Need for The Study:
Dermatophytosis,
also referred to as “tinea†is a very common clinical problem caused by superficial
mycoses that infect skin, hair, and nails[1][2].
According to WHO, the reported worldwide prevalence is about 20% to 25% [3][4],
whereas approximately 30 to 70% adults suffer from asymptomatic superficial
mycosis. The incidence of this disease increases with the passage of age [3].
It is clinically manifested by well demarcated, annular, pruritic, and scaly
lesions with central clearing [1][5]. Dermatophytes
are a larger group of over 51 species divided into six major genera i.e. Trichophyton,
Microsporum, Epidermophyton, Nannizzia, Lophophyton, and Arthroderma [6]. Clinically,
it is categorized by the name of body parts affected i.e. tinea capitis (head);
tinea corporis (body); tinea cruris (groin); tinea unguium (nail), and tinea
pedis (feet) [1][5].
Among
these subtypes, tinea corporis is the commonest type characterized by dermatophytosis
of glaborous skin except palms, soles, and groin area [4][7]. It
is treated by both topical and oral antifungal agents in conventional medicine [1][4][5][7].
Systemic antifungals include terbinafine; grisofluvin; itraconazole, and fluconazole[1][4][5][7],
but failure reports of systemic therapy and resistance is the most alarming concern;
especially mutation in the sequalene peroxidise enzyme that leads to the drug
resistance[8]. High recurrence rate was also reported if these therapies
are discontinued [9]. Thus, it creates some potential space for
further exploration of alternative treatment modality, and Unani medicine may
play an important role in its management.
In
Unani system of medicine, QÅ«bÄ is clinically synonymous with Tinea [10]
[11]. Moreover,
QÅ«bÄ has been extensively described in various classical text books with
special focus on its classification, pathology, prevention, and treatment [12]. QÅ«bÄ
is defined as annular, dry, and pruritic eruptions [11]
caused by amalgamation of Mirra Sawda’ (bilious melanchole) into blood
or Ruá¹Å«bat-i Ghalīẓ and Balgham-i Shor (saline
phlegm) [10]
which is diverted towards the skin by Quwwat-i Ṭabī’yya (natural faculty)
resulting in pruritic skin lesion [13].
The
line of treatment of QÅ«bÄ is based on TeḥlÄ«l (resolvent) and Talá¹Ä«f-i
MawÄd (demulcent)[12];
and there are many single and compound drugs mentioned in Unani classical
literature such as Marham-i DÄd [14], Ḥabb-i
QÅ«bÄ [15], Ushaq
(Dorema ammoniacum) with vinegar [13]; Samagh-i
‘Arabi (Acacia gummi) with Sirka [12], Saresham
MÄhi (Gelatinum/Isinglass) and Kundar (Boswalia
serrate) mixed with vinegar [13] for
topical application.
Among
these, Halela Zard (Terminalia chebula Retz.) mixed with Sirka
(vinegar) is recommended for the treatment of QÅ«bÄ [11][13]which
possesses TeḥlÄ«l and Talá¹Ä«f properties. After the extensive
online and hand search of literature sources on QÅ«bÄ, it’s found that no
trial was conducted to validate the safety and efficacy of this drug in the patients
of QÅ«bÄ.
Keeping
all facts in consideration, the present study has been designed to conduct on QÅ«bÄ
with topical use of Halela Zard and Sirka, entitled “Therapeutic Evaluation of Topical Halela
Zard in Treatment of QÅ«bÄ (Tinea Corporis) - A Randomised Standard Controlled Trialâ€.
Review of Literature:
Dermatophytosis,
publicly called as ringworm[3][4], is
a fungal infection of skin that have global significance. It is highly
prevalent in tropical and subtropical regions of the world [7]. Tinea
is a Latin word implying the worm of serpentine nature for skin lesion [3]. Dermatophytes
are inoculated into the host skin through penetration followed by full-blown
lesions mediated by proteases, serine-substilisins, and fungolysin which cause
digestion of keratin network into oligopeptide or amino acid and act as potent
immunogenic stimuli[16].
