Management of Vicharchika

Management of Skin Diseases in Ayurveda with Special Reference to Vicharchika

Dr.Aswathy S.

PG Scholar, Dept. of Agadatantra, Govt.Ayurveda Colllege, Tvpm

Vicharchika Lakshanam

Vicharchika is characterized with itching, boil, syaava twak (blakish discolouration) and profuse oozing.

Nidanam

Virudhahara and Dushivisha are the two major factors responsible for Vicharchika.

Virudhahara

Virudh (Vi+rudh+ktha) is virodha visishta, distinguished incompatibility.

Dravyas (In short all the drugs and diet) that which causes uthklesa (agitates, enrages, move doshas from their normal place) and do not expel it out is termed as virudha.

Types of virudha in samanya kushta nidana

Intake of cilcima with payas (samyoga virudha), use of santharpana & apatharpana without sequence (karma virudha), excessive intake of drava snigdha guru aahaara(mathra virudha), intake of food during ajeerna (vidhi virudha) Improper administration of panchakarma or apathya in panchakarma.vidhi,ahara without emesis of vidagdham.(undigested food). Divaswapna soon after lunch. Sudden diving in cold water or drinking cold water after srama (avastha virudha)

Important srothas affected by virudha

Mathra virudha

Atimathra sevanam, guru seetha atisnigdha atimathra sevanam, vidaahi annapanam & snigdhoshna dravya, medyanam cha athi bhakshanam and atimathra ajirnam will vitiate the following srotas respectively annavaha, rasa vaha, raktha vaha,medovaha and purisha vaha srothas.

Vidhi Virudha

Sushkanna sevanam, abhishyandhi & guru, vaathalaanam cha sevanam, athyabhishandhi and athyasana ajeerna will vitiate udaka vaha, mamsa vaha, asthivaha, majjavaha and purisha vaha srotas respectively.

Akaala bhojanam vitiates annavaha srotas due to Kala virudha and Sithoshna akrama sevanam vitiates swedavaha srotas due to Karma virudha.

Dushivisha

Dushivisha is defined as any kind of poison originating from inanimate(stavara) or animate(Jangama) sources or any artificial poison (Kritrima visha) retained in the body after partial expulsion or which has provisionally undergone detoxification, by the anti-poisonous drugs, forest fire, the wind or the sun. The skin manifestations of the dushivisha also increase due to the same aggravating factors of dushi visha like dushitha desha, kala, anna, diwaswapna, ajeerna etc.

Samprapti

Exposure to etiological factors like Sthavara visha, Jangama visha, Virudhahara, occupational pollutants etc. undergoes metabolism in the body. In the next step the toxins undergoes accumulation at the ashaya or dhatu level (Chaya and prakopa avastha). These toxins get kapha avarana in due course of time. Up to this level no signs and symptoms are seen. Hence, it is a subclinical condition. After exposure to secondary like dushitha desha, Kala, anna, divaswapna, ajeerna etc. vitiation of doshas and dhatus cause dosha dushya Sammurchana (Prasara avastha). In the next stage, poorvaroopa (premonitory symptoms) are seen like Angagourava, jwara, atisara etc. (Sthanasamsraya Avastha)

 Subsequently, onset of signs and symptoms are seen depending on the tissues involved, if rasa dhatu is involved rasa dushti lakshanas are seen (Vyakti avastha), if raktha dhatu is involved kushta, visarpa, Kota, raktapitta etc.(Bheda avastha)  will occur.

Diagnosis

Diagnosis is on symptomatic basis. Kandu, Syava, Pidaka, Bahusrava/Lasika are the main and important symptoms. According to Susrutha samhitha  Ruja, Rooksha and Raji are also present along with the above symptoms.

