Clinical Evaluation of a Topical Unani Polyherbal Formulation in the Management of Photodamaged Facial skin: An open-label Standard Controlled Trial

Introduction

Ageing is a natural process of life. With increasing age, the skin suffers progressive morphological and physiological decrement. Hyperpigmentation, Wrinkles, and roughness of skin are some of the symptoms of aged skin. Exposure to sunlight, pollution, stress, nicotine, etc aggravates Skin aging. This study aimed to determine the efficacy and safety of polyherbal formulation and compare its efficacy with the standard drug tretinoin in subjects of moderate to advanced Photoaged facial skin. Ingredients of polyherbal formulation are Aarade baqla (Vicia faba), Jau (Hordeum vulgare), Nakhud (Cicer arietinum),Masoor (Lens esculenta), Tukhm e turb (Raphanus sativus), Khardal (Brassica nigra), Haldi (Curcuma longa), Kateera (Cochlospermum religiosum).

Methods

This was a randomized open-label standard controlled study. 82 eligible subjects were allocated equally into test and control groups by computer-generated random numbers. In the test group, a paste of 15 gm polyherbal formulation in milk, and the control group, 0.025% Tretinoin 1 gram was used topically on the face once a day for two months. The response was assessed by theclinician using following different scales for different parameters.

Assessment of Skin hyperpigmentation

It was assessed by the Skin Hyperpigmentation Index online calculator (SHI). It describes the ratio of two scores, namely the hyperpigmented skin of the affected area and normal sun-protected skin from the same patient. The image was recorded with a Digital microscope-Win7 from a hyperpigmented area and normal sun-protected area. Both the images were uploaded on https://shi.skinimageanalysis.com/ and calculated the mean value of hyperpigmentation. SHI ranges from 1 (no hyperpigmentation) to 4 (maximum hyperpigmentation) where scores between 1 and 2 showed as light hyperpigmentation, 2-3 as medium hyperpigmentation, and scores between 3 and 4 as severe hyperpigmentation.

Assessment of Fine wrinkles

Fine wrinkles number was determined by digital photography. The photographs were taken through Canon EOS 1500D DSLR Camera with an 18-55 mm Lens. Three images were taken of each subject's face (right, left, and center full face) on Baseline and Day 15th, 30th, 45th, and 60th to assess visible changes/improvement in their fine wrinkles score.

Assessment of Nasolabial Fold

Modified Fitzpatrick Wrinkle Scale (MFWS) was used to assess Nasolabial folds. The scale comprised four main classes of Nasolabial wrinkling: 0, 1, 2, and 3 representing absent, fine, moderate, and deep wrinkles, respectively, and three inter classes i.e., 0.5, 1.5, and 2.5 to estimate wrinkle depth. The definitions of the entire classes of the scale are as follows: Class 0 = No wrinkle. No visible wrinkle; continuous skin line; Class 0.5 = Very shallow yet visible wrinkle; Class 1= Fine wrinkle. Visible wrinkle and slight indentation; Class 1.5= Visible wrinkle and clear indentation. <1-mm wrinkle depth; Class 2= Moderate wrinkle. Visible wrinkle, 1- to 2-mm wrinkle depth; Class 2.5= Prominent and visible wrinkle. More than 2-mm and less than 3-mm wrinkle depth; Class 3=Deep wrinkle. Deep and furrow wrinkle; more than 3-mm wrinkle depth.

Assessment of Forehead lines score

Forehead lines were assessed (number and depth) by a Validated Grading Scale for Forehead Lines. The Forehead Lines Grading Scale is a 5- point photonumeric rating scale that was developed to objectively quantify resting (static) and hyperkinetic (dynamic) forehead lines. The scale ratings are 0 for no wrinkles, 1 for no wrinkles present at rest but fine lines with facial expression, 2 for fine wrinkles present at rest and deep lines with facial expression, 3 for fine wrinkles present at rest and deeper lines with facial expression, and 4 for deeper wrinkles at rest and deeper furrows with facial expression.

Assessment of lateral canthal lines

The number of lateral canthal lines was determined by a Validated Grading Scale for Crow's Feet. The Crow's Feet Grading Scale is a 5- point photonumeric rating scale developed to objectively quantify the severity of crow's feet. This scale was applied to two separate evaluations of crow's feet: at rest (static) and with expression (dynamic). The scale ratings are 0 for no wrinkles, 1 for very fine wrinkles, 2 for fine wrinkles, 3 for moderate wrinkles, and 4 for severe wrinkles.

