Therapeutic evaluation of Topical Halela Zard in treatment of Quba (Tinea Corporis) - A randomised Standard Controlled Trial

Need for The Study:

Dermatophytosis,also referred to as “tinea†is a very common clinical problem caused by superficialmycoses that infect skin, hair, and nails[1][2].According to WHO, the reported worldwide prevalence is about 20% to 25% [3][4],whereas approximately 30 to 70% adults suffer from asymptomatic superficialmycosis. The incidence of this disease increases with the passage of age [3].It is clinically manifested by well demarcated, annular, pruritic, and scalylesions with central clearing [1][5]. Dermatophytesare a larger group of over 51 species divided into six major genera i.e. Trichophyton,Microsporum, Epidermophyton, Nannizzia, Lophophyton, and Arthroderma [6]. Clinically,it is categorized by the name of body parts affected i.e. tinea capitis (head);tinea corporis (body); tinea cruris (groin); tinea unguium (nail), and tineapedis (feet) [1][5].

Amongthese subtypes, tinea corporis is the commonest type characterized by dermatophytosisof glaborous skin except palms, soles, and groin area [4][7]. Itis treated by both topical and oral antifungal agents in conventional medicine [1][4][5][7].Systemic antifungals include terbinafine; grisofluvin; itraconazole, and fluconazole[1][4][5][7],but failure reports of systemic therapy and resistance is the most alarming concern;especially mutation in the sequalene peroxidise enzyme that leads to the drugresistance[8]. High recurrence rate was also reported if these therapiesare discontinued [9]. Thus, it creates some potential space forfurther exploration of alternative treatment modality, and Unani medicine mayplay an important role in its management.

InUnani system of medicine, QÅ«bÄ is clinically synonymous with Tinea [10][11]. Moreover,QÅ«bÄ has been extensively described in various classical text books withspecial focus on its classification, pathology, prevention, and treatment [12]. QÅ«bÄis defined as annular, dry, and pruritic eruptions [11]caused by amalgamation of Mirra Sawda’ (bilious melanchole) into bloodor Ruá¹­Å«bat-i Ghalīẓ and Balgham-i Shor (salinephlegm) [10]which is diverted towards the skin by Quwwat-i Ṭabī’yya (natural faculty) resulting in pruritic skin lesion [13].

Theline of treatment of QÅ«bÄ is based on TeḥlÄ«l (resolvent) and Talá¹­Ä«f-iMawÄd (demulcent)[12];and there are many single and compound drugs mentioned in Unani classicalliterature such as Marham-i DÄd [14], Ḥabb-iQÅ«bÄ [15], Ushaq(Dorema ammoniacum) with vinegar [13]; Samagh-i‘Arabi (Acacia gummi) with Sirka [12], Saresham**MÄhi (Gelatinum/Isinglass) and Kundar (Boswaliaserrate) mixed with vinegar [13] fortopical application.

Amongthese, Halela Zard (Terminalia chebula Retz.) mixed with Sirka(vinegar) is recommended for the treatment of QÅ«bÄ [11][13]whichpossesses TeḥlÄ«l and Talá¹­Ä«f properties. After the extensiveonline and hand search of literature sources on QÅ«bÄ, it’s found that notrial was conducted to validate the safety and efficacy of this drug in the patientsof QÅ«bÄ.

Keepingall facts in consideration, the present study has been designed to conduct on QÅ«bÄwith topical use of Halela Zard and Sirka, entitled “Therapeutic Evaluation of Topical HalelaZard in Treatment of QÅ«bÄ (Tinea Corporis) - A Randomised Standard Controlled Trialâ€.

Review of Literature:

 Dermatophytosis,publicly called as ringworm[3][4], isa fungal infection of skin that have global significance. It is highlyprevalent in tropical and subtropical regions of the world [7]. Tineais a Latin word implying the worm of serpentine nature for skin lesion [3]. Dermatophytesare inoculated into the host skin through penetration followed by full-blownlesions mediated by proteases, serine-substilisins, and fungolysin which causedigestion of keratin network into oligopeptide or amino acid and act as potentimmunogenic stimuli[16].

