Twak sr

“A Study of Twak Shareera w.s.r to Vicharchika” By

Dr. Geeta Dolli.

A dissertation submitted to the

RRR aaa jjj iii vvv GGG aaa nnn ddd hhh iii UUU nnn iii vvv eee rrr sss iii ttt yyy ooo fff HHH eee aaa lll ttt hhh SSS ccc iii eee nnn ccc eee sss ,,, KKK aaa rrr nnn aaa ttt aaa kkk aaa ,,, BBB aaa nnn ggg aaa lll ooo rrr eee .

In partial fulfillment of the requirements for the degree of

AYURVEDA VACHASPATHI - M.D (AYURVEDA)

In

RACHANA SHAREERA

Co-Guide Guide Dr.Ashwinikumar Dr. N.G. Mulimani

MD (S.R.) MD (S.R.)

Post Graduate Department Of Rachana Shareera

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

2010.

RRR aaa jjj iii vvv GGG aaa nnn ddd hhh iii UUU nnn iii vvv eee rrr sss iii ttt yyy ooo fff HHH eee aaa lll ttt hhh SSS ccc iii eee nnn ccc eee sss ,,, KKK aaa rrr nnn aaa ttt aaa kkk aaa ,,, BBB aaa nnn ggg aaa lll ooo rrr eee .

Declaration by the candidate

I, here by declare that this dissertation/ thesis entitled “A

Study of Twak Shareera w.s.r to Vicharchika” Is a bonafide and

genuine research work carried out by me under the guidance of

Dr. N.G.Mulimani Professor & H.O.D. Department of Rachana

Shareera.

Date:

Place: Bidar

Signature of the candidate Dr. Geeta Dolli

RRR aaa jjj iii vvv GGG aaa nnn ddd hhh iii U UU nnn iii vvv eee rrr sss iii ttt yyy ooo fff HHH eee aaa lll ttt hhh SSS ccc iii eee nnn ccc eee sss ,,,

KKK aaa rrr nnn aaa ttt aaa kkk aaa ,,, BBB aaa nnn ggg aaa lll ooo rrr eee .

Copyright

Declaration by the candidate

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

Signature of the candidate Dr. Geeta Dolli.

RRR aaa jjj iii vvv GGG aaa nnn ddd hhh iii U UU nnn iii vvv eee rrr sss iii ttt yyy ooo fff HHH eee aaa lll ttt hhh SSS ccc iii eee nnn ccc eee sss ,,,

KKK aaa rrr nnn aaa ttt aaa kkk aaa ,,, BBB aaa nnn ggg aaa lll ooo rrr eee .

CERTIFICATE BY THE GUIDE

This is to certify that the dissertation entitled “A Study of

Twak Shareera w.s.r to Vicharchika” is a bonafide research work

done by Dr. Geeta Dolli, 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.N.G.Mulimani

MD(SR) Professor & H.O.D.,

Department of Rachana Shareera NKJ Ayurvedic Medical College & P G Centre

Bidar – 585403 Karnataka.

Signature of the Co-Guide Dr.Ashwinikumar

MD(SR) Asst.Professor

Department of Rachana Shareera NKJ Ayurvedic Medical College & P G Centre

Bidar – 585403

EEENNNDDDOOORRRSSSEEEMMMEEENNNTTT BBBYYY TTTHHHEEE HHHOOODDD,,, PPPRRRIIINNNCCCIIIPPPAAALLL///

HHHEEEAAADDD OOOFFF TTTHHHEEE IIINNNSSSTTTIIITTTUUUTTTIIIOOONNN

This is to certify that the dissertation entitled “A Study of

Twak Shareera w.s.r to Vicharchika” is a bonafide research work

done by Dr. Geeta Dolli under the guidance of Dr.

N.G.Mulimani Prof. & H.O.D. department of Rachana

Shareera.

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

Seal and signature of H.O.D. Dr .N.G.Mulimani. MD(SR) 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 Acharyalu. M.D. (Basic principles)

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

ACKNOWLEDGEMENT

I offer my salutations to Shirdi Saibaba for giving me strength to overcome all

the difficulties during this Thesis work and achievements in my life.

It is beyond the words to express my gratitude towards my esteemed perents

Smt.Sharanamma & Sri.Bheemrao.Dolli. For their patience cooperation. On this

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

Mailare, and my kids Premsai & Preetam.

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

untiring encouragement during this work.

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

guide Dr. N.G.Mulimani and co-guide Dr. Ashwinikumar waghmare for their

unforgettable parental affection and patience cooperation to give suggestions at every

step in accomplishing the present work.

It is a privilege for me to express my sense of gratitude 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.Shelly Divyadarshan, Dr.Sanjeev kumar Joteppa,

Dr.Anup Bosgikar for their valuable suggestions.

I converse my genuine thanks to Dr.Sapna, Dr.Brahmanand.Swamy and

Dr.Somnath.Patil for their valuable guidance & honest shore up.

It is a privilege for me to express my thanks to all my classmates

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

I feel great pleasure to thanks to my friends Dr.Jyoti.Hullale

Dr.Jyoti.Rajole.Dr.Geeta.Kumar. For their support.

My most respect to my perental in-laws Smt.Tejamma &

Sri.Sharanappa.Mailare. & my thanks to my brother Mr Amarnath Dolli,

Mrs.Vijaylakshmi & sister Mrs.Sangeeta, brother in low Mr.Gurunath Mudhale for

their encouragement.

My deepest gratitude to all my seniors and juniors for their support.

I sincerely thank all those who have directly or indirectly contributed to the successful

completion of this thesis work.

Dr.Geeta.Dolli.

List of Tables

1. Showing names of Twacha in different Samhitas 13

2. Showing layer wise distribution of skin diseases 14

3. Showing the comparison of thickness of Twacha according to Sushruta and Dalhana 15

4. Showing twach and Panchabhuta relation 16

5. Showing the Sign and symptoms of Vicharchika 31

6. Showing the Clinical features of Eczema and Vicharchika 72

7 . Showing the Varna of the Vicharchika 76

8. Showing the Lakshanas of the Vicharchika 77

9. Showing the sex of the Vicharchika patients

78

10. Showing the age of the Vicharchika patients 79

1 1 . Showing the prakruti of the Vicharchika patients 80

12. Showing diet of the Vicharchika Patients 81

13. Showing occupation of the Vicharchika Patients 82

13. Showing Areas of the Vicharchika patients. 83

List of Graphs

1. Showing the Varna of the Vicharchika 76

2. Showing the Lakshanas of the Vicharchika 77

3. Showing the sex of the Vicharchika 78

4. Showing the age of the Vicharchika patients 79

5. Showing the prakruti of the Vicharchika patients 80

6. Showing diet of the Vicharchika Patients 81

7 . Showing Occupation of the Vicharchika patients 82

8. Showing Areas of the Vicharchika Patients 83

List of figures

1. Showing Anatomy of the skin

2. Showing Melanocyte and Melanin

3. Showing Langerhans cells

4 . Showing Layers of Epidermis

5 . Showing Irritant Eczema

6 . Showing Atopic Infantal Eczema

7 . Showing Seborrheic eczema of scalp

8 . Showing Dishydrotic Eczema

9 . Showing Nummular Eczema

10 . Showing Allergic Eczema

1 1 . Showing Histology of Eczema

Contents

1. INTRODUCTION 1 – 3

2. OBJECTIVES 4

3. REVIEW OF LITERATURE 5-68

A) AYURVEDIC REVIEW 5-32

a) Historical Review of Twak 5-7

b) Twak Shareer 8-23

c) Disease Ayurvedic Review of Vicharchika 24-32

B) MODERN REVIEW 33-68

a) Anatomy of skin 33-56

c) Disease Eczema review 57-68

4. METHODOLOGY 69-71

5. OBSERVATIONS & RESULTS 72-83

6. DISCUSSION 84-95

7. CONCLUSION 96-97

8. SUMMARY 98-99

9. REFERENCES 100-107

10. BIBLIOGRAPHY 108-1 17

1 1 . ANNEXURE I – IV

I] MASTER CHART I

I I] MODEL CASE SHEET PROFORMA I I – IV

Abbreviation

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. Vi. - Vimanasthana

11. Sha - Shareera

12. Ni - Nidanasthana

13. Chi. - Chikitsasthana

14. Ut. - Uttarasthana

15. B.P.ma.kh - Bhavaprakasha.Madhyama khanda

16. Ka.chi. - Kashyapa chikitsa.

“A Study of twak Shareera w.s.r to Vicharchika”

ABSTRACT

Ayurveda is an ancient medical science which has given importance to the

Pancha Gnyanendriyas among them Twagindriya or Spershanendriya is important

one. The Sparshanendriya is the Sense organ which is meant for the sense of touch. It

covers and protects the surface of the body from the heat, cold and external infections

etc.

Most of the diseases which are exclusively exhibited on the skin are termed as

‘kustha’ in Ayurveda. Kustha is one among the astha-mahagadas because there is a

change in the structural appearance of the skin. Two types of kusthas has been

envisaged in ayurvedic classics i.e. Mahakustha and Kshudra kustha.Among 18

kusthas 7 are mahakusthas and 11 are kshudra kusthas.Vicharchika is a type of

kshudra kustha.

According to Acharyas symptoms of Vicharchika like-.sakandu, pidika,

shyava, bahusrava, raji, arti, and ruksha.and are found in tamra and vedini layers of

twak.

Objective of this study were complete literary review on twak shareera with

modern, And Vicharchika with Eczema. To know the structural changes in

vicharchika is based on clinical and histopathological studies. Finally, the correlation

of vicharchika and eczema is done on the basis of symptoms and results of

histopathological investigations.

Literary study will be undertaken from different Samhitas,Modern

science,Journals and websites.Diagnosed patients of Vcharchika are clinically

examined for signs and symptoms.Structural abnormalities are observed in

histopathological study.

So, after the histopathological study changes are found in the epidermal and

dermal layers.The symptoms of Vicharchika and Eczema show tremendous similarity

with each other.

Key words: Twak shareera, Kustha, Vicharchika, Twacha varna, Erythema, Eczema,

Acanthosis, Lichenification,Parakeratosis,Hyperkeratosis.

Introduction

“A Study of Twak Shareera w.s.r to Vicharchika” 1

INTRODUCTION

Ayurveda is one of the most reliable medical sciences. The principles of other

science have changed from time to time, but the basic principles of ayurveda have not

changed. Beyond this acharyaSusruta is specially honored for his outstanding study in

shareera i.e. Anatomy.

Acharya Susruta states that the aim of describing “shareera sthanam” is to acquire a

complete knowledge of the shareera . This is necessary for vaidya. For the vaidya, the

reasons are clearly stated in the ayurvedic literature (Su.Su 3/16).

If the vaidya wants to be an expert in ayurveda he should learn the shareera

thoroughly all his doubts he should perform the practical i.e. treat the patients.

Acharya charaka stated that the vaidya who has good knowledge of sharira i.e

anatomy can only understand the people are human best (Cha.sha.6/9).

Above words of acharya charaka clearly mentions the importance of study of

shareera. It mentioned earlier susruta samhita has its special importance. Susruta makes

the knowledge of Ayurveda more practicle & useful. His great contribution to ayurvedic

sharira includes description & classification of various body structures like sira,

Dhamani,Snayu , Asthi,Twacha etc.

Twak shareera is very elaborately explained in our classics.We can find description

regarding layers of skin in Brihatrayi and Laghutrayi. Acharya Sushruta has mentioned in

the shareera sthana about the formation of twak at the level of embryogenesis and has

given the simily to the formation of cream on the milk. He has also described the

thickness of each layer & several diseases which manifest in different layers of the twak.

Introduction


Human skin is a biological marvel. It is the protective covering of the body. It’s

soft, pliable, strong, waterproof and self repairing. It is like a large container, without it

all our delicate insides would spill right out.

Structurally integumentary system is most complex structure & highly specialized,

hence it is grouped in the sense organ.This is most extensive organ system has the

accessory structures, including hair, nails, glands, and specialized nerve receptors for

stimuli such as touch, cold, heat, pain, and pressure

Its functions include protection of internal structures, prevention of entry of

disease-causing microorganisms, temperature regulation, excretion through perspiration,

pigmentary protection against ultraviolet sunrays, and production of vitamin D. The body

stores about half of its fat in the underlying hypodermis.

Kustha vyadhi is a major disease affecting the community. In Bruhatrayi’s, Kustha

is mentioned as Astha mahagadas. Kustha is socially as well as structurally gives

demarcation in the body.

Vicharchika is very old disease mentioned in ancient science among the kustha, and

is catagorised in different ways i.e.kshudra kustha, ksudra roga & sadhya kustha. All

kustha are having tridoshaja origin so, vicharchika can be said in same way i.e. kapha is

responsible for kandu, pitta is responsible for srava & shyava indicates the presence of

vata. Despite of its tridosha origin various acharyas mentioned different dominancy in

vicharchika. It also suggests specific symptoms complexes.

As per symptomatology & pathogenesis, vicharchika have been directly correlated

with eczema in modern science, i.e.sakandu (excessive itching), pidika

Introduction


(pappules,vesicles,pustules), shyava (erythema with discoloration), bahusrava (profuse

discharge,oozing), raji (thickening,lichenification of skin), arti (pain) ,ruksha (dry lesion).

SELECTION OF TOPIC:

Now a days, modern science reached top of the hill by great advance particularly in

dermatology as topic is concerned & also availability of powerful antibiotics, antifungals,

antihistaminics, steroids ect, but better management could not be searched out till today.

Few drugs are available for symptomatic relief only there indiscriminate is most

undesirable.

