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|title=Kushtha Nidana

|title=Kushtha Nidana

|titlemode=append

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|keywords=Kushtha, Mandal, Kapala, Kakanak, Audambar, Rishyajihva, Pundareeka, Sidhma, causes of skin diseases, discoloration of skin

|keywords=Kushtha, Mandal, Kapala, Kakanak, Audambar, Rishyajihva, Pundareeka, Sidhma, causes of skin diseases, discoloration of skin, psoriasis, eczema, skin disorders, fungal infection, charak samhita, ayurveda, lichen planus

|description=Nidana Sthana Chapter 5. Diagnosis and etiopathogenesis of Skin diseases

|description=Nidana Sthana Chapter 5. Diagnosis and etiopathogenesis of Skin diseases

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}}

}}

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=== Introduction ===

== Introduction ==

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The term ''kushtha'' literally means disfigurement of skin. Thus all the dermatological manifestations have been clubbed under the term ''kushtha''. For which Charak has devoted two full chapters, the fifth chapter in [[Nidana Sthana]] dealing with the etiopathogenesis and the seventh chapter in the [[Chikitsa Sthana]] deals with etiopathogenesis and treatment. Dermatological diseases have been classified into four groups, which include seven types of ''kushtha'' (dermatosis), seven types of ''visarpa'' (a form of acute dermatitis like erysipelas), seven types of ''pidaka'' (papular presentations) and three types of ''kilasa'' (vitiligo) ([[Sutra Sthana]] 19/3). However, looking to the clinical importance, acuteness and progression, one full chapter has been devoted to ''visarpa'', one of the major dermatological conditions (Cha.Chi. 21).Some other clinical presentations like Urticaria (''udarda, kotha''), ''nilika'' (bluish discoloration of the skin), ''tilalklaka'' (mole), ''piplu''(port wine mark on skin), ''vyanga'' etc. have also been explained briefly at other places. Detailed description and classification of ''pidaka'' (papules) is given in the seventeenth chapter of [[Sutra Sthana]].  

The term ''kushtha'' literally means disfigurement of skin. Thus all the dermatological manifestations have been clubbed under the term ''kushtha''. For which Charak has devoted two full chapters, the fifth chapter in [[Nidana Sthana]] dealing with the etiopathogenesis and the seventh chapter in the [[Chikitsa Sthana]] deals with etiopathogenesis and treatment. Dermatological diseases have been classified into four groups, which include seven types of ''kushtha'' (dermatosis), seven types of ''visarpa'' (a form of acute dermatitis like erysipelas), seven types of ''pidaka'' (papular presentations) and three types of ''kilasa'' (vitiligo) ([[Sutra Sthana]] 19/3). However, looking to the clinical importance, acuteness and progression, one full chapter has been devoted to ''visarpa'', one of the major dermatological conditions (Cha.Chi. 21).Some other clinical presentations like Urticaria (''udarda, kotha''), ''nilika'' (bluish discoloration of the skin), ''tilalklaka'' (mole), ''piplu''(port wine mark on skin), ''vyanga'' etc. have also been explained briefly at other places. Detailed description and classification of ''pidaka'' (papules) is given in the seventeenth chapter of [[Sutra Sthana]].  

The concept of micro-organism and parasitology was established by Charak and he had the knowledge that micro-organisms are responsible for the causation of dermatological manifestations (Cha. VI. 7/11). Their treatment is to be followed like the treatment of ''kushtha''. In the symptomatology of ''kushtha'' presence of ''krimi'' is described as one of the symptoms, which denotes visible worms usually maggots (''samsvedaja krimi'')(Cha. Ni. 5).

The concept of micro-organism and parasitology was established by Charak and he had the knowledge that micro-organisms are responsible for the causation of dermatological manifestations (Cha. VI. 7/11). Their treatment is to be followed like the treatment of ''kushtha''. In the symptomatology of ''kushtha'' presence of ''krimi'' is described as one of the symptoms, which denotes visible worms usually maggots (''samsvedaja krimi'')(Cha. Ni. 5).

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===Sanskrit Text, Transliteration and English Translation===

==Sanskrit Text, Transliteration and English Translation==

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Now I shall expound the chapter on diagnosis of ''kushtha'' (dermatosis).  