Assessment of Facial Skin Roughness

The Allergan Skin Roughness Scale was used for facial skin roughness assessment. The area of assessment for the Allergan Skin roughness Scale is the area between the nasolabial fold to the preauricular cheek and from the inferior orbital rim to the mandible. The Allergan Skin Roughness Scale assigns a grade from none (0) to extreme (4) that describes the severity of skin coarseness, crosshatching, and elastosis in the midface area. The scale grading are 0 (None) Smooth visual skin texture, 1 (Minimal) Slightly coarse and uneven visual skin texture, 2 (Moderate) Moderately coarse and uneven visual skin texture; may have early elastosis, 3 (Severe) Severely coarse visual skin texture, cross-hatched fine lines; may have some elastosis, and 4 (Extreme) Extremely coarse visual skin texture, cross Hatched deep creases; extreme elastosis.

Assessment of Facial Dullness

Dullness was assessed on a clinical basis with an arbitrary scoring ranging from 0 to 9 where 0-3=mild, 3.5-6=moderate, and 6.5-9=severe facial skin dullness.

Assessment of quality of life

Subjects' life quality was assessed by the Dermatology Life Quality Index questionnaire. It consists of 10 questions. Each question is scored on a four-point Likert scale: Very much = 3, A lot = 2, A little = 1, Not at all = 0, Not relevant = 0 and Question unanswered = 0. The DLQI is calculated by adding the score of each question, resulting in a maximum of 30 and a minimum of 0. Where, 0-1= no effect at all on patient's life, 2-5 = small effect on patient's life, 6-10 = moderate effect on patient's life, 11-20 = very large effect on patient's life, 21-30 = extremely large effect on patient's life.

Results

Both groups showed a significant improvement in Fine Wrinkles, Forehead Lines, Crow's Feet, Roughness, Dullness, Nasolabial Fold, Hyperpigmentation, and Quality of Life parameters. (P < .001) A large number of subjects in the control group reported mild to moderate redness, itching, dryness, and blackening of the skin, while in the test group, absolutely no side effects were reported during treatment.

Conclusion

The effects in both groups were substantial, but the polyherbal formulation is safe and effective for use in photoaged facial skin. It may be a more feasible easily accessible cheap and safe formulation to prevent skin aging and restore skin elasticity and make skin brighter. Further studies to evaluate the efficacy of formulation on objective parameters using standard instruments should be done for appropriate measurements of parameters.

Evaluating the safety and efficacy of a polyherbal Unani formulation in dyslipidaemia-a prospective randomized controlled trial

ETHNOPHARMACOLOGICAL RELEVANCE

Unani System of Medicine offers treatment for obesity and dyslipidaemia. Jawarish Falafili (JF) is a Unani polyherbal pharmacopoeial preparation. It has been used in the treatment of obesity for a long time. Dyslipidaemia is a recognised modifiable risk factor for hypertension, ischemic heart disease and stroke. Limitations of the current conventional therapy have provided scope for research of a potential drug in this medical condition. It was hypothesised that JF may ameliorate dyslipidaemia in human participants.

AIM OF THE STUDY

The main objective of this study was to evaluate the safety and efficacy of the JF.

MATERIALS AND METHODS

This was a prospective randomized, active-controlled, open-label and parallel-group study. We randomized 74 participants of dyslipidaemia into treatment (n = 38) and control (n = 36) groups. Of them, 30 participants in each group completed the trial. The participants of any sex aged between 30 and 60 years, with serum total cholesterol (TC) ≥200 mg/dl and/or serum triglycerides (TG) ≥150 mg/dl and/or low-density lipoprotein cholesterol (LDL-C) level ≥130 mg/dl and/or high-density lipoprotein cholesterol (HDL-C) level <40 mg/dl were enrolled in this study. The participants of the treatment group were treated with JF (10 gm/day) once and atorvastatin (20 mg/day) was given to the control group for 90 days once at night daily.

RESULTS

We observed a significant reduction (treatment group versus control group) in mean serum TC by 22.89% versus 19.36%, TG by 29.90% versus 23.26% and LDL-C by 29.16% versus 27.92% from baseline (p < 0.05). But the change in mean serum HDL-C levels post-treatment was insignificant in both groups (p > 0.05). On intergroup comparison, the magnitude of the difference of mean TC, TG, LDL-C and HDL-C levels between the groups was not statistically significant (p > 0.00.05).

CONCLUSIONS

This study concluded that JF and atorvastatin were equally effective in controlling dyslipidaemia. They were tolerated well by all participants and found safe during the course of treatment.

