ROLE OF JALUKAVACHARAN AND MAHAMANJISHTADI KWATH IN THE MANAGEMENT OF MUKHADUSHIKA W.S.R TO ACNE VULGARIS- A CASE STUDY

Acne vulgaris is a disease of the pilosebaceous follicle characterized by noninflammatory (open and closed comedowns) and inflammatory lesions (papules, pustules, and nodules). There are four major factors involved in the disease production viz. increased sebum production, cornification of pilosebaceous ducts, microbial involvement and inflammation. This condition is found commonly in puberty. In Ayurveda, it is termed as Mukhadushika In Ayurveda Mukhadushika is described under the heading of Kshudrarogas. The Shalmali thorn like eruption on the face due to vitiation of Kapha, Vata and Rakta which are found on the face of adolescent are called as Mukhadushika or YuvanPidika. Although vata, kapha and rakta are mentioned as dosha-duṣya involved in the pathogenesis of the disease, pittaja symptoms are also found in the disease like daha and paka. Patient was suffering from Acne over face (Pidika), Burning sensation over face (Daha), Itching over face (Kandu), and Discolouration of skin (Vaivarnya) since 6 months. Patient was treated with jalukavacharan and mahamanjishtadi kwath.


Introduction
Skin is the mirror of our state of heath. Its appearance reflects our age, origin, health and even state of mind. It is important to pay attention of this part of the body. Tvak according to Ayurveda is not only the outer covering of body, but it is a Gyanendriya which encomposed the body from within also. The most common ailment that a teen suffers in this age is acne. They mostly occur in the youths or the Yuva and in form are like small pustules or boils or Pidika hence they are called "Yuwan Pidika". And for the same reason it is also called "Tarunyapidika". This disease affects Http://www.granthaalayah.com ©International Journal of Research -GRANTHAALAYAH [26] the face and vitiates the facial appearance; this is why it is called 'Mukhadushika". As per modern science the symptoms of Yuwan Pidika resembles acne vulgaris.
Acne is chronic inflammatory dis-ease of the pilosebaceous glands present in the skin of the face1.This disease is characterised by the formation of comedowns [blackheads], erythematous papules, and in a few cases, nodules or cyst and scarring. There are four major factors involved in the disease production viz, increased se-bum production, cornification of pilosebaceous ducts, microbial involvement and production of inflammation .This condition is found commonly in puberty Many synthesis drugs like benzoyl peroxide, antibiotics, ant androgens are used to treat this disorder but these drugs also exhibit several side effects like dry-ness of skin, dermatitis, darkening of the skin, and recurrence after with drawl.S. In Ayurveda, this disease is described as "Mukhdushika""or "Yuwan pidika".
Ac-cording to Ayurveda, the Shalmali Kantak like eruption on the face due to vitiation of Kapha, Vata and Rakta which are found in adolescents are called Mukhdushika. There is no single disease which causes more psychic trauma, more maladjustment between parents and children's, more general insecurity and feeling of inferiority and greater sums of psychic suffering than does acne.

Aim and Objectives
Role of jalukavacharan and mahamanjishtadi kwath in the management of mukhadushika w.s.r to acne vulgaris-A case study.

Case report
The present case study is a successful Ayurvedic management of acne vulgaris. 25-year-old female patient visited to the OPD of SSNJ Ayu college, solapur. With following complaints-

History of Present Illness
The patient had above complaints since last 6 months. In this period she experienced small pustules over her both cheeks. Also she had itching and burning sensation over those areas.
The patient tried various allopathic local as well as systemic drugs but none could prevent the relapse of acne.So she came to the OPD for Ayurvedic treatment.
Past history-Dengue before 1 year Typhoid before 2 year.  Aakruti (Built)-Madhyam Patient was given 4 sittings of jalaukavacarana on a 7day interval along with the mahamanjishtadi kwath internally 10 ml pashhatbhakta continuously for 28 days.

