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Introduction

The word “Kushtha” has defined as “Kutsita Rupavarna”. Trivrutam (Shyama) has described as the most effective drug in the managementof Kushtha. Kushtha has described under the list of Kshetriya Roga.[1] The Charaka Samhita and Sushruta Samhita classify skin diseases into two categories. The MahaKushtha (Major) and Kshudrakushta (Minor). [2] According to classical texts, Vicharchika has cardinal symptoms i.e. Kandu (Excessive itching), Pidika (Vesicle/Boil/Pustule), Shyavata (Discoloration), Bahu-srava, (Profuse oozing), Lasikasrava, Raji (Marked lining/ Lichenification), Ruja (Pain), Rukshata (Excessive dryness). Vicharchika is Kapha pradhana tridoshaja vyadhi and Rasa (Twak), Rakta, Mamsa and Kleda (Ambu) are Dushya of it. The main causative factor for all the Roga is Agnimandhya. [3] some studies showed a higher prevalence of eczema in female and fungal infection in male in India. [4] Mostly 10-15% cases present before general practitioners referring to skin diseases and about 30% of all the skin diseases are eczematous. [5] Vicharchika (Eczema) is one of them & it is immense challenge due to its recurrence. Due to lack of physical exercise, unhygienic, mental stress, overeating, sedentary lifestyle Vicharchika is commonly observed in india. Ayurveda aims for the restoration of the equilibrium of the Dhatu, there are mainly three types of Chikitsa. The therapies that are comprehended under this are: Shodhana, Shamana, Nidana parivarjana

Etymology: [6] The word “Kushtha’ is derived from – ‘kush nishkarne’ which implies ‘to destroy’, ‘to scrap out’ or to deform, by adding the suffix ‘kta’ which stands for firmness or certainty. Thus, the word Kushtha means that which destroys with certainty. Bhavaprakasha has been commented that Vicharchika has been named, to stress its importance among Kshudra Kushtha.

Definition of Vicharchika: [7]        

The disease, which coats/covers the skin in particular manner, causes cracking of skin of hands and feet mainly. Eczema means distinctive reaction of the epidermis to a variety of agents, endogenous and/or exogenous, characterized clinically by itchy eruption, erythematous papules, oedema, vesicle, scaling, vesicles leading to weeping and/or lichenification, and histological evidence of spongiosis. [8] According to Charaka Vicharchika means         dark colour eruption with itching and profuse discharge. [9]According to Sushruta Samhita Vicharchika is a condition in which the skin has linear rough lesions with intense itching and pain but when the same symptoms appear at the feet alone, it is termed as "Vipadika".[10] According to Ashtanga Hridaya, Vicharchika the blackish eruptions with intense itching and watery discharge i.e. Lasikadhya is referred as Vicharchika. [11]

Site of Vicharchika:

Acharya Charaka has not mentioned any particular sites for precipitation for Vicharchika. However, Acharya Sushruta has mentioned 'Gatreshu’. Dalhana has commented that hare the word Gatra is used for Panipada. [12] According to Bhoja when twak dalana, kharata, rukshata occurs in pani, then it is said to be Vicharchika. If the same occurs in pada, then it is called as Vipadika.

Nidana Panchaka:

Nidana: As the detail description of Vicharchika is not available in the texts, only the symptom complex is mentioned, being a one of the Kushtha, the general description of Kushtha in terms of Nidana, Purvarupa, Upshaya/Anupshaya, Samprapti, Chikitsa and Upadrava may be consider for Vicharchika.

Mithya Ahara: Mithya Ahara is related with food articles, faulty food patterns and sequences, excessive intake of alcohol and psychological disturbance during meal.

Others Nidana: Some scattered references regarding Nidana of Kushtha are also found in the classics, which are as follows:

Samsargaja Hetu: [17] Kushtha is Aupasargika Roga and stated that Kushtha spreads from one Man to another due to Prasanga, Gatrasamsparsha, Nihishwasat, Sahabhojanat etc.

Kulaja Nidana: [18] Kulaja Nidana is due to Beejadushti. Sushruta has mentioned Kushtha as Adibalapravritta Vyadhi i.e. the original cause of the disease is attributed to defects of Shukra and/or Shonita. Sushruta has also explained that the children of Kushtha patients may also suffer from Kushtha.

