An open labelled clinical study to evaluate the effect of Manjistha Lepa on...

[Full title: An open labelled clinical study to evaluate the effect of Manjistha Lepa on Savarnikarana of Vrana Vastu w.s.r. to scar]

ORIGINAL ARTICLE October 2023 Journal of Ayurveda and Integrated Medical Sciences | October 2023 | Vol. 8 | Issue 10 14 An open labelled clinical study to evaluate the effect of Manjistha Lepa on Savarnikarana of Vrana Vastu w.s.r. to scar Sushma SV 1 , Rakesh RN 2 , Sahana Kamath 3 1 Third Year Post Graduate Scholar, Dept. of P.G. Studies in Shalya Tantra, Sri Dharmasthala Manjunatheshwara College of Ayurveda, Udupi, Karnataka, India. 2 Associate Professor, Dept. of P.G. Studies in Shalya Tantra, Sri Dharmasthala Manjunatheshwara College of Ayurveda, Udupi, Karnataka, India. 3 Assistant Professor, Dept. of P.G. Studies in Shalya Tantra, Sri Dharmasthala Manjunatheshwara College of Ayurveda, Udupi, Karnataka, India. I NTRODUCTION Ayurveda includes every aspect of a living thing's over all physical and mental wellbeing. The definition of Ayu includes the body, sense organs, mind, and soul. Shalya Tantra is one among eight branches of Ayurveda, sheds light on various Surgical and Para surgical interventions for the treatment of various diseases. Acharya Sushrutha gave much more importance to the treatment of Vrana . Address for correspondence: Dr. Sushma SV Third Year Post Graduate Scholar, Dept. of P.G. Studies in Shalya Tantra, Sri Dharmasthala Manjunatheshwara College of Ayurveda, Udupi, Karnataka, India. E-mail: sushmagowdasv 23@gmail.com Submission Date: 11/08/2023 Accepted Date: 23/09/2023 Access this article online Quick Response Code Website: www.jaims.in DOI: 10.21760/jaims.8.10.2 Vrana Vastu is the scar formed on the skin after the Vrana is healed. It remains for the rest of life even after the healing of Vrana is completed. This Vrana Vastu forms discoloration of skin, to treat this discoloration of skin various procedures are explained in Vaikrutapaha Chikitsa of Vrana, which helps to restore the normal skin color after healing. Cosmetology was given utmost importance even in the Vedic period. It emphasizes not only on physical beauty but also on psyche beauty for the purpose of attaining an admirable personality. Skin being largest organ of the body not only attracts attention directly. But also acts like first line of body defense [5] Which is also prone to wounds and injuries commonly leading to scar or post inflammatory pigmentation, this acquired skin disorder can also be a complication of laser therapy. The prevalence rate of scar is >70% [6] Wound healing [7] is a series of mechanism which may lead to altered skin pigmentation causing unpleasant appearance and cosmetic concern by formation of scar hence management of scars and pigmentations are A B S T R A C T Vranavastu is the scar formed on the skin after the Vrana is healed. It remains for the rest of life even after the healing of Vrana is completed [1] This Vranavastu forms discoloration of skin, to treat this discoloration of skin various procedures are explained in Vaikrutapaha Chikitsa [2] of Vrana, which helps to restore the normal skin color after healing. Cosmetology [3] was given utmost importance even in the Vedic period. It emphasizes not only on physical beauty but also on psyche beauty for the purpose of attaining an admirable personality. Reference of Manjishta [4] used in skin disorders is mentioned in C haraka Samhitha under Varnya Gana This study is carried out in a single group of 30 diagnosed cases of Vrana vasthu . This study is based on clinical evaluation of effect of Manjishta Lepa in Vrana Vasthu . Obtained observations and results have been analyzed in terms of Ayurveda and Contemporary science. Key words: Manjistha, Savarnikarana, Vrana, Scar

