study of twak shareer wsr to kitibha kustha

“Study of Twak Shareer w.s.r to Kitibha Kustha” By

Dr. Sapna Hiremath.

A dissertation submitted to the

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In partial fulfillment of the requirements for the degree of

AYURVEDA VACHASPATHI - M.D (AYURVEDA)

In

RACHANA SHAREERA

Co-Guide Guide Dr. N.G. Mulimani Dr. J.K. Bhargava

MD (S.R.) M.S.A.M.

Post Graduate Department Of Rachana Shareera

N.K.J. Ayurvedic Medical College & PG Centre, Bidar.

2009.


Declaration by the candidate

I, here by declare that this dissertation/ thesis entitled

“Study of Twak Shareer w.s.r to Kitibha Kustha” Is a bonafide

and genuine research work carried out by me under the guidance

of Dr. J.K. Bhargava, M.S.A.M. Professor & H.O.D.

Department of Rachana Shareera.

Date:

Place: Bidar

Signature of the candidate Dr. Sapna Hiremath.


Copyright


I here by declare that the Rajiv Gandhi University of Health

Sciences, Karnataka shall declare the rights to preserve, use and

disseminate this dissertation/ thesis in print or electronic format for

academic/ research purpose.

Date:

Place: Bidar

© Rajiv Gandhi University of Health Sciences, Karnataka



CERTIFICATE BY THE GUIDE

This is to certify that the dissertation entitled “Study of

Twak Shareer w.s.r to Kitibha Kustha” is a bonafide research

work done by Dr. Sapna Hiremath, in partial fulfillment of the

requirement for the degree of Ayurveda Vachaspathi - M.D.

(Ayurveda).

Date: Date: Place: Bidar Place: Bidar

Signature of the Guide Dr. J.K. Bhargava

M.S.A.M. Professor & H.O.D.,

Department of Rachana Shareera NKJ Ayurvedic Medical College & P G

Centre Bidar – 585403

Signature of the Co-Guide Dr. N.G. Mulimani

MD (SR). Professor,

Department of Shareera Rachana Bidar Institute of Medical Sciences

Bidar – 585403 Karnataka.

EEENNNDDDOOORRRSSSEEEMMMEEENNNTTT BBBYYY TTTHHHEEE HHHOOODDD,,, PPPRRRIIINNNCCCIIIPPPAAALLL/// HHHEEEAAADDD OOOFFF TTTHHHEEE IIINNNSSSTTTIIITTTUUUTTTIIIOOONNN



work done by Dr. Sapna Hiremath under the guidance of

Dr. J.K. Bhargava Prof. & H.O.D. department of Rachana

Shareera.

Date: Date: Place: Bidar. Place: Bidar.

Seal and signature of H.O.D. Dr .J.K.Bhargav M.S.A.M. Prof & H.O.D Dept. Of Post Graduate Studies In Rachana Shareera N.K.J. A.M.C. & PG Centre, Bidar – 585403 Karnataka.

Seal and signature of the Principal/Dean

Dr.K.V.L.N Acharyulu. M.D. (Basic principles)

N.K.J. A.M.C. & PG Centre, Bidar – 585403 Karnataka.

Abbreviations

ABBREVIATIONS

1. Cha. - Charaka samhita

2. Su. - Sushruta samhita

3. A.S. - Astanga sangraha

4. Su (Dalhana) - Dalhana tika on Sushruta samhita

5. A.H. - Astanga hridayam

6. Sha. Pra. - Sharangadhara Prathama kanda

7. Ayu. Sha. - Ayurveda Shareera rachana

8. B.P. Pu. - Bhavaprakasha Purvarda

9. M.Ni. - Madhava Nidana

10. Y.R. - Yogarathnakara

11. D.G. - Dravyaguna

12. Vi. - Vimanasthana

13. Sha - Shareera

14. Ni - Nidanasthana

15. Si. - Siddisthana

16. Chi. - Chikitsasthana

17. Ut. - Uttarasthana

ABSTRACT

Introduction:

Ayurveda describe the organization of the body in term of doshas, dhatus and

malas.Twacha is one among the updhatus which provide protective layer over the

body that protect from the heat, cold & external infection.

The union of sukra(spermatozoa) & sonita(ovum) while being cooked

(processed by heat) give rise to the formation of seven twaka (skin) just like formation

of cream when milk is boiled. Acharya sushrut and other Acharyas are described

twaka shareeram in detail.Acharya sushrut defined Twacha as upadhatu of mamsa

dhatu.Twacha is one among the panch jyanendriya,which carry sensation of touch.&

It covers external part as well as internal part of body.

Since antiquity human being often suffered from many type of diseases, out

of them skin disease is one of the major problem for the community, because there is

a change in the structural appearance of the skin & it make entire body ugly.

There are different theories among the Acharyas regarding the number of

layers.Acharyas Charak consider that Twacha is made up of six layers where other

Acharyas consider seven layers.In this layers of twacha ,different type of diseases

observe in different layers. Out of this, a very commonly seen “Kustha” disease is

found in one of the twacha.Kustha is a skin disease.

“Kitibha” is one among the type of Ksudra kustha which is common and chronic

disorder of twacha. Acharyas describe symptoms of kitibha like - red, with dry &

silvery white scale which may be obvious only after scrapping the surface, skin is not

sweating , resemble the scale of fish, producing sound (while scratching) rough,

itching course & black in colour.(AS.Ni 4/22.) Although twacha has been explained

in our classic, we get very vague and very less description about the disease related to

twacha sharer.And it is outermost protective layer of the body,so it becomes essential

to know the structural and anatomical changes occur in the Kitibha.Now a days

Kitibha disease largely spread in the human being. While diagnosing the patients of

Kitibha kustha ,there is difficulty regarding the identification of structural deformity

,hence need is felt to study the kitibha & twak sharer.

REVIEW OF LITERATURE 1) Description available regarding twak sharer in Ayurvedic classics. 2) Description of kitibha kustha.has been explained in Ayurvedic classics. 3) Description available in modern text book regarding skin. 4) Description of psoriasis available in modern text.

MATERIAL AND METHODS:

SOURCE OF DATA

1. Literary & conceptual study will be undertaken by data compilations from

Brihatrayis, Laghutrayis & other classical texts including journals, presented

papers, previous thesis work done & correlated, analysed with the knowledge

of contemporary science on the subject.

2. A special case proforma will be prepared with all the points of

KITIBHA.Observation of minimum 30 patients will be selected for study.

Structural abnormality will be observed with the help of Skin Biopsy.

Design of the study :

a) Clinically diagnosed 30 patients of kitibha

b) Clinically examination is carried out by skin biopsy.

c) Skin biopsy will be taken of each patient to assess the structural changes in the

twacha layers in case of kitibha & will be analysed statistically.

A) Inclusive criteria:

Diagnosed patients of kitibha

Patients having pratyatma lakashanas of kitibha

Patients of both the sex between middle age group will be selected.

B) Exclusive criteria:

Burn

Leprosy

Other skin diseases.

C) Assessment criteria:

Diagnosed patients of kitibha kustha are clinically examined for signs &

symptoms, structural abnormalities are observed in skin biopsy examination &

correlated with anatomical features.

Observations:

1) There is some controversy regarding number of Twacha. Some Acharyas have

told six types of Twacha while some have told seven types.

2) Acharya Charaka and Acharya Sushruta both have told different Vyadhis in

layers of Twacha. e.g.Sushruta told Kitibha in fourth layer.

3) Measurement of thickness of Twacha told by Sushruta is near about same

which is quoted in modern textbooks. The measurement of Dalhana doesn’t

matches with the modern measurement.

4) The symptoms of Kitibha and psoriasis show tremendous similarity with each

other.

5) After histopathological study the aupitz sign and fish like appearance is seen

under microscope.

Discussion:

Kitibha Kushtha –Psoriasis:

• Klinna - Sticky in nature

• Mahavastum - Lesions are found all over the body.

• Khara Sparsha – Rough in touch

• Parusha – Hard in nature(crack).

• Vruttam – Round in shape.

• Ghana – Solid

• Sravi and Shyava – In chronic condition psoriatic patches on the skin are

exudative in nature and blackish discolouration.

The lakshanas of kitibha kustha mentioned by Charaka, Vagbhata and Sushruta

are described here in detail in comparison with psoriasis.

Key words:

Kitibha Kustha, Twacha Shareera, Twacha Varna, Psoriasis, parakerotosis,

Orthrokeratosis, Rete ridge, Auspitz sign. Silver scales, Epidermopoiesis,

“Study of Twak Shareer w.s.r to Kitibha Kustha” By

Dr. Sapna Hiremath.

A dissertation submitted to the


In partial fulfillment of the requirements for the degree of

AYURVEDA VACHASPATHI - M.D (AYURVEDA)

In

RACHANA SHAREERA

Co-Guide Guide Dr. N.G. Mulimani Dr. J.K. Bhargava

MD (S.R.) M.S.A.M.

Post Graduate Department Of Rachana Shareera

N.K.J. Ayurvedic Medical College & PG Centre, Bidar.

2009.



I, here by declare that this dissertation/ thesis entitled

“Study of Twak Shareer w.s.r to Kitibha Kustha” Is a bonafide

and genuine research work carried out by me under the guidance

of Dr. J.K. Bhargava, M.S.A.M. Professor & H.O.D.

Department of Rachana Shareera.

Date:

Place: Bidar



Copyright


I here by declare that the Rajiv Gandhi University of Health

Sciences, Karnataka shall declare the rights to preserve, use and

disseminate this dissertation/ thesis in print or electronic format for

academic/ research purpose.

Date:

Place: Bidar

© Rajiv Gandhi University of Health Sciences, Karnataka



CERTIFICATE BY THE GUIDE



work done by Dr. Sapna Hiremath, in partial fulfillment of the

requirement for the degree of Ayurveda Vachaspathi - M.D.

(Ayurveda).

Date: Date: Place: Bidar Place: Bidar

Signature of the Guide Dr. J.K. Bhargava

M.S.A.M. Professor & H.O.D.,

Department of Rachana Shareera NKJ Ayurvedic Medical College & P G

Centre Bidar – 585403

Signature of the Co-Guide Dr. N.G. Mulimani

MD (SR). Professor,

Department of Shareera Rachana Bidar Institute of Medical Sciences

Bidar – 585403 Karnataka.

EEENNNDDDOOORRRSSSEEEMMMEEENNNTTT BBBYYY TTTHHHEEE HHHOOODDD,,, PPPRRRIIINNNCCCIIIPPPAAALLL/// HHHEEEAAADDD OOOFFF TTTHHHEEE IIINNNSSSTTTIIITTTUUUTTTIIIOOONNN



work done by Dr. Sapna Hiremath under the guidance of

Dr. J.K. Bhargava Prof. & H.O.D. department of Rachana

Shareera.

Date: Date: Place: Bidar. Place: Bidar.

Seal and signature of H.O.D. Dr .J.K.Bhargav M.S.A.M. Prof & H.O.D Dept. Of Post Graduate Studies In Rachana Shareera N.K.J. A.M.C. & PG Centre, Bidar – 585403 Karnataka.

Seal and signature of the Principal/Dean

Dr.K.V.L.N Acharyulu. M.D. (Basic principles)

N.K.J. A.M.C. & PG Centre, Bidar – 585403 Karnataka.

Abbreviations

ABBREVIATIONS

1. Cha. - Charaka samhita

2. Su. - Sushruta samhita

3. A.S. - Astanga sangraha

4. Su (Dalhana) - Dalhana tika on Sushruta samhita

5. A.H. - Astanga hridayam

6. Sha. Pra. - Sharangadhara Prathama kanda

7. Ayu. Sha. - Ayurveda Shareera rachana

8. B.P. Pu. - Bhavaprakasha Purvarda

9. M.Ni. - Madhava Nidana

10. Y.R. - Yogarathnakara

11. D.G. - Dravyaguna

12. Vi. - Vimanasthana

13. Sha - Shareera

14. Ni - Nidanasthana

15. Si. - Siddisthana

16. Chi. - Chikitsasthana

17. Ut. - Uttarasthana

A

Figure No.1. Showing the Anatomy of the skin

Figure No.4. Showing the palm planter psoriasis

B

Figure No. 5. Showing the Psoriasis of nails

Figure No. 6. Showing the Guttate psoriasis

C

Figure No. 7. Showing the psoriasis of the scalp

Figure No. 8. Showing the arthropathic psoriasis

Figure No. 9. Showing the erythrodermic psoriasis

D

Figure No. 10. Showing the pustular psoriasis

Figure No. 11. Showing the Flexaral psoriasis

E

Figure No. 12. Showing the Rupioid psoriasis

F

Figure No. 13. Showing the Genital psoriasis

G

Figure No. 14. Showing the Histology of the psoriasis

ACKNOWLEDGEMENT

I offer my prayers to Revansiddeshwar, Shirdi Saibaba who gave me strength to overcome

all the difficulties during this Thesis work.

I bow my head on the feet of His Holiness Sri Sri Sri Shivkumar Swamiji the President of

C S S, Bidar, for his endless service to society.

