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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


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

and Stree Roga, under my guidance.

Signature of Guide

Dr. MAMATHA K.V. M.D. (Ayu) Professor.

Date: Dept.of Prasooti Tantra and Stree Roga, S.D.M.C.A, Udupi. Place: Udupi


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.

Date:

Place: Udupi DR. SHUBHA

© Rajiv Gandhi University of Health Sciences, Karnataka

Acknowledgement

“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.


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


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


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


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


“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


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



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



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


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.



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.



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.


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.


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.


“Clinical Efficacy of Khadiradi yoga avachoornana in Kachchu” Historical review

• Similarly the treatment modalities or the treatment options are elaborated in

Charaka Samhita chikitsa stana 12th chapter14, Sushruta samhita chikitsa stana

20th chapter 15Astanga Samgraha uttara tantra 37th chapter16, Astanga Hradaya

uttara tantra 32nd chapter17.

• Vanga sena18, Yoga Ratnaakara19,Chakra Datta20 and Madhava Nidana21 have

followed Sushruta samhita.

• The yoga formulated for this particular thesis contains selected drugs from

kustagna gana, (khadira, amalaki, haritaki, saptaparna, haridra)22, kandugna

gana (mustaka, nimba)23, vedanastapana gana (shireesha)24, vibhitaki (on

pralepa imparts dahahara property)25, gandhaka26 and dugdhapaashana27 (both

have twakdoshahara property) are mentioned in different classics.

• The avachurnana concept is explained in Charaka Samhita28 and Sushruta

Samhita29.

Modern era

• Pathology, clinical presentation and management of genito-inguinal intertrigo

is explained in text book of Gynecology30 as well as in Text book and Atlas of

Dermatology.31


Review of Research Literature

REVIEW OF RESEARCH LITERATURE

• G.K. chastd-chakramarda ka kshudrakust per prabhav. MMM Govt.

Ayurvedic College, Udaipur - 1988.

“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Review of Research Literature

• L.N. Sharma-Aargvadh ka prabhavaatmaka Adhyayana on kshudrakust.

MMM Govt. Ayurvedic College, Udaipur - 2001.


Twak Sharira

“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Twak Sharira

Twak Shaarira

Twak or the skin is the site of vaata, domain for rasa and rakta. It covers the

whole body, surrounds the orifices which are meant for the excretory process. It

protects the internal structures and organs. It also acts as the barrier for the external

pathological causes like trauma, chemicals, radiation, pathogens. It acts as the

platform for the manifestation of symptoms of various diseases like jwara and kamala

and thus helps in the diagnosis of the disease. Sometimes it is a major part of the

disease process as in dermatological conditions. It plays a major role in the external

appearance of the person and thus his or her personality. Thus twak has multifaceted

function. When it gets diseased, or when it is in trouble, naturally it needs attention as

these physiological functions are likely to be getting affected with varying severity.

Kachchu/intertrigo is one of the localised cutaneous skin disorders. To

understand the skin diseases or kushta, it becomes essential to understand the

twakshaarira elaborately as it is involved in each and every step of samprapti and

samprapti vighatana i.e., starting from the aetiopathogenesis till the mode of action of

the drug used to cure it.

Twak “iuÉMçü CÌiÉ, iuÉÍcÉÌiÉ, iuÉcÉÉÇ xÉÇuÉÉUhÉå” 32

Means that which covers.

“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.



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.


“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


“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.


“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


“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.


“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



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.


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.

MücNû-MåülÉ eÉsÉålÉ YuÉOûhÉÉÌiÉ SÏmrÉiÉå CÌiÉ | 81

• -eÉsÉmÉëÉÇiÉÈ

• MücNû-AlÉÔmÉÉå SåvÉ:

eÉsÉmÉëÉrÉÇ AlÉÔmÉÇ xrÉÉiÉç mÉÑÇÍxÉ MücN: iÉjÉÉ

ÌuÉkÉ: |

• MücNÕû – MüÇQÕû -vÉ. Mü. SìÓÓ.28

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.


“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


“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

diseases can be divided into 2 aspects-

a)Sarva daihika –generalised dermatological disorders eg-masurika, visarpa

b)Ekadeshoththita-localized dermatological disorders eg- vrashana kachchu or

paadadari

Depending on the severity of the leison the dermatological diseases can be

classified into

a)Incurable or curable with difficulty-like visarpa or mahakusta

b)Easily curable –vrushana kachchu, youvana pidika.

If all the above aspects are considered, the skin manifestation or

dermatological disorders are considered as or under the heading of kushta in

ayurveda.

In the classics depending on the severity of symptoms and the nidanas the skin

disorders are explained under the kushtaadhikara or in kshudra roga and in kushta the

diseases are classified as mahakushta and kshudra kushta

Kushta


“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Disease Review MüÉsÉålÉ xÉuÉïÇ uÉmÉÑÈ –zÉUÏUÇ MÑüwhÉÉÌiÉ iÉxqÉÉiÉç iÉiÉç MÑü¸Ç

CÌiÉ EcrÉiÉå |41

Kushta is a pathological entity, which in the broad term encompasses any

discolouration or disfiguration to the skin. The diseases range from grave diseases like

maha kushta to minor and even non painful but mildly discolouring lesions like

vyanga or nilika

Kushta is pathological condition where in there is discolouration of the skin or

the skin manifestation at some stage of the pathological condition. It is the

understanding of the literature that the skin diseases need the involvement of rakta

and kledadhikyatha for the completion of samprapti.

Kachchu is explained in kshudraroga adhyaya. In this pathology

- the disease manifests in the skin and the pathology proper is in the skin.

- there is discolouration of the skin in the form of redness, maceration or

blackish discolouration.

- even the doshic involvement told for the kachchu is kapha and rakta.

- the disease needs kledadikyatha for the manifestation of the symptoms.

As the pathology of kachchu is fulfilling the criteria needed to be under the

heading of kushta, it can be considered under the broad heading of kushta.

Kshudra roga


“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Disease Review ¤ÉÑS ì- AkÉqÉ, AsmÉ

The word kshudra means low level, little, small, which does not need much

consideration.82

UÉåaÉ-ÂeÉÌiÉ CÌiÉ UÉåaÉçÈ

-ÂMçü xÉÉqÉÉlrÉÉiÉç UÉåaÉÈ

Roga is a condition which is predominated with pain, or unpleasant sensation

or feeling. The condition or the stage that hurts or pains the body or mind is called

roga. Because of invariable presence of pain as a symptom the diseased conditions in

general are called as roga.

¤ÉÑSìUÉåaÉ-xuÉsmÉ urÉÉÍkÉ 43

Kshudra roga is a pathological condition which develops in the body with less

severity. Or it is the disease with less severity or less painful symptoms, or which

causes less morbidity or which disturbs the day to day activities to least extent, or

which will get cured with easy treatment modalities or which will stay for shorter time

with less discomfort.

The diseases categorised under kshudra roga having swalpa or less nidana, less

symptoms or less treatment or simplier treatment modalities exception being

agnirohini and valmika. Hence they are called kshudra roga

The diseases like guda bramsha and kunakha are adhama to look at or looks

alpa ie, dirty or low. So, they are included in the group of kshudra roga.

The diseases listed under kshudra roga are said to be advitiya i.e., there are no

subtypes of the diseases like vaataja or pittaja or kaphaja depending on the doshas or

rasaashrita or raktashrita depending on the dushyas. But the involvement of doshas

and dushyas are told for each and every kshudra roga but no sub categories.

SynonymsThe synonyms are-xuÉsmÉ, AkÉqÉ ¢ÔüU -uÉæeÉrÉÇÌiÉ




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 + - - +



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 + - - + +/ - +



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 + - - + + + + +



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 + - - - - - - -




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


“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


“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.



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.


“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.



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.



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


“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Disease Review -lepana with karanja,triphala tiktaka siddha ghrita

-rasaanjanla lepa

Paama kandvadi chikitsa

-siduradi lepa-contains sindura, jiraka dvaya, haridra, daru haridra, manashila,

maricha, kajjali (gandhaka+paarada) mixed with ghrita and externally applied in the

form of lepa

-saindhavadi lepa-contains saindhava, chakramarda, sarshapa, pippali mixed with

kanji and externally applied.

-jiraka taila

-brahat sinduradi taila

-brhat marichadi taila

-maaheshwara ghrita

-maamsyadi kandunaashaka gana lepa-contains jataamaamsi, raktachandana,

shamyaaka, karanja patra, nimba patra, sarshapa, yashti, kutaja, daaruharidra,

-baakichi bija, kaasamarda, chakramarda, haridra, daaruharidra, saindhava lavana

mixed with kaani and applied externally

-arka taila.

Pathyapathya 63

Kshudra rogas resemble the diseases explained generally in other contexts (i.e.

saamanya rogas). Kshudra rogas also manifest due to dosha dushya sammurchana like

other diseases.

It is the responsibility of the physician to decide the pathyapathyas considering

the vaataadi doshas, rasaadi dushyas, roga bala, rogi bala, the avasta of the disease

and to advice the patient.

So when we apply this rule the pathya pathya are

Pathya-snana, uthsadana, sheetala dravyas, varnya , swedaghna dravyas, dourgandhya

hara dravyas, kapha pittahara dravas, not exposing to hot environment etc.