Tinea corporis is a
superficial dermatophytic infection of skin other than those involving scalp,
beard, hands, feet, and groin[4][7]. It is characterized by one or more circular,
sharply circumscribed, and slightly erythematous dry scaly, usually
hypopigmented patches [17]. In Unani literature, QÅ«bÄ
is defined as roughness or scaly skin which is black or red in colour. The primary cause of QÅ«bÄ
is Mirra-Sawda’ (bilious melanchole) produced by excess intake of black
bile producing foods [10]. Moreover, QÅ«bÄ
may be Damawī (sanguineous) due to putrefied blood and morbid fluid
mixing in the blood; Raá¹Å«bÄ« due to excess heat and infection and SawdÄwÄ«
due to burnt humours or excessive black bile. The sanguineous lesion appears
reddish, while Raá¹Å«bÄ« lesion is whitish to reddish and yellowish in
colour. However, the lesion of SawdÄwÄ« QÅ«bÄ appears deep brown in color [18].
According to Ibn SÄ«nÄ, QÅ«bÄ
may be of certain types, such as QÅ«bÄ DamawÄ« (sanguineous) marked by
oozing of fluid from the annular lesions; it may also be caused by saline
phlegm mixed with abnormal black bile resulting in dry lesions. Few other types
are QÅ«ba SÄ‘ī (creeping ring worm), KhabÄ«th (malignant/morbid),
and putrefied one[12].
IsmÄÄ«l JurjÄnÄ« said that QÅ«bÄ is caused by pruritic Khilá¹-i FÄsid (morbid humour) or Khilt-i Ghaliz (thick humour) and SawdÄwÄ«
(black bilious) blood. The other potential cause is diversion of morbid matter
from internal to external part of the body resulting in QÅ«bÄ under the
influence of Quwwat-i Tabī’yya [13]. It
is treated on the principle of Tanqiya (elimination
of morbid material from the body), Teḥlīl (resolution)
and Talá¹Ä«f-i MawÄd (attenuation) [12].
Hence, drugs which eliminate Sawda’ out of the body are employed in its
treatment besides resolvent and dessicant drugs. A number of single and
compound drugs have been prescribed by Unani scholars in treatment of QÅ«bÄ.
Moreover, various regimenal procedures such as Ta‘līq al-‘Alaq (leeching)
[12]; ḤammÄm
(therapeutic bath) [12][13]; HijÄma
bi’l SharṠ(wet cupping) [13], and
Faá¹£d (venesection) are also prescribed [10][12]. Among
these single drugs, Halela Zard is a potent antifungal plant based single
drug and it possesses Mushil-i Ṣafra’ (cholagogue),
QÄbiḠ(astringent), and Muqawwi-i Mi’da (stomachic) actions
as mentioned in Unani classical literature [19][20]. The
renowned Unani scholar Ahmad al-Hasan al-JurjÄni has written in his voluminous
book “DhakhÄ«ra KhwÄrizm ShÄhi†that Halela Zard (Terminalia
chebula) should be mixed with Sirka (vinegar) and applied topically
on the dermatophytic lesion[13].
Halela Zard (Terminalia
chebula, Retz.) belongs to the family of Combretaceae. Its habitat is
throughout India, especially West Bengal; Tamil Nadu; West Coast, and Western Ghats.
Its fruit is used for thee therapeutic purpose, and the chief chemical
constituents are chebulin; palmitic acid, and behenic acid. The reported pharmacological actions are anti-inflammatory;
carminative; digestive; laxative; purgative; antiseptic with indications in
wound; ulcers; inflammation; skin diseases; neuropathy, and general debility [21]. Dutta
B K and Rubini B , et al reported that the aqueous extract of Terminalia chebula
fruit has potent anti-fungal activity, especially against Trichophyton
rubrum [22] [23]. Sirka
is an acidic agent which helps in reduction of growth of the fungus [16].
Thus,
it is hypothesized that Halela Zard along with Sirka as a vehicle
will be very effective in amelioration of tinea corporis as the reported
antifungal action and its use in treatment of QÅ«bÄ by Unani scholars. The
control drug “Terbinafine†is a standard drug for treatment of tinea with significant
antifungal action [24][25][26].
Keeping
the above concepts and claim in view, the present study entitled “Therapeutic Evaluation of Topical Halela
Zard in Treatment of QÅ«bÄ (Tinea Corporis) - A Randomised Standard Controlled Trial†has been designed for the
treatment of T. corporis. List
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