Efficacy of herbal anti-microbial soap in Tinea corporis: A randomized controlled study

ETHNOPHARMACOLOGICAL RELEVANCE

Curcuma longa L., Azadirachta indica A Juss. Cassia tora L. has been used in Unani medicine for various skin ailments. Several researches have been conducted on these plants which have shown anti-microbial, anti-bacterial, anti-fungal, antiviral, anti-oxidant, wound healing, anti-inflammatory, and immune modulation activities. Skin diseases and the use of these drugs are mentioned in classical Unani literature like The Canon of medicine, Continens Liber, Hippocratic treatments, The Complete Book of the Medical Art etc. AIM: The aim of the study was to formulate anti-microbial soap and to evaluate its clinical efficacy of in the management of Tinea corporis.

MATERIALS AND METHODS

The anti-microbial soap was prepared by hydroalcholic extracts of Curcuma longa L., Azadirachta indica A Juss. and Cassia tora L. The prepared soap was evaluated for various physicochemical parameters, microbiological evaluation, stability study, skin irritation, In-vitro anti-microbial activity, GCMS analysis, and a clinical trial was carried out to evaluate its efficacy. A Single Blind Randomized Placebo Controlled trail on 30 patients aged between 18 and 60 years of either gender was carried out. The participants were randomly allocated to receive either anti-microbial soap or Placebo soap for 4 weeks. Subjective parameters including erythema, pruritis and desquamation were assessed weekly while as objective parameter including Photograph of lesion, Total Symptom Score (TSS) and KOH mount was assessed at baseline and at the end of the trial.

RESULTS

The improvement in subjective parameters was found significant in test group. Erythema, scaling, and desquamation was completely relieved by 70%, 80% and 25% patients respectively in test group while as none of the patients got complete relief in control group. There was statistically significant reduction in average TSS 8.65 ± 0.6708 to 3.05 ± 1.35 p < 0.001. KOH mount turned negative in 80% patients in test group while as only 20% turned negative in control group.

CONCLUSION

It is concluded that Unani drugs can be utilized in better way by modifying into a convenient dosage form. Anti-microbial soap was formulated by adding minimal additives to achieve effectiveness, with cost effective benefits and less or no side effects. Anti-microbial soap was effective in management of management of Tinea corporis. Moreover further studies on large sample size are required to fine-tune these observations.

Traditional Indian medicine in China: The status quo of recognition, development and research

ETHNOPHARMACOLOGICAL RELEVANCE

Traditional Indian medicine is one of the oldest medical systems and remains popular worldwide. Traditional medicine systems in China and India have historical origins pertaining to mutual learning, reference, and development from medical theory to the drugs used. The exchange of traditional medicine between China and India began in the Qin and Han Dynasties (221 BC-220 AD), prospered in the Tang Dynasty (618-907 AD), and declined after the Song Dynasty (960-1279 AD). It was also directly related to the rise and fall of Buddhism. The traditional medicines of the two countries are highly complementary because of differences in geographical climate and the modernisation process of traditional medicine.

AIM

This review aimed to understand the spread and development of traditional Indian medicine in China to further promote exchange and cooperation between China and India in the field of traditional medicine.

MATERIALS AND METHODS

We performed a systematic search of MEDLINE via PubMed, CNKI, Science Direct, Sci-Hub, and other databases using the terms 'traditional Indian medicine' or 'Indian medicine' or 'Ayurveda' or 'Yoga' or 'Unani', and limiting the search to articles published between 1958 and 2019. We analysed the sources, publication date, type, and topic of the retrieved articles/studies.

RESULTS

Based on the results of research on traditional Indian medicine carried out by Chinese scholars, 518 academic papers and 60 classic works published in China and abroad were collected. The results showed the following. First, Chinese scholars have systematically investigated traditional Indian medicine including its composition, management, and education; the scale of medicinal and pharmaceutical plants; protective measures of intellectual property rights of traditional medicine; and international promotion of Yoga. Second, studies have examined the development status of traditional Indian medicine in China including the spread of Yoga in the country and the industrial scale of, education in, existing problems in, and clinical research on Yoga. In addition, Chinese scholars conducted research on and the translation of classic works and terms of Ayurveda, and studied the theory, treatment, and medicine thereof. Third, the historical exchange and trading status of traditional medicine between India and China have been discussed, including the exchange of traditional medicine between the two countries, effect of traditional Indian medicine on Chinese Buddhism, and minority medicine and trade in medicinal materials between the two countries.

