Comparative Study of Arjun Twak Lepa and Arjun Twak Kukkutand Pottali in Management of Vyanga with Special Reference to Melasma

Background: A person's beauty and self-confidence are both enhanced by healthy and glowing facial skin.A darkening of the skin caused by an excess of the pigment melanin in the skin is known as hyperpigmentation.Vyanga is a Kshrudraroga with appearance of Niruja (painless) and Shavavarna Mandalas (bluish-brownish) on the face. Melasma, one of the hyper pigmented disorders, can be compared to it.based on clinical features. Whole raw egg/egg yolk alone/with herbs have shown very good results in tightening of skin, complexion and healing in skin disorders, when it is locally applied. So, in present study egg is used with Arjun Twak Churna in the form of Pottali in experimental group for better result in management of Vyanga. Aim and Objectives: To study the effect of Arjun Twak Kukkutand Pottali on MSI (Melasma Severity Index) and to compare the effect of ArjunTwak Kukkutand Pottali and Arjun Twak Lepa on MSI. Original Research Article Shelotkar et al.; JPRI, 33(33B): 209-217, 2021; Article no.JPRI.70578 210 Methodology: Total no. of 44 patients will be enrolled (22 in each group). In control group for a period of 21 days, Arjun Twak Lepa will be available for local use. While in experimental group, ArjunTwak Kukkutand Pottali will be given for local application for 21 days. The assessment will be done on 0 & 21 st day. Results: Changes will be observed as per subjective & objective parameters. Conclusion: ArjunTwak Kukkutand Pottali will be more effective on MSI (Melasma Severity Index).


INTRODUCTION
A person's beauty and self-confidence are both enhanced by healthy and glowing facial skin. Acne, hyperpigmentation, and other factors can affect the complexion and texture of the facial skin.Hyperpigmentation is described by darkening of the skin caused by an excess of the pigment melanin in the skin. Although it is common in middle age and beyond, it can be seen in much younger patients.It is common and usually harmless, but it causes discomfort to those who have it for cosmetic reasons. Hyper pigmentation presents no medical threat. Thus the condition deserves serious attention [1].
Vyanga is a Kshrudraroga with appearance of Niruja (painless) and Shavavarna Mandalas (bluish-brownish) on the face. When it comes to the face, it is one of the most widespread illnesses. Melasma, one of the hyper pigmented disorders, can be compared to it, based on its clinical features. Melasma is an acquired skin pigmentation disorder that is additional prevalent in persons of Oriental, Hispanic, and Indo-Chinese descent and affects women far more frequently than men. Melasma, like other skin disorders, has a negative psychosocial effect that degrades one's quality of life and emotional well-being. To assess the severity of the disease and the efficacy of therapeutic options in Melasma, valid and reliable scoring systems are required.Furthermore, as with other diseases, not only should this scoring system be able to assess severity, but it should also be able to predict prognosis and help we choose the best treatment option [2].
In Ayurveda, very good medicines are available for skin diseases. Massage with oils, application of medicine pastes, and other procedures leave the skin smooth, soft, and glowing [3]. In addition, there is a description of bloodletting.as good therapy for skin diseases [4]. Drugs with Kushthaghna, Kandughna, RakstaPrasadaka, Twak Prasadaka and Varnayakara Properties aid in the management of Vyanga, which balances the Doshas and aids in Rakstashoadhana (blood purification).And ultimately, can cause cutaneous depigmentation, which is the removal of blackish skin discoloration. ArjunTwak Churna has been chosen for research based on these considerations.
Another drug in trial group is raw egg. Whole raw egg/egg yolk alone/with herbs have shown very good results in tightening of skin, complexion and healing in skin disorders, when it is locally applied [5]. Intracellular & extra cellular glutathione content of egg white plays an important role in skin healing. In addition, the effects of anti-oxidants such as vitamin A, E, and C, as well as trace elements such as zinc, copper, and selenium, were discovered. It has previously been demonstrated that L-Argin present in eggs reduces inflammation, speeds up necrotic tissue cleansing, and accelerates epithelial cell growth with depigmentation [6].
Till today study on melasma including external application of egg is not carried out. So, in present study egg is used with ArjunTwak Churna in the form of Pottali in experimental group for better result in management of Vyanga.

Case Definition
Diagnosed cases of Vyanga, with appearance of thin, Niruja(painless) and Shavavarna Mandalas (blackish/brownish patches) on face.

Research Question
Whether Arjun Twak Kukkutanda Pottali is more effective than Arjun Twak Lepa in Vyanga management, with a special focus on Melasma.

