Clinical evaluation of Trivṛta powder (Operculina turpethum Linn.) and Aragvadha Patra Lepa (paste of leaves of Cassia fistula Linn.) in the management of Vicharchika (eczema)

Introduction

Any disorder which affects the skin needs primary attention as it reflects the pathology inside the body and can cause embarrassment. Hence, any disorder affecting skin must be noticed very early and the treatment modalities should be started as early as possible. Skin diseases have increased markedly nowadays because of changed work culture, faulty food habits, lack of exercise, changing lifestyle and increasing pollution.[1]

Ayurveda describes the wide spectra of skin disorders as “Kushtha” and is classified into two divisions, i.e., Maha Kushtha and Kshudra Kushtha. Vicharchika is enlisted under Kshudra Kushtha. All type of Kushtha are Tridoshaja (involving vitiation of these biohumours), hence Vicharchika is also Tridoshaja in origin. Most of the texts have described that Vicharchika has Kapha dominancy and comes under Raktapradoshaja Vikara (disorder occurring due to vitiation of blood). Vicharchika to a greater extent resembles eczema. Eczema is an inflammatory condition of the skin response to many injurious agents characterized by groups of vesicular lesions with a variable degree of exudates and scaling. In some cases, dryness and scaling predominate, with slight inflammation. In more acute cases, there may be considerable inflammation and vesicle formation.[2] The prevalence of eczema has been found to have increased substantially in the latter half of the 20^th century, with eczema being found to increase between the late 1940s and 2000.

Modern medical science treats eczema with systemic steroids and other therapeutics to give symptomatic relief. No doubt, the use of steroids suppresses eczema, but it costs deeply in the severe long-term toxicity, including osteoporosis, skin fragility, susceptibility to infection and pituitary-adrenal axis suppression.

Therefore, world is looking toward other system of medicine, especially Ayurveda for this problem. Kushtha and its subtypes have been considered as a “Sapta Dravyasamgraha” (combination of seven pathological factors). Rakta Dushti (vitiation of blood) is one of the important causes of Kushtha.

Virechana Karma (medicated purgation) is indicated not only for Pitta Dosha but also in Kapha and vitiated Rakta. Regular purgation by Trivritta (Operculina turpethum Linn.) eliminates aggravated Dosha (humor). It is also observed that cleansing of bowel is one of the most important treatments before administration of any drug, especially rejuvenation therapy,[3] and in case of Trivritta by the effect, it is laxative and by the virtue of characteristic taste and properties, it helps to treat Kushtha. According to Acharya Sushruta, if Kushtha is located in Tvak (Rasa), Shodhana (purification) and Lepa (local application) should be used.[4] Depending on invading nature of disease, the treatment principle of Kushtha may change in addition to previous Dhatugata treatment. Acharya Charaka has categorically mentioned the different categories of external Kushthahara Lepa and has even given equal importance to external application and internal (Shamana) therapy.[5] Hence, for the clinical study, Aragvadha Patra Lepa[67] (paste of leaves of Cassia fistula Linn.) was selected for local application.

Hence, the present study was aimed to assess and compare the efficacy of Trivritta powder (Operculina turpethum Linn.) given orally along with local application of Aragvadha Patra Lepa (paste of leaves of Cassia fistula Linn.) and locally applied paste of Aragvadha leaves alone in the management of Vicharchika Kushtha.