Now we shall expound the chapter "Kushtha Nidana" (Diagnosis and etiopathogenesis of Skin diseases). Thus said Lord Atreya.[1-2]

As propounded by Lord Atreya.[1-2]

==== Pathogenic factors in ''kushtha'' ====

=== Pathogenic factors in ''kushtha'' ===

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The pathology of skin diseases origin from the deranged physiology of seven factors connected to skin. They are ''vata, pitta'' and ''kapha'' ''doshas'' in aggravated state and ''dhatus'', namely, ''tvak'' (the word ''tvak'' represents skin. Since the skin is organ in which ''rasa dhatu'' is present, ''tvak'' word is used instead of ''rasa dhatu'' ), ''mamsa, shonita'' and ''lasika'' that get deranged due to aggravated ''dosha''. So seven type of ''kushtha'' are manifested by these seven morbid factors. Thus preliminary and manifested ''kushtha'' gradually afflicts the whole body. [3]

The pathology of skin diseases origin from the deranged physiology of seven factors connected to skin. They are ''vata, pitta'' and ''kapha'' ''doshas'' in aggravated state and ''dhatus'', namely, ''tvak'' (the word ''tvak'' represents skin. Since the skin is organ in which ''rasa dhatu'' is present, ''tvak'' word is used instead of ''rasa dhatu'' ), ''mamsa, shonita'' and ''lasika'' that get deranged due to aggravated ''dosha''. So seven type of ''kushtha'' are manifested by these seven morbid factors. Thus preliminary and manifested ''kushtha'' gradually afflicts the whole body. [3]

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==== Possible types of ''kushtha'' ====

=== Possible types of ''kushtha'' ===

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Variation in single ''dosha'' cannot cause ''kushtha''. Even in ''kushtha'' with similar presentations, the clinical features in terms of sensation in skin, colour, site of skin lesion, other symptoms, and treatment may vary depending on the variation in vitiation of (qualities of) ''dosha''. Therefore there are seven or eighteen or innumerable types of ''kushtha''. The variations in qualities of vitiated ''dosha'' lead to further differentiation in types of diseases, except in incurable conditions. As there might be innumerable types of ''kushtha'' leading to expansion of text, only seven types of ''kushtha'' are described here. [4]

Variation in single ''dosha'' cannot cause ''kushtha''. Even in ''kushtha'' with similar presentations, the clinical features in terms of sensation in skin, colour, site of skin lesion, other symptoms, and treatment may vary depending on the variation in vitiation of (qualities of) ''dosha''. Therefore there are seven or eighteen or innumerable types of ''kushtha''. The variations in qualities of vitiated ''dosha'' lead to further differentiation in types of diseases, except in incurable conditions. As there might be innumerable types of ''kushtha'' leading to expansion of text, only seven types of ''kushtha'' are described here. [4]

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==== Seven types of ''kushtha'' ====

=== Seven types of ''kushtha'' ===

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Thus, there are seven types of specific ''kushtha'', however depending on degree of superior and inferior involvement of etiology, permutation and combinations ''kushtha'' may be innumerable. [5]

Thus, there are seven types of specific ''kushtha'', however depending on degree of superior and inferior involvement of etiology, permutation and combinations ''kushtha'' may be innumerable. [5]

==== Common etiological factors of ''kushtha'' ====

=== Common etiological factors of ''kushtha'' ===

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Above causative factors lead to simultaneous aggravation of all the ''tridosha'', weakness in the skin etc. four ''dushyas''. Aggravated ''doshas'' lodge themselves in these weakened factors and after localization, further vitiate them and manifest ''kushtha''. [6]

Above causative factors lead to simultaneous aggravation of all the ''tridosha'', weakness in the skin etc. four ''dushyas''. Aggravated ''doshas'' lodge themselves in these weakened factors and after localization, further vitiate them and manifest ''kushtha''. [6]

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==== Premonitory signs of ''kushtha'' ====

=== Premonitory signs of ''kushtha'' ===

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The clinical manifestations of skin diseases are preceded by or associated with loss or excessive sweating (at the site of localization of vitiates ''doshas''), excess rough or excess smooth skin, discoloration, itching, pricking sensation, numbness, severe burning sensation, tingling sensation, goose bumps, xerosis on palpation, hot flashes, heaviness, swelling, if there is tenderness it indicates the possibility of suppurated, burnt, bitten, broken, injured and dislocated parts and even smaller ulcers become chronic, non healing.[7]

The clinical manifestations of skin diseases are preceded by or associated with loss or excessive sweating (at the site of localization of vitiates ''doshas''), excess rough or excess smooth skin, discoloration, itching, pricking sensation, numbness, severe burning sensation, tingling sensation, goose bumps, xerosis on palpation, hot flashes, heaviness, swelling, if there is tenderness it indicates the possibility of suppurated, burnt, bitten, broken, injured and dislocated parts and even smaller ulcers become chronic, non healing.[7]

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==== Specific features of ''kapala kushtha'' ====

