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Evaluation of the efficacy of Varnya Yoga in Vyanga W.S.R.T Melasma By PRASAN V JOSHI, Department of Kayachikitsa, Post graduate studies and research center D.G. MELMALAGI AYURVEDIC MEDICAL COLLEGE, Gadag - 582 103

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Vyanga kc046 gdg

  1. 1. “Evaluation of the efficacy of Varnya Yoga in Vyanga W.S.R.T Melasma” By PRASAN V JOSHI Dissertation submitted to the Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore J In partial fulfillment of the degree of Ayurveda Vachaspati M.D. In Kayachikitsa Under the Guidance of Dr. Shiva Rama Prasad Kethamakka M.D. (Ayu) (Osm), C.O.P. (German) M.A., [Ph.D] (Jyotish) Department of KayachikitsaPost Graduate Studies & Research CenterD.G. MELMALAGI AYURVEDIC MEDICAL COLLEGE, GADAG 2006-2009
  2. 2. D.G.M.AYURVEDIC MEDICAL COLLEGEPOST GRADUATE STUDIES AND RESEARCH CENTER GADAG, 582 103 This is to certify that the dissertation “Evaluation of the efficacy of Varnya Yoga in Vyanga W.S.R.T Melasma” is a bonafide research work done by PRASAN V JOSHI in partial fulfillment of the requirement for the post graduation degree of “Ayurveda Vachaspati M.D. (Kayachikitsa)” Under Rajeev Gandhi University of Health Sciences, Bangalore, Karnataka. Date: Guide Place: Prof. Dr. Shiva Rama Prasad Kethamakka M.D. (Ayu) (Osm), C.O.P (German), M.A., [Ph.D] (Jyotish) Professor in Kayachikitsa DGMAMC, PGS&RC, Gadag
  3. 3. J.S.V.V. SAMSTHE’S D.G.M.AYURVEDIC MEDICAL COLLEGE POST GRADUATE STUDIES AND RESEARCH CENTER GADAG, 582 103 Endorsement by the H.O.D, principal/ head of the institution This is to certify that the dissertation entitled “Evaluation of the efficacy of VarnyaYoga in Vyanga W.S.R.T Melasma” is a bonafide research work done by PRASAN VJOSHI under the guidance of Prof. Dr. Shiva Rama Prasad Kethamakka, M.D. (Ayu)(Osm), C.O.P (German), M.A., [Ph.D] (Jyotish), Professor in Kayachikitsa in partial fulfillment ofthe requirement for the post graduation degree of “Ayurveda Vachaspati M.D.(Kayachikitsa)” Under Rajeev Gandhi University of Health Sciences, Bangalore,Karnataka.. Professor & HOD (Dr. G. B. Patil) Dept. of Kayachikitsa Principal, PGS&RC DGM Ayurvedic Medical College, Date: Gadag Place: Gadag Date: Place:
  4. 4. Declaration by the candidate I here by declare that this dissertation / thesis entitled “Evaluation of the efficacy ofVarnya Yoga in Vyanga W.S.R.T Melasma” is a bonafide and genuine research workcarried out by me under the guidance of Prof. Dr. Shiva Rama Prasad Kethamakka,M.D. (Ayu) (Osm) M.A. (Jyotish), [Ph.D (Jyotish)], Professor in Kayachikitsa, DGMAMC,PGS&RC, Gadag.DatePlace PRASAN V JOSHI
  5. 5. Copy right Declaration by the candidate I here by declare that the Rajiv Gandhi University of Health Sciences, Karnatakashall have the rights to preserve, use and disseminate this dissertation/ thesis in print orelectronic format for the academic / research purpose.DatePlace PRASAN V JOSHI© Rajiv Gandhi University of Health Sciences, Karnataka
  6. 6. Acknowledgement Any research is not an individual effort. It is a contributory effort of manyhearts, hands and heads. I am very much thankful to the subjects of this study. I am extremely happy to express my deepest sense of gratitude to my belovedand respected guide Prof. and H.O.D. Dr. K.Shiva Rama Prasad, M.D., C.O.P.(German), M.A., [Ph.D.], for his guidance and timely help. I express my gratitude to Dr. V. V. Varadacharyulu former Professor and H.O.Dfor his advice and encouragement in every step of this work. I am sincerely grateful to Dr. G. B. Patil, Principal, for his encouragement andproviding all necessary facilities for this research work. I extend my gratitude to Dr. R. V. Shettar, Dr. G. Purushottamacharyulu, Dr. P.Shivaramudu, Dr. M. C. Patil, and Dr. G. S. Hiremath. Dr. G. Danappagoudar. Dr. S.N. Belawadi. Dr. Nedugundi, Dr. Samudri, Dr. Kuber sankh. Dr. Mulgund. Dr. J.Mitti. Dr. Mulki Patil. Dr. Yasmin A.P, Dr. B. G .Swami, Dr Veena. Kori, I express my immense gratitude to my statistician Nandakumar, Tippanagoudar(Lab), V.B. Mundinamani (librarian) and Shyavi and Kerur for facilitating me incollection and production of my thesis. I take this opportunity to thank Dr. K.C.Das,Dr.Basavaraj.G, My deep senses of gratification to my inspirations of this study are my parentsVaradendra.G.Joshi and Sharada.V.Joshi I express my deepest sense of gratitude tomy Uncles Dr K.G.Joshi and late Shri. Gururaj.G.Joshi. I express my heartfeltgratitude to my brothers, Santosh and Ananda for constant help and encouragement tomove ahead. I take this moment to express my thanks to all my Post gratudecolleagues Dr Ashok M.G. Dr. Shivaleela, Dr. Kamalaxi, Dr. Sulochana,Dr.Vijayalakshmi, Dr. Sanjeeva, Dr.Neeraj, Dr. Veena. Jigalur, Dr. Mukta. Hiremath,Dr. Mukta. Arali. Dr. Anupama, Dr.Ishawar, Dr. Praveen Naik, Dr. V S Kanti, Dr.Bodake, Dr Trupti. Dr. Kavitha. Dr. Sarvamangala, Dr. Jaya M, Dr. Kalavati, DrSavitha, Dr. Adarsha, Dr. Nataraja, Dr. Udaya, Dr Shaileja, Dr. Ravi, Dr. Shivakumarand Mr. Shakti. Last but not least I express my deepest thankfulness whose names are not takenhere but helped me a lot along with my kith and kilns to my family members. PRASAN V JOSHI
  7. 7. Abstract of “Evaluation of efficacy of Varnya yoga in Vyanga w.s.r.t. Melasma”Key words: Vyanga, Melasma, Tab – Varnya, Cream – Varnya Vyanga vis- a- vis Melasma is one of the important disease pertaining tohyper Pigmentation disorders. It is considered under Kshudra rogas, which occursmainly due to vitiation of Vata, Pitta and Rakta. The study objective is to evaluateefficacy of Varnya yoga in Vyanga vis–a-vis Melasma. Simple random samplingtechnique with single group clinical trial is adopted. In the disease Vyanga animportant sign is the presence of niruja, tanu, shyava varnayukta mandala onmukhapradesha. Melasma is an asymptomatic, acquired and chronic condition withhyper pigmented macular lesion, develops slowly and symmetrically over molar area,bridge of the nose, forehead and temples and upper lips, more commonly seen infemale than male and is not accompanied by inflammation or any other systemicsymptoms. In this condition hyper pigmentation is due to increased melanocytesactivity in epidermal and dermal layer. Brhajaka pitta is mainly related to Varna of twacha. So Pitta is the maineculprit to cause Vyanga. Here all ingredients of Varnya yoga are Pittashamaka,Chandana is raktaprasadana, Padmaka , Manjista ,Payasya , Sita and Lata are Varnya.The parameters show High significance with Varnya yoga. Among subjective andobjective parameters, the parameter size and color shows more net mean effect thanthe other parameters. The parameter kandu, daha and Rukshat do not have more effectin this study. The parameter Snigdhata can be considered for the study and it showedimprovement after the treatment. Thus it is fair to conclude that the Varnya Yoga iseffective in Vyanga.
