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Skin diseases in Integrative Medicine (view source)

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Diagnosis and Management of Skin diseases in Integrative medicine
 
Diagnosis and Management of Skin diseases in Integrative medicine
 
(This article is based on a lecture delivered by Dr S R Narahari, MD (dermatology in biomedicine), Director, Institute of Applied Dermatology, Kasaragod, Kerala, India, in Prof.M.S.Baghel Memorial Lecture Series on Aug 09, 2021.)  
 
(This article is based on a lecture delivered by Dr S R Narahari, MD (dermatology in biomedicine), Director, Institute of Applied Dermatology, Kasaragod, Kerala, India, in Prof.M.S.Baghel Memorial Lecture Series on Aug 09, 2021.)  
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<div style='text-align:justify;'>
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==Integrative Medicine==
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The use of interventions from traditional medicine alongside biomedical (Western medicine) treatments for a biomedical diagnosis is integrative medicine.<ref>Rees L, Weil A. Integrated medicine. BMJ. 2001 Jan 20;322(7279):119-20. doi: 10.1136/bmj.322.7279.119. </ref>  The assessments for improvement (clinical outcomes) are made using biomedical parameters. Integrative medicine mainly focuses on prevention, improvement in the quality of life and healing, and holistic treatment. The present article provides insights into integrative medicine practices in skin diseases with evidence from peer-reviewed publications.
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Integrative Medicine
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===Diagnosis through Integrative Medicine===
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The use of interventions from traditional medicine alongside biomedical (Western medicine) treatments for a biomedical diagnosis is integrative medicine.   The assessments for improvement (clinical outcomes) are made using biomedical parameters. Integrative medicine mainly focuses on prevention, improvement in the quality of life and healing, and holistic treatment. The present article provides insights into integrative medicine practices in skin diseases with evidence from peer-reviewed publications.
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In integrative medicine, a disease is diagnosed by contemporary medical science parameters and its comparable condition in alternative medicine.  For example, in Psoriasis, annular, erythematous, xerosis lesions with an uneven surface are diagnosed as guttae psoriasis. The relative terms as explained in Ayurvedic classics in the context of Kushtha are listed in table 1. It shows that guttae psoriasis resembles mandala kushtha. 
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{| class="wikitable"
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|+ Table 1: Guttate Psoriasis (Mandala Kushtha)
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|-
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! Symptom  !! Relative terms in Ayurveda
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|-
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| | Annular ||  Mandala
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|-
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| | Erythematous ||  Rakta varna
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|-
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| | Xerosis ||  Ruksha/Parusha
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|-
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| | Uneven surface ||  Khara
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|-
 +
|}
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Fig 1: Guttate Psoriasis (Mandala kushtha)
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Clinical examination in integrative medicine gives a mutual orientation with different medical systems.
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Some general dermatological features and their Ayurvedic correlations in Lichen Planus<ref>Narahari SR, Prasanna KS, Sushma KV. Evidence based integrative dermatology. Indian J Dermatol 2013;58:127- 31.</ref> are given in table 2.
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{| class="wikitable"
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|+ Table 2: General dermatological features of Lichen Planus
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|-
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! Symptom  !! Relative terms in Ayurveda
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|-
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| | Violaceous ||  Shyava/ Asita
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|-
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| | Elevated ||  Utseda
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|-
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| | Uneven surface ||  Khara
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|-
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| | Pruritic||  Kandu
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|-
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|}
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Fig 2: Fig 2: Lichen Planus
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Specific nomenclature resembling lichen planus is not observed in [[Ayurveda]] classics. However, in such cases, [[Ayurveda]] describes them based on pathophysiological features and still recommends treatments.
