“A Clinical Evaluation of Efficacy of Khadiradi Yoga Avachurnana in Kacchu w.s.r. to genito-inguinal intertrigo ” By DR. SHUBHA, B.A.M.S. Dissertation submitted to the Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore In partial fulfillment of the requirements for the degree of MASTER OF SURGERY (AYU.) In PRASUTI TANTRA AND STREE ROGA Under the guidance of Dr. MAMATHA K.V. M.D. (Ayu) Professor Dept of Prasooti Tantra and Stree Roga, S.D.M. College of Ayurveda, Udupi. Co-Guide Dr. Vidya Ballal. M.D. (Ayu) Lecturer Dept of Prasooti Tantra and Stree Roga, S.D.M. College of Ayurveda, Udupi. S. D. M. COLLEGE OF AYURVEDA, UDUPI 2008-09
A Clinical Evaluation of Efficacy of Khadiradi Yoga Avachurnana in Kacchu w.s.r. to genito-inguinal intertrigo, Shubha, Department of post graduate studies in Prasooti Tantra & Stree roga, S. D. M. COLLEGE OF AYURVEDA, UDUPI
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“A Clinical Evaluation of Efficacy of Khadiradi Yoga
Avachurnana in Kacchu w.s.r. to genito-inguinal intertrigo ”
By
DR. SHUBHA, B.A.M.S.
Dissertation submitted to the Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore In partial
fulfillment of the requirements for the degree of
MASTER OF SURGERY (AYU.) In
PRASUTI TANTRA AND STREE ROGA
Under the guidance of Dr. MAMATHA K.V. M.D. (Ayu)
Professor Dept of Prasooti Tantra and Stree Roga,
S.D.M. College of Ayurveda, Udupi.
Co-Guide Dr. Vidya Ballal. M.D. (Ayu)
Lecturer Dept of Prasooti Tantra and Stree Roga,
S.D.M. College of Ayurveda, Udupi.
S. D. M. COLLEGE OF AYURVEDA, UDUPI
2008-09
DEPARTMENT OF P. G. STUDIES IN PRASUTI TANTRA AND STREE ROGA
S.D.M. COLLEGE OF AYURVEDA, UDUPI-574118 Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka.
DECLARATION BY THE CANDIDATE
I hereby declare that this dissertation entitled “A Clinical Evaluation of
Efficacy of Khadiradi Yoga Avachurnana in Kachchu w.s.r. to
genito-inguinal intertrigo”, is bonafide and genuine research work
carried out by me under the guidance of Dr. Mamatha K.V., Professor, Dept. of
Prasooti Tantra and Stree Roga and Co-Guide Dr. Vidya Ballal. Lecturer, Dept. of
Prasooti Tantra and Stree Roga, S.D.M. College of Ayurveda, Udupi.
Dr. Shubha
Date: Dept. of Prasooti Tantra and Stree Roga
Place: Udupi
DEPARTMENT OF P. G. STUDIES IN PRASUTI TANTRA AND STREE ROGA
S.D.M. COLLEGE OF AYURVEDA, UDUPI-574118
CERTIFICATE BY THE GUIDE
This is to certify that “A Clinical Evaluation of Efficacy of Khadiradi
Yoga Avachurnana in Kacchu w.s.r. to genito-inguinal intertrigo”, is
bonafide and genuine research work carried out by Dr. Shubha in partial
fulfillment of the requirement for the degree of M.S. (Ayu) in Prasooti Tantra
DEPARTMENT OF P. G. STUDIES IN PRASUTI TANTRA AND STREE ROGA
S.D.M. COLLEGE OF AYURVEDA, UDUPI-574118
ENDORSEMENT
This is to certify that “A Clinical Evaluation of Efficacy of
Khadiradi Yoga Avachurnana in Kacchu w.s.r. to genito-
inguinal intertrigo”, is bonafide and genuine research work carried out
by Dr. Shubha under the guidance of Dr. Mamatha K.V., Professor, Dept. of
Prasooti Tantra and Stree Roga and Co-Guide Dr. Vidya Ballal, Lecturer Dept.
of Prasooti Tantra and Stree Roga, S.D.M. College of Ayurveda, Udupi.
Signature of H.O.D. Signature of Principal Dr. V.N.K. USHA Dr.U.N. PRASAD. MD(Ayu) MD(Ayu) Dept. of Prasooti Tantra S.D.M.C.A, Udupi. and Stree Roga, S.D.M.C.A, Udupi.
Date: Date:
Place: Udupi Place: Udupi
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
KARNATAKA
COPYRIGHT
I hereby declare that the Rajiv Gandhi University of Health Sciences,
Karnataka shall have the rights to preserve, use and disseminate this
dissertation in print or electronic format for academic / research purpose.
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Acknolwedgement
ACKNOWLEDGEMENT
At the very juncture of completing my dissertation work as a part of post graduation
curriculum, I would like to thank all the people who helped me directly or indirectly.
On the occasion of completion of this work, I bow my head with utmost devotion to
almighty for blessing me with the courage to complete the post graduation.
I would like to thank my parents without whom I would not have made this task and I
bow my head at their feet. I would like to thank
Sri. Ashok Raj Yermal, without whom, starting this task would have been a difficult
one.
I would like to thank Dr. D. Veerendra Hegde, who gave me the opportunity to do my
masters in his prestigious institution SDM College of Ayurveda, Udupi.
I would like to express my deep gratitude towards my Honourable guide Dr. Mamatha
.K. V., who is the backbone of my career as Obstetrician and who encouraged me in
every part of curriculum.
I would like to thank my co-guide Dr. Vidya Ballal who supported me thorough out
my career in this institution.
I express my sincere regard to Dr. VNK Usha, Dr. Krishna Bai, Dr. Ramadevi, Dr.
Suchetha, and Dr. Veena for their invaluable support.
I would like to pay my gratitude to Mrs. Anitha Kini, Microbiologist and Dr.
Somayaji at KMC Manipal, Dr. Muralidhar Ballal, General Manager, SDM Pharmacy
of Ayurveda, Dr. Chaitra, Dr. Rajalakshmi, Dr. Padmakiran, Dr. Srikanth, Dr.
Niranjan, Dr. B. V. Prasanna, Dr. Muralidhara sharma, Dr. Sethumadhava, Dr.
Sujatha, Mr.Harish Bhat, librarian for their timely help.
Department of Prasooti Tantra and Stree Roga 2
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Acknolwedgement I would like thank Dr. Y.N. Shetty, and Dr. Deepak for giving me the opportunity to
do my clinical trials in the hospital.
I would like to thank my better half, who shouldered me in my all tasks and problems.
I would like to thank my daughter and my in laws, my brothers for their love, care and
support.
I would like to thank my batch mates Dr. Sujatha, Dr. Shilpa, Dr. Sukanya, Dr. Kavya
and Dr. Vijayalakshmi for their timely help. I would like to thank my friends of other
departments for their timely support and help.
I would like to thank hospital and pharmacy staff for their cooperation.
Last but not the least my heartfelt thanks to all those people and friends who helped
me and encouraged me on the stage and off the stage.
Department of Prasooti Tantra and Stree Roga 3
Abstract
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Abstract
ABSTRACT
Kachchu is a simple localised dermatological infection of the genito-inguinal
region, occurs because of unhygienic observance, manifests in the form of
inflammation followed by secondary bacterial or fungal infections and can be best
correlated to genito inguinal intertrigo.
It is most prevalent in this costal region, obese females, pregnancy, and
puerperium and in perimenopausal women presenting with menorrhagia. In all these
conditions, improper disposal of sweat because of occlusion is the main aetiology.
Even though it rarely causes systemic manifestations, its mere presence itself
is disturbing because of intractable itching and pain. It may delay the proper healing
of episiotomy wound and may cause difficulty in walking because of severe pain.
Candida powder is the highest selling medicine for the intertrigo as the
incidence of intertrigo is as high as 40% in some particular seasons. In the Ayurveda
fraternity, there is no established preparation which can be preserved, safe in all the
epochs of life in females and easy to apply. After understanding the disease in
ayurvedic and modern medicinal system perspective Khadiradi yoga choorna-a new
ayurvedic formulation is prepared on the basis of stringent ayurvedic principles.
Hence an attempt is made to work out the efficacy of the khadiradi yoga
avachurnana in kachchu with special reference to genito inguinal intertrigo in females.
Key words - Kachchu, itching. intertrigo
Department of Prasooti Tantra and Stree Roga 5
Abbreviations
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Abbreviations
ABBREVIATIONS
i.e., that is
Sha ka. Dru Shabda kalpa druma
NaCl Sodium chloride
Etc. Etcetra
Eg Example
ATP Adinosine Tri Phospate
Gm Grams
Da Daltons
OPD Out patient department
IPD In patient department
HIV Human immunodeficiency virus
Vg Vaginal
C.S. Charaka Samhita
S.S. Sushruta Samhita
A.S. Astanga Sangraha
A.H. Astanga hridaya
R.N Raja Nighantau
D.N Dhanwantara Nighantu
K.N Kaiyadeva Nighantu
G.N Gada Nigraha
B.P Bhava Prakasha
CH.D Chakra Datta
% Percentage
Department of Prasooti Tantra and Stree Roga 7
List of Contents
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” List of Contents
LIST OF CONTENTS
Sl. No Contents Page No
1 Introduction 16 2 Objectives of the study 20 3 Review of ancient literature 22 4 Review of research literature 25 5 Skin morphology 27 6 Disease review 36 7 Drug review 54 8 Concept of avachurnana 74 9 Concept of absorption 76 10 Methodology 83 11 Observations 86 12 Survey 109 13 Result of clinical study 112 14 Results of phyto chemical analysis 127 15 Results of microbiological study 133 16 Discussion 141 17 Conclusion 163 18 Summary 167 19 Bibliography 170 20 Annexure 180
LIST OF GRAPHS
Graph No Description Page No.
1 Effect of treatment on pain 113 2 Effect of treatment on itching 114 3 Effect of treatment on size of the lesion 115 4 Effect of treatment on redness 117 5 Effect of treatment on discolouration of lesion 118 6 Effect of treatment on warmth 119 7 Effect of treatment on roughness 120 8 Effect of treatment on tenderness 121 9 Effect of treatment on discharge 122 10 Effect of treatment on oedema 124 11 Effect of treatment on blisters 125
Department of Prasooti Tantra and Stree Roga 8
List of Figures
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” List of Figures
LIST OF COLOUR PLATES
Sl.No. Description Page No.
1 Khadira-specimen and plant 73 2 Saptaparna- specimen and plant 73 3 Nimba- specimen and plant 73 4 Haridra- specimen and plant 73 5 Shirisha- specimen and plant 73 6 Amalaki- specimen and plant 73 7 Vibhitaki- specimen and plant 73 8 Haritaki- specimen and plant 73 9 Musta- specimen and plant 73 10 Dugdha pashana 73 11 Gandhaka 73 12 Khadiradi yoga choorna 73 13 Acute intertrigo 188 14 Acute intertrigo with blisters 188 15 Intertrigo with maceration 188 16 Chronic intertrigo with lichenification 188 17 Pregnancy induced hyperpigmentation 188 18 Gaping of episiotomy wound in the presence of genito-inguinal
intertrigo 190
19 Intertrigo before and after the application of khadiradi yoga choorna. 189 20 Candida albicans-culture-colonies 139 21 Candida albicans with hyphae 139 22 E coli and staphylococcus aureus 139 23 Pseudomonas auruginosa 139 24 Sensitivity tests with kahdiradi choorna incorporated into agar. 140 25 Aqueous, Chloroform and Ethanol extracts 73
Department of Prasooti Tantra and Stree Roga 10
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” List of Figures List of figures
Sl. No.
Description Page No.
1 Age Distribution of Patients 87 2 Religion Distribution of Patients 88 3 Socio economic Status Distribution of Patients 88 4 Occupation Distribution of Patients 89 5 Education Distribution of Patients 90 6 Marital Status Distribution of Patients 90 7 Population Distribution of Married Women 91 8 Incidence of type of Diet 91 9 Incidence of Bathing Habits 92 10 Use of Clothing/Type of occlusion 93 11 Distribution of population according to Prakruti 93 12 Distribution of population according to Samhanana 94 13 Aahaarashakti 94 14 Predominant Rasa 95 15 Sweating in Patients 96 16 Micturition Frequency 96 17 Micturition – Associated complaints 97 18 Presence of Vaginal Discharge 97 19 Gestational Age 98 20 Presence of Episiotomy Wounds 99 21 Location of Episiotomy Wound – Peurperium 99 22 Mode of Onset of intertrigo 100 23 Duration of intertrigo 101 24 Nature of Area Involved 101 25 Nature of Skin involved 102 26 Presence of Vedana 103 27 Nature of Vedana 103 28 Character of Vedana 104 29 Intensity of Vedana 104 30 Presence of Kandu 105 31 Intensity of Kandu 105 32 Extension of Lesion 106 33 Discolouration of Lesion 107
34-a Presence of Blisters 108 34-b Size of the lesion 108
Department of Prasooti Tantra and Stree Roga 11
List of Tables
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” List of Tables
LIST OF TABLES
Sl. No. Description Page
No. 1 Layers of Twak according to charaka 30 2 Layers of Twak according to sushrutha 30 3 Tabulation of Kshudra roga according to different authors 43 4 Properties of Khadira as per different authors 60 5 Properties of Saptaparna as per different authors 61 6 Properties of Shireesha as per different authors 63 7 Properties of Mustaka as per different authors 64 8 Properties of Haridra as per different authors 66 9 Properties of Nimba as per different authors 67 10 Properties of Amalaki as per different authors 68 11 Properties of Haritaki as per different authors 69 12 Properties of Vibhitaki as per different authors 70 13 Clinical parameters 85 14 Incidence by age 87 15 Incidence by religion 88 16 Incidence by socio economic status 88 17 Incidence by occupation 89 18 Incidence by education 89 19 Marital status distribution of the patients 90 20 Population distribution of married women 91 21 Icidence by type of diet 91 22 Incidence of Bathing Habits 92 23 Use of Clothing/Type of occlusion 92 24 Incidence by prakruthi 93 25 Incidence by samhanana 94 26 Incidence by ahara shakti 94 27 Incidence according to the Predominant rasa 95 28 Incidence according to the Sweating in patients 96 29 Incidence according to the Micturition frequency 96 30 Incidence according to the Micturition associated complaints 97 31 Incidence according to the Presence of vaginal discharge 97 32 Incidence according to the Gestational age 98 33 Incidence according to the Presence of episiotomy wound 99 34 Incidence according to the Location of episiotomy wound 99 35 Incidence according to mode of onset 100 36 Incidence according to duration of intertrigo 100 37 Incidence according to dampness of the area 101 38 Incidence according to the nature of the skin 102 39 Incidence according to the presence of vedana 102 40 Incidence according to the nature of vedana 103 41 Incidence according to the character of vedana 103 42 Incidence according to the intensity of vedana 104 43 Incidence according to the presence of kandu 105
Department of Prasooti Tantra and Stree Roga 13
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” List of Tables
44 Incidence according to the intensity of kandu 105 45 Incidence according to the extension of lesion 106 46 Incidence according to the colour of the lesion 106
47-A Incidence according to the presence of blisters 107 47-B Incidence according to the size of lesion 108 48 Results of preliminary survey done in Gynec OPD 110 49 Effect of Khadiradi yoga choorna on the severity of pain during
the course of the treatment 113
50 Comparison of statistical results between the Test group and
control group on the severity of pain during the course of the treatment
114
51 Effect of khadiradi yoga choorna on the severity of itching during the course of treatment
114
52 Comparison of statistical results between the Test group and control group on the severity of itching during the course of treatment
115
53 Effect of khadiradi yoga choorna on the size of the lesion during the course of the treatment-
115
54 Comparison of statistical results between the Test group and control group on the size of the lesion during the course of the treatment
116
55 Effect of Khadiradi yoga choorna on the redness during the course of the treatment
116
56 Comparison of statistical results between the Test group and control group on the redness during the course of the treatment
117
57 Effect of khadiradi yoga choorna on the discolouration of the lesion during the course of the treatment
118
58 Comparison of statistical results between the Test group and control group on the discolouration of the lesion during the course of the treatment
118
59 Effect of Khadiradi yoga choorna on the warmth during the course of the treatment
119
60 Comparison of statistical results between the Test group and control group on the warmth during the course of the treatment
120
61 Effect of Khadiradi yoga choorna on the roughness during the course of the treatment
120
62 Comparison of statistical results between the Test group and control group on the roughness during the course of the treatment
121
63 Effect of Khadiradi yoga choorna on the tenderness during the course of the treatment
121
64 Comparison of statistical results between the Test group and control group on the tenderness during the course of the treatment
122
65 Effect of Khadiradi yoga choorna on the discharge during the course of the treatment
122
66 Comparison of statistical results between the Test group and control group on the discharge during the course of the treatment
123
67 Effect of Khadiradi yoga choorna on the edema during the course 124
Department of Prasooti Tantra and Stree Roga 14
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” List of Tables
of the treatment 68 Comparison of statistical results between the Test group and
control group on the edema during the course of the treatment 125
69 Effect of Khadiradi yoga choorna on the blisters during the course of the treatment
125
70 Comparison of statistical results between the Test group and control group on the blisters during the course of the treatment
126
71 Priliminary phyto chmical analysis o Khadiradi yoga choorna 128 72 Final results of the test drug 126
Department of Prasooti Tantra and Stree Roga 15
Introduction
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Introduction
INTRODUCTION Human psyche has an innate tendency of affronting to get rid of any
illness, simple or complicated, but definitely creating the discomfort in that
person. In this modern era, where etiquette are highlighted, people tend to be or
pretend to be very neat with cultured social behaviors wherein a simple problem
like intertrigo will cause set back.
Female gender is the unique creation of this universe that is present in
most of the species on this earth. Woman serves different roles in different stages
of her life and contributes to build a family and thus a society. She will undergo
different physical and psychological changes in her life as she reaches different
stages of her life which include puberty, reproductivity, pregnancy, labour,
puerperium and menopause and her responsibilities still go on. During these
stages, there will be many physiological changes. Among them one of the feature
common in all is vaginal secretions which will vary in nature, quantity, quality
and duration.
Reproductive system in females is a dynamic organization in the body
which regularly undergoes cyclic changes. During menstruation, there will be
menstrual discharges. During ovulation there is ovulatory mucus discharge.
Pregnancy is characterised by increased vaginal secretions. Delivery of the
conceptus is followed by puerperium which has different types of discharges per
vaginum for longer duration. Peri-menopausal age in most of the females is
characterised by abnormal bleeding patterns and so on. In between all these
physiological challenges, there are pathological conditions marked by increased
vaginal secretions like-PID, vaginitis, polyps and what not.