  8. 8. Contents of “Evaluation of efficacy of Varnya yoga in Vyanga w.s.r.t. Melasma” By Prasan. V. JoshiChapter Content Pages1 Introduction 1 t0 42 Objectives 5 t0 83 Literary Review 9 to 364 Methods 37 to 445 Results 45 to 656 Discussion 66 to 907 Conclusion 91 to 928 Summary 93 to 959 Bibilographic References i to iv10 Annex 1 – Master charts data of trial 1 to 811 Annex 2 - Case sheet 1 to 6 -1-
  9. 9. Tables of “Evalua tion of efficacy of Varnya yoga In Vyanga w.s.r.t. Melasma”SL TITLE OF TABLE PAGE1 Number of layers of Twacha and manifestation of diseases 122 Thickness of Twacha and reflection of diseases. 123 Layers of twacha according to different Acharyas 134 Correlation of Twacha with skin layers 135 Factors aggravating Dosha and Raktadhatu in Vyanga 236 Rupa of Vyanga according to different Acharyas 237 Vyadhi Vyavachedaka Nidana of Vyanga 248 Samprapti Ghatakas of Vyanga 259 Treatment modalities of Vyanga mentioned by different Acharyas 3110 Showing Drug Review 3411 Objective variables 4212 Gender wise Result 4613 Age wise Results 4714 Religion wise Results 4815 0ccupation wise Results 4916 Economic status wise results 5017 Diet wise results 5118 Vyasana wise Results 52 -2-
  10. 10. 19 Results by duration of the disease 5320 Distribution of patients by Presenting complaints 5421 Distribution of patients by associated features 5522 Distribution of patients by Lesion distribution 5623 Distribution of patients by Rasa and Guna of Ahara 5724 Results by Vihara 5825 Results by Manasika Hetu 5926 Results by Colour of Lesions 6027 Results by Number of lesions 6128 Results by size of lesions 6229 Results of Varnya yoga 6330 Statistical analysis of Results 64 -3-
  11. 11. Figures and Photos of “Evalua tion of efficacy of Varnya yoga In Vyanga w.s.r.t. Melasma”SL TITLE OF FIGURES AND PHOTOS PAGE1 Picture Showing skin structure 182 Picture Showing Melanocytes 183 Schematic Diagram of Vyanga Samprapti 264 Ingredients of Trial drug Varnya yoga 345 Fair and Lovely colour grading scale, Varnya tablet and cream 376 Patient’s photo’s before and after the treament 457 Distribution of patients by Gender 468 Results by Age 479 Distribution of patients by Religion 4810 Results by Occupation 4911 Results by Eccanomical status 5012 Results by Diet 5113 Results by Vyasana 5214 Results by Duration of disease 5315 Distribution of patients by presenting complaints 5416 Distribution of patients by associated features 5517 Distribution of patients by Lesion distribution 5618 Distribution of patients by Rasa and Guna of Ahara 57 -4-
  12. 12. 19 Results by Vihara 5820 Results by Manasika hetu 5921 Results by colour of lesion 6022 Results by Number of lesion 6123 Results by size of lesion 6224 Results of Varnya yoga 6325 Schematic representation of mode of action of lepa 80 -5-
  13. 13. CHAPTER – 1 INTRODUCTION The beauty and attraction of individual is reflected in the skins health(including general health). The colour of the skin is important biologically,cosmetically and socially. Skin diseases though afflicts bodily but gives lot ofpsychological disturbances. In this modern world, human being is becoming more andmore mechanical. It is obvious that we are not in harmonious cohesion with nature inwhich we are living. This moving away from the nature and modern life style has itsadverse effects on his Psychic and Somatic planes. The health in Ayurveda is defined as the homeostasis of the Tridoshas,Sapthadhatus and Trimalas. These when are impaired results in the ruja from whichthe roga meaning disease is etymologically originated.1This pain makes the humanbeing to lead a miserable life. Hence it is important to maintain these in normalcy. Ayurveda, a holistic health science is providing its service to mankind sinceancient time. It has not only curative perspective, but also maintains the uniqueconstitutional balance of a person. Still the same is continuing with more and moreglobal support. From the time of ancient Indian to present, all cultures and through span ofcenturies, mankind has been preoccupied with youth and physical appearance. Atsome point in lifetime of every men and women, concern with quality of his / her skinbecomes a priority. The skin would reflect any unhealthy state of the physique or thepsyche as beauty manifests through the appearance of the complexion of the skin.Introduction to Evaluation of the efficacy of Varnya Yoga in Vyanga W.S.R.T. Melasma 1
  14. 14. Human skin is biological marvel. Skin is the largest organ in the body both byweight and surface area. Whether we admit it or not, society places a high value onappearance. Today in market the corporate world is attracting the public towards cosmetics asAyurvedic products so we can say that Ayurveda is the reason behind glowing,glittering and beautiful faces. The word cosmesis (Gr- Kosmesis) means, The preservation, restoration or bestowing of bodily beauty. Surgical correction pf disfigured physical defects.2 Face the most important and beautiful organ of the body is affected by certainanomaly at the any age of the life. Early physical and psychological precautionarymeasures are essential in either of the sexes, as any minor ailment may affect fromunattractive look to a permanent disfigurement, which may result in inferioritycomplex or sometimes even isolation. The disease ‘Vyanga’ is one such diseasecounted under Kshudra roga (which mainly affects the glowing complexion of aperson by producing Shyava varny mandalas on mukhapradesh).3 Kshudraroga Rogas are minor diseases having simple etiology and symptoms,but in exceptional cases these can produce a marked cosmetic disability and give riseto much mental stress. As Vyanga is a distressing disorder, there is a definite need fortreatment as a disease and of cosmetic value too essential. In the disease Vyanga an important sign is the presence of niruja, tanu, shyavavarnayukta mandala on mukhapradesha.4According to Modern view, the mandalascan be taken under the heading of pigmental disorder. The disease Vyanga can becorrelated with hyper pigmentation with special reference to Melasma. In this, thepatches of hyper pigmentation are seen especially on cheeks, nose, forehead andIntroduction to Evaluation of the efficacy of Varnya Yoga in Vyanga W.S.R.T. Melasma 2
  15. 15. chin.5Their treatment varies according to the primary cause of the disease. But itincludes an external application of creams containing hydroquinone andhydrocortisone, which is found to be sensitive in few patients.6 Some times frequentand long-term usage of these preparations may produce the irritation. The chances ofreoccurrence are more after discontinuation of the treatment. So there is a definiteneed for treatment to overcome this problem. At the same time effective, safe andeconomically cheaper method of treatment is also essential. Ayurveda relatively proved to be efficacious in the treatment of skin diseases.Shodhana and shamana therapies are the two procedures mainly adopted in thetreatment of diseases. The general line of treatment of Vyanga includes Vamana,Virechana, Raktamokshana, Abhyang, Lepa and Abhyantaroushadhi.7 In Ayurveda, skin is a route of administration of drugs, is considered equallyimportant, as the other routes of administration and many preparations in differentforms are available in classics, which are to be used topically in variety of diseases.The Lepa helps in removing the doshas locally.8 So lepa was selected for the management of Vyanga to make the treatmentsimple, effective and convenient to the patients. In the pathology of Vyanga vata, pitta and rakta are vitiated. As the drayas ofVarnya Mahakashaya gana has tikta, madhur rasa; madhura vipaka; sheeta veerya;raktashodhak and vyangaghna (varnya).9 It pacifies vata, pitta and rakta. Thus, presentstudy is intended to know the effect of the Varnya yoga internally and externally aslepa in Vyanga, as these are explained as capable of destroying hyper-pigmentationfound on mukhapradesh.Introduction to Evaluation of the efficacy of Varnya Yoga in Vyanga W.S.R.T. Melasma 3
  16. 16. Incidence / Prevalence of Vyanga The exact incidence is not known but it is a common skin condition amongdarker individuals. It is relatively more frequently encountered among females. Researches on Vyanga(1) Effect of Nasya Karma in Vyanga by Prakash, P.G. Thesis, 1994, Mysore(2) Clinical management of Vyanga with Manjishtha-Madhu Alepa with and without Kumkumadi Taila Nasya by Anitha, P.G. Thesis, 1999, Hyderabad(3) A study on Ayurvedic Cosmetic formulations w.s.r. to Vyanga Roga, Swapna C., P.G. Thesis, 2000, Trivendrum(4) Evaluation of the efficacy of Mukha Lepa in Vyanga w.s.r. to Arjuna tvak lepa and Pancha-Nimba choorna internally- A clinical study by Angadi Savita S., P.G. Thesis, 2001, Bangalore(5) Raktachandnadi Lepa Nirmana evam Uske Guna-Karmo ka Vyanga ke Pariprekshya mein Aturalayein Adhyayana by Sahu Swapna, P.G. Thesis, 2002, NagpurIntroduction to Evaluation of the efficacy of Varnya Yoga in Vyanga W.S.R.T. Melasma 4
