DERMATOLOGY IN AYURVEDA

SKIN IN AYURVEDA-TWACHA

• The embryological evolution of the skin(twacha) is attributed to the union of sukra and sonita by Acharya Susruta.

• It is a collection of various elements(dhatus and updhatus) distributed with their function.

• A/C to Vagbhata, due to the paaka by its dhaatwagni, rakta becomes skin, just like the deposition of cream on the surface of the boiling milk.

• Thus, twaka is also called as rakta santanika.

• Formation of skin from raktha has been influenced by multiple bhootha elements as that in rakhta as Sushruta told us.

• The structure and smell of skin may have major contribution from Bhoomi bhootha, while the circulatory components may  Jalabhootha.

• Pigmentation from Agnimahabhootha,  sensations may have origin from Akashbhooth.

• So each structural  appendage may be have qualitative resemblance with their basic elements and so in both diagnostic as well as therapeutics aspects, it is essential to be aware of the relation bw these basic aspects.

PART-1=LAYERS OF TWACHA(SKIN)

•      Structural  basics of skin starts with the reference of layers of the skin, where most of the pathological shifts evolve. The skin has 7 layers;

• AVABHAASINI

• LOHITHA

• SWETHA

• TAAMRA

• VEDINI

• ROHINI

• MAMASADHARA

1)AVABHAASINI

• First, outermost, thinnest layer.

• Luster = status of this layer.

• Acharya Charaka mentions this as UDAKADHARAA, which means that is the one that holds the aqueous tissue(LASIKAA) within.

• Responsible for retaining the fluids and nourishes the lower layers of tawacha.

• Secretes the sweat and sebaceous material from the pores(SVEDA).

• Dehydration of the skin which predisposes scaling and hyperkeratinization also affects the outermost layers.

• Condition like  “SIDHMA”  and  “PADMINEEKANTAKA” manifest here. These lesions are characterized by scaling and keratoderma or black heads.

2)LOHITA

• Second in sequence.

• Slightly thicker than A.

• Red due to the presence of peripheral blood vessels in it. Hence, Charaka named it as Asrukdhara.

• Has rich micro vascularity and superficial component.

• Condition characterized by various colored lesions on the skin like NAEVI.

POLYPS, WARTS(TILA  VYANGA, NYACHA, KAALAKA) etc. originates here.

3)SHVETAA

• Third layer, where the anastamoses of superficial and deep components of blood vessels happen.

• Anastomoses are developed highly at the level of the upper part of the dermis and around folliculo-sebaceous-apocrine units.

• Lesions characterized as seborrheic keratoses and acitinic keratoses may originates(charamadala, ajagalika, mashaka) in this layer.

4)TAMRA

• Fourth layer.

• Lesions characterized by a copper discoloration and rich capillary network which worsen on exposure to sunlight.

• Kushtha, kilaasa originate in this layer.

• Innermost vascular component or deep plexus where the secretions of vasodilatation are produced.

• Acute and chronic allergic responses are very prominent in this layer.

5)VEDINEE

• Fifth layer, responsible for sensation.

• Vedin means to know, to perceive.

• Has plenty of good nerve supply

• Pain, burning and itching , herpectic lesions happens due to erosion of this layer.

6)ROHINEE

• Pre Maamasadhara layer means 6^th layer forms a covering to many organs.

• Condition are more grave in this layer, i.e. tumors, mumps,

• Agnikarma, kshar karma such ayurvedic surgical intervention can be done in this layer.

• Crucial layer and if injured, difficult to cure.

7)MAAMSADHARAA

• Last and innermost layer, which is adhering to the muscled through which the blood vessels are traversing.

• Functional excellence of this portion provides adequate blood supply to other portion of the skin and help in waste drainage through venous return.

• Diseases like Bhagandra, arsha and different types of Vidradhi can be seen in this layer.

TVACHA/SKIN AND DOSHAS

• Tvacha is one of the site of vata and pitta(A.H. Sha. 12/13).

• Sparsa is the function of vaatha(Ch. Su.8/10) and skin has been considered as location of Sparashanendriya.

• Bhrajaka pitta is located on skin for giving luster and color(Ch. Su. 12/12).

• Snighdta, mruduta, sthirata, sheetata, prasannata, snigdha varnata are attributed to kapha. This is also responsible for Ropana Karma(self-healing process).