Krimija Hetu: [19] Acharya Sushruta has mentioned that all types of Kushtha originate from Vata, Pitta, Kapha and Krimi.Charaka has also indicated that causative factors & treatment of Raktaja Krimi is as same as Kushtha.

PURVA RUPA [20] Vicharchika is a type of Kshudrakustha, so Purvarupa of Kustha can be considered as a Purvarupa of Vicharchika. Purvarupa Avastha is sign of Dosha Dushya Sammurchhana stage under the fourth Kriya Kala.

RUPA : Rupa are mentioned at 5th Kriyakala at Vyakti stage. Full manifestation of Vicharchika is mentioned various Ayurvedic classics which is being tabulated as follows :

1. Kandu: Kandu is produced by the vitiated Kapha dosha. It is a condition of severe itching and is most distressful symptom. Acharya Charaka has used the adjective "Sa" while Acharya Sushruta has used the adjective "Ati" with it, which indicates its severeness in the patient of Vicharchika

2. Pidika:  Charaka has been explained that, when the vitiated Pitta gets accumulated in Twacha and Rakta creates inflammation and redness then it is known as Pidika. "Peedayati Iti Pidika" i. e. Which causes pain In Vicharchika, generally the small circumscribed, easily palpable lesions are found in-groups.

3. Srava: Srava means discharge. Acharya Charaka has used the adjective "Bahu" meaning 'profuse discharge'. The vitiated Pitta and Kapha produce this. Vagbhatta has used the word Lasikadhya and Indu in his Shashilekha commentary defines it as 'Jalaprayah' meaning the nature of the discharge resembles to that of water Contrary to other Achryas, Sushruta has mentioned the "Rukshata" (dryness) in Vicharchika. Rukshata is the cardinal symptom of Vata. It seems if the Vata is dominant, the lesion will be dry, while in the dominance of Kapha or Pitta, it will be wet.

4. Shyava: Shyava means dark or blackish discoloration of skin. This is the characteristic feature of the lesions of Vicharchika, mentioned by all Acharyas except Sushruta. It is due to vitiated Vata.

5. Raji: Sushruta has described this symptom. Dalhana explained it as Rekha, means linings Scratching may produce linear markings. Moreover, in chronic cases rubbing scratching may produce lichenification, thickening and often some pigmentation of skin also. Raji is caused by vitiated Vata.

6. Ruja: Sushruta and Kashyapa have mentioned this symptom. Ruja means Vedana i. e. pain or irritation to the patient due to chronic nature of the disease. Ruja is the cardinal symptom of Vata.

7. Rukshata: Acharya Sushruta has mentioned it. This symptom is due to vitiated Vata. It indicates the dryness in the lesion.

8. Rakta: Rakta means redness in the lesion. It is produced by the vitiated Pitta. This symptom has been mentioned in Bhela Samhita. In Kashyapa Samhita, instead of Rakta, the word "Lohita" has been used.

9. Praklinna: Praklinna means wet. Due to continuous discharge the lesion becomes wet. This sign is mentioned only in Bhela Samhita, caused by vitiated Kapha and Pitta.

10. Vrana: This symptom has been mentioned in Kashyapa Samhita. Vrana means ulcerated lesion. Because of scratching Vrana may be created. This is due to vitiated Pitta.

11. Paka: This symptom has been mentioned in Kashyapa Samhita. Due to the infection in Vrana, purulent discharge may trickle. Paka is caused by vitiated Pitta.