  17. 17. CHAPTER 2 OBJECTIVES OF THE STUDY Vyanga is a ‘Kshudra Roga’. Then why this problem has been selected forResearch work? There are certain specific reasons behind the selection of problem. Inrecent era everybody wants to succeed in his /her field and to go ahead than others. Soit becomes necessary that each and everyone should have some extra qualities whichmake his personality different to others. Success depends on individual’s workingefficiency, knowledge and personality. Thus personality plays an important role toachieve goals and to place one on the top in the society. A good personality helps notonly in business and carrier but also in day to day communication. The increaseddemand of beautification is evident by number of beauty contests, beauty centers,various cosmetic items like creams, lotions, soaps, powder and chemical reagent etc. Cosmetology has developed as a special branch in modern medical scienceand is in great demand in public. A variety of treatment modalities exist and newerones are continuously being introduced to tackle the cosmetic problems like scars,wrinkles, hyper pigmentary skin problems etc. There is enough description regarding maintenance of natural beauty inclassical texts but there was no need to separate the cosmetology as a special branchat that period. Now it is the time to highlight the Ayurveda in the world of cosmeticwith its unique aspects. The adverse reactions of modern cosmetics and higher cost oftherapy are also one of the causes to look towards Ayurveda for its humeral approach.Increased sophistication of today’s population also increases the demand ofcosmetics. Manufacturers have fully exploited this demand.Objectives of Evaluation of the efficacy of Varnya Yoga in Vyanga W.S.R.T. Melasma 5
  18. 18. Many unscientific cosmetic products are available named as herbal or naturalproducts in the market. In this atmosphere people expect a lot from Ayurvedicphysician for effective, cheaper and harmless therapy. The incidence of Vyanga is increasing at a rapid rate due to environmentalfactors, occupational reasons, use of cosmetics etc. Female suffer more than male dueto hormonal changes occurring at particular stage. Vyanga directly affects the beautyof face. Person may feel inferiority; isolation etc. thus psychological problems mayalso arise. Modern medical science has also some limitation to cure the disease likeVyanga.Therefore, there is a need for proper understanding of such problems of the societythrough Ayurvedic perspectives and to find some effective steps of management.The present research work has been planned with following aims and objectives.Aims and objectives of the study;(1) To study the disease Vyanga with its etiopathology and symptomatology to Ayurvedic as well as modern literature(2) To asses the efficacy of Lepa and Abhyantara prayoga with Varnya yoga in themanagement of Vyanga with Reference to Melasma.(4) To evaluate the efficacy of Varnya yoga with reference to Pitta dosha.(5) To study about Ayurvedic approach in the field of Cosmetology.Reasons to Choose Following Therapies for Present Study: Ayurveda believes that the management of pigmentation disorders of the skin,which are giving agony to psyche that is Manas, includes Topical administration ofthe drugs along with systemic medication. Considering these factors present study isundertaken to minimize the hyper pigmentation, which is the typical nature of thisdisease. Here an attempt is estimated to make the sufferer free from clinical symptom.Objectives of Evaluation of the efficacy of Varnya Yoga in Vyanga W.S.R.T. Melasma 6
  19. 19. Varnya Mahakashaya Gana mentioned in Charaka samhita said to be timetested. This Varnya yoga contains mainly Pitta shamaka drayvas. Pitta (Bhrajaka)dosha is the main culprit to cause vikruti of Varna, so this yoga is used internally.Yogaratnakara advocates the similar combination with slight modification in theingredients for external use, so its efficacy on external use along with internalmedication is established. In Charaka samhita Varnya maha kashaya is advised for internal use. In thesedays patients prefer to take tablets than kashayas and tablets are more convenient totake internally. So for these reasons fortified tablets of 500 mg of Varnya mahakashaya gana are prepared. Lepa kalpana is one of the main components of Bahi parimarjana chikitsa.Lepa or external application of medicinal drugs is the choice of treatment in variousskin disorders, swellings, painful conditions etc. It also has a cosmetic value as itregulates the pigmentation of skin in hyper or hypo pigmentation. So for this reasonlepa is selected as a therapy for this clinical trial. Lepa is a procedure where the medicine is made in the form of paste withmilk or kanji or gomutra or water and applied to the skin. But For the convenience ofapplication, for better absorption of the drugs and to provide therapeutic efficacy thecream is prepared with the ingredients of Varnya maha kashaya gana.Research question:Whether internal administration of contents of Varnyamahakashaya gana in the formof tablets and external application in the form of cream is effective in vyanga vis- a-vis Melasma or not?Objectives of Evaluation of the efficacy of Varnya Yoga in Vyanga W.S.R.T. Melasma 7
  20. 20. Hypothesis:(1) Internal administration of contents of Varnyamahakashaya gana in the form oftablets and external application in the form of cream is effective in vyanga vis-à-visMelasma.(2) The Varnya yoga is Pitta shamaka and Varnya.Objectives of Evaluation of the efficacy of Varnya Yoga in Vyanga W.S.R.T. Melasma 8
  21. 21. CHAPTER 3 LITERARY REVIEWHISTORICAL REVIEW The meaning of historical review is to trace out a continuous chain ofknowledge and by that come to know that where at present. The history of medicine isas old as human civilization. Plenty of disorders have been found referred in theancient literatures of Veddic period, either directly having the disease itself or byhaving the nature of the disorder.Etymology of word Vyanga Vyanga – “vikrutani angani yasya”. 10 It means deformity of the body part. Heir vikruti of anga ie, Twak not meansthe anatomical deformity but it is related with vikruti of varna as in this disese varnaof twak changes to Shyava varna.Samhita kala: Most of the Acharyas have mentioned Vyanga in the chapter of ‘KshudraRoga.Charaka Samhita Maharshi Charaka and Sushruta have considered Vyanga as a ‘Raktaja Roga’too.11 Maharshi Charaka has given common samprapti for Tilakalaka, Piplu, Vyangaand Neelika in Trishothiya Adhyaya.12 Maharshi Charaka has described abovediseases along with description of local swelling (Ekdeshiya Sotha) of other organs inTrishothiya Adhyaya. Though there is no or rarely elevation of skin is found in abovediseases, it seems that due to local manifestation of the disease, he has described themin this chapter. As Maharshi Charaka has not mentioned the chapter of the ‘KshudraRoga’, the detail or separate description about the disease Vyanga is not found.Literature of Evaluation of the efficacy of Varnya Yoga in Vyanga W.S.R.T. Melasma 9
  22. 22. Sushruta Samhita Maharshi Sushruta has also considered Vyanga as Raktaja Roga like wiseMaharshi Charaka. More than this Maharshi Sushruta was the first person who hasgiven a detail and separate description of the disease Vyanga in the chapter of‘Kshudra Roga.13Astanga Sangraha A little advanced description was given by Vagbhata He gave the DoshanusaraLakshana of the disease.14Kashyapa Samhita Maharshi Kashyapa described Raktaja Roga15 he did not consider Vyanga inthose lists of Raktaja Roga like Sushruta and Charaka.Madhyakala : Acharya Madhavakar16, Sharangadhara, 17 Yogaratnakar 18and Bhavamishra 19has mentioned the disease.DISEASE REVIEW Before startling any research on a disease, the researcher should have theknowledge of Anatomy and physiology of related disease. The researcher shouldexplain etiology, Pathologenesis and available different treatment modalities of thedisease. If necessary the information available in other system of science can becollected and correlated. Considering all these points here, Shareera Rachana andKriya of twacha, Nidanaa panchaka and different types of Chikitsas for vyanga areexplained in detail. In this study Vyanga is compared with Melasma of contemproryscience and its Physiopathology is explained in detaile.Literature of Evaluation of the efficacy of Varnya Yoga in Vyanga W.S.R.T. Melasma 10
  23. 23. RACHANA SHARIRA OF TWCHA: It is necessary to go through the pre-requisite knowledge of the disease beforeproceeding into the study of the disease. Shareera is the base on which the subject ofmedicine stands. The detailed knowledge of Anatomy and Physiology is important toknow the pathogenesis of the disease without which the treatment is not successful.Vyanga is considered as one of the dwiteeya twagaasrita (lohita) kshudraroga.20Herein this context the primary knowledge of shareera rachana and shareera kriya of thetwacha is dealt.Etymology of Twak: The word Twacha is derived from “Twacha samvarane”means, the one, which covers entire body. 21Definition: One of the indriyadhisthana, which completely cover meda, shonita andall other dhatus of the body and gets covered all over the body. It is considered as theseat of sparshanendriya as well as one among the main seat of vata.22Formation of Twak: Twak is the upadhatu of mamsa, so ultimately twak is formedby mamsa23. It is one among the matrujabhavas.24 At the time of fertilization shukra, shonita and atma become united to formgarbha. Its growth is rapid and nourished by tridoshas. Seven folds of the layers ofskin are formed and deposited on this rapid transforming product in the same manneras the layers of cream is formed and precipitated on the surface of the boiling milk.25Twak is formed by the paka of rakta, by its dhatvagni. After the paka of rakta, by itsdhatvagni, rakta becomes dry in the form of skin like the deposition of cream on thesurface of the boiling milk.26Panchabhutikatva of Twacha: Body constitutions are the result of Panchamahaboota combination. All the mahabootas take part during formation of bodyorgans in Garbhavastha.27Panchamahabootas is also responsible for varnottapatti.Literature of Evaluation of the efficacy of Varnya Yoga in Vyanga W.S.R.T. Melasma 11