Methodology for Leech Therapy
Source of leeches: -All the leeches used in trial were purchased from a reputed biological product supplier, India

Procedure of Leech Therapy
Preparation of the leeches: On every sitting new leeches were used for the procedure. Leeches were first prepared by keeping in haridrajala (Turmeric water), prepared by adding few pinches of haridrachurna(turmeric powder) in a kidney tray half filled with fresh water. When the leech became active i.e. move very fast in the vessel then it was taken out and transferred in to a vessel containing fresh cold water. Preparation of patient: Patients was given mild abhyanga followed by bashpsvedana over the face for few minutes to increase the superficial circulation and facilitate the blood-letting. The face was then cleaned by dry cotton to remove all the greasiness over the area. After that, patient was made to lie in a comfortable position. Leech Application: Pricks by lancet were done near the pustules/papules for application of leeches at the particular site. Prepared active leeches were then kept over the oozing blood. When a leech was attached to a site, wet cotton pad was placed over it. In most of the patients, 4-5 leeches of 3-4inches were used on an average, that used to suck 50-80 ml of blood. Leech Management: Generally after 30-45 minutes, leech automatically detaches from the site. Haridrachurna was then sprinkled over the leech's anterior sucker for inducing vomiting. Sometimes gentle squeezing of the leech was required to expel out the sucked blood. After expelling all the blood from its gut, leech becomes active again and stored in fresh water. Patient Management: When the leech detaches itself from the site, there occurs a secondary bleeding from the site of bite for 2-4 hours or more. Satdhautaghrita (Purified fat) was applied over the bite lesions. Few minutes later, cotton gauze pieces with were kept over the bleeding sites with firm pressure to absorb the secondary bleeding. When it got attached to the site forming a clot, patient was advised not to unplug it before next day morning to avoid any bleeding. In few patients, in whom blood was not checking, tight compression bandaging was also done to check the bleeding.
Picture taken before treatment Picture taken after treatment

Aaha Rand Vihar Advised During Treatment Pathya
Green grams, rice,wheat, green vegetables, fruits, mostly red Adequate sleep at night. Daily minimum 10-15minutes of pranayam in fresh Air. Paadabhyang daily while sleeping. Washing face every time after coming from outside environment and while sleeping.

