ACNE VULGARIS IN AYURVEDA- A REVIEW

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1 INTERNATIONAL AYURVEDIC MEDICAL JOURNAL International Ayurvedic Medical Journal, (ISSN: ) (August, 2017) 5(8) ACNE VULGARIS IN AYURVEDA- A REVIEW Pandey Krishna Kant 1, Tripathi Arun Kumar 2 1 MD (Panchkarma), Chief Consultant, Renature- Superspeciality Ayuveda, Haldwani, Uttarakhand, India 2 Professor / Director, Ayurvedic & Unani Services, Uttarakhand Govt., Dehradun, Uttarakhand, India kkpandey.dr@gmail.com ABSTRACT Acne vulgaris is one of the most prevalent skin disorder found in adolescent age group around the world. In Ayurvedic texts, disease has been described by the name of Mukhadūṣikā or Yuvānpiḍikā. No description of the disease is present in Ayurvedic text Caraka Samhitā but Ācārya Suśruta in Suśruta Samhitā has described the disease under KṣudraRoga chapter. Kapha, Vāta and Rakta are vitiated during the pathogenesis of the disease and form Śālmalī thorns like lesion over face. Alvulgaris descrip- though described in short, symptoms resemble very closely with the modern acne tion. Regarding the treatment, Abhyanga, Vamana, Nasya, Raktamokṣana are indicated for the man- texts for the agement of the disease. Various Lepana drugs are also mentioned in different Ayurvedic treatment. Keywords: Acne Vulgaris, Mukhadūṣikā, Yuvānpiḍikā, Ayurveda, KṣudraRoga INTRODUCTION Acne vulgaris is one of the most commonly seen diseases in adolescence. It is a chronic inflammatory disease of pilo-sebaceous units characterized by the development of com- and less edones in forms of papules, pustules commonly nodules. Approximately 95% to 100% of adolescent boys and 83% to 85% of adolescent girls aged 16 to 17 years are afflicted with this disease. 1 Although, Acne itself is not life threatening, it causes a severe distress to the human psyche. This disease causes a severe psychosocial bur- the stigma on den in the patients, displaying their skin for the world to seee and criticize on a daily basis. Between 30% and 50% of ado- difficulties lescent experience psychological associated with acne, including concern about their body image, embarrassment, social im- anger, pairment, anxiety, frustration, depres-

2 sion, and poor self-esteem 2. Acne not only causes emotional distress, but also the anxiety evoked by acne aggravates the skin condition, thereby creating a vicious cycle. 3 In Āyurveda, a very similar description is given is by Āyurvedic stalwarts by the name of Mukhadūṣikā, due to its nature of deteriorating the beauty of one s face. As the disease is seen in adolescent age group, Yuvānpiḍikā term is also given by the Ācāryas. SuśrutaSamhitā is the first Āyurveda text to explain Mukhadūṣikā. This disease is mentioned in most of the texts as Kṣudra-roga. ĀcāryaSuśruta have mentioned the vitiation of Vāyu, Kapha and Rakta in the pathology of the disease 4. ĀcāryaVāgbhatta has mentioned the role of Meda in the pathology of Mukhadūṣikā which resembles the modern theory of sebum involvement in the pathogenesis of acne. In this paper, all the etiological factors, pathogenesis and treatment modalities mentioned in the Ayurvedic texts are reviewed in a systematic way. METHODOLOGY References were collected from the classical Ayurvedic texts including the Bruhattrayīgrantha i.e. Caraka Samhitā, Suśruta Samhitā, Aṣtānga Hṛudaya. LITERARY REVIEW Description of the disease:- In Caraka Samhitā [1000 B.C.], there is no description of any disease by the name of Mukhadūṣikā/ Yuvānpiḍikā. Although in Sutra Sthāna Tristreṣhnīya Adhyāya, Piḍikā is described as BāhyaMargāśritaRoga. 5 In Triśothīya Adhyāya, Ācārya Caraka has mentioned that the vitiated Pitta in Tvaka & Rakta produces a reddish Śotha called Piḍikā. 6 In Suśruta Samhitā ( B.C.), Kṣudraroga Nidāna Adhyāya there is description of Mukhadūṣikā under Kṣudra-roga 4 which correlates with the modern acne vulgaris description. In Aṣtānga Sangraha (6 th Century), a description similar to Suśruta Samhitā is present, by the name of Yuvānpiḍikā. 7 In Aṣtānga Hṛudaya (7 th Century), Mukhadūṣikā 8 is described with symptomatology similar to Acne Vulgaris. In HāritaSamhitā (1000 B.C.), description of Mukhadūṣikā same as that of Suśruta is found. Mādhava Nidāna (7th Century) also followed Acharya Suśruta for disease description under KṣudraRoga 9. In Śārṅgadhara Samhitā: (13 th century), Vaktra-Snigdhatā & Piḍikā mentioned at last as the mala of ŚukraDhātu. 10 A short description of Yuvānpiḍikā is also given 11 while describing the Kṣudra-roga. In Yoga-Ratnākara (1600 A.D.), Kṣudra-roga Nidāna Cikitsā Adhyāya, there is a brief description of symptomatology along with treatment of Yuvānpiḍikā. 12 On summarizing, some Ācārya have mentioned the disease by the name of Mukhadūṣikā while others have called it Yuvānpiḍikā. Following description is found regarding the disease in different Samhitā:- श णत 4 IAMJ: AUGUST,