Materials and Methods

Observations and Results

Maximum patients were in the age group of 36–45 years and 58.73% were males, 92.06% belonged to Hindu community, 82.53% were married, 28.57% had graduation level education, 30.15% patients were from service class, 70.36% were from urban area, 76.19% belonged to middle class and 71.42% were vegetarian. Deha Prakriti (body constitution) illustrated that maximum patients, i.e. 39.68% were of Vata-Kapha Prakriti and 74.60% patients had Rajo-Tama Prakriti (psychological make up) as a Manasika Prakriti (psychological makeup). Nearly 41.26% patients had chronicity of the disease for more than 1 year and 73.01% had a negative family history of eczema. Majority of patients (55.55%) were taking allopathic treatment and remaining 7.93% were taking Ayurvedic treatment. About 62.5% patients had irregular bowel habits. Almost 34.92% patients had sound sleep and 30.15% of the patients were in habit to take day sleep. About 50.79% patients were consuming Lavana Rasa (salty taste) and 41.26% were habituated to Amla Rasa (sour taste), predominant food articles. Agni-wise distribution showed that Mandagni (unpaired digestive system) was found in 50.79% of the patients. Krura Koshtha (constipated bowel habits which require laxative) was found in 42.85% patients.

Majority of the patients (79.36%) had a gradual onset of the disease. The 100% patients were in habit of taking Viruddha Ahara (incompatible diet) such as Samyoga Viruddha (incompatibility of combination), Virya Viruddha (incompatibility of potency) and Samskara Viruddha (incompatibility of mode of preparation) while 50.79% were taking Matra Viruddha Ahara (incompatibility of quantity). Krama Viruddha Ahara (incompatibility of sequence) was practiced by 49.20% of the patients. Rest 20.63% of the patients were taking Vidhi Viruddha Ahara (incompatibility of rules for eating).

Nearly 33.33% patients reported aggravation of the symptoms in summer season and 28.57% of the patients reported aggravation of the symptoms during rainy season. 56.66% patients were suffering from Shushka type of Vicharchika (dry eczema), whereas 43.33% were with Sravi type of Vicharchika (wet eczema) [Table 1].

Table 1

General observations of patients in clinical trial (n=63)

All the patients (100%) had Vaivarnya (discoloration), Kandu (itching) and Pidaka (eruption). 73.33% patients had Raji (lining/thickening of skin), 56.66% patients had Rukshata (dryness), 43.33% patients had Srava (oozing), 40% patients had Ruja (pain) followed by 38.33% patients who had Daha (burning sensation) and 23.33% patients had Shotha (inflammation).

In group A, effect of trial drug Trivritta powder along with Aragvadha Patra Lepa on subjective parameters showed that there was a statistically extremely significant (P < 0.0001) improvement in itching, oozing, and eruption. Very significant improvement was found on burning (P = 0.0078) and significant improvement was found on discoloration (P = 0.0156), pain (P = 0.0156) and Shotha (inflammation) (P = 0.0313). No significant improvement was found on dryness (P = 0.0625) and Raji (P = 0.0625). In group B, trial drug Aragvadha Patra Lepa (paste) provided statistically significant improvement on discoloration (P = 0.0313), itching (P = 0.0156), oozing (P = 0.0313) burning sensation (P = 0.0313) and eruption (P = 0.0156) and no significant improvement on pain (P = 0.500), Raji (thickening of the skin) (P = 0.125), dryness (P = 0.250) and Shotha (inflammation) (P = 0.0625) [Table 2, Graphs 1, and 2].

Graph 1

Effects of Group A on subjective parameters (n = 30). BT: Before treatment, AT: After treatment

Graph 2

Effects of Group B on subjective parameters (n = 30). BT: Before treatment, AT: After treatment

Table 2

Effect of therapy in subjective parameters in Group A and Group B (Wilcoxon matched paired single ranked test)

On comparing the effect of the two groups, it was found that there was extremely significant difference (P < 0.0001) between the two groups in itching, oozing, burning sensation and eruption. Mean difference of group A was greater than group B. This implies that clinically group A was better than group B in relief on itching, oozing, burning and eruption [Table 3]. The percent relief in all the cardinal symptoms has been depicted in Graph 3.

Graph 3

Percentage relief in subjective parameters in Group A and Group B (n = 60), BT: Before treatment, AT: After treatment

Table 3

Intergroup comparison between Group A and Group B on subjective parameters in the patients of eczema (Mann-Whitney test)

Routine hematological and biochemical investigations were carried out in both groups before and after the treatment. However, no significant differences were found in laboratory parameters. From the above results, it is observed that the treatment of group A is proved to be better than treatment group B.

