Vhatkar Nikhil D.pdf

“A Clinical Study On Effect Of Local

Application With Jyotishmati-Apamarga

Kshara Taila In The Management Of Shvitra

(Vitiligo) in children”

By

Nikhil D. Vhatkar

Dissertation Submitted to the

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE,

KARNATAKA

In partial fulfillment of the requirements for the degree of

AYURVEDA VACHASPATI

M.D. (Ayu.)

In

KAUMARABHRITYA

Under the guidance of

Dr. SHAILAJA.U M.D. (Ay.), Ph.D.,

H.O.D & PROFESSOR

DEPARTMENT OF POST GRADUATE STUDIES IN KAUMARABHRITYA

SDM COLLEGE OF AYURVEDA AND HOSPITAL

HASSAN - 573 201

2011

DEPARTMENT OF POST - GRADUATE

STUDIES IN KAUMARABHRITYA

SHRI DHARMASTHALA MANJUNATHESHWARA

COLLEGE OF AYURVEDA & HOSPITAL

HASSAN - 573 201

Certificate

This is to certify that the Dissertation entitled “A Clinical Study On

Effect Of Local Application With Jyotishmati-Apamarga Kshara Taila In The

Management Of Shvitra (Vitiligo) in children” is the bonafide record of

research work conducted by “Nikhil D. Vhatkar” under my direct

supervision and guidance as a partial fulfillment for the award of the

degree of M.D. in Ayurveda - Kaumarabhritya.

The candidate has fulfilled all the requirements of ordinances laid

down in the prospectus of Rajiv Gandhi University of Health Sciences,

Bangalore, Karnataka for the award of Degree of Ayurveda Vachaspati

(MD Ayu.) in Kaumarabhritya.

I am fully satisfied with her work and recommend this

dissertation to be forwarded for adjudication.

Date: Guide & Supervisor Place: Hassan Dr. Shailaja U. H.O.D. & PROESSOR Dept. of P. G. Studies in Kaumarabhritya,

S D M College of Ayurveda & Hospital,

Hassan

DEPARTMENT OF POST - GRADUATE STUDIES IN

KAUAMARABHRITYA

SHRI DHARMASTHALA MANJUNATHESHWARA

COLLEGE OF AYURVEDA & HOSPITAL

HASSAN – 573 201

(Affiliated to R.G.U.H.S, Karnataka, Bangalore)

ENDORSEMENT BY THE HOD AND HEAD OF THE INSTITUTION

This is to certify that the Dissertation entitled “A Clinical Study On


Management Of Shvitra (Vitiligo) in children” is the bonafide record of research

work conducted by “Nikhil D. Vhatkar” under the guidance of Dr. Shailaja

U, Professor and H.O.D., Dept. of P. G. Studies In Kaumarabhritya, S D M

College of Ayurveda, Hassan.

Dr. Shailaja U. Dr. Prasanna N. Rao. Prof .& H.O.D. Principal

Dept. of P. G. Studies in Kaumarabhritya S D M College of Ayurveda,

S D M College of Ayurveda, Hassan Hassan

Prof. Gurdip Singh Director, Post Graduate Studies

S D M College of Ayurveda, Hassan

Date: Place: Hassan

Review of Literature

A Clinical Study On Effect Of Local Application With Jyotishmati-Apamarga Kshara Taila In The Management Of Shvitra (Vitiligo) in children 64

Anatomy of Skin :



Aaragwadha Apamarga

Jyotishmati Tila

Observation


Graph No.1 Shows incidence of Shvitra Graph No.2 Shows incidence of (Vitiligo) in different age groups: Shvitra (Vitiligo) in different sex groups:

Graph No.3Shows incidence of Shvitra Graph No.4 Show incidence of habitat of

(Vitiligo) in different communities: different Shvitra (Vitiligo) patients :

21

19

0

5

10

15

20

25

7 - 9 years 10 - 12 years

Group A

Group B

Total

25

19

0

5

10

15

20

25

30

Male Female

Group A

Group B

Total

36

40

5

10

15

20

25

30

35

40

Hindu Muslim

Group A

Group B

Total 13

27

0

5

10

15

20

25

30

Rural Urban

Group A

Group B

Total

Observation


Graph No. 5 Show incidence of Shvitra Graph No.6 Shows incidence of shvitra

(Vitiligo) as per socio-economic status: as per food habits :

Graph No.7 Shows incidence of earlier Graph No. 8 Shows incidence of Deha

treatment history in the patients : Prakruthi in Shvitra patients :

of Shvitra:

3

15

22

0

5

10

15

20

25

Poor U M C L M C

Group A

Group B

Total

11

29

0

5

10

15

20

25

30

35

Group A

Group B

Total

16

24

0

5

10

15

20

25

30

Present Absent

Group A

Group B

Total

20

13

7

0

5

10

15

20

25

V.P. V.K. P.K.

Group A

Group B

Total

Observation


Graph No. 9 Shows incidence of dietic factors described to produce Shvitra

Graph No.10 Shows incidence of Viharaja Nidana in Shvitra patients

7

11

19

5

0

2

4

6

8

10

12

14

16

18

20

Virudhara onlyAti Mash, Mulaka, Dadhi, Amla sevana onlyBoth 1 & 2 None

Group A

Group B

Total

16

89

5

0

2

4

6

8

10

12

14

16

18

Intake of cold water after exposure to

sunlight

Cold water bath after expoxure to

sunlight

Both None

Group A

Group B

Total

Observation


Graph No. 11 Shows incidence of chronicity of Shvitra

Graph No.12 Shows incidence of number of mandalas (patches)

5

11

8

15

0

2

4

6

8

10

12

14

16

1-3 months 4-6 months 7-9 months 10-12 months

Group A

Group B

Total

17

7

15

10

2

4

6

8

10

12

14

16

18

1-5 mandalas 6-10 mandalas 11-20 mandalas Above 20

Group A

Group B

Total

Observation


Graph No.13 Shows incidence of distribution Graph No.14 Shows incidence of presence distribution of Mandalas of mandalas : of black spots in observed patch before

treatment

Graph No.15 Shows incidence of colour of Graph No.16 Shows incidence of number of patch in Shvitra (vitiligo) vegas after koshstashudi medicine given before treatment

:

12

28

0

5

10

15

20

25

30

Symmetrical Asymmetrical

Group A

Group B

Total

15

25

0

5

10

15

20

25

30

No spots 1-5 spots

Group A

Group B

Total

34

6

0

5

10

15

20

25

30

35

40

White Light pink

Group A

Group B

Total

1413 13

0

2

4

6

8

10

12

14

16

3 to 4 5 to 6 7 to 8

Group A

Group B

Total

Observation


Graph No. 17 Shows incidence of distribution of size of Mandalas :

4

18

12

6

0

2

4

6

8

10

12

14

16

18

20

< 5 square cm 6 -10 square cm 11 - 15 square cm 15 - 20 square cm

Group A

Group B

Total

Results


Graph No. 18 Graph No.19 Showing improvement in Showing improvement in Appearance of Itching sensation Colour change in observed over observed Shvitra (Vitiligo) Shvitra (Vitiligo) patch : patch :

Graph No.20 Graph No.21 Showing improvement in Bleb Showing improvement in reduction in size formation in observed Shvitra of observed Shvitra (Vitiligo) patch: (Vitiligo) patch :

47.05

70.58

0

-12.5-20

-10

0

10

20

30

40

50

60

70

80

End of 1st month End of 2nd month

Group A Group B

41.37

65.51

0 1.78

0

10

20

30

40

50

60

70


GroupA Group B

10

30

0 00

5

10

15

20

25

30

35


Group A Group B

25

67.5

0 00

10

20

30

40

50

60

70

80


Group A Series 2

Results


Graph No.22 Shows improvement in appearance of black spots in observed Shvitra (Vitiligo) patch :

Graph No. 23 Showing Over-all Percentage Improvement :

10

0

30

00

5

10

15

20

25

30

35


Group A Group B

70.5865.51

30

60.7167.5

-12.5

1.78 0 0 0

-20

-10

0

10

20

30

40

50

60

70

80

Appearance of Itching

sensation

Colour change Bleb formation No. of black spots

Size of observed

patch

Group A Group B

Results


Study Group (Group A): Before treatment After treatment

Before treatment After treatment

Results




RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA

DECLARATION BY THE CANDIDATE

I hereby declare that this dissertation / thesis entitled “A Clinical Study On


Management Of Shvitra (Vitiligo) in children” is a bonafide and genuine research

work carried out by me under the guidance of Dr. Shailaja. U, Professor and H.O.D.,

Dept. of P. G. Studies in Kaumarabhritya, S D M College of Ayurveda and Hospital,

Hassan.

Date: Signature of the candidate

Place: Hassan Nikhil D. Vhatkar

COPYRIGHT

DECLARATION BY THE CANDIDATE

I hereby declare that the Rajiv Gandhi University of Health Sciences,

Karnataka shall have the rights to preserve, use and disseminate this

dissertation/ thesis in print or electronic format for academic/

research purpose.

Date: Signature of the candidate

Place: Hassan Nikhil D. Vhatkar

© Rajiv Gandhi University of Health Sciences, Karnataka

ACKNOWLEDGEMENT

My gratitude, which is the mother of all virtues and most capital of all duties,

has all there order and diligence to all those who graciously involved in this venture

of mine. There is much greatness of mind in acknowledging a good turn, as in doing

it.

I humbly, seek this opportunity to bow my head to the feet of almighty Lord

Ganesh, Lord Bhairavanatha and Lord Dhanwantari for showering their

blessings and empowering me to this eventful outcome without any impediments.

The truth dawns on me that, the language of words suffers very stringent

limitation to express my gratitude and indebt to the sacrifices of my most beloved

and respected parents Shri. Dhondiram Balavant Vhatkar and Sou. Malan

Dhondiram Vhatkar, who are the cause for me to take this noble profession and

shape me into what I am today,.

I pay my respectful salutations to his Holiness Poojya Sri Veerendra

Heggadeji, a founder father of SDMCA&H, Hassan and a fountainhead of

educational movements, for his divine blessings in disguise and who has been kind

enough to provide me an opportunity to render my service in this esteemed

institution. At this juncture, I am extremely grateful to Prof. S. Prabhakar, vice-

president and Dr. Yashovarma, secretary, S.D.M.E.S. Ujire.

The sacred blessings of national fame personality Poojya Professor Dr. C.

H. S. Sastry, whose insurmountable enthusiasm and best supervision made this

work materialized shape. I will be ever grateful for his invaluable guidance,

constructive suggestions, fatherly love and affection and thought provoking ideas in

every stage of my study.

My vocabulary falls short of suitable words to express my recondite sense of

indebtedness to my benevolent teacher Principal Prof. Prasanna.N.Rao, who has

been a guiding force and instrumental in all the proceedings of my life and stood as

an excellent encouraging stanchion in all strides in accomplishing this meticulous

effort.

The words are inadequate to express with profound reverence my heartiest

gratitude and indebtedness to my guide Dr. Shailaja U., H.O.D. SDMCA&H,

Hassan for his untiring help, close and constant attention with constructive and

valuable suggestions at every steps of this work.

It is beyond the reach of my language to inscribe the profound respect and

devotion towards affectionate Prof. Gurdip Singh for their constant support,

timely guidance and valuable suggestions to get this work done successfully.

I am thankful to Dept. of Dravyaguna, & Dept. Of Rasashashtra S.D.M

College of Ayurveda and Hospital, Hassan for providing me the drugs for my

research work.

I am thankful to our librarian Mr. Chandrasekhar, Mr. Krishnegowda,

Mr. Nagaraj & Digital Library in-charge Mr. Ravi Kumar & Mr. Dharma for their

great co-operation.

I express my gratitude and cordial thanks to my close friends Dr. Rahul,

Dr. Amol & Dr. Sheetal for providing support during my thesis work.

I should be very thankful to my well-wisher and loving friends Dr. Pankaj,

for supporting and praying for my success in my life.

I can’t forget my beloved seniors Dr. Abhijit, Dr. Shine, Dr. Purrushottam,

Dr. Raghamala, Dr. Veena, Dr. Arthi, Dr. Rahul, Dr. Prasad, Dr. Pravin,

Dr. Shwetha for their kind support. I am also specialy thankful to my juniors

Dr.Jyoti B., Dr.Pratibha Murthi, Dr.Niraja, Dr.Sahana, Dr.Saraswati, Dr.Basaveshwari and all who helped me knowingly and unknowingly.

I fail in my duty if I do not recall the support rendered by my friends.

I thank all my seniors, juniors and classmates for their timely suggestions

and help.

I thank my patients who exhibited high level of patience and subjected

themselves for cooperating with me in every stage of my clinical work and also

technical and non technical staff members of the department of Kaumarabhritya.

Last but not the least I extend my thanks to all those who have been directly

or indirectly associated with study at various levels but not mentioned in this thesis.

Dr. NIKHIL D. VHATKAR.

ABBREVIATIONS

Ri. Ve. : Rigveda

Ath. Ve : Atharvaveda

Ya. Ve : Yajurveda

Ma.Sm : Manu smrithi

Pa : Panini

A.K : Amarakosh

M. M. W : Monier Monier Williams

Ca.Sa.Su : Charaka Samhita Sutrasthana

Ca.Sa.Sha : Charaka Samhita Sharirasthana

Ca.Sa.Vi : Charaka Samhita Vimana

Ca.Sa.Chi : Charaka Samhita Chikitsa Sthana

Ca.Sa.Ka : Charaka Samhita Kalpasthana

Ca.Sa.Si : Charaka Samhita Siddisthana

Ca.Sa.Ni. : Charaka Samhita Nidanasthana

Su.Sa.Su : Sushruta Samhita Sutrasthana

Su. Sa.Sha : Sushruta Samhita Sharirasthana

Su. Sa. ni : Sushruta samhita nidanasthana

Su. Sa. chi : Sushruta samhita chikitsasthana

Su.Sa.Ut. : Sushruta Samhita Uttaratantra

A. sa. su : Astanga sangraha sutra sthana

A. sa. Sha : Astanga sangraha shareera sthana

A. sa. Ni : Astanga sangraha nidana sthana

A. sa. chi : Astanga sangraha chikitsa sthana

A.Hri.Su. : Astanga Hridaya Sutrasthana

A.Hri.Sha. : Astanga Hridaya Sharirasthana

A.Hri.ni. : Astanga Hridaya nidana sthana

A.Hri.chi. : Astanga Hridaya chikitsa sthana

Be.Sa.ni : Bhela Samhita nidanasthana

Be.Sa.Chi : Bhela Samhita Chikitsasthana

Ha.Sa : Harita Samhita

Ka.Sa.su : Kashyapa Samhita sutrasthana

Ka.Sa.Sha : Kashyapa Samhita Shareerasthana

Ka.Sa.Chi : Kashyapa Samhita Chikitsthana

Ka.Sa.ka : Kashyapa Samhita kalpasthana

Ka.Sa.Si : Kashyapa Samhita Siddisthana

Ka.Sa.khi : Kashyapa Samhita khilasthana

Y.R : Yoga Ratnakara

Sha.Pu. ka : Sharangadhara Samhita Purvakanda

Sha.ut. Ka : Sharangadhara Samhita uttarakhanda

Bhi.Rat : Bhashajya Ratnavali

Ma Ni : Madhava Nidana

Ga.Ni : Gada Nigraha

Bh. Pra : Bhava Prakasha

C.D : Chakra Dutta

T. B. A. D : Text book and Atlas of Dermatology

M : Mixed Diet

V : Vegetarian

U. M. C : Upper Middle Class

L. M. C : Lower Middle Class

V. P : Vata Pittaja

V. K : Vata Kaphaja

P.K : Pitta Kaphaja

B.T : Before treatment

A.T : After treatment

S.D. : Standard Deviation

S.E : Standard Error

G. S : Grading score

Sl.No : Serial Number

SYMBOLS

+ : Present

- : Absent

df : Degree of freedom

< : Lesser than

> : Greater than

% : Percentage

P : Probability

t : Test of significance

ABSTRACT

“A clinical study on effect of local application with Jyotishmati-Apamarga

Kshara Taila in the management of Shvitra (Vitiligo) in children.”

Background:

The Shvitra (Vitiligo) affects the estimated 1% of world population. The

disease may start at any age but usually seen in childhood at 10 years of age or in

second decade of life. Based on some dermatological out patient records it is roughly

estimated to be between 3 – 4% in India. Based on the symptoms, Shvitra can be

correlated with Vitiligo.

Objectives:

1. To evaluate the effect of local application with Jyotishmati-Apamarga Kshara

Taila in the management of Shvitra.

2. To observe the effect of local application with Tila Taila (control) in the

management of Shvitra.

3. To compare the effects of both the groups to ascertain the utility of local

application with Jyotishmati-Apamarga Kshara Taila in the management of

Shvitra.

Methods:

45 patients between the age group of 7 – 12 years attending the

Kaumarabhritya OPD and I P D of S.D.M College of Ayurveda and Hospital, Hassan

with diagnosis of Shvitra were taken up for the study after following the criteria laid

as above. Their age, sex, religion, socioeconomic status, food habits family history,

dehaprakruthi etc. were noted as given in master chart. Where there is more than one

patch of vitiligo in any patient only one patch was selected for the study. However

where improvement was found in that particular patch, patient was advised to treat

other patches also with the same drug. The size of the observed patch was

approximately measured in square centimeters by multiplying its breadth and length.

These 45 patients were divided randomly in to two groups.

1. Group A – Study group – containing 23 patients.

2. Group B – Placebo group – containing 22 patients.

Out of a total number of 45 patients taken for the study, five dropped out in

the middle and did not continue treatment. The left out 40 patients constituted of 20 in

study group and 20 in placebo group.

Complete history and clinical examination of all these patients was carried out

and recorded in a specially designed pro-forma by the Post-Graduate Department of

Kaumarabhritya of S.D.M. College of Ayurveda and Hospital Hassan. Their findings

are given in the enclosed master chart.

Result:

After two months of treatment statistically significantly result seen in study

group with respect to assessment criteria as follows:

1. Appearance of itching sensation over observed Shvitra (Vitiligo) patch with an

improvement of 70.58% (p >0.001)

2. Colour change in observed Shvitra (Vitiligo) patch with an improvement of 65.51%

(p >0.001)

3. Bleb formation on observed Shvitra (Vitiligo) patch with an improvement of 30%

(p 0.01)

4. Number of black spots appearing in observed Shvitra (Vitiligo) patch with an

improvement of 60.71% (p >0.001).

5. Decrease in size of Shvitra (Vitiligo) patch with an improvement of 67.50% (p

>0.001)

After two months of treatment statistically insignificantly results seen in placebo

group with respect to all assessment criteria’s.

Interpretation:

Apamarga Kshara produces irritation of depigmented skin over observed

Shvitra (Vitiligo) patches and may helps in removal of depigmented skin.

Apamarga has Rakta-Pitta Prasadanakara action and Jyotishmati has Pitta

Santpakara action. Hence they may be increase the activity of Bhrajaka Pitta leading

to formation of melanin pigments in Tvak (skin) resulting in normal Varna of the

patches.

Conclusion:

Jyotishmati-Apamarga Kshara Taila if continued for longer time for

treatment of Shvitra (Vitiligo) may give much better results.

(Key wards - Shvitra; Vitiligo; Apamarga, Jytishmati)

Table of Contents

Page No. 1. Introduction 1 - 3 2. Objectives 4 3. Review of Literature Ayurvedic Review 5 - 43 Modern Review 44 - 64 Drug Review 65 - 86

4. Methodology 87 - 90 5. Observations 91 - 102 Results 103 - 116

6. Discussion 117 - 124

7. Conclusion 125 8. Summary 126 - 127 9. References & Bibliography 128 - 132 10. Annexure 133 - 150

LIST OF TABLES

Sl. No Table name Page no.

Table 1 Showing varnothpathi based on combination of Pancha

mahabhuta according to different authors

9

Table 2 Showing layers of skin according to Charaka 9

Table 3 Showing layers of skin according to Sushruta 10

Table 4 Showing layers of skin according to Sharangadhara 10

Table 5 Showing nidanas of Shvitra according to different authors 21-23

Table 6 Showing lakshanas of Shvitra according to different

authors

26-27

Table 7 Showing sapeksha nidana of Shvitra 28

Table 8 Showing sadhyasadhyata of Shvitra 34

Table 9 Showing difference between Shvitra and Kustha 35

Table 10 Showing list of drugs used internally and externally in

Shvitra

38-40

Table 11 Showing pathyapathya of Shvitra 45-47

Table 12 Showing cells present in skin 48

Table 13 Showing Relation of hormones & skin 58

Table 14 Showing differential diagnosis of vitiligo 67

Table 15 Plants which are mixed to Mridu Kshara to make it

Madhyama Kshara

73

Table 16 Medicinal plants which are mixed to make Madhyama to

Tikshna Kshara

76

Table 17 Medicinal Plants useful for the preparations of Mridu

Kshara as prescribed in Shushruta Samhita

77

Table 18 The Physical characters of well prepared Teekshna Kshara 78

Table 19 The Physical properties of improperly prepared Kshara,

described by Sushruta as doshas of Kshara

79

Table 20 Incidence of Shvitra (Vitiligo) in different age groups 91

Table 21 Incidence of sex in Shvitra (Vitiligo) patient’s in different

groups

91

Table 22 Incidence of Shvitra (Vitiligo) in different communities 91

Table 23 Incidence of habitat in Shvitra ( Vitiligo) 92

Table 24 Incidence of socio-economic status 92

Table 25 Incidence of shvitra as per food habits 92

Table 26 Incidence of earlier treatment history in the patients of

Shvitra

93

Table 27 Incidence of Deha Prakruthi in Shvitra patients 93

Table 28 Incidence of Aharaja Nidanas described to produce

Shvitra

93

Table 29 Incidence of Viharaja Nidana in Shvitra patients 94

Table 30 Incidence of chronicity of Shvitra 94

Table 31 Incidence of number of mandalas (patches) 94

Table 32 Incidence of distribution of mandalas 95

Table 33 Incidence of presence of black spots in observed patch

before treatment

95

Table 34 Incidence of colour of patch in Shvitra (Vitiligo) before

treatment

95

Table 35 Incidence of size of Mandalas 96

Table 36 Incidence of number of Vegas after Koshstashudhi

medicine given

96

Table 37 Clinical improvement of signs after one month of

treatment in study group

103

Table 38 Clinical improvement of signs after two months of

treatment in study group

104

Table 39 Clinical improvement of signs after one month of

treatment in placebo group

105

Table 40 Clinical improvement of signs after two month of

treatment in placebo group

106

Table 41 Comparison of results of Appearance of Itching sensation

over observed Shvitra (Vitiligo) patch of group A and

group B at the end of first month

107

Table 42 Comparison of results of Appearance of Itching sensation

over observed Shvitra (Vitiligo) patch of group A and

group B at the end of second month

107

Table 43 Comparison of results of colour change in observed

Shvitra (Vitiligo) patch of group A and group B at the end

of first month

108

Table 44 Comparison of results of colour change in observed


108

of second month

Table 45 Comparison of results of bleb formation on observed


of first month

109

Table 46 Comparison of results of bleb formation on observed


of second month

109

Table 47 Comparison of results of number of black spots in

observed patch of group A and group B at the end of first

month

110

Table 48 Comparison of results of number of black spots in

observed patch of group A and group B at the end of

second month

110

Table 49 Comparison of results of size of the observed patch of

group A and group B at the end of first month

111

Table 50 Comparison of results of size of the observed patch of

group A and group B at the end of second month

111

Table 51 Over-all Percentage Improvement 112

LIST OF GRAPHS

Sr.

No.

Graph Title Page

No.

1 Incidence of Shvitra (Vitiligo) in different age groups 97

2 Incidence of sex in Shvitra (Vitiligo) patient’s in different

groups

97

3 Incidence of Shvitra (Vitiligo) in different communities 97

4 Incidence of habitat in Shvitra ( Vitiligo) 97

5 Incidence of socio-economic status 98

6 Incidence of shvitra as per food habits 98

7 Incidence of earlier treatment history in the patients of Shvitra 98

8 Incidence of Deha Prakruthi in Shvitra patients 98

9 Incidence of Aharaja Nidanas described to produce Shvitra 99

10 Incidence of Viharaja Nidana in Shvitra patients 99

11 Incidence of chronicity of Shvitra 100

12 Incidence of number of mandalas (patches) 100

13 Incidence of distribution of mandalas 101

14 Incidence of presence of black spots in observed patch before

treatment

101

15 Incidence of colour of patch in Shvitra (Vitiligo) before

treatment

101

16 Incidence of size of Mandalas 101

17 Incidence of number of Vegas after Koshstashudhi medicine

given

102

18 Improvement in Itching sensation over observed Shvitra

(Vitiligo) patches in different groups

113

19 Improvement in colour change over observed Shvitra (Vitiligo)

patches in different groups

113

20 Improvement in bleb formation over observed Shvitra (Vitiligo)


113

21 Improvement in reduction of size of observed Shvitra (Vitiligo)


113

22 Improvement in appearance black spots over observed Shvitra

(Vitiligo) patches in different groups

114

23 Over-all percentage of improvement 114

INTRODUCTION

Introduction


INTRODUCTION

Since the beginning of the civilization the disease Shvitra is considered to be a

great social stigma and persons suffering from it could not command respectable

position in society. This disease does not cause any pain, ulcer or discomfort, but it

creates an inferiority complex in the person affected. Based on the symptoms, Shvitra

can be correlated with Vitiligo. The disease may start at any age but usually seen in

childhood at 10 years of age or in second decade of life. Based on some

dermatological out patient records it is roughly estimated to be between 3 – 4% in

India. The vitiligo affects the estimated 1% of world population.

“Some diseases do not take life, but they just ruin it.”

- Stephen Rothman.

Vitiligo is a common pigmentary disorder of great socio-medical importance.

It is defined as a circumscribed, acquired, idiopathic, progressive, hypomelanosis of

skin and hair, often familial and characterized by total absence of melanocytes

microscopically. This definition excludes post-inflammatory, chemically induced

depigmentation, those associated with melanoma, secondary to various dermatoses

and after burns.

Shvitra is considered as one of the varieties of Kusta in the Ayurvedic classics,

caused due to vitiation of Tridoshas and Dhatus like Rasa, Rakta, Mamsa and Meda.

Depending upon the duration of the disease and the involvement of Dhatus, the

disease becomes prognostically bad. While explaining Rakta Pradoshaja Vikara,

Shvitra is also mentioned.

According to modern science Vitiligo or Shvitra is a local hypo-

pigmentation of skin. Melanin is the most important pigment of skin formed from

phenylalanine & tyrosine under the influence of M.S.H. of anterior pituitary. Vitiligo

has an uncertain etiology for which autoimmune, self destructing, neural hypothesis

are suggested. In these hypothesis autoimmune hypothesis is mostly accepted & some

how the pigment could not be formed due to lack of certain enzymes in the tissues.

Introduction


Shvitra (Vitiligo) is characterized by milky white macules on skin.

Modern medicine has developed many treatment modalities still a large group of

people fail to get the achieved results and is refractory to treatment. In spite of

advanced modern technology and medicine the treatment of Vitiligo is not

satisfactory.

We get the reference of Shvitra right from Vedic literature, where the principle

line of treatment is mentioned as Sramsana and the use of Lepa after Sramsana.

According to Ayurveda “Shvetha Bhavchwitra” that is Shveta Bhavata is called

Shvitra. In spite of the use of various preparations by modern doctors, the cure rate in

Shvitra is considerably low & the incidence of such cases appears to be on the

increase. Lot of work was done on the use of Bakuchi, yet with poor results.

Shvitra is a disease where Bhrajaka Pitta present in Tvak is involved, Virechana

is considered as the best line of treatment if Pitta is involved, classics also mentioned

Sramsana as a line of treatment for Shvitra. Aragvadha phala majja has Sramsana

guna and is also indicated for Virechana in Bala since it is Mrudu; so Aragvadha

phala majja Kashaya was selected as a Koshtashudhikara dravya in the present study.