I express my sincere gratitude to most honourable and esteemed teacher, guide and

co-guide Dr. J.K. Bhargav and Dr. N G Mulimani respectively for their unforgettable parental

affection and patience cooperation to give suggestions at every step in accomplishing the present

work.

I am very much thankful to Prof. K. V. L. N. Acharyulu, Principal, for his untiring

encouragement and providing me an opportunity to join this reputed institution.

It is a privilege for me to express my sense of indebtedness to my savant teachers

Dr. S B Kottur, Prof. P G Bhatt, Dr. P V Savnur and for their inspiring support.

My most respects to Dr.Ashwini wagmare , Dr.Shelly Divyadarshan , Dr.Sanjeev kumar

Joteppa, Dr.Anup Bosgikar for their valuable suggestions.

I feel great pleasure to thanks to my classmates Dr.Santosh Dixit. Dr.Anita Murki,

Dr.Shankerling, Dr. Raghavendra, for their patience cooperation

It is a privilege for me to express my thanks to all my junior friends

Dr. Geetha Dolle, Dr.Satyamma, Dr. Rajshekhar Tokre, Dr. Vivek, Dr.Shivsharanayya,

Dr.Akkamahadevi, Dr. Suharini Sulgunte.

On this occasion with a great reverence I offer my gratitude to my Husband Dr.

Brahmanand Swamy, and my son Master Atharva.

I feel great pleasure in expressing my pranamas at the lotus feet of my mother-in-law

Smt.Shakunatala and father-in-law Sri. K. V. Swamy, my mother Smt. Sarala and father

Sri V.N. Hiremath and Amma Bhagwan who have cooperated during of this work

May Lord Dhanwantari bless all with hitayu and sukhayu who helped me directly and

indirectly in completing this work.

I sincerely thank all my patients for their support in completing this work successfully.

Dr. Sapana. V. Hiremath

List of Tables

1. Showing names of Twacha in different Samhitas 10

2. Showing layer wise distribution of skin diseases 10

3. Showing the comparison of thickness of Twacha according to Sushruta and Dalhana 11

4 . Showing the Sign and symptoms of kitibha kustha 20

5. Showing comparison between twak shareera with ayurvedic and modern view 32

6. Showing the Clinical features of Psoriasis and Kitibha kustha 48

7. Showing the Varna of the Kitibha Kustha 56

8. Showing the Lakshanas of the Kitibha Kustha 57

9. Showing the areas of the Kitibha Kustha 58

10. Showing the sex of the Kitibha kustha patients 59

1 1 . Showing the age of the Kitibha kustha patients 60

12. Showing Prakruti of the Kitibha Patients 61

13. Showing Diet of the Kitibha Patients 62

List of Graphs

1. Showing the Varna of the Kitibha Kustha 56

2. Showing the Lakshanas of the Kitibha Kustha 57

3. Showing the areas of the Kitibha Kustha 58

4. Showing the sex of the Kitibha kustha patients 59

5. Showing the age of the Kitibha kustha patients 60

6. Showing Prakruti of the Kitibha Patients 61

7 . Showing Diet of the Kitibha Patients 62

List of figures

1. Showing Anatomy of the skin Plate A

2. Showing healthy skin and psoriasis skin 34

3. Different Clinical Forms Of Psoriasis 36

4. Showing the palm planter psoriasis Plate B

5. Showing the Psoriasis of nails Plate C

6. Showing the Guttate psoriasis Plate D

7 . Showing the psoriasis of the scalp Plate E

8. Showing the arthropathic psoriasis Plate F

9. Showing the erythrodermic psoriasis Plate G

10. Showing the pustular psoriasis Plate H

1 1 . Showing the Flexaral psoriasis Plate I

12 . Showing the Rupioid psoriasis Plate J

13. Showing the Genital psoriasis Plate K

14 . Showing the Histology of the psoriasis Plate L

Contents

1. INTRODUCTION 1 – 3

2. OBJECTIVES 4

3. REVIEW OF LITERATURE 5 – 43

A) AYURVEDIC REVIEW 5 – 20

a) Twacha shareer 5 – 1 1

b) Twacha Kriya Shareer 12 – 17

c) Disease Ayurvedic Review of Kit ibha Kustha 18 – 20

B) MODERN REVIEW 21 – 43

a) Anatomy of skin 21 – 31

b) Physiology of the skin 33

c) Disease Psoriasis review 34 – 44

4 . METHODOLOGY 45 – 47

5. OBSERVATIONS & RESULTS 48 – 62

6. DISCUSSION 63 – 67

7 . CONCLUSION 68

8. SUMMARY 69

9. REFERENCES 70 – 78

10. BIBLIOGRAPHY 79 – 81

1 1 . ANNEXURE I – IV

I] MASTER CHART I

I I] MODEL CASE SHEET PROFORMA I I – IV

Introduction

INTRODUCTION

Ayurveda is an ancient pathy which was uniquely practiced before five

thousand years. Its origin is being linked to Atharvaveda and it makes a holistic

approach towards life.

Ayurveda follows laws of nature and propounds number applied doctrines for

the understanding of life, health and diseases. Many of these doctrines are valid even

in today’s running life and may throw a new light on several undissolved issues

regarding science of medicine and solve many uncertainties.

In Ayurvedic classics like Charaka Samhita, Sushruta Samhita etc. a huge

knowledge regarding Shareer. Nidana and Chikitsa are available. For an expert

Vaidya to treat a disease thorough knowledge about the disease and Shareer of its

related part is very mandatory.

One who knows Shareer (i.e. anatomy and physiology of human body) in

detail, only he can know and understand Ayurveda which can bring happiness to the

universe1.

For any successful Vaidya or Shalya Chikitsaka thorough knowledge of

Shareer is very essential for diagnosis and treatment or to perform surgical

procedures.

So, are who wants to have undoubtful knowledge of Shalyatantra, he should

go for dissection and study each and every macro and micro structure of human

body2. But these are many structures in the human body which can not be visualized

by naked eyes. It is possible to explain these minute structures only in this modern era

with the help of advanced technology which has given us ZOOM view. Although in

ancient classics some description of such minute structures is available. It was

possible for Acharyas with the help of “Gnyanachakshu” and “Tapaschakshu”.

“Study of Twak Shareer w.s.r to Kitibha Kustha” 1

Introduction

It is not possible to see minute structures in the body with the help of naked

eyes. They each are visualized only with the help of Gnyanachakshu and

Tapaschakshu3.

In Ayurveidc texts knowledge of Ayurveda is classified in eight main

branches.

Kaya (Medicine), Bala (Pediatrics), Grahachikitsa. Urdhwanga

(Ophthalmology & ENT), Shalya (Surgery), Danshtra (Toxicology). Jara

(Rejuvenation) and Vrisha (Virilification) are the eight branches of Ayurveda4.

The knowledge of these eight branches is present in various texts like

Brihatrayi, Laghutrayi and other textbooks. The authors of these texts have given

special contributed of to a particular branch. So they are considered master of that

branch.

Acharya Sushruta is master in Shareer (Anatomy), Acharya Charaka is master

in Chikitsa (Medicine), Acharya Madhava is famous for Nidana (Diagnosis) and

Acharya Vagbhata is famous for basic principles of Ayurveda described in

Sootrasthana5.

In Sushruta Samhita, Acharya Sushruta has described the structures of human

body in detail. He studied the human body by the technique of human body

preservation and dissection which is very much different from today’s method

Acharya Sushruta was the first to dissect human body.

In Shareersthana of Sushruta Samhita, detail knowledge of human body is

present. In Garbhavyakarana adhyaya, a detail description of Twacha Shareer is

present which will be studied in further topics. Also relation of Tamra Twacha and

Kitibha kustha will be studied.


Introduction

SELECTION OF TOPIC:

Today there is a cosmetic era. People are getting more and more

consciousness about healthy skin. Especially females are seeking more attention

towards healthy skin to be top in the fastest growing field of fashion.

So, to fulfill people’s demand and giving them healthy skin. We must study

the anatomy and physiology of skin and its variation from one person to another

because every individual have different nature of skin depending upon his Prakruti

and many other factors. After studying the nature of one’s skin. We will be in a

position to advice do’s and don’ts or treatment to that person accordingly.

But before doing this, the basic thing is to study normal anatomy and

physiology of skin. So the subject is selected.

There is another reason for doing extensive study of Kitibha which can be

compared to Psoriasis according to modern science.

Today about 30% people are getting affected with skin diseases especially in

tropics. Tinea Virsicolor, Eczema, Dermatitis. Leukoderma is some of the common

skin problems people are facing. Out of this psoriasis is a disease occurring in skin

which is as common as uneasily curable.

It is mainly associated with scales on palm sole, scalp and hands which are

having itchy nature. Due to this complaint (itching), one may loose his concentration

from his routine work and may land up in awkward situation affecting his civil life.

So, the second part of this thesis will be to study kitibha according to

Ayurveda. Psoriasis according to modern science and compare these diseases

according to their symptoms.


Aims and Objectives

AIMS AND OBJECTIVES

1) To make comprehensive literary study on twak shareer.

2) Comparative study of twak sharer with modern and ayurvedic view.

3) To give appropriate & elaborate description on kitibha & its relation with the

4th layer of skin.

4) To study regarding kitibha kustha with modern correlation.


Ayurvedic Review

REVIEW OF LITERATURE

Literary study will be done under four sections:

A) Review of Twacha Shareer. B) Review of Anatomy of Skin. C) Review of Kitibha\Kushta. D) Review of Psoriasis.

AYURVEDIC REVIEW

Section A

Review of Twacha Shareer

In any field of medicine, theoretical knowledge should be accompanied by

practical knowledge. With only one of these, one can not be perfect.

It is said in Ayurvedic texts also a good theoretical knowledge accompanied

by deep practical knowledge is always helpful to expand the boundaries of knowledge

in any field6.

As far as concerned to Shareer Rachana one must have good theoretical

knowledge with perfect and right concepts in mind accompanied with dissection of

the human body to confirm the concepts and ideas.

Acharya Sushruta has described all the structures of human body by doing

dissection. His method of dissection was very unique and much different from today’s

method.

After stating how an ideal dead body should be and technique of preservation

and decomposition of the dead body, he tells to start dissection from outermost

covering of the body i.e. skin.

After full decomposition of the dead body Sushruta tells to separate layers of

skin one by one go deep and visualize structures underneath the skin. From this, it is

crystal clear that skin is the outermost covering of the body7.


Ayurvedic Review

It can be confirmed by description of various parts of the body commencing

skin furnished so far can not be obtained apart from Shalya gnyana8.

Definition:

The external covering of the body is called Twak or Twacha9. A type of

Indriya which envelops the body is called Twagindriya or Sparshanendriya10. As per

Charaka. Twacha envelops shadanga Shareer11.

Etymology of twacha: Twag + Kwip Twacha

Synonyms:

01. Twacha: This word is derived as ‘Twacha Samvarane’ which means covering

of the body.

02. Charma: This word is derived from ‘Chara’ which means movement i.e.

nature of moving.

According to modern science, cells of epidermis are continuously being

produced, remain for some period and become dead and they are replaced by

newly produced cells. This mechanism can be correlated to Ayurveda

‘Shiryate tat shareeram’ law in this way “Charma” is related to movement so

the name has given.

03. Chhavi: It means to illuminate the complexion, Twacha enlights colour of a

person.

04. Chhadani: It means to cover Twacha envelops all organs of the body.

05. Sparshan: To give tactile sensation. Twacha plays main role in perception of

tactile sensation.

06. Asrukdhara: It means to hold the blood inside the body. Thus Twacha

prevents bleeding tendency.


Ayurvedic Review

Twacha Utpatti:

Acharya Sushruta has a good sense of observation of nature and application of

that observation to explain many laws, principles and structures of human body. This

application is called Drushtanta. While explaining genesis of Twacha Sushruta has

also given a simple and accurate Drushtanta of Santanika i.e. cream on mild surface.

During the Paka of Shukra and Shonita by Agni or Pitta dosha, seven types of

Twacha appear on the surface of body of Garbha just like while heating milk cream

appears on its surface12

Acharya Vagbhata quoted that from the Paka of Raktadhatu seven types of

skin appear just like cream on milk13.

Acharya Charaka has not given any description regarding genesis of

Twacha14.

Origin of Twacha:

Acharya Charaka has described that every structure of the body develops from

Shadbhavas in that twacha is matruja bhava15. Acharya Vagbhata stated that Twacha

develops from Vayu mahabhoota15.

Number of Twacha:

There is a great controversy in various Ayurvedic texts regarding number of

Twacha. After studying above lines we come to the conclusion that Acharya Charaka.

Vriddhavagbhata, Bhela and Kashyapa have stated 6 types of Twacha. While Acharya

Sushruta and Bhavaprakasha have started seven types of Twacha16.

Different types of Twacha in Brihatrayi and Laghutrayi:

In Brihatrayi:

A) Charaka Samhita:

In ShareersankhyaShareer Adhyaya of Shareersthana, Acharya Charka has

described six types of Twacha.


