chapter the detail treatment of kushta is given.22Gadanigraha Vaidya shodhal has described kushta roga in cha.36 of dvitiya khanda.23 itsclassification is as per charaka (7-maha kushta & 11-kshudra kushta) while dhatugatatvais described as per sushruta. 6
    • Conceptual Study ETYMOLOGY AND PARIBHASHA OF VICHARCHIKAVyutpatti of kushta: Before entering into the etymological derivation of vicharchika as it isconsidered, one of the varieties of Kshudra kushta the Vyutpatti and paribhasha of kushtais explained first. Derivation of the word kushta says, ‘Kus Nishkarshane’ + ‘Kta’ (Shabdakalpadruma) To destroy, to scrap out, – by adding the suffix ‘Kta’. Stands for firmness orcertainty. Thus the word Kushta means that which destroys with certainty.Paribhasha of kushta: “Kushnati Sharirastha Shonitam Vikrute.”In Shabda Kalpadruma it has been described as ‘Kusnati Rogam’ which mean the diseasewhich causes embarrassment.24In Ashtanga Sangraha25 it is mentioned that, ‘Kalen opekshitam Yasmat Sarvam Kushnati Tadvapuhu.’ This means that if it left unattended it makes the body kutsit so it is called Kushta. Arunadatta opines that Kushta is that which causes vitiation as well discolourationof skin.26 “Kalen sarva vapuhu –shariram, krushnati tasmatvata kushta mityuchyate”Vyutpatti of vicharchikaGlancing into the etymological derivation of Vicharchika, Vachaspatyama explains, When ‘charcha’ Dhatu is prefixed with ‘Vee’ & suffixed by ‘Navul’, the wordVicharchika of feminine gender is formed which is a type of Svalpa Kushta.27ShabdaKalpadruma Vicharchika belongs to feminine gender & is formed from ‘Charcha Tarjane’Dhatu by adding ‘Navul’ to it, & is a type of disease.28 7
    • Conceptual StudyVicharchika Paribhasha: Shabdakalpadruma describes two main features found in Vicharchika i.e.cracking of the skin mainly occurs on the skin of hands & legs ‘Visheshena chare-ayatepadasya Tvak vidaryate Anaya iti Vicharchika’ which means the disease whichcoats/covers the skin in particular manner and causes cracking of skin of hands & feetmainly.29According to Acharya Charaka Vicharchika is defined as ‘Sa Kandu Pidaka Shyava Bahu Srava Vicharchika’.30 Means the skin disease where eruptions over the skin appear with darkpigmentation, itching with profuse discharge from the lesion.Vicharchika according to Sushruta is ‘Rajyo Atikandu Atiruja Sa Ruksha Bhavanti Gatreshu Vicharchikayam’. Accordingly the condition in which skin is dry with severe itching & markedlinings are present is Vicharchika. Further more he added that if the same conditionappears at the feet with pain, then it is known as ‘Vipadika’. 31 Acharya Madhava, Vagbhata & Bhavamishra have described almost samedefinitions as Acharya Charaka. 8
    • Conceptual Study ANATOMY AND PHYSIOLOGICAL ASPECTS OF SKIN Tvak Shareera And Kriya Kushta is a disease of skin and so to understand the total etiopathogenesis ofdisease, normal structure of the skin should be considered. Tvacha is a sthana of Sparshanendriya. Tvacha, Charma words are used for theskin in all Ayurvedic classics.Etymology of Tvak: tvagiti | tvachati | tvacha samvarane ||. It means the covering of the body.32 Tvacha Dhatu is used in the sense of covering.Definition: Tvacha is one among the Indriyadhisthana, which completely covers meda,shonita and all other Dhatus of the body and is extensive all over the body. It isconsidered as the seat of Sparshanendriya as well as one among the main seat of Vata andpitta.33,34Formation of Tvak: According to Charaka, Tvak is the Upadhatu of Mamsa so; ultimately Tvak isformed by Mamsa.35 And also said that it is a Matrujabhava because it is coming through ovum.36 According to Sushruta, Tvak has developed after the fertilization of the ovum. Atthe time of fertilization Shukra, Shonita and Soul becomes united for the manifestation ofGarbha. Its growth is rapid and nourished by Tridosha. Seven folds of the layers of theskin are formed and deposited on this rapid transforming product in the same manner asthe layers of cream are formed and precipitated on the surface of the boiling milk.37 According to Vagbhata, Tvak is formed by the Paka of Rakta Dhatu by itsDhatvagni. After the Paka of Rakta, by its Dhatvagni, Rakta become dry in the form of 9
    • Conceptual Studyskin like the deposition of cream on the surface of the boiling milk. Thus, Tvak is alsocalled as “Rakta Santanika”.38Panchabhautikatva of Tvacha: All the organs are made of Panchamahabhuta.39 So, Tvacha should have a Panchabhautika constitution also. Tvacha being a Dravya, its Panchabhautika constitution can be understood asfollows – Table No. 1: Panchabhoutikatva of Tvak: Mahabhuta Effect1) Prithvi Tvacha has been considered as the Upadhatu of Mamsa Dhatu that shows it is stable.2) Jala Due to the presence of Jala Mahabhuta Tvacha is snigdha and firm.3) Agni Tvacha has the specific Varna and lusture.4) Vayu Tvacha is the Adhisthana of Sparshanendirya.5) Akasha Presence of some micro channels of Sveda forming organ.Layers of Skin (Tvacha): There are some different opinions regarding the number of the layers of the skin(Tvacha) among the ancient Acharyas. Maharshi Charaka has mentioned six layers of skin but only first two layers arenamed and rest of the four layers are counted as producing diseases.40 10
    • Conceptual Study Table No. 2: Layers of Skin – Charaka: Layer ContainsUdakadhara Udaka means watery substance or lymphAsrukdhara Blood capillaries.3rd Manifestation of Sidhma and Kilas.4th Manifestation of Dadru and Kushta.5th Manifestation of Alaji and Vidradhi.6th Manifestation of Arunshi. If this layer is injured then the individual gets trembled and enters in to the darkness.Maharshi Sushruta has mentioned seven layers of skin along with their specific name,thickness and prone origination of the disease.41 Table No. 3: Layers of Skin – Sushruta:Sr. Layers Thickness Reflection of disease Ancient Modern (in Vreehi) (mm) 1 Avabhasini 1/18 0.05 – 0.06 Sidhma, Padmini Kantaka 2 Lohita 1/16 0.06 – 0.07 Tilkalaka, Vyanga, Nyachha 3 Sveta 1/12 0.08 – 0.09 Charmadala, Ajagallika, Mashaka 4 Tamra 1/8 0.12 – 0.15 Kilas, Kushta 5 Vedini 1/5 0.20 – 0.50 Kushta, Visarpa 6 Rohini 01 1.00 – 1.10 Granthi, Apachi, Arbuda, Sleepada, Galaganda. 7 Mamsadhara 02 2.00 – 2.10 Bhagandara, Vidradhi, Arsha 11
    • Conceptual Study Maharshi Vagbhata has also described seven layers of skin but names are notmentioned. Commenting on Vagbhata, commentator Arundatta and Hemadri have namedthem according to nomenclature given by Sushruta. Sharangdhara has also mentioned seven layers of the skin along with the probableonset of disease. The name of first six layers is same as Sushruta but 7th layer is calledSthula, which is the site of Vidradhi.42 Acharya Gangadhara has clarified the difference in opinion between Charaka andSushruta on the basis of the different opinions regarding the layers of Tvacha. Heexplained the third layer of Charaka counting as two parts – superficial & deep. Thesuperficial part is considered as third layer (Shveta) while the deep part as a fourth layer(Tamra) as mentioned by Sushruta.43 Table No. 4: Layers of Skin - Different Acharyas:Sushruta Charaka Arundatta Sharangdhara Bhela Avabhasini Udakadhara Bhasini Avabhasini Udakadhara Lohita Asrukdhara Lohita Lohita Asrukdhara Sveta 3rd Sveta Sveta 3rd Tamra 4th Tamra Tamra 4th Vedini 5th Vedini Vedini 5th Rohini 6th Rohini Rohini 6thMamsadhara Mamsadhara Sthula Thus, fundamentally there is no difference in the number of layers said by variousAcharyas. Dr. B.G. Ghanekar has correlated the layers of the skin described by Sushrutaand modern anatomy. 12
    • Conceptual StudyTable No. 5: Tvacha – Modern Co-relation:Ancient Term Modern Term Parts of SkinAvabhasini Stratum CorneumLohita Stratum Lucidum EpidermisSveta Stratum GranulosumTamra Malpighian layerVedini Papillary layerRohini Reticular layer DermisMamsadhara Subcutaneous tissue and Muscular layerKriya Sharira of TvachaTvacha and Dosha: Tvacha is one of the sites of Vata and Pitta. Skin has been considered as Sparshanendriya adhisthana which is the function ofVata. Bhrajaka Pitta is located on the Tvacha for giving luster and colour, where asSnigdhata, Shlakshanata, Mruduta, Sthirata, Sheetata, Prasannata, Snigdha Varna areattributed to Kapha. For Ropana Karma (self-healing process), Kapha is the responsiblefactor.Tvacha And Dhatu : Rasa: In the context of Tvak Sara Purusha Lakshana it has been also said as RasaSara. 1st layer of Tvacha, Udakadhara also contains Rasa (lymph). So, it can be easilyunderstood that there is a relation between Tvacha and Rasa. Rakta: Among its functions Varna Prasadana (provide color of skin) and MamsaPushti have been mentioned.44 Mamsa: Tvak is Upadhatu of Mamsa.45 13
    • Conceptual StudyTvacha and Mala: Sveda: It is Mala of Meda which is excreted by Tvacha. Sveda maintains theluster and humidity of skin.46 Nails and hairs are Mala of Asthi Dhatu and Tvakgata Sneha is the Mala of MajjaDhatu. The study of Indian classics reveals that skin disorders are afflicting the humanbeing since time immemorial.MODERN REVIEW S K I N47 Figure No. 1: Cross-Section of Skin:The skin is the first line of defense against the environmental agent and mirror of internalpathology.Embryological Description: The skin is developed from the surface ectoderm and its underlying mesenchyme(mesodermal cells).1) Surface ectoderm gives rise to the Keratinizing general surface epidermis and its appendage, the pilosebaceous units, sudariferous glands and nail units at about 8 – 10 14
    • Conceptual Study weeks of gestation.2) Malacocites, nerves and specialized sensory receptors arise from the neuroectoderm.3) Dermis and its other elements in the skin i.e. Langerhans cells, macrophages, mass cells, fibroblasts, blood vessels, connective tissue, lymph vessels, muscles and lipocytes originate from the mesoderm.Macroscopic Structures : The skin is the organ of integumentory system i.e. covering system of the body. Itis formed by about – 8% of the total body mass 2.2 square meter covering area 16% of total body weight 4.5 – 5.0 kg weight Most of the body, skin is average 1 – 2 mm thick. Skin is a fascinating organ as itforms a self-renewing and self-repairing interface between the body and its environmentand is a major site of intercommunication in both directions between the two. Within limit, it forms an effective barrier against microbial invasion and hasproperties, which can protect against mechanical, chemical, cosmetic, thermal andphototic damage. Skin has also good friction properties assisting locomotion andmanipulation by its texture. It is elastic, can be stretched and compressed within limit.Microscopic Structure: It is characterized by the epidermis, dermis and adenexa.Epidermis: It is a compound tissue consisting mainly of a continuously self-replacingkeratinized stratified squamous epithelium. It takes 28 days for the keratinocytes to movefrom the stratum basal to stratum corneum. Epidermis contains four strata (layers):Stratum basal, Stratum spinosum, Stratum granulosum and a thin stratum corneum, butwhere the friction of exposure is more e.g. finger tips, palms, soles, the epidermis has afifth layer named Stratum Lucidum in between corneum and granulosum.1) Stratum Basal (Stratum Germinativum):It is the deepest layer of the epidermis and formed by a single row of cuboidal orcolumnar keratinocytes, some of which are stem cells that undergo cell division to 15
    • Conceptual Studycontinually produce new keratinocytes. Four types of cells are germinated through thislayer, which are keratinocytes, melanocytes, langerhans cells and merkels cells. Keratinocytes: They are principal cells of the epidermis, about 90% of total cells,which produce the protein keratin. It is a tough, fibrous protein and it also helps to protectthe skin and save their deeper tissue from heat, microbes and chemicals. Keratinocytesare undergoing characteristic change as they progressively move upward from basal layerto cornified layer. This cell is synthesized from precursor of keratinuous protein, tono-filaments which are more in number at the cells of upper side. At the mature stage ofkeratinocytes, in the corneum strata, nuclei and cytoplasmic organelle graduallydisappear. It also produces lamellar granules, which release a waterproofing sealant. Melanocytes: They are the dendritic cells, 8% of total epidermal cell and alsosynthesize and secrete melanin-containing organelle called melanosomes. Their long,slender projections (Dendrites) extend in all direction between adjacent keratinocytes andtransfer melanin granules to them. Melanin is a brown-black pigment, which contributesto skin color and absorbs damaging ultra-violate (UV) light. The ratio of the melanocytesto keratinocytes in the basal layer is 1:4 to 1:10. Langerhans Cells: They are originated from the mesenchymal precursors in thebone marrow and migrate to the epidermis. They constitute a small portion of theepidermal cells. Langerhans cells, play a role in induction of graft rejection,immunosurveillance and in immune reaction of the delayed hypersensitivity typeespecially, allergic contact dermatitis. They also produce interleukin – 1 that is requiredfor T cell activity. They are easily damaged by UV light. Merkel’s Cells: They are located above the basement membrane and containintracytoplasmic neurosecretory granules. Myelinated nerves supply the cells that loosetheir myelin sheaths near the epidermis and continue onward as unmyelinated axonssurrounded by cytoplasm and basement membranes of Schwann’s cells. It is attachedwith tactile (merkel’s) disc, which is flattened process of a sensory neuron.2) Stratum Spinosum (Prickle cell layer) It lies superficial to the basal layer and it consists of 5 to 12 layers of polyhedralkeratinocytes connected to each other by intercellular bridges. Cells of this layer become 16
    • Conceptual Studymore flattened superficially. Cells are joined tightly to other cells by desmosomes, whichare bundles of intermediate filaments of the cystoskeleton. These arrangements provideboth strength and flexibility to the skin. For holding the cells intercellular cement is alsothere.3) Stratum Granulosum: It is 3 to 5 layers thick of flattened keratinocytes that contains darkly staininggranules of a protein called kertohyalin. The lipid-rich secretion produced by the lamellargranules, works as a water repellent seal that retards loss of body fluid and entry offoreign materials. This layer is a border mark in between the deeper – metabolicallyactive strata and the dead cells of the more superficial strata.4) Stratum Lucidum: It is present only in the skin of fingertips, palms and soles. It consists of 3 – 5layers of clear, flat, dead keratinocytes that contain densely packed intermediatefilaments and thickened plasma membrane.5) Stratum Corneum: This is the most superficial layer consisting of anucleated, flattened, cornified, 25– 30 layers of dead keratinocytes. These cells are continuously sheded and replaced bycells from the deeper strata. It serves as an effective water-repellant barrier and alsoprotects against injury and microbes. Constant exposure of skin to friction stimulates theformation of a callus, an abnormal thickening of the epidermis.Adnexa of the Epidermis: It contains the eccrine glands, apocrine glands and the pilosebaceous apparatus.Eccrine Glands: These are distributed all over the body except the vermillion borders ofthe lips, nailbeds, labia minora, glans penis and inner aspect of the prepuce. Their densityis maximum on the palms, soles and axillae. There are two types of secretory cells namedas large, pale, glycogen rich cells and dark staining, smaller cells. The pale cells, initiatethe sweat formation while the dark cells modify it by actively reabsorbing sodium. Themajor function of sweat is to dissipate heat by evaporation.Apocrine Glands: They are located in the axillar, areolae, periumbilical, perianal, 17
    • Conceptual Studycircumanal area, prepuce, scrotum, mons pubis, labia minora, external ear canal(ceruminous glands) and eyelids (moll’s glands). Apocrine secretions have no function inman.Hair Follicles: It guards the scalp from injury and sunrays, decrease heat loss, protecteyes from foreign particles.Sebaceous Glands: They are lipid-producing structures that arise as outgrowth from theupper portion of hair follicles. They are distributed all over the body except palms andsoles.Nail Unit: It is comprised of the nail plate and the tissues around and underneath it. Thenail unit helps in the appreciation of the fine and tactile stimulation, protect the terminalphalanges from trauma.Dermoepidermal Junction (DEJ): It represents a highly specialized attachment betweenthe basal keratinocytes and papillary dermis. It helps in the attachment between thedermis to the epidermis, provides support and regulates the permeability across theepidermal – dermal interface.On electron microscopic study it consists of following layers – Plasma membrane of the basal keratinocytes Lamina lucida – 30nm thick Lamina densa – 40nm thick Fibrous zone The dermoepidermal junction is actively affected in various bullous dermatitis.Dermis The dermis rests upon the subcutaneous fat and is 15 – 40 time thicker than theepidermis. The dermis is composed mainly of non-cellular connective tissue containingcollagen, elastic fibers and ground substances within which are embedded the nerves,blood vessels, lymphatics, muscles and pilosebaceous, apocrine and eccrine sweat unit.The few cells present in the dermis include fibroblasts, macrophages and someadipocytes. The dermis can be divided into – 18
    • Conceptual Study 1) Superficial – papillary region 2) Deeper – reticular region1) Superficial – Papillary Region: It is about 1/5th thickness of the total dermis. It consists of areolar connective tissue containing fine elastic fibers. Elastic fibers play a role in maintaining the elasticity of the skin.2) Deeper – Reticular Region: It consists dense, irregular connective tissue containing bundle of collagen and some coarse elastic fibers. Both these provide strength, ability to stretch, elasticity to skin etc.Pigmentation of the Skin: Melanin, carotene and hemoglobin- these three pigments give skin a wide varietyof color. Melanin is located mostly in the epidermis, carotene is mostly in the stratumcorneum and dermis, and hemoglobin is in red blood cells within capillaries in thedermis.Immunology of Skin: The skin is an important immunological organ and normally contains nearly allthe elements of cellular immunity with the exception of B-Cells. Much of the originalresearch into immunology was done under the skin as a model. The immunologicalcomponent of skin can be divided into. 1. Structures 2. Cells 3. Functional systems 4. Immunogenetics.(1) Structure: The epidermal barrier is an important example of innate immunitysince most microorganisms that have contact with the skin don’t penetrate it. Equally thegenerous blood and lymphatic supplies to the dermis are important channels throughwhich immune cells can pass to or from their sites of action.(2) Cells: Langerhans Cells: The langerhans cells of the epidermis are the outermostsentinels of the cellular immune system. They are dendritic, bone - marrow derived cellscharacterized ultrastructurally by a unique cytoplasmic organelle known as the “Birbeck 19
    • Conceptual Studygranule”. Langerhans cells play an important role in antigen presentation. Dendritic cellsare also seen in the dermis. These lack the birbeck granule but their other characteristicsuggests that they too can present antigen. T-Lymphocyte: T-Lymphocytes are now believed to circulate through normalskin where they are thought to mature. Different types of T-Cells are recognized. i.e.1) Helper - Facilitate immune reaction2) Delayed hypersensitivity - Specially sensitized.3) Cytotoxic suppressor - Regulate other lymphocytes.Surface receptors detectable by the use of monoclonal antibodies on tissue sections helpto categories the subgroups. Helper T- Cells often show the CD-4 receptors andsuppressor T- Cells shows the CD-9. B-lymphocytes are not found in normal skin but areseen in some diseased conditions. Mast Cell: These are normal residents of the dermis as are macrophages; bothmay be recruited to the site during inflammatory reactions. Keratinocyte: It has recently been recognized to have an immunologicalfunction. They can produce pro-inflammatory cytokines (specially interteukin-1) and canexpress on their surface immune reactive molecules such as MHC Class II antigens e.g.HLA – DR and Inter cellular Adhesion molecules (ICAM-I)(3) Functional Systems: Skin Associated Lymphoid Tissue: The skin with its attained blood supply,lymphatic drainage, regional lymph nodes, circulating lymphocytes and resident immunecells can be viewed as forming a regulatory immunological unit. Cytokines: Cytokines are soluble molecules that mediate action between cells.They are produced by T - lymphoctyes and sometimes by other skin cells includinglangerhans cells, keratinocytes, fibroblasts, endothelial cells and macrophages.Eicosanoids are nonspecific inflammatory mediators (e.g. Prostaglandins, Thromboxanesand Leukotrienes) and are produced from Arachidonic acid by mast cells, macrophagesand keratinocytes. Adhesion Molecules: The Adhesion molecules particularly ICAM-1 are cellsurface molecules found on lymphocytes and some times on endothelial cells and 20