=== Specific features of ''kapala kushtha'' ===

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Dry, crimson red in color, coarse, unevenly spread, having rough edges, thin and slightly elevated periphery, severe numbness, covered with bristling hair, afflicted with extreme piercing pain, having mild itching, burning sensation, less serous and pus discharge, having acute manifestation and quick progression, are infested with maggots  and appear like a black or blackish red piece of broken earthen pot.(1)

Dry, crimson red in color, coarse, unevenly spread, having rough edges, thin and slightly elevated periphery, severe numbness, covered with bristling hair, afflicted with extreme piercing pain, having mild itching, burning sensation, less serous and pus discharge, having acute manifestation and quick progression, are infested with maggots  and appear like a black or blackish red piece of broken earthen pot.(1)

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==== ''Audumbara kushtha'' ====

=== ''Audumbara kushtha'' ===

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The color of affected part of skin is coppery, covered with coppery-rough (thick) hair, have plenty of thick discharge of pus, blood and lymph accompanied with itching, moistened, sloughing, burning sensation and suppuration, having acute manifestation and quick progression, associated with rise in temperature and infested with maggots, appear like the ripe fruit of ''Udumbara'' (Ficus racemosa Linn) in color.(2)

The color of affected part of skin is coppery, covered with coppery-rough (thick) hair, have plenty of thick discharge of pus, blood and lymph accompanied with itching, moistened, sloughing, burning sensation and suppuration, having acute manifestation and quick progression, associated with rise in temperature and infested with maggots, appear like the ripe fruit of ''Udumbara'' (Ficus racemosa Linn) in color.(2)

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==== ''Mandala kushtha'' ====

=== ''Mandala kushtha'' ===

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Skin is unctuous, heavy, elevated with smooth, fixed and yellowish margins, white and reddish in appearance, filled with white hairlines associated with copious, thick, white  and slimy discharge, excessive oozing and itching,  infested with numerous maggots, lesions are slow to spread & progression, round in shape.(3)

Skin is unctuous, heavy, elevated with smooth, fixed and yellowish margins, white and reddish in appearance, filled with white hairlines associated with copious, thick, white  and slimy discharge, excessive oozing and itching,  infested with numerous maggots, lesions are slow to spread & progression, round in shape.(3)

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==== ''Rishyajihva kushtha'' ====

=== ''Rishyajihva kushtha'' ===

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In this skin is rough, downy red, blackish in the center as well as in the periphery, have the appearance of shades of blue, yellow and coppery tinge associated with acute onset and spreading, with less itching, oozing and maggot infestation, having excessive burning sensation, ulceration, piercing pain (suppuration) as if pierced with bristles, with elevated center and thin margins; surrounded with rough papules and  having large circumference  and shape like that of the antelope (''rishyajihva'') tongue. (4);

In this skin is rough, downy red, blackish in the center as well as in the periphery, have the appearance of shades of blue, yellow and coppery tinge associated with acute onset and spreading, with less itching, oozing and maggot infestation, having excessive burning sensation, ulceration, piercing pain (suppuration) as if pierced with bristles, with elevated center and thin margins; surrounded with rough papules and  having large circumference  and shape like that of the antelope (''rishyajihva'') tongue. (4);

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==== ''Pundarika kushtha'' ====

=== ''Pundarika kushtha'' ===

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''Pundarika kushtha'' has following features: In this type, the skin is white with reddish shade, with red margins covered with red lines and blood vessels, elevated, with copious thick blood, pus and serous discharge, associated with itching, maggots infestation, burning sensation and suppuration, and having acute manifestation and quick progression, appears like the petals of lotus(or Butea monospemum flower). (5);

''Pundarika kushtha'' has following features: In this type, the skin is white with reddish shade, with red margins covered with red lines and blood vessels, elevated, with copious thick blood, pus and serous discharge, associated with itching, maggots infestation, burning sensation and suppuration, and having acute manifestation and quick progression, appears like the petals of lotus(or Butea monospemum flower). (5);

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==== ''Sidhma kushtha'' ====

=== ''Sidhma kushtha'' ===

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In this type, skin is rough and downy red in color, with external margins fissured and thin, unctuous at the center, having white and red shades, numerous lesions, associated with mild pain, itching, burning sensation, purulent and serous discharge, having mild initiation and progression, and less maggots infestation, appear like flower of ''alabu'' (Lagenaria siceraria Standi (bottle gourd)) – are to be known as ''sidhma kushtha''(6);

In this type, skin is rough and downy red in color, with external margins fissured and thin, unctuous at the center, having white and red shades, numerous lesions, associated with mild pain, itching, burning sensation, purulent and serous discharge, having mild initiation and progression, and less maggots infestation, appear like flower of ''alabu'' (Lagenaria siceraria Standi (bottle gourd)) – are to be known as ''sidhma kushtha''(6);