A number of yogas are mentioned for the purpose of external application after

Shodhana by many classics for Shvitra. Yogaratnakara and Vangasen Samhitha have

mentioned the use of Jyotishmati-Apamarga Taila for the treatment of Shvitra.

Apamarga has Rakta-Pitta Prasadanakara action and Jyotishmati has

Pitta Santpakara action. Hence they may be increase the activity of Bhrajaka Pitta

leading to formation of melanin pigments in Tvak (skin) resulting in normal Varna of

the patches..

By considering the nature of the disease, chronicity and its impact on

the psychological aspect of the children and Gunas of Aushadhi which may be very

helpful in treatment of Shvitra, present dessertion “the clinical study on the role of

local application with Jyotishmati-Apamarga Kshara Taila in the management of

Shvitra (Vitiligo)” is taken up.

Introduction


The entire study has been presented under various headings as follows :

The first part review of literature provides various literary factors of Shvitra as

available in authentic Ayurvedic and modern texts. This chapter also includes details

of Shvitra Chikitsa along with pharmacodynamics, properties, chemical composition

of the drugs, which were taken for the study.

The next part clinical study includes materials and methods as well as clinical

observations recorded in Shvitra patients along with statistical analysis of

observations.

The third important part discussion enlightens the observations from

the present study and other reported studies and research works.

The last part summery and conclusions provides in a nutshell, the entire study

including conclusions derived out of it.

Finally the thesis has been concluded with bibliography, references and an

appendix.

OBJECTIVES

Objectives


OBJECTIVES

Shvitra (Vitiligo) is considered as a great social stigma as it creates an

inferiority complex in the person affected, though it does not cause any pain, ulcer or

discomfort. Shvitra may start at any age but usually seen in childhood at 10 years of

age or in second decade of life. The children getting Shvitra becomes unable to

mingle with other children in the society and the social stigma continues to exist.

The incidence of the disease is alarming. Based on some dermatological out

patient records it is roughly estimated to be between 3 - 4% in India

We get the reference of Shvitra right from Vedic literature, where they have told

many Lepas for Shvitra. Ayurvedic Samhitas mentioned about the need of Shodhana

in Shvitra and described the use of many Lepas for Shvitra. Hence there is a

necessarity to explore the indigenous source for the treatment. So, A clinical study on

effect of local application with Jyotishmati-Apamarga Kshara Taila in the

management of Shvitra (Vitiligo) was taken up with the following objectives.

Objectives of the study:

1. To evaluate the effect of local application with Jyotishmati-Apamarga

Kshara Taila in the management of Shvitra.





Shvitra.

REVIEW OF

LITERATURE



Historical review

It is the past that has created the present. Knowing the history of the disease gives us

the knowledge regarding the origin of the disease, presentation of the disease during

those days and our ancestor‟s knowledge about them.

Vedic period (2500 BC – 1000 BC)

In Rig Veda a story is narrated where Shveta Kusta is mentioned. Ghosha daughter of

Kakshivat suffered from Sheta Kusta so did not get married. For this she prayed the

Ashwinis when her age has advanced. The Ashwinis cured her from Shveta Kusta and

restored her youth and beauty, and she got married12. In Rig Veda, the word Kilasa is

used for the white spots found over the body of the deer, which has resemblance with

the disease Shvitra13.In Atharvaveda the term Kilasa is used when prayers are offered

to the drugs to cure diseases like Kilasa and Khalitya. In Koushika sutra of

Atharvaveda Rama, Krishna, Asikni and Rajani are the herbs described as a remedy

for the diseases Kilasa and Khalitya. The fourth drug appreciated in the maintenance

of colour is Rajani or turmeric14 In Yajurveda there is a reference mentioning that

Chandra or moon was affected by the disease kilasa15 In Manu-smrithi there is a

reference stating that persons suffering from Shvitra and their progeny are

disqualified for marriage16. Sama veada probably has no reference of Shvitra.

Reference of Shvitra is also found in Panini vyakarana sutra17

Samhita kala (1000 BC – 100 AD)

Acharya Caraka describes Shvitra in Kusta chikitsa adhyaya of chikitsa

sthana after explaining other types of Kusta. Special emphasis is given to the Nidanas

of Shvitra in this book18

Acharya Susrutha mentioned Shvitra in Kusta Nidana of Nidana sthana where the

difference between Kusta and Kilasa, types of Shvitra and its Sadhyasadhyata is

explained19. The treatment of the disease is mentioned in Chikitsa sthana20. In

Dalhana commentary of Nidanasthana Bhoja‟s opinion on types of Shvitra is

mentioned21.



In Kashyapa samhita scattered references regarding disease Shvitra are available. In

Sutrasthana while classifying the diseases Shvitra is said to be three types22. In

Shareerasthana it is mentioned that the disease Shvitra is caused due to vitiation of

Tvakgata udaka23. In Chikitsastahana definition of Shvitra is mentioned and

enumerated as five types24. In Kalpasthana it is mentioned that the person suffering

from Shvitra should not take Ikshu rasa25. Lashuna and Gandhasarpi are indicated in

Shvitra26. In Siddhisthana Virechana and Niruha Basthi are indicated for Shvitra27.

In Bhela Samhita Lakshanas of Shvitra are mentioned in Chikitsasthana28.

In Harita Samhita Pandura Kusta Chikitsa is mentioned, which is similar to Shvitra

Chikitsa29.

Sangraha kala (800 AD – 1700 AD)

In Astanga Sangraha the Nidana, Lakshana, Bheda and Sadhyasadhayta of Shvitra are

mentioned30. In Chikitsasthana a separate chapter is dedicated for Shvitra Chikitsa31.

In Astanga Hridaya similar references like Astanga Sangraha are available32.

Madhava Nidana described the difference between Kusta and Kilasa, its type‟s

Lakshanas and Sadhyasadhayata as well33.

In Sharangadhara Samhita Shvitra types34 and many yogas are described for its

treatment.35

Bhavaprakasha mentioned a combined opinion of Charaka and Sushruta by explaining

Dhatugata and Doshaja shvitra. He explained Sadhyasadhyata and treatment of

Shvitra36.

Yogaratnakara explained Samanya Lakshana, Sadhyasadhyata and Chikitsa37.

Bhaishajya Ratnavali described many yogas for the management of Shvitra38.

Gada Nigraha explained the types, Lakshanas, Sadhyasadhyata and Chikitsa of

Shvitra39.

Chakradautta mentioned many yogas for Shvitra under Kusta Chikitsa40.



Review of previous research works-

1. Ojha D. – Studies on etiology, pathology and management of vitiligo.

1973, B H U, Varanasi. (Ph. D.)

2. Mishra S. – Clinical trial of some indigenous drug on Shvitra. 1986,

Gopabandhu Ayurveda Mahavidyalaya, Bhubaneshwar.

3. Sharma M, Avalgujadi gutica in Shvitra (Bahya prayoga) and datri kadira

kwatha (Abhyantara), 1989, National Institute of Ayurveda, Jaipur.

4. Burman S, Therapeutic effect of tuttadi Lepa in Shvitra. 1994,

Gopabandhu Ayurveda Mahavidyalaya, Puri.

5. Prabhakar S. – A clinical study on the effect of Somarajyadi choorna

(internally) and Somarajyadi Lepa (externally) in Shvitra. 1996, Dr. B. K.

R. R. Govt. Ayurveda college, Vijayawada.

6. Venkataiah G. – Organotherapy (Krishna karma) in the management of

Shvitra. 1996, Dr. B. K. R. R. Govt. Ayurveda college, Vijayawada.

7. Sarda C. L. – A clinical study on management of Shvitra w. s. r. to

Caraka‟s “Yat Cha Anyat Kushthanghnam, Shvitram eva tat Shastam

Khadirodaka Samyuktam.”. 1996, Gujarath Ayurveda University,

Jamnagar. (Ph. D.)

8. Sharada M. K. - A Clinical Study on the Management of Shvitra (Vitiligo)

With Special Reference to Lepa. 2003, S. D. M. College of Ayurveda and

Hospital, Hassan.



Ayurvedic Review

Before proceeding to study Vikruthi one should know the Prakrutha form 41. There

fore it is necessary to look in to the Prakrutha rachana and Kriya of Tvacha, because it

is the seat where the disease Shvitra manifests.

Tvacha is derived from “Tvach-Samvarne” Dhatu meaning the covering of the body42.

Skin formation:

Sushtura described the formation of Tvacha in the developing foetus. He says that

after fertilization of ovum Tvacha develops just like a cream on the surface of milk.43

Charaka and Astanga sangraha kara opine Tvak as a matruja angavayava.44

Vagbhata described the formation of Tvacha due to Paka of Rakta Dhatu by its

Dhatvagni in the foetus. After Paka, it dries up, to form Tvacha, just like the

deposition of cream over the surface of boiled milk45.Tvak is mentioned as a Vayuvya

Anga by all the authors.

Varnotpattikarana in garbha:

The complexion does not depend only on karma but it depends on the Tejo

mahabhuta. Different complexions arise on the basis of association of Tejomahabhuta

with other mahabhutas46.

Astanga Sangrahakara mentioned causes of Varnotpatti as follows,

1. The garbha attains shukla Varna if shukra has the colour of ghrutha manda.

The garbha attains gouravarna if shukra is of taila Varna and garbha attains

Krishna Varna if shukra is like madhu.

2. The colour of garbha depends on ahara taken by garbhini. The garbha attains

gouravarna if she consumes madhuradravyas and by udaka vihara. The garbha

attains krishnavarna if she consumes vidahi padarthas and if she consumes the

combination of madhura and vidahi padartha garbha attains shyama Varna.

3. Varna depends on desha, kala and anuvrutti (mode of living) 47.

4. Hareetha explained varnotpathi on the basis of doshas48.



Table 1: Varnothpatthi based on combination of Pancha Mahabhutas

Varna C.S / A.S S.S H.S

Gaura Teja + Jala +

Akasha

Teja + Jala Pitta

Krishna Teja + Pruthvi +

Vayu

Teja + Pruthvi Vata + Raktha

Shyama All mahabhutas in

equal proportion

-- Vata + Kapha and

Raktha + Kapha

Gaurashyama -- Teja + Jala +

Akasha

--

Krishnashyama -- Teja + Pruthvi +

akasha

--

Pingala -- -- Pitta + Raktha

Tvak is made out of all mahabhutas with the predominace of Vata.49

Layers of the skin:

a) Charaka described six layers of skin but while elaborating these layers he has

named only two layers the rest four layers have been described in terms of the

diseases50.

Table 2: Layers of the skin according to Charaka

No. Layers Diseases

1 Udakadhara -

2 Asrugdhara -

3 Third Layer Sidhma, Kilasa

4 Fourth Layer Dadru, Kushtha

5 Fifth Layer Alaji, Vidradhi

6 Sixth Layer Arunshi

b) Sushruta has described seven layers of skin along with the specific names. He has

also mentioned the thickness of each layer along with the diseases, which are prone to

that layer51.



Table 3: Layers of the skin according to Sushruta

Name Thickness Diseases Avabhasini 1/18 of the Vrihi Sidhma, Padmakantaka Lohita 1/16 of the Vrihi Tilakalaka, Nyachcha, Vyanga Shweta 1/12 of the Vrihi Charmadala, Ajagallika,

Mashaka Tamra 1/8 of the Vrihi Kilasa & Kushtha Vedini 1/5 of the Vrihi Kushtha & Visarpa Rohini 1 Vrihi Granthi, Arbuda, Galaganda,

Apachi, Shleepada Mamsadhara 2 Vrihi Bhagandhara, Vidradhi, Arsha

c) Vagbhatta has described seven layers of skin similar to Sushruta. He has not

given any description. Commentator Arunadatta and Hemadri have named

them according to Sushrtua52.

d) Sharangdhara has also mentioned seven layers of skin along with the probable

onset of diseases. The names of first six layers are same as Sushruta but

seventh layer is named as “Sthula” which is the site of Vidradhi53.

Table 4: Layers of skin according to Sharangadhara

Name Diseases

Avabhasini Sidhma

Lohita Tilakalaka

Shweta Charmadala

Tamra Kilasa & Shvitra

Vedini All types of Kushtha

Rohini Granthi,Galaganda, Apachi

Sthula (2 vreehi) Vidradhi

Dr. Ghanekar has written commentary on Sushruta Sharira Sthana. He has

correlated the layers of skin mentioned by Sushruta with the latest anatomy of skin as

under54

.



Ancient Term Modern Term Types of skin

1) Avabhasini Stratum Corneum

2) Lohita Stratum Lucidum Epidermis

3) Shweta Stratum Granulosum

4) Tamra Malpighian layer

5) Vedini Papillary Layer

6) Rohini Reticular Layer Dermis

7) Mamsadhara Subcutaneous tissue and

Muscular layer

Relation of doshas with Tvacha

Vata:

Among the five types of Vata PranaVata is the one, which controls all the Indriyas.

Udana Vata maintains the varna55.

Pitta:

Pitta situated in Tvak is called bhrajaka Pitta and does Tvak bhrajana56. Arunadutta

comments as the Pitta located in the skin is designated as Bhrajakagni and is

responsible for digestion and absorption of the substances used for Abhyanga,

Parisheka, Avagaha and Lepa. The Bhrajaka Pitta located in Tvak manifests the

colour in Avabhasini layer57.

Relation of Tvak with Dhatus

The mobile water (interstitial fluid) in the body is 10 Anjalis and the Udakadhara

layer helps in evaporation of such fluid to maintain body temperature58. Among the

Sapthadhatusaras the first Sara explained is Tvak sara59.

Nirukti

The term Shvitra is derived from the root shvith – which means shveta varna

(white colour). When the suffix rik is added to the root shvith, by the rule, letter ka is

deleted resulting in, formation of the word Shvitra.

Paribhasha:

Shvirta has been defined in different ways, but all definitions carry the same meaning.



Shvetate iti shvitram – Shvitra is a disease of white patches.

Shveta bhava micchanthi Shvitram – disease characterized by white colour60.

Shvetate anena iti shevta kustam – Kusta characterized by white colour61.

Paryaya:

1. Shvitra – Shvetate iti Shvitra – which is characterized by white colour.

2. Kilasa – Kila Varna yasyati kshiyathi vikruti karothi yat - gives vikruta varna.

3. Shveta kusta – Shvetate anena iti Shveta kustam62– Characterized by shveta

varna.

4. Charuna – Reddish brown color of the morning, i.e. Dawn.

5. Daruna – Difficult to treat

Shvitra Nidan (Etiology of Shvitra)

Clinical significance of a disease is based on its etiological factors which a physician

can conform by proper interrogation about the diet, regimen and exact reason of

onset.

Except Caraka, no other Acharya has given specific etiology for Shvitra. He

considered Shvitra under Kustha roga prakarna, Acharya Sushruta has stated that

Kilasa is a type of Kustha64. Vriddha Vagbhata and Vagbhata described that the

etiology of Shvitra is similar to Kustha65.

As per Ayurvedic principle of treatment, avoiding the etiology is the way of

treatment, so if the treatment of Kustha and Shvitra is similar, the etiology of both

should be similar66. Based on the this statements one can take the etiology of Kustha

as etiology of Shvitra, which can be divided into following types -

Fig No 1 : Classification as per Nidana

SHVITRA NIDAN

Abhyantara Kulaja Nidan Bahaya Nidan

Nija Beeja Bhagavyava Dushti Agantuja

1. Aharaja

2. Viharaja

3. Vaidyakruta Vranaja Agnidagdha



4. Pragnyaparadha

5. Manasika

6. Nidanarthakara

I. Abhyantara Nidana

(a) Aharaja Nidana

Viruddha Ahara

Achary Caraka has mentioned the important role of diet especially Viruddhahara in

the cause of Shvitra. He mentioned the disease Shvitra along with other diseases

owing to intake of Viruddhahara67.

Defination of Viruddhahara

1. Substances which are contrary to Dehadhatus are considered as Viruddha

(antagonistic). This antagonism may be interms of guna, samyoga, samskara,

desha, kala, matra etc or by Swabhava68.

2. The entire (drug or) diet, which excites the dosha but fails to get eliminated from

the body, becomes harmful69.

According to Acharya Sushruta whatever food one could take if antagonistic to the

body, vitiates Vata etc doshas but it does not get eliminated or remove doshas from

body like Vamana or Virechana are considered as viruddha70.

Vagbhata described that viruddhahara at times may cause instantaneous death like

Visha (Poison), or may cause slow poisoning like Garavisha71.

Vruddha Vagbhata emphasizes about the character of viruddha substance, that the

substance which vitiates doshas but does not get eliminated from the body, with its

antagonistic nature to deha dhatus and will stay in the body72.

Brihatreayi has described viruddhaharas, e.g. taking fish with milk together is

incompatible, because both are madhura rasa, madhur vipaka, abhishyandi (obstructer

for channels). But both have viruddha virya i.e. milk – shita and fish – ushna, due to

opposite viryas, it vitiates blood and due to being abhishyandi, creates obstruction in

channels. Hence one should not take any fish along with milk particularly chilichima.



Factors responsible for Dietetic incompatibility

Acharya Craka has given eighteen factors responsible for dietetic

incompatibility. Those are drugs and diets which are at variance with –

1.Desh

2.Kala

3.Agni

4.Matra

5.Satmya

6.Dosha

7.Samskara

8.Veerya

9. Kostha

10. Avastha

11. Kram

12. Parihar

13. Upachar

14. pak

15. Samyog

16. Hridya

17. Sampat

18. Vidhi

all are un-whole-some.73

These are illustrated below –

1. Desh viruddha – In take of ruksh and tikshna substances in jangal desh, snigdh

and sheetal substances in anupa desha etc.

2. Kala viruddha – In take of sheetal and ruksha substances in cold climates (winter),

katu and ushna substances in hot climate (summer).

3. Agni viruddha – In take of guru ahara when the Agni is manda and in take of

laghu ahara when Agni is tikshna. Similarly intake of food at variance with

vishama and Sama Agni.

4. Matra viruddha – Intake of honey and ghee in equal quantities.

5. Satmya viruddha – Intake of madhura rasa and shita virya substances by a person

who is satmya to katurasa and ushna virya.

6. Dosha viruddha – Utilization of aushadha, ahara and vihara having similar

qualities with doshas but at variance with the satmya of individual.

7. Samskara viruddha – Aushadha and ahara when prepared in a particular way

produce poisonous effect for example meat of peacock roasted with castor stick.

8. Virya viruddha – Intake of substances having shita virya in combination with

those of ushna virya.

9. Koshtha viruddha - Administration of mild purgative in a small dose for a person

of krura koshtha and administration of strong purgatives in large doses for a

person having mrudu koshtha is koshtha viruddha.



10. Avastha viruddha – Intake of Vata aggravating food by a person after exhaustion,

sexual act and physical exercise or intake of Kapha aggravating substances by a

person with sedentary (alasi) habits.

11. Krama viruddha – If a person used to take food before evacuation of his bowel

and bladder or without appetite or after feeling of excessive hunger.

12. Parihar viruddha – Intake of ushna substances after taking the meat of sukara.

13. Upchara viruddha – Intake of sheetal aushadha ahara and drava after drinking of

ghee etc. snigdha substances.

14. Paka viruddha – Preparation of food etc with a bad or rotten fuel and

undercooking, overcooking or burning during the process of preparation.

15. Samyoga viruddha – Intake of sour substances with milk. Milk is a madhura rasa

and shita virya substance; where as sour substances have amla rasa and ushna

virya. So both are mutually contradictory in their nature.

16. Hridya viruddha – Taking of unpleasant substances. There is a great role of mind

in the digestion of food, because agni may be normal but without equilibrium state

of mind digestion gets hampered. So one should take food which is pleasant to the

mind.74

17. Sampad viruddha – Intake of substances which are not matured, over matured or

putrefied.

18. Vidhi viruddha – One should eat in lonely place not in open (public) place.

These eighteen types are viruddhas taught by acharya Caraka. By these above

viruddhas Agni is disturbed. If Agni is disturbed pachana karma is disturbed.

Causes for antagonism

Dietetic substances are antagonistic to the deha dhahus by the incompatiblity

of their rasa, guna, virya, vipak and prabhav or by samskara, matra, desh, kala,

samyoga and parihara etc. or by swabhava. It means whole-some substances also

become unwhole-some because of the above reasons.75



Mithyahara

Acharya Caraka has emphasized on the method of taking diet by giving eight

factors. These are called Astavidhaahara Visheshayatanani. If one has taken food

against these eight factors then it is called mithyahara or Mithyayoga of food76.

Eight factors determining the utility of food

The eight factors which determine the utility or otherwise of various types of food are

1. Prakrithi (nature of the food articles)

2. Karana (Method of their processing)

3. Samyoga (Combination)

4. Rasi (Quantity)

5. Desh (Habitat)

6. Kala (time i.e. stage of the disease)

7. Upayoga samstha (rules governlng the intake of food)

8. Upayokta (whole-some ness to the individual who intakes it) 77.

If the person has taken diet contravening the above said eight factors then the

digestion of the food is not proper, then the metabolism (formation of dhatus) is also

disturbed. This leads to improper supplement of deha dhatus. In the whole some diet

person should avoid Samasan, Adhyasan, Amatrasan and Vishamasan.

Samasan – Pathya and apathya dravya taking together is called samasan.

Adhyasan - In take of food before the previous food is digested.

Vishamasan – Untimely diet or irregular diet78.

Amatraasan - It is of two types –

Diet taken in low quantity than normal amount.

Diet taken in high quantity than normal amount79.

If the diet is taken in less quantity it causes Vibandh, Avairshya, Anayushya,

Anaujasya, destructs Tvaksar and causes Vata rogas80.

If food is taken in excess quantity all the three doshas are vitiated and cause visuchika

and alasaka81.

By taking Viruddha Ahara and mithyaahara the Agni is disturbed. If the

Jatharagni is disturbed which is the seat of pachana karma (digestion) other agnis

Ranjakagni, Bhrajakagni, Alochakagni, Bhutagnis and Dhatwagnis are not nourished.

So they fail to do their prakrita karya.



The name of pachaka Pitta itself is Agni. So by the sevana of Viruddha and

mithya aharas, this Agni will be disturbed along with other agnis or pitas which are

under the control of pachaka Pitta will be disturbed. So due to disturbance of Ranjaka

Pitta, Bhrajaka Pitta and Alochak Pitta and their function of pigmentation is also

disturbed giving the disease Shvitra.

(b) Viharaja Nidana

Vihara means physical exercise of person which causes strain to Indriyas. It is

of two types.

Viruddhavihara Mithya vihar

(i) Viruddha Vihara

It means doing opposing types of work at the same time or one after other

without any time gap e.g. - person who once gets exhausted with exercise, heat or

sunlight, using the cold water for drinking or for bathing or cold air with air cooler is

Viruddha Vihara.

Skin is the very important and largest sense organ which is affected more by

these Viruddha Viharas and getting damaged. This damage may leads to Shvitra.

(ii) Mithya Viharaja Nidan

One should do labour according to the strength of his body. If the labour

exceeds the body strength then it is called Mithya Vihara81. By this Mithya Vihara

vitiation of Doshas occur leading to the disease Shvitra.

For example -

Night awaking (Ratri Jagarana).

Day sleep (Diva Swapna).

Exercise or sexual act after vomiting.

(c) Vaidya Krita Nidana - ( Iatrogenic)

These are the Nidanas produced due to the fault of doctor. In Ayurvedic treatment,

Panchakarma therapy is having an important place. While doing these procedures, if

the doctor does not have proper knowledge of it, he may commit mistakes. e.g. In the

procedure of vomiting, if the vomiting is not proper then there will be aggregation of

Kapha or if the vomiting is excessive then the aggravation of Pitta occurs. In the same

way other faulty procedures of Panchakarma may cause Shvitra.



(d) Pragyaparadhajanya Nidan

Following are some examples of "Pragnya-paradha” which may cause Shvitra.

Untruthfulness of speech

Ingratitude

Bleshphemy against the

God

Not respecting elderly

people and teachers

Sinful actions

Evil acts of past lives

Disgrace to teachers

Stealing others things

Not giving, offerings like

homa, bali etc to God

(e) Manasika Nidan (Psychological Causes)

Psychological factors like tension, fear and anger are responsible for Psychic

diseases. Not only psychic diseases, these causes also lead to diseases of body

channels by vitiating Vata, Pitta or Kapha. These are termed as psychosomatic

illnesses. The Psychological factors increase the raja and tama qualities, which in turn

vitiates the Vata, Pitta and Kapha Doshas giving rise to various diseases. In the case

of Shvitra these causes are, e.g. –

Homicide of Brahmanas (Brahman vadh)

Homicide of Ladies (Stree vadh)

Homicide of Sajjan (Sajjan vadh) etc.

(f) Nidanarthakara Nidan

If a disease becomes the causative factor of another disease then it is called

Nidanarthakara Nidana. e.g. - Improper treatment of Vrana leads to Shvitra.

II. Kulaja Nidan

This can be taken as Beeja-Bhagavayava Dushti, i.e. chromosomal and genetic

factors. The word Beeja means seed i.e. fertilized ovum, sperm Beejabhaga means

chromosome, which is derived from Bhaga, i.e. part of Beeja. The word Beeja

Bhagavayava means 'gene' which is Avayava i.e. part of Beejabhaga i.e. chromosome

Beejabhaga i.e. chromosomes constitute the parts of ovum and sperm and are

responsible for the hereditary characters. A defective chromosome or a part of

chromosome i.e. gene is responsible for Abnormalities of sex organs and defects in a

particular organ. Members of certain families are inherently predisposed to develop

certain diseases82.



Health as well as disease is primarily determined by quality of the genes. A

person with all the genes of good quality leads a healthy and vigorous life of hundred

years, provided he gets good food, pure air, and clean water and follows dietatis of his

conscience. Genes play an important role in the causation of all natural diseases.

III. Bahya Nidana

These are the Nidanas by which there is no Sanchaya of Doshas. Immediately

by exposure itself they are producing the disease. It is also called Agantuja. It is

divided in to two types Vranaja and Agnidagdhaja. Because of external trauma if

Shvitra is produced then it can be considered as Vranaja and if the Shvitra is produced

by burn; then these two causes can be considered under Bahya Nidana.