Comparison

Vicharchika is symptomatically almost similar to acute eczematous dermatitis. Sub acute eczema also shows some similarity with Vicharchika. Eczema can be defined as a catarrhal inflammation of the sensitive skin. The term Eczema literally means ‘boil out’ (ec = out, zema = boil) Eczema clinically represents pruritus, erythema, oedema, papules, vesicles, scaling and lichenification. Vesicles, through secondary infection may turn in to pustules. There are three stages of evolution of eczema, viz acute, subacute and chronic. Acute eczema shows erythema, oedema, vesicles, oozing, crusts and sometime blisters. Subacute eczema shows diffuse erythema, oedema, scabbing and scaling of skin. Chronic eczema depicts moderate erythema, scaling and eventually lichenification. For practical purposes eczema has been grossly divided in to two main groups: endogenous and Exogenous. In exogenous eczema the causative factor is one coming from outside the body, where as in endogenous eczema the factor is an internal one. Atopic dermatitis, Seborrhoeic dermatistis, Asteatotic dermatitis, nummular dermatitis, Stasis dermatitis, Autoeczematization etc are coming under Endogenous Eczema. Exogenous eczema includes contact dermatitis, infective eczema, photodermatitis, radiational eczema etc.

Sl No.	Vicharchika	Acute Eczema
1.	Kandu	Pruritus
2.	Pidaka	Papules, vesicles
3.	Syava	Erythema
4.	Bahusrava/lasika	Oozing

Role of Agadatantra in the management of Vicharchika

A study conducted in Kerala state by Dermatology department of Kasturba Medical College, Mangalore found that 11.6 % patients suffered from dermatological problems. Of these, 43.41% had cutaneous infection and 57.7% had non infectious dermatoses (Vicharchika). Reports from other parts of the country also showed similar results. On closely examining and taking history of the non infectious dermatitis cases we can infer the cause of the skin manifestation is Dooshivisha or Gara Visha. Habit of taking incompatible food (Viruddhaahara), intoxication due to air and water pollution (people inhabiting in industrial area), Occupational intoxication, Agricultural intoxication (use of pesticide, weedicide), use of Alcohol, smoking habits etc can be found in the history of Vicharchika patients. We can manage Vicharchika effectively by using Agadas mentioned in the classics to detoxify the Dooshivisha. Clinical studies conducted in our departments shows non infectious as well as infectious dermatitis can be treated successfully by using the principles of management of Dooshivisha along with General Kushta Chikithsa.

Treatment Protocol

According to the amount of aggravated dosha and rogibala treatment is divided into Sodhana and samana. In prabhootha dosha, Sodhana is indicated. If dosha kopa is less Samana Chikithsa is enough. If the patient is very weak only Samana Chikithsa can be used even in prabhootha dosha condition.

Sodhana

In Sodhana Chikithsa Snehanam and Swedanam should be done as poorvakarma. After proper snehanam and Swedanam sodhana procedures such as Vamanam, virechana, rakthamoksha etc should be done according to the dosha predominance and Peyadikrama should be followed after sodhana along with Samana medicines.

Snehanam- Vicharchika is a Kapha predominant skin disease so Nimbadi ghrutham is suitable for Snehapana. In some cases other doshas also vitiates along with Kapha so we can use the following medicines according to the dosha predominance.

Sl.No	Dosha predominance	Medicine for Snehapana
1.	Thridoshajam	Aragwadha Mahathikthaka ghrutam, mahavajrakam ghrutham/thailam Gugguluthikthakam ghrutam
2.	Vathapaithikam	Thikthakam Ghrutam
3.	Kaphavathajam	Vajraka ghrutam/vajrakam thailam
4.	Vathikam	Nisothamadi ghrutham.
5.	paithikam	Patoladi ghrutam
6.	Kaphajam	Nimbadi ghrutham

Swedanam- After Snehana Ushnaambu Snanam or Ooshma swedam (Aragwadha patram, Karanja patram, Neelini patram, Haridra, Thulasi patram and Nimba patram) should be followed for swedana.

Vamanam- for vamana Mustadi Choornam (Sidharthaka snana yogam) is indicated.

Virechanam- Thrivruthadi Kashayam (Thrivruth, Thriphala and Danti), Mustadi Choornam, and avipathi choorna are indicated for virechana.

Vasthi- Asthaapana-daarvyaadi yogam for Vasthi.

Nasyam-saindhavaadi nasyam.

Rakthamoksham-  Jaloukavacharana & prachaana are very effective in Vicharchika especially in the case of Stasis Eczema, it is done at the site of lesion. In other vicharchika cases Siravyadha is indicated with Vreehimukha sasthra at 2 angula above Kshipra marma.

The patients suffering from Kushta(skin diseases) have to undergo subsequently Nasya Karma once in every 3 days, Vamana once in every 15 days, virechana once in every month and Rakthamoksha in every 6 monts.

