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Introduction

Ahiputana is most common disorder affecting the developing infants mentioned in Ayurvedic text classics.Ahiputana is kapharakta predominant childhood disorder mentioned in ayurvedic classics.1,2,3 It occur due to the improper cleaning after defecation, urination, excessive, sweating unhygienic condition leads to itching in gudapradesh produce eruption with srava.2 Napkin Rash is a similar clinical condition told in the contemporary science which is caused by to unhygienic conditions and use of diapers. Diaper rash is one of the most common skin disorders in infants and children. The reported incidence and age of onset vary worldwide, related to differences in diaper use, toilet training, hygiene, and child-rearing practices in different countries. In Pediatric Practice, diaper rash represents 10 to 20 percent of all skin disorders evaluated by the general pediatricians .According to the 1990-1997 National Ambulatory Medical Care Survey, there were 8.2 million pediatric visits for diaper rash, and the calculated risk of developing diaper rash throughout childhood was one in four. In infants, the estimated prevalence of diaper rash ranges from 7 to 35 percent.4 Diaper rash can develop as early as  one week of age, but the peak incidence occurs between 9 and 12 months.5 Many drugs are mentioned for internal use, for external application and preventive measures have been described in detail in Ayurvedic Samhithas and Modern Science to overcome Ahiputana/Napkin Rash. So, a remedy which would be easy to follow, efficacious, cost effective and free from all side effects should be adopted. In all the allopathic medications (ointments) Zinc Oxide is a main content used for treating Napkin Rash.6,7 Triphala Khadira Kwath Dhawan8 is mentioned in the Bhaishajaratanavali which contains drugs like Amalaki, Haritaki, Bibhitaki, and Khadir which are having khaphaghna, pittaghna, vranaropak and raktashodhak properties. Therefore, an attempt is made to Study the clinical evaluation of Triphala Khadira Kwath Dhawan in Ahiputana w.s.r. to Napkin Rash in children.

AIMS & OBJECTIVES

To evaluate the clinical efficacy of Triphala Kwath Dhawan in Ahiputana

MATERIALS AND METHODS:

Sample size: 30 patients Drug: Triphala Khadir Kwath Dhawan.

Duration: 7 days

Frequency: Twice a day

STUDY DURATION: Total 7 days

TIME OF ASSESSMENT: 3rd day and 7th day

Sources of Data

The patients: A 30 Children attending to OPD of Kaumarbhritya, Padma Ayuvedic hospital Terdal with complaint of fulfilling the criteria of selection.

Table no.1 The composition of trial drug:

No.	Drug	Latin name	Part Used
1	Amalaki	Emblica officinalis	Phala
2	Haritaki	Terminalia chebula	Phala
3	Bibhitaki	Terminalia bellerika	Phala
4	Khadir	Acacia catechu	Twak

METHOD OF COLLECTION OF DATA:

A special proforma (CRF-Case report form) was made by taking clinical history from patients. Subjective and objective parameters were included in case report form and it will be documented before treatment and after treatment.

STUDY DESIGN: An open label clinical study.

SAMPLE SIZE: Total 30 patients diagnosed with  Ahiputana  were  selected  randomly.

INCLUSIVE CRITERIA

Children of age group of 6 month to 1 year diagnosed as the case of Ahiputana/Napkin Rash with the presenting Symptoms like Kandu, Ruja, Raga, Srava and Pitika and  symptoms of Ahiputana/Napkin Rash not more than 10 days.

EXCLUSION CRITERIA

Children suffering from any other systemic disorders e.g. acute  gastro  enteritis with dehydration, Helminthic infection, Lactogen intolerance, etc Ahiputana with secondary infection Singalized skin infection.

SUBJECTIVE PARAMETERS :

Kandu (Itching ) :

• No kandu-               0
• Mild (No disturbance while doing work ) 1
• Moderate ( Disturbs the Work )    2
• Severe ( Disturbs the sleep )                  3

Raga (Erythema ) :

• Normal skin colour - 0

•Mild redness- 1

•Moderate red - 2

•Severe / Deep brown- 3

Pidaka (No Eruption ) :

•No pidaka -0

•1 to 2 pidika - 1

•3 to  4 pidika -3

•More than 4 pidika - 4

Daha( Burning sensation ) :

•No daha -1

•Mild daha-2

•Moderate daha -3

•Severe daha-4

Srava( Discharge):

•No discharge -1

•Dropping-2

•Staining-3

•Scanty-4

Distribution- Shape distribution with sparing of genitocrural fold:

No rash-0

Perianal region-1

Perianal an buttocks-2

Perianal, buttocks genitalia-3

Tide mark dermatitis

•Area affected by rash

•Nil

•1 to 2 cm

•2 to 3 cm

•3 to 5 cm

Observation & Results:

Age:In this study among 30 patients 12 patients (40%) belonged to the age group of below 6 –  8 months, 10 patients (33%) belonged to the age group of 10-12 months, and 8 patients (27%) belonged to 8-10 months. The incidence is higher during 6-8 month of age group mainly because its weaning time and child may easily prone for infection and number  stool episode is more during this time .