Skin diseases like eczema get a suitable atmosphere specially in developing

countries, because of fast life style, industrial & occupational hazards, repeated use of

chemical additives ect. Disease of skin makes much more handicap in society because

with an ugly skin presence no one wants to touch them & forbidden by everyone &

beauty & personality loss, which leads to under stress.

There is a popular adage that “skin patients are never cured & never die" & hardly

even constitute an emergency. The patients with skin disease is unemployable i.e. any job

in which he or she is in the public eye or involved in food preparation (catering). 60%

has a significant skin condition including psyche involvement.

So now adays vicharchika disease is largely spread in the human beings. While

diagnosing the patients of vicharchika there is difficulty regarding the identification of

structural deformity, hence need is felt to study the vicharchika & twak shareera in

particular.

Aims and Objectives

AIMS AND OBJECTIVES

1) To make comprehensive study on Twak Shareera with modern (Skin).

2) To give appropriate and elaborate description on vicharchika.

3) To study structural changes in Twacha in vicharchika with modern

correlation.

“A Study of Twak Shareera w.s .r to Vicharchika” 4

Ayurvedic Review

HISTORICAL REVIEW

History informs us about the past time; it helps to reveal hidden ideas of the

related subject. The word Twak as well as its abnormalities due to disease.

Vedic period:

Rigveda: 63

In the rigveda mentioned that runs the chariot of the body with soul and

mentioned as one among the seven organs.

Atharvaveda: 64

While describing indriyas, we find reference regarding twak in different diseases

like kushta, Halima, kilasa etc.

Post vedic period

This period has various medical and non medical literatures in the form of

samhita, brahmana, purana and unpunished etc.

In the agnipurana described that in the 5th month of embryonic life there will be

formation of

skin and blood65.

Samhita kala:

Ayurveda was well developed at the time of samhita kala, it was known as golden

era of ayurveda. This kala gives a great knowledge about twak shareera and its related

diseases.

“A Study of Twak Shareea w.s.r to Vicharchika”

5

Ayurvedic Review

Charaka samhita:

In the 7th chapter of shareera sthana acharya charaka has explained about the

layers of the skin and the diseases which occur in each layers9.

Sushruta samhita:

Susrutachrya has explained about skin very minutely, he has described

embryological development of skin and its layers .He has described the pramana &

characters of each layer of twak8.

Astanga sangraha:

Vrudha Vagbhata has compiled the description of susruta and charaka about

formation of skin and layers of the skin in shareera sthana 5th chapter. Also we get

references about formation of skin in the same chapter17.

Astanga hrudaya:

Acharya vagbhata in astanga hrudya he mentioned the embryological

development of twak in 3rd chapter4.

Kaashyapa samhita:

References regarding twak are available in shareera, sankulya shareera adhyaya

.while explaining the sara purushas he explained that twak sarapurusha will be free

from skin disease 66


6

Ayurvedic Review

Sharangadhara samhita

He has followed susrutas view sharangadhra given detailed description about

seven layers of skin in the 5th chapter of poorva khanda also he explained about the

diseases related to the different layers of the skin67.

Bhela samhita:

In the shareera sthana 7th chapter he has followed charakas view and explained

about skin layers 68.

Hareeta samhita:

He has described the role of doshas in determining the varna of garbhasta shishu

in shareera sthana and also included twak as one of the vayaviya dravyas51.

Bhavaprakasha:

Bhavamishra has the same view like susruta.

He explained the 7 layers of skin & its embryological development as susruta

&also mentioned twak as one of the pittasthana19.


7

Material and Methods

MATERIAL AND METHODS

INCLUSIVE CRITERIA:

1) Diagnosed patients of Vicharchika.

2) Patients of both sex irrespective of age group.

EXCLUSIVE CRITERIA:

3) Systemic disorders.

4) Burn.

5) Leprosy

STUDY DESIGN;

The study of twak shareera with special reference to Vicharchika has been

designed as follows

1) Literary study.

2) Clinical study.

3) Histopathalogical study.

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

Laghutrayi and other classics of Ayurveda. Definition of Twacha its etymology

genesis and synonyms are compiled from 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 of Twacha told by Sushruta and

Dalhana is done.

69

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

Upadhatu, Srotas, Varna, Prakruti, Sara and Indriya is studied.

“A Study of Twak Shareera w.s.r to Vicharchika”


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

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

layers, functions and appendeges of skin is done.

Also study of Vicharchika Vyadhi from all the Samhitas is done. The

causative factors of vicharchika, its symptoms dosha Pradhanya and classification is

studid. Compilation of information regarding eczema is done form the textbooks of

dermatology. This compilation includes study of causative factors, pathogenesis

symptoms. Clinical features and investigations.

Finally, the correlation of Vicharchika and Eczema 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 eczema were examined for the

clinical study of the disease. The morphology of lesions, nature of symptoms, and

area of predilection were studied.

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

changes in this disease. So only eight patients were accepted to take skin biopsy has

been studied. That biopsy report has been enclosed in this thesis.


70


3) Histopathological study:

The histopathological study can be done by skin biopsy.

A) Skin biopsy:

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

punch biopsy and scissor biopsy etc. But we done skin biopsy by scalpel skin biopsy

(Elliptical excision) method because this method provides enough tissue for the

histopathologist to see the overall pattern of the lesion, which is critical for diagnosis,

it is most commonly used 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 cannot

get enough tissue.

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

ellipse of tissue is taken by the use of scalpel in the region of the full thickness of the

skin .The tissue is preserved in Formalin, & send to lab.

B) Laboratory experiment:

It includes Tissue fixation, Examination.

First tissue fixation is done by using 95% concentrated ethyl alcohol (ethanol) &

paraffin, Then tissue is processed by automated tissue processor, it cut into sections of

size 6-8 microns. Then this section is mounted on glass slide & stained by H & E

(Hematoxylin & eosin), then it is covered by a cover slip. This Preparation is

examined under 10X and 40X microscope.


71

Observation


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

different layers of Twacha. e.g.Sushruta told Vicharchika in fourth & fifth

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 Vicharchika and Eczema show tremendous similarity with

each other.

Table No. 6. Showing the Clinical features of Eczema and Vicharchika

Sl.No. Title Vicharchika Eczema

1. Location Tamra &Vedini Epidermis And papillary layer

of dermis.

2. Colour Rakta & Shyava Reddish & blackish brown

colour

3. Symptom

Kandu, pidika, shyava,

bahusrava/ruksha, arti,

raji.

Excessive itching, papules,

erythema, discharge/dry lesion,

pain, lichenification

(thickening).

4. Areas

Predilection Pani, pada mainly.

Both Palms and Soles, hands,

legs, scalp, trunk & folding of

body.

5) After histopathological study the spongiosis (inter cellular oedema) with acanthosis

(thickening), parakeratosis, hyperkeratosis & cellular infiltration were seen under

microscope. After histopathological reports of skin biopsy epidermis is affected in

most of the patients and dermis is affected in few patients.

Observation


Observation


Diagnosed 30 patients of eczema compared with vicharchika were selected

randomly for the thesis work. All the selected patients were thoroughly examined and

selected based on exclusive and inclusive criteria. The assignment revealed the

following statistics, Presented in the tables and graphs and they are self explanatory

hence no further descriptions are given.

Tabular Representation:

A) Varna of “Vicharchika”

Table No. 7. Showing the Varna of the Vicharchika

Varna No. of Patients Percentage Shyava 12 40% Rakta 13 43% Sweta 05 17% Shyava-rakta 1 3% Shyava-sweta 0 0% Rakta-sweta 1 3%

Graph No.1. Showing the varna of vicharchika

Observation


B) Lakshanas of Vicharchika:

Table No. 8. Showing the Lakshanas of the Vicharchika

Lakshana No. of Patients Percentage Vedana 20 66% kandu 20 66% Daha 23 76% Vedana-kandu 9 30% Vedana-daha 16 53% Kandu- daha 13 43%

Graph No.2. Showing the lakshanas of vicharchika

Observation


C) Sex-wise Distribution:

Table No. 10. Showing the sex of the Vicharchika patients

Sex No. of Patients Percentage

Male 19 63%

Female 11 37%

Graph No.3. Showing the sex of vicharchika patients

Observation


D) Age-wise Distribution:

Table No. 11. Showing the age of the Vicharchika patients

Age Patients Per%

10-20 4 13%

20-30 3 10%

30-40 9 31%

40-50 10 33%

50-60 1 3%

60-70 2 7%

70-80 1 3%

Graph No.4. Showing the age of vicharchika patients

Observation


E) Prakruti – Wise Distribution:

Table No. 12. Showing Prakruti of the Vicharchika Patients

Prakruti Patients Per%

Vatapittaja 14 47%

Vatakaphaja 4 13%

Pittakaphaja 5 16%

Tridoshaja 7 23%

Graph No.5. Showing the prakruti of vicharchika patients

Observation


F) Diet – Wise Distribution:

Table No. 13. Showing Diet of the Vicharchika Patients

Diet Patients Per%

Vegetarian 8 27%

Regularly mixed 8 26%

Irregularly mixed 14 47%

Graph No.6. Showing the diet of vicharchika patients

Observation


G) Occupation – Wise Distribution:

Table No. 13. Showing Occupation wise Patients

Occupation Patients Per%

Labours 16 53%

House wife 8 27%

Other 6 20%

Graph No.7. Showing the occupation of vicharchika patients

Observation


H) Areas of Predilection:

Table No. 9. Showing the areas of the Vicharchika

Areas No. of Patients Percentage

Face/scalp 7 23%

Hands 10 33%

Legs 13 43%

Foot 7 24%

Palms 2 7%

Trunk 1 3%

Foldings of body 8 27%

Graph No.8. Showing the areas of vicharchika patients

Discussion

DISCUSSION

Discussion on Historical review

The study of twak shareera w.s.r to Vicharchika can be discussed as follows.

Ayurveda is an ancient medical science which has given importance to the

Pancha Gnyanendriya in that Spershanendriya as one of important, which covers &

protects the surface of the body from external heat, cold & infections. Most of the

disease which are exclusively exhibited on the skin & under the category of kustha &

is one among the astha-mahagadha because of the change in the structural appearance

of the skin.

If we go through historical review of literature pertaining to twak mentioned

Rigveda as one among the seven organs & in Atharvaveda while describing indriya

twak as Spershanendriya & different diseases like kustha,halimaka,kilasa etc. During

post vedik period various medical & non medical literatures are available in

Samhita,Brahman Upanishad,puranas etc.In agni purana described that in fifth month

embryonic period there will be formation of skin & blood.

In Samhita kala, it was golden era of ayurveda gives great knowledge about

twak shareera & their related diseases.

In Charaka Samhita explained six layers of the skin & diseases which occurs in

each layer.In Susruta explained the twak shareera in very minute level & its

embryogenesis, layers, pramana & characters of each layer of twak. Astanga sangraha

& hrudaya also its layers & embryological development explained.

There is references are available in kashyapa samhita explained sara purusha

laxanas & twak sara purusha is free from skin disease . In Sharangadhara samhita


84

Discussion

followed the sushrutas view & given detailed description of seven layers & diseases

related to different layers of the skin. Bhela samhita followed the charakas view &

diseases of each layers of skin. In Harita samhita described the role of doshas in

determining the varna of garbhastha shishu & included twak as one of the vayaviya

dravya. Bhavaprakasha has the same view of sushruta, he explained the seven layers

of skin & its embryological development as similar to that of sushruta & mentioned

that twak one of the pitta sthana.

Discussion on Twak shareera

The external covering of the body is called twacha. It is also called as

“Twagindriya or Spershanendriya” which is responsible for sense of touch or sparsha.

It covers the surface of the body, holds the blood inside, illuminates the complexion &

protects from the heat, cold, & external infections etc.

Etymology of twacha is samvarane meaning is covering of the body.

Twacha,charma,chhavi,chhadini,sparshana & asrukdhara are the synonyms of the

skin.

Acharya Charaka described six types of twacha namely udakadhara holds

rasadhatu & lasika inside and prevents loss from the body. Asrukdhara which holds

the numerous blood vessels. Then he mentioned in numbers like Trutiya, Chaturtha,

Panchami & Shasti and narrated the sidhma, kilasa in trutiya,dadru in chaturtha,

Alaji,vidradhi in panchami, hence loss of consciousness in excision of shastidhara.

Acharya Vagbhata also same view of charaka & also regarding vyadhis occurring in

different layers. Sushruta, Sharangadhara, Bhavaprakasha have mentioned seven

layers of twacha and same view regarding vyadhis occurring in different layers.


85

Discussion

The organogenesis of twacha occur during paka of Shukra & Shonita by Agni,

just like while heating of the milk cream is formed on its surface. Modern

Embryology also supports this view. Embryologically the Integumentary system is

not derived from a single layer. Different cells of the skin & its appendages have

different origin.From the different sites they migrate to the skin.

According to modern view Epidermis of skin is outermost layer and an average

adult carries around about 2kg of dead skin, billions of tiny fragments of skin are lost

every day. Hair follicle, arrector pilli muscle, nails & skin glands are formed by

Surface Ectoderm. Dermis is formed by mesenchyme (mesoderm) derived from

dermatomes of somites.

Twacha is a Matruja Bhava due to its soft nature & it is having predominance

of vayu mahabhoota & spersha as visista guna.In all Indriya, spershanendriya is such

an entity that occupies all other indriya also.