Lepanam

Lepana is indicated only if vitiated doshas take aasraya in twak.

Ø      Sidharthaka /Musthaadi choornam for Blackish discolouration

Ø      Nimba haridradi choorna wth butter milk for sopha and pidaka,

Ø      Thriphala choorna for the purpose of sodhana & ropana,

Ø      Eladi gana  choorna with buttermilk/hot water if kandu & pidaka,

Ø      for discolouration / lichenification Eladi gana choorna with milk /coconut milk, Nimbapathradi choorna in butter milk, Guloochyadi choorna with hot water,

Ø      if pain & oozing Guggulu Panchapala choorna for dhoopana,

Ø      karanja mula swaras + kalka of nimb pathra & nirgundi pathra for non healing puss filled vranas

Ø      application of a paste of Thila cooked in milk if sopha with pain

Dhaara:

Ø      If more pus & oozing persists Thriphala + CuSO4 (Thutham) is used for dhara, after oozing subside plain thriphala kashaya is used for kshalana,

Ø      ksheera vriksha twak kashaya dhara / ksheera vriksha ksheera kashaya dhaara if more pain & burning sensation,

Ø      Guloochyaadi kashaya dhaara if burning sensation,

Ø      aaragwadha twak kashaya if oozing is present,

Ø      karanja pathra kashaya for kapha vathaja condition with kandu,

Ø      Gairika+Harithaki+Kupeelu pathra kashaya dhara, and Paaranthy pushpa dhaara for oozing with burning sensation

Samana Chikitsa

After completing the Shodhana karma, shamana chikitsa is indicated to subside the residual doshas. Shamana Chikitsa is also very useful in those patients who are unable to undergo or contraindicated for Sodhana Chikitsa. For Samana therapies following medicines are used in clinical practice

Kashayas- Manjishtadi Kashaya is effective in Vicharchika because it is indicated in kaphaja kushta with kand and sraava. Other medicines used according to the dosha predominance of the disesase are listed below.

Sl.No.	Dosha predominance/ indication	Medicine
1.	kapha vathaja	vajrakam kashayam
2.	Pitta kapha	Nimbanilavaakdi kwatham, Patolakaturohinyadi kwatham, Patolamoolaadi kwatham, Guluchyadi kwatham
3.	Kapha pitha	Nisothamadi Kashayam, Aaragwadhaadi kashaya
4.	Vatha kaphajam	Chitraka sobhanjanam kashayam
5.	Thridosha	Mahavajrakam kashayam
6.	Vatha paithikam with Vedana pidaka syaavatha	Thikthakam Kashayam
7.	vesicle formation with burning sensation	Guloochyaadi kashaayam

Gutika Yogas- visha vilwadi gutika, vilwadi Gutika, Dooshi vishari gutika with madhu in all condition especially with fever and infection, kaisora guggulu can be used with hot water for Kaphaja condition with manjishtaadi kashaya for pithaja condition and with milk for vathaja condition, Amrutha guggulu, Panchanimbadi gutika Thriphala guggulu,etc can also be used with Khadira Kashaya. Mukkamukkadukaadi gutika and Gopichandanadi gutika can be used if infection and fever is present.

Choorna Yogas- Haridra khandam,Vyoshadi vatakam, Thaaleesadi choornam can be used if itching is more, Guduchi satwam with milk if burning sensation is more, Guggulu panchapalam choornam and thriphala choornam for kapha pitha condition. Brihath panchanimbadi choornam with kashayas of khadira&asana sara is used for itching and oozing, Naraaayana choornam –after snehana for virechana

Arishta and Asava Yogas- pippalyasavam can be used in all conditions, amrutharishtam+punarnnavasavam if infection is present. Abhayarishtam, Khadirarishtam, Dasamoolarishtam, in Pithaja condition Duralabhaarishtam and Useerasavam, & in Kaphapithaja condition- madhookasavam and moolakaadyarisham can be used.

Lehya Yogas- in kaphaja condition Manibhadra gulam, Dasamoola Hareethaki and Dasamula lehyam, & in pithaja condition Danthee harithaki and madhusnuhi rasayana can be used. In Thridosha condition-Gandhaka Rasayana can be used for 41 days with strict pathya.

