Dadru is a skin disease described in Ayurveda correlated with the dermatophytosis conditions in contemporary science due to its clinico-pathological relevance. Its incidence rate is increasing day by day due to various contributing factors such as antifungal drug resistance, epidemiological conditions, poor sanitation etc. The biggest challenge in its mitigation is preventing its recurrence. The goal of the treatment of the disease is to understand its pathology related with its personal and general etiology. The prevalence rate can be minimized by following the proper preventive and curative measures discussed here. Various investigations, such as skin scarping for fungus by 10 % KOH (potassium hydroxide) , fungal culture, direct PCR, antifungal susceptibility testing are available to identify the specific fungal strain, which will be helpful in treating the disease and recalcitrant cases. Along with this, the regional and topographical species prevalence must be analyzed. So, that the physician can understand the area wise pattern and pesentation of dermatophytosis.  Screening of the fungal species should be done to analyze the cause of recurrence. Many of the classical formulations in Ayurveda have excellent results in the management of Dadru, both externally and internally. Indication of all the formulation differs from one person to another. Maintenance of personal hygiene and dietary restriction is mandatory but there is also huge need of analyzing the antifungal property of the formulation.  Multicentric, large scale randomized controlled clinical trials should be conducted pan India for validation of the positive result of the classical formulations upon Dadru, as described in Ayurveda.

Introduction

Skin is the largest organ which serves as the covering for all the internal organs as well as act like a cocoon and shields us from a wide range of external stimuli and harmful environment. As the largest organ of the body, the skin covers a surface area of 18 square meters and accounts for approximately 18% of the total body weight. A healthy skin always denotes wellbeing of the internal homeostasis of a person. Minimal to severe changes in skin’s color, texture or sensation indicates any physiological changes or pathological pressure upon body homeostasis. Any disease of the skin is always anguishing & put the patient in mental dilemma. It also contributes remarkable social impediment because it is visible.  Ayurveda describes all kinds of diseased skin conditions under Kushtha. As per the classical texts of, the word Kushtha means “Kushnati angam” or “ Kushnati Vapuh iti” means the condition in which body’s natural complexion and aura get masked or darkened.  Dadru is one of those, which also creates anxiety, both physiological & psychological irritability. In this modern era of hustle & bustle, a vast research in Ayurveda has taken place upon different skin disorders. Dadru is one among those intractable skin ailments which is long waiting for a delve into basics of its epidemiology & evidence-based elixirs as described in the Samhitas along with the patterns and prevalence across India. In India, Cutaneous dermatophytosis is most commonly caused by the dermatophytes belonging mainly to the genera Trichophyton (especially Trichophyton rubrum), Microsporum and Epidermophyton floccosum1. Dadru(~Dermatophytosis) is a kind of Kushtha Roga(~skin disease) coming under the sub heading of kshudrakushtha & mahakushtha according to Acharya Charaka & Acharya Sushruta respectively2,3. Chakrapani explained that kshudrakushtha has Alpa (less) Dosha and lakshanas (symptoms) in comparision to Mahakushtha4. So, it is known as kshudrakushtha. The separate Nidana (causative factors) and Samprapti (pathogenesis) of Dadru kushtha were not explained in the texts. But, in this regard the classical texts have apparently considered the Samanya Nidana and Samprapti of Kushtha. The condition of the Dadru kushtha is generally understood as a Rakta Doshaja Kapha-pitta Pradhana Twak Vikara3 presenting with symptoms Kandu (itching), Utsanna mandala (annular lesions with raised border and central clearing), raga (redness) and pidaka (eruptions). Those clinical features, replicates the features of Cutaneous dermatophytosis or Tinea as described in contemporary science, which is a “Superficial fungal infection of skin” the most common dermatological manifestation with overall global prevalence of 20-25%5. It has become a significant health problem affecting children, adolescents and adults worldwide. In India 5 out of 1000 people suffer from Tinea infections6. It has been observed that since over past few years, Dadru in India is increasingly becoming ungovernable, recalcitrant and sometimes with a rebellious clinical presentation even after the standard treatment protocol. India, being a tropical country with favorable hot humid climate for fungus is having a substantial rise in extensive and relapsing cases of superficial dermatophytosis among its population on daily basis of clinical practice. Hospital-based studies have reported disease burdens ranging from approximately 36.6% to 78.4%7, while the topographical prevalence estimation always vary from region to region. However, the treating Physicians are also providing the best evidence-based care as described in the texts. But, still the prevalence of Dermatophyte infection is gradually becoming more resilient in clinical pattern all across India. The increasing burden of dermatophytosis, alongside concerns regarding antifungal resistance, treatment non-adherence and relapse, creates a strong rationale for re-probing age old Ayurvedic principles. The classical understanding of Dadru along with a holistic framework addressing diet, lifestyle changes, personal hygiene and checking the triggering environmental factors may help in controlling the relapse. Now, it is the need of the hour for amalgamation of finding out the multiple causative factors responsible for the Dermatophytosis across the country with its prevalence and deep introspection of ancient principles of Samhitas to analyze the basic pathogenesis, prevention and management. Therefore, the present paper is focusing on classical descriptions of Dadru along with the dermatological investigations, which can be used as an evidence for analyzing and diagnosing a case. So that it would provide a stepping stone for Integrative research and evidence based Ayurvedic managementof Dadru (Cutaneous dermatophytosis) in India.