During all these stages, she has to maintain the hygiene of genital part,
sometime with pads and sometime without pads. As the skin of vulva and groin
are highly susceptible for the infection and hygiene playing a great role in
maintaining the normalcy and healthiness of that part, there is a high possibility of
getting infection in the skin of the surrounding area in unhygienic susceptible
patients.
Department of Prasooti Tantra and Stree Roga 17
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Introduction
Pathological conditions associated with increased vaginal
secretions/discharges or bleeding of varied aetiology, which may or may not
require sanitary pads, most of the times, will be commonly associated with a
cutaneous infection called intertrigo. If the hygiene of the genito-inguinal region is
not maintained properly along with the intertrigo, there may be further
manifestation of super added secondary infections by bacteria and fungi.
Obesity and gain in the weight during pregnancy, peri-menopausal age or
otherwise also will add up to the problems as it will increase the compactness of
the perineal region and the dampness of the part. This will trigger the onset of the
infections like intertrigo which will pose problems because of pain and itching,
which sometimes becomes unbearable.
Puerperal stage which is marked with lochial discharge, use of sanitary
pads, increased perspiration, and many times the sedentary life of the patient will
trigger the manifestation of the infections like genito inguinal intertrigo. The
lesion may interfere in the easy and early healing of episiotomy wound in
puerperal period.
Genito-inguinal intertrigo - a mild form of superficial skin inflammation
may or may not be associated with secondary bacterial or fungal infection causes
discomfort in day-to-day activities even in menorrhagia associated with or without
obesity. In genito-inguinal intertrigo, people feel a lot of discomfort as there is
intense itching and pain which is caused due to friction, so one wants to get rid of
the problem.
Especially this costal region having high humidity and hot climate and
where in there is severe sweating in both rainy and summer seasons predispose
intertrigo. Obesity, diabetes, sanitary pads and using tight synthetic undergarments
are the other factors predisposing the intertrigo. In the costal regions, the
incidence of genito-inguinal intertrigo in females is ranging from 28%-49%
according to different researches.
Department of Prasooti Tantra and Stree Roga 18
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Introduction
We get very less description regarding genito-inguinal intertrigo in the text
books of dermatology and gynaecology. Although it is one of the most prevalent
pathologies in females especially in costal region and in hot and humid
atmosphere this pathology is not explored much. There is very less medical input
and least documented research is available. There are countable number of
allopathic medicines and in them candid powder is the universally used product.
In Ayurveda there is no single patent product meant for that. No thesis works
being done exclusively on genito inguinal intertrigo in ayurvedic field.
Kachchu/(Vrashana Kacchu) is explained in Sushruta Samhita with
specific cause i.e. unhygienic conditions 1. Here Vrashana refers to the anatomical
location rather than the anatomical structure, as the etiology and disease are not
gender specific.
In the classics we get the utility of pralepa and kashaaya parisheka in the
management of kacchu 2. But application of pralepa apart from interfering with
day-to-day activities may cause clumsiness to the patient, as the sweating
increases the moistness of pralepa and the kashaaya parisheka may have a short
span of action.
Hence an effort is made to use the dusting process with the objective to
alleviate the inconveniences related with the patient and the preparation of the
medicine, and to hasten the process of smooth recovery.
The study involves the evaluation of the dusting process using selected
drugs from kustagna, kandugna and vedanastapana gana in cases of genito-
inguinal intertrigo as a gynecological complaint, during pregnancy and
puerperium.
Department of Prasooti Tantra and Stree Roga 19
Objectives of study
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Objectives
OBJECTIVES OF THE STUDY
The objectives of the study are
• To carry out the conceptual study of Kachchu / genito-inguinal intertrigo.
• To evaluate the clinical efficacy of Khadiradi Yoga Avachurnana in Kacchu
w. s. r. to genito-inguinal intertrigo in females.
Department of Prasooti Tantra and Stree Roga 21
Historical Review
“Clinical Efficacy of Khadiradi yoga avachoornana in Kachchu” Historical review
Historical review In vedic period
• The word ksetriya is used for kushta 3.
• The word vrushana is mentioned in atarvaveda (9-12-13).
• Atarvaveda mentioned about kushta4.
• Different drugs like aamala, khadira are metioned.5
• Vibaadha is used as synonym for khadira6 .
• Haridra is mentioned in Rugveda.7
• External applications of drugs such as haridra are mentioned8.
• Shereesha is mentioned in shaantha varga.9
In Brahmana & Upanishad 10
• In jaimineeya brahmana-there is reference of paama.
• The word vrushana is mentioned.
In samhita kala
• Among Brihat-trayis KShudra roga is explained in Sushruta samhita nidana
stana 13th chapter51, Astanga Samgraha uttara tantra 36th chapter11, and
Astanga Hradaya uttara tantra 31st chapter12. Charaka samhita has not
explained kshudra roga in separate chapter. But in the footnote given in
Astanga Hridaya says that even in Charaka Samhita these diseases have been
explained but not under the heading of or the adhikara of kshudra roga, but in
the context of Shotha. In Charaka Samhita these diseases are explained in
Charaka Samhita sutra staana 18th chapter13
• In Sushrutha samhita we get the first reference of the word kshudra roga and a
separated chapter has been attributed to that. Under the heading of kshudra
roga many skin manifestations are explained and in another chapter its
treatment modalities are explained. Kachchu is one of the kshudra roga first
explained by Sushrutha.
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“Clinical Efficacy of Khadiradi yoga avachoornana in Kachchu” Historical review
• Similarly the treatment modalities or the treatment options are elaborated in
“Twak, charma, vestana” etc words are used in the Ayurvedic classics in
different contexts. These words are used in the meaning of covering something or
enveloping some parts of the body or surrounding a particular structure or organ.
Twak is the domain of vaata (vaatastaana). It is the seat of sparshanendriya
(sense of tactile) It is the place for the rasa and rakta . In many instances it is seen that
twak is used as an analogue for the rasa dhaatu.
Twak nirmaana
According to charaka it is the upadhaatu of mamsa 33.Twak is one of the
maatruja bhava, which is very essential for the formation of garbha 34.
Department of Prasooti Tantra and Stree Roga 28
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Twak Sharira
According to sushruta, - once the garbha is formed, it gets nourished by the
tridoshas and grows very fast in the favourable environment. During its development
twak is formed in the form of 7 layers. Sushruta has explained it with a beautiful
simile that, as the layers of the cream is formed on the top of the boiling milk in the
same way the twak is formed during the formation of garbha35.
According to Vaagbhata- Twak is formed by rakta dhaatu during the paaka of
raktadhaatu by its corresponding dhaatwagni.36
Panchamahabhuta siddanta and tridosha siddanta are the fundamentals of
diagnosis and treatment of ayurveda.According to basic concept of ayurveda, all the
anga pratyangas are made up of panchamahabhuta but in varying proportions. So,
twak is also made up of five mahabhutas.
It is the seat of sparshanendriya attributed to vayu mahabhuta.
It is having brajaka pitta, -attributed to agni
It is the seat of rasa and rakta-attributed to aap
It occupies the avakasha and space is there in sweat glands -attributed to aakasha
It is having stira swabhava –attributed to pratwi.
The panchamahabhutas combine with each other in different proportions and
form three doshas. Dosha saamyatha is considered as health and their derangement or
vitiation is called as disease. It applies to the whole body i.e., sarvadaihika vyadhi or
to a local organ/part ie., eka deshothita vyadhi. So homeostasis of each and every part
of the body is maintained by normalcy of the doshas. So, it is the seat of vaata /
sparshanendriya-atrributed to vaata. It is the seat of bhrajaka pitta-attributed to pitta.
It is having snigdha guna- attributed to kapha.
It is the platform for the movement of rasa and rakta. It is the upadhatu of
mamsa. Through the skin the sweat is excreted out of the body which is the mala of
meda37. It covers all parts of the body and the forms the protective layer.
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“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Twak Sharira Layers of twak
According to Charaka38
Table No-1
Layers Diseases/symptoms
udakadhara Bahya twak
Asrakdhara
3rd layer Sidhma, kilasa
4th layer Dadrukusta
5th layer Alaji, vidradhi
6th layer Tama pravesha
First two layers are given the names, but the disease is not mentioned. For
other four layers the possible diseases that might occur in the particular layer is
mentioned. For the 6th layer, they have mentioned that if it is injured, person will
faint.
According to Sushruta39
Table No-2
Layers Thickness (in vrihi pramans Diseases
Avabhasini 1/18th Sidma, padma kantaka
Lihita 1/16th Tilakalaka,vyanga,
nyachcha
Shwetha 1/12th Charmadala, ajagallika,
mashaka
Taamra 1/8th Vividha kilasa kushta
Vedini 1/5th Kusta visapra
Rohini 1 Granthi, apachi, arbuda,
shlipada, galaganda
Mamsadhara kala 2 Bhagandhara, vidradhi,
arsha
Department of Prasooti Tantra and Stree Roga 30
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Twak Sharira Anatomy of skin 40
Synonyms-integument, cutis, skin
It is an anatomically and physiologically specialized boundary lamina
essential to life. It is a major organ of the body forming 8% of its total mass and
having an area of between 1.2-2.2m2. Thickness ranges 1.5-4.0mm. Skin covers the
entire external surface of the body and is continuous with the mucosae of the
alimentary, respiratory and uro-genital tracts at their respective orifices.
Structurally it is complex and highly specialized. It is formed as an intimate
association between keratinized stratified squamous epithelium superficially-the
epidermis, a deeper layer of moderately dense connective tissue- the dermis. Because
of this it is within the most effective barrier against microbial invasion and
dehydration and against mechanical, chemical, osmotic, thermal and photic damage.
It limits and regulates heat loss, is a major sensory surface with elaborate
systems of varied receptor types, is capable of limited excretion and absorption and
carries out many specialized biochemical functions including the formation of vitamin
D3, from precursor steroids under the action of ultraviolet light.
Normal hormonal changes can affect the appearance and function of specific
areas of the skin. Health age and disease aspect are reflected in the skin. The
appearance of the skin is affected by pigmentation, hair, distribution of follicles, and
presence of sudorific glands. These are changed according to age, metabolic changes,
pregnancy and local pathologies.
Microscopic structure of the skin
The Epidermis - Is composed of keratinized stratified squamous epithelium. In this
tissue there is a continuous replacement of cells, a mitotic layer at the base replacing
cells shed at the surface. As they move they differentiate into keratinocytes. They also
include pigment forming melanocytes, phagocytic Langerhans cells and neurally
associated Merkel cells.
Department of Prasooti Tantra and Stree Roga 31
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Twak Sharira Epidermis is divided into - stratum basale,
- stratum spinosum,
- stratum granulosum,
- stratum lucidum and
- stratum corneum.
The first three layers are metabolically active and grouped as germinative zone
or stratum Malpighii. The more superficial strata of cells having terminal
keratinisation constitute the cornified zone. In addition it is also having epidermal
appendages including glands-sebaceous, sudorific, apocrine ceruminous etc, hair
follicles, hairs and nails.
The stratum basale - includes single layer of cells which lies in contact with the
basal lamina,. It constitutes stem cells, keratinocytes of various stages and non
keratinocytes. The majority of basal cells are columnar to cuboidal and are attached to
hemidesmosomes to the basal lamina. Melanin granules are also present in many of
these cells.
The stratum spinosum - contains more mature keratinocytes several layers deep, the
cells packed closely and inter digitating by means of numerous projections and
indentations at their surfaces which are linked by many desmosomes. Internally these
cells possess large number of keratin filament bundles. Since the sells are anchored
together, this stratum provides much tensile strength and coherence to the surface of
the skin. The melanin is derived from epidermal melanocytes , the granules are most
numerous in the deeper parts of this stratum and are gradually degraded by the
keratinocytes so that in the surface layers they are usually absent.
The stratum granulosum - Here the cells become flattened and acculumate many
large, dense, basophilic granules. Nuclei and other organells disintegrate. Cells
contain densely staining keratinohyalin granules , carbohydrate, lipids and hydrolytic
enzymes in the form of transverse or obliquely oriented lamellae. These eventually
discharge their contents into the intercellular spaces of the upper layers of this stratum
Department of Prasooti Tantra and Stree Roga 32
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Twak Sharira creating a thick, waterproof layer of lamellar cement, rich in neutral lipids, between
the cells of the stratum corneum.
The stratum lucidum - Here the cells are more keratinized.
The stratum conreum - It has closely packed layers of flattened, dead keratinocytes.
In thin skin this stratum is only few cells deep. The intercellular space is filled with a
thick layer of lipidic cement.
Epidermal dendritic cells - They are regularly scattered throughout the epidermis.
Langerhans Cells - Their cell bodies are situated in the base of the stratum spinosum
and their extensively branched dendrites are insinuated between the surrounding cells.
The cytoplasm contains many mitochondria, granular endoplasmic reticulum and a
well developed Golgi Complex. Langerhans cells have similar features of connective
tissue macrophages, including immunochemical reactivity with macrophage-specific
monoclonal antibodies.
The dermis The dermis consists of irregular, moderately dense, soft connective tissue. Its
matrix consists of an interwoven collagenous meshwork, with a varying content of
elastin fibres, proteoglycans (the glycosaminoglycans being predominantly hyaluronic
acid and dermatan sulphate, with some chondroitin- 6 sulphate) fibronectin and other
matrix components, blood vessels, lymphatic vessels and nerves. Nonstriated
myocytes occur in the dermis as arrector pili. Mechanically dermis provides
considerable strength to the skin by virtue of the numbers and arrangement of its
collagen fibres and it also has elastic recoil because of its elastin content.
The dermis can be divided into two distinct zones
– Narrow superficial- papillary layer
– Deeper- reticular layer.
Department of Prasooti Tantra and Stree Roga 33
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Twak Sharira The papillary layer - it is immediately deep to the epidermis and is specialized to
provide mechanical anchorage, metabolic support and tropic maintenance to the
overlying tissue, as well as housing rich networks of sensory nerve endings and blood
vessels. Its superficial surface is marked by numerous papillae which inter digitate
with recesses in the base of the epidermis and form the dermo-epidermal junction at
their interface. In thin skin, especially in the regions with little mechanical stress and
minimal sensitivity, papillae are few and very small while in the thick skin of the
flexor aspects of the hands and feet they are much larger, closely aggregated and
arranged in curved parallel lines following the pattern of ridges and grooves typical of
these surfaces.
The reticular layer - merges with the deep aspect of the papillary layer. Its bundles
of collagen fibres are thicker than those in the papillary layer and interlace with them
and with each other to form a strong yet deformable three dimensional lattice, in
which many of the fibres are parallel to each other and within which lays a variable
number of elastic fibres.
Sebaceous glands - are small saccular structure lying in the dermis and present over
the whole body except the thick hairless skin of palms, soles etc. They secrete an oily
substance –sebum over the skin surface and onto hairs. In ano-rectal surfaces there are
large individual glands. Sebum is a complex mixture of di and triglycerides, free fatty
acids with smaller proportions of wax esters, squalene, cholesterol esters and
cholesterol.
The free fatty acids content of the sebum has antibacterial and antifungal actions.
Thus it prevents the infection of the skin by bacteria and fungi.
The lipid nature of the sebum keeps the skin smooth and oily. It protects the skin from
unnecessary desquamation and injury caused by dryness.
The lipids of the sebum prevent heat loss from the body.
Sudorific/Sweat glands - They are of two types-
– eccrine glands, numerous and present over almost all of the body
surface
– apocrine glands, confined to few restricted areas
Department of Prasooti Tantra and Stree Roga 34
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Twak Sharira
Eccrine sweat glands - are long un-branched tubular structures, highly coiled, with
wider secretory portion situated deep in the dermis or hypodermis. They are absent
from labia minora, glans penis, glans clitoris, nipple, margins of lips etc.
They secrete a clear odourless fluid, hypotonic tissue fluid and containing
small quantities of many substances, predominantly sodium and chloride ions but also
ureas, lactate, amino acids, immuno-globulins and other proteins, bicarbonate,
calcium ions etc. When initially secreted, the fluid is similar in composition to tissue
fluid but is modified as it passes along the duct by the action of its lining cells, which
resorb sodium and chloride and some water too. The hormone aldosterone enhances
this activity. Secretion is stimulated chiefly by temperature rise, but in certain areas of
the body the gland reacts most strongly to emotional stimuli.
Apocrine sweat glands - are particularly large glands of the dermis or hypodermis.
They typically discharge into the apical regions of hair follicles. They are present only
in a few areas of the body, namely axillae, peri-anal region, areolae, peri-umbilical
skin, prepuce, scrotum, mons pubis and labia minora. Here their secretory region is
wide.
Apocrine sweat glands are non functional till puberty and start functioning
only at the time of puberty. In old age the function of these glands gradually declines.
The secretions within these glands are a proteinaceous, thick milky fluid which at
first is sterile and odourless but undergoes bacterial metabolism to generate potent
odorous compounds musky or urinous in smell.It is also added up by the growth of
the micro organisms. It includes short chain of fatty acids etc.
Pheromones - Apocrine glands are believed to secrete a group of chemical substances
called pheromones. It is mostly present in the urine and vaginal secretions and other
secretions of the body. They are often odourless and are considered as air born chemo
signals.
Department of Prasooti Tantra and Stree Roga 35
Disease Review
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Disease Review ÌlÉÂÌ£ü & mÉËUpÉÉwÉÉ
• uÉÚwÉhÉ – qÉÑwMüÉå AÇQûMüÉåvÉÉå uÉÚwÉhÉ 79
uÉÚwÉÑ xÉåcÉlÉå 26
Vrushana is derived from the root vashu sechane which means andakosha, and is
also called as mushka. MücNÒû-MücduÉÉÇ iÉÑ mÉÉqÉÉ ÌuÉcÉÍcÉïMüÉÇ 80
• MüwÉ ÌWûÇxÉÉrÉÉqÉç
• MüwÉå¶É cÉ -AqÉU MüÉåvÉ27
•
The word kachhu is derived from the root word “kasha himsaayaam” which
means that which causes violence or that which troubles like anything or that
which tortures may be at somatic or psychological level.
Such a feature is found in diseases like paama, kachchu and vicharchika. In
these diseases the symptom which troubles the patient most is the intense itching.
The word kacchu is derived from the root word “kachcha” means that which is
related with water or water sites, and it has been further clarified as “jalapranta” i.e.,
the site of water, or water reservoir, or the place where the water is in abundant
quantity, or the area in which the water content is more.
The word “kachcha” is related with “anupa desha”. It has been described that the
areas with excessive water is called as anupa desha or in other way it is told that in
kachcha pradesha the water content is more. Gujarat is called as kachcha pradesha as
the humidity is more in that region.
Department of Prasooti Tantra and Stree Roga 37
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Disease Review
Kachchu is related with kandu i.e., itching or pruritis. In the places where there is
more water content, the people are more prone to suffer from itching, or the severity
of itching is more. And if we apply this to sharira desha we can understand that the
itching is more in moist areas, or the parts of the body with dampness are prone to
suffer from the itching.