Table 5: Nidanas of Shvitra

S. N.

Nidanas C.S

S.S

A.S

A.H

B.P

Y.R

M.N

B.S

H.S

G.N

Aharaja nidana 1 Amlathi sevana + - - - + + + - - + 2 Ati drava ahara + - - - + + + - - + 3 Ati snigdha ahara + - - - + + + - - + 4 Ati guru ahara + - - - + + + - - + 5 Ajeerna + + - - + + + + - + 6 Adhyashana + - - - + + + + - + 7 Ahitashana + - - - + + + + - + 8 Asathmya ahara - + - - - - - - - - 9 Ati dadhi sevana + - - - + + + - - + 10 Chilichima + milk + - - - - - - - - - 11 Haviprashana - - - - - - - - + - 12 Pippali + kakamachi +

lakucha with dadhi + sarpi

- - - - - - - + - -

13 Garmyanupoudaka + haritha shaka

- - - - - - - + - -

14 Madhu + mamsa after ushnaahara sevana

- - - - - - - + - -

15 Ushna ahara after madhu and madhaya sevana

- - - - - - - + - -

16 Gramya oudaka anupa mamsa with milk

- + - - - - - - - -



17 Ati masha mulaka pistanna tila Kshara and guda sevana

+ - - - + + + - - +

18 Ati Madhya amla sevana after intake of ksheera

- - - - - - - + - -

19 Ati madhu phanita matsya lakucha mulaka kakamachi sevana during ajeerna

+ - - - - - - - - -

20 In take of yavaka and chanaka with ksheera

+ - - - - - - - - -

21 Ati dadhi takra kola kulatha masha athasi and kusumba snehasevana

+ - - - - - - - - -

22 Intake of mathsya+mamsa+ksheera + nimbuka

- - - - - - - + - -

23 Lavanathi sevana + - - - + + + - - + 24 Mithyahara - + + + - - - - - - 25 Mathsyathi sevana + - - - + + + - - + 26 Ati navanna sevana + - - - + + + - - + 27 Papodaka sevana - - - - - - - - + - 28 Viruddhahara + + + + + + + + - + 29 Vidagdhahara + - - - - - - + - - 30 Vidahi ahara + - - - - - - + - - Viharaja nidana 1 Ativyayama

atisantapa after atibhukta

+ - - - + + + - - +

2 Ati maithuna + - - - - - - - - - 3 Ati vyayama + - - - - - - - - - 4 Bhaya + - - - - - - - - - 5 Chardhi nigraha + + - - + + + - - + 6 Divaswapna + - - - + + + - - + 7 Gramyadharma after

intake of vidagdha ahara

- - - - - - - + - -

8 Chardhi nigraha after intake of mithya samsarga ahara

- - - - - - - + - -



9 Intake of sheeta and ushna padartha with out difference

+ - - - - - - - -

10 Mithya vihara - + + + - - - - - - 11 Parishrama + - - - - - - - - - 12 Rathri jagarana - - - - - - - - + - 13 Sheetambu sevana

after atapa sevana + + - - - - - + - -

14 Sheetambu snana or sevana after long walk

- - - - - - - + - -

15 Tevra dhoopa sevana + - - - - - - - - - 16 Vegavarodha + + - - + + + - - + 17 Vyayama during

ajeerna + - - - + + + - - +

Anya nidana 1 Anyasthi apaharana - + + + - - - - - - 2 Bhramhana, sthree,

sajjna vadha - + + + - - - - - -

3 Gohathya - - - - - - - - + - 4 Poorvakrutha karma - - + + - - - - - - 5 Sadhu ninda and

vadha - - + + - - - - - -

6 Vipra and guru garshana

+ - - - + + + - - +

Chikitsa sambandhi nidana 1 Vidahi vidagdha

aharaasevana with out shodhana

+ - - - - - - + - -

2 Vyayama and gramya dharma after snehapana and Vamana

- + - - - - - - - -

3 Intake of santharpana and apatharpana with out differentiating

+ - - - - - - - - -

4 Panchakarma apachara

+ - - - + + + - - -

5 Ati snehapana + - - - - - - - - - Vishista nidana 1 Papa karma + - - - - - - - - - 2 Krithagna bhava + - - - - - - - - - 3 Poorva kritha karma + - - - - - - - - -



4 Guru gharshana + - - - - - - - - - 5 Viruddhahara + - - - - - - - - -

Purva Rupa (Prodromal Features)

In Ayurveda, Acharyas have not given any specific prodromal features of

Shvitra. But Acharya Sushruta, Vagbhata, Bhel and Kashyap have been stated that

Shvitra is produced like Kushta, so Purvarupa are also similar to Kushta.

Most of the Acharyas included Shvitra in Kushta Rogadhikara. Hence they

considered the Purvarupa of Kushta as Purvarupa of Shvitra83. But in general these

Purvarupas of Kushta are not seen in Shvitra. However few features seem to be

similar with prodromal features of Shvitra.

Rupa (Clinical Features)

Exposure to etiological factors causes vitiation of Doshas (Sanchaya and

Prakopa).Vata, Pitta and Kapha after vitiation of these Doshas while circulating

(Prasara) in the body, where-ever they get Khavaigunya (Khavaigunya or Srotodushti)

is stated to produce Srotorodha (occlusion or obstruction) of the Srotas. There, these

Doshas are retained and interact with Dushyas of the affected region. This

phenomenon is called Doshadushya Sammurchana, which is called Vyadhi84.

Indistinct symptoms present in the Purvarupa stage when manifested clearly

and show the features or symptoms indicating specific disease (Vyadhi) are Rupa85.

These clinical manifestations give us an important clue to the diagnosis; the

stage of the disease, differential diagnosis, prognosis and treatment of disease.

Cardinal feature of Shvitra is development of depigmented patches on the

skin.

Lakshanas

The Lakshanas of Shvitra mentioned in the classics can be classified under two

catogaries.

Samanya Lakshanas Vishishta Lakshanas

Shvitra word itself means Shvetha Varna of Tvacha, it is the cardinal feature

of the disease. Acharyas while mentioning the difference between Shvitra and Kusta

mentioned Shvitra as aparisravi86. Yogarathnakara mentioned Pandura Varna, Sasrava



and Kandu as Samanya Lakshana of Shvitra, most probably it refers to Vranaja

Shvitra87.

Acharya Charaka explained Daruna, Charuna and Shvitra as three names of

kilasa and are caused by Tridoshas. Colour of the skin varies when Doshas are

situated at different Dhathus. These are –

o When doshas are situated in Raktha dhatu – Raktha Varna

o When doshas are situated in Mamsa dhathu - Thamra Varna

o When doshas are situated in Medo dhathu – Shweta Varna88

In this context dhatu gatatwa of Shvitra up to Meda dhathu is explained.

Acharya Bhela mentioned the precence of Shali shuka prathikasha loma,

shukla lohitha Anyonya mandala as samanya lakshana89.

Vishista Lakshanas90:

Acharya Charaka did not mention the Doshaja classification of Shvitra.

Astanga hridaya, Bhavaprakasha, Madhavanidana, Gadanigraha, followed the opinion

mentioned in Astanga sangraha, which is as follows.

Vathaja Shvita

Pittaja Shvitra

Kapahaja Shvitra

Vathaja Shvitra

Aruna Varna Mandala -Ishat Lohitha Varna as commented by Bhava Prakash

Parushatha-roughness

Paridhwamsi-powder like material on scratching the patch

Rookshatha-roughness, Dhathu involved is Raktha Dhathu

Pittaja Shvitra

Padmapatra Varna –colour of lotus leaves (dull white as seen in dorsal aspect)

Daha-burning sensation in the lesion

Roma Vidhwamsatha-distruction of hair at the site

Dhathu involved is Mamsa Dhathu

Kaphaja Shvitra

Shvetha Varna –white colour of the leasion

Snigdhatha -unctousness

Bahala -thick



Kandu –itching at the site

Ghanatha – pusta as commented by Bhava Prakasha

Dhathu involved is Medho Dhathu

Table 6: Showing the Lakshanas Described In Ayurvedic Classics

Sl no

Lakshana C.S S.S A.S A.H

B.S B.P Y.R

G.N

M.N

H.S

K.S

Samanya lakshana

1 Aparisravi - + + + - + - + + - -

2 Anyonya mandala

- - - - + - - - - - -

3 Caused by tridosha

+ + + + - + - + + - -

4 Kandu - - - - - - + - - - -

5 Pandu varna - - - - - - + - - - -

6 Swetha varna + - - - - - - - - - +

7 Sasravi - - - - - - + - - - -

8 Shali shuka like roma

- - - - + - - - - - -

9 Shukla lohita varna

- - - - + - - - - - -

10 Ashraya in raktha mamsa meda

+ - + + - + - + + - -

Vishista lakshana

Vataja

1 Aruna varna - + + + - + - + + - -

2 Parusha - + - - - - - - - - -

3 Paridhwamsi - + - - - - - - - - -

4 Rukshatha - - + + - + - + + - -

5 Rakthashrita + - + + - + - + + - -

Pittaja

1 Mamsashrita + - + + - + - + + - -



2 Padmapatra prakasha

- + + + - + - + + - -

3 Paridaha - + + + - + - + + - -

4 Romavidhwamsi

- - + + - + - + + - -

5 Raktha/ tamra Varna

- - + + - + - + + - -

Kaphaja 1 Bahala - + - - - - - - - - -

2 Guru - - + + - + - + + - -

3 Ghana - - + + - + - + + - -

4 Kandu - + + + - + - + + - -

5 Medashrita + - + + - + - + + - -

6 Snigdha - + - - - - - - - - -

7 Shweta varna - + + + - + - + + - -

Sapeksha Nidana

It is essential to rule out other possible diseases, which are having similar

symptoms. The cardinal feature of Shvitra i.e, Tvacha Shwetata and Aparisravi are

not present together in any of the disorders mentioned in the classics. Sidhma, which

is one of the Mahakusta, simulates Shvitra. Differentiating features between these two

are as shown in the table no.7. 91

Table 7: Sapeksha nidana of Shvitra

Sl no Distinguishing features

Shvitra Sidhma

1. Dosha Tridoshaja Kapha – Vataja 2. Dhatu Rakta – mamsa –

meda Sapta dhatu

3. Poorvaroopa -- Present 4. Color sweta Sweta, tamra, alabu pushpavat 5. Thickness tanu or thin Tanu or thin 6. Itching -- Present 7. Roopa

Aparisravi or no change on scratching

Rajo ghrustam vimunchati or powder like material on scratching

8. Area of lesion Occurs anywhere Most common in upper part of the body



Bheda: Bheda is a part of Sankhya Samprapti.

Classification according to etiology 92

1. Doshaja

a. Atmaja – caused by Vata, Pitta or Rakta and Kapha

b. Paraja – caused by Paragatra Sparsha.

2. Vranaja – caused by Vrana

According to Dosha93

1.Vataja Raktashrita 2.Pittaja Mamsashrita 3.Kaphaja Medashrita

According to Ashraya94

1. Raktashrita 2.Mamsashrita 3. Medashrita

According to prognosis95

1. Sadhya 2. Asadhya



SAMPRAPTI

The manner in which the Doshas are vitiated and traversing throughout the body and

produce the symptom is termed as Samprapti96.

Ayurveda describes in detail the various stages of evolution of diseases. Such as –

(1) Chaya i.e. accumulation of Doshas because of action of etiological factors

(2) Prakopa i.e. further increase in the Doshas,

(3) Prasara i. e. dissemination of Doshas which correspond to the stage of septicemia,

or toxemia.

(4) Sthana Sanshraya i.e. localisation of Dosha in a particular tissue or organ

(5) Vyakta i.e. manifestation of disease because of derangement of functions of the

organ involved.

(6) Bheda i.e. further differentiation into the sub-type of the disease.

Caraka has given etiology and clinical features. But he doesn't give any

description about pathogenesis (Samprapti). He has mentioned Kilasa as Tridoshaja,

Dwidoshaja and Ekdoshaja. Both Shvitra and Kushta are Tridoshaja.

Acharya Sushruta interpreted Shvitra as a type of Kushta. According to him,

by Nidan Sevana Vata is vitiated and associated with vitiated Pitta and Kapha, spreads

in those Siras, which are going in Tiryak Marga and their Sthana Sansraya occurs on

the skin (Tvak, Rakta, Mamsa and Lasika). These vitiated Doshas enter in the skin, if

not treated in proper way, they gradually enter the Rakta and Mamsa etc. Dhatus,

vitiate them and produce Kushta (Shvitra) 97.

Kilasa is a type of Kushta, and is limited to only skin98. Pathogenesis

explained by the Harita for Kilasa is very much specific, because no other text has

given such type of pathogenesis. According to him, major Dosha Pitta contaminated

with Rakta is carried by vitiated Dosha, Vata and gets lodged in Tvak. By his opinion

Pitta carried by Vata, when contaminates Rakta produces Pandura Varna in skin99.

This Pandura Varna of Tvak is known by the name of Shvitra or Pandura

Kushta. But other Acharyas opine that the vitiated Rakta; Mamsa and Medodhatu as

responsible for Shvitra.

Acharya Bhela says that by Nidana sevana, Kapha Dosha when gets excited

and lodges in Tvak, Rakta and Mamsa, produces Kushta (Shvitra) 100. Acharya Bhela



described Shveta Kushta along with Kshudra Kushtas. Hence we can consider the

pathogenesis of Shvitra similar to Kustha.

According to Chakrapanidatta, commentator of Charaka samhita by the Nidan

sevana (Ahara Vyatyas) Vitiation of Tridoshas take place. This vitiation leads to the

Shaithilya of Tvak, Lasika, and Rakta and Mamsa Dhatus which means that there is

production of Ama 101. Vihara Vyatas and Vegarodhatmak Nidana leads to the 'Kha'

Vaigunya of Varnotpadak avayav of Tvacha which is Bahya Nivesa Sthana of Rasa

and Raktavaha Srotas. Because of this 'kha' vaigunya dosha dushya Sammurchana

takes place in the Shithila, Tvak, Lasika, Rakta or Mamsa. In this Dosha Dushya

Sarnrnurchana, by the association of one, two or three Doshas with one, two or three

Dhatus depending on the Papakarma of the person (which will give Shighratva,

Chiratva, Tanutva and Ghantva) Asankhyey Kushta, or Kshudra Kushta or Maha-

Kushta or Shvitra Kushta is produced. Hence this is the common Samprapti for all

type of Kushta Rogas but depending on the type and amount of Nidana Sevana the

type of Kushta produced gets changed102.

Fig. No. 2 Schematic representation of Samprapti

Abhyanthara nidana sevana Vitiation of Dosha Agni mandya Formation of Ama

Dusta dosha sanchara in tiryag gata Siras

Vrana Stanika Brajaka Pitta Kshaya Shvitra



Acharya Vagbhata, Sodhaa, Bhavamishra, Yogratnakara and Madavkara

described Shvitra as Tridoshaja Vyadhi and interpreted Shvitra as a type of Kushta.

Hence the pathogenesis of Kushta can be accepted as pathogenesis of Shvitra.

According to them vitiated Doshas vitiates Tvak, Rakta, Mamsa and Lasika, produce

Kushta (Shvitra) 103.

Kashyapacharya has given the description of Shvitra in this way. 'Udaka

present in the skin is 10 Anja1is. By this Udaka only Rakta and Sharir Dhatus are

nourished. If this Udaka gets vitiated then Dadru, Kandu, Vicharchika, Kilasa and

other skin diseases occur104.

Acharya Sarangadhara has counted Shvitra in Kushta Roga. According to him

Shvitra is of three types Vataj, Pittaj and Kaphaja105.

Based on the scientific analysis of metrical texts pathogenesis of Shvitra is

clarified in this way. Excitation of Tridoshas leads to Agni Vaishamya which results

in increased Vata, this Vata enforces Pitta and Kapha into Bahyarogamarga by

Tiryaggami Siras. During this period Tridoshas vitiate the skin and attain Sthana

Sansraya in Tvak. By the obstruction or Sanga where the excited Dosha gets

lodged in the Tvak, there it vitiates Rakta, Mamsa and Medo Dhatus gradually

producing Vataja Shvitra of Aruna varna, Pittaja Shvitra of Tamra varna, or Kaphaja

Shvitra of Shveta varna. If these Doshas get lodged in deeper Dhatus from skin then

Shvitra becomes incurable.

If a pregnant lady takes excessive Sleshmala food then the fetus develops

Shvitra. This means that dietetic indulgence made by mother during pregnancy also

causes Shvitra in the baby. This indicates the association of Sleshma in the

pathogenesis of Shvitra106. In the formation of varna (Skin colour) Udana Vayu also

takes part. Hence vitiation of Vayu causes Varna vikruti107.

Illustration of Participants of Pathogenesis

1. Dosha - Vata - Samana, Apana, Udana.

Pitta - Pachak, Bhrajak, Ranjak and Alochak

Kapha - Avalambak

2. Dushya - Ras, Rakta, Mamsa and Meda.

3. Srotas - Rasavaha.



4. Srotodushti - Sanga.

5. Adhisthan - Udbhavasthan - Amashaya samutha

Vyadhi-vyaktasthan - twacha.

6. Vyadhi Swarup- Chirakari.

Sadhyasadyata - Ayurvedic Concept

Shvitra being a Papatmaja Vyadhi is Kruchchra Sadhya. Shvitra responds to

treatment in those who practice Dana – Dharma along with the treatment; thereby

they get rid of their Papatmaja Vyadhi by getting rid of their Pap.

Sadhya Shvitra

The two Scholars have given the description of the region affected, where in

the hairs are not of 'Raktavarna', the region being small in size and not very close to

each other, not too white and of recent origin, the central portion of which is elevated

and is not caused by burns is curable108.

Asadhya Shvitra

The form where in the lesions extend and become confluent are situated very

close to each other so they can not be differentiated from one another or are multiple,

covered with red hair and of more than a year‟s duration are incurable. Especially

where in the lesions have invaded the palmer and the planter surfaces, the anal area,

the genitals the lips and cicatrix due to burns though of recent origin are incurable109.

The Shvitra situated in Medo Dhatu is relatively most difficult to treat than that in

Mamsa and Rakta.

If the depigmented patches coalesced and the palmer plantar aspects of hands,

legs, lips and a genital organ are associated with this disease, and if the hairs on this

Shvitra affected area become white, then that Shvitra is incurable110.



Table 8: Sadhyasadhyata of Shvitra

Sl no

Lakshana C.S S.S A.S A.H B.P M.N Y.R G.N

Sadhya lakshana 1 Araktha loma + - - - - - - - 2 Thanu + - - - - - - - 3 Pandu + - - - - - - - 4 Natichirottitam + - - - - - - - 5 Madhya vaksha chochunam + - - - - - - - 6 Ashukla loma - - + + + + - + 7 Abahalam - - + + + + - + 8 Nava / avarshati krantha - - + + + + - + 9 Agni dagdha - - + + + + + + 10 Mitha asamsrusta / paraspara

animilitha - - + + + + - +

Asadhya lakshana 1 Sambadha mandala - + - - - - - - 2 Raktha roma + + - - - - - - 3 Agni dagdha - + - - - - - - 4 Paraspara abhinna + - - - - - - - 5 Bahu + - - - - - - - 6 Varsha ganotpanna + - - - - - - - 7 Anthe jatham - + - - - - - - 8 Present in guhya pani thala

osta - - + + + + - +

Differences between Shvitra and Kushta

The differences mentioned in samhitas are as follows –

Tvak Dosha is the name given to Kushta where as Shvitra pertains to the skin.

Hence it is also included in Kushta rogadhikara111.

The vitiated Doshas and Dushyas if untreated for a long time undergo

Swedata, Kledata and Kodhata. By this Sukshma Krimi (Microscopic organisms) will

be produced, in those areas and this Krimi will eat or erode gradually hair, skin,

ligaments, arteries and cartilages. Because of this the condition is called Kushta. And

the Shvitra Kushta which is pertaining to skin is separated from Kushta (leprosy) and

is called Bahya Kushta112.



Table 9: Showing the Differences

Sr. No. Shvitra Kustha 1. It is pertaining to skin only

and is called Bahya Kushta Kushta occurs in Rakta, mansa meda etc. internal dhatus.

2. No Secretions obtained from Shvitra affected area.

Secretions obtained by the death of internal dhatus in Kushta.

3. Shvitra is not an infectious disease and produced· due destruction of to the melanocytes, by this absence of melanin leads to depigmentation. This pigment gives colour to the skin and protects body from external atmosphere.

Kushta is produced by varied micro-organisms.

4. In the Shvitra affected area sense of touch is normal.

But in Kushta loss of sensation of affected area will be observed.

5. It is not a infections disease. Hence patient of Shvitra need not be kept away from Society.

Kushta is an infections disease. Hence Isolation of patients of the Kustha is necessary.



CHIKITSA

Shvitra is a Bhibhatsya Vyadhi when compared to Kusta and the disease soon

becomes Asadhya if not treated. So the treatment should be started as early as

possible similar to putting off the fire of a burning house113.

Chikitsa can be mainly divided in to three types‟ Daivavyapashraya, Yukthi

vyapashraya and Satvavajaya114.

Aushadha prayoga can be mainly done in two forms

1) Anthahparimarjana where Aushadha and ahara dravya are given internally.

2) Bahi parimarjana where Aushadha dravya are used externally in the form of

abhyanga, Lepa, sweda, parisheka and unmardana115.

Aushadha given acts in two forms

1) Shodhana where vitiated Doshas are removed out of the body through Urdhwa and

Adho marga116.

2) Shamana where Doshas are brought in to normalacy with out expelling them out117.

Shvitra is a disease in which Yukthivyapashrya Chikitsa in the form of Shodhana and

Shamana is administered. Both Bahya and Abhyanthara prayoga of Oushadha Dravya

is done. Daivavyapashraya Chikitsa is also mentioned in the context of kusta

Line of treatment of Shvitra

The treatment of Shvitra should begin with a Vishesha Shodhana that is by

Vamanadi kriya118 followed by administration of Malayu rasa with Guda for the

purpose of Sramsana. The person whose Shareera is made Snigdha by Snehapana

should be anointed with Taila and exposed to sunlight as per his Bala. If the person

feels thirsty due to Virechana Peya should be given to him119.

The drug Malayu Rasa given for the purpose of Sramsana is commented as

Bakuchi Kwatha by Arunadutta120and Kakodumbarika by Chakrapani121.

Yogarathnakara indicates the intake of Khadirodka and Anna after Vamana,

Virechana and Raktha Mokshana, and then Malayu rasa with Guda should be given

after which the person has to take Manda and Yavagu as pathya122.

Certain Kwathas are told by different authors, which have to be given before the

patient is exposed to sunlight.

1) Bakuchi Kwatha with Guda acts as Sramsaka and also patient is exposed to sun

light after consuming it123.



2) Kakodumbara + Vibhitaki kwatha with Bakuchi kalka124.

3) Acharya Charaka mentioned exposure to sunlight after Sramsana, for three days125.

4) Bakuchi choorna given bhavana with Gomoothra should be consumed with

Kwatha of Kakodumbara + Madanaphala + Karanja + Vibhitaki during pratha kala126.

5) Vibhitaki and Kakodumbara kwatha with Bakuchi choorna should be administered

for two to three days127.

Blebs which develop due to exposure to sunlight should be opened by a thorn

after which Shamana Aushadhis are given internally and externally. Gadanigraha

specifies the intake of Takra without salt after the blebs are opened128.

Savarneekarana is one among the sixty upakramas mentioned by Sushrutha to

bring back the normal colour of the skin at the site of a healing wound.

Savarneekarana includes Krishna karma and pandu karma. Krishna karma can be used

in treatment of Vranaja Shvitra129.

Daivavyapashraya Chikitsa130

After Vamana, Virechana, Raktha Mokshana and Virookshana Sakthu is given

as Pathya. After all these procedures shvitra gets cured if papa of the patient gets

reduced131. As Papakarma is a Vishista Nidana of Shvitra, Daivavyapashraya chikitsa

has a greater role in reducing it.

With all the Yukthi vyapshraya chikitsa the patient has to follow –

1. Vratha –that is surya aradhana

2. Dharma –controlling the ninditha chitha vrithi

3. Yama –controlling the indriyas

4. Seva –doing the seva of dana and thyaga sheela purusha

5. Dwija seva and guru pooja

6. Performing pooja of shiva, shivasutha that is ganesha, tara ana surya

7. Roupyadana or giving silver as alms, helps in curing Shvitra



Table 10: List of drugs used internally and externally

Sl no

Name of the yoga C.S S.S A.H A.S B.P Y.R B.R G.N C.D

Virechana dravyas 1 Patola muladi kwatha - - + - - - - - - 2 Manibhadra yoga - - + - - - - - - 3 Malayu rasa + guda + - + + - - - + - Shamanoushadhis - Kwatha 1 Malayu + asana+

priyangu + shatapushpa + - + - - - - + -

2 Badrodumbaradi yoga - + - - - - - + - 3 Dhatriyadi kwatha - + - - - - - + + 4 Khadiradi kashaya + - - - - + - - - 5 Vibhitaki Tvak +

malayu mula + bakuchi churna

- - - - + - - - -

6 Bakuchi + amalaki + khadira

- - - - + - + - -

7 Dhatri khadira kwatha - - - - - - + - - 8 Vibhitakyadi kwatha - - - - - - + - - 9 Manjistadi mahakashaya - - - - - - + - - 10 Gomutradi yoga - + - - - - - - - Churna 1 Musthadi churna + - + - - - - - - 2 Pancha nimba churna - - - - - - + + + 3 Khadirasaradi churna - - - - - - - + - Avaleha 1 Bhallataka avaleha - - - - - + - - - 2 Panchanimbavaleha - - - - + - - - - 3 Mahabhallataka guda - - - - - - + - - 4 Mahabhallataka avaleha - - - - + - - - - Asava - Arista 1 Madhvasava + - - - - - - - 2 Kanaka bindwarista + - - - - - - - - 3 Gomutrasava - - + - - - - - - Vati 1 Swambu guggulu - - - - + - - - - 2 Swetari rasa - - - - - - + - - 3 Triphala gutika - - - - - + - - - 4 Shashilekha vati - - - - - + - - -



5 Vijayeshwara rasa - - - - - + - - - Ghrutha 1 Thiktaka ghrutha - - + - - - - - - 2 Mahathiktaka ghrutha - - + - - - - - - 3 Mahavajraka ghrutha - - + - - - - - - 4 Avarthaki ghrutha - - + - - - - + - 5 Somaraji ghrutha - - - - + - - - - Bahya oushadhi – taila 1 Mahavajraka taila - - + - - - - - - 2 Aragvadhadhy taila - - - - - - - - + 3 Swalpa marichadhya taila - - - - + - - - + 4 Visha taila - - - - - + + - + 5 Kusta rakshasa taila - - - - - - + - - 6 Marichadya taila - - - - - + + - - 7 Kandarpasara taila - - - - - - + - - 8 Jyothishmathi taila - - - - - + - - - 9 Laghu vishagarbha taila - - - - - - - + - Ghrutha 1 Mahaneela ghrutha - + - - - - - - - Lepas 1 Shiki Pitta Lepa + - + - - - - - - 2 Krishna sarpodbhava

masi + aksha taila - + + - - - - - -

3 Savarnakara Lepa - - + - - - - - - 4 Gajalinda kshara +

bakuchi - + + - - - + - +

5 Bhallatakadi Lepa - - + - - - - + + 6 Burnt skin of elephant +

taila - + + - - - + - +

7 Puti keeta + aragvadhakshara

- + + - - - + - -

8 Kukkuta pureesha yoga - + - - - - - - - 9 Avalgujadi varthi - + - - - - - - - 10 Thuttadi Lepa - + - - - - - - - 11 Shvitranashana Lepa - - + - - - - - - 12 Marichadi Lepa - - + - - - - + - 13 Bhallataka Lepa - - + - - - - - - 14 Aragvadha shatchurna

pradeha - - - - - - - + +

15 Puthikadi Lepa - - - - - - - + +



16 Avalguja beejadi Lepa - - - - - - - - + 17 Shweta jayanthi mula

kalka - - - - - - + - +

18 Shiladi Lepa + - - - - + - - - 19 Triphaladi Lepa - - - - - + - - - 20 Ayorajadi Lepa - - - - - + - - - 21 Kadalikshara + kharasthi

bhasma + goraktha + - - - - - - - -

22 Malathi koraka Kshara+ hasthi mada

+ - - - - - - - -

23 Neelotpala + kusta +saindhava + gaja mutra

+ - - - - - - - -

24 Mulaka beeja + avalguja + gomutra

+ - - - - - - - -

25 Kakodumbara + avalguja + chitraka + gomutra

+ - - - - - - - -

26 Bakuchi beejadi Lepa + - - - - - - - - 27 Bakuchi + haratala +

manashila + gunja + chitraka

- - - - + - + - -

28 Neelaparajitha mula Lepa - - - - + - - - - 29 Manashila + apamarga

bhasma - - - - - - + - -

30 Gandhaka + chitraka + pippali + haratala + haritaki

- - - - - - + - -

31 Gruhadhumadi Lepa - - - - - - - + - 32 Sudarshana mulayoga - - - - - - - + - 33 BakuchyadiLepa - - - - - - - + -

TREATMENT PRINCIPLES & CONCEPT OF SHODHANA IN CHILDREN

The Vata Pitta Kapha and Asrik in Baala are similar to that of an adult but

lesser in quantities. So the physician according to his intelligence should use Alpa

anna pana and Oushadha in children because the dose of the drug and diet mainly

depends on Agni, Bala and Vaya of the person132.