Taila Yogas – in kapha pithaja condition Guggulumareechaadi thailam, in raktha pithaja condition Panchavalkalaadi tailam and in kaphaja condition kachooradi thailam & Dinesa valyadi Keram can be used. In paithika sopha with ruja Paaranthyadi keram can be used.

Pathya

• Rakthasali, Sastika, and Priyangu, Yusha (Soup made by pulses mudga and harenuka), mamsarasa of Ena, sikhi, Svavit Lava, Tititri, prasata, Yusha and Rasa should be prepared by using antitoxic drugs and diets which do not produce Vidaha
• Saindhava, tanduliyaka (amaranthus spinosus), Jivanti (Lepatadenia reticulate), Varthaka (Solanum melongena), Sunisannaka (marselia minuta) etc. Amalaki (Emblica officinalis), Dadima (Punica granatum) as amla dravyas

Apathya

• Navadhanya (freshly harvested grains), Kulatha (Dolichos biflorus), Tila (gingelly), Souvira,  Phanitham (a kind of Jaggery), Sura(alcoholic drink), Foods and drugs which are Tikshna, Ushna Vidahi, particularly tikshna Dravyas
• Ajeerna, Adhyasana, divaswapna, Vyavaya(Sexual intercourse), Krodha, athapa (Sun rays)
• Tailam, tamboolam, lavana, guda, amla, sarsapa, narikela, takra, Kshara dravyas, mamsa dravyas, sura, dadhi, shaka, athya-atapa, panasa, athya-adhwana, dhooma, Vyapath chintha etc

Follow-up :Vicharana Snehapanam, Sapthasamaadi gulika(act as a Rasayana),Paadaadi choornam with hot water for one month,

Clinical Data

A randomized control study to evaluate the efficacy of Vishavilwadi agada in the management of Dooshivishajanya Vicharchika conducted in the Dept. of Agadatantra, Govt.Ayurveda College, Thiruvananthapuram by Dr. Krishna Singh proves the effectiveness of Vishavilwadi Agada in the treatment of Vicharchika. Patients with typical signs and symptoms of vicharchika were taken for study. Patients got good symptomatic relief after the treatment; ESR and differential cell count were also normalized. The mean scores of Kandu before treatment were 2.2 and 2.0 for the study and control groups respectively. After treatment, it was decreased to 0.4 for both the groups. The mean difference noticed was 1.8 and 1.6 respectively. The mean scores of Pidaka before treatment were 1.7 and 1.5 for the study and control groups respectively. After treatment, it was decreased to 0.3 and 0.1 respectively. The mean difference noticed was 1.4 for both groups. The mean scores of Syava before treatment were 2.0 and 1.9 for study and control groups respectively. After treatment, it was decreased 0.7 and 0.8 respectively. The mean difference noticed was 1.3 and 1.1 respectively. The mean scores of ESR before treatment were 24.2 and 37.0 for the study and control groups respectively. After treatment, it was decreased to 17.6 and 18.2 respectively. The mean difference noticed was 6.6 and 18.8 respectively. The medicine used in the control group was Patoladi Kwatha; it is also an agada preparation.

The Scope of Agadatantra in Oncology

THE SCOPE OF AGADATANTRA IN THE MANAGEMENT OF CARCINOMA WITH SPECIAL REFERENCE TO SIREESHARISHTA, AN ANTI TOXIC PREPARATION IN THYROID CA – A CASE STUDY 

*Dr. Aswathy S., **Dr.Manju S.R

Changing trends in lifestyle, habits etc in the modern era leads to increase in morbidity. Due to rapid growth of industry, over increasing number of automobiles, use of pesticides in agriculture for high yield etc leads to environmental pollution. Industrial wastes pollute our air, water, land etc. These pollutants accumulate in human body and causes serious disorders. Pesticide intake is another area from which endangering the human health. In low concentration they may not cause any problem but they accumulate in the environment and build up a toxic concentration in food chains.