Hypothesis
Arjun Twak Kukkutanda Pottali is more effective than Arjun Twak Lepa in Vyanga management, with a special focus on Melasma.

Null Hypothesis
Arjun Twak Kukkutanda Pottali is not more effective than Arjun Twak Lepa in Vyanga management, with a special focus on Melasma.

Selection of Materials
The raw material will be procured from reliable sources and will be authenticated by department of Dravyaguna MGAC & RC.

Main Ingredient with Procedure
ArjunTwakLepa-5gm ArjunTwak Churna along with sufficient amount of Madhu to make Lepa. Apply Lepa on affected area once a day. After application leave it to dry. Then wash with Luke warm water.

Arjun Twak Kukkutand Pottali -5gm
ArjunTwak Churna along with 1 Kukkutand (Egg). Then Pottali will be prepared using cotton cloth. Applying pottali in circular manner on affected are once a day. After applying Pottalifor 15 min, leave the face pack to dry. Then wash with Luke warm water.

Trial design-
A randomized standard comparative clinical trial. Study setting -The study will be conducted at MGACH & RC, Salod, Wardha.

Inclusion Criteria
1. Subjects irrespective of sex, religion, occupation and chronicity less than 5 years will be selected for the study. 2. For the study, subjects between the ages of 20 and 50 will be chosen.

Subjects with cardinal features of Vyanga
includes thin, painless, blackish/brownish patch on the skin of the face.

Interventions
The total duration of the intervention will be the same for both groups which will be for 21 days and fallow up will be on 15 days in both groups (Table 1). [7] Subjective and objective criteria will be used to evaluate the therapy's effectiveness.

Subjective Criteria
It includes itching and burning sensation.

Objective Criteria
It includes skin/lesion color, texture (dry/oily), luster, number of lesions, size of lesions, darkness and photographs.

Fig. 1. Melasma area severity index score
Three parameters are used to calculate the melasma area severity index (MSAI) score: Area (A), Darkness (D), and Homogeneity (H) of involvement where in forehead (f) constituents 30 %, right malar region (rm) 30%, left malar region (lm) 30% and chin (c) 10%. For each of the four facial areas, the MSAI score is calculated by multiplying the area of involvement's value by the sum of the severity ratings for darkness and homogeneity. The total score range is 0-48. Higher the score, higher is the severity.
The following formula will be used for calculation is: Grading for parameters of Melasma Area Severity Index Score.
Overall Assessment The following criteria will be used to make an overall assessment: CD -Clinically deteriorated that is, increase in severity score against initial score CS -Clinically stable that is, severity of score remains same as against initial score CI-1 -Clinically improvement mild that is, one grade reduction against initial score CI-2 -Clinically moderate that is, two grade reduction against initial score CI -3 -Clinically good that is, three grade reduction against initial score

Criteria for Discontinuing or Modifying Allocated Interventions
The subject will be withdrawn from the study if any untoward incidence, features of drug sensitivity or any other disease or problem arises, the subject will be offered free treatment till the problem subsides. Secondary outcome -We will see the effect of ArjunTwakKukkutandPottali on Melasma area severity index score.
Statistical analysis -The data will be analyzed by using 'Wilcoxon's test.
Time duration till following up -The patient will be followed up during treatmentfor 21 days.

Schedule of enrollment or intervention -
ArjunTwakKukkutandPottali for local application will be given from 0 to 21 days.
Recruitment -Total 44 (22 in each group) [8] patients will be selected by strait forward arbitrary resting lottery strategy, and Principle Investigator will assign and enlist the patient.

Methods -Data collection, management and analysis.
Data collection method -Will be done as per assessment criteria.
Objective criteria-It includes skin/lesion color, texture (dry/oily), luster, number of lesions, size of lesions and darkness and photographs &melasma severity index score.
Data management -The information passage coding will be finished by principle investigator.
Dissemination policy -The information will be dispersed by paper distribution. Creation qualification rules and any proposed utilization of expert scholars.
Informed consent material -With all the data models assent structure and other related documentation will be given to members.