Even though in the classics, the word vrushana kachhu is explained, the disease is
not specific to the male gender. The nidanas that are explained like- absence of bath
or not maintaining the hygiene etc. are same for both sexes. The samprapti explained
can happen in both male and female genders. The symptoms explained in the texts are
same for both male and female. By seeing above criteria, here by the word vrushana
we can/should consider the anatomical location/region rather than anatomical part.
Probably it suggests the more compactness of the scrotal region in between the thighs.
Even in obese female patients the perineal part is the prone place for the infection and
inflammation because of its compactness and excessive sweating and occlusions
predispose the onset of kachchu.
Twak vikara
Twak or the skin is the site of vaata, adhishtana for rasa and rakta. It is the
main organ that creates the impression of the physical/external personality. So, when
Department of Prasooti Tantra and Stree Roga 38
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Disease Review it gets diseased or when it suffers naturally it drags the attention and the person seeks
the treatment to get rid of the ailments.
The manifestation of dermatological symptom has got 2 aspects
a) Manifestation in the form of symptom, but the pathology is somewhere else. The
skin acts as a platform for the exhibition of the symptoms. They are labelled as
dermatological symptoms. Eg-Santapa in jwara
Pitavabhasatha in kamala
Pandutwa in pandu
b) The disease itself manifests in the skin and they are labelled as purely
Dermatological diseases. Eg-skin eruptions in masurika, visarpa
-sidma kusta
Depending on the extent of the lesion, whether they are localised or generalised, the
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Disease Review
Department of Prasooti Tantra and Stree Roga 42
Swalpa-little, less, small, minor
Adhama-low level, less significiant,
Krura- related with violence,
Depending on the feature of the disease again they are classified into-
-swlpa- diseases with less severity. Eg- mashaka, vyanga, or tilakalaka etc.
-adhama-dirty diseases like Eg- gudhdha guda, sharkararbuda, kunakha etc.
-Krura-more severe diseases or that which cause trouble or discomfort
to the patient. Eg- masurika, visphota, agnirohini etc.
Another classification of kshudra rogas available depending on the severity is
-laghu kshudra roga –eg-tilakalaka
-tikshna kshudra roga-eg- agnirohini and valmika
In Sushruta samhita it is said that the kshudra rogas are explained after
explaining the mahavyadhi, adhika vyadhi and madhyama vyadhis like vidradhi.
These set of pathological entities are grouped under the heading of kshudra
roga as they have swalpa nidana i. e., minimal number of causes or causes with less
severity. Further clarifying it is said that because of alpatwa of hetu, lakshana and
chikitsa these pathologies are grouped under kshudra roga which indirectly represent
their nature. But it also includes rohini and valmikadi tridhoshaja vyadhis. These
diseases have baahulyatha of hetu i.e., multiple causes leading into complex
pathologies and they are asadhya.
The below chart shows kshudra rogas mentioned by different
authors.44,45,46,47,48,49,50,51,52
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Disease Review Table No-3
Name of the disease Charaka
samhita
Sushruta
samhita
Astanga
Samgraha
Astanga
Hradaya
Yoga
Ratnakara
Chakra
Datta
Vanga
sena
Baishajya
ratnavali
Bhava
prakasha
Ajagallika + + + + + + + +
Yavaprakhya + + + + - + + +
Andhaalaji Alaji + Alaji - + Antra
Alaji
Antra
alaji
+ antraalaji
Vivruta + + + + - + +
Kachchapika + Kachchapi Kachcha
pi
+ - + + +
Valmika + + + + + + + +
Indravrudda + - - + - Indra
vrudda
+
Panasika + + + + - + + Panasa
Paashana
Gardabha
+ + + + - + + +
Jaala
Gardabha
+ + + + + + + + +
Kakshaa + + + + + - + + +
Visphotaka + + Visphota Visphota + - - +
Department of Prasooti Tantra and Stree Roga 43
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Disease Review
Agnirohini + + + + - + + +
Chippa + Chipya Chipya + + + + +
Kunakha + + + + - + + +
Anushayi + - - Anushayya + + + +
Vidaarika + + Vidaari Vidaari + + + + +
Sharkara
Arbuda
+ + + - + + +
Paama + - - - - - +
Vicharchika + - - - - - +
Rakasa + - - - - - +
Paadadaarika + - - Paadadaari Paada
dari
Paada
Dari
+ Daari
Kadara + + + + + + + +
Alasa + + + + alsaka + + +
Indralupta + - - + + + + +
Daarunaka + - - + + + + +
Arumshika + - - + + + + +
Palita + - - + - + + +
Masurika + + + + - - - +
Youvana + - - + +/ - +
Department of Prasooti Tantra and Stree Roga 44
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Disease Review
Pidika taarunya
pidaka
Padmini
Kantaka
+ Padma
Kantaka
Padma
Kantaka
+ + + + +
Jatumani + + + + - + + +
Mashaka + Masha Mashaa Maasha - Maasha + Mashaka
Charmakila + + + - + + +
Tilakaalaka + + + + - - + +
Nyachcha + - - + - + + +
Vyanga + + + + Mukha
vyanga
+ + + +
Parivartika + - - + Pari
kartika
Pari
vartika
+ +
Avapatika + - - + + + + +
Virudhdha prakasha + - - + + + + +
Sannirudhdha
Guda
+ Ruddha
guda
Ruddha
guda
+ - + + +
Ahiputana + - - + + + + +
Vrushana
Kachchu
+ - - + + + + +
Gudabramsha + - - + + + + +
Department of Prasooti Tantra and Stree Roga 45
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Disease Review
Mukha
Dushika
- + + - - + -
Pitika Pidaka - - + - - - -
Gandhana - + + + - + - Gandhaa
Raajika - - + - - - -
Gaardabhi - + + Gaardabhik
a
- Gaarda
bhika
- Gaardabhi
ka
Erivellika - + + + - + - +
Lanchana - + + - - - -
Nilika + - - + + - + - +
Prasupti - + + - - - -
Utkota - + + - - - -
Vidhda - + - - - - - Indra
viddha
Araajika - + - - - - -
Shukara
Damshtra
- - - + + + - +
Khalli - - - - + - -
Paadadaaha - - - - + - -
Kota - + - - - - -
Romantika + - - - - - - -
Department of Prasooti Tantra and Stree Roga 46
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Disease Review
Department of Prasooti Tantra and Stree Roga 47
Khalitya - - - - - + - -
Sharkara - - - - - - + -
Shyavapidika - - - - - - - - +
Glaani - - - - - - - - -
Udgaara - - - - - - - - -
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Disease Review Kachchu
First enumeration of kshudra roga is available in Sushruta samhita. Here the
diseases included range from those which are completely painless but cosmetically
important and never cause systemic involvement (eg-tilakalaka) to grave diseases (eg-
agnirohini) which can be fatal. Kachchu comes somewhere in the middle of this
range. This disease is a minor skin pathology, localised, but painful, partially affects
the day to day activities, can be cured by simple treatment modalities.
Kachchu is one type of dermatological disease that develops in the vrushana
pradesha wherein the vrashana pradesha refers to the anatomical location rather than
the anatomical organ.
Nidana-
Snaana utsadana hinatha
Kanduyanath
The specific nidana told for the kachchu is unhygienic condition and followed
by scratching that area by the person.
The other nidanas told in the text that can be included under nidana are-
Prasangaat
Gaatra samsparshat
Saha vastra dharana
These are some of the causitive factors told in the list of etiological factors of
oupasargika roga53 like kushta can be considered for kachchu also.
Since kachchu can be considered under the broad heading of kushta, even
kushta saamanya nidanas can be considered. But the specific nidanas are told for the
kachchu act as precipitating cause.
Snaana-It is explained as an important regime explained in dinacharya.54 Taking
snana (bath) regularly is said to be urjaa bala prada i.e., it rejuvenates and imparts
strength to the body. It increases the capacity of the body and enables the body to
Department of Prasooti Tantra and Stree Roga 36
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Disease Review work. It also acts as dipana, vrushya and ayushya i.e., It increases the agni, acts as
aphrodisiac, and increases the longevity.
It removes mala and sweda. It relieves kandu and daaha.
It takes off shrama. ie., fatigue. It is also said to be paapahara.
In the commentary while commenting on the word dipana it has been told
specifically that bath will enhance the pitta namely bhrajaka pitta that is present in the
twak. So, snana is designated as dipana. It increases the agni that is present in the
twak locally.
Bhrajaka pitta is said to be important to impart the lusture to the skin and is
responsible for the metabolism of the drugs applied to the skin in various forms.
Utsaadana-55 In Sushrutha samhita , acharya Jejjata while commenting tells that there
are 3 types of procedures-udvarthana, uthsadana, and udgarshana.
Udgharshana with sasneha kalka is called uthsadana. Rubbing the body parts
with unctuous pastes is called uthsadana.
Both udvarthana and uthsadana dilate the sira mukhas, increases the agni
present in that part of the twak and acts as varnya i.e., imparts normal colour and
lusture to the skin. Probably it is acting on both brajak and ranjaka pitta.
Especially uthsadana is indicated in females as they are considered as delicate
personalities. It is also ideal to do in delicate body parts like genito-inguinal region. If
instead of unctuous paste if dry paste is used it my damage the skin.
Its uses are-
-It does the kapha shamana
-Strenghthens and stabilizes the body parts
-Liquifies the medas
-Acts as twak prasadana – nurtures the skin in all aspects.
-It does the vaata shamana
-It acts as varnya
-It relieves the siramukha avarodha
Department of Prasooti Tantra and Stree Roga 37
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Disease Review -It auguments the twakgata agni, there by it helps to absorb and metabolize the
medicaments applied to the body in various parts.
-Relieves from the bad odour of the body
-Reduces the itching.
- Removes the mala that are caused and accumulated due to sweating.
-Brings lightness to the body.
Mala-In ayurveda mala is the excretory product of the body. They are purisha, mutra
and sweda.56 Other malas include kha malas ie., the waster products or the products
that are to be excreted out of the body like akshi mala, naasa mala, grana mala etc.
Mala or the kitta bhaga is also explained at the dhatu’s level like kapha is the kitta
bhaga rasa and sweda is the mala of meda and so on.
In the context of kachchu, mala is described as twak upalepa. The coating of
the skin that is present over it which is meant for discarding or wearing off or
desquamating is called as mala. In other words the mala will be present on the skin in
the form of a layer.
Dead cells are present over the skin in the form of a layer and during a span of
time they get desquamated and removed. If it is not cleaned properly, it may get
accumulated especially in the inguino-perineal region.
Bath and mild scrubbing will remove the layer of exfoliated cells present on
the surface of the body presence of which is the main cause of the manifestation of
intertrigo.
The snaana and utsaadana i.e., rubbing with fine powder for the exfoliation of
the dead cells is told in the classics to remove the layer of dead cells that is forming
the outermost covering. Without the presence of the water, the rubbing may cause
scratches or may cause minute trauma which will manifest in the form of rashes.
Only bath with water without rubbing will not fulfil the purpose of hygiene as the
mere water splashing will not remove the dead layer as it need some smooth physical
agent like fine powder.
Department of Prasooti Tantra and Stree Roga 38
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Disease Review
As a prophylactic measure snana and uthsadana removes mala and sweda that
gets accumulated in the genital region. They also relieve the kandu, which is both the
effect and cause of kachchu.
Taking bath and uthsadana are the nidana parivarjana chikitsa. After the
manifestation of the disease, the snana etc. act as kandugna. They increase the brajaka
pitta, and help in the metabolism of the medicaments applied to the genital region.
Thus they help to cure the condition.
Swedat praklidyate57-The sweat even though is considered as mala, it is required for
the maintenance of the moistness and oilyness of the skin. Being the mala of meda, it
has the property of sneha and being a part of the kleda, it has the property of kleda.
When the quantity and quality of the sweda mala is normal, it maintains the normalcy
of the body and reflects the healthiness of the person. If it gets altered in its quantity
or quality, either it will produce the disease pathology or it reflects the symptom of
the disease pathology. Ati sweda causes kandu and sharira dourgandhya.
The sweat is composed of the secretions of the sweat glands, sebaceous
glands, and the secretions of the other glands that are present in the particular local
regions. Sweating encompasses the complex mechanisms of body response like vaso
constriction and vaso dilatation, secretory functions of the different glands.
It is also associated with local immune system of the skin in particular part,
including macrophages and many other unknown body tissue defence mechanism.
Gaatra samsarshat and saha vastra dharana-These two are the etiologies listed in the
causative factors for the oupasargika rogas like kushta. These nidanas can also be
considered for the kachchu as kachchu is a form of kushta.
Even in intertrigo, wearing new synthetic undergarments without washing and
contracting the intertrigo from the husband are documented.
Department of Prasooti Tantra and Stree Roga 39
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Disease Review Prone persons or predisposing factors
-The person in whom there is excessive perspiration
-The physiological or pathological condition in which there is excessive perspiration
-The local condition in which the perspiration is not disposed properly because of
some other reasons which will simulate the condition of excessive perspiration.
In a person who is not following the hygienic measures like snana and
utsadana, the mala that is accumulated in the vrushana pradesha, gets moistened by
the sweat and produces intense itching. When the person scratches that area
immediately there is manifestation of blisters and discharges. This condition is called
as kachchu. This pathology occurs mainly because of kapha and rakta.
Symptoms
Kandu-this symptom is directly attributed to the kapha dosha57. In Kachchu one of
the vitiated dosha is kapha and kandu is the predominant feature. Kandu is also a
feature of atisweda pravruti which indicates the swedavaha srotodushti58. In such
condition kandu is associated with bad odour of the skin. Even in the pathogenesis of
kachchu it is said that when the accumulated waste products in the vrushana region, it
gets moistened by excessive sweating, it produces itching.
In the genito-inguinal intertrigo, because of the accumulation of sweat in the
skin folds there will be maceration, which will produce intense itching.
Sphota- It is attributed to the kapha and pitta59. As rakta is having the features of pitta
when pitta gets vitiated it vitiates rakta. When both the vitiated doshas get lodged in
the space in between the twak and mamsa, they produce various forms of eruptive
disorders, which may manifest as a symptom or as a separate specific pathological
entity. In kachchu the doshas are localised and are not involving the gambhira dhatus
as in kusta vyadhi. In kachchu it is said, itching is responsible for the manifestations
of the eruptions.
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In genito-inguinal intertrigo friction in the form of itching or friction with
cloths or opposite skin surfaces act as the triggering factor for the formation of
blisters.
Srava-discharges are attributed to pitta60. It may be associated with kotha or may
manifest without kotha. According to the doshas involved and diseases in which it is
manifesting, the nature of the srava changes. In kachchu, because of pitta/rakta
vitiation, there are discharges from the genito-inguinal area. Its manifestation is
triggered by the process of itching.
The discharges in intertrigo will be in the form of oozing, having watery
consistency. Dampness which is already present in the genito-inguinal part, secretions
of the sebaceous glands and excessive sweating, all these contribute to the discharges.
Samprapti ghataka
• Dosha-kapha, pitta
• Dushya-rakta, sweda,meda
• Srotas-raktavaha,swedavaha,medavaha
• Dustiprakara-atipravrati
• Udbhava stana-amashaya
• Sancharastana-sarvashareera
• Adhistana-vankshana
• Vyaktastana-twak
• Rogamarga-baahya
• Vyadiprakara-saadya.
Nidaana-snaana utsaadana hinata, kledadikyatha
Poorva rupa-swedadikyatha.
Rupa-kandu, sphota, srava
We do not get the direct reference of upashaya and upadrava in the classics.
Since the snana uthsadana hinata are considered as the causes, proper advocation of
snana uthsadana can be considered as upashaya.
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If the nidanas are continued there will be blister formation, which may extend
upto buttock region, causing kachchu mentioned in kshudra kushta. Or once the
vranas are formed from the sphota, vrana upadrava can be considered.
Since it is considered under the broad heading kushta kushta nidana, purva roopa,
upashaya and upadrava can also be considered.
Samprapti/Pathogenesis
A person who is having excessive perspiration due to various causes, if does
not maintain the local hygiene properly especially in the inguino-perineal or genito-
inguinal region, then there will be kledana of that part. Kledana which occurs because
of excessive perspiration causes dampness of genito-inguinal area. It has been
specified in the literature that the mala that is present in the vrushana pradesha gets
affected by the kleda or the mala will get moistened. In such condition the itching
starts in that particular local area. When the person scratches then there will be
manifestation of blisters or sphotas associated with or followed by srava. This
condition is called as (vrushana) kachchu i.e., kachchu occurring in vrushana
pradesha. This occurs mainly because of kapha and rakta prakopa.
Treatment of kachchu 61
-udvartana with choorna prepared out of sarjambu, kusta, saindhava, and sita
-tiphala kola khadira kashaya for vrana ropana
-badaritwak and saindave pralepana
-kapaala tutta choorna prayoga externally
-paama roga chikitsa and ahiputanavat chikitsa
-pralepa with kaasisa, tutta, haritaala, rasanjana with amlapista
Treatment of ahiputana62
-samshodana and vrana prakshalana with triphala khadira kwatha.
-lepa with shanka, souvira yasti
-Grita paana –ghrita made out of patola patra, triphala rasanjana.
-kasisa, gorochana, tutta, haritaala, rasanjana with amla kanji applied externally
-jalouka avacharana
-karanja triphala tiktaka ghrita
-Sarpi paana with ghrita made out of karanja, triphala tikta
Department of Prasooti Tantra and Stree Roga 42
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Disease Review -lepana with karanja,triphala tiktaka siddha ghrita
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Disease Review Differential diagnosis of intertrigo Tenia cruris- It is a dermatophyte infection of the groins. It is less common in
females. It is localized to groins, thighs and buttocks. Clinically it presents as bilateral
symmetrical, itchy, half-moon shaped or small circumscribed, well defined, multiple
scaly plaques, papulo-vesicular lesions at the active border, with central clearance is
often incomplete. Borders are raised. Chronic scratching may lead to lichenification.
Secondary bacterial infection may supervene. Weeping maceration and areas of
postulation may also occur.
Hyper-pigmentation of pregnancy-A generalized increase in skin pigmentation is
seen during pregnancy. The hyper-pigmentation is most marked over the nipples,
areola and external genitalia. Sometimes the axillae, the area around the neck and the
medial surface of the thighs become pigmented. The pigmentation usually fades away
after the delivery.
The hyper-pigmentation may be due to the hormonal changes occurring during
pregnancy, and women also have a genetic and racial predisposition.
Seborrheic dermatitis-It involves the hair bearing skin of the labia majora, extends
to perineum and natal cleft. Secondary infection may occur with scratching and results
into scaling and fissures.
Psoriasis-It is a genetically determined, chronic relapsing and remitting inflammatory
dermatosis characterized by scaling pink plaques in a symmetrical distribution.