    • Conceptual Studykeratinocytes. By interacting with leukocyte functional antigens they help to bind T-cellsand increase cell traffic to the area.(4) Immunogenetics: The tissue type antigens of an individual are found in the MajorHisto-compatibility Complex (MHC) located in man on the HLA gene cluster onchromosome 6. The MHC Class-II antigens of which the commonest is HLA-DR areexpressed on B-lymphocytes, Langerhans cells, sometimes T-cells, Macrophages,Epithelial cells and Keratinocytes. They are vital for immunological recognition but alsoare involved in transplant rejection. In addition the appearance of specific HLA genes is associated with an increasedlikelihood of certain diseases, some of which are Autoimmune in nature.Physiology of Skin: Thermo Regulation Protection Cutaneous sensation Excretion and absorption Synthesis of Vitamin D Immunity Blood reservoir Socio-sexual communication Individual identification 21
    • Conceptual Study NIDANA One of the fundamental principles of Ayurveda is the Karya – Karana Siddhaanta.The Kaarya – the production of the disease is not possible without the Kaarana – Nidanaor Hetu. Ultimately the aim of the physician is to cure as well as to prevent the disease.More over, the knowledge of nidana is useful to provide proper guidance for therapy aswell as in the prevention of the disease. Though, there is no specific description about etiological factors of the diseaseVicharchika, it being a variety of Kshudra Kushta, the etiological factors of the Kushtaare to be accepted as the etiological factors of the Vicharchika. Etiological factors of Kushta & hence of Vicharchika, mentioned in differentAyurvedic texts may be classified into following groups. 1. Aharaja Hetu 2. Viharaja Hetu 3. Acharaja Hetu 1. Aharaja Hetu Aharaja Hetus are chief responsible factors in the production of the Kushta (skin diseases). Among them Virudha & Mithya Ahara are the main dietary factors. a) Virudha Ahara – ‘Virudha’ or ‘Vairodhika’ is the technical terms for incompitable or antagonistic. It means that, which acts as antagonistic to physiological factors.48 b) Mithya Ahara – Mithya Ahara means improper Diet. ‘The diet which is opposite to Ashtau Ahara Vidhi Visheshayatanani’ is designated as Mithya Ahara.49 2. Viharaja Hetu Viharaja Hetu (causes pertaining to activities) also play an important role in the production of skin disease. Mithya Vihara, Vegadharana & Panchakarmapacharan 22
    • Conceptual Study are few such main Vihara Hetus. a. Mithya Vihara – It means improper activities. The activities opposite to ‘Svasthavritta’ (regimes which are laid for being healthy) is the ‘Mithya Vihara’. b. Vega Vidharana – It may be included under the heading of Mithya Vihara, but being a peculiar type of Mithya Vihara it is counted under a separate heading. Acharya Charaka has stated thirteen types of ‘Vegas’ – natural urges in Sutrasthana, the suppression of which are harmful to the body.50 It seems that, amongst the above Vegas, the suppression of Vamana, Mutra & Purisha may produce skin disease. c. Panchkarmapacharin – It is also a significant cause in the production of skin disease. Chakrapani has commented that ‘Panchakarmapacharinam’ means improper activities during the Panchakarma therapy may lead to skin disease.51 3. Achara Hetu It means causes pertaining to behaviour. Good morals (Sadvritta) are also necessary for a man to be healthy. In Nidana Sthana & Vimana Sthana, Acharya Charaka has mentioned theinvolvement of Krimi in the disease Kushta.52 Acharya Sushruta has also stated that alltypes of Kushta originate from Vata, Pitta, Kapha & Krimi.53 So Krimi may be taken asone of the probable causative factor for Vicharchika. According to modern medical science, allergy is the main responsible factor in thepathogenesis of the disease, ‘Eczema’. Factors which are not homologous to the Prakrutican also be said as the probable causative factor of Kushta & ultimately of Vicharchika. Responsible factors for Kushta vyadhi are to be accepted as the etiologicalfactors of Vicharchika, which are tabulated below. 23
    • Conceptual StudyTable No. 6: Nidanas of Vicharchika:No. Nidana CS54 SS55 AS56 BS57 HS58A AHARA HETU(a) Virudha Ahara –1 Intake of chilchim fish & milk + + + + +2 Intake of food mostly containing - - - - - Hayanaka,Yavaka,Chinaka,Uddalaka & Koradusha alongwith Ksheera, Dadhi, Takra, Kola, Kulattha, Masha, Atasi, Kusumbha & Sneha3 Intake of Mulaka & Lashuna with Ksheera +4 Continuous intake of Gramya, Audaka & - + - + - Anupa Mamsa with Ksheera5 Use of Pippali, Kakmachi, Lakucha with - - - + - Dadhi & Sarpisha6 Use of meat of dear with milk - - - + -7 Use of Mulaka with Guda - - - + -8 Excessive use of alcohol & milk - - - + -9 Intake of articles having sour taste with milk - - - + -10 Excessive use of green vegetables with milk +11 Intake of honey & meat after taking hot diet - - - + - & vice-versa12 Use of fish, citrus & milk together - - - + -(b) Mithya Ahara – + - - + +1 Excessive use of Navanna, Dadhi, Matsya, Amla & Lavana2 Excessive use of Tila, Ksheera & Guda + - - + +3 Drava, Snigdha, Guru aharanam atyartha + - - + + sevanam4 Excessive oleation + - - - - 24
    • Conceptual Study5 Continuous & excessive use of Madhu & + - - - - Phanita6 Intake of food that would cause burning + - - - - sensation7 Intake of food during indigestion + + - + +8 Adhyashana + + - + +9 Asatmyahara - + - + -10 Intake of polluted water - - - - -B VIHARA HETU(a) Mithya Hetu1 To do physical exercise & to take sun bath - + - + + after heavy meals2 To perform sexual act during indigestion - + + + +3 To do exercise/sexual act after Snehapana & + - - - - Vamana4 Sudden change from cold to heat or heat to + + - + + cold without following the rules of gradual change5 Sudden change from Santarpana to + - - - + Apatarpana & vice-versa6 Entering into cold water immediately after + - - + + one is affected with fear, exhaustion & sunlight7 Mithya sansarga Sevana - - + - -(b) Vega Vidharana1 Withholding of the natural urges i.e. Mutra & - + - - - Purisha vega, etc.2 Suppression of the urge of emesis + + - + +(c) Panchakarmapcharaj1 Panchakarma Kriyamane nishidha sevana + - - - - 25
    • Conceptual Study2 Improper administration of Snehapana - - - - -C ACHARA HETU1 Insulting acts to Brahmins, Teachers & other - + + + + respectable persons2 Indulgence in sinful activities in present or + + + + + past life3 Use of money or material acquired by unfair - + + - - means4 Censuring or killing virtuous persons - + + - - 26
    • Conceptual Study SAMPRAPTI The process of evolution of the disease, right from the contact of the Nidana withthe body, to the manifestation of the disease in its full form is known as Samprapti orpathogenesis.59 The knowledge of Samprapti not only helps in the comprehension of the specificfeatures of a disease, but also is also useful in deciding its line of treatment. Most of the Acharyas have described the common Samprapati of the diseaseKushta but they haven’t emphasized on the Samprapti of the Vicharchika. However, inthis context, commentator Gayadas quotes the references of Bhoja describing sameSamprapati of Vicharchika as Kushta. Before going into further details about Sampraptiof Vicharchika, it is necessary to have a glance at the classical descriptions. While describing the Samprapati of Kushta, which itself is applicable tovicharchika with the pradhanta of kapha dosha. Acharya Charaka opines the dual partplayed by the etiological factors. These factors apart from vitiating the kapha pradhanathree Doshas from their norms also cause shithilta in the four Dhatus i.e. Tvak, Rakta,Mamsa & Lasika (Shaithilyam Aapadyante). During the second stage of development ofthe disease, the aggravated Doshas proliferate in their respective habitats & gainmomentum. These circulating Doshas get lodged in the above Dhatus (Sthana –Adhigamana), where the vitiation of Dhatus takes place due to their shaithilyata. Thisleads to manifestation of the pathology as Kushta. Due to indefinite permutations &combinations of Dosha, Dushya, Sthana, etc., Kushta may present itself in infinitevarieties.60 Acharya Sushruta holds the point of view that Vayu in combination with theagitated Pitta & Kapha enters into the Tiryag siras (vessels or ducts) which aretransversely spread (Sirah Samprapadya) & reach to Bahya Roga Marga (SamuddhuyaBahyam maargam Prapti) to produce Kushta. Susruta has opined pitta pradhanta invicharchika.61 27
    • Conceptual Study Acharya Vagbhata has stated that aggravated kapha pradhana tridoshas getlodged into Tiryag Siras (Sirah Prapadhya), cause shaithilyata in the Tvak, Rakta,Mamsa, Lasika & Vitiate them to produce Vicharchika.62 Commentator Gayadas quotes the reference of Bhoja, while describing theSamprapti of Vicharchika that the doshas, after being aggravated, Vitiate the Tvak &Mamsa to produce Pidaka which is accompanied by Daha & Kandu. The conditionwhereby, the skin cracks becomes dry, coarse & is positioned in the feet its nomenclatureis changed to Vipadika. Madhava and vangasena has the opinion same as charaka. If itmanifests itself all over the body (except feet) it is known as Vicharchika.63 According to Charaka Samhita Due to various Nidana Sevana, Tridosha getsvitiated simultaneously & produces shaithilya in the Tvak, Mamsa, Rakta & Ambu. ThenTridosha gets localised in Shithila Dhatu & vitiating them with Lakshanotpatti of KushtaRoga which is applicable to vicharchika. According to Acharya Sushruta, Nidana Sevana causes vitiation of Vata, whichcarry vitiated Pitta & Kapha to the Tiryag gami Sira at the level of Bahya roga marga i.e.Tvak, Rakta, Mamsa & Ambu. Here, these vitiated Dosha gets seated. If these Doshas arenot treated properly, they may penetrate the deeper Dhatus of body. On the basis of the above descriptions of Samprapti of Kushta, an effort has beenmade to resynthesize the Samprapti of Vicharchika as follows- 28
    • Conceptual StudyFigure No. 2: Samprapti of Vicharchika Nidana Sevana Doshavrudhi Pitta Prakopa Kapha Prakopa Vata Prakopa Agnimandya Amavisha Rasen Saha Mishribhuya Vaigunya Dhatushithilta (Tvak, Rakta, Mamsa, Lasika) Prasara – Tiryag – Sira Sthanasamsharya – Bahya Roga Marga Dosha – Dushya Sammurchhana Srotodusti – Rasavaha, Raktavaha, Mamsavaha Tvagadeen dushya dushti Vicharchika lakshana 29
    • Conceptual StudySanchaya stage In hypersensitivity reaction of skin viz in contact dermatitis, absorption of drugsor chemicals into the body induces a cell mediated immunity, where T-primedlymphocytes are formed & some of these T-primed lymphocytes are responsible for theimmunological memory & subsequent skin contact with the same chemical or drug, laterinduces a delayed type of hypersensitivity reaction. The period from the contact ofallergen to the skin, till the production of primary T-lymphocyte can be taken asSanchaya stage of Samprapti of Vicharchika. Prakopa stage If the condition/Hetu persists more, then the continuous indulgence of the patientsin etiological factors leads to sufficient production of T-primed lymphocytes for cellmediated immune response. This can be said as Prakopa Avastha of Samprapti. Prasara avastha Prasara stage can be seen when T-lymphocytes join the re-cirulation in blood,lymphnodes, lymphduct etc. Further more, subsequent antigenic challenge results into themigration of these specific cells from the blood in to the tissues containing the antigen.Sthana Sanshraya In this stage, the primed T-lymphocyte binds the antigen which has stimulatedtheir production & this results into release of lymphokinase, which causes acuteinflammatory reaction of delayed type with cellular infiltration, accumulation &activation of macrophages. Tissue injury characterized by slow developing reaction, results in the productionof symptoms like itching, vesiculation, redness & discharge. This stage can be said asVyakti of the disease. 30
    • Conceptual StudyFigure No. 3: Shatkriyakala in Vicharchika Contact of Allergens to skin (Sanchaya) Production of primary T-lymphocytes (Prakopa) Produced in sufficient no. for cell Mediated immune response Join the recirculation pool I.e. in blood, lymphnodes, etc. (Prasara) Migration of these cells in subsequent Antigenic challenge from blood to tissue (Sthana Sanshraya) T-lymphocytes bind to the Antigen By surface receptors Release of lymphokinase causes activation of macrophage (Inflammatory reaction of delayed type) Intching, vesiculation, redness, discharge (Vyakti) Chronicity (Bheda) 31
    • Conceptual Study SAMPRAPTI GHATAKAS OF VICHARCHIKADoshas – TridoshaDushya – Tvak, Rakta, Mamsa, LasikaAgni – Jatharagni & Dhatvagni MandyaSrotas – Rasa, Rakta & MamsavahaSrotodushti Prakara – Sanga & VimargagamanaUdbhavasthana – AmapakvashayaSanchara – Tiryag SiraAdhisthana – TvachaVyadhi marga – BahyaSvabhava – Chirakari Each of Samprapti Ghatakas can be described as follows –Dosha – Tridosha Kapha (Charaka), Pitta (Sushruta), kapha (Vagbhata), vatapitta (Vangasena &Basavarajeeya) pradhana.Vicharchika is Kapha Pradhana Vyadhi according to Charaka, Vagbhata, Sharangdhara& Bhavaprakasha. Whereas Sushruta says as Pitta Pradhana & Madhava, Vangasena &Basavarajeya describes as Vata Pittaja. Pathogenesis caused by Vayu generates the symptoms like Atisveda, AlpaAgni etc. Due to Virudha, Asatmya & Ahita Ahara sevana it provocates Pitta Dosharesulting Ama Utpatti & Agnimandya i.e. – Jatharagni as well as Dhatvagni. Among the5 varieties of Pitta Dosha, Bhrajaka Pitta is the main responsible factor for this disease,which produces the symptoms like Vaivarnya, Daha, Srava.Dushyas – Tvak, Rakta, mamsa & Ambu are four responsible constituents forVicharchika. 32
    • Conceptual StudyTvak –Tvacha is the Indriya adhisthana of Sparshnendriya which has Vata dominance.So its vitiation causes symptoms like Kandu, Rukshata & Vedana.Rakta – Acharya Charaka shows the vitiation of Rakta producing Oedema & Redness inthe skin. Charaka also describes Shyavata i.e. Vaivarnya & Kandu as Shonitaja Vikara.64Mamsa – If pathology is not stopped in time, Dosha provokes deeper Dhatus like Mamsadushti. Toda, Sphota, Karkashta, Pidaka, etc. are the results of Mamsa dusti inVicharchika.Ambu – Charaka has mentioned Vicharchika as Bahusravayukta & Vagbhata supportingthis, has told Vicharchika as Lasikadhya. Srava, Praklinna, Lasikadhya etc are the resultof Ambu dushti.Srotas & Srotodushti Vicharchika is a disease of vitiated Rakta, hence involvement of Rasavaha,Raktavaha & Mamsavaha Srotas are influenced. In this disease, two types of Srotodushti are observed i.e. ‘Sanga’ & ‘Vimarga-gamana’ of Dosha from Koshtha to Shakha. Amavisha accumulate with Doshas &Dhatus & create the ‘Sanga’ where the Kha-vaigunya is present. Sthana Sanshraya takesplace here, finally leading to Vyakti stage of Vicharchika. One of the sign Bahusrava canbe compared to Vimarga gamana of Lasika dhatu, which is the result of Sanga of theRasavaha Srotas.Agni & Ama Mithya ahara, Ahita ahara & Virudha ahara are the main important causativefactors of the disease. They cause vitiation of Jatharagni resulting into formation of Ama& Amavisha. Jatharagnimandya later on produces Dhatvagnimandya – subsequentlyleading to Alpa Vyadhi Kshamatva of the body.Classification of Kushta Acharyas have classified Kushta in two type’s viz. Maha Kushta & KshudraKushta. There is no explanation about the difference between the two types by thesetexts, which have been cleared by commentators. Chakrapani says that in Kshudra Kushta involvement of Dosha & appearance of 33
    • Conceptual StudyLakshanas are less in comparison to Maha Kushta, while commenting on the term‘Mahat’, Acharya Dalhana pointed out that it has the ability to penetrate deeper Dhatu incontrast to Kshudra Kushta.65 In Nyaya Chandrika commentator Gayadas mentions thatMaha Kushta occurs due to excessive Dosha – ‘Bahu Bahula Dosha Arambhata’.Srikanthadatta says in Madhava Nidana commentary that Doshic involvement inUttarottar Dhatu is Shighra in Maha Kushta.66The difference between Maha Kushta & Kshudra Kushta can be tabulated as below – Maha Kushta Kshudra Kushta 1) Bahudosha 1) Alpadosha 2) Bahu Lakshana 2) Alpa Lakshana 3) Excessive pain 3) less pain 4) Penetrates deeper 4) less tendency to Dhatu rapidly penetrate deeper Dhatus 5) Mahat Chikitsa 5) Alpa Chikitsa 6) Chronic 6) Less Chronic 7) Loss of function of 7) Less functional Skin like anaesthesia deformity of skinClassification according to different Acharyas –Table No. 7: Types of Maha Kushta: Name C.S67 S.S68 A.H69 B.S70 B.P71 M.N72 Kapala + + + + + +Audumbar + + + + + +Mandala + - + + + +Rishyajihv + + + + + +Pundarika + + + + + + Sidhma + - - + + +Kakanaka + + + + + + 34
    • Conceptual Study Dadru - + + - - - Aruna - + - - - -Table No. 8: Types of Kshudra Kushta: Name C.S73 S.S74 A.H75 B.S76 B.P77 M.N78 Ekakushta + + + + + +Charmakhya + _ + + - - Kitibha + + + + + + Vipadika + _ + + + + Alasaka + _ + + + + Dadru + _ _ + + +Charmadala + + _ _ - - Pama + + + + + + Visphotaka + _ + _ + + Shataru + _ + + + +Vicharchika + + + + + +Sthularushka - + _ _ - -Mahakushta - + _ _ - - Visarpa - + _ _ - - Parisarpa - + _ _ - - Sidhma - + + _ - - Rakasa - + _ _ - -Gajacharma - _ _ _ + + Kachchu - _ + _ + + Svitra - _ _ + - - Vishaja - _ _ + - - 35
    • Conceptual StudyClassification according to HaritaHarita in the 19th chapter of 3rd sthana described some different types as follows79 – 1) Mandalika 6) Hastibala 2) Gojihva 7) Lohitamandala 3) Bahuvrana 8) Kandu 4) Kinam 9) Karmaja 5) Sahaja 10) Pandura Kashyapa in kushtachikitsadhyaya has classified the 18 types of Kushta as 9Sadhya & 9 Ashadhya kushtas.80Sadhya Kushtas Asadhya Kushtas1) Sidhma 1) Poundarika2) Vicharchika 2) Svitra3) Pama 3) Rishyajivha4) Dadru 4) Shatarushka5) Kitibha 5) Oudumbara6) Kapala 6) Kakanaka7) Sthularushka 7) Charmadala8) Mandala 8) Ekakushta9) Vishaja 9) Vipadika There are no as such classifications explained for disease of vicharchika, butbased upon the explaination by different authors dosha pradhanta in the disease ofvicharchika can definitely be identified. 36
    • Conceptual Study PURVARUPA The signs & symptoms which appear, before real manifestation of the disease areknown as ‘Purvarupa’. In general, the Purvarupa appears in the fourth stage of‘Kriyakala’. i.e. ‘Sthana Sanshraya stage’, the stage in which the ‘Prakupita Doshas’having proliferated & spread over the parts other than their natural habitat & due to‘Srotovaigunya’ or pathological involvement of the related Srotas, they implicate & leadto ‘Dosha Dushya Sammurchhana.’81 At this stage, if active management is undertaken,further progress of disease can be stopped. It is easier to get rid of the disease at the‘Purvarupa’stage. There is no classical description regarding the Purvarupa of Vicharchika, butbeing a variety of Kshudra Kushta, the Purvarupa of Kushta should be considered as itsPurvarupa. This can be summarized in the following table –Table No. 9: Purvarupas of Vicharchika:No. Purvarupa CS82 SS83 AH84 BS85 KS861 Asvedanam + + + + +2 Atisvedanam + + + + +3 Parushyam + +4 Atishlakshnata + + + +5 Vaivarnyam + + + +6 Kandu + + +7 Nistoda + + + +8 Suptata + + +9 Paridaha + + +10 Pariharsha +11 Lomaharsha + + + + +12 Kharatvam + + +13 Ushmayanam + +14 Gauravam + + +15 Shvayathu + 37
    • Conceptual Study16 Visarpagamanam Abhikshanam +17 Bahya Chhidreshupadeha +18 Pakva-Dagdha-Danshta-Bhagna-Kshata + upashkhaliteshu Ati Matram Vedna19 Svalpanam api Vrananam dusti +20 Kothonnati + +21 Svalpanam Api Vrananam Asamrohnam +22 Shrama + +23 Klama + + 38
    • Conceptual Study RUPA Rupa appear during the 5th Kriyakala & this is also referred to as the ‘Vyakti’stage during the progressive process of manifestation of the disease. Rupa ofVicharchika, according to different Ayurvedic classics are summarized in the followingtable – Table No. 10: Rupas of Vicharchika:No. Rupa CS87 SS88 AH89 AS90 BS91 KS921 Kandu + + + + - -2 Pidaka + - + + - -3 Shyava + - + + - -4 Rakta - - - - + +5 Srava + - + + + +6 Rajyo - + - - - -7 Ruja - + - - - +8 Ruksha - + - - - -9 Praklinna - - - - + +10 Shyama - - - - - +11 Vrana - - - - - +12 Paka - - - - - +The interpretation of the above mentioned Rupas of Vicharchika is as follows-A. Vedana Vishesha 1) Kandu Kandu may be defined as a condition of severe itching sensation in the body. It is the most distressful symptom for the patient of Vicharchika. Acharya Sushruta has used the adjective ‘Ati’, while Charaka has used the adjective ‘Sa’ with it. It indicates that it is present in severe form in the patient of Vicharchika. From the doshik point of view, Kandu is produced by the vitiated Kapha. If this is associated with Pitta it will result into Daha followed by itching. 39