Ayurvedic Review

According to Charaka 6 types of Twacha17:

01. Udakadhara: It is an outermost layer of Twacha. As per the name it holds

Rasadhatu and Lasika inside the body and prevents their loss from the body.

02. Asrukdhara: It is the layer next to Udakadhara which has supplied by

numerous blood vessels and it holds blood inside the body itself.

Acharya Charaka has given names only to first two layers of Twacha. He

described next layers of Twacha on the basis of Vyadhis occurring in them.

03. The third layer is the seat of manifestation of Sidhma and Kilasa.

04. The fourth layer is the seat of manifestation of Dadru and Kushtha.

05. The fifth layer is the seat of manifestation of Alaji and Vidradhi.

06. The sixth layer is one on excision of which causes loss of consciousness.

B) Sushruta Samhita:

In Garbhavyakarana Adhyaya of Shareersthana. Acharya Sushruta has

described seven types of Twacha their thickness and diseases occurring in each layer.

These seven types of Twacha are as follows the first and an outermost layer of

Twacha is Avabhasini which reflects all sort of complexions also brighten five types

of shades. It is the seat of Sidhma and Padmakantaka18.

The second layer is called as Lohita and it is the seat of Tilakalaka Nyachha

and Vyanga19. The third layer is Shweta and it is the seat of Charmadala Ajagallika

and Mashaka20. The forth layer is called tamra which is the seat of varius types of

Kilasa and Kushtha21.

The fifth layer is Vedini which is the seat of Kushtha and Visarpa22. The sixth

layer is Rohini which is the seat of Granthi Apachi Arbuda Shlipada and Galaganda23.

The innermost and seventh layer is Mamsadhara which is the seat of Bhagandara.

Vidradhi and Arsha24.


Ayurvedic Review

C) Astanga Sangraha:

In Anga Vibhaga Shareer Adhyaya of Shareersthana. Vriddha Vagbhata has

described seven layers of Twacha.

Acharya Vagbhata has given description of Twacha more or less similar to

Charaka. According to him.

01. First layer is Udakadhara.

02. Second layer is Asrukdhara.

03. Third layer is the seat of Sidhma and Kilasa.

04. Fourth layer is the seat of all types of Kushtha.

05. Fifth layer is the seat of Alaji and Vidradhi.

06. Sixth layer is Pranadhara25.

D) Ashtanga Hridaya:

Acharya Vagbhata has not given any details of twacha except the genesis of

Twacha.

In Laghutrayi:

E) Sharangadhara Samhita:

In Kaladikakhyana Adhyaya of Prathama Khanda Sharangadhara described

seven Twachas.

According to Sharangadhara:

01. First layer is Avabhasini seat of Sidhma.

02. Second is Lohita seat of Tilakalaka.

03. Third is Shweta seat of Charmadala.

04. Fourth is Tamara seat of Kilasa and Shwitra.

05. Fifth is Vedini seat of all Kushtha.

06. Sixth is Rohini seat of Granthi ganda and Apachi.

07. Seventh is Sthoola the seat of Vidradhi and it is thick equal to two Vrihi26.


Ayurvedic Review

F) Madhava Nidana:

There is no description regarding Twacha in Madhavanidana.

G) Bhavaprakasha:

According to Bhavaprakasha there are seven types of Twacha

01. The first is Avabhasini which is the seat of Sidhma.

02. The second is Lohita seat of Tilakalaka.

03. The third is Shweta seat of Charmadala.

04. Fourth is Tamara seat of Kilasa and Shwitra.

05. Fifth is Vedini which is the seat of all Kushtha.

06. Sixth is Rohini which is the seat of Granthi, Ganda and Apachi.

07. Seventh is Sthoola, the seat of Vidradhi27.

Table No. 1. Showing names of Twacha in different Samhitas:

Charaka Sushruta Vagbhata Sharangdhara Bhavprakash01. Udakdhara Avabhasini Udakdhara Avabhasini Avabhasini 02. Asrukdhara Lohita Arukdhara Lohita Lohita 03. Sidhma Kilasa Shweta Sidhma

Kilasa Shweta Shweta

04. Dadru Kushtha Tamra Sarva Kushtha

Tamra Tamra

05. Alaji Vidradhi Vedini Alaji Vidradhi

Vedini Vedini

06. On cutting one feels Blindness

Rohini Pranadhra Rohini Rohini

07. --- Mamsadhara --- Sthoola Sthoola

Table No. 2. Showing layer wise distribution of skin diseases: Charaka Sushruta Vagbhata Sharangdhara Bhavaprakasha 01. --- Sidhma

Padmakantaka --- Sidhma Sidhma

02. --- Tilakalaka Nyacha, Vyanga

--- Tilakalaka Tilakalaka

03. Sidhma, Kilasa

Charmamdala Ajgallika, Mashaka

Sidhma Kilasa

Charmadala Charmadala

04. Dadru, Kushtha

Kilasa, Kushtha Sarva Kushtha

Kilasa Shwitra Kilasa Shwitra

05. Alaji, Vidradhi

Kushtha, Visarpa

Alaji, Vidradhi

Sarva Kushta Visarpa Kushta

06. Blindness Granthi, Apachi, Arbuda etc.

Blindness Granthi Apachi

Granthi, Apachi, Arbud

07. --- Bhagandara, Arsha, Vidradhi

--- Vidradhi Vidradhi


Ayurvedic Review

Thickness of Twacha:

In various Ayurvedic texts, there is a description of Twacha, its layers and

diseases occurring in each layer of Twacha. Sushruta Samhita is unique for the

description of Thickness of twacha.

Here, Sushruta describes thickness of Twacha in the measurement of Vrihi

Pramana. (Vrihi – Rice Grain) So, Avabhasini Twacha is thick = 1/18th part of 1 Vrihi

and likewise about other layers of Twacha. But this measurement of Twacha is not

throughout same for all the body parts. It differs according to various body parts28.

The measurement of thickness of Twacha mentioned above is applicable for

only thick skin on muscular parts of the body. It is not applicable for forehead and

small fingers29.

According to Dalhana, a commentator of Sushruta Samhita twenty parts of 1

rice grain should be done and then thickness of Twacha should be determined e.g.

Avabhasini Twacha is thick = 18/20 parts of 1 Vrihi30.

Table No. 3. Showing the comparison of thickness of Twacha according to Sushruta and Dalhana:

Twacha Sushruta Modern measurement Dalhana Modern

measurement Avabhasini 1/18 0.055 18/20 0.90 Lohita 1/16 0.062 16/20 0.80 Shweta 1/12 0.083 12/20 0.60 Tamra 1/8 0.125 8/20 0.40 Vedini 1/5 0.200 5/20 0.20 Rohini 1 1 1 1 Mamsadhara 2 2 2 2

Total:3.525 Total: 5.9

So, according to Sushruta and Dalhana, there is a great controversy regarding

thickness or Twacha.

Sushruta : 3.5 Vrihi

Dalhana : Appr. 6 Vrihi


Ayurvedic Review

If practically observed and thickness of 1 vrihi is measured it becomes average

1mm. So, the thickness of twacha told by Sushruta and Dalhana expressed in modern

measured will be:

Sushruta : 3.5 mm

Dalhana : Appr. 6 mm

If we want to compare this measurement with modern measurement (skin

thickness = 1.5 to 4 mm), then Sushruta seems to be perfect and more accurate in

telling thickness of skin. Because according to Dalhana, it becomes 6mm which is

highly impossible.


Ayurvedic Review

TWACHA KRIYA SHAREERA

Twacha & Tridosha relation:

01. Vata Dosha:

While describing abodes of Doshas, Vagbhata says Twacha is one of the

abode of Vatadosha. Out of 5 types or Vata, especially Prana and Udana are directly

related to Twacha. Pranavayu is responsible for the tactile sensation. Twacha is able

to perceive sensations like cold, heat, roughness, smoothness with the help of

Pranavayu itself31.

The other type of Vata i.e. Udana Vayu produces varna and if it gets vitiated

then there is discolouration of skin32.

2. Pitta Dosha:

Besides Vatadosha. Twacha is an abode of Pittadosha also Nabhi, Amashaya,

Sweda, Lasika, Rakta, Rasa, Druk(Drushti) and Sparshana (Twacha) are the abodes of

Pitta. Out of five types of Pitta. Bhrajaka Pitta is mainly related to Twacha33.

Bhrajaka Pitta is situated in the skin and its main function is Bhrajana of

Twacha34 (i.e. to maintain the Teja of Twacha).

The Pitta in the skin is known as Bhrajaka pitta, which is responsible for

absorption of drugs externally in the form of massage, bath, dipping, paste etc. and

also illuminates various shades of complexion35.

3. Kapha Dosha:

One of the Gunas of Kapha is Snigdha due to this Guna of Kapha oily nature

of Twacha is maintained. If Kshaya of Kapha dhatu happens, then Snigdha guna

decreases and due to this Twacha becomes dry and cracky in nature.


Ayurvedic Review

Twacha & Saptadhatu relation:

There is a very close relation between Saptadatus and Twacha.

01. Rasa : Twacha is a huge structure and it requires nourishment

of Rasadhatu for its well beings.

02. Rakta : Raktadhatu is present in raktavahi Dhamnis. Twacha is

richly supplied by Raktadhatu and also called as

Asrukdhara.

03. Mamsa : Twacha is theMoolasthana of Mamsavaha Srotasa. Vasa

and shat Twacha are generated from the mamsa itself.

So that mamsa dhatu and Twacha are intimately related

to each other.

04. Meda : The mala of meda dhatu is Sweda and Sweda is

expelled out of the body through Twacha and in this

way these two are related.

05. Asthi : The kitta of Asthi are Kesha and Loma which emerge

out from Twacha.

06. Majja : Mala of Majja is Sneha of Netra. Purisha and Twacha.

Twacha & Mala Relation:

Twacha is mainly related to Sweda. Twacha is having innumerable

Bahirmukha srotamsi through which Sweda is excreted out f the body. Thus Twacha

acts as biggest Malayana of body. Decrease in amount of Sweda causes hair loss, loss

of sensation and cracks in the skin36.


Ayurvedic Review

Twacha & Panchamahabhoota Relation:

Each and every structure of the body is having Panchabhautik constitution

even on the cell level also.

Twacha is also having Panchabhautik nature.

Element Structure Parthiva Kesha, Loma Aapya Rasa, Lasiak Tejas Kanti, Varna Vayviya Sparsha, Samvedna Akashiya Lomakoopa, Sweda Vahi Nalika

Twacha & Upadhatu Relation: Every Dhatu have its own Upadhatu Vasa and Shat – Twacha are Upadhatu of

Mamsadhatu37.

Twacha & Srotasa Relation:

Twacha is closely related to Swedavaha Srotasa and mamsavaha Srotasa.

01. Swedawaha Srotasa:

Meda and Lomakoopa are the roots of Swedavaha Srotasa out of which

Lomakoopa are present in the skin in the form of numerous openings. Also twacha

acts as a medium for evaporation of Sweda outside the body38.

02. Mamsavaha Srotasa:

According to Sushruta and Charaka, Snayu and Twacha are the roots of

mamsavaha Srotasa39.

Twacha and Varna Relation:

Varna of a person is expressed in the Twacha. It is determined during foetal

life. In Charaka Shareera the varna of a foetal is determined in sixth month of

intrauterine life40.


Ayurvedic Review

This Varna is of four types:

Teja element is the main factor for the complexion. When at the time of

conception. It is predominantly associated with Aapa element, it makes Gaura Varna.

If Prithvi dhatu is predominant, then it produces Shyma (black) Varna. Predominance

of Prithvi and Akasha with it produces Krishna Shyama (black sky) Varna. While

predominance of Aapa and Aakasha element produces. Gaura Shyama (Fair Sky)

complexion41.

Some Acharyas say that diet taken by a pregnant woman determines

complexion of the foetus. But Charaka has described three types of Varna.

Tejas element in combination with Udaka and Antariksha produces Avadata

(fair) Varna with Prithvi and vayu produces Krushna (black) Varna and with the same

amount of all elements produces Shyama (Blackish) Varna42. On the other hand.

Charka describes four types of Varna in Indriyasthana. These are Krishna (black)

Shyama (Blackish), Shyamavadata and Avadata43 (fair).

Twacha & Prakriti Relation:

01. Vata Prakruti: Persons having Vata prakruti have Ruksha, Khara. Twacha

and is of Sheeta Sparsha. It is blackish in colour and almost having no sweat

or less sweat.

02. Pitta Prakruti: Persons of Pitta Prakruti have fair or yellowish Twacha

having Ushana Sparsha and there is profuse sweating from the skin with bad

odour.

03. Kapha Prakruti: People having Kapha Prakruti have soft, while (Gaura) and

oily skin.


Ayurvedic Review

Twacha & Sara Relation:

Sara is considered to be the cream part of the respective Dhatu. Each Dhatu has its sara

and in the person having sarata of particular Dhatu, there are all good characters of that Dhatu.

