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MANAGEMENT OF SKIN & SOFT TISSUE INFECTIONS WITH AYURVEDA w.s.r. Ayurvedic Rasayan Chikitsa DR.SHAILESH S. PHALLE MD (AYURVEDA MEDICINE ) Ayurved consultant at Ayusanjivani ayurveda www.ayusanjivani.com INTRODUCTION : Suffered by everyone at least once in life time, most common infection and challenge to a physician in his day today practice but unfortunately the most misdiagnosed and mismanaged these days. SSTI s can be defined as an inflammatory microbial invasion of the epidermis ,dermis and subcutaneous tissues. ‘‘ Over use of antibiotics is a global problem’’. Anatomy of skin : Skin and Soft Tissue Infections General Considerations : Primary vs. Secondary infections Portal of entry(micro organism entry) Status of host defenses (IMMUNITY ) Associated manifestations Toxicity, severity of illness Localization and morphology of lesions Environmental exposure Classification : SSTI may be classified according to the 1.Layer of infection 2.Severity of infection 3.Microbiologic aetiology. (A-The practice guidelines of the infectious Diseases Society of America (IDSA) For the diagnosis element of SSTI’s) Classifies into five categories 1-Superficial uncomplicated infection : (includes Impetigo,Erysipelas and Cellulitis) 2-Necrotising infection 3-Infections associated with bites and animal contact 4-surgical site infections 5-Infections in the immunocompromised host Classifications : B-Classification according to the layer affected : Epithelium :Varicella and measels Keratin layer :Ring worm (Dermatophyte fungi ) Epidermis :Impetigo (streptococcus pyogenes , staph.aureus) Dermis :Erysepelas (streptococcus pyogens ) Hair follicles :Folliculitis ,boils,carbuncles(S.aureus) Sebum glands :Acne (Propionobacterium acnes) Subcutaneous fat: Cellulitis (Beta hemolytic Strepto. ) Fascia : Necrotising fascitis (strept.pyogenes and anaerobic infection) C-Purulent OR non –purulent : 1-Purulent : e.g. Furuncle,abscess,carbuncles,Folliculitis 2-Non –purulent : e.g. cellulitis,erysipelas,Impetigo Classification :continued D-Eron classification ,based on the severity of local and systemic signs is also useful 1-class1:SSTI but NO signs or symptoms of systemic toxicity or co-morbidities. 2-Class 2 :Either systemically unwell or systemically well but with COMORBIDITY that may complicate or delay resolution. 3-CLASS-3: TOXIC AND UNWELL (Fever,tachyacardia,tachypnoea and or hypotension ) 4-class 4 :SEPSIS SYNDROME and life threatning infection. SECONDARY PYODERMAS Bite wounds Infections of burns, wounds, or underlying dematitis Diabetic wound infections Decubitus Surgical ulcers wound infections Manifestation Characteristics Microbiology Comments Purulent SSTIs : Abscess : Collection of pus within dermis, Folliculitis: Immunocompetent patients: Staphylococcus Inflammation of hair aureus follicles Immunocompromised patients: gram-negative Purulence limited to organisms (e.g., epidermis Klebsiella, Proteus, or Common on beared,arms Enterobacter species) back,buttocks Polymicrobial, commonly skin flora (staphylococci erythema with fluctuance and streptococci), organisms from adjacent on palpation, mucous membranes overlying pustule may be present Considered complicated if perianal or perineal areas are affected Common in body areas associated with friction and heavy perspiration Furuncle : Purulence surrounding hair follicles and more extensive than follculitis Immunocompetent patients: S. aureus Immunocompromised patients: gram-negative extends to subcutaneous organisms (e.g., tissue .Carbuncle is Klebsiella, Proteus, or mixture (coalescence ) of Enterobacter species) several furuncles. Common in body areas associated with friction and heavy perspiration Nonpurulent SSTIs : Cellulitis Unlike erysipelas,the borders are not elevated or sharpely demarcated, warmth edema, Streptococci without Often occurs with trauma; abscess formation, sequelae may include staphylococci with abscess lymphangitis, necrotizing infections, gangrene Pain Regional lymphadenopathy Erysipelas Intense erythema; welldemarcated