  24. 24. The combination of Jala, Akasha & Agni mahabhootas gives avadata varna.TheKrishna varna produced by the combination of Prithvi, Vayu & Agni mahabhootas.Mahabhootas in equal proportion gives Shyama varna.28Layers of Twacha: There are some different opinions regarding the number of thelayers of the Twacha among the ancient Acharyas. Maharshi Charaka has mentionedsix layers of twacha, but only first two layers are named and rest of the four layers arecounted as producing diseases.29 Table No. 1. Number of skin layers and manifestation of diseases SI.NO KALA CONTENTS 1 Udakadhara - 2 Ashrukdhara - 3 3rd Manifestation of sidhma and kilas. 4 4th Manifestation of dadru and kustha 5 5th Manifestation of Alaji and vidradhi 6 6th Manifestation of ArunshiMaharshi Sushruta has mentioned seven layers of skin along with their specificname, thickness and prone origination of the disease.30 Table No. 2. Layers and thickness of twacha and reflection of diseases. SL LAYERS THICKNESS REFLECTION OF DISEASE (IN VREEHI) 1 Avabhasini 1/18th Sidhma, Padmini, Kantaka. 2 Lohita 1/16th Tilakalaka, Vyanga, Nyachha. 3 Sweta 1/12th Charmadala, Ajagallika, Mashaka. 4 Tamra 1/8th Kilas, Kustha. 5 Vedini 1/5th Kustha, Visarpa. 6 Rohini 01 Granthi, Apachi, Arbuda, Sleepada, Galaganda 7 Mamsadhara 02 Bhagandara, Vidradhi, Arsha.Literature of Evaluation of the efficacy of Varnya Yoga in Vyanga W.S.R.T. Melasma 12
  25. 25. Sharangadhara has also mentioned 7 layers of the skin along with probable onset ofdisease. The name of first six layers is same as Sushruta, but 7th layer is called Sthula,which is the site of Vidradhi.31 Table No. 3. Different layers of twacha according to different Acharyas SUSHRUTA CHARAKA ASTANGA SHARANGADHAR BHELA Avabhasini Udakadhara Udakadhara Avabhasini Udakadhara Lohita Asrukdhara Asrukdhara Lohita Asrukdhara Sweta 3rd 3rd Sweta 3rd Tamra 4th 4th Tamra 4th Vedini 5th 5th Vedini 5th Rohini 6th 6th Rohini 6th Mamsadhara - - Sthula - Thus, fundamentally there is no difference in the number of the layers said bythe various Acharyas. Dr. B.G. Ghanekar has correlated the layers of skin describedby Sushruta and modern anatomy. Table No. 4. Correlation of twacha with skin (modern science) Anicient Term Modern Term Parts of skin Avabhasini Stratum Corneum Epidermis. Lohita Stratum Lucidum Epidermis. Sweta Stratum Granulosum Epidermis. Tamra Malpighian Layer Epidermis. Vedini Papillary Layer Dermis. Rohini Reticular Layer Dermis. Mamsadhara Subcutaneous tissue and Muscular Layer Dermis.KRIYA SHARIRA:Twak and Tridosha relations:1. Vata dosha: Vata dosha has definite relation with twacha, as it is adhistana ofsparshanendriya. 32 Udana vayu is responsible for varna.33Literature of Evaluation of the efficacy of Varnya Yoga in Vyanga W.S.R.T. Melasma 13
  26. 26. 2. Pitta dosha: Prabha is the main function of pitta dosha34and twacha is the seat ofPittadosha.35When pitta gets vitiated, and then twacha becomes peeta varna36andwhen pitta kshaya occurs then laxanas like prabhahani are seen.Bhrajaka Pitta: Twacha is seat of bhrajaka pitta, as it responsible for colour & complexion oftwacha. The drugs used for abhyanga, parisheka, lepa, avagaha etc are absorbed withthe help of bhrajaka pitta.37Ranjaka Pitta: By its rasaranjana karma, indirectly Ranjaka pitta gives varna to twacha.383. Kapha dosha:Kaphapradhana prakriti purushasare attractive.39which indicates that kapha is mainlyresponsible for luster and texture of the twacha.Twak and Dhatu relations:Rasa: The sara of rasa dhatu is assessed by looking in to the skin and the roma, twakroukshata is the sign manifested in the rasa kshaya, shaithya is generated as a result ofrasa dhatu vruddhi40hence it is postulated that twacha is nourished by rasa dhatu and itis responsible for the maintenance of the temperature of the body in its normalcy.Rakta: Among its functions Varna prasadana (provide colour of skin) and mamsapushti have been mentioned. The manifestation of raktapradoshaja vyadhis likeVisarpa, vyanga, Tilakalaka etc, occurs through twacha which indicates the relationbetween Twacha and Rakta.41Literature of Evaluation of the efficacy of Varnya Yoga in Vyanga W.S.R.T. Melasma 14
  27. 27. Mamsa: The prasada bhaga of Mamsa nourishes the twacha, as it is the upadhatu ofMamsadhatu.42Twacha is moola of mamsavaha srotas.43Majja: The majjasara purusha is having snigdha twacha44 and twacha sneha is majjamala.45It establishes a relation between twacha and majja.Shukra: If the parental Shukra is like ghritamadavat, tailavat or like madhu then in thefuture the child gets gaura, Krishna or shyama varna respectively.46Twak and Mala relations:Sweda: It is mala of meda, which is excreted through twacha. It is said as udakaswaroopa maladravya which gets nishpatana from the romakoopa and twakrandra.47The karya of sweda is told as maintenance of shareera ardrata and twaksoukumaryata.48The kshaya and vruddhi lakshanas of sweda are manifested in thetwacha only.49Concept of Varna : In Ayurveda the word ‘Varna’ is used for both for colour and complexion.Every person has some particular skin colour and complexion. Many combinations offair and dark colour and complexion are visible. Genetic factor is important indetermination of an individuals basic skin colour. As the skin colour is mainlydependent upon genes, nothing more can be done but complexion and radiance of theskin can be maintained or increased by taking proper care as protection from excesssunlight, frequent cleaning etc.Literature of Evaluation of the efficacy of Varnya Yoga in Vyanga W.S.R.T. Melasma 15
  28. 28. Definition of varna “Varnabhedena glani harsha rouksha sneha vyakhyatha |” 50 According to Charaka ‘Harsha’ and ‘Sneha’ words indicate that the meaningof the Varna is not just colour but it includes all the parameters of healthy and radiantskin. A soft good healthy skin gives glowing appearance and a radiantcomplexion.49The total health of the skin is reported by its texture, color, tone, luster,complexion etc. In Ayurveda, terms like Kanti, Prabha, Chhaya, Varna etc. are usedregarding the subject. Among them Varna word is used in a broader aspect whichincludes most of the parameters which are necessary for healthy skin. In this way,Ayurveda has its own detail and deeper sense regarding the subject.Prakrita Varna :According to Maharshi Charaka four colours are considered as normal colour. 51 1) Krishna 2) Shyama 3) Shyamavadat 4) AvadatMaharshi Charaka said that the colour which is since birth is normal and if it changesin later age due to some disease condition it is called Vikrita.52Vikrita Varna : 1) Nila 2) Shyama 3) Tamra 4) Harita 5) ShuklaLiterature of Evaluation of the efficacy of Varnya Yoga in Vyanga W.S.R.T. Melasma 16
  29. 29. If colour is changed by Rasayana Therapy, it is also Prakrita though it is changed atlater age. Factors Responsible for Creation of Colour and Complexion are53(A) Genetic Factors • Kula (Hereditary or germinal) • Jati(Racial) e.g. In Nigro - Krishna Varna In Japanes - Shwetabhpitta In Europian - Gaura Varna In Indian - Gaura / Shyama / Krishna(B) Desha (Climatic) • Shita pradesha - Gaura Varna • Ushna pradesha - Krishna Varna • The other factors like Matrija ahara and vihara,Pancha mahabhootas, Tridoshas, Dhatus and Agni are responsible for the varna of shareera.Literature of Evaluation of the efficacy of Varnya Yoga in Vyanga W.S.R.T. Melasma 17
  30. 30. THE SKIN FIG.No – 1 PICTURE SHOWING SKIN STRUCTUREFIG .No– 2 PICTURE SHOWING THE MELANOCYTESLiterature of Evaluation of the efficacy of Varnya Yoga in Vyanga W.S.R.T. Melasma 18
  31. 31. THE SKINNORMAL STRUCTUR The skin is the external organ that protects against mechanical trauma, UVlight, and infection. In addition, the skin is concerned with thermoregulation,conservation and excretion of fluid, sensory perception and of course, has aestheticrole. The histology of normal skin shows some variation in different parts of thebody. In general it is composed of 2 layers, the epidermis and the dermis, which areseparated by an irregular border. Cone shaped dermal papillae extends upwards in tothe epidermis.54EPIDERMIS: The epidermis is composed of the following 5 layers from base to the surface. 1. Basal cell layer (Stratum germinatum): The basal cell layer consists of a single layer of keratinocytes that forms thejunction between the epidermis and dermis. The nuclei of these cells areperpendicular to the epidermal basement membrane. These are hyperchromatic andnormally contain a few mitoses indicating that the superficial epidermal layersoriginate from the basal cell layer. These cells are interconnected each other and withthe overlying squamous cells by desmosomes. Depending upon the complexion of theindividual melanocytes, which are type of dendritic cells, are seen interspersed in thekeratinocytes of the basal layer.55 Melanocytes: The chief determinant of the colour of the skin is the pigment melaninproduced by melanocytes. Melanocytes synthesize and secrets melanin containingLiterature of Evaluation of the efficacy of Varnya Yoga in Vyanga W.S.R.T. Melasma 19
