A Case Series of 1st and 2nd Degree Burn Patients managed with Manjistadi Vikeshika - An Ayurvedic Contact Layer Dressing

R Sumukhi; Padma; KM Sweta

A Case Series of 1st and 2nd Degree Burn Patients managed with Manjistadi Vikeshika - An Ayurvedic Contact Layer Dressing

Sumukhi R.^1*, Padma.², Sweta K.³

DOI:

^1* R Sumukhi, Post Graduate Scholar, Dept. of Shalya Tantra, Sri Sri College of Ayurvedic Science and Research, Bangalore, Karnataka, India.

² Padma, Associate professor, Dept. of Shalya Tantra, Sri Sri College of Ayurvedic Science and Research, Bangalore, Karnataka, India.

³ KM Sweta, Associate professor, Dept. of Shalya Tantra, Sri Sri College of Ayurvedic Science and Research, Bangalore, Karnataka, India.

Burn wounds having coagulative necrosis, is the most devastating and painful condition causing major physical, mental, emotional and social trauma. According to the depth of the necrosis, burns are classified into degrees or grades. The use of ointments, oils, and other topical treatments is a messy operation that does not serve the objective of contact layer dressing. Additionally, there is no uniformity for the amount of drug used in each dressing, resulting in drug wastage. In Bhaishajya Ratnavali, Manjishtadi Taila is mentioned for the management of burns, which possesses Raktapitta Shamaka, Daha Prashamana & Vrana Ropaka properties. Considering the above qualities, this Yoga is taken in the form of Vikeshika for the study. Manjistadi Vikeshika seems to have the qualities of an ideal contact layer dressing, desired healing within 21days of time period. Also, it showed negligible post burn complications and achieved early pigmentation i.e., Savarneekarana.

Keywords: Ayurveda, Burns, contact layer dressing, Vikeshika, Healing

Corresponding Author	How to Cite this Article	To Browse
R Sumukhi, Post Graduate Scholar, Dept. of Shalya Tantra, Sri Sri College of Ayurvedic Science and Research, Bangalore, Karnataka, India. Email:	R Sumukhi, Padma, KM Sweta, A Case Series of 1st and 2nd Degree Burn Patients managed with Manjistadi Vikeshika - An Ayurvedic Contact Layer Dressing. J Ayu Int Med Sci. 2022;7(9):186-195. Available From https://www.jaims.in/jaims/article/view/2092

Introduction

Burns result from thermal, electrical, chemical injuries or due to exposure to radiation.^[1] It carries potential complications such as cosmetic disfigurement, permanent physical damage and mental trauma.^[2]

According to W.H.O - an estimated 180,000 deaths every year are caused by burns - the vast majority occur in low and middle-income countries and is common in all ages and gender. For developing countries like India, it is one of the major health problems. In India, over 1 million people are moderately or severely burnt every year.^[3] Burns are classified into grades or degrees according to the depth of necrosis:

First degree burns: There is simply hyperaemia of the skin with slight oedema of the epidermis. There is only microscopic destruction of the superficial layers of the epidermis, which are desquamated within a few days.^[1]

Second degree burns: The entire thickness of the epidermis is destroyed. Blebs or vesicles are formed between the separating epidermis and dermis. Vesiculation is the hall mark of the second-degree burn.^[1] In contemporary sciences, paraffin gauze is extensively utilized as a dressing material in burn wounds. It allows for easy and painless dressing changes, maintains adequate moisture, promotes exude drainage, and is cost effective, but it does not aid in the prevention of post-burn complications. Apart from these features, it does not hold any medicinal property to promote wound healing.^[4]

The use of ointments, oils, and other topical treatments is a messy operation that does not serve the objective of contact layer dressing. Additionally, there is no uniformity for the amount of drug used in each dressing, resulting in drug waste. In Ayurveda, Acharya Sushruta has mentioned in detail about types and Lakshanas of Agni Dagdha Vrana. In Bhaishajya Ratnavali, Acharya Govind Das has mentioned Manjishtadi Taila for the management of burns. The Taila includes Manjistha, Rakta Chandana, Murva, Tila Taila etc., which possesses the properties of Raktapitta Shamaka, Dahaprashamana and Vrana Ropaka. Considering the above qualities, this Yoga is taken in the form of Vikeshika for the study.^[6]

Drugs like Silver sulfadiazine tend to form pseudoeschar and delay the wound healing process^.[5] Therefore, the need of the hour is to develop eco-friendly, easy accessible, cost- effective way to treat 1^st and 2^nd degree burns and avoid post burn complications.

Even though there are references for Vikeshika, Pata/Varti means “lint” that is, a fine fabric mesh or a gauze used in dressing wound^[7], In Ayurvedic classical texts, unlike modern system of medicine, there aren’t much research works being published regarding application and standardization of Vikeshika. The current study is taken up in an attempt to develop a cost effective, easily applicable dressing material which would facilitate all the requirements for an ideal contact layer dressing in the management of Agni Dagdha Vrana.