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In table 3, symptoms of lymphedema and its relative biomedical terms are explained. Lymphoedema is known as Shleepada in [[Ayurveda]]<ref>Narahari, S. R., Ryan, T. J.,Prasanna, K. S. and Aggithaya, G. M., Integrating modern dermatology and Ayurveda in the treatment of Vitiligo and lymphedema in India. International Journal of Dermatology, 2011;50: 310–334</ref>.  The table contains essential clinical features of the disease.<ref>Narahari S. Treating lymphodema patients in Indian villages. J Lymphodema, 2011;6:87-90</ref>
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{| class="wikitable"
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|+ Table 3: Features of lymphedema (known as Shleepada in Ayurveda)
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|-
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! Biomedical terms !! Relative terms in Ayurveda
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|-
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| | Dependent oedema of foot|| Bahushopha  pada
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|-
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| |Black pigmentation ||Krishna
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|-
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| |Pricking pain or pain without any cause ||Theevra Thoda or Arthi or Animitta rujam
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|-
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| | History of fever||Bahusho jwara
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|-
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| | Discharge||Samsrava
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|-
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| |Soft ||Mrudu
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|-
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| |Heaviness ||Gurutwa
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|-
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| | Largely oedematous||Adhika shopha
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|-
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| | The warmth of the limb/ fever||Jwara yukta
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|-
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| | Oily/shiny||Snigdha/Snigdha varna
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|-
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| |With Nodules/ warty growth ||Bahukantakai parivrtam
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|-
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| | Huge in size||Sthoola
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|-
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| |The feeling of heaviness[continuous] ||Guru Gurutwamanisham
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|-
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|}
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Fig 3:  Lymphedema
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{| class="wikitable"
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|+ Table 4: Vitiligo (Swithra)
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|-
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! Symptom !! Comparable terms in Ayurveda
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|-
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| |Absence of hair on lesional skin in hairy areas (differentiate it from Leprosy) || Roma vidhwamsa
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|-
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| | Color of lotus petal|| Padmapatraprateekasha
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|-
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|}
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Fig 4:  Vitiligo
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The above examples show that the final diagnosis could be similar even though the nomenclatures are different in two different medical systems. In an integrated system, both systems learn from each other.
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===Local pathology (sthaneeyavikruti)===
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While examining a patient through Ayurveda, the vitiated doshas must be carefully examined and understood. Ayurveda selects an appropriate drug for a chosen patient, whereas modern medicine selects a patient for a chosen drug. The examination of the status of dosha in skin diseases can be done based on clinical features, as shown in the example (table 5).<ref>Narahari S.R, Ryan TJ, Aggithaya GM,Prasanna KS. Evidence based approaches for Ayurvedic traditional herbal formulations: Toward an Ayurvedic CONSORT model. Journal of Alternative and complementary medicine 2008;14: 769–776.</ref>
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{| class="wikitable"
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|+ Table 5: Local pathologies and dosha specific clinical features in lymphoedema 
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|-
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! Vata dosha !! !! Pitta dosha!! !! Kapha dosha !!
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|-
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| | Ayurvedic terms|| Relative biomedical terminologies||Ayurvedic terms ||Relative biomedical terminologies ||Ayurvedic terms ||Relative biomedical terminologies
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|-
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| |Ruksha  ||Xerosis ||Daha  ||Burning sensation ||Snigdha/snigdha varna ||Oily/ shiny
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|-
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| |Bahushopha pada ||Dependent edema of foot||Raktavarna ||Erythema/ redness||Shwetabha ||Whitish
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|-
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| | Sphutana ||Fissures  ||Peeta varna ||Yellowish discoloration  ||Drudham/ sthiram ||Organized
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|-
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| |Krishna  ||Black pigmentation  ||Samsrava  ||Discharge  ||Bahukantakai parivrtam ||With nodules/ warty growth
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|-
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| | Teevrathoda/ arthi/ animittarujam|| Pain ||Mrudu  ||Soft ||Sthoola  ||Huge in size
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|-
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| |Bahushajwara ||History of fever  ||Gurutwa  ||Heaviness  ||Gurutwamanisham  ||The feeling of heaviness (continuous)
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|-
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| | || ||Adhika shopha ||Largely edematous  ||Sheetanvita ||Cold to touch
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|-
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| | || ||Jwara yukta ||The warmth of the limb/ fever ||Adhika shopha  ||Largely edematous
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|-
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|}
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{| class="wikitable"
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|+ Table 6: Vata dosha specific features in vitiligo
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|-
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! Symptoms  !! Allopathic terms
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|-
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| | Ruksha  ||Xerosis on inspection 
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|-
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| | Aruna  ||Dusky red color 
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|-
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| | Mandala  ||  Annular
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|-
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| |Parusha  || Xerosis on palpation
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|-
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| |Paridhwamsi  ||Galloping lesions with repigmentation or exploded
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|-
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| |Krishna || Dark repigmentation within the lesional skin when examined for the first time
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|-
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|}
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Fig 5: Vata Dominance Vitiligo
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==Clinical methods in [[Ayurveda]]==
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Diagnosis through Integrative Medicine:
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The core concept of integrative medicine is ‘adhere to the basics of each system of medicine being integrated. If another system cannot explain certain concepts of one medical system, it should not be rejected. Instead, it should be accepted and included. ‘Amsha-amsha kalpana’ of [[Ayurveda]] is similar to the system by system examination of biomedicine. Researchers have shown that ayurvedic clinical examination goes beyond the ten types of clinical examination (dashavidapariksha; the classical [[Ayurveda]] teaching).  Clinical methods in [[Ayurveda]] can be categorized as shown in table 7.