Samprapti of Vicharchika

In classics, there is no separate description regarding the Samprapti of Vicharchika. But being a variety of Kushtha, the common Samprapti of Kushtha should be considered. Acharyas has given vivid description of Samprapti of Kushtha in general. According to Charaka Samprapti of Kushtha is as follows. By various causative factors as mentioned in Kushtha Nidana, all the three Doshas are simultaneously provoked; the four Dushyas (Twacha, Mansa,Rakta & Lasika) thin out or lose their tone. In these deranged four Dushyas, the provoked Doshas get located. This causes them to become vitiated and so the Kushtha or the skin disease is Produced. [31] According to Chakrapani Dutta, the vitiated Doshas, which become steady or stationary in the four Dushyas, they cause moving, which cause Visarpa. Acharya Sushruta has stated that the causative factors, which at first derange and aggravate Vata Dosha. This vitiated Vata takes hold of Pitta and Kapha which are also deranged & aggravated and throws them into the Tiryaka Siras through which displace them to the surface of the body. Wherever the thrown Dosha are deposited circular patches appear over the skin. If these vitiated Doshas are not brought into normalcy they penetrate deeper and deeper into the Dhatus. [32] Acharya Vagbhatta is of the view that the vitiated Doshas reach Tiryaga Siras. Then it passes to the skin, the Lasika, the Blood, and the Muscular tissue to make them deranged, weakened and then they pass on to the external surface of the patients body causing Kushtha[33]

Dosha: Vitiation of all the three Doshas simultaneously causes Kushtha. Though Vicharchika is also a Tridoshaja Vyadhi, but Acharyas hold a difference of opinion regarding the predominant Dosha. Charaka, Vagbhatta Madhav Nidana, Shrangadhara and BhavaPrakash are of the opinion of Kapha predominance, while Sushruta considers Vicharchika as Pitta Pradhana. Among commentators, Dalhana states Pitta and Arunadatta, Indu and Shrikanthadutta Kapha predominance. From the above discussion it is clear that most of the Acharyas have accepted Vicharchika to be a Kapha dominant disease. Only Sushruta and his commentator Dalhana, consider it to be a Pitta dominant disease, owing to the symptoms like Kandu, Daran etc. Involvement of Kapha and Vata are conspicuous in this disease. In this context, commentator Shrikanthadutta has agreed to the involvement of Tridoshas with Kapha dominance in Vicharchika and explains that Kandu occurs due to Kapha, Bahusrava due to Pitta and Shyavata due to Vata in this disease. From the above discussion it is clear that Vicharchika is a Tridoshaja Vyadhi, but it is the physician who has to decide which Dosha is dominant in a particular patient of Vicharchika.

Dushya: Acharya Charaka has postulated that when the four Dushyas are vitiated by three provoked Doshas in different amount of morbidity, manifestations of different varieties of Kushtha takes place. These four Dushyas are - Twak, Rakta, Mansa and Lasika.65 In this context, Chakrapani has commented that, at the onset when Kushtha is produced four Dushyas only as a rule become deranged. But later on other Dushyas Meda, Asthi, Majja, Shukra etc. are also deranged as the infection travels deeper and deeper till it involves the whole body. According to Sushruta the Kushtha is first located in the skin, later on it progressively deeper & deeper Dhatus. This clearly mentions that in all varieties of Kushtha, the skin is compulsorily involved at first. After this, the general pathology of the skin, the special pathology starts in other Dhatus, as the time passes on. Lakshanas of Raukshyam is due to Twakdushti and Paka &Atikandu are due to Raktadushti. Bahusrava is due to Rasadushti, Ruja is due to Mansadushti, Pidika is due to Rakta and Mansadushti and Shyava is due to Twak & Raktadushti. The knowledge of Dushyas is necessary for the treatment as well as to know the prognosis of the individual.

Srotas: Srotas are the channels of transportation throughout the body. Here in Vicharchika, Rasavaha, Raktavaha, Mansavaha and Udakavaha Srotas are vitiated. Lakshanas of Bahusrava and Raukshyam are due to Rasavaha Srotodushti. Kandu and Sthiratvam are due to Mansavaha Srotodushti.

Ama and Agni: As stated by all the Acharyas, the main root cause of all the diseases is disturbance of the Agni. Jatharagnimandya and Dhatvagnimandya produce Ama. Ama thus produced along with pradhana Dosha Dushti plays a vital role in the pathogenesis of Vicharchika. Ama has the properties comparable to that of Visha and is thus termed as Amavisha. Acharya Bhoja has stated the pathogenesis of Vicharchika and Vipadika in common and commented that vitiated Doshas lodging in Twacha and Mansa, producing symptoms of burning and itching is termed as Vicharchika and when this type of symptoms are present in feet, then it is known as Vipadika. [34]