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==== ''Kakanaka kushtha'' ====

=== ''Kakanaka kushtha'' ===

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In this type, the skin is having color of ''Gunja'' (Abrus precatorius) seed in the beginning but later on associated with symptoms of all sinful ''kushtha'' subsequently having many colors. This is incurable, while others are curable. [8]

In this type, the skin is having color of ''Gunja'' (Abrus precatorius) seed in the beginning but later on associated with symptoms of all sinful ''kushtha'' subsequently having many colors. This is incurable, while others are curable. [8]

==== Prognosis ====

=== Prognosis ===

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The incurable disease never give up its incurability (never become curable). The curable disease may sometimes become incurable due to misconduct (not following the diet and lifestyle regulations properly). The six (types of) ''kushtha'' are curable except ''kakanaka''. However if not treated properly, they may become incurable due to lack of timely management, improper management and constantly excess aggravation of ''doshas''. [9]

The incurable disease never give up its incurability (never become curable). The curable disease may sometimes become incurable due to misconduct (not following the diet and lifestyle regulations properly). The six (types of) ''kushtha'' are curable except ''kakanaka''. However if not treated properly, they may become incurable due to lack of timely management, improper management and constantly excess aggravation of ''doshas''. [9]

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==== Complications of ''kushtha'' ====

=== Complications of ''kushtha'' ===

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During this stage, a patient of ''kushtha'' afflicts with complications such as- excessive discharge, ulceration of body parts, sequestration of body  parts (necrosis of phallenges), thirst, fever, diarrhea, burning sensation, debility, anorexia, indigestion. Such types of ''kushtha'' should be known as incurable. [11]

During this stage, a patient of ''kushtha'' afflicts with complications such as- excessive discharge, ulceration of body parts, sequestration of body  parts (necrosis of phallenges), thirst, fever, diarrhea, burning sensation, debility, anorexia, indigestion. Such types of ''kushtha'' should be known as incurable. [11]

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==== Summary ====

=== Summary ===

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Thus ends the fifth chapter on [[Kushtha Nidana]] in [[Nidana Sthana]] in the treatise composed by Agnivesha and as redacted by Charak.

Thus ends the fifth chapter on [[Kushtha Nidana]] in [[Nidana Sthana]] in the treatise composed by Agnivesha and as redacted by Charak.

=== ''Tattva Vimarsha'' / Fundamental Principles===

== Tattva Vimarsha (Fundamental Principles) ==

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*''Kushtha'' is the result of combined and simultaneous involvement of all the three ''dosha'' and subsequently vitiation of the four body constituents i.e. ''rasa'' (''twak'', or skin), ''mamsa''(muscle tissue), ''rakta''(blood), and ''lasika''(lymph).

*''Kushtha'' is the result of combined and simultaneous involvement of all the three ''dosha'' and subsequently vitiation of the four body constituents i.e. ''rasa'' (''twak'', or skin), ''mamsa''(muscle tissue), ''rakta''(blood), and ''lasika''(lymph).

*The curable disease can become incurable due to improper management, exposure to causative factors and aggravation of ''dosha''.

*The curable disease can become incurable due to improper management, exposure to causative factors and aggravation of ''dosha''.

=== ''Vidhi Vimarsha'' / Applied Inferences ===

== Vidhi Vimarsha (Applied Inferences) ==

Three chapters are devoted to dermatological disorders, present chapter and [[Chikitsa Sthana]] chapter 7 ([[Kushtha Chikitsa]]) and 21([[Visarpa Chikitsa]]). The present chapter deals with seven types of ''kushtha'', while in [[Kushtha Chikitsa]], all eighteen types have been described and have been given the name of ''Mahakushtha'' (major) and ''Kshudra kushtha'' (Minor). After reviewing the symptoms of seven major types it is clear that it covers a progressive disorder of skin leading to loss of organs and impaired sensation (sensory neuropathy). According to some commentators ''Kshudra kushtha'' is a  group of mild and localized skin diseases, which runs a chronic course.

Three chapters are devoted to dermatological disorders, present chapter and [[Chikitsa Sthana]] chapter 7 ([[Kushtha Chikitsa]]) and 21([[Visarpa Chikitsa]]). The present chapter deals with seven types of ''kushtha'', while in [[Kushtha Chikitsa]], all eighteen types have been described and have been given the name of ''Mahakushtha'' (major) and ''Kshudra kushtha'' (Minor). After reviewing the symptoms of seven major types it is clear that it covers a progressive disorder of skin leading to loss of organs and impaired sensation (sensory neuropathy). According to some commentators ''Kshudra kushtha'' is a  group of mild and localized skin diseases, which runs a chronic course.

