Introduction

In Ayurveda every skin disorder is included under heading of Kusta. Ayurveda also implements broad line of management of skin disorders like medicinal and Para surgical approach. Vicharchika is considered as Kshudra Kushta in Ayurvedic classics with elaboration of its management in various aspects.(1) The clinical presentation of Vicharchika with symptoms like Kandu (Itching), Srava (Discharge), Pidaka (Pustules), Raji (Scratches), Ruja (Pain), Vaivarnyata (Discoloration of skin) etc.(2) The Eczema is the nearest clinical entity of modern science which can correlate with Vicharchika.(3) Vicharchika shows pathology with vitiation of tridosha but according to law of predominance it shows Pitta & kapha as major vitiation.(2) The Rakta and Twak is considerably included in pathology as dushya in Vicharchika.(2) All conservative management of Vicharchika has their own limitations with respect to care & its cure. Acharya Sushruta clearly mentioned that if all conservative management fails then the disease should consider as blood vitiated diseases and Raktamokshana is to be considering as choice of treatment.(4)

The existing treatment in modern science for Eczema consists of reassurance, elimination of predisposing causes and palliative measures. It is also said that no specific medication can cure eczema, though few drugs give symptomatic relief only.(5) Modern dermatology employs systemic and local administration of steroids for the management of eczema.(6) Despite an initial response, maintenance therapies with small doses of systemic and topical glucocorticoids usually produce hazardous ill-effects.(7) Similarly electrotherapy, ultraviolet therapy, hydrotherapy, X-ray therapy, etc. are having their own limitations and these therapies are neither popular nor much responding.

Raktamokshana is an effective and safe remedy for the Vicharchika; as major reason for vicharchika is Rakta dushti. Sushruta Samhita details practical guidelines for blood letting which is considered half treatments (Ardha chikitsa)(8)Various methods are employed for blood letting; like Shringa (Horn application), Jalouka (Leech), Alabu(Gourd), Prachhana (Scarification) and Siravyadha (Vein puncture) etc. These therapies are very well advocated in all Ayurvedic texts. Blood letting is effective in all types and stages of Vicharchika. In fact many researches already have been done in this field, but it is need of an hour is to focus on the Raktamokshana therapy to replenish it so that a concrete statement can be made as to which modality helps in which stage of this condition. The surgeon should make use of his yukti according to his experience (Yathabhyasa) to select the disease as well as patient. Raktamokshana should be done according to the procedures (Yathanayaya). (8)

Jalaukavacharana is ancient and famous modality of Raktamokshana which can be used in delicate persons and having pittaghna property. (9) It can be also a choice of treatment where the doshas are deep seated in disease pathologies. (8)

Shringavacharana is the type of Raktamokshana in which cow horn is utilized for the purpose of bloodletting with help of manual mouth aspiration.(9) The acharya Sushruta emphasized the guna of Shringa as Madhura (Sweet), Snigdha (Oily) and Ushna (Hot) which made it vataghana in nature. (9) it is indicated in diseases which are seated at skin level or superficial.(8) Both modalities having their own significance Hence this proposed study was undertaken to evaluate the efficacy and to standardize Jalaukavacharana and Shringavacharana methods of Raktamokshana in Vicharchika.

Aims & Objective

To evaluate and compare the efficacy of Jalaukavacharana (Leech Application) and Shringavacharana (Horn Application) in the management of Vicharchika w. s. r. Eczema

Materials and Methods:

Study Design

Present study was randomized, open clinical research at OPD/IPD levels with appropriate sample. The patients included in the clinical trial were divided into two groups viz.

Materials:

1) Patients – Total 62 patients were divided into two groups, 30 and 32 patients in Group A & Group B respectively.

2) Raktamokshana Devices:

a. Jalaukavacharana Material – Fresh Jalauka and Turmeric Powder

b. Modified Shringa instrument-* optic fibre tube attached with vacuum pump and pressure regulator. (As Shown in Image 1 to 4)

· It’s a innovative work conducted by scholar first time as a Ph.D. work, The Article has been published in International Journal of Ayurvedic Medicine and Pharmacy: Volume 2, Issue 5, September - October 2011 (IJRAP-ISSN 2229-3566)

· Group A Treatment of Vicharchika (Eczema) with Jalaukavacharana (Leech Application)

· Group B Treatment of Vicharchika (Eczema) with Shringavacharana (Horn application)

Source of Patients

Cases of Vicharchika (Eczema) were selected randomly irrespective of their Age, Sex, Religion, Occupation, Caste, Creed etc. and were randomly assigned in all groups, from OPD & IPD of Department of Shalyatantra I.P.G.T. & R.A. Hospital, Gujarat Ayurved University, Jamnagar,

Inclusion Criteria

1) Patients presenting with classical signs and symptoms of Vicharchika (Eczema) like Kandu, Vaivarnyata, Srava, Shotha, Vedana, Pidaka etc.