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In integrative medicine, a disease is diagnosed by contemporary medical science parameters and its comparable condition in alternative medicine.  For example, in Psoriasis, annular, erythematous, xerosis lesions with an uneven surface are diagnosed as guttae psoriasis. The relative terms as explained in Ayurvedic classics in the context of Kushtha are listed in table 1. It shows that guttae psoriasis resembles mandala kushtha.   
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{| class="wikitable"
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|+ Table 7: Methods of clinical examination in Ayurveda
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|-
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! Clinical methods in Ayurveda  !! Comparable biomedical terminologies
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|-
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| | Prakriti  ||Biological constitution of the body
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|-
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| | Dosha  || Primary life force
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|-
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| | Dushya  || Deranged basic body tissues and excretions
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|-
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| | Desha  || Habitat
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|-
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| | Vaya  || Age
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|-
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| |  Pramana  ||Body measurement
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|-
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| |  Sara  || Firmness or strength
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|-
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| | Samhanana  || Acquired body build
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|-
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| |  Kala  || Seasonal and duration
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|-
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| |  Vyayama shakti || Exercise capacity
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|-
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| | Agni/Kostha and Ahara  ||Assessment of digestive process and dietary habits and disorders related to it 
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|-
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| | Sattva  || Behavior patterns
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|-
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| |  Satmya || Compatible dietary habits
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|-
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| |  Bala  || Immunity of the patient
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|-
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| |  Roga avastha  || Stage of the disease
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|-
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| |  Bhaishajya  || Clinical pharmacology 
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|-
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|}
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The above details of patient information contribute to the Ayurvedic diagnosis and drug selection.
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[[Dosha]] theories and personalized medicine are essential concepts of [[Ayurveda]], meaning clinical presentation and its pathophysiology are of prime importance. In biomedicine, clinical presentations, diagnosis, and co-morbidities are also given prime importance. In addition, clinical methods and differential diagnosis are in greater detail than in [[Ayurveda]].
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==Skin diseases in [[Ayurveda]]==
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In [[Ayurveda]], seven major skin diseases (mahakushtha) and 11 minor skin diseases (kshudrakushtha) are explained. Mainly this classification is based on the [[dosha]] combination. The skin lesion is examined according to color, shape, appearance, sensation, spreading in the body, pain, and discharge. For example, the symptoms of Kapalakushtha and its attributes are given in Table 8.
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{| class="wikitable"
 +
|+ Table 8: Clinical features of kapalakushtha
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|-
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! Symptom  !! Biomedical description !! Attributes
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|-
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| | Krishna ||Hyperpigmented || Color
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|-
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| | Kapalabha  ||Dusky red  || Color
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|-
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| | Ruksha  ||Concave in shape like mud pot  ||Shape 
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|-
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| | Parusha  || Dry on inspection  || Appearance
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|-
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| | Tanu || Atrophic lesions  || Appearance
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|-
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| | Toda bahula ||Severe pricking pain  ||Pain 
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|-
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| | Vishama  || Poor prognosis  || Prognosis
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|-
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|}
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In modern dermatology, skin lesions are also categorized based on history, morphology, pattern of distribution, and others.  Rather than disease, those 11 minor skin diseases need to be considered as lesional skin morphology. In the Institute of Applied Dermatology, Kasargod, Kerala, Ayurveda doctors are asked to determine [[dosha]] vitiation of specific skin lesions. Dermatologists also examine the same patients to confirm the current diagnosis. Thus, the conditions are diagnosed and treated with an integrative approach.
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==Stages of disease==
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Fig 6: Stages of disease
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[[Ayurveda]] describes different stages of the disease by different names. For example, fig 6 can be discussed below.
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Fig 6 (a) is Lichen rubour planus. Since it is erythematous (raga), annular (mandala) and papular (pidaka), this is considered as dadru as per [[Ayurveda]]. Fig 6(b) &6(c) are hypertrophic lichen planus. There is hypopigmentation observed in the middle, surrounded by violaceous color. The lesions are thickened (ghana), elevated (utseda) with rough edges (rukshambahi). All represent [[Kapha]] [[vata]] [[dosha]] dominance. It is essential to know the stage of disease (roga avastha) to guide specific and selective treatment options.