    • Conceptual StudyPhenomena of Itch The exact mode of activation of the receptors is not clear, but histamine andcertain enzymes which split proteins & therefore lead to itching because of damage ofskin cells with the release of histamine/intercellular protease enzymes. In hypersensitivity conditions an antigen-antibody reaction occurring on thesurface of skin cells may cause the release of histamine leading to itching. Figure No. 4: Phenomenon of Itch Antigen – Antibody reaction (On the surface cells of skin) Histamine/Intracellular protease enzymes Production of Kinin – like polypeptides Stimulation of primary nerve fibres (Non medulated) Ascend in the spinothalamic tract (Anterolateral) (Terminating in thalamus) Itch 2) Daha When Vata carries away the prakruta Pitta from its location, it producesburning sensation.93 It can be said, both vitiated Pitta and vitiated Vata can produce Daha. 3) Ruja This symptom is mentioned by Acharya Sushruta & Kashyapa. Dalhanahas defined it as Vedana. Due to excessive scratching, this symptom may appear in the 40
    • Conceptual Studycases of Vicharchika. As Acharya Sushruta has considered the disease as Pittaja vikara &its Lakshanas indicate the vitiation of Vata & Pitta. Hence, Ruja can be taken as asymptom of dry form of Vicharchika. According to Modern medicine also, usually there is no pain in eczema but when it is associated with secondary infection & pyoderma, pain may be felt.B. Texture 4) Rukshata It indicates the dryness in the lesion. It has been mentioned by Acharya Sushruta. This Lakshana is produced by the vitiation of Vata. The terms ‘Kharatva’ & ‘Parushata’ shows the degree of dryness. 5) Kharatva According to Shrikanthadatta, Rukshata along with Karkasha Sparsha is Kharata.94 Lack of Snigdhata is generally indicated by word Khara. It is an important premonitory symptom of Vata Pradhana Kushta. 6) Parushata According to various Acharyas the term ‘Parushya’ has the Following meaning – - Yogindranath Sena Parushata means Kathinata - Gangadhara Absence of Chikkanata - Hemadri Kharata In short, Tvak Parushya means increase in Khara Guna of Vayu & decrease in Snigdha & Drava Guna of Kapha Dosha. 41
    • Conceptual Study 7) Paka It is produced by vitiated Pitta as explained by Acharya Kashyapa95 which results in purulent discharge, as observed when the disease is superimposed by secondary infections. 8) Vrana Means ulcerated lesion. This symptom has been mentioned by Acharya Kashyapa. Vrana may be created by excessive scratching & discharge. 9) Pidaka The etymology of the word Pidaka by the Vachaspatyam96 & Shabdakalpadruma97 is ‘Pidayate iti Pidaka’ means which creates Peeda (trouble). Moreover it is mentioned that ‘Kushtadhikare Pidadayake Kshudrasphotaka’ means in relevance of Kushta chapter, Pidaka should be taken as ‘Kshudra Sphotaka’ which is troublesome. Acharya Charaka in ‘Trishothiya Adhyaya’ has explained that the vitiated Pitta gets accumulated in Tvacha & Rakta, creates inflammation & redness and is called as Pidaka.98 Chakrapani has emphasized upon the difference between Pidaka & Visarpa, that although they have common etiological factors yet Visarpa has the nature of spreading at a fast pace while Pidaka is steady or localized.99 10) Srava This symptom is presented in the disease, ‘Vicharchika’ by all Acharyas exceptSushruta. Sushruta has explained dry lesions. Acharya Charaka has used the adjective‘Bahu’ & said Bahusrava in Vicharchika means there is profuse discharge. AcharyaVagbhata has mentioned it with the word ‘Lasikadhya’. Indu has defined it as Jalaprayah, means the nature of the discharge resembles tothat of water (Lasika Jalaprayah).100 42
    • Conceptual Study According to Charaka Samhita ‘Srava’ is produced by the vitiated Pitta &Kapha. Whereas according to Madhukosha commentary – ‘Bahusrava’ is produced byvitiated Pitta.101 Most of the Acharyas have stated Vicharchika as Sravayukta (wet) lesionwhile Acharya Sushruta has denoted the ‘Rukshata’ – dryness in Vicharchika. It seemsthat if the Vata is dominant the lesion will be dry, while in the dominance of Kapha orPitta, it will be Sravi. 11) PraklinnaPraklinna means ‘with more wetness – more Kleda’. Due to Excessive discharge thelesion becomes ‘Praklinna’. This sign is stated only by Acharya Bhela.102C. Texture 12) RajyoThis sign has been notified by Acharya Sushrutas commentator Dalhana who explained itas Rekha means linings – (Raajyo Rekha).103 In the dry type of Vicharchika, Raji may develop due to thickening of the lesionwith marked linings. 13) Vaivarnya When the colour of skin alters from its original appearance it is termed asVaivarnya. It is an important symptom of Kushta. One of the alterations of skin colour inVicharchika may be Shyava, Rakta, Shyama, etc. Eczema usually begins with redness ofthe skin then followed by dark brownish & blackish-brown colour which can becompared with the above Varnas i.e. - Shyava, Rakta & Shyama. Shyava means dark orblackish discolouration. This sign has been mentioned by all Acharyas except Sushruta.Acharya Susruta has not mentioned the colour of the lesion of Vicharchika. 43
    • Conceptual Study Shyama means black. This discolouration is mentioned by Kashyapa.104Shyama Varna of lesion may be found prominently in the chronic stage of Vicharchika.Probably it resembles with ‘Shyava’ said in other Samhitas. Rakta indicates redness in the lesion. This symptom has been mentioned inthe Bhela Samhita.105 Acharya Kashyapa has used the word ‘Lohita’ which indicatesRakta or Shyama Varna. 44
    • Conceptual Study ECZEMA – DISEASE REVIEW106 The skin is outermost cover of the body and it suffers different types of injurieslike physical, chemical, actoparasitic and infective in origin. These various insults are theorigin of many of the dermatosis i.e. eczema or dermatitis.Etymology: The Greek word ‘Ec’ means out and ‘Zeo’ means boil. Thus, whole word ‘ekzein’means, to boil out.Definition: Eczema or dermatitis is an inflammatory response of the skin to multiple agents,characterized by erythema, edema, vesiculation, oozing, crusting and later lichenification. Dermatitis and eczema are synonymous but dermatitis is specially used forexternal injury like contact of industrial dermatitis whereas eczema is used forendogenous or constitutional causes dermatitis. Acute eczema may be weeping, crustingand vesicle formation and subacute or chronic may be dryness, scaling, fissuring andlichenification.ETIOLOGY OF ECZEMA Essential factors are two viz. 1) An allergic (sensitive) skin and 2) Exposure toirritant. The eczema is a specific type of allergic cutaneous manifestation of antigen-antibody reaction, which is characterized by superficial inflammatory edema of epidermisassociated with vesicle formation and itching.PREDISPOSING FACTORS Age: Infancy, puberty, menopause Familial Predisposition: Allergic reaction i.e. atopic. Debility: This lowers resistance power. Climate: Extreme heat, dampness, cold. Psychological: Enhances the allergic reaction. Local: Dry winter cracks skin, hyperhydrosis, lower resistance of skin and suchdiseases like xeroderma, ichthyosis, greasy skin, varicose vein etc. 45
    • Conceptual StudyEXCITING FACTORS Cosmetics: In cosmetic preparations, chemicals, its derivatives or othermedicaments mixture causes dermatitis. This problem is very serious in developingcountries due to quality compromise and competition e.g. perfumes and preparationcontaining tars, formaldehyde are common irritants; Vaseline, deodorant are alsocommon causes of dermatitis; Hair bleaches such as ammonia persulphate; hair dyes –paraphenylendediamine may produce acute dermatitis; Lipstick, Nail polish, eyebrowpencil may also act as irritant. Wearing Materials: Common harmful substances are clothes, furs, spectacleframes, artificial jewelleries, chappals, etc. Nylon clothes are not good for tropical climate, which interferes with theabsorption and evaporation of sweat. In textile industry chrome and formaldehyde areimportant agents causing dermatitis. Artificial jewelleries (made from nickel, nylon hair nets) also causes skin reactionto relevant area of the body. Rubber chappals or other footwear may cause dermatitis on soles. Natural rubberis not responsible for sensitization but adhesive, dye and such additives likemercaptobenzothiazole, butyl phenol formaldehyde, resins, oil etc. may cause eczema. Medicaments: Some medicaments cause untoward effects due to the Overdoses,Intolerance, Side effects, Idiosyncracy, Secondary effect, Hypersensitive allergicreactions and etc. Medicament may cause complications like contact dermatitis at the treatmentarea, dermatitis medicamentosa or drug eruption. Anesthetic (cocaine), antipruritic, anti-histaminic cream, sticking plaster, penicillin, sulpha drugs, formalin etc. act as allergenic. Industrial And Occupational Agents: Industrial pollutions and increased use ofchemical synthetics are supposed to be the causes of eczema. 80% of all occupationaldermatitis is caused by primary skin irritants and allergens, careless and frequent use offungicides and pesticides also cause dermatitis. Agriculturists And Gardener: Plants, weed, insecticide, fertilizers, oils. Housewife: Soap, detergent, nail polish, dye, fluorescent whitening agents,laundry products etc. 46
    • Conceptual Study Painter: Terpentine, paints. Textile Worker: Formaldehyde, solvent dye etc. Hair Dresser: Nickle dermatitis is common. Builders: Cement is highly irritant, lime, wood, paint, kerosene, turpentine etc. Automobiles: oil, petrol, grease etc. Plants: It is a known cause of phyto-dermatitis. Plant may act as mechanical, chemical or physical irritant and cause dermatitiswith redness, blister and ulcer. Mostly it affects the exposed area i.e. face, hand etc.Common irritant plants are marking nut, purging nut, Arka, mustard etc. Plant dust,pollens; act as sensitizers and causes dermatitis by contact or inhalation. Resins are madefrom pine trees and used for stationary, medicament, cosmetics etc. Plastics: A new and increasingly frequent causes of dermatitis is from acrylic andepoxy polymers or resins. About 90% of contact dermatitis are epoxy polymers, resinsfrom bisphenol – A. Smoking: It can have the disastrous effect on the skin as the sun does; accordingto researchers, smoking diminishes the levels of circulating estrogen, which results indryness and disintegration of the skin tissue. It is still controversial that whether the endogenous factors are more important orexogenous factor in eczema. Endogenous Factors: Diet, mental or emotional conflicts (strain and stress), focalsepsis, state of digestion, nutrition and metabolism, diathesis etc. Exogenous Factors: Infection, irritant, sensitizers (plant, cosmetics etc.), climateetc. Role of Gastrointestinal Tract: The skin is 8% of the body weight and uses upto about 1/8th of the body’s protein; hence, it is affected early in malnutrition. Inexperimental study on malnutrition, dryness of skin and hyper pigmentation wereobserved as early signs (study on human being at second world war) older person,proceed to a mild icthyosis and the associated hyperkeratosis is often a sign of slow turnover. Mal-absorption syndrome has been reported in patients with a variety ofdermatological disorders, including psoriasis, eczematoid dermatitis etc. Clinical and 47
    • Conceptual Studylaboratorial evidence of significant mal-absorption was infrequent, possibly owing to thelimited length of small intestine involved in this skin disorders. Deficiency And Effects : Vitamin A Excessive dryness of skin Vitamin B Dermatitis – may be seborrhoiec type Nicotinic acid well known triad of dementia, diarrhea and dermatitis. Vitamin C Non-healing wound, echymosis. Protein Dry hyperkeratotic, hyper-pigmented scale Food Allergy: Hyper-sensitivity of the food depends on the frequency ofingestion and on the level of tolerance elicited. Infrequent ingestion is more likely tocause allergy than tolerance. A high level of iodine in a diet induces glistering indermatitis herpatiformis. The recent study has shown that, specific milk proteins, egg white, particular speciesof fish, meats of all kinds, have proven that they give rise to allergic reactions. Amongthe different categories of plant foods, legumes cause very frequently allergic disorders.Wheat gluten of wheat flour, soya flour, pea nut, beans and lentils, edible fungi, fats andoils of animal and plant origin found to produce allergic symptoms in few number ofindividuals. Some vegetables like carrot, spinach, cabbage, asparagus, onion, garlic,sweet potato, white potato, cauli flower and pumpkins cause allergy to some individuals.Among the fruits, bananas, oranges, grapes, and apples are the principal offenders.Externally, the use of cosmetics like perfumes, nail polish, lipsticks, creams, deosprays,hairdyes and soaps, artificial jewellery usually made out of nickel, leather belts, shoes,nickel buttons, tend to cause allergic reactions. Some chemicals used by professionals, weeds like parthenium; chemicalsin the fertilizers have proved to produce allergic reactions on constant use. Role Of Climate : It is responsible for many skin diseases. Atmosphere and watervapours are giving protection against sunburn in winter, cloudy days, morning and 48
    • Conceptual Studyevening. The light sensitivity dermatitis is also exacerbated by heat, friction or pressure.Ultraviolet rays such as – U.V.A. It damages to skin in the presence of sensitizers such as drugs. U.V.B. It damages to skin and produce sun burn. U.V.C. It damages to skin at mountain place. Exposure to sun light is a major cause of aging of the skin and to degenerativedisease of the epidermis and dermis that accompany age.Pathophysiology: Eczemas begin with erythema and edema followed by the appearance of minutevesicles in the area. The vesicles rupture and this gives rise to an oozing of fluid,alternatively it may dry up with scaling and crusting. After healing there may be residualpigmentation left. Sometimes, it becomes chronic and skin becomes lichenified i.e.thickened with exaggerated skin marking and hyper pigmentation. Its stages may berepresented on the basis of the lesion with their characteristic features. Acute Stage: Erythema, edema, vesiculation, oozing, crusting Sub-acute Stage: Hyper-pigmentation, scaling, crusting Chronic Stage: Lichenification (a combination of thickening, hyper-pigmentationand prominent skin markings).HISTOPATHOLOGY OF ECZEMA In different stages of the disease histopathological changes are described asbelow: Erythema or reddening with congestion shows edema of the epidermis(spongiosis) and of the dermis (hyperemia and edema of the papilae) with exudation ofplasma and dipedesis of cells which accumulate as a perivascular infiltration. Theepidermis edema is both inter-cellular and extra-cellular. Vesiculation, where the connecting fibrils of the cell break in the process of fluidcollection and small vesicles are formed which become confluence and pushed up from 49
    • Conceptual Studythe deeper layer to the surface. In certain cases e.g. ‘dry’ eczema and seborrhoeic eczema, desication occurs atthe stage with formation and shedding of small crusts and the epidermis reformsunderneath them. Exudation, however, is the more common sequel from rupture or the vesicles withweeping and oozing, the so-called weeping eczema. The openings made of the rupturedvesicles continue to drain away exudates, which comes mainly from the edema of thepapillary body. Crust formation results from drying of the exudates, Which is commonly secondarily infected with pyogenic organisms. Throughout these stages an acanthosis or thickening of the cells frommultiplication of cells are found. There is imperfect keratinization of the cells whichretain their nuclei, cling together and are imperceptible shed in scales. Desquamation concludes the process with shedding of the scales and crust andreformation of the epidermis beneath. When the disease tends to become chroniclichenification may results with acanthosis, infiltration of the papillary layers andthickening of the skin.CLASSIFICATION OF ECZEMAEczema accounts for a very large proportion of all skin diseases. The classification of allthe clinical forms is difficult, not only because nomenclature is controversial, but alsobecause in so many cases multiple causative factors are implicated and because two ormore forms of eczema may be present in the same patient simultaneously orconsecutively. The following classification include the principal forms of eczema andalso, by convention, certain conditions which do not necessarily show the histologicalchanges of eczema at all stages. Depending upon the causative or provocative factors, theeczema has been classified mainly in two group’s i.e. exogenous and endogenouseczema. 50
    • Conceptual StudyI) ETIOLOGICAL CLASSIFICATIONA) EXOGENOUS ECZEMA - An external cause for the eczema is identifiable andwhen this is removed, eczema does not recur such as1) Irritant dermatitis2) Allergic contact dermatitis3) Infective dermatitis4) PhotodermatitisB) ENDOGENOUS ECZEMAS - An internal cause or an inherent property of the skinis responsible for the occurrence of eczema, such as1) Atopic eczema2) Seborrhoeic dermatitis3) Stasis Dermatitis4) Nummular eczema5) Juvenile planter dermatosis6) Pompholyx7) Eczema associated with systemic disease8) Eczematous drug eruptionsC) COMBINED ECZEMA - Both etiological factors are responsible for it such asXerotic eczema.II Morpho-clinical classification : • Acute Dermatitis: Due to acute insult in the skin mechanism gradually inter- cellular edema occurs then it produces space in keratinocytes and lymphocyte (migration in that area) after this intra-epidermis vesicles formation takes place due to degeneration and liquefaction of cells and debriges. At the later stage, they may rupture or form large vesicles (bullae), which contain fibrin degenerated epithelial cell, polymorphonuclear leucocytes and lymphocytes. After all this 51
    • Conceptual Study process, the nutrition of outer layer is hampered so parakeratosis occur. Severity of the insult shows varying degrees of edema, vascular dilatation and congestion and inflammatory exudates such as plasma cells then WBC – lymphocyte, eosinophil, neutrophil and later RBC. • Sub-acute Dermatitis: It is less severe than acute, so the lesion becomes less vesicular edema and vesiculation, but its presence is there. The epidermis is acanthotic and parakeratosis is marked. The surface is covered with a mixture of fibrin, degenerated papilla covered by fibrin and debris is seen. macrophages are mainly present in inflammatory exudates i.e. Numular dermatitis. • Chronic Dermatitis: If the eczema runs to months or years, is called chronic. In this condition the epidermis has a marked acanthosis with elongation of the rete ridges. Vesicles became disappear but slight inter-cellular edema may present, lymphocyte, eosionophil, macrophage, firbroblast seen in inflammatory process. After all skin becomes histologically thickened or lichenified. E.g. Neurodermatitis (lichen simplex chronicus).TYPE OF DERMATITIS (ECZEMA)A) Exogenous DermatitisContact Dermatitis: It’s name itself suggests that it is the result of contact between theskin and foreign substance. Contact dermatitis is an inflammatory response in skin causedby an exogenous agent or agent that directly or indirectly injures the skin. This injurymay be caused by either an inheritant characteristic of a compound (irritant contactdermatitis) or induce an allergens-specific immune response (allergic contact dermatitis). The clinical lesion of contact dermatitis may be acute (wet and edematous) orchronic (dry, thickened and scaly) depending on the persistence of the insult. Substancethat causes dermatitis may be grouped into two general category :Primary Irritant: It is a toxic substance that causes contact dermatitis in the vastmajority of the people on first exposure to it. Irritant effect may be induced by aconcentrated acid or base which directly damages the skin.The Sensitizer: Excites dermatitis only after the skin has become sensitized by previousexposure. Sometime a single exposure is enough to sensitize but usually repeated 52
    • Conceptual Studyexposure are necessary. It may be also called irritant contact dermatitis (ICD) and allergiccontact dermatitis (ACD) respectively.Allergic Contact Dermatitis (ACD) Table No. 11: Hypersensitivity (allergic) reactions:Reaction type Mediation Typical Reaction Type I – Immediate type IgE Anaphylactic, Asthma, Atopic Type II IgG Autoimmune, Pemphigus Vulgaris Type III Immune complex Extrinsic Allergic alveolitis, Serum sickness Type IV – Delayed type Cell Contact sensitivityFeatures Of Allergic Contact Dermatitis : • Typical eczematous lesion varying from erythema to violent, vesiculation, pustulation, oozing and crusting. • Accompanied by marked itching. • The sticky parts of plants containing phenolic oil resin or plant derived antigen substance are usually responsible. • Usually occurs on exposed part.Irritant Contact Dermatitis : It is generally strictly demarcated and often localized to area of thin skin (eyelid,intertriginous area) or to area where the irritant was occluded. The most common area ofinvolvement is hand. Recurrence totally depends upon irritant nature Lesions may range from minimal skin erythema to area of marked edema vesicles and ulcers. The site always give a clue to the probable contactant i.e. wrist eczema probably due to the watch and in axilla due to the deodorant or clothing etc. Patch test may help to detect or exclude the possible irritant factors which are mentioned earlier in exciting cause of dermatitis. 53