  32. 32. organelles called melanosomes. Besides the epidermis, external hair root sheaths andhair bulbs, melanocytes are found in the dermis, eyes and a few other tissues.Melanocytes have small nuclei with clear cytoplasm containing melanin granules andare usually spaced as every tenth cell in the basal layer. They are always positive withdopa reaction. The other types of dendritic cells in the basal layer are Langerhanscells which belong to mononuclear phagocyte system. Melanosome development in the melanocytes occurs in four stages. Oncemelanasomes are formed, melanized and transported to the tips of the dendrites, theyare transformed to the surrounding keritinocytes of the epidermal melanin unit.The tip of the melasnasome containing dendrite is embedded in the cytoplasam of akeritinocyte which pinches off a part of the dendrite like aphagocyte. This process oftransfer of melanasomes to keratinocytes is known as apocopation. In the epidermis,melanosomes are arranged above the nucleus of the keratinocytes, towards the skinsurface.Types of melanins: There are two types of melanins(1) Eumelanins: Eumelanins give the brown or black color to the skin and the hair.(2) Phaeomelanin: This is responsible for yellow to reddish brown shades of hair Color.Both Eumelanins and Phaeomelanin are derived from the amino acid tyrosine. Thedistribution of epidermal melanocytes varies in different parts of the body. Thereis no sexual or racial variation in the density of melanocytes in the skin. Thedifference in the color is due to the differences in the size, packaging, distribution anddegradation of melanosomes within keratinocytes. Melanosomes in dark skin arelarger, more numerous, more melanised and more slowly degraded. The melanocytesLiterature of Evaluation of the efficacy of Varnya Yoga in Vyanga W.S.R.T. Melasma 20
  33. 33. of black color skin are larger and more dendric. Epidermal melanocytes diminish innumber with ageing.Melanocytes stimulating factors: Ultraviolet light, harmones such as melanocytestimulating hormone (MSH),adrenocorticotropic hormone (ACTH), estrogen andthyroxine.Functions of melanocytes: Melanocytes protect the skin from the injurious effects of sunlight, especiallyits UV spectrum.562. Prickle cell layer (stratum spinosum, stratum malpighil): This layer is composed of several layers of polygonal prickle cells orsquamous cells. The layers becomes flat as they near the surface so that their long axisappears parallel to the skin surface and posses’ an intercellular bridge or tonfilaments. These intracellular cytoplasmic tonofilaments contain PAS – positivematerial that is precursor of keratin.3. Granular cell layer (Stratum granulosum): This layer consists of 1to 3 layers of flat cells containing kerotohyalinebasophilic granules, which are PAS – negative. Granular cell layer is much thicker inpalms and soles.4. Stratum lucidum: The layer is present exclusively in palms and soles as a thin homogenous,eosinophilic, non-nucleate zones.5. Horny layer (stratum corneum): The stratum corneum is also normally devoid of nuclei and consists ofeosinophilic layers of keratin.Literature of Evaluation of the efficacy of Varnya Yoga in Vyanga W.S.R.T. Melasma 21
  34. 34. Intra epidermal nerve endings are present in the form of Merkel cells, which are touchreceptors.DERMIS: The dermis consists of two parts - the superficial papillary dermis and thedeeper reticular dermis. The dermis is composed of fibro collagenic tissue containingblood vessels, lymphatics and nerves. Beside these structures, the dermis contains cutaneous appendages or adnexalstructures. These are sweat glands, sebaceous glands, hair follicles errectores pilorumand nails.57VYANGANIDANA PANCHAKA Starting from the indulgence in the causative factors up to the completemanifestation of the disease including prognosis comes under Nidana panchakas. Theperfect knowledge of which is very much essential for a proper diagnosis and a line oftreatment.NIDANA For every action to take place a reason is required which is termed as nidana inthe context of disease manifestation process. It may be depicted as the causative factoror basic factor, which induces a disease.Literature of Evaluation of the efficacy of Varnya Yoga in Vyanga W.S.R.T. Melasma 22
  35. 35. Table No. 5 showing the factors aggravating dosha and Raktadhatu in Vyanga 58Nidana Vata prakopa Pitta prakopa Rakta dustiAaharaja Apatarpana Katu Excess Ushna Ruksha Amla Excess Lavana Kashaya Ushna Excess Kshara Tikta Tikshna Excess Amla Vidahi Excess Katu Dadhi ViruddhannaViharaja Aayaasa Aatapa Divasvapa Vyayma Aatapa Jagarana Anala Vega- Abhighata VidharanaManasika Atishoka KrodhaKalaja Greesma Sharada RituPOORVA ROOPA No one author has explained the Poorva roopa of Vyanga in the classics.ROOPA:Table No:6 Showing the Rupa of Vyanga according to different Acharyas59 - 63Sl No. Characteristics Sushruta A.H M.N B.P Y.R1 Shyava varna + + + + +2 Nirujam + _ + + +3 Tanu + + + + +4 Mandal + + + + +Literature of Evaluation of the efficacy of Varnya Yoga in Vyanga W.S.R.T. Melasma 23
  36. 36. VYADHI VYAVACHEDAKA NIDANA:There are some diseases having almost nearer to same clinical features like Vyangawhich are counted under differential diagnosis.64 Table No.7 Vyadhi Vyavachedaka NidanaFeature Vyanga Mashaka Tilakalaka Nyaccha Neelika Krishna Krishna Shyava/Colour Shyava Krishna /Nila like Masha like Tila Krishna Any part of Any part of Any partSite Mukha the the of the Shareera+Mukha Shareera Shareera Shareera Elevated/ Non – Non -Elevation Elevated Non Non -elevated elevated elevated elevatedShape Mandala Like Udad Like Tila Mandala Mandala-- -- -- -- Since birth --SAMPRAPTI:The Samprapti of Vyanga is not explained in detaile in any of the classical texts.According to Sushruta:Krodha and Aayasa cause vitiation of Vata and Pitta. The vitiated doshas reaches themukha and produces the disese called as Vyanga. In this disease the shyava varna ismainly due to the predominance of Vata Dosha.65According to Astanga Hrudaya: Vata and Pitta gets aggravated by Shoka and Krodha etc produces tanu,shyava varna, niruja mandalas on the face to be termed as Vyanga.66Literature of Evaluation of the efficacy of Varnya Yoga in Vyanga W.S.R.T. Melasma 24
  37. 37. According to Charaka: The aggravated pitta gets dried up in combination with rakta and produces skindisease Vyanga.In other references, we find the same Samprapti as mentioned inSushruta.67Table.No. 8 showing Samprapti Ghataka:Dosha Vayu ,Pitta.Dooshya Dhatu Rasa , Rakta.Upadhatu TvakSrotas Rasavaha,RaktavahaAgni Jatharagni,Dhatvagni(Rasagni, Raktagni)Marga ShakhagataSthana TvakLiterature of Evaluation of the efficacy of Varnya Yoga in Vyanga W.S.R.T. Melasma 25
  38. 38. NIDANA-SEVANA Dooshya Dosha Agni Srotodushti Daurbalya Prakopa Vikriti Vata PittaKhavaigunya Rasa Rasavah Dushti Rakta Raktavah Dushti Twacha of mukha(Sthana Sansraya)Vyakta Lakshana (Nirujam, Tanukam, Shyav Mandal) VYANGAFIG.No 3Literature of Evaluation of the efficacy of Varnya Yoga in Vyanga W.S.R.T. Melasma 26
  39. 39. All the causative factors mentioned as above, have fourfold effect uponDosha, Dooshya, Agni and Srotas. Due to these various Nidanas(1) Dosha chaya especially of Vata and Pitta Dosha.(2) Dooshya daurbalya in the form of Rakta prakopa as well as vigunotpatti of Rasa dhatu.(3) Agni vikriti which again helps in Dosha prakopa and Dooshya daurbalya.(4) Rasavah and Raktavah Srotas vaigunya take place. Dooshya daurbalya leads tosthanasansraya. This is the actual stage of Dosha Dooshya Sammurchhana. Thevitiated Vata dosha along with Rakta and Pitta dosha produce Shyava (blackish)discolouration which is nothing but the rupavastha of the disease Vyanga. At thisstage exact clinical features of the disease are evident according to the involvement ofthe doshas.BHEDA: According to the Dosha predominancy, the disease Vyanga may be categorizedinto four subtypes as,(1) Vatika: The mandalas are charectersticaly having Shyava varna. On sparshamadalas are Khara or Parusha.(2) Paittika: The varna of this type of mandalas may be either Tamra or Nila.(3) Kaphaja: The mandalas of this type having Sweta varna and it may be associated with kandu.(4) Raktaja: The mandalas are Rakta or Tamra Varna and may be with daha.68Literature of Evaluation of the efficacy of Varnya Yoga in Vyanga W.S.R.T. Melasma 27