Clinically presents with symmetrical pinkish-red plaques covered with silvery scale
on the pubis, labia, peri-anal region and natal cleft.
Lichen simplex chronicus-It is the end stage of many inflammatory skin diseases. In
the active phase many skin diseases will be having itching and therefore subjected to
repeated friction by scratching. Here the skin is thickened with exaggerated skin
markings (lichenification). Scaling is present and excoriation due to recent scratching
can be seen within the thickened or erythematous areas.
Department of Prasooti Tantra and Stree Roga 44
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Disease Review Lichen sclerosis-It is an inflammatory skin disease associated with autoimmune
disorders such as vitiligo, pernicious anemia, thyroid disease. Mostly seen in post
menopausal women. The surface is wrinkled and atrophic, thickened and slightly
warty. It may be associated with haemorrhagic blisters. There is severe intractable itch
in the night. There may be associated dysuria or constipation
Cutaneous pattern of Lichen planus-It is an inflammatory disease of the skin and
the mucus membrane. There may be papules, plaques or follicular papules with a
purplish/red appearance. There is severe itching and excoriation
Differential diagnosis of kachchu
Dadru-It is one of the maha kustas explained in the Sushrutha samhita. It is
characterised by pidakas having the colour like atasi pushpa or taamara varna and is
visarpini. According to charaka it is (sita kushta) considered under alpa kushta.It is
characterised by sakandu pidika, vrutta bahala, mandala and udgatha. Here its place is
not limited to genito inguinal region. It does not need the nidanas like snaana utsadana
hinatha and kanduyanatha.
kachchoo-It is considered as kshudra kusta as per Sushruta. It is characterized by
sphota, daaha and may be seen in sphik, paani and paada. Here its place is not limited
to genito inguinal region. It does not need the nidanas like snaana utsadana hinatha
and kanduyanatha.
Ahiputana-It is also considered as one of the kshudra roga. It occurs in the children
because of improper disposal or cleaning of urine and feaces. It occurs because of
kapha and rakta prakopa. Because of swedana and mala kledana there well be
manifestation of kandu. Because of kandu there is immediate manifestation of sphota
and srava and some times vrana. It is a ghora or daruna vyadhi.
Department of Prasooti Tantra and Stree Roga 45
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Intertrigo64
Definition: It is an inflammatory dermatitis involving the skin folds
(inflammation of opposed skin surfaces). It is a common clinical condition
manifested in the skin.
It is more common in hot humid climates and in obese persons where there are
added factor of occlusion. Sweating caused by heat and moisture and friction of
opposing skin surfaces are the primary causative factors.Obesity and Diabetes
Mellitus predispose the condition. In obese patients the abdominal folds may also
involved. Tight fitting clothes particularly underwear and sanitary pads are also
contributory.
Lesions can occur in groins (genito-inguinal region), retro-auricular, axillae,
under pendulous breasts, inter-digital, inter-toe and inter-gluteal folds.
Chronic bacterial or candidial infection eventually supervenes. Streptococcus
pyogenes is the commonest offender. Intertriginous areas are readily colonized
and infected by a variety of microorganisms such as staph. Aureus, strep.
Pyogenes, c. albicans, less commonly by e. coli, Proteus epp. and occasionally
pseudomonas aeruginosa.
Main Features:
Heat, moisture, friction and sweat retention induce maceration and
inflammation of these areas. Chronic bacterial or candidial infection eventually
supervenes.
Usually starts as bilateral or unilateral symmetrical well marginated,
erythematous areas confined to the folded skin areas in apposition such as the genito-
crural, genito-inguinal, infra-mammary, and axillary folds. Subsequently sweat
retention induces maceration and inflammation of these areas leading to erythematous
lesions. However maceration is confined to the central skin.
Department of Prasooti Tantra and Stree Roga 46
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Initially the skin is red and slightly macerated. The folds when separated show
erythema of contiguous surfaces, covered by a macerated horny layer forming a sort
of smegma, usually with a deep fissure. In the advanced stages, there may be
complete denudation of the surface. Itching, burning, pain, exudation and offensive
odour are the common symptoms.
On examination-erythematous, raw, moist, macerated and eroded areas with well-
defined fringed edge can be seen. Intertrigo with massive colonization occurs
commonly in obese individuals of either sex. It may show a sharp margin, but this
edge is usually a simple curve where the opposed skin surfaces meet. There is an
upward extension from the groin as well as down the thigh. In severe cases, painful
erosions, fissures exudation, crusting, scaling and sometimes pustulation develop.
In candidial intertrigo satellite pustules are characteristic. Coryneforms add to the
damage by their proteolytic action that generates an offensive odor.
Skin infections and immunity during pregnancy- Skin diseases get modified during
pregnancy. Dermatoses may either worsen or improve or remain unchanged and
unpredictable during pregnancy. The cell mediated immunity is depressed. Certain
infections like candidiasis worsen. Candidia, genital warts and herpes simplex can be
transmitted to the baby during child birth.
Complications:
Secondary impetigo, cellulitis.
Superimposed secondary c.albicans infection
Treatment:
– Prompt the dryness by removing occlusive conditions and by use of
compresses and absorbing powders.
– Aluminium acetate solution for wet oozing leisons.
– A soothening powder during day and a cream at bedtime are advisable.
Department of Prasooti Tantra and Stree Roga 47
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– Antibacterial and antifungal drugs should be used if there is such
infection.
– If inflammation is severe, mild topical steroid application for a short
period with above measures.
– Avoid fluorinated steroids.
– Ventilation of the area is very important.
– Attend the predisposing factors like obesity, DM, friction with clothing
and excessive physical activity.
Histopathological features in intertrigo65
The term dermatitis and eczema are usually as synonyms and refer to an
inflammation of the skin. Dermatitis may be acute, subacute or chronic.
Spongiosis is an important finding in most cases of dermatitis and the term
spongiotic dermatitis is occasionally used with eczema. Spongiosis refers to the
accumulation of edema fluid between epidermal keratinocytes, which may progress to
form vesicle or bulla. Spongiotic dermatitis may be classified into-
1. Acute spongiotic dermatis
a. Stratum corneum is normal
b. Epidermis is of normal thickness
c. Variable spongiosis with intraepidermal vesiculation
d. Papillary dermis is edematous
e. A lympho-histiocytic infiltrate is present around the superficial plexus
of blood vessels with exocytosis of lymphocytes into spongiotic foci.
2. Subacute spongiotic dermatitis
a. Stratum corneum shows parakeratosis and crust formed of coagulated
plasma,lymphocytes and neutrophils.
b. Epidermis shows moderate acanthosis
c. Mild to moderate spongiosis with microvesicualtion
d. Papillary dermis shows edema
e. Superficial perivascular lympho-histiocytic infiltrate is less prominent.
Department of Prasooti Tantra and Stree Roga 48
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3. Chronic dermatitis
a. Hyperkeratosis with parakeratosis and hypergranulosis
b. Moderate to marked acanthosis
c. Minimal spongiosis
d. Prominent papillary dermal fibrosis is a characteristic feature seen as
vertical streaks of collagen in the papillary dermis.
e. Sparse dermal inflammatory infiltrate.
Allergic contact dermatitis
Early stage- Spongiosis is most prominent in the lower epidermis. Spongiosis results
in vesicles at different horizontal and vertical levels of the epidermis in a very orderly
pattern. Mild to moderately heavy infiltrate of lymphocytes, macrophages and
Langerhans’ cells with accentuation around the superficial plexus is seen in the upper
dermis. Eosinophils in small numbers are usually present in the infiltrate.
Exocytosis of lymphocytes and sometimes of eosinophils is seen.
Well established lesions are characterized by-
-slight epidermal hyperplasia
-Marked edema of papillary dermis
-Scale crust in the stratum corneum
-Spongiosis in discrete foci; if marked, vesciles appear
-Mounds of parakeratosis
-Superficial, perivascular and interstitial infiltrate of lymphocytes may contain
eosinophils in variable numbers.
Chronic lesions are characterized by-
-Compact orthokeratosis, with occasional subtle scale-crust formation
-mild spongiosis
-uneven focal hypergranulosis
-Psoriasiform hyperplasia of epidermis
-Coarse bundles of collagen in vertical streaks in a thickened papillary dermis.
Department of Prasooti Tantra and Stree Roga 49
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Disease Review Irritant contact Dermatitis-The histopathological findings depend upon the nature
and concentration of the irritant.
Very strong irritants produce
-Marked ballooning of deratinocytes in the upper dermis
-Necrosis of epidermal cells
-Spongiosis in the areas adjacent to necrotic epidermis
-neutrophils in areas of ballooning and necrosis
Mild to moderately strong irritants show
-Epidermal spongiosis
-Superficial dermal edema.
-Superficial predominantly perivascular infiltrate of lymphocytes.
Pustular lesions seen in irritant contact dermatitis show-
-subcorneal vescicles with neutrophils
-cellular debris
-Fibrinous exudate
Dermatophytosis/Superficial fungal infections
-means superficial infection of the skin, hair, nails due to a group of related
filamentous fungi, the dermatophytes. They are ketatiniphilic and normally invade
only the dead keratinized tissues of the stratum corneum of the skin. They generate
proteases that digest keratin.
Histopathology
-stratum corneum shows the presence of neutrophils which is suggestive but not
diagnostic of tines corporis.
-Sandwitch sign refers to the presence of fungal organisms in stratum corneum
sandwitched between two zones of cornified cells, the upper being othokeratotic and
the lower consisting partially of parakeratotic cells.
-Other histopathologic fatures are those of acute, subacute or chronic spongiotic
dermatitis depending upon the degree of reaction of skin to the presence of fungi.
-The diagnostic histopathologic feature is the demonstration of fungal hyphae and
spores in the horny layer by special stain.
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Candidiasis
May cause Acute superficial candidiasis, Genital candidiasis etc.
Histopathology in case of superficial candidiasis
-Orthokeratosis and parakeratosis
-Neutrophils scattered within the epidermis
-Spongiform and sub-corneal pustules
-Oedema of the papillary dermis
-Superficial perivascular and interstitial mixed cell infiltrate of lymphocytes around
venules and neutrophils mostly in the interstitium
-Pseudohyphae in cornified layer which appears as dark blue streaks oriented nearly
perpendicular to the skin surface
-Epidermis may be hyperplastic in chronic cases
-Neutrophils penetrate the entire thickness of the skin
-Demonstration of the causative organism in the stratum corneum.
Difficulties in diagnosis 66
Three main factors render both clinical and histological diagnosis of vulvar
skin disease extremely difficult. They are-
Women are naturally reluctant to seek medical attention when vulvar
symptoms first appear. Often specialist medical attention is sought only when the
lesion persists and has failed to respond to, or has been exacerbated by self
medication, which also modifies the histological changes, rendering diagnosis
difficult.
The vulva, as with other covered flexural sites, is a warm, moist area that
experiences friction from skin surfaces and clothing. These physical factors change
both the clinical and histopathological appearances of the original skin disorders such
that characteristic features can sometimes be modified or lost. Because of the
environment, bacterial, yeast and fungal infections can thrive, especially if the
underlying skin disease, friction, or scratching weakens the continuity of the skin
surface. The presence of the specialized skin structures such as terminal hair follicles,
Department of Prasooti Tantra and Stree Roga 51
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Disease Review apocrine and vestibular glands adds to the range of disorders that affects the vulva and
perineal area.
Pruritus is the most frequent symptom associated with vulvar skin diseases.
Patients find it impossible to desist from scratching the lesions, even unknowingly.
This persistent frictional trauma produces loss of the surface epidermis in the initial
phases, with the production of numerous excoriations. In the logn term it produces
chronic thickening of the epidermis (lichenification) and fibrosis of the underlying
dermis, which can mask the initial causative disorder.
Common dermatosis that commonly affect the vulva are
Acute and chronic dermatitis (eczemas)-All forms of endogenous and
exogenous dermatitis can affect the vulva, and may present in an acute or chronic
phase.
Acute dermatitis of vulva
Clinically acute dermatitis is characterized by redness and vesiculation of skin.
As vesicles rupture onto the surface, the area shows exudation, the exuded vesicle
fluid forming a crust on the skin surface on drying. Histologically the epidermis
shows variable focal spongiosis, frequently with parakeratosis overlying it, and there
may be a range of inflammatory cells in small numbers within the spongiotic area of
epidermis. Larger spongiotic areas form into spongiotic vesicles, which rupture to
produce the clinically apparent exudate lesion. The dermis shows a perivascular
lymphocytic infiltrate and there may by associated dermal edema as manifest by
separation of of collagen fibres and the presence telangiectatic lym phatics and dilated
capillaries. This is modified by the effect of scratching mainly in the form of acute
excoriation, and non specific thickening of the epidermis and fibrosis of the dermis if
the scratching has been long standing.
Chronic dermatitis of vulva
Clinically the skin is reddened or hyperpigmented with excoriations where the
surface has been traumatized. Lichenification with thickening and exaggeration of
skin markings is often present secondary to chronic rubbing and scratching.
Department of Prasooti Tantra and Stree Roga 52
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Disease Review Histologically there is variable thickening of the epidermis and overlying
hyperketratosis. The thickened epidermis shows elongated rete ridges and there is
fibrosis of papillary dermis with thickening of capillary walls. Increased numbers of
chronic inflammatory cells mainly lymphocytes are found around upper dermal
vessels. In many cases that clinically have the appearances of a chronic dermatitis,
histological examination reveals features of a more acute inflammation, namely
epidermal spongiosis. It is also called sub acute dermatitis to imply that the chronic
skin inflammation is still active and not quiescent or inactive.
Exogenous vulvar dermatitis.
They are contact irritant dermatitis and contact allergic dermatitis.
Contact irritant dermatitis of vulva-
Of the vulva in children is seen in the form of napkin dermatitis due to the
irritant effects of urine on the vulvar skin. This can also occur later in life if there is
stress incontinence. Ii clinically presents with sharply delineated itchy sore
erythematous papules and plaques that may be weeping and eroded if acute or
lichenified in chronic cases.
Contact allergic dermatitis is a type 4 delayed hypersensitivity reaction in
which sensitized lymphocytes respond to a specific allergen that has penetrated the
skin. The skin has been previously exposed to allergen for sensitization to occur,
occasionally by a single previous exposure. Clinically it presents with eroded weeping
erythematous patches.
Department of Prasooti Tantra and Stree Roga 53
Drug Review
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Drug Review Bheshaja is one of the four limbs of maha chikitsa chatushpaada67. Hence
equal importance is given to the treatment modalities as well as drugs used in curing
ailment as vaidya i.e., physician and rogi i.e., patient.
While explaining the characteristics of an ideal drug it has been enumerated
that the drug should possess good qualities or multiple qualities so that it can be used
in multiple conditions or in a patient with multiple pathologies. It should have good
qualities in rich proportions. It should be suitable to the patient, i.e., compatible to the
patient. It should retain its properties even in different forms of preparations68.
Retention of its properties or its active principles in different form of
preparations as a characteristic of an ideal drug is told as some drugs cannot be
converted into some specific forms, and all the preparations are not ideal for all the
regions and all types of pathology.
Depending on the disease the symptoms may manifest in any one part of the
body or in multiple parts. In ayurveda this is explained in the form of different
rogamargas. Depending on the pathologies an herb can be given in different forms. If
the pathology is in the kosta, one can go for vati, kashaya or oil based preparations
depending on the dosha. If it is in twak, along with internal medications, even topical
applications are advised.
For bahudoshavasta, line of treatment includes shodhana with panchakarma
followed by shamana medications.For alpadoshavasta, like vrushana kachchu external
application with specific drugs is told.
The treatment changes depending on the rogi bala. In sukumara patients, who
cannot tolerate the treatment shamana oushadi is advised. Even though in the classics
we get the reference of ghrita preparation for internal medication in case of kachhu, it
cannot be given in garbhini presenting with kachchu. Here the topical application is
the line of treatment.
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Administration of internal medication in the form of swarasa, kalka, kwatha,
choorna, vati, ghrita, arista depends on the strength of the kostagni and the pathology.
Application of the medicines over the surface of the body is disease specific, and
ayurveda gives preference to the consideration of the involved doshas.
Depending on the pathology, the external application are told in different forms
• Types: according to tantrantara-swetha, raktha, pita, krishana
Ashodita gandhaka dosha-It increases body temperature, produces brashachitta
vibrama (CNS symptoms secondary to toxic levels) raktaja vyadhi. It destroys
prasannata(healthy status) surupatha(good physical outlook which reflects good
health), sharirabandhana (integrity of the body), prabha (lusture), and bala(strength).
Types of gandhaka shodhana
• Ghee is made liquid on low fire and equal amount of gandhaka powder is
added. When gandhaka dissolves properly it is sieved through a clean cloth
into milk. Then it is washed thoroughly with hot water. The same procedure is
repeated for three times.
• Milk is taken in a vessel and ghee is added. The mouth of the vessel is closed
with a clean cloth. Gandhaka powder is spreaded over it and it is closed with
another mud lid (Sharava). Edges are sealed. Then it is kept in a pit and upalas
are burnt over the lid. The gadhaka melts and drops into milk. When the vessel
is cooled the gadhaka is removed and washed with hot water.
• Gandhaka is heated with sarshapa taila, tilataila or kusamba taila and is sieved
through the cloth into the milk. Later it is washed with hot water.
• It is heated with bringaraja swarasa and sieved into milk for seven times.
• It is heated with chornodaka and lavana dravaka and sieved into milk for
seven times.
Qualities of Shuddha gandhaka-It removes garavisha, cures kshudra kushta, kasa,
shwasa, dadru, relieves from shaaririka and manasika dosha and cures ama. It is good
for eyes and rasayana when used judiciously. It increases the qualitites of parada.
It is having kustagna, kandugna properties. It is indicated in dermatological conditions
like dadru, visarpa, kshudra kusta, paama etc. It also removes ama and does shoshana
(dries up).
Department of Prasooti Tantra and Stree Roga 71
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Drug Review Some of the preparation of gandhaka that are indicated in different skin pathologies
are as follows
-When it is used with ripened kadaliphala it cures skin diseases.
-Gadhaka with karpura, soubhagya, mruddarasringa mixed with coconut oil applied
externally cures even daruna pama.
-Gandhaka with soubhagya, shalaniryasa, sphatika and nimbu swarasa cures dadru.
-Gandhaka lepa, prakshalana and internal administration with tilataila is useful in
pama, kandu, vicharchika etc. skin diseases.
-Shuddha gandhaka given internally with madhy relieves dadru, charmadala and
paama.
Some of the well known preparations of gandhaka are-
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Drug Review Concept of Avachurnana
The word avachoornana 78contains 2 words- ava+choorna
The word ava is derived from the root “mvaadim-param-set”.Means gatou,
praptou, praveshe, aadane 76i.e., to obtain, to enter, to borrow, to move
The word choorna77 is derived from the root “chrnyate pishyate yat” and
“sampeshnena jaata rajah” which means “pesha chornikaranam” i.e., the product
which is got from the act of pounding or the very fine dust got from pounding the
drug.