SKIN AND DHATU

• RASA;

In the context of twak sara purusha lakshana it has mentioned that twak saratha and rasa saratha and rasa saaratha are one and the same.

The fluid compartment retained by the udakadhara, that is the first layer of skin, also includes the circulating rasadhaathu.

• RAKTA;

Varnna, the one which is illustrated by skin is the contribution of raktha, since varnnaprasaadana is the function of raktha (Su.Su.15/6).

• Mamsa;

Twak is updhatu of mamsa (Ch.Chi.15/7).

SKIN AND MALA

• SWEDA;

It is mala and meda which is excreted by skin/twacha. Sweda maintains the

luster and humidity of skin (Ch.Su.15/5).

Nails and hairs, the appendages of skin and mala of asthi dhatu and twakgata sneha is the mala of majja dhatu (Ch.Su.46/271).

PART-2=KUSHTHA

¢Kushta is a compendium of various skin diseases, divided into two groups i.e. major (maha kushtha) and ii. minor (kshudra kushtha). Seven types of major and eleven types of minor skin disorders or dermatosis are described here as guidelines to understand diagnosis and treatment principles of various skin disorders.

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ETIOLOGY/NIDANA

-Viruddha annapana, excessive intake of drava, snigdha and guru dravyas; restraining natural urges like vomiting etc; exercising or coming in contact of excessive heat after eating excessive quantity of food.

-Indulging in habits such as, taking shita quality food etc. followed by ushna quality or either fasting followed by heavy meals.

-Having cold water immediately after exposure to scorching sun, exertion and fear, eating uncooked or raw foods or having meals although previously taken meals have not been digested. Indulging in food and other habits which have been restricted during the phase of Panchakarma

– Consuming new grains, curds, fish, excessive salty and sour food items. Black grams, radish, food prepared from flour paste, sesame, milk and jaggery products. Indulging in sexual activity even if the food is not well digested (sexual intercourse immediately after taking food), sleeping during day time, insulting peers like brahmin / guru and other respected personal and doing sinful acts are the etiological and risk factors of kushtha.

PATHOGENESIS/SAMPRAPATI

• The vitiated three doshas- vata, pitta, kapha along with impaired tvak, rakta, mamsa and ambu together constitute seven essential entities which play role in pathogenesis of kushtha.

• Kushtha can be classified into seven mahakushtha (major skin disorders) and eleven kshudrakushtha (eleven minor skin disorders). Single dosha cannot cause kushtha on its own i.e. kushtha is not an nanatmaja (disease caused by single specific dosha) disease.

PREMONITORY SIGNS AND SYMPTOMS/LAKSHANA

• Decreased touch sensation, excessive sweating or absence of sweating (which may be localized or generalized), change in color (discoloration), papules on skin, horripilation, pruritus, pricking pain, physical exhaustion, mental fatigue, severe pain in ulcerated area, sudden appearance and chronic the ulcers, burning sensation, numbness are the premonitory symptoms of skin disease

TYPES/BHEDA/PRAKARA

¢ Eighteen types of skin diseases;

Henceforth 18 types of kushtha alongwith their signs and symptoms are described viz. kapāla, udumbara, maṇḍala, rṣyajihva, puṇḍarīka, sidhma, kākaṇaka, ekkuṣṭha, carmākhya, kiṭibha, vipādikā, alasaka, dadru, charmadala, pāmā, visphōṭaka, śatāru and vicārchikā SEVEN MAJOR KUSHTHA

1.Kapala Kushtha;

The clinical presentation of kapala kushtha is as  follows:

Color –- krṣr̥ ̥ṇa (blackish), aruṇa (reddish) Nature – kapāla (similar to broken piece of earthen pot)

Touch – rūkṣa (dry), paruṣa (rough), tanu (thin)

Associated symptoms – severe pain

Sadhya /sadyata – Difficult to cure

2. UDUMBARA KUSHTHA

The clinical presentation of udumbara kushtha is as follows:

Color – Similar to udumbara fruit

Nature – rāgaparīta (redness), lōmapiñjara (hair on the patch become brown) Associated symptoms – burning sensation pruritus and pain

3.MANDALA KUSHTHA

The clinical features of mandala kushtha are as follows:

