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Vicharchika kc012 udp

  1. 1. 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
  2. 2. 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
  3. 3. 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.
  4. 4. 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.
  5. 5. 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
  6. 6. 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.
  7. 7. 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
  8. 8. 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
  9. 9. 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
  10. 10. 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
  11. 11. 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
  12. 12. 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
  13. 13. 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
  14. 14. 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.
  15. 15. 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
  16. 16. 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
  17. 17. 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
  18. 18. 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
  19. 19. 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
  20. 20. 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
  21. 21. 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
  22. 22. 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
  23. 23. 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
  24. 24. 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
  25. 25. 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
  26. 26. 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
  27. 27. 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
  28. 28. 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
  29. 29. 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
  30. 30. 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
  31. 31. 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
  32. 32. 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
  33. 33. 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
  34. 34. 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
  35. 35. 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
  36. 36. 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
  37. 37. 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
  38. 38. 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
  39. 39. 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
  40. 40. 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
  41. 41. 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
  42. 42. 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
  43. 43. 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
  44. 44. 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
  45. 45. 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
  46. 46. 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
  47. 47. 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
  48. 48. 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
  49. 49. 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
  50. 50. 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
  51. 51. 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
  52. 52. 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
  53. 53. 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
  54. 54. 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
  55. 55. 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
  56. 56. 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
  57. 57. 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
  58. 58. 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
  59. 59. 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