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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 5  |  Issue : 4  |  Page : 156-162

Leads towards management of dermatophytosis (Dadru) with ayurvedic intervention - An experience


Department of Roganidana Evum Vikriti Vigyana, All India Institute of Ayurveda, New Delhi, India

Date of Submission22-Feb-2022
Date of Acceptance24-Nov-2022
Date of Web Publication29-Dec-2022

Correspondence Address:
Dr. Medha Lakkawar
Department of Roganidana Evum Vikriti Vigyana, All India Institute of Ayurveda, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jacr.jacr_12_22

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  Abstract 


Dermatophytosis is a superficial fungal infection of the skin caused by dermatophytes, a group of fungi that invade and grow on dead keratinized tissues. It is common in day-to-day practice affecting all the age groups of the population. Fungal infections have a higher rate of recurrences and if not treated early, can lead to the development of a more extensive nature. In Ayurveda, this clinical entity can be correlated with Dadru kushtha (~skin disease having circular lesion) which is described under the broad heading Kushtha roga (~skin diseases). Vitiated Pitta-kapha dosha causes progressive erythematous cutaneous eruptions in the form of circular lesions with elevated borders and itching that subsides by the administration of Pitta-kapha shamaka internal and external formulations. In the present case, a 23-year-old female patient, with symptoms of Dadru kushtha has been treated successfully with Chakramarda beeja churna, Tankana bhasma, Sarivadyasava, and Marichyadi tailam. Encouraging results were found with complete remission in Kandu (~itching), Daha (~burning sensation), Raga (~redness), Pidaka (~eruptions), and Utsanna mandala (~elevated circular skin lesion) after 28 days of regular treatment with no recurrence during the 15 days of follow-up. Following treatment, a potassium hydroxide examination of a skin sample revealed a substantial reduction in dermatophytes. The present case report illustrates the significance of Ayurvedic treatment including Shamana chukitsa (~pacifying therapy) and Bahirparimarjana chikitsa (~external therapies) in the management of Dadru kushtha.

Keywords: Chakramarda, dadru kushtha, dermatophytosis, tinea corporis


How to cite this article:
Lakkawar M, More A, Rai S, Tiwari SS. Leads towards management of dermatophytosis (Dadru) with ayurvedic intervention - An experience. J Ayurveda Case Rep 2022;5:156-62

How to cite this URL:
Lakkawar M, More A, Rai S, Tiwari SS. Leads towards management of dermatophytosis (Dadru) with ayurvedic intervention - An experience. J Ayurveda Case Rep [serial online] 2022 [cited 2023 Jan 28];5:156-62. Available from: http://www.ayucare.org/text.asp?2022/5/4/156/365928




  Introduction Top


According to the Global Burden of Disease observations, skin disease is the fourth leading cause of nonfatal burden in the global context of health.[1] Among skin diseases, the prevalence of superficial mycotic infection worldwide is 20%–25% of which dermatophytes are the most common agents. The last few years have seen a steep rise in the cases of chronic dermatophytic infections in the Indian subcontinent.[2] Dermatophytosis designated as tinea is a superficial fungal infection that affects different body parts, including nails and hair. Infections caused by dermatophytes are in the superficial, nonliving cornified layer of the skin as dermatophytes are unable to invade the deeper skin layers. The infection has been named according to the anatomic locations involved in the body site after the word tinea, for example, tinea capitis (infection in the scalp), tinea pedis/Athlete's foot (feet), tinea manuum (hands), tinea unguium or onychomycosis (nails), tinea cruris/jock itch (groin area), tinea corporis (trunks, arms), and tinea barbae (beard area).[3] On physical examination, the pattern of manifestation will be single or multiple characteristic ring-shaped (ringworm) erythematous cutaneous lesions. These annular lesions demonstrate sharp margination with a raised erythematous scaly inflammatory edge that may contain vesicles with centrally clear normal skin. The degree of inflammation is variable.[4] The tinea infection may reach epidemic proportions in geographical areas with higher humidity, high population density, and poor hygienic conditions and in immune-compromised people.[5]

In Ayurveda classics, skin diseases are explained under the heading of Kushtha. Clinical features of Dadru kushtha (~skin disease having circular patches) are explained as Kandu (~itching), Raga (~erythema), Pidaka (~eruptions), and Utsanna mandala (~elevated circular lesion).[6],[7],[8] It is Tridoshaja vyadhi (~vitiation of all three regulatory functional factors of the body) with the predominant vitiation of Pitta and Kapha dosha.[9]

Based on clinical presentation, Dadru can be correlated with dermatophytosis (superficial fungal infection). In contemporary science, dermatophytosis infection is managed by various topical and systemic antifungal agents and local corticosteroids which show adverse effects on long-term use.[10]


  Patient Information Top


A 23-year-old housewife visited the skin outpatient department (OPD) on November 22, 2021, with the chief complaints of two reddish-black circular lesions (~Raga) over the groin and buttocks with severe itching (~Kandu) and mild burning sensation (~Daha) for 1 year. She consulted an allopathic dermatologist for the same and was diagnosed with tinea corporis. She took the allopathic treatment terbinafine 250 mg OD and clotrimazole cream local application BD for 1 month and experienced significant relief. However, soon after stopping the treatment, an exacerbation of circular and red patches with itching and burning sensation was noticed. Then, she consulted skin OPD for the possibility of treatment.