METHODS:

Following different factors are closely connected with dadru for its occurrence, aggravation, mitigation and becoming recurring in nature. Some of them are personal reasons and some are geological conditions. Let’s discuss one by one.

I. Epidemiology & National Patterns:

Now-a-days, Dadru has relatively become a matter of higher anxiety for a treating physician. The epidemiology along with the clinical pattern has become so oscillating that, sometimes it is creating huge confusion in diagnosing a case aptly. Till now, there is no latest, reliable, single study available upon the entire population of India, which can present the national percentage of prevalence of Dermatophytosis. But, numbers of published data are there from hospitals or community studies with wide variation depending on various factors.

II. Regional prevalence:

Latest research studies show, in South India, community-based studies have reported 6.09%-27.6% & in North India, 61.5%prevalence rate8. Substantial proportions of dermatophyte infection have been found in East India with variable absolute prevalence. Different studies suggest that, reported prevalence of dermatophytosis of the skin in India is ranging from about 6% to over 60%of the population9, depending on various region& risk factors. Northeast India shows high proportions of dermatophyte species with increase in chronic recurrent cases10,11.

III. Topographical Prevalence:

In the general Indian population, many community studies show there is a prevalence of active cutaneous dermatophytosis likely in the range of ~7-25% in areas of hot humid climate with overcrowded population & relatively higher in case of lower socio-economic groups. Coastal Part of South, East and some parts of Northeast India has faster growth rate of Dermatophytes & have higher reported prevalence8. (Table no.1)

Table no.1: Prevalence according to common causative species in India12,13:

IV. Terminology & Correlation

Descriptions in Samhitas:

Dadruis a Kustha (~ skin disease) as described by the Samhitas. Its classification is as follows-

Table no.2: showing classification and references of dadru described in different samhitas.

Charak Samhita 3quotes:

Dadru is a kind of Kustha predominantly kapha-pittaj having Kandu (~itiching), raaga (~erythema), pidaka (~eruptions) and udgata mandala (~elevated circular lesion).

Sushrut Samhita 2quotes:

Dadrukushthais because of Kapha predominance. Two varieties of Dadru – Sita and Asita are described in the commentry by Dalhana which can be interpreted clinically.

Nevertheless, the vyadhi Dadru is understood within the broader term Kustha involving the Dosha-dushya sammurchhana with purvaroopa & roopa of raga, mandala, kandu, pidaka.

V. Ayurvedic Management approaches:

As Dadru is a kushtha of Kapha-pitta vitiation and Rakta dhatu dushti, the therapeutic objective must be reducing these doshic predominance.  The classical principle is always individualized according to the chronicity, extent of the lesions, agni, koshtha and associated symptoms. Along with these above, prevention of reinfection is also very important. Restoration of skin integrity without any complication is the core of the principle of management which is as follows:

A. Nidana parivarjana:

It is the most essential part of treatment in Dadru which is a must follow lifestyle advise.

• Keep the affected area clean and dry.
• Avoid wearing nonbreathable, synthetic & tight garments.
• Avoid sharing the soap, comb, towel regularly.
• Avoid washing the clothes of entire family together in a single vessel.
• Avoid scratching &applying steroid mixed OTC products locally.

B. Shodhana:

After analyzing the physical strength of the patient, dosha predominace, kaala and chronicity, Shodhana may be planned.

• Virechana is suitable when pitta-rakta predominant features such as profound redness, burning & elevated inflamed margins of the lesions predominate.
• Vamana may be performed carefully in case of Ati-kandu (~intense itching), kleda and when heaviness of the lesions & the body is found.
• Raktamokshana may be considered when chronic inflammation is present due to misuse of steroidal products with a state of incognito condition. It must not be performed when there is active dermatophytosis present.

C. Shamana:

• Under shamanachikitsa, different formulations are used in different individuals after analysing the clinical pattern. The common therapeutic implications are kapha-pittahara, kushthaghna, kandughna, krimighna & raktaprasadana.
• Commonly used Internal medications are as follows:

Table no.3: Describing the specific Ayurvedic medicines and their function on dadru

D. Vahirparimarjana:

Local therapy is equally important as internal medication in Dadru, as it is a superficial skin infection,the external therapy always carries a major role in the improvement. The moto behind Vahirparimarjan is to reduce kandu, kleda, raga, pidaka and mandala which ultimately reduces or nullifies the local mycological burden without any complications. 