In case of Twacha, Rasasara is considered as Twaksara. As Rasadhatu is spread all over the

Twacha. Rasasara is considered as Twaksara44. Twaksara person have a fresh, lustrous, smooth

skin with deep routed and tender hair45. According to Charaka, Twaksara person is having

unctuous smooth, soft, clear, fine, less numerous, deep routed and tender hair46.

Twacha & Rogamarga Relation:

There are three types of Rogamarga these are Shakha, Marma, Asthi, Sandhi and

Koshtha. Twacha is included in Shakha marga alongwith Rakta and other dhatus. These come

in Bahya Rogamarga47.

Twacha as a Gnyanendriya:

Human body is made up of Pancha Gnyanendriya and Panch Karmendriya. Ear, Skin,

Eyes, Tongue and Nose are five sense organs according to Ayurveda48. These organs are the

abodes of their respective Indriyas49. Twacha is one of Gnyanednriyas which is Vayaviya in

nature50.

The Indriya, which is responsible for reception of touch sense is Sparshnendriya and

Twacha is its abode (i.e. Adhishthana)51

The important property of Vayu is Sparsha and its reception through Sparshanendriya

to enable all the movements in the body to bring lightness to body and to create impulses in

body52.

In all Indriyas, Sparshanendriya is an entity that occupies all other Indtriyas, Mana is

also intimately related to Twacha as it is also all encompassing as well as Twacha occupies the

whole body53.

Prithvi, Jala, Teja and Vayu are characterized by Kharatva (roughness), dravatva

(Liquidity), Chalatva (mobility) and Apratighata (Unobstructibility) respectively. All these

attributes are perceived by tactile sense organ. Touch together with its absence is perceived by

tactile sense organ54.


Ayurvedic Review

DISEASE REVIEW:

Kitibha:

The disorder kustha is said to occur in the 4th and 5th layer of skin (su.sha.4/4).

Nidana of kitibha:

There is no specific reference regarding the etiological factor for kitibha

kustha, at the same time no particular aetiology has been depicted for any of the

different varieties of kustha specifically. The general causes have been described

which becomes aetiological factors for the formation of kustha.

For example – taking diet against the regimen given in the literatures specially

eating guru and virudha and asatmya ahara, eating during indigestion after

consumption of liquid substances or post vomiting period, after exercise, after coitus

etc, eating non-veg with milk etc , entering extreme heat, causing sudden vomiting

with holding vomiting ( Su. Ni 5/4)

Further it is stated that the effect of karma like murder of a Brahmin, lady,

pious person, abducting other women etc causes kustha (Su. Ni 5/30)

It is stated that kustha occurs even after the rebirth of person afflicted with

disease in the previous life. (Su. Ni 5/31)

In susrutha chikitsa 9/9 the similar aetiology has been given in nutshell.

Charaka 7/48, M.N. 49/1-5, B.P 54, given the similar opinion regarding the aetiology

of kustha in genera.

This general description of aetiology in respect to kustha is applicable too

either of the 18 kusthas and this applies to kitibha kustha too.

Samprapti:

The vitiated doshas, influence the dhatus in general and rakta in particularly

the above said factors vitiated pitta, rakta and sleshma along with vayu which is


Ayurvedic Review

vitiated and increased, move along tiryak sirah and erupt in bahya marga and exhibit

their present. The lodging of vitiated and increased doshas caused circumscribed

lesion on the skin. Then this doshas get localized increase and if neglected enter the

other dhatu. Su.Ni.5./5, cha. Chi9-10, M.Ni.49/6 BP 54/6.

Astanga hrudaya states, the aggravated doshas enters the channels and vitiates

the twacha, lasika , raktas and muscles and discolouration of skin noted ( A.S.Ni 14/3-

5, A.H.Ni 14/2-3)

Purvarupa:

In general their will be roughness of skin horripilation (Roma harsha) itching

(kandu), excessive sweating or no sweating at all, sometimes anesthesia of the part,

blackish discolouration seen as a premonitory symptom of kusthas ( Su.Ni. 5/4)

Charaka further says burning sensation, instantaneous appearance of ulcer,

excessive pain, all explanation of patches etc as the premonitory symptoms (Cha.Chi.

7/11-12)

The kusthas are said to occur due to Vata, Pita and also due to formation of

krimi or bacteria. However, dosha predominance is supreme in manifestation of this

disease (Su.Ni.5/6).

Roga lakshana:

As far as aetiology, pathology and premonitory symptomatology is concerned,

all the acharyas have given the general description of kustha only. However the

symptomatology has been specified by all the authors as far as the separate varieties

are concerned.

The symptoms of kitibha are circumscribed, eruption, discharge, thick skin,

itching, glossy or blackish in colour, cloudy in colour (Su.Ni 5/13)

Ca.Ci 7/21, M.Ni 49/17, B.P 54/25, Y.R.Ni 20/20,


Ayurvedic Review

Agree with the susrutha’s opinion along with addition of parusha, sparsha.

Astanga sangraha adds to above symptoms cryptation on scratching (A.S.Ni 14/22)

Table No. 4. Showing the Sign and symptoms of kitibha kustha:

Sr.No Sign & Symptoms

Susrutha Samhitha

Yoga Ratnakar

Bhava Prakasha

Caraka Samhitha

Kashyapa Samhitha

A.S A.H

1 Shyava - + + + + -

2 Khara sparsha - + + + + +

3 Parusha - + + + + +

4 Krsna varna + - - - + +

5 Aruna varna - - - - + -

6 Srava + - - - + -

7 Vrdhi manti - - - - + -

8 Guruni - - - - + -

9 Prashanthani - - - - + -

10 Punha punha utpadante - - - - + +

11 Vrutha + - - - - -

12 Ghana + - - - - -

13 Ugra kandu + - - - - +

14 Snigdha + - - -- - -

15 Ruksha - - - - - +


Modern Review

MODERN REVIEW

Anatomy of the Skin:

Normal skin:

The skin is tough and a uniform protective covering of the entire surface of the

body and deeper tissues, with its all derivatives know as Integument (Latin – a

covering). It contains the peripheral ending of many sensory nerves. Skin regulates

body temperature and possesses limited excretory and observing powers. In adults skin

covers about 2m.sq area and has weight of approximately 4-5kg. Its thickness is 0.5 – 4

mm depending on its location. The thickness of the skin increases gradually after birth

until age of 30 and then slowly begins to thin down. The human skin shows wide

regional variation in structure like scalp, face, ear lobes, back, palms and soles etc.

The skin is a largest organ in the human body it consist of vascular connective

tissue named corneum dermis and an external covering of epithelium called as

epidermis. The sweat gland, sebaceous glands and hair follicles are embedded beneath

it and called as appendages of development of skin in foetus.

Deep to dermis is sub-cutaneous layer this layer is also called superficial

fascia or hypodermis, consist of aeriolar and adipose tissues. Fibres from dermis

extent into the sub-cutaneous layer inturn attaches to the underline tissues and organs.

So, the skin is composed of 3 distinct layers from surface of downward and they are,

A. Epidermis

B. Dermis

C. Hypodermis.


Modern Review

Embryological formation of skin:

A. Epidermis - Surface ectoderm, melanoblast (dendritic cells) from neural crest.

B. Dermis - Mesenchyme derived from dermatomes of Somites.

C. Nails - Ectoderm of each digital tip, later migrates to dorsal surface.

D. Hair - Surface ectoderm, which is modified to form hair follicles.

E. Sebaceous glands – Arise as diverticula’s from hair follicles.

F. Sweat glands - Develop as down growth from the epidermis later canalized.

Epidermis:

The epidermis is formed by non-vascular stratified epithelium. It varies in

thickness from 0.04 mm on the eyelid to 1.6 mm on the palms with an average

thickness of less than 0.17mm (1/200th of an inch) in most areas except for those areas

chronically exposed to pressure and friction but it may exist to an extent at birth.

The most superficial layers of cells from the horny zone (Stratum chorneum)

which may be separated by maceration from deeper stratum turned as germinative

zone. There is network of linear furrows of variable size divide the surface into

number of polygonal or lozenge shaped areas. These furrows are conspicuous

opposite the flexures of joint. The lines are fine but very distinct upon the palmer

surface of hands, fingers and soles of the feet. The lines of the tips of finger and

thumbs from distinct pattern.

The deeper surface of epidermis is accurately molded upon the papillary layer

of corneum which prevent the epithelium from being stripped off. The surface of the


Modern Review

skin by sharing stresses it is metabolically active, stratified squamous, cornifying

epithelium i.e. populated 4 types of cell. Keratinocytes is for the most part and

Melanocytes, langerhans cell and marked cells in decreasing sparsity.

Epidermis:

The stratified, squamous, cornifying epithelium that is populated by 4 types of cells.

a. Keratinocytes

b. Melanocytes

c. Langerhan cells

d. Merkel cells

A. Keratinocytes:

90% of epidermal cells are Keratinocytes they produce a protein called

keratin. These substances helps waterproof and protect the skin and underlying tissues

from light, heat, microbes, many chemicals. Anchoring junctions, desmosomes held

Keratinocytes to one another.

Epidermal Keratinocytes undergoes characteristic changes as they are

progressively moved upward from basal of epidermis to the chornified layer. Four

interrelated cellular layer i.e. basal, spinosum, granular, chornified can be recognized

as successive stage of differentiation of germinal Keratinocytes to chornified

keratinocyte.

Epidermal chornification is a form of cellular differentiation that results in the

formation of the outermost dead layer of skin.


Modern Review

B. Melanocytes:

Melanocytes are dendritic cells Melanocytes are pigment producing cells of

neuro ectodermal origin. This cell synthesized melanin from tyrosin, a pigment

responsible for skin colour and essential for protection from UV light. Amount of the

melanin in Keratinocytes determines the skin colour. Facial differences in colour are

the result of metabolically active Melanocytes.

Melanocytes appear microscopically as clear cells in and immediately beneath

the basal layer of epidermis. The nucleus of a Melanocytes is smaller and more deeply

basophilic then that of Keratinocytes.

The ratio of Melanocytes to Keratinocytes in the basal layer of epidermis

varies from 1:4 to 1:10 depending on the region of body ex:- Melanocytes are more

abundant in the skin of chicks then in that of abdomen.

There are two classes of integumentary melanin. Eumelanin produced in

ellipsoidal melanosomes (Eumelanosomes) account for the brown and black colours

of both skin and hair. Pheomelanin, produced in perikal melanosomes

(pheomelanosome) account for the lighter colour of hair, ranging from yellow to

reddish brown.

It is the amount of melanin in Keratinocytes that determines the degree of

pigmentation of skin and hair. The principle function of melanin is to protect the skin

from the harmful effect of sunshine by scattering and observing ultraviolet.


Modern Review

D. Langerhans cells:-

Are the macros phases like antigen producing cells located above the basal

layer of keratinocyte, which interact with hyper t cells with assisting with the immune

response may be a possible source of prostaglandin.

Langerhans cells first described by Paul Langerhans in 1868. although this cell

constitute about 4% of the cell population of epidermis, regional variation occurs in

their distribution their number varying between 460 and 1000 per (mm)sq of

epidermis. The cross sectional appearance of langerhans cell granules has been

likened in shape to a tennis racket, vesicular dilation at one end at a rod like segment.

A langerhan cell plays an important role in various immune process including

allergic contact dermatitis, immune tolerance and surveillance against neoplasio.

E. Merkel cells:

Merkel cells are non pigmented dedrosides cytoplasmic dense core granules,

which function as touch receptors and also interact with separates t cells in assisting

with immune response. Endothelial cells are not found since the epidermis lack blood

vessels. Nutrient delivery and waste transport are by diffusion. There are capillary

networks in the papillary dermis which provide this function.

Merkel cells make contact with the flattened portion of ending of sensory

neuron called as tactile (merkel) disc and are thought to function in the sensation of

touch.

In 1875 fried rich merkel identified unique cells of the basis of epidermal rate

ridges that were in contact with nerves fibrils. He named cells as “TOUCH CELLS”.


Modern Review

The names of 5 layers of epidermis from deepest to the most superficial are:

1) Stratum basale (basale-base):

This layer is also called stratum germinativum to indicate its role in germinating

new cells. this single layer of cuboidal to columnar shaped cells contains stem

cells. which are capable of continued cell division & melanocytes.

The stem cells multiply, producing Keratinocytes which push up towards the

surface & become part of more superficial layers. the nuclei of Keratinocytes

degenerate & die. Eventually, the cell remnants are shed from the surface layer of

epidermis. During embryological development, other stem cells are migrating into

the dermis & give rise to sweat & oil glands & hair follicles. the stratum basale

also contain tactile cells (merkel cells) that are sensitive to touch.

2) Stratum spinosum (spisum-throne like or prickly):

This layer contains of prickle cells, which is composed of several layer of

polyhedral cells. From these plaques numerous fine fibrils (tonofibrils) radiate

into the cell cytoplasm. Some maintain that the fibrils do not exist as such in

living unfixed cells. When the cells are isolated these desmosomes are broken &

surfaces of cells are beset with numerous short than like processes, named prickle

cells. These layers contain of 8-10 closely fitted rows of polyhedral cells. These

cells are able to synthesis protein but can not reproduce. Long projections of

melanocytes extend among the Keratinocytes, which take in melanin by

phygocytosis of these melanocyte projections.