Discussion
Day by day, People are becoming more conscious of their beauty and skin. Ayurveda texts have described the vata, kapha and rakta as the chief culprit dosha responsible for the disease, although raktaja/pittaja symptoms are found to be more pronounced in the patients. As piḍika is the chief complaint found in the patients, which is a rakta dushtilakṣana. Acharya Vagbhatta has given a term medogarbhapiḍika which can be assumed to be a lesion withwhitish tinge or a lesion filled with Meda like substance i.e. sebum. On correlating this with modern description of acne lesion, this can be a closed comedone filled with sebum or a pustule. Acharya Susruta has described the piḍika like salmali-kantaka. As salmali kantaka suggests a piḍika with semi-solid/solid consistency which correlates it with acne lesion-papule or nodule. A salmali kantaka like piḍika is suggestive of a lesion filled with puya (pus) but in apakvavastha (unripen), which shows involvement of kapha as Acharya Susruta has told that puya is not possible without kapha. Thus, this lesion can be correlated with papule (if small) or nodule (if large). And when this piḍika becomes pakva due to the involvement of pittaas Acharya Susruta has mentioned that paka is not possible without Pitta, this can be correlated with a pustule. Other than piḍika and ruja no other signs or symptoms of mukhadusika are found in the Ayurveda texts while modern medical science has explained few associated symptoms found in the disease like itching, discoloration, pain, swelling, discharge etc. As Ayurveda advocates the use of yukti in undescribed conditions, all these symptoms are obvious due to the involvement of vitiated vata, Pitta and kapha in the disease. Due to vitiation of vata, Pain (vedana), watery discharge and scar formation is possible while Pitta involvement can cause paka and daha. Blackish discoloration of skin occurs due to vitiated vata. Discoloration is also caused by vitiated Pitta because Pitta is responsible for imparting different colors to the skin. Vitiation of kapha can lead to the formation of puya, sotha, kleda/snigdhata, ghanasrava (thick discharge) and kandu. All these symptoms correlate mukhadusika with Acne vulgaris involving face only.
In all kṣudra-rogas, rakta-dushti is seen as the prime pathology. While raktamokṣana is advocated as the preferred method of sodhana in rakta-dushti. As mukhadusika is also a kṣudra-roga, above statement is not an exception to it. Acc. to Acharya Susruta, jalaukavacarana is the preferred method of bloodletting in bala (children), nari (female), durbala (weak), bhiru (fearful) and sukumara (tender nature). As majority of our patients were going to be female which comes in bhiru/nari category, also the major age group in which this disease occurs belongs to sukumara category, jalaukavacarana was selected as the primary intervention. Jalauka is also said to be the best Anusastra (used in place of sastra (surgical instrument) in those who fears from surgery) by AcharyaVagbhatta. jalaukavacarana, being a painless procedure, is more suitable than siravedha to most of the patients. As in mukhadusika, vitiated dosha/dhatu/mala get accumulated in srotas (Lomakupa (follicles)), causing blockages and leads to piḍika formation. jalaukavacarana being a bio-purificatory method removes deeply seated toxins by letting out blood, clearing Srotasa and pacifying vitiated dosha. As jalaukavacarana is the preferred way of blood-letting in sukumaraPṛakṛiti, therefore it was selected here for raktamokṣana. Although the amount of oozed blood in case of leech therapy is very less in comparison to tradition venipuncture, but the efficacy should not be judged by the amount of blood. Leech application not only removes blood from the site but also injects biologically active substances which help to manage various ailments. Like Hirudin and Calin, which act as anticoagulants, also preventing inflammation and slow cleansing of wound. Histamine by its vaso-dilating property allows more blood to come to the site of leech application or lesion thus replacing old stagnant blood with fresh blood. Overall, all biologically active substances render thrombolytic, anti-inflammatory and immune stimulant action. Secondary bleeding for few hours, due to hirudin, causes removal of toxins along with increased circulation to that particular area, promoting faster wound healing without any scar formation. A healthy cell gets sick when it is deprived of needed oxygen and nutrition, and is unable to remove toxins accumulated during metabolism. Active substances in leech saliva help the cells to absorb necessary nutrition and eliminate toxins. During leech therapy, leeches are placed directly on the site of lesion, so that they can feed directly on the pus and at the same time, more leeches are placed around the diseased area to get rid of the pooled blood. Because pooled blood causes pressure, leading to tenderness bloodletting, on the other hand, relieves the patient from pain. Also, it is already proven that leech saliva contains analgesics which may be the reason behind pain relief. It can also be assumed as the leech sucks stagnant blood, sodhana of the morbid dosha via sucked blood occurs, which in turn results in the srotosuddhi (cleansing of body channels) and trapped vata gets relieved which was responsible for the pain. According to modern science, leech injects anti-inflammatory and bacteriostatic substances with its saliva which helps in subsiding the associated symptoms. Relief in infective/inflammatory conditions by jalaukavacharana can be attributed to results obtained by this study. Jalaukavacharana is indicated by Acharyas in raktaduṣti with pitta involvement. In mukhadusika also, there is primarily rakta-dushti due to Pitta and kapha. As jalaukavacarana removes vitiated Pitta/rakta, which causes reduction in paka, daha and no. of pustules & cysts. It also reduces the pooled blood and pus which results in srotosodhana. Srotosodhana leads to anuloman of obstructed vata which may be the reason for significant relief in pain. As vitiated Pitta imparts different colours to the skin while rakta causes improved complexion , sodhana of the vitiated Pitta and rakta by jalaukavacarana improves complexion by relieving vaivarnyata which might be the reason behind the reduced vaivarnyata in the patients involved in this study.

Conclusion
Hence it is concluded that jalaukavacharan long with oral administration of mahamanjishtadi kwath is highly effective in the management of mukhdushika.