Layers of the Twak :

There is some controversy regarding the number of Twacha in various

ayurvedic texts. Acharya Sushruta tells seven types of Twacha (twacha sapta) while

Charaka and Vagbhata tell six types, and also regarding Vyadhis occurring in

different layers. Though we cannot exactly correlate these layers with that mentioned

in modern science, the following comparisons can be made with the contemporary

science on the basis of colour, appearance, and structural involvement of the layers.


86

Discussion

Avabhasini & Lohita . . . . . . . Stratum corneum

Avabhasini is the first layer of skin.This layer illuminates the varna of the skin

and the five types of chaya (avabhasanyati varna, chaya iti avabhasini). Lohita -

Second layer of skin.The name indicates that this layer is also pigmented and the

diseases occurring in this are pigmentation disorders.

Stratum Corneum contains cells that are completely filled with keratin &

melanin units.Skin colour is mainly due to amount of pigment the melanocytes can

produce and transfer to the keratinocyte.It is told that the tanning of the skin is due to

increased production of melanin as well as its transfer to keratinocyte. This tanning of

skin is lost when melanin i.e. Keratin units are shed off from Stratum Corneum ie.

The colour of skin is reflected in this layer.

Avabhasini and Lohita can be compared with Stratum Corneum.The diseases

manifested in these layer are mostly pigmentation related disorders.i.e.padmakantaka,

Tilakalaka, vyanga etc.

Sweta . . . . . . . Stratum lucidum

Sweta is the third layer of skin.The name implies that it is clear (white) layer.

The diseases are mentioned as Mashaka, Charmadala, Ajagallika which occurs due to

defects in pigmentation.

The Stratum Lucidium is also called the clear layer as it is highly refractive.It

contains droplets of intermediate substance eledin, which is eventually transformed to

keratin.The diseases which occurs due to the localized overgrowth of melanocytes and

melanin.


87

Discussion

Tamra . . . . . . . Stratum spinosum and Stratum granulosum .

Tamra is the fourth layer. Kilasa & Kushta are diseases that are likely to occur

in this layer.

Stratum Spinosum contains keratinocytes with bundles of

tonofilaments.Melanocytes and Langerhans cells are present in this layer At sites of

allergic dermatitis langerhans cells are believed to take up antigen and present it

lymphocytes in a form to which they can react by generation of antibodies.Stratum

Granulosum contain darkly stained protein granules keratohyaline which converts

tonofilaments into keratin.

Tamra varna of the skin may be due to keratohyaline pigment.The

melanocytes & langerhans cells present in stratum spinosum and granulosum may

be responsible for kilasa and kushta respectively.

Vedini . . . . . . . Stratum basale and papillary dermis.

Vedini is the fifth layer of skin.It forms adhishtana of Visarpa and Kushta.The

name suggests the presence of sensory receptors in this layer.

Stratum Basale and papillary dermis contain merkels disc which serves as

mechanoreceptors.Papillary dermis contains tactile receptors, Meissner corpuscles

&free nerve endings that give rise to sensations of pain, warmth, tickling etc. Stratum

Basale also contains langerhans cells and keratinocytes.

The sensory receptors in this layer are responsible for vedana or pain. Pain is seen

in the diseases of this layer. In Visarpa along with skin manifestations pain is also a

predominant feature. In some kushta (skin diseases) also pain is experienced.


88

Discussion

Rohini . . . . . . . Reticular dermis

Rohini is the sixth layer.The word meaning of Rohini is that which is growing

or ascending. The diseases present in this layer also presents abnormal

growth.Granthi, Apachi, Sleepada , Galaganda are likely to occur in this layer.

The reticular dermis contains fibroblasts, collagen, reticular fibres and a few

adipose cells. This region possesses rich lymphatic and vascular supply. Adnexal

tumours,adipose tumours are likely to occur in this layer.

Twak is not involved in the samprapti of diseases mentioned in this layer.It

may due to the presence of adipose tissue , rich lymphatic and vascular supply these

diseases are considered in this layer.

Mamsadhara . . . . . . Superficial fascia

Mamsadhara is the seventh layer. Bhagandara ,Vidradhi, Arsas are likely to occur in

this layer.

Arshas,Bhagandara, Vidradhi as the samprapti of all these disorders will not

specify the role of twak, but the vyakta sthana of all manifestations are clearly

observed through the twak only

Pramana of twak (Thickness):

Acharya Susruta has explained the pramana of each layer of skin as having

thickness of 1/18 th,1/16th, 1/12th, 1/8 th ,1/5 th , 1& 2 vreehi or yava.Here the total

thickness of skin is 3.5 yavs.


89

Discussion

Dalhana clarifies that the measurement is to be taken as parts of 1/20th of

vreehi.The thickness of each layer will be 18/20, 16/20, 12/20, 5/20, 1 & 2 vreehis,the

total thickness being 5.95 yavas.

According to Susruta the measurement of thickness of twacha is broadly

applicable for the rich muscular parts & cannot be considered in the region of scalp or

less fleshy areas.

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

thickness =1.5 to 4 mm).then Susruta seems to be perfect & more accurate in telling

thickness of skin.

Considering relation of doshas with twacha, vata dosha especially prana have

close relation with twacha, Pranavayu is responsible for the perception of touch

sensation. Udanavayu produces Varna and if it 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

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

relation of Twacha with other Dhatus.Among malas Twacha is mainly related to

sweda. This is excreted through innumerable openings on it.


90

Discussion

Twak as sense organ:

Twak is said to be one of the gnyanendriya concerned with sensation of

touch according to our classics. Charaka has given prime importance to spasanendriya

by quoting that tactual contacts and mental contacts are the 2 types of contacts.

In the contemporary sciences also the skin is considered as a organ of

sensation. An array of cutaneous receptors carry information concerning various

stimuli, The highly branched myelinated & nonmyelinated free terminals which end

with in the dermis and lower layer of epidermis acts as an important sensory

component. They may be mechano, chemo, thermo & nociceptors in all types of skin

Varna of twak

Rakta dhatu is varna prasadana ie it enhances the colour of the skin. Bhrajaka

pitta also have a role in regulation of skin colour. In the modern science colour of the

skin depends upon the Melanocytes, Keratinocytes & Hemoglobin present in the

blood.

The role of Twak in Thermo regulation

Chakrapani opines that the regulation of body heat and variations in the colour

of the twak are the functions of Brajaka pitta. Skin plays a significant role in the

thermo regulation of the body.

The skin contributes to thermoregulation, the homeostatic regulation of body

temperature in two ways, by liberating sweat at its surface & by adjusting the flow of

blood in the dermis.


91

Discussion

Discussion on Vicharchika

Vicharchika is a type of Kushtha which occurs in ‘Tamra & Vedini’ Twacha

according to Sushruta. It is tridoshaja vyadhi having predominance of pitta, & Kapha.

It is characterized by blackish brown eruptions associated with itching sensation, pain

& excessive exudation/dry lesion.It occurring all over the body,but more on hands &

legs.

Discussion on Eczema

Eczema is affects epidermal layers & papillary layer of dermis. It is

characterized by excessive itching, pain, papules, Erythematic with discoloration,

profuse discharge/drylesion, on the skin of all parts of body, Eg.legs, hands, Palms,

soles, trunk, scalp, face &,folding of the body.

Eczema and Vicharchika :

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

Ayurveda, which can exactly be correlated with Eczema. Many research workers have

tried to attribute eczema with one or other type of kustha. All the workers included

eczema under kshudra kustha, but on co-relation with specific type they differed.

Some correlated it with Vicharchika & others with pama kustha .Here, Vicharchika

sign & symptoms are correlated as Eczema because the description & characteristic

features of the disease are co-inciding with description of eczema than any other type

of kustha. In vicharchika the lesions are having Kandu, Pidika, Shyava, Bahusrava,

Raji, arti, & ruksha. But in Eczema the lesions are having Exessive itching after it

may/may not produce burning, Papules/vesicles or pustules, Erythema with

discoloration, profuse discharge, Thickening or Lichenification of skin, Pain & Dry in


92

Discussion

nature, on the skin of all parts of body, Eg. Legs, hands,Palms,soles,trunk scalp, face

&,folding of the body.

The description & characteristic features of Vicharchika are very closely matched

with the description of Eczema.

Vicharchika --- Eczema

Kandu – Exessive itching it may/may not produce burning.

Pidika – Papules / Vesicles / pustules.

Shyava – Erythema with discoloration.

Bahusrava – profuse discharge.

Raji – Thickening.

Arti – Pain.

Ruksha – Dry lesion.

Discussion on Histology:

It is based on biopsy reports of histopathological examination of the skin. After

histopathological study the spongiosis with acanthosis (thickening),parakeratosis,

hyperkeratosis & cellular infiltration were seen under microscope. So that structural

changes are found in the Epidermis & Dermis layers of the skin.

• Spongiosis: Intercellular oedema with associated lymphocyte

exocytosis.


93

Discussion

• Acanthosis: Increased thickness of prickle cell layer, the results of

hyperplasia, (often with hypertrophy) of the prickle cell.

• Hyperkeratosis: Excessive formation of keratin, resulting the horny

layer being thicker than is normal for the skin of the area affected.

• Parakeratosis: An abnormal form of Keratinization in this condition

granular layer of the epidermis is disappear.

Discussion on Observation

Age: Out of 30 patients, 10 patients are of 40 – 50 age group & 9 patients are

30-40 age group, remaining are related to different age group. So Vicharchika

can occur in any age. But more in thirty to fifty age group in my study.

Sex: Out of 30 patients, 19 male patients & 11 female patients, so it shows that

males are more affected than the females, in my observational study.

Diet: Out of 30 patients 22 patients are mixed diet taking persons & 8 patients

are Vegetarians,and the persons are habituated with virudha ahara ,dietic

allargies are important role in causation of disease.

Occupation: Out of 30 patients, 16 patients are labours, 8 patients are house

wives, 6 patients related to other fields .This is also important in causing

vicharchika. The labours are more prone to expose sunlight and various chemical

contacts, fertilizers, plants etc.

94

Prakruti: Out of 30 patients 14 patients are assessed as vata pittaja prakruti, 7

tridoshaja, 5 pittakaphaja, 4 vatakaphaja prakruti patients. So vatapittaja prakruti

persons are more prone to suffer from vicharchika.


Discussion

Varna: Among 30 patients, Rakta varna is observed in 13 patients, Shyava

varna in 12 patients & Sweta varna in 5 patients. And more rakta varna patients

are seen.

Sites of Eczema: Among 30 patients, the vicharchika found on legs /foot in 13

patients, 10 patients on hands/palms, 7 patients on face/scalp & folding, 1 patient

all over the body.


95

Conclusion

Conclusion

The following conclusions can be drawn by the observations based on literary &

Histopathological study & discussion.

Twacha is one of the sensory organ of the body which covers surface and protects

against heat, cold,infection etc.

1. Acharya Sushruta opines that ,there are seven types of twacha & out of these

seven twacha Vicharchika occurs in fourth & fifth layer of twacha i.e. Tamra

& Vedini.

2. Acharya Sushruta,s measurement regarding thickness of twacha is seems to be

more accurate. 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 text books of Anatomy.

3. Vicharchika is a type of Kustha & Eczema is a type of skin disease has most

of the same symptoms which are correlated on the basis of literary,

histopathological & clinical observationalstudy of both Ayurveda & modern

science.

4. On the bases of signs and symptoms and histopathological report findings,

Vicharchika can be correlated with allergic eczema

5. The Histopathological reports shows, structural changes are found in

Epidermis & Dermis layers of the skin.

6. The present study is carried out on 30 patients, so which is a small sample.

The patients selected were having different types of eczema.


96

Conclusion

Here suggestion is given for the further study to conduct on large

number of patients concentrating on particular types of Eczema in multi-

centers, after which a clear conclusion can be drawn.


97

Summary

SUMMARY

The dissertation entitled “A STUDY OF TWAK SHAREERA W.S.R TO

VICHARCHIKA” comprises of 8 chapters namely Introduction, Objectives, Review

of literature, Methodology, Observation, Discussion, Conclusion & Summary.

1. Chapter : General idea regarding Ayurveda, Rachana shareera,Twak

shareera, &

Vicharchika (Eczema) has been covered in the introduction part of dissertation along

with need of this study in the present scenario has been highlighted.

2. Chapter: Gives an idea about Aims & Objectives of the study.

3. Chapter : Review of literature is subdivided in to Historical review, Ayurvedic

review & Modern review.

Historical review section comprises of references pertaining to Twak.

In Ayurvedic review the layers of skin along with its measurement &

diseases that are likely to occur in each layer, its relation with dosha, dhatu,mala

panchamahabhuta its importance as sense organ, Varna of twak is depends on

predominant dosha at the time of conception is mentioned in detail. Also there is

nidana samprati lakshanas of vicharchika were discussed.

In the first part of modern review detail anatomy of skin has been explained.

In the second part eczema, its types, causes, features & histopathology were discussed

& photo plates of types of eczema were also presented in this chapter.

98

4. Chapter: Methodology explains about the method of data collection,inclusion

Criteria,exclusion and assessment criteria


Summary

5. Chapter: The signs and symptoms of vicharchika and eczema and

histipathological Studies are presented in the observation chapter.

6. Chapter: It comprises the details of comparison of the collected data with those

mentioned in the ancient literature & modern science.

7. Chapter: Conclusion drawn from various sections of the work are given.

8. Chapter: Summarizes the entire work.


99

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82. http:www.blackwell publishing .com/ skin sys- fin.html.

83. Young Barbara and John W Heath; Wheater’s Functional Histology ;4th edition

2003;Churchill Livingstone Edinburg;Pp :413; Page no.:164.



2000; Pp: 2092; Page No.:401



2000; Pp: 2092; Page No.:409.