Modern Review

3) Stratum granulosum – ( granulum – little grain ):

This layer is also known as granular layer. It comprises 2 or 3 layers of fusiform

cells. Which contain numerous granules which stain readily haematoxylin due to

accumulation of readily stainable granules of keratohyline in their cytoplasm? In

this layer, keratin, the water proofing protein is produced. In the stratum

granulosum, the cells appears in various stages of degeneration & as a rule, break

down & cell death occurs.

4) Stratum lucidum (lucidus- clear):

This is clear layer appears in section as a homogeneous or deeply seated layer,

composed of closely packed cells in which traces of flattened nuclei may be

found. This layer consists of 3-4 rows of clear, flat dead cells. It is best seen in

regimen where the horizon is thick skin of the palms & soles of the feet.

5) Stratum corneum(corneum- horny):

It is known as horny layer. It consists of several layers of horny, epithelial cells, in

which no nuclei are discernable & their protoplasm has been converted into a

material known as keratin. The outer most cells containing the tough protein

keratin are known as Keratinocytes. They consist of 25-30 rows of dead flat cells.

The cells are continuously shed & replaced by the newly divided cells.

The stratum corneum serves as an effective barrier against light, heat, bacteria &

many chemicals.


Modern Review

Dermis:

It is a 2nd inner layer of the skin. The dermis consist mostly of comparatively

non cellular connective tissue composed of collagen, elastic fibres & ground

substance, in which nerve, blood vessels, lymph vessels, muscles & pilsebaceous

apocrine & ecrine sweat units are embedded. The mature dermis also contains a

variety of cells scattered freely in varying numbers thought its structures. in

descending numerical order, these free cells of dermis are fibroblasts, mast cells,

histocytes, langerhans cells, lymphocytes & very rarely esinophils. Plasma cells are

not seen in normal dermis any where except muco-cutaneous junction.

The fully formed dermis may be divided into 2 components. (1) A thin

adventitial dermis, which is the combination of papillary dermis & periadnexal dermis

(2) A larger component reticular dermis. The adventitial dermis is characterized by

thin, haphazardly arranged collagen fibroblast, abundant ground substance & a highly

developed micro circulation composed of arterials, capillaries & venules.

The larger component of the dermis (reticular dermis) extends from base of

papillary dermis to sub cutaneous fat. It consists of irregularly arranged course elastic

fibres interspersed between thick collagen bundles that are mostly oriented parallel to

skin surface. Proportionally, there are fewer fibroblasts, blood vessels & less ground

substance & in this layer than adventitial dermis.

The corium is highly tough flexible & highly elastic, it is very thick in the

palms & soles, thicker on the posterior than on the anterior aspect of body & on

lateral than on medial side of limbs. It is exceedingly thin & delicate in the eye lids,

scrotum & penis.


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Structural anatomy:

The corium consists of felted connected tissue with a varying number of

elastic fibres, numerous blood vessels, lymphatic vessels & nerves. The connective

tissue is arranged in 2 layers, deeper (reticular) & superficial(papillary) layer.

Unstirred muscular fibres are found in superficial layers wherever hairs are

present; they are also present in subcutaneous aeriolar tissue of scrotum, penis, labia

majora & nipples.

It is derived from the mesoderm & its thickness is varying from 2-4 mm.

dermis is vascularised & innervated. It is composed of connective tissue containing

collagenous & elastic fibres, which provides strength & elasticity to the dermis.

A] Papillary layer:

The papillary layer consist of numerous highly sensitive & vascular eminences

, termed papillae which rise perpendicularly .The papillae are minute conical

projections , having round or blunted extremities ,which may be surfaces of

epidermis. On the general surface of the body & especially in parts endowed with

slight sensibility, they are few in number & exceedingly minute. But upon the palmer

surfaces of hands & fingers & plantar surfaces of feet & toes, they are larger &

closely aggregated together & arranged in parallel curved lines forming elevated

ridges seen on the epidermis.

Each ridge contains 2 rows of papillae & between the rows the ducts of sweat

gland pass outwards to open on the summits of the ridges. Each papillae consist of

very small & closely interlacing bundles of finely fibrillated tissue, with a few elastic


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fibres, within this tissue there is a capillary loop & in some papillae especially in

palms of hands & fingers. There are tactile corpuscles.

Papillary layer has many small, elongated projections called rete peges, also

contains loops of capillaries & these projects into epidermis. Size & arrangement of

dermal papillae from ridge which are external surface of epidermis & provide

attachment of epidermis to dermis & its collagen fibres. In some dermal papillae are

present meissner’s corpuscles, the nerve ending sensitive to light touch.

B] Reticular layer:

It consist of strong inter lacing bands, composed cheaply of white fibrous

tissue & containing some yellow elastic fibres, which vary in number in different

parts. In the deeper part the fasciculi are course & large intervals left by their

interlacement are occupied by adipose tissue & sweat glands. below reticular layer,

there is subcutaneous areolar tissue which except in a few situations contains fat. The

connective tissue bands in reticular layer lie for the main part in parallel bundles so

that if conical object is stabbed through skin & then withdrawn it leaves a linear

wound since the fibres are forced apart with much rupture. The directions taken by the

parallel bundles vary in different part of the body & constitute what are termed the”

cleavage lines”, which heal with formation of scar tissue, where as the incision across

these lines, owing to retraction of the several fibres lead to the formation of the broad

scar.

The cleavage lines are arranged longitudinally in the skin of the limbs & more

or less horizontally in the trunk & neck. With increasing age the yellow elastic fibres

atrophy and the skin loses much of its elasticity and become wrinkled. If the skin

becomes much stretched (as by rapidly growing tumours, fat deposition or pregnancy)


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the fibres in reticular layer may undergo partial rupture, followed by scar formation;

these areas may show on the surface as white streaks. These are commonly seen in the

anterior wall of abdominal wall after pregnancy and known as linear gravidarum.

In many regions the skin is separated from deep fascia or other structures by

loose areolar tissue and where the skin is freely movable over the deeper structures.

Elsewhere, however, the skin may be firmly anchored to structures like the

periosteum over” subcutaneous” parts of bones or to the deep fascia in regions related

to movements of underlying joints. In joints there are permanent creases known as

“flexure lines”; they are particularly evident on the palm of the hand and flexor

surfaces of the digits, where they are arranged in relation to the movements of the

digits.

The remaining reticular layer is made of dense irregular, collagenous tissue,

which allows strength & flexibility in every direction. The primary cell of this layer is

fibroblast, which produce the key structure of extra cellular matrix protein namely

collagen & elastin. These cells produce the key adhesive proteins used to attach

epidermal cells to the basement membrane & are used for epidermal cell migration &

replication. The fibronectin is a key fibroblast derived signal protein for the

orchestration of the healing ground substance or matrix. This is made of

polysaccharide protein complexes known as GAG or hyaluronic acid, which is semi

fluid that allows cells & connective tissue orientation, provide nutrients diffusion to

the cells & also provides scaffolding for cell migration. The space between interfacing

connective tissue fibres are occupied by adipose tissue, blood vessels, sweat glands,

nerves & hair follicles. It is attached to the underlined structure by the subcutaneous

layer of tissue.


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Aim to give appropriate and elaborate description of Kitibha and its relation

with the 4th layer of the skin.

According to Sushruta kushtha occur in 4th and 5th layer of twacha i.e. Tamra

and Vedini according to Charaka and Vagbhata kushtha found in 4th layer of twacha

kitibha is a one of the kshudra kustha (so kitibha kustha found in 4th layer of twacha).

In psoriasis the stratum basale stratum spinosum layer of epidermis is mostly

get affected, which is compare with the 4th layer of twacha in ayurveda.

And, in late stage of psoriasis, papillary layer of dermis get affected which is

compare with 5th layer (vedini) 5th layer of twacha

Dr. Ghanekar while commenting on Sushruta Sharira Sthana has correlated the

layers of skin with the anatomy of skin as under.

Table No. 5. Showing comparison between twak shareera with ayurvedic and modern view:

Sl.No. According to Sushruta

According to Charaka &

Vagbhata Modern Term Layer of

skin

1. Avabhasini Udakdhara Stratum Corneum

2. Lohita Asrukdhara Stratum Lucidum

3. Shweta Sidhma, kilasa Stratum Granulosum

4. Tamra Dadru, kustha Malpighian layer

Epidermis

5. Vedini Alaji, vidradhi Papillary Layer

6. Rohini Blindness Reticular Layer Dermis

7. Mamsadhara ---- Subcutaneous

tissue and Muscular layer

Hypodermis


Modern Review

PHYSIOLOGY OF THE SKIN The skin is a metabolically active organ with vital functions including the

protection and homeostasis of the body.

a. Regulation of body temperature:

Skin does the evaporation of sweat and converts the high temperature into

lower elevated body temperatures or to the normal. Changes in the flow of

blood to the skin also help the regulation of body temperature.

b. Protection:

The skin is considered under the Integumentary system. It provides a physical

barrier that protects the underlying tissues from physical abrasion, bacterial

invasion, and dehydration and UV radiation.

c. Sensation:

The skin contains abundant nerve endings and receptor that detect stimuli

related to temperatures, touch, pressures and pain.

d. Immunity:

Sweat of the epidermal cells is important components of the skin immune

system, which tends off foreign invaders.

e. Excretion:

Sweat is the vehicle for loss of a small quantity of ions and several organic

compounds along with removal of heat and some part of water.

f. Blood Reservoir:

The dermis is a house of extensive networks of blood vessels that carry 8 to

10% of the total blood flow in a resting adult. In moderate exercise this flow

increase, which helps to dissipate the heat from the body. While during the

exercise skin’s blood vessels constrict so this allows more blood to circulate

through contracting muscles.

g. Synthesis of Vitamin – D:

Synthesis of vitamin D begins with activation of a precursor molecule in the skin by

ultraviolet rays in the sunlight. Enzymes in the liver kidneys then modify this

molecule and produces calcitrol, the most active from of vitamin D.


Modern Review

DISEASE REVIEW

Psoriasis:

Figure No. 2. Showing healthy skin and psoriasis skin

An extremely common dermatosis of world wide distribution. Affects any age

group, generally young adult of both sexes. Genetic predisposition present.

Approximately three million peoples affected. It appears suddenly or gradually.

Autosomal dominant inheritance with incomplete penetrance or multifactor strong

association with HLA-B/B, HLA – BW17 and HLA – Cw6.

Environmental factors contribute trauma, sunlight, infection, emotional stress,

climatic changes may precipitate relapse. Patients with AIDS present severe psoriasis.

In many cases, psoriasis goes away and can come back repeatedly overtime. Site of

predilection: - Knees, elbows, hands, lumbosacral region the palm and sole, the scalp

and nails, male genitals. Lesions often localized to the site of trauma.

Psoriasis is characterized by skin cells that multiply upto 10 times faster than

normal. Normally, skin cells that are formed in the deepest layer of skin are getting

mature and sloughed off the body surface and replaced by underlying cells. This cycle

is approximated need 2-4 weeks and this process is called Keratinization, but in


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psoriasis, the immune system is mistakenly activated, resulting in an abnormally rapid

skin cell cycle. This mean the cells move from deepest layer of skin to the surface in

about 4 to 7 days. Since they migrate so quickly, they do not have time to properly

mature. So immature cells are sloughs off which looks silvery, white dry scaly in

nature.

Causes of psoriasis:

The cause disease of the immune system, when immune system is accidentally

activated (natural protection against bacteria, virus and other foreign invaders) which

resulting in an acceleration of normal skin cell of psoriasis is unclear. Psoriasis is now

recognized as an inflammatory cycle. This in term causes an accumulation of skin

cells on the surface of the skin. Heredity, environmental, diet and psychological

factors may also play a role.

Classical Psoriasis:

Asymptomatic or often itchy, red scaly papules and plaques of varying in size

and configuration and sharp delineation distributed on the extensors of the body,

flexors sometimes involved. Lesions covered with varying amount of loosely attached

silvery white scales overlying an adherent translucent membranous scale. Removal

latter reveals punctuate bleeding spot (from the elongated capillary looks in dermal

papillae) the characteristic Auspitz Sign.

Course unpredictable and variable; spontaneous remission and relapses of

characteristic feature most of (patients worsen in winter, some in summer).

Patients will ill define erythematous and a warm lesion indicates unstable form

could progress on to erythroderma. Lesion with pronounced mound. Like scales in

seen in rupioid psoriasis.


Modern Review

Basic pathogentic mechanism of the disease will understand. Chief cutaneous

manifestations result from hyperplasia of the epidermis. Epidermopoiesis is more

rapid and transit time of epidermal cells diminished; immature nucleated epidermal

cells present in the stratum corneum (Parakeratosis).