3 The eruptions like Śālmalī thorn, on the face during adolescence caused by vitiated Kapha, Vāta and Rakta are known as Mukhadūṣikā. प ट 8 The painful and nodular eruptions filled with Meda (sebum) inside are known as Mukhadūṣikā. 8 य न म नन य व नन, 13 According to ĀcāryaDalhan, the Piḍikā which occurs specifically in adolescent age group or Yuvāvasthā (Adolescence)are known as Yuvānpiḍikā. As the disease causes disfigurement of face, therefore in Ayurvedic texts Mukhadūṣikā name is given to the disease. There are no specific etiological factors mentioned regarding the disease in the Āyurveda texts. Only Kapha, Vāta and Rakta are said to be involved in the pathology. 1. This explains the site of the disease and the age in which it occurs. Disease occurs in the face i.e. cheeks, chin, nose and forehead. It is seen in the youth i.e. adolescent age group. 2. It explains the shape of the Piḍikā. ŚālmalīKantaka has a conical shape. In most of the patients, shape of the Piḍikā is found to be conical. 3. प ट This indicates that Piḍikāof Mukhadūṣikāare painful in nature. But in patients it varies from mild tenderness to unbearable pain. 4. घन This explains the consistency of Piḍikā. The Piḍikā are thick, hard and indurated. This can be due to the KaphaDoṣa involvement in the disease. 5. This is specifically said by Ācārya Vāgbhatta which correlates with modern description of acne. It says that the Piḍikā are filled with medaand modern pathology also explains blockage of ducts due to sebum. Other than these symptoms, Doṣika symptoms like Kandū (itching), Dāha (burning), Pāka (pus formation), Śotha (swelling), Srāva (discharge), Vaivarnyatā (discoloration)are also seen in the disease. IAMJ: AUGUST,

4 Hypothetical Samprāpti: Description of the treatment:- Instead of oral medications, majority of Ayurmentioned vedic classical texts have mainly the Śodhana Cikitsā (purification processes) and Lepa (local face packs) for the disease. Ācārya Suśruta has mentioned Vamanakarma (Emesis) for Yuvānpiḍikā. 14 AṣtāngaSangraha has indicated Lepana, (local application of face packs) Vamana and Sirāvedha (bloodletting) for Yuvānpiḍikā. While in Aṣtānga Hṛudaya, Nasya (errhine therapy) along with Lepana, Vamana and Sirāvedha is indicated for the treatment. 15 So the treatment can be summarized as:- Table 1: SuśrutaSamhitā AṣtāngaSangraha AṣtāngaHṛudaya Cakradatta Ācārya Cakrapāṇi in his textt Cakradatta, has mentioned Sirāvedha, Lepana, Vamana and Abhyanga (local massage) along with various Lepa like SiddārthakādiLepaa and Lodhrādi- Lepa for the treatment of Yuvānpiḍikā. 16 ĀcāryaŚārṅgadhara has described various Le- 18 pa for the treatment of Yuvānpiḍikā. In YogaRatnākara, Treatment mentioned is similar to Cakradatta i.e. Siravedha, Pralepa, Abhyanga. 19 Vamana, Lepana Lepana, Vamana, Sirāvedha Lepana, Vamana, Nasya, Sirāvedha Sirāvedha, Lepana, Vamana, Abhyanga 17 IAMJ: AUGUST,