Apathyas-ushna, tikshna abhishyandhi ahara, unhygienic conditions, kapha pittakara

ahara vihara, rakta prakopaka ahara vihara etc.


“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.


“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.



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.



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.



– 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.



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.


“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.



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,


“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.


“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.


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.


“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Drug Review

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

- dry preparations-choorna-udvarthana, udgarshana, avachoornana

- wet preparations-with water-pralepa,alepa pradeha

- with oil

- oily preparations-grita or taila lepana

- multiple liquid preparations-madhugrita lepana

-

In ayurveda for the selection of each formulation specific guidelines are told and

insisted to select the patient depending on the clinical presentation.The medicinal

preparations told for kachchu in the classics contain saindhava or the preparations are

in the form of kashaya. Even ghee prepared out of specific herbs is told for internal

medication.

This costal region has high percentage of humidity, so salts absorb moisture from

the atmosphere and get liquefied. So, powder preparations having salts cannot be

preserved for long and the drug powder will become a semisolid paste or get spoiled

because of dampness.

Advising kashaya parisheka in pregnancy involves a tedious job of preparing the

kashaya everyday as kashaya should be used in fresh form. This is having the

practical problem that many patients will not be ready for this tedious work.Ghrita

which is told for the internal administration contains drugs which are not best suited

for pregnancy and during purperium.

So, khadiradi yoga is formulated and selected for a very prevalent conditions like

kachchu which is easy to administer/apply and can be preservable.


“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Drug Review Criteria for the selection of drugs and the form of the drug i.e., powder form

(choorna)

- It should be economical

- It should be easily available

- It should be a botanically identified plant. It should not be a controversial drug

- It should not be in the list of endangered species. So, while collecting the drug

we will not be destroying the species.

- Collection of the drug/part of the drug should not hamper its propagation.

- It should be convertible into the finest powder form as it is the desired form

- It should have a long shelf life in the powder form especially in the high

humid environment of the costal region.

- It should not react with co-drugs or the other components of the final product

physically or chemically to form a final product which forms other than

powder form. eg: slumping, sticking, absorbing the moisture forming a paste

etc. which ultimately hampers the free flow the drug.

- It should not be irritant to the skin, i.e. , as far as possible it should be hypo

allergic.

- It should be safe during ovulation, pregnancy, puerperium and lactation.

- It should not have any teratogenic properties.

- If it enters vagina it should not produce any unwanted symptoms.

- It should be easy for preparation and application

- It should not delay wound healing or impair wound healing.

To formulate a new drug Acharyas have given the guidelines that, a physician

should consider the doshas involved in the samprapti and every attempt should be

made for the samprapti vighatana. So, the drug should be selected on the basis of their

doshagnata and their prabhava as well as rogi and vyadhi bala which is the

fundamental principal of Ayurveda.

Khadiradi yoga choornna

Accordingly the drugs of khadiradi yoga is selected which contains khadira,

triphala, saptaparna, shirisha, nimba, haridra, musta, gandhaka and dugda pashana.



It is the formulated yoga. Here the drugs are having the property of

kaphapittahara guna, kustagna, kandugna, vedanastapana, shoola prashamana and

daha prashamana gunas.

Acharya Madhava in his work Madhava Nidhana told the methodology of

naming a formulation. He said that in a formulation with many herbs the name of the

formulation should be after the 1st mentioned drug69. Accordingly the formulated

drug powder is named after the name of the 1st herb i.e., khadira. The word “aadi”

suggests etc. or in other words the formulation contains other drugs starting with

khadira.

Quantity of each herb in the yoga

Acharya Maadhava has told that, if in the classics the dose of the ingredients is

not specified then it is the rule that one should take the drugs in equal parts70. Even

though this rule is told for the classical preparations we used this rule to determine the

quantity of each ingredient except dugdha pashana. As per this rule, except dugha

paashana, all the other drugs are taken in equal quantities.

Criteria to select the dose of dugda pashana

All the drugs except dugda pashana are taken in equal quantity in powder form

and mixed together thoroughly. This powder is divided into 3 groups of 5 samples

each. To the 1st group 50% dugdha paashana powder is added. To 2nd group 25% of

powder of dugda paashana is added and to the 3rd group 10 % dugda paashana powder

is added.

A clinical pilot study was done for 15 patients divided into three groups

having 5 patients in each group. Here in 1st group where in the drug has 50% dugda

paashana did not show much relief, 2nd group showed marked relief and the 3rd group

complained about roughness of powder and little burning sensation.

On the basis of this pilot study, the quantity of the ingredient is fixed as follows.

• The yoga formulated for this particular thesis contains selected drugs

from



• kustagna gana, (khadira, amalaki, haritaki, saptaparna, haridra.). • kandugna gana (mustaka, nimba).

• vedanastapana gana (shireesha).

• Dahahara (vibhitaki).

• twakdoshahara (shudda gandhaka., dugdhapaashana )

• All the drug powders except dugdhapaashana are taken in equal

parts/quantities.

• To this 25% Dughapaashana is added.

Yoga paribhasha

The word yoga is derived from the root word “yuj samadhou, yujir yoge, yuj

samyamane” which means to get incorporated in, mixing up, being together,

shuffling, putting together, being together, planning, idea and according to

amarakosha it also suggests bheshaja.

So, yoga is a formulation made up of several ingredients mixed together. As

per this definition, since the selected drug is a mixture of several ingredients it can be

called as yoga. Hence this formulation is named as Khadiradi yoga choorna.

All the herbal ingredients are collected and dried in sun. Then they are

powdered in the micropulvariser and the floating particles are collected to obtain

vastra gaalitha choorna. The particle size will be approximately No. 100-120 (There

will be 100-120 pores in 1 square inch).

Gandhaka is purified by heating it and pouring it into hot milk sieving through

the cloth and finally washing with hot water properly. This is powdered and mixed to

the above mixture.

To the above mixture powdered 25% dugdha paashana is added.After adding

all the ingredients the resultant mixture is mixed using doubling up methods.

The final product is packed in specially arranged pre-holed containers with net weight

being 50gm.


“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Drug Review Khadira

• Botanical Name: Acacia catechu.

• Family: Mimosideae

• Syn: gaayatri, raktasaara, kantaki, baalapatra, yajneeya, dantadhavana

• Rasa: Tikta, Kashaya,

• Guna: Laghu, rooksha,

• Veerya: sheeta

• Vipaka: Katu

• Karma:Kapha-pitta shaamaka

• Gana: Charaka- kustagna, Kashaya skandha

Sushrutha –Saalasaaradi.

Raja nighantu-shalmalyadi varga

Bhava prakasha-vataadi varga

Khadira is listed in agroushadha and is the drug of choice in kustagna. It is

also having the properties like krimigna, kushtagna and acts as sarva twak naashana.

It also cures conditions like pittasra, shotha, kandu and vrana.For different

dermatological conditions khadira can be used in various types of treatment

modalities like snana, pana, ashana lepa or pralepa avachurnana udvartana etc.

Bark is useful as an astringent. It is also used in skin diseases. Its extract

shows antibacterial and fungicidal action.Bark is also bitter and acrid. It cures itching,

ulcers, boils and inflammation. It is also useful in many types of vaginal discharges.

Table no-4

C. S S.S A.H R.N K.N D.N B.P CH.D

Krimighna + +

Shwithragna - +

Kustagna + + + + + + + +

kandugna - + + +

Vranagna + + + +

Medagna - +

Sarva twak

doshagna

+ + +

Shotha +



Saptaparna • Botanical Name: Alstonica scholaris

• Family: Apocyanaceas

• Syn: vishala, suparnaka,vishamachchada, sharada, shalmali patraka, vishala

twak, saptachchada

• Rasa: Tikta, Kashaya

• Guna: Laghu, snigdha

• Veerya: Ushna

• Vipaka: Katu

• Karma: Kapha-pitta shaamaka, Tridoshahara

• Gana: Charaka-kustagna, udarda prashamana, tikta skandha,Kashaya skandha,

Sushruta &Vaagbhata- aaragwadadi, laakshadi, adhobhagahara.

Saptaparna is one of the drug listed in shatkashaya yogas and in the classics its

use is enumerated in different forms like snana, paana and avachurnana etc.

Internal and external administration use of saptaparna in various forms will said to

cure kushta, vrana and krimi. Saptaparna kalka lepa is advised in dustavrana. It also

said to alleviate to shoola and ruja.

The alchoholic extract of bark is found active against streptomyces aureus.

Table No-5

C.S S.S A.H R.N K.N D.N B.P CH.D G.N

Kustagna + + + + + + + +

Krimighna + + + + + + + + +

Dustavarna + + + + + + + +

Shoola - - - - - - - - +

Ruja - - - - - - - - +


“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Drug Review Shereesha

• Botanical Name: Albizzia lebbeck

• Family: Mimosideae

• Syn: Shukapriya

• Rasa: Kashaya, Tikta, Katu

• Guna: Laghu, rooksha, Tikshna

• Veerya: Eshad ushna

• Vipaka: Katu

• Karma: Kapha-pitta shaamaka (tridoshahara) varnya

• Gana: Chrakaa - vishagna, vedanastapana Kashaya skandha

Sushruta - Saalasaaradi

It is one of the constituents of dashangalepa which is mainly used in

inflammatory conditons of skin with swelling and in many other skin pathologies. It

acts as shothagna.External application of shirisha with ghrita is explained in the

conditions like visarpa and shirisha twak lepana is said to relieve the kushta. It is also

having vranagna and daaha shaamaka properties when used with other suitable drugs.