Sushma SV et al. Effect of Manjistha Lepa on Savarnikarana of Vrana Vastu w.s.r. to scar ISSN: 2456-3110 ORIGINAL ARTICLE October 2023 Journal of Ayurveda and Integrated Medical Sciences | October 2023 | Vol. 8 | Issue 10 15 important. Mismanaged scar can develop into a hypertrophied scar or a keloid. As we know the cosmetic procedures in the present era are mostly invasive, costlier with considerable side effect and are not so feasible to common man [8] So there is need of Ayurvedic remedies in cosmetology which will be easily available with good outcomes and devoid of side effects. Scar are a natural and normal part of healing following an injury to the skin. Vranavastu [9] was mentioned by Sushruta which is formed after wound healing. The context of Vaikrutapaha Chikitsa of Shasti Upakrama like Pandu Karma and Krishna Karma [10] was found in Sushrutha Samhitha and the concept of Savarnikarana was mentioned by Acharya Charaka [11] and Vagbhata. [12] Manjishta [13] used in skin disorders is mentioned in C haraka Samhitha under Varnya Gana . It also has Vranahara, Varnya and Raktha Shodhaka [14] properties. A IMS AND O BJECTIVES To assess the efficacy of Manjistha Lepa in Savarnikarana of scars M ATERIALS AND M ETHODS Literary Source The Literary data of Vrana Vastu and Manjishta Churna was collected from Ayurvedic texts, contemporary reputed published journals and retrorespective studies. Sample Source 30 patients diagnosed with Scar or Pigmentation on skin resulted due to ulcers or wounds are selected from the IPD and OPD of S.D.M Ayurveda Hospital, Udupi. Drug Source Manjishta in dry form was identified and Churna was prepared in SDM Pharmacy Udupi. Method of collection of data 30 subjects fulfilling diagnostic and inclusion criteria was selected and taken for the clinical trial with consent. Study Design Single group open labelled clinical study with pretest and posttest design. Sample Size 30 patients fulfilling inclusion criteria was selected. Diagnostic Criteria ▪ Patients were investigated according to the proforma prepared for the study. ▪ Patients diagnosed with scar or pigmentation of skin after wound healing. ▪ The age group of 18-60 years was selected. ▪ Size of the scar measuring upto 25 sqcm. Inclusion Criteria ▪ Patients are selected in the age group of 18-60 years. ▪ Patients with scar or pigmentation of skin after wound healing. ▪ Post-operative scar ▪ Size of the scar measuring up to 25 sqcm. Exclusion Criteria ▪ Malignancy. ▪ Keloid. ▪ Patients suffering from skin disease like leucoderma, leprosy was excluded. Method of preparation of Lepa Dry Manjishta roots was collected and pounded into fine powder. This powder was mixed with sufficient quantity of water to make into the form of Lepa . Intervention Method of Application The area of scar selected was cleaned with normal saline and dried with a sterile gauze. The freshly prepared Manjishta Lepa was applied over the scar, with thickness of ½ Angula (0.75 cm) [15] in opposite to the direction of hair follicles and was kept until it dries up.

Sushma SV et al. Effect of Manjistha Lepa on Savarnikarana of Vrana Vastu w.s.r. to scar ISSN: 2456-3110 ORIGINAL ARTICLE October 2023 Journal of Ayurveda and Integrated Medical Sciences | October 2023 | Vol. 8 | Issue 10 16 Duration of treatment The Lepa was applied once daily for a duration of 28 days. Manjistha Roots Manjistha Churna Observation period ▪ The patients were observed on 0 th , 7 th , 14 th and 28 th days. ▪ Follow-up of the patient was done after 2 weeks. Study Period Follow Up Day 0 Day 7 Day 14 Day 28 Day 42 BT AT-1 AT-2 AT-3 AT-4 Assessment Criteria Subjective parameters Pain Vancouver Scar Scale [16] None 0 Occasional 1 Requires medication 2 Itching None 0 Occasional 1 Requires medication 2 Objective parameters Pigmentation Vancouver Scar Scale [16] Normal 0 Hypo pigmentation 1 Mixed pigmentation 2 Hyperpigmentation 3 Colour of skin Visual analog scale [17] Perfect 1 Slight mismatch 2 Obvious mismatch 3 Gross mismatch 4 To compare the color of the scar with normal skin color by using the above parameters with the help of Fitzpatrick scale [18] Shape of scar Grading Remains unchanged Grade 3 Reduction in shape/ size from 25 % - 50% Grade 2 Reduction in shape/ size from 50% - 75% Grade 1

