EFFICACY OF JALAUKAVACHARNA IN THE MANAGEMENT IN THE ACNE VULGARIS: A CLINICAL STUDY

Lalita Sharma 1 ,Alok Srivastava 2 ,Pretya juyal 3 , Priya kutiyal 4 and Vandana Chauhan 5 . 1. MD Scholar , Department of Panchakarma,U.A.U, Rishikul Campus Haridwar. 2. Professor , Department of Panchakarma,U.A.U, Rishikul Campus Haridwar. 3. MD Scholars , Department of Panchakarma,U.A.U, Rishikul Campus Haridwar. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History Received: 08 August 2019 Final Accepted: 10 September 2019 Published: October 2019


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due to obstruction and inflammation of sebaceous follicles [a subtype of pilo-sebaceous units].The primary acne is micro-comedo lesion which involves inflammation and follicular keratinization and ultimately leads to hyperplasia of sebaceous glands alongwith overcolonization. Host immune response also contributes to the clinical condition . There are various theories and researches which suggest the pathology of acne, but are not well proven. These mainly involve [2] : 1. Increased sebum production(due to increased end organ sensitivity to Androgen) 2. Follicular epidermal hyperproliferation 3. Increased microbial colonization ( especially Propionibacterium acnes) 4. Release of inflammatory mediators(especially cytokines) These events are not individual events, and are affected by each other [3] Increased chances of exposure to the pollutant of industrialization may be a factor for this situation.It can effect rural and urban both areas especially between puberty at 30 years of age [4] .The prevalence of facial acne in 16-18 year olds ranges from 81 to 95% in boys and 79 to 82% for girls [5] . Sometimes it is appeared as major cause of depression in case of young females, so it is a complicated pathological condition especially in young adults. In younger persons, Acne Vulgaris is more common and more severe in males. It does not always clear spontaneously when maturity is reached. 12% of women and 3 % of men over 25 have acne Vulgaris [6] . The rate does not decrease until the fourth or fifth decade of life.
In Ayurveda clearly it is not mentioned in text especially with all clinical features and conditions but it can be correlated with Mukhdooshika or Yauvanpidika described in Charak Samhita and Sushrut Samhita respectively.Means the skin lesions, resembling the sprouts on the bark of Shalmali appearing on the face of teenagers caused due to kapha, vata & rakta together is known as Mukhdooshika [7] .Symptomatically Mukhdooshika and Yauvanpidika are somewhat similar with slight difference in doshik phenomenan.Yauvanpidika has involvement of kapha and vata and in Mukhdooshika, kapha predominancy but description of both clearly indicates rakta dushti hence clinical features shows involvement of seat of Ras and Rakta both. Seat of rakta is between twaka and mamsa.Management of Acne vulgaris in modern medicine has very low spectrum as it has often limits with corticosteroids, antibiotics and antinflammatory drugs. All these drugs have good effect instantaneously but fail to prevent reoccurance. Although these drugs have efficacy but possible definite adverse effects . In Ayurveda so many types of remedies are described to treat such type of disorder including external application, non-invasive surgical procedures, parasurgical procedures and especially Panchakarma. As per Ayurvedic discription the disease has Kapha, Vata and Rakta involvement so according to development of disease treatment should have Shodhana property. Vamana Karma and Raktamokṣana are chief purificatory procedures mentioned for the treatment of Mukhdooshika along with dozens of topical applications and oral medications. As Vamana Karma is an exhaustive and has more complication then other procedures, most of the patients of Mukhdooshika belong to Sukumar Prakriti and student profile so Raktamokshana is more suitable for them as a Shodhana procedure. Most of the patients of Mukhaduṣhika belong to Sukumara Pṛakṛiti and student profile. So Raktamokṣana is more suitable for them as a Shodhana procedure. Raktamokṣana in the form of Jalaukavacharana is a method, which do Shodhana and Rakataprasadana and is much safer, less complicated and an almost painless procedure as compared to others. Thus, it is recommended for the fearful, physically weak, women and tender natured people. Jalaukavacharna can provide a safe and economic remedy for this common ailment. Present research has been selected to study whether "JALAUKAVACHARNA' is better in the management of Acne vulgaris. Jalaukavacharna in the management of Acne vulgaris was done to analyse and evaluate the complete concept and aetiopathogenesis and treatment of Acne Vulgaris based on clinical study in light of Ayurvedic and modern medicine.

Grading And Overall Assessment Scale-
Effect of the therapies were compared before and after the treatment on the basis of self-formulated scoring scales based on subjective parameters associated with the disease.