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

Kapha : Avalambaka, Kledaka

Dushya : Twak, Rakta, Mamsa, Lasika

1. Agni: Jatharagnimandya, Dhatvagnimandya and Amavisha
2. Srotasa: Rasavaha, Raktavaha, Mamsavaha, Swedavha

Srotodushti : Vimargagamana, Sanga

1. Udbhava : Amashaya

Sanchara : Tiryaka-gami-sira

1. Adhisthana : Twak,

Rogamarga : Bahya

Prabhava : Chirakari (chronic)

SADHYA-ASADHYATA[35]

Sadhya : Vata-Kaphaja, Navin (Superficial Dhatugata)

Kricchhasadhya: Kapha-Pittaja, Vata-pittaja.

Yapya : Medagata.

Asadhya:Tridoshaja, Purana (Deeper Dhatugata)According to acharya Vicharchika is a Sadhya type of Kustha According to modern science, eczema is curable condition but cure of this disease is affected in tropical countries by heat, humidity and prevalent unhygienic condition.

Upadrava: Prasravana (excessive discharge), Angabheda (pain), sequestration of body part, thirst, fever, diarrhea, burning sensation, debility, anorexia and indigestion and above all mismanaged diseases creates Krimi which harms to Shira, Snayu, Twak and Tarunasthi. These Upadravas are found in secondary infection of eczema.

Chikitsa Of Vicharchika:

The principle of treatment is three fold in Ayurveda as Nidana Parivarjana, Apakarshana and Prakriti Vighata -this treatment given by Charaka in krimi chapter. This treatment is given on the basis of Rogabala, Rogabala, Kala, Vayu, Agni, etc. [36]

Nidana Parivarjana: Nidana are main causative factors to increase the disease because samprapti starts by Nidana. Therefore first step for management is to avoid the Nidan. It stops the further progression of the disease by restricting vitiation of Doshas.

Apakarshana (Shodhana): The therapy which aims at the radical removal of the causative morbid factors of somatic disease is called as Samshodhana. Acharya Sharangadhara says that, Among the Pancha Shodhana, Vamana, Virechana, and Raktamokshana are indicated in the Kushtha. Vamana is to be applied in the treatment of Kapha predominant Kushtha, Virechana and Raktamokshana in the treatment of Pitta predominant Kushtha.

Snehana: Acharya Vagbhatta says that Kushtha Rogi should be given Snehapana in the stage of Purvarupa Avastha.

Swedana: Swedana is generally done by Nadi Sweda or Bashpa Sweda. This procedure liquefies the Doshas.

Shodhana: [37] Kushtha is Tridoshaja Vyadhi .Therefore, first prominent Doshas should be treated and then Anubandhya Dosha should be treated, Acharya Charaka also says in Vata dominance Ghrita Pana, in Kapha dominance Vamana and in Pitta dominance Virechana and Raktamokshana are to be carried out.Means when the morbid Doshas are rarer potent, the patient should be treated with Shodhana. For this purpose Raktamokshana is to be done at every six months. Virechana is to be given at every one month. Vamana is to be given at every 15th day.

Basti: Acharya Charka says in Vata Dosha Pradhan Kushtha first give Virechana, Niruha Basti and then give Anuvasana -Basti of Madhuphaladi siddha taila.

Raktamokshana: [38] Sushruta have described to perform Shiravedha from five main superficial veins. Charaka have advised Siravedha by classical instrument Alabu Shring etc.

1. If the patches of Kushtha are Sthira, Kathina and Mandala, Prastara and
2. Nadi Sweda should be done and Rubbed with Kurcha. The blood oozing out through this process should there after be eliminated.
3. Bhela that the Raktajanya and Sannipataja Kushtha are initially treated with Siravyadha. In Alpa Kushtha Pracchanna is indicated, either with the help of Jalauka, Alabu or Shrunga.
4. Site for Raktamokshana: Siravyadha can be done at Lalata, Hasta and Pada also. Siravyadha can be done 2 angula above the Kshipra Marma.
5. Snehapana is necessary after Raktamokshana and Virechana to control the aggravation of Vata.
6. Eventhough bahu doshavastha is found in Kushtha, only little quantity of dosha should be eliminated repeatedly otherwise aggravated Vata destroys the bala.
7. Repeated administrations of Vamanadi procedures are mentioned: Vamana once in 15 days, Virechana once in 30 days, Rakta mokshana once in 6 months and Nasya for once in 3 days. [39]

Nasya: it is used in Krimi, Kushtha & Kapha Vikara, Nasya is also indicated. The Nasya is prepared with rock salt, Danti, black pepper, and fruit of Pongamia pinnata and of Embelia ribes.