''Kushtha'' and ''visarpa'' - both the diseases have the same seven causative factors (three ''dosha'' and four ''dhatu'' type disorders), where ''kushtha'' is chronic and ''visarpa'' is acute and may be life threatening,  In ''visarpa'', ''rakta'' is dominant which makes it spread rapidly, treatment is bloodletting. In case of ''kushtha'' all seven factors are involved with little bit variation.

''Kushtha'' and ''visarpa'' - both the diseases have the same seven causative factors (three ''dosha'' and four ''dhatu'' type disorders), where ''kushtha'' is chronic and ''visarpa'' is acute and may be life threatening,  In ''visarpa'', ''rakta'' is dominant which makes it spread rapidly, treatment is bloodletting. In case of ''kushtha'' all seven factors are involved with little bit variation.

==== Causes of ''Kushtha'' ====

=== Causes of ''Kushtha'' ===

Diet and lifestyle play a significant role in health and disease. What, how and when diet should be taken is important. In ''kushtha'', alternating opposite character of food like hot/cold, nourishing/ non nourishing foods if taken one after the other is an etiological factor. Many other such etiological factors have been listed. All the etiological factors mentioned, also help in the growth of parasites like maggots at the involved skin.  

Diet and lifestyle play a significant role in health and disease. What, how and when diet should be taken is important. In ''kushtha'', alternating opposite character of food like hot/cold, nourishing/ non nourishing foods if taken one after the other is an etiological factor. Many other such etiological factors have been listed. All the etiological factors mentioned, also help in the growth of parasites like maggots at the involved skin.  

Early diagnosis is important and stages have been described for disease manifestation. ''Poorvarupa'' (prodromal symptoms) occur in the fourth stage of disease manifestation and if the disease is diagnosed at this level, early control and better treatment may be possible. Though in the stage of ''poorvarupa'' it may not be possible to diagnose the type/subtype of disease, however type of ''dosha'' can be decided and accordingly treatment can be started. (7)

Early diagnosis is important and stages have been described for disease manifestation. ''Poorvarupa'' (prodromal symptoms) occur in the fourth stage of disease manifestation and if the disease is diagnosed at this level, early control and better treatment may be possible. Though in the stage of ''poorvarupa'' it may not be possible to diagnose the type/subtype of disease, however type of ''dosha'' can be decided and accordingly treatment can be started. (7)

==== Classification of ''kushtha'' ====

=== Classification of ''kushtha'' ===

The ''mahakushtha'' has been classified under seven types as per their ''dosha'' predominance accordingly symptomatology of these has been described. All the body physiology and pathology is designated to a particular ''dosha'' thus the diseases are basically diagnosed on the basis of three ''dosha'' and their combinations. The color, texture, secretions, margins, and types of pain associated with these lesions, as wsell as their progression have been classified on the basis of three ''dosha''.

The ''mahakushtha'' has been classified under seven types as per their ''dosha'' predominance accordingly symptomatology of these has been described. All the body physiology and pathology is designated to a particular ''dosha'' thus the diseases are basically diagnosed on the basis of three ''dosha'' and their combinations. The color, texture, secretions, margins, and types of pain associated with these lesions, as wsell as their progression have been classified on the basis of three ''dosha''.

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===== Layers of skin =====

==== Layers of skin ====

Charak and Sushruta both have enumerated the layers of skin and the thickness of layers and diseases occurring in these layers have also been narrated. Their possible modern equivalence as given by some scholars in Ayurvedic texts is as follows:

Charak and Sushruta both have enumerated the layers of skin and the thickness of layers and diseases occurring in these layers have also been narrated. Their possible modern equivalence as given by some scholars in Ayurvedic texts is as follows:

Leprosy can be referred in seven types of Kushtha. Vivid description of the disease is available in the texts and almost all the aspects of pathogenesis is detailed including its contagiousness. The serious complications like disfigurement of limbs and loss of phalanges has also been described.

Leprosy can be referred in seven types of Kushtha. Vivid description of the disease is available in the texts and almost all the aspects of pathogenesis is detailed including its contagiousness. The serious complications like disfigurement of limbs and loss of phalanges has also been described.

==== Research works on ''Kushtha''====

=== Research works on ''Kushtha''===

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! rowspan="1"| Name of author and title of thesis

! rowspan="1"| Name of author and title of thesis

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=== Related Chapters ===

== Related Chapters ==

* [[Kushtha Chikitsa]]

* [[Kushtha Chikitsa]]