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• Neurological examination in children (cranial nerves, motor/sensory/cerebellar)
• Jalaseershaka (Hydrocephalus) - types, signs, VP shunt
• Apasmara (Epilepsy) - classification, epilepsy syndromes, management
• Ataxia, Floppiness/Hypotonia, Cerebral Palsy (full classification + Rx)

• ADHD, ASD (with red flags + screening tools)
• Temper tantrums, Learning disabilities, Breath holding spells
• Pica (Mritbhakshana), Thumb sucking, Enuresis (Shayyamutra)
• Mental retardation (IQ classification, Down syndrome), ICDS

• Status Epilepticus - time-based protocol with drug doses
• Febrile seizures - simple vs complex, management
• Acute breathlessness, Poisoning (antidote table), Shock (fluid resuscitation)
• Burns (Parkland formula), Foreign body aspiration (Heimlich), Anaphylaxis, CPR

• All 5 main procedures with pediatric modifications + special procedures (Netrakalpa, Karna, Nasya)
• Key exam points (Basti = Ardhachikitsa)

• Tanner stages (complete) for boys and girls
• Pubertal sequence, ARSH clinics, RKSK programme

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TOPIC 16 - TWAK ROGAS (Dermatological Disorders)

Kaumarabhritya - Exam-Oriented Detailed Notes

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SECTION A - AYURVEDIC SKIN DISEASE FRAMEWORK

Twak (Skin) - Ayurvedic Basics

• Primarily Pitta and Kapha (skin diseases are Pitta-Kapha dominant)
• Vata also contributes in dryness, cracking conditions
• Rakta Dushti (vitiation of blood) is the cornerstone of most skin diseases

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1. KUSHTHA (Skin Diseases - Broad Category)

Definition

Nidana (Causes) of Kushtha

• Aharajanya: Viruddhahara (incompatible foods - e.g., fish + milk), excessive sour/salty/pungent foods, excessive sesame, alcohol, fermented foods
• Viharajanya: Suppression of natural urges (Vega Dharana), excessive sun exposure, contact with infected persons
• Manasika: Stress, grief, excessive emotional disturbances

Classification of Kushtha

Samanya Lakshana (Common features of Kushtha)

• Aswedanam (absence of sweating) or Atiswedanam (excessive sweating)
• Kandu (itching)
• Mahavastu (large spreading lesions)
• Srava (exudation)
• Daha (burning)
• Raga (redness/erythema)
• Vedana (pain)
• Suptata (numbness) - in Mahakushtha

Treatment of Kushtha (General)

1. Shodhana (Purification/Panchakarma):
   • Vamana - for Kapha dominant Kushtha
   • Virechana - for Pitta dominant Kushtha (most common)
   • Raktamokshana (bloodletting) - Pradhan Chikitsa for Kushtha; Jalaukavacharana (leech therapy)
2. Shamana (Palliative):
   • Khadira (Acacia catechu) - specific herb for all Kushtha; Khadirarista - classical formulation
   • Manjishtha, Neem (Nimba), Haridra (turmeric), Bakuchi (Psoralea)
   • Arogyavardhini Vati - classical formulation for all skin diseases
   • Mahamanjishthadi Kashaya
   • Gandhaka Rasayana - for all types of Kushtha (especially chronic)
3. Pathyapathya:
   • Pathya (do): Light food, bitter vegetables, old rice, barley, wheat, green gram, bitter gourd, garlic
   • Apathya (avoid): Viruddha ahara (incompatible food), fish + milk, excessive sour/salty/sweet, fermented food, day sleep, suppression of urges

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2. CHARMADALA (Eczema / Dermatitis)

Ayurvedic Correlation

Modern Equivalent: Eczema / Dermatitis

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3. ATOPIC DERMATITIS (AD) - Detailed

Definition

Epidemiology

• Affects 15-20% of children worldwide
• Onset: >90% present before 5 years of age (key exam fact)
• Infantile form begins at 4-6 months of life

Pathogenesis

• Th2-mediated immune response (in acute phase)
• Key cytokines: IL-4, IL-13 (Th2); IL-17, IL-22 (Th17 in chronic phase)
• Filaggrin gene mutation - impaired skin barrier; allows allergen penetration
• IgE mediated sensitization - elevated total IgE
• Staphylococcus aureus colonization worsens disease (superantigen effect)
• TARC/CCL17 elevated - correlates with disease severity

Clinical Features by Age

Diagnostic Criteria (UK Working Party / Hanifin & Rajka)

1. History of rash in skin folds (flexures)
2. History of asthma or hay fever (or in first-degree relative if child <4 yr)
3. History of dry skin in the past year
4. Visible flexural dermatitis
5. Onset in the first 2 years of life