border painful plaque Beta-hemolytic streptococci, commonly Streptococcus pyogenes More common with extremes of age (very young or old) Staphylococci or streptococci Commonly seen in preschool-aged children; associated with poor hygiene, humid or warm temperatures Impetigo Crusted exudates with pustules or vesicles, common on face and extremities Moderate: SIRS Severe: septic, failed treatment, immunocompromised, deep involvement Stevens, DL, Bisno, AL, Chambers, HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014. Empiric Oral Treatment against MRSA Daum, RS. Skin and soft-tissue infections caused by methicillin-resistant Staphylococcus aureus. N Engl J Med. 2007; 357:380-90. Treatment plan of SSTIs Antibiotics : PENICILLIN Antifungal Medications steroids I & D AND Dressing care Nutrition Improve Immunity What about resistant ?? Recent data has shown us:Emerging resistance Community acquired (CA)- Methicillin-resistant Staphylococcus aureus (MRSA) greatest concern ?? What we have to do ? Better understanding of mechanisms of antimicrobial resistance. - e.g.selective pressure Better understanding of risk factors predisposing to CAMRSA infection Future : Molecular testing for resistance organisms Newer antimicrobials ? Adopt immunomodulator medicines for treatment Building a better mouse trap ? ROLE OF RASAYANA : Ayurveda is aimed for the maintenance of dhatusamya . It is basically achived by preservation of health. Concept of rasayana is designed for both condition that is health as well as disease. Rasayana works at various levels in the body and overall result in absolute state of vyadhikshamatva . Here more emphasis is given on the improvement of internal invironment rather than cure and destruction of disease agent . Rasayan chikitsa is capable to full fill this aim. Results of various studies on rasayan shows that it works as a immunomodulator in both conditions that is health and disease. “SEVEN DHATUS- Rasayan karma” Dhatu or Body Tissue 1. 2. Rasa Rakta 3. 4. 5. 6. 7. Mansa Meda Asthi Majja Shukra Medicinal Plants Guduchi, Neem, Haridra, Punarnava, Neem Aswagandha Pippali Aswagandha, Guduchi Guduchi Aswagandha With Imunocin Host Defense mechanism prevails, eradicating microbes IMMUNITY COMPONENTS ENHANCERS Ashwagandha Punarnava PIPPALI Haridra Guduchi Tulsi,Neem HERBAL INGREDIENTS TO IMPROVE IMMUNITY HERBS & IMMUNITY Improves phagocytic activity of the polymorphonuclear cells. Enhances immunoglobulin synthesis. Increases the chemotaxis of polymorphs at the site of infection. Possesses antibacterial, anti-inflammatory and wound healing properties. Exhibits potent antioxidant activity. 1.ASHWAGANDHA (Withania somnifera) Withania somnifera or Indian winter cherry Ashwagandha is a stimulant of immune system. It increases concentration of red blood cell counts and white blood cell counts & enhances the function of T cells & B cells. Ashwagandha Possess great healing properties therefore has great effects in healing wounds and injuries. Ashwagandha Works as a rasayan i.e. a substance that helps in preventing early aging (antioxidant properties ) and rejuvenates whole body to provide youth. Ashwagandha extracts, has strong pleiotropic biological effects related to immune health and stress reduction. These include increasing cytokine levels and phagocytosis, as well as reducing corticosterone levels. North American Journal of Medical Sciences 2011 July, Volume 3. No. 7. Immune enhancing effects of WB365, a novel combination of Ashwagandha (Withania somnifera) and Maitake (Grifola frondosa) extracts Vaclav Vetvicka, Jana Vetvickova Department of Pathology, University of Louisville, Louisville, KY, USA 2:GUDUCHI (Tinospora cordifolia) Guduchi helps to increase the effectiveness & functioning of protective WBC(Innate & Adaptive) and builds up the body's own defense mechanism .