  Clinical Findings Top


On dermatological examination, there was a single circular (18 cm in diameter), erythematous plaque with some vesicular eruptions over the lower part of the trunk with a slightly raised reddened demarked edge. Another single circular blackish dry patch, 22 cm in diameter, was present on the buttocks and lower part of the back. These lesions were associated with the symptom of Kandu and Daha. Other physical parameters were normal. She indicates that the lesions first developed about a year earlier and have been spreading steadily. No specific history of any major illness, drug allergy, or previous surgery was given by the patient. Positive family history showing the same complaints of the erythematous patch with itching to her spouse was observed. Her appetite was good, her bowels were regular, and her bladder was regular. No specific history of addiction was noted. Sleep is disturbed due to itching. Pallor, icterus, clubbing, cyanosis, and lymphadenopathy are absent on general examination. Blood pressure, respiratory rate, the temperature were within normal limits. Systemic examination did not reveal any abnormality. Prakruti of the patient was Vata-pittaja.

Ashtavidha pariksha (~Eight-fold examination)

Nadi (~pulse) was 78/min, regular with Vata-Pitta dominance, Mutra (~urine) was Samyak (~normal), 5–6 times/day and 0–1 times/night, Mala (~stool) and Jiwha (~tongue) were Nirama (~processed and digested food particles), Shabda (~sound) was Spashtha (~clear), Sparsha (~tactile examination) was Anushnasheeta (~not too hot), Drik (~eyesight) was Prakruta (~normal) and Akruti (~body stature) was Madhyama (~average built).

Samprapti ghataka (~Main pathophysiological components)

The primary Nidana sevana (~causative factor) was the patient's contact history of sharing a bed and clothes with an infected person. Vitiated Dosha was Pitta-kapha pradhana tridosha. Dushya (~pathognomonic factors) were Twak (~blood plasma), Rakta (~blood), Mamsa (~muscular tissue), and Lasika (~body fluids). The status of Agni (~digestive fire) was Jatharagnimandya and Dhatvagnimandya (~impaired metabolism). The involved Srotas (~structural or functional channels) in the manifestation of disease were Rasavaha (~channels of plasma), Raktavaha (~channels of blood plasma), Mamsavaha (~fascio-muscular tissue), and Swedavaha (~sweat conveying channels). Srotodushti (~mode of the system involved) was Sanga (~obstructed vitiated body humor) and Vimargagamana (~vitiation of body humor to other places), Marga (~disease manifestation place) of the disease was Bahyaroga marga, Adhisthana (~site) was Twacha (~skin), and nature of the disease was Chirakari (~chronic).

Differential diagnosis

Mandala kushtha

Points in favor are Utsanna mandala (~elevated round lesions), and Rakta varna (~erythema) are the clinical features of the Mandala kushtha which are similar to the features of Dadru kushtha. Points against diagnosis are Kandu may or may not be present in Mandala kustha but Kandu is the key feature of the Dadru kushtha.


  Diagnostic Assessment Top


Potassium hydroxide examination (Direct microscopy)

The identification of dermatophytes was performed through a microscopic examination using 10% potassium hydroxide (KOH). Keratinocytes are obtained by scraping the perimeter of the plaques, mounting the sample on a glass slide with 10% KOH solution, and the slide slightly heated with a burner. Then, after 5 min, the slide was observed under a 10X and 40X microscope for dermatophyte identification.[11] The scraped skin sample of the patient before starting the treatment showed a positive result for 10% KOH examination. Based on clinical symptoms and, KOH examination, the case was diagnosed with Dadru kustha.


  Timelines Top


Assessment of the skin lesions was done on the first visit and intermittent monitoring was done weekly, for the next consecutive 4 weeks. The follow-up was done on the 15th day after stopping the treatment.