    • Conceptual StudyHand Dermatitis : It is the most common presentation of contact dermatitis andfrequently related to occupation exposures, it runs in chronic course and may beassociated with other cutaneous disorders such as atopic dermatitis or may occur by itself.Chronic excessive exposure to water and detergent may irritate or aggravate thesedisorders. It may present with dryness and cracking of the skin of the hands as well aswith variable amount of erythema and edema. Variant of hand dermatitis, dyshidroticeczema, present with multiple, intensely pruritic, small papules and vesicles occurring onthe thenar and hypo-thenar eminencies and the sides of the fingers. Lesion tends to occurin crops that slowly form crusts and heal. The use of rubber gloves to protect dermatiticskin is sometimes associated with the development of delayed type of hypersensitivityreactions to agent used for cross-linking rubber. These reactions can be detected by patchtest.Neurodermatitis: It is also termed as a lichen simplex chronicus. It may represent the end stage of avariety of pruritic and eczematous disorders. These conditions may be defined as thelichenification process resulting from the chronic scratching and rubbing of the skinunder stress and anxiety such as young people, menopause and neurotic person. Theoriginal pruritic stimulus is usually unknown but the itch-scratch-itch cycle continuousunabated. Thus skin become lichenified – thickened, infiltered and pigmented and criss-cross margins become more prominent. Common area involved includes the posteriornuchal region, dorsum of the feet or ankle.Infectious Eczematoid Dermatitis: The skin in the region of an infected wound or sinus is macerated with dischargeand will react with an eczematous reaction may produce inflammation i.e. the bacteria,toxins, denatured protein, together with the local medication will sensitize the skincausing an eczema like reaction.Air-Borne Contact Dermatitis: The labourer, farmers, industrial workers, gardeners who works in open and 54
    • Conceptual Studyrepeatedly exposed to dust, pollens and other particles suspended in the air are oftenaffected by air-borne contact dermatitis.Photo Dermatitis: It is usually evoked in association with chemicals, which are innocuous to the skinin absence of light exposure. Photo sensitivity reactions may either be photo allergic orphoto toxic, depending upon whether the immune system is participating or not. The phototoxic reaction may be elicited in any individual provided there isenough light energy of appropriate wavelength and adequate concentration of the agent.However, in photo allergic dermatitis, the absorbed light energy promotes aphotochemical reaction between the chemical and skin proteins resulting in the formationof photo antigen. There is sensitization to this photo antigen and on subsequent exposure,an eczematous response is elicited. Itching and burning on area exposed to sunlight, followed by eczematousresponse in the form of erythema, edema, vesiculation and oozing. On healing, this areamay show hyper-pigmentation. Exposure withdrawal test is positive in photo dermatitisalso. Using a blackened x-ray film with a window may also perform photo patch test.B) Endogenous Eczema (Idiopathic Dermatitis): There are no evidence of external causes or irritants, but sensitization comes tointernal body product or toxins through the media of focal sepsis, metabolites etc. Familial predisposition or psychosomatic influence or both are main causativefactors for it.Atopic Dermatitis: The word “atopic” refers to a tendency for access inflammation inthe skin, lining of the nose and lungs. It often runs in families. These families may haveallergies such as hay fever or asthma.Genetic factors, environmental, emotional causes, all of these play a role in the causation.Provoking Factors: Dry hyperirritable skin with a low itch threshold, which is aggravated by wool fabrics and emotional factors. 55
    • Conceptual Study Family history of atopic diathesis Increased susceptibility to bacterial, viral and fungal skin infectionsClinical Features: Pruritus and scratching Course with exacerbation and remissions. Lesions typical of eczematous dermatitis Positive family history or personal history of allergy. Clinical course lasting longer than six week. Asthma and hay fever, itchyosis vulgaris and Contact urticaria may associateInfantile Eczema Phase:Onset – about 3rd month of life.Characteristic feature – erythematous lesion, itchy rash (pruritus is a prominentsymptoms) itching can be continuous and may be most noticeable at night. Dry or mildoozing and crusting,Site – face, particularly on chicks, scale but patch can appear anywhere. Other featuresinclude pityriasis Alba, scalp scaling and keratosis pillories. Usually it disappears at the age of two years when child begins to crawl, theextensor aspect of knees get involved. The eczema spread to the trunk and become widespread. High proportion of patients gets recurrence in late childhood, adolescent or earlyadult life. It also spreads without family predisposition, called simple variety of infantileeczema. The progress is marked by spontaneous remission and exacerbations. Somepatients scratch the skin until it bleeds and crusts and finally may get infected.Childhood Phase:Site – most of the elbow and knee flexures. Site of neck, wrist and ankle are alsoinvolved.Feature – lesion with vesiculation, discoid patches, lichenification at the age of 12 years,90% of eczema become clear.Adult Phase:Site – flexure region. 56
    • Conceptual StudyFeature – itch can be severe and cause much more distress to patients and families,eruption may become generalized, lichenification very rare, in teens and young adults,the patches typically occurs on the hand and feet.Seborrhoeic DermatitisEtiology: Constitutional disturbances of sebaceous gland. Exacerbation of the disease may be precipitated by emotional stress.Symptomatology: Yellowish, oily, scaly patches of skin (greasy scales overlyingerythematous patches of plaque). Itching or burning may also present.Infancy: Cradle cap, with scattered erythematous patches on the head and neck andassociated napkin rash.Adult: Scaling in the scalp, blepharitis, red scaly patches in nasolabial fold, around theears and on the presternal area are characteristic, inter trigo may occur.Location: Most common site is scalp (severe dandruff), face including eyebrow, eyelid,glabella, nasolabial fold or ears, central chest, axilla, groin, submammary fold and glutealcleft. Seborrhoeic dermatitis may be evident within the first few weeks of life andwithin this context it occurs in the scalp (cradle cap), face or groin. It is rarely seen inchildren beyond infancy but becomes evident again during adult life. Although, it isfrequently and extensively seen in patients with Parkinson’s disease, in those who hadcerebro-vascular accidents and in those with Human Immunodeficiency Virus (HIV)infection, the overwhelming majority of individuals with seborrhoeic dermatitis have nounderlying disorders. The yeast pityrosporum ovale is increased in the scaly epidermis in this conditionand is now implicated in its pathogenesis, although the mechanism is not entirely clear.Nummular Dermatitis (Discoid Eczema) Definition : Nummular Dermatitis is characterized by round coin-shapedeczematous lesions, papulovesicular and oozing or scaly erythematous, usually affectingthe extensors of the limbs. It is more commonly seen in adults past the age of 50 years. 57
    • Conceptual Study Etiopathogenesis : Whether nummular dermatitis is an eczematous reactionpattern with diverse etiologies or a distinct clinical entity is not known for certain. Itfrequently occurs in those with xerotic skin, perhaps denoting a relationship withasteatotic eczema. Though increased bacterial colonization is known in affected skin, itsetiologic role is not proved. Round eczematous or dry scaly lesions occur in atopicdermatitis. But if other features of atopic dermatitis are present, they represent atopicdermatitis rather than a separate entity. An increased incidence of atopy has been reportedin patients of discoid eczema but there are contradictory reports too. A number of factorshave been suggested as causative agents. Allergic contact dermatitis is relatively commonin persistent discoid eczema. The most common allergens implicated are rubber,chemicals, formaldehyde, neomycin, chromium and nickel. Discoid eczema has also beenreported to occur due to sensitivity to aloe and methyldopa. Pathology: Focal areas of spongiosis and intraepidermal vesicles are seeninitially. The dermis shows papillary edema and a perivascular lymphohistiocyticinfiltrate. In the dry lesions psoriasiform epidermal changes with focal spongiosis areseen along with a mixed infiltrate of lymphocytes, histiocytes and a few eosinophils inthe edematous papillary dermis. The overlying epidermis shows parakeratosis alternatingwith orthokeratosis. The features resemble those of allergic contact dermatitis. Clinical features: Mild to moderate itching is the main complaint. The lesionsappear as erythematous edematous papules or vesicles that coalesce to form roundeczematous lesions one to several centimeters in diameter. Their number is variable, fromfew to many. They are usually symmetrically distributed on the dorsal aspects of thehands and feet, extensors of the arms and legs, and occasionally on the thighs or trunk.After oozing stops, crusts start forming. Later the lesions become dry, scaly and lesserythematous. Sometimes the initial lesions are well-defined. Postinflammatoryhyperpigmentation develops as the lesions subside. Constant rubbing or scratching maylead to hyperpigmentation. Diagnosis: The diagnosis of nummular dermatitis is essentially clinical. There areno diagnostic tests. 58
    • Conceptual Study Differential Diagnosis of nummular eczema: Atopic dermatitis, allergic contact dermatitis, irritant contact dermatitis,polymorphous light eruption, psoriasis, tinea corporis, autoeczematization, mycosisfungoides, small plaque parapsoriasis. The above classification of Differential Diagnosis shows common nummularappearing lesions. In atopic infants and children with atopic dermatitis, discoid lesions ofeczema are seen but a personal and family history of atopy and other clinical features ofatopic dermatitis help to differentiate it. Allergic contact dermatitis lesions are notusually round and are asymmetrical. Irritant contact dermatitis sometimes producesround lesions but a history of irritant contact is helpful. Psoriatic lesions are sometimesround. They are non-itching, but are characterized by typical scaling. Tinea corporislesions are annular and active peripherally. Fungi can be demonstrated by laboratorytests. Autoeczematization or eczematous spread from a focus of eczema (eg-stasisdermatitis on the legs) produces discoid lesions but the history of their evolution and theinitiating condition identifies the process.Cheiro Pompholyx (Dyshidrosis): It is a variant of eczema in which recurrent vesicles or bullae affect the palms andfingers or soles or both. It is characterized by remissions and relapses, which aresometimes provoked by heat, emotional stress or an active fungal infection in the feet. Itis reported that the ingestion of small amount of nickel in susceptible patients may triggeran attack. Repeated attack makes a thick hyperkeratotic skin with deeply set vesicles. Feature: Deep seated vesicles (look like an embedded sage grain), tingling,burning, itching, vesicles become dry within 14 days and subside otherwise becomesinfected.Stasis Eczema (Disseminated Eczema) It usually affects person like teacher, labourer, rickshaw puller, athletes etc. wherethe whole work requires long hours of standing. This causes venous incompetence, whichmay leads to varicose vein with tortuous, dilated veins over the leg and chronic edema,(due to stasis of blood on that leg). It also termed as varicose eczema. Early findings in stasis dermatitis may consist of mild erythema and scaling 59
    • Conceptual Studyassociated with pruritus. The typical initial site of involvement is over the medial aspectof the ankle, often over a distended vein. In later stage lesion become graduallypigmented, due to chronic erythrocyte extravasation leading to cutaneous hemosiderindeposition. In chronic stage dermal fibrosis occur that is clinically recognized as brownyedema of the skin. Stasis dermatitis is often complicated by secondary infection and contactdermatitis. In severe or later stage, the oxygenation of the part is impaired, resulting inthe stasis ulcer. Its margins may develop pseudoepitheliomatous hyperplasia andsubsequent malignant transformation.C) Mixed DermatitisAsteatotic Eczema: Synonyms – Xerotic eczema or winter itch. It is combined type of eczema where both causes i.e. exogenous and endogenous,are present. It is mildly inflammatory variant of dermatitis that develops most commonlyon the lower leg of elderly individuals during dry time of year. Fine cracks with or without erythema, resembling cracks seen in china clay orporcelain characteristically develop on the anterior surface of the lower extremities.Pruritus is variable. Asteatotic eczema responds well to avoidance of irritant, rehydrationof the skin and application of topical emollients. Eczema management has three main goals i.e. Healing the skin and keeping it healthy Preventing flares Treating symptoms when they do occurs First of all identify the exacerbating factors and avoid those circumstances, whichtrigger the skin immune system and the itch-scratch-itch cycle.Skin Care: It is required for perfection of beauty, take daily bath and after it applymoisturized cream immediately. Soap should be avoided, bath oils are not usuallyhelpful, after bath is finished the person should air-dry the skin or pat it to dry gently(avoiding rubbing or brisk drying) and apply a lubricant immediately. Lubrication 60
    • Conceptual Studyrestores the skin moisture and increases the rate of healing and establishes a barrieragainst further drying and irritation. Lotion, have a high water or alcohol content andevaporate more quickly, so they are not the best choice. Cream and ointments work betterat healing the skin. Any preparation should be as free of fragrance and chemical aspossible.Prevention of Eczema: The following suggestion may help to reduce the severity andfrequency of flare-ups. Moisturize frequently Avoid sudden changes in temperature or humidity Avoid sweating or overheating Reduce stress Avoid scratchy material e.g. wool or other irritant Avoid harsh soaps, detergents and solvents Avoid environmental factors, that trigger allergies e.g. pollens, moulds, mites and animal dander. Be aware of any food that may cause an outbreak.Topical Application: Eczema is usually dry and itchy. So, application of lotion or creamis the most common treatment to keep the skin as moist as possible. This treatment isgenerally most effective when applied directly after bathing within 3 minutes so that, themoisture from the bath is “locked in”. Cold compresses applied directly to itchy skin canalso help in relieving itching.Corticosteroid: If the condition persists, worsens or does not improve satisfactorily,another effective treatment is the application of corticosteroid cream or ointments toreduce inflammation.Antibiotics: If infectious eczema or secondary infection occurs in eczema, it may becured with topical and oral antibiotics to kill the bacteria, which causes repeatedinfections.Antihistaminic: Itch is the result of histamine-induced inflammation; so antihistaminicdrugs are useful in severe itching in eczema. 61
    • Conceptual StudyTar treatment and phototherapy: These are also used and can have positive effect,however tar can be messy. Phototherapy requires special equipment (light). Tarpreparations can be very helpful in healing very dry, lichenified area.Cyclosprine A: If eczema is resistant to all modalities (therapy) then this may be used,which modifies immune response. Topical immunomodulators (TIMs): TIMs are topical drugs that modulate theimmune response (after the reactivity of cell – surface immunological responsiveness).One drug in this class-tacrolimus- has been approved by the food and drug administration(FDA) for treatment of moderately severe eczema.Biological Agents: It is a new type of drug based on molecules that occur naturally in thebody like the protein IFN and thymopentin and similar agent are used to reestablishbalance in the immune system.Immunosuppressive drugs: It may help for treating severe cases. 62
    • Conceptual Study UPADRAVA According to Charaka, Upadrava of Kushta are Prasravana, Angabheda, 107Angapatana, Trishna, Jvara, Atisara, Daha, Daurbalya, Arochaka & Avipaka.Vicharchika being a type of Kshudra Kushta, out of these, in Vicharchika Updravas likePrasravana, Daha, Daurbalya, and Arochaka & Avipaka may occur. Arishta lakshanas:According to vagbhata and Bhavaprakasha the person whose body has decayed, eyes arered, voice is destroyed, has mandagni, the body is eaten by maggots, one who is occupiedby trishna and atisara is sure to die by kushta. and who is not doing panchakarmas likevamana, virechana etc.will be killed by kushta.108 UPASHAYA ANUPASHAYA After investigating a disease with the help of nidana, samprapti, purvarupa andrupa, one may still be in doubt in diagnosing the disease and also to adopt the proper lineof treatment. In such cases upashaya and anupashaya will guide us to some extent. The oushadhas, aharas, viharas, which proves to be comfortable or which givesrelief either by acting directly against the cause of the disease, or the disease itself or toboth, are called as upashaya. The opposite of Upashaya, i.e. if the patient feels discomfortby the use of oushadha, ahara and vihara it is called as anupashaya. In our classics, the upashaya anupashaya of vicharchika is not mentioned by theacharyas. The diagnosis of vicharchika can be easily made by the pratyatma lakshanas. However, the causative factors themselves may be taken as anupashaya, as thesemay also act as aggravating factors of the presenting symptoms. 63
    • Conceptual Study SADHYA - ASADHYATA Charakacharya while explaining the sadhya asadhyata of kushta roga says that,ekadosholbana kushta will be sadhya. Even vata kapha prabala kushta is also sadhya. But kapha pittaja and vata pitta prabala kushta is kricchra sadhya vikara. Charakaopines that a weak patient of kushta having all symptoms along with balaheenata, trishna,daha, agnimandya and krimi should be avoided by the physician as it is asadhya.109 Acharya Sushruta says that, the patient who has full control over his sense organsand the vyadhi which has reached only the tvak, rakta and mamsa is sadhya. If thevyadhi reaches medodhatu, it becomes yapya, when it reaches further it is asadhya.110 Acharya Vagbhata mentions that, the doshas will be severely aggravated afterasamyak vamana or virechana. In such condition, kushta chikitsa will be asadhya;therefore the doshas must be eliminated cautiously. Along with this quotation, acharya Vagbhata also gives the same opinion asCharaka and Sushruta. To this he adds one point saying raktaja and mamsaja kushta iskashta sadhya and tvakgata kushta is sadhya.111 When vicharchika presents with kaphapradhanata where in tvak, rakta and mamsa dhatus are involved it is sadhya and when itpresents with vatapitta or vatakapha pradhanta, it is considered as kashtasadhya.PROGNOSISDermatitis and eczema are, as a rule, curable conditions. Eczema are non infective exceptwhen they are impetiginized and of the infective variety. They do not leave scars. Patientneeds reassurance of these points. It must be remembered that epidermis is an ectodermalstructure and so takes time to heal. Energetic treatment, over treatment or ill treatmentmay worsen the condition. Acute eczema heals readily in about 1 to 4 weeks withtreatment; chronic eczema takes a little longer time to disappear. 64
    • Conceptual StudySapeksha Nidana Table No. 12: Sapeksha Nidanas of Vicharchika: Type of Colour Type of lesion Associated Site Kushta symptoms Charaka 112Vicharchika Shyava Pidaka Kandu, Bahusrava Dadru Raga Pidaka Kandu (Mandalaudgatum) Pama Sveta Pidaka Kandu Chiefly on Aruna (Bahu) Sphika, Pani, Shyava Pada Sushruta 113 Sidhma Tanu Akshatakari, Upper part of Kandu body Vipadika Raji, Ruksha Kandu, Daha, Ruja Pada Charmadala - Kandu, Ausha, Hast-Pada Chusha Tala Rakasa Pidaka Kandu, Sravahina Sarva Sharira Vicharchika Raji, Ruksha Kandu, Arti, Ruja Gatra (Pani Pada) 65