It is having kandugna and can be used in dermatological conditions like paama.

Udvartana using shirisha with other suitable drugs will check the impurities of skin

and reduces excessive perspiration especially in medoroga.

Acharya Sushrutha said that shirisha can be safely used in soothika. He also

said that it is safe even in females who underwent mooda garbha aaharana and shatra

karma.

Bark is bitter and cures skin diseases, relieves itching excessive perspiration

inflammation and blisters.The alchoholic extract of stem bark contains cardenolide

glycosides of digitoxin nature and anthraquinone glycosides. The 1st group of

glycosides has antidermatpphytic activity and the 2nd group has antibacterial activity.

They also showed activity against other aerobes, yeast and some specific protozoans.



Table No-6

C.S S.S A.H R.N D.N K.N B.P G.N CH.D

Kustagna + + + + + + + +

Shothagna + + +

Vedanastapana + +

Varnya +

Raktashodhaka + +

Vishagna + +

Pamaagna + +

Vranaropana +

kandugna + +

Daha nashana +

Mustaka • Botanical Name: Cyperus rotundus

• Family: Cyperaceae

• Syn: musta, vaarida

• Rasa: Tikta,katu, Kashaya,

• Guna: Laghu, rooksha,

• Veerya: sheeta

• Vipaka: Katu

• Karma:Kapha-pitta shaamaka

• Gana:Charaka-truptighna,trashnaanigrahana,lekhaneeya, kandughna,stanya

shodhana

Sushruta –mustadi, vachaadi.

Musta lepana will cure agantuja vranas and is useful in kapha pittaja vyadhis and will

destroy the jantus.

Its tubers are credited with anti-inflammatory properties. Drug is rich in Cu, Fe, Mg

and Ni. B-sitosterol isolated from the tubers exhibits significant anti-inflammatory

activity in rats and this activity is comparable to hydrocortisone and phenylbutazone.

Methanolic extract of plant stimulates the production of melanin in cultured

melanocytes.


“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Drug Review Table No-7

C.S S.S A.H R.N D.N K.N G.N B.P CH.D

Kustagna

Kandugna +

Vranagna +

Vedanastapana

Jantugna +

Haridra • Botanical Name: Curcuma longa

• Family: Scitaminaceae

• Syn: nishaa, kaanchani, varaparnini, peevari, peeta, nishaakya, krumighna,

yoshitpriya, varunavarnini,

• Rasa: Tikta, katu

• Guna: ruksha, laghu

• Veerya: ushna

• Vipaka: katu

• Karma: kapha-vaata shamaka, pitta rechaka shamaka

• Gana: Charaka-kustaghna, lekhaneeya, kandughna, vishaghna

Sushruta– haridradi, mustadi, shleshma prasaadana

It is one of the content of dashanga lepa and rakta shodhaka and cures many

skin diseases. It is kaphapittahara, rakta shodhaka, kushtagna, kandugna, shothagna,

beneficial in conditions like vranagna.

It imparts good lusture to the skin and hence it is included in under varnya

dravyas. In sthoulya udvartana with haridra said to alleviate the deha dourgandhya,

i.e., bad odour of the body caused due to excessive perspiration caused due to obesity.

Haridra kalka prayoga is beneficial in kushta chikitsa especially to treat the

conditions like paama and kachchu. The utility of udvartana with nishadi choorna in

pathologies like paama etc charma vikaras is explained in classics.



The juice of fresh rhizome is used as antiparasitic for skin diseases. External

application is done in ulcers and inflamed areas. Oil of turmeric, distilled from dry

rhizomes has antiseptic properties.

Curcumin, one of the active principles of haridra has anti inflammatory

activity in both exudative and proliferative inflammation. The extracts show the

presence of steroids and it is likely that steroids are responsible for anti inflammatory

action. Water extract is more potent and is similar to that of hydrocortisone. Petrolium

ether extract is good analgesic and similar to that of indomethacin.

Alchoholic extract and essential oil showed bactericidal activity. Curcumin

acts as bacterio-static agent with respect to staphylococci. Oil acts against bacteria

and fungi including human pathogens i.e., it has potent antimicrobial activity.

Turmeric oil is said to inhibit the in vitro activity of hyaluronidase, an enzyme

considered to be involved in the development of the inflammation. It inhibits

experimentally induced edema. The oil exhibited marked bactericidal activity against

both gram +ve and gram –ve bacteria especially against the species of staphylococcus

and klebsilla. It also showed anti-fungal activity.

The extract of turmeric exhibited antibacterial activity. The extract along with

the extract of Emblica officinalis showed better antibacterial activity compared to

individual ingredients.

Curcumin in vivo acts as anti inflammatory by exhibiting cyclo-oxygenase

activities in human platelets. The rhizomes have curcumin related phonolics which

possesses antioxidant and anti inflammatory action.

paste of turmeric with astringents, bitters and aromatics is applied externally

to bruises, sprains and indolent ulcer. This paste is also applied in skin afflictions such

as prurigo, ringworm, scabis and in eczema. Rarely does it act as allergic to cause

contact dermatitis.



It also has anti inflammatory action with respect to inhibition of activated

proteases responsible for acute inflammatory processes. The volatile oil is found to

inhibit trypsin as well as hyaluronidase enzymes. Alchoholic extract showed

antimicrobial activity.

Table No-8

C.S S.S A.S R.N D.N K.N B.P G.N CH.D

Kustagna + + + +

Kandugna + +

Krimigna +

Vishagna +

Varnya + +

Vragna + + +

shothagna +

paamagna +

Nimba • Botanical Name: Azadirachta indica

• Family: Meliaceae

• Syn: pichumarda, tiktaka, arishta, paribhadra, hinguniryasa

• Rasa: tikta, kashaya

• Guna: laghu

• Veerya: sheeta

• Vipaka: katu

• Karma: kapha-pitta shaamaka

• Gana: Charaka - kandughna, tikta skandha

Sushruta – Aaragwadadi, guduchyadi, laakshaadi

Bhava prakasha-guduchyadi varga

Nimba can be used in different forms for internal administration and also for

external local application in the form of lepana or snaana. External application will

reduce the burning sensation.



It is useful in diseases caused to due to kaphapitta and acts as kustagna,

kandugna, krimigna and shothagna. Its efficacy in curing the kusta is emphasized and

explained that it does cure kushta within a span of a month. Praising the qualities of

nimba it has been said that it is useful even in “pralepa maatrean” and “prashamam

yaati vegatah” i.e., just by the external application it can cure conditions like paama,

dadru, vicharchika, kandu etc, skin diseases and efficacy can be seen quickly because

of fast action.

It is also beneficial in the treatment of vrana as it does the paachana of apakva

vrana and vishodhana of pakva vrana. It also acts as vrana shodhaka and vrana

ropaka. Bhavamishra added grahi guna in the list of properties of nimba. Nimba is

used as shodhaka dravya in pathological conditions where there is purulent discharge

from the yoni and explained in yoni roga. Nimbatwak dhopana and nimba kwatha

prakshalana is used to get rid of paichchilya dosha of yoni. It is supposed to

strengthen the yoni. Nimba kwatha avagahana is beneficial in conditions involving

shotha.

Bark contains many active ingredients including tannin, B-sitosterol etc. Almost every

part of the tree is bitter and all the parts are having B-sitosterol. Plant extracts are

shown to have antibacterial properties. Bark is also having astringent property and is

useful in cutaneous diseases. The strong decoction of leaf and bark is antiseptic.

The extracts shown to inhibit the activity of Micrococcus pyogenus vas aureus and is

also having prominent fungicidal activity. Ethanolic extract of stem bark exhibited

marked antibacterial and antifungal activity against Bacillus megaterium and

Aspergillus niger. Terpenoids of the plant part extracts exhibit antibacterial, antibiotic

and insecticidal property.

Table No-9


Kustagna + + + + + + +

Kandugna + + +

Krimigna + + + + +

Shothagna +

Vranagna + + + + + + +


“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Drug Review Amalaki

• Botanical Name: Emblica officinalis

• Family: Euphorbiaceae

• Syn: dhaatri, vayasta, vayasya, abhaya, amritha,vrushya

• Rasa: amla pradhana lavana varjita pancha rasa

• Guna: laghu, ruksha, sheeta

• Veerya: sheeta

• Vipaka: madhura

• Karma: tridoshahara, pitta shamaka, ayahstaapana, rasaayana

• Gana: Charaka -vayahstapana, virechanopaga

Sushruta –triphala, parushakadi

It acts as shothagna and daha prashamaka.

Fruits are rich sources of vit C. Fruit, leaves and barks are rich in tannin. Fruit

has tannic acid, gallic acid, resinous matter etc. It also acts on dermatosis and is

having anti inflammatory property.