Color – white and red

Nature – sthira (slow progress), styāna/ghana

(compact), snigdha, elevated round patches

Associated symptoms – patches are matted

Sadhyasadhyata – Difficult to cure

4.RISHYAJIVHA KUSHTHA

The clinical features of rishyajivha kushtha are as follows:

Color – Rakta paryanta anta śyāvaṁ (red in edges and brown inside)

Nature – karkaśa (rough), it resembles the tongue of rṣya ,a type of deer with blue testicles

[Cha.Sa. Chikitsa Sthana 7 / 17 Chakrapani]

Associated symptoms – pain

5.PUNDARIKA KUSHTHA

The clinical features of pundarika kushtha are as follows:

Color – White with red edges Nature – resembles lotus petals, elevated patches

Associated symptoms – burning sensation

6.SIDHMA KUSHTHA

The clinical features of sidhma kushtha are as follows:

Color – white coppery, color resembles flower of alabu (lagenaria siceraria)

Nature – thin

Associated symptom – particles resembling dust are observed, it is located mostly on chest due to dominance of kapha on ura pradesh [Cha.Sa Chikitsa Sthana 7/19 Chakrapani].

7.KAKANAKA KUSHTHA

The clinical features of Kākaṇaka kuṣṭha are as follows:

Color – resemble gunjā (abrus precatorious) i.e.

red in color

Nature – does not get suppurated Associated symptoms – Pain and incurable, all the three doshas are present

ELEVEN KSHUDRA KUSHTHA

1.Eka kuṣṭha

The clinical features of eka kushtha are as follows:

Nature – resembles scales of fish

Location – Extensive

2. .CHARMAKHYA KUSHTHA

The clinical features of charmakhya are as follows:

Nature – skin is thick resembling elephant skin

3.KITIBHA KUSHTHA

The clinical features of are as follows:

Color – It is blackish brown

Nature – Rough similar to scar tissue and hard to touch

Touch similar to the granulation process in wound.

4.VAIPADIKA KUSHTHA

The clinical features are as follows:

Location – Hand and legs

Nature – cracks in palms and sole Associated symptoms – severe / excruciating pain

5.ALASAKA KUṢHTHA

The clinical features are as follows:

Nature – Nodules

Associated symptoms – Pruritus

Color – redness

6.DADRU KUSHTHA

The clinical features are as follows:

Color – redness Nature – Elevated circular patch with pidaka

Associated symptoms – Itching

7.CHARMADALA KUSHTHA

The clinical features are as follows:

Color – Redness

Nature – pustules, cracks in skin which are crusted

Associated symptoms – Itching

8.PĀMĀ KUṢṬHA

The clinical features are as follows:

Color – white, reddish, brownish blackish

Nature – Itching

Associated symptoms –piḍakā (erruptions)

9. VISPHŌṬA KUṢṬHA

The clinical features are as follows:

Color – white reddish in appearance

Nature – erruptions and pustules with thin skin

10.ŚATĀRU KUṢṬHA

The clinical features are as follows:

Color – reddish, blackish

Nature – ulcerated

Associated symptoms – burning sensation and pain

11.VICĀRCIKĀ KUṢṬHA

The clinical features are as follows:

Color – blackish brown

Nature – excessive exudation, eruptions

Associated symptoms – pruritus

DOSHA DOMINANCE IN TYPES OF KUSHTHA

GENERAL GUIDELINES FOR DIAGNOSIS

• Tridosha are involved in pathogenesis of all types of kushtha.

• Depending on dosha predominant symptoms are manifested and treatment should be decided on the basis of symptoms shown in specific kushtha

• The dosha presenting important and specific symptoms should be alleviated firstly followed by the treatment of associated dosha.

• Specific kushtha determine the predominance of specific dosha and vice versa is also true i.e. predominance of dosha determines the specific type of kushtha.

• Similarly specific symptoms determine the causative factors vice versa causative factors determine the specific symptoms.

• Symptoms due to dosha predominance include dryness, atrophy, pricking pain / paraesthesia, pain, constriction or loss of elasticity, hardness, roughness, horripilation, blackish, brownish, slight reddish in color are manifestation of vata dosha.

• Burning sensation, redness, exudation, suppuration, offensive smell, stickiness / moist and sloughing of body parts are the symptoms caused by predominance of pitta dosha.

• Kapha dosha is responsible for symptoms like whitish discoloration, cold in touch, pruritus, non-progressive / slow progression of disease, elevated; heaviness and oiliness are presented along with maggot’s formation and stickiness like symptoms.