5 Yoga-Ratnākara DISCUSSION There are no specific etiological factors mentioned regarding the disease in the Āyurveda texts. Only Kapha, vātaand Rakta are said to be involved in the pathology. Ācārya Caraka has stated involvement of vitiated Pitta along with Rakta in pathophysiology of Piḍikā 6. So involvement of Pitta can also be considered here. As Medogarbhatā (filling Meda inside the Piḍikā) is one of the symptoms of the disease, the causative factors which vitiate Meda can also be incorporated as Nidāna of Mukhadūṣikā. In Bhāvapṛākaśa, Svabhāva 20 is mentioned as the cause of the disease. In support of this context, it should be noted that ĀcāryaCaraka has stated that during thefirst half of childhood stage Dhātu are in Aparipakvāvasthā (immature phase), while in second half of childhood stage where adolescent ( Tārunya) phase is started, Dhātu gradually increases (Vivardhamāna) 21, which may cause an instability and can give rise to certain ailments which occurs due to Svabhāva of Dhātu variation. Ācārya Śārṅgadhara has quoted that Vaktra- Snigdhatā and Yuvānpiḍikā are Śukra Dhātu s waste product (Mala) 22 which also supports the Svabhāva theory because during above said age ŚukraDhātu starts to appear. Thus all the etiological factors which vitiate Vāta, Pitta and KaphaDoṣa along with the vitiation of Rasa, Rakta and MedaDhātu can be considered as the culprit for causing the disease. Sirāvedha, Lepana, Abhyanga Āyurveda texts have described the Vāta, Kapha and Rakta as the chief culprit Doṣa responsible for the disease, although Raktaja/Pittaja symptoms are found to be more pronounced in the patients. As Piḍikā is the chief complaint found in the patients, which is a Rakta-DuṣtiLakṣana. 23 ĀcāryaVāgbhatta has given a term Medogarbhā Piḍikā which can be assumed to be a lesion with whitish tinge or a lesion filled with Meda like substance i.e. sebum. This can be correlated with the modern description of acne lesion. i.e a closed comedone filled with sebum or a pustule. ĀcāryaSuśruta has described the Piḍikā like Śālmalī-Kantaka. As Śālmalī-Kantaka suggests a Piḍikā with semi-solid/solid consistency which correlates it with acne lesion- papule or nodule. A Śālmalī-Kantaka like Piḍikā is suggestive of a lesion filled with Pūya(pus) but in Apakvāvasthā, which shows involvement of Kapha as ĀcāryaSuśruta has told that Pūya is not possible without Kapha 24. Thus, this lesion can be correlated with papule (if small) or nodule (if large). And when this Piḍikā becomes pakva due to the involvement of Pitta, as ĀcāryaSuśrutahas mentioned that Pākais not possible without Pitta,this can be correlated with a pustule (if small) or cyst (if large). Other than Piḍikā and Rujā 28 no other signs or symptoms of Mukhadūṣikā are found in the Āyurveda texts while modern medical science has explained few associated symptoms found in the disease like itching, discoloration, pain, swelling, discharge etc. As Āyurveda advocates the use of Yukti in undescribed condi- IAMJ: AUGUST,

6 tions, all these symptoms are obvious due to the involvement of vitiated Vāta, Pitta and Kapha in the disease. As per Ayurvedic theory, vitiation of Vata causes Rujā (pain), water discharge and scar formation while vitiation of Pitta causes Pāka (Inflammation)and Dāha (Burning sensation) causes Blackish discoloration (ŚyāvaVarna) of skin occurs due to vitiated Vāta. 25 Discoloration is also caused by vitiated Pitta because Pitta is responsible for imparting different colors to the skin. 26 Vitiation of Kapha can lead to the formation of Pūya (Pus formation), Śotha (Swelling), Kleda/Snigdhatā (Oiliness), GhanaSrāva (thick discharge)and Kandū (Itching). All these symptoms correlate Mukhadūṣikā with Acne vulgaris. Regarding the treatment, Ācāryas have mentioned Vamana, Nasya and Raktamokṣana as Śodhana therapy in the treatment of Mukhadūṣikā. Both ĀcāryaSuśruta and Vāgbhatta have indicated Vamana Karma to cure the disease because Kaphais one of the main Doṣa involved the pathogenesis and to remove vitiated Kapha from the body, Vamana in best therapeutic modality. While, according to Ācārya Vāgbhatta, Meda which is the Dūṣya involved in the pathogenesis, is also Kaphasadharmi(properties similar to Kapha). Therefore, Vamana Karma, which primarily eliminates Kapha, is justified as the treatment. ĀcāryaVāgbhatta has indicated NasyaKarma for the treatment of Mukhadūṣikā. As Nasya Karma is preferred in Ūrdhva- JatrugataVikāra, 27 (disease occurring above clavicle) which can be a reason for its indication in Mukhadūṣikā, a Ūrdhva- JatrugataVikāra. ĀcāryaVāgbhatta and Cakrapāṇi have mentioned Raktamokṣana as a treatment for Mukhadūṣikā. Ācārya Caraka has opined Raktamokṣana in all the Raktaja diseases, while ĀcāryaSuśruta as mentioned it in various Kṣudra-Roga too. Arundatta has indicated Sirāvedha of Lalāta region 28, where frontal and temporal veins are found. As Rakta is one of the Doṣa/Dūṣya involved in the formation of Samprāpti (pathogenesis), its removal is possible only through Raktamokṣana. Raktmoksana (bloodletting) is the preferred way of treatment in Raktaj disorders as per Ayurvedic texts. Raktamokṣana removes the vitiated blood and clears the Srotāvarodha (blockage in channels), thus breaking the Samprāpti. There are various methods explained in the Samhitās for the Rakta-śodhana. However, In Mukhadūṣikā, Ācārya have indicated Sirāvedha (phlebotomy)as the preferred Raktamokṣana method. But most the patient of the Mukhadūṣikā used to be of adolescent age group and of female sex, which belongs to SukumāraPṛakṛiti (tender nature)and Siravedha being a Śastra Karma(surgical method) is not easily accepted by them as preferred treatment modality. Ācāryas have also indicated Jalaukāvacārana (Leech application) for blood letting in strī (female), bhīru (frightened) and SukumāraPṛakṛiti (tender nature or those who can t bear pain). Ācārya Suśruta has even termed Jalaukāvacārana as Parama SukumāraVidhi (most uncomplicated me- IAMJ: AUGUST,