Most commonly used local approaches are:

• Lepa/Pralepa: Pastes prepared from Nimba, Khadira, Karanja, Chakramarda/Kaasamarda, Haridra, Daruharidra, Vidanga, Gandhaka, Aaragvadha are classically quoted as Kusthaghna, but in adverse effect cases(burning, blistering or intense itching) it should be discontinued.
• Prakshaalana: Cleansing decoctions are used prepared appropriately from selected kusthghna formulations followed by complete drying on the skin.

Taila and Malahara:

• Gandhakadya Malahara (R.T - 8/63-65)
• DadruVidravana Malahara (R.T – 8/59- 62)
• Dadrughna Malahara (R.T – 8/60)
• Chakramarda Taila (Ca.Chi- 7/73)
• Karanja Taila (B.R.57/26)
• Nalpamaradi Taila (S.Y- taila prakarana-26)
• Tulasyaadi Taila (S.Y)

E. Pathyaapathya:

Dietary and daily regimen alone cannot alleviate the clinical condition in Dadru. It must be individualized. 

Table no.4: Showing Pathya-pathya in dadru

Evidence from modern studies:

Dadru (~Dermatophytosis) is one of the mostcommon skin disease, which can vary in clinical presentation with severity. Along with different species of dermatophytosis, the presentation of the disease also depends upon the topographical condition, personal regimen pattern and individual’s immunity.

Discussion

• Dadru is a type of Kushtha with Rasa, Rakta and Mamsadhatu (~ deeper into subcutaneous tissue) involvement, manifesting with Kandu, Raaga, Mandala and Pidaka 14. Thus, all of the classical formulations which are intended for treatment for Dadru are having katu, tikta rasa and Usna virya.
• Superficial fungal infection of the skin is common among people who wear occlusive, non-cotton inner wearings which cause limited airing of the affected sites & trap more moisture on the skin. Washing off the clothes together with the infected ones in a single vessel cause high fomite load & familial spread. Environmental factors like hot humid climate15, overcrowding, positive spouse history (through conjugal spread) etc. exaggerate the symptoms of Tinea.
• More overly it can be inferred that the Malahara which are advised to use in  Dadru are Madhura & Katu in Rasa, Laghu & Ruksha in Guna with Ushna virya and Katu Vipaka. All of these properties of Malahara are Hetu Pratyanika and Vyadhi Pratyanika. Thus, acts as a Kushthaghna, Kandughna & Dadrughna Dravya16.
• Dadru is a variety of Kushtha with Rasa, Rakta and Mamsadhatu (~ deeper into subcutaneous tissue) involvement, manifesting with Kandu, Raaga, Mandala and Pidaka17. Ayurveda advocates the Laghu Manjisthaadi kwatha, on regular Pana (~oral intake/drinking) possesses kushtha vinashana (~ skin diseases curing) properties18.
• No doubt, the effect of many classical formulations upon Dadru has satisfactory result according to many of the evidence-based research sources, but the results can be more reliable if the researches would be performed in multicentric controlled studies with larger sample size pan India.
• Species based Incidence & prevalence studies should be done pan India.

• It is the high time, for probe-oriented treatment in cases of Dadru. It should be documented and diagnosed through clinical acumen achieved from classical texts & confirmed or excluded through different diagnostic parameters by standardized dermatological examination and pathological investigations.
• Investigations, such as skin scarping for fungus by KOH (potassium hydroxide) mount, fungal culture, direct PCR, Wood’s lamp examination, Antifungal susceptibility testing should be done. These tests are helpful in confirmatory diagnosis in refractory cases and identify specific fungal strain, which will ease the treatment.
• The classical formulations which have been found with higher efficacies in the management of Dadru should undergo broth micro dilution for determination of MIC, time killing kinetic assay & other biochemical tests which can prove the antifungal potentiality of the drug.

Conclusion

Dadru as a disease needs a through attempt to tackle with its variants according to the etiological conditions. Since, the prevalence rate is following an increasing trend and the recurrence rate is also following the higher side, Both Ayurvedic and contemporary science has its efficacy in relation to the challenges in treating this most common disease from its recurrence. Along with classical diagnostic methods, the updated diagnostic procedures should be followed for the confirmation of specific infection. It ensures early diagnosis and carries prognostic value, which ultimately paves the way for successful management of Dadru. The understanding about wide range of causative factors and triggering factors helps directly in improving the quality of life of the patient. As Prevention is better than cure, the patient can be advised to follow basic personal hygiene, specific dietary habits to improve the immunity against the disease causing fungus, which prevents the recurrence in future. Analyzing the area wise prevalence and distribution of Dermatophytosis helps to know the degree of infection transmitting capacity from person to person.  The classical formulation which has a prompt action and positive response upon the Dadru affected skin should undergo broth micro dilution test for determination of MIC value of the drug, which can primarily determine the antifungal property of the drug. Huge number of Multicentric RCTs should be conducted throughout India for the validation of the positive response of the drug internationally. The factors described above are largely influencing the disease occurrence, hence vigilant approach in dealing the disease will be helpful for its prevention and treatment.

Conflict of interest- Nil

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