Introduction :
Anal warts (also called "condyloma acuminata") are a condition that affects the area around and inside the anus. They may also affect the skin of the genital area. They first appear as tiny spots or growths, perhaps as small as the head of a pin, and may grow quite large and cover the entire anal area. Usually, they do not cause pain or discomfort to afflicted individuals and patients may be unaware that the warts are present. Some patients will experience symptoms, such as itching, bleeding, mucus discharge and/or a feeling of a lump or mass in the anal area. They are caused by the human papilloma virus (HPV), which is transmitted from person to person by direct contact. HPV is considered a sexually transmitted disease (STD). Warts, histopathologically , characteristically rise above the skin surface due to enlargement of the dermal papillae, have parakeratosis8.
In Ayurveda, warts can be compared with Charmakeela.The pathogenesis of this disease is due to vitiation of Vata along with Kapha over the skin causing the development of hard nail structures called Charmakeela1,2.
In Ayurveda, the features are described on the basis of domination of the Doshas. Warts may be caused due to any of the three doshas. In Vata dominated Charmakeela, patient feels pricking type of pain, in Kapha domination it appears like nodule without changing the color of the skin and in Pitta dominated Charmakeela due to vitiation of Rakta (blood), it appears blackish in colour, dry, oily and hard in nature1,2.
According to modern science, different types of warts have been identified, which are differing in shape and site, as well as the type of human papilloma virus involved. These include8:
(i) Common warts – These occur generally on the hands and the knees. They are simply upraised surfaces on the skin.
(ii) Flat warts – These can occur on the face, hands, legs and knees. These warts are flat and are almost of the colour of the skin.
(iii) Filiform warts – These are present only on the face. They may be near the eyelids or the lips. These warts are finger like or threadlike in appearance.
(iv) Plantar warts – These are painful warts that are generally formed on the soles of the feet.
(v) Mosaic warts – These are clusters of plantar warts.
(vi) Genital warts – These are warts that grow predominantly on the genital areas.
In Ayurveda, various treatment principles are explained like administration of drugs internally, external application of drugs and parasurgical procedures (E.g. Ksharakarma) .The aim of treatment in Warts is to destruct the overgrown papillae by use of local chemical, electrical or diathermy cauterization, cryosurgery or even excision of diseased area. In Ayurvedic classics for destruction of any such lesion kshara are prescribed.kshara are the substances which act as caustic or corrosive agent for any growth when used externally. According to Ayurvedic texts kshara karma is said to be superior to any other surgical or parasurgical measures because it does chedana, bhedana, lekhana and patana karma instead of its saumya nature and it can be applied even in the narrowest place. Aim of study is to see the effect of Apamargakshara with snuhiksheer for destruction of overgrowth in warts. These treatments are very much effective and minimal invasive. Considering these facts, ApamargaKshara with Snuhiksheer have been selected as a trial drug as a local application in the case of Anal warts.
Presentation of Case :
A 39-year-old female patient presented to our Institute hospital with chief complaint of mass over perianal region also having itching over it since six months.
For the above complaints she went to multiple institutes andtook antibiotics, antifungals,and local treatment for the warts.
On arrival, her general condition was good. The patient was systemically alright.There were no other medical or surgical illnesses. There were multiple cauliflowers like growth around anus with c/o itching over it. On this, the patient was admitted into female surgery ward and Ayurvedic preparations like Arogyavardhinivati, Mahamanjishtadi kwatha were started as she have been already received many other therapies for wart. Meanwhile, initial and routine blood investigations were sent to the lab. These initial haematological reports like TLC , DLC Count, platelet count, urine routine and microscopic, BT, CT, LFT ,KFT ,blood sugar level were in normal limits. Hb% was less 9.9 gm%. HIV, VDRL and HbsAG were negative too. On the basis of clinical examination and by visual inspection,clinical diagnosis of anal warts was made. Now there was a need of proper and regular cleaning and local application of kshara over warts. For this purpose, it was decided that a Ksharapreparationi.e. Apamargakshara mixed with snuhiksheer will be used as a local application with the help of a stab sticks, means regular cleaning of warts with normal saline and then local application of Kshara preparation. Along with this the progress in the condition of warts was closely observed and recorded to assess the efficacy of this Kshara preparation on warts. Interestingly, the results were very encouraging and clearly suggest that this local medicament works as a best treatment for destruction of overgrown papillae.
Material And Methods :
1- Kshara was prepared by burning of Apamarga dried plant collected from the nearby Marda, Dist. Chandrapur, Maharashtra, India .
2- Fresh Snuhiksheer collected from Snuhi plant.
3- Fresh Nimbooswaras.
4- Internal medications like Arogyavardhini, Manjishthadikwatha(internal medicines are having limited role).
Method of Application of Kshara Preparation :
After clearance of menses on second or third day (as kshara is contraindicated in menstruating women), patient was made to lie down in lithotomy position. Part preparation of Anal and perianal area carefully done. Warts were cleaned properly by normal saline. After this the prepared Kshara preparation i.e. Apamarga kshara mixed with snuhi ksheer was applied with sterile swab stick over warts & wait for two minutes for better cauterization. Precaution should be taken not to spill on the healthy skin. After two minutes of ksharakarma, perianal area washed with sterile water and fresh Nimboo swarasa applied over cauterized area. This process was repeated on second day.