2) Patients between the age group 10-70 years

Exclusion Criteria

1) Use of Systemic antibiotics or anti-mycotic drugs in the previous 4 weeks.

2) Known cases AIDS (HIV Positive), Tuberculosis, Anemia and Cardiac Diseases, Leprosy, Hepatitis A, B, C.

Laboratory Investigations

1) Routine hematological investigations

RBS, TLC, DLC, Hb%, ESR & PCV, L.F.T., R.F.T, Lipid Profile

2) Urine examination

Macroscopic and Microscopic

Methodology

Group A

Modality Jalaukavacharana

Dose: One sitting per week

Period of trial 30 days (4 week)

Diet: To follow appropriate diet

Procedure:

Patients were given snehana karma before procedure the part was cleaned and fomented with Luke worm water. Then the fresh leeches after activation in the turmeric Powder were applied on the affected part. After application the leech were made to vomit with turmeric powder and the wound was dressed up by pressure bandage. Average 28 ml blood was removed. Duration of Leech application was Average 56 min.

Group B

Modality Shringavacharana

Frequency One sitting per week

Period of trial 30 days (4 week)

Diet To follow appropriate diet

Procedure Patients were given bahya abhyanga (Local oil Massage) and nadi swedan karma(Sudation) before procedure, small 25 incisions were given at or near the lesion, approximate 1mm deapth by 11 no surgical blade were maintained. The innovated Shringa (Optic Tube) was applied from its base over the incised point. The Shringa (Optic Tube) was fixed by pressing it over the skin. The suction was made from the apex of Shringa with vacuum pump with constant 250 mm of hg pressure. The created vacuum in the Shringa (Optic Tube) removed the vitiated blood up to average 27ml. Average 27 min was required for procedure. After completion of the procedure the wound was dressed up with antiseptic dressing after haemostasis.

Advice (8)

Do’s

1) Laghu ahar (Light Digestive food)

2) Light Exercise

3) Yavagupan (Use of digestive soups)

Don’t’s

1) Anger

2) Hard work

3) Sexual Intercourse

4) Sleeping by day

5) Excessive talking’s

6) Physical Exercise

7) Spicy & Salty food

Assessment Criteria:

Subjective Parameters

1 Kandu (Itching)

2 Vedana (Pain)

3 Vaivarnyata (Discoloration of Skin)

4 Srava (Secretions)

6 Pidaka (Rashes)

7 Rukshata (Dryness)

Objective Parameters

1 Size of Patches (Calculated the area of Patches in measurement Length x Breadth = cm²)

2 Shotha (Swelling) (Calculated by direct measurement in cm)

Kandu (Itching)

· No itching 0

· Relive spontaneously + 1

· Relive by itching + 2

· Disturbs routine + 3

· Require medication + 4

Vaivarnya (Discolouration)

· Normal colour 0

· Light Brown +1

· Break Brown +2

· Dark Brown +3

· Black Brown +4

Srava (Discharge)

· No discharge 0

· Occasionally discharge +1

· Discharge on itching +2

· Relive spontaneously +3

· Not at all relive +4

Vedana (Pain)

· No pain 0

· Occasionally pain +1

· Mild pain on touch +2

· Mild to moderate pain +3

· Severe pain +4

Pidika (Rashes)

· No Pidaka 0

· Starting of Pidaka +1

· Moderately developed Pidaka +2

· Spreaded over extremities +3

· Severely spreaded all over body +4

Rukshata (Dryness)

· No scratch imprint after scratching 0

· Mild scratch imprint after scratching +1

· Scaling on every scratch +2

· Scratching causes eruption +3

· Spontaneous eruption & Stretching of skin +4

Follow up

· The follow up of every patient was maintained up to 30 days (Weekly) after completion of treatment.

Statistical Analysis:

The obtained data were analyzed statistically. Scored values of assessment were analyzed through wilkoxon sign rank test within group and unpaired t test was used for intergroup comparison. For intra group comparison of investigational values paired‘t’ test while intergroup comparison unpaired t test was used. The values were expressed as mean ±SEM. ‘t’ test level of P<0.05 and P<0.01 were considered as statistical significant and highly significant respectively.