    • Conceptual Study CHIKITSA Chikitsa is the kriya which makes the dosha, dhatu and malas to be insamyavastha and in the same time which makes the disease to get cured.114 The primeimportance of chikitsa lies in breaking up of the samprapti. The treatment explained in our classics for kushta in general has the sameapplicability for vicharchika also. In kushta chikitsa, shodhana karma is advised prior toall other types of treatment. When the doshas have aggravated severely, the shodhanatherapy is indicated to eliminate them. Depending upon the dosha pradhanyata,snehapana is indicated in vata pradhana tvak roga, Vamana in shleshmottara andVirechana and Raktamokshana in pittottara tvak roga. Repeated vamana by using kutaja, madanaphala, madhuka, patola, nimba andyashti. Virechana using trivruth, danti, and triphala has to be adopted, mean whilewatching that the patients bala is not getting deteriorated. After shodhana chikitsa,shamanoushadhi of tikta and kashaya dravyas must be administered.115 Acharya Sushrutaadvises the shodhana chikitsa in the purva rupa itself. The Acharyas Vagbhata, Sushruta have stressed the necessity of repeated shodhanain kushta chikitsa. They state that, Vamana must be administered once in every 15 days,virechana must be administered once in every 30 days, nasya must be done once in every3 days and siramokshana to be done once in every 6 months. Acharya Yogaratnakaraalso opines the same, but instead of administration of nasya, acharya has mentioned lepato be done once in every 3 days.116Depending upon the adhishtana of kushta, Acharya Sushruta opines that117a) When kushta lodges in the tvak - Samshodhana and alepana should be done.b) If it enters the rakta dhatu - Shodhana, lepana, kashayapana and raktamokshana should be done.c) If it further enters mamsa dhatu - along with the above procedures, arishtha and mantha should be administered. 66
    • Conceptual Studyd) When the medodhatu is involved - The disease will become yapya Acharya Harita also says that; sveda and alepa must be given in tvakasthakushta. Raktamokshana in raktastha kushta, virechana in mamsastha kushta and kvathapana and pachana in medosthitha kushta.118This principle is adopted for vicharchika also.Considering these points, ‘vicharchika chikitsa’ can be designed in the following manner. In bahudoshavastha when patient is shodhana yogya plan the treatment with thetikta, katu, deepana, snehana, virechana or vamana as suitable, followed byshamanoushadhies including rasayana and bahya chikitsa. The other group who are unfitfor shodhana can be directly planned with shamanoushadhies and bahya chikitsa.Samshodhana : It is a procedure for purification of the body by radical elimination of morbidvitiated Dosha through nearer root. The doshas uprooted by Langhana and Pachana mayget further aggravation but eliminated by Shodhana do not recur.119 Samshodhana meanspurification (Shabdakalpadruma). Synonyms : Cleansing, purifying, cleaning, refining, eradication, removal invarious laxicons. (M. Monier William and Apte). Alpa Dosha may cure with only Langhana, Madhyama Dosha may be cured withLanghana and Pachana but Pravara Dosha only eradicated by Doshavasechana. Kushtabeing Bahudosha (vitiation is in greater extent)120 vyadhi, Tridoshaja Vyadhi121 andTiryaggata (Shakhashrita) Vyadhi.122 All this factors make Kushta “Duschikitsya” Hence, Shodhana is only answer for Kushta, Shodhana acts as Malapaha(uprooting dosha), Rogahara (removing the disease) and Bala Varna Prasadana (normalstrength and colour of body) etc. which is helpful in Kushta.123 Among the differentPurificatory measures raktamokshana is more suitable in kushta. Where Pitta ispredominant, blood letting should be done after purgation.124 Shodhana is indicated in alldhatugata Kushta, specially Raktamokshana is advised in Rakta and Mamsagata Kushtaalong with some medicament.125 67
    • Conceptual study RAKTAMOKSHANA At the outset bloodletting, seems to frighten the patients particularly in the presentera where all the sophisticated measures are available. Raktamokshana not only purifiesthe channels but also lets the other parts become free from disease and action is fasterthan other remedies.126 Charaka has also indicated its efficacy in Raktaja Roga.127 Raktamokshana is formed by two words, Rakta-‘Rang’ or ‘Rage” dhatu with‘Kta’ suffix which means to dye, to colour. Mokshana -“Moksha , Avasun” Dhatu withsuffixed ‘Yu’ which means that to release, to let, to separate, to expel, to drive out, tolive, to pass, to deplete (Amarkosha part II).So combined meaning is that a process inwhich the vitiated blood is expelled out from the body.Classification of Raktamokshana : Various types of Raktamokshana are shrunga, jalauka, alabu, suchi, prachchana,siravedha, vigharshana, ghatiyantra.128Indications of raktamokshana: Kushta, Visarpa, Pidaka, Raktapitta, Asrugdara,Gudapaka, Arbuda, Vidradhi.129Contraindication Of Raktamokshana : Patients of Sarvanga Shotha, Pandu ,Arsha, Udara, Shosha etc.Bala, Vruddha,Ruksha, Kshatakshina, Bhiru, Parishranta, Stri etc. should avoid this procedure.130 Below the age of 16 years and above the 70 years, Asnigdha, Asvedita, Vatarogi,Atisara, Snehapitta etc. are coming under the Rakta Asravya.131 Sharangdhara said that Raktamokshana should not be performed in emptystomach, Murccha, Atinidra, Bhaya, Mada and Vegavarodha state.132 Raktmokshana (Instructions) It should be done according to Aturabala, Rogabala and Ashaya (site of diseases). The blood letting should be done once in a week or performed even 3 – 4 times. For achieving more effect, bleed after 15 days with Snehana and Svedana.133 Season should be neither hot nor cold nor cloudy/windy atmosphere. But in case of emergency Raktamokshana can be done at any time.134 It should be done in Sharad Kala.135 68
    • Conceptual study Quantity of expulsion : According to Charaka, it depends upon the roga-rogi-bala, but it should be performed till the Rakta becomes “Shuddha” (purified).136 According to Sushruta and Vagbhata it should be 1 Prastha – 64 tolas – 16 pala. 1 tola = 12 gm. Uttama Matra 1 Prastha = 768 gm. Madhyama Matra ½ Prashta = 384 gm Adhama matra ¼ Prastha = 192 gm. Samyak Lakshana : Bleeding stop automatically, lightness in the body, freshness in mind and total reduction of diseases etc.137Pathyapathya : After Raktamokshana patients should be given Laghu and DeepaniyaAhara and neither too hot nor too cold.138 Vagbhata added with Snigdha and ShonitaVardhaka Ahara.139 While Mamsa Rasa of deer and goat, milk, Sali rice was advised.Patient should avoid Vyayama, Maithuna, Krodha, Sheeta Snana, Vayu, Shoka,Divasvapna, Kshara, Amla, Lavana ,Katu Ahara .140Jalauka (Medicinal Leech) - Historical Review The history of jalauka begins since Rigveda, kaushika sutra continuing to theBrihatrayees.There is evidence of therapeutic bloodletting among ancient, Egyptians,Aztec, Babylonians and Hindus although the first written records of the practice is foundin the corpus hippocraticum. Among the modern authors, Dr. Apolo 200 B.C. was thefirst physician to describe regarding the leech. Among the four therapies of Unanimedicine aims leeches are explained under the regimental therapy JALAUKA The term Jalauka (leech) may be etymologically interpreted to mean creaturewhose life (Ayu) or whose longevity is depends upon water, whereas the derivativemeaning of the term Jalauka is based upon the fact of their dwelling (“oka” – dwellingplace) in water (Jalam).141SYNONYMS: Jalauka is having various names, which are – Jalayuka, Jalaua, Jaluka, Jalaluka, Jalalauka, Jalita, Jaloka, Jalauga, Jalatani, 69
    • Conceptual studyJalaukas, Jalasuchi, Jalaukasu, Jalasarpini, Raktapata, Ruktapa, Raktapayini, Vanini,Vedhini, Venika.CLASSIFICATION OF JALAUKA: Acharya Sushruta has classified Jalaukas in two main categories:142 1. Savisha (Venomous) 2. Nirvisha (Non-venomous) Each category again includes six varieties of Jalauka.I Savisha JalaukaThe Savisha jalaukas are Krishna, Karbura, Alagarda, Indrayudha, Samudrika,Gochandana. The Savisha jalauka originates in the decomposed urine and fecal matter oftoads and poisonous fishes in ponds of stagnant and turbid water.143 Such types ofjalaukas are having the following characters according to the Ayurvedic texts: Thick inmiddle portion, while both ends are thin, Slow locomotion, Fatigue, Middle partelongated, Delay in sucking, Not commandable type, Sucks little quantity of blood.Features Of Savisha Jalauka Bite: According to Sushruta and Vagbhata if Savisha Jalauka is applied then a personsuffers from Burning, Itching, Swelling, Drowsiness, Fever, Delirium, Unconsciousnesss,Irresistible inclination to scratch the seat of bite, Inflammation, Edema, Boil, Erysipelas,Vitiligo, Vertigo.144Treatment Of Savisha Jalauka Bite: The bite of Indrayudha Jalauka is Asadhya. The Venomous (Savish) Jalauka bitewas considered as Mahagada and Pana, Lepana, Nasya etc. should be performed.2. Nirvisha Jalauka: The Nirvisha jalaukas are Kapila, Pingala, Shankumukhi, Mushika,Pundarikamukhi, Savarika. They originally grow in decomposed vegetable matter, as thepurified stems of the several aquatic plants known as Padma, Utpala, Nalina, Kumuda,Pundarika and common zoophytes, which live in clear water. According to Sushruta, the leeches are found in Yavana (Turkesthana), Pandya 70
    • Conceptual study(south region country – Deccan), Sahya (the tract of land traversed by the Ghatmountains), Pautana (modern Mathura), and etc.145General Characters: Types of Nirvisha Jalauka are characterized by following points: Strong and large bodied, Ready suckers, Greedy (Mahashana), Shyava (Varna), Vrutta (round), Blue coloured lining in dorsal side of the body, back is Kashaya in colour.146 Acharya Vagbhata further classifies the leeches according to sex. Those which aredelicate, having thin skin, small sized head, the lower body being large are femaleJalauka and those with opposite characters i.e. hard skin, big head along with being semilunar in look with large front portion are male. The male Jalaukas are advised in highlyvitiated Dosha and chronic diseases whereas female Jalaukas are advised in Alpa Doshaand acute disorders.147Length Of Jalauka: The maximum length of Jalauka has been reported 18 Anguli, big Jalauka may beused only for blood letting in animals i.e. horse, elephant, etc. For human being 4, 5 and 6Anguli Pramana Jalauka should be preferred.148Collection and Preservation of Leech: Acharya Sushruta has told that the leeches can be caught with a piece of wetleather, in tanks, streams and where there are lotuses. There is another method to collectthe leeches i.e. the fresh meat of dead animals, fish or milk must be applied on the thighof an animal or the human and kept in water for some time. Jalauka will be attracted andwill catch the place. Then remove them from the skin of the person with the applicationof Saindhava (rock salt) and collect.149 Prevention from leech bite at collection: Leeches are best removed with a fewdrop of briny alcohol or strong vinegar. Wearing knee high waterproof leather boot andclosely woven trousers in leech-infested area can reduce their incidents.Time Of Collection: Acharya Dalhana has mentioned that the best time for collectingleeches is Sharad Ritu (Autumn).Preservation of Leeches: After collecting the leeches, they should be kept in a wide and 71
    • Conceptual studynew earthen pot. The pure water of tank with lotus should be filled into the pot. Feed itwith leaf of lotus plants (Kamala Nala), Shaivala etc., the meat of pig and other animals,which are living in watery and marshy areas, and powder of stem of small plants. Onevery third day the water should be changed and feeding should be dropped inside thepot. After seven days the pot should be changed. Vagbhata mentioned that the pot shouldbe changed every five days. Poisonous leeches must be thrown out.150Indications of Jalaukavacharana: Only Vagbhata has mentioned diseases where Jalaukavacharana is indicated viz. –Gulma, Arsha, Vidradhi, Kushta, Vatarakta, Galaroga, Netra Roga, Visha Dansha andVisarpa.151 Acharya Sushruta has advocated Raktamokshana by Jalauka specially to king,rich people, children, old aged, coward, weak, females and delicate people.152Contraindication of Raktamokshana can be considered as contraindication ofJalaukavacharana.Species: Hirudo Medicinalis (Medicinal Leech) The body is about 5 – 10 cm long and dorsoventrally flattened with serratemargins and about 95 annuli. The color is yellowish brown It can stretch up to 20 – 30cm and is capable of ingesting a large quantity of blood.Leech Constituent: Each leech will feed for 30 minutes to an hour removing around 20ml of bloodbefore falling off, although bleeding from the wound afterwards can results in a bloodloss of ten times this amounts. The therapeutic effect is released not only by the loss ofblood but also by the secretions, which the leech emits in to the wound. Hirudin: The drug as a systemic anti-coagulant free of some of heparin’s side effects. It is also termed as anti-coagulin by inhibiting the cleavage by thrombine of fibrinogen and a synthetic tripeptide substance. Thus, continuous bleeding from wound made by leeches occurs for a long time even after the leech has detached itself. It keeps the wound opened for the approximately 30 minutes for the sucking act and keeps the blood fluidy.It also works as diuretic and antibiotic. Calin: It also prevents the blood coagulation. 72
    • Conceptual study Destabilase: It also completely blocks the spontaneous aggregation of human platelet. It also ensures the protective antithrombotic effect. A human blood plasma kallikrein inhibitor: It is capable of blocking the amidolytic activity of the enzymes in an irreversible manner and also suppresses the kininogenesis activities of kallikerein (Article in Russia). Hyaluronidase: It is “spreading factor” that ensures that the other active substances which are active at the bitten areas can be spread. (Article in Russia) An anaesthetic substance leads to pain insensitivity (analgesic effect) when sucking or such pain killer chemical, which stops you from feeling of bite.ADVANTAGES OF LEECHES Today, systemic bloodletting is restricted to a few limited conditions includingpolycythemia and haemochromatosis but this therapy is a special form of small bloodletting. It has always proven its miraculous effect in the field of medicine time to time. In the failure of adequate venous return from a graft, Leeches are now regularly used in such cases to keep the blood oozing into the tissue until the venous congestion is relieved and normal venous drainage of the graft can develop properly. Leech therapy may be an effective therapy for rapid reduction of pain associated with osteo- arthritis of the knee Leeches are anti-phlogistic, used for the local obstruction of the blood. They are used in acute inflammation, abscess, boils, in bruises, sprains and blows.153A medicinal leech can once bite, victims can bleed for hours, allowing oxygenated blood to enter the wound area until vein re-grows and regain circulation. The leech saliva has helped in degradation of fibrinogen, inhibition of factor XIIIa and lysis of fibrin clots. LIMITATIONS AND SOLUTIONSThere is a significant risk of infections, particularly in those procedures where thevascularity of the tissues is compromised. Hirudo medicinalis has an endosymbioticbacterium almost 20% of infectious complications seen after leech therapyPseudolymphomas are rare but not worthy side effect of medicinal leech therapy.(Journal of the American Academy of Dermatology – 2002) Historical account warns of the transmission of syphilis, AIDS, hepatitis, after the re- 73
    • Conceptual study application of leeches used on infected patients. So leeches should be used only once after which they should be disposed away. More recently, Aeromonas, hydrophilia, the leech’s Natural gut flora has been isolated from wound infections after leech treatment. So, proper prophylactic antibiotic should be provided before the leech application. The leech therapy may not be used in case of – o Haemorrhagic diathesis (haemophilia) o Arterial diseases and the modifications in the capillaries in case of diabetes (diabetic micro-angiopathy). COMPLICATIONS The histamine emitted by the leech can lead to allergic reactions immediately or within few days. Soreness (erysipel) after the bite rarely appears. A small scar at the bitten area may remain for weeks. A plaster allergy is more often found after a treatment with leeches, therefore it is advisable to use skin preserving, hypoallergen plasters.Thus, it is very much true till today that – The clinician who knows all about the leeches, habitat and their method ofcollection, varieties, storage and method of application is successful in treating thediseases amenable to them.154In our classics many yogas have been described as Sarvakushtahara, which can be actingwell even on vicharchika. The yogas pertaining to vicharchika are enlisted as below.GRITHAS1) Tikta shatphala gritha C.S, Y.R2) Pancha tiktaka gritha Y.R3) Maha tiktaka gritha C.S, Y.R4) Maha khadira gritha C.S, Y.R 74
    • Conceptual study5) Guggulu panchatiktaka gritha A.H, B.R6) Nimbadi gritha H.S7) Neeligritha Vang, G.N.KVATHAS1) Nava kashaya C.D, B.R, Y.R2) Patoladi kvatha G.N3) Guduchyadi kvatha Y.R4) Aragvadhadi kvatha H.S.5) Haridradi kashaya G.N6) Manjishtadya maha kashaya G.N7) Khadirasara kashaya Kalyan.8) Khadirodaka Y.RCHOORNAS1) Panchanimba choorna Y.R.2) Patolyadi choorna G.N3) Pashupathi Choorna G.N4) Navayasa Choorna Sha.S5) Shashanka lekhadi Choorna C.DGUTIKAS1) Sarvanga sundari Gutika Y.R2) Ekavimshatiko guggulu B.P, Y.R.3) Triphala modaka Y.R4) Haridradi Vatika G.N5) Pathyadi gutika C.DRASAYOGAS1) Talakeshvara rasa B.P2) Kushta Kuthara rasa R.R.S 75
    • Conceptual study3) Dhanvantari rasa R.R.S4) Nagarjuna vati R.R.S5) Udayabhaskara rasa B.RASAVA ARISHTA1) Madhvasava C.S2) Triphalasava C.S3) Khadirakalpa B.STAILAS1) Arkadi taila BR, Sha.S, G.N, BP2) Visha taila Y.R, G.N3) Haridradi taila H.S4) Doorvadya taila C.D, G.N5) Mahasindooradya taila C.D, G.N,6) Manjishtadya taila Y.R7) Vajra taila Y.R, C.D8) Trina taila C.D, G.N9) Chitrakadi taila Y.R10) Kushtadya taila C.S11) Shveta Karveeradya taila C.SLEPAS1) Pakva sarshapapralepa C.D2) Gandha pishtika lepa R.S.S3) Manahshiladi lepa C.D4) Vishadi pralepa C.D5) Aragvadha dala pishtalepa B.R.6) Edagajadi lepa C.D, B.R., C.S 76
    • Conceptual Study PATHYA - APATHYA Many of the allergic reactions in people observed in recent days are caused orexacerbated by foods not agreeing with them. The food regimen plays a vital role in thehuman body. The proper administration of it promotes the health and its abuse leads todisease. In our classics, this phenomenon is implied to pathya apathya. Here pathyaapathya is told for both ahara and vihara. Our acharyas have not dealt with precisepathya - apathya of vicharchika separately. So, the pathya apathya explained underkushta can be considered here also.Pathya Ahara and vihara In tvak vikara, the pathya aharas are, green gram, barley, puranashali, yava,godhuma, koradoosha, mudga, masoora, adhaka, priyangu, jangala mamsarasa, tiktashakhas like Vasa, Patola, Nimba, Punarnava, Mandukaparni, Arka, Aragvadha, Bakuchi,Bhallataka Khadira and Triphala, leaves of nimba, mudga, nagakeshara, keshara, oils ofsarshapa & tila, vegetables like vasa, guduchi, shunthi, arkapushpi are to be consumed.155Apathya Ahara and vihara The apathya aharas are adhika amla, lavana , dadhi, dugdha, guda, tila, masha,nishpava, kulatha, vrintaka, anoopa mamsa and matsya sevana, madya, ikshurasa andheavy food items. Divasvapna, alcoholic drinks and vyavaya have to be avoided.156 77
    • Conceptual Study DRUG REVIEW-1) Udayabhaskara rasa157Shudha Tamrabhasma 10 partsMaricha 2 partsShudha Vatsanabha 2 partsDose - ½ to 1 rattiIndications – galita kushta, sphutita kushta, vipula mandala kushta, vicharchika, dadru,pama, all types of kushtas.Maricha158Botanical names- Piper nigrumFamily- PiperaceaeProperties – Rasa- katu Guna- laghu, tikshna, snigdha Virya – anushna Vipaka- madhura Doshaghnata- Kaphavatahara Karma- dipana, pramathi, rasayana, jvara, kushta, shula, agnivardhana,krimi.Vatsanabha159Botanical Name – Aconitum FeroxFamily – RanunculaceaeProperties- Rasa- madhura Guna- laghu, ruksha, tikshna, vyavayi, vikasi Virya – ushna Vipaka – madhura Doshaghnata - kaphavatashamaka 78
    • Conceptual Study Karma – vatakaphahara, jvarahara, kushtaghna, shothaghna, Agnimandya, apachi Prabhava- rasayanaTamra bhasma160Adverse effects of ashodhita tamra- impure copper if used internally afflict complexion& causes vomiting, giddiness, burning sensation, depletion of tissue elements, diarrhoea& fainting.Properties- Rasa- tikta, kashaya Guna- tikshna, sukshma Vipaka- madhura Virya- ushna Doshaghnata - pittakaphahara Karma - jathararoga, kushtaharaDose – 125 mg BD (empty stomach)Anupana – honey.(3) Arkadi taila161Sarshapa tailaArka patra svarasaHaridra kalkaSarshapa162Botanical Name – Brassica CampestrisFamily – CruciferaeProperties – rasa – katu, tikta Guna – laghu, ruksha, tikshna Virya – ushna Vipaka – katu Doshaghnata – kaphavatanashaka Karma – kandu, kushta, krimi. 79
    • Conceptual StudyArka163Botanical name – Calotropis giganteaFamily – AsclepiadaceaeProperties – Rasa – katu, tikta Guna – laghu, ruksha, tikshna Virya – ushna Vipaka – katu Doshaghnata- kaphavatanashaka Karma –vishaghna, dipana, kandu, vrana, krimi, kushta, shvayathu.Haridra164 –Botanical name – Curcuma longaFamily – ZinzeberaceaeProperties – Rasa – katu, tikta Guna – laghu, ruksha, ushna Virya – ushna Vipaka – katu Doshaghnata - kaphapittanashaka Karma – kaphavatahara, lekhana, vishaghna, varnya.Indications – krimi, vrana, varnya, tvagdosha, 80