Tinea corporis is asuperficial dermatophytic infection of skin other than those involving scalp,beard, hands, feet, and groin[4][7]. It is characterized by one or more circular,sharply circumscribed, and slightly erythematous dry scaly, usuallyhypopigmented patches [17]. In Unani literature, QÅ«bÄis defined as roughness or scaly skin which is black or red in colour. The primary cause of QÅ«bÄis Mirra-Sawda’ (bilious melanchole) produced by excess intake of blackbile producing foods [10]. Moreover, QÅ«bÄmay be DamawÄ« (sanguineous) due to putrefied blood and morbid fluidmixing in the blood; Raá¹­Å«bÄ« due to excess heat and infection and *SawdÄwÄ«*due to burnt humours or excessive black bile. The sanguineous lesion appearsreddish, while Raá¹­Å«bÄ« lesion is whitish to reddish and yellowish incolour. However, the lesion of SawdÄwÄ« QÅ«bÄ appears deep brown in color [18].

According to Ibn SÄ«nÄ, QÅ«bÄmay be of certain types, such as QÅ«bÄ DamawÄ« (sanguineous) marked byoozing of fluid from the annular lesions; it may also be caused by salinephlegm mixed with abnormal black bile resulting in dry lesions. Few other typesare QÅ«ba SÄ‘ī (creeping ring worm), KhabÄ«th (malignant/morbid),and putrefied one[12].

IsmÄÄ«l JurjÄnÄ« said thatQÅ«bÄ is caused by pruritic Khilá¹­-i FÄsid (morbid humour) or Khilt-i Ghaliz (thick humour) and SawdÄwÄ«(black bilious) blood. The other potential cause is diversion of morbid matterfrom internal to external part of the body resulting in QÅ«bÄ under theinfluence of Quwwat-i Tabī’yya [13]. Itis treated on the principle of Tanqiya (eliminationof morbid material from the body), TeḥlÄ«l (resolution)and Talá¹­Ä«f-i MawÄd (attenuation) [12].Hence, drugs which eliminate Sawda’ out of the body are employed in itstreatment besides resolvent and dessicant drugs. A number of single andcompound drugs have been prescribed by Unani scholars in treatment of QÅ«bÄ.Moreover, various regimenal procedures such as Ta‘lÄ«q al-‘Alaq (leeching)[12]; ḤammÄm(therapeutic bath) [12][13]; HijÄmabi’l Shará¹­ (wet cupping) [13], andFaá¹£d (venesection) are also prescribed [10][12]. Amongthese single drugs, Halela Zard is a potent antifungal plant based singledrug and it possesses Mushil-i á¹¢afra’ (cholagogue),QÄbiḠ(astringent), and Muqawwi-i Mi’da (stomachic) actionsas mentioned in Unani classical literature [19][20]. Therenowned Unani scholar Ahmad al-Hasan al-JurjÄni has written in his voluminousbook “DhakhÄ«ra KhwÄrizm ShÄhi†that Halela Zard (Terminaliachebula) should be mixed with Sirka (vinegar) and applied topicallyon the dermatophytic lesion[13].

Halela Zard (Terminaliachebula, Retz.) belongs to the family of Combretaceae. Its habitat isthroughout India, especially West Bengal; Tamil Nadu; West Coast, and Western Ghats.Its fruit is used for thee therapeutic purpose, and the chief chemicalconstituents are chebulin; palmitic acid, and behenic acid.  The reported pharmacological actions are anti-inflammatory;carminative; digestive; laxative; purgative; antiseptic with indications inwound; ulcers; inflammation; skin diseases; neuropathy, and general debility [21]. DuttaB K and Rubini B , et al reported that the aqueous extract of Terminalia chebulafruit has potent anti-fungal activity, especially against Trichophytonrubrum [22] [23]. Sirkais an acidic agent which helps in reduction of growth of the fungus [16].

Thus,it is hypothesized that Halela Zard along with Sirka as a vehiclewill be very effective in amelioration of tinea corporis as the reportedantifungal action and its use in treatment of QÅ«bÄ by Unani scholars. Thecontrol drug “Terbinafine†is a standard drug for treatment of tinea with significantantifungal action [24][25][26].

 Keepingthe above concepts and claim in view, the present study entitled “Therapeutic Evaluation of Topical HalelaZard in Treatment of QÅ«bÄ (Tinea Corporis) - A Randomised Standard Controlled Trial†has been designed for thetreatment of T. corporis.

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