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Fig 7: Lymphedema: Differential diagnosis (vyavachedhanidhana)
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In both these conditions, erythema (rakta varna), discharge (srava) and papular lesions are present. Therefore, it is considered as [[pitta]] predominant condition. However, the same treatment fails in one patient but improves the condition in another. One patient developed more pain, which is considered as aggravation of [[vata]]. Biopsy of the patient in (b)revealed that the condition was lymphangiosarcoma arising from lymphoedema, while the patient who got relief by treatment is lymphoedema with lymphangiectasia and lymphorrhoea (a). 
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==Treatment of skin disorders==
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===Importance of [[agni]], ama==
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The assessment of [[agni]] (digestion and metabolism) and ama (accumulated undigested biological waste in the digestive tract) is vital for treating a skin disorder. The importance of treating [[ama]] is shown in figure 7. The [[ama]] aggravates by the treatment for vitiligo without amapachana (digestion of [[ama]]). When [[ama]] is treated, the vitiligo also decreases. So if [[ama]] is present, treatment to remove it should be given at the beginning.
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Fig 8: Importance of amapachanain  vitiligo
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Integrative therapies should not compromise biomedical pathology, neither the principles of Ayurveda.  Table 9 shows that mutual dialogue between the systems of medicine leads to the integrated treatment protocol
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{| class="wikitable"
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|+ Table 9: Integrated Ayurveda and yoga treatment for lymphology guidelines
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|-
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! International Society of Lymphology consensus requirements<ref>Executive Committee of the International Society of Lymphology. The diagnosis and treatment of peripheral lymphedema: 2020 Consensus Document of the International Society of Lymphology. Lymphology. 2020;53:3-19. </ref>  !! IntegratedAyurveda elements 
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|-
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| | Skincare to improve the barrier function of the skin  ||Washing and soaking in hot infusion (phanta) to heal chronic wounds, care of bacterial entry lesions
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|-
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| | Lymph drainage  ||Udwarthana  (Indian manual lymph drainage ) and Yoga
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|-
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| | Breathing  ||Yoga
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|-
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| | Movements  ||Yoga
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|-
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| | Compression therapy ||Bandhana
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|-
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|}
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The rotating ankle movements as a Yoga exercise (Gulphachakrasana) are practised for lymphoedema patients. An increase in radioisotope clearance from lymphatics of lower limbs with even small-amplitude ankle movements is reported by Prof Peter Mortimer.<ref>Mortimer PS, Simmons R, Rezvani M. The measurement of skin lymph flow by isotope clearance –reliability, reproducibility, injection dynamics and the effect of massage. J Invest Dermatol 1990; 95: 677–682.</ref>  Yoga and asana bring mobility,joint and muscle pump activation and dermal stretch. It is hypothesized that Yoga may induce drainage of lymph.<ref>Narahari SR, Ryan TJ, Aggithaya MG. How Does Yoga Work in Lymphedema? J Yoga Phys Ther 2013; 3:135. doi: 10.4172/2157-7595.1000135</ref> 
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The above approach to chronic disease care leads to better treatment not provided by a single system alone. Figure 9 below shows the response of Lymphatic Filariasis (lymphoedema) following integrative medicine treatment. A clinic to lab research-based developed from such studies might provide new treatments for chronic disease.<ref>Karayi AK, Basavaraj V, Narahari SR, Aggithaya MG, Ryan TJ, Pilankatta R. Human skin fibrosis: up-regulation of collagen type III gene transcription in the fibrotic skin nodules of lower limb lymphoedema. Trop Med Int Health. 2020;25:319-327. doi:10.1111/tmi.13359</ref> 
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Fig 9: The patient arrived for treatment on June 2 2017 (left), and returned for follow up on January 21 2018 (right).
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==Conclusion==
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Integrative medicine bridges the gap between biomedicine and [[Ayurveda]]. It allows the re-purposing of drugs within [[Ayurveda]]. Integrative medicine helps [[Ayurveda]] stage the disease; by adopting modern investigations, effectiveness of treatment can be improved. At the same time, intersectoral collaboration helps modern medicine to use evidence-based traditional medicines. [[Prakriti]] based studies will add more knowledge to pharmacodynamics. Especially in chronic conditions, integrating [[Ayurveda]] and Yoga could be an example for WHOs innovative care for chronic conditions.<ref>Innovative Care for Chronic Conditions accessed from the WHO website https://www.who.int/chp/knowledge/publications/icccglobalreport.pdf on the 18th September 2019</ref> In order to develop a treatment protocol of integrative medicine, a sound knowledge of applied and translational science is required.
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</div>
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==References==
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