Table No-10


kandugna

Kustagna

Vedana

Stapana

Shothagna + +

Krimigna

Hareetaki • Botanical name: Terminalia chebula

• Family: Combretaceae

• Syn: pathya, vijaya, shiva, amrita, abhaya, vayastha, jaya, haimaavathi

• Rasa: kashaya pradhana lavanavarjitha pancharasa

• Guna: laghu, ruksha



• Veerya: ushna

• Vipaka: madhura

• Karma: Tridhoshahara, anulomana, rasaayana, lekhana

• Gana: Charaka- prajaastapana, jvaraghna,kustaghna, kasaghna, arshoghna

Sushruta –triphala, amalakyadi, parushakadi, trivritadi

It is having kushtagna, kandugna, and shothagna properties and is said as

“twak amayagni”.On external application this drug will relieve the srotovibandha i.e.,

it will cleanse the srotas and removes the blockade.

In sthoulya, the utility of haritaki is mentioned and said that it will be useful to

reduce swedadikyatha and sharira dourgandhya (bad body odour due to excessive

perspiration) In such conditons and in medo roga, haritaki udvartana followed by

snana is indicated. Its use is advised even if the sthoulyatha is complicated with

pidikas.In kushta the usefulness of pathyadilepa is explained.

Flesh of dried fruit is rich in tannin. It contains around 30-32% of tannin.

A fraction obtained by treating the 80% alcoholic extract of fruits with HCL and

extracting with ether showed reasonably high activity against a number of bacteria

and fungi.

Fruit pulp used in different forms, show anti inflammatory action. Fruits are useful in

skin diseases, itching and pain. Even in yunani system it is said as blood purifier.

External application of the paste is good for burns and scalds.

Table No-11


Kustagna + +

Kandugna +

Shothagna +

Vedanasta

Pana


“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Drug Review Vibheetaki

• Botanical Name: Terminalia bellerica

• Family: Combretaceae

• Syn: akshaphala, kaalidruma, karshaphala

• Rasa: kashaya

• Guna: laghu,ruksha

• Veerya: ushna

• Vipaka: madhura

• Karma: kapha-pittahara, bhedana

• Gana: Charaka- jvarahara, virechanopaga

Sushruta- triphala, mustadi

Vibhitaki phala majja lepa will reduce the burning sensation and is useful in

all painful conditions. It also destroys the krimi.

Fruits have 21.4% tannin-both condensed and hydrolysable types, B-sitosterol,

gallic acid etc. The extract of fruit possesses antibacterial properties against

micrococcus pyogenes and aureus. Bark is useful in skin diseases. Fruit is bitter and

relieves inflammation.

Table No-12


daahahara +

Kustagna

Kandugna

krimigna +

Gandhaka • Syn: gandha paashana, putigandha, shulvari, Gandhi, rasagandhaka,

sugandhika, gandhika, gandha, shougandhika, atigandha, pamari,

kitanaashana, bali, balirasa, kushtari, sharabhumija, navanita, daityendra,

gandhamaadana, kitaghna, kruragandha

• Swarupa: nirmala, rajanisamaprabha, diptimana, navanitakomala

• Rasa: katu



• Guna: laghu, snigda

• Veerya: ushna

• Vipaka: madhura

• Karma:twak doshaghna, paachaka, atyanta rasayana

• 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).


“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-

-Dadruvidravana malahara

-Gandhakadhya malahara

-Gandhaka taila

Dugda paashaana • Syn:dugdi, dugdapaashanika, ksheerashiva, dugdha shila, diptika, soudha,

vajraabha, dugdha, gomedasannibha.

• Rasa: madhura

• Guna: ruksha

• Veerya: sheeta/alpa ushana

• Vipaka:katu

• Karma:pitta shamaka, twakdaaha prashamana, grahi, vranaropaka

It reduces pitta and acts as twak daaha shaamaka. It is having kustagna

property and its external application is indicated in skin diseases like sidma.

It is also having vrana ropaka property.



Acacia catechu/khadira Alstonica scholaris/saptaparna

Albizzia lebbeck/shirisha Cyperus rotundus/mustaka

Curcuma longa/Haridra Azadirachta indica/nimba

Emblica officinalis/amalaki Terminalia chebula/haritaki

Terminalia bellerica/vibhitaki Gandhaka Dugda pashana

Khadiradi yoga aqueous chloroform ethanol

Choorna extract extract extract


“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


“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


“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.



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.


“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


“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)


“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.



- 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



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.


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.


“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.


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

intertrigo are taken.

Incidence observation

1) Table No 14 Age Distribution of Patients

Number of Patients Age Test

Group Control Group

Total %

18-23 8 7 15 25.00% 24-29 11 13 24 40.00% 30-35 5 5 10 16.67% 36-41 3 1 4 6.67% 42-47 1 2 3 5.00% 48-53 2 2 4 6.67% Total 30 30 60

Figure No-1

0

5

10

15

18‐23 24‐29 30‐35 36‐41 42‐47 48‐53

Age

Age Distribution

Test Group

Control Group

In the present study out of 60 patients 40 % women belonged to age group 24-29

years, 25% females belonged to age group 18-23 years, 16.67% females of 30-35 years age

group and 6.67% females were of age group 36-41years. Rest of them was between 42-

53years.


“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Observations

2) Table No-15 Religion Distribution of Patients

Number of Patients Religion Test

Group Control Group

Total %

Hindu 17 20 37

Figure No-2

0

5

10

15

20

Hindu Muslim Christian

Religion

Religion Distribution

Test Group

Control Group

61.67% Muslim 8 6 14 23.33% Christian 5 4 9 15.00% Total 30 30 60

In this study out of 60 patients 61.67% of females were Hindus, 23.33% females were

Muslims and rest 15.00% women were Christians.

3) Table No-16 Socio economic Status Distribution of Patients

Number of Patients Social Status Test

Group Control Group

Total %

Lower 4 5 9 15.00%

Figure No-3

0

5

1 0

1 5

2 0

L o w e r M id d le U p p e r

S o c ia l S t a t u s

S o c ia l S ta tu s

Te s t G r o u p

C o n tr o l G r o u p

Middle 20 18 38 63.33% Upper 6 7 13 21.67% Total 30 30 60



Out of 60 patients 63.33% women were belonging to middle socio economic status,

15.00% women were belonging to lower class and 21.67% women were belonging to upper

socio economic status.

4) Table No-17 Occupation Distribution of Patients

Number of Patients Occupation Test

Group Control Group

Total %

House Wife 24 21 45 75.00% Others 1 3 4 6.67% Bidi Worker 4 6 10 16.67% Social Worker 1

Figure No-4

0

20

40

Occupation

Occupation Distribution

Test Group

Control Group

In this present study, 75.00% of women were housewives and 16.67% women belong to

other professionals.

5) Table No-18 Education Distribution of Patients

0 1 1.67% Total 30 30 60

Number of Patients Education Test

Group Control Group

Total %

Primary 5 4 9 15.00% High School 14 15 29 48.33% College 4 4 8 13.33% Graduate 5 6 11 18.33% Illiterate 2 1 3 5.00% Total 30 30 60



Figure No-5

0

5

10

15

Education Distribution

Test Group

Control Group

Education

In the present study, 45.00% women completed high school level education, 18.33%

women completed graduation, 15.00% women completed primary level education, 5 %

women completed PUC, and 5 % women were illiterate.

6) Table No-19 Marital Status Distribution of Patients

Figure No-6

0

10

20

30

Married Unmarried

Marital Status

Marital Status

Test Group

Control Group

In the present study 95.00% women were married and 5.00% were unmarried.

Number of Patients Marital Status Test

Group Control Group

% Total

Married 27 30 57 95.00% Unmarried 3 0 3 5.00% Total 30 30 60


“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Observations 7) Table No-20 Population Distribution of Married Women

Figure No-7

0

5

10

15

Married ‐ non pregnant

Pregnant Perimenopausal Peurperium

Distribution of Married Women

Test Group

Control Group

Married Women

In the present study, 52.63% females were pregnant, 24.56% females were puerperium,

17.54% females were married but not pregnant and 5.26% females were in the peri-

menopausal age.

8) Table No-21 Incidence by type of Diet

Figure No-8

0

10

20

30

Mixed Vegetarian

Aahara ‐ Diet

Test Group

Control Group

Diet

Number of Patients Distribution Test

Group Control Group

Total %

Married - non pregnant 4 6 10 17.54% Pregnant 15 15 30 52.63% Peri Menopausal 1 2 3 5.26% Puerperium 7 7 14 24.56% Total 27 30 57

Number of Patients Diet Test

Group Control Group

Total %

Mixed 26 24 50 83.33% Vegetarian 4 6 10 16.67% Total 30 30 60



Out of 60 patients 83.33% women were having mixed diet and 16.67% women were

having vegetarian diet.

9) Table No-22 Incidence of Bathing Habits

Figure No-9

0

10

20

30

Once in 2 days Once in 3‐4days Daily

Bathing Habits

Test Group

Control Group

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.