Observations and Results:

In present Clinical trial total 63 patients were registered. 31 and 32 patients were in group A, and Group B respectively. Among 63 patients, 71.428% were male while remaining i.e. 28.572% patients were female. The maximum number i.e. 44.44% of patients were in age group of 41 –60 years. The data of Deha Prakriti illustrated that maximum figures of patients i.e. 61.90% had Vatakapha Prakriti, while 14.28% were of Vata-Pitta Prakriti and 23.82% patients had Pitta-Kapha Prakriti. As far occupation concerned maximum number of patients was in general official services i.e.30.158%, 12.698% were in business, 25.396% were housewives. 92.063% patients from urban resident & 7.937% were from rural areas. Religion showed 92.063% Hindu and 4.76 % Muslims were observed. On the basis of socioeconomic approach 84.12% were middle class, 14.28% were poor and 1.58 % were rich. As per educational status all patients i.e. 100% were literate. (Table no 1) Vicharchika exhibited 92.063% as Shushka variety and 7.937% suffered from Sravi. Presence of the cardinal symptom of Vicharchika like Vaivarnyata (100%), Kandu (100%), Pidaka 95.238%, Raji 100%, Rukshata (100%) and Ruja 1.587% proved their prevalence (Table no 2).

The magnificence of present clinical trial showed highly significant consequences in both groups. In Group A cardinal symptoms Kandu, Vaivarnyata, Raji, Rukshata, Size of patches, Pidaka relived significantly showed p value <0.001, other like Vedana, Shotha, Srava were relived but statistically insignificant. (Table no 3) In group B the pacification of cardinal symptoms were also notify highly significant rate as group A (Table no 4). The utmost hematological and biochemical lab investigations showed insignificant changes

Discussion:

General Observations

Patient with age group of 41 –60 were up to 44.44% the reason may by chance. In study maximum 71.428% patients were of male gender. The male patients are frequently faced the causative factors of skin disorders like cement, mud, coal tar etc due their profession, Tobacco chewing, smoking, alcohol, longstanding are prevalent causes for male involvement in this disease. Maximum numbers of patients had Vata-Kapha Prakriti 61.90%, but the numbers of the patients in other groups are very nearer to it. Married patients were 76.190% but the rationality is still unpredictable. Occupational point of view general service men were showed their predominance up to 30.158% just by chance or the prolonged sedentary posture may causative factor. Socioeconomic approach showed maximum number was in middle class group up to 84.12%, 92.063 exhibited by dwelling status of patients with in urban class just by chance.

Disease Vicharchika

Amid all Kshudra Kustha Vicharchika is common. The occurrence may be due to climatic condition, because these types of diseases occur chiefly in humid area and the place where this study was carried out is humid region. Vicharchika is a condition where patient presents with the severe painful itching skin eruptions and dryness of the skin which can be rightly correlated to Eczema.

Result

In leech application the hirudin (Content of Leech saliva) showed rapid action in reliving symptoms 60% patients got reliving from 2^nd sitting.

In Raktamokshana procedures, Shringavacharana was modified; instead of mouth suction vacuum pump was utilized with constant pressure 250-300 mm of hg. This pressure was estimated threw a serve work of 60 healthy volunteers which showed the average human aspirating capacity is 220 mm of hg. The dimensionless suction in Shringavacharana procedure got its standardization along with suitable and scientific background. Utilization of vacuum pump avoids aspiration of blood in performer’s mouth.

As result concerned in (Group A) Jalaukavacharana & (Group B) Shringavacharana shows incredible outcome in pacification of symptoms because it is a prime modality of Raktamokshana which can act in any kind of vitiation of blood or also beneficial if the vitiation of doshas present systemically.

In group B the pacification of the symptoms are mostly similar to Group A with p value but percentage change shows better results in group A as showed (table no 5).

Conclusion

The outcome of present clinical trial show highly significant consequences in both groups. In Group A cardinal symptoms Kandu, Vaivarnyata, Raji, Rukshata, Size of patches, Pidaka relived significantly showed p value <0.001, other were relived but remained statistical insignificant. In group B the pacification of cardinal symptoms were also notify highly significant rate as group A with p value <0.001. The most of hematological and biochemical lab investigations didn’t shows remarkable changes The Raktamokshana methods Jalaukavacharana and Shringavacharana are both effective in the management of Vicharchika.

References:

1. Sushruta, Sushruta Samhita, with Ayurvedtatvasandipika. Kaviraj Dr Ambikadatta Shastri edition 2010. Nidansthan,Varanasi: Chaukhamba Sanskrit Sansthan; 2010.365p.