Excessive Shodhana and Rakta Mokshana is contraindicated in Baala.

Medicines which are Snigdha, Mrudu and which do not produce Daha should be

given orally or in the form of Lepa133.



Vamanadi kriya is contraindicated for Mrudu and Paratanthra Bala. Seeing the

ability of Vak and Chesta in the bala alpa mathra oushadhi should be given134.

Commenting on this Chakrapani mentioned that baalas are of two types‟ Swatantra

and Paratantra. If the child is Paratantra, Vamanadi kriyas are contraindicated and in

Swatantra baala Vamanadi kriya can be performed, but it should be Mrudu in

nature135.

Shodhana Oushadhis on basis of Ksheerada Ksheeraannada and Annada

classification of Vaya is mentioned136.

By observing all these opinions, it is clear that therapies like Vamana and

Vrechana should not be Teekshna when adopted in children instead should be given

mildly considering the age of the child.

CONCEPT OF VIRECHANA

Virechana is one amoung the five types of shodhana where Doshas are

removed from Adhomarga and is considered as the best Pittahara Chikitsa137.

Types of Virechana

Sharangadhara explained four types of Virechana138

1) Anulomana – Dravyas that do the paka of mala and breaks it and removes it

through adhomarga eg Harithaki

2) Sramsana- Dravyas which remove the mala stuck in the kosta without causing paka

of mala. Eg Aragwadha

3) Rechana – Dravyas which remove the mala by making it Drava irrespective of its

pakwa or apakwatha is called rechana eg Trivrit

4) Bhedhana- Dravyas which breaks the pinditha and badha mala and removes it

through adho marga eg-katuki

Among the four types of Virechana, sramsana is indicated in shwithra.

VIRECHANA IN CHILDREN

Adopting the treatment principles mentioned for Bala, Mrudu Virechana could

be administered in Swatantra bala.

Aragwadha can be given for Virechana especially for Sukumara and Bala, as it

is Mrudu and does not produce any complications139, 12 different yogas have been

explained in Aragwadhakalpadhyaya especially for children140.



Aragwadha is explained as Sramsaka, Kosta PittaKaphahara and Kosta shudhikara141.

Acharyas mentioned Aragwadha Phalamajja with Ksheera for Virechana in baala142.

CONCEPT OF LEPA

Lepa means the one, which is used for anointing.

Different authors mentioned different types of Lepas.

Types of Lepa according to sushrutha143

1. PraLepa – It is applied in a thin and cold form and may be applied where pidana

karma is not necessary. Used in the cases of raktha and Pitta pradhana shotha.

2. Pradeha – It is thick or thin warm or cold based on doshic involvement and it

should not be allowed to dry completely. It is used in Vata and sleshma

pradhana shotha.

3. ALepa -It has the quality of both praLepa and pradeha

4. Lepa used for wound is called kalka or nirudha Lepa

Types of Lepa according to Astanga sangraha144

Astanga sangrahakara told pradeha is sheetha, thanu and used in raktha Pitta vikara.

He mentioned 10 types of Lepa based on its action.

1) Snaihika Lepa – This is ment for Vata dosha & is prepared with snigdha dravya.

2) Nirvapana Lepa – This is ment for Pitta dosha and used in Pittaja & vishaja

shotha, Agni & ksharadagdha wounds. Sheeta veerya dravyas are used.

3) Prasadhana Lepa – It has raktha prasadana property.

4) Sthambhana Lepa – In addition to the property of nirvapana Lepa it has

raktastambhaka property.

5) Vilayana Lepa – It is used in shelshmaja & medajashotha.

6) Pachana Lepa – It does the pachana of apakva shotha.

7) Pidana Lepa – Rooksha, picchalia dravyas are used, useful in sookshama vrana.

8) Shodhana Lepa – It is indicated in ashudda vrana. Shodhana dravyas are used.

9) Ropana dravya – Used for Ropana of shuddha vrana.

10) Savarnakara Lepa – Helps in attaining normal skin colour.

Types of Lepa according to Charaka) 145

1) Shodhana –It is Tvak shudhikara

2) Ropana praLepa –It is used to bind the torn skin



3) Kanthikara Lepa –It is used in vrana shaithilyatha and has prasadana property

4) Mardavakara Lepa – It is used in saruja Katina sthbdha and nisravya vrana

5) Savarnakara Lepa –It is used for enhancing the colour and complexion

6) Varnakara Lepa – It helps in bringing back the prakrutha Varna of twacha

7) Romasanjanana Lepa – It is used for the reproduction of the destroyed roma.

8) Tvak karshnya karaka Lepa – It produces krishnathwa of Tvak at applied site.

General rules to be followed during application of Lepa

1) PraLepa should be applied uniformly & thickness should be 1/3rd of an anguli.

2) Before applying the Lepa, the previous Lepa, which is dried, should be removed.

If not it increases the doshas.

3) Lepa should be removed with out washing it in water.

4) Lepa used once should not be used again by making it wet.

5) After applying Lepa nothing should be covered over it

6) Fresh Lepa should not be applied over the dried Lepa.

7) The Lepa should not be too thin because it dries up before it reaches the moola

stana & reduses the dosha146.

8) The thickness of the Lepa should be equal to the wet skin of a buffalo147.

9) A Lepa should be applied in opposite direction of romakoopa, and then it enters

the roomakoopa & reaches the swedavaha Srotas & Siramukha.

10) Lepas should not be completely dried except where pidanakarma is necessary. If

dried it produces pain148.

11) Lepa should not be applied during night time because during night, the ushnata of

shareera goes out through roomakoopa; if Lepa is applied the ushanatha is

retained inside, which vitiates the doshas149.

12) Lepa prepared in the previous day should not be used.

13) Lepa prepared should not be kept for long time since it looses its veerya150.

General uses of Lepa151

It is used in the case of avidagdha shopha

1) It does twacha shuddi & also purifies mamsa & raktha

2) It reduces daha, toda & kandu.

3) It can be applied in diseases of marmasthana & guhya sthana, where it does the

shudhi & shamana of the diseases.



Amount of sneha, which is to be used in aLepa152

1) Pittaja shopha - 1/6th part

2) Vataja - 1/4th part

3) Kaphaja - 1/8th part

Pathyapathya

Pathya is hita for patha i.e Srotas and priya for mana, that which is ahita and

apriya for patha and mana respectively is apathya153.

One who follows pathya ahara vihara with shraddha, takes vishista oushadhi and

does punya karma gets rid of kusta quickly154.

Hence following the pathyas mentioned, and avoiding apathya will help in

preventing the further aggravation of the disease. Since Shvitra is mentioned as a

kusta bheda the pathyapathya of the disease kusta can be taken for Shvitra also. The

pathyapathya of Shvitra is enlisted below.

Table 11: Pathyapathya of Shvitra155

Sl no

Pathyapathya C.S S.S A.S A.H Y.R G.N B.R C.D

Pathya 1 Laghu anna + - - - - - + - 2 Thiktashaka + - + + - + + + 3 Bhallataka + - + + - + + - 4 Thriphala + nimba + - - - - - + - 5 Anna + ghruta + - - - - - - - 6 Purana dhanya + - - - - - + + 7 Jangala mamsa + - + + - + + + 8 Mudga + - + + - + + + 9 Patola + - + + - + + - 10 Shali - - + + - + + + 11 Yava - - + + - + + + 12 Godhuma - - + + - + + - 13 Priyangu - - + + - + - - 14 Masura - - + + - + - - 15 Tuvari - - + + - + - - 16 Khadira - - + + - + + - 17 Rakthashodaka oushada siddha

Madhya - - + + - + - -

18 Bakuchiyukta annapana - - + + - + - -



19 Adhaki - - - - - - + - 20 Makshika - - - - - - + - 21 Ashada masa Phala - - - - - - + - 22 Brihathi phala - - - - - - + - 23 Kakamachi - - - - - - + - 24 Lashuna - - - - - - + - 25 Punarnava - - - - - - + - 26 Meshashrungi - - - - - - + - 27 Chakramardha - - - - - - + - 28 Pakwathala - - - - - - + - 29 Chitraka - - - - - - + - 30 Jathiphala - - - - - - + - 31 Nagakesara - - - - - - + - 32 Kumkuma - - - - - - + - 33 Purana ghruta - - - - - - + - 34 Koshataki - - - - - - + - 35 Karanja - - - - - - + - 36 Tila taila - - - - - - + - 37 Sarshapa taila - - - - - - + - 38 Nimba taila - - - - - - + - 39 Ingudi taila - - - - - - + - 40 Sarala taila - - - - - - + - 41 Devadaru taila - - - - - - + - 42 Shimshipa taila - - - - - - + - 43 Agaru taila - - - - - - + - 44 Gomutra - - - - - - + - 45 Karamutra - - - - - - + - 46 Ustra mutra - - - - - - + - 47 Ashwa mutra - - - - - - + - 48 Aja mutra - - - - - - + - 49 Kasturi - - - - - - + - 50 Gandhaka - - - - - - + - V1haraja pathya 1 Cutting of kesha and nakha - + - - - + - - 2 Vishrama - - - - - - - Apathya 1 Guruahara + - - - - - - - 2 Amlaahara + - + + + + + - 3 Payas + - + + + + + -



4 Dadhi + - + + + + + - 5 Anupa mamsa + - + + + + + - 6 Matsya + - - - - - - - 7 Guda + - + + + + + - 8 Tila + - + + + + + - 9 Ushna ahara - - + + + + - - 10 Lavana - - + + + + - - 11 Masha - - + + + + + - 12 Mamsa - + - - - + - + 13 Sura - + - - - + + + 14 Virudha pana - - - - - - + - 15 Viruda ashana - - - - - - + - 16 Dravanna - - - - - - + - 17 Guruanna - - - - - - + - 18 Navanna - - - - - - + - 19 Vidahi anna - - - - - - + - 20 Vistambi anna - - - - - - + - 21 Mulaka - - - - - - + - 22 Udaka of sahyadri and vindhya - - - - - - + - 23 Vishamashana - - - - - - + - Apathya vihara 1 Stree sanga - + - - - + - + 2 Papakarma - - - - - - + - 3 Kruthaghna bhava - - - - - - + - 4 Guruninda - - - - - - + - 5 Gurugarshana - - - - - - + - 6 Ati nidra - - - - - - + - 7 Chandramshutapa - - - - - - + - 8 Atisweda - - - - - - + - 9 Vegavarodha - - - - - - + - 10 Vyayama - - - - - - + -



Modern View

Skin is the largest organ in the body, having a surface area of 1.8 m2 and

making up about 16% of body weight.

Anatomy

The skin consists of two parts. The outer one is epidermis, which is thinner

and composed of epithelium, and inner subcutaneous layer, which is thicker and

contains connective tissue is called Dermis. The dermis is also called the superficial

fascia or hypodermis, which consists of areolar and adipose tissue. The subcutaneous

layer, in turn, attaches itself to underlying tissues and organs.

Epidermis:

Thickness of epidermis ranges from 0.04 mm (eyelids) to 0.16 mm (palms / soles). It

undergo continuous turnover of the layers, and requires 28 days for keratinocytes to

move from stratum basale to stratum corneum, 52 days for epithelial cycling.

Cells present in Skin:

Cells Origin Functions

Keratinocytes Ectodermal, move

upward from

stratum basale to

stratum corneum

Synthesize tonofilaments which is

precursor of keratin. Keratinocytes mature

to form cornified cells (loss of nucleus).

Melanocytes

(Ratio of

keratinocytes to

melanocytes is 4:1

to 10:1)

Neural crest These dendritic cells containing

melanosomes secrete melanin. Imparts

colour and gives protection against UV

light.

Langerhan‟s cells Mesenchymal Dendritic cells with intra-cytoplasmic

granules.

Role in immune reaction of delayed

hypersensitivity

Merkel‟s cells Neural crest Dendritic cells with intra-cytoplasmic

granules. Function as slow adopting touch

receptor.



The names of the five layers, from the most superficial to the deepest are as

follows:

Stratum corneum:

This is the most superficial layer, which consists of 25 to 30 rows of flat, dead

cells completely filled with keratin. These cells are continuously shed and replaced by

cells from deeper strata. The stratum corneum serves as an effective barrier against

light and heat waves, bacteria, and many chemicals.

Stratum Lucidum:

Normally, this layer is limited to thick skin of the palms and soles. It consists

of three to five rows of clear, flat, dead cells that contain droplets of an intermediate

substance that is formed from Keratomyelin and is eventually transformed to Keratin.

Stratum granulosum:

Stratum granulosum consists of about three to five rows of flattened cells that

develop darkly staining granules of a substance called Keratomyelin. This compound

is the precursor of keratin. Keratin forms a barrier that protects deeper layers from

injury and microbial invasion and makes the skin waterproof.

Stratum spinosum or Malpighian layer:

This prickle cell layers lies upon the basal layer and has 8 to 10 rows of

polyhydral cells that fit close together. This layer involves most of the pathological

conditions of the skin.

Stratum basalis or Germinativum:

This layer forms the lowest, most sensitive, single row of columnar cells,

which is capable of continued cell division. As these cells multiply, they push up

towards the surface and become part of the upper layers. The stratum basalis also

contains tactile (Merkel) discs that are sensitive to touch.

Dermis:

Dermis contains two layers. The outer portion of the dermis, which is about

one fifth of the thickness of the total layer, is named the papillary region. The deeper

portion of the dermis which consists of dense irregular connective tissue containing

interlacing bundles of collagen and coarse elastic fibers is called reticular region. The

dermis chiefly consists of white fibrous tissue, elastic fibers and non-striped muscles



and contains blood vessels, nerves, hair, sweat glands and sebaceous glands and nerve

corpuscles.

The reticular region is attached with underlying organs, such as bone and

muscle, by the subcutaneous layer, also called the hypodermis or superficial fascia.

Sebaceous glands:

They are scattered all over the skin in association with the hair follicles. They

are absent in hairless portion of the body like palms of the hands, soles and side of the

feet.

These lipid-producing glands are out growth of hair follicles except

Meibomian glands (eyelids), buccal mucosa of vermilion border of lip (Fordyce spot),

prepuce (Tyson glands), and female breast areola (Montgomerry tubercles).

Outermost single layer of geminative cells mature into innermost lipid rich

cells, which on disintegration produce sebum, which is secreted by the sebaceous

duct.

Sweat glands: These are of two types,

These are of two types,

Eccrine glands – They are the ordinary small sized sweat glands, which are

distributed all over the skin except on the beds of nails, margins of lips and the glans

penis.

Apocraine glands – They occur in the axillae, areola and nipples of breasts,

umbilicus, around the anus and genitalia. They are specialized sweat glands.

Hair:

Hair is found on almost every part of the body surface except on the palms and

the soles, the dorsal surface of the terminal phalanges, the inner surface of the labia,

the inner surface of the prepuce and the glans penis.

Melanocytes:

Melanocytes can be found in nearly every tissue. But they are most common

in superficial epidermis, hair follicals, dermis, eye, around blood vessels, peripheral

nerves and the sympathetic chain. In the basal layer of the human epidermis, there are

about two billion melanocytes distributed through out the body. A reduction in the

number of melanocytes occurs in the skin with advancing age.



Biochemistry of Melanin:

Melanin is a complex polymer synthesized from tyrosine and have two forms,

1. Eumelanin – It is more common and gives a brown-black colour. It is a high

molecular weight polymer of complex structure formed by oxidative

polymerization.

2. Phaeomelanin – It is less common and produces yellow or red colour. It is

synthesized from dopaquinone and cysteine.

Most common and natural melanins are mixtures of Eumelanin and

Phaeomelanin. Melanins act as energy sink and free-radical scavengers, and absorb

the energy of UV radiation.

Structure of melanocytes:

Melanocytes form a network of dendritic cells in the basal layer of epidermis.

They are also found in the external hair root sheaths and in the bulbs of the hair

follicles. It is these scretory melanocytes, which behave as unicellular glands

producing melanosomes, which are transferred to the surrounding epidermal

keratinocytes. The transfer of melanosomes involves the insertion of tip of the

dendrite of the melanocytes that becomes embedded in the cytoplasm of

keratinocytes.

The end becomes pinched off and a package of melanosomes is transferred to

keratinocyte that acts as a phagocyte. The melanosomes are packed according to size,

the larger ones as single units and the smaller ones as complexes of two or more.

Melanocytes are distinguishable from the keratinocytes by their lack of desmosomes,

tonofibrils and by a more lucent cytoplasm. The characteristic feature of this cell is

the presence of special cytoplasmic organelles, the melanosomes on which melanin is

formed by the action of the enzyme tyrocinase. The developing melanosomes show

varying degrees of electron density, the more fully melanized being very dense.

Melanocyte function

Melanocytes are located in the basal layer. In this location, they produce the

pigment melanin in elongated, membrane-bound organelles known as melanosomes.

Melanin is packaged into granules which are moved down dendritic processes and

transferred by phagocytosis to adjacent keratinocytes. In the inner layers of the



epidermis, melanin granules form a protective cap over the outer part of keratinocyte

nuclei.

In the stratum corneum, melanin granules are uniformly distributed to form a

UV-absorbing blanket which reduces the amount of radiation penetrating the skin.

Four stages of melanosomal antagony are recognized.

1. Stage one is a membrane bounded spherical vesicle may show tyrocinase activity.

According to classical theory, tyrocinase is produced on membrane bound ribosome

and transferred via the endoplasmic reticulum to the golgi apparatus where it

accumulates in vesicles that are derived from the golgi bodies.

2. In stage two melanosomes are oval in shape and show numerous melanofilaments

with and without cross – linking.

3. In stage three the internal structure of melanosomes is partially obscured by the

deposition of melanin.

4. In stage four, the mature melanosome appear electron dense.

Keratinization:

In the process of Keratinization, cells newly formed in the basal layers

undergo a developmental process as they are pushed to the surface. As the cells

relocate, they accumulate keratin. At the same time the cytoplasm, nucleus, and other

organelles disappear, and the cells die. Eventually, the keratinized cells are

desquamated and are replaced by underlying cells that, in turn become keratinized.

Kinetic studies show that, on average the dividing basal cells replicate every

200 to 400 hrs. The resultant differentiating cells take about 14 days to reach the

stratum corneum and a further 14 days to be shed. The cell turnover time is

considerably shortened in Keratinization e.g. Psoriasis.

Pigmentation of the skin:

Pigments, melanin, carotene and hemoglobin – give skin a wide variety of

colors. Melanin is located mostly in the epidermis; carotene is mostly in the stratum

corneum and dermis; and hemoglobin is in red blood cells within capillaries in the

dermis. Color of the human skin is derived from a variety of chemical and physical

properties associated with the structure. Normal skin color is dependent on

hemoglobin, (oxygenated / reduced state) carotinoids and melanin pigment. Five

pigments are known to influence the skin color. They are,



1. Melanin is a pigment which is found more in stratum malpighi. Melanin contributes

color and quality to skin and protects the organism from the ultraviolet rays. It is in

the form of granules, which vary from light brown to black in color. Melanin is

formed from the amino acid tyrosine by the action of the enzyme tryosinase and

copper protein complex. Hence it is clear that copper ions are essential for normal

pigmentation of skin.

2. Melanoid is supposed to be a degradation product of melanin and is diffusesd

through out the epidermis. Melanoid has a different absorption band of visisble light.

3. Carotene is yellow orange pigment in lipid rich areas like stratum corneum,

subcutaneous fat etc. this adds yellow color to the skin of women than in men.

4. Oxy-hemoglobin imparts reddish hue to the skin color and it is evident in areas

where there is rich arterial supply like face, neck, palm, soles and nipples.

5. Reduced hemoglobin contributes bluish or purple character to skin color and is

more evident in lower areas of the trunk.

Two types of melanin pigmentation occur in man. The first constructive skin

color, that is the amount of melanin pigmentation, which is genetically determined in

the absence of sun exposure and other influences. The other facultative or inducible

skins color or tan which results from sun exposure.

Variation in the thickness of the skin may modify the skin color. Subjects with

thin epidermis have a reddish color complexion and with a thicker epidermis look

yellowish. Thicker epidermis is less transparent than the thin one. As the transparent

stratum corneum scatters light slightly, the deeper layer appears blue.

The skin remains light colored when the pigment appears in the center of the

melanopores and dark when it is dispersed to their periphery.

Three different mechanisms may be involved in the control of color change.

Firstly, the pigment cell may act as an independent effect or respond directly to the

stimulus of light. There is evidence that this can occur in some fish and amphibians

and the tanning of human skin both immediate and delayed can be considered as an

analogous process. Secondly, the movement of pigment with the melanophore may be

under the nervous control. Thirdly the activity of pigment cells or melanocytes may

be under hormonal influence. Pitutary hormone causes expansion of melanophores or

promotes the formation of melanin in epidermal melanocytes.



Bruno – Bloch is the person who elucidated the mode of melanin formation.

According to him melanin is formed from tyrosine through the intermediatory stage of

dioxyphenyl – alanine (dopa). Melanocytes contain enzymes, which convert tyrosine

in to melanin.

Tyrosine Tyrocinase DOPA Dopa oxidase Melanin

Scientist like Fitz patric have extensively studied the ultra structure of

melanocyte and melanin formation. From the golgi body of the cell arises a vacuole

like premelanozome, which incorporates zinc and becomes a melanosome. This later

becomes heavy and loses tyrocinase activity to be formed in to melanin granule.

Melani formation is physiologically under the control of M S H of the pitutary gland.

The sun, UV rays, X – rays etc. stimulate melanin formation, while ascorbic acid

tends to reduce it.

Blood supply of skin:

There are two horizontal and parallel systems of plexuses, which supply the

skin. The plexus or network of blood vessels exists between the dermis and the

subcutaneous tissue. Its exact position can never be accurately described. Each

arteriole supplies an area of skin and each venous plexus is associated with it drains

the same area.

Nerve supply:

The nerve supply of the skin is very complicated, and the pathways for the

mediation of sensations through various nerves are very much under debate. The

varied sensations arising from skin are derived from a diverse population of cutaneous

nerve endings or receptors, thus tactile, temperature and pain sensations each of which

are sub served by different groups of receptors.

Functions of the skin:

The skin is a metabolically active organ with vital functions including the

protection and homeostasis of the body. It has many functions, the most

important of which is as a barrier to protect the body from noxious external

factors and to keep the internal system intact.

[a] Regulation of body temperature:

Via heat loss Sweat evaporation - Eccrine sweat gland.

Vasomotor regulation - Vasculature



Via heat conservation Body hair, Insulation provided by body fat.

[b] Protection:

The skin is considered under the Integumentary system. It provides a physical

barrier that protects the underlying tissues from physical abrasion, bacterial

invasion, dehydration, and UV radiation.

Water loss - Stratum corneum

Water gain - Stratum corneum

Toxic substance penetration - Stratum corneum

Microbial attack - Stratum corneum

Mechanical injury - Stratum corneum + dermis

[c] Sensation:

The skin contains abundant nerve endings and receptors that detect stimuli

related to temperatures, touch, pressure and pain.

[d] Immunity:

Sweat of the epidermal cells (Langerhan‟s cells) has important components of

the skin immune system, which tends off foreign invaders.

[e] Excretion:

Sweat is the vehicle for loss of a small quantity of ions and several organic

compounds along with removal of heat and some part of water.

[f] Blood reservoir:

The dermis is a house of extensive networks of blood vessels that carry 8 –

10% of the total blood flow in a resting adult. In moderate exercise this flow

increases, and helps to dissipate the heat from the body. While during the

exercise skin‟s blood vessels constrict so this allows more blood to circulate

through contracting muscles.

[g] Synthesis of Vitamin – D:

Synthesis of vitamin D begins with activation of a precursor molecule in the

skin by ultraviolet rays in the sunlight. Enzymes in the liver kidneys then modify

this molecule and produces calciferol, the most active form of vitamin D.



Table No. 13 Hormones and the Skin:

No. Hormone Site of production Effect

1. Vitamin D In dermis from precursors though action of UV radiation.

Important for absorption of calcium and calcification

2. Corticosteroids Adrenal cortex -Receptor on several cells in both epidermis and dermis -Produce vasoconstriction -Reduce mitosis by basal cells -Anti-inflammatory effect on leucocytes

3. MSH and ACTH

Pituitary gland Stimulate melanogenesis

4. Estrogens Adrenal cortex and Ovaries

Stimulate melanogenesis

5. Epidermal Growth Factor

Skin -Receptors found on -Keratinocytes, hair, follicles, sebaceous gland & sweat gland duct cells

6. Cytokines and eicosanoids

Cell membrane On immune function, inflammation and cell proliferation

The skin is the site of production of one hormone i.e. vitamin D, but it is often

a target organ for other hormones and is frequently affected in endocrine diseases.

Vitiligo:

The origin of the term vitiligo is obscure like the disease itself. Some believe

that it is from the Latin word vitellus – means vale that is pale pink flesh of a calf,

while others tell that it‟s from the word vitium – means blemish (pale).

Synonyms:

1. Vitiligo – Depigmented or Hypopigmented patches that result from absence or

reduction of melanocytes due to unknown cause.

2. Leukoderma – Term is applied for depigmented patches of known cause like

burns, contact with chemicals like phenols or following an inflammatory skin

disease.



Etiology of vitiligo:

Vitiligo is a multifactorial malady. Influence of genetic predisposition varies

from 10 – 35 % and in cases of positive family history 1 – 2 family members are

affected.

1. Nutritional causes – defect in copper, protein and vitamins in diet. Prolonged

consumption of diet poor in proteins. Digestive upsets amoebiasis, helminthes,

chronic diarrhea and dysentery

2. Endocrine causes – Association of the disease vitiligo is seen with

thyrotoxicosis and diabetes. Among endocrine factors anterior pituitary is

possibly the most important. Intermediate lobe of pituitary secretes

melanocyte-stimulating hormone, which further stimulates melanin formation

and dispersal.

3. Trophoneurosis and autoimmune imbalance – it includes emotional stress and

strain.

4. Infections and toxic products – Enteric fever, Ill health, Focal sepsis.

5. Chemical causes - Drugs and chemicals like quinines, guana furacin,

amylphenol, chlorthiazide, broad-spectrum antibiotics, beta-blockers and

chloroquin. Chemicals are known to inhibit melanogenisis enzymatic actions

and several chain biochemical reactions. They also cause inter ference with

nutrition of the tissues.

6. Misscellaneous factors - contact with rubber and ferric cyanide induce vitiligo,

pressure, trauma, tight wearing of sarees and dhotis can precipitate vitiligo

lesion.

7. Industrial chemicals and dyes containing water and foods may cause vitiligo.

But not proved.

8. Severe trauma like burns can destroy pigment cells resulting in vitiligo.

9. Vitiligo has assumed epidemic proportions in several parts of India especially

in Gujarat and Rajasthan.

10. Vitiligo is usually associated with following disorders



a. Pernicious anemia

b. Addison‟s disease

c. Graves disease

d. Hyperthyroidism

e. Hypothyroidism

f. Thyroiditis

g. Hyper Parathyroidism

h. Diabetes mellitus

i. Rheumatic disorders

j. Malignant melanoma and

internal malignancy

k. Gastritis

l. Gastric carcinoma

m. IgA deficiency

n. Myasthenia gravis

o. Suppression of the thymus

p. Sezary „s syndrome

q. Ulcerative colitis

r. Thymoma

s. Acquired hyper-gamma

globulinaemia

t. Auto immune hemolytic anemia

u. Vogt – koyanagi – harada

syndrome

v. Mucocutaneous candidiasis

w. Biliary cirrhosis

x. Downs syndrome

y. AIDS

Clinical features of vitiligo:

Clinical profile

About 1-2% of general population suffers from vitiligo. Both sexes are equally

affected. Family history is present only in about 25% cases. The disease commonly

begins at second to 4th decade of life.

