Ayurvedic management of Dadru (dermatophytosis): A case report

Smrutimayee Sahoo; Pramod Yadav; Pradeep Kumar Prajapati

doi:10.4103/jacr.jacr_6_21

CASE REPORT

Year : 2022 | Volume : 5 | Issue : 2 | Page : 62-67

Ayurvedic management of Dadru (dermatophytosis): A case report

Smrutimayee Sahoo¹, Pramod Yadav², Pradeep Kumar Prajapati²
¹ Chandibaunsamula, Kendrapada, Odisha, India
² Department of Rasa Shastra and Bhaishajya Kalpana, All India Institute of Ayurveda, New Delhi, India

Date of Submission	18-Jan-2021
Date of Acceptance	24-Dec-2021
Date of Web Publication	28-Jun-2022

Correspondence Address:
Dr. Smrutimayee Sahoo
Khetrabasi Niwas, AIIMS Nagar, Patrapada, Lane 12, Plot No. 230, Bhubaneswar, Odisha
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jacr.jacr_6_21

Abstract

Diagnosis and management of skin diseases are a challenge for practitioners. Dadru is a common clinical condition, which is considered under the broad heading of Kustha (~skin disorders). Dadru is a Pitta-Kapha Dosha predominant disease which is characterized by Raga (~reddish discoloration), Pidaka (~eruptions), Kandu (~itching at the site of the lesion), and Mandala (~elevated circular patches). On the basis of clinical features, it has the closest resemblance with dermatophytosis which is a superficial infection caused by a group of fungi. It is a major health problem having faster spreading in nature. We present here a case of 24-year-old male having lesions on the medial side of the lower left leg and left knee, thus diagnosed with Dadru with chronicity of four years. He was treated with the internal administration of Siddharthaka yoga kwatha and external application of Siddharthaka yoga ointment. The total treatment duration was 28 days. Significant remission in clinical features of Kandu, Raga, Pidika, and Mandala was observed within 28 days of treatment without any complication, which becomes an evidence and base for further research works with a larger sample size.

Keywords: Dadru, Kushta, Siddharthaka yoga

How to cite this article:
Sahoo S, Yadav P, Prajapati PK. Ayurvedic management of Dadru (dermatophytosis): A case report. J Ayurveda Case Rep 2022;5:62-7

How to cite this URL:
Sahoo S, Yadav P, Prajapati PK. Ayurvedic management of Dadru (dermatophytosis): A case report. J Ayurveda Case Rep [serial online] 2022 [cited 2023 May 30];5:62-7. Available from: http://www.ayucare.org/text.asp?2022/5/2/62/348699

Introduction

Skin, the largest organ of the body, performs multiple important functions such as protection from external stimuli, regulation of heat, secretion, excretion, formation of Vitamin D, respiration, sensory perception, and immunological functions of the body.^[1] In Ayurveda, it is considered to be one among the five Buddhindriya^[2] (~sensory organs) which is responsible for Sparsh gyan (~touch sensation).^[3] It is also considered the seat of Bhrajaka pitta.^[4] Ayurveda has considered most of the skin disorders under the umbrella of Kustha. Kustha is said to be one among the Ashtamahagada (~eight major diseases) which are difficult to manage.^[5] Kustha has been classified into two major subtypes on the basis of its severity and the area involved. It is the most common among all dermatoses and affects all age groups. Dadru is a Pitta dosha predominant disease associated with Kapha dosha. It is presented with Raga (~reddish discoloration), Pidaka (~eruptions), Kandu (~itching at the site of the lesion), and Mandala udgama (~elevated circular lesion).^[6]

Clinically, signs such as Pidaka, Kandu, Raga, and Mandala of Dadru closely resemble features observed in the clinical presentation of tinea infection/dermatophytosis/ringworm infection. Dermatophytosis is a superficial infection caused by a group of fungi, dermatophytes, Trichophyton rubrum being the most common agent in India which is transmitted by contact with the infected individuals.^[7] Its faster spreading nature and the cost of treatment is a major public health problem. Several factors such as age, sex, illiteracy, poor hygiene, and environmental conditions play a major role in influencing the higher spread of infection. About 20%–25% of the world's population is infected with dermatophytes, and the rate of incidence is increasing steadily in India.^[8] In one of the studies, the prevalence rate of Tinea corporis was found to be 78% among 297 clinically diagnosed cases of fungal infection in a tertiary care hospital of rural India.^[9]

Tinea is usually treated with antifungal drugs and corticosteroids, which cure the disease within a few days, but there are maximum chances of reoccurrence. The body may become resistant to long-term use of topical antifungal drugs along with corticosteroids which may also be accompanied by some complications.