2000; Pp: 2092; Page No.:406.



2000; Pp: 2092; Page No.:405.

88. I.B Singh,G.P Pal, Human Embryology 8th edition, Macmillan Publishers India

ltd;2007; pp361;page 98.


116

http://www.blackwell/

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2000; Pp: 2092; Page No.:399.



2000; Pp: 2092; Page No.:400.


Brothers Medical Publications (P) Ltd ;New Delhi ;PP 280 ;Page no 19.

92. . http:// www.net doctor.co.uk / skin.

93. http:// www.net doctor.co.uk / skin.

94. Principles of Anatomy and Physiology :By G.J. Tortora and S.R. Grabowski,

published by Harper Collins College publishers, New Yord, 10th edition,

2003.pp1103,pg.151.

95. Ronald Marks; Roxburgh common skin diseases;17th edition ;Arnold

publishers,A member of Hodder Headline group; Pp: 328; Page No.: 172

96. Chaurasia B. D., General Anatomy; 4th edition 2009; CBS Publishers and

distributors; New Delhi; Pp: 262; Page No.:181

97. P.N.Behl-Practice of dermatology ,1988,CBS Publishers.New Delhi.pg126.

98. Histopathology of skin; Water.F.Lever.

99. Medical Laboratory Technique, Ramnik Sood,Jaypee publications.

100. Fitzpatrick’s color atlas and Synopsis of Clinical Dermatology;5thedition

2005,pp1085,pg18.


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http://www.net/

http://www.net/

Case sheet

DEPARTMENT OF P.G. STUDIES IN RACHANA SHAREER N.K.J AYURVEDIC MEDICALCOLLEGE & PG CENTRE, BIDAR. RESEARCH CASE SHEET TITLE: A STUDY OF TWAK SHAREER W.S.R. TO VICHARCHIKA Research scholar: Dr.Geeta Dolli Co-guide:Dr.Ashwinikumar .W. Guide: Dr.N.G.Mulimani. 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):

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:

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

Ayurvedic Review

Disease Review

Most of the diseases which are exclusively exhibited on the skin are termed as

‘kushta’ in Ayurveda. They are so called because these diseases account for a great

deal of misery and suffering in the body. Owing to illiteracy, unhygienic conditions

and poverty etc. a large portion of our society is suffering from one or the other skin

disease.

Kushta is one among the ashta-mahagadas told by Sushruta owing to the

difficulties one has to undergo during treatment and also to the results achieved after

treatment. Even today, Dermatologists do face problems in treating some of the skin

disorders which are of recurring in nature. Hence it can be said that skin disorders

‘were’ and ‘are’ troublesome for both the physician and the patient.

Two types of Kushtas have been envisaged in ayurvedic classics viz. Maha

Kushta and kshudra kushta. Among the 18 Kushtas 7 are maha kushtas and 11 are

kshudra kushta. Vicharhika is a type of kshudra kushta.

VICHARCHIKA

Etymology:

Vicharchika word is derived from “Charcha” dhatu, Vee- prefix and ‘Navul’-

suffix. It means that a type of Swalpa (Minor type) Kustha. (Vachaspatyam part 6, Pg.

4896).

Vicharchika is formed by “Charcha Tarjane” Dhatu by adding ‘Navul’ to it.

Means a type of disease. (Shabdakalpadrum, part 4)


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Ayurvedic Review

Thus, Vicharchika is derived from “Charcha Adhyane” by adding prefix ‘Vee;

to it. The word Adhyane has two syllables viz. Adhi and Ayne. Adhi means above and

Ayne means spread out. Thus it reads as “Visheshate Charchate Adhi Eyate Anaya

Sakandu Kshudrapidika Swarupena Charmani Upariti Vicharchika”, which means

Kshudrapidika spreads with Kandu elevated on the surface of the skin is termed as

Vicharchika.

Nirukti of Vicharchika

Shabdakalpadrum describes two main features founded in Vicharchika i.e.

cracking of the skin mainly occurs on the skin of hands & legs ‘Visheshena care-ayate

padasya Twak vidaryate Anaya iti Vicharchika’ which means the disease which

coats/covers the skin in particular manner & causes cracking of skin of hands & feet

mainly.

Definition

1. According to Acharya Charaka Vicharchika is defined as ‘Sa Kandu Pidika Shyava

Bahu Srava Vicharchika’. (Ch.chi. 7/26)

Means the skin disease where eruptions over the skin appear with dark

pigmentation, itching with profuse discharge from the lesion.

2. Vicharchika according to Sushruta is ‘Rajyo Atikandu Atiruja Sa Ruksha Bhavanti

Gatreshu Vicharchikayam’. (Su.Ni. 5/13)

According to Susruta the condition in which skin is dry with severe itching

& marked linings present in Vicharchika. Furthermore he added that if the same

condition appears at the feet with pain, then it is known as ‘Vipadika’.


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Ayurvedic Review

Acharya Madhava, Vagbhata & Bhavamishra have described almost same

definition as Acharya Charaka. (M.N.49/23, B.P.Ma.Kh 54/26, A.H.Ni 14/6, 17)

Kashyapa describes Vicharchika as blackish brown eruption with intense

itching & pain. (Ka. Chi.9/2)

While Acharya Harita considered a multiple pin head sized eruptions with

ulceration & itching in Vicharchika. ((Ha. Ut.4/42)

Bhel narrates Vicharchika as a dark red coloured deep-rooted lesion with

moisture or oozing. (Bhel. Chi. 6/16)

Nidana

There is no specific description about etiological factors of the disease

Vicharchika but it is being a variety of Kshudra Kustha, the etiological factors of the

Kustha are to be accepted as the etiological factors of the Vicharchika.

Etiological factors of Kustha and may be same factors causes Vicharchika as

mentioned in different Ayurvedic texts may be classified into following groups.

1. Aaharaja Hetu (causes related to food habit)

2. Viharaja Hetu (causes of other activities)

3. Aacharaja Hetu (causes of behavior)

1. Aaharaja Hetu

Aaharaja Hetu are chief responsible factors in the production of the Kustha

(skin diseases). Among them Viruddha & Mithya Ahara are the main dietary

factors.


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Ayurvedic Review

A. Viruddha Ahara – There are eighteen types of Viruddha Ahara.

‘Viruddha’ or ‘Vairodhika’ is the technical terms for incompatible or

antagonistic. It means that, which acts as antagonistic to physiological factors and

remains in the body and produce various diseases. Acharya Charaka has stated that

the substances acting antagonistic to ‘Dehadhatu’ are Vairodhika (Ch. Su. 26/8).

B. Mithya Ahara – Mithya Ahara means improper Diet.

2. Viharaja Hetu

Viharaja Hetu (causes pertaining to activities) also plays an important

role in the production of skin disease. Mithya Vihara, Vegadharana &

Panchakarmapacharan are few such main Vihara Hetus.

a. Mithya Vihara – It means improper activities. That is sudden changes from

cold to heat & vice-versa, entering into cold water immediately after

one is afflicted with fear, exhaustion & sunlight etc are said to be the

causative factors for the Kustha as stated in the table.

b. Vega Vidharana – The suppression of Vamana, Mutra & Purisha vegavarodha

may produce skin disease.

c. Panchkarmapacharen – It is also a significant cause in the production of skin

disease. Moreover, improper administration of Snehapana therapy is also

said to be the causative factors for skin disease.

3. Aachara Hetu

It means causes pertaining to behavior. Good morals are also

necessary for a man to be healthy. Sadvritta is the conduct of nobles in

respect to physical, verbal & mental behavior. Aachara hetu is also said to be


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Ayurvedic Review

as one of the causative factors for Kustha, i.e. insult to Brahmins, Teachers &

other respectable persons. Indulgence in sinful activities, etc. are said to be the

causative factors for such disease.

Acharya Charaka has mentioned the involvement of Krimi in the

disease Kustha. Acharya Sushruta has also stated that all types of Kustha

originate from Vata, Pitta, Kapha & Krimi. So Krimi may be taken as one of

the probable causative factor for Vicharchika (Su. Ni. 5/5). (Ch.Ni5/10)

Samprapti (Pathogenesis)

Discription of Samprapti according to Acharya Charaka & Sushruta is as follows,

According to Charaka Samhita (chi 7) Due to various Nidana Sevana,

Tridosha gets vitiated simultaneously & produces shaithilya in the Tvak, Mamsa,

Rakta & Ambu. Then Tridosha gets seated in Shithila Dhatu & vitiating them with

Lakshanotpatti of Kustha Roga.

According to Acharya Sushruta, Nidana Sevan causes vitiation of Vata, which

carry vitiated Pitta & Kapha to the Tiryaka gami Sira at the level of Bahya roga marga

i.e. Tvak, Rakta, Mamsa & Ambu. Here, these vitiated Dosha gets seated. If these

Doshas are not treated properly, they may penetrate the deeper Dhatus of body and

produces various types of kusta roga in that vicharchika is one. (Sushruta Ni. 5/3)


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Ayurvedic Review

Virudha & Mithya Mithya

Ahara Vihara

Achara Mithya

Papakarma

Constant Nidana Sevana

Cause

Vitiation of Three Dosas Saithilyotpatti in Four Dusyas (vata,pitta,kapha) (twak,mamsa,rakta,ambu)

Dosas reside in Dusyas and Vitiate them

Travel through Tiryakgamisira

Spreads all over the skin developing Kandu, Vaivarnya and other symptoms.

Kusthotpatti

Vicarcika

Samprapti Ghataka Of Vicharchika-Summarized As –

1) Saptako Dravya Sangraha :

Dosha : Tridosha, Kapha Pradhana (all Acharya except Su. & M.)

Pitta Pradhana (Su)

Vata-pitta Pradhana (M.)

Vata: Vyana, Samana

Pitta : Pachaka, Bhrajaka


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Ayurvedic Review

Kapha: Avalambaka, Kledaka

Dushya: Twak, Rakta, Mamsa, Lasika

2) Agni : Jatharagnimandya, Dhatvagnimandya and Amavisha

3) Srotasa : Rasavaha, Raktavaha, Mamsavaha, Swedavaha

Srotodushti: Vimargagamana, Sanga

4) Udbhava : Amashaya

Sanchara marga: Tiryaka-gami-sira

5) Adhisthana : Twak,

Rogamarga: Bahya

Prabhava: Chirakari (chronic)

PURVA RUPA

Vicharchika is a type of Kshudrakustha, so Purvarupa of Kustha can be

considered as a Purvarupa of Vicharchika In general there 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, itching, blackish discoloration of the

skin instantaneous appearance of ulcer, excessive oozing.


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Ayurvedic Review

RUPA: Full manifestation of Vicharchika is mentioned various Ayurvedic classics

which is being tabulated as follows:

Rupa Ch. Su. A.H./A.S. M.N. Bh. Ka. B.P. Ha.

Subjective Symptoms pain, all explanation of patches etc as the premonitory

symptoms (Cha.Chi. 7/11-12)

Kandu + + + + + + + -

Vedana - - - - - + - -

Ati-ruja - + - - - - - -

Daha - + - - - - - -

Color of Pidika (Lesion)

Shyava + - + + + - + -

Shweta - - - - - - - +

Rakta - - - - + + - -

Srava (Nature of discharge)

Bahusrava + - - + + + + -

Ruksha - + - - - - - +

Lasikadhya - - + - - - - -

Praklinna

(Mamsenopachita)

- - - - + - - -

Raji - + - - - - - -

Pakavati - - - - - + - -

Table No. 5. Showing Signs and Symptoms of Vicharchika.


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Ayurvedic Review

According to Sushruta, the lesion of Vicharchika is Ruksha so it becomes

Ruksha Vicharchika (dry eczema) (Su. Ni. 5/13) others have mentioned either Srava

(Ch. Chi. 7/26, Bh. Chi. 6/26, Ka. Chi. 9/2, M. N. 49/23, Ha. Sha. 3/43) or Lasika

(A.H. 14/6, 17) in lesion called wet type of Vicharchika.

Among the lakshanas the related doshas can be as follows

Vata – Rukshata, shoola, shyava,

Pitta-daha,srava,paka,kleda,rakta

Kapha – Atikandu, kleda.

Doshic Dominance In Vicharchika :

Charaka - Kapha

Vagbhata - Kapha

Sushruta - Pitta

Sadhyasadhyata

Even though kushta is considered to be one of the mahagadas by Sushruta, it is

considered sadhya, if dooshyas of Twak, Rakta and mamsa are only involved with

doshas vata and shleshma. In kashyapa samhita, Vicharchika is considered sadhya

among 9 sadhya kushta rogas.


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Ayurvedic Review


TWAK SHAREERA

Literature review gives a logical flow of ideas regarding concerned topic, it

gives an un biased & comprehensive view of the previous research on the topic, &

also use of proper terminology. It helps to collect current & relevant references.

Etymology:

Twag+kwip=Twacha

Twak samvarane

According to amarakosha, twaka dhatu is used in the meaning of covering.

Definition:

Twachca is that which completely covers medas shonita & all other dhatus of the

body1. The external covering of the body is called twak.2

A type of indriya which envelops the body is called twagindriya3.

Synonyms:

Twacha – covering of body.

Charma – means nature of moving.

Chhavi – means to illuminate the complexion.

Chhadani- means to cover.

Sparshan – to give tactile sensation.

Asrukdhara – it means to hold the blood inside the body.

Ayurvedic Review


Twak utpatti:

According to vagbhata twak is formed by the essence of rakta just like creamy

layer is formed from boiled milk 4.

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 also

Sushruta has give a simple and accurate Drushtanta of Santanika i.e. cream on milk

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 surface. 5.