Clinical features

A typical lesion is a well-defined de pigmented (milky white) macule, often

showing a variable number of depigmented hair and no change in skin texture. In

many cases the margin is hyper pigmented and in some may be inflammatory. Some

times a depigmented area surrounded by a comparatively hypopigmented zone is seen

to separate from normal skin by a thin hyper pigmented rim.

The number, size, shape and location of individual macules vary widely.

Frequently the intial macule occurs on exposed areas (such as dorsal surface of hand,

elbow, feet, legs, knees, neck and face), body folds (such as axilla, groin, and

submammary region in woman), lips and genitals. When the lesion occurs bilaterally

distribution is generally more or less symmetrical. The lesions get enlarged as if the

normally pigmented surrounding skin assumes a concave shape at the border.



Common sites of vitiligo lesions include extensor bony surfaces such as peri orbital

region, sites of ankle, knees, elbows and peri orificial areas. The peri tibial region is

the most commonly affected site in India.

Achromotrichia is a common feature of vitiligo lesions on hairy parts. The number of

such hairs varies and it is rare to find all the hairs white uniformly over a macule.

Some cases show localized vitiligenious macule with a variable degree of eczematous

reaction resembling chemical leucoderma, but new lesions may develop elsewhere.

Koebner‟s phenomenon is often observed in vitiligo vulgaris. Minor trauma, such as a

scratch mark, laceration or stiches on the skin, results in development of a

corresponding linear depigmented macule, within 2 – 4 weeks.

Types of vitiligo

1. Vitiligo vulgaris / Nondermatomal vitiligo:

In this form of vitiligo widespread and symmetrical patches involving

extremities and trunk are found. Common sites include skin of forearm, palms,

soles, elbows, knee, lips, eyelids, upper trunk, genitals, axilla and groins. The

other types of vitiligo vulgaris are

a. Acro-orificial - it involves acral area like fingers, toes, palms, soles and

periorificial areas like lips, perioral, peri ocular and glans penis.

b. Vitiligo universalis – Total or near total affection of the whole body will be

present

c. Lip tip subtype – here lesions are restricted to the lips and the distal part of

fingers and toes.

d. Some time static lesions distributed at distant sites are seen.

2. Vitiligo pseudosegmentalis / Viltiligo Zosteri formis / Dermatomal /

Segmental

Here patches are limited to the region of one or two nerve segments.

Vitiligo focalis where patches are seen over one region of the body is a sub type of

dermatomal type or it may be a variant of non-dermatomal type.

In few cases both typical dermatomal lesions and vitiligo vulgaris like scattered

lesions are seen.



Types based on prognosis

1. Active progressive stage (V1) – New lesions developing, increasing in size

and border ill defined.

2. Quiescent / Stable (V2) – Lesions are stationary in size and have well defined

hyper-pigmented border with no development of new lesions.

3. Improving (V3) – The size of the lesion decreases with well defined border

and signs of spontaneous repigmentation is seen. No new lesions develop.

Involvement of other pigment epithelium:

Various ocular abnormalities chiefly involving retinal pigment layers have

been noted among many vitiligo patients. In retina two pigment layers that is the inner

pigment epithelium adjacent to neuro retina and outer choroids show evidence of

destruction of pigment cells giving the retina a tigroid appearance. Following

destruction of the choroids there may be reactive proliferation of glial cells resulting

in yellowish discoloration of retina. In some patients of vitiligo rapidly progressive

chorio retinitis markedly impairs the visual activity. Dilution of retinal pigment due to

healed choriod retinitis may be detected.

Associated skin disorders:

It includes canitis, alopecia areata, atopic eczema, psoriasis, scleroderma,

Lichen planus, and Lichen simplex, halonaevus and icthiosis vulgaris. The

significance of this association is not well understood it appears to be more than

coincidental.

Course of the disease:

It is unpredictable and uncertain, most often shows slow progression. Lesion

in psedo segmental type remains static for an indefinite period after a certain degree

of regional extention. Vitiligo vulgaris lesions develop on different areas in

succession with varying rapidity. In some extension of individual lesions and

development of new lesions at different sites take place in episodic bouts.

Many lesions remain static for an indefinite period or show some degree of

spontaneous regression with development of pigment spots, others may show

repigmentations of some lesions, extension of others and appearance of new lesions at

other sites simultaneously. Some times the lesions disappear but may again reappear.

Residual depigmentation may be left behind after repigmentation of a large macule.



EXAMINATION OF SKIN

Examination of skin plays a very important role in the diagnosis of switra.

Examination is carried out as follows.

Darshana pareeksha:

By inspection following factors are to be noted.

1. Distribution and arrangement of patch – Areas where the patch is located is

noted and whether the patch is generalized or localized, whether the patches

are symmetrical or asymmetrical and the exact location of the patches whether

it is present over exposed area scalp region, hand, extensor or flexor aspect

etc. are noted.

2. Morphology of the patch

– By naked eye examination also morphology can be explained. If the patch is

an early primary lesion the help of magnifying glass is needed.

– Shape and size: These factors are noted, as the shape of the patch is oval or

irregular or rectangular and size of the individual patch.

– Color: It is a very important factor whether the patch is pure white,

erythamatous or pinkish. In ayurvedic view, the color of the patch depends

upon doshic involvement and is noted as aruna varna, tamra varna, swetha

varna.

– Margins: Margin of the patch is inspected to know whether it is hyper

pigmented or inflamed.

Sparshana pareeksha:

This pareeksha is carried out to know the rooksha, snigdha etc. qualities of the

patch, that is to say the extent of the patch, temperature of the patch and to see any

elevation in the patch. Tests to know about the sensation of the patch are very

important which are as follows.

i. Pin and needle prick test: This test is done to know the deep and

superficial pain sensation.

ii. Hot and Cold touch test: This is to test the hot and cold sensation in

the patch.



Special investigations:

Wood’s lamp examination:

Diagnosis of vitiligo is made by inspection with wood‟s lamp. Ultra violet

light of 356 nm wavelength is obtained by passing the beam through a wood‟s filter

composed of nickel, vitiligo patch appears milky white.

Skin biopsy:

Skin biopsy will show absence of melanocytes and melanin in the affected

area.

Differential diagnosis of vitiligo:

Most patients presenting with the complaint are worried about the diagnosis of

leprosy and vitiligo, hence sypmpethetic attention and careful assessment of this

complaint are essential. The diseases considered for differential diagnosis are

- Vitiligo

- Albinism

- Naevus depigmentosus

- Leprosy

- Petiriasis versicolor



Table No. 14 Differential diagnosis of vitiligo

Sl.

No

Distinguishing

features

Albinism Navus

depigmentosus

Vitiligo Leprosy Pitiriasis versicolor

1 Age Congenital Congenital Acquired Acquired Acquired

2 Distribution Complete/ partial Unilateral Any area Any area Trunk, neck and face

3. Course Stationary Stationary Progressive Progressive Progressive, worse in monsoon and

summer when sweating occur.

4. Hyper pigmentory

border

- - Present Inflammatory -

5. Heredo – familial Hereditary Non hereditary - - -

6. Other features Hairs and eyes may be

affected

- Hairs may be

affected

Anesthesia,

thickened nerves

Furfuraceous scaling, pin head

macules and large patches of

microscopic examination



Pathology of vitiligo:

In vitiligo there is a marked absence of melanocytes and melanin in epidermis. Exact

pathogenesis is not fully elucidated, but some theories are explained.

1. Immune hypothesis:

Primarily there may be some kind of biochemical trauma to melanocytes

resulting in release of some antigenic substances and subsequent auto

immunization. Alternatively there may be certain immune cells directed against

certain antigenic components of autologuse melanocytes. The circumstantial

evidence for this hypothesis is frequent association of vitiligo with many

autoimmune disorders.

2. Neural hypothesis:

This hypothesis theorizes that destruction of melanocytes occur as a

consequence of liberation of some unusual neurochemical mediator or due to

gross alteration in ratio of normal neurotransmitter substances in the lesion. Study

of electron microscopy shows abnormality of terminal portion of peripheral

nerves.

3. Auto toxic, self destructive or Free radical hypothesis:

The recent hypothesis tells that an intermediate metabolite of melanin

synthesis cause destruction of melanocytes or the normal process of melanosome

destruction proceeds unabated to cause melanocyte death. This theory is based on

an experimental study on cutaneous de-pigmentation by chemical compounds that

have selective lethal effect on functional melanocytes.

4. Melanocytes growth factor reduction hypothesis:

It has been proposed that de-pigmentation in vitiligo might be due to

reduced local and circulating levels of growth factor which is necessary for the

normal proliferation and maintenance of Melanocytes i.e. M.S.H.

Prognosis of vitiligo:

The prognosis is unpredictable and unsatisfactory. There is no indicator of a good

prognosis. Following are the factors, which lead to poor prognosis.

1. Lesion on the resistant sites such as bony prominences, non-fleshy areas, non-

hairy areas and mucosal areas. They comprise the sides of the ankles, front of



the wrists, back of the elbows, dorsum of feet and hands (specially the

knuckles), palms, soles, nipples, areola, lips and genitals.

2. The greater the percentage of associated white hair, the worse the prognosis.

3. Persistent friction or itching on the affected areas.

4. Emotional liability and psychic turmoil of the patients.

5. If it is associated with systemic ailments.

6. If herido – familial background is present.

7. Old age.

8. Iatrogenic factors, including injudicious administration of topical or systemic

medicines, particularly photo chemotherapeutic agents.

Management of vitiligo:

In the absence of clear understanding of etiopathogenesis there is no ideal

treatment.

Principles of treatment are as follows

V1 stage – Correct the cause and give nutritional supportive therapy

V2 stage – Give specific treatment of vitiligo orally and topically.

V3 stage – If no further improvement with V2 treatment, adopt surgical treatment.

Treatment of vitiligo can be mainly divided under

1. General aspects

2. Specific

3. Surgical

4. Cosmetic Camouflaging

5. Bleaching

General:

Explanation of the nature of the disease, its unpredictable course, prognosis

and reassurance is given to the patient. Educating the patient regarding the good

general health and balanced nutritious diet enriched with adequate good quality

protein specially the phenylalanine and tyrosine, vitamins B complex and E and

minerals such as copper, zinc and iron.



Patients are instructed to avoid physical, chemical and emotional trauma as far

as possible and also avoidance of soap, detergents containing phenolic compounds

and rubber goods.

Specific:

It can be given orally and topically.

Systemic:

Ammeimajus (meladinine-p), Psoraliacorylifolia (seeds), Psoralin, Meosoralin

or Macsoralin one tablet contains 10 mg active substance ammidin and Ammodin and

the daily dose is 10 – 20 mg. It should be followed by expoture to sun 2 hours later.

To achieve this, it is preferable to take the dose early in the morning.

Side effects:

A sense of heat in the body, nervousness and some times hypertension,

giddiness and an allergic eczematous reaction is seen. If the side effects are mild the

drug can be continued in small doses.

Local:

Local ammimajus or psoralin ointment, Croton oil babchi (Psoralia cardifolia),

or bergamot oil locally.all these have photosensetizing action. They produce erythema

and at times blisters, which are more common in those, who have not taken systemic

psoralins previously. When this occurs further application should be stopped and

soothing lotion or cream should be prescribed. Later it it can be used in a diluted form

and less frequently.

A cream containing 10% para amino benzoic acid is applied to the normal skin

surrounding the vitiligo patches; particularly the face, before the paint is used or

irradiation is given. This helps to avoid disfiguring hyper pigmentation of the border

areas.

Treatment using a combination psoralin derivities or any other

photosensitizing agent orally or topically, followed by irradiation with long wave ultra

violet light (320 - 400 wavelength) constitutes photo chemotherapy, the predominant

modality of treatment for vitiligo. Photosensitization induced by the psoralin group of

drugs in conjunction with long wave UV rays irradiation from an artificial source is



called PUVA therapy, when sun exposure is utilized as a source of UVA it is called

PUVASOL therapy

Corticosteroids: With the current inclination of viewing vitiligo as auto immune

disorder a number of corticosteroid preparations in different forms and routes (topical,

intralesional and oral) have been used in last 3 decades with encouraging results.

Surgical treatment: it includes

Thin thiersch grafting – Thin split thickness grafts are performed in cases

with long standing quiescent lesions, ranging from 6 – 100 cm2 in area.

Epidermal grafting – Normally pigmented epidermis is separated from the

dermis of the donor site by suction blistering of the skin at a negetive pressure

of 200 mm of Hg.

Mini grafting – implanting small punch grafts 3 – 4 mm apart with in minute

beds perforated in the depigmented recipient area forms mini grafting. It has

been noted that pigment cells proliferate and migrate from the mini grafts in to

adjacent achromic skin.

Transplantation of vitro cultured epidermis-bearing melanocytes.

Cosmetic camouflaging:

Suitable cosmetic preparations like silver nitrate or potassium permanganate

solutions in variable strengths help the patient by mashing the achromic macules.

Bleaching:

In extensive vitiligo with scattered pigmented islands of skin and with out any

hope of recovery, removal of the remaining pigment to give the skin a uniformly

white appearance may be cosmetically desirable.



DRUG REVIEW

Ayurveda considers Oushadha as one of the four essential

components for maintaining health. The drug which is rich in pharmacological

activities, which could be made into various forms of medicaments, having specific

therapeutic action and available in plenty are praised by the legendaries of science.

Ample of references are available in the classics regarding the wonders a good drug

can produce as well as the ill effects an improper drug can create. The combinations

of medicines described in the textbooks of Ayurveda are the products of thorough

analysis and clinical trials. Many of them indicated in the context of various disorders

are able to work both in the curative as well as preventive perspective.

The drugs that were used in the study are -

1) Aragwadha phalamajja

2) Apamarga Kshara

3) Jyotishmati Taila

4) Tila Taila

Aragwadha

Botonical name: Cassia fistula

Family: Caesalpinioideae

Kula: Shimbikula

Gana: Kustaghna, Kandughna,

Tikthaskanda, Virechana (Charaka)

Aragwadhadi, Shyamai, Sleshmasamshamana,

Adhobhagahara (Sushrutha)

Aragavdhadhi, Shyamadi (Vaghbata)

Rasa: Madhura and Tikta

Guna: Mrudu, Guru, Snigdha

Veerya: Sheeta

Vipaka: Madhura

Doshaghnata: Kapha Pittahara

Karma: Sramsana



Chemical composition:

Seeds: Sugar, Glactomannan.

Flowers: Fistuline, Leucopelargonidin, Tetramen

and Haempherol.

Pods: Fistulic acid.

Bark and heart wood: Barbaloin, Fistucalidin and recine.

Leaves: Rhein, Sennosoids A and B.

The aqueous extract of the fruit pulp has significant purgative action.

Purgation action is maximum in 6 – 9 hours and lasts for 24 hours as per research.

Useful parts: Phalamajja, Roots, Leaves, Flowers, Bark, Seeds.

Dosage:

Phalamajja: 5 –10 grams

For Virechana – 10 – 20 grams

Moola Twak Kwatha: 50 – 100 ml

Mode of action:

The recommended dose in the present study was Aragvadha Phalamajja

Kashaya prepared with 20 grams of Aragvadha phalamajja. By the presence of Prithvi

and Aap mahabhootha in Aragwadha the doshas will be made to pass through the

Guda. Vata, Mala, Pitta, Udaka and Kapha are excreted by Sramsana respectively.

Aragwadha contains gluten a glycoside, which produces the purgative action.

Apamarga

Botanical name : Achyranthes aspera Linn.

Family : Amaranthaceae

Kula : Apamarga kula .

Gana : Shirovirechana, Krimighna, Vamanopaga [ Charaka],

Arkadi [Suhshruta]

Rasa : Katu, Tikta

Guna : Laghu, Ruksha, Tikshana

Veerya : Ushana

Vipaka : Katu



Doshaghanta : Kapha – Vata shamaka

Kapha – Pitta samshodhaka

Karma : Deepana-pachana, Krimighna, Rocana, Sangrahi,

Pittasaraka, Pittasamshodhaka

Chemical Compositions :

The plant ( whole herb ) and seeds contain alkaline

substance specially potash

Synonyms:-

Dhamargava, Mayuraka, Pratyak parni, Pratyak puspha , Keeshavalli,

Kinihi, Kharamanjari, Adhahasalya , Durgraha Shikari, Mayurashikhi , Aghata.

Kannada Name:- Uttarane.

English Name:- Choff tree [ prickly chaff flower ]

Hindi Name:- [ Chichidi] , Chirhita, Chirachita, Chichrha.

Bengali Name :- Apang.

Telugu Name:- Apamargam.

Punjabi Name :- Puthakanda

Marathi Name :- Aghada

Classical categorization :-

Charaka- Sirovirecanopaga, Krimighna, Vamanopaga

Sushruta- Arkadi Vagbhata- Arkadi

Botanical Description:-

Annual or perennial herbs , 30-90 cm tall, often with a woody base

stms simple or branched from the base, often tinged with reddish, purple, ribbed,

visceral pubescent. Obtusrly 4 amgled , leaves varieable, ovate – elliptic or obovate –

rounded plant is very variable in habit. Degree of hairness, size & shape of leaves &

length of spikes flowers greenish white, numerous, in axillary or terminal spiks , seeds

subcylidrical, truncate at the apx. Round at the base, reddish brown.throughout India ,

plant is found as a waste places roadsides, hedgs, gardens, fields or farms.

Part used:- whole plant [ panchanga]

Pharmacodynamics:- [Ayuvedic]

Rasa:- Katu, Tikta..

Guna:- Laghu, ruksha, Teekshna.



Veerya:- Ushna.

Vipaka:- Katu.

Doshaghnata:- Kaphavatashamaka, Kaphapitthasamshoshaka.

Rogaghnata:-

Netraroga, Vrana, Vrishchikadashana, Sarpadansha, Karsnashoola,

Pama,

Aruchi, Chardi, Agnimandhya, Udararoga, Shoda,Adhmana, Arsha, Pittashmari,

Krimi, Hridroga, Raktavikara, Pandu, Gandamala, Amavata, Shosha, kasa shwasa &

in charma rogas.

Doses:-

Juices: - 10-20 ml

Root powder: - 3/ 6 gm.

Seeds: - 3gms

Kshara: [water soluble extract of ash] – ½-2gm.

CHEMICAL CONSTITUTES:-

Ecdysene, ecdysterone, inokosterone, oleanolic acid and glycoside from

roots, Saponin A & B from seeds along with hentriacontane, two new Saponin C& D

and oleanolic acid based Saponins from fruit alkaloids achyranthine and betaine from

the whole plant are reported.

MODE OF ACTION : -

Apamarga has Katu-Tikta Rasa, Katu Vipaka, Ushna Virya and Rakta-

Pitta Prasadanakara action. So it may help in proper functioning of Bhrajaka Pitta.

KSHARA KARMA:-

Historical review:

Prevedic & Vedic period: - No relevant references are available.

Samhita Period: -

Various references of Ksharas are found in the Samhitas with detailed

description about the preparation and usage of the same, both internally and externally

in various diseases.

Sushruta says that Kshara is superior to Shastra and other Anushastras

because of its unique functions like Chedana [excision] and Bhedana [incision]

karmas, relieving the derangement of tridoshas etc.



According to Vagbhata, Kshara is a very good substitute for surgical

operations and they do the function of Chedana and Bhedana in the delicate areas and

diseases where the Shastras can be used with difficulty or in those diseases where

Shastra karma is not possible.

Kshara may be used in very difficult cases very liberally. Charaka has

dealt in detail about the internal uses of Kshara than its external uses. In Bhela

samhita, we find the usage of kshara internally as well as externally, particularly in

arsho chikista where he describes about the application of pratisaraneeya kshara after

surgical excision of arshas.

In Kashyapa samhita, Dwivraneeya chikitsadhyaya, author describes

about the applicaton of ksharasutra in the disease “arakeelika”. In Madhavanidana,

Sharangadara Samitha, Yogaratnakara and other literatures of Ayurveda, likewise

description about Kshara is found.

MODREN PERIOD:

Kshara is being used extensively n therapeutics and as well as in clinical

studies in the management of diseases like Arshas, Bhagandara , Vrana, Charmakeela,

Kadara etc. In morden medicine, alkalies and caustics which can be considered as

kshara are being used both internally and externally in various diseases. The

application of caustic chemicals to the tissues can be used to the advantage to treat

certain lesions.

VYUTPATTI

The word “Kshara” is derived from the root “Kshar” which means “to

melt away” or “to perish away”. The morden equivalent term for kshara is alkali or

caustic. The term „alkali‟ is derived from an Arabic word “aquili” which means

“substance derived from the ash”. The word caustic is derived from the Greek word

“Kaushitcos” which means “to burn”.

According to Monnier Williams Dictionary, Kshara: melt away,

perishable. In Amarkosa, Kshara has been used in the sense of “Kacha”; it may also

mean „Chapala‟ Rasa. “Kacha” is derived from the root meaning to fasten or to shine.

Kshara also means “ash”.



NIRUKTI

Kshara is defined as that which moves or melts. Acarya Sushuta has

defined Kshara as- Tatra ksharanad kshananadva kshara : means which cleans the

excessive morbid doshas and which destroys the skin or tissues.[Dalhana teeka :

ksharanad twangmamsadi chalanat shatanat ] Kshanana means to make ksheena or to

destroy by reducing.

Charaka defines Kshara as the one which, because of its corrosives nature,

scrapes away the abnormal tissues form its locations and drags it down after

dissolving.

Many more authors have given similar definition for Kshara.

Paryayas of Kshara:-

1. Kaach 2. Bhasma 3. Guda 4. Dhatu dravaka 5. Sarja kshara

6. Dhusara 7. Lavana 8. Modini 9. Soubhagyam 10. Tankanam

IMPORTANCE OF KSHARA:-

Kshara is an alkaline substance obtained by processing the ash of drugs.

They are considered as Anushastras because of various actions like Chedana, Bhedana

etc., even in the absence of shastras. Kshara has been deemed to be superior to

shastras & anushastras because of its actions as said above i.e., Chedana, Lekhana and

alleviation of tridoshas and also being used for specific functions. Kshara is that

which cuts off tvak , mamsadi, putrified tissues and removes the vitiated doshas.

Ksharanat – means by producing injury in skin, muscle etc. Kshara derived from the

drug possesses various properties like – it is Sarva rasayukta, Katu, Lavana rasa

pradhana etc. Due to Teekshna & Ushna guna, it has many functions such as Dahana,

Pachana, Vidarana and Vilayana, and also does Shodhana & Ropana karma. By the

action & it rest the purified issued by carrying it down disintegrating the vitiated

twak, manasadi tissues. Ksharas serves the purpose even in the shastras & where

shastra chikitsa is contraindicated & fit to be used in places where sharp instrument

can be used with difficulty such as nasa arsha &arbudha , where treatment with sharp

instrument does not succeed & in diseases by ati prakupita doshas. Anushastras are

bamboo, quartz , kacha , kuruvinda, leeches , agni, nail, leaves of gojihva ,

sphephalika & shaka, sprints, hairs & Anguli. Apamarga & Chitraka plant kshara was



prepared acc. to the procedure mentioned in the classics by our acharyas. The

principle behind the preparation of kshara was based as pr the need of the study

required for clinical trial.

Classification of Kshara :-

1. On the basis of administration :-

a) Pratisaraneeya Kshara – External application.

b) Paneeya Kshara – Internal application.

Acarya Vagbhata opines the same by considering them as

a) Bhaya Parimarjaneeya.

b) Antah parimarjneeya.

2. On the basis of Concentration:-

a) Mrudu Kshara.

b) Madhyama Kshara.

c) Teekshna Kshara.

3. On the basis of Origin:-

a) Vanaspatijanya – Herbal.

b) Pranijanya – Animal.

c) Khanijajanya – Mineral.

4. According to season of preparation:-

a) Uttama – prepared in Greeshma Ritu ( Summer )

b) Madhyama – prepared in Sharad Ritu ( Winter )

c) Adhama – prepared in Varsha Ritu (Rainy )

5. The Paneeya Kshara is also further classified on the basis of Kshara Varga:-

a) Kshara Dwaya.

b) Kshara Traya.

c) Kshara Panchaka .

d) Kshara Ashtaka.

Pratisaraneeya Kshara :-

The tem Parteesarana is used to denote healing or dressing the edges of

a wound or an instrument used for anointing a wound.



Classical Method of Preparation of Pratisraneeya Kshara:-

Acharya Shushruta has dedicated the whole of 11th chapter of Sutra

Sthana to describe Kshara. After review in all the classical texts, Sushruta‟s maneuver

seems to be ideal regarding the preparation of Pratisaraneeya Kshara.

The physician who prepares the Kshara should have a clean bath in the

morning of Sharad Ritu in an auspicious day. He fasts that day & goes up the hills &

looks for such plants which are middle aged and free from insects. The panchangas of

such plants are collected, dried up & made into small pieces. Then these are burnt

with limestone. While burning, the dispersed parts of the plants are kept with the help

of tilnala. When the ash cools down it should be mixed well with six times of water or

cow‟s urine , then filtered twenty one times in a big vessel through a piece of cloth.

The residual portion is thrown away and the filtrate ( Ksharodaka) should be kept on

mandagni and continuously stirred well until it turns reddish brown and attains

picchilata or get reduced to 1/3 rd . If this is heated till powder form, Mrudukshara is

obtained. If not then, from the ksharodaka eight palas has to be taken and mixed with

Shankanabhi, Shukti and Kata sharkara, each in eight palas, to make Prativapa. In the

meantime, heating should be continued and prativapa should be mixed. Care should

be taken that it is not too liquid nor too dried up. The solution thus obtained is known

as Madhyama Kshara. Madhyama Kshara should be heated up again by adding some

medicinal plants such as danti, chitraka etc., with this a thick solution is obtained

which is known as Tikshna Kshara. If Tikshna Kshara loses its potency then it should

be mixed new kshara and heated again to maintain sufficient concentration.



Table No. 15: Plants which are mixed to Mridu Kshara to make it Madhyama

Kshara:-

Sl. No. Sanskrit Name Source

1 Bhasma Sarkara Secreted drops from plant edges

during burning became solid form.

2 Kata Sharkara or Sudha

Sarkara

Unburnt , semi burnt pieces of

limestone (CaO )

3 Shukti Animal product

4 Sankha Nabhi Animal product (CaCo3)

Table No.16: Medicinal plants which are mixed to make Madhyama to Tikshna

Kshara:-

Sl.

No.

Sanskrit Name Latin Name Family

1 Danti Baliospemummontanum

Muell

Euphorbiaceae

2 Dravanti Crotontiglium Euphorbiaceae

3 Chitraka Plumbagozeylanica Linn Plumbaginaceae

4 Langali Gloriosasuperba Liliaceae

5 Hingu Ferulanorthax Bioss. Apiaceae

6 Vacha Acoruscalamus Linn. Araceae

7 Shukti Mytilusmargarferns Pearl ( Oyster)

8 Pravala Coralliumrubrum Animal product( CaCo3)

9 Bida lavana Navasada Mineral product ( NH4Cl)

10 Sauvarchala

Lavana

Rock Salt Mineral product (NaCl)



DANTI: -

Latin name:- Baliospemummontanum Muell.

Family:- Euphorbiaceae.

Rasa:- Katu.

Guna:- Guru, Teekhsna.

Veerya:- Ushna.

Vipaka:- Katu.

Doshagnata:- Kaphapitahara.

Karma:- Deepana, Shothakara, Vedana Shamaka.

DRAVANTI:-

Latin name :- Crotontiglium .

Family:- Euphorbiaceae.

Rasa:- Katu.

Guna:- Guru, Ruksha, Teekhsna.

Veerya:- Ushna.

Vipaka:- Katu.

Doshagnata:- Kaphapitahara.

Karma:- Deepana, Shothakara, Vedana Shamaka.

CHITRAKA:-

Latin name:- Plumbagozeylanica Linn.

Family:- Plumbaginaceaea.