Sushma SV et al. Effect of Manjistha Lepa on Savarnikarana of Vrana Vastu w.s.r. to scar ISSN: 2456-3110 ORIGINAL ARTICLE October 2023 Journal of Ayurveda and Integrated Medical Sciences | October 2023 | Vol. 8 | Issue 10 17 Reduction in shape/ size > 75% Grade 0 Subjective parameter within the group Itching on the scar - Wilcoxan sign rank Table 1: Comparison of Mean of Itching of the Scar Parameter Mean Score P Value Itching of scar 0-7 th day 0.23 1.0 Itching of scar 14 th day 0.20 0.31 Itching of scar 28 th day 0.03 0.06 Itching of scar 42 nd day 0.0 0.03 Objective parameter within the group Colour of the scar - Wilcoxan sign rank Table 2: Comparison of Mean of Colour of the Scar Parameter Mean Score P Value Colour of scar 0 - 7 th day 3.03. 1.0 Colour of scar 7- 14 th day 2.26 0.00 Colour of scar 14 - 28 th day 1.93 0.0 Colour of scar 28 - 42 nd day 1.03 0.0 Shape of the scar - Wilcoxan sign rank Table 3: Comparison of Mean of shape of the Scar Parameter Mean Score P Value Shape of scar 0- 7 th day 3.0 1.0 Shape of scar 7- 14 th day 2.1 0.0 Shape of scar 14- 28 th day 1.7 0.0 Shape of scar 28-42 nd day 0.9 0.0 Comparing the results before and after the intervention using Wilcoxon signed rank test, reveals that it is statistically highly significant with the p value being 0.00 Paired T Test Objective Parameter - Within the group Size of the scar - Paired t test Table 4: Observations on Area of the Scar after Application of the Lepa Size of the scar Mean Score P Value Size of the scar BT 7.55 0.20 Size of the scar 0-7 th day 7.49 0.20 Size of the scar 7-14 th day 4.50 0.00 Size of the scar 14-28 th day 2.98 0.00 Size of the scar 28- 42 nd day 1.64 0.00 Comparing the results before and after the intervention using Paired T test, reveals that it is statistically highly significant with the p value being 0.00 Observations on Size of the Scar after Application of the Lepa In present study out of 30 patients, after comparing before and after treatment. The p value for color of scar after treatment on 7 th day for the variable size of scar using Wilcoxon signed rank test, results obtained was found statistically was not significant as the p value was 0.20. The mean color of the scar was reduced after the treatment on 14 th , 28 th and 42 nd day was found statistically highly significant with p value 0.00. There was Gradual reduced in size of the scar during the course of treatment with the help of Manjishta Lepa. Observations on color of the Scar after Application of the Lepa In present study out of 30 patients, after comparing before and after treatment. The p value for color of scar after treatment on 7 th day for the variable size of scar using Wilcoxon signed rank test, results obtained was found statistically was not significant as the p value was 1.0.