Key Clinical Signs

• Dennie-Morgan lines - extra fold under lower eyelid
• Hertoghe sign - thinning of outer 1/3 of eyebrows
• Pityriasis alba - white patches on face (hypopigmented)
• Keratosis pilaris - rough follicular papules on upper arms
• Lichenification - thickening + accentuation of skin lines from chronic scratching
• Atopic dirty neck - reticulate pigmentation on neck

Complications

• Secondary bacterial infection: Staphylococcus aureus (most common)
• Eczema herpeticum (Kaposi varicelliform eruption) - HSV superinfection; punched-out erosions; medical emergency
• Cataracts, keratoconus (eye complications)
• Growth retardation (from prolonged steroid use)

Treatment

• Hydrocortisone 1% - face, eyelids, intertriginous areas
• Betamethasone valerate - trunk, limbs
• Do NOT use fluorinated steroids on face (causes atrophy)
• Apply once/twice daily; "fingertip unit" concept

• Tacrolimus 0.03% (child), 0.1% (adult); Pimecrolimus 1%
• Steroid-sparing agents; safe for face and sensitive areas
• Do not cause skin atrophy

• Virechana (Pitta-dominant), Vamana (Kapha-dominant)
• Nimbadi Churna, Mahamarichyadi taila (local application)
• Khadirarishta, Manjishthadi Kashaya
• Kumkumadi taila - for anti-inflammatory, skin restoration

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4. ARUMSHIKA (Acne / Folliculitis in Children)

Ayurvedic Description

Modern Correlations

1. Follicular hyperkeratinization (plugging of pilosebaceous unit)
2. Increased sebum production (androgens stimulate sebaceous glands)
3. Cutibacterium acnes (previously P. acnes) colonization
4. Inflammation

• Non-inflammatory: Open comedones (blackheads), closed comedones (whiteheads)
• Inflammatory: Papules, pustules, nodules, cysts

• Mild: Comedones + few papules/pustules
• Moderate: Many papules/pustules, some nodules
• Severe (Nodulocystic): Nodules, cysts, scarring

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5. VISARPA (Erysipelas / Cellulitis)

Ayurvedic Description

1. Vata Visarpa
2. Pitta Visarpa
3. Kapha Visarpa
4. Tridosha Visarpa
5. Agni Visarpa (Erysipelas - modern)
6. Kardama Visarpa
7. Granthi Visarpa

Modern: Erysipelas vs Cellulitis

• Bullous impetigo: S. aureus (phage type 71); flaccid bullae → honey-colored crust
• Non-bullous (Crusted) impetigo: S. pyogenes; honey-colored crust on face; nasal-labial area
• Treatment: Mupirocin (topical), Fusidic acid; systemic: Amoxicillin-clavulanate or Flucloxacillin

• Rakta mokshana (bloodletting) - most important
• Lepa (external application): Chandana, Kumkuma, Sariva paste
• Internal: Triphala, Manjishtha, Neem
• Pitta-shamaka measures

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6. SCABIES (Pama in Ayurveda)

Ayurvedic Correlation

Modern: Scabies

• Over 100 million persons affected worldwide annually
• Transmitted by close personal contact; fomites (mite survives off human skin for 3 days)
• Incubation: 1-8 weeks after first exposure (4-6 days if re-exposed)

• Female mite burrows into stratum corneum and lays eggs
• Average mites per host: < 20 (in classic scabies)
• Itching = type IV hypersensitivity reaction to mite, eggs, and feces

• Cardinal symptom: Intense pruritus, worse at night
• Pathognomonic sign: Burrow - linear, grayish, 5-15 mm track (site of female mite)
• Papules, vesicles, pustules in characteristic distribution
• Distribution: Interdigital web spaces (first sign), wrists, elbows, axillae, waist, genitalia (penis/scrotum in males), breasts (areola in females), buttocks
• Children: Can involve face, scalp, palms, soles (unlike adults)
• Excoriations + secondary bacterial infection common

Variants

Diagnosis

• Clinical diagnosis (history + examination is usually sufficient)
• Dermoscopy: "Delta-wing jet with contrail" sign (mite + burrow)
• Skin scraping + microscopy: Mites, eggs, scybala (feces) under mineral oil/KOH
• "Burrow ink test": Apply ink over suspected burrow, wipe off - ink persists in burrow

Treatment

• Apply from neck down (include face/scalp in infants and children)
• Leave on for 8-14 hours (overnight)
• Wash off; repeat in 1-2 weeks
• Treat all household members simultaneously

• 200 mcg/kg single dose orally; repeat in 1-2 weeks
• Used in: Norwegian scabies, permethrin failure, mass treatment programs
• Contraindicated in children <15 kg or <5 years (due to immature blood-brain barrier)

• Antihistamines (hydroxyzine) for itching
• Mid-potency topical steroids for post-scabetic eczema
• Treat secondary bacterial infection

• Wash all clothing, bedding, towels in hot water (>50°C)
• Items that cannot be washed: seal in plastic bag for 72 hours (to kill mites)
• Treat all close contacts and family members