Aim and Objective

To evaluate the effect of Manjishtadi Vikeshika in Agni Dagdha Vrana with special reference to 1^st and 2^nd Degree Burns.

Materials and Methods

Drug Review	Manjishta[9]	Rakta Chandana[10]	Murva[11]	Tila Taila[12]	Madhuchista[13]
Botanical name	Rubia cordifolia Linn.	Pterocarpus Santalinus Linn.	Marsdenia tenacissima Wight & Arn	Sesamum indicum linn.	Cera Alba
Family	Rubiaceae	Fabaceae.	Asclepiadaceae	Pedaliaceae
English	Indian madder	Red Sandalwood	White nishoth	Sesame, Gingelly oil seeds	Bee wax
Synonyms	Jingi, Vastra Ranjini, Mandukaparni, Yojanavalli, Lohitaka	Tila Parna, Raktasara, Asukla Chandana, Raktavrksa	Tikta Valli, Pilu Parni, Madhurasa, Madhusrava.		Mathana, Madhukosha, Siktaka, Madhulita, Madhishita
Part used	Root	Heartwood	Root	Seeds, Oil	Wax
Rasa	Madhura, Tikta	Madhura, Tikta	Tikta, Kashaya	Madura, Tikta, Kashaya	Madhura
Guna	Guru, Ruksha	Guru, Ruksha	Guru, Ruksha	Guru, Snigdha	Snigdha, Mrudu
Virya	Ushna	Sheeta	Ushna	Ushna
Vipaka	Katu	Katu	Katu	Madhura
Karma	Kapha Pittahara, Varnya, Vishagna	Kapha Pittahara, Caksusya, Vrsya	Kapha Vata Hara, Jwara Hara	Vatahara, Twachya, Balya, Keshya	Vrana Ropaka, Visarpa, Bhagnasandhanakrit
Indication	Jwara, Mutrakrcchra, Kushta, Sotha, Raktatisara, Visarpa, Prameha,	Daha Prashamana, Rakta Pitta, Kustagna, Vishagna	Daha Prashamana, Kustagna, Vishama Jwara, Prameha	Tvak Prasadana, Krimigna, Yogavahi, Tvakdoshahrut, Atidagdha.	Bhagna, Kushta, Visarpa, Raktapitta, Agnidagdha,

Intervention
Preparation of Manjistadi Vikeshika

1. Under Aseptic measures, Manjishtadi Taila was be prepared as per the classical reference of Taila Kalpana.^[16]

2. Madhuchishta was added to the Taila in 1:10 proportion.

3. 5ml/100cm² of this Sikata Taila was impregnated over the gauze of 10cm X 10cm and covered in wax paper and packed in silver zipper pouch.

4. After that Ethylene oxide Sterilization was done.

5. The prepared Vikeshika was stored in a cool place.

6. A sample of the batch was sent for microbial study to ensure sterility before application. (fig.1)

Equal quantity of Manjishta, Murva, Rakta Chandana -course powder
16 parts of Jala added to course powder

Boiled in Mandagni and reduced

Filtering Kashaya
1 part of Kalka Dravya (50ml)
Kalka Dravya added to 4 parts of Tila Taila
Adding Kashya to Taila
Taila Paka

Filtered Manjishta Taila

Tests for perfection - Shabda Heena Agni Nikshipte

Obtained 150 ml oil

Manjishtadi Taila stored

Vikeshika 10X10cm impregnated in Manjishtadi Sikata Taila

Vikeshika packed in wax paper

Application

1. Wound was cleaned with normal saline.

2. Manjishtadi Vikeshika was applied and dressed with sterile pads and roller bandage accordingly. Each dressing was changed once in 48hrs

Case Study

Case 1 : A 56 year-old female patient presented with a history of accidental boiling hot oil spillage during cooking over the right hand and sustained 1% superficial second degree burn over dorsum of the right hand and wrist (Fig.2A). Patient had no other associated complaints or surgical history. The blister was debrided and the wound was dressed with Manjistadi Vikeshika once in 48hrs (Fig.2B).

Fig.2A (01/09/21)

Fig.2B (07/09/21)

Case 2: A 36 year-old male patient presented with the burn wound over the right upper thigh region due to electrocution since 2 days causing 2% second-degree deep burn (Fig.3A). Patient had a history of OCD. The wound was cleaned with normal saline and dressed with Manjistadi Vikeshika once in 24 hrs (Fig.3B).

Fig.3A (20/05/21)

Fig.3B (30/05/21)

Case 3: A 51 year-old female patient with no significant medical history, approached with history of hot spillage of tea during cooking causing 1% superficial second degree burn over the anterior aspect of the right knee (Fig. 4A). The wound was cleaned with normal saline and was dressed with Manjistadi Vikeshika once in 48 hrs (Fig.4B).