Rasa:- Katu.

Guna:- Laghu, Ruksha, Teekhsna.

Veerya:- Ushna. Vipaka:- Katu.

Doshagnata:- Kaphavata shamaka, pittvardhaka..

Karma:-Lekhana, Deepana, Pachana.

LANGALI:-

Latin name:- Gloriosasuperba.

Family:- Liliaceae.



Rasa:- Katu,Tikta.

Guna:- Laghu, Teekhsna.

Veerya:- Ushna.

Vipaka:- Katu.

Doshagnata:- Kaphavata shamaka.

Karma:- Deepana, Balya, Rakta, Shodhaka.

HINGU:-

Latin name:- Ferulanorthax Bioss.

Family:- Umbellliferae.

Rasa:- Katu .

Guna:- Laghu, Snigdha , Teekhsna.

Veerya:- Ushna.

Vipaka:- Katu.

Doshagnata:- Kaphavata shamaka, pitta vardhaka.

Karma:- Deepana, Vedana sthapana, pachana.

VACHA:-

Latin name:- Acoruscalamus Linn.

Family:- Araceae.

Rasa:- Katu, Tikta.

Guna:- Guru, Teekhsna.

Veerya:- Ushna.

Vipaka:- Katu.

Doshagnata:- Kaphavata shamaka, pitta hara.

Karma:- Shotahara, vedana shamaka, arshoghna.

SHUKTI (Pearl Oyster):-

Latin name:- Mytilusmargarferns

Rasa:- Madhura.

Guna:- Kshareeya.



Veerya:-Sheeta.

Vipaka:- Mdhura

Doshagnata:- Raktapitta nashaka.

Karma:- Deepana, Shulahara, Udara roga nashaka.

PRAVALA (Coral, Calcium Carbonate, CaCo3):-

Latin name :- Coralliumrubrum

Rasa:- Kshareeya.

Guna:- Sheeta.

Veerya:-Sheeta.

Vipaka:- Mdhura

Doshagnata:- kaphavatanashaka, raktapitta shamaka.

Karma:- Deepana, pachana, Balya.

SOUVARCHALA LAVANA:-

Latin name:- Unaqua Sodium Chloride.

Rasa:- Lavana.

Guna:- Teekshna.

Veerya:-Ushna.

Vipaka:- Madhura.

Doshagnata:- Kaphavata shamaka.

Karma:- Agnideepaka, Virechaka.

VIDA LAVANA: -

Mineral product ( NH4Cl)

Rasa:- Lavana.

Guna:- Kshara, Teekshna.

Veerya:-Ushna.

Vipaka:- Madhura.

Doshagnata:- Kapha shamaka, Vatahara.

Karma:-Vatanulmana, Deepana, Vibandha hara..



Table No.17: Medicinal Plants useful for the preparations of Mridu Kshara as

prescribed in Shushruta Samhita:-

Sl. No. Sanskrit Name Latin Name Family

1 Apamarga Achyranthus aspera Linn Amaranthaceae

2 Kutaja Holarrhena antidysentrica Apocynaceae

3 Paribhandra Erythrina indica Lamk Fabacesea

4 Asva Karna Dipterocarpus turbinatus gaertn.f. Dipterocarpaceae

5 Vibhitaki Terminalia bellerica Roxb. Combrataceae

6 Aragvadha Cassia fistula Linn Caesalpinoidea

7 Tilvaka Seasamum indicum DC Pedalianceae

8 Arka Calotropis gigantean(l.) Dryand Asclepiadaceae

9 Snuhi Euphorbia neriifolia Linn Euphorbiaecae

10 Palasha Butea monosperma (Lam.) Kuntz. Fabaceae

11 Nakramala Pongamia pinnata (Linn.) Merr. Fabaceae

12 Vrisa Adhathoda vasica Nees Acanthaceae

Properties of Kshara:-

Rasa:- Katu.

Virya:- Ushna.

Varna:- Shukla.

Guna:- Sowmya, Tikshna, Agneya.

Doshagna:- Tridoshagna.

Karma:-

Dahana, Pachana, Darana, Vilayana, Shodhana, Ropana, Sthambak ,

Lekhana.

Prepared Kshara, being a composite of many drugs alleviates the three

doshas. Being white in colour it is plain. In spite of placidity, its actions like

cauterizing, digesting and splitting is carried out as it is made of drugs having the

property of pungent, hot, sharp, digestive and suppurative. When used, it is cleansing,

heating, absorbant and scarping. When used internally, it destroys Krimi, Amadosha,



Kapha gata Twak rogas, Gara visha and Gulma. Further if it is used in excess, it can

result in impotency.

Table No.18: The Physical characters of well prepared Teekshna Kshara:-

Sl. No. Physical Character Sushruta Vagbhata

1 Na ati teekshna ( not too strong) + +

2 Na ati mrudu ( not too mild) + +

3 Na ati Shukla ( not too white) + +

4 Shlakshna ( thin) + +

5 Pichhila ( Slimy ) + +

6 Abhishyandi ( unspreading ) + +

7 Sheeghra karita ( quick acting ) + +

8 Shiva + -

9 Shikhari - +

10 Sukhanirvapya - +

11 Alparakthata - +

Tests for perfectness:

Acharyas have explained the method to assess the potency of

Ksharas using Erandanala; accordingly, if the Kshara burns the Erandanala in 100

matrakala,then it is Tikshna Kshara, if it burns in less than 100 matrakala,then it is a

Atitikshna Kshara and if fails to cause any sign of burning even after 100 matrakala,

then it is considered as a Atimridu Kshara.

Indications of Kshara Karma:-

Kshara karma has been prescribed in good number of diseases by ancient

acharyas. Sushruta has indicated it in sixteen conditions. :



Table No. 19: The Physical properties of improperly prepared Kshara, described

by Sushruta as doshas of Kshara:-

Sl. No. Conditions Sushruta Vagbhata

1 Ati mruduta (to mild) + +

2 Ati ushnata ( too hot) + +

3 Ati shweta ( too white) + +

4 Ati teekshnata ( too sharp) + +

5 Ati pitchila ( too slimy) + +

6 Ati Visarpita ( too spreading ) + +

7 Ati sandrata ( too thick ) + +

8 Apakwata ( uncooked) + +

9 Heenadravyata ( with less potency ) + +

10 Ati tanu ( very thin) + +

Indication of pratisaraneeya kshara according to Brihat trayeekaras :

CHARAKA SUSHRUTA VAGBHATA

1 Kusta Kusta Kusta 2 Kitibha Arshas Arshas

3 Arbuda Visarpa Visarpa 4 Kilasa Vrana Bhagandara

5 Dusta vrana Vatarakta Galaganda 6 Nadi vrana Bhagandara Nadi

vrana

7 Charma keela Galaganda Kantha roga 8 Vyanga Karna roga Netrarbuda

9 Mashaka Nasarbuda Nasarbuda 10 Bahividradhi Nasaadhimanya

Nasaadhimanya

11 Krimi Nasaarshas Nasaarshas 12 Visha Jattumani

13 Upajihwa Mashaka 14 Upakusha Adhijihwa

15 Danta vaidarba Valmeeka 16 Charmakeela Upadamsha

17 Dadru

(Three Types of Rohini)

18 Mandala 19 Bhagandara 20 Arsha



Containdications of Kshara Karma :-

Before the application of Kshara it is necessary to observe the fitness

of the patient, contraindications of Kshara can be classified into following groups:-

According to diseases –

Jwara, Hrudroga, Shiraroga, Panduroga, Arochacaka,

Sarvangashopha, Raktajagulma, Udararoga are contraindicated in general.

According to physical & mental state of the patient –

Children, Phobic people , Aged, Menstruating women , Pregnant women

, Physical weak persons.

According to sites –

Arteries, Joints, Vital parts, Cartilages, Veins, Ligaments, Throat,

Umbilicus, Penis, Insufficient musculature, Nail bed, Testis, all parts of the eye

expect eye lid.

According to seasons –

summer, autumn and cloudy weather are contraindicated. The above

contraindications are applicable for both Paneeya & Pratisaraneeya Kshara.

Apart from these, few anatomical sites and some diseases may also be

fit for contraindications of Pratisaraneeya Kshara. Excessive use of Kshara leads to

Pumsatva Upagatha. Charaka said Kshara helps in digestion but excessive use of it

causes impairment of vision. Vagbhata described that due to Katurarsa , Kshara is

injurious to Hridaya, Kasa, Chakshu, Ojus and Shukra. Further Shushruta has

observed that Kshara may be ineffective in Kshara sadyavyadhi also if it is

complicated by edema, pain in the bones , aversion for food, pain in precardial region

and joints . However, external application of Apamaraga Kshara is indicated in

children, weak persons and Decrepit.



UNSUITABLE SITES FOR KSHARA KARMA :-

Khhara should not be appliend on marma, sira, snayu, asthisandhi,

tarunasthi, sevani, dhamani , gala, nabhi, nakhantara pradesha, mushka, shepha srota,

alpamamsa pradesha and netra (except in vartma rogas).

CAUTION WHILE USING KSHARA :-

When the Kshara is applied by a less intelligent person, it acts like a

poison, fire, sharp instrument, lightning and thunder and causes death.

SIGNS OF SAMYAK DAGDHA LAKSHANAS:-

When the kshara has been properly applied, the disease gets relieved,

the patient feels comfortable and cessation of discharge occurs.

SIGNS OF HEENA DAGDA LAKSHANAS:-

When the kshara application is inadequate, features of pain, irritation,

heaviness and aggravation of disease occur.

SIGNS OF ATIDAGDHA LAKSHANAS:

When there is excessive application of Kshara, there is burning

sensation, inflammation, reddish discolouration, discharge, body ache, fatigue, thirst,

fainting or even death.

Chemical Composition of Kshara:-

Prof. A.R. Vasudeva Murthy, describes the chemical composition of

Kshara in his Indian tradition of Chemistry & Chemical technology , as follows:

The wood ashes contain Potassium & Sodium Carbonate ( K2CO3&

Na2CO3 ). Limestone & sea shells contain Calcium carbonate ( CaCO3) . On heating

strongly carbonate decomposes into calcium oxide ( CaO ) , quick lime and carbon

dioxide ( CO2) escapes into the air. Calcium oxide reacts with water vigorously and

with Potassium / Sodium carbonate gives rise to Calcium carbonate which comes

down as precipitate . Alkali hydroxide (KOH) remains in the solution which may be

concentrated in terms of the following equations

CaCo3 → CaO + CO2↑

1. CaO + H2O→Ca (OH) 2

2. K2CO3 + Ca( OH)2→2KOH + CaCO3



Drug Analysis :-

Apamarga Kshara :-

Description :- Fine powder , dull white in colour.

Odour :- Faint.

Taste :- saline.

Identification:- An aqueous solution yields reaction characteristic of Sodium and

Potassium.

Water soluble matter - 96-98 %

Water insoluble – 1.02%

Moisture content – 8.1%

Water insoluble organic matter (carbonaceous) – nil

PH – 12.2

Potassium content – 27.45%w/w

Sodium content – 20.83%w/w

Jyotishmati

Latin Name : Celastrus panniculatus

Family : Celastraceae

English Name : Black oil tree, climbing staff tree.

Hindi : Malkangani, Malkai, Malkamni.

Kannada : Gouri Kayi.

Synonyms-

The word synonym is the word identical or word denoting the same thing.

1. Jyotishmati- Jyoti = Bright, shining, Mati = Intelligence. In which the Jyoti

resides or that which brightens intelligence is Jyotishmati.

2. Peeta Taila - The seeds of Jyotishmati yields oil which is yellowish in color.

3. Kaakandaki- Fruit resembles the egg of crow.

4. Kanguni- It is Agnidepaka, Budhivardhaka and gives Sukha to body.

5. Vega- Spread very fast or it induces enthusiasm.

6. Others are Malkangi, Medhya, Pooti Taila, Swarna Lata etc.



Distribution:

It is found in sub-Himalaya tracts and up to 6000 ft in central India and

province in India, It has spread from Jheleem to Assam and in eastern Bengal, Bihar

and Burma.

It is also seen in hilly parts of Bombay, South Gujarat and in Madras presidency.

Commonly occurs in all parts of Karnataka.

Habit:

A large deciduous climber with stem up to 23 cm diameter and 18 m height,

some times twining dexterously but more often rambling. Twigs fairly smooth,

reddish brown, densely covered with small elongate whitish lenticels. Bark pale

brown, rough with hallow cracks, exfoliating in small soft scales.Stem - 7.5- 10 mm

not fibrous, pink finely streaked with red or reddish brown, the juice turning blue on

the blade of a knife.Leaves - 6.3 - 10 by 3.8 - 7.5 cm, broadly elliptic obviate,

abruptly short- acuminate, crenate- serrate, rather coraicaous, glabrous, lateral nerves

arching. Petiole-7.5to15 mm long. Flowers - 3.8 mm diameter, in terminal drooping,

panicle 5- 20 cm long.Capsules - 1to 1.3 cm diameter, depressed- globose, 3- lobed,

bright- yellow, 3 - 6 seeds. Seeds completely enclosed in an orange - red aril.

Chemical Constituents

Seeds yield brownish oil (52.2%) with unpleasant taste. Oil contain

coloring matter, fat contains formic acid, acetic acid, benzoic acid. Fleshy aril yields

fat. Alkaloid celastrine, panicalatine.

Rasapanchaka

Rasa : Katu, Tikta

Guna : Tikshna, Snigdha, sara

Virya : Ushna

Vipaka : Katu

Dosa Karma : Snigda Ushana passify Vata and Kayu,Tikta and Ushana

passify Kapha .

Prabhava : Medhya



Samsathanika Karma –

On Nadi Samsthana Medhya, due to Ushana Guna improves grasping

power. And on Pachana Samsthan it does Deepana due to its Katu, Tikta and Ushana

Guna,Vata Anulomana due to its Snigdha,Ushana Guna.

Prayojyanga : Beeja and Beeja Taila.

Matra : Beeja = 1to 2 gm.

Beeja Taila = 5 to 15 drops

MODE OF ACTION :

Jyotishmati has Katu-Tikta Rasa, Katu Vipaka, Ati-Ushna Virya and

Pitta Santpakara action. Thereby it may enhance the proper formation of Bhrajaka

Pitta in Tvak.

Method of oil extraction

The fresh seeds of Jyotishmati are taken and dried in sun light. All the

impurities is taken out and then subjected for oil extraction. Method used for the oil

extraction is by crushing the seeds in an electric fitted crusher.

Tila

Botanical name : Sesamum indicum

Family : Pedaliaceae

Kula : Tilakula

Rasa : Madhura, Kashaya, Tikta, Katu

Guna : Guru, Snigdha

Virya : Ushna

Vipaka : Madhura

Doshaghnata : Vatashamaka, Kapha-pittaprakopi

Chemical Composition :

Seed Oil The tila seeds (Sesame seeds) contain many vitamins like thiamine,

niacin, riboflavin, nicotinic acid, pantothenic, folic and ascorbic acids, choline,

inositol, pyridoxine, vitamin A, and tocopherol. Sugars present are glucose, sucrose,

galactose, planteose and raffinose. The fatty acids in the seeds are myristic, palmitic,

stearic, arachidic, oleic, linoelic, hexadecenoic and linoceric acids. Sesamin isolated

from seed oil and three stereoisomeric forms of sesamin, viz. sesamin, asarinin and

epiasarinin



METHOD OF PREPARATION OF THE DRUG COMPOUND:

The Jyotishmati-Apamarg Kshara Taila was prepared by General Method

of preparation of Kharapaka Taila as per Sharangdhar Samhitha.

Contents of Jyotishmati-Apamarg Kshara Taila were as follow:

1) 1 part - Apamarga Kshara used as Kalka.

2) 4 part - Jyotishmati Taila.

3) 16 part - Apamarga Kshara Jala.

Process of Talia Siddhi :

Apamarga Kshara was taken as Kalka and Apamarga Kshara Jala was taken

as Drava dravya and mixed together in Sneha patra. Jyotishmati taila was then added

as Sneha. Then this mixture boiled on Mandagni and stirred continuously upto

appearance of Kharapaka Lashanas.This procedure seven times done.

Lakshanas of Taila Siddhi :

1) A small quantity of Kalka taken out at the end of boiling and rolled in

between the fingers, if it assumes a varthi ( wick – like shape )

2) Kalka does not produces crackling sound if thrown on fire

3) Appearence of Phena ( froth, bubbles ) at the terminal stages of sneha paka

respectively

Lakshanas of Kharapaka :

1) The Kalka does not yield any sneha and is hard rough due to excess of heating

MATERIALS AND METHODS

Materials & Methods


Materials and Methods

Objectives of the study

The present study named, “A clinical study on effect of local application

with Jyotishmati Apamarga Kshara Taila in the management of Shvirta

(Vitiligo) in children” was carried out with following objectives -

4. To evaluate the effect of local application with Jyotishmati-Apamarga Kshara

Taila in the management of Shvitra.





Shvitra.

Materials for the study

(A) Source of data:

40 patients of Shvitra attending the Kaumarabhritya O.P.D. and I.P.D. of

S.D.M.C.A. Hospital, Hassan and Chikkmagalore will be selected for the study.

(B) Methods of collection of data :

The diagnosed cases of Shvitra will be selected for the study based on the

Diagnostic criteria and Inclusion criteria as mentioned.

1) Diagnostic criteria :

1. Lakshanas of Shvitra as mentioned in Ayurvedic classics.

2. Borders of patches hyperpigmented and well defined.

3. Sensation is normal.

4. Absence of scaling, crusting

2) Inclusion criteria :

1. Patients with Sadhya Lakshana of Shvitra.

2. Patients in the age group of 7 to 12 years.

3. Patches up to 1 year old.

4. Size of patches less than 5cm × 5cm.

Materials & Methods


3) Exclusion criteria :

1. White anesthetic spots which are characteristic of leprosy.

2. Patients below 7 year and above 12 years.

3. Vitiligo patches complicated by eczema.

4. Patches arising on the finger tips, near nail bed, on the lips, over mucosal

layer and in genital area.

(B) Drug Materials taken for the study :-

1. Aragvadha Phala Majja Kashaya

2. Jyotishmati-Apamarga Kshara Taila

3. Tila Taila

Method of study

45 patients between the age group of 7 – 12 years attending the

Kaumarabhritya OPD and I P D of S.D.M College of Ayurveda and Hospital, Hassan

with diagnosis of Shvitra were taken up for the study after following the criteria laid

as above. Their age, sex, religion, socioeconomic status, food habits family history,

dehaprakruthi etc. were noted as given in master chart. Where there is more than one

patch of vitiligo in any patient only one patch was selected for the study. However

where improvement was found in that particular patch, patient was advised to treat

other patches also with the same drug. The size of the observed patch was

approximately measured in square centimetres by multiplying its breadth and length.

These 45 patients were divided randomly in to two groups.

1. Group A – Study group – containing 23 patients.

2. Group B – Placebo group – containing 22 patients.

Out of a total number of 45 patients taken for the study, five dropped out in

the middle and did not continue treatment. The left out 40 patients constituted of 20 in

study group and 20 in placebo group.

Complete history and clinical examination of all these patients was carried out

and recorded in a specially designed pro-forma by the Post-Graduate Department of

Kaumarabhritya of S.D.M. College of Ayurveda and Hospital Hassan. Their findings

are given in the enclosed master chart.

All these patients were screened with following routine investigations.

Materials & Methods


Laboratory investigations

Blood:

Hemoglobin estimation,

Total leukocyte count,

Differential WBC count,

Erythrocyte sedimentation rate.

Mode of administration of drug:

All patients of both the groups were administered the drugs as follows –

1. All patients of both the groups will be administered Aragvadha Phala Majja

20 grams with warm milk after Abhyanga and Svedana, in the morning on

empty stomach.

2. Local application of Jyotishmati-Apamarg Kshara Taila and Tila Taila to

study and control groups respectively followed by sunexposure 30 minutes,

twice daily for the period of 2 months.

Duration of the treatment:

Patients of both the groups (study and control) will be advised to apply

the drugs given to them daily twice followed by sunexposure for 30 minutes, for the

period of two months.

Criteria for assessment:

Patients of both the groups were examined initially, at the end of one month

and at the end of two months for changes in the patches if any.

The criteria for assessment included,

1. Appearance of itching sensation over observed Shvitra (vitiligo) patches.

2. Alteration in the colour of observed Shvitra (vitiligo) patches.

3. Bleb formation on observed Shvitra (vitiligo) patches.

4. Number of black dots appearing in the observed Shvitra (vitiligo) patches.

5. Change in the size of observed Shvitra (vitiligo) patches.

Materials & Methods


The criteria kept for grading to observe any improvement is as following.


a. If no Itching sensation over observed 1

b. If Itching sensation over observed 0

2. Colour change in the observed Shvitra (vitiligo) patches.

a. No change in colour (White) 3

b. Light pink 2

c. Dark pink 1

d. Normal skin colour 0


a. If no bleb formation 1

b. If bleb formation 0

4. Number of black spots in observed Shvitra (vitiligo) patch

a. If no black spots appear 2

b. If less than three spots appear 1

c. If three or more spots appear 0

5. Size of the observed Shvitra (Vitiligo) patch

a. If size remains same or increases 2

b. 10% reduction in size 1

c. If more than 10% reduction 0

Follow up:

Follow up study will be done after completion of course of the treatment

for a period of 1 month in every fortnight to ascertain whether relief provided by the

drug is sustained.

OBSERVATIONS

Observation


OBSERVATION

Out of 45 patients three from group A and two from group B did not

continue the treatment and had been dropped out in the middle. Thus totally 40

patients remained in the present study. The left out 40 patients constituted of 20 in

study group (Group A) and 20 in placebo group (Group B).

Table No.20 Incidence of Shvitra (Vitiligo) in different age groups :

Sl. No

Age groups

No. of patients in Study group

% No. Of patients in Placebo group

% Total %

1 7– 9 11 55.00 10 50.00 21 52.50

2 10 – 12 9 45.00 10 50.00 19 47.50

In this study it was observed that shvitra more often makes its beginning in

younger children as observed above 52.50% of cases belong to the age group of 7 –

9 years.

Table No.21 Shows sex incidence of Shvitra (Vitiligo)

Sl. No

Sex No. of patients in

Study group

% No. Of patients in

Placebo group

% Total %

1 Male 14 70.00 11 55.00 25 62.50

2 Female 6 30.00 9 45.00 15 37.50

Though shvitra effects equally both males and females, the overall incidence

in this small group of study shows a higher incidence in males (62.50%).

Table No.22 Incidence of Shvitra (Vitiligo) in different communities : Sl. No

Community

No. of patients in Study group

% No. Of patients in Placebo group

% Total %

1 Hindu 18 90.00 18 90.00 36 90.00

2 Muslim 2 10.00 2 10.00 4 10.00

Observation


The present study with the few patients (40) of Shvitra showed a higher

incidence of Shvitra in Hindus. 90.00% of the cases in the present study belonged to

Hindu community while only 10.00% of cases were from Muslim community. None

were christian.

Table No.23 Show incidence of habitat :

Sl. No

Habitat No. of patients in

Study group

% No. Of patients in

Placebo group

% Total %

1 Rural 6 30.00 7 35.00 13 32.50

2 Urban 14 70.00 13 65.00 27 67.50

Habitat incidence of Shvitra patients in the present study shows that majority

of patient‟s i.e. 67.50% were from urban locality and only 32.50% of patients were

from rural area.

Table No. 24 Show incidence of socio-economic status :

Sl. No

Socio economic

status

Study group

% Placebo group

% Total %

1 Poor 2 10.00 1 05.00 3 07.50

2 U M C 7 35.00 8 40.00 15 37.50

3 L M C 11 55.00 11 55.00 22 55.00

In the present study Shvitra (Vitiligo) appears to arise more in Lower middle

class (55.00%), than in Poor class (7.50%) and in Upper middle class (37.50%).

Table No. 25 Shows incidence of shvitra as per food habits :

Sl. No

Food Habit Study group

% Placebo group

% Total %

1 Vegetarian 6 30.00 5 25.00 11 27.50

2 Non vegetarians (mixed diet)

14

70.00

15

75.00

29

72.50

The incidence of food habit in the present study showed that majority of

patients of Shvitra was non-vegetarians (mixed diet) (i.e.72.50%) when compared to

vegetarians in whom the incidence is 27.50%.

Observation


Table No.26 Shows incidence of earlier treatment history in the patients of Shvitra :

Sl. No

Treatment history

Study group

% Placebo group

% Total %

1 Present 9 45.00 7 35.00 16 40.00

2 Absent 11 55.00 13 65.00 24 60.00

It is observed that 24 out of 40 patients (60.00%) came direct to SDM Hospital

for treatment of Shvitra without going anywhere; where as 16 patients (40.00%) had

given history of having taken treatment earlier without any success.

Table No.27 Shows incidence of Deha Prakruthi in Shvitra patients :

The Deha Prakruthi was assessed as per the chart followed in Shareerakriya

department of S.D.M. College of Ayurveda, Hassan.

Sl. No

Prakruthi Study group

% Placebo group

% Total %

1 Vata-Pitta 9 45.00 11 55.00 20 50.00

2 Vata-Kapha 7 35.00 6 30.00 13 32.50

3 Pitta-Kapha 4 20.00 3 15.00 7 17.50

The incidence of Deha Prakruthi in the present study showed that

majority of patients suffering from Shvitra were of Vata Pitta Prakruthi i.e. 50.00%

when compared to Vata Kapha and Pitta Kapha Deha Prakruthi which was 32.50%

and 17.50% respectively.

Table No. 28 Shows incidence of Aharaja Nidanas described to produce Shvitra :

Sl. No

Nidana described in ayurvedic texts

Study group

% Placebo group

% Total %

1 Virudhahara only 4 20.00 3 15.00 7 17.50

2 Ati Masha, Mulaka, Dadhi, Amla sevana

only

6 30.00 5 25.00 11 27.50

3 Both 1 & 2 9 45.00 10 50.00 19 47.50

4 None 1 05.00 2 10.00 3 07.50

Observation


Incidence of Aharaja Nidana in the patients showed that 47.50% of patients

are found consuming Viruddhahara and Ati Masha, Mulaka, Dadhi and Amla

padarthas as a routine in their diet

Table No.29 Shows incidence of Viharaja Nidana in Shvitra patients

Sl. No.

Nidana described in ayurvedic texts

Study group

% Placebo group

% Total %

1 Intake of cold water after exposure to sunlight

9 45.00 7 35.00 16 40.00

2 Cold water bath after exposure to sunlight

4 20.00 4 20.00 8 20.00

3 Both 4 20.00 5 25.00 9 22.50

4 None 3 15.00 4 20.00 7 17.50

It is observed from the above chart that Shvitra is found more

(40.00%) among those using cold water after sun exposure and those who are not

accustomed to do so.

Table No. 30 Shows incidence of chronicity of Shvitra

Sl. No

Chronicity (In months)

Study group

% Placebo group

% Total %

1 1 – 3 2 10.00 3 15.00 5 25.00 2 4 – 6 5 25.00 6 30.00 11 27.50 3 7 – 9 6 30.00 2 10.00 8 20.00 4 10 – 12 7 35.00 9 45.00 15 37.50

The incidence of chronicity 0f Shvitra in the present study showed that in

majority of patients the disease was 10 – 12 months old (37.50%)

Table No.31 Shows incidence of number of mandalas (patches)

Sl. No

No. of patches (mandalas)

Study group

% Placebo group

% Total %

1 1 – 5 9 45.00 8 40.00 17 42.50

2 6 – 10 1 05.00 6 30.00 7 17.50

3 11 – 20 9 45.00 6 30.00 15 37.50

4 Above 20 1 05.00 0 00.00 1 02.50

Observation


In the present study 42.50% of patients (17) had less than 5

mandalas of Shvitra while in 37.50% of patients it was between 11-20 madalas, in

17.50% of patients it was between 6-10 mandalas and only 02.50% of patients more

than 20 mandalas were found.