10) Table No-23 Use of Clothing/Type of occlusion

Number of Patients Bathing Habits Test

Group Control Group

% Total

Once in 2 days 6 6 12 20.00% Once in 3-4days 3 4 7 11.67% Daily 21 20 41 68.33%

Total 30 30 60

Number of Patients Clothing Test

Group Control Group

% Total

Heavy clothing 4 6 10 16.67% Pads 11 13 24 40.00% Synthetic undergarments 15 11 26 43.33% Total 30 30 60



Figure No-10

0

5

1 0

1 5

U se o f C lo th in g

Te st G ro u pC o n tr o l G ro u p

Cloth ing

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.

11) Table No-24 Distribution of population according to Prakruti

Number of Patients Prakruti

Test Group

Control Group

% Total

Kapha 3 4 7 11.67% Kapha + Pitta 17 15 32 53.33% Kapha + Vata 7 9 16 26.67% Pitta + Vata 3 2 5 8.33% Grand Total 30 30 60

Figure No-11

0 5 10 15 20

Kapha Kapha + Pitta

Kapha + Vata

Pitta + Vata

Prakruti

Test Group

Control Group

Prakruti

Out of 60 patients 45.00%, 8.33% females were having kapha pitta and pitta kapha

prakruti respectively.21.67% females were having kapha vaata prakruti, 11.67% females were

having kapha prakruti, and 5.00% females were having vaata kapha prakruti, 5.00% females

were having vaata pitta prakruti and 3.33% females were having pitta vaata prakruti.



12) Table No-25 Distribution of population according to Samhanana

Number of Patients Samhanana

Test Group

Control Group

% Total

Avara 1 2 3 5.00% Pravara 13 10 23 38.33% Madhyama 16 18 34 56.67% Total 30 30 60

Figure No-12

0

5

10

15

20

Avara Pravara Madhyama

Samhanana

Test Group

Control Group

Samhanana

Out of 60 patients 56.67% women were having madhyama samhanana, 38.33% females

were having pravara samhanana and 5.00% women were having avara samhanana.

13) Table No- 26 Aahaarashakti

Number of Patients Aahaarashakti

Test Group

Control Group

% Total

Avara 4 6 10 16.67% Madhyama 16 13 29 48.33% Pravara 10 11 21 35.00% Total 30 30 60

Figure No-13

0

5

10 15 20

Avara Madhyama Pravara

Aahaarashakti

Test Group

Control Group

Aahaarashakti



In the study 48.33% women were having madhyama ahara shakti, 35.00% females were

having pravara ahara shakti and 16.67% women were having avara ahara shakti.

14) Table No-27 Predominant Rasa

Number of Patients Rasa Test

Group Control Group

Total %

amla katu 5 3 8 13.33% amla lavana 2 1 3 5.00% amla madhura 4 6 10 16.67% katu 5 5 10 16.67% katu amla lavana 1 2 3 5.00% katu lavana 3 4 7 11.67% katu madhura 3 5 8 13.33% lavana 1 1 2 3.33% lavana madhura 3 1 4 6.67% madhura 3 2 5 8.33% Total 30 30 60

Figure No-14

0

2

4

6

Predominant Rasa

Test Group

Control Group

Rasa

In the present study 16.67% women were preferring katu, and amla madhura rasa,

13.33% women used to like katu madhura and amla katu, 11.67% women were using katu

lavana ahara.


“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Observations 15) Table No-28 Sweating in Patients

Number of Patients Sweating

Test Group

Control Group

Total %

Excessive 24 25 49 81.67% Normal 6 5 11 18.33% Total 30 30 60

Figure No-15

0 20

40

Excessive Normal

Sweating in Patients

Test Group

Control Group

Sweating

In this present study out of 60 patients 81.67% women had excessive sweating and

18.33% women had normal sweating.

16) Table No-29 Micturition Frequency

Number of Patients Frequency

Test Group

Control Group

Total %

4 - 5/day 3 1 4 6.67% Increased frequency 27 29 56 93.33% Grand Total 30 30 60

Figure No-16

0

10

20

30

4 ‐ 5/day Increased frequency

Frequency Of Micturition

Test Group Control Group

Frequency



In the present study, out of 60 patients 93.33% women had increased frequency of

micturition and 6.67% had normal frequency.

17) Table No-30 Micturition – Associated complaints

Number of Patients Associated Pain

Test Group

Control Group

% Total

Stress incontinence 2 2 4 6.67% Urge incontinence 9 11 20 33.33% None 19 17 36 60.00% Total 30 30 60

Figure No-17

0

5

10

15

20

Stress incontinence

Urge incontinence

None

Micturition ‐ Associated Complaints

Test GroupControl Group

Associated Complaint

Out of 60 patients 26.67% women had urge incontinence, 6.67% women had stress

incontinence and 60.00% women had not micturition associated problems.

18) Table No-31 Presence of Vaginal Discharge

Number of Patients Presence of Vaginal Discharge Test

Group Control Group

% Total

Vg discharge 20 21 41 68.33% Menorrhagia 2 0 2 3.33% Lochia 3 4 7 11.67% No Discharge 5 5 10 16.67% Total 30 30 60

Figure No-18



0 5

10 15 20 25

Presence of Vaginal Discharge

Test Group

Control Group

Presence

In this present study, out of 60 patients, 68.33% women had 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.

19) Table No-32 Gestational Age

Number of Patients Gestational Age Test

Group Control Group

% Total

17w - 22w 1 1 2 6.67% 23w - 28w 1 2 3 10.00% 29w - 33w 2 3 5 16.67% 34w - 39w 11 9 20 66.67% Total 15 15 30

Figure No-19

0

5

10

15

17w ‐ 22w 23w ‐ 28w 29w ‐ 33w 34w ‐ 39w

Gestational Age


Age

In the present study, out of pregnant women population, 66.67%pregnant patients were in

34-39 weeks, 16.67% pregnant patients were in 29-33 weeks, 10.00% were in 23-28 weeks

and 6.67% women were in 17-22 weeks.



20) Table No-33 Presence of Episiotomy Wounds

Number of Patients Presence of

Episiotomy wounds

Test Group

Control Group

% Total

Present 7 7 4 87.50% 1Absent 1 1 2 12.50% Total 8 8 16

Figure No-20

0

5

10

Present Absent

Presence of Episiotomy Wound

Test Group

Control Group

Presence In the study, out of 16 puerperal women, 87.50% women had episiotomy wound and

ther

1) Table No-34 Location of Episiotomy Wound - Peurperium

e was no episiotomy wound in 12.50% women.

2

Number of Patients Location

Test Group

Control Group

% Total

Not on the lesion 3 5 35.71% 2On the lesion 5 4 9 64.29% Total 7 7 1 4

Figure No-21

0

2

4

6

Not on the lesion On the lesion

Location of Episiotomy Wound ‐ Puerperium


Location



In the present study, out of puerperal women population, in 64.29% women the intertrigo

was on the episiotomy lesion and in 35.71% women the intertrigo was not on the episiotomy

lesion.

22) Table No-35 Mode of Onset of intertrigo

Number of Patients Mode Test

Group Control Group

Total %

Gradual 3 4 7 11.67% Recurrent 12 14 26 43.33% Sudden 15 12 27 45.00% Total 30 30 60

Figure No-22

0

5

10

15

Gradual Recurrent Sudden

Mode of Onset

Test Group

Control Group

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



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

60 days each.

24) Table No-37 Nature of Area Involved/dampness

Number of Patients Nature of Area Test

Group Control Group

Total %

Dry 6 8 14 23.33% Moist 24 22 46 76.67% Total 30 30 60

Figure No-24

0

20

40

Dry Moist

Nature of Area Involved

Test Group

Control Group

Nature



In this present study, in 76.67% women the genito inguinal area was moist and in 23.33%

women the genito inguinal area was dry.

25) Table No-38 Nature of Skin involved

Number of Patients Nature of Skin Test

Group Control Group

Total %

Rough 8 10 18 30.00% Smooth 22 20 42 70.00% Total 30 30 60

Figure No-25

0

10

20

30

Rough Smooth

Nature of Skin Involved

Test Group

Control Group

Nature

In this present study, 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.

26) Table No-39 Presence of Vedana

Number of Patients Presence of Vedana Test

Group Control Group

Total %

Present 30 30 60 100.00% Total 30 30 60

Figure No-26



0

10

20

30

Present

Presence of Vedana

Test Group

Control Group

In the current study all the 100% women had pain.

27) Table No-40 Nature of Vedana

Number of Patients Nature of Vedana Test

Group Control Group

Total %

Continuous 9 12 21 35.00% Intermittent 21 18 39 65.00% Total 30 30 60

Figure No-27

0

10

20

30

Continuous Intermittent

Nature of Vedana

Test Group

Control Group

Nature In the present study, 65.00% women had intermittent pain and 35.00% women had

continuous pain.

28) Table No-41 Character of Vedana

Number of Patients Character of Vedana Test

Group Control Group

% Total

Burning 11 12 23 38.33% Dull 3 3 6 10.00% Numbness 1 2 3 5.00% Pricking 15 13 28 46.67% Total 30 30 60



Figure No-28

0

5

10

15

Burning Dull Numbness Pricking

Charactre of Vedana

Test Group

Control Group

Character

In this current study, 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.