Sushma SV et al. Effect of Manjistha Lepa on Savarnikarana of Vrana Vastu w.s.r. to scar ISSN: 2456-3110 ORIGINAL ARTICLE October 2023 Journal of Ayurveda and Integrated Medical Sciences | October 2023 | Vol. 8 | Issue 10 18 The mean color of the scar was reduced after the treatment on 14 th , 28 th and 42 nd day was found statistically highly significant with p value 0.0. Manjistha is included under Varnya Dashemani . Ushna Veerya accelerates the action of Bhrajak Pitta ( Agni ), which is responsible for skin color and luster. Due to Tikta Rasa and Katu Vipaka have Kushthaghna property and Kashaya Rasa has Varnya action Observations on itching of the Scar after Application of the Lepa In present study out of 30 patients, after comparing before and after treatment. The p value for color of scar after treatment on 7 th , 14 th and 28 th day for the variable size of scar using Wilcoxon signed rank test z value is results obtained was found statistically was not significant as the p value was 1.0, 0.31, 0.06 The itching of the scar was reduced after the treatment on 42 nd day was found statistically highly significant with p value 0.03. Kandu is the symptom of Kapha mainly but it is due to dryness of skin and Vata dosha is the main reason behind it . Madhura Rasa of Manjistha pacifies the Vata dosha relieving Kandu . Kandughana action is performed by Tikta Rasa Observations on shape of the Scar after Application of the Lepa In present study out of 30 patients, after comparing before and after treatment. The p value for shape of scar after treatment on 7 th day for the variable size of scar using Wilcoxon signed rank test and the results obtained was found statistically not significant as the p value was 1.00. The mean shape of scar was reduced after the treatment on 14 th , 28 th and 42 nd day and was found statistically highly significant with p value 0.000. The shape of scar during treatment was found to improve gradually and found to be statistically highly significant after 42 nd day with p value 0.00. Rakta Prasadana by Tikta Rasa of Manjistha along with other factors contributes to nature the skin and maintain its proper luster and texture and prevent the Vairupya / shape caused due to tearing of skin. CONCLUSION Cosmetology was given utmost importance even in the Vedic period. It emphasizes not only on physical beauty but also on psyche beauty for the purpose of attaining an admirable personality. Wound healing is a series of mechanism which may lead to altered skin pigmentation causing unpleasant appearance and cosmetic concern by formation of scar, hence management of scars and pigmentations are important. So, there is need of Ayurvedic remedies in cosmetology which will be easily available with good outcomes and devoid of side effects. Using Manjishta Lepa in scar has proven effective both clinically and statistically by reducing itching, shape, size and colour of the scar. It also has properties like Vranahara, Varnya and Raktha Shodhaka . The treatment is effective in reducing the size of the scar in almost patients and 78% of patients had reduced in size of the scar. Hence this less interventional, economical method which helps to bring back normal colour associated with least adverse effect. Before Treatment

Sushma SV et al. Effect of Manjistha Lepa on Savarnikarana of Vrana Vastu w.s.r. to scar ISSN: 2456-3110 ORIGINAL ARTICLE October 2023 Journal of Ayurveda and Integrated Medical Sciences | October 2023 | Vol. 8 | Issue 10 19 After Treatment Before Treatment After Treatment REFERENCES 1 Trikamji VJ, editor. Commentary Nibanda Sangraha of Dalhana of Sushrutha Samhita of Sushrutha, Sutra Sthana; Vranasrava Vigyaniyam Adhyaya: Chapter 22, Verse 3. Varanasi: Chaukambha Surbharati Prakashan; 2014;107. 2 Trikamji VJ, editor. Commentary Nibanda Sangraha of Dalhana of Sushrutha Samhita of Sushrutha, Chikitsa Sthana; Dvivraniya Chikitsitam Adhyaya: Chapter 1, Verse 8. Varanasi: Chaukambha Surbharati Prakashan; 2014;397. 3 Trikamji VJ, editor. Commentary Nibanda Sangraha of Dalhana of Sushrutha Samhita of Sushrutha, Chikitsa Sthana; Dvivraniya Chikitsitam Adhyaya: Chapter 1, Verse 94. Varanasi: Chaukambha Surbharati Prakashan; 2014;405. 4 Kaur M. Care in Ayurveda. Ayoham Journal 2010- 2011;14. 5 Behl PH, Agarwal A, Srivastav G. Practice of dermatology, 10 th ed. New Delhi: CBS publishers & distributors; 2007;29. 6 Nouveau S, Agarwal D, Kohli M, Bernerd F, Misra N, Nayak CS. Skin Hyperpigmentation in Indian Population; Insights and Best Practice, Indian J Dermatol, 2016;61(5):487-95. 7 Shenoy KR, Shenoy A. Manipal manual of surgery, 4 th edition. New Delhi: CBS publishers & distributers Pvt. Ltd; 2014;5. 8 Williams NS, Bulstrode CJK, O Connell PR, editors. RCG Russell Bailey & Loves short practice of surgery, 24 th ed. London: Holder Arnold; 2004;258. 9 Trikamji VJ, editor. Commentary Nibanda Sangraha of Dalhana of Sushrutha Samhita of Sushrutha, Sutra Sthana; Vranaprashnam Adhyaya: Chapter 21, Verse 40. Varanasi: Chaukambha Surbharati Prakashan; 2014;107. 10 Trikamji VJ, editor. Commentary Nibanda Sangraha of Dalhana of Sushrutha Samhita of Sushrutha, Chikitsa Sthana; Dvivraniya Chikitsitam Adhyaya: Chapter 1, Verse 94. Varanasi: Chaukambha Surbharati Prakashan; 2014;405. 11 Trikamji AJ, editor. Commentary Ayurveda Dipika of Chakrapanidatta of Charaka Samhitha of Charaka, Chikista Sthana; Dvivraniya Chikistam Adayaya: Chapter 25, Verse 116. Varanasi: Chaukambha Surbharati Prakashan; 2019;596. 12 Paradakara BHS, editor. Commentary Sarvangasundara of Arunadatta and Ayurveda Rasayna of Hemadri of