2. Sushruta, Sushruta Samhita with Nibandhasangraha of Dalhanacharya and Nyayachandrika Panchika of Gayadasa. Yadava T. Nidhana Stana. 7 ^thed. Varanasi: Chaukhambha Surabharati Prakashana; 2002. 285, 283p.

3. Ronald marks, Roxburgh’s common skin diseases, 17th Edition, chapter 8 Eczema (dermatitis) Arnold 2003.107p.

4. Sushruta, Sushruta Samhita, with Ayurvedtatvasandipika. Kaviraj Dr Ambikadatta Shastri edition 2010. Sharirsthana,Varanasi: Chaukhamba Sanskrit Sansthan; 2010.91p.

5. Eczema (Dermatitis), sign and symptoms, available on http://en.wikipedia.org/wiki/Eczema

6. Dr. KK Lo, Medical Bulletin, the Hong Kong Medical Diary, Practical Approach for“Eczema” Vol.15 NO.11 November 2010, Available on http://www.fmshk.org/database/articles/04mb1_5.pdf

7. Dr Haisook's Medicopedia, Cortisol/Glucocorticoids/Corticosteroids (actions and side effects), Available on http://medicopedia.wordpress.com/2009/01/17/cortisolglucocorticoidscorticosteroids-actions-and-side-effects/

8. Sushruta, Sushruta Samhita with Nibandhasangraha of Dalhanacharya and Nyayachandrika Panchika of Gayadasa. Yadava T. Shareera Sthana.7 ^thed. Varanasi:Chaukhambha Surabharati Prakashana; 2004..383, 379p.

9. Sushruta, Sushruta Samhita with Nibandhasangraha of Dalhanacharya and Nyayachandrika Panchika of Gayadasa. Yadava T. Sutra Sthana. 7 ^th ed. Varanasi: Chaukhambha Surabharati Prakashana; 2004. 55,56p.

Table 1. General observations: n=63

Sr. No.	Observations	Results in % (Maximum)
1	Age(41 –60years)	44.44
2	Sex (Male)	71.428
3	Marital status (Married)	76.190
4	Occupation (Service)	30.158
5	Dwelling Status (Urban)	92.063
6	Religion (Hindu)	92.063
7	Socio economic status (Middle class)	84.12
8	Educational Status Literate	100
9	Prakriti (Vata-kapha)	61.90
10	Type of Vicharchika	92.063

Table no. 2 Subjective and Objective Parameters

Subjective &Objective Parameters	Present	Present %	Absent	Absent%
Viavarnyata	63	100	00	100
Kandu	63	100	00	100
Srava	07	11.11	56	88.888
Ruja	01	1.587	62	98.4127
Pidaka	60	95.238	03	4.761
Shotha	00	00	63	100
Rukshata	63	100	00	00
Raji	63	100	00	00

Table no 3 Group A Jalaukavacharana Wilcoxon Signed Rank Test

Subjective &Objective Parameters	N	Day	Median	25%	75%	W	P
*Kandu*	31	BT 1^st Day	3.000	3.000	4.000	-496.000	<0.001*
*Kandu*	31	AT 30^th Day	1.000	0.250	1.750	-496.000	<0.001*
*Vedana*	31	BT 1^st Day	0.000	0.000	0.000	-1.000	1.000
*Vedana*	31	AT 30^th Day	0.000	0.000	0.000	-1.000	1.000
*Size of Patches*	31	BT 1^st Day	78.000	56.000	127.000	-496.000	<0.001*
*Size of Patches*	31	AT 30^th Day	60.000	40.000	94.500	-496.000	<0.001*
*Vaivarnyta*	31	BT 1^st Day	3.000	3.000	4.000	-406.000	<0.001*
*Vaivarnyta*	31	AT 30^th Day	1.000	1.000	2.000	-406.000	<0.001*
*Pidaka*	31	BT 1^st Day	3.000	3.000	4.000	-378.000	<0.001*
*Pidaka*	31	AT 30^th Day	1.000	1.000	3.000	-378.000	<0.001*
*Srava*	31	BT 1^st Day	0.000	0.000	0.000	-21.000	0.031
*Srava*	31	AT 30^th Day	0.000	0.000	0.000	-21.000	0.031
*Shotha*	31	BT 1^st Day	0.000	0.000	0.000	0.000	1.000
*Shotha*	31	AT 30^th Day	0.000	0.000	0.000	0.000	1.000
*Rukshata*	31	BT 1^st Day	3.000	3.000	4.000	-496.000	<0.001*
*Rukshata*	31	AT 30^th Day	1.000	0.000	1.750	-496.000	<0.001*
*Raji*	31	BT 1^st Day	3.000	3.000	5.000	-351.000	<0.001*
*Raji*	31	AT 30^th Day	1.000	1.000	3.000	-351.000	<0.001*
*shows highly significant result