29) Table No-42 Intensity of Vedana

Number of Patients Intensity of Vedana Test

Group Control Group

Total %

Mild 6 8 14 23.33% Moderate 10 8 18 30.00% Severe 14 14 28 46.67% Total 30 30 60

Figure No-29

0

5

10

15

Mild Moderate Severe

Intensity of Vedana

Test Group

Control Group

Intensity In the current study, out of 60 patients 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.


“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Observations 30) Table No-43 Presence of Kandu

Number of Patients Presence

Test Group

Control Group

Total %

Present 30 30 60 100.00% Total 30 30 60

Figure No-30

0

10

20

30

Present

Presence of Kandu

Test Group

Control Group

Nature

In the current study all the 100% women had pain.

31) Table No-44 Intensity of Kandu

Number of Patients Intensity

Test Group

Control Group

% Total

Mild 1 2 3 5.00% Moderate 4 2 6 10.00% Severe 25 26 51 85.00% Total 30 30 60

Figure No-31

0

10

20

30

Mild Moderate Severe

Intensity of Kandu

Test Group

Control Group

Intensity Out of 60 patients 85.00% women presented with severe kandu, 10.00% women

presented with moderated kandu and 5% women presented with mild kandu.


“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Observations 32) Table No-45 Extension of Lesion

Number of Patients Extension Test

Group Control Group

% Total

Vulva 18 17 35 58.33% Thigh 10 12 22 36.67% Lower abdomen 1 1 2 3.33% Buttocks 1 0 1 1.67% Total 30 30 60

Figure No-32

0

5

10

15

20

Vulva Thigh Lower abdomen

Buttocks

Regions

Extension of Lesion

Test Group

Control Group

In the present study out of 60 patients 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.

33) Table No-46 Discolouration of Lesion

Number of Patients Colour Test

Group Control Group

% Total

Black 6 5 11 18.33% Blackish red 7 8 15 25.00% Macerated 12 14 26 43.33% Red 5 3 8 13.33% Total 30 30 60

Figure No-33



0 2 4 6 8

10 12 14

Black Blackish red

Macerated Red

Discolouration of Lesion

Test Group

Control Group

Colour

In the present study, out of 60 patients 43.33% women had macerated lesion, 25.00%

women had blackish red lesion, 18.33% women had blackish lesion and13.33% women had

red coloured lesion.

34) Table No-47-A Presence of Blisters

Number of Patients Presence of Blisters Test

Group Control Group

Total %

No 24 26 50 83.33% Yes 6 4 10 16.67% Total 30 30 60

Figure No-34-a

0

5

10

15

20

25

30

No Yes

Presence of Blisters


Presence

Out of 60 patients only16.67% women had the development of blisters and 83.33%

women never had blisters.


“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Observations 35) Table No-47-B Size of Lesion

Number of Patients Size of Lesion Test

Group Control Group

% Total

No Lesion 0 0 0 0.00% 0 - 2 cm 0 0 0 0.00% 2 - 4 cm 2 0 2 3.33% Greater than 4 cm 28 30 58 96.67% Total 30 30 60

Figure No-34-b

0

5

10

15

20

25

30

No Lesion 0 ‐ 2 cm 2 ‐ 4 cm Greater than 4 cm

Size of Lesion

Test Group

Control Group

Size Out of 60 patients, 96.67%women had lesion bigger than 4 cm and 3.33% women had

lesion of 2-4cm size.


Survey

“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Survey A preliminary survey was done to know the incidence of the inguinal intertrigo in

patients seeking treatment in prasoothi and stree roga department. Here 1st entering

100 patients are considered for the survey. Here three sets were considered.

They are-

– First 100 patients entering OPD irrespective of their complaints-whether

obstetric or gynaecological

– First 100 obstetric patients entering OPD irrespective of their gestational ages

or obstetrical outcomes.

– First 100 gynaecological patients entering OPD irrespective of their parity or

other details.

The survey was done in Rainy season-July

Winter season-December

Summer season-May

Three rutusandi kalas - sharad and varsha-september

-shishira and hemantha-march

-grishama and varsha-june. Results are as follows-

Table No-48

May July December June September March

Intertrigo 21 30 6 26 33 15

Tenia cruris/eczema 1 3 2 1 3 0

Hyperpigmentation 10 12 8 10 21 8

Obstetric patients

Intertrigo 17 18 4 19 18 10



Gynec patients

Intertrigo 5 10 2 6 14 8




“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Survey In the Survey highest incidence of patients were noted in the month of July and in

September. They two periods are considered as rutu sandhi kala.

Most of the patients were belonging to obstetric group which includes pregnant and

puerperal women.

In most of the pregnant women, intertrigo was seen co-existing with the

hyperpigmentation.


Results

“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Results


The effects of Khadiradi yoga avachoornana in kachchu with special reference to

intertrigo is given below. The statistical analysis was done based on the observations

done before treatment and after treatment.

Statistical results for Khadiradi yoga choorna Table no- 49 Effect of Khadiradi yoga choorna on the severity of pain during

the course of the treatment-

a) Attribute: Pain Test: Paired t-Test Sample size: 30

Effect of drug on Pain Group BT

Mean Test AT

Mean d % SD SE t P

AT1 0.345 1.80 83.92% 0.848 0.114 15.748 <0.001 AT2 0.0545 2.091 97.48% 0.800 0.108 19.387 <0.001

Test Group

2.145

AT3 0.0364 2.109 98.32% 0.809 0.109 19.333 <0.001 AT1 0.688 1.625 70.26% 0.806 0.202 8.062 <0.001 AT2 0.438 1.875 81.06% 0.719 0.180 10.434 <0.001

Control Group

2.313

AT3 0.250 2.063 89.19% 0.772 0.193 10.688 <0.001 Graph No-1

0

0.5

1

1.5

2

2.5

BT AT1 AT2 AT3

Pain

Test Group

Control Group

The statistical analysis revealed that the mean score for pain before the

treatment was 2.145 for the test group and 2.313 for the control group which got

reduced to 0.0364 in test group and to 0.250 in control group after the treatment

(P<0.001).

The change that occurred with the treatment in Test Group is greater than

would be expected by chance; there is a statistically significant change (P =

<0.001).The change that occurred with the treatment in Control Group is greater than

would be expected by chance; there is a statistically significant change (P = <0.001).



Table no-50 Comparison of statistical results between the Test group and

control group on the severity of pain during the course of the treatment

b) Attribute: Pain Test: Unpaired t-Test

Comparison on Pain Test Group

Mean Control

Group mean d SD SE t P

0.145 0.459 0.313 0.220 0.127 -1.940 0.124

The difference in the mean values of the two groups is not great enough to reject the

possibility that the difference is due to random sampling variability. There is no statistically

significant difference between the input groups (P = 0.124).

Conclusion Both the drugs have almost the same effect on Pain

Table no-51 Effect of khadiradi yoga choorna on the severity of itching during

the course of treatment-

c) Attribute: Itching Test: Paired t-Test Sample size: 30

Effect of drug on Itching Group BT

Mean Test AT

Mean d % SD SE t P

AT1 0.418 2.382 85.07% 0.686 0.102 23.320 <0.001 AT2 0.0727 2.727 97.39% 0.592 0.0798 34.180 <0.001

Test Group

2.800

AT3 0.0545 2.745 98.04% 0.645 0.0869 31.588 <0.001 AT1 1.063 1.875 63.82% 0.806 0.202 9.603 <0.001 AT2 0.625 2.313 78.73% 0.946 0.237 9.773 <0.001

Control Group

2.938

AT3 0.563 2.375 80.84% 1.025 0.256 9.271 <0.001 Graph No-2

0

0.5

1

1.5

2

2.5

3

3.5

BT AT1 AT2 AT3

Itching

Test Group

Control Group

The statistical analysis revealed that the mean score for itching before the treatment

was 2.800 for the test group and 2.938 for the control group which got reduced to 0.0545 in

test group and to 0.563 in control group after the treatment (P<0.001).



The change that occurred with the treatment in Test Group is greater than would be

expected by chance; there is a statistically significant difference (P = <0.001).The change that

occurred with the treatment in Control Group is greater than would be expected by chance;

there is a statistically significant difference (P = <0.001).


control group on the severity of itching during the course of treatment

d) Attribute: Itching Test: Unpaired t-Test

Comparison on Itching Test Group

Mean Control


0.182 0.750 0.569 0.273 0.157 -2.889 0.045

The difference in the mean values of the two groups is greater than would be

expected by chance; there is a statistically significant difference between the input groups (P

= 0.045).