    • Methodology MATERIALS & METHODSAims of Study: • To carry out a comprehensive literary study on Vicharchika with parlance of Eczema. • To evaluate the total effect of jalaukavacharana, oral medication with Udayabhaskara Rasa and topical application of arkadi taila in Vicharchika.Source of data: Minimum 20 patients diagnosed as vicharchika in OPD and IPD of S.D.M. Ayurvedic Hospital, Udupi were taken for study. Inclusion criteria: 1) Patients showing pratyatma lakshanas of vicharchika like pidaka, kandu, bahu srava and shyava varna 2) Patients between age group of 16 to 60 years. 3) Patients fit for jalaukavacharana. Exclusion criteria: 1. Patients with any other systemic illness like diabetes mellitus. 2. Patients suffering from other allergic manifestations like bronchial asthma. 3. Patients unfit for raktamokshana 4. Patients on corticosteroid treatment Design: The 20 selected patients were subjected to single blind; pre-test and post-test design clinical study. A special proforma was prepared incorporating all points of history taking, physical examination and laboratory investigations, accordingly the selected patients were subjected to detailed clinical history as well as complete physical examination. 81
    • Methodology Random selection of the patients was made for this study irrespective of their gender, caste or creed. Investigations:- • Hematological routine investigations: Hb, TC, DC, ESR, • Fasting and random blood sugar when necessary were conducted, Interventions: - All 20 patients selected for the study were subjected to jalaukavacharana in the beginning at the site of lesion. This was followed by oral administration of udayabhaskara rasa in a dose of 250 mg tid for 30 days. During this period external application of arkadi taila was also carried out twice a day so that the lesions were completely anointed with the taila.Jalaukavacharana Purva Karma: The leeches were taken out of their receptacles and sprinkled over with watersaturated with pasted turmeric. Then for a moment (Muhurta) they were kept in a pot ortank full of water, till they regain their natural vivacity and freshness (Vigataklama).Once they were free from natural urges (Muktapurisha) they were applied to the affectedpart.Pradhana Karma: Jalauka were held with small, white, wet cloth, gauze or cotton by covering its mouth.If Jalauka is not able to stick to the desired spot, the affected part was sprinkled over withdrop of milk or blood or ghee or butter or slight incision was made into the lesion. After all efforts, if Jalauka didn’t hold at the desired spot, other fresh leeches wereapplied. After application of Jalauka, their body was covered with a piece of thin and wetlinen or with a piece of white cotton. To confirm that the leech has started sucking blood, the mouth of leeches assumingthe shape of a horseshoe and the raised and arched position made after the attachment tothe seat of the lesion (Aswakhuravata Ananam, Unnamya Va Skandham) was looked for.While sucking, the leeches were covered with a piece of linen and constantly sprinkledover with cold water. Jalauka sucks vitiated blood.165 A sensation of itching and pain at the seat of the application indicates that freshblood is being sucked, so the leeches were removed. 82
    • Methodology If leeches refuse to fall off after the production of the desired effect or catches theaffected part out of their fondness for the smell of blood or due to their greed (Laulya)should be sprinkled with the dust of powdered Saindhava (rock salt).Paschat Karma: After falling off, the leeches were dusted over with rice powder and their mouthlubricated with a composition of oil and common salt. Then they were held at the tail-end with the thumb and the fore finger of the lefthand and their backs gently rubbed with the same finger of the right hand from tail to themouth with a view to make them vomit or eject the full quantity of blood, they hadsucked from the seat of disease. The process was continued until they manifest the fullest symptom of disgorging.Leeches, that had vomited the entire quantity of blood sucked as above, would brisklymove in quest of food if placed in water, while the contrary should be inferred from theirlying dull and inert. Leeches not made to emit the entire quantity of the sucked bloodstand in danger of being attacked with an incurable disease particular to their genuswhich is known as Indramada.166 The leeches were then put into a new pitcher and treated as before, after they hadfully vomited the sucked blood. Used leech should be restricted for reuse at least 7days167. An ulcer wound incidental to an application of leech was rubbed with honey orwashed with spray of cold water or bound up with an astringent (Kashaya), sweet andcooling plaster, according to the quantity of blood removed from the part. In case of full and proper bleeding (Samyak Yoga) the wound was rubbed with Shatadhauta (Literary: 100 times washed) Ghritam, or a piece of cotton, soaked in the same substance, applied as a compressor over the part. The wound should be rubbed with honey in case of insufficient bleeding while it should be washed with copious quantity of cold water if extensive bleeding (Atiyoga) sets in. Similarly in cases marked by the absence of any bleeding (Mithya yoga) a sour, sweet and cooling plaster should be applied over the wound.168 83
    • MethodologyASSESSMENT CRITERIA: The pratyatma lakshanas of vicharchika like kandu, pidaka and bahu Srava, daha,raji, vaivarnya and rukshata were graded and assessed accordingly. Patients wereexamined for the change in the symptoms on 1st, 2nd, 3rd, 7th, 14th, 21st, & 30th day oftreatment and then results were analyzed by using paired ‘t’ test.Kandu (Itching) No itching 0 Often mild type of itching (once/twice in a day) 1 Moderate itching along with moderate itching episode (once/twice in a 2 day). Moderate itching along with severe itching episode (three to four times in 3 a day) Severe itching episode more than 5 times a day even night and blood spot 4 came out.Daha (Burning sensation) No burning sensation even after rubbing 0 Mild type of burning sensation, sometime and not disturbing normal 1 activity. After mild type of burning sensation 2 Severe burning sensation disturbing normal activity 3Srava (Discharge) No discharge 0 Moisture on the skin lesion 1 Weeping from the skin lesion 2 Weeping from the skin lesion followed by crusting 3Rukshata (Dryness/Roughness) No dryness 0 Dryness with rough skin (Ruksha) 1 Dryness with scaling (Khara) 2 Dryness with cracking (Parusha) 3 84
    • MethodologyPidaka (Eruption) No eruption in the lesion 0 Scanty eruption in few lesion 1 Scanty eruption in at least half of the lesion 2 All the lesions full of eruption 3Vaivarnya (Discolouration) Nearly normal skin color 0 Brownish red discoloration 1 Blackish red discoloration 2 Blackish discoloration 3Raji (Thickening Of Skin) No thickening of the skin 0 Thickening of the skin but no criss-cross marking 1 Thickening of skin with criss-cross marking 2 Severe lichenification 3Criteria for Overall Effect Of Therapy• Complete Remission: 100% relief in the sign and symptoms with plain skin surface and significant changes in color of the affected skin lesion toward normal were considered as complete remission.• Marked Improvement: More than 75% relief in the sign and symptoms were recorded as marked improvement with marked improvement in pigmentation and thickening of the skin.• Moderate Improvement: 50 – 74% relief in sign and symptoms were considered as moderately improved with moderate improvement in pigmentation and thickening of the skin.• Improvement: Patients showing improvement in between 25 – 50% in sign and symptoms with slight improvement of pigmentation and thickening of the skin was taken as improvement.• Unchanged: Below 25% relief in sign and symptoms was considered as unchanged. 85
    • Observations OBSERVATIONS The following observations were made during this study. Observationswere made before the treatment, during the treatment and after the treatment. In thepresent study, 20 patients fulfilling the inclusion criteria of Vicharchika were studied.Following pages contain the descriptive statistical analysis of the patients studied alongwith the observations as listed below.Incidence observation: As per the prepared proforma, observations were made regarding the incidence ofAge, Sex, Occupation, Religion, Socio-economic status, marital status, Habitat, Dietfactors.Distribution of 20 patients according to different Age group: In this study it was found that the incidence was highest in the age group of 31-40years and 41-50 years each constituting 20% of total number of patients. The incidence ofother age groups is shown in the table below.Table No 13: Incidence of Age: Age (in years) No of patients % 16-20 3 15% 21-30 6 30% 31-40 5 25% 41-50 4 20% 51-60 2 10%Graph No 5: Incidence of Age: 6 5 4 No. of Patients 3 2 1 16-20 21-30 31-40 41-50 51-60 Age of Patients 86
    • ObservationsDistribution of Sex of 20 patients: In the sample taken for the study, 70% were males in comparison to 30% offemales.Table No 14: Incidence of Sex:Sex No of patients %Male (M) 14 70%Female (F) 6 30%Graph No 6: Incidence of Sex: 14 12 10 No. of 8 Patients 6 4 2 0 M F Sex of Patients 87
    • ObservationsDistribution of 20 patients according to Occupation: Maximum number of patients were Students (30%), 20% were Agriculturists. Theincidence of other occupation is shown in the table below.Table No 15: Incidence of Occupation:Occupation No of patients %Student (S) 6 30%Business (B) 3 15%Housewife (H) 2 10%Professional (P) 2 10%Agriculture (A) 4 20%Others (O) 3 15%Graph No 7: Incidence of Occupation: 6 5 4 No. of Patients 3 2 1 0 S B H P A O Occupation 88
    • ObservationsDistrubution of 20 patients according to Marital Status: Majority of patients were unmarried (45%) and 30% were married. The otherincidence of marital status is given in table below.Table No 16: Incidence of Marital status:Marital status No of patients %Married (M) 7 35Unmarried (UM) 9 45%Divorce (D) 1 5%Widow/widower (W) 3 15%Graph No 8: Incidence of Marital status: 9 8 7 6 No. of 5 Patients 4 3 2 1 0 M UM D W Marital status 89
    • ObservationsDistribution of 20 patients according to Religion: 65% patients were Hindus, 5% were Muslims and 15% were Christians.Table No 17: Incidence of Religion:Religion No of patients %Hindu (H) 13 65%Muslim (M) 1 5%Christian (C) 3 15%Others (O) 3 15%Graph No 9: Incidence of Religion: 14 12 10 No. of 8 Patients 6 4 2 0 H M C O Religion 90
    • ObservationsDistribution of 20 patients according to Socio- economic status: Majority of patients belonged to the Middle middle class (35%), 15% each werein lower middle class, upper middle class and rich class. The other incidence of socio-economic status is given in table below.Table No 18: Incidence of Socio-economic status:Socio-economic status No of patients %Very Poor (VP) 2 10%Poor (P) 4 17%Lower middle class (LM) 7 29%Middle class (M) 3 12%Upper middle class (UM) 5 21%Rich (R) 5 21%Graph No 10: Incidence of Socio-economic status: 8 6 no. of patients 4 2 0 VP P LM M U R socio-economic status 91
    • ObservationsDistrubution of 20 patients according to Educational status: Majority of patients were found in graduate class and in primary education class(33% each) and 25% were found in secondary education class.Table No 19: Incidence of Educational status:Education No of patients %Illiterates (I) 4 20%Primary school (P) 3 15%Middle school (M) 5 25%Higher secondary (HS) 4 20%Graduation (G) 2 10%Post-graduation (PG) 2 10%Graph No 11: Incidence of Educational status: 25 20 15 Percent 10 5 0 I P M HS G PG Education 92
    • ObservationsDistribution of 20 patients according to Habitat: 75% of the patients in this study were from urban area and 25% were from ruralarea.Table No 20: Incidence of Habitat-I:Habitat No of patients %Sadharana (S) 2 10%Anupa (A) 18 90%Jangala (J) 0 0%Graph No 12: Incidence of Habitat-I: 18 16 14 12 No. of 10 Patients 8 6 4 2 0 S A J Habitat of Patients 93
    • ObservationsTable No. 21: Incidence of Habitat-II:Habitat No of patients %Urban (U) 11 55%Rural (R) 9 45%Graph No. 13: Incidence of Habitat-II: 12 10 8 No. of Patients 6 4 2 0 U R Habitat 94
    • ObservationsDistribution of patients according to Ahara: 35% patients had vegetarian diet and 65% had mixed diet.Table No 22: Incidence of Ahara:Ahara No of patients %Vegetarian (V) 7 35%Mixed (M) 13 65%Graph No 14: Incidence of Ahara: 14 12 10 No. of 8 Patients 6 4 2 0 V M Ahara 95
    • ObservationsDistribution of patients according to Vyasana: 55% patients were not addicted to any habits. The incidence of otheraddiction is shown in the table below.Table No 23: Incidence of Vyasana:Habit No of patients %Smoking (S) 3 15Alcohol (A) 2 10Snuff (Sn) 1 5Tobacco (T) 1 5Pan & gutkha (O) 2 10None 11 55Graph No 15: Incidence of Vyasana: 12 10 8 No. of 6 Patients 4 2 0 S A SN T O N Vyasana 96
    • ObservationsDistribution of patients according to Prakruti: A majority of patients belonged to Pitta Prakruti (25%) and 20% belonged to eachof Vaata and vatapitta Prakruti. The details of other incidence are tabulated below.Table No 24: Incidence of Prakruti:Prakruti No of patients %Vaata (V) 4 20%Pitta (P) 5 25%Kapha (K) 3 15%VaataPitta (VP) 4 20%VaataKapha (VK) 2 10%PittaKapha (PK) 2 10%VaataPittaKapha (VPK) 0 0%Graph No 16: Incidence of Prakruti: 25 20 15 Percentage 10 5 0 V P K VP VK PK VPK Prakruti 97
    • ObservationsDistribution of patients according to Sara: 30% patients were found in pravara Saara, 45% were found as madhyama Saaraand remaining 25%were found in avara Saara.Table No 25: Incidence of Sara:Saaratah No of patients %Pravara (P) 6 30%Madhyama (M) 9 45%Avara (A) 5 25%Graph No 17: Incidence of Sara: 9 8 7 6 No. of 5 Patients 4 3 2 1 0 P M A Saara of Patients 98
    • ObservationsDistribution of patients according to Samhanana: 6% Patients were of Avara Samhanana, 9% were of Madhyama Samhanana and5% were of Pravara Samhanana.Table No 26: Incidence of Samhanana:Samhanana No of patients %Pravara (P) 5 25%Madhyama (M) 9 45%Avara (A) 6 30%Graph No 18: Incidence of Samhanana: 9 8 7 6 No. of 5 Patients 4 3 2 1 0 P M A Samhanana of Patients 99
    • ObservationsDistribution of patients according to Satmya: Analysis of Saatmya revealed that 30% were Avara Satmya, 55% were ofMadhyama Saatmya and 15% were of Pravara Saatmya.Table No 27: Incidence of Satmya:Satmya No of patients %Pravara (P) 3 15%Madhyama (M) 11 55%Avara (A) 6 30%Graph No 19: Incidence of Satmya: 12 10 8 No. of 6 Patients 4 2 0 P M A Satmya of Patients 100
    • ObservationsDistribution of patients according to their Satva: The analysis of satva revealed 15% had Avara Satwa, 70% had Madhyama Satvaand 15% had Pravara Satva.Table No 28: Incidence of Satva:Satvatah No of patients %Pravara (P) 3 15%Madhyama (M) 14 70%Avara (A) 3 15%Graph No 20: Incidence of Satva: 14 12 10 No. of 8 Patients 6 4 2 0 P M A Satwa of Patients 101
    • ObservationsDistribution of patients according to Ahara- Abhyavaharana Shakti: 15% Patients had Avara-Abhyavarana Shakti, 60% had Madhyama-Abhyavaharana Shakti and 25% had Pravara- Abhyavaharana Shakti.Table No 29: Incidence of Ahara- Abhyavaharana Shakti:Aahaara-Abhyavaharana sakti No of patients %Pravara (P) 5 25%Madhyama (M) 12 60%Avara (A) 3 15%Graph No 21: Incidence of Ahara- Abhyavaharana Shakti: 12 10 8 No. of 6 Patients 4 2 0 P M A Ahara-Abhyavarana Shakti 102
    • ObservationsDistribution of patients according to Aahara-Jarana shakti: 3% of the Patients had Pravara- Jarana Shakti, 14% had Madhyama- Jarana Shaktiand 3% had Avara-Jarana Shakti.Table No 30: Incidence of Ahara-Jarana Shakti:Ahara- Jarana Sakti No of patients %Pravara (P) 3 15%Madhyama (M) 14 70%Avara (A) 3 15%Graph No 22: Incidence of Aahara-Jarana Shakti: 14 12 10 No. of 8 Patients 6 4 2 0 P M A Ahara-Jarana Shakti 103
    • ObservationsDistribution of patients according to Vyayama Shakti: 25% 0f the Patients had Pravara Vyayama Shakti, 60% had Madhyama VyayamaShakti and 15% had Avara Vyayama Shakti.Table No 31: Incidence of Vyayama ShaktiVyayama Shaktitah No of patients %Pravara (P) 5 25%Madhyama (M) 12 60%Avara (A) 3 15%Graph No 23: Incidence of Vyayama Shakti 12 10 8 No. of 6 Patients 4 2 0 P M A Vyayama Shakti 104
    • ObservationsDistribution of patients according to Vaya: 45% of the Patients were Bala, 55% were Madhyama and no Vriddha Patientswere registered.Table No 32: Incidence of Vaya:Vayatah No of patients %Bala (B) 9 45%Madhyama (M) 11 55%Vriddha (V) 0 0%Graph No 24: Incidence of Vaya: 12 10 8 No. of 6 Patients 4 2 0 B M V Vaya of Patients 105
    • ObservationsDistribution of Patients according to Nidana: The analysis of Nidanas reveals that 30% of the Patients consumed MithyaAhara, 20% consumed Viruddha Ahara. The detail of the remaining Nidanas is tabulatedin the following table.Table No. 33: Incidence of Nidana:Nidanas No. Of % PatientsA) Aharaja1) Virudha (VA) 4 20%2) Mithya (MA) 6 30%B) Viharaja1) Mithya (MV) 3 15%2) Vegavidharana (VV) 4 20%3) Panchakarmapchari (PV) 1 5%C) Acharaja (Ac) 2 10%Graph No. 25: Incidence of Nidana: 6 5 4 No. of 3 Patients 2 1 0 VA MA MV VV PV Ac Nidanas 106
    • ObservationsDistribution of patients according to Symptamatology: The symptoms Kandu, Pidaka and Vaivarnya were observed in all the patients(100%), Rukshataa in 40% of patients and Bahusrava and Daha were found in 35% ofpatients. The symptom Raji was not registered in any of the Patients.Table No 34: Incidence of Symptomatology:Symptamatalogy No of patients % of patientsKandu (K) 20 100%Pidaka (P) 20 100%Vaivarnya (V) 20 100%Bahusrava (B) 7 35%Daha (D) 7 35%Raji (R) 0 0%Rukshata (Ru) 8 40% Graph No 26: Incidence of Symptomatology: 20 18 16 14 No. of 12 10 Patients 8 6 4 2 0 K P V B D R Ru Symptoms 107
    • Results RESULTSEffect on Kandu: The effect of shodhana and shamana on Kandu before and after the treatmentin 20 patients is given below. Statistical analysis revealed that the mean Kandu score ofVicharchika, which was 2.800 before the treatment was reduced to 1.700 after thetreatment and this change that occurred with the treatment, is statistically highlysignificant (P<0.001). Further details with standard deviation, standard error of mean, ‘t’value, P value is given below.Table No 35: Effect on Kandu (add ±SD to bt and at in bracket) Mean Difference Paired ‘t’ Test in MeansBT AT S.D. S.E.M ‘t’ P2.800 1.700 1.100 1.585 0.363 3.030 <0.001(±1.196) (±0.590)Table No 36: Effect on Severity of Kandu during the course of treatment. Mean score BT AT Day 1 Day 7 Day 14 Day 21 Day 30 2.80 2.75 2.65 2.15 1.70 (±1.196) (±0.046) (±0.119) (±0.110) (±0.590)Graph No. 27: Effect on severity of Kandu during the course of treatment 3 2.8 2.75 2.65 2.5 2.15 2 Mean 1.7 1.5 1 0.5 0 D1 D7 D14 D21 D30 No. of Days 108
    • Results Effect on Pidaka: As revealed by the statistical analysis, the improvement in symptom Pidakabefore and after the treatment with shodhana and shamana are given below. The meanscore observed in Pidaka before the treatment was 2.050, which reduced to 1.000 afterthe treatment. This remission of the symptom after the treatment is statistically highlysignificant (P<0.001). Particulars of statistics are given below.Table No 37: Effect on Pidaka: Mean Difference Paired ‘t’ Test in MeansBT AT S.D. S.E.M ‘t’ P2.050 1.000 1.050 1.356 0.311 3.376 <0.001(±0.786) (±0.360)Table No 38: Effect on Severity of Pidaka during the course of treatment: Mean score BT AT Day 1 Day 7 Day 14 Day 21 Day 30 2.05 2.30 1.65 1.65 1.00 (±0.786) (±0.029) (±0.052) (±0.052) (±0.360)Graph No. 28: Effect on severity of Pidaka during the course of treatment 2.5 2.3 2 2.05 1.65 1.65 1.5 Mean 1 1 0.5 0 D1 D7 D14 D21 D30 No. of Days 109
    • Results Effect on Vaivarnya: The severity of Vaivarnya was assessed before and after thetreatment. Statistical analysis revealed that the mean Vaivarnya score, which was 2.200before the treatment, came down to 1.000 after the treatment and this change isstatistically highly significant (P<0.001). The Particulars of statistical values are tabledbelow.Table No 39: Effect on Vaivarnya: Mean Difference Paired ‘t’ Test in MeansBT AT S.D. S.E.M ‘t’ P2.200 1.000 1.200 1.585 0.363 3.305 <0.001(±1.585) (±0.960)Table No 40: Effect on Severity of Vaivarnya during the course of treatment Mean score BT AT Day 1 Day 7 Day 14 Day 21 Day 30 2.20 2.40 2.20 1.80 1.00 (±1.585) (±0.031) (±0.086) (±0.113) (±0.960)Graph No. 29: Effect on severity of Vaivarnya during the course of treatment 3 2.5 2.4 2.2 2 2 1.8 Mean 1.5 1 1 0.5 0 D1 D7 D14 D21 D30 No. of Days 110
    • ResultsEffect on Bahusrava: The mean score in Bahusrava before the treatment was 0.800, whichreduced to 0.010 after the treatment, and this change is statistically highly significant(P<0.001). The particulars are tabled below.Table No 41: Effect on Severity of Bahusrava during the course of treatment Mean score BT AT Day 1 Day 7 Day 14 Day 21 Day 30 0.80 0.75 0.45 0.35 0.010 (±1.152) (±0.002) (±0.018) (±0.024) (±0.490)Graph No. 30: Effect on severity of Bahusrava during the course of treatment 1 0.8 0.8 0.75 0.6 Mean 0.4 0.45 0.35 0.2 0 0.01 D1 D7 D14 D21 D30 No. of Days 111
    • ResultsEffect on Daha: With regard to the symptom Daha in patients of Vicharchika, statisticalanalysis revealed that the mean Daha score which was 0.80 before the treatment camedown to 0.001 after the treatment and this change is statistically highly significant (P <0.001) the particulars of statistical values are tabled below.Table No 42: Effect on Severity of Daha during the course of treatment Mean score BT AT Day 1 Day 7 Day 14 Day 21 Day 30 0.80 0.80 0.55 0.35 0.001 (±1.196) (±1.196) (±0.010) (±0.024) (±0.308)Figure No. 31: Effect on severity of Daha during the course of treatment 1 0.8 0.8 0.8 0.6 Mean 0.55 0.4 0.35 0.2 0 0.001 D1 D7 D14 D21 D30 No. of Days 112