Discussion:-Probable Mode Of Action Of Jalukavacharna:-
As in Mukhadushika, vitiated Doṣa/Dhatu/Mala get accumulated in Srotas (Lomakupa), causing blockages and leads to Pidika formation. Jalaukavacharana being a bio-purificatory method removes deep seated toxins by letting out blood, clearing Srotasa and pacifying vitiated Dosha. As Jalaukavacharana is the preferred way of blood-letting in Sukumara Prakriti, therefore it was selected here for Raktamokshana.Although the amount of sucked 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 substance [8] 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 386 biologically active substances renders thrombolytic, anti-inflammatory and immune stimulant action [9] . 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. Biologically active substances in leech saliva help the cells to absorb necessary nutrition and eliminate toxins [10] .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, Shodhana of the morbid Dosha via sucked blood occurs, which in turn results in the Srotoshuddhi 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 [8] .A study revealed that Staphylococcus aureus bacteria, which causes infection of blood, bones and lungs, feeds on iron. Therefore, lesser the available iron in the system, less the chance of staphylococcus infection being present [11] . Relief in infective/inflammatory conditions by Jalaukavacharana can be attributed to results obtained by this study. Jalaukavacharana is indicated by Acharyas in Rakta-Dushti with Pitta involvement [12] . In Mukhadushika also, there is primarily Rakta-Dushti due to Pitta and Kapha.As Jalaukavacharana removes vitiated Pitta/Rakta, which causes reduction in inflammation, burning and no. of pustules & cysts. It also reduces the pooled blood and pus which results in Srotoshodhana. This Srotoshodhana causes normalization of Kapha and further reducing Kandu and no of comedones, papules & nodules. Srotoshodhana also leads to Anulomana of obstructed Vata which may be the reason for significant relief in pain.As vitiated Pitta imparts different colours to the skin [13] while Rakta causes improved complexion [14] , Shodhana of the vitiated Pitta and Rakta by Jalaukavacharana improves complexion. and 75% reductions were found in nodule and pustule count respectively while 66.7% relief was found in comedones count followed by a 50% reduction in no. of papule. On Scars count 0% result was obtained. 5. 88.89% relief was observed in inflammation, 84.61% relief was observed in Pain, 60.71% in secretion,91.30% in itching followed by 92.3% relief in Burning. 6. After the intervention completion, there was 5% patient of grade IV and grade III acne which were 15% and 40% respectively, before treatment. 7. Before treatment there were 40% patient of grade II which also got reduced to 13.33% got complete remission after the completion of intervention.

Results of Jalaukavacharana
On analyzing Subjective parameters, data suggests that Jalaukavacharana was most effective on nodular ,comedones and Papular lesions. It was found to be highly beneficial in reducing Inflammation, Pain, Secretion and Itching. Jalaukavacharana provided complete resolution in 13.3% patients. Leech removes vitiated Rakta from the nearby area which causes Srotoshodhana locally. By this Srotoshodhana, vitiated Pitta as well as Kapha which were residing in the blood get removed. This Shodhana reduces the lesions which were occurring due to Rakta-dushti. Also, it subsides the associated symptoms that were occurring due to the vitiated Pitta like inflammation and discoloration. As relief was seen in Kapha symptoms i.e. Itching as well, therefore Jalaukavacharana must be removing vitiated Kapha also, to some extent.Srotoshodhana causes anulomana of trapped Vata, therefore reduction in Vedana and Blackish discoloration was also observed. Recent studies have reported presence of analgesic substances in leach saliva, which supports this particular effect of Jalaukavacharana.
Effect of Jalaukavacharana was more pronounced on pustules and nodules in comparison to comedones. The rationale behind this seems to be that comedones were occurring in a widespread manner all over the face while nodules and pustules were localized to few areas only and those sites were given preference while leech application. That"s why the effect of Jalaukavacharana was found to be more on those areas.
Also, comedones (Medogarbha pidika) are supposed to be formed due to the vitiated Kapha and Sadharmi Dhatu (Meda). While Jalaukavacharana is said to be more effective in Pitta vitiated diseases in comparison to Kapha 387 vitiated conditions although it showed effectiveness in reducing Kaphaja symptoms also to some extent. That may be a reason for better reduction in pustular lesion where vitiated pitta was also involved in comparison to comedones countreduction.
Due to Srotoshodhaka property of Jalaukavacharna which can be assumed responsible for additional relief in pustules and Medogarbhata causing further reduction in no of comedones. Jalaukavacharna(fig 1-3