Dhumpana: Charaka described that Dhumpana with Shirovirechana drugs are mentioned. They may be used collectively or singly for Dhumpana, in the cases where krimi or parasites are located in the head as well as in the case of leucoderma.

Prakriti Vighata:

Shamana: Shamana therapy is very useful in treatment of Kushtha. After completing the Shodhana karma, Shamana Chikitsa is indicated to subside the remaining Doshas. In present life style when people do not have enough time from their busy schedule for Shodhana therapy in such cases Shamana therapy is to be advised. Charaka has described Shamana therapy with Tikta and Kashaya Dravyas.

Kshara prayoga:

1. In case of anaesthetic patches, Shastra is contraindicated and Kshara should be applied after elimination of blood and dosha.
2. The Lepa prescribed for Kushtha becomes instantaneously efficaceous only after the elimination of impurities in the blood and in Koshtha.
3. The drugs like Kushtha, Amrutasanga, Daruharidra, Kasisa, Kampillaka, Musta, Lodhra, Sougandhika, Sarja Rasa, Vidanga, Manashila, Haratala, Karaveera twak are indicated for Avachrnana in Vicharchika. [40]

table 1

table 2

table 3

Discussion

Eczemas begins with erythema and edema followed by the appearance of minute vesicles in the area. The vesicles rupture and this gives rise to an oozing of fluid, alternatively it may dry up with scaling and crusting. After healing there may be residual pigmentation left. Sometimes, it becomes chronic and skin becomes lichenified i.e. thickened with exaggerated skin marking and hyper pigmentation. It’s stages may be represented on the basis of the lesion and its characteristic i.e.

Acute Stage : Erythema, edema, vesiculation, oozing, crusting

Sub-acute Stage: Hyper-pigmentation, scaling, crusting

Chronic Stage: Lichenification (a combination of thickening, hyper-pigmentation and prominent skin markings).

For management of eczema in modern science lotion or cream is the most common treatment, also application of corticosteroid cream or ointments and topical and oral antibiotics used. long term use of steroid produce side effects. Lubrication restores the skin moisture increase the rate of healing and establishes a barrier against further drying and irritation. Lotion, have a high water or alcohol content and evaporate more quickly, so they are not the best choice. Cream and ointments work better at healing the skin. Any preparation should be as free of fragrance and chemical as possible. In ayurveda Rakta (blood) is said to be one of the main Dushya in Tvak Vikara(skin diseases). Tikta and Kashaya Rasdominance drugsalsohave Raktashodhaka (blood purifier) and Raktaprasad anaproperties. Acharya Charaka has described that Khadira is best Kushtaghna Dravya. Guduchi isa proved immune-modulator and also a very potent Rasayana drug. The ayurvedic yoga (formulation) is a very potent Shamana (pacifying) type of Aushada(medicine). Shamana Aushadha has strength of curing Doshic imbalance and maintaining Dosha in a balanced state.Its Immunomodulatory activity reduces hypersensitivity reaction. It also helps in reducing severity and risk of allergy. Ayurvedic key ingredients also having Kushtaghana, Kandughana, Krimighna, Rasayana, Vrana Shodhana and also Varnya properties. Recent research work shows that these drugs are having potent pharmacological action like antiallergic, anti-inflammatory, immunomodulatory, cytoprotective, antioxidant and antimicrobial properties.

Conclusion

Vicharchika is a chronic relapsing type of disorder. Vicharchika is Kapha-Pitta predominant Tridoshaja Kushtha. Ayurvedic treatment modalities can help in reducing the symptoms of Vicharchika like Kandu, Vaivarnya (discolouration), Pidika (papules/nodules), Rukshata (dryness), Srava (oozing), Daha (burning sensation), Raji (lichenification) and Ruja (pain),and finally in breaking the pathogenesis of Vicharchika