PART-3=PRINCIPLES OF MANAGEMENT

• In vataja kushtha, firstly administer ghritapana, whereas in kaphaja kushtha vamana procedure should be done and in pittaja kushtha, virechana along with raktamokshana should be first line of treatment.

• For vamana and virechana drugs mentioned in Kalpa Sthana should be used. Prachhana karma i.e. blood letting by rubbing with coarse device should be carried out if dushya dushti is less and venesection should be carried out in condition where dosha dusya dusti is strong.

• Patients with excessive vitiated dosha should be given shodhana therapy repeatedly; taking care about their prana (strength). Excessive elimination of dosha may increase vata dosha which may bring about weakness and in rare condition endanger the life of patient.

• After shodhana and letting of blood, sneha should be administered since after shodhana, vata dosha enters the shuddha koshtha of patient and is cause for immediate bala kshaya.

VARIOUS FORMULATIONS

• If dosha are utklishta and located in hridaya or kushtha is manifested in the upper part of body, then vamana should be administered with help of fruit of kuthaja, madanaphala and madhuka along with juice of patola and nimba.

• Sheeta rasa (cold effusion), pakva rasa(decoction), honey and madhuka should be used for vamana.

• Trivrita, danti and triphala are to be used for virechana in kushtha. Sauviraka, tushodaka, alodhana, asava, sidhu are types of aushadi kalpana to be used in virechana. Further sansarjana karma should be followed as per order.

• Darvi, brihati, patola, pichumarda, madanphala, kritamala, kalinga, yava and musta should be used along with sneha for asthapana.

• After virechana and asthapana basti still if there is excess of vata than give anuvasana basti should be given. In such condition sneha fortified with madanaphala, madhuka, nimba, kutaja, and patola should be used.

• Saindhava, dantī, maricha, phaṇijjhaka, pippali, fruit of karanja and vidanga should be used for nasya especially in case of krimi and kapha pradhan kushtha.

• Drugs mentioned in Sutra Sthana for vairechanika dhuma should be used in krimija kushtha and kilasa and also disease affecting the upper part of the body.

• If the patches are stable and hard, then give fomentation by prastara sweda ornadi sweda method and later on with the help of kurcha (a surgical instrument) scrub the patches so that there is increased flow of rakta in that specific area along with blood letting.

LOCAL TREATMENTS

• If the patches are elevated then swedana with lukewarm poultice of meat of aquatic animals should be followed by scrubbing with sharp edge surgical instrument for blood letting.

• For blood letting shringa (horn), alabu (gourd) may be used. Especially in alpa kushtha, prachana, virechana and/or use of jaluka should be done.

• Lepa explained in kushtha become efficient if applied after raktamokshana and other shodhana procedures.

• When there is loss of sensation and/or surgical interventions is prohibited, kshara should be used after rakta and dosha are eliminated.

• If kushtha is hard like stone with numbness, it is stable (not spreading) and chronic insuch cases antidotes should be given internally prior to the application of poison in the form of lepa followed by application of antidote.

• If there is numbness around the patch of kushtha associated with complete loss of sensation along with anhidrosis, and pruritus then for scrubbing in such condition brush (kurcha) prepared from danti, trivrita, karavira, karanja, kutaja or leaves of jāti, arka, nimba or surgical instruments, samudra phena, dried cowdung should be used followed by application of lepa.

• In pittaja kushtha line of treatment followed in vata kaphaja kushtha should be followed along with kapha, pitta and rakta should be eliminated and tikta (bitter), kashaya (astringent) drugs are to be used for pacifying the dosha.

• Ghee fortified with tikta (bitter) drugs and line of treatment of raktapitta should be followed internally and externally for treatment of pittaja kushtha.

• Treatment of different kushtha categorized on basis of aggravated dosha has been explained henceforth treatment for pacifying of kushtha is being explained wherein defect in skin is general symptom.
• Dārvi or rasāñjana along with cow’s urine helps in treatment of kushtha. Similarly haritaki along with trikatu or gud and taila for period of one month is helpful.

• Root of patola and gavakshi, contents of triphala (haritaki, bibhataki and amalaki) taken separately in one pala quantity each. Trayamana and katuki in quantity, should be taken together. One pala of this combination should be boiled in water and administered for elimination of dosha.