Diet:The study revealed that, all patients were belonging to vegetarian diet (100%). Study was conducted only for the maximum age of one year so there is no mixed or non vegetarian food.

Discussion on Results

Kandu(Itching):Kandu is mainly due to stanikkapha dusti. Triphalakhadir having laghu, ruksha, guna and kashaya rasa causes stanikkapha shaman and relives the kandu.

Daha (burning sensation):

Burning sensation of patient can be because of two causes either daha or due to itching. dahais always aggravated by pitta and itching by due to stanikkapha. The tikta kashaya rasa of khadir cuses kapha shaman and and Sheet viryaof khadir causes daha shaman.

Raga (Erythema):

Erythema is associated with raktadusti. Tiktarasa having raktadustinashak properties, Tikta kashayarasatmak khadir and triphala normalize the stanikrakta prakop in this way reduces the redness of skin and achive normal skin colour.

Srava(Exudation)

Srava is mainly due to kaphadoshavikruti haritaki, bibhitaki having ushna virya, ruksha guna and kashaya rasa which are kaphashamak property. All these together causes kaphashaman and reduces srava.

Pitika:

Pitika caused by the stanikrakta pitta dushti, pittashamak properties of all contents of triphala and khadir also normalize stanikraktaprakop as pitta and rakta having ashrayashrayisambhandha. Hence helps in reduction of pitika and achieve normal skin.Among the 30 patients 18 patients shown Good Improvement i.e. more than 75% relief from the treatment and 12 patients showed that Marked Improvement i.e. improvement between 50-74.9%. The overall result of the therapy ‘TriphalaKhadirDhawan’ has shown good results in all the diagnostic parameters of the disease Ahiputana. After giving treatment to 30 patients with Triphala Khadir kwath Dhawan, the normal skin texture was achieved in all 30 patients aftertreatment. All the signs and symptoms of Ahiputanagot subsided on 7th day of treatment. After treating Ahiputana with Triphala Khadir Dhawan the affected area  got  gone astray after treatment in all 30 patients.

On Kandu before the treatment the mean score was 1.50 and reduced to 0.36 after the treatment and this change that occurred with the treatment, is statistically highly  significant (P<0.01). The values of standard deviation, standard error of Mean, ‘t’ value,   P values are given above in the table.

On  Daha  before the treatment  the  mean  score  was 1.63  and  reduced  to  0.43  after the treatment  and  this  change  that  occurred  with  the  treatment,  is  statistically significant (P<0.01). The values of standard deviation, standard error of Mean, ‘t’ value, P values are given above in the table.

On Skin colour before the treatment the mean score was 1.66 and reduced to 0.46 after the treatment and this change that occurred with the treatment, is statistically significant (P<0.01). The values of standard deviation, standard error of Mean, ‘t’ value, P values are given above in the table.

On  distribution-W  shape  distribution with sparing  of  genitocrural  folds  before the treatment  the  mean  score  was  1.06  and  reduced  to  0.26  after  the  treatment  and  this change  that  occurred with  the  treatment, is  statistically significant (P<0.01). The  values of standard deviation, standard error of Mean, ‘t’ value, P values are given above in the table.

On Tide mark dermatitis before the treatment the mean score was 1.56 and reduced to 0.43 after the treatment and this change that occurred with the treatment, is statistically significant (P<0.01). The values of standard deviation, standard error of Mean, ‘t’ value, P values are given above in the table.

On  Pitika  before the  treatment  the  mean score  was 1.26  and reduced to  0.33  after the treatment  and  this  change  that  occurred  with  the  treatment,  is  statistically significant  (P<0.01). The values of standard deviation, standard error of Mean, ‘t’ value, P values are given above in the table.

On  Srava before the treatment  the mean  score  was  1.33 and reduced  to  0.36  after   the treatment  and  this  change  that  occurred  with  the  treatment,  is  statistically significant (P<0.01). The values of standard deviation, standard error of Mean, ‘t’ value, P values are given above in the table.

table

table

Observation & Results:

Age:In this study among 30 patients 12 patients (40%) belonged to the age group of below 6 –  8 months, 10 patients (33%) belonged to the age group of 10-12 months, and 8 patients (27%) belonged to 8-10 months. The incidence is higher during 6-8 month of age group mainly because its weaning time and child may easily prone for infection and number  stool episode is more during this time .

Diet:The study revealed that, all patients were belonging to vegetarian diet (100%). Study was conducted only for the maximum age of one year so there is no mixed or non vegetarian food.