Sushma SV et al. Effect of Manjistha Lepa on Savarnikarana of Vrana Vastu w.s.r. to scar ISSN: 2456-3110 ORIGINAL ARTICLE October 2023 Journal of Ayurveda and Integrated Medical Sciences | October 2023 | Vol. 8 | Issue 10 20 Ashtanga Hrudaya of Vagbhata, uttara sthana; vrana pratisheda adhyaya: chapter 25 verse 61, Varanasi: Chaukamba Surabharati Prakashana; 2020;868. 13 Trikamji AJ, editor. Commentary Ayurveda Dipika of Chakrapanidatta of Charaka Samhitha of Charaka, Sutra Sthana; Shadvirechana Shatasriteeya Adayaya: Chapter 4, Verse 8. Varanasi: Chaukhambha Surbharati Prakashan; 2019;32. 14 Hegde PL, Harini. Text Book of Dravya Guna Vijnana. Chaukhambha publications Volume 2, 2014;184. 15 Trikamji VJ, editor. Commentary Nibanda Sangraha of Dalhana of Sushrutha Samhita of Sushrutha, Chikitsa Sthana; Dvivraniya Chikitsitam Adhyaya: Chapter 1, Verse 6. Varanasi: Chaukhambha Surbharati Prakashan; 2014;397 Pp.824. 16 Baryza MJ, Baryza GA. The Vancouver Scar Scale: an administration tool and its interrater reliability. J Burn Care Rehability. 1995;16(5):535-8. 17 Micomonaco DC, Fung K, Mount G, et al. Development of new visual analog scale for the assessment of area of scar. J Otolaryngol head neck Surg 2009;38(1):77 – 89. 18 Fitzpatrick TB. The validity and practically of sun reactive skin types I through vi. Archives of Dermatology. 1988;124(6):869-871. ******************************* How to cite this article: Sushma SV, Rakesh RN, Sahana Kamath. An open labelled clinical study to evaluate the effect of Manjistha Lepa on Savarnikarana of Vrana Vastu w.s.r. to scar. J Ayurveda Integr Med Sci 2023;10:14-20. http://dx.doi.org/10.21760/jaims.8.10.2 Source of Support: Nil, Conflict of Interest: None declared. Copyright © 2023 The Author(s); Published by Maharshi Charaka Ayurveda Organization, Vijayapur (Regd). This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by-nc-sa/4.0), which permits unrestricted use, distribution, and perform the work and make derivative works based on it only for non-commercial purposes, provided the original work is properly cited

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Ayurveda, Kapha, Kandu, Shalyatantra, Manjishtha, Vrana, Varṇya, Vairupya, Katuvipaka, Vranavastu, Madhurarasa, Shcar, Vatadosha, Manjishta, Tikta Rasa, Kashaya Rasa, Ayurvedic remedies, Wound healing, Inclusion criteria, Exclusion criteria, Clinical study, Clinical trial, Statistical Significance, Study design, Visual analog scale, Paired T test, Hair follicle, Ayurvedic text, Ushna veerya, Subjective parameter, Varnya dashemani, Objective parameter, Vranahara, Normal saline, Manjistha churna, Skin disorder, Rakta prasadana, Charaka Samhitha, Bhrajak pitta, Cosmetology, Skin Pigmentation, Open labelled clinical study, Sterile Gauze, Fitzpatrick Scale, Vancouver Scar Scale, Vaikrutapaha Chikitsa, Post Graduate Scholar, Sushrutha Samhitha, Manjistha Lepa, Keloid.