Table No.32 Shows incidence of distribution of mandalas

Sl. No

Distribution Study group

% Placebo group

% Total %

1 Symmetrical 5 25.00 7 35.00 12 30.00

2 Asymmetrical 15 75.00 13 65.00 28 70.00

In the present study 70.00% of patients of Shvitra showed assymetrical

distribution of Mandalas while 30.00% of patients of Shvitra showed symmetrical

distribution of Mandalas.

Table No.33 Shows incidence of presence of black spots in observed patch before

treatment

Sr.No Black spots Study group

% Placebo group

% Total %

1 No spots 8 40.00 7 35.00 15 37.50

2 1- 5 12 60.00 13 65.00 25 62.50

Before treatment 37.50% of patients did not show any black spots in the

observed patch. 62.50% of patients showed 1 – 5 black spots in the observed patch.

Table No. 34 Shows incidence of colour of patch in Shvitra (Vitiligo) before

treatment : Sl. No

Colour Study group

% Placebo group

% Total %

1 White 18 90.00 16 80.00 34 85.00

2 Light pink 2 10.00 4 20.00 6 15.00

Incidence of colour of the Shvitra patch in the present study showed that in

majority of patients i.e. in 85.00% (34) the lesion was of white colour and only in

15.00% of patients the colour of the lesion was of light pink.

Observation


Table No.35 Shows incidence of size of Mandalas :

In present study the size of Shvitra (VItiligo) patch measured in

square cm for convenience of comparison between before treatment and after

treatment size of Shvitra (Vitiligo) patch.

Sl. No

Size of Shvitra patch taken for study( in square cm)

Study group

% Placebo group

% Total %

1 < 5 2 10.00 2 10.00 4 10.00

2 6 – 10 8 40.00 10 50.00 18 45.00

3 11 – 15 8 40.00 4 20.00 12 30.00

4 15 – 20 2 10.00 4 20.00 6 15.00

In the present study in majority of patient‟s i.e. 45.00 % (18) the

patches were of in between 6 -10 sq.cm. and in 30.00% of patients patches were of in

between 11 – 15 sq. cm.In 15.00% and 10.00% of patients patches were of in between

15 – 20 sq. cm. and < 5 sq. cm. respectively.

Table No. 36 Shows incidence of number of Vegas after Koshstashudhi medicine

given:

Sl. No

Number of Vegas

Study group

% Placebo group

% Total %

1 3 - 4 6 30.00 8 40.00 14 35.00

2 5 - 6 8 40.00 5 25.00 13 32.50

3 7 - 8 6 30.00 7 35.00 13 32.50

In present study incidence of 3-4 Vegas after Koshstashudhi seen in

35.00% of Shvitra (Vitiligo) patients & 5-6 & 7-8 Vegas after Koshstashudhi seen in

32.50% of shvitra (Vitiligo) patients.

RESULTS

Results


Results of improvement in Shvitra (Vitiligo) based on the criteria of assessment:

Group A ( Study Group ): Table No.37 Showing clinical improvement of signs after one month of treatment

Signs seen in observed shvitra (Vitiligo) patch

Mean (G.S) Mean difference

% of improvement

S.D S. E. t - value

P – value

Inference

BT AT

Appearance of Itching sensation

0.85 0.45 0.4 47.05 0.50 0.11 3.55 >0.01 Significant

Colour change 2.9 1.7 1.2 41.37 0.41 0.09 13.07 >0.001 Highly significant

Bleb formation 1 0.9 0.1 10.00 0.30 0.06 1.45 <0.05 Not significant

No. of black spots

1.4 0.75 0.65 46.42 0.48 0.10 5.94 >0.001 Highly significant

Size of observed patch

2 1.5 0.5 25 0.51 0.11 4.35 >0.001 Highly significant

The effect of the study drug provides highly significant result in colour

change, no. of black spots and size of observed Shvitra (Vitiligo) patch with p values

at >0.001 and significant result in appearance of itching sensation over Shvitra

(Vitiligo) patch with p values at >0.01 at the end of first month of treatment.

However, it gives insignificant results on the clinical criteria i.e. bleb formation on

Shvitra (Vitiligo) patch with P value < 0.05.

Results


Group A ( Study Group ): Table No. 38 Showing clinical improvement of signs after two months of treatment :



% of improvement

S.D S. E. t - value

P – value (df-12)

Inference

BT AT



Colour change

2.9 1 1.9 65.51 0.30 0.06 27.60 >0.001 Highly significant

Bleb formation

1 0.7 0.3 30.00 0.47 0.10 2.85 0.01 Significant

No. of black spots



2 0.65 1.35 67.50 0.48 0.10 12.33 >0.001 Highly significant

The effect of the study drug provides highly significant result in appearance of

itching sensation, colour change, no. of black spots and size of observed Shvitra

(Vitiligo) patch with p values at >0.001 at the end of second month of treatment.

However, it gives significant results on the clinical criteria i.e. No. of black spot

observed in Shvitra (Vitiligo) patch with P value 0.01.

Results


Group B ( Placebo Group ): Table No. 39 Showing clinical improvement of signs after one month of treatment :



% of improvement

S.D S. E. t - value

P – value (df-12)

Inference

BT AT


0.8 0.8 0 0 0 0 0 <0.05 Not significant

Colour change

2.8 2.8 0 0 0 0 0 <0.05 Not significant

Bleb formation

1 1 0 0 0 0 0 <0.05 Not significant

No. of black spots

1.3 1.3 0 0 0 0 0 <0.05 Not significant



The effect of the placebo drug provides insignificant result in all clinical

criteria‟s i.e. appearance of itching sensation, colour change, bleb formation, no. of

black spots and size of observed Shvitra (Vitiligo) patch with p values at <0.05 at the

end of first month of treatment.

Results


Group B ( Placebo Group ): Table No. 40 Showing clinical improvement of signs after two month of treatment :



% of improvement

S.D S. E. t - value

P – value

Inference

BT AT


0.8 0.9 - 0.1 - 12.5 0.30 0.06 1.45 <0.05 Not significant

Colour change

2.8 2.75 0.05 1.78 0.22 0.05 1 <0.05 Not significant

Bleb formation


No. of black spots

1.3 1.3 0 0 0 0 0 <0.05 Not significant

Size 2 2 0 0 0 0 0 <0.05 Not significant

The effect of the placebo drug provides insignificant result in all clinical

criteria‟s i.e. appearance of itching sensation, colour change, bleb formation, no. of

black spots and size of observed Shvitra (Vitiligo) patch with p values at <0.05 at the

end of second month of treatment.

Results


Table No. 41 Comparison of results of Appearance of Itching sensation over

observed Shvitra (Vitiligo) patch of group A and group B at the end of first

month:

Groups Mean

Mean difference

% of improvement

S.D S.E t - value

P – value

Inference

BT AT

Group – A 0.85 0.45 0.4 47.05 0.50 0.11 3.55 >0.01 Significant

Group - B 0.8 0.8 0 0 0 0 0 <0.05 Not significant

Effect of study drug given in group A proved to be significant with respect to

appearance of itching sensation over observed Shvitra (Vitiligo) patch with an

improvement of 47.05% (p>0.01) where as the placebo drug given in Group-B

showed insignificant results at the end of first month of treatment.

Table No. 42 Comparison of results of Appearance of Itching sensation over

observed Shvitra (Vitiligo) patch of group A and group B at the end of second

month:

Groups Mean

Mean difference

% of improvement

S.D S.E t - value

P – value

Inference

BT AT

Group – A 0.85 0.25 0.6 70.58 0.50 0.11 5.33 >0.001 Highly significant

Group - B 0.8 0.9 - 0.1 - 12.5 0.30 0.06 1.45 <0.05 Not significant

Effect of study drug given in group A proved to be highly significant with

respect to appearance of itching sensation over Shvitra (Vitiligo) patch with an

improvement of 70.58% (p>0.001) where as the placebo drug given in Group-A

showed insignificant results at the end of second month of treatment.

Results


Table No. 43 Comparison of results of colour change in observed Shvitra

(Vitiligo) patch of group A and group B at the end of first month:

Groups Mean

Mean difference

% of improvement

S.D S.E t - value

P – value

Inference

BT AT




respect to colour change in observed Shvitra (Vitiligo) patch with an improvement of

41.37% (p>0.001) where as the placebo drug given in group B showed insignificant

results at the end of first month of treatment.

Table No. 44 Comparison of results of colour change in observed Shvitra

(Vitiligo) patch of group A and group B at the end of second month:

Groups Mean

Mean difference

% of improvement

S.D S.E t - value

P – value

Inference

BT AT

Group – A 2.9 1 1.9 65.51 0.30 0.06 27.60 >0.001 Highly significant

Group - B 2.8 2.75 0.05 1.78 0.22 0.05 1 <0.05 Not significant



65.51% (p>0.001) where as the placebo drug given in group B showed insignificant

results at the end of second month of treatment.

Results


Table No. 45 Comparison of results of bleb formation on observed Shvitra

(Vitiligo) patch of group A and group B at the end of first month:

Groups Mean

Mean difference

% of improvement

S.D S.E t - value

P – value

Inference

BT AT

Group – A 1 0.9 0.1 10.00 0.30 0.06 1.45 <0.05 Not significant

Group - B 1 1 0 0 0 0 0 <0.05 Not significant

Effect of study drug given in group A proved to be insignificant with respect

to bleb formation on observed Shvitra (Vitiligo) patch with an improvement of 10%

(p<0.05) also the placebo drug given in group B showed insignificant results at the

end of first month of treatment.

Table No. 46 Comparison of results of bleb formation in observed Shvitra

(Vitiligo) patch of group A and group B at the end of second month:

Groups Mean

Mean difference

% of improvement

S.D S.E t - value

P – value

Inference

BT AT

Group – A 1 0.7 0.3 30.00 0.47 0.10 2.85 0.01 significant


Effect of study drug given in group A proved to be significant with respect to

bleb formation in observed Shvitra (Vitiligo) patch with an improvement of 30%

(p0.01) where as the placebo given in group B showed insignificant results at the end

of second month of treatment.

Results


Table No. 47 Comparison of results of number of black spots in observed patch

of group A and group B at the end of first month:

Groups Mean

Mean difference

% of improvement

S.D S.E t - value

P – value

Inference

BT AT

Group – A 1.4 0.75 0.65 46.42 0.48 0.10 5.94 >0.001 Highly significanct



respect to increase in number of black spots in observed Shvitra (Vitiligo) patch with

an improvement of 46.42% (p>0.001) where as the placebo given in group B showed

insignificant results at the end of first month of treatment.

Table No. 48 Comparison of results of number of black spots in observed patch

of group A and group B at the end of second month:

Groups Mean

Mean difference

% of improvement

S.D S.E t - value

P – value

Inference

BT AT




respect to increase in number of black spots with an improvement of 60.71%

(p<0.001) where as the placebo given in group B showed insignificant results at the


Results


Table No. 49 Comparison of results of size of the observed patch of group A and

group B at the end of first month:

Groups Mean

Mean difference

% of improvement

S.D S.E t - value

P – value

Inference

BT AT

Group – A 2 1.5 0.5 25 0.51 0.11 4.35 >0.001 Highly significant


Effect of study drug proved to be highly significant with respect to increase in

size of Shvitra (Vitiligo) patch with an improvement of 25% (p>0.001) where as the

placebo given in group B showed insignificant results at the end of first month of

treatment.

Table No.50 Comparison of results of size of the observed patch of group A and

group B at the end of second month:

Groups Mean

Mean difference

% of improvement

S.D S.E t - value

P – value

Inference

BT AT

Group – A 2 0.65 1.35 67.50 0.48 0.10 12.33 >0.001 Highly significant



respect to increase in size of Shvitra (Vitiligo) with an improvement of 67.50%

(p>0.001) where as the placebo given in group B showed insignificant results at the


Results


Table No. 51 Showing Over-all Percentage Improvement:

Sr. No. Signs seen in observed shvitra (Vitiligo) patch

Group A Group B

1. Appearance of Itching sensation

70.58 % - 12.5%

2. Colour change 65.51% 1.78% 3. Bleb formation 30.00% 0% 4. No. of black spots 60.71% 0% 5. Size of observed patch 67.50% 0%

DISCUSSION

Discussion


DISCUSSION The colour of the skin plays a very important role in the society especially in

India. Shvitra is a depigmentary disorder of the skin. This disease does not cause any

pain or ulcer but it creates an inferiority complex in the affected child.

We get the references of Shvitra right from Vedic literature where the

principal line of treatment is mentioned as Sramsana and many Lepas are mentioned

for application after Sramsana.

Shvitra is a disease where Bhrajaka Pitta present in Tvak is involved,

Virechana is considered as the best line of treatment if Pitta is involved.

Aragvadha phalamajja is mentioned as a Sramsana dravya and is harmless and

conveniently used in children. Hence Aragvadha phalamajja was selected for the

purpose of Koshtashudhi.

A number of Yogas are mentioned for the purpose of external application after

Shodhana by many classics for Shvitra. Yogaratnakara and Vangasen Samhitha have

mentioned the use of Jyotishmati-Apamarga Taila for the treatment of Shvitra.

Apamarga has Rakta-Pitta Prasadanakara action and Jyotishmati has Pitta

Santpakara action. Hence they may be increase the activity of Bhrajaka Pitta leading

to formation of melanin pigments in Tvak (skin) resulting in normal Varna of the

patches..

So far as this study is concerned group A patients were given Koshtashudhi

with Aragvadha phalamajja followed by application of study drug i.e. Jyotishmati-

Apamarga Kshara Taila on the Shvitra (Vitiligo) patches daily twice followed by sun

exposure for 30 minutes and group B patients were given Koshtashudhi with

Aragvadha phalamajja followed by application of placebo drug i.e. Tila taila daily

twice on the Shvitra (Vitiligo) patches followed by sun exposure for 30 mintues.

Discussion on incidence and results:

The present study was planned in two groups, aimed to manage Shvitra with

Aragvada phalamajja given for Koshtashudhi in both the groups. After Koshtashudhi

study drug is used for application in group A, and placebo drug was advised to be

applied in group B. This was continued for two months with a follow up for 1 month.

Discussion


The discussion on the incidence is as follows,

Age incidences:

This study shows that 52.50% of patients are between 7-9 years. Where as

worldwide study in the particular research gives the prevalence of vitiligo at the age

of 10 years of life in children or between 2nd to 4th decades of life.

Sex incidence:

Both male and female children are described to be affected equally, where as

in this study the incidence of Shvitra is found 62.50% in female patients. As Shvitra

(Vitiligo) causes social stigma so for cosmetic purpose female patients were coming

more in number as compared to male for the treatment of same.

Incidence of Shvitra (Vitiligo) in different communities:

In present study 90.00% of children belonged to Hindu community and the

Muslims were found to be 10.00%, this may be because of predominance of Hindu

residents in this area. None were Christian.

Incidence of habitat

In the present study 67.50% of patients were hailing from urban area and

32.50% of patients were from rural area. This may be because of increased awareness

for treatment in urban residents compared to rural people.

Incidence of socio economic status

In present study Shvitra (Vitiligo) appears to arise more in Lower middle

class (55.00%), than in Poor class (7.50%) and in Upper middle class (37.50%).

The number of Shvitra (Vtiligo) patients was more in lower middle class as our

SDM hospital set up more convenient for them.

Incidence of immunization

Present study showed 100%of patients immunized because of maximum

health awareness. However the immunization status of a child appears not to play any

role in the genesis or incidence of the disease.

Incidence of food habits:

The incidence of food habit in the present study showed that majority of

patients of Shvitra was non-vegetarians (mixed diet) (i.e.72.50%) when

compared to vegetarians in whom the incidence is 27.50%. This may due to

Virudha ahara sevana was more in non-vegetarians such as fish & milk etc.

Discussion


Incidence of family history

All the modern text books mentioned a hereditary prevalence of about 25%

but in the present study 100% were showing negative family history and no one

showed positive family history of Shvitra. But this does not deny the significance of

family history, since the present study consists only of a small group.

Incidence of treatment history

In present study it is observed that 24 out of 40 patients (60.00%) came direct

to SDM Hospital for treatment of Shvitra without going anywhere; whereas 16

patients (40.00%) had given history of having taken treatment earlier without any

success.

Incidence of Deha Prakruti

The incidence of Deha Prakruthi in the present study showed that majority

of patients suffering from Shvitra were of Vata Pitta Prakruthi i.e. 50.00% when

compared to Vata Kapha and Pitta Kapha Deha Prakruthi which was 32.50% and

17.50% respectively.

Incidence of Aharaja Nidanas

In present study incidence of Aharaja Nidana in the patients showed that

47.50% of patients are found consuming Viruddhahara and Ati Masha, Mulaka, Dadhi

and Amla padarthas as a routine in their diet. The prevalence of these Nidanas were

found to be more since these food items are consumed in the daily food in this

locality, but it appears when these items are consumed excessively it may predispose

to Shvitra. Dr. Chavali in his Ph.D. thesis considered that Viruddha substances do not

get digested to body components but remain as foreign substances in circulation

invoking immunological reactions. Thus Viruddahara by invoking such

immunological reaction could produce Shvitra, if it could be considered as a disorder

of autoimmunity.

Incidence of Viharaja Nidanas:

The incidence of Viharaja Nidana in the present study showed that 40.00%

patients were using cold water after sun exposure, 20.00% patients were using Cold

water bath after exposure to sunlight and 22.50% patients were using both Viharaja

Nidanas. Only 17.50 % patients were not found with any of Viharaja Nidanas.

Discussion


Incidence of chronicity

The incidence of chronicity of Shvitra in the present study showed that in

majority of patients the disease was 10 – 12 months old (37.50%) followed by 4 – 6

months old in 27.50%. In very few patients chronicity was seen less than 4 months as

patients coming for treatment after unsatisfactory result of modern medicine.

Incidence of number of mandalas

In present study 42.50% of patients (17) had less than 5 mandalas of Shvitra

while in 37.50% of patients it was between 11-20 madalas, in 17.50% of patients it

was between 6-10 mandalas and only 02.50% of patients more than 20 mandalas

were found.

Incidence of distribution of mandalas

In present study 70.00% of patients of Shvitra showed assymetrical

distribution of Mandalas while 30.00% of patients of Shvitra showed symmetrical

distribution of Mandalas.

Incidence of size of Mandalas :

In the present study in majority of patient‟s i.e. 45.00 % (18) the patches were

of in between 6 -10 sq.cm. and in 30.00% of patients patches were of in between 11 –

15 sq. cm.

In 15.00% and 10.00% of patients patches were of in between 15 – 20 sq. cm.

and < 5 sq. cm. respectively.

Incidence of black spots in the observed patch

In the present study there were 37.50% of patients did not show any black

spots in the observed patch. 62.50% of patients showed 1 – 5 black spots in the

observed Shvitra (Vitiligo) patch because before including them in study they were

taking another treatment for the Shvitra (Vitiliogo) which was stoped 1week before

starting the study.

Incidence in colour changes of observed patches

Incidence of colour of the Shvitra patch in the present study showed that in

majority of patients i.e. in 85.00% (34) the lesion was of white colour and only in

15.00% of patients the colour of the lesion was of light pink.

Discussion


Incidence of number of Vegas after Koshstashudhi :

In present study incidence of 3-4 Vegas after Koshstashudhi seen in 35.00% of

Shvitra (Vitiligo) patients & 5-6 & 7-8 Vegas after Koshstashudhi seen in 32.50% of

shvitra (Vitiligo) patients.

In present study all patients under gone Koshstshudhi with Aaragwadha

phalamajja, as Aaragwadha known for Sramasana, all patients shown Avara Lashanas

of Koshstashudhi.

Discussion on effect of study drug on different assessment criteria:

1. Appearance of itching sensation over observed Shvitra (vitiligo) patches:

Effect of study drug given in group A proved to be significant with

respect to appearance of itching sensation over observed Shvitra (Vitiligo) patch with

an improvement of 47.05% (p>0.01) after one month and 70.58% (p>0.001) after two

months of treatment.

`In present study after local application of study drug over Shvitra

(Vitilgo) patches appearance of itching sensation was markedly noticed as study drug

contains Apamarga Kshara which is having Ksharana property. So study drug causes

irritation of depigmented skin over Shvitra (Vitiligo) patches hence appearance of

itching sensation over observed Shvitra (Vitiligo) patches were seen.

2. Alteration in the colour of observed Shvitra (Vitiligo) patches:



41.37% (p>0.001) after one month and 65.51% (p>0.001) after two months of

treatment.

In present study alteration in the colour of observed Shvitra (Vitilgo) patches

after local application of study drug was moderately seen as Apamarga is known for

Rakta-Pitta Prasadhanakar and Jyotishmati is known for Pitta Santapakara action.

After the local application of study drug may be the proper action of Bhrajaka Pitta

took place so that alteration in the colour of Shvitra (Vitilgo) patches was

moderately observed. Therefore for getting good results the duration of application of

study drug should be increased.

Discussion


3. Bleb formation on observed Shvitra (vitiligo) patches:

Effect of study drug given in group A proved to be insignificant with respect

to bleb formation on observed Shvitra (Vitiligo) patch with an improvement of 10%

(p<0.05) after one month and proved to be significant with an improvement of 30% (p

0.01) after two months of treatment.

In the present study bleb formation on observed Shvitra (Vitilgo) patches was

seen in few patients only after local application of study drug. As study drug contains

Apamarga Kshara which has Tikshana Guna, Ushana Virya and Ksharana property.

Due to Teekshna & Ushna guna, it has many functions such as Dahana, Pachana,

Vidarana and Vilayana, and also does Shodhana. Thus the Apamarga Kshra does

irritation of depigmentated skin leading to Visphota (bleb) formation due to Pitta

Prakopa.

4. Number of black spots appearing in the observed Shvitra (vitiligo) patches:


respect to increase in number of black spots in observed Shvitra (Vitiligo) patch with

an improvement of 46.42% (p>0.001) after one month and 60.71% (p<0.001) after

two months of treatment.

In the present study after the local application of study drug the number of

black spots appearing in the observed Shvitra (Vitiligo) patches was moderately seen.

As Apamarga has Katu; Tikta Rasa, Laghu; Ruksha; Tikshana Guna, Ushana Virya,

Katu Vipaka and Rakta-Pitta Prasadanakara action and Jyotishmati has Katu, Tikta

Rasa; Tikshna, Snigdha, sara Guna; Ushna Virya,Katu Vipaka and Pitta-Santpakara

action. Hence there may be increase in the activity of Bhrajaka Pitta leading to

formation of melanin pigments in Tvak (skin) resulting in appearance of black spots.

Therefore for getting good results the duration of local application of study

drug should be increased.

5. Change in the size of observed Shvitra (vitiligo) patches:

Effect of study drug proved to be highly significant with respect to decrease in

size of Shvitra (Vitiligo) patch with an improvement of 25% (p>0.001) after one

month and 67.50% (p>0.001) after two months of treatment.

Discussion


In the present study reduction in the size of observed Shvitra (Vitiligo) patches

were moderately seen after two months of treatment with local application of study

drug hence for getting good results the duration of local application of study drug

should be accordingly increased.

Discussion on effect of placebo on different assessment criteria:

The effect of the placebo drug was insignificant with 0% improvement in all

assessment of criteria throughout the study. As placebo drug doesn‟t have any

significant role on Bhrajaka Pitta.

Table No. 52 Overall observation in all criteria of the Study group and

placebo group:

Improvement based on criteria

Group A no. of patients

% Group B no. of patients

%

Complete Improvement (100%)

0 0% 0 0%

Marked Improvement (66-99%)

0 0% 0 0%

Moderate Improvement (33-66%)

10 50% 0 0%

Mild Improvement (0-33%)

7 35% 0 0%

No Improvement (<0%)

3 15% 20 100%

Consideration of overall effect of the therapies showed no complete or marked

cure in patients of study group but mild improvement and moderate improvement

were seen in 35.00% and 50.00% of Shvitra (Vitiligo) patients respectively.

It is found that placebo group who had undergone Kostashudhi once did not

show any improvement. Hence Koshstashudhi alone may not help in treating Shvitra,

where as local treatment is found to be more effective after Koshstashudhi chikitsa in

the present study.

Discussion


General observations

During the course of the study it has been observed that one patient of study

group developed Vispota and the improvement was fast in that patient.

During re-pigmentation two processes were observed, first pattern was re-

pigmentation from the periphery to centre, which showed delayed reduction of size.

Second pattern was where the mandalas developed pigmented spots in between, later

configured the normal skin colour by aggregation.

The pigmentation process was quick in small mandalas when compared to

bigger ones. Mandalas having white hair (four cases) did not respond quickly to the

treatment. In the patients who followed the advised Pathya, relief was found earlier. In

modern medicine also tyrosine rich diet is advised for Shvitra (Vitiligo) patients.

Even after the course of the study no patient showed increase in signs and no

recurrence was seen in study group patients Discussion on study drug ( Jyotishmati-Apamarga Kshara Taila) :

Yogaratnakara and Vangasen Samhitha have mentioned the use of

Jyotishmati-Apamarga Kshara Taila for the treatment of Shvitra.

Kshara has been deemed to be superior to Shastras & Anushastras because of

its actions as said above i.e., Chedana, Lekhana and alleviation of Tridoshas and also

being used for specific functions. Kshara is that which does Lekhana of Tvak ,

Mamsadi and removes the vitiated Doshas. Ksharanat – means which produces skin

injury.

As Apamarga Kshara has Teekshna & Ushna guna, it has many functions such

as Dahana, Pachana, Vidarana and Vilayana, and Shodhana. Due to these properties

Apamarga Kshara produces irritation of depigmented skin over observed Shvitra

(Vitiligo) patches and may helps in removal of depigmented skin and will encourage

formation of normal skin with better pigmentation.

Apamarga has Katu, Tikta Rasa,Laghu, Ruksha, Tikshana Guna, Ushana

Virya, Katu Vipaka, Rakta-Pitta Prasadanakara action and Jyotishmati has Katu, Tikta

Rasa; Tikshna, Snigdha, Sara Guna; Ushna Virya,Katu Vipaka, Pitta-Santpakara

action. Hence they may be increase the activity of Bhrajaka Pitta which leads to

stimulation of melanin pigments in Tvak (skin) resulting in normal Varna of the

patches.

CONCLUSION

Conclusion


CONCLUSION

The conclusion derived from the present study is as follows

1. Though no Poorvaroopa lakshanas are described in Ayurveda, one case of Shvitra

gave prodromal symptom of itching at the place where patch was developed later.

This could be due to Viruddha ahara alone invoking auto-immunological response

but it was also seen that after application of study drug over Shvitra (Vitiligo)

patch, Itching sensation was noticed as improving sign.

2. The Lakshnas of Doshaja Shvitra, as mentioned in classics were not found in the

patients taken for the study.

3. Early improvement is seen if Visphota is developed on application of study drug.

4. Improvement is earlier if re-pigmentation starts with pigmented spots which later

configured to normal skin color; when compared to repigmentation, which occurs

from periphery to center.

5. The pigmentation process is earlier in small patches when compared to bigger

one.

6. Patches having white hairs responded late to treatment.

7. The patches over the outer border of palm and sole respond quickly to treatment.

8. The improvement could be earlier if tyrosine rich diet is given to the patients.

9. Placebo group who had undergone Koshtashudhi once did not show any

improvement; hence, Koshstashudhi alone may not help in treating Shvitra.

However, it needs a further study to find as to wether repeated Koshstashudhi

helps in Shvitra or not.

10. Local treatment is found to be more effective after Koshstashudhi chikitsa in the

present study. It is possible that local application even without Koshstashudhi may

help in treating the Shvitra; however, this also needs further study.

11. The same drug compound if continued for longer time may give much better

results.

SUMMARY

Summary


SUMMARY

The dissertation starts with the conceptual part of the subject taken for the study both

from modern and Ayurvedic concepts.