Acharya Charaka has not given any description regarding genesis of Twacha6.

Origin of Twacha:

Acharya Charaka has described that every structure of the body develops

from Shadbhavas in that twacha is matruja bhava7. Acharya Vagbhata stated that

Twacha develops from Vayu mahabhoota.7

Number of Twacha:

There is a great controversy among various Ayurvedic texts regarding number

of Twacha. After studying number of twacha we come to the conclusion that Acharya

Charaka, Vriddhavagbhata, Bhela and Kashyapa has stated 6 types of Twacha. While

Acharya Sushruta and Bhavaprakasha has stated seven types of Twacha8.

Ayurvedic Review


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.

According to Charaka 6 types of Twacha: 9

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.

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 diseases occuring in them.

The Trutiya is the seat of manifestation of Sidhma and Kilasa.

The Chaturtha is the seat of manifestation of Dadru and Kushtha.

The Panchami is the seat of manifestation of Alaji and Vidradhi.

The Shasti is one on excision of which causes loss of consciousness.

Ayurvedic Review


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 outermost layer of

Twacha is Avabhasini which reflects all sort of complexions also brighten Pancha

chaya. It is the seat of Sidhma and Padmakantaka.10

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

Vyanga.11 The third layer is Shweta and it is the seat of Charmadala Ajagallika and

Mashak.12 The forth layer is called tamra which is the seat of varius types of Kilasa

and Kushtha.13

The fifth layer is Vedini which is the seat of Kushtha and Visarpa14. The sixth

layer is Rohini which is the seat of Granthi Apachi Arbuda Shlipada and Galaganda15.

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

Vidradhi and Arsha16.

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.

First layer is Udakadhara.

Second layer is Asrukdhara.

Third layer is the seat of Sidhma and Kilasa.

Ayurvedic Review


Fourth layer is the seat of all types of Kushtha.

Fifth layer is the seat of Alaji and Vidradhi.

Sixth layer is Pranadhara17.

D) Ashtanga Hridaya:

Acharya Vagbhata in Astanga hridaya 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.

First layer is Avabhasini seat of Sidhma.

Second is Lohita seat of Tilakalaka.

Third is Shweta seat of Charmadala.

Fourth is Tamara seat of Kilasa and Switra.

Fifth is Vedini seat of all Kushtha.

Sixth is Rohini seat of Granthi, ganda and Apachi.

Seventh is Sthoola the seat of Vidradhi and it is thick equal to two Vrihi18.

Ayurvedic Review


F) Madhava Nidana:

There is no description regarding Twacha in Madhavanidana.but the description of

various kustha diseases mentioned.

G) Bhavaprakasha:

According to Bhavaprakasha there are seven types of Twacha

The first is Avabhasini which is the seat of Sidhma.

The second is Lohita seat of Tilakalaka.

The third is Shweta seat of Charmadala.

Fourth is Tamara seat of Kilasa and Shwitra.

Fifth is Vedini which is the seat of all Kushtha.

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

Seventh is Sthoola, the seat of Vidradhi19.

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

Ayurvedic Review


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

Twacha pramana:

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 Lohita is 1/16,Sweta is 1/12,Tamra 1/8,Vedini1/5, Rohini is 1,Mamsadhara is 2

Vrihi. But this measurement of Twacha is not throughout same for all the body parts.

It differs according to various body parts20.

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 fingers21.

Ayurvedic Review


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 Vrihi22.

Table No. 3. Showing the comparison of thickness of Twacha according to

Sushruta and Dalhana

Twacha Sushruta Modern measurement

DalhanaModern 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 of Twacha. Sushruta : 3.5 Vrihi

Dalhana : Approximately. 6 Vrihi

If we practically observed the 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


Panchabhoutikaatva of twak :

All the structures of the body are having panchabhoutika constitution, even on

the cellular level also.Acc. to Acharya charaka panchagnanendriyas are made up of

panchamahabhuta.The sense organs perceive the respective objects according to

predominance of their constituent mahabhuta.Twak has been predominate of vayu &

prithvi23.

Acc to Vagbhata twak is vayu predominant organ24.

Twacha is also having Panchabhautik nature.

Table No. 4. Showing the relation between Twacha and Panchamahabhuta.

Element Structure

Parthiva Kesha, Loma,Nakha

Aapya Rasa, Lasiak

Tejas Kanti, Varna

Vayviya Sparsha, Samvedna

Akashiya Lomakoopa, Sweda Vahi Nalika

Twak as matruja avayava :

Acharya charaka has considered twak as one of the matruja avayavas25.

Twak as Indriya

Indriya is the source of obtaining the knowledge & performing actions.These are in

the sookshma form present in some specific places of the body,which are known as

Ayurvedic Review


Indriya adhisthana.karna twak,netra,jihwa & nasa are the panchendriyas26. The

indriya which is responcible for reception of touch sense is sparshanendriya.

Susrutacharya also considers twak as one of the Gnyanendriya27.

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 Ayurveda28.

These organs are the abodes of their respective Indriyas29. Twacha is one of

Gnyanednriyas which is Vayaviya in nature30.

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

Sparshnendriya and Twacha is its abode (i.e. Adhishthana) 31

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

Sparshanendriya to enable all the movements in the body to bring lightness to body

and to create impulses in body32.

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 body33.

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 organ34.

Ayurvedic Review


Twak in relation with Dosha

01. Vata Dosha:

Vagbhata says Twacha is one of the sthana of Vatadosha. Out of five 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 itself35.

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

then there is discolouration of skin36.

2. Pitta Dosha

Twak is considered as one of the pitta sthanas37.Pitta residing in the twak known

as Bhrajaka Pitta & it is responsible for digestion & absorption and also it helps in

expression of varna of the twak & enables the digestion & utilization of substances

used through Abhyanga,parisheka,avagaha etc.It indicates the glow of one’s natural

complexion38.

Charakacharya said that the production of normal & abnormal colour of the

twak is belongs to the pitta dosha.

Acharya Vagbhata observes, Bhrajaka pitta situated in the twak imparts the

luster & radiance of the twak39.

Chakrapani comments on the context as the regulation of the body heat & variations

in the colour of the twak as the functions of the Bhrajaka pitta40.

3. Kapha Dosha:

One of the Gunas of Kapha is Srigdha due to this Guna of Kapha moistness

Ayurvedic Review


and oily nature of Twacha is maintained. If Kshaya of Kapha dhatu, then Snigdha

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

Twacha & Saptadhatu relation:

There is a very close relation between Saptadatus and Twacha.

01. Rasa : At several places twak has been used as a synonym of rasa

Dhatu like twak sara purusha. Twacha is a huge structure

I 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 are related.

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

out from Twacha.

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

Twak as Mala of Medodhatu:

In Charaka chikitsasthana,we will get references that twak is the mala of

medodhatu.

Twacha is mainly related to Sweda. Twacha is having innumerable Bahirmukha

sukshma chidra through which Sweda is excreted out of 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 skin41.

Twacha & Upadhatu Relation:

All Dhatus have their own Upadhatus, Vasa and Shat – Twacha are Upadhatu

of Mamsadhatu42.

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 evapouration of Sweda outside the body43.

02. Mamsavaha Srotasa:

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

mamsavaha Srotasa44. The viddha laxana of mamsavaha srotas leads to swayathu,

mamsa shotha, siragranthi and even marana.

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Twacha & Sara Relation:

Sara means the essence 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 Twaksara45. Twaksara person

have a fresh, lustrous, smooth skin with deep routed and tender hair46. According to

Charaka, Twaksara person is having unctuous smooth, soft, clear, fine, less numerous,

deep routed and tender hair47.

Twacha & Rogamarga Relation:

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

and Koshtha. Twacha is included in Shakha roga marga alongwith Rakta and other

dhatus. This comes in Bahya Rogamarga48.

Twacha & Prakruti 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.

Twak as Vranavastu

Acharya Charaka has given twak an important place in ashta vrana vasthus49.

Ayurvedic Review


Varna of twak

Susrutacharya opines that Tejas is the causative factor of complexion at the time

of conception.When tejas is associated with Ap dhatu it results in fair complexioned

child & with Prithvi,Krishna varna occurs .Tejas along with prithvi & akasha causes

Krishna shyama varna & with Aap & Akasa causes gaura shyama varna50.

Acharya Hareetha mentioned that the predominance of vata at the time of

conception causes syama varna,pitta causes gaura varna,Kapha causes snigdha

shyama varna for Krishna varna.Vata & Rakta & for pingala varna pitta& rakta

predominance is seen51.

The colour of the skin depends on deeds of previous life & also on

panchmahabhuta predominance.Teja predominantly associated with Aap &Akash

gives rise to gaura varna and that with prithvi & vayu causes Krishna varna while the

combination of these in equal pro portion causes syama varna in fetus52.

In the context Chaya & Prabha, Acharya charaka explains in Indriyasthana as

the chaya circumscribes the complexion of the body,where as prabha illuminates the

complexion53.Bhrajaka pitta situated in the Twak imparts the lusture & radiance of the

twak54.Rakta dhatu imparts the colour to the twak & mamsapusti ie nourishes the

mamsadhatu inthe body55.

Twak in Diseases

Twak in doshadusti

Vagbhatacharya says that vata when increased produces black discolouration,

impairment of sensory functions56. Pitta when increased causes yellow57 and Kapha

whitish discoloration of skin.In pitta kshaya there will be loss of prabha58.

Ayurvedic Review


In Udararoga

There will be visible veins (balivnasho jathare) on the abdomen region in the

purvarupa of udara59.

In the context of pandu & Kamala

There will be discoloration of the twak ranging from pandu, haridra & haritha

varna which pandu varna is the predominant colour.There will be roughness of skin &

absence of sweating.In kamala face, nails etc will occur60 yellow colour.

In the context of Poorvaroopa of Kusta

The skin becomes rough with excess or absence of sweat.There will be

pricking pain, itching and loss of sensation61

In the context of Vicharchika

Achatrya explains that, there will be increased itching sensation.Skin becomes

rough & there will be cracked lines in the hands and feet 62.

.

Modern Review


DISEASE REVIEW

Eczema:

The terms ‘Eczema’ & ‘Dermatitis’ are synonyms. They refer to distinctive

reaction patterns in the Skin, which can be either acute or chronic & are due to a

number of causes.

Definition –

Eczema is a specific type of Allergic cutaneous manifestation, which is

characterized by superficial inflammatory Oedema of epidermis associated with

vesicle formation, Itching & Redness.

General predisposing causes of eczema –

1. Age – Infancy, Puberty, Menopause

2. Family history – Familial sensitiveness is an important factor. There is usually

a personal/family history of Allergy.

3. Allergy – Asthma, Eczema, Hay fever, etc. genetic predisposition is

responsible for the disease in certain families.

4. Debility – Malfunctioning in immune regulation

5. Climate – Extreme heat, dampness or severe cold

6. Psychological factors – Responsible for hypersensitivity reaction.

7. Local factors-Hyperhydrosis, Varicose veins, etc.

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Exciting cause of Eczema

The following causes irritation & sensitizes the skin –

1. Chemicals – used in insecticide, fertilizer, oil, cement, etc.

2. Plants – Contact with various types of plants, which act either as irritant or

sensitizer is known as Phyto dermatitis. It usually occurs on the exposed part,

particularly the face & hands. Due to inhalant allergies from pollens may

cause acute recurrence of dermatitis on the head, neck, limbs, hands & even

parts covered by clothes.

E.g. Marking nuts, Cashew nuts, Euphorbia.

3. Clothing & Footwear – Common offending substances are clothes, rubber

chappals & footwear, spectacle frames, water straps, furs, suspenders, artificial

jewelleries, etc. severe itching & purparic dermatitis on the body. The

distribution of which is typical is caused by various clothing like terry cot,

nylon, etc. Rubber contact dermatitis is caused by the additive , Resins, Oils,

etc.

4. Cosmetics – Hair dyes, particularly the derivatives of paraphenylenediamine

& kumkum are the common. Hair oil, deodorants, nail paint & removers are

also responsible for allergic contact dermatitis.

5. Medicaments – Contact dermatitis caused by medicaments is common

complication in the treatment of skin disease, & is termed as dermatitis

medicamentosa. A cutaneous eruption that had developed from the use of a

drug systemically viz. by mouth, inhalation or parenterally. For e.g. –

Penicillin extract, Sulphonamides, Chlorthiazide, Methyldopa.

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6. Infections – Eczema resulting from sensitization to certain organisms like

streptococci, staphylococci, dermatophytes & yeast organisms is known as

infective eczema or infections eczematoid dermatitis.

7. Diet & Digestion – Spices, condiments, tea, coffee & alcohol taken in excess

amount causes predisposition to allergic conditions & dermatosis. Indigestion

also aggravates skin disease.

8. Focal sepsis – Internal septic focus shedding toxins or causing bactereamia are

also exciting cause of Eczema.

Classification of Eczema;

1. Etiological classification Eczema

Exogenous Endogenous

Irritant(contact) Allergic

Atopic Seborrhoeic Discoid Pompholyx Asteatotic Stasis Neuro

The morphological classifications are, (Clinical)

1. Acute.

2. Subacute. &

3. Chronic stage.

• The acute stage is characterized by itchy erythema followed by oedema, papules,

vesicles, oozing & crusting. Most of the typical eczemas of moderate intensity

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stats with these morphological fetures. it lasts for maximum two weeks & then

lesions starts to heal

• The sub-acute stage, characterized by papules & scaling with moderate oedema

& erythema. Acute eczema may pass through this stage before it heals

complitetely or becomes chronic.