CONCLUSION

India attaches great importance to the management of, education in, and industry of traditional medicine, and has made various efforts to protect intellectual property rights. Indian Yoga is very popular in China, and Chinese scholars have conducted some clinical research thereon. However, regulatory systems and legislation for Yoga are lacking in China. At present, traditional Chinese medicine scholars have an enhanced understanding of the term Yoga and less knowledge of the terms Ayurveda, Siddha, Unani, and similar concepts. We suggest that Chinese scholars further study the classic works, basic theories, treatment of clinical diseases, medicinal materials, and prescriptions compounding traditional Indian medicine. The results of this study highlight directions for Chinese scholars to pursue in further studying traditional Indian medicine comprehensively, and will help promote exchange and cooperation between China and India in the field of traditional medicine.

Aatrilal (Ammi majus L.), an important drug of Unani system of medicine: A review

ETHNOPHARMACOLOGICAL RELEVANCE

Ammi majus L. (Aatrilal) a member of the family Apiaceae, is native to Egypt and widely distributed in Europe, the Mediterranean, and West Asia. It has been used for the treatment of various dermatological disorders particularly vitiligo in the Unani system of Medicine for ages. In traditional medicine, fruits are used as an emmenagogue as well as a diuretic, blood purifier and to treat leprosy, urinary and digestive disorders.

AIM OF THE REVIEW

This paper aims to highlight the medicinal properties of Aatrilal in view of its temperament and phytoconstituents; to signify its potential in the treatment of vitiligo and other ailments as mentioned in Unani system of medicine and also to explore its phytochemistry, pharmacological and clinical studies.

MATERIALS AND METHODS

Aatrilal was explored in classical Unani literature for its temperament (mizaj), medicinal properties and therapeutic uses. Published works available on PubMed, Science Direct, and Google Scholar were referred to collect all the available information regarding its phytochemicals and pharmacological studies. All relevant articles up to 2020 were referred including 15 classical Unani books, 15 English books, 72 research, and 3 review papers. The plant's scientific names were validated using 'The Plant List' (www.theplantlist.org). Standard Unani Medical Terminology published by Central Council for Research in Unani Medicine in collaboration with the World Health Organization was used to describe the appropriate Unani terminologies. Glossary of Indian Medicinal Plants and different indexed journals were consulted for botanical and English names.

RESULTS

Aatrilal has been used in traditional medicine for ages. Due to controversies in its identity, it was adulterated and substituted with many drugs. The real identity of Aatrilal is now established as the fruit of A. majus L. Despite having numerous pharmacological activities, it is considered the first-line drug for the treatment of vitiligo. It is a rich source of furanocoumarins (xanthotoxin, also known as 8-methoxypsoralen, bergapten, imperatorin, isopimpinellin) with other compounds viz. flavonoids, terpenoids, proteins, essential oil constituents, etc. It has been reported for anti-inflammatory, analgesic, antibacterial, antiviral, cytotoxic, and many other activities. Clinical trials have shown the therapeutic potential in vitiligo and other skin disorders.

CONCLUSION

Based on the available literature, it can be concluded that Aatrilal is a drug that has been effectively used in Unani system of medicine for centuries to treat the cases of vitiligo and other dermatological disorders. It has been studied extensively for its phytopharmacological properties. Raw extracts of A. majus form the crux of the main research. Many potentially bioactive compounds are included in the essential oil, but to our knowledge, no detailed studies of its biological activity are yet available. Therefore, our suggestion is to focus future research on essential oil and its ingredients.

Concept of 'Ihtiraq' in Unani Medicine - A correlation with oxidative stress, and future prospects

ETHNOPHARMACOLOGICAL RELEVANCE

In recent years, oxidative stress (OS) and the generation of ROS have been recognized as a fundamental pathology contributing, at least partially, to a number of important diseases. However, the therapeutic application has been simplistically limited to using antioxidants with little correction of diseases, and many biomarkers of OS, although confirming and quantifying the magnitude of this pathology, are not suggestive of the underlying causes behind generation of a large amount of free radicals. Unfortunately, research has not noted the multi-implication parallel phenomenon of Ihtiraq (Combustion) in Unani Medicine, which possesses much richer etiopathological sub-typing and much more variegated selective and specific treatments (and prophylactics) corresponding to each sub-type of Ihtiraq; the identification of each sub-type's molecular counterparts can be used to develop not only sub-types of OS pathologies and corresponding selective treatments/prophylactics but also non-biomolecular factors. Eminent Unani physicians described a deteriorative phenomenon, which they termed as 'Ihtiraq' which stands for extreme metabolism or 'combustion' and is recognized as a fundamental pathology, contributing as a major factor to the development of chronic diseases. Further, Unani Medicine also possesses a pathophysiological phenomenon called 'Hararat Ghariba' (Unnatural Heat) whose diverse associations with Ihtiraq may be correlatable as upstream, parallel, or downstream associations of OS and consequent pathologies.

