Clinical efficacy of Vrukshamla Beeja Taila (Kokum Butter) in the Management of Padadari (Cracked Heels)

Mohammed, Joshi, and Tantrady: Clinical efficacy of Vrukshamla Beeja Taila (Kokum Butter) in the Management of Padadari (Cracked Heels)

Authors

Padadari (cracked heals) is one of the commonest occurring podiatric diseases in our society. It occurs in a person, who walks excessively, which eventually leads to Sthanika Vatadushti (localized vitiation of Vatadosha), due to increased rukshatwa, in their Padapradesha, leading to the occurrence of Daree (Cracks) at Padapradesha that is often associated with Ruja (Pain).[1] Sometimes, in severe condition, the routine becomes very cumbersome; especially when it’s associated with bleeding and infection in cracks. The commonly experienced symptoms of Padadari are Vedana (Pain), Rukshatwa (dryness), Kharatwa (Roughness), Kandu (itching) and, seldom, Daha (burning sensation).

Seed-oil of Vrukshamla (Garcinia indica Choisy.) is called as Ghee or oil of Kokum, which is used in cracked hands and feet and various other skin ailments by folklore vaidyas of Western Ghat as it’s very nutritious, unctuous, Mardavakara (gives mrudutwa (softness)).[2] Various uses of it have been mentioned in Ayurveda, including the use as an ingredient in different Varti and Malahara Kalpanas and such other preparations.[3]It is also used in dysentery and diarrhea-with-mucus, applied externally to ulcerations, fissured-lips, chapped skin and skin diseases.[2]

Although some of such folk healing prescriptions have been referred in the classical texts, practical understanding remains inaccessible to most of the people. Documentation of local health traditions was made priority decades ago primarily to preserve the knowledge from disappearing. However, not enough work has been done to examine the efficacy of various medicinal uses of plants used by tribal people and villagers; or to protect this knowledge from being purloined and claimed as a discovery. The use of Vrukshamla beeja taila (VBT) is commonly practiced by the people of Western Ghats in India and its clinical effect in Padadari is neither analytically studied, nor documented before. Hence, here, an attempt has been made to study the clinical effect of VBT in the management of Padadari.

Plant Material

Seeds of Vrukshamla were collected from Udupi district and surrounding forest area of South Kanara.

Preparation of Vrukshamla beeja taila

Traditional boiling-method was followed in this study; for which the collected seeds were dried completely under sunlight. Thereafter, the kernels were obtained by removing the seed-coat manually. Kernels were further subjected to trituration with sufficient quantity of water, for the preparation of paste. That was mixed with 3 litres of water (per kg of seed-kernel) in a vessel and subjected to heat on mild flame for very long time. After some time, a layer of oil started floating on the water, which was skimmed off and taken into another vessel. This second vessel was also simultaneously subjected to the heat on the other stove, until the remnant of water evaporates and the oil remains alone. This oil was allowed to cool down at room temperature and solid Kokum butter was obtained. Heating the first vessel was continued until no or negligible quantity of oil floated. Obtained quantity of Kokum butter was 40 gm per kg of seed-kernel.

Clinical Study

Source of data

A single blind clinical study was conducted on 23 patients suffering from Padadari. Patients were randomly selected from OPD and IPD of SDM Hospital of Ayurveda, Kuthpady, Udupi.

Inclusion criteria

Patients of all ages, regardless of their gender, having cracked heels, were considered for the study.

Exclusion criteria

Patients suffering from the systemic diseases; like diabetes mellitus, hypertension, metabolic syndrome were excluded. Also, those, who were suffering from psoriasis; genetic conditions, like down syndrome; autoimmune conditions like plantar keratoderma, etc. were not considered for the study.

Blood investigations

Prior to selecting the patients for the study, complete haemogram with ESR and random/post prandial blood sugar test were performed in all of them to ensure the absence of exclusion criteria.

Methodology

Prepared VBT was given to the patients (40gm per patient). Then, they were asked to apply it externally on their cracked heels after cleaning their heels by washing with lukewarm water, twice a day, for 15 days. They were asked to melt the drug each time, prior to the application, by indirect-heating method that is heating in a vessel, which is kept on hot water. The procedure of first application of the drug was done by the investigators on each patient for the purpose of demonstration. They were also advised to avoid the contact with dust & mud and wear soft, clean, cotton cloths while going out of the house. First follow up was conducted on 7th day of the treatment and then on 15th day of the treatment, for each patient; and the assessment was made after the course of therapy.

Assessment criteria

Objective parameters like number of the cracks; depth of the cracks, assessed by using a small, toothpick-like stick, which was further correlated with measuring tape to calculate the corresponding length; length of the lesion, mild oozing and color were considered.

Subjective parameters like pain (Vedana), burning (daaha), itching (Kandu) and dryness (Shushkata) were used (Table 1).

In this study, in order to concise, precise and effective statistical interpretation; the statistical data (scores) obtained from both different feet (right and left) of the patients were combined by calculating the arithmetic mean for subjective parameters (Table 1) and the summation for objective parameters (Table 2). As subjective parameters are quite easily influenced by individual feelings and opinions, the arithmetic mean of the scores of both soles of a patient was preferred over the summation of them in each respective patient; whereas the objective parameters are not influenced by individual feelings and opinions, the summation of the scores of both soles of a patient was preferred over the arithmetic mean of them in the each respective patient.