            The extensive use of chemical drugs, the use of pesticides and industrial pollution has proved to be causing diseases like cancer, skin diseases, allergic diseases, congenital deformities etc If we study the incidence of cancer and skin disease like psoriasis it shows an exponentially increasing pattern. Incident rate of this life threatening disease is increasing every year. In India nearly 2.5 million persons suffering from cancer at any given time. Around 70,000 new cases are added each year. The age adjusted mortality rate is 61 per 1, 00,000 males and 58 per 1, 00,000 females. In india, more people are stricken with cancer in this decade when compared to the earlier decades of last century. These all are due to this changing lifestyle, industrialization, use of pesticides and insecticides etc. We are frequently exposed to chemical carcinogens like poly cyclic hydrocarbons, nitrosamine and many others through the air we breathe and the things we consume. Adding substances food to increase the taste and palatability will cause cancer. Processing of food in high temperature will leads to the production of pyrogenic compounds like polycyclic aromatic hydrocarbons. Many of these compounds are now known to be potent mutagens and carcinogens.

            Ayurveda, the traditional system of India has an effective and well developed antitoxic treatment system. Agadathanthra, one of the 8 classical disciplines (Ashtanga) of Ayurveda deals with management of toxicity. If we deeply study the principles of Agadathanthra and the etiology of cancer like diseases we can infer that the diseases are mostly due to toxic substances which enter through food, air, water or medicine etc. Some of the toxin produces acute symptoms and some produces symptoms after a long time. If we consider Dooshivisha, Gara and Viruddhahara concepts of Agadathanthra most of the etiological factors and pathology of cancer come under these three headings.

Any kind of poison originating from inanimate or animate sources or any artificial poison (Kritrima visha) retained in the body after partial expulsion or which has provisionally undergone detoxification, by the anti-poisonous drugs, forest fire, the wind or the sun is termed Dooshivisha ( Latent poison)Due to the low potency of this poison, it usually won’t causes sudden death. And also due to the enveloping (avarana) action by Kapha, this low potency poisons is retained in the body for long period without producing any grave or fatal symptoms

Those substances which cause ‘utkleshya’ of the doshas but unable to remove it from the body constitutes Viruddha. It is also antagonistic to the dhatus. Those dravyas which are incompatible with the dhatu of the body are viruddha. Some act adversely due to their mutually contradictory properties, some by combinations, some by method of preparations, some by virtue of the place, time and dose and some by their nature. 

            According to Vagbhata, viruddha is so intimately related to ‘Amavisha’ that it leads to symptoms of poison. Ahara which is viruddha in nature is like visha and gara. Considering these we can infer that frequent exposure to carcinogens and unwholesome food habits are etiological factors of cancer. So we can treat this type of diseases effectively by the principles of Agadathanthra. Many antitoxic preparations are very effective in the management of Cancer, Psoriasis, Allergic rhinitis and bronchitis, Atopic dermatitis etc where an involvement of Visha (poison) in the etiology it may be extrinsic in the case of cancer or intrinsic in the case of atopic dermatitis and allergic bronchitis where IgE plays the roll. Agada preparations are also effective in the management of autoimmune disorders, toxoplasma etc.

            Here effectiveness of one such Agada formulation is described in detail with the help of a case study. Before going to the drug details we have to discuss the general management of Cancer. Because administration of Agadas along with general management gives more good result than administration of Agada alone. In all type of cancer visha in the form of Ama is present. So ‘Ama nirharana’ is the initial or first line management of all type of cancer. Sodhanam, Langhanapachanam and Langhanam are the treatment for prabhutha, madhyama and alpa dosha respectively. But in the case of cancer patient is very weak due to the disease. So sodhanam and langhanam should not be advisable. We can do mridulanghana and pachana, for that ‘Sasundilajapeya’ is given along with mild pachana oushadhas like Drakshadi Kashyam. After getting some ‘bala’ to the patient strong amapachana drugs like pachanamrutham Kashayam, Sapthasaram Kashayam etc can be given. Pathyakrama stated in Visha chikithsa should be followed. Because non-veg food, Guru Ahara, Oily foods etc. will increase the Ama and thereby help the progression of disease. There is a great need of Amino acids for the growth and proliferation of Tumour cells and also for Neovascularization (Angiogenesis) So all protein diet should be avoided. Peyadi is only advisable. Specific Agada preparations are given along with this treatment protocol.