Figure No. 3. Different Clinical Forms of Psoriasis

Types of psoriasis:

1. Plaque psoriasis (psoriasis vulgaris):

Most commonly seen 80% of psoriasis is plaque psoriasis appears as dry,

scaly, inflamed patches of the skin. Silvery in colour, silvery white scales are

slough out on rubbing the area, affected area found all over the body.

2. Palm planter psoriasis:

Varied manifestations well defined red plaques with thick scales or

hyperkeratosis fissured, erythematous, ill defined plaques on the heels or other

parts of soles and palms often bilaterally symmetrical.


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3. Guttate psoriasis:

Adolescent and young males. Generally follows streptococcal phryngitis.

Crop of small oval or circular erythematous plaques with minimal scaling.

Trunk and proximal part of extremities affected.

4. Psoriasis of nails:

Common all nails may be affected, finger nails minored often.

Common presentation – pitting of nails plates, subungual hyperkerionatosis,

onycholysis dystrophy and yellowish or greenish discoloration. Associated

with psoriatic lesions elsewhere; occasionally isolated manifestation. Classic

psoriatic arthritis often associated with the nail involvement

5. Psoriasis of the scalp:

Common well marginated red scaly discrete or confluent plaques.

Palpable lesion when associated with seborrhoeic dermatitis labeled as

seborrhic psoriasis or cebhoriasis

6. Psoriatic arthropathic:

Uncommon associations both sexes affected females more often may

precede accompany or follow appearance of skin lesions. Nail involvement

frequent classic form – distal interphalengeal joints, often asymmetrically

muilance variety – joints of the hand and toes and sacro iliac joint. Destruction

of joint and bones associated postural psoriasis. Rheumatoid – like arthritis

uncommon sero negative.

7. Erythrodermic psoriasis:

May follow chronic or unstable psoriasis; may start de-novo. Irritant

tropical therapy or photo therapy may precipitate. Characteristically bright red

erythematic with extensive, moderate and severe scaly. Almost the entire


Modern Review

cutaneous surface involved. No island of normal skin associated nail and scalp

involvement. Thermo regulation poor; patient feel cold recovery- complete

clearing or reversion to plaque psoriasis; serious and occasionally fatal

outcome.

8. Postural psoriasis:

Localized or generalized:

Localized: - Generally palm planter with or often without associated

psoriasis elsewhere on the body; superficial pustules on an erythematous

background pustule sterile.

Generalized:

Rare serious could be fatal. Spontaneous evolution (particularly in

children) or precipitated by systemic infection, irritant applications or

withdrawl of cortico steroids. Affects previously diseased or unaffected skin.

Generalized or extensive superficial sterile postule. Confluence leads to takes

of pus paronychial involvement trouble sound severe constitutional symptoms-

fever, erthrgeal, leukocytosis, hypo- albimenemia, hypocalcaemia seen.

9. Rupioid psoriasis:

Uncommon cone shaped lesions with the heaped up dark gray scales

not as easily removable.

10. Flexural psoriasis:

Inverse distribution confined to the flexors- axillary, gluteal,

inflammatory or retro auricular folds scaly less pronounced due to moistness

candidal super infection may occur.


Modern Review

11. Genital psoriasis:

Male genitals more frequently affected. Well marginated erythematous

lesions, scaling minimal.

• Histology of psoriasis:

Parakeratosis and spartanly orthrokeratosis. Loss of granular cell layer.

Uniform, club shaped elongation of the rete ridges and supra papillary thinning of

the epidermis. Neutrophilic infiltrate in the epidermis and a sub corneal pustule

(munro’s microabsces ) Spongy form postulation ( kogoj’s pustule) in stratum

malpighii in postular psoriasis. Papillary blood vessels dilated, elongated and

torchues, Perivascular mononeuclear in filterated

Impetigo herpetiformis:

Rare perhaps a variant of postular psoriasis seen in late pregnancy. Postulation

on an erythematous back ground. Associated toxemia serious may be fatal. High fetal

and perinetal mortality. Recurs with the subsequent pregnancy.

The term psoriasis comes from the Greek word meaning to itch and was first

used by Galen, to describe a scaly itchy rash on the eyelids and genitalia, which was

probably not psoriasis as we know it today. But eczema, description of skin disorders

compatible with psoriasis is present in the old statement. Interestingly, it appears that

psoriasis was grouped with leprosy by the Greeks and subsequently, until the 19th

century. These grouping led to psoriasis being rejected by the community and there

are reports of their being burned at the stake in 14thcentury. It was not until the first

half of 19th century that psoriasis was described as a separate and definite clinical

entity.


Modern Review

Morphology of the Lesion:

The typical psoriatic lesion is a raised red scaly patch with a sharply

demarcated edge between clinically involved skin and the plaque. The size of this

lesions are varies from a few millimeters to several centimeters and are may be large

confluent areas of psoriasis the trunk or limbs on rare occasions this may be extend to

involved all the skin .

If the scale is thick the plaque has a grayish white colour. However to, if the

scale is not too thick the patch so psoriasis has a predominantly red colour. If the

plaque is excoriated with a wooden spatula (Grattage) The red patch develops a white

flaky surface as the scale in psoriasis is loosely bound. These are a useful sign in

distinguishing psoriasis from other dermatosis. Another useful sign is removed of all

the scale by more vigorous excoriation with the spatula, and then a red glistening

surface with capillary bleeding points appears. Occasionally when the scaling the

plaque is very thick deep fissures develop which can be painful.

Rare forms of psoriasis are the so called rupioid lesions. These are thicker than

common plaque psoriasis and have a conical shape. They have a yellowish brown

colour and are most frequently seen on the feet, the appearance is produced by the

thicker and more adherent scale, which becomes heaped.

Age of Onset:

Psoriasis may begin at any age. However it is rare before the age of 5yrs. The

average age of onset has been found to be in the 20”s in most large studies 10% of

patients have an onset before 10yrs, 35% before 20yrs and 58% before 30yrs of age.

However, average age of onset is not the same in the different clinical patterns of

psoriasis this may be due to different genetic and or environmental factors which

determines the clinical expression of the disease, and age of onset is one of them.


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Symptoms:

In the majority of the patients psoriasis gives rise to very few physical

symptoms. It is likely to lead to many more psycho social problems because of

appearance of the rash.

Itching:

A Small proposition of patients, approximately 5-10% will complain of

irritation. Only in a minority of these does the irritation become severe enough to

warrant specific anti itch therapy. If the itch is severe then active treatment to clear

psoriasis is the best approach.

Pain:

Psoriasis will cause pain if the skin splits and fissures develop. Fissures are

most commonly seen in flexural and intertriginous psoriasis, thick plaque psoriasis

over joints and in severe psoriasis on palms and soles

Scaling:

Patient often complains bitterly of the excessive scaling of the skin when there

is scale involvement this give rise to dandruff on the cloth. When there is extensive

involvement of the skin, patients produced a sure of scale when they take their cloths

off, and they will find it too embarrassing to go to hotels or stay with friends. Some

get over this problem by taking a small vacuum cleaner or dust pan and brush with

them

Loss of mobility:

Confluent psoriasis over joint may lead to lack of mobility as psoriasis is not

as piably as normal as normal skin. This may be severe problem when the hands are

involved


Modern Review

Skin patches:

- Dry and rough in touch.

- Usually round and covered with silvery scales.

- Raised patches of skin are hard in nature.

- Accompanied by red border

- In chronic condition patches are exudative and sticky in nature with

blackish discolouration.

Shivering:

This occurs in erythrodermic psoriasis patient a great deal of heat in this form

of the disease because of the increased blood flow through the skin.

Constitutional upset:

Fever and malaise occur with generalized postural psoriasis.

Psychosocial aspect:

In the majority of the patient the appearance of the rash is the only side effect

which effect the rash on the (patient) usually depends on the personality of the

individual many patients with severe disease appear to cope well, while other minimal

involvement find it difficult to accept the disability. Obviously the rash is visible i.e.

on the hand or face then this may lead to greater problems.

In the majority of patients in psoriasis there will be some withdrawl from

social contact. Apart from the appearance there is a still widely held belief by the non

sufferers that psoriasis is a contagious disorder and therefore sufferer should be

avoided. This in addition to the appearance of the rash lead to isolation. The age of

onset of psoriasis is important in degree of harm it may cause socially. The adolescent

will have more problems adjusting then the mature adult in a family situation.

Psoriasis is also been shown, not surprisingly, to have an effect on sexual behavior,


Modern Review

the effect being greater upon women the majority of patients will not include in

sporting activity, particularly swimming. For this reason will not take holydays in the

sun and sea.

Psoriasis may also lead to problem with employment if there is involvement of

the hands and the face occupations involving coming into contact with public will be

difficult in this situation. The two psychological disorders which are increased in

psoriasis are – depression and obsesstinal status.

These would appear to be direct result of the physical disability in the subject

which possible pre disposition to this status.

Natural history of prognosis:

Psoriasis runs a variable course, and it is not possible to predict if and when

spontaneous resolution may occur, if the disease will remain static, or whatever it will

become more extensive. However the various clinical patterns of psoriasis tend to

have difficult prognosis.

Plaque psoriasis, which begins in childhood and adolescence, then to have a

poorer prognosis that late onset disease and it, is more likely to be persistent. Other

poor prognostic signs are extents of disease and appearance of new lesions. When the

rash is very wide spread remission are less likely to in sue. If the patients find the

involvement is gradually increasing the remission is unlikely in the near future. In

long term follow up studies of patients with plaque psoriasis the incidence of

spontaneous remission has been found to be approximately 40%.

Guttate psoriasis usually has a good prognosis and 955 of patient the irruption

will disappear within 3-4 months of onset. Occasionally the guttate psoriasis may

convert into plaque disease and prognosis is that of the later which is unpredictable

and variable. Patients who have had one attacks of guttate psoriasis are likely to


Modern Review

develop further episodes if they have infections with the streptococcus or certain

viruses.

Guttate psoriasis may occur in individuals who have no previous lesions are

those who have plaque disease. In the later the guttate lesions clear after 3-4 months,

but plaque disease in variably persist.

The prognosis in erythrodermic psoriasis tends to be poor. Patients with this

form of the disease need active treatment often with symptomatic drugs. The natural

history of the disease modifies by treatment. The majority of patients often the active

phase may revert to extensive chronic plaque disease, which again usually requires

long term active systemic therapy. Erythrodermic phase are likely to reoccur, unless

there is an identifiable curse which can be prevented or patients are maintained on

indefinite systemic therapy.

Generalized postular psoriasis has a risk death the acute episode of postulation

may last many week but it is now modified with therapy ones the postular phase has

subsided the condition usually revet to the chronic plaque state. However further

bouts of acute postular psoriasis associated with acrodermatitis continue tend to have

a bad prognosis.

Localized postular psoriasis on the palms and soles tends to be very persistent

over a 10 yrs period only approximately 25% patients are likely to achieve a

diminution. The disease however is not commonly seen in the elderly, so presumably

spontaneous remission does occur but only after 20-30yrs.

Acrodermatitis continua (postular involvement around the nails and on the nail

bed) have a poor prognosis in the elderly. The condition is very persistent and not

responsive to treatment usually gradually progresses to wide spread plaque disease

with a tendency to generalized postular psoriasis.


Materials and Methods

MATERIAL AND METHODS

Study design:

The study of twak shareera with special reference to kitibha kustha has been

designed as follows

1) Literary study.

2) Clinical study.

3) Histopathalogical study.

1) Literary study: All the information regarding “Twacha” collected from

Brihattrayi, Laghutrayi and other classics of Ayurveda. Definition of Twacha its

etymology genesis and synonyms are complied form different texts. Compilation of

number names and Vyadhis occurring to the layers of Twacha is done and their

comparative study is done. Comparative study of thickness f Twacha told by Sushruta

and Dalhana is done.

Also relation of Twacha with other factors like Doshas, Dhatus, Malas,

Upadhatu, Srotasa, Varna, Prakruti, Sara and Gnyanendriya is studied.

In case of modern aspect of “Twacha” all the information regarding anatomy

of skin is complied from textbooks of anatomy. Study of embryology of skin. Its

layers, functions and glands is done.

Also study of kitibha Vyadhi form all the Samhitas is done. The causative

factors of Katibha, its symptoms dosha Pradhanya and classification is studies.

Compilation of information regarding psoriasis is done form the textbooks of

dermatology. This compilation includes study of causative factors, pathogenesis

symptoms. Clinical features and investigations.

Finally, the correlation of Kitibha and psoriasis is done on the basis of

symptoms and results of histopathological investigations.



2) Clinical Study:

This study is done at various skin clinics under the guidance of

Dermatologists. Already diagnosed 30 patients of psoriasis were examined for the

clinical study of the disease. The morphology of scales, nature of symptoms area of

predilection was studied.

The patients were convinced for the biopsy of skin to rule out whether the

stratum most alone gets affected in this disease. So only seven patients skin biopsy

has been in the study. Those biopsy reports have been enclosed in this thesis.

Photographs of patients are taken to show the morphology of scales. Also

scraping of scales is done and they are processed with KOH to rule out the auspitz

sign is seen.

3) Histopathological study:

The histopathological study can be done in two steps i.e. skin biopsy and skin

scrapping.