• The chronic stage: The eczema lasts over months or years, it becomes chronic,

characterized by thickened skin & pigmented with prominent criss-cross

markings (lichenification). This is end result of all types of long-standing

eczemas.

Contact dermatitis (chemical eczema)

It develops within a few hours after contact with the offending agent (allergen

to which the patient is potentially hypersensitive).

Features

Eruption develops briskly, spreading far beyond the original point of contact.

Eruption has ill-defined margin, fading at the periphery.

Brisk oedema & uniform vesiculation.

Usually occurs on the exposed parts.

It is mainly due to following causes –

• Plants

• Clothing & footwear

• Cosmetics

• Occupational chemicals

• Medicaments

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Contact Allergic Eczema

This is due to a delayed hyper sensitivity reaction following contact with

antigens or haptens. Previous exposure to the allergen is required for sensitization &

the reaction is specific to the allergen or closely related chemicals.

The Eczema reaction occurs wherever the allergen contacts the skin &

sensitization persists indefinitely. It is important to determine the original site of the

rash before secondary spread obscures the picture, as this often provides the best clue

to the contactant. There are many easily recognisable patterns, e.g. –

Eczema of ear lobes, wrists & back due to contact with nickel in costume,

jewellery, Eczema of the hands & wrists due to rubber gloves. Oedema of the lax skin

of the eyelids & genitalia is a frequent concomitant of allergic contact eczema.

Industries commonly affected – workers in various trades are prone to skin eruptions.

Infectious Eczematoid Dermatitis

This type of Eczema results from sensitization to certain organisms like

streptococci, staphylococci, dermatophytes & yeast.

Infective Eczema can be divided further into three sub types.

a. Post traumatic infective eczema

It starts with a crack in the skin brought on by an injury, blister, an insect bite,

etc. This gets infected, sensitization results in eczematization & a well defined

circular or oral patch of eczema consisting of erythema, oozing & crusting is

formed. If there are several patches, the intervening skin is completely clear.

Modern Review


b. Follicular infective eczema

It involves hairy regions like the scalp, beard & legs. When it occurs on the

scalp, it is often labelles as seborrhoeic dermatitis. It starts, usually with

pityriasis capitus which gets complicated by one or several itchy patches of

oozing, pits & crusting. The eczema spreads to the forehead, retro-circular

folds & cheeks.

c. Flexural infective eczema

The flexures are the sites of preditection, common examples, the neck folds,

the axillae, and the bends of elbows, the groins & the popliteal fossae. It starts

with a crack in the depth of the fold, & the two opposing surfaces are equally

affected like the leaves of a book. The inner part looks moist & red, only at

periphery is crusting clearly evident. In the groin, it usually complicates

simple intertrigo, oozing & crusting are added to the redness & maceration of

intertrigo.

Infantile Eczema

This occurs in children between the age of 3 months & 2 years. The exact

classification of infantile eczema is not well established but there is general belief that

there are 2 types of infantile eczema –

1. With high familial predisposition to an allergic disease – the atopic variety

2. Without familial predisposition – the simple variety

Dietetic allergies may also play an important role in the causation & infants

who are over fed, & are too rapidly introduced to adult food stuffs, frequently

suffer from infantile eczema.

Modern Review


Atopic Eczema

Atopy is a genetic predisposition to form excessive IgE which leads to a

generalized & prolonged hypersensitivity to common environmental antigens,

including pollen & the house dust mite. Atopic individuals manifest one or more of a

group of diseases that includes asthma, hay fever, urticaria, food & other allergies, &

this distinctive form of eczema.

Etiology

Atopic disease show maternal imprinting i.e. they are inherited more often

from the mother than from the father. The prevalence of atopic eczema is increasing

& has increased between 2 to 5 fold over the last 30 years. It now affects 1 in 10

school children.

Environmental factors such as exposure to allergens have been shown to have

a role in the etiology of atopic eczema.

Diagnosis criteria for Atopic Eczema

Itchy skin & at least three of the following –

♦ History of itch in skin creases (or cheek if <4 years)

♦ History of Asthma/hay fever (or in 1st degree relative if <4 years)

♦ Dry skin

♦ Visible flexural eczema (cheeks, forehead, outer limbs in <4 years)

♦ Onset in first 2 years of life.

Modern Review


Atopic Eczema – Distribution & Character of Rash

Infancy – The eczema is often acute & involve the face & trunk

The napkin area is frequently spread

Childhood – The rash settles on the backs of the knees, fronts of the elbows,

wrists and ankles.

Adults – The face & trunk are once more involved; lichenification is common

Disseminated (Eczematides)

It is characterized by tiny, papular, vesicular & occasionally bullies crusted

lesions occurring singly or in small patches resulting from sensitization to the

products of primary active eczema being conveyed by the blood stream to distinct

sites producing dissemination of the eczematous process. This process is called auto-

sensitization, brought on particularly by the use of strong medicament, irritants or

sensitizers applied to the primary eczematous site.

Pompholyx (Dyshidrotic)

Recurrent vesicles & bullae occur on the palms, palmar surface of the fingers

& soles & are excruciatingly itchy. This form of eczema can occur in atopic eczema

& in the exogenous eczema. It can be provoked by heat, stress & nickel ingestion in a

nickel – sensitive patient but is often idiopathic.

Discoid Eczema

This is a common form of eczema recognized by discrete coin-shaped lesions

of eczema associated with alcohol excess, & of elderly men. It can occur in children

with atopic eczema & tends to be more stubborn to treat.

Modern Review


Seborrheic eczema

Seborrheic eczema is a very common chronic dermatosis characterized by

redness & scaling & occurring in regions where the sebaceous glands are most active,

such as the face & scalp,& in the body folds. In infancy this type of eczema starts as

cradle cap on the scalp which develops in to slight exudation & thick crusting. This

eczema spreads from the scalp to the auricular region, the periphery of the face &

neck.

Varicose dermatitis

This is simply traumatic, chemical or infective eczema complicating varicose

veins or ulcers of the legs. Itching in varicose legs may start eczema by excoriation,

secondary infection & by the use of medicaments, in this the dorsum of the foot &

lower part of the leg show telangiectosis, oedema & pigmentation.

Asteatotic Eczema

This is frequently seen in the hospitalized elders, especially when the skin is

dry. Low humidity caused by central heating, over washing & diuretics are

contributory factors. It occurs most often on the lower legs as a rippled or crazy

poving pattern of fine fissuring on an erythematous background.

Gravitational (Stasis) Eczema

This occurs on the lower legs & is often associated with signs of venous

insufficiency (oedema red or bluish discoloration. Loss of hair indurations,

haemosiderin pigmentation & ulceration).

Modern Review


Photodermatitis

Dermatitis in this condition is confined to the exposed parts of the body viz

face, neck, ‘V’ of the chest, hands & external surface of the fore arms & dorsa of feet

& the adjoining parts of legs. The integument is sensitive to sunlight & ultraviolet

rays.

Neurodermatitis

(Synonym – Lichen simplex chronicus)

Affecting more commonly neurotic people, this condition may be defined as

the lichenification process resulting from chronic scratching & rubbing of the skin

under stress & anxiety. The condition is common amongst young people &

menopausal women. These patients tend to tear off their skin when they cannot get at

others for social reasons. Any emotional conflicts particularly those arising from sex,

financial & social problems may initiate itching, scratching produces further irritation,

& a vicious cycle is established resulting in Lichenification.

Modern Review


Histology of eczema

In acute eczema.

Epidermal changes.

1. Inter cellular oedema-Spongiosis. (With associated lymphocyte exocytosis).

2. Intraepidermal vesicles-seen.

3. Mononuclear perivascular infiltration-seen.

4. Thickening of the epidermis-acanthosis seen

5. Parakeratosis seen.

In chronic eczema- 1.Acanthosis

2. Hyperkeratosis

3. Mononuclear cell infiltration.

Dermal changes; in both acute & chronic dermatitis.

Vasodilatation, perivascular infiltration seen.

Acanthosis: Increased thickness of prickle cell layer, the results of

hyperplasia, (often with hypertrophy) of the prickle cell.

Hyperkeratosis: Excessive formation of keratin, resulting the horny

layer being thicker than is normal for the skin of the area affected.

Parakeratosis: An abnormal form of Keratinization in this condition

granular layer of the epidermis is disappear.

Modern Review


Prognosis in Eczema:

Dermatitis & Eczema are, as a rule, curable conditions. Eczemas are non-infective

except when they are impetiginized & of the infective variety. They do not leave

scars. The patient needs reassurance of these points.

It must be remembered that epidermis is an ectodermal structure, & so, takes time

to heal. Patient must be watched; energetic treatment is to be strongly discouraged.

Once warned, the patient will readily co-operate.

Acute eczemas heal readily, in about 1- 4 weeks, with treatment. Chronic

eczemas, in which anatomical & functional changes set in, take time to disappear.

Disseminated & generalized eczemas are not only slow to heal, but are accompanied

by ill health .infantile & atopic eczemas are troublesome & uncomfortable. The

former lasts till the age of two unless it develops into atopic eczema which may

continue till the age of twenty five or even through life. Its course is marked by

spontaneous remissions & exacerbation. Climatic extremes, psychotic stresses & poor

health, aggravate dermatitis & eczema. The cure of conditions is related in tropical

countries, by heat, humidity & prevalent unhygienic conditions.

Fig.No.5 Showing Irritant contact Eczema.

‐

Fig.No.6.Showing Atopic Infantile Eczema

Fig.No.7 Showing Seborrheic Eczema of Scalp

Fig.No.8 Showing Dishydrotic Eczema of Sole

‐

Fig. No.11 Histology of Eczema.

Modern Review

MODERN REVIEW

Fig. no. 1 Integumentary system

INTEGUMENTARY SYSTEM

The skin is a largest organ in the human body in surface area & weight. It is the

general covering of the entire external surface of the body including external auditory

meatus & the outer surface of tympanic membrane. It contains the peripheral sensory

nerve endings. The human skin shows wide regional variation in structure like

scalp,face,palms & soles etc.


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Modern Review

Types of skin69:

Hairy skin/hirsute/thin skin: This type of skin will be hairy with sebaceous

glands. Here the epidermal layers are thin, Stratum spinosum & granulosum is usually

identifiable but Stratum corneum is thinner & stratum lucidum is usually lacking.The

contour of the dermo epidermal junction is less than that of thick skin.

Non hairy/Thick skin : Thick skin requires number of sweat glands for

sustained cooling activity. Their keratinized layer is thicker but lacks of sebaceous

glands. The non hairy skin areas are palm, soles, etc.

Surface irregularities of skin70:

The skin is marked by three types of surface irregularities –

The tension lines, the flexure lines, & papillary ridges.

Tension lines : These are the network of linear furrows which divide the surface in

to polygonal shaped areas; these some extent corresponds to variations in the pattern

of fibers in the dermis.

Flexure lines : These are permanent lines along which the skin folds during

habitual movements of the joints..The skin is thin along these lines& firmly bounds to

the deep fascia, these lines are prominent opposite the flexure lines of the joints,

particularly on the palms, soles & digits.

34

Papillary ridges : These are confined to palms, soles & their digits. They forms

narrow ridges separated by fine parallel grooves, they correspond to patterns of

dermal papillae. Three major patterns in the human finger prints include loops, whorls


Modern Review

& arches. The pattern of papillary ridges particularly those of fingers &thumb are

morphologically stable throughout the life & different in different individuals.

HISTOLOGY OF NORMAL SKIN:

The skin is composed of three distinct layers,

1. Epidermis,

2. Dermis, &

3. Hypodermis.

Epidermis :

It is the outermost layer of the skin, in the most of the regions of the body

epidermis is varies in the thickness, from about 0.04 mm on the eyelid to 1.6 mm on

the palms with an average thickness of less than 0.17mm in most areas except for

those areas chronically exposed to pressure & friction.

Epidermis is composed of keratinized Stratified squamous epithelium, highly

impermeable to water & has high capacity for degeneration after damage. It has no

vascular supply of its own & for its nourishment it has to depend on dermis.

35

Epidermis is structurally formed by a superficial cornified zone & a deep

germinative layer. In the germinative layer new cells are constantly being reproduced,

& they push older cells to the surface.As the skin cells move away from their source

of nourishment,they become flatten & shrink, loose their nuclei. As they move from

germinative layer to horny layer they turn into a lifeless protein called Keratin, after

serving a brief protective function, the keratinocytes are imperceptibly sloughed off

.This process of living cells evolution called keratinization takes about four weeks71.


Modern Review

Cells of epidermis :

Epidermis is formed by two main types of cells,

Keratinocytes & dendritic cells.

Dendritic cells of epidermis are Melanocytes, Langerhans cells & Merkel cells.

Keratinocytes : 90%

90% of epidermal cells are keratinocytes & are held together by desmosomes.

They produce a protein called keratin; these substances helps water proof & protect

the skin & underlying tissues from light, heat, microbes, & many chemicals. Keratin

consists of more than 40 insoluble proteins that serve as units for the formation of

intermediate filament polymers, the later constituting a major network in the

cytoplasm of keratocytes72.

Keratinocytes posses intercellular bridges & ample amount of stainable

cytoplasm.The major proliferative population of keratocytes is housed in the lowest

part of the viable epidermis.The proliferative compartment that is the two lower

rows of keratocytes in a normal epidermis,has a cell cycle of 13 days,the reneval time

of normal epidermis has been estimated to be about 26 days,divided approximately as

13 days time it takes viable keratocytes to travel from the base of the epidermis to the

cornified layer,& another 13 days for the time it takes dead keratocytes to be shed at

last73.