Fig.4A (10/11/21)

Fig.4B (17/11/21)

Case 4:A 61 year-old male patient sustained a scald burn due to accidental spillage of oil and he suffered 2% deep second-degree burn over the lateral aspect of the right leg just above ankle joint

(Fig.5A). The wound was cleaned with normal saline, and was dressed with Manjistadi Vikeshika once in 48hrs (Fig.5B).

Fig.5A (01/02/22)

Fig.5B (10/02/22)

Results

In case 1, re-epithelialization of the wound was seen with normal pigmentation in 7 days (Fig.2A). Patient had reduction in pain and burning sensation from severe to no symptoms gradually in 6 days and had no discomfort during dressing change.^[14]

Subjective Parameter - VAS Scale

Absent	0
Mild pain	1-3
Moderate pain (++)	4-7
Severe pain (+++)	8-10

No burning sensation	0
Mild burning sensation	1-3
Moderate burning sensation	4 - 7
Severe burning sensation	8 -10

Parameter	Objective Parameter Assessment[15]	BT	AT
Size	1 = Length x width <4 sq cm2 = Length x width 4--<16 sq cm3 = Length x width 16.1--<36 sqcm 4 = Length x width 36.1--<80 sqcm 5 = Length x width >80 sq cm	Case 1 - 22cm X 5cm Case 2 - 12cm X 16cm Case 3 - 7cm X 5cm Case 4 - 5.5cm X 4.5cm	5cm X 0.8cm 2.7cm X 8cm 1.5cm X 0.6cm 1cm X 0.9cm
Depth	1 = Non-blanchable erythema on intact skin 2 = Partial thickness skin loss involving epidermis & or dermis	2	1
Edges	1 = Indistinct, diffuse, none clearly visible 2 = Distinct, outline clearly visible, attached, even with wound base	2	1
Exudate type	1 = None 2 = Bloody 3 = thin, watery, pale red/pink 4 = Serous: thin, watery, clear 5 = Purulent: thin or thick, opaque, tan/yellow, with or without odour	5	1
Exudate amount	1 = None, dry wound 2 = Scant, wound moist but no observable exudate 3 = Small 4 = Moderate	2	1
Skin surrounding the wound	1 = Pink or normal for ethnic group 2 = Bright red & or blanches to touch 3 = White or grey pallor or hypopigmented 4 = Dark red or purple & or non-blanchable	2	1
Peripheral tissue edema	1 = No swelling or edema2 = Non-pitting edema extends <4 cm around wound3 = Non-pitting edema extends >4 cm around wound	2	1
Epithilialiaztion	1 = 100% wound covered, surface intact2 = 75% to <100% wound covered & or epithelial tissue extends >0.5cm into wound bed3 = 50% to <75% wound covered & or epithelial tissue extends to <0.5cm into wound bed 4 = 25% to < 50% wound covered5 = < 25% wound covered	3	1

In case 2, re-epithelialization of the wound was seen in 10 days, without any complication like infection and the wound was healed almost to half of its size in a time period of 1month. The pain and burning sensation reduced from severe to no symptoms in 10 days (Fig.3A)

In case 3, re-epithelialization of the wound was seen with normal pigmentation in 7days (Fig.4A). patient had reduction in pain and burning sensation from severe to no symptoms gradually in 6 days and had no discomfort during dressing change.

In case 4, re-epithelialization of the wound was seen in 10 days, without any complication like infection. The pain and burning sensation reduced from severe to no symptoms in 10 days

Discussion

Acharya Sushruta in Vranalepana Bandhavidhi Adhyayaopakrama has explained, the qualities of Vikeshika as, it should not be Ati Snigdha, Ati Rooksha, Vishama. If it is Ati Snigdha, it will cause more Kledha. If it is Ati Rooksha, it leads to Vrana Chedha. And if it is Durnyasa (not properly applied), it will damage the margins of the Vrana, delaying wound healing.^[8]

These quality standards mentioned by Acharya Sushrutha are similar to contact layer dressing.

Vikeshika serves the purpose by sustained release of drug thereby resulting faster healing and its sterility has lowered the risk of contamination.

Manjistadi Taila possesses the properties of Raktapitta Shamaka, Daha Prashamaka & Vrana Ropaka.

Acharya Sushruta has prescribed specific time durations for change of dressing depending on amount of Srava and seasonal variations, to regulate moisture in the wound and to give adequate resting period for it to heal and was accordingly being done.

Even though Acharyas have contraindicated bandana vidhi in Dagdha Vrana, shithila Bandha was done in order to avoid wound contamination.