Table no 4 Group B Shringavacharana Wilcoxon Signed Rank Test

Subjective &Objective Parameters	N	Day	Median	25%	75%	W	T+	P
*Kandu*	32	BT 1^st Day	3.000	3.000	3.000	-528.000	0.000	<0.001*
	32	AT 30^th Day	1.000	0.000	1.000	-528.000	0.000	<0.001*
*Vedana*	32	BT 1^st Day	0.000	0.000	0.000	-3.000	0.000	0.500
	32	AT 30^th Day	0.000	0.000	0.000	-3.000	0.000	0.500
*Size of Patches*	32	BT 1^st Day	71.000	54.000	240.000	-528.000	0.000	<0.001*
	32	AT 30^th Day	62.000	46.000	220.000	-528.000	0.000	<0.001*
*Vaivarnyta*	32	BT 1^st Day	3.000	3.000	4.000	-496.000	0.000	<0.001*
	32	AT 30^th Day	1.000	1.000	1.000	-496.000	0.000	<0.001*
*Pidaka*	32	BT 1^st Day	3.000	3.000	3.000	-435.000	0.000	<0.001*
	32	AT 30^th Day	1.000	1.000	2.000	-435.000	0.000	<0.001*
*Srava*	32	BT 1^st Day	0.000	0.000	0.000	-1.000	0.000	1.000
	32	AT 30^th Day	0.000	0.000	0.000	-1.000	0.000	1.000
*Shotha*	32	BT 1^st Day	0.000	0.000	0.000	0.000	0.000	1.000
	32	AT 30^th Day	0.000	0.000	0.000	0.000	0.000	1.000
*Rukshata*	32	BT 1^st Day	3.000	3.000	3.500	-496.000	0.000	<0.001*
	32	AT 30^th Day	1.000	0.000	1.000	-496.000	0.000	<0.001*
*Raji*	32	BT 1^st Day	3.000	3.000	3.000	-435.000	0.000	<0.001*
	32	AT 30^th Day	1.000	1.000	2.500	-435.000	0.000	<0.001*
*shows highly significant result

Table no.5 Unpaired T test in Group A and Group B

Subjective &Objective Parameters	N	Day	Mean	±SEM	Std Dev	% Change ↓	Difference	T	P
Kandu	31	Group A	68.817	±4.162	23.171	69	-9.308	-1.750	0.085
	32	Group B	78.125	±3.342	18.902	78.125%	-9.308	-1.750	0.085
Vedana	31	Group A	3.226	±3.226	17.961	0.3	-3.024	-0.556	0.580
	32	Group B	6.250	±4.348	24.593	6.250	-3.024	-0.556	0.580
Size of Patches	31	Group A	22.396	±2.158	12.014	22.4	8.074	3.088	0.003
	32	Group B	64.063	±3.558	20.129	64.063	8.074	3.088	0.003
Vaivarnyta	31	Group A	55.645	±4.755	26.474	56	-8.417	-1.423	0.160
	32	Group B	64.063	±3.558	20.129	64.063	-8.417	-1.423	0.160
Pidaka	31	Group A	51.651	±4.952	27.570	52	51.651	-2.754	0.697
	32	Group B	54.405	±4.997	28.266	54.405	51.651	-2.754	0.697
Srava	31	Group A	12.903	±5.225	29.094	13	68.817	78.125	0.085
	32	Group B	2.083	±2.083	11.785	2.083	68.817	78.125	0.085
Shotha	31	Group A	0.000	±0.000	0.000	00	3.939	1.209	0.231
	32	Group B	0.000	±0.000	0.000	0.000	3.939	1.209	0.231
Rukshata	31	Group A	70.430	±4.683	26.073	70	-3.528	-0.541	0.591
	32	Group B	73.958	±4.548	25.729	73.958	-3.528	-0.541	0.591
Raji	31	Group A	50.707	±5.566	30.991	50.7	-6.883	-0.923	0.359
	32	Group B	57.589	±4.976	28.147	57.589	-6.883	-0.923	0.359

Image no.1: Showing Shringayantra and its Specifications

Image 2: Component of modified Shringayantra

Image 3: Component of modified Shringayantra

Image 4: Component of modified Shringayantra with optic Fiber Tube

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