7 thod) of Raktamokṣana. 29 Therefore, Jalaukāvacārana being the easiest and almost painless method, can be used as a preferred way of Raktamokṣana in Mukhadūṣikā. Āyurveda texts have mentioned numerous of external medications for Mukhadūṣikā and other kṣudra-roga. SiddārthakādiLepa, LodhrādiLepa, ŚālmalīKantakaLepa, VataśungādiLepa are few examples. These Lepa consists of various UṣnaVīrya (hot) and Rakta-Prasādaka ( blood cleanser) herbs which helps in pacifying the aggravated Vāta, Kapha and Rakta after absorption of their Vīrya (potent part) through the Romakūpa and Śirāmukha present over the skin pores. 30 CONCLUSION Thus from the above data, it can be concluded that although described in few verses in the Ayurvedic texts, Mukhadūṣikā, has a strong resemblance with Acne Vulgaris with Vāta, Kapha and Rakta along with Meda involvement in the etiopathology. And PanchkarmaChikitsā (especially Vamana, Nasya, and Raktamokṣana) & various Lepa can be used for the treatment of the disease. REFERENCES 1. Burton JL, Cunliffe WJ, Stafford I, et al. The prevalence of acne vulgaris in adolescence. Br J Dermatol 1971; 85(2): Baldwin HE. The interaction between acne vulgaris and the psyche. Cutis 2002; 70(2): Koblenzer CS. Psychodermatology of women. ClinDermatol 1997; 15(1): Suśruta, SuśrutaSamhitā with NibandhaSangraha commentary by Dalhanacharya, and the NyayacandrikaPaṅjika of Sri Gayadāsa Acharya, edited From the beginning to the 9thAdhyāya of Cikitsāsthāna by Vd. YadavajiTrikamji Acharya and the rest By Narayan Rama Acharya Kavyateertha, eighth edition, Published by ChaukhambaOrientalia, Varanasi, (2005); Nidānasthāna 13/39 Pg. no Agnivesha, Charaka, Charaka Samhita, ChakrapaniAyurvedDipikaVyakhya, edited by Dr. LakshmidharaDivedi, reprint ed. ChaukambhaKrishnadas Academy, Varanasi, 2013; Sutra Sthana, TristreṣhnīyaAdhyāya, 11/49, P N Agnivesha, Charaka, Charaka Samhita, Chakrapani Ayurved Dipika Vyakhya, edited by Dr. Lakshmidhara Divedi, reprint ed. Chaukambha Krishnadas Academy, Varanasi, 2013; Sutra Sthana, TriśothīyaAdhyāya, 18/24, P N Vāgbhatta, Aṣtānga Sangraha, Cikitsā Sthāna, Kṣudra-roga Pratiṣedha Adhyāya, 27/31 8. Vāgbhatta, AṣtāngaHṛudaya, with the commentaries, Sarvaṅgasundarā of Arundatta and Āyurvedarasāyana of Hemādri, Edited by Pt. Hari Sadashiva Shastri- Paradakara Bhisagacharya, Published by Chaukhamba Surbharati Prakashana, Varanasi, 2007, Uttara tantra, 31/5, Page Madhavakara. MadhavaNidanam with Madhu Kosha Sanskrit commentary by Shri. Vijayarakshita and ShrikantaDatta, with the Vidyotini Hindi commentary, edited by YadunandanaUpadhaya, Varanasi, IAMJ: AUGUST,

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