Table 1

Scoring of subjective parameters

   Right SoleLeft SoleMeanComment, if any
1.Pain0 – Absent    
  1 – Present on walking    
  2 – Mildly present at rest    
  3 – severely felt at rest    
2.Burning0 – Absent    
  1 – Present on walking    
  2 – Mildly present at rest    
  3 – severely felt at rest
3.Itching0 – Absent    
  1 – Present on walking    
  2 – Mildly present at rest    
  3 – severely felt at rest    
4.Dryness0 – Absent    
  1 – Present    

Statistical tool

Paired-t Test for statistical analysis of both, viz. subjective and objective, parameters.

Table 2

Scoring of objective parameters

   Right soleLeft soleTotal
1.Number of Cracks   
2.Depth of Cracks (in mm)   
3.Length of the lesion (in cm)   
4.Oozing0 – Absent   
  1 – Watery   
  2 - Bloody   
5.Colour0 – Pink   
  1 – Whitish Pink   
  2 – Pinkish White   
  3 – White   

The assessment of results was made by adopting the standard methods of scoring the signs and symptoms of Padadari. On the basis of all subjective as well as objective parameters, it can be stated that the effect of the intervention was found to be statistically significant, except oozing, where the ‘P’ value was 0.328, which is > 0.20. This is indicative of the change that occurred with the treatment is not great enough to exclude the possibility that the difference is due to chance. That is, probably due to the presence of oozing (serous bleeding with no sign of infection observed) on day-0 (BT) in only one out of total 23 patients (Table 3).

Table 3

Effect of the treatment of VBT

ParameterNumber of patients (as per BT)TIME OF OBSERVATIONMEAN SIZEMDSDSE‘t’ value‘p’ value
   BTDT/AT     
Pain15Day-7 (DT)0.8480.06520.7830.2290.04774.807< 0.001
  Day-15 (AT)0.8480.000.8480.0000.0004.736< 0.001
Burning Sensation4Day-7 (DT)0.1740.0000.1740.0000.0002.1520.043
  Day-15 (AT)0.1740.0000.1740.0000.0002.1520.043
Itching Sensation9Day-7 (DT)0.6520.1300.5220.3440.07183.4250.002
  Day-15 (AT)0.6520.0000.6520.0000.0003.3470.003
Dryness of Lesion22Day-7 (DT)0.9570.4130.5440.4920.1035.234< 0.001
  Day-15 (AT)0.9570.02170.93530.1040.021719.59< 0.001
Number of Cracks23Day-7 (DT)24.3917.9136.4788.8211.8395.115< 0.001
  Day-15 (AT)24.3913.82610.5657.8721.6418.059< 0.001
Depth of Cracks21Day-7 (DT)2.2391.3570.8821.4850.3104.434< 0.001
  Day-15 (AT)2.2390.8171.4220.9630.2014.855< 0.001
Length of Lesion23Day-7 (DT)25.3620.4414.9186.6941.3966.437< 0.001
  Day-15 (AT)25.3616.0659.2946.5821.37210.11< 0.001
Oozing1Day-7 (DT)0.0870.0000.08700.0000.0001.000> 0.20
  Day-15 (AT)0.0870.0000.08700.0000.0001.000> 0.20
Colour of Lesion23Day-7 (DT)1.8700.8261.0440.8340.1744.362< 0.001
  Day-15 (AT)1.8700.04351.82650.2090.04358.509< 0.001

BT: Before Treatment: Day-0

DT: During Treatment: Day-7

AT: After Treatment: Day-15

The statistically significant results in all assessment parameters; except oozing parameter; show the drug VBT is effective in the management of Padadari. Yet, on the 15th day of the treatment, most of the patients didn’t receive 100% results in all parameters. This indicates the need of more days of treatment duration, than merely 15 days, for better improvement. The rate of improvement in each patient was according the severity of Padadari, before treatment.

Probable mode of action of VBT

In general, overall, Vrukshamla is a amla rasa pradhanadravya and has amla vipaka; both, amla rasa and amla vipaka, perform the vatahara action.[4] Moreover, it’s a Ushnaveeryatmaka dravya; thus it helps to normalize vitiated vatadosha by being Ushna. The seeds used for the preparation VBT are usually obtained from Pakwa Phala. So, some properties of Pakwa Phala might be present in its seeds and so in seed-oil as well. Pakwa Phala is said to be Katu, Kashaya and Amla.[5] Hence, that could be the reason for the Vranaropana karma by Katu & Kashaya rasas and Stambhana karma by the Kashaya rasa of Kokum butter. Also, like any oil, kokum butter is Snigdha; which again helps in the correction of vitiated Vatadosha. In fact, it has butter-like solid consistency at room temperature, which provides unmeasurably high viscosity. In other words, it works by a phenomenon of Samanya-Vishesha Siddhanta. That is it replaces the absence of Snigdhata, Ushnata, Mruduta, Soumyata at Padapradesha and nullifies the opposite properties of vitiated Vatadosha, such as Rukshata, Sheetata, Kharata, Kathinyata, etc. In addition, the process of external application of VBT provides the gentle massage to the feet, which is quite natural phenomenon, which also, probably, helps in increased local vascularity. This increased vascularity encourages faster healing.

Figure 1

Assessment of the depth of the crack

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Figure 2

Heels of the patients before and after the treatment

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CONCLUSION

Although the efficacy of VBT is already claimed by traditional Vaidyas; this clinical study showed that it has a significant effective in the management of Padadari. It was also found that the majority of the patients received more improvement in subjective parameters than the objective parameters, within the course of 15 days, depending upon the severity of their disease before treatment; which showed the necessity of longer duration of the treatment course for complete recovery