(immune system) Guduchi inhibits growth of bacteria and enhances the buildup of Surface Barriers . Research suggests that Guduchi possesses antibacterial, anti-inflammatory, antirheumatic, and anti-allergic properties. The direct drug treatment to J774A cells showed activation as assessed by biochemical assays. Enhanced secretion of lysozyme by macrophage cell line J774A on treatment with Tinospora cordifolia and lipopolysacharide was observed, suggesting activated state of macrophages. The enhanced inhibitory effects of T. cordifolia (direct effect) and T. cordifolia treated cell supernatant (indirect effect) on the bacteria (E. coli) indicates the susceptibility of bacteria. This study is an attempt to check the potential significance of the T. cordifolia to be used as immunomodulator for activation of macrophages. Int Immunopharmacol. 2004 Jun;4(6):841-9. Immune response modulation to DPT vaccine by aqueous extract of Withania somnifera in experimental system. Gautam M, Diwanay SS, Gairola S, Shinde YS, Jadhav SS, Patwardhan BK. Source : Bioprospecting Laboratory, Interdisciplinary School of Health Sciences, University of Pune, Pune 411007, Maharastra, India. [email protected] Abstract : The immunostimulation was evaluated using serological and hematological parameters. Treatment of immunized animals with test material (100 mg/kg/day) for 15 days resulted in significant increase of antibody titers to B. pertussis (P=0.000007). Immunized animals (treated and untreated) were challenged with B. pertussis 18,323 strain and the animals were observed for 14 days. Results indicate that the treated animals did show significant increase in antibody titers as compared to untreated animals after challenge (P=0.000003). Immuno protection against intracerebral challenge of live B. pertussis cells was evaluated based on degree of sickness, paralysis and subsequent death. Reduced mortality accompanied with overall improved health status was observed in treated animals after intracerebral challenge of B. pertussis indicating development of protective immune response. Copyright 2004 Elsevier B.V. Indian J Pharmacol. 2008 Jun;40(3):107-10. Immunomodulatory effect of Tinospora cordifolia extract in human immuno-deficiency virus positive patients. Kalikar MV, Thawani VR, Varadpande UK, Sontakke SD, Singh RP, Khiyani RK. CONCLUSION: Tinospora cordifolia extract, a plant derived immunostimulant, significantly affected the symptoms of HIV. This was validated by clinical evaluation. However not all of the objective parameters studied by us, Tinospora cordifolia could be used as an adjunct to HIV/AIDS management. 3.NEEM (Azadirachta indica) : Neem enhances immune system by boosting both the lymphocytic and Leukocytes systems, including "Killer T”, “B Cells”, “Neutrophils”, “Macrophages”. Compounds of Neem helps to control fungi that can causes athlete's foot, ringworm and candida. It having anti fungal as well as antibacterial property. 4.PUNARNAVA (Boerhaavia diffusa) : Punarnava produces significant leucocytosis. Studies have revealed that punarnava is an excellent diuretic, anti-inflammatory, mild laxative and is a heart tonic. Punarnava is also used in treating obesity, improving appetite, jaundice, and general fever. 5.TULSI (Ocimum sanctum) : Tulsi is an immuno-modulator is an agent that balances and improves the immune response of the body in fighting antigens & exhibits anti–microbial property. Tulsi is rich in antioxidants and is recommended to guard against free radicals and protect body cells. Tulsi is an adaptogen that helps the body adapt more efficiently to stress & reduce the intensity and negative impact of the stress. 6.HARIDRA (Curcuma longa) : Haridra is nature’s own antiseptic and antimicrobial which helps to fight against recurrent infections. Haridra possesses powerful antioxidant properties and has been prescribed in the treatment of inflammatory, biliary, and respiratory disorders.. Haridra has anti-hepatotoxic (liversupporting) properties. 7.PIPPALI (Piper longum) : Pipali is most commonly used to treat respiratory infections, bronchitis, diseases of spleen, tumor, cough and asthma. Pippali acts as an anti-allergic and hepatoprotective. Non healing ulcers : Non healing ulcers : Cellulitis : Eczema : Psoriasis : THANK YOU……………………