  40. 40. MODERN CONCEPT:Melasma: Synonyms: Melasma, Mask of pregnancy, Liver spotDefinition: Melasma is an asymptomatic, acquired and chronic condition with hyperpigmented macular lesion, develops slowly and symmetrically over molar area, bridgeof the nose, forehead and temples and upper lips, more commonly seen in female thanmale, and is not accompanied by inflammation or any other systemic symptoms.Etiology: (1) Exposure to UV radiation (2) Pregnancy (3) Hormonal therapy (4) Cosmetics (5) Ant seizer medication (6) Genetic (7) Miscellaneous → Thyroid autoimmune disorders and Hepatic disorders.Pathogenesis: Melanocytes are increased in number and activity, with an associated increasein the formation, size and melanisation of melanosomes. The melanosomes aresubsequently transferred to the epidermis and or dermis. Within the keratinocytes,melanosomes are packed singly.Literature of Evaluation of the efficacy of Varnya Yoga in Vyanga W.S.R.T. Melasma 28
  41. 41. Clinical features: Symmetrical irregular sharply limited light brown / dark brown pigmentationof face.Treatment: • Sun protection: it is very important. Use a broad-spectrum very high protection factor sunscreen of reflectant type and apply it to the whole face. • Avoid irritating the skin. No strong soaps or abrasive cleaners – use only a mild soap or cleanser for washing. Bleaching creams: these contain hydroquinone, which inhibits formation ofnew pigment. These must applied for at least 6 months to obtain worthwhilelightening of pigmentation. Even then, just a wiff of summer sun can darken thepigment again and spoil months of hard work. Avoid applying bleaching cream tonormal skin, as this will lighten as well.Prognosis: The predominantly epidermal type of melasma responds better than thepredominantly dermal type. Melasma of pregnancy fades away within a few monthsof delivery.69CHIKITSA: Various Ayurvedic texts prescribed the various types of effective medicinesfor the disease Vyanga. In addition certain special yogas are mentioned which notonly cure the Vyanga but also they are said to increase the beauty, luster andcomplexion of the face.Literature of Evaluation of the efficacy of Varnya Yoga in Vyanga W.S.R.T. Melasma 29
  42. 42. Mainly two types of the therapies are found to be advised for the diseaseVyanga as A. Shodhana therapy like Vamana, Virechana, Nasya, Raktamokshana etc. B. Shamana therapy in the form of internal medicines and external application of drugs in the form of Lepa, Oils etc.70A. Shodhana Therapy: Though Vyanga is a Kshudraroga and locally manifested disease, it also requiresspecial treatment like Shodhana in advanced stage of the disease. Many classical textsindicated Shodhana therapy for the disease Vyanga.71, 72B. Shamana Therapy: For the treatment purpose many herbal as well as mineral preparations insingular or compound form are advocated either internally, externally or both ways.Local or External applications: As the disease has locally spread over the skin of the face the local or externalapplications have immediate impact upon the Vyanga. In Ayurvedic and Allied texts,many drug recipes are prescribed for the topical use in the form of powders, pastes,oils, ghee etc. The method advised for the application may be as Prakshalan,Swedana, Abhyanga, Lepana, Udvartana, and Gharshana etc.Literature of Evaluation of the efficacy of Varnya Yoga in Vyanga W.S.R.T. Melasma 30
  43. 43. Table No. 9 showing the treatment modalities of Vyanga mentioned by differentAcharyas73 - 79Treatment modalitie Cha S.S A.H A.S B.P Y.R B.R CDLepa - + + + + + + +Abhyanga - - + + + + + +Pradeha - + - - _ - -Pana - - - - + _ - -Nasya - - + + - - -RaktamoKshana - + + + + + - -Vamana - - - + - - -Virechana - - - + - - -ChikistaThe Ayurvedic classics have mentioned three types of treatment as80 1) Antah Parimarjana 2) Bahi Parimarjana 3) Shastra Pranidhana Bahi Parimarjana means, the medicine intended for external use only. For thatpurpose, in Ayurveda different forms of external applications are described for theconvenience of treatment of different diseases. They are Lepa, Udvartana, Upanaha,and Abhyanga etc. So far as the Lepa Kalpana is concerned, Acharya Charaka has described 32formulations of Lepas in ‘Aaragvadhiya Adhyaya’81 but neither he himself norLiterature of Evaluation of the efficacy of Varnya Yoga in Vyanga W.S.R.T. Melasma 31
  44. 44. commentator Chakrapani touched the various pharmaceutical aspects of LepaKalpana.Synonyms Lepa:Aalepana is also known as Lipta, Lepa, and Lepana.Definition of Lepa: Wet medicinal drugs are maid into paste form, if the drugs are in dry state theyare converted into paste form by adding little quantity of water and grinding. Thispaste is used in external application and called Lepa Kalpana.82Importance of Lepa Kalpana: Maharshi Sushrut has mentioned the importance of Lepa Kalpana very well bygiving a nice example. By poring water over burning house, the fire is extinguishedimmediately; in the same manner the Lepa pacifies the provoked local Doshas bylocal application.83Types of Lepa Kalpana:There are 3 types of Lepa according to their action - Doshaghna Lepa: - Includes drugs which act directly on the Doshas. Vishagna Lepa: - Includes a drug which nullifies the poisonous substances. Varnya Lepa: - Local application over the face to improve colour andcomplexion. Chandana, Manjishtha, Ushira, Sariva are some of the drugs which areattributed with this Varnya Property. So many Varnya Lepas are quoted in our texts.84PATHYAPATHYA: According to Yogaratnakar, Pathyapathya is depending on dosha, Dooshya, andavastha of the Vyanga. i.e., indulgence in the dietary regimen and mode of life whichLiterature of Evaluation of the efficacy of Varnya Yoga in Vyanga W.S.R.T. Melasma 32
  45. 45. aggravate the Tridosha as well as Rakta dhatu, should be avoided and on the contrarythe diet and drugs which bring about the equilibrium states of the body should beutilized. As Vyanga is a skin disease, pathyapathya explained for kustha can be appliedto Vyanga. 85Pathya:Ahara: Guna : Laghu, hita. Shuka dhanya : Shasthikashali, yava, godhuma. Shimbidhanya : Mudga, adaka, masura. Shakha : Nimbapatra,patolapatra,brihatiphala, chakramarda, meshashrangi. Mamsa : Jangala mruga. Mootra : Cow, camel, buffalo.Apathya:Ahara: Guna : drava,guru, vidahi, visthambi, Shimbidhanya : masha, Shakha : moolaka, amla phala, tila. Mamsa : anupa mruga. Miscellaneous : Dadhi, ksheera, madhya, guda.Vihara: Suryarashmi, divaswapna, vyayama, veganirodha,Literature of Evaluation of the efficacy of Varnya Yoga in Vyanga W.S.R.T. Melasma 33
  46. 46. Review of literatureDRUG REVIEW Table.No.10 Showing Drug ReviewSl Drug Family Latin name Parts used Rasa Guna Veerya Vipaka Doshaghnatano1 Shweta Santalaceae Santalum album Kanda sara Tikta,Madhura Laghu,Ruksha Sheeta Katu Kapha, Pitta chandana2 Tunga Guttiferre Calophyllum Kanda Kashaya, Laghu, Sheeta Madhura Kapha Pitta (Punnaga) inophyllum twakk Madhura Ruksha3 Padmaka Rosaceae Prunus cerasoides Kanda Kashaya, Tikta Laghu, Sheeta Katu Kapha,Pitta twak Snigdha4 Ushira Graminae Vetiveria Moola Tikta Madhura Ruksha, Sheeta Katu Kapha, Pitta zizanoides Laghu5 Madhuka Fabaceae Glycyrrhiza glabra Moola Madhura GuruSnigdha Sheeta Madhura Tridosha6 Manjista Rubiaceae Rubia cardifolia Moola Madhura, Tikta GuruSnigha Ushna Katu Kapha, Pitta7 Sariva Asclepidaceae Hemidesmus Moola Madhura, Tikta GurgSnigdha Sheeta Madhura Tridosha (sweta) Indicus8 Payasya Convolvylaceae Ipomea digitata kanda Madhura Snigdha sheeta Madhura Pitta Sheeta9 Sita Poaceae Cynodondactylon Panchanga Kashaya, Laghu Sheeta Madhura Kapha pitta (Swetadurva) Madhura10 Latha Poaceae Cynodon linearis Panchanga Kashaya, Laghu Sheeta Madhura Kapha pitta (Krishnadurva) Madhura Evaluation of the efficacy of Varnya Yoga in Vyanga W.S.R.T. Melasma
  47. 47. DRUG REVIEW(1) Shweta Chandana 86 Synonyms : Gandha sara, Malayaja, Srikandha, Mahara, Bhadrasriya Doshaghnata :Kapha pittahara Karma :Dahaprashamana & Raktaprasadana Chemical composition :Santalol, Santene, Santalenes, Santelenon, Teresantalol, Nor Tricycloekasantalal, 1- Santenone, Teresantalic acid(2) Tunga87 Synonyms : Punnaga,88 Padmaka, Kimijalaka Doshaghnata :Kapha pittahara Karma :Dahaprashamana Chemical composition :Friedelin,Sitosterol, Canophylol, Calophylloide, Inophyllide, Inophylum A, B & D,Calophylin.B(3) Padmaka89 Synonyms :Padmagandhi Doshaghnata :Kapha pittahara Karma :Garbhasthapana,Vedanasthapana,Vrishya, VarnyaChemical composition : Pudumin A, Genistein, Prunetin, Genkwanin, cerasinone, Cerasidin, CerasinLiterature of Evaluation of the efficacy of Varnya Yoga in Vyanga W.S.R.T. Melasma 34
  48. 48. (4) Ushira90 Synonyms : Nalada, Amranala, Jalavasa, Saugadhaka, Haripriya Doshaghnata :Kapha Pittahara Karma :Pacana & Sthambhana Chemical composition : Allokhusiol, Benzoic acid, Epizizanol, Eudesmol, Eugenol, Isokhusenoloxide, Isovalenic acid, Khusimil acetate, Vanilin, Zizanol(5) Madhuka91 Synonyms :Klitaka, Madhuyasti, Madhulika, Jalayasti Doshaghnata :Tridoshahara Karma :Rasayana, Vrishya, chukshushya Chemical composition :Glycyrrhizia, Glycyrrhizic acid, Liquiritin, Glabrin,Licuraside, Hispaglabradin, Glabrene(6) Manjista92 Synonyms :Jingi, Vastra ranjini,Vikasa, Raktanga Doshaghnata :Kapha Pittahara Karma :Swarya, Varnya Chemical composition :Antitumour cyclic Hexapeptides, Anthraquin, Munjistin, Purpuroxantin, Rubiatriol, Rubiofolic acid, Rubiadin, Purpurin, Ruberythric acidLiterature of Evaluation of the efficacy of Varnya Yoga in Vyanga W.S.R.T. Melasma 35