People with skin disease are more contemplated regarding their cosmetic purpose, although there is a wide range of dermatological formulations available. Many formulations are mentioned in Ayurveda classics for treatment of Dadru, which may be modified according to their suitability and convenience in different cases. Conversion of classical dosage forms into modern dosage forms is necessary to increase their acceptance. Hence, a popular formulation from Charaka samhita was selected in the present case report. The patient was treated with Siddharthaka yoga ointment (externally) which is a modified dosage form of Siddharthaka snana yoga (~formulation for medicated bath).^[10]

Patient Information

A 24-year-old male with the chief complaints of reddish patches and severe itching over the medial side of the left knee joint and medial side of the lower left leg associated with sleeplessness visited the OPD. These symptoms persisted intermittently for the past four years. The patient was apparently healthy four years back, then he gradually developed round and reddish patches with itching over the medial side of the left knee joint and medial side of the left leg which gradually progressed to the present size (11 cm in length and 9 cm width). On local examination, two lesions were found, having Utsanna mandala, Pidika, and Raga. Central clearing was present, whereas discharge was absent [Figure 1]. There was no involvement of the scalp or other parts of the body on examination. Vitals recorded as blood pressure – 126/80 mmHg, pulse – 82/min, temperature – 98.8°F, and respiration rate – 20/min of the patient were within normal limits. No history of major illness and drug allergy was reported. Informed consent was obtained by the patient before enrolment. Photomicrographs of lesions were taken before and after treatment for the presence/absence of spores. The patient had intermittently taken allopathic treatment, i.e., fluconazole tablet for three years under medical supervision along with external application (Luliconazole cream).

Figure 1: At 0 day

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Clinical Findings

Potassium hydroxide (KOH) microscopy – The diagnosis was made from the skin scrapings by direct microscopic examinations with 10% KOH before and after the treatment. From the above clinical features, the condition was diagnosed as Dadru supported with pathological examination.

Timeline

The timeline for drug treatment is placed in [Table 1].

Table 1: Timeline of treatment

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Diagnostic Assessment

Assessment of Dadru^[11] was done on the basis of improvement in objective and subjective parameters such as changes in the size of lesions, number of Pidika, reduction in the frequency of Kandu, and reduction in the redness of lesions. The severity of the symptom in the form of grading is mentioned in [Table 2]. Occasional itching seen for 2-3 minutes without disturbing the routine activity is considered as Mild (Grade 1), Itching occurring frequently, disturbing the routine activity every time but not disturbing sleep, lasts for longer time, essentially scratching every time and recurs 3-4 times in 12 hrs is considered as moderate (Grade 2) and Frequent itching disturbing routine activity and sleep, lasts for 20-30 mins, Very essentially scratching every time and recurs 8-10 times in 12 h is consider as severe itching (Grade3).

Table 2: Assessment criteria for Dadru

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Therapeutic Interventions

The patient was advised of internal administration of Siddharthaka yoga kashaya^[12] and the local application of Siddharthaka yoga ointment. The patient was asked to prepare Kashaya by adding four times of water and reduce to one fourth after boiling.^[13] The patient was advised to follow the diet and lifestyle measures mentioned for Kushta such as to avoid day sleep, intake of excessive hot and cold items, and indulgence in physical exercise after taking food. They were also instructed to keep away from the intake of mixture of milk and fish items, curd, jaggery, salty and sour things, etc., prefer to take Laghu anna (~light diet like green gram porridge), Sali dhanya (~brown rice), Tikta rasa (~bitter taste drugs as Patola and Methi), and Mudga (~green gram), and prefer to use Sarshapa taila (~mustard oil) for both internal use^[14] and external application.^[15]

Follow-Up and Outcome

The treatment showed a significant result without reoccurrence of any signs and symptoms during the course of the treatment of 28 days and follow-up period of 14 days. After seven days of the treatment, mild reduction in itching and redness was observed [Figure 2]. After 14 days of treatment, a reduction in inflamed margins and redness was seen [Figure 3]. After 28 days of treatment, there was a complete reduction in itching, redness, inflamed margins, and plaques subsided significantly [Figure 4]. There was no recurrence observed during 14 days of follow-up after the treatment. The changes in the lesion observed during therapy are placed in [Table 3] in graded form. There was no complaint of any adverse drug reactions such as nausea, vomiting, diarrhea, and abdominal cramps. Microscopic examination of the scraped sample before initiation of treatment from the lesion revealed the presence of fungal cells [Figure 5]. Microscopic examination was repeated after 28 days of treatment, and the lesion did not reveal the presence of spores [Figure 6].

Figure 2: After treatment of 7 days

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Figure 3: After treatment of 14 days

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Figure 4: After treatment of 28 days

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Figure 5: Microscopic findings before treatment

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Figure 6: Microscopic findings after treatment

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Table 3: Treatment findings

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Discussion

In recent years, there has been a significant rise in the incidence of chronic dermatophyte infections of the skin which are difficult to treat. Acharya Charaka has mentioned Kustha as Deergha roganam indicating its chronic nature.^[16] Common reasons for the failure of conventional therapy may be due to poor adherence to treatment, reinfection from close contact, drug resistance, misdiagnosis, and infection with uncommon species.^[17] Steroids may be helpful in the initial improvement of the symptoms, but chronic use leads to complications such as atrophy, telangiectasia which are more prominent when lesions are present in flexures.^[18] Oral antifungal agents are known to cause systematic side effects apart from being hepatotoxic. Therefore, it becomes necessary to find a suitable and safe alternative for the management of the condition. Siddharthaka snana is mentioned as beneficial for dermatosis, edema, and anemia,^[19] and it can be used for Snana (~bathing), Pana (~drinking), and Udgharshana (~rubbing the powders). Snana and Udgharshana have their limitations in terms of poor patient compliance issues. Hence, the approach of developing Siddharthaka yoga ointment containing Siddharthaka yoga was adopted. Bases used for the preparation were Sarshapa taila, hard, soft, and liquid paraffin in a definite ratio.

Probable mode of action of Siddharthaka yoga kashaya and ointment

Siddharthaka yoga, a herbal formulation, indicated in Kustha chikitsa consisting of Musta (Cyperus rotundus Linn.),^[20] Madanaphala (Randia dumetorum Lam.),^[21] Haritaki (Terminalia chebula Retz.), Bibhitaki (Terminalia bellirica Roxb.), Amalaki (Emblica officinalis Gaertn.),^[22] Karanja (Pongamia pinnata Pierre.),^[23] Aragvadha (Cassia fistula Linn.),^[24] Kalinga (Holarrhena antidyscenterica [ROTH.] A.DC.)^[25] Darvi (Berberis aristata DC.),^[26] and Saptaparna (Alstonia scholaris R.Br.)^[27] in equal quantity, and it has been well-documented for their antifungal, wound healing, anti-inflammatory, and antioxidant activities. Besides, most of the ingredients have Katu, Tikta Rasa which is beneficial for Kustha. Many of them are mentioned as possessing Kanduhara, Krimihara, Dahahara, Kusthahara, Vranaropana, Deepana, Rakta shodhana, Kostha sudhikara, Pachana, Vamaka, and Virechaka properties.

Because of Katu, Tikta, Kashaya rasa, Siddharthaka Yoga Kashaya acts as Ama pachana, Agni-deepana, Rakta Prasadana, Kledashoshana, Pitta-Kapha shamana. It is more effective in Dadru as it is a Pitta-kapha predominant Vyadhi. Some drugs such as Triphala and Aragwadha are Virechaka. This Virechaka property is very essential for disintegrating Dosha dushya samurchhana in Kustha. Frequent Shodhana is also indicated in Bahudoshaja vyadhi like Kustha.^[28]

All these drugs also have the properties such as Ushna, Tikshna guna, Ushna virya (~hot potency), and Katu vipaka; this exhibits Sukshmata (~increased penetration through channels) and Tikshnata (~quick acting). The topical application of the ointment reaches the deeper tissues through Siramukha (~opening of veins) and Swedavahi srotas (~sweat carrying channels) and stains it with its Sukshma and Tikshna property. Due to its Ushna, Tikshna, and Sukshma properties, it deblocks the obstruction in Swedavahi srotas and allows the local toxins to flow out through the Sweda, thus clearing out the microchannels. Itching, the main symptom in Dadru is caused due to aggreviation of Kapha dosha. Ushna and Tikshna properties of Siddharthaka Ointement helps in alleviating Kapha dosha which has resulted in significant decrease in itching. Also, the base used in the preparation of ointment kept the skin at the lesion area hydrated and helped in reduction of itching and healing of lesion.

Limitations of the present study

Different dermatophyte strains could not be identified in this work.

Conclusion

A case of Dadru was managed with internal administration of Siddharthaka yoga kashaya and external application of Siddharthaka yoga ointment along with recommended dietary measures, and complete remission was achieved in a short duration (28 days) without any complications. No recurrence was noticed during the follow-up period of 14 days. However, studies on a larger sample size need to be conducted to further explore its safety and clinical efficacy in terms of dose and duration of therapy. Identification of specific fungal strains is also required to substantiate the claim of antifungal activity of Siddarthaka yoga.

Declaration of patient consent

Authors certify that they have obtained patient consent form, where the patient has given his consent for reporting the case along with the images and other clinical information in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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