    • ResultsEffect on Rukshata: According to Statistics, the improvement in symptom Rukshata before and afterthe treatment is given below, the mean score observed before the treatment was 1.050,which reduced to 0.30 after the treatment, which is statistically highly significant.(P<0.001).Table No. 43: Effect on severity of Rukshata during the course of treatment Mean score BT AT Day 1 Day 7 Day 14 Day 21 Day 30 1.05 1.00 0.70 0.45 0.30 (±1.395) (±0.047) (±0.012) (±0.035) (±0.470)Figure No. 32: Effect on severity of Rukshata during the course of treatment 1.2 1.05 1 1 0.8 0.7 Mean 0.6 0.45 0.4 0.3 0.2 0 D1 D7 D14 D21 D30 No. of Days 113
    • ResultsTable No. 44: Over all Effect of the treatment:Effect No. of Patients %Complete remission (CR) 5 25%Marked improvement (Ma I) 2 10%Moderate improvement (Mo I) 5 25%Mild improvement (Mi I) 7 35%Unchanged (U) 1 5%Graph No. 33: Overall Effect of the Treatment 35 30 25 20 Percent 15 10 5 0 CR Ma I Mo I Mi I U Overall Effect 114
    • Discussion DISCUSSIONAny hypothesis becomes a principle only after it is discussed and established from all theangles.169 Thus success in treatment signifies the correct application of all therapeuticmeasures. Discussion improves the knowledge and discussion about shastra becomes thebase of establishment of the concept,170 as a part of this, discussion has been divided intothree parts viz. conceptual Part, drug Part and clinical Part. Conceptual Part: Skin diseases were found in form of blemishes of skin since the time immemorial.Various ancient texts mentioned Kushta in general and the Vicharchika in particular sinceVedic period to present era. Virudha Ahara produces ill effect in different ways according to intensity of foodand its susceptibility explained by Hemadri.171 With this concept it can be said that Virudha Ahara produced immediate fatalityby type-I hypersensitivity reaction – Anaphylactic shock, and delayed, latent fatality bytype – IV cell mediated (delayed) hypersensitivity reaction, Rogajanaka by Type-II,antibody mediated cytotoxic reaction and type III immune complex. Vicharchika is culprit of beauty, personality and social life among the skindiseases. So many remedies (in different pathy’s) were invented for the same but due tothe modern era’s life style and various insults to the skin, diseases became morevulnerable. Vicharchika has been mentioned in almost all Ayurvedic texts, either in form ofKshudra Kushta, Kshudra Roga or Sadhya Kushta. Various Acharyas mentionedVicharchika with different Doshic involvement along with their symptomatologicalcomplex. Charaka says that Vicharchika has a Kapha dominancy because, there is anexcess itching, discolouration, boil, profuse oozing, which also indicates its initial oracute stages. Sushruta says that Vicharchika has Vata dominancy with characteristics likeRaji (marked lining) and Atikandu (excess itching) and Arti (pain) and Ruksha (dryness)etc., which indicate chronic or later stage. Thus, this separation may also suggestdifferent stages of Vicharchika. Even the difference of opinion about the dosha 115
    • Discussioninvolvement favours that vicharchika can present as a tridoshaja vyadhi as explained inthe general context of kushta. Kushta is a disease of skin, so first of all before entering into the pathogenesisproper a detailed understanding of shareera and kriya is necessary. Tvak is a Sthana ofSparshanendriya, Upadhatu of Mamsa and Matruja Bhava. Tvacha has a direct relationbetween Dosha-Dhatu-Mala-a structural and functional unit of the body. In modernreview, skin described with embryological, macroscopic and microscopic structure andalso having immunological component i.e., its structure, cells (Langerhan’s cell, T-lymphocytes, mast cells and keratinocytes), functional system and immunogenetics The etiopathogenesis is also similar to eczema i.e. Virudha, Mithya Ahara andvihara, and other nidana may act as metabolic toxins or other irritants and producesensitization of skin. In initial stages of Vicharchika when pruritis becomes severe, ultimately skinintactness may get ruptured and watery discharge may be produced which is alsomentioned by Vagbhata that Vicharchika has a characteristic feature, Lasikadhya whileIndu explained it with Jalapraya i.e., watery discharge. The symptomatology of Vicharchika is similar with eczema i.e., Sakandu(excessive itching), Pidaka (boil/pustule/vesicle), Shyavata (discolouration/hyperpigmentation), Bahusrava (profuse oozing) and later Raji (markedlinings/lichenification/Criss-cross marking), Ruja (pain), Saruksha (excessive dryness). After viewing all concepts it can be said that Vicharchika is a clinical entity inwhich the lesion has the Shyava colour of Pidaka with excessive itching and oozing,which may develop anywhere in the body (Gatreshu), either wet or dry. Eczema can be considered in the same category because first manifestation ofeczema is erythema or reddening of skin, edema, vesiculation, oozing, crusting and laterlichenification. Due to the intra and extra environmental changes within the body and itsreactions against them, may produce extreme stages of Vicharchika. Main place ofetiopathogenesis, is in Tvak (Adhisthana), Rakta (blood and lymph), Mamsa (deepcutaneous tissue) and Lasika (sweat gland apparatus). So many remedies are mentioned for the management of Kushta (Vicharchika), 116
    • Discussionbut increase in the various insults to the skin, diseases have not subsided till today.Shodhana, Shamana and Nidana Parivarjana, these three measures should be taken forgetting complete remission. Shodhana may be recommended for Bahudosha, but Shamana is also essential forremoving the remained Dosha after Shodhana process and when etiopthogenesis isconcerned to the skin, external application is also essential.Drug Part : In this section, Udayabhaskara rasa, Arkadi taila and Jalauka have been describedwith detail description of classical texts. Udayabhaskara rasa has been explained as a rasa yoga indicated in galita kushta,sphutita kushta, vipula mandala kushta, dadru, pama, vicharchika and all types ofkushtas. Arkadi taila is one of the yogas mentioned for external application havingindicated in krimi, kushta, kandu, vicharchika and all types of kushta. Jalauka has been described with etymology, definition, types, collections andpreservation and indication along with modern perspective i.e. systemic position, leechconstituents of Hirudomedicinalis, general actions through modern texts and researchpaper.Discussion on Methodology This is a single blind clinical study with a pre-test and post-test design. 20 patientsbetween the age group of 16 to 60 years suffering from vicharchika were taken for thestudy from O.P.D and I.P.D of SDM college of ayurveda hospital, udupi. The pratyatmalakshanas of vicharchika like kandu, pidaka, vaivarnya, bahusrava, daha, raji andrukshata were mainly considered for the diagnosis. As a routine, hematologicalinvestigations were carried out in all the patients taken for the study. In the present study,on the basis of Vicharchika, which is a disease of Rakta Pradosha, Tridoshaja Prakopa,afflicting bahya Roga Marga and a type of Kushta, for the purpose of ShodhanaJalaukavacharana, for Shamana Udayabhaskara Rasa and for External ApplicationArkadi Taila were selected. In the present study, 20 patients were registered which were 117
    • Discussionsubjected to jalaukavacharana in the beginning at the site of lesion this was followed byoral administration of Udayabhaskara rasa in a dose of 250 mg tid for 30 days. Duringthis period external application of Arkadi Taila was also carried out.Jalaukavacharana : Jalaukavacharana was performed in all 20 patients. Maximum leechrequirement was reported as 4 – 5 per patient for one sitting (Leech has been used once).Most of time, during biting and entire Jalaukavacharana process, patients did not facediscomfort, but only 64% patients felt pricking pain, 36% patients felt itch on the affectedlesion. After leech application Samyak Vamana Lakshana in leech were observed,vomitous blood color was 71% times blackish, thin with bubbles (Safena) indicates Vatadominancy; 42% time bright red and thin indicates Pitta dominancy and 28% time red,thick blood indicates Kapha dominancy.Clinical Part:Based upon the small sample size of patients it is not possible to give conclusive remarksabout the observations found during the clinical study. But a probable interpretation canbe drawn out from the available data. Age: In the present study the entire patients were grouped into 7 age groups. Among them maximum 20% patients were belonging to 31-40 and 41 – 50 years of age group. This shows the high incidence in madhyamavastha. This age is golden period for individuals when mental stress and other exposure i.e. occupational, environmental, unwholesome food were more which leads to dermatitis. This is followed by 15% patients who were in 0-10, 11-20 and 21-30 years of age group. Finally 10% and 5% of the patients were belonging to 51– 60 and 61 – 70 years of age group, which may come in less exposure. Generally eczema may occur in any stage of life but most common in infant, puberty and menopause. In present study any infant case, puberty and menopausal history was not reported. 118
    • DiscussionSex: The sex wise distribution of the patients reveals that 30% of the patients werefemale while 70% patients were male. So it can be said that in this study males aremore affected than females which coincides with the observation of incidence.Occupation: Out of 20 patients of Vicharchika reported, maximum number ofpatients i.e. 30% were students, followed by 20% patients were Agriculturists, 15%patients each were businessmen and belonging to others, 10% patients each werehousewife and professionals. Students more exposed to stress and agriculturists whoare exposed to irritant substances in the form of pollens or fertilizers are having ahigher tendency. Housewives are more exposed to household appliances, which arecommon causative factors for Vicharchika. Professionals like teachers, engineers arehaving job with continuous standing may prone to stasis to eczema. Others includethe labourers who live with polluted environment and unhygienic condition whichmay provoke the eczematous condition, retired person who also called as aged, theirbody nourishment may not be proper, so immune compromise takes place which isone of the causative factors for dermatitis. Businessman like carpenters works withchemical dye or other allergens, which may produce irritation and manifestation ofeczema.Marital Status : In this series 30% were enjoying marital life, 45% were unmarried,15% were widow/widower and 10% were divorced patients. It can be said thatunmarried persons due to their negligence towards food habits and daily hygiene aremore prone to this disease.Religion: Maximum number of patient’s i.e. 65% were Hindus, 5% were Muslims,and 15% were Christian and others respectively. This indicates the dominance of theHindu population in the locality of study.Socio-economic Status: In this series, each 35% of patients were from middle middleclass, followed by 15% patients each were from lower middle, upper middle and richclass and 10% patients each were of very poor and poor class. As the data isdistributed any conclusion can not be drawn on this basis.Education: In this series, 25% patients were in middle school, followed by 20%patients each were of higher secondary and illiterate respectively, 15% patients were 119
    • Discussionof primary school and 10% patients each were graduate and post-graduate. So, it canbe said that all people may be affected from eczema either uneducated or ignorant tohealthy life style or educated because of heavy work and stressful life.Habitat: In this series, maximum number of patient’s i.e. 55% were coming fromurban area, whereas 45% patients were from rural area so it can be said that patientsfrom urban area are more susceptible for eczema than rural area due to unhygienic,polluted and industrial environment. In the other category 90% patients belonged toanupa desha while 10% patients were of sadharana desha. This specifies the role ofhumidity in the causation of eczema.Ahara : Maximum number of patients i.e. 65% were mixed while rest of the patientsi.e. 35% was taking vegetarian type of diet. So, it can be concluded that the nidanalike guru, vidahi, ushna, tikshna and matsya sevana definitely plays a role in thecausation of kushta.Vyasana (Addiction): Maximum number of patient’s i.e. 70% were havingaddiction of tobacco in different way i.e. Pan and Gutakha (30%), chewing tobacco(20%) and snuff (20%). Smoking habit and alcohol addiction each was found in 15%of the patients. Tobacco and smoking are considered to be the prominent aggravatingfactors to eczema.Prakruti: In Sharira Prakruti, maximum number of patient’s i.e. 25% werebelonging to pitta Prakruti, 20% of patients each were of vata and vata-Pitta Prakruti,15% of patients were of kapha Prakruti and 10% patients each were of vata-kapha andpitta-kapha Prakruti. Here pitta having ushna, tikshna guna has contributed in diseaseprocessSara: Maximum number of patients i.e. 45% were of Madhyama Sara, 30% were ofPravara Sara and others i.e. 25% were Avara Sara. Sara gives a direct idea to generalbody constituent, strength and immunity of body.Samhanana : Maximum number of patients i.e. 45% were of MadhyamaSamhanana, 30% of patients were of avara category and other 25% were Pravara.Samhanana gives idea about general body built.Satmya: Maximum number of patient’s i.e. 55% were having Madhyama Satmya,whereas 30% were having Avara Satmya and 15% were having Pravara Satmya. 120
    • Discussion Satmya means agreeable substance which can be taken regularly and definitely the pravara satmya people have lesser incidence of disease. Satva: Maximum number of patient’s i.e. 70% were belonging to Madhyama Satva followed by 15% each belonging to Avara Satva and Pravara Satva. Avara Satva may provoke Vicharchika. Satva indicates the stability of mind against disease. Ahara Shakti: Maximum number of patients i.e. 60% were having Madhyama Abhyavaharana Shakti followed by 25% and 15% of the patients were having Pravara and Avara Shakti respectively. 70% of them had madhyama jarana shakti followed by avara and pravara 15% each. Ahara Shakti including Abhyavaharana and Jarana Shakti, which indicates the turn over of the body energy. Its Avara state can be attributed to Agnidushti. Vyayama shakti: 60% of them had madhyama vyayama shakti, followed by 25% pravara and 15% avara vyayama shakti respectively. Unless there are complications the vyayama shakti is not depleted in skin disorders. Drug History: Maximum number of patient’s i.e. 78% had tried many type of medicines but could not get any response, only 22% patients were not taking any medicine. Here it may be said that this 22% patients were fresh cases, while maximum patients were chronic and multiple drug resistant. Agni: In this study, 40% patients were reported with Tikshnagni, 35% patients with Samagni followed by 25% with Mandagni and no patients with Vishamagni were reported. Samagni is responsible for health but out of which maximum patients were reported with Mandagni – a causative factor for all the diseases and also other types of vitiated Agni were reported which serves atmosphere (Kha-vaigunya in skin) and allergence (metabolic toxins) for manifestation of eczema. Nidana : Aharaja Nidana: Out of all patients 30% were consuming mithya Ahara while20% were taking Virudha Ahara in daily routine. Among the Virudha Ahara, 13% patients were taking Lavana with Dugdha, 34%patients were taking Tila, Guda and Dadhi, 30% of patients were taking Dugdha withAmla Dravya and 8% patients were taking Matsya and Dugdha. These types of VirudhaAhara are mentioned in the etiology of Kushta. 121
    • Discussion Among the Mithya Aharas Dadhi was reported in 47% of patients, Matsya in 17%patients, Dravapraya Anna in 43% of patients, Guru Prayaha Anna in 39% of patients,bakery items in 52% of patients and fermented food in 60% of patients. These all arefactors to provoke Vicharchika. Bakery items and fermented food may produceindigestion, metabolic toxins and excess acid at digestion, which may act as chemicalallergens. The Ahara like, Ushna, Tikshna, Vidahi, Mulaka, Garlic, Onion were reportedin 19% of patient’s food. Masha, Navannapana were reported in 36% of patients andexcess use of Taila was reported in 25% of patients routine food, which all are mentionedas etiological factors in classical texts. Masala i.e. Kokum, pickle, vinegar, bakingpowders were consumed by 20% of patients. Different types of Aharaja nidana may be responsible for Vicharchika, diet andstate of digestion is responsible for diathesis of eczema. Metabolic toxins, internal bodyproducts, element of diet and drug may act in different ways and provoke the allergicreaction, which may provide internal atmosphere to endogenous eczema and exogenouseczema also. Viharaja Nidana: 20% of patients reported suppression of the natural urges i.e.vomiting, bowel evacuation etc. which is an etiological factor of Kushta. Vegadharanamay provoke the Dosha and Agnimandya leads to Kushta. 17% of patients were doingexercise after eating,responsible for Agnimandya, then Kushta. After eating heavy workshould be restricted, because that time, requires energy for digestion. 60% patients tookcold water bath or drink after completion of exercise or sun exposure or fear. Suddenchanges in environment of skin may produce excessive blood circulation, endocrinedisturbance and may cause eczema. 39% of patients were exposed to sun after takingheavy meal. Strong sun exposure may produce photosensitization in such patients andwhen sun exposure has occured after heavy meal or cold bath it may act seriously. 36%patients were habituated to Divasvapa, which is also an etiological factor of Kushta. 21%of patients had incomplete Panchakarma therapy. It is again a cause of Chirakari SadhyaVikara of Panchakarma Vyapad i.e. Kushta, Visarpa etc. 30% patients were living inunhygienic condition and 17% of patients were living in polluted environment. These allare etiological factors of eczema and act as allergen or irritant to particular part, in thatindividual. Role of these are discussed earlier under conceptual part. 122
    • Discussion Acharaja Nidana : 10% of patients were having Chinta, bhaya and Krodha.These cause Vata-pittaja Prakopa, Agnimandya and Kushta. Emotional conflict maydisturb endocrine secretions which lead to skin manifestations. Pradhana Vedana (Cardinal Symptoms): Kandu, pidaka and vaivarnya were reported in all the patients, rukshata in 40% patients while bahusrava and daha each were reported in 35% patients. Vaivarnya in 100% patients either in the form of Rakta (21%) or Shyava (56%) or Krishna (34%), state of lesion was reported. So, the first three features may be considered as cardinal symptoms EFFECT OF THERAPY This clinical work is designed to carry out a comprehensive literary study on Vicharchika. And also to evaluate the total effect of jalaukavacharana, oral medication with Udayabhaskara Rasa and topical application of arkadi taila in Vicharchika. In the combined effect of shodhana and shamana Highly significant results in the cardinal symptoms were observed in Kandu, Pidaka, Vaivarnya, bahusrava, daha and Rukshata which were relieved by 60.21%, 49.87%, 51.39%, 48.75%, 43.75% and 41.72% respectively. The results thus obtained were statistically significant.The Effect of Therapies on Individual Signs and Symptoms:Kandu: It was relieved by 60.21% by the combined effect of jalaukacharana andshamana. It is caused by vitiated Kapha, Pitta and Vata. So, here Tridosha vitiation isresponsible. Result may be due to expelling out of vitiated morbid doshas (toxins).Pidaka: 49.87% relief was observed in combined effect of shodhana and shamana.Leeches are anti-phlogistic, used for the local obstruction of the blood. Hence, they areused in acute inflammation, abscess, boil etc. Due to this reason Pidaka may be subsided.Vaivarnya : 51.39% relief was found in the combined effect of shodhana and shamana.Jalauka allows oxygenated blood to enter the wound area, which may provide better colorto skin. 123