Its characteristics are explained as follows71-It is the dust or the powder which
is got from properly pounding the very dry drug or completely dried drug and sieved
through the cloth.
Fine powders will retain their complete potency till paksha traya paryantha
i.e., for about 1and1/2 months.
In shabda kalpa druma –ava+choorna+karmaani77
-choornikrita dravyam
Acharya Charaka has explained the procedure of avachoornana as
“choornasya vikiranam” The process of spreading or dusting the very fine drug
powder over the lesion is called avachoornana.
In charaka while explaining the treatment for kushta, it is said that the
Shatkashaya yogas can be used for snana (bath), paana (oral medication), aalepana
(external application), pragharshana (rubbing on the leison) and for avachurnana
(dusting on the leison)72
In Sushruta samhita the avachoornana procedure is defined as “vranoopari
choornaprakshepa”.73 i.e.,the depositing the fine drug powder over the lesion is call
Department of Prasooti Tantra and Stree Roga 74
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Drug Review avachoornana Here it is told in the list of shasti upakramas i.e., as a measure of”
vranopakrama.”74
It is used for two purposes –shodhanaartha75
-ropanaartha
If the lesion is having foul smelling discharge or ooze if the lesion is moist, or
more dampness is there in and around the leison or mucoid secretions are there then
initially drugs having shodhana property should be used for different types of
external applications like washing with kashaya or dusting with choorna etc.
If the lesion is devoid of above features or if the lesion appears shudda (shudda vrana)
then for different types of external application drugs having ropana property should be
used.
Lepa
Synonyms-aalepa, lepa, lipta, lepana
Types of application-Depending on the thickness of the local application of
medicines especially pastes (lepas) Acharya Sharngadhara classified the lepas as
follows
Pralepa- It is having the qualities like – shita (cool), tanu (thin), avishoshi (dry). It is
useful in diseases caused because of pitta dosha.
Pradeha- It is having the qualities like – arda (moist), Ghana (solid), and ushna
(hot/warm), and is beneficial in diseases caused by shleshma and vaata
Types of powder
Coarse powder-18-20 No. sieve
Fine powder- No. 60 sieve
Vatra gaalita powder (very fine powder)-No. 100 -120sieve
Department of Prasooti Tantra and Stree Roga 75
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Drug Review Absorption and availability of a locally applied drug
Skin has many essential function, including protection, thermoregulation,
immune responsiveness, biochemical synthesis, sensory detection and social and
sexual communication. Therapy to correct dysfunction in any of these activities may
employ chemical agents that can be delivered systemically, intra-lesionally or
topically and physical agents to which the skin can be exposed.
A unique aspect of dermatological pharmacology is the direct accessibility of
the skin as a target organ for the diagnosis and treatment. In most of the
dermatological conditions topical agents are employed alone or in conjunction with
phototherapy and/or systemic medications in the management.
Therapeutic agents can reach epidermal keratinocytes and immuno-competent
cells in the epidermis and the underlying dermis that are involved in the pathogenesis
of numerous cutaneous diseases. Topical agents can be applied directly to the skin but
must penetrate into the tissue to achieve efficacy. Appropriate use of topical agents
requires an appreciation of the factors that influence percutaneous absorption.
Skin and topical application Skin acts as a two way barrier to prevent absorption or loss of water and
electrolytes. This barrier resides in the outermost layer of the epidermis, the stratum
corneum, as evidenced by approximately equal rates of penetration of chemicals
through isolated stratum corneum or whole skin. Having lost their nuclei and
cytoplasmic organelles, the corneocytes of the stratum corneum are nonviable. The
cells are flattened, and the fibrous keratins are aligned into disulfide cross-linked
macro-fibers in association with filaggrin, the major protein component of the
keratohyalin granule.
Each cell develops a cornified envelope resulting from cross-linking of
involucrin and keratohyalin, forming and insoluble exoskeleton that acts as a rigid
scaffold for the internal keratin filaments. The intercellular spaces are filled with
hydrophobic lamellar lipids derived from membrane coating granules.
Department of Prasooti Tantra and Stree Roga 76
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Drug Review
The combination of hydrophilic cornified cells in hydrophobic intercellular
material provides a barrier to both hydrophilic and hydrophobic substances. In
dermatological diseases, the thickened epidermis may further diminish the penetration
of pharmacological agents into the dermis.
Types of local applicants are-
- Dusting powder,
- paste,
- lotion,
- drops,
- Ointments etc.
Types of local applicationTranscutaneous-Here galvanic current allows the penetration of drugs applied to the
skin into deeper tissues.
Inunctions-Drugs are rubbed into the skin.
Adhesive units- Here drugs are delivered to the affected desired site slowly.
Absorption and bioavailability 1)Simple or passive diffusion-Here molecules of the solvent and solute are
constantly in random motion and those that reach the lipid bilayer of cell membrane
get dissolved in it and rapidly transported across it through membrane down the
concentration gradient.
Eg.: Water-carries water and water soluble substances of small molecular
weight <700 like urea and alcohol.Hydrophobic lipid soluble molecules-(O2 N2 )
molecules of unionized ,lipid soluble drugs, small uncharged hydrophilic
molecules are transported like this.
2)Facilitated diffusion-Carrier protein carries the molecules from an area of higher
concentration to lower concentration
3)Active transportation-Here the molecules are carried against the gradient by using
the ATP.
Department of Prasooti Tantra and Stree Roga 77
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Drug Review Rate of absorption is needed to
- to determine the frequency of administration
- to ascertain the duration of effective action
- predict the onset of desired or undesired effects of the drug.
The route of administration determines the biological lag (i.e., the time between
administration and the development of the response)
Bioavailability-It is the amount or % of the drug that is absorbed from a given dosage
forms and reaches the systemic circulation following non-vascular administration.
Bioassay-It is used to measure the concentration of a specific active ingredient in the
given sample.
Principles of drug administration ensures that
-The drug must enter the skin in adequate concentration.
-It should be able to provide high concentration with minimal systemic absorption.
Drugs are applied to the skin in the form of various formulations in a variety
of pharmacologically inactive vehicles. Their effects depend upon the
pharmacological properties of the active drug/drugs and physical properties of the
vehicle.
Principles of absorption-Drug entry into the skin is determined by absorption of the
drugs into the skin-which depends on the following factors.
Partition co-efficient of the drug- It is the rate of diffusion of the drug from the
vehicle to the skin surface. Again this is dependent on the qualities of the vehicle.
It occurs between the vehicle and corneum stratum, which again depends upon the
lipid solubility of the drugs. Partitioning of the drug between the vehicle and stratum
corneum is the specific physiochemical feature of the individual drug.
State and Degree of the hydration of the stratum corneum- Hydration reduces
resistance to diffusion of drug. Increased hydration increases the drug penetration.
Drug absorption is increased with hydration, defined as an increase in the water
Department of Prasooti Tantra and Stree Roga 78
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Drug Review content of the stratum corneum that is produced by inhibiting in trans-epidermal loss
of water. Methods of hydration include occlusion with an impermeable film,
application of- lipophilic occlusive vehicles such as ointments and soaking dry skin
before occlusion.
The drug concentration-As the concentration of a particular ingredient increases in
the particular drug the absorption of that ingredient increases proportionately to a
certain level.
Regional anatomic variation-
Thickness of the skin- Skin thickness depends on the age of the person, and the
location in the body. Thicker the skin, lower the drug absorption.
Permeability generally is inversely proportional to the thickness of stratum corneum.
Drug penetration is higher on the face, in intertriginous areas and especially in the
perineum. Consequently the skin in these regions may be more susceptible to irritant
and allergic contact reactions. Skin sites that are naturally occluded by apposing
surfaces, such as the axillae, groin and infra-mammary areas, also may be vulnerable
to drug related toxicity such as atrophy from potent glucocorticoids.
In soles the thickness is more and the absorption is less. In genitals and in eyelids the
skin is thin and the absorption is comparatively more.
Aging/aged skin- is less permeable to the drugs.
Area/Site of the lesion-scrotal and vulval absorption is very high
Quantity of the preparations applied-Quantity again depends on the extent of the
lesion or the size of the lesion. The quantity is described and indicated for one
application for one specified and indicated area in the body of adults. As per this rule
the specified quantities are as follows
- -Face, head, hand, ano-genital area -2-4gm
- Anterior and posterior trunk-3-5gm
- Legs-around 4-8gm
- Entire body - 25-30gm (approximately 30 g is required to cover the body
surface)
Department of Prasooti Tantra and Stree Roga 79
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Drug Review Altered barrier function- In some dermatological conditions because of the
abnormality of stratum corneum the drug absorption may be increased or decreased.
- Presence of inflamed skin-Inflammation changes the tissue permeability, and
the oedema provides the liquid medium. These two mechanisms allow higher
penetration of the drug.
- Use of occlusive dressing-It increases the penetration of the drug by 10 folds
- Absorption of the drug also depends on presence and the quality of the
vehicle.
Application frequency-Topical agents are often are applied twice daily. The stratum
corneum may act as a drug reservoir that allows gradual penetration into the viable
skin layers over a prolonged period.
Vehicle-
Treatment of skin ailments is usually topical. Usually the topical preparation has two
parts.-The active ingredients
- The vehicles (liquids, powders, oils and creams)
Many factors influence the rate and extent to which topical medications are
absorbed. Most topical medications are incorporated into bases or vehicles that are
applied directly to the skin. The chosen vehicle can influence drug absorption and
provide therapeutic efficacy. They act by-
- They form a reservoir for the active ingredient.
- They allow local release of suitable amounts of the active drug.
- They provide a reasonably safe infrastructure for practical applications.
Many vehicles are used for their physical actions-soothening, lubricating, cooling
drying, moistening, softening, hydrating and protecting effects.
Topical preparations-
Powders/ Dusting powder
- They act by their physical property of absorbing moisture.
Department of Prasooti Tantra and Stree Roga 80
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Drug Review
- They contain ingredients like-talc, starch, chalk,talc cellulose, zinc magnesium
stearate and magnesium silicate.
- They can also provide a cooling effect by increasing the effective surface area
of the skin.
- They protect skin surfaces by reducing friction by their lubricating action
especially in the intertriginous areas such as axillae, groins and in the skin
folds under female breasts.
- Magnesium silicate if gets into the wounds or body cavities it may cause
granulomas.
Wet dressings-
- They are used to treat sub acute inflammation, after severe exudation is
stopped. Evaporation of the water from the lotion imparts the cooling effect.
- The residual dry powder acts as protective. But sometimes they cause
excessive drying.
Lubricating preparations-
- Include oils,
- Indicated for dry and scaling disorders.
- All the water based formulations must contain preservatives.
- Lotions are contra indicated if they form crusts or sometimes they excessively
dry the skin.
Counter-irritant and rubefacient- are irritant, that stimulate nerve endings in the intact
skin to relieve pain in the skin. Their precise mode of action is not known.
In case of localized pruritus- covering the lesion and minimal pressure by medicines
may help.
Drug delivery in dermatological diseases- In case of topical preparations, the molecules can penetrate the skin by three routes.
They are-through –intact stratum corneum
-sweat ducts
-sebaceous folliculi
Department of Prasooti Tantra and Stree Roga 81
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Drug Review
The surface of the stratum corneum presents more than 99% of the total skin
surface available for percutaneous drug absorption. Passage through this outer most
layer is the rate-limiting step for percutaneous absorption.
Preferable characteristics of topical drugs include low molecular mass
(600Da), adequate solubility in oil and water and a high partition coefficient.
Except for very small particles, water soluble ions and polar molecules do not
penetrate intact stratum corneum.
Metabolism The stratum corneum, i.e., the superficial keratin layer is both principal barrier
to penetration of drugs into the skin and it also acts as a reservoir for drugs.
After the adsorption depending upon the specific composition of the drug it
may be stored in the skin for prolonged periods.
A drug readily diffuses from the stratum corneum unto epidermis and then into
dermis, where it enters capillary circulation and thus into the systemic circulation.
There may be a degree of pre-systemic (1st pass) metabolism in the epidermis and
dermis, a desirable feature to the extent that it limits the systemic effects.
The major steps involved in percutaneous absorption include the establishment
of a concentration gradient, which provides the driving force for drug movement
across the skin; release of drug from the vehicle (partition coefficient); the drug
diffusion across the layers of he skin(diffusion coefficient).
The viable epidermis contains a variety of enzyme systems capable of
metabolizing drugs that reach this compartment including epoxide hydrolase,
transferases such as N-acetyl-transferases, and sulfatases. They influence the influx
and efflux of certain chemicals. Here substrate turnover is considerably less.
Department of Prasooti Tantra and Stree Roga 82
Material and Methods
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Material and Methods Material and Methods:
Sources of data for the clinical study
Minimum of 60 female patients suffering from genito-inguinal intertrigo were
selected from OPD and IPD of SDM Hospital of Ayurveda and taken for the study.
Method of collection of the data for the clinical study
It was a single blind clinical study, with pre-test and post-test design, wherein
60 diagnosed female patients of genito-inguinal intertrigo of age group 20-55 years
were selected & made into 2 groups of 30 patients each. One group was given candid
powder (a proved drug as control) & the other group was given khadiradi yoga
churna.
A special proforma was prepared with all points of history taking, symptoms,
physical signs and lab investigations as mentioned in our classics and allied sciences.
The parameters of signs and symptoms were scored on the basis of standard method
of statistical analysis.
INTERVENTION:The drug powder was dusted to the affected area twice daily after
cleaning the part with pre boiled water and drying the area with clean gauze.
DOSE: Approximately 5gm of the powder was dusted on the surface of the affected
skin twice in 24 hours.
DURATION OF ADMINISTRATION: 5 days to 3 weeks.
FOLLOW-UP: One week later, after the medication is stopped.
INVESTIGATIONS: Routine investigation if needed.
Inclusion Criteria: - Patient aged 20-50 years.
-Diagnosed cases of genito-inguinal intertrigo/kacchu in otherwise healthy female
patients.
-Genito-inguinal intertrigo/kacchu with gynecological conditions wherein
administered drugs do not have an action on the lesion.
- Diagnosed cases of genito-inguinal intertrigo/kacchu in pregnancy in all three
trimesters.
-Diagnosed cases of genito-inguinal intertrigo/kacchu in puerperal state.
Department of Prasooti Tantra and Stree Roga 84
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Material and Methods Exclusion criteria:
- Patients with intertrigo with other skin diseases.
- Chronic intertrigo with atrophic changes.
-Intertrigo with complications like septicemia.
-Patients with systemic diseases like diabetes, HIV and immuno compromised state.
-Patients on steroid treatment.
-Intertrigo in locations other than genito-inguinal region.
-Intertrigo with gynecological conditions wherein administered drugs have an action
on the lesion.
Assessment Criteria:
The assessment was made on the basis of changes in the following subjective and
objective parameters.
Table No-13
Pain Subjective parameters
Itching
Area of the lesion
Redness (Sign of Inflammation)
Discoloration
Warmth
Edema
Roughness
Discharge
Tenderness
Objective parameters
Blisters
Results obtained were given as:
• Completely cured.
• Mildly reduced.
• Not reduced but status quo maintained.
• Aggravated.
• Association of complications if any.
Department of Prasooti Tantra and Stree Roga 85
Observations
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Observations Following observations are made during the study. Observations are made before,
during and after the treatment.60 patients fulfilling the inclusion criteria of kachchu and
In the current study, out of 60 patients, 45.00% women had sudden onset, 43.33% women
have recurrent onset and 11.67% women had gradual onset.
23) Table No-36 Duration of intertrigo
Number of Patients Duration Test
Group Control Group
Total %
1 day - 3 days 8 6 14 23.33% 4 days - 7 days 13 11 24 40.00% 8 days - 15 days 5 7 12 20.00% 16 days - 29 days 1 2 3 5.00% 30 days - 60 days 2 2 4 6.67% > 60 days 1 2 3 5.00% Total 30 30 60
Department of Prasooti Tantra and Stree Roga 100
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Observations
Figure No-23
0
5
10
15
Duration
Duration of Intertrigo
Test Group
Control Group
In this study, in 40.00% women the intertrigo started 4-7days back, in 23.33% females -
1-3days back, in 20.00% women – 8-15 days back and in 5.00% women about 30 days and
-30 patients had over all cure rates of 94.24%. -None of the patient encountered complications solely due to the drug. -None of the patients had aggravation of symptoms.
Phytochemical Analysis
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Phytochemical Analysis Preliminary Phyto-chemical analysis of khadiradi yoga choorna
This was a preliminary study of the thesis drug. It is a qualitative analysis
where in we will come to know about the basic chemical ingredient of the compound.
This analysis was carried out in three media-aqueous, chloroform and ethanol media.
Five grams of the drug powder was taken in 3 glass containers. For the first
container 100 ml of distilled water was added, for the second container 100 ml of
chloroform was added and for the third container 100 ml of ethanol was added. All
the three containers were covered with a glass lid and kept undisturbed overnight.
Next day morning the contents of all the three containers sieved through the sieving
papers and the solutions are collected in the separated containers.
Organoleptic characters
Aqueous solution –colour- orange
With ethanol-brown
With chloroform-yellow
Then the preliminary phyto-chemical analysis of the solutions was carried as per the
guidelines. The results were as follows-
Table No-71 Preliminary phyto-chemical analysis of khadiradi yoga choorna
A) Proteins
Aqueous solution chloroform Ethanol
Biuret test -ve -ve -ve
Ninhydrin test -ve -ve -ve
Xanthoprotein test +ve -ve +ve
Hopkin-cole test +ve +ve -ve
Sulphur test -ve +
ve
+ve
Xantho protein test showed that there is nitro derivatives of aromatic amino acids and
sodium salts of nitroderivatives of amino acids in ethanol extract.
Department of Prasooti Tantra and Stree Roga 128
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Phytochemical Analysis Hopkin-cole test showed that in aqueous extract and in choloroform extract there are
Indole group of tryptophan.
Sulphur test-Sulphaur containing aminoacids of proteins are present in choloroform
extract and ethanol extract.