Melanocytes : 8%

Melanocytes are dendritic cells & produce pigment melanin,which is responcible

for skin colour & absorb UV light & shield the genetic material from damaging by


36

Modern Review

UV .The ratio of Melanocytes in the basal layer of epidermis varies from 1:4 to 1:10

depending on the rigion of body.

Melanocytes posses long slender projections called dendrites extend between

keratinocytes vescicles containing multiple melanosomes are pinched off from the

tips of melanocyte dendrites & transfer granules of melanin to keratinocytes.Due to

this transfer melanocytes may contain less melanin then keratinocytes.The difference

in skin colour are mainly due to difference in type & amount of skin colour from

sunlight is due to the rapid movement of melanin into keratinocytes & also due to

additional melanin synthesis by UV light74.

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 abserving ultraviolet.

Fig. no. 2 Melanocyte and Melanin


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Modern Review

Langerhans cells :

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.

Langerhans cells are stellete in forms & contain small membrane bounded granules

of unusual shape called Birbeck granules. Its nucleus is irregular & lack bundles of

keratin desmosomes are also absent.

These cells are similar to that of ‘T’ lymphocytes & macrophages & participate in

the immune response of the body. They also occur in other stratified squamous

epithelium including those of oral cavity, esophagus & vagina75.

The cross sectional appearance of langerhans cells granules is like in shape of

tennis racket.

Fig.no.3.Langerhans cell.


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Modern Review

Merkel cells:

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”

They are more abundant in areas such as finger tips which has important role in

sensory reception. The naked terminals of mylinated afferent nerves end in opposition

to these cells forming merkel cell neurite complexes.

Merkel cells are non pigmented dedrosides cytoplasmic dense core granules, and

also interact with separates T cells in assisting with immune response. Endothelial

cells are not found since the epidermis lack of blood vessels. Nutrient delivery and

waste transport are by diffusion. There are capillary networks in the papillary dermis

which provide this function76.

The names of 5 layers of epidermis from deepest to the most superficial are77:

(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


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Modern Review

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-thron like or prickly):

This layer contains of prickle cells, it lies above the basal layer & contains 8-

10 closely fitted rows of polyhedral cells. Cells of this layer connected each other by

spine like protoplasmic projections. This is composed of several layers of polyhedral

cells. They contain the precursors of the epidermal lipids in the form of disk like lipid

bilayer membranes. A prominent feature of these cells is the presence bundles of

keratin filaments that radiate from the perinuclear region & end in numerous

desmosomes along the boundary between the adjacent cells.

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

This layer is also known as granular layer. It comprises 3 to 4 layers of flattened

cells. That develops darkly staining granules of a substance called keratohyline. In

this layer, keratin & 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. They do not have limiting membranes and may be incorporated in there

periphery.

4) Stratum lucidum (lucidus- clear):

This is clear layer as it is highly refractive it is found in thick palmo-planter skin

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

This layer consists of 3-5 layers of clear, flat dead cells that contain droplets

intermediate substance eledin, which is eventually transformed to keratin this is a

translucent, thin layer of cells.


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Modern Review

5) Stratum chorneum(chorneum- horny):

It is known as horny layer. It is uppermost layer of epidermis. 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 chorneum serves as an effective barrier against light, heat, bacteria &

many chemicals.

The names of 5 layers of epidermis from deepest to the most superficial are77:

Fig. no. 4 .Shows Layers of Epidermis from deepest to the most superficial.


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Modern Review

Dermis:

It is a second inner layer of the skin. The dermis composed of connective

tissue containing collagen, elastic fibres & ground substance, in which nerve, blood

vessels, lymph vessels, muscles & sebaceous apocrine & ecrine sweat units are

embedded. The mature dermis also contains a variety of cells scattered freely such as

macrophages, fibroblasts, mast cells, histocytes, langerhans cells, lymphocytes & very

rarely esinophils. Plasma cells are not seen in normal dermis anywhere except muco-

cutaneous junction.

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.

Besides elastic fibers & collagen, the dermis contains the extra fibrilar matrix,

which is extra cellular & composed of a complex mixture of proteoglycan,

glycoproteins ,glycosaminoglycans ,water & hyaluronic acid. The most significant

glycosaminoglycans ,which bind proteins to form the protioglycans of the skin , or

chondroitin sulphate ,dermatin sulphate ,keratin suphate, heparinsulphate , heparin

,versican & perlecan .These are involved in assuring the tightness of skin78 .

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 fibers, which provides strength & elasticity to the dermis


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Modern Review

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.

Papillary layer:

This is immediately deep to the epidermis. It forms about 1/5th of total dermis,

it consists of areolar connective tissue containing fine elastic fibers & provides

mechanical metabolic support to overlying tissue.

Its superficial surface is marked by small finger like projections called dermal

papillae. These papillae indent the epidermis & may contain loops of capillaries, some

contains tactile receptors & nerve endings those are sensitive to touch .Dermal

papillae of the thick skin caused ridges in the overlying epidermis79.

Reticular layer:

This is the deep aspect of the papillary layer. Consists of dense, irregular

connective tissue containing interlacing bundles of collagen fibers arranged in an

orthogonal pattern. The reticular fibers are special type of very thin collagen fibers, &

are found entwined among collagen bundles. In histopathological sections they appear

fragmented, spaces between fibers are occupied by hair follicles, nerves, oilglands,

ducts of sweat glands & a small amount of adipose tissue. The combination of

collagen & elastic fibers in the reticular layer allows strength & flexibility in every

direction80.


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Modern Review

Dermo-epidermal junction:

The interphase between the dermis & epidermis & also epidermal appendages’

forms dermo-epidermal junction. It can be divided into 4 zones.First one is epidermal

portion which includes intermediate filaments hemidesmosal plaques & plasma

membrane of basal keratinocytes.Basal portion of Lamina Lucida is the second layer

which is electrolucent & the electron dense zone called lamina densa is the third layer

which lie parallel & contiguous to lamina lucida. It is composed of type 4 collagen

fibers & other antigenic components. The fourth zone is Sub lamina densa, it have the

curved structure, the anchoring fibrils whose one end is attached to lamina dense &

the other end to the papillary dermis. Each of these zones has specific structures,

biochemical composition & functional properties81.

Hypodermis :

44

The hypodermis is the innermost layer of the skin. It attaches with the reticular layer

of the dermis to underlying organs such as bone & muscle. It is composed of type of

cells specialized in accumulating & storing fats, known as adipocytes.The

hypodermis acts as an energy reservoir. The fat which is accumulated in the

adipocytes can be put back into the circulation by venous route .When there is lack of

energy providing substance to the body then they convert into energy. The

hypodermis passively participate in thermoregulation since fat is a heat insulator. The

hypodermis is distributed all over the body but it has a tendency to accumulate over

the abdomen & shoulders in men, & below the waist, around the thighs, hips &

buttocks in women. The hypodermis contains loosely arranged elastic fibers, fibrous

bands anchoring the skin to the deep fascia & fat, except in the eyelids, penis,

scrotum, nipple & areola82.


Modern Review

Appendages of skin :

Skin has different types of appendages, principally hairs, sebaceous glands,

sweat glands & nails which are derived from surface epithelium.

Hair – These are highly modified keratinized structures produced by hair follicles

which are essentially cylindrical down growths of surface epithelium ensheathed by

collagenous tissue. Each hair has a medulla, cortex, and cuticle. The medulla in the

centre contains soft keratin and air. The cortex, the innermost thickest layer, has the

pigment that gives hair color. The cuticle, the outermost layer, has cells that overlap

like scales. Both the cuticle and cortex have hard keratin.

The hair root in a hair follicle is embedded beneath the skin. The hair shaft

protrudes from the skin. Hair sheds and is replaced constantly during growth and rest

phases. Hair has a protective function, eyebrows keep sweat from running into the

eyes, nose and ear hairs filter dust from the air, and scalp hairs protect against

abrasion and overexposure to sun rays.

In addition to generating the hair shaft, the hair follicle provides a protective

niche to several stem cell populations in the skin, including keratinocyte stem cells,

melanocyte stem cells, a population of epidermal neural crest stem cells, and the

dermal stem cell compartment, known as the dermal papilla. These stem cells are

required most visibly during wound healing.

Hair follicles extend into the dermis; the deep ends expanded parts are called

hair bulbs. A papilla protrudes into the hair bulb and provides nutrients for the

growing hair. The hair follicle walls have an inner epithelial root sheath and an outer

dermal root sheath. The epithelial root sheath has an inner and an outer layer that thins


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Modern Review

as it approaches the hair bulb. It becomes the matrix, the actively growing part of the

hair bulb that produces the hair.Arrector pili muscles are smooth muscle cells attached

to hair follicles. When they contract, they pull the hair into an upright position,

causing skin dimples (goose bumps). The sympathetic nervous system regulates these

muscles; cold temperatures or fright can activate them.83

Nails – These are flattened elastic structures of a horny texture placed on the distal

parts of the dorsal surfaces of the fingers and toes. The nail is divided into six specific

parts - the root, nail bed, nail plate, eponychium (cuticle), perionychium, and

hyponychium.

The root of the fingernail (germinal matrix) actually lies beneath the skin

behind the fingernail and extends several millimeters into the finger. The fingernail

root produces most of the volume of the nail and the nail bed. This portion of the nail

does not have any melanocytes, or melanin producing cells. The edge of the germinal

matrix is seen as a white, crescent shaped structure called the lunula.

The nail bed that extends from the edge of the germinal matrix to the

hyponychium. The nail bed contains the blood vessels, nerves, and melanocytes. As

the nail is produced by the root, it streams down along the nail bed, which adds

material to the undersurface of the nail making it thicker. It is important for normal

nail growth that the nail bed be smooth. If it is not, the nail may split or develop

grooves that can be cosmetically unappealing.

46

The nail plate is the actual fingernail, made of translucent keratin. The pink

appearance of the nail comes from the blood vessels underneath the nail. The

underneath surface of the nail plate has grooves along the length of the nail that help

anchor it to the nail bed.


Modern Review

Eponychium is the cuticle of the fingernail. The cuticle is situated between the

skin of the finger and the nail plate fusing these structures together and providing a

waterproof barrier. The perioncyhium is the skin that overlies the nail plate on its

sides. The perionychium is the site of hangnails, ingrown nails, and an infection of the

skin called paronychia. The hyponychium is the area between the nail plate and the

fingertip. It is the junction between the free edge of the nail and the skin of the

fingertip, also providing a waterproof barrier.84

Sweat Glands

They occur in almost every part of the skin. There are two kinds of sweat

glands which differ greatly in both the composition of the sweat and its purpose-

Eccerine sweat glands are exocrine glands distributed over the entire body

surface but are particularly abundant on the palms of hands, soles of feet, and on the

forehead. Each consists of a single tube, the deep part of which is coiled into an oval

or spherical ball which is situated in the deeper layers of corium or in subcutaneous

tissue. These are merocrine in nature as they produce sweat that is composed chiefly

of water with various salts without demonstrable cell disintegration.

The primary function is body temperature regulation. The sweat glands are

controlled by sympathetic cholinergic nerves which are controlled by a center in the

hypothalamus. The hypothalamus senses core temperature directly, and also has input

from temperature receptors in the skin and modifies the sweat output, along with other

thermoregulatory processes.85

Apocrine glands are mainly present in the armpits, eyelids, areola nipple of

breast and around the genital area. They are larger than eccerine sweat glands and


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Modern Review

produce thick secretion. In females they show involution changes related to each

menstrual cycle. They are developed in close association with hairs and their ducts

typically open into the distal end of hair follicles. The secretion of glands varies with

their anatomical position .In some areas of the body, these sweat glands are modified

to produce wholly different secretions, including the cerumen of the outer ear.

Mammary glands are apocrine glands modified to produce milk.86

Sebaceous Glands

They are small sacculated glands lodged in the substance of dermis .They

occur in most parts of the dermis especially in scalp ,face, apertures of ear, nose,

mouth and anus but absent in palms of hands and soles of feet.

Each gland consists of a single duct which emerges from a cluster of oval or

piriform alveoli .Each alveolus is composed of a basement membrane enclosing a

number of epithelial cells. Outer cells are continuous with the cells lining the duct.The

remainder is filled with larger cells containing fat, but in the centre the cells are

broken up leaving acavity filled with their debris and a mass of fatty matter, which

constitutes sebum cutaneum.

As the sebaceous glands produce their secretion by complete fatty

degeneration of their central cells they are classed as holocrine glands. Ducts open

most frequently into hair follicles. It also opens into general surface as in labia

minora, glans penis and margins of lips .Sebum acts as a lubricant of the hair and skin

protecting skin from the effect of moisture or dessication and hairs from becoming

brittle.It also have some bactericidal action.Its secretory activity is controlled by

hormones particularly androgens.87


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Modern Review

Embryology of skin 88:

The skin is derived from three diverse components.

(a) The epidermis is derived from the surface ectoderm. This is at first single

layered, the ectoderm cells proliferate to give rise to typical stratified

squamous epithelium. Many of superficial layers are shed off. These get

mixed up with secretions of sebaceous glands to form a whitish sticky

substance (vernix caseosa) which covers the skin of the newborn

infant.

(b) Epidermal ridges develop between the third & fifth months of fetal age .Soon,

there after characteristic patterns (whorls, loop & arch) are formed on the tips

of fingers & toes. The patterns are genetically determined & are different for

each person.

(c) Melanoblasts of the epidermis are derived from the neural crest.

(d) Cells of Markel & Langerhans appear in the epidermis between 8 & 12 weeks

of intrauterine life.

(e) The dermis is formed by condensation & differentiation of mesenchyme

underlying the surface ectoderm. This mesenchyme is believed to be derived

from the dermatome of somites.