Discussion on Results

Kandu(Itching):Kandu is mainly due to stanikkapha dusti. Triphalakhadir having laghu, ruksha, guna and kashaya rasa causes stanikkapha shaman and relives the kandu.

Daha (burning sensation):

Burning sensation of patient can be because of two causes either daha or due to itching. dahais always aggravated by pitta and itching by due to stanikkapha. The tikta kashaya rasa of khadir cuses kapha shaman and and Sheet viryaof khadir causes daha shaman.

Raga (Erythema):

Erythema is associated with raktadusti. Tiktarasa having raktadustinashak properties, Tikta kashayarasatmak khadir and triphala normalize the stanikrakta prakop in this way reduces the redness of skin and achive normal skin colour.

Srava(Exudation)

Srava is mainly due to kaphadoshavikruti haritaki, bibhitaki having ushna virya, ruksha guna and kashaya rasa which are kaphashamak property. All these together causes kaphashaman and reduces srava.

Pitika:

Pitika caused by the stanikrakta pitta dushti, pittashamak properties of all contents of triphala and khadir also normalize stanikraktaprakop as pitta and rakta having ashrayashrayisambhandha. Hence helps in reduction of pitika and achieve normal skin. Among the 30 patients 18 patients shown Good Improvement i.e. more than 75% relief from the treatment and 12 patients showed that Marked Improvement i.e. improvement between 50-74.9%. The overall result of the therapy ‘TriphalaKhadirDhawan’ has shown good results in all the diagnostic parameters of the disease Ahiputana. After giving treatment to 30 patients with Triphala Khadir kwath Dhawan, the normal skin texture was achieved in all 30 patients aftertreatment. All the signs and symptoms of Ahiputanagot subsided on 7th day of treatment. After treating Ahiputana with Triphala Khadir Dhawan the affected area  got  gone astray after treatment in all 30 patients.

Discussion

Khadir is having tikta, kashaya rasa, sitavirya alleviates pitta kapha.acharya charak mentione it as best kusthaharadravya.It has also properties of switraghna, kandugnha, kusthgna, krimihara. Khadir is known to have antibacterial and antifungal properties that inhibit the growth of bacteria and fungi that cause most of the skin problems. The presence of catecnin (flavonoids) ,catechu tannic acid  ,tennis  a  chemical composition present in khadir it causes contraction of skin cells and a reduction in the inflammation of the surrounding areas of the wound. There by khadir helps for better absorption. Kashaya rasa of  khadir  holds twakprasaak and  rhaktashodak  properties  which ultimately leads raktaprasadaan and reduction of vaivarnyata of skin.Drug used in study mainly Triphala that is Haritaki, Bibhithaki , Amalki mainly this drug contains kashaya Tikta predominant Rasa and this are having Vranaropaka , Raktakapha shaman guna, it exibhit sangarahi,shasirkledaupyukta and lekhangun as which is esssential for healing. Triphalakwath contains active compound in them such has Gallic acid,Chebulini acid, Ellagic acid,Favanoids,,Tannins and plyphenols which are responsible for its anti- inflammatory, antiviral, antibacterial, antioxidant properties. It improves circulation and possesses astringent property. It fasten the healing process. According to Ayurveda, it has krimighna and Vronaropan properties. It does not have side effects such as itching, allergy, blisters like that of modern antibiotics. In ahiputana vitiated kapha and raktadoshas increases local temperature and inflammation which does not allow bandaging.They should only be treated with prakshalayet(cleaned out) twice daily.  Dhawanawhich  is one of the forms  prakshalana  will  clean out the kledain ahiputana by Kashaya rasa  and rukshagunaof triphala. The symptoms such as rough skin, rashes, blisters, itchiness, irritation, burning, inflammation, and Sravacan be treated by cleaning the affected skin with Triphala Khadir Kwath (decoction). These Khadir and Triphala are easily available, cost-effective drugs.

Conclusion

Considering the observations and results, the present study approves alternative hypothesis. From this study we can conclude that Ahiputana is more commonly seen in patient of age between 6 months to 1-year babies. This treatment in ahiputana is found to be cost effective ,safe ,and easy implement in general practice. Triphala and khadir drugs are easily available easy to prepare and easy to use. Among the 30 patients 18 patients showed Good Improvement i.e., more than 75% relief from the treatment and 12 patients showed that Marked Improvement i.e., improvement between 50-74.9%. The overall result of the therapy ‘Triphala Khadir Dhawan’ has shown good results in all the diagnostic parameters of the disease Ahiputana/Napkin Rash. The conclusions may not be applied as universal because of small sample size and short time for study. Present study pattern can be contributed in the form of prospective clinical study with increased sample size. Other drug mentioned for Ahiputana can be selected for comparative study with Triphala khadir kwathdhawan.