A) Skin biopsy:

There are different methods of skin biopsy like shave biopsy, scalpel biopsy,

punch biopsy and scissor biopsy etc. But we did skin biopsy by punch skin biopsy

method because it is most commonly used and get full thickness of skin sample in

small area. And even also need only one or two stitches needed to close the wound.

This is helpful for cosmetic purpose. In other types of biopsy we can not get full

thickness of skin and even need more stitches to close the wound.

Procedure: The skin in cleansed and local anaesthesia is administered. A

small cylindrical punch is screwed into the region through the full thickness of the

skin and plug of tissue is removed.

B) Skin Scrapping:

It is done by scraping the scales with sterile blade and they are collected in a

clear bulb and can be examined under the microscope.



Laboratory experiment:

It includes 2 methods

1) KOH mount (without heating)

2) KOH Preparation (with heating). This experiment is done by KOH

preparation.

First one drop of KOH (Potassium Hydroxide with calcoflour white) is placed

on a clear glass slide. Then collected specimen of scales is immersed in drop of KOH.

Cover slip is kept on the specimen. KOH mixture is heated by passing the slide

through a Bunsen burner flame several times. Preparation is examined under 10X and

40X. auspitz sign and whitish silvery scale appearance is observed.


Discussions

DISCUSSION

Twacha is the external covering of the body. It is also called “sparshanendriya

or twagndriya” which envelops the body. It plays a great role in perception of

sensations like touch, pain, heat, cold.

The organ genesis of twacha occur during paka of Shukra and Shonita by

Agni, seven types of Twacha gets formed on the surface of Garbha just like while

heating milk cream is formed on its surface. Twacha is a Matruja Bhava and it is

having predominance of Vayu mahabhoota and sparsha Vishishta guna.

There is some controversy regarding number of Twacha in various texts.

Acharya Sushruta tells seven types of Twacha while Charaka and Vagbhata tell six

types. Also regarding Vyadhis occurring in different layers there is variation in

opinion of Acahryas e.g. Sushruta tells Kitibha occur in fourth and fifth layer of

twacha while Charaka and Vagbhata tells it in fourth layer.

Thickness of Twacha told by Sushruta and Dalhana is having great difference.

Sushruta seems to be more accurate in telling thickness of Twacha which is more or

less same to the thickness quoted in modern textbooks of Anatomy.

Considering relation of Doshas with Twacha, Vata dosha especially Prana and

Udana have close relation with Twacha. Pranavayu is responsible for the perception

of touch sensation. Udanavayu produces Varna and if its gets vitiated then there will

be discolouration of the skin. If pitta dosha is considered. Bhrajaka Pitta is situated in

Twacha which maintains Teja of Twacha. It is responsible for absorption of drugs

externally in the form of massage, oils, paste etc. kapha dosha is having Snigdha

guna. If Snigdha guna decreases then Twacha will be dry and cracky in nature.

Considering relation of dhatus with Twacha. Rasa dhatu is present in Twacha

and it gives nourishment to it for its well being. Twacha is supplied by numerous


Discussions

Raktavahi dhamanis and Raktadhatu is present in these Dhamanis. Also there is

relation of Twacha with other Dhatus. Twacha is mainly related to Swedamala which

is excreted through innumerable openings on it.

Twacha reflects Varna of an individual. Twacha is one the gnyanendriyas

which is Vayaviya in nature. Its abode is Sparshanendriya which is responsible for the

touch sensation.

In all Indriyas, Sparshanendriya is an entity that occupies all other Indriyas

also. Mana is intimately related to Twacha as it’s is also all encompassing.

Skin is the outermost covering of the body. It is composed of sweat glands,

sebaceous glands, hairs, nails and numerous openings.

It is divided into two layers outer epidermis and inner dermis. Epidermis is

divided into 5 layers and populated by 4 types of cells. Dermis is also divided into 2

layers. Skin is supplied by sebaceous glands which keep the skin surface oily and

sweat glands which excrete waste materials of the body through sweat.

Skin is having protective functions helps in general sensation helps in

excretion of waste products of metabolism synthesize Vitamin – D maintains water

balance and stores fats, water and salts.

Kitibha is a type of Kushtha which occurs in ‘Tamra’ Twacha according to

Sushruta. It is having predominance of Vata and Kapha. It is characterized by scales

which are white silvery or coppery which give dustlike stain after rubbing and which

occurring all over the body .

Psoriasis is affects mainly stratum spinosum and basale. It is observed in any

age of the patient. It is characterized by white, coppery and yellowish patches on the

skin of all parts of the body eg. Knees, palms, soles, lumbo sacral region, genital,

scalp, elbow, hands etc these patches give dust like silvery scales after rubbing.


Discussions

Discussion on observation:

Age:

Out of 30 patients 15 patients are of the 30 – 40 age group and Vata and Kapha

prakruti persons this may be the cause for the psoriasis occur in this age group.

Diet:

It is observed that out of 30 patients 18 patients are mixed diet and consuming more

non-vegetarian food is one among the cause for formation of psoriasis or Kitibha

kustha

Prakruti:

Out of 30 patients 15 patients are assessed as Kaphaja Prakruti persons and these

persons are prone to suffer from psoriasis.

Site of Psoriasis:

It is observed out of 30 patients the psoriasis found 8 patients in hands, 8 patients in scalp,

6 patients in lumbo sacral region, 4 patients in elbow joints, 2 patients in knees and 2 patients in

genitals and hands are prone appear psoriasis.

Sex:

Out of 30 patients 18 patients are males and 12 patients are females, so it shows that

males are more affected than the females.

Varna:

Among 30 patients shweta varna is observed in 18 patients tamra varna

observed in 5 patients and the pita varna is observed 07 patients and 03 - 03

shweta-tamra and pita-shweta varna.

Psoriasis and Kitibha Kustha:

It is difficult to say what psoriasis is in terms of Ayurveda. There is no disease

in Ayurveda which can exactly be correlated with Psoriasis. Many research workers

have tried to attribute psoriasis with one or other type of Kushtha. All the workers


Discussions

included psoriasis under Kshudra Kushtha, but while on co-relation with specific type

they differed. Some correlated it with Kitibha and others with Sidhma or Eka

Kushtha. Here, Kitibha Kushtha sign and symptoms are correlated as psoriasis

because the description & characteristic features of it are co-inciding with description

of psoriasis than any other type of Kushtha. In Kitibha the lesions are Klinna, Khara

sparsha, Parusha, Kandu, Ruksha, Vrutta and Ghana. But is psoriasis the lesions are

dry, rough in touch, round, hard in nature, crack on rubbing, psoriasis the lesion are

distributed all over the body. Description & characteristic features of Kitibha

Kushtha very closely match the description of psoriasis.

Kitibha Kushtha –Psoriasis:

• Klinna - Sticky in nature

• Mahavastum - Lesions are found all over the body.

• Khara Sparsha – Rough in touch

• Parusha – Hard in nature(crack).

• Vruttam – Round in shape.

• Ghana – Solid

• Sravi and Shyava – In chronic condition psoriatic patches on the skin are

exudative in nature and blackish discolouration.

• Punha punha utpadaute – psoriasis goes away and can come back repeatedly

overtime.

The lakshanas of kitibha kustha mentioned by Charaka are described here in detail

in comparison with psoriasis.


Discussions

Mahavastum:

It means that lesions are found all over the body or coverer large area of the body.

Charaka says that the Sapta Dravya lesions are produced where the Doshas settle191.

It indicates that the uninvolved skin is also abnormal. It has been postulated &

supported by some experimental evidence that the uninvolved normal appearing skin

of psoriatic subjects is abnormal. Using the nude mice model to study psoriatic skin

removed form a psoriatic host, it was found that clinically involved psoriatic

epidermis maintained its high level of plasminogen activator activity & increased

labeling index when grafted on nude mice (Fraki et al, 1983). Moreover epidermis

from clinically uninvolved normal appearing psoriatic skin develops a significant

increase in plasminogen activator activity to the level of involved epidermis after

grafting & this is accompanied by a high thymidine-labeling index. Normal control

skin maintains it slow level of plasminogen activator & normal labeling index after

grafting to the nude mice. The data suggest that skin from psoriatic patients can

manifest marker of psoriasis, independent of psoriasis Thus the Clinical features of

psoriasis and Kitibha Kushta are almost similar. Mainly the plaque psoriasis can be

readily correlated to that of Kitibha Kushtha.


summary

SUMMARY

01. It is conceptual observation study entitled study of twak shareer w.s.r. kitibha

kustha.

02. Kitibha kustha is a disease is mentioned as the one of the Asthamagadha and

this disease is very well correlated to skin disease (psoriasis).

03. In this study it was observed that the Kitibha kustha is mainly seen in between

age group of 30 to 40 years (50%) and it is more common in males (60%) and

may be because of more intake of mixed diet has also shown its role in the

causation of the disease.

04. Regarding kustha bedha out of 30 cases 15 patients are pertaining to kaphaja

kustha and 05 patients are vataja and 04 patients are pittaja, 03 patients are

vata kaphaja and 03 patients are pitta kaphaja.

05. About the site of psoriasis out of 30 patients 08 patients in hand, 08 patients in

scalp and remaining patients psoriasis found in lumbo sacral and genitals.

06. Out of 30 patients silvery scales found in almost all the cases.

07. Vedana, daha is found in limited patients.

08. On the basis of sign and symptoms and histo-pathalogical findings kitibha

kustha can be correlated to psoriasis.

09. The thickness of the skin as told by Acharya Sushruta in our classics is almost

similar to explanation of the modern authors.

10. Further, study is needed with large sample in multi-centres then only the clear

conclusion can be drawn.


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47. §ÉrÉÉå UÉåaÉqÉÉaÉÉï CÌiÉ – zÉÉZÉÉ, qÉqÉÉïÎxjÉxÉlkÉrÉÈ

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Bibliography

BIBLIOGRAPHY

1) Prof. Srikanth murthy K.R. sushrut samhita (sharer 4/4) chaukambha,

Varanasi,U.P. vol-1,2nd edition 2004,pp 289 on 50 pg.

2) Prof. Srikanth murthy K.R. sushrut samhita (sharer 4/4) chaukambha,

Varanasi,U.P. vol-1,2nd edition 2004,pp 289 on 51 pg.

3) Prof. Srikanth murthy , Astanga Samgraha of Vagbhata ,(sharer 5/16)

chaukhamba orientalia 5th edition U.P. vol-II, 2nd edition 2005.pp 622 on 62

pg.

4) Sharma P.V.Agnivesa charak samhita (nidan 5/14)) redacted by charaka and

Dridabala,chaukamba surabharati prakashan, Varanasi,U.P, vol-1,4th edition

2003, pp 544 on 277pg.

5) Prof.Srikanth murthy K.R. Madhav nidanas (rog viniscaya)of madhavkar

(chi.49/18) chaukambha orientalia,varanasi ,U.P. ,5th edition , 2003.,,pp 329

on 161 pg.

6) Clinical Anatomy – Richard S.Snell 7th edition 2003.pp 1012, pg 5 to 7

7) Principal of anatomy and physiology by Tortora Grabowski 10th edition

2003.pp 1104 pg 140.

8) A.P.I. Text book of medicine by G.S. SAINANI.1999 .pp 1367 pg 1198.

9) Ashtanga Hridaya: Commentary by Arundatta (Sarvangasundari) and

Hemadri (Ayurveda Rasayana), Chaukhamba Orientalia, Varanasi, 1982.

10) Ashtanga Sangraha: By Vagbhata with commentary of Indu, Atreya

Prakashna, Pune, 1980.

11) A Sanskrit – English Dictionary: By Monier and Williams, First edition,

1993.


Bibliography

12) Bhavaprakasha Samhita: Acharya Ramanath Dwivedi, chaukhamba

Publication, 1st Edition.

13) Charaka Samhita: Poorvardha & Uttarardha, Chaukhamba Bharti Academy.

14) Charaka Samhita Ayurveda Dipika Tika: By Chakrapanidatta, Nirnaysagar

Press, Bombay.

15) Parishadya Shabdarth Sharir: By Ayurvedacharya P. Damodar Sharma

Gaud.

16) Sushruta Samhita: Kaviraj Ambikadatta Shastri, A.M.Ss. Chaukhamba

Sanskrit Sansthan.

17) Sushruta Samhita: Ayurveda Rahasya Deepika Commentary by Dr. B.G.

Ghanekar, 13th edition, 1998, publication Meherehand Laxmandas, New

Delhi.

18) Suhruta Samhita: Dalhana Nibandha Sangraha Commentary, published by

krishnadas Academy.

19) Sharangdhara samhitha: Acharya Yadavji Trikamji, Chaukhamba

Publication.

20) Shabdakalpadrooma: Raja Radhakant dev, Naga Prakashana, Delhi.

1) A Textbook of Dermatology: Moschella and Hurley, 2nd edition part (1) and

(2).

2) Clinical oriented Anatomy: By Richard L. Drake, Wayne Vogal, Adam

W.M. Michell, Published by Churchill Livingstone, Edinburgh, London, 1st

Edition 2005.