    • DiscussionSrava: It was relieved by 48.75% in the combined effect of shodhana and shamana.Ushna and Tikshna Guna of vitiated Pitta are responsible for Srava. Jalaukavacharanacorrects the vitiation of Pitta, hence reduces the Srava.Rukshata: It was relieved upto 41.72% by the combined effect of shodhana andshamana. Dryness in different extent is due to loss of moisture in skin, so someemollients are necessary. Moisturizing effect of the oil may have decreased the Rukshataof the affected area.Daha: 43.75% relief was observed by the combined effect of shodhana and shamana. Inthis symptom both the therapies have provided better result.Probable Mode of Action Vicharchika has been considered as Tridoshaja, Rakta Pradoshaja, ShakhagataVyadhi. Various etiological factors may produce Dosha, Dushti, Dhatu Shaithilya, Kha-vaigunya and Agnimandya, which all leads to Kushta (Vicharchika). Disease is a final outcome of all the pathogenesis and the treatment is one thatbreaks all steps of pathogenesis. So for this study Arkadi taila, Udayabhaskara rasa andJalaukavacharana were selected. So, their probable mode of action (Samprapti Vighatana)is given below:Probable Mode Of Action Of Udayabhaskara rasa :Udayabhaskara rasa containing Tamra Bhasma, Shuddha Vatsanabha and ShuddhaPippali is selected for the present study. Tamra Bhasma having Tikta and Kashaya rasa,Madhura vipaka, ushna virya shows pittakaphahara karma and kushtaghna karma.Vatsanabha having madhura rasa, katu vipaka and ushna virya, and laghu, ruksha,tikshna, vyavayi, vikasi gunas shows vatakaphahara, kushtaghna and rasayana karma.Aconitum ferox exhibits diaphoretic action which is definitely going to help a lot in skindisorders. Pippali is having pharmacodynamics i.e. Tikta-Katu Rasa, Ruksha-Laghu Guna,Ushna-Virya, Katu Vipaka and Kapha-vatahara properties which all are useful inbreaking of etiopathogenesis of Vicharchika i.e. 124
    • Discussion Vicharchika occurs due to Agnimandya by Virudha Ahara, Vihara. So, Pippali correct it by its Guna, Rasa, Virya and Vipaka which all may enhance Agni. It is having Vata-kaphahara property and Rasa Guna suppress Pitta, so Tridosha Prakopa may be corrected. Dhatu Shaithilya and Kha-vaigunya may require Rasayana because Vicharchika is a disease of skin where epidermal cells become degenerated and hypersensitive. So Rasayana may provide best quality of Dhatu (Rasa, Rakta, Mamsa, Lasika) which leads to preventive as well as curative aspect of disease172Kandu (Itching) may have been corrected by kaphahara property, pidaka may beconsidered as Shotha which is corrected by pharmacodynamics, Bahusrava (Oozing) mayhave corrected by Rasayana, Laghu, Ruksha Guna. Pitta is responsible for body color sonormalcy of doshas rectifies the vaivarnyaOther features like Raji, Arti, and Daha etc. may suppress by Rasayana effect of Pippali.So, Pippali breaks all steps of etiopathogenesis and may give better effect in Kushta.Long pepper is a rejuvenator of rasa and rakta dhatu and is useful in skin disorders.Pippali is having Tvachya Rasayana properties so it may be helpful for normalization ofskin from all points of view i.e., color, thickness, lusture, complexion etc.Probable Mode Of Action Of Local Application: Essential oils are composed of very small molecules that are easily absorbed in tothe body, just like nature intended. Just below the top layer of skin is a thicker dermiswhere nerves, hair follicles, sebaceous glands, sweatglands, blood vessels and lymphvessels are situated. Under the dermis is the subcutaneous fatty layer. Applying essentialoils to the skin is a quick and efficient way to introduce them in to the blood, nerves andlymph. Many essential oils are lipophilic, meaning that by their molecular design theywant to jump in to tissues containing protein, like our skin. In present study, Arkadi taila containing Arkapatra swarasa, Haridra kalka andSarshapa taila was selected for local application. Arka having laghu, ruksha, tikshna andushna gunas shows kaphavatahara, raktashodhana, krmighna, kushtaghna, kandughnaaction. As it is a diaphoretic, antidermatosis, therefore it is used in dermatosis. Haridrahaving similar gunas shows raktaprasadana and raktavardhana, kushtaghna action.Turmeric is used in several skin disorders. It improves skin complexion. It is also useful 125
    • Discussionin pruritis. Vicharchika being a Chirakari (chronic) disease, Raji, Pidaka and Shyavamay require this type of pungent remedy but without oily media it can’t work. So,Sarshapa taila containing lenolenic acid may act as a powerful agent for cutaneousabsorption. The Sarshapa seeds contain about 25-50% of stable oil, which is refered askatutaila by susruta173. Thus, mixture of Sarshapa taila, Arka patra swarasa and Haridrakalka may act locally by Snigdha, Tikshna and Ushna Guna. Topical drugs also enhance the skin metabolism, so healthy repairing may alsotake place. Oils having Vegetable fats contain hydrocarbons which are also helpfulmedia for cutaneous absorption. So all actions are favourable to break theetiopathogenesis of skin. Thus, the Local application of Arkadi taila may provide better relief inVicharchika. In clinical experience, this Taila was found better in wet lesion.From the above explainations we can observe that the drugs used in this study are mainlyof ushna, tikshna, Sukshma, ruksha, laghu gunas having katu and Tikta rasa, katu vipakaand ushna virya. Katu rasa contains vayu and agni mahabhutas, while Tikta rasa containsvayu and Akasha mahabhutas. Katu vipaka shows ruksha, laghu and vatavardhaka gunas.Ushna virya is svedajanaka. While their overall karma is raktaprasadana, kushtaghna,kandughna and svedaghna. Varna is located in avabhasini layer of skin due to bhrajaka pitta. Due to pittavikaras there is skin discolouration. Due to which the skin becomes pita, rakta nila incolour.Vata and kapha also get vitiated and thereby reduce the concentration of bhrajakapitta causing shyavaruna and shukla varna. Vitiated pitta in turn vitiates rakta whichfurther cause discolouration of skin. Varnya dravyas like haridra are useful in suchconditions where they correct the pitta and in turn purify the blood.Kandu is caused by excess of kapha and its seat is in tvacha or kala. Hence Kaphaharadravyas like pippali, vatsanabha and tamra Bhasma are selected. Sveda is a mala of sharira which is refered as Medodhatu-mala in shastras. It is amedium for the excretion of water, salt and nitrogenous wastes from the body. The sweatis acidic due to the origin of fatty acid from the sebaceous glands. The sweat and urineboth have a role to play in the excretion of water and salts but the former does not dependupon the blood pressure. The sweat glands are related to both sympathetic and 126
    • Discussionparasympathetic nerve branches but the medicines are known to act only on theparasympathetic nerve branches. Sweda is formed from jala and agni mahabhuta. Henceby samanya-vishesha siddhanta the drugs having jala and agni gunas are svedajanaka.Jaliya dravyas excrete the sveda by increasing their concentration in the body. On theother hand the agneya dravyas by their ushna and tikshna gunas stimulate the dhamanisand the svedavaha granthis beneath the skin which in turn acts as svedajanaka.Probable Mode Of Action Of Jalaukavacharana : Jalaukavacharana has been considered as a therapy for Raktapradoshaja vyadhi(Blood born disease), Tridosha Prakopaka (vitiated body humour) and chirakari (chronic)diseases. For excess quantity of dosha, Shodhana may be required so; Raktamokshanaamong the shodhanas may provide better relief than other Shodhana174 particularly whenRakta is vitiated. Sushruta stated that Raktamokshana not only purifies the channels, butalso let the other parts become free from diseases and action is so fast than otherremedies175 . Vitiated Rakta may be depleted by application of Leeches after slightscraping on the lesion of Kushta. Thus, it is well proved that Jalauka gives better effectin Raktaja Roga or Kushta on the basis of classical references. Jalauka sucks the impureblood only with ideal example of Swan by Vagbhata, this concept is discussed here witha different angle. Leeches applied on skin, sucks the blood from superficial area, and might be from capillaries or extra-cellular area, so it may be more impure than other body channels. By experiment, PO2 of leech expelled blood and PO2 of arterial blood was measured. The suggestive findings were that PO2 of leech expelled blood was comparatively less than the arterial blood of human (interaction between student and teacher RAV – New Delhi, 2003). Leech sucks blood from limited area and when leeches are applied only in pathogenic area, it can be said that leech expells blood from the site where the pathological state is more. Hence, it can be said that leeches give best effect in Vicharchika by expelling the morbid, vitiated Dosha and Dhatus. But the effect of therapy is not only by 127
    • Discussion expelling the vitiated blood but leech also emits some enzymes in the wound. So Jalaukavacharana has also provided – Normalization and improvement of capillary as well as collateral blood circulation. Expressed anti-inflammatory effect. Immuno-stimulation and immuno-modulating effect. Early wound healing effect. This action may be an effect of some salivary enzymes like Hirudin –anticoagulant effect, diuretic, antibiotic action, Calin – preventing blood coagulation, andthe action of eglin, hyaluronidase, antithrombin, antitrypsin and antichymotrypsin etc. 128
    • Conclusion CONCLUSION Conclusion is the determination established by investigation in various ways anddeduction by means of various reasons176 . On the basis of the present study, followingconclusions can be drawn.1) Vicharchika is a disease of agriculturists, housewives, industrial workers who areopen to the assault of irritant substances. It is also chronic in nature so after remission,there are chances of recurrence.2) Vicharchika condition is more aggravated by dry and cold weather, and also whenexcessive sweating occurs. Sunlight and irritant material also precipitates the conditions.3) Patients doing Adhyashana, Vishamashana and Virudhashana are more prone toVicharchika. Such addictions like smoking and chewing tobacco may be also harmful inthe disease.4) Personal hygiene like Snana etc. Have utmost importance.5) General emotional expression also interfere in skin condition i.e. anxiety, depression,tense mind activate the sympathetic nerve stimulation which produce indigestion, skinmanifestation etc.6) Virudha Ahara and Mithya Ahara, contributes a major role in manifestation ofVicharchika. Today’s bakery items and fermented fast food also play a vital role inoccurrence of Vicharchika. All these types of Ahara either disturb in digestion or producecertain harmful substances (allergens).7) Sudden change in atmosphere is also one of the etiologies of Vicharchika.8) Rasa, Rakta, Mamsa and Svedavaha Srotodushti were found chiefly and Kapha andVata were main Dosha who vitiate these Dhatu and Srotas.9) Jalaukavacharana provided better relief in Kandu, Pidaka and Srava while externalapplication of arkadi taila provided better relief in Vaivarnya, Rukshata and Kandu.10) Jalauka expels the vitiated blood according to site, when Jalauka is attached to theskin, where blood supply is less, it sucks more vitiated blood. On the other handCapillary, Vein and Arterial blood contains respectively less vitiation. Therefore whenJalauka is attached to an area close to these channels, it can suck out the vitiated blood, inaccordance with the intensity of vitiation. 129
    • Conclusion11) After long time attachment of Jalauka, enzymes relieved by it starts collateralcirculations, so leech sucks blood from far area also. It may be from arterial or majorveins.12) The major effect of Jalaukavacharana is not only by expulsion of vitiated blood butalso by such enzymes which are emitted by Jalauka.13) It was also observed that Jalauka attached to site in very short time at first sittingwhile after few sittings this period was longer. It also can be said that vitiated blood wasbecoming gradually reduced.14) External application of arkadi taila provided better relief in thickening of skin.Burning sensation was produced in new and less lichenified lesion which may be due topungent nature of Sarshapa Taila.15) Internal administration of Udayabhaskara rasa has also contributed in the reduction ofsymptoms like daha, vaivarnya.16) After the completion of therapy, it was found that the combined effect of theshodhana and shamana line of management provided complete remission in 25%, markedimprovement in 10%, mild improvement in 35%, moderate improvement in 25% and norelief in 5% of patients. 130
    • Summary SUMMARY The thesis entitled “A clinical study to evaluate the effect of Shodhana andShamana in the management of Vicharchika.” comprises of five parts viz. ConceptualPart, Drug Part, Clinical Part, Discussion, Summary and Conclusion. The first part of the thesis is devoted to the conceptual study of the disease. Thehistorical aspect of the disease Vicharchika is consisting of various descriptions regardingthe disease Vicharchika, starting from various period up to the various places of India, thedescriptions available regarding the skin in general and the Vicharchika in particular inVedic period (pre-samhita period). Samhita period and the review of previous researchwork have also been compiled here, which have been carried out in the various places inIndia. The part of disease review – Vicharchika comprises etymological derivation,definition and classification of disease, from both Ayurveda and modern point of view. InAyurvedic part etymology, definition, types according to different classical texts ofVicharchika is included and it also describes Nidana Panchaka from various classicaltexts. Modern disease review consist etymology, pathophysiology and histopathology andvarious etiological factors, types and management of eczema. Anatomy and physiologyof skin has been mentioned before pathogenesis for a better understanding of the same. In management part, Shodhana by Jalaukavacharana, Shamana by Udayabhaskararasa and External application by Arkadi taila have been discussed. Jalaukavacharana hasbeen elaborated with its historical importance both in Ayurvedic classics as well asModern perspectives. Classical method of jalaukavacharana, some miraculous effect ofHirudo Medicinalis, Limitation and Solution and General tips for the procedure havebeen discussed in detail. The second part of the thesis is devoted to the drugs, selected for the presentstudy. Here the properties and actions for Shamana drug i.e. Udayabhaskara rasa andArkadi taila used for external application have been compiled from various availableAyurvedic treatises and their ingredients have been also described. Jalauka is alsodescribed here with its etymology, definition, types, collections and preservation andindications along with its modern aspect i.e. systemic position, leech constituent of 131
    • Summarymedicinal leech and general action through modern texts and research papers. The third part of the disease deals with the combined clinical study carried out on20 patients of Vicharchika with Jalaukavacharana in the beginning at the site of lesionfollowed by Udayabhaskara rasa internally in the dose of 250 mg tid for 30 days, duringthis period external application of Arkadi taila was also carried out. The materials and themethodology of the present study have been mentioned in this part clearly. The clinicalstudy has been carried out by following the scientific methodology of the research. Thedata of the patient investigated from different angles have been presented here. Thecritical notes and comments of all the investigated data have been also presented alongwith the concerned parameters individually. The fourth part is devoted to an ample discussion on the classical explainations ofthe disease, based on the conceptual, drug and clinical study of the present series. Criticaldiscussion and comments have been offered to all the parameters of the clinical study andlastly overall effect of the recipes have been presented there. The fifth and last part comprises the summary and conclusion of the presentstudy. Apart from that, the salient features of the present study have been presented inthis part under the caption of conclusion 132
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    • Annexure PROFORMA S.D.M.College of Ayurveda, Kuthpady, Udupi P.G Department of Kayachikitsa Topic:A CLINICAL STUDY TO EVALUATE THE EFFECT OF SHODHANA AND SHAMANA IN THE MANAGEMENT OF VICHARCHIKA Name: Serial No: Age: Date: Sex: M / F DOA: Occupation: stu./business/hw/professional/agri/others DOD: Marital status: M / UM/D/W Bed No: Religion: H / M / Ch / Others OPD No: Social status: VP / P / LM/MM/UM/R IPD No: Education: I/P/M/HS/GR/PG Postal address: place: S/A/J/R/U Pradhana Vedana: kandu/pidaka/shyavata/srava/daha/raji/rukshata Anubandhi Vedana: Vartamana Vyadhi Vrittanta: Onset of skin lesions: Sudden / Gradual / Insidious Site of onset: head&neck/arms/trunk//hands/legs//feet 153
    • AnnexureCharacteroflesion:nummular / anular / cricinate / arcuate / gyrate / linear / grouped / reticulate Extent of the lesion: head&neck/arms/trunk/hands/legs/feet Factors causing the symptoms: i) Local: ii) Systemic: erythymanodosum/SLE/dermatomyositis/systemicsclerosis/DM iii) Infections iv) Contact: chemicals/dyes/earrings/necklace/chappals v) Inhalants: dust/pores/pollens vi) Season: spring/autumn vii) Drugs/ Clinical stimulus: Treatment taken so far: Poorva vyadhi Vrittanta: H/O DM/HTN/BR. ASTHMA Kulaja Vrittanta: FAMILY AGE Living/dead (If dead cause ) Health Status Other Father Mother Brother Sister Son Daughter 154
    • AnnexureVayaktika Vrittant: Ahara: Veg. / Mixed Cold water /beverages: Regular / Occasional Butter milk/Curds: Regular / Occasional Spicy food/ Fried items: Regular / Occasional Ice creams: Regular / Occasional Sweets/Oily food : Regular / Occasional Fish / milk: Regular / Occasional Bowel: Regular / Irregular / Well formed / Hard /Loose Frequency: ____ / 24 hrs. Micturation : Scanty / Normal / Excessive _______ D/N Sleep Normal / Disturbed - Day ____ H. Night ____ H. Koshtha: Krura / Mrudu / Madhyama Emotional Makeup: Normal / Tensive / Depressed / Sentimental Vyasana:Smoking /Alcohol/coffee/Tea/Snuff/Tobacco/Pan&Gutka Kshuda: Poor / Moderate / Good Rutusrava vrittant: Menstrual cycle: Regular / Irregular. Bleeding days…… Associated with………… Menarche age:Prasootika vrittant: No of deliveries: G P L A D Age of last child: 155
    • Annexure Astasthana Pareeksha: (Rogi Pariksha ) Nadi: ……../min. Drik: Prakrita/Vaikrita Mala: Prakrita/Vaikrita Akriti: Mootra: Prakrita/Vaikrita Deha bhara:…….Kgs Jiwha: Prakrita/Vaikrita Dehoshma:……degree F Shabda: Prakrita/Vaikrita Shvasa gati:……../ min. Sparsha: S / U /AU / AS Raktachapa: ……./ mm of Hg Prakrutyadi Dashavidha Pariksha: Prakrititascha: V/P/K/VP/VK/PK/VPK Satmatascha: P / M / A Vikrititascha: Satwatascha: P/M/A Saratascha: P/M/A Aharashaktitascha: Samhananatascha: P/M/A Abhyavaharana shakti: P /M /A Pramanatascha: P/M/A Jarana shakti: P /M /A Vyayamashaktitascha: P / M / A Vayatascha: B/M/V Vikriti Pariksha: (Roga Pariksha) HETU Ahar Vihara Achar KalaViruddhahar panchakarmaapachari viruddhachara UshnakalaAmannasevana Ativyavaya sheetakalaAdhyashana DiwashayanaNavannasevana PapakarmaDadhisevana ChardivegadharanaMatsyasevana AtibhojanaTila,lavana,amlaAtiGuruahara 156
    • AnnexureAsatmyaaharaAhitashanaGramya,anoopa, Sheetambusevana afterudakamamsasevana shrama&Bhaya PURVARUPA Asvedanam Kharatva Daha Atisvedanam Ushmayana Tvakparooshata Vaivarnya Gourava Romaharsha Kandu Sparsha ajanatva Angapradeshasvapa Toda Unnata Krishnata Atishlakshnata Kotha Atishlakshna Suptata Shrama Sheegrautpattichirasthita Paridaha Klama Nimittealpeapikopanam Lomaharsha Vranadhikata 157
    • Annexure RUPA Vata Pitta Kapha Roukshyata Daha Sheetata Shosha Raga Shveta varna Toda Paka Utseda Ayama Parisrava Snigdhata Parushata Visragandha Kandu Kharata Kleda Sthirata Harsha Angapatana Gouravata Shyava arunata Tvak swapa Kleda Sparsha hani Krimi utpatti pidikodgama GhanaSAMPRAPTI GHATAKAS: Dosha: Dushya: Agni: Ama: Srotas: Srotodushti prakara: Udbhava sthana: Sanchara sthana: Vyakta sthana: Roga marga: Vishishta Pareeksha: General examination: C.V.S: R.S: GIT: 158
    • Annexure GUS: C.N.S: Locomotor.S: DUSHYATAH PARIKSHARakta Lasika Tvaka MamsaAtisveda Alpasveda Sparsahani BahalRomaharsa Avil Mutra Ruksata TodKandu Daurgandhya Sveda SphotDurgandha Kotha Kandu SthirSupti Kushta Vivarna Karkasha KanduExamination of the skin: INSPECTION – 1) Extent&Distribution– symmetrical/asymmetrical/localized 2) Hyperpigmentation –brown/yellow/redness/others 3) Hypopigmentation –localised/generalized 4) State of Skin – a) sweating– absent/increased/decreased/normal/local/ general b) elasticity –normal/increased/decrease c) greasiness –normal/increase/decrease d) tension –wrinkled/tense/normal e) thickness –hypertrophy/normal/atrophy 5) Examination of lesion – 159
    • Annexure Primary Lesion –srno primarylesion shape size colour distribution margin surface Sur.area1) Macule2) Papule3) Vesicle4) Wheals5) Plaque6) Bullae7) Nodule8) PustuleSecondary Lesion –srno. secondarylesion shape size colour distribution margin surface Sur.area1) Excoriation2) Scaling3) Scarring4) Crusting5) Fissures6) Ulceration7) Erosion Investigations: (If necessary) Hb: gm% Tc: cells/cu.mm RBS: mg/dl Dc:N L M B E % Urine sugar: nil/0.5%/1%/1.5%/2% ESR: mm/at end of 1 hr Urine albumin: nil/trace Sapeksha Nidana: Vyadhi Vinischaya: 160
    • AnnexureChikitsa: a) Udayabhaskara rasa 250 mg tid b) Arkadi taila for E/A bd c) Raktamokshana (leech application) for 30 daysDiet & Regimen: Avoid hot, Oily, spicy food. Avoid contact with causative factorsAssessment: ASSESSMENT BT AT CRITERIA (FOLLOW UP) END OF End of End of 2ND End of 4rth 1st week 3rd week week WEEK Kandu Pidaka Vaivarnya Bahusrava Daha Raji RukshataResponse of Treatment: Good Moderate Mild No 161