            In the case of cancer fresh cases do not report to Ayurvedic physicians (exceptions are there). Only those who try modern aids such as Surgery, Chemotherapy and Radiotherapy come for Ayurvedic treatment. Chemotherapy and Radiotherapy will produce harmful toxic effects along with their beneficial effects. In Chemotherapy first few doses will act as therapeutic doses and it destroys the neoplastic cells and don’t cause much damage to healthy tissues. But further doses will cause serious damage to healthy tissues. Body fails to eliminate the excess drugs which lead to accumulation of these chemicals in the body and causes health problems for a long period. These chemicals are inexcretable and indigestible by our body systems which lead to production of Ama. The Ama produced shows the lakshanas of visha. In radiation therapy, the ionization of the water content of the cells will produce peroxide and other toxins which cause toxic effects on the body. In radiation there is ‘pitha’ vitiation also. In both radiotherapy and chemotherapy there will be anorexia, nausea, fatigue, malaise and drowsiness as acute symptoms. After some days along with the above symptoms there will be purpura, haemorrhage, mouth infection, ulceration of mouth and GI tract, diarrhoea, hair loss etc occurs. These all symptoms resemble the lakshanas of Ama, Gara and Dooshivisha. In such conditions we will have to resort treatment of dooshivisha, gara and Ama. Purification therapy followed by administration of Agada formulations and Rasayana therapy are useful. Moorvadi choornam stated in garaprakaram and vilwadi gulika give better result in reducing these symptoms. Kosathakyadi Yavagu (vega veganthara chikithsa), Dooshi vishari Agada etc may give good results in these conditions. Dooshi vishari Agadam can be used as a rasayana after purification therapy. Durva ghrutham mentioned in mandalivisha prakarana is very effective in reducing the harmful symptoms of radiation therapy. It can use both internally and externally. But internal use is advisable only after getting proper ‘agni deepthi’. Kalyanaka ghrutham also can be used. Paranthyadi thailam is very useful in healing of squamus cell carcinoma. It can also be used as a lepana for reducing the burning sensation produced by Radiation therapy.

 If suitable Agada formulation is used along with above stated general management it will give good result in the treatment of cancer. In this particular case we use Sireesharishta along with general drugs. Sireesharishta, an agada preparation which is indicated in all type of ‘Visha vyapad’ was used for this study. The main ingredient of Sireesharishta is the bark of Sireesha (Albizia lebbek), the most potent anti toxic drug. The other ingredients are Pippali, Priyangu, Kushta, Ela, Neelini, Nagakesara, Rajani and Darvi.

   Sireesha(Albizia lebebek) Courtesy:Nirmal Roberts,www.treknature.com

This drug is given to a lady of 30 years old presented with diffuse enlargement over left side of the neck, FNAC report showed Medullary thyroid CA in this area. She had lose of appetite, Loose stools, fatigue, pin prick sensations over affected side and left axillary region as associated symptoms. Her calcitonin level in blood (a tumour marker in thyroid carcinoma which helps in diagnosis and prognosis) was 12692 IU before the administration of the medicine. Sireesharishta was given to the patient for 30 days along with Annabhedi sindhooram, Chukkumthippalyadi gulika and sapthasaram kashayam for reducing the associated symptoms like fatigue, lose of appetite, chills and fever etc. Peyadikrama was followed strictly.

The medicines except Sireesharishta were changed according to the feedback from the patient. After one month the calcitonin level decreases to 8401 IU and enlargement of the neck also reduced. This study was conducted by Dr.C.D.Sahadevan, an eminent Ayurvedic physician in the field of Oncology. He uses principles of Agadathanthra in managing diseases like cancer, autoimmune disorders etc. This is a single case study we have to do this study in a large sample to find out the exact efficacy of this Agada. The aim of this paper is to show the potency of Agada preparations in the management of life threatening diseases. We, the Agada practitioners can do a lot of things in life threatening conditions.

                                                     Dr.C.D.Sahadevan

            Emergence of new treatment modalities like administration of ASV and lack of practical knowledge in practicing snake bite etc leads to decline of snakebite management in Ayurveda. This situation leads to produce some misconcepts among physicians that Agadathanthra is an outdated science now a day. As the practice of Agadathanthra does not much the treatment of snake poison alone, there is still ample scope for this branch of Ayurveda and its practice. We have to do lot of researches in antitoxic preparations and find out the diseases where the Agada can effectively use.

------------------------------------------------------------------------------------------------------------

*Final Year PG Scholar, Department of Agadathanthra, Govt. Ayurveda College, Thiruvananthapuram

**Professor and Head, Department of Agadathanthra, Govt. Ayurveda College, Thiruvananthapuram