3) Gray’s Anatomy: By Henry Gray edited by Peter Williams and others.

Published by Churchill Livingstone Edinburgh, London, 37th edition.


Bibliography

4) Histopathology of skin: Water F. Leaver.

5) Human Embryology : BY I.B. Singh published by Rajiv Beri, for

Macmillan India Limited, New Delhi 7th Edition 2003.

6) Illustrated Synopsis of Dermatology and STD: by Neena Khanna,

PEEPEE Publications, 1st edition.

7) Medical laboratory Technique : Ramnik Sood, Jaypee Publicaitons.

8) Principles of Anatomy and Physiology :By G.J. Tortora and S.R.

Grabowski, published by Harper Collins College publishers, New Yord, 8th

edition, 1996.

9) Practice of Dermatology : P.N. Bhel, 7th edition CBS publications.


Conclusion

CONCLUSION

From the observations based on literary and histopathological study and

discussion the following conclusions can be drawn.

1) According to Acharya Sushruta there are seven types of Twacha and out of

these seven Twacha. Kitibha occurs in fourth and fifth layer of Twacha i.e.

Tamra and Vedini.

2) Sushruta seems to be more accurate in telling thickness of Twacha. His

measurement of thickness of all the layers of Twacha expressed in modern

units is very much similar to the thickness of skin given in modern textbooks

of Anatomy.

3) Kitibha vyadhi a type of Kushtha and psoriasis a type of skin disease have

most of the same symptoms which are correlated on the basis of literary,

histopathalogical and clinical study of both Ayurveda and modern science.

4) Kitibha is mostly correlated with the plaque type of psoriasis.

5) The present study is carried out on 30 patients so which is a small sample. The

patients selected were having different types of psoriasis/kusthas. Here

suggestion is given for the further study to conduct on large number of

patients concentrating on particular types of psoriasis in multi-centres, after

which as clear conclusion can be drawn.


Observations

OBSERVATIONS

1) There is some controversy regarding number of Twacha. Some Acharyas have

told six types of Twacha while some have told seven types.

2) Acharya Charaka and Acharya Sushruta both have told different Vyadhis in

layers of Twacha. e.g. Sushruta told Kitibha in fourth layer.

3) Measurement of thickness of Twacha told by Sushruta is near about same

which is quoted in modern textbooks. The measurement of Dalhana doesn’t

matches with the modern measurement.

4) The symptoms of Kitibha and psoriasis show tremendous similarity with each

other.

Table No. 6. Showing the Clinical features of Psoriasis and Kitibha kustha

No. Title Kitibha Psoriasis

1. Location

cÉiÉÑjÉï iÉqÉë lÉÉqÉ ÌuÉÌuÉkÉ ÌMüsÉÉxÉ MÑü¸ÉÍkÉ¸ÉlÉÉ | xÉÑ.zÉÉ. 4/3 mÉÇcÉqÉÏ ÌuÉïÌSÌlÉ lÉÉqÉ MÑü¸ÌuÉxÉmÉïÅÍkÉ¸ÉlÉÉ |

Stratum Spinosum & basale of epidermis. And papillary layer of dermis.

2. Colour iÉÉÇqÉë LuÉÇ µÉåiÉ uÉhÉï Coppery and silvery colour

3. Symptoms ZÉU, UÉåqÉWûwÉï MühQÒû AxuÉåS AjÉuÉÉ AsmÉxuÉåS

Rough, horripilation, itching, no or mild sweating

4. Scales rÉSìeÉÉ bÉ×¹Ç ÌuÉqÉÑŠÌiÉ After scratching the patches dust like silvery scales can be obtained

5. Areas Predilection qÉWÉûuÉixÉÇ

Both Palms and Soles, hands scalps and lumbo sacral region, nails and genitalia.

5) After histopathological study the aupitz sign and whitish silvery scales appearance

is seen under microscope. After report of skin biopsy, Stratum spinosum and stratum


Observations

basale layer of epidermis are affected in most of the patients and papillary layer of

dermis is affected in very few patients.


Observations


Observations

Thirty patients were selected randomly for the thesis work. All the selected

patients were thoroughly examined and diagnosed and selected based on exclusive

and inclusive criteria. The assignment revealed the following statistics. As these

tables and graphs are self-explanatory no further descriptions are given.

Tabular Representation:

A) Varna of “Kitibha”

Table No. 7. Showing the Varna of the Kitibha Kustha

Lakshana No. of Patients Percentage Shweta 18 60% Tamra 05 17% Pita 07 23% Shweta Tamra 03 10% Tamra Pita 00 0% Pita Shweta 03 10%

0

10

20

30

40

50

60

Per%

No. of Patients Percentage

Varna

Varna of Kitibha

ShwetaTamraPitaShweta TamraTamra PitaPita Shweta


Observations

B) Other Lakshanas:

Table No. 8. Showing the Lakshanas of the Kitibha Kustha

Lakshana No. of Patients Percentage Kandu 5 17% Raja (Scales) 5 17% Vedana 2 7% Daha 1 3% Kandu Raja 9 30% Kandu Vedana 3 10% Raja Daha 5 17%

0

5

10

15

20

25

30

Per%


Laxana

Other Laxana of Patients

KanduRaja (Scales)VedanaDahaKandu RajaKandu VedanaRaja Daha


Observations

C) Areas of Predilection:

Table No. 9. Showing the areas of the Kitibha Kustha

Lakshana No. of Patients Percentage

Knees 2 7%

Elbow 4 13%

Hand 8 27%

Scalp 8 27%

Lumbo Sacral Region 6 20%

Genetalia 2 7%

0

5

10

15

20

25

30

Per%


Predilection

Areas of Predilection:

KneesElbowHandScalpLumbo Sacral RegionGenetalia


Observations

D) Sex-wise Distribution:

Table No. 10. Showing the sex of the Kitibha kustha patients

Lakshana No. of Patients Percentage

Male 18 60%

Female 12 40%

MaleFemale

0

10

20

30

40

50

60

Per%

Sex

Sex-Wise Distribution

No. of PatientsPercentage


Observations

E) Age-wise Distribution:

Table No. 11. Showing the age of the Kitibha kustha patients

Age Patients Per%

20-30 5 17%

30-40 15 50%

40-50 6 20%

50-60 4 13%

0

10

20

30

40

50

Per%

Patients Per%

Age of Patients

Age-wise Distribution

20-3030-4040-5050-60


Observations

F) Prakruti – Wise Distribution:

Table No. 12. Showing Prakruti of the Kitibha Patients

Prakruti Patients Per%

Vataja 5 17%

Pittaja 4 13%

Kaphaja 15 50%

Vata – Pittaja 0 0%

Pitta-Kaphaja 3 10%

Vata-Kaphaja 3 10%

05

101520253035404550

Per%

Patients Per%

Prakruti of Patients

Prakruti - Wise Distribution

VatajaPittajaKaphajaVata – PittajaPitta-KaphajaVata-Kaphaja


Observations

G) Diet – Wise Distribution:

Table No. 13. Showing Diet of the Kitibha Patients

Diet Patients Per%

Vegetarian 10 33%

Non – Vegetarian 2 7%

Mixed 18 60%

0

10

20

30

40

50

60

Per%

Patients Per%

Diet of Patients

Diet-Wise Distribution

VegetarianNon – VegetarianMixed


Case Sheet

DEPARTMENT OF P.G. STUDIES IN RACHANA SHAREER

N.K.J AYURVEDIC MEDICALCOLLEGE & PG CENTRE, BIDAR. RESEARCH CASE SHEET TITLE: STUDY OF TWAK SHAREER W.S.R. TO KITIBHA KUSTHA. Research scholar: Dr.Sapana Hiremath Co-guide:Dr.N.J. Mulimani. Guide: Dr.J.K.Bhargava. PRILIMINARY DATA: Name: Age : Sex : Religion: Occupation: Address: D.O.A.: D.O.D.: OPD/Ward/Bed: Diagnosis: Result : HISTORICAL DATA: PRADHAN VEDANA (Chief complaint): VEDANA VRITTANT (H/O Present illness): POORVA VYADHI VRITTANT (Past history): VIYAKTIKA VRITTANT (Personal history): KOUTUMBIKA VRITTANT (Family history):

I

Case Sheet SYSTEMIC EXAMINATION

1) Respiratory system: 2) C.V.S. :

B.P. 3) Abdomen: 4) C.N.S.: 5) Urinary system:

GENERAL EXAMINATION A)ASHTAVIDHA PAREEKSHA Nadi: Shabda: Mala: Sparsha: Mutra: Druk; Jiwha: Aakruti: B)DASHAVIDHA PAREEKSHA Prakritaha: Sarataha : Samharana: Satwataha : Aharshakti: Vyayamshakti: Vayaha : Pramana : Vikrititaha pariksha: Hetu (causative factor) Poorva roopa (premonitory factor) Roopa (symptoms) C)LOCAL EXAMINATION Inspection: Palpation : Percussion : Auscultation:

II

Case Sheet SAMPRAPTI

A) Udbhava sthana: B) Dosha : C) Agni : D) Sanchara : E) Adhishtana(dhatus involved) Rasa: Mamsa: Rakta: Ambu(lasika): F)Vyaktasthana INVESTIGATION Skin Biopsy Blood: TLC,DLC,ESR,Hb%,FBS,PPBS,CT,BT. Urine: Routine Microscopic Vyavacheda nidana(Differential Diagnosis): Vyadhi vinischay(Diagnosis): RESULT: Signature of the PG scholar Signature of co-guide Signature of guide

III

Sl.No.

OPD No. Date Name of

Patient Age Sex Address Prakruti DietVarna

Sweta Tamra

1 17770 11/19/2008 Eqbal 43 M Chidri K V + -2 18599 11/26/2008 Rajni Kanth 30 M Bidar K RM + -3 19855 12/10/2008 Dhanraj 44 M Bidar P V - -4 20473 12/17/2008 Sharnappa 66 M Janwada K V + -5 20558 12/18/2008 Diwakar 30 M Bidar V RM - +6 20717 12/20/2008 Aruna 44 F Aurad K V + -7 21990 12/24/2008 Ramadevi 35 F Mailoor K RM + -8 21345 12/29/2008 Roopa 21 F Zaheerabad PK V + -9 21487 12/31/2008 Lokanna 56 M Hallhalli K RM + -10 21010 1/1/2009 Sadanand 44 M Santhpur P IRM - -11 21855 1/3/2009 Kallappa 33 M Nagur K RM + -12 22660 1/12/2009 Shymrao 50 M Bidar V V - +13 2991 1/21/2009 Prashanth 44 M Bidar VK IRM + +14 2633 1/28/2009 Indira 15 F Bidar K RM + -15 2579 1/30/2009 Asha 30 F Bidar V V - +16 4041 2/12/2009 Mallu 36 M Amlapur K IR + -17 2701 2/18/2009 Sultana 36 F Aurad VK IRM + +18 4873 2/19/2009 Pankaja 33 F Bhalki P RM - -19 7363 3/12/2009 Sidhanna 35 F Bhalki K V + -20 7526 3/13/2009 Sangamma 42 F Markhal PK IRM + -21 8258 3/19/2009 Usha 25 F Bidar K IR + -22 9328 3/31/2009 Yamuna 39 F Amlapur V V - +23 22538 7/13/2009 Chinnamma 38 F Naubad PK RM + -

24 22700 7/14/2009 Dinesh 27 M Chitta VK IR + +25 23176 7/17/2009 Nagnath 36 M Bidar K V + -26 23571 7/27/2009 Ramlu 36 M Bhalki V IR - +27 23718 7/21/2009 Vimal 35 M Markhal K IR + -28 24005 8/23/2009 Kiran 36 M Chitta P RM - -29 24108 8/25/2009 K.L. Udpaudi 30 M Mirjapur K IR + -30 24130 8/24/2009 Vikas 22 M Chidri K RM + -

Raja (Scales) Kandu Vedana Dahu

Area of Predilection

Peeta Knees Soles Elbow Hand Palm Scalp Lumbo Sacral Gendalia

- + + - - - - - + - - - -- + + - - - - - + - - - -+ + - - + - - - + - - - -- + + - - + - - - - - -- + - + - - - - + - - - -- + + - - - - + - - - -- - + - - - - - - + - -+ + + - + + - - - - - +- - + - - - - - + - - - -+ + - - + - - - - + - -- - + - - - - - + - - - -- + - + - - - + - - - -- + + + - - - - - + - -- - + - - - - - + - - - -- + - + - - - - - - + -- + + - - - - - - - + -- + + + - - - - - + - -+ - - - + - - + - - - -- - + - - - - - - - + -+ + + - + - - - + - - - -- + + - - - - - - + - -- - - + - - - - + - - - -+ + + - + - - - - + - -

- - + + - - - - - - + -- + + - - - - - - - - +- - - + - - - - - + - -- + + - - - - - - - + -+ + - - + - - - - + - -- + + - - - - + - - - -- + + - - - - - - - + -

study of twak shareer wsr to kitibha kustha

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