• After the combination has been digested by jatharagni of patient, soup of animal and birds residing in arid land along with old shali type of rice should be given. The preparation when administered for 6 days cures kushtha, shotha, grahani, arsha, mutrakricha, halimaka, chest pain and pain in bladder region along with vishama jwara.

MUSTADI CHURNA

• Musta, trikatu, triphala, manjishthā, dāruharidra, two panchamūla (brihat and laghu) saptacchada, bark of nimba, viśāla, chitraka, mūrvā are taken in equal quantity and powdered together. This powder should be mixed with nine times of saktu and should be prescribed with honey and ghrita. It is among the best treatment for kushtha which should be given everyday.

• The combination is also useful in shotha, pāṇḍu, śvitra, grahaṇīdoṣa, arśa, braghna, bhagandar, piḍakā, kaṇḍū, kōṭhā.

BENEFITS OF LELITAKA (SULPHUR)

• Lelitaka (sulphur) when administered with juice of jāti (āmalaki) along with honey is beneficial in 17 types of kushtha. Similarly use of makshika (copper pyrite) with cows’ urine too is very beneficial.

• Gandhaka (sulphur) and/or suvarṇamākṣika when used for processing of rasa (mercury) acts as the best medicine in treatment of all disease especially kushtha.

• Similarly kushtha patient should regularly consume parada (mercury) with vajra shilajatu or yogaraja which helps in curing of all diseases.

-Madhvasava

-Kanaka bindu arishta;

Every morning if this preparation is taken then in one month mahakuṣṭha gets cured and within 15 days ksudrakuṣṭha is cured. It is also useful arśa, śvāsa, bhagandar, kasa, kilasa, prameha and shosha. Skin achieves golden complexion after having kanakabindu. . It is useful in all vataja, pittaja and kaphaja kushtha.

                          ———-E. T. C————

PART-4 DIET AND LIFESTYLE IN KUSHTHA

• Easily digestible and wholesome food, green leafy vegetables bitter in taste, food and ghee prepared by fortifying with bhallataka, triphala and nimba, one year old cereals, meat of animals inhabiting from arid area, preparations of mudga and patola.

• Avoid heavy to digest, sour food, milk, curd, meat of animals residing in marshy area, fish, jaggery and sesame.

• Ela, kuṣṭha, dārvi, śatapuṣpā, chitraka, viḍaṅga, rasāñjana and abhaya taken together and their paste when applied has a very efficacious role in kushtha.

• Chitraka, ela, bimbi, vrṣr̥ aka, triv̥   rt ̥r ā, arka and shunthi should be powdered together̥ and trichurate with palāśa kshara and fortify it with cows urine for eight days. Application of this paste followed by sun exposure leads to bursting and dissolution of maṇḍala.

Siddharthaka snana( medicinal bath);

-Powder of musta, madanphala, triphala, karañja, āragvadha, kaliṅgaka, yava, dārvi, saptaparna are boiled in water and used for bath. This preparation is called as siddhārthaka snana.

-Decoction of above combination is useful for vamana and virechana procedures. It helps in promotion of color and complexion. It is also useful in tvagdōṣa, kuṣṭha, śōpha and panduroga.

External applications;

-Lepa of kuṣṭha (herb), seeds of karañja and ēḍagaja is useful in kuṣṭha roga. Similarly, paste of seeds prapunnāḍa, saindhava, rasāñjana, kapittha, lōdhra, root of white variety of karavīra, fruits of kuṭaja and karañja, bark of dāruharidra along  with tender leaves of jati is useful in kuṣṭha.

-Paste of lōdhra, dhātakī, seeds of vatsaka (kuṭaja), naktamāla and malati is to be used externally for udvartan and lepa.

-Paste of bark of shirīṣa or flowers of kārpās, leaves of rājavrk ̥r ksha or paste of̥ kākamācī are 4 different types of lepa useful in kuṣṭha.

Following six decoctions viz.

1.Dārvi, rasāñjana

• Nimba, paṭōla
• Heart wood of khadira
• Āragvadha
• Triphala
• Saptaparna Seventh decoction is of tiniśa anddecoction of āśvamāra.

All of the above decoctions should be used for bathing, drinking, in the form of lepa, for scrubbing and for dusting. The same decoctions can be used for fortifying of medicated ghee and oil.

Contributor- DR. Mohit Sandhu