  49. 49. (7) Sariva93 Synonyms :Ananta, Anantamoola, Asphota, Gopi, Shyama Doshaghnata : Tridoshahara Karma :Grahi ,Shukrala Chemical composition : Hyperoside, Hexatriacontane,Sitisterol, Hemidisminine(8) Payasya ( Ksheeravidari)94 Synonyms :Shukla,Ksheerashukla,Ksheerakanya,Payasvini, Ikshuvalli, Doshaghnata :Pittashamaka Karma :Varnya,Brihmana,Vrishya, Mootrala, Swarnya. Chemical composition : Carbohydrates & Proteins(9) Sita ( Shweta durva)95 Synonyms : Sataparva Doshaghnata : Kapha Pittahara Karma : Varnya, Prajashapana Chemical composition : Methoxy Propionic acid, Benzoic acid, Phytol, Sitosterol(10) Lata (Shyama durva) 96 Synonyms : Sataparva Doshaghnata : Kapha Pittahara Karma : Varnya, Prajashapana Chemical composition : Methoxy Propionic acid, Benzoic acid, Phytol, SitosterolLiterature of Evaluation of the efficacy of Varnya Yoga in Vyanga W.S.R.T. Melasma 36
  50. 50. CHAPTER 4 MATERIALS AND METHODS Before starting any research work it is necessary to list out the materials requiredand the methods used for research. So in this chapter materials and methods which arerequired for this clinical study are explained in detaile.Sources of data a) Patient: Patients are selected from O.P.D of D.G.M.A M.C. and H. after fulfilling theinclusion and exclusion criteria.b) Literary: Required literary information for the intended study are procured from both theAyurvedic and Modern textbooks and they are updated with recent journals of both thefaculties.c) Trail drug:97 Abhyantara : The tablets prepared with Varnya Mahakashaya Gana are used. Bahya : The cream prepared with Varnya Mahakashaya Gana is used.Preparation of cream: The powder of all the drugs are boiled with water up to 60c, when the quantityreduces to 1/4, it is filtered. Againe it is boiled up to 60c and this procedure is repeatedtill it becomes thick. Then the extract is coolected. Like this active ingredients arecollected. Active ingredients are mixed with emulsifying agents and triturated in modernpastille. After emulsifying the liquid paraffin is added then triturated in the sameMethods of Evaluation of the efficacy of Varnya Yoga in Vyanga W.S.R.T. Melasma 37
  51. 51. direction, after some time we will get fine, non greesable cream. Then to this sandllewood perfume is added and stored in a sterile, air tight container. It is water in oil type ofemulsion.98d) Instruments • Measuring tape • Fare and lovely color index scale • 30 patients of VyangaMethod of collection of data: (a) Study design: The patients with Vyanga within the age group of 15 yrs to 45 yrs. were selectedrandomly from O.P.D of D.G.M.A M.C. and H. after fulfilling the inclusion andexclusion criteria irrespective of their sex, occupation and socio-economic status. The size of sample was 30 excluding the dropouts. The present study is a singlegroup study where in, patients were assigned in one group. It is a Simple randomsampling technique clinical trial.(b) Sample size: 30 patients were taken for the planed study as a single group.Exclusion criteria: Patients with secondary systemic involvement. Patients suffering with other systemic disorders like renal failure, hepatic disorders and endocrine system related disorders. Associated with any other systemic and metabolic disorders are excluded because, they may alter the results of observation.Methods of Evaluation of the efficacy of Varnya Yoga in Vyanga W.S.R.T. Melasma 38
  52. 52. Pregnant womens are excluded because even though the drug composition is herbal and safe still may be placental barrier and affect the foetus. Lactating mothers are excluded because even though the drug composition is herbal and safe still may have effect over food (milk) of infant. Women’s using oral contraceptives are excluded because it may alter the results of observation. Patients below 15 years and above 45 years, incident rate is very less in these age groups. Vyanga (Hyper pigmentation) caused since birth is excluded because, the prognosis is very bad in these conditions.Inclusive criteria: Patients with classical sign and symptoms of Vyanga are selected. Patients belong to either gender between the age groups of 15 to 45 years.Diagnostic criteria: As per the clinical features of Vyanga mentioned in classics, cases are diagnosed.Fair and Lovely color index scale is used to grade the color of pigmentation. They are – 1. Mukhamaagatya mandalam i.e. Circumscribed patches over face 2. Tanukam i.e. Light brown pigmentation of the facial skin 3. Shyavam i.e. Dark brown pigmentation of the facial skin 4. Neerujam i.e. Painless patchesMethods of Evaluation of the efficacy of Varnya Yoga in Vyanga W.S.R.T. Melasma 39
  53. 53. Posology: Abhyantara : 3gms / 24 hrs in three divided doses or 50 mg / kg body Weight / 24hrs distributed in equal doses. Anupana : Boiled and cooled water Bahya : One finger tip twice daily or sufficient quantity of the Cream is used.Method of application of Varnya cream: Patients were advised first to clean the face properly. Take one finger tip orsufficient quantity of Varnya cream according to size of the lesion and apply over theaffected area of the face. Then Massage it for 10 minutes leads to cream to penetrateproperly deep in the skin. Whole procedure had to be done twice in a day.Study duration: For 30 days simultaneously internal and external Varnya yoga was used.Follow up: The duration of follow up was30 daysAssessment of results: The subjective and objective parameters of base line data to pre and postmedication will be compared for assessment of the results. All the results will beanalyzed statically for value using pared ‘t’test.Methods of Evaluation of the efficacy of Varnya Yoga in Vyanga W.S.R.T. Melasma 40
  54. 54. Subjective parameter: Both signs and symptoms of Vyanga as well as Melasma explained in Ayurvedicand modern texts respectively will be the subjective parameters. 1. Mukhamaagatya mandalam (Circumscribed hyper pigmented patches on the face) 2. Neerujam (Painless patches) 3. Tanukam (Light pigmentation) 4. Shyavam (Brownish pigment)Objective parameters: Fair and lovely graded scale is used to assess the change in the color of the skinon affected area before and after the treatment. Which is distributed rating from 01 to 26Investigations:The following routine investigation is undertaken to estimate the patient’s general healthcondition but has no significance with Vyanga. Hb% (to assess the general health of the parient)Assessment Criteria: Assessment of signs/symptom before and after was main criteria.Assessment of Variables: Clinical assessment was made for the severity of the disease and for the clinicalimprovement regarding for the severity of individual symptoms assessment was framedas follows.Methods of Evaluation of the efficacy of Varnya Yoga in Vyanga W.S.R.T. Melasma 41
  55. 55. Table.No.11ASSESMENT OF OBJECTIVE VARIABLESVARIABLES B. T A. TColour of MandalaSize of MandalaNumber Of MandalaGRADING FOR THE OBJECTIVE VARIABLESA) Color: Colour of the lesion is graded from 1 to 26 by using Fair and lovely colourgrading scale.B) Size: G1 - Total disappearance of the Mandalas G2 – ½ to 2 sq.cm. G3 - 3 to 5 sq.cm. G4 - > 5 sq. cm. When the lesions are multiple, the size of the largest lesion is taken in toconsideration.C) Number of Mandalas: G1 – Absence of Mandalas. G2 – 1 to 2 G3 – 3 to 5 G4 - > 5.Methods of Evaluation of the efficacy of Varnya Yoga in Vyanga W.S.R.T. Melasma 42
  56. 56. SUBJECTIVE VARIABLES: 1) Daha 2) Kandu 3) Snigdata 4) RukshataASESSNMENT ON CLINICAL IMPROVEMENT: Clinical improvement of the disease was based on improvement in the clinicalfinding and reduction on the severity of the symptoms of the disease grading for theclinical improvement for individual variables.Grading for the clinical improvement for individual variables: 1. Good: Reduction in the color of lesions Nil number Nil size 2. Moderate: Reduction in the color of lesion Reduction in number of lesions Reduction in size 3. Poor: Reduction in the color of lesion No change in number of lesions Reduction in size of lesionsMethods of Evaluation of the efficacy of Varnya Yoga in Vyanga W.S.R.T. Melasma 43
  57. 57. 4. No response: No change in the color of lesion No change in number of lesions No change in size of lesionsIf sub parameters, Kandu and Daha are not relieved the step down of results are doneStatistical analysis: The data were collected from both group before, during and after treatment and atthe end of follow up and statistically analyzed by using student’s‘t’ test in consultationwith the biostatistician.Methods of Evaluation of the efficacy of Varnya Yoga in Vyanga W.S.R.T. Melasma 44
  58. 58. CHAPTER – 6 RESULTS Present study registers 30 patients and no one patient was left out the trial.The30 patients of Vyanga viz. Melasma, fulfilling the criteria of diagnosis and inclusivecriteria were included as a single group for the present study. All the patients were examined before and after the trail, according to the casesheet format given in the annex. Both the subjective and objective criteria wererecorded along with validation of disease state. The data recorded are presented underthe following headings. A. Demographic data B. Evaluating disease Data C. Result of the Varnya yoga D. Statistical analysisResults of Evaluation of the efficacy of Varnya Yoga in Vyanga W.S.R.T. Melasma 45