Discussion

Trivritta has Madhura (sweet), Kashaya (astringent),[9] Katu (pungent), Tikta (bitter),[10] Rasa (taste), Katu Vipaka (post digestive effect) and Ushna Virya (hot potency), which is pacifying Kapha and Pitta, for it also easily and safely eliminates the body wastes, so it corrects vitiated Pachaka Pitta and helps in purifying Raktadhatu and thereby combating Rakta Dushti (blood impurity). Pachaka Pitta controls other Pitta in the body including Bhrajaka Pitta which is also vitiated in Vicharchika. This might have the reason of its action in getting relief in discoloration, itching, burning sensation and eruptions. Katu (pungent) and Tikta (bitter) Rasa of Trivritta does Lekhana (scraping) of Pravriddha (increased) Mamsa Dhatu. Excessive Kleda in Vicharchika is produced due to vitiated lymph, which is Apa Mahabhuta Pradhana (having dominancy of secretion). Trivritta has Ruksha Guna (dry quality) and hence, helps to dry up the discharge, which might be the reason of getting relief in Srava and Pidika. Trivritta does Ama Pachana, removes Sanga (obstruction) from Srotasa (channels) and does Srotomukha Vishodhana (opening of pores of channels). Due to this, Vata gets pacified and helps in Samprapti Vighatana (reversing of pathogenesis). Trivritta is also having Krimighna (antimicrobial) property.[11] Krimi is mentioned as a causative factor of Kushtha. Hence, it directly acts on Vicharchika Kushtha (eczema) (antibacterial activity[12] and anti-inflammatory activity[13]).

Acharya Sushruta has mentioned Lepa (paste) (local application) as the treatment of Kushtha, as it is a type of Shodhana (purification). Lepa (paste) pacifies provoked local Dosha by local application. Furthermore, Acharya Charaka has described Lepa (paste) as “Sadyah Siddhi Karaka (providing instant effect).”[14] Application of ingredients of Lepa (paste) enters into Romakupa (hair follicle) and further gets absorbed through Svedavahi Srotasa (channels of sweat) and Siramukha (opening the skin pores) leading to desired effects. Aragvadha Patra has Kushthagna (anti-Kushtha), Kandughna (anti-itching), Kriminashaka (antimicrobial) and Rakta Shodhaka (blood purifier)[15] properties due to which is acts on Vicharchika by virtue of its antibacterial and antifungal activities,[1617] anti-itching activity.[18] wound healing[19] and anti-inflammatory activity.[2021] Aragvadha Patra Lepa (paste) along with Takra (butter milk) creates irritation and penetrates the skin. Therefore, it provides early improvement. In this way, the treatment of group A (Nitya Virechana by Trivrit along with Aragvadha Patra Lepa is proved to be better than group B (Aragvadha Patra Lepa) [Figures 1–3].

Figure 1

Before treatment status of skin lesion of patient in group A

Figure 2

After 15 days effect of Trivritta powder along with paste of Aragvadha leaves (group A) on the skin lesion

Figure 3

After treatment effect of Trivritta powder along with paste of Aragvadha leaves on the skin lesion (group A)

Conclusion

Trivritta along with Aragvadha Patra Lepa (paste) has provided significant results on itching, oozing, burning sensation, eruptions, discoloration, pain and inflammation in comparison to only Aragvadha Patra Lepa (paste). Hence, the combination action of Trivritta powder and Aragvadha Patra Lepa (paste) is effective to check the etiopathogenesis of eczema and thus it can be concluded that Trivritta powder along with Aragvadha Patra Lepa (paste of leaves of Cassia fistula Linn.) is safe and cost-effective treatment for Vicharchika Kushtha (eczema).