Ayurvedic treatment of Pama

• Lepa: Gandhaka (sulfur) paste - direct anti-parasitic
• Nimbadi Taila, Mahamarichyadi Taila (topical)
• Internal: Gandhaka Rasayana, Khadirarishta
• Sulfur-based preparations directly kill Sarcoptes scabiei

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7. ECZEMA - Additional Points

Contact Dermatitis

• Most common ICD in infants
• Caused by prolonged contact with urine/feces (ammonia), friction
• Spares the skin folds (creases) - this distinguishes it from candidal infection
• Candidal superinfection: Beefy-red erythema involving folds + satellite lesions
• Treatment: Barrier creams (zinc oxide), frequent diaper change; antifungal if Candida

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MEDICINES, PROCEDURE-BASED THERAPIES, PATHYAPATHYA & REFERRAL CRITERIA

Key Ayurvedic Medicines for Skin Diseases

Procedure-Based Therapies (Panchakarma for Skin Diseases)

Pathyapathya (Diet & Lifestyle Guidelines)

• Old rice, barley, wheat (light grains)
• Bitter vegetables: Bitter gourd (Karela), drumstick leaves
• Green gram (Mudga) - best pulse for Kushtha patients
• Garlic, Turmeric, Neem leaves in diet
• Avoid suppression of natural urges

• Viruddha ahara (incompatible foods) - especially fish + milk
• Excessive sour, salty, spicy foods
• Curd (especially at night), sesame seeds (Tila) in excess
• Fermented foods, alcohol
• Day sleep (Divaswapna) - causes Kapha-Pitta aggravation
• Excessive sweating followed by cold exposure
• Exposure to dust, smoke, chemicals

• Identify and avoid trigger foods (in atopic dermatitis): cow's milk, eggs, peanuts, tree nuts
• Omega-3 fatty acid rich foods (anti-inflammatory)
• Avoid harsh soaps, detergents
• Use fragrance-free, hypoallergenic products

Counseling of Parents/Patients

• Disease is chronic but manageable; not contagious
• Regular moisturization is the key
• Identify and avoid triggers (dust mites, pet dander, foods, sweat)
• Follow step-up treatment; do not stop steroids abruptly
• Scratch-itch cycle - cut nails short; use cotton clothing

• Treat entire family simultaneously
• Environmental decontamination is essential to prevent recurrence
• Itching may persist 2-4 weeks even after successful treatment (dead mites still antigenic)

• Avoid self-medication
• Regular follow-up essential for chronic conditions
• Avoid using face creams containing steroids without prescription

Referral Criteria

1. Erythroderma (>90% BSA involved) - medical emergency
2. Eczema herpeticum (HSV superinfection of eczema)
3. Norwegian/Crusted scabies in immunocompromised
4. Suspected Leprosy (Mahakushtha with anaesthesia/nerve involvement)
5. Severe/Nodulocystic Acne (requires isotretinoin)
6. Failure to respond to standard treatment within 4-6 weeks
7. Diagnostic uncertainty (biopsy needed)
8. Suspected malignancy (non-healing ulcer, pigmented lesion with ABCDEs)

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QUICK REVISION TABLE - TWAK ROGAS

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HIGH-YIELD ONE-LINERS FOR EXAM

• Rakta Mokshana = Pradhan Chikitsa for Kushtha (especially Mahakushtha)
• Khadira = specific drug for all types of Kushtha
• Viruddha ahara = most important nidana (cause) for Kushtha
• Atopic Dermatitis: >90% onset before 5 years; Th2 mediated; Filaggrin gene mutation; flexural distribution in older children
• Scabies: Nocturnal itch + burrows = pathognomonic; Permethrin 5% = first line; treat entire household
• Norwegian scabies = thousands of mites; seen in immunocompromised; treat with ivermectin
• Eczema herpeticum = HSV superinfection of eczema; punched-out erosions; emergency
• Auspitz sign (psoriasis) = pinpoint bleeding on removal of scale
• Koebner phenomenon = skin disease appearing at site of trauma (seen in psoriasis, vitiligo, lichen planus)
• Hanifin & Rajka criteria = diagnostic criteria for Atopic Dermatitis
• Impetigo = honey-colored crust in children; non-bullous = Strep; bullous = Staph
• Diaper dermatitis = spares the folds; candidal superinfection involves the folds + satellite lesions
• Bakuchi (Psoralea) = specific drug for Shwitra (Vitiligo)
• Mahatikta Ghrita = specific formulation for Mahakushtha
• Gandhaka Rasayana = specific for chronic Kushtha + scabies (Pama)

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Sources: Fitzpatrick's Dermatology (Volumes 1 & 2), Rosen's Emergency Medicine, Textbook of Family Medicine, Schwartz's Principles of Surgery, plus Ayurvedic Kaumarabhritya texts (Kashyapa Samhita, Sushruta Samhita)