Conclusion The test drug is more effective in treating the Itching among patients

Table no-53 Effect of khadiradi yoga choorna on the size of the lesion during

the course of the treatment-

e) Attribute: Size Test: Paired t-Test Sample size: 30

Effect of drug on Size Group BT

Mean Test AT

Mean d % SD SE t P

AT1 1.891 1.073 36.20% 0.658 0.0893 12.006 <0.001 AT2 1.236 1.727 58.27% 0.781 0.105 16.409 <0.001

Test Group

2.964

AT3 0.745 2.218 74.83% 0.686 0.0924 23.995 <0.001 AT1 2.125 0.875 59.17% 0.619 0.155 5.653 <0.001 AT2 1.688 1.313 43.77% 0.704 0.176 7.456 <0.001

Control Group

3.000

AT3 1.375 1.625 54.17% 0.885 0.221 7.344 <0.001 Graph No-3

0

0.5

1

1.5

2

2.5

3

3.5

BT AT1 AT2 AT3

Size

Test Group

Control Group



The statistical analysis revealed that the mean score for size before the treatment was

2.964 for the test group and 3.000 for the control group which got reduced to 0.745 in test

group and to 1.375 in control group after the treatment (P<0.001).






control group on the size of the lesion during the course of the treatment

f) Attribute: Size Test: Unpaired t-Test

Comparison on Size Test Group

Mean Control

Group mean D SD SE t P

1.291 1.729 0.439 0.377 0.217 -1.105 0.331


possibility that the difference is due to random sampling variability. There is not a statistically


Conclusion Both the drugs have similar effect on treating the Size of the lesion

Table no-55 Effect of Khadiradi yoga choorna on the redness during the

course of the treatment-

g) Attribute: Redness Test: Paired t-Test Sample size: 30

Effect of drug on Redness Group BT

Mean Test AT

Mean d % SD SE t P

AT1 0.0182 0.691 97.46% 0.466 0.0659 10.987 <0.001 AT2 0.000 0.709 100.00% 0.458 0.0618 11.473 <0.001

Test Group

0.709

AT3 0.0182 0.691 97.46% 0.466 0.0659 10.987 <0.001 AT1 0.0625 0.500 88.81% 0.632 0.158 3.162 0.006 AT2 0.0625 0.500 88.81% 0.516 0.159 3.873 0.002

Control Group

0.563

AT3 0.188 0.375 66.61% 0.619 0.155 2.423 0.059



Graph No-4

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

BT AT1 AT2 AT3

Redness

Test Group

Control Group

The statistical analysis revealed that the mean score for redness before the treatment






there is a statistically significant change (P = 0.002).


control group on the redness during the course of the treatment

h) Attribute: Redness Test: Unpaired t-Test

Comparison on Redness Test Group

Mean Control


0.0121 0.104 0.0922 0.0725 0.0418 -2.181 0.095




Conclusion Both the drugs have similar effect on treating the Redness of the lesion



Table no-57 Effect of khadiradi yoga choorna on the discolouration of the lesion

during the course of the treatment-

i) Attribute: Discolouration Test: Paired t-Test Sample size: 30

Effect of drug on Discolouration Group BT

Mean Test AT

Mean d % SD SE t P

AT1 0.909 1.327 59.35% 0.818 0.110 12.037 <0.001 AT2 0.545 1.691 75.63% 0.900 0.121 13.933 <0.001

Test Group

2.236

AT3 0.218 2.018 90.25% 1.027 0.139 14.570 <0.001 AT1 1.063 0.813 43.36% 0.655 0.164 4.961 <0.001 AT2 0.563 1.313 70.03% 0.704 0.176 7.456 <0.001

Control Group

1.875

AT3 1.000 0.875 46.67% 1.147 0.287 3.050 0.008 Graph No-5

0

0.5

1

1.5

2

2.5

BT AT1 AT2 AT3

Discolouration

Test Group

Control Group

The statistical analysis revealed that the mean score for discolouration before the

treatment was 2.236 for the test group and 1.875 for the control group which got reduced to

0.218 in test group and to 1.000 in control group after the treatment (P<0.001).






control group on the discolouration of the lesion during the course of the

treatment

j) Attribute: Discolouration Test: Unpaired t-Test

Comparison on Discolouration Test Group

Mean Control


0.557 0.875 0.318 0.272 0.157 -1.252 0.279






Conclusion Both the drugs have similar effect on treating the discolouration of the lesion

Table no-59 Effect of Khadiradi yoga choorna on the warmth during the


k) Attribute: Warmth Test: Paired t-Test Sample size: 30

Effect of drug on Warmth Group BT

Mean Test AT

Mean d % SD SE t P

AT1 0.109 0.673 86.06% 0.474 0.0639 10.536 <0.001 AT2 0.0182 0.764 97.70% 0.459 0.0578 13.208 <0.001

Test Group

0.782

AT3 0.0182 0.764 97.70% 0.459 0.0578 13.208 <0.001 AT1 0.375 0.375 50.00% 0.619 0.155 2.423 0.059 AT2 0.188 0.563 75.07% 0.512 0.128 4.392 <0.001

Control Group

0.750

AT3 0.188 0.563 75.07% 0.659 0.157 3.576 0.003 Graph No-6

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

BT AT1 AT2 AT3

Warmth

Test Group

Control Group

The statistical analysis revealed that the mean score for warmth before the treatment










control group on the warmth during the course of the treatment

l) Attribute: Warmth Test: Unpaired t-Test

Comparison on Warmth Test Group

Mean Control


0.0485 0.250 0.202 0.108 0.0623 -2.913 0.044



= 0.044).

Conclusion The test drug has better effect in reducing the Warmth

Table no-61 Effect of Khadiradi yoga choorna on the roughness during the


m) Attribute: Roughness Test: Paired t-Test Sample size: 30

Effect of drug on Roughness Group BT

Mean Test AT

Mean d % SD SE t P

AT1 0.0182 0.345 94.78% 0.517 0.0697 4.955 <0.001 AT2 0.000 0.364 100.00% 0.522 0.0704 5.164 <0.001

Test Group

0.364

AT3 0.000 0.364 100.00% 0.522 0.0704 5.164 <0.001 AT1 0.0625 0.313 83.47% 0.479 0.120 2.611 0.020 AT2 0.0625 0.313 83.47% 0.479 0.120 2.611 0.020

Control Group

0.375

AT3 0.0625 0.313 83.47% 0.479 0.120 2.611 0.020 Graph No-7

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

0.4

BT AT1 AT2 AT3

Roughness

Test Group

Control Group

The statistical analysis revealed that the mean score for Roughness before the


0.000 in test group after the treatment (P<0.001) and to 0.0625 in control group after the

treatment ( P =0.020).








control group on the roughness during the course of the treatment

n) Attribute: Roughness Test: Unpaired t-Test

Comparison on Roughness Test Group

Mean Control


0.00607 0.0625 0.0564 0.0105 0.00607 -9.302 <0.001



= <0.001).

Conclusion The test drug has better effect in reducing the Roughness

Table no-63 Effect of Khadiradi yoga choorna on the tenderness during the


o) Attribute: Tenderness Test: Paired t-Test Sample size: 30

Effect of drug on Tenderness Group BT

Mean Test AT

Mean d % SD SE t P

AT1 0.609 1.527 83.17% 0.879 0.119 12.888 <0.001 AT2 0.0545 1.782 97.06% 0.937 0.126 14.107 <0.001

Test Group

1.836

AT3 0.0545 1.782 97.06% 0.994 0.134 13.591 <0.001 AT1 0.500 1.313 72.42% 0.793 0.198 6.619 <0.001 AT2 0.188 1.625 89.63% 0.719 0.180 9.043 <0.001

Control Group

1.813

AT3 0.188 1.625 89.63% 1.025 0.256 6.343 <0.001 Graph No-8

0

0.2

0.4

0.6

0.81

1.2

1.4

1.6

1.8

2

BT AT1 AT2 AT3

Tenderness

Test Group

Control Group



The statistical analysis revealed that the mean score for tenderness before the



` The change that occurred with the treatment in Test Group is greater than would be





control group on the tenderness during the course of the treatment

p) Attribute: Tenderness Test: Unpaired t-Test

Comparison on Tenderness Test Group

Mean Control


0.239 0.292 0.0527 0.180 0.104 -0.248 0.816




Conclusion Both the drugs have similar effect on Tenderness

Table no-65 Effect of Khadiradi yoga choorna on the discharge during the


q) Attribute: Discharge Test: Paired t-Test Sample size: 30

Effect of drug on Discharge Group BT

Mean Test AT

Mean d % SD SE t P

AT1 0.127 0.618 82.95% 0.490 0.0661 9.350 <0.001 AT2 0.000 0.745 100.00% 0.440 0.0593 12.575 <0.001

Test Group

0.745

AT3 0.000 0.745 100.00% 0.440 0.0593 12.575 <0.001 AT1 0.438 0.375 46.13% 0.719 0.180 2.087 0.054 AT2 0.188 0.625 76.88% 0.619 0.155 4.038 0.001

Control Group

0.813

AT3 0.250 0.563 69.25% 0.512 0.128 4.392 <0.001



Graph No-9

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

BT AT1 AT2 AT3

Discharge

Test Group

Control Group

The statistical analysis revealed that the mean score for discharge before the





occurred with the treatment in Control Group is not great enough to exclude the possibility

that the difference is due to chance (P = 0.054)


control group on the discharge during the course of the treatment

r) Attribute: Discharge Test: Unpaired t-Test

Comparison on Discharge Test Group

Mean Control


0.0423 0.292 0.250 0.130 0.0752 -2.894 0.044



= 0.044).