(f) Nails –develop from the surface ectoderm.

(g) Hair –also derived from surface ectoderm.

(h) Sebaceous gland-is formed as a bud arising from ectoderm cells.


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Modern Review

(i) Sweat gland –develop as a down growth from the epidermis, first it was solid

later canalized. The lower end of the down growth becomes coiled & forms

the secretary part of the gland.

Blood supply of skin89 :

Blood enters the skin from the underlying muscles & sub cutis via small

perforating arterioles which form an anastomosing horizontal reticular plexus

at the interface between cutis & dermis. From this plexus, some arterioles pass

deeply to supply the adipose tissue, sweat glands & hair follicles.

The other arterioles pass superficially giving off anastomotic collaterals

to glands & hair follicles & form a second major horizontal plexus, at the

junction of the reticular & papillary dermis, the papillary plexus. Capillaries

from this plexus loop into the dermal papillae. Usually one loop per papilla &

the loops drain into a superficial venous plexus intertwined with the arteriolar

papillary plexus. This venous plexus in turn drains into a flat intermediate

plexus. In the reticular layer which further drains into a deeper plexus,

receiving from capillary beds surrounding glands & hair follicles &closely

associated with the arteriolar plexus.

In the deeper layers of dermis arteriovenus anastomosis are common in

glabrous skin, some of these are surrounded by thick sphincter like group of

smooth muscle &pursue a convoluted course & are called glomera. These non

striated muscle elements are under autonomic control. So heat exchange can

be regulated by vasoconstriction of afferent arterioles of the general cutaneous


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Modern Review

supply. The arteriovenus anastomoses provide for a deep circulation in the

skin under thermal conditions which might otherwise reduce blood supply of

the skin to dangerous levels.

Lymphatic drainage of skin90:

Numerous lymphatic vessels terminate in the dermis & drain deeply first

into a dermal network in the papillary layer & finally in to a network at the

junction of dermis &superficial fascia. Deep to this zone the lymph flows

through wider channels provided with valves into main lymphatic area. The

lymphatic drainage of skin is quite profuse & free anastomosis appears to

occur between vessels at all levels.

Innervations of skin91:

Skin is a major sensory surface & has a rich nerve supply by mylinated &

non mylinated sensory nerve fibers of cerebrospinal & autonomic nerves.

Cutaneous nerves sense provides us with a wealth of information about

the external environment & its interactions with the skin. The afferent and

efferent nerve endings penetrate the superficial fascia & ramify through the

reticular & papillary layers of the dermis .conspicuous nerve plexuses are

formed around hair follicles & in the papillary layer of dermis beneath the heat

loss in epithelium.

An array of cutaneous receptors carries information concerning various

stimuli, their duration & their spatial & temporal patterning. The highly

branched mylinated & non mylinated free terminals which end within the


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dermis & lower layer of epidermis acts as an important sensory component.

They may be mechano, chemo, thermo & nociceptors in all types of skin.

Colour of the skin92:

Melanin, carotene & hemoglobin are three pigments that give skin a

wide verity of colors.

The amount of pigment in the skin is determined by the amount of

melanin being produced by the body. Cutaneous pigmentation is the outcome

of two important events.

The synthesis of melanin by melanocytes & the transfer of melanosomes to

surrounding keratinocytes.

The number of melanocytes in human skin of all types is constant, but the

number, size & the way in which the melanosomes are distributed within

keratinocytes vary. The melanin content of human melanocytes is

heterogeneous not only between the different skin types but also between

different sites of the skin from the same indvisual. This hetrogenicity is highly

regulated by gene expression, which controls the overall activity & expression

of melanosomal proteins within individual melanocytes. These distinct

patterns of melanosome type & distribution are present at birth & and are not

determined by external factors (sun exposure). They are responsible for the

wide variety of skin complexion.

The epidermis consists of two types of cells melanocytes &

keratinocytes . The skin colour of various races is determined mainly by the


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number of melanin contents & distribution of melanosomes produced &

transferred by each melanocyte to a cluster of keratinocytes surrounding it.

The second main determinant of skin colour is the oxygenated

hemoglobin of the dermal vascular bed particularly the superficial papillary

plexus. These of course viewed through the overlying epidermis whose

surface layer scatter reflect some of the light & is somewhat opalescent, giving

well oxygenated skin a pink colour. Where less oxygenated blood is present a

bluish hue results.

Skin colour is dependent on blood flow also varies with ambient temperature ,

exercise ,emotional state ,hemoglobin content of the blood & various other

features often affected by general health.

The skin & the immune system93:

Skin provides protection from foreign invaders in several ways, apart from

the physical barrier there are specialized cells of immune system. Some of

these cells detect invasion by foreign proteins such as bacteria or viruses &

other cells have the function of destroying & removing such materials.

When an antigen comes in contact with cells of the immune system these

cells produce antibodies that fit around the invading antigen in a unique way.

The antibody antigen combination is recognized by other cells within the

immune system family, which then move & destroys the invader. In the type

of immune reaction called mast cells, these contain powerful signaling

chemicals such as histamine which, when released activate the other

component of the immune system.


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Histamine has marked local effect on the skin. At the contact site the

skin swells & become red ,due to opening up of the blood vessels & leakage

in to the tissues from within the blood vessels & the lymphatic system

surrounding the contact site of skin blood vessels contract restricting the flow

of blood & so causing the skin to pale ‘wheel & flare’ reaction.

These usually act over longer time scales. In allergic contact dermatitis

for example it takes two or three days for the immune system cells to

recognize the presence of the irritation & to recruit more cells locally to deal

with the situation. Such a delay makes it harder to work out what caused the

allergic reaction in the first place.

The principle task of immune system is to protect the host by eliminating

or neutralizing foreign molecules. The epidermis is a site of antigen entry &

destruction. It also contains cells which participate in the initiation &

regulation of immune response. These include psoriasis, cancer & eczema.

Specialized cells called langerhans cells present in the epidermis, present

antigen to T lymphocytes & can initiate antigen specific immune responses.

Keratinocytes are capable of secreting a wide verity of immunomodulating

cytokines that can regulate many immune responses. T –cells are not usually

present in the epidermis, arriving when mediated by langerhans cells &

cytokines. The epidermis is a formidable barrier both physically & chemically.

Its PH controls the presence & balance of microbes on its surface to further

inhibit dangerous inhabitation.

Thermoregulation of the skin94:


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The skin contributes to thermoregulation, the haemostatic regulation of

body temperature, in two ways by liberating sweat at its surface and by

adjusting the flow of blood in the dermis. In response to high environmental

temperature or heat produced by exercise , the evaporation of sweat from the

skin surface helps lower body temperature in response to low environmental

temperature, production of sweat is decreased which helps conserve heat.

During moderate exercise, the flow of blood through skin increases which

increases the amount of heat radiated from the body.

The dermis houses an extensive network of blood vessels that carry 8-

10% of the

total blood flow in a resting adult, for this reason the skin acts as a blood

reservoir.

During very strenuous exercise, however skin blood vessels constrict

somewhat, diverting more blood to contracting the skeletal muscle & the

heart. Because of this shunting of blood away from the skin, however, less

heat is lost from the skin & body temperature tends to rise.

Skin in Different Ages95

Skin of the Neonate and Infants

Epidermal appendages and dermo-epidermal junction are anatomically fully

developed in the full term neonate. The main difference between neonatal and adult

skin is the presence of vernix caseosa and the structure of dermis. The total thickness

of the dermis of the neonate is lesser than that in adult. The secretion of sebaceous


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Modern Review

glands contributes to Vernix caseosa.. It dries rapidly and starts to flake off within a

few hours after birth, this consists of lipids that may protect the skin from infection.

Skin and Menopause

There are no specific structural changes in the skin after menopause. But dry

skin, thinning of the epidermis and dermis and loss of dermal elasticity may be

occurring due to low circulating estrogen.

Skin in Old Age

The epidermis becomes thinner on non light exposed sites with the passing of

years. The permeability of the skin also changes with the age. The individual

keratinocytes shrink with age. Blood vessels decrease in number but thicken with age.

The main structural changes are observed in the dermis of aged skin. Dermal

connective tissue loses much of its proteoglycan ground substance and collagen fibers

become mainly tough, insoluble and hevily cross linked. The irregularity of

pigmentation, sensory perception decreases and the threshold for pain increases with

ageing.

Skin and Pregnancy

During pregnancy alterations in the appearance of the skin are hyper pigmentation in

areas which are already pigmented, particularly the nipples, areola, and genital areas.

Dark areas appear symmetrically across the cheeks, around the eyes and forehead

giving a mask like appearance the chloasma or melasma. The nails often turn

brittle.Striae gravidarum are commonly seen in this time.

Physiology of skin96:


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1. Protection - skin protects the body from mechanical injuries,

bacterial infections, heat & cold, wet & drought, acid & alkali & the

actinic rays of the sun.

2. Sensory - skin is sensory to touch, pain & temperature.

3. Regulation of body temperature - heat is lost through evaporation of

sweat & heat is conserved by the fat & hair.

4. Absorption - oily substances are freely absorbed by the skin.

5. Secretion - skin secrets sweat & sebum.

6. Excretion - the excess of water, salts & waste products are excreted

through the sweat.

7. Regulation of PH - a good amount of acid is excreted through the

sweat.

8. Synthesis - in the skin vita-D is synthesized from ergestrol by the

action of ultraviolet rays of the sun.

9. Storage - skin stores the chlorides.

10. Reparative - the cuts & wounds of the skin are quickly healed.


57

a

Sl.No. OPD No. Date Name of

Patient Age Sex occupation Address Prakruti Diet Varna Vedana Kandu Daha Area of predilection

Shyava Rakta Sweta Scalp Face hands Palms Trunk legs foots foldings

rt lt rt lt rt lt rt lt

1 30058 22/7/10 Kanteppa 39 M Labour Bhalki VP V - + - + + + - - - - - - - + - + - -

2 30261 23/7/10 Abdul 42 M Labour Bidar VP RM - + - + + + - - - - - - - + + - - -

3 30531 25/7/10 Nawaz 19 M Labour Bhalki VPK RM - + - - + + + + + + + + + + + + + +

4 30611 26/7/10 Ramchandra 45 M Teacher Nittur VP IRM + - - + - + + + - - - - - - - - - -

5 30762 28/7/10 Sheela 19 F Student Bidar VPK V - + - - + + - + - - - - - + - - - +

6 31346 30/7/10 Manikappa 65 M Labour Bidar VK RM - - + + + - - - - - - - - + - - - -

7 31463 30/7/10 Usha 34 F House wife Hallikhed PK V + - - - + + - - + - - - - - - - - -

8 31539 31/7/10 Rajanikant 36 M Labour Rajgira PK V - - + - + + - - - - - - - + + - - +

9 31850 08/01/2010 Vijay 35 M Technision Nagur VK RM + - - + + - - - + - - - - - - - - -

10 32234 08/04/2010 Kavya 34 F House wife Chitta VP IRM - + - + - + - - + - - - - - - - - -

11 32335 08/06/2010 Pachayya 54 M Farmer Santapur VPK V - + - - + + - - - - - - - - + - - -

12 32250 08/08/2010 Rajkumar 36 M Milk Man Chitta VP IRM + - - + + + - - - - - - - - - + + -

13 32635 08/09/2010 Gopal 40 M Teacher Aurad VP RM - - - + - + - + + + - - - - - - - +

14 32986 08/11/2010 Mallamma 19 F House wife Aurad VK IRM + - - + + + - - + + - - - - - - - -

15 33113 08/12/2010 Dropati 22 F House wife Santapur VPK IRM - + - + - + - - + + - - - - - - - -

16 33234 13/8/2010 Rayappa 48 M Labour Bhalki VP IRM + - - + - + - - - - - - - + + - - +

17 33313 14/82010 Vimalabai 75 F House wife Halhalli VP V + - - + - + - - - - - - - + + - - +

18 33412 15/8/2010 Sanjeev 48 M Labour Chitta VK IRM - - + + + - - - - - - - - - + - - -

19 33510 16/8/2010 Sangamma 42 F House wife Halli VP V - + - + - + + + - - - - - - - - - +

20 33763 17/8/2010 Prabhakar 38 M employee Bidar PK RM + + - - + - - - - - - - - + - - - -

21 33976 19/8/2010 Kamalabai 44 F House wife Bidar VP IRM - - - + - + + + - - - - - - - - - +

22 34958 26/8/2010 Kailash 44 M Labour Santapur VP IRM + - - + + + - - - - - - - - - + - -

23 35167 28/8/2010 Veena 19 F worker Myloor VP IRM + - - + - + - - - - + + - - - - - -

24 35763 09/01/2010 Devidas 44 M worker Myloor PK RM - + + - + - - - - - - - - - + - - -

25 35696 09/02/2010 Annapurna 20 F Worker Bidar PK IRM + - - + + + - - + + - - - - - - - -

26 36321 09/03/2010 Veeresh 22 M Labour Bidar VPK IRM - + - + + - - - - - - - - - - + - -

27 36768 09/07/2010 Sulochana 31 F House wife Bidar VP IRM + - - - + + - - - - - - - - - + - -

28 36605 09/07/2010 Rachappa 34 M Labour Bidar VPK RM - + - - + + + + - - - - - - - - - -

29 37036 09/10/2010 Vishwanath 60 M Farmer Bidar VPK IRM - - + - + - - - - - - - - + - - - -

30 37174 09/11/2010 Parameshw 44 M peon Bidar VP S - + - + - + - - + - - - - - - - - -

Master Chart

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