  Therapeutic Intervention Top


After the case conceptualization, the patient was put on Ayurveda conservative management along with Yukti (~logic) as per involved pathogenesis (~Samprapti). The patient was prescribed Chakramarda beeja churna (powder of Cassia tora Linn.) with potable water for local application for 2–3 h once a day, Tankana bhasma twice a day for local application, and Sarivadyasava (20 ml) twice a day after meal with equal quantity of water for 3 weeks. In the 4th week, Udvartana by Chakramarda beeja churna with potable water for 15 min once a day, Marichyadi taila added with 1–2 g of Tankana bhasma for local application before going to bed was advised [Figure 1]. Along with treatment modality, dietary and lifestyle modifications were advised. The patient was advised to avoid incompatible food items such as junk/fast food and excessive oily-salty-spicy food. He was also advised to avoid daytime sleep and avoid contact with infected ones. The patient is suggested to maintain personal hygiene by taking bath daily, wearing loose-fitting clean clothes, and changing clothes two times a day. The patient was guided to wash all used clothes after soaking in warm water and drying them in sunlight.
Figure 1: Therapeutic intervention. QS- Sufficient quantity

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  Assessment Criteria Top


The assessment criteria were based on the clinical characteristics of Dadru kushtha.[12] The photographs of affected areas were taken before initiation of treatment, subsequently on every visit (every 7th day), and after follow-up [Figure 2] and [Figure 3]. Photographs of microscopic KOH examinations were taken before and after the study [Figure 4].
Figure 2: Depicting lessions of the hypogastric regions. (a) Before treatment, (b) 7th Day, (c) 14th Day, (d) 21st Day, (e) 28th Day, (f) After follow-up

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Figure 3: Depicting lesions of the buttocks region. (a) Before treatment, (b) 7th Day, (c) 14th Day, (d) 21st Day, (e) 28th Day, (f) After follow-up

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Figure 4: Potassium hydroxide examination of skin scrapped sample. (a) Before treatment, (b) After treatment

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  Follow-Up and Outcome Top


Assessment of the patient for Dadru was done according to grading criteria in [Table 1] and [Table 2], After the completion of the treatment period, all the symptoms (Kandu, Daha, Raaga, number of Mandala, and Pidaka) at both lesions get completely disappeared with no recurrence after 15 days of follow-up. No adverse drug response was seen throughout the treatment and during the follow-up period. Due to relief in itching, the quality of sleep was improved. The scraped skin sample taken from the site showed the presence of one to two dermatophytes in direct microscopy (KOH) examination.
Table 1: Assessment criteria

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Table 2: Observations

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  Discussion Top


Kushtha is one of the contagious diseases (~Aupasargika roga) and stated that it is spread by Prasang (~mutual contact), Gatrasamsparsha (~direct physical contact) Vastra malyanulepanam (~sharing clothes), Sahashayya (~sharing beds), Sahabhojan (~sharing food) with an infected person,[13] which is the main causative factor in the present case. Thus, Krimi (~microorganism) get enters through Sveda (~perspiration) ultimately vitiates Tvachasthit pitta-Kapha pradhana tridosha and vitiates Tvak and Rasa dhatu (~primary product of digested food), Rakta dhatu (~blood tissue), Mamsa dhatu (~muscle tissue), Lasika (~lymph), i.e. Kushtha saptak dravya sangraha (~sevenfold pathogenic substances of Kustha) which further causes Rasa and Raktvaha strotodushti leads to the manifestation of pathology of Dadru kushtha. Based on symptomatology, itching is suggestive of Kapha dominancy and an erythematous patch with vesicles and pustules is suggestive of Pitta dominance.

The principal management of Kushtha includes Shodhana karma (~treatment modality based on the principle of removal of vitiated Dosha), Shamana chikitsa (~internal administration of drugs), and Bahirparimarjana (~topical applications). As the dermatophytes are unable to invade the deeper skin layers and grow only on superficial layers, external therapy plays a major role in treating the disease. Considering the involvement of Dosha and Dushya (~pathognomonic factors) and analysis of causative factors of the disease, the drugs having Pitta-Kaphaghna properties were administered.

Probable mode of action of chosen formulations

Chakramarda beeja churna lepa

A synonym of Chakramarda (Cassia tora Linn.) is Dadrughna which itself explains its antimicrobial property. Another name Chakri (~round in nature) that it is effective in ringworm conditions. The drug has Laghu (~light), Ruksha (~dry) Guna (~Property), Katu (~pungent) Rasa (~taste), Katu (~pungent) Vipaka (~biotransformation), Ushna (~hot potency) Virya (~active principles), and Kusthaghna (~antipruritic) Prabhava (~specific action).[14]

Its Laghu, Ruksha guna, and Ushna virya cause Lekhana (~emaciating), leading to the removal of Kleda (~watery waste) and Snigdhata (~oily) and acts as Kapha vata shamaka, whereas Katu rasa acts as Pitta shamaka. Dadrughna (~antifungal), Kushthaghna, Vishaghna (~antidote for poisons and toxins), and Krumighna (~antimicrobial) qualities of this plant are explained in classics.[15] Antimicrobial and antifungal properties of Cassia tora have been reported which may account for its clinical effect.[16],[17],[18] [Figure 5] Chrysophenol, chrysophanic acid-9-anthrone, anthraquinones, emodin, physcion, and rhein are the components of Cassia tora which shows antifungal activity.[19],[20]
Figure 5: Mechanism of action of intervention