B) Carbohydrates
Aqueous solution chloroform Ethanol
Molisch’s test +ve +ve +ve
Iodine test -ve -ve +ve
Fehling’s test +ve +ve +ve
Benedict’s test +ve -ve +ve
Fehling’s test and Benedict’s test -reducing sugars are present in all three extracts
Non reducing sugars such as sucrose
Aqueous solution chloroform Ethanol
Benedict’s test -ve -ve -ve
Non reducing sugars are absent in all the three extracts
Tannins
Aqueous solution chloroform Ethanol
Gelatin +ve +ve +ve
Anthocyanins
Aqueous solution chloroform Ethanol
Acqueous NaOH
test
-ve -ve -ve
Concentrated
H2So4 Test
-ve +ve +ve
Department of Prasooti Tantra and Stree Roga 129
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Phytochemical Analysis Glycosides
Aqueous solution chloroform Ethanol
Molisch’s test +ve +ve +ve
Concentrated
H2SO4 Test
+ve +ve +ve
Keller Kiliani test +ve +ve +ve
Saponin
Aqueous solution chloroform Ethanol
Foam test +ve -ve -ve
Flavanoid
Aqueous solution chloroform Ethanol
Flavanoid test +ve
Pew’s test
(Zn/HCl) for
dihydroflvanonols
-ve -ve -ve
Shinoda test
(Mg/HCl)
-ve -ve -ve
Aqueous NaOH
test solution
-ve +ve +ve
Concentrated
H2SO4 test
+ve +ve +ve
Phenols
Aqueous solution chloroform Ethanol
phenol +ve -ve +ve
Steroids
Aqueous solution chloroform Ethanol
Salkowski test +ve +ve +ve
Department of Prasooti Tantra and Stree Roga 130
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Phytochemical Analysis Alkaloids
Aqueous solution chloroform Ethanol
Mayer’s test -ve -ve +ve
Dragendroff’s test -ve -ve -ve
Interpretations of the phyto chemical analysis of Khadiradi yoga choorna
Khadiradi yoga choorn is used in the powder form. It is dusted over the skin
lesions and the clinical efficacy is seen. There it is thought to act in the damp
environment of the genito-inguinal region, which is inflamed.
So, from the preliminary phyto chemical study, the results of the acqueous
solution is used to give the interpretation. Here only those test results are interpreted
in which the aqueous media has showed positive results.
Aqueous solution can be used in two forms-Hot extract. eg- Decoctions
- Cold extract eg-dissolving the drug in the
distilled water or in normal saline in room temperature.
Depending on the above results hypothetically we can say that the cold aqueous
extract of Khadiradi yoga choorna is having the following properties.
Proteins - Proteins are helpful to kill some of the germs. They also help to dry up the
local area and restrict the growth of the micro organisms.
Carbohydrates - They are the energy producers. They may help the localized cells by
providing them the nutrients and thus help to fight against the organisms.
Carbohydrates are the energy source for even the bacteria but only in the damp
environment. When the proteins dry up the skin surface, the organisms will not get the
nutrients to grow and colonize.
Glycosides - They are known to be anti bacterial and anti fungal. They directly act on
the organisms and reduce their growth and actually kill the bacteria.
Saponins - Act as cleansers. It may regulate in the controlling the growth by
restricting the further growth of the bacteria.
Department of Prasooti Tantra and Stree Roga 131
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Phytochemical Analysis Phenols - They act as detergents. It removes slough and helps in debridement.
Steroids - They are known as potent anti inflammatory agents and helpful to reduce
the inflammation.
Tannins - They dry up the skin. They are also known to constrict the peripheral micro
vaso circulation. Because of vaso constriction the oozing decreases. Most of the
bacteria and fungi are known to derive their nutrients in the damp environment and
multiply. Because of the dryness of the skin there reduction of nutrient supply to the
bacteria. When the skin dries up the other chemicals present in the drug like phenols,
proteins, carbohydrates and steroids act against the micro organisms,
Over all we can hypothetically say that the steroids, phenols, glycosides, and
proteins present in the Khadiradi yoga choorna, will collectively act both at the host
tissue level and even at the organism level. The drugs present in the Khadiradi yoga
choorna collectively act and induce the dryness, reduce the oozing, cleanse the debris,
cut short the nutrient supply to the micro organisms, there by restrict their
multiplication and growth. They may also act as bacteriocidal and fungicidal. We
cannot also rule out the possibility of nullification of the toxins released by the
organisms.
When we see the properties of the above ingredients, and the results of the
chloroform and ethanol extracts, in which some of the main contents are not seen, we
can definitely say that the aqueous extract of the drug is more efficacious than ethanol
and chloroform extracts.
Department of Prasooti Tantra and Stree Roga 132
Microbiological Study
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Micorbiological Study Microbiological study
Research work done in the clinical field will always get strength if it is
supported by the in vitro study. So, Microbiological tests done to identify the
organisms in the smear taken from the patient and to see the sensitivity of Khadiradi
yoga choorna on those organisms.
Intertrigo is primarily an inflammatory condition of the skin folds which will
eventually gets infected by superadded secondary opportunistic fungal or/and
bacterial infections.
Cutaneous Infections of the genital area- It comprises of two main organisms- Bacteria and fungus. In fungus group
there are two groups. They are - candida and dermatophytes. In candida group,
candida albicans is the main culprit, but other types like candida globrata can also be
involved.
In Bacteria group- there may be streptococcus pyrogens, staphylococcus
aureus, E. coli and pseudomonas aeruginosa.
Candida albicans, staphylococcus aureus, E. coli and pseudomonas aeruginosa
are commensal and pathogen. Commensal is an organism which is seen in the healthy
living body without causing any pathology. Pathogen is an organism which will cause
pathology in the living body-may be systemic or local, superficial or deep.
When the host tissue immune drops they will turn into pathogen and will
cause opportunistic infection. So, they are more prevalent in immuno-compromised
patients like who are on long term antibiotics, after organ transplantation, long term
steroid therapy and in HIV patients. In all these patient there are chances of systemic
fungal infection.
When there is lack of hygiene in the genital parts, along with obesity and
excess sweating, inflammation of the skin occurs. When there is drop in the host
tissue immune level particularly cellular immunity due to inflammation, candida
Department of Prasooti Tantra and Stree Roga 134
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Micorbiological Study albicans and other bacteria acquires pathogenicity by changing its gene structure and
causes infection. For changing the gene structure it needs warmth, dampness, and
particular level of pH etc.
When the candida acquires pathogenicity, hyphae start growing and they cause
colonies in that area. Presence of hyphae, fast multiplication and high number of
organisms per colony will microbiologically decide its pathogenesis.
Culture of the Candida albicans- To grow the candida in the laboratory set up the following culture media is
required. Here two types of media are used. They are-
-Muller Hilton agar (MHA)
-Sabourad’s dextrose agar (SDA)
Agars can be manually prepared or commercial one can also be used. Their
constitution is as follows-
Peptone-1%
Dextrose-4%
Agar-2%
Distal water-100%
Depending on the physical state of the agar, its concentration changes as follows
For solid-2%
Semisolid-1.5%
Liquid-0%
The ideal pH of the media should be 5.6. So, one should check pH before
adding the agar. After mixing the constituents, the media is sterilized at 121.F for 15-
20 minutes.
Method of taking the smear- A sterile cotton swab is taken and rubbed on the intertrigous lesion. Under
aseptic method, the mouth of the test tube containing the culture media is heated for
Department of Prasooti Tantra and Stree Roga 135
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Micorbiological Study while in the tip of the flame to avoid contamination and the swab is introduced into
the test tube without touching the walls of the test tube. It is gently rubbed against the
agar media and taken out. The test tube is closed with a sterile lid to prevent further
contamination. -The test tube is incubated at 37.c for 2 days. After 2 days, if candida
albicans is present, its colonies will be seen which are having the characteristic
features of oil paint appearance.
In this method the swabs taken from 10 clinically diagnosed patients revealed the
colonies of candida albicans.
Sensitivity test (AFST)-It is called as antifungal susceptibility test.
Here the sample can be used in two types
- in the powder form or
- in the aqueous form.
To get the aqueous solution broth dilution method is used and the resultant solution is
used for the further tests.
Broth dilution- Here the test drug is serially diluted into various concentrations in
water or normal saline and then tested for sensitivity.
Anti fungal susceptibility test can be done by two methods. They are as follows.
1. Stokes’s method-Here lawn culture is done. Then the drug powder is
sprinkled over the culture and it is incubated at 57.C for 18-24hours. Then the
readings are taken. Results are interpreted as –whether it is susceptible or
resistant.
2. Well method-Here a suspension of the drug is done initially in normal saline
(5 g powder in 5 ml NS). In the centre of the media a small well of dimension
2mm*2mm is made with a red hot needle and a required amount of the drug
suspension is placed and it is incubated at 37.C for 18-24 hours. Then the
readings are taken. Results are interpreted as –whether it is susceptible or
resistant.
Department of Prasooti Tantra and Stree Roga 136
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Micorbiological Study
Both Stokes’s method and Well method was adopted and the sensitivity was tested
against Candida albicans.
When the powder was used, there was no inhibition of the fungal growth.
When the drug was used in the aqueous media, there was partial inhibition of the
growth of the fungus.
Bacteriological study-
Culture of bacteria-For this nutrient agar is used. It is readily available in the
market or one can prepare it. It is having following ingredients.
Nutrient agar
Contents are-
Peptone-4g
Nacl-2g
Beef extract-2g
Distilled water-100ml. Mix all these thing together and check the pH. It should be 7.4.
Then add 2g Agar, mix thoroughly.
To prepare the commercially available agar, we have to mix the agar powder
1g in 50 ml distilled water and mixed. In both the methods, then it is sterilized at
121.F for 15 minutes and 15 pounds pressure. Then the agar poured into culture plates
under aseptic measures and allowed to solidify. Smear is taken in the same method as
told previously and culture is done.
In three patients the colonies of E coli, staphylococcus aureus and in one
patient pseudomonas aeruginosa is seen.
Sensitivity test-
Such 3 culture plates were prepared and lawn culture is done with E. coli,
Staphylococcus aureus and pseudomonas aeruginosa to separate plates and incubated
at 37.c for 24 hours. Next day the culture of the respective bacteria are seen. After
Department of Prasooti Tantra and Stree Roga 137
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Micorbiological Study confirming that there is no contamination, the sensitivity test is carried out by
Stokes’s method and as well as well method. Again these culture plates were
incubated at 37.c for 24 hours. Next day result were seen
In another method, while culture media is being prepared, 10gm of the drug
powder is added to the agar mixture after confirming the pH. Mixed thoroughly and
as usual sterilized at 121.F for 15 minutes and 15 pounds pressure. Then the culture
plates were prepared in the traditional method. Another three culture plates were
prepared without adding the kahdiradi choorna. To this lawn culture is done with E.
coli, Staphylococcus aureus and pseudomonas aeruginosa to separate plates and
incubated at 37.c for 24 hours. Next day the culture of the respective bacteria are seen.
Results.
1) In the powder form the drug is found ineffective against all the three bacteria.
2) In the well method, the drug is found to partially inhibit the organisms in E coli,
Staphylococcus aureus, and slightly Pseudomonas aeruginosa.
3) In the culture plates where in the agar contains the Khadiradi choorna in it then the
organisms were inoculated, the organisms were not grown in all the three plates. In
the control group the organisms developed in all the three plates.
Confirmation of pathogenicity in microbiology-
For candida -Hyphal growth, increased cell division
For staphylococcus aureus-Golden colour pigment production
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Micorbiological Study
Candida albicans-culture
E coli Staphylococcus aureus
Pseudomonas aeruginosa
Department of Prasooti Tantra and Stree Roga 139
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Micorbiological Study Sensitivity test results Staphylococcus aureus and E coli
Agar prepared with khadiradi choorna
Sensitivity ring seen No growth of organisms
Pseudomonas aeruginosa
Stokes method and Well method
Sensitivity ring is seen No growth is seen
Candida albicans
Stokes method
growth seen
Well method
Sensitivity ring is seen (zig zag)
Department of Prasooti Tantra and Stree Roga 140
Discussion
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Discussion
Discussion “Aturasya vikara prashamanam” is one of the aims of Ayurveda. Health is
been given the utmost importance in Ayurveda whatever the severity may be. When
systemic or local manifestations affect a person’s day to day life, he/she seeks the
treatment. Out of the many health issues, dermatological complaints have their own
place in the field of medicine.
Skin manifestations are the common problem with which a person suffers
from one or the other day in his life time. It may be grave like leprosy or minor like
intertrigo. Viral infections with cutaneous manifestations like masurika and
romanthika are included under the broad heading kushta. They may be generalized or
localised. They may be in the exposed part or in the private parts. They may also be
involved with systemic manifestations like fever or septicaemia or may not have any
symptoms except simple discolouration.
In Ayurveda skin diseases are explained under two heading-kushta and
kshudra roga. Diseases explained under kushta includes pathologies with cutaneous
manifestations along systemic symptoms, where as the diseases explained under
kshudra roga comprises of moderate to minor pathologies like kachchu and nilika
(exceptions being guda bramsha, agni rohini and valmika). Of many diseases
explained under kshudra roga, kachchu is one among them. Kachchu is mentioned as
a separate disease entity for the first time in Sushrutha samhita. Later books like
Astanga hridaya, Yoga ratnakara, Madhava nidhana,Chakra datta followed Sushruta.
Discussion on kachchu
The word kachcha refers to the region where in the humidity or water content
is more. It also refers to kandu. According to this derivation, kachchu is a pathology
which occurs in that part of the body having more dampness and is mainly consists of
itching. Vrushana pradesha is having more dampness because of the compactness of
the anatomical structures and is more prone for kachchu. Probably because of this
reason, the disease is named as (vrushana) kachchu. But this pathology is not specific
for males and can also be seen in females in the inguinal region.
Department of Prasooti Tantra and Stree Roga 142
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Discussion
Snana utsadana hinatha and kanduyanatha are considered as the specific
nidanas for the manifestation of (Vrushana) kachchu. Because of the nidanas, the
accumulated sweda mala which is in the form of a layer over the vrushana pradesha,
gets moistened by excessive perspiration and causes the symptom kandu. If the person
scratches there will be manifestation of sphota and srava. This disease mainly occurs
because of kapha and rakta vitiation. Since the disease is not specific to male gender,
by the word vrushana we have to consider the anatomical location than anatomical
organ. Sweda is the mala of meda. So, in stula purusha sweda pravruti is more, and
hence such patients are more prone to get this pathology.
Overall we can say that kachchu occurs in such a place or site where in
sweating is more and local hygiene is less as in case of genito-inguinal part.
Discussion on intertrigo
Intertrigo is a cutaneous inflammatory disorder that mainly affects the skin
folds. For the manifestation of intertrigo occurring in the genito-inguinal region
excessive dampness in that region, along with sweating, and unhygienic conditions
are required. Mainly unhygienic conditions like not taking bath, wearing unhygienic
undergarments, new synthetic undergarments without washing them, improper drying
of the used undergarments, using the damp undergarments, heavy clothing, and
frequent washing of the genitals which makes the undergarments wet and of course
incontinence of urine and faeces will cause the intertrigo in the genito-inguinal region.
In this modern era, wearing the sanitary pads for longer duration and disposal at
infrequent intervals can be considered as one of the main aetiologies. Obesity,
diabetes mellitus and excessive perspiration will precipitate the pathology in the
genito inguinal region because of its compactness, occlusion, and dependent area for
the sweat flow in the body.
Even though the genito-inguinal intertrigo is basically an inflammatory skin
disorder it will usually be complicated by secondary bacterial or/and fungal
infections. It initially starts with inflammation of the superficial layers of the skin,
sometimes followed by blister formation with or without maceration. Usually it
involves the skin folds wherein the sweat is not disposed off properly.
Department of Prasooti Tantra and Stree Roga 143
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Discussion
Intertrigo is not a pathology which is specific to male or female gender, or nor
it is specific to genital region. But still it is more prevalent in females especially in the
genito-inguinal region because of different forms of occlusion and retention of
sweating. Effects of occlusion are more marked in pregnancy, puerperium, increased
p/v bleeding or discharges and obesity.
In kachchu and in Intertrigo, aetiology is accumulation of sweat in the genito
inguinal region which moistens the superficial layer of the skin which will be
containing the dead exfoliated cells. Further, the friction, which may be in the form of
scratching, will eventually be followed by the formation of blisters and maceration.
With all these aetiologies and symptomatologies, the kachchu can be best
correlated to the dermatological disease intertrigo occurring in the genito-inguinal
region.
In both cases because of etiological factors- there is itching followed by blister
formation and exudation from the inflamed skin surfaces. Scratching because of
intractable itching and friction of the skin surface with the opposite skin surface or
friction with the undergarment acts as precipitating factor.
Why genito-inguinal intertrigo should be considered in OBG
• Health is the ultimate goal of Medicine, whatever the branch may be and the
aim should be to help the patient to get relieve from the disease.
• Females do give the first preference to the gynecologists for the diseases
related to genital parts.
• Since obstetric and gynecological patients can also be presenting with the skin
disease in the genital parts, the obstetricians should be well versed with the
skin manifestations of the vulva and the surrounding region.
Department of Prasooti Tantra and Stree Roga 144
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Discussion
• The clinical and pathological features of the dermatological diseases are
modified by the unique environment of the vulva. The skin of the vulva differs
notably from the remaining body surface by its moist, friction-prone and
bacteria-rich environment. The local condition predisposes the vulva to the
development of certain dermatological disorders. The clinical and pathological
manifestations of dermatosis may differ from those occurring elsewhere in the
body because of the local factors.
• Genital area is a damp area. The aeration is less because of the compactness
and occlusion and is more prone to get the infections like intertrigo.
• In gynecological conditions like increased white discharge, increased p/v
bleeding etc because of increased moistness, use of sanitary pads and pre-
existing infection there are every chances of developing infections in that
anatomical region.
• During rainy and summer season where moistness and sweating are more,
every 3rd pregnant patient who is entering the OPD is having genito-inguinal
intertrigo as the associated complaint.
• The genito-inguinal part is expected to be healthy during labor and is also
prone for infections like intertrigo because of prevailing dampness and the
increased compactness of that region during pregnancy
• In neglected cases, the intertrigo may extend to transverse incision in the
abdomen and interfere in its healing.
• In puerperium increased discharge of lochia, use of sanitary pads may
precipitate this or may exaggerate the condition in prone persons.
• Obesity may also act like precipitating factor. Obesity can be seen during
pregnancy, perimenopausal age and in some of the gynecological diseases like
PCOD.
Department of Prasooti Tantra and Stree Roga 145
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Discussion
• The rate of absorption of drugs in that area even in the non-pregnant state is
higher than other parts of body, which gets further increased during
pregnancy. The drugs which are used for the external application should not
harm the fetus, should not interfere with the normal course of pregnancy or
should not cause any unwanted results in the skin in that part, as episiotomy is
the probable procedure in the future.
• Drugs that are used for the local application should not interfere with the
resolving infection of vagina or cervix or they should not predispose the
ascending infection.
• Intertrigo is explained in the text books of gynecology, in the context of
infectious diseases of vulva, i.e., this pathological entity is a part of
gynecology.
Discussion on survey results
The survey was done to know the incidence of genito inguinal intertrigo in
patients attending the Gynec OPD. It showed that around 30% of the patients seeking
the consultation from the Gynec OPD are having the manifestation of intertrigo. It
also showed that most of the patients were from obstetric group. Highest number of
patients were in September i.e., sharad rutu. It is marked by pitta and kapha
pradhanyatha. Pitta is predominant in sharad rutu, and kapha starts accumulating in
hemantha rutu.