Criteria for Assessment :
Clinical Features:
A. Pain
B. Mucous Discharge
C. Itching
D. Mass or Growth over perianal area
These clinical features were noted on admission and at the time of discharge, on the basis of following chart
A) Table no 1 showing gradation of pain :
| Grade | Pain |
| Grade 0 | No Pain |
| Grade 1 | Localised feeling of pain |
B) Table no 2 showing gradation of Discharge :
| Grade | Discharge |
| Grade 0 | No discharge, dry |
| Grade 1 | Scanty discharge, occasional |
| Grade 2 | Often discharge |
C) Table no 3 showing gradation of Itching :
| Grade | Discharge |
| Grade 0 | Itching absent |
| Grade 1 | Itching Present |
D) Table no 4 showing gradation of Mass or Growth :
| Grade 0 | Nil |
| Grade 1 | Upto 25% of baseline |
| Grade 2 | Upto 50% of baseline |
| Grade 3 | Above 50% of baseline |
Observation :
| Parameteres | 0th Day |
1st Day | 2nd Day | 5th Day | % improvement |
| Pain | 0 | 0 | 0 | 0 | 0 |
| Discharge | 0 | 0 | 0 | 0 | 0 |
| Itching | 1 | 1 | 0 | 0 | 100 |
| Mass or Growth | 3 | 3 | 2 | 1 | 66.67 |
Discussion :
Warts are very unpleasant to look, as this skin lesion causes a lot of embarrassment .Anal warts are relatively common. Anal Warts are caused by the HPV (Human Papilloma Virus) and affect the area around the anus. They are highly contagious. People usually get anal warts by coming in direct contact with genital warts on a partner’s genitals or anus during vaginal, anal or oral sex. The incidence of warts is highest in children and young adults8. There is evidence that these warts can become cancerous if left untreated for a long time In Ayurveda, various treatment principles explained like administration of drugs internally, external application of drugs and parasurgical procedures (E.g. Ksharakarma) .The aim of treatment in Warts is to destroy the overgrown papillae by use of local chemical, electrical or diathermy cauterization, cryosurgery or even excision of diseased area. In Ayurvedic classics for destruction of any such lesion kshara are prescribed.Kshara are the substances which act as caustic or corrosive agent for any growth when used externally. According to Ayurvedic texts kshara karma is said to be superior to any other surgical or parasurgical measures because it performs chedana, bhedana, lekhana and patana karma inspite of its saumya nature and it can be applied in a narrowest place.So, in this present study local application of Apamarga Kshara mixed with snuhiksheer used for the management of Anal warts. After using the above management, patient was evaluated on criterias like itching, mass or growth which showed significant improvement i.e. 100% in the case of itching and 66.67% improvement in mass or growth. In the management of the warts, the procedures described above will be beneficial in specific type of the wart. The above procedures may destroy the colonies of the virus and recurrence can be avoided.
Conclusion :
The parasurgical methods like kshara karma which are described by our Acharyas are effective, easily practicable and can avoid the recurrence.
According to Ayurvedic texts kshara karma is said to be superior to any other surgical or parasurgical measures due to it performs chedana, bhedana, lekhana and patana karma instead of its saumya nature and it can be applied in a narrowest place1,2.
Kshara is the best treatment for destruction of overgrown papillae1.
Application of Apamargakshara with snuhiksheer gives better result in destruction of overgrown papillae found in warts.
So, Apamargakshara mixed with snuhiksheer is safe, less painful, easy to apply, cheap, easily available and highly effective treatment for Warts and most suitable for developing countries like India.
*, ** & *** M.S. (Scholars)
**** Guide , HOD & Professor, Department Of Shalyatantra, Government Ayurved College, Nagpur.
***** Co Guide, Associate Professor, Department Of Shalyatantra, Government Ayurved College, Nagpur.
Acknowledgement :
Special thanks to Dr Nita Kedar, Dr Bhagyashri Sakharkar, Dr Madhuri Bhandare
References :
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2. Sharma Priyavat., editor. Sushruta, Sushrutasamhita, Nidanasthana, ArsharogaNidana Adhyaya.1st ed. 18.Vol. 2. Varanasi: ChukhambaVisvabharati; 2005. p. 24.edited and translated in English.
3. UpadhyayaVaidyaYadunandana., editor. 57. Vol. 7. Varanasi: ChaukhambaPrakashan; 2001.
4.Vagbhata, AshtangaHrudaya, Nidanasthana, ArshanidanaAdhyaya. Edited with Vidyotini Hindi Commentary by KavirajAtrideva Gupta.
5. Dr. Sharma Priyavat, Dravyagunvidnyan, ChaukambhaPrakashan, 3rd edition 2005, page no.430, 542.
6. Dr. K.C. Chunekar, BhavaPrakashNighantu, Chaukambha Publication, 2008, page no. 805
7. Nadkarni K.M., IndianMateriaMedica. 3rd ed. Mumbai, India: Popular Prakashan Private Limited; 2009. p. 890 &960.
8.Khopar U. 6th ed. India: Bhalani Publishers; 2009. KEM Hospital and Seth GS Medical College, Mumbai, An Illustrated Hand book of Skin Diseases and Sexually Transmitted Infections; pp. 63–9.