  59. 59. A) Demographic data: The details of Age, Gender, Religion, and Occupation etc. of the 30 patientsare as follows:(1) Distribution of patients according to GenderTable No 12: Results by gender in Vyanga with Varnya yoga Gender GR MR PR NR Total Percentage Male 04 03 03 00 10 33.3 % Female 06 06 08 00 20 66.6 % Total 10 09 11 00 30 100Among 30 patients, 10 (33.3 %) are males out of this 4 got good , 3 moderate and 3poor response. 20 patients (66.6 %) are Females in this study, out of this 6 got good, 6moderate, 8 poor response.Fig no. 06: showing the distribution of patients according to Gender Male 33% Female Male 67% FemaleResults of Evaluation of the efficacy of Varnya Yoga in Vyanga W.S.R.T. Melasma 46
  60. 60. (2) Distribution of patients according to AgeTable No -13: Results by age in Vyanga with Varnya yoga Age in years GR MR PR NR Total Percentage 20 -30 05 04 06 00 15 50 % 30-40 02 02 00 00 04 13.33 % 40-50 03 02 06 00 11 36.66% Total 10 08 12 00 30 100Among the 30 patients, 15 patients are in between the age group of 20-30 years(50%), out of this 5 got good response, 4 moderate and 6 poor response. 04 patientsare in between the age group of 30-40 years(13.33%) out of which 2 got goodand 2got moderate response. 11 patients are are in between the age group of 40-50 years(40 %), out of this 3 got good, 2 got moderate and 6 got poor response in this study. Fig no. 07: Results by Age in Vyanga with Varya yoga 6 5 4 GR MR 3 PR 2 NR 1 0 20-30 30-40 40-50Results of Evaluation of the efficacy of Varnya Yoga in Vyanga W.S.R.T. Melasma 47
  61. 61. (3) Distribution of patients according to ReligionTable No -14: Results by Religion in Vyanga with Varnya yoga Religion GR MR PR NR Total Percentage Hindu 08 08 10 00 26 86.6 % Muslim 03 00 01 00 04 13.3 % Christian 00 00 00 00 00 00 % T0tal 11 08 11 00 30 100Among the 30 patients 26 patients are Hindus (86.6%), out of this 8 patients got good,8 falls under moderate and other 10 got poor response. 4 patients areMuslims(13.3%)out of this 3 got good and 1 got poor response. None of the patientsare Christians, in this study. Fig no. 8: showing the distribution of patients according to Religion Muslim 13% Christian 0% Hindu Hindu 87% Muslim ChristianResults of Evaluation of the efficacy of Varnya Yoga in Vyanga W.S.R.T. Melasma 48
  62. 62. (4) Distribution of patients according to OccupationTable No -15: Results by occupation in Vyanga with Varnya yoga Occupation GR MR PR NR Total % Sedentary 02 00 03 00 05 16.6 Active 08 08 07 00 23 76.66 Labo 01 01 00 00 02 6.66 Total 11 09 10 00 30 *Among 30 patients, 5 (16.6 %) are Sedentary, out of this 2 patients got good responseand 3 got poor response. 23 (76.6%) are Active, out of which 8 patients got good, 8falls under moderate and 7 got poor response. 02 (6.6 %) are Laborer in occupationout of this 1got good and other 1 moderate response in this study. Fig no. 09: Results by Occupation in Vyanga with Varnya yoga 8 7 6 5 GR MR 4 PR 3 NR 2 1 0 Sedentary Active LaboResults of Evaluation of the efficacy of Varnya Yoga in Vyanga W.S.R.T. Melasma 49
  63. 63. Table No -16: Results by Economical status in Vyanga with Varnya yoga Economical status GR MR PR NR Total Percentage Poor 03 04 02 00 09 30 % Middle 05 05 07 00 17 56.6 % Higher class 02 00 02 00 04 13.3 % Total 10 09 11 00 30 100Among 30 patients, 9 (30 %) are under Poor class, out of this 3 got good, 4 moderateand 2 poor response.17 (56.6 %) are of Middle class, out of this 5got good. 5moderate and 7 got poor response. 4 patients (13.3) are from Higher class, out of this2 got good and 2 poor responses in this study. Fig no. 10: Results by Economical status in Vyanga with Varnya yoga 7 6 5 GR 4 MR 3 PR NR 2 1 0 Poor Middle Higher classResults of Evaluation of the efficacy of Varnya Yoga in Vyanga W.S.R.T. Melasma 50
  64. 64. (6) Distribution of patients according to DietTable No -17: Results by diet in Vyanga with Varnya yoga Diet GR MR PR NR Total Percentage Vegetarians 05 05 07 00 17 56.6% Mixed 05 05 03 00 13 43.3 % Total 10 10 10 00 30 100Among 30 patients, 17 (56.6 %) were Vegetarians out of this 5 got good, 5 moderateand 7 poor response. 13 patients (43.3 %) had Mixed diet out of this 5 got good, 5moderate and 3 got poor response. Fig no. 11: Results by Diet in Vyanga with Varnya yoga 10 9 8 7 GR 6 MR 5 PR 4 NR 3 2 1 0 VEG MixedResults of Evaluation of the efficacy of Varnya Yoga in Vyanga W.S.R.T. Melasma 51
  65. 65. Table No- 18: Showing the distribution of Patients by Vysana:Vysana GR MR PR NR Total PercentageTea/Coffee 06 07 07 00 20 66.66%Tobacco 00 00 00 00 00 0%Smoking 00 00 00 00 00 0%None 04 04 02 00 10 33.33%Among 30 patients 20(66.66%) patients were had habits of drinking Tea/coffee, out ofwhich 6 got good, 7 moderate and other 7 poor response. 10(33.33%) patients not hadany habits, out of this 4 were responded good, 4 moderate and 2 were respondedpoorly. Fig No-12: Showing the Results by Vyasana 7 6 5 GR 4 MR 3 PR NR 2 1 0 Tea/Coffee Tobacco Smoking NoneResults of Evaluation of the efficacy of Varnya Yoga in Vyanga W.S.R.T. Melasma 52
  66. 66. (B) Data related to DiseaseTable No-19: Showing the Results by duration of the disease Duration GR MR PR NR Total Percentage 1-12Months 03 03 02 00 08 26.67% 12-24 Months 04 02 03 00 09 30% Above 24Months 03 04 06 00 13 43.33% Total 10 09 11 00 30 100 Among the 30 patients 08 patients had a duration 1-12Months (26.67%), Outof 8 patients, 3 got good response, 3 got moderate response and another 2 fells underthe category of poor response. 09 patients had duration 12-24 Months (30%). Out of 9patients, 4 got good response, 2 were responded moderately and 3 fells under thecategory of poor response. 13 patients had duration above 24Months (43.33%), out ofwhich 3got good response, 4 moderate and 6 poor responses. Fig No- 13: Showing the results by duration of the disease 6 5 GR 4 MR 3 PR 2 NR 1 0 1-12Months 12-24 Months Above 24MonthsResults of Evaluation of the efficacy of Varnya Yoga in Vyanga W.S.R.T. Melasma 53
  67. 67. (1) Distribution of patients by presenting complaintsAlmost all the symptoms selected as the presenting complaint as analyzed reflects thesaid complaints of the text, Mandalas on Mukha (30 patients), Shyava Varna (19patients), Neeruja (30 patients), Tanu mandalas (11 patients). The cardinal signsShyava varna, Mandalas on Mukha, Neeruja and Tanu mandalas. The graph andtabulations are shown below.Table no. 20: Distribution of patients by presenting complaints Presenting complaints No. of patients Percentage Mandalas on Mukha 30 100 Shyava Varna 19 63.3 Niruja 30 100 Tanu mandalas 11 36.6Fig no 14: Distribution of patients by presenting complaints 30 25 20 15 10 5 0 Mandalas on Shyava Varna Niruja Tanu mandalas Mukha No. of patientsResults of Evaluation of the efficacy of Varnya Yoga in Vyanga W.S.R.T. Melasma 54
  68. 68. (2) Distribution of patients by associated featuresDaha and Kandu may be considered as associated complaints of Vyanga, whichoccurs rarely. In this study daha observed in 3 patients and Kandu in 2 patients.Table no 21: Distribution of peatients by associated features Associated features No. of peatients Percentage 03 10 Daha Kandu 02 6.6 Fig no 15 : Distribution of patients by associated features 3 2.5 2 1.5 No. of peatients 1 0.5 0 Daha KanduResults of Evaluation of the efficacy of Varnya Yoga in Vyanga W.S.R.T. Melasma 55
  69. 69. Table No- 22: Showing the Patients by Lesion Distribution:Distribution GR MR PR NR Total PercentageKapola 08 03 01 00 12 40%Lalata 03 01 01 00 05 16.6%Shanka 00 01 00 00 01 3.3%Chibuka 00 00 01 00 01 3.3%Ganda 01 01 00 00 02 6.6%Akshikuta 01 00 00 00 01 3.3%Nasa 05 02 01 00 08 26%Total 18 08 04 00 30 100Among 30 patients, 12patients had lesion over Kapola (40%), 7 patients had lesionover Lalata(23%) ,5 patients had lesion over Shanka(16%)3patients had lesion overChibuka(10%)11 patients had lesion over Ganda(36.66%),one patient had lesion overAkshikuta(3.3%),12 patients had lesion over Nasa(40%), in this study. Fig no 16: showing Results by Distribution of lesions. 8 7 6 5 GR 4 MR PR 3 NR 2 1 0 Kapola Shanka Ganda NasaResults of Evaluation of the efficacy of Varnya Yoga in Vyanga W.S.R.T. Melasma 56
  70. 70. (3) Distribution of patients by Ahara nidanaTable no 23: Ahara nidana observed in the study Ahara nidanas No. of peatients Percentage Katu, Ushna 03 10 Katu, Ruksha 06 20 Katu,Amla,Ruksh 02 6.6 Rooksh,Ushna 01 3.3 Rooksh,Lavana 01 3.3 Lavana,Katu,Ushna 07 23.3 Amla,Katu,Ruksh,Ushna 02 6.6 Madhura,Lavana 01 3.3 Katu,Madhura,Ruksh 01 3.3 Amla,Lavana,Ruksh,Ushna 01 3.3 Rooksh,ushna,katu 05 16.6Maximum patients are interested to take (23.3 %) Lavana, Katu and Ushna Aharaswhich causes Pitta prakopa and Rakta dusti.Fig. Distribution of Patients by Rasa and Guna of Ahara 7 6 5 4 3 2 1 0 ku kr ka ru rl lku akru ml kmr alu ruk No. of peatientsResults of Evaluation of the efficacy of Varnya Yoga in Vyanga W.S.R.T. Melasma 57

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