DISCUSSION
The beauty of a person's face is enhanced by a smooth and glowing complexion, which also boosts self-confidence.In a general dermatology clinic, acquired hyperpigmentation disorders of the skin are among the most common complaints. Melasma is known to have a negative impact on patients' emotional well-being and social lives, as well as a significant influence on the quality of life. Melasma affects the skin and reduces the glowing complexion of the face.Despite the advent of powerful pigmenttargeting lasers, the treatment for melisma remains challenging. It should not be dismissed as simply a cosmetic entity because it often evokes emotional distress. In addition, stigma may be associated with melasma, particularly in Asian cultures. Melasma is a reverting hyper melanosis characterized by sun-exposed areas of the face, neck, and forearms have hyper pigmented patches. It is a chronic, acquired cutaneous hyper melanosis. UV (ultraviolet) radiation exposure is thought to be a key factor in its development.
This condition is known in Ayurveda as Vyanga, and it is caused by Vata Pitta Dosha as well as Manasik Nidan (psychological etiological factors) such as Krodha (Anger), Shoka (Sorrow) and Ayasa (Mental exertion) are the main culprits [9].Treatment modalities and other strategies for hyperpigmentation are typically unsatisfactory because it exhibits alleviation and cessation due to a variation of influencing elements such as frequent exposure to UV rays, pollution, stress, and hormonal fluctuations.The usage of topical steroids in the treatment of Melasma has been documented in modern medicine.However, there are some side effects to topical steroids, such as irritation and rashes. As a result, better management methods must be sought.
Arjuna Twak has Rakta Prasadak (blood soother), Twakprasadak (Skin soother) and Varnyakar (Enhancing complexion) properties. They aid in the management of Vyanga, as well as pacifying aggregated Doshas (Body Humors) and assisting in Rakta shodhana (Blood purification or detoxification).Another drug of trial group is Egg white. Raw egg has some properties which shows good results on skin, when it is locally applied. The glutathione content of egg white, both intracellular and extracellular, plays an important role in skin healing.In addition, the effects of anti-oxidants such as vitamin A, E, and C, as well as trace elements such as zinc, copper, and selenium, were discovered.It has previously been demonstrated that L-Argin present in eggs reduces inflammation, speeds up necrotic tissue cleansing, and accelerates epithelial cell proliferation with depigmentation. [10].
Many studies have been conducted on the management of melasma, but none have been conducted on the effect of local application of raw egg in the management of melasma. to cure Vyanga is cited in many classical text. This combination is not only good for vyanga but also for glaring appearance of skin [12]. Rajaratnam R, evaluated interventions for Melasma [13]. Mapari et al, evaluated efficacy of Vatankuradi Lepa in the management of Vyanga w.r.t. Melasma. The number of skin lesion were statistically was not significant but effect of medication on MSAI score was significant, thus providing its efficacy [14]. Mundhe SS, studied effect of VarunTwakLepa in management of Vyanga. Here progress of Melasma Severity Index score indicated that Varun Twak Lepa is found to be efficient in reducing the severity in pigmentation. As per types Vatun Twak Lepa is more efficient in epidermal [15]. Wake S et al, studied comparative effect of Ingudi Phalamajja Lepa and Ananatamul Ghana in management of Vyanga (Melasma) [16].
There are some studies showed effects of local application of egg. Pieroni A at el, studied Ethnopharmacognostic survey on the natural ingredients used in folk cosmetics, cosmeceuticals and remedies for healing skin diseases in the inland marches, Central-Eastern Italy. Here they used raw egg as folk medicine in skin and hair diseases [17].The combination of red cabbage and egg white has a significant effect on the healing of second-degree burn wounds, with the treated group experiencing faster repair processing, 100% recovery, or fewer scars according to a study of Hassanzadeh et al [18]. Another study by Hassanzadeh et al. discovered that the egg yolk and silver sulfadiazine group healed wounds faster than the negative control group [19]. Jensen S at el, published study on reduction of facial wrinkles by hydrolyzed water-soluble egg membrane associated with reduction of free radicle stress and support of matrix production by dermal fibroblasts. The topical use of water soluble egg membrane on facial skin significantly reduced the wrinkle depth by protection from free radicle damage at cellular level and induction of several antioxidants response elements, combined with stimulation of human dermal fibroblasts to secret high level of matrix components [20,21].
Strength -If Arjun Twak Kukkutand Pottali works, it will be give the best equal methodology for management of Vyanga.

LIMITATIONS
Sample size is small, for better results it can be increased.

CONCLUSION
Many studies have been conducted on management of Melasma but study on effect of local application of egg on Melasma, not yet conducted. Arjun Twak Kukkutand Pottali will be more effective than Arjun Twak Lepa on subjective & objective parameters.

CONSENT OR ASSET
The made consent will be taken from the patient before starting the assessment. During the investigation, the classification of every patient will be kept up.