AIM OF THE STUDY

The aim of the study is to: 1. Explore the correlation of the phenomenon and etiopathology of Ihtiraq and OS and the treatment and prevention of the pathologies arising from them. 2. Extrapolate Ihtiraq, its types, causes, prevention, and treatment to OS, hitherto existing as a fundamental and monolithic pathology of increased ROS, to hypothesize its molecular-level sub-typing, as well as to propose selective interventions in these molecular sub-types of OS in place of the existing use of only basic antioxidants such as Vitamin C.

MATERIAL AND METHODS

This review is presented with a noteworthy insight into Unani concepts and a thorough study of classical Unani literature by Ibn Sina (10th century), Zakaria Razi (9th century), Ibn Rushd (12th century), Ibn al-Nafees (13th century), Majusi (10th century), and Jurjani (11th century), and comparative detailed study of modern concepts of OS from literature databases, as well as Google, recent researches, and review articles.

RESULT

The study showed very close correspondences between the phenomenon, etiopathology, and treatment and prevention of Ihtiraq in Unani Medicine and OS in contemporary biomolecular medicine. It also revealed sub-types of Ihtiraq and corresponding selective Unani treatments and prophylactics including drugs and non-drug factors.

CONCLUSION

After a comprehensive study and analysis of the most recent researches and classical theories, it can be stated that OS can be seen as a molecular level expression of Ihtiraq. Further, various components of Ihtiraq may be used to hypothesize molecular sub-types of OS and propose corresponding specific interventions.

Oxidative stress in Vitiligo patients and administration of Munzij and Mushil therapy, a poly herbal Unani formulation - hospital-based study

Background Vitiligo, a skin disorder is viewed as a multifactorial process with major role of reactive oxygen species in concert to destroy or incapacitate melanocytes. In Unani system of medicine the treatment of Bars (Vitiligo) starts with removal of harmful materials from the body with Munzij and Mushil (MM), a poly herbal Unani formulation. Methods Herein, oxidative stress related parameters as MDA, SOD, GPx and CAT have been estimated in the 21 clinically diagnosed Vitiligo in-patients and subsequently these parameters were evaluated during and after administration of MM therapy and compared with 21 healthy subjects. Results There was significant difference in the parameters viz., SOD (p<0.001) and CAT (p<0.005) activity at the baseline with no statistical significant difference in MDA and GPx activity among Vitiligo subjects and controls. After MM therapy there was no statistical significant difference among the values of these parameters in Vitiligo subjects. Conclusions The results suggest that there is imbalance in the oxidant-antioxidant status of Vitiligo subjects and the MM therapy is not found to significantly change the levels of oxidative stress related parameters.

Clinical efficacy of Unani medicine Renax for treatment of Urolithiasis

Stone formation occurs most commonly in acute and chronic renal failure. A kidney stone is a solid lump made up of crystals that separate from the urine and build up on the inner surfaces of the kidney. The current study was conducted to investigate the clinical efficacy of Unani medicine Renax in comparison with allopathic medicine (Spironolactone + Furosemide) to treat urolithiasis. The study was conducted in District Dera Ghazi Khan, South Punjab region. This was case control, randomized, double blind clinical study. All patients were examined by the Physician and given either herbal or allopathic medicine for Urolithiasis. The patients were divided "into two groups" a control group and test groups. A Total of 24 patients were completely cured out of 50 by use of Renax while a total of 9 patients was cured out of 50 with allopathic medicine (Spironolactone + Furosemide). This study validated the claim of traditional healer for use of Unani medicine in the treatment of urolithiasis.

Antimicrobial and wound healing potential of Marham-e-Aatshak (A Herb-o-Mineral formulation)

Marham-e-Aatshak (MA) is a Unani ointment, with wide use for treating chronic and infectious wounds since long time. This study was designed to screen the antimicrobial and wound healing potential of MA to validate the ethno-therapeutic claims. The agar diffusion method was used to study the antimicrobial action of MA as well as for all of its ingredients. Inhibition zone diameters were measured and MIC values were calculated. Wound healing activity was studied in models of both, excision and incision wounds. Wound contractibility was measured at different intervals in excision wound model; similarly tensile strength was measured in incision wound model. MA and its ingredients showed remarkable inhibitory activity against most of the organisms. In excision wound, a significantly enhanced wound contraction and significantly reduced epithelialization period was observed. In incision wound, significant increase in the mean breaking strength in the test group was observed. The results indicate that MA is capable of fighting against wound infections and able to potentiate the natural healing process.