Post burn complications were negligible with Manjistadi Vikeshika and early pigmentation i.e., Savarneekarna was also achieved in 2 weeks of time.

Conclusion

Manjishtadi Vikeshika, is a cost effective, easily applicable dressing material which would facilitate all the requirements for an ideal contact layer dressing, and which possess desired healing in the management of Dagdha Vrana. Manjistadi Vikeshika dressing caused no irritation during the application in situ. There was negligible discomfort on every dressing change thus reducing the agony during dressing in burn patients. The whole process of wound care seemed easy and effective.

Reference

1. Das.S. A Concise Textbook of Surgery, 10th edition. Kolkata: S. Das .13; 2018. p 62-77.

2. Vishwas H Vidhate, B.N Deshpande, Madhavi Banarase, Priyanka Bhosale. Management of burn wound with local application of Jeerakaghrita. J Biol Sci Opin 2016;4(2):29-32 http://dx.doi.org/10.7897/2321-6328.0428 [accessed on 2021-07-08]

3. World Health Organization: WHO. Burns [Internet]. Who.int. World Health Organization: WHO; 2018 [cited 2021 Jul 9]. Available from: https://www.who.int/news-room/fact-sheets/detail/burns [accessed on 2021-07-05]

4. Singh A, Singh L, Gupta R, Saxena S, Kaneria R. Effect of Liquid Paraffin Gauze Dressing In Burn Wounds: A Prospective Study. International Journal of Scientific Study [Internet]. 2019 [cited 2021 Jul 9];(2). Available from: http://www.ijss-sn.com/uploads/2/0/1/5/20153321/02_ijss_may_oa_02_-_2019.pdf [accessed on 2021-07-08]

5. Uptodate.com- topicals agents and dressings for local burn wound care. [0604 -115.99.174.48 - 0AED21F646 - PR14 - UPT - 20210708-14:21:31GMT] – XL. 1. UpToDate [Internet]. Uptodate.com. 2021 [cited 2021 Jul 15]. Available from https://www.uptodate.com/contents/topical-agents-and-dressings-for-local-burn-wound-care [accessed on 2021-08-09]

6. Mishra B, Bhaishajya ratnavali. 48th chapter - Sadhyovrana chikitsa, verse 20. Varanasi: Chaukhamba prakashana; 2012. p.770-771.

7. Sri Surendra Pratap, Shabda kalpadruma of Raja radha kanta deva, edition third, vol 4 reprint. Delhi, Nag publishers; 1967.p.373.

8. Acharya Yadavaji Trikamji.(Ed.). Sushruta samhitha of Sushruta, sutra sthana; Vranalepana bandhavidhi adhyayaopakrama: Chapter18, Verse 21. Delhi: Chaukhambha Sanskrit Sansthana, 2015; p.88

9. Shastry J L N, Dravyaguna vijyana, Varanasi: Chaukamba Orientalia; 2015. Volume II. P.277- 281.

10. Shastry J L N, Dravyaguna vijyana, Varanasi: Chaukamba Orientalia; 2015. Volume II. P.730- 731.

11. Shastry J L N, Dravyaguna vijyana, Varanasi: Chaukamba Orientalia; 2015. Volume II. P.846- 847.

12. Shastry J L N, Dravyaguna vijyana Varanasi: Chaukamba Orientalia; 2015. Volume II. P.882- 883.

13. Beeswax Uses As per Ayurveda, Composition, Research [Internet]. Easy Ayurveda. 2018 [cited 2021 Jul 9]. Available from: https://www.easyayurveda.com/2018/01/12/beeswax-bee-wax-madhuchista/ [accessed on 2021-07-08]

14. Medknow Publications. Visual analogue scale (VAS) for assessment of children’s pain perception [Internet]. ResearchGate. ResearchGate; 2013 [cited 2021 Jul 9]. Available from: https://www.researchgate.net/figure/Visual-analogue-scale-VAS-for-assessment-of-childrens-pain-perception_fig1_259499877 [accessed on 2021-07-10]

15. BATES-JENSEN WOUND ASSESSMENT TOOL Instructions for use [Internet].; Available from: https://wwwoundcare.ca/Uploads/ContentDocuments/BWAT.pdf [accessed on 2021-07-09]

16. Dr P M C Murthy, English translation on Sharangadhara Samhitha of Sharangadhara Acharya, Madhyama Khanda: chapter 9, verse 10. Varanasi: Chaukhamba Sanskrit Series office, 2013:200.

Manuscript Received	Review Round 1	Review Round 2	Review Round 3	Accepted
2022-09-01	2022-09-03	2022-09-10	2022-09-17	2022-09-24
Conflict of Interest	Funding	Ethical Approval	Plagiarism X-checker	Note
Nil	Nil	Yes	16%

Case Report

Manjistadi Vikeshika

Journal of Ayurveda and Integrated Medical Sciences