Second big group is in May and June when there is rakta prakopa. As kachchu
is predominated by the kapha and pitta dosha, during the starting of rainy season and
ending of the rainy season where there is more heat in the atmosphere, sweating is
more and also the moistness is more because of rain, kachchu is more prevalent.
Intertrigo is more prevalent in hot humid season, which will precipitate the
skin fold friction in the genito inguinal region. Hot humid season will also increase
the sweating and thus dampness in the genito inguinal region. Because of the
Department of Prasooti Tantra and Stree Roga 146
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Discussion mechanical factor i.e., friction there occurs inflammation which will change the
homeostasis between the commensals and the host tissue immune level in the genito
inguinal region. This will trigger the onset of secondary bacterial and fungal infection
in that region. Hotness and humidity is more prevalent when summer ends and rainy
season starts, and similarly at the end of rainy season. This period is nothing but the
rutu sandhi kala as told in the ayurvedic literatures.
Incidence of genito-inguinal intertrigo is more in third trimester gestation.
This could be because of increased weight gain during third trimester, increased
perspiration as pregnancy is a hyper metabolic stage and thermogenic stage and
increased compactness of the perineal region. More over pregnancy is an immuno
compromised state. In the last trimester, since the gravid uterus, particularly the
presenting part of the foetus presses against the bladder there will be increased
frequency of micturition, stress incontinence and some times urge incontinence. This
will increase the dampness around the vulva and also increases the chances of friction
by wetting the undergarments. All these will contribute to the manifestation of
intertrigo in the third trimester.
Second largest group is puerperium. Puerperium is marked with lochial
secretion for longer duration, sometimes there is co-existing episiotomy. Patients will
use pads. Patients will be asked to appose their thighs to have the better healing of
episiotomy wound. In puerperium also there will be increased perspiration. Occlusion
of the vulval part with sanitary pads, increased sweating and compactness of the
perineal region will precipitate the manifestation of the intertrigo.
Incidence of intertrigo is more in people taking katu amla and lavana pradhana
ahara. Katu, Amla and lavana rasa will cause syandana of kleda and increase the
sweating in the body. If it is associated with occlusion in the genito inguinal part, then
it will precipitate the disease kachchu.
Discussion on treatment aspects
Many treatment modalities are told in the classics, which includes, application
of herbal powder combination having saindava or haratal as one of the constituent.
Department of Prasooti Tantra and Stree Roga 147
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Discussion Saindava melts in this hot humid environment, so such combination cannot be
preserved for long. Safety of haratala application to genital area during pregnancy and
puerperium is questionable. Patoladi ghrita is also mentioned which is difficult to take
during pregnancy and puerperium.
Application of pralepa may not serve the purpose as it may liquefy because of
increased sweating. Washing with kashayas will include a tedious job of preparing the
kashaya, and after application it will remain in the place for a short while and hence
may prove less efficacious.
So, a new formulation is done strictly based on the ayurvedic principles and a
combination of powder is prepared. The combination contains kahadira, triphala,
haridra, shirisha, musta, saptaparna, nimba and gandhaka and dugda pashana. They
have kustagna, kandugna, vedanastapana, dahaprashaman and varnya property. The
combination of powder is named as khadiradi choorna after the name of the first drug-
khadira. All the drugs except dugha pashana are taken in equal quantity. To that 25%
of dugda pashana is mixed which is based on the observations got by the pilot study.
All the drugs are taken in the form of vastra galitha choorna and mixed thoroughly by
doubling up method.
Concept of avachurnana is mentioned in brhatrayis. It is one of the vruna
shashti upakrama. It is having both shodana and ropana property. Here the drug
powder is sprinkled over the lesion. Because of the simplicity of the procedure and as
this procedure is agreeable to all category of patients including pregnant, puerperium
and peri-menopausal patients this method is adopted. Avachoornana is also suitable
for a sthanika twakgata vyadhis like kachchu.
Dusting powders having clotrimazole with out without steroids are advised for
intertrigo in the contemporary modern medicine system. Clotrimazole is an imidazole
belonging to azole group of antifungals. It is widely used for topical application. It is
having broad spectrum antifungal activity along varied range of antibiotic activity.
Clotrimazole inhibits the fungal cytochrome P450 enzyme and thus impairs ergosterol
synthesis leading to a cascade of membrane abnormality of fungus. Even though it is
Department of Prasooti Tantra and Stree Roga 148
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Discussion claimed to be having 60-100% cure rate it needs 2-4weeks application. Irritation,
stinging and burning sensation is experienced by some patients. If there is secondary
bacterial infection in the intertrigo, proper antibiotics should be given. Steroids can be
used for their anti-inflammatory property. Since in the culture study, candida albicans
is got, and candid powder is a proved drug for intertrigo, it is taken as the drug for the
control study.
Discussion on methodology, observations and resultsIt was a single blind clinical study with a pre test and post test design. Here 60
patients between the age group of 20-60 years were selected from the OPD and IPD
of SDM hospital of ayurveda, udupi. The pratyatma lakshanas of kachchu and
intertrigo were considered for the selection. Here for the test group comprising of 30
patients, khadiradi yoga avachurnana was done and for another group of 30 patients
candid powder dusting was done. Candida is a popularly used drug for the intertrigo
and its efficacy is well proved. The results were compared.
Age – In this study, all patients belong to madhyama avasta i.e., between 18 -53 years.
In females, during this reproductive and sexually active period, there will be
menstrual cycle, pregnancy, puerperium, menopause, and pathological states like PID,
irregular bleeding p/v because of varied aetiologies. So this group is considered. In
the present study, highest number of patients i.e., 40% females were of 24-29years.It
may represent the age of women seeking obstetric advise, in this region.
Marital status- In this study, 95% patients were married. This group comprises of
pregnant, puerperium and peri-menopausal age group patients. Patients with
gynaecological disorders are also from this group. Vaginal discharge is more common
in sexually active females. Pregnancy, puerperium, or peri-menopausal bleeding are
most important stages of the life in which females where in there is need for the usage
of sanitary pads. Using sanitary pads and presence of vaginal discharges are the main
precipitating factors. So, unmarried females registered are less in this study.
Distribution of the patients according to different stages- In the present study,
52.63% females were pregnant, 24.56% females were puerperium, 17.54% females
Department of Prasooti Tantra and Stree Roga 149
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Discussion were married but not pregnant and 5.26% females were in the peri-menopausal age.
This may represent the population visiting the OPD of SDM hospital as well as
increased incidence of intertrigo in pregnant patients and puerperium patients.
Occupation-In this study, 75% females were housewives. As this study considers
female patients in different stages, pregnant females in 3rd trimester and in puerperium
will be at home leading a sedentary life. Pregnant and puerperium patients comprise
of largest proportion in this study.
Religion-Maximum number of patients i.e., 61.67% registered in this group is
Hindus. This indicates the dominance of Hindu population in the locality where in this
particular study was undertaken.
Socio-economic status-Maximum numbers of patients (63.33%) were belonging to
the middle socio-economic status. This may represent the dominance of middle class
people attending this charitable hospital.
Education-Most of the patients (45%) registered in this study were completed high
school level.
Ahara- Maximum number of patients (83.33%) was having mixed diet. This will
explain the prevalent food pattern in this costal region. Non vegetarian diet is rich in
proteins and fat. They help to increase in the body weight. Obesity is one of the
triggering factors in the manifestation of the intertrigo.
Incidence of bathing habits- In this study out of 60 patients, 68.33% females were
having daily bath, 20.00% of females were having bath once in 2 days and 11.67%
females were having bath once in 3-4 days. Either this observation inconclusive or it
needs a study in a large population.
Type of occlusion- Out of 60 females registered for this study, 43.33% women were
using synthetic undergarments, 40.00% females gave the history of using sanitary
pads and 16.67% females were wearing heavy clothing. This suggest that occlusion in
Department of Prasooti Tantra and Stree Roga 150
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Discussion the genito inguinal area which will hamper the proper disposal of the sweating in that
particular region is acting as one of the cause or it is creating a favourable
environment for the manifestation of the development of the intertrigo.
Predominant ahahra rasa- Most of the patients were using katu, amla ,lavana and
madhura rasa.These rasas cause the pitta and kapha vitiation and amla and lavana rasa
will cause syandana of kleda. So, this particular food habit may contribute to form a
damp environment in the genito inguinal region in prone patients.
Sweating- 81.67% patients had excessive sweating. Ati sweda pravruti causes the
kandu. In kachchu it is said that, sweat moistens the mala that is present in the groin
region and causes the kandu and further manifestation of the disease. Excessive
sweating in the genito inguinal region causes the friction of the skin fold because the
sodium chloride in the sweat is said to cause the apposition and stickyness of the skin
surfaces. This will predispose the manifestation of the intertrigo eventually.
Problems associated with micturition- 93.33%females presented with increased
frequency of micturition and 26.67% females presented with urge incontinence. This
may wet the undergarments, which will cause subsequent friction. It may also harbour
the organisms which will be responsible for the manifestation of intertrigo like E. coli.
Both the features are seen during pregnancy, puerperium, vaginitis, and in UTI.
Presence of vaginal discharge- 68.33% women had vaginitis with vaginal discharge,
3.33% women had increased p/v bleeding, 11.67%women had lochial discharge and
there was no vaginal discharge in 16.67% women. Presence of discharge per vaginum
either needs pads, or they may disturb the normal eco system of organisms in the
genito inguinal area. It also increases the chances of occlusion and compactness of
that particular region.
Gestational age-In the population of pregnant patients registered for this study,
66.67%pregnant patients were in 34-39 weeks. This suggests that incidence of
intertrigo is more in patients near the term. This may be due to various causes like
Department of Prasooti Tantra and Stree Roga 151
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Discussion increased sweating, increases compactness of the genito inguinal region, change in the
eco system of the genito inguinal area as a preparation for labor, etc.
Presence of episiotomy wound- In the population of puerperal patients’ group who
underwent vaginal delivery, registered for this study, 87.50% women had episiotomy
wound. Presence of a wound in the perineal region adds to the inflammation in that
particular region.
Location of episiotomy wound in relation to intertrigo- In the present study in
64.29% women the intertrigo was on the episiotomy lesion. Presence of the wound
even though intentionally created, adds to the inflammation on that particular region.
The pathogens causing the intertrigo may enter into the wound, contaminate that area
and may cause wound gaping or infection. In such cases wound debridement and re-
suturing may be required. In the presence of infection like intertrigo if untreated,
proper healing of the episiotomy wound is either delayed or there may be some other
complications like wound gaping.
Mode of onset of intertrigo-45.00% women had sudden onset, 43.33% women have
recurrent onset and 11.67% women had gradual onset. It may suggest that acute and
recurrent onsets are very frequent.
Duration of intertrigo since onset- In 40.00% women the intertrigo started 4-7days
back, in 23.33% females - 1-3days back, in 20.00% women – 8-15 days back and in
5.00% women about 30 days and 60 days each respectively. In the acute onset
patients tends to report early as there is intense itching, pain, and blisters. Once it
reaches chronic stage, with little maceration, pain reduces, so patient may ignore it
unless they are in pregnancy or puerperium.
Nature of the area involved-In 76.67% women the genito inguinal area was moist in
70.00% females the skin of the genito-inguinal area was smooth and in 30.00%
females the skin of the genito inguinal area was rough. In the acute and macerated
lesions the area will be moist and smooth. In chronic lesions the area will be rough
because of lichenification.
Department of Prasooti Tantra and Stree Roga 152
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Discussion Presence of pain –All the patients had pain but of varied nature. Out of them, 65.00%
women had intermittent pain and 35.00% women had continuous pain. In intertrigo,
continuous pain will be present in the presence of acute inflammation, and
intermittent pain will be present in the vaning stage of acute inflammation, and in the
presence of intermittent friction,
Character of pain-46.67% females were complaining of acute pricking pain, 38.33%
females were complaining of burning pain,10.00% females were complaining of dull
pain and 5.00% females were complaining of numbness. Acute pricking pain and
burning pain is present in acute stage and dull pain is present in macerated stage and
chronic stage may present with numbness because of lichenification. It can be
interpreted as acute phase is due to pitta and chronic phase with maceration is
dominated by kapha.
Intensity of pain- 46.67% women were complaining of severe pain, 30.00% females
were complaining of moderate pain and 23.33% women said that pain is mild. In
acute stage pain is more and in chronic stage the pain is less.
Kandu- Itching is an intractable symptom which is seen in this pathology. All the
patients had itching. 85.00% women presented with severe kandu. 10.00% women
presented with moderate kandu and 5% women presented with mild kandu. Kandu is
attributed to kapha. It may be or may not be present with pain. Itching is present in the
presence of maceration.
Extension of lesion- In 58.33% women the intertrigous lesion was extended up to
vulva, in 36.67% women the lesion was extended to thighs, in 3.33% women the
lesion was extended to lower abdomen and in 1.67% women it was extended to
buttocks. The ecosystem of inguinal region and vulva are same and both are in the
compact region. So, the lesion easily tends to spread to vulva. In fat females it may
even spread to lower abdomen folds or thighs or even to buttocks.
Disolouration of the lesion- 43.33% women had macerated lesion, 25.00% women
had blackish red lesion, 18.33% women had blackish lesion and13.33% women had
Department of Prasooti Tantra and Stree Roga 153
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Discussion red coloured lesion. The lesion will be red during acute phase, may or may not be
associated with maceration, and as it becomes chronic the colour changes into black.
Presence of blisters- Only16.67% women had the development of blisters and
83.33% women never had blisters. Since the sample size is small, it is inconclusive.
Prakruti-In sharira prakruti, maximum number of patients (45%) registered was
having kapha pitta prakruti. The doshas which were involved in the manifestation of
the kachchu are kapha and pitta. So, this disease is more prevalent in the patients
having kapha and pitta prakruti.
Samhanana-Maximum number of patients (56.67%) was having madhyma
samhanana. But considerable number of patients (38.33%) was having obesity. In
obese patients unhygienic measures will usually cause the genito-inguinal intertrigo.
Agni-maximum number of patients were having madhyma agni.
Effect of therapy-Effect of treatment on individual signs and symptoms
Kandu- It is an intractable feeling, which patients want to get rid off. By the 3rd week
it is reduced by 98.04%. It is caused by kapha, and in case of kachchu it is caused also
by the accumulation of moist layer of mala which includes sweda mala also. Since the
drug contains- mustaka, nimba, haridra and gandhaka, which are known for their
kandughna property, there is marked reduction in the symptom kandu. Once the
kandu is reduced, further pathology which will manifest from the act of scratching
will also stop.
Vedana-At the end of 3rd week it is reduced by 98.32%. It is caused by tridosha
depending on the stage of the disease. In acute inflamed condition it is because of
vaata and pitta, and in macerated stage it is because of kapha. This drug contains
shirisha which is having vedanastapana property. Along with that the vibhitakai and
talc powder present will reduce the burning sensation present in the acute condition.
Department of Prasooti Tantra and Stree Roga 154
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Discussion When the pain reduces its corresponding sign tenderness will also reduce. There was
reduction of 97.06% after the treatment.
Srava-At the end of second week itself it is reduced by 100.00%. This symptom is
caused by pitta. In kachchu it is present in the absence of kotha. The drug is dusted in
fine powder form. Avachurnana itself is having shoshana property. Along with that
kadhira, nimba, dugda pashana are having kashaya, tikta rasa sheeta virya. Thus it
also acts as pittahara. Tannins present in the drugs are known to cause drying effect.
Edema– At the end of second week there was 98% reduction and at the end of 3rd
week there was 100% reduction. Shotha is caused by vitiated kapha pitta. Most of the
drugs in Khadiradi churna are shothagna in nature. They also act as kapha shamaka.
Discolouration of the lesion- At the end of the treatment there was 90.25%
reduction. In some patients with chronic intertrigo, the skin colour has come back to
normal. The kachchu or the genito-inguinal intertrigo may present in three forms.
They are
-acute lesion with redness and without maceration,
-acute lesion with or without redness but with maceration
-sub acute lesion with minimal redness but blackish discolouration.
The mustaka, vibhitaki, gandhaka, nimba, and dugda pashana reduce the acute
redness. Kadira, shirisha, triphala, saptaparna, gandhaka, haridra will relieve the
maceration. Kadira and haridra act as varnya. They remove the blackish
discolouration and help the skin to get normal colour.
Redness- At the end of the treatment there was 97.46% reduction. It is the symptom
of acute inflammation which can be attributable to pitta. Nimba, mustaka, dugdha
pashana, gandhaka act as pittahara and reduce the signs and symptoms of acute
inflammation.
Blisters- At the end of the treatment there was 100.00% reduction. Blisters occur due
to the action of scratching. It occurs due to the vitiated pitta and kapha. The drugs act
Department of Prasooti Tantra and Stree Roga 155
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Discussion as both kapha pittahara and kustagna. Khadira, shirisha, saptaparna, mustaka and
nimba act as shothagna and vranaghna.
Roughness-At the end of the treatment there was 100.00% reduction. This occurs
because of lichenification due to chronic inflammation and continuous act of
scratching. The drug reduces the dampness and itching which are the triggering
factors for the continuation of the pathology and for chronicity. Haridra and nimba
have lekhana property. They help to remove the excessively keratinized skin. Some of
the drugs also act as varnyas. On the whole this combination help to regain the normal
colour and texture of the skin.
Warmth- At the end of the treatment there was 97.70% reduction. It is a sign of acute
inflammation. It is a feature of pitta. The drug contains pitta hara drugs like nimba,
haridra, mustaka, gandhaka, dugdha pashana. Thses drugs also have sheeta virya and
hence reduce the warmth caused due to the infection.
Size of the lesion- At the end of the treatment there was 74.83% reduction. When the
vicious cycle of the pathology breaks up the body will gradually come to normalcy.
When the inflammatory signs and symptoms reduce which indicate that the infection
is coming under control then automatically the size of the lesion will reduce.
Gradually the peripheral regions revert to normalcy.
Attribution of relief in symptoms to phyto chemical analysis Priliminary phyto chemical analysis of the drug done showed that it contains
proteins, carbohydrates, tannins, saponins, phenols, glycosides and steroids in the
aqueous extract. Tannins and proteins are known to cause the dryness of the skin
causing the constriction of the gland ducts and minor degrees of peripheral vaso
constriction. This will reduce the oozing and because of reduction of oozing the
dampness decreases and the organisms stop proliferating. Glycosides are both anti
bacterial and anti fungal. Steroids are known for potent anti inflammatory action.
Saponins and phenols act as cleansers and detergents. They remove the slough and
thus make the local area unsuitable for the growth of the micro organisms.
Department of Prasooti Tantra and Stree Roga 156
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Discussion Discussion on microbiological study of khadiradi yoga
Culture of the organism was done to know the type of organisms. In all the
smear of 10 patients, there was growth of candida albicans. In 3 patients there were
growth of E. coli and Staphylococcus aureus and in 1 patient there was growth of
pseudomonas aeruginosa. As per the text books these organisms and streptococcus
pyogens are detectable in the intertrigous lesion.
So, sensitivity of khadiradi yoga choorna on these organisms is checked in in-vitro
study. Here two methods were followed. They are-
1) The drug was used once the organisms were cultured.
2) The drug was used before the culture of the organism.
In the first method, the drug was used in two forms. They are-
1) In the powder form as in the clinical study, the drug was administered to the patient
in the powder form.
2) In the cold aqueous extract form-Here aqueous extract is done using normal saline,
as in the clinical study, the drug was sprinkled on the sweaty area which will be rich
in NaCl.
In the second method, Khadiradi yoga choorna was incorporated into the agar and
culture media was prepared, and then the organisms were inoculated.
Results – In experimental set up the drug did not show any inhibitory action on the
candida albicans when it was used in the powder form. But in aqueous form, it
showed partial inhibition of the candida albicans.
Sensitivity study of Khadiradi choorna done to see the effect on
staphylococcus aureus, E. coli and pseudomonas aeruginosa revealed that the drug
when sterilized at 120.c acts as bacteriostatic for all the three species. In aqueous
media the drug partially inhibits the bacteria of all the three species. In the powder
form it seldom inhibits the organisms.
Probable explanation could be like this.
-When the culture media is prepared without the drug, the organisms is inoculated
first and then the drug is added. There will not be any moisture content in it. So, in the
Department of Prasooti Tantra and Stree Roga 157
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Discussion experimental set up, the drug reaction which would be expected to take place in the
aqueous media will not take place. So, micro organisms will dominate.
-When we sterilize the drug powder with the agar the drug will be in the aqueous
media. So, in that high temperature there can be possibility of chemical reactions in
the aqueous media which may work like this-
-The drug may react with the agar making it unavailable or non usable for the
microorganisms
- The drug may react with the organisms and may kill them
- The drug may not allow the organism to multiply.
In clinical study, we are applying the drug to a damp area, which is having high
temperature than rest of the body, because of the occlusion the temperature still more
increases. Inflammation also increases the temperature. The area is having a particular
pH and there is a combination of bacteria and fungi which are in the form of
commensals. In such a condition, when the drug is applied, it will be acting in an
aqueous media, in a comparatively hot area, and over the combination of the micro
organisms.
Mode of action of Khadiradi choorna Living body is a dynamic structure, in which innumerable numbers of
chemical reactions are going on - some are for the constructive purpose and some for
the destructive purpose, but, both the anabolic and catabolic processes will be taking
place for the maintenance of homeostasis of the body. It is also established that in the
living body there will be so many other micro organisms including bacteria and
fungus living in harmony with the body. They are called commensals. They are
friendly with the living human body. But some of them will become opportunistic
pathogens only when the body immune system drops. This drop in the immune
system may be systemic or local. When we consider the local immune system like in
the genito-inguinal region, it is governed by specific combination of particular
temperature, pH, vaso motor changes and macrophages and so on. Action of many
other unknown mechanisms taking place in the skin of genito-inguinal region can not
be ruled out in the prevention of the local skin health.
Department of Prasooti Tantra and Stree Roga 158
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Discussion
Genito-inguinal region is an eco system of many bacteria and fungus. In
normalcy, there would be some homeostasis between. When the body immune system
breeches because of specific aetiological factors, the balance in between the
microorganisms’ is lost as well as the homeostasis between the genito inguinal skin
and the commensals gets impaired. Thus one or the other micro organism will get the
pathogenisity and multiply in number to form colonies.
Presence of unwanted biological materials like exfoliated skin cells, retained
sweat and secretions of other glands present in that part (which includes sebum) may
provide a good environment for the growth of the organisms. When the compactness
of the genito inguinal part increases, there will be improper disposal of sweat and
reduced aeration. The NaCl present in the sweat causes the stickiness between the
skin folds and initiates the friction. Friction between the moist sticky skin folds causes
the inflammation because of cell damage, which will cause a cascade of changes in
the host as well as in the commensals. In the host, the skin changes are typical for the
inflammation. In the commensals, the total host environment causes the mutation of a
particular gene which will give them pathogenicity.
Khadiradi yoga choorna is having 11 drugs selected from different ganas. They are-
• vibhitaki (on pralepa imparts dahahara property).
• shudda gandhaka.
• dugdhapaashana (both have twakdoshahara property).
Kachchu is a sthanika twakgata vikara having kandu, sphota and srava as
cardinal symptoms. These symptoms are also associated with ruja, daha, shotha and
raga invariably.
The drugs in Khadiradi yoga choorna are having kushtagna, kandugna,
vedanasthapana, dahaprashamana, shothagna, vranaghna and varnya property. Each
and every symptoms of the disease are combated by the drug.
Department of Prasooti Tantra and Stree Roga 159
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Discussion
More over the drug is used in the powder form. The very pathogenesis of
kachchu starts from the kledana of the mala present in the genito inguinal region.
Powder form of the drug and presence of dugda pashana and other kashaya rasa yukta
drugs impart dryness to the skin of genito inguinal region. This will also break the
chain of pathogenesis causing kachchu.
Most of the drugs are having the kapha pitta hara property. So, the Khadiradi
yoga choorna pacifies the vitiated doshas responsible for the manifestation of
kachchu.
Nimba and dugda pashana have lekhana property which will help to remove
the unwanted layer in that region. More over haridra imparts lusture. All together the
drug helps the skin in the genito-inguinal region to regain the normalcy.
The components of the Khadiradi yoga choorna is having proteins,
carbohydrates, saponins, phenols, tannins, glycosides and steroids in the cold aqueous
extract in vitro. When the drug powder is sprinkled into the genito inguinal region
which is damp in nature, the same chemicals (as in the cold aqueous extract) are
released in to the aqueous media.
Proteins and tannins impart dryness to the skin. Tannins constrict the opening
of gland ducts and peripheral vaso constriction and reduce the oozing. Saponins and
phenols act as cleansers and help in the debroidement. Steroids act as anti
inflammatory and thus analgesic .Glycosides present in the drugs directly act as anti
bacterial and anti fungal.
Powder is the preferred form of medication in intertrigo. Powder form itself is
having the drying property and it reduces the skin fold friction. Thus even from the
modern parameter also the drug proves itself in the treatment of kachchu.
In the classics it is said that bhrajaka pitta/dehoshma is responsible for the
metabolism of the drug applied to the skin. According to the concept vruddhih
samanaih sarvesham, during snana /bath the ushma enters inside the twak and
increases the bhrajaka pitta as ushma is one of the guna of the pitta. So, daily
Department of Prasooti Tantra and Stree Roga 160
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Discussion regimens like snana and uthsadana will increase the brajaka pitta in the skin. It is said
that even in the pathological condition brajaka pitta is responsible for the action/
metabolism of the drug that is applied on the skin.
The active principles of the drug may also act at the host tissue level and they
may undergo first phase metabolism in the skin itself before entering into the systemic
circulation. This first phase metabolism of the drug in the skin fold of the genito
inguinal region may aid to many changes like alteration of pH and local temperature
of that area, drying the skin of that area change in the total local atmosphere of the
local skin that has triggered the pathogenecity of micro organisms. Once the
dampness of the area reduces, there is no nutritive media for the bacteria and fungus
to grow and hence their growth may be reduced.
Any sophisticated experimental set up cannot simulate the living human body.
Even though the drug is found to be inactive against candida albicans and other
bacteria in the power form in in-vitro study, efficacy of the drug is proved in the
patients clinically. Improvement is seen in the patients. The possible explanation
could be like this.
The drug acts in the dynamic host environment particularly at host tissue level.
The drug acts on the combination of organisms. There may be a synchronised sequel
of events like interaction between those micro organisms with in themselves,
interaction of the micro organisms with the local immune system, interaction
between the micro organism and the host body, vaso constriction, vaso dilation, vaso
motor changes, pH of that particular area-all these things may take part during the
application of the drug.
Even though the drug is applied in the powder form, some of its components
say active principles are dissolvable in the aqueous media. The interaction of the
active principles of the drug with each other in that particular temperature and pH,
with the microorganism or with the interactions of the micro organism may act to
combat the disease and help to heal the intertrigo.
Department of Prasooti Tantra and Stree Roga 161
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Discussion Special observations
1) In 4 patients using Khadiradi yoga choorna, the lichenification got completely
regressed and excoriation diminished. This was not seen in any patients using
candid.
2) In control group, 5 patients developed episiotomy wound dehiscence and in
test group only one patient had episiotomy wound dehiscence.
3) None of the patients showed allergic reactions to Khadiradi yoga choorna.
4) In control group, in 8 patients the lesion reappeared again after a gap of 1-4
months gap. In test group, there was no such incidence.
5) The drug has not caused the formation of granulomas in the episiotomy
wound.
6) It has not increased the vaginitis when intertrigo was co-existing.
7) No teratogenic effects were observed because of the use o Khadiradi yoga
choorna.
Scope for further study
-To have further specific phyto chemical analysis of Khadiradi yoga choorna, and
in different forms like kashaya, phanta etc.
-To have more specific microbiological study with pre test and post test smear in
same patient.
-To establish the sensitivity against specific subspecies of the candida and
bacteria.
-To establish the sensitivity in broth dilution method
-To establish the sensitivity in different temperatures.
-To establish the exact action of the drug against micro organisms-whether static
or cytic, if so, at what level etc.
-To establish whether the drug is acting at commensal stage or at pathogenic stage
-To establish active principles in Khadiradi yoga choorna.
-To establish teratogenic effects of the drug.
-To evaluate the efficacy of the drug with different thickness in vivo and in vitro
-To establish the efficacy, conducting the trial in larger sample group and
repeatedly.
Department of Prasooti Tantra and Stree Roga 162
Conclusion
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Conclusion
CONCLUSION Human being is suffered from the one or the other type of skin disease from
time-immemorial. We can get the reference of different types of kusta in different
classical literatures starting from vedic literature, and the treatment for the same is
mentioned in them. As the science developed, description of kushta and its treatment
modalities widened.
Kachchu is a shanika twakgata vikara, manifesting in the vrushana pradesha in
persons who do not maintain hygiene of the genito inguinal region. We get the first
reference of kachchu in Sushrutha samhita.
Kachchu occurs because of vitiated kapha and rakta. It manifests in the
persons who do not do snana and uthsadana regularly. In such persons, the sweda
moistens the mala present in the vrushana pradesha and causes kandu. When the
person scratches, it produces sphota and srava. Since this nidana, samprapti and
vyadhi can occur in both males and females by the prefix vrushana we should
consider the anatomical location rather than the anatomical organ.
In the modern parallels genito-inguinal intertrigo occurs when the sweating
increases the friction between the skin folds in that region. It starts as inflammation
and eventually gets secondary bacterial and fungal infections and may present with
itching, blisters and dampness. By seeing the etiological factors and the presentation
of the disease the kachchu can be best correlated to genito-inguinal region.
Genito inguinal intertrigo is more seen in pregnant and puerperal patients, as
in both conditions there is increased sweating. It is more frequent in females with
increased p/v discharges and p/v bleeding. Obesity and Diabetes mellitus are the
precipitating factors. All these conditions will result in the occlusion leading to
improper disposal of sweat. Sweat retention increases friction between skin folds and
the pathology of genito inguinal starts
It is also seen more in sharad-varsha rutu sandhi kala and in beginning of
greeshama-varsha rutu sandhi kala. During these period, there is increased sweating
Department of Prasooti Tantra and Stree Roga 164
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Conclusion because of increased atmospheric humidity and heat of summer and this predisposes
the onset of the intertrigo. In this time occlusion of the genito inguinal part by various
means like pads and unhygienic undergarments will precipitate the pathology.
In Ayurveda, kashaya parisheka, and internal administration of ghrita are
explained to treat kachchu. Because of practical problems associated with these this in
pregnancy and puerperium, from the selected drugs kustagna, kandugna and vedana
sthapana gana Khadiradi choorna is prepared. It contains-kahdira, shirisha, nimba,
musta, saptaparna, triphala, haridra, and shoditha gandhaka in equal quantities and
25% of dugda pashana which was decided on the result of the pilot study. On the
whole Khadiradi choorna acts as kustagna, kandugna, daha prashamana, shoola
prashamana, shothagna, vrana ropana and varnya property.
Avachurna is the mode of procedure adopted to administer the drug as the
disease kachchu is a sthanika twakgata vikara. Avachoornana acts as both shodana
and ropana purpose as mentioned in the classics. Since it is used in thin layer form, it
does not produce the occlusion effect and also imparts the drying effect.
The qualitative phyto chemical analysis of Khadiradi yoga choorna done
showed the presence of proteins, carbohydrates, saponins, tannins, Glycosides and
steroids in cold aqueous media than in chloroform extract and methanol extract, and
they impart the actions like peripheral vaso constriction, drying effect, reduces the
oozing, and inhibit the growth of the pathogens.
Its microbiological studies indicated that the Khadiradi yoga choorna inhibits
the growth of E. coli, Staphylococcus aureus and Pseudomonas aeruginosa, and
partially inhibits the growth of fungus.
In the clinical study which was done to see the clinical efficacy of khadiradi
yoga avachoornana in kachchu shows that warmth, itching, roughness, dampness and
blisters respond to khadiradi choorna better than candida. On pain, tenderness,
redness, warmth, colour, size of the lesion, Khadiradi choorna is having the effects as
that of the candid powder which is having the proved efficacy.
Department of Prasooti Tantra and Stree Roga 165
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Conclusion
In the classical text books of Ayurveda, acharyas have explained the
guidelines to identify the disease on the basis of doshas and dushyas and to formulate
the treatment modalities. The science also gives the scope for new formulations
depending upon the concept of samprapti vighatana. Many times efficacy of the
ayurvedic product is difficult to prove in modern parameters even with sophisticated
instruments and methods. It will be having its own limitations and backlogs as a
living human body cannot be simulated exactly in the experimental set up. Repeated
trials and invention of new techniques will help to establish the facts of science and
thus helps to use the science for the betterment of the mankind.
Department of Prasooti Tantra and Stree Roga 166
Summary
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Summary
Summary The dissertation is entitled “Evaluation of the clinical efficacy of Khadiradi yoga
avachoornana in kachchu with special reference to genito inguinal intertrigo”
essentially aims to evaluate the effectiveness of ayurvedic formulation in the
management of kachchu.
It consists of –
Introduction -It consists of basic information regarding the disease and the
formulations. It tells about the necessity of the exploration of the disease as very less
medical input is there regarding intertrigo.
Historical review - Deals with the reference of kushta in vedic literature, puranas and
in samhitas. It also deals with reference of individual components of Khadiradi yog
and avachoornana concept as well as the intertrigo in gynecology.
Review of previous research works - mentions about the researches done in kshudra
kusta.
Conceptual study - of disease and the drug
-comprises of ayurvedic review and modern review
This starts with the twak sharira as it is the basis for the physiology,
pathology and treatment of the skin disorders. Disease review proper starts with the
concept of kusta in ayurvedic classics, enumeration of skin disorders into kushta and
kshudra roga, list o kshudra rogas according to different acharyas, nirukti and
paribhasha of kachchu, nidana, samprapti and chikitsa of kachchu.
In modern review-anatomy and physiology of skin, aetiology, aetiopathogenesis, role
of micro organisms in the causation of intertrigous lesions and treatment of intertrigo
are told. Further histopathological features of intertrigous lesions and difficulties in
diagnosing the lesions histopathologically are narrated.
Drug review-This unravels the method of preparation of khadiradi yoga choorna
starting from the selection, fixing the dose of each components, fixing clinical dose,
criteria to select the drug in powder form, concept of absorption, concept of
Department of Prasooti Tantra and Stree Roga 168
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Summary avachoornana and basic information regarding each component of khadiradi yoga
choorna. It also includes the phyto chemical analysis of the drug and its probable
interpretations.
Observations-This section includes the different observation done on the test group
as well as the control group. It also includes the preliminary survey done in Gynec
OPD to know incidence of the disease.
Results-It includes the statistical results of the clinical trial, preliminary phyto
chemical analysis of Khadiradi yoga choorna and microbiological study done.
Discussion-This section includes analysis of and interpretation of conceptual study,
results of clinical study, phytochemical study and microbiological study and scope for
further research.
Conclusion-This section includes the conclusion based on the study done. It also
highlights the limitations of the modern parameters in proving the efficacy of the
ayurvedic medicines.
Summary-This section includes the gist of the dissertation work and highlights the
main content of every section.
Department of Prasooti Tantra and Stree Roga 169
Bibliography
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Department of Prasooti Tantra and Stree Roga 177
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Department of Prasooti Tantra and Stree Roga 179
Annexure
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Annexure
Annexure
Clinical Evaluation of Efficacy of Khadiradi Yoga Avachurnana in Kacchu w.s.r. to genito-inguinal intertrigo
Dept. of Prasoothi Tantra and Stree Roga, SDMAC, Udupi.
Scholar - Dr. Shubha, B.A.M.S
GUIDE: Dr. Mamata K.V., M. D. CO-GUIDE: Dr. Vidya Ballal, M. S. (Ayu)
Information Data 1. Aatura Vivara
Name OPD No Age IPD No Sex Bed No & Room No Religion D.O.A. Education D.O.D. Occupation Address Marital Status Social Status
2. Vedana Samuchraya
a. Pradhana vedana i. Vrana
Nature of onset Sudden/gradual/recurrent Sites involved Extension of lesion Duration Colour of lesion Association with swelling Nature of area involved Dry/Moist Nature of skin involved Rough/Smooth Course of illness
ii. Vedana
Present/ absent/ numbness Nature Continuous/intermittent Character Burning/pricking/dull Intensity Mild/moderate/severe Duration
Approximately, 5 gm of drug powder is dusted on the surface of the affected skin twice in 24 hours after cleaning the part with pre-boiled water and drying the area with clean gauze.
12. Assessment Criteria Scorings
a. Subjective Nil 0 Nil 0
Mild 1 Mild 1 Moderate 2 Moderate 2
Pain
Severe 3
Itching
Severe 3
b. Objective
No lesion 0 Normal 0 0 - 2cm 1 Black 1 2 - 4cm 2 Red 2
Size
Above 4cm 3
Color
Absent 0 Absent 0 Present 1 Present 1
Warmth
Swelling
Absent 0 Absent 0 Mild 1 Present 1
Moderate 2 Absent 0
Tenderness
Severe 3
Redness Blisters
Present 1
Absent 0 Absent 0 Roughness Present 1
Discharge Present 1
Department of Prasooti Tantra and Stree Roga 185
“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Annexure 13. Complications 14. Results
Completely cured Partially cured Not reduced but status quo maintained Aggravated Association of complications if any