Conclusion The test drug has better effect in reducing the Discharge



Table no-67 Effect of Khadiradi yoga choorna on the edema during the course

of the treatment-

s) Attribute:Edema Test: Paired t-Test Sample size: 30

Effect of drug on Edema Group BT

Mean Test AT

Mean d % SD SE t P

AT1 0.0364 0.564 94.00% 0.501 0.0675 8.352 <0.001 AT2 0.0182 0.582 97.00% 0.498 0.0671 8.668 <0.001

Test Group

0.600

AT3 0.000 0.600 100.00% 0.494 0.0667 9.000 <0.001 AT1 0.0625 0.500 88.81% 0.516 0.159 3.873 0.002 AT2 0.000 0.563 100.00% 0.512 0.128 4.392 <0.001

Control Group

0.563

AT3 0.125 0.438 77.80% 0.512 0.128 3.416 0.004 Graph No-10

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

BT AT1 AT2 AT3

Edema

Test Group

Control Group

The statistical analysis revealed that the mean score for edema before the



(P<0.001).


would be expected by chance; there is a statistically significant difference (P =

<0.001). The change that occurred with the treatment in Control Group is greater than


<0.001).




control group on the edema during the course of the treatment

t) Attribute:Edema Test: Unpaired t-Test

Comparison on Edema Test Group

Mean Control


0.0182 0.0625 0.0443 0.0625 0.0361 -1.179 0.304




Conclusion Both the drugs have similar effect on treating the Edema

Table no-69 Effect of Khadiradi yoga choorna on the blisters during the


u) Attribute: Blisters Test: Paired t-Test Sample size: 30

Effect of drug on Blisters Group BT

Mean Test AT

Mean d % SD SE t P

AT1 0.000 0.127 100.00% 0.336 0.0454 2.806 0.007 AT2 0.000 0.127 100.00% 0.336 0.0454 2.806 0.007

Test Group

0.127

AT3 0.000 0.127 100.00% 0.336 0.0454 2.806 0.007 AT1 0.0625 0.250 79.87% 0.447 0.112 2.236 0.041 AT2 0.0625 0.250 79.87% 0.447 0.112 2.236 0.041

Control Group

0.313

AT3 0.125 0.188 60.06% 0.544 0.136 1.379 0.188 Graph No-12

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

BT AT1 AT2 AT3

Blisters

Test Group

Control Group

The statistical analysis revealed that the mean score for blisters before the



(P<0.001).





0.007).The change that occurred with the treatment in Control Group is not great

enough to exclude the possibility that the difference is due to chance (P = 0.188)


control group on the blisters during the course of the treatment

v) Attribute: Blisters Test: Unpaired t-Test

Comparison on Blisters Test Group

Mean Control


0.000 0.0833 0.0833 0.0361 0.0208 -4.000 0.016



= 0.016).

Conclusion The test drug has better effect in reducing the Blisters

Final Results of the Test drug Table No-72

Parameter No. of patients cured completely

% of cure

Pain 29 96.67% Itching 29 96.67% Size 20 66.67% Redness 29 96.67% Colour 27 90.00% Warmth 29 96.67% Redness 30 100% Tenderness 29 96.67% Discharge 30 100% Swelling 29 96.67% Blisters 30 100% Average 94.24%

-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.


“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


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


Benedict’s test -ve -ve -ve

Non reducing sugars are absent in all the three extracts

Tannins


Gelatin +ve +ve +ve

Anthocyanins


Acqueous NaOH

test

-ve -ve -ve

Concentrated

H2So4 Test

-ve +ve +ve


“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Phytochemical Analysis Glycosides


Molisch’s test +ve +ve +ve

Concentrated

H2SO4 Test

+ve +ve +ve

Keller Kiliani test +ve +ve +ve

Saponin


Foam test +ve -ve -ve

Flavanoid


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


phenol +ve -ve +ve

Steroids


Salkowski test +ve +ve +ve


“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Phytochemical Analysis Alkaloids


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.


“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.


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


“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


“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.


“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


“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

-observation of haemolytic action

-+ve coagulase test

Pseuomonas aeruginosa-fruity smell/urgy/acrid smell

-Pigment production like black or greenish


“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Micorbiological Study

Candida albicans-culture

E coli Staphylococcus aureus

Pseudomonas aeruginosa


“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)


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.



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.



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.



• 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.



• 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


“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.


“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


“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


“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


“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


“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.


“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


“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.


“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


“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.


“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


“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.



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-

• kustagna gana, (khadira, amalaki, haritaki, saptaparna, haridra.).

• kandugna gana (mustaka, nimba).

• vedanastapana gana (shireesha).

• 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.



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


“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.


“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.


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


“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.


“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.


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


“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.


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No.6



No.245


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

iii. Kandu

Present/ absent Duration Daytime/season/menstruation Intensity



iv. Kleda/Srava

Present/ absent Colour Consistency Smell

v. Sweating (Sweda Pravrathi) - Normal/ excessive / absent

vi. Presence of any blisters -

b. Anubandha Vedana

i. Presence of episiotomy wound/vaginal pathology etc. ii. Presence of vaginal discharge

iii. Other complaints 3. H/o present illness 4. H/o past illness 5. Family history

i. Husband having genital/inguinal fungal infection ii. Others.

6. Personal history

i. Aahara

Appetite Good/moderate/poor Diet Veg / Mixed Predominent rasa Particular food habit if any - History of adhyashana/ virudhashana/ samashana/ etc.

ii. Vihaara

I) Personal hygiene

Bathing etc. Use/nature of Undergarments Pads Tampons Use of local applicants

II) Nature of work/life style

Sedentary Laborious Sitting Walking Standing Traveling

III) Use of OCP/ mechanical barrier method/IUCD etc.



iii. Bowels

regular/ irregular/ constipated/ loose motion Frequency/day Nature of stools if specific

iv. Micturition

Frequency – Regular / irregular Day- night - Associated with pain/burning sensation Associated with stress incontinence/ urge incontinence Others

v. Maanasika chinta/ achinta/ harsha/ shoka /kroda etc

vi. Sleep

sound/disturbed/irregular Day - night -

vii. Addictions if any

viii. Aggravating factors

Food Season Clothing Association with menstruation/vaginal discharge etc. Others

ix. Relieving factors

Food Season Clothing Other measures

7. OBG History Patient is -

Unmarried Married Puerperium Menopausal Pregnant

i. Unmarried LMP

Vaginal discharges Normal /excess physiological/ pathological Others

ii. Married

LMP - Pariety - Nulliparous/ multiparous Use of OCP/ IUCD/ mechanical barrier method/ family planning

Vaginal discharge Normal/excess physiological/ pathological Others



iii. Pregnancy LMP - Gravida- Gestational age - H/o of genito inguinal intertrigo in previous pregnancy

Vaginal discharge Normal /excess physiological/ pathological Specific condition related to pregnancy

Anaemia, PET, impaired GTT, Hyperemesis gravidarum, excessive weight gain etc.

iv. Puerperium Date of delivery Mode of delivery Normal delivery + episiotomy

Instrumental delivery + episiotomy LSCS

H/o associated complications during labour

Nature of vaginal discharge Normal /excess physiological/ pathological Location of episiotomy wound with relation to lesion site

Others

v. Menopausal

Occurrence H/o bleeding per vagina Vaginal discharges Normal /excess physiological/ pathological H/o mass per vagina Others

8. Treatment history

i. General Examinations

Eyes Temp Resp. Rate Nails BP Nourishment Tongue Pulse Lymph nodes

CVS RS CNS GIT CVS Others

ii. Systemic examination

Prakruti Vyayama shakti Saara Aahara shakti

Abhyavaharana Jarana

Samhanana Vaya Pramana Desha Satwa Vikriti Saatmya

iii. Dashavidha pariksha

iv. Local Examination of lesions I) Inspection

No. of lesions Shape Sites involved Redness Extension Discharge Swelling Dryness/atrophy



Colour Blisters

II) Palpation

Size in cm. Numbness Local warmth Roughness Tenderness Consistency of Discharge

9. Samprapti

Ghatakas

Nidaana Dosha

Dooshya- dhatu mala

Strotas Srotodusti prakaara Udbhava staana Sanchara staana Vyakta staana Adhistaana Rogamarga Vyadhi prakaara Sadhya/ krachrasadhya/ asaadhya Sampraapti

10. Investigations 11. Sthanika chikitsa

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


“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

15. Conclusions Date: Signature: Observation Table

Symptoms D1 D7 D14 D28

Pain

Itching

Size

Redness

Colour

Warmth

Roughness

Tenderness

Discharge

Swelling


Cases

“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Cases Case 1 (after 3 weeks treatment)

Case 2 (after 3 weeks treatment)

Case 3 (after 1 week treatment)


Case 5 (after 2weeks treatment) Case 6 (after 4 days treatment)


Department of Prasooti Tantra and Stree Roga

188

“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Cases Case 8(after 1 week treatment)

Case 9 (after 3 weeks treatment) Case 10 (after 3 weeks treatment)

Case 11 (after 3 weeks treatment)

Case 12 (after 1week treatment) Case 13(after 3 weeks treatment)

Gaping of the episiotomy wound in the presence of genito-inguinal intertrigo


189

“Clinical Efficacy of Kadiradiyogavachoornana in Kachchu” Cases Acute inflammatory stage-intertrigo

Macerated stage-intertrigo

Intertrigo with blisters

Chronic stage / Stage of lichenification

Hyperpigmentation of pregnancy


190