The study was carried out on 23 patients of Shvitra in whom lepa of study

drug was applied locally daily twice followed by sun exposure for 30 minutes for two

months after subjecting the patients for Koshstashudhi karma. A similar treatment

was given with local placebo application in 22 patients exactly the same way as in the

study group. But 3 patients and 2 patients dropped out off study from study and

placebo groups respectively.

Both Ayurvedic and modern concepts in historical aspects of Shvitra, anatomy

and physiology of skin, Nirukti, Paribhasha, Paryaya, Nidana, Bheda with Roopa,

examination of skin and differential diagnosis, Samprapthi, Sadhyasadhyata, Chikitsa

of Shvitra, treatment principle in children and Pathyapathya of all these aspects are

dealt in detail. The conceptual study ends with drug review in which details of

description of each drug taken for the study was given.

Clinical study forms the second part of the dissertation.

A comparative study was undertaken to evaluate the effect of local application

of the trial drug on Shvitra in study group. After Koshtashudhi, local application was

applied daily twice followed by sunexposure for 30 minutes for two months. Similarly

a placebo was applied locally after Koshtashudhi in placebo group. The study drug

consisted of Apamarga Kshara & Jyotishmati Taila.

The criteria for assessment of the results taken were -


2. Alteration in the colour of observed Shvitra (vitiligo) patches.


4. Number of black dots appearing in the observed Shvitra (vitiligo) patches.

5. Change in the size of observed Shvitra (vitiligo) patches.

Improvement was further studied by giving grading score to the above criteria.

After two months of treatment statistically significantly result seen in study

group with respect to assessment criteria as follows:

Summary


1. Appearance of itching sensation over observed Shvitra (Vitiligo) patch with an

improvement of 70.58% (p >0.001)

2. Colour change in observed Shvitra (Vitiligo) patch with an improvement of 65.51%

(p >0.001)

3. Bleb formation on observed Shvitra (Vitiligo) patch with an improvement of 30%

(p 0.01)

4. Number of black spots appearing in observed Shvitra (Vitiligo) patch with an

improvement of 60.71% (p >0.001).

5. Decrease in size of Shvitra (Vitiligo) patch with an improvement of 67.50% (p

>0.001)

After two months of treatment statistically insignificantly results seen in

placebo group with respect to all assessment criteria‟s.

Jyotishmati-Apamarga Kshara Taila if continued for longer time for

treatment of Shvitra (Vitiligo) may give much better results.

REFERENCES

References


REFERANCES

1. T. B. A. D-pp 518, 519 Vol – 1

2. A Hand Book of Vitiligo and Colour Atlas PP 6

3. Su. Sa. ni – 5/17

4. Ca. sa. Chi – 7/174

5. Ca. sa. su – 28/12

6. T. B. A. D-pp 518.Vol – 1

7. Ca. sa. Chi – 7/162

8. Ba. pra. Vol. 1 – pp 68/ 149 -150

9. Rajamartanda 8/8 (Dravyaguna Vijanyan by Dr. Pande)

10. Prof. Sastry C.H.S. in the department of pediatrics in S.D.M college of ayurveda hassan,

suggested use of Sweta Aparajita moola with Ewe‟s milk locally in cases of vitiligo and this

was tried successfully in few cases (personal communication).

11. C. Chi. 7/167

12. Ri. Ve. Mandala 1, suktha 117, shloka 7, vol. 1

13. Ri. Ve. Mandala 5, suktha 53, shloka 1, vol. 2

14. Ath. Ve – Hym 23/ 1 khanda 1

15. Ya. Ve – 30/21

16. Ma. Sm – 3/7

17. Pa. – 5/2/120

18. Ca. sa. Chi – 7

19. Su. sa. ni – 5

20. Su. sa. Chi – 9

21. Su. sa. ni – 5 (Dalhana)

22. Ka. sa. su – 27/51

23. Ka. sa. sha – 4/33

24. Ka. sa. Chi – 9/2

25. Ka. sa. Ka – 7/106.2

26. Ka. sa. Ka – 2/98

27. Ka. sa. si – 7/5, 14

28. Be. sa. Chi – 6/28

29. Ha. Sa – 39/39

30. A. sa. ni – 14/39 – 43

31. A. sa. Chi – 22

32. A. hri. Ni – 14, A. hri. Chi – 20

33. Ma. Ni – 49

34. Sha. Pu. K – 7/90

35. Sha. Ut. K – 11/40 – 44

36. Ba. pra. Ma. K -54

References


37. Y. R – Kustanidana chikitsa prakarana

38. Bai. Rat – 54

39. Ga. Ni – 36, Vol. 2

40. C. D – 50

41. Ca. sa. Chi. 15/4- Chakrapani

42. Ca. sa. sha – 7/16

43. Su. sa. sha – 4/4

44. A. sa. Sha. 5/14

45. Ca. sa. sha – 4/12, A. sa. sha – 5/10, A. hri. Sha – 3/3, Ka. Sa. sha – ¾

46. Su. sa. sha – 2/35, Ca. sa. sha – 8/15

47. A. sa. Sha. 1/65

48. Ha. sa. Sha– 1/31 – 33

49. A. sa. Sha. 5/17

50. Ca. sa. Sha. 7/4

51. Su. sa. Sha. 4/4

52. A. hri. Sha. 3/8- Arunadutta

53. Sha. Pu. K. 5/19-22

54. Su. sa. Sha. 4/4 - Ghanekar

55. A. hri. Su. 12/4

56. A. hri. Su. 12/14

57. A.hri. Su. 12/14 - Arunadutta

58. Ca. sa. Sha. 7/15

59. Ca. sa. Vi. 8/103

60. Ka. sa. Chi. 9/2

61. Amarakosha

62. Amarakosha

63. Ca. sa. Chi. 7/173

64. Su. sa. Ni. 5/17

65. A. hri. Ni.14/37

66. Su. sa. U 1

67. Ca. sa. Su. 26/102,103

68. Ca. sa. Su. 26/81

69. Ca. sa. Su. 26/85

70. Su. sa. Su. 20/20

71. A. hri. Su. 7/29

72. A. S. Su. 9/25

73. Ca. sa. Su. 26/86-87

74. Ma. Ni. 6/8

75. A. sa. Su. 9/26

References


76. Ca. sa. Vi. 9/21

77. Ca. sa. Vi. 9/21

78. A. sa. Su. 10/34

79. A. sa. Su. 10/34

80. A. sa. Su. 11/11

81. A. sa. Su. 11/12

82. C. S. Sha.4/30

83. Su. sa. Ni 5/4, Bh. S. 6/16-17, Ka. S. Khi. 1

84. Ma. Ni.

85. Va. Ni. 1

86. Su.Sa.Ni.5/17,A.hri.Ni.14/37–39,Ba.pra.Mad.54/45-46,Ma.Ni.49/38-39,

Ga.Ni 36/38

87. Y. R – Kustanidana chikitsa prakarana – 26

88. Ca. sa. Chi – 7/173

89. Be. sa. Chi – 6/28

90. Su. sa. ni – 5/17, A. hri. Ni – 14/38, Ba. pra. Mad – 54/45 - 46, Ma. Ni – 49/38

- 39, Ga. Ni – 36/39 – 40, A. sa. ni – 15/40

91. Ca. sa. Chi – 7/152

92. Su. sa. Ni. 5/17- Daihana, Ba. Pra. Mad. 54/46

93. Su.sa.Ni.5/17, A.sa.Ni.15/40, Ba.Pra.Mad.54/46,Ma.Ni.49/37-39,

Ga.Ni.36/38-40

94. Ca. sa. Chi – 7/174

95. Ca. sa. Chi – 7/175 – 176, Su. Sa. ni – 5/17, A. hri. Ni – 15/42 – 43, A. hri. Ni – 14/40, Ma. Ni

– 49/40 – 41, Y. R – Kustanidana chikitsa prakarana – 27, Ba. pra. Mad – 54/47 – 48, Be. sa.

Chi – 4/ 34, Ga. Ni – 36/41–42

96. Ma. Ni. 1

97. Su. sa. Ni. 5/3

98. Su. sa. Ni. 5/17

99. H. S. 50

100. Bhel. Ni.5/5-6

101. Ca. Chakrapani

102. Ca. Chakrapani

103. A. hri. Chi. 14/2-3

104. Kasyapa S. Sharira

105. Sha. sa. 7/90

106. A. hri. Sha. 1/48

107. A. hri. Su. 12/5

108. Ca. sa. Chi. 7/176, A. S. Ni.14/40

109. A. S. Ni.14/43, Ca.sa. Chi. 7/175

References


110. Su. Ni. 5/17

111. Su. Ni. 5/17

112. A. hri. Ni. 14/4-6

113. A. hri. Chi. 20/11, Ga. Ni. 36/227

114. Ca. sa. Su. 11/54

115. Ca. sa. Su. 11/55

116. Sha. Pu. K. 4/8

117. Sha. Pu. K. 4/2

118. Ca. sa. Chi. 7/162- Chakrapani

119. Ca. sa. Chi. 7/162-163, A. hri. Chi. 20/2-3, Ga. Ni. 36/228

120. A. hri. Chi 20/2

121. Ca. sa. Chi. 7/163

122. Y.R.- Kusthanidana chikitsa prakarana- 202

123. A.hri. Chi.20/2

124. A.hri. Chi.20/2, Ga. Ni. 36/232

125. Ca. sa. Chi. 7/164

126. Ga.Ni- 36/233-234

127. Ga.Ni- 36/236-239

128. Ca. sa, C hi. 7/164-165, A. hri. Chi. 20/5, Ga.Ni- 36/230

129. Su. sa. Chi. 1/90-93

130. A.hri. Chi.19/98, Ga. Ni. 36/226

131. Ca. sa. Chi. 7/172

132. Ka. Sa. Khi. 3/117 – 118, Ca. sa. Chi.30/282, A. hri. Ut.2/30, Ma. Ni.68/16

133. Ka. sa. Su. 27/66

134. Ca. sa. Chi. 30/283-284

135. Ca. sa. Chi. 30/283-Chakrapani

136. A. hri. Ut. 2/31-33

137. Ca. sa. Ka. 1/4 –Chakrapani

138. Sha. Pu. K. 4/3-6

139. Ca. sa. Ka. 8/5

140. Ca. sa. Ka. 8

141. Ba. Pra. Haritkyadi varga 1/149-150

142. Ka. sa. Khi. 7/61

143. Su. sa. Su. 18/6-7

144. A. sa. Ut. 30/89

145. Ca. sa. Chi. 25/110-118

146. Ca. sa. Chi. 21/98-105

147. Su. sa. Su. 18/12

148. Su. sa. Su. 18/4-5

References


149. Ba. Pra. Pu. 6/104, Su. sa. Su. 18/13

150. Su. sa. Su. 18/15-16

151. Su. sa. Su. 18/8-10

152. Su. sa. Su. 18/11

153. Ca. sa. Su. 25/45

154. Su. sa. Ni. 5/31

155. Ca. sa. Chi – 7/82 – 83, Su. Sa. chi – 9/72, A. sa. chi – 21/26, A. hri. Chi.19/25–27, Y. R.–

Kustanidana chikitsa prakarana – 220, Ga.Ni. 36/45–47, Bai.Rat. 54/372–381, C. D – 50/167

156. http://www.medicinalplantskr.org/SOURCES_OF_INFORMATION_ON_M_1.HTM

157. http://www.bergeriesurlelac.ca/bergerie_analyse_lait_en.html

http://www.bergeriesurlelac.ca/bergerie_analyse_lait_en.html

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to the translation of H H Wilson, Parimal publications, 1st edition – 1997,

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banarasi das publishers, Delhi, Reprint – 1997.

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355, 213, 348, 597, 514, 85, 86, 282 – 289, 442 – 448.

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brother‟s publications, New Delhi, 4th edition - 1999, p. 855

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ANNEXURE

Annexure


POST GRADUATE DEPARTMENT OF KAUMARABHRITHYA

S.D.M. COLLAGE OF AYURVEDA & HOSPITAL

HASSAN (KARNATAKA)

PROFORMA FOR CLNICAL STUDY

A CLINICAL STUDY ON EFFECT OF LOCAL APPLICATION WITH

APAMARGA KSHARA YUKTA JYOTISHMATI TAILA IN THE

MANAGEMENT OF SHVITRA (VITILIGO) IN CHILDREN.

Name: Serial No:

Age: yrs Sex: M / F OPD / IPD No:

Religion: H / M / C / others D.O.S.T:

Occupation: D.O.C.T:

Socio-economic Status:

Address:

Phone No :

Roga pareeksha :

Pradhaan vedana :

Aruna varna mandala

Paridhwamsi ( powder like material on starching )

Padmapatra varna

Daha

Roma vidhwamsatha ( distruction of hair at the site )

Shvetha varna

Kandu

Spread in body

Number of lesions

Nature of lesions

Rogi pareeksha

A) Prakruthitha

Kula pareeksha/vrittantha

Jatha poorvika vrithantha

Annexure


Jathottara pareeksha

Status of prana/ conciousness

Samskriti achieved/ Samskaras performed

Anya viruddhabhi samskriti

Prakruthi Satva

Agni bala Ahara intake

Sathmya Kosta

Dehabala Samhanana

Bhara Pramana

Sara Danta

Vikruthi

Dosha vichara

Assesment of vata, pitta and kapha

Nadi Drika

Mutra Akruthi

Mala Raktha bara

Jihwa Tapa krama

Shabdha Swasana

Sparsha Samata/ Niramata

Dushya pareeksha

Sambaddha stroto pareeksha

Sthanika pareeksha/ Local examination of selected lesion for study :

Laboratory investigation

Blood: B.T. A.T.

Hb%:

T.C.:

Urine:

Koshtha Shuddhi with Argvadha Kashaya :

No. of vegas:

Annexure


Local application

Drug :

Placebo :

EFFECT OF LOCAL APPLICATION WITH

Sl no

Assessment criteria Before treatment

End of 1 st month

End of 2 nd month

Follow Up

1 Appearance of itching sensation over

observed Shvitra (Vitiligo) patch.

2 Alteration in the colour of observed

Shvitra (Vitiligo) patch.

3 Bleb formation on observed Shvitra

(vitiligo) patch.

4 Number of black dots appearing in the

observed Shvitra (vitiligo) patch.

5 Change in the size of observed Shvitra

(vitiligo) patch.

Signature of student Signature of Guide

Annexure


The criteria kept for grading to observe any improvement is as following:


a. If no Itching sensation over observed 1

b. If Itching sensation over observed 0

2. Colour change in the observed Shvitra (vitiligo) patches.

e. No change in colour (White) 3

f. Light pink 2

g. Dark pink 1

h. Normal skin colour 0


a. If no bleb formation 1

b. If bleb formation 0

4. Number of black spots in observed Shvitra (vitiligo) patch

d. If no black spots appear 2

e. If less than three spots appear 1

f. If three or more spots appear 0

5. Size of the observed Shvitra (Vitiligo) patch

d. If size remains same or increases 2

e. 10% reduction in size 1

f. If more than 10% reduction 0

STUDY GROUP (GROUP - A)

*(A- Vruddahara, B- Masha,mulaka,dadhi,amla, C-Intake of cold items after hot exposure,

V-P – Vata-Pitta Prakruti, V-K – Pitta-Kapha Prakruti, P-K – Pitta-Kapha Prakruti.)

Sr. No.

Name

OPD no.

Age in yrs

Sex

Religion

Prakruthi

Place

Socio economic status

Diet

Family history

Nidana

A B C

1. Spoorthi 3830 9 F Hindu K-P Rural U.M.C Veg. -ve _ + _

2. Shashidhara 3866 11 M Hindu K-P Urban U.M.C Mix. -ve + _ +

3. Mohammed

Sameer

3519 11 M Muslim V-P Urban U.M.C Mix. -ve + _ +

4. Namratha 3364 11 F Hindu V-P Urban L.M.C Veg. -ve _ + _

5. Karthik S. 3583 8 F Hindu P-V Urban U.M.C Mix. -ve _ _ +

6. Muskan 3370 8 F Hindu P-V Rural L.M.C Veg. -ve _ _ _

7. Sneha 3873 10 F Hindu P-V Rural L.M.C Mix. -ve _ + _

8. Harshavardhana 3261 8 M Hindu V-P Urban U.M.C Mix. -ve _ _ +

9. Kunal 3892 12 M Hindu P-V Urban L.M.C Veg. -ve _ _ +

10. Rabiya Khan 3897 11 F Muslim P-V Urban U.M.C Mix. -ve + _ _

11. Prasad 3899 6 M Hindu P-V Urban L.M.C Mix. -ve _ _ _

12. Yash S. 3830 8 M Hindu P-V Urban L.M.C Mix. -ve _ _ _

13. Santosh 3868 11 M Hindu V-P Urban L.M.C Mix. -ve _ + +

14. Chidankumar 3739 8 M Hindu V-P Rural Poor Mix. -ve _ _ _

15. Shashank 3301 6 M Hindu P-V Urban L.M.C Veg. -ve _ _ _

16. Akshay 3806 12 M Hindu P-V Urban L.M.C Mix. -ve + _ +

17. Dore swammy 3927 8 M Hindu P-V Rural Poor Mix. -ve _ + +

18. Harsh 3932 7 M Hindu P-V Urban U.M.C Veg. -ve _ _ _

19. Sumanth 2357 12 M Hindu P-V Rural L.M.C Mix. -ve _ _ +

20. Chethan 3946 9 M Hindu P-V Urban L.M.C Mix. -ve _ + _

Study Group (Group – A)

Sr.No. Patient’s Name D.O.S.T. D.O.C.T 1 Spoorthi 11-4-2011 19-7-2011 2 Shashidhara 25-4-2011 20-7-2011 3 Mohammed Sameer 25-4-2011 25-7-2011 4 Namratha 26-4-2011 25-7-2011 5 Karthik S. 26-4-2011 25-7-2011 6 Muskan 26-4-2011 25-7-2011 7 Sneha 3-5-2011 6-8-2011 8 Harshavardhana 10-5-2011 13-8-2011 9 Kunal 10-5-2011 8-8-2011

10 Rabiya Khan 11-5-2011 8-8-2011 11 Prasad 14-5-2011 20-8-2011 12 Yash S. 18-5-2011 16-8-2011 13 Santosh 19-5-2011 18-8-2011 14 Chidankumar 19-5-2011 18-8-2011 15 Shashank 24-5-2011 25-8-2011 16 Akshay 24-5-2011 25-8-2011 17 Dore swammy 27-5-2011 28-8-2011 18 Harsh 30-5-2011 30-82011 19 Sumanth 8-6-2011 10-6-2011 20 Chethan 10-6-2011 10-6-2011

(D.O.S.T.- Date of starting treatment, D.O.C.T. – Date of completion of treatment)

Study Group (Group - A)

Sl. No.

Appearance of Itching sensation over observed Shvitra (Vitiligo) patch

Colour change in observed Shvitra (Vitiligo) patch

Bleb formation in observed Shvitra (Vitiligo) patch

No. of black spots in observed Shvitra (Vitiligo) patch

Size of observed Shvitra (Vitiligo) patch

BT End of 1st mo.

End of 2nd mo.

Follow up End of 3rd mo.

BT End of 1st mo.

End of 2nd mo.


BT End of 1st mo.

End of 2nd mo.


BT End of 1st mo.

End of 2nd mo.


BT End of 1st mo.

End of 2nd mo.


1. 1 1 0 1 3 2 1 2 1 1 1 1 2 1 1 1 2 2 1 2

2. 1 0 0 0 3 1 1 1 1 1 0 1 1 0 0 0 2 1 0 0

3. 0 0 0 0 3 2 1 1 1 0 0 1 1 0 0 0 2 1 0 0

4. 1 1 0 0 3 2 1 1 1 1 1 1 1 0 0 0 2 1 0 0

5. 1 0 0 1 3 2 1 2 1 1 1 1 2 1 1 1 2 2 1 1

6. 0 0 0 0 2 1 1 1 1 1 1 1 2 1 0 0 2 2 1 1

7. 1 1 1 1 3 2 1 2 1 1 1 1 1 1 1 1 2 2 1 1

8. 0 0 0 0 3 2 1 2 1 1 0 1 1 1 0 0 2 1 1 1

9. 1 0 0 1 3 1 1 1 1 1 0 1 2 1 0 0 2 1 0 0

10. 1 0 0 1 2 1 1 1 1 0 0 1 1 1 1 1 2 1 0 1

11. 1 1 1 1 3 1 1 1 1 1 1 1 1 1 1 1 2 2 1 1

12. 1 1 0 1 3 2 1 2 1 1 1 1 2 2 1 1 2 2 1 1

13. 1 1 0 1 3 2 1 2 1 1 1 1 1 1 1 1 2 1 0 1

14. 1 0 0 0 3 2 1 1 1 1 0 1 1 0 0 0 2 1 0 0

15. 1 0 0 0 3 1 1 1 1 1 1 1 2 1 1 1 2 1 1 1

16. 1 1 1 1 3 2 1 2 1 1 1 1 1 0 0 0 2 2 1 1

17. 1 1 1 1 3 2 1 1 1 1 1 1 2 1 1 1 2 2 1 1

18. 1 1 1 1 3 2 1 2 1 1 1 1 2 1 1 1 2 2 1 1

19. 1 0 0 0 3 2 1 1 1 1 1 1 1 0 0 0 2 1 1 1

20. 1 0 0 1 3 2 1 2 1 1 1 1 1 1 1 1 2 2 1 2

Placebo Group (Group – B)

Sr. No.

Name

OPD no.

Age in yrs

Sex

Religion

Prakruthi

Place

Socio economic status

Diet

Family history

Nidana

A B C

1. B.M.Abhishek 2678 10 M Hindu V-P Urban U.M.C Mix. -ve _ _ +

2. Vasuki 4051 8 M Hindu V-P Rural Poor Mix. -ve _ + _

3. Bhuvan 3367 12 M Hindu V-P Urban L.M.C Mix. -ve _ _ _

4. Janavi 3681 9 F Hindu V-K Urban U.M.C Veg. -ve _ _ _

5. Chandan 2799 8 M Hindu V-P Rural L.M.C Mix. -ve _ _ +

6. Mahesh 3332 10 M Hindu V-P Urban L.M.C Mix. -ve _ + +

7. Neha Taslim 4067 11 F Muslim P-K Urban U.M.C Mix. -ve + _ _

8. Samiya 4066 9 F Muslim V-P Rural L.M.C Mix. -ve _ _ _

9. Arpith Gowda 4069 9 M Hindu V-K Urban U.M.C Mix. -ve + _ +

10. Punyashree 3965 8 F Hindu P-K Rural L.M.C Veg. -ve _ + _

11. Subhadha 4047 11 F Hindu V-P Urban L.M.C Mix. -ve _ _ _

12. Sharan 3925 10 M Hindu V-K Urban U.M.C Mix. -ve _ _ +

13. Sanjitha 3800 8 F Hindu P-K Urban L.M.C Mix. -ve _ + _

14. Suresh kumar 3823 10 M Hindu V-P Urban L.M.C Mix. -ve + _ +

15. B.S.Chaitra 3705 10 F Hindu V-K Rural U.M.C Mix. -ve _ _ _

16. Anusha K.S. 2740 10 F Hindu V-P Urban L.M.C Veg. -ve _ _ _

17. Ruschika 3607 7 F Hindu V-K Rural L.M.C Veg. -ve _ _ _

18. Prajwal 3305 7 M Hindu V-P Urban U.M.C Mix. -ve _ _ +

19. Nikhil 3279 12 M Hindu V-K Rural L.M.C Mix. -ve _ + _

20. Varshith 4062 8 M Hindu V-P Urban U.M.C Veg. -ve _ _ _

*(A- Vruddahara, B- Masha,mulaka,dadhi,amla, C-Intake of cold items after hot exposure,

V-P – Vata-Pitta Prakruti, V-K – Pitta-Kapha Prakruti, P-K – Pitta-Kapha Prakruti.)

Placebo Group (Group – B)

Sr.No. Patient’s Name D.O.S.T. D.O.C.T 1 B.M.Abhishek 14-4-2011 19-7-2011 2 Vasuki 14-4-2011 17-7-2011 3 Bhuvan 23-4-2011 26-7-2011 4 Janavi 23-4-2011 26-7-2011 5 Chandan 23-4-2011 26-7-2011 6 Mahesh 24-4-2011 26-7-2011 7 Neha Taslim 25-4-2011 25-7-2011 8 Samiya 25-4-2011 25-7-2011 9 Arpith Gowda 25-4-2011 25-7-2011 10 Punyashree 25-4-2011 25-7-2011 11 Subhadha 25-4-2011 25-7-2011 12 Sharan 25-4-2011 25-7-2011 13 Sanjitha 25-4-2011 25-7-2011 14 Suresh kumar 25-4-2011 25-7-2011 15 B.S.Chaitra 25-4-2011 25-7-2011 16 Anusha K.S. 25-4-2011 11-8-2011 17 Ruschika 25-4-2011 20-8-2011 18 Prajwal 25-4-2011 16-8-2011 19 Nikhil 25-4-2011 18-8-2011 20 Varshith 25-4-2011 27-8-2011

(D.O.S.T.- Date of starting treatment, D.O.C.T. – Date of completion of treatment)

Placebo Group (Group - B)

Sl. No.

Appearance of Itching sensation over observed Shvitra (Vitiligo) patch

Colour change in observed Shvitra (Vitiligo) patch

Bleb formation in observed Shvitra (Vitiligo) patch

No. of black spots in observed Shvitra (Vitiligo) patch

Size of observed Shvitra (Vitiligo) patch

BT End of 1st mo.

End of 2nd mo.


BT End of 1st mo.

End of 2nd mo.


BT End of 1st mo.

End of 2nd mo.


BT End of 1st mo.

End of 2nd mo.


BT End of 1st mo.

End of 2nd mo.


1. 0 0 1 1 3 3 3 3 1 1 1 1 2 2 2 2 2 2 2 2

2. 1 1 1 1 3 3 3 3 1 1 1 1 1 1 1 1 2 2 2 2

3. 1 1 1 1 2 2 1 2 1 1 1 1 2 2 2 2 2 2 2 2

4. 1 1 1 1 3 3 3 3 1 1 1 1 1 1 1 1 2 2 2 2

5. 1 1 1 1 3 3 3 3 1 1 1 1 1 1 1 1 2 2 2 2

6. 1 1 1 1 3 3 3 3 1 1 1 1 2 2 2 2 2 2 2 2

7. 1 1 1 1 3 3 3 3 1 1 1 1 2 2 2 2 2 2 2 2

8. 1 1 1 1 3 3 3 3 1 1 1 1 1 1 1 1 2 2 2 2

9. 1 1 1 1 2 2 2 2 1 1 1 1 1 1 1 1 2 2 2 2

10. 0 0 0 1 3 3 3 3 1 1 1 1 1 1 1 1 2 2 2 2

11. 1 1 1 1 3 3 3 3 1 1 1 1 1 1 1 1 2 2 2 2

12. 0 0 0 1 3 3 3 3 1 1 1 1 1 1 1 1 2 2 2 2

13. 1 1 1 1 3 3 3 3 1 1 1 1 2 2 2 2 2 2 2 2

14. 1 1 1 1 3 3 3 3 1 1 1 1 1 1 1 1 2 2 2 2

15. 1 1 1 1 2 2 2 2 1 1 1 1 1 1 1 1 2 2 2 2

16. 1 1 1 1 3 3 3 3 1 1 1 1 1 1 1 1 2 2 2 2

17. 1 1 1 1 3 3 3 3 1 1 1 1 0 0 0 1 2 2 2 2

18. 1 1 1 1 3 3 3 3 1 1 1 1 2 2 2 2 2 2 2 2

19. 1 1 1 1 2 2 2 2 1 1 1 1 1 1 1 1 2 2 2 2

20. 0 0 1 1 3 3 3 3 1 1 1 1 2 2 2 2 2 2 2 2

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