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Tankana bhasma

Tankana (Borax-Na2B4O7 10H2O) is a salt of tetra boric acid, an important compound of Boron, which is also known as sodium biborate. Tankana is described under Kshara Varga. Kshara has the property of Ksharana (~cutting). Tankana bhasma has Katu Rasa, Teekshna (~sharp), Ruksha guna, Ushna veerya, Katu vipaka, Kaphaghna, and Vata shamaka properties. The actions of Tankana are Kapha vishleshaka (~mucolytic), Vata vikara naashaka, Agni deepaka, and detoxifier.[21]

Due to these properties, the drug enters the pores and gets easily absorbed into the capillary network to minor veins and further into circulation, and then action was carried out by its Katu rasa. Katu rasa removes Keda from the lesion and surrounding tissues, counters the Krimi, scrapes muscle tissue, brings lysis of clotted blood, and depresses the wound[22] which will pacify the Doshas and ultimately leads to breaking the pathogenesis.

Studies have also proved its anti-inflammatory[23],[24] antiseptic, antibacterial, antifungal action of borax and boric acid, specifically against bacterial strains  Escherichia More Details coli, Pseudomonas aeruginosa, Staphylococcus aureus, Streptococcus pyogenes, and fungal strains Candida albicans and Aspergillus niger.[25],[26]

Sarivadyasava

Sarivadyasava contains Sariva (Hemidesmus indicus R. Br.), Mustaka (Cyperus rotundus Linn.), Lodhra (Symplocos racemosa Roxb.), Nyagrodha (Ficus bengalensis Linn.), Guduchi (Tinospora cordifolia [Willd.] Miers.), etc., Most ingredients of this formulation are Tikta (~bitter), Kashaya (~astringent) Rasa, Sheeta (~cold) Virya, Katu vipaka, thus pacifying Pitta, Rakta (due to Sheeta virya), and Kapha (~due to Katu vipaka). Its Raktashodhaka (~blood purifier), Raktaprasadaka (~blood purifier), and Pidaka nashaka effect is well documented.[27] Various studies revealed antibacterial, antioxidant, antithrombotic, anti-inflammatory, anti-ulcerogenic activity, and wound-healing activities of H. indicus R. Br.[28]

Udvartana by chakramarda beeja churna

Udvartana is a therapeutic procedure in which the patient is advised to rub or massage the whole body with drugs in a direction opposite to the orientation of hairs with some pressure for 15 min and followed by a warm water bath after an hour. Udvratana by Chakaramarda beeja is indicated in the management of Kushtha.[29] Udvartana by Chakramarda beeja churna with water alleviates Tvachasthita Vata dosha, removes excess Kapha dosha and Meda, reduces itching, helps in reducing sweating, increases the stability of the body, enhances the skin texture and skin color, improves Tvakshtha agni, i.e. Bhrajaka pitta, gives strength to the skin,[29],[30] and helps in reducing the recurrence of symptoms and act as Rasayana (~rejuvenating) for the skin.

Marichyadi taila

As a result of Laghu, Ruksha Guna of Chakramarda beeja, the dryness increases in the applied part of the skin. Snigdha dravya should be utilized to alleviate the dryness. Here, Marichyadi tailam was selected as it is indicated in Dadru kushtha.[31] Maricha (Piper nigrum Linn.), Haratala (orpiment or arsenic trisulfide-AS2S3), Manashila (Arsenic disulphide-AS2S2), Arka (Calotropis procera Linn.), etc., used in this oil are Ushna, Tikshna in Guna and Ushna virya by which it penetrates into the skin and Snigdha nature of oil reduces dryness, itching, and other symptoms of Dadru. Tankana mixed with Marichyadi taila helps in better penetration of Taila drugs into the skin by its Ksharana (corrosive nature), Tikshna, and Ushna guna.

The combination of all the medications possibly helps as Doshapratyanika (~antagonizing Doshas) and Dhatupratyanika (~antagonizing Dhatus) and removes Kleda, purifying the channel, thus breaking pathogenesis. The observations of KOH examination of the scrapped skin sample also infer the action of the administered drug [Figure 4].


  Conclusion Top


This case report suggests that Ayurvedic Shamana and Bahirparimarjana chikitsa are effective in managing dermatophytic infections without causing side effects. The treatment chosen was individualized, cost-efficient, and safe, with no side effects, inferring that, Ayurvedic medicines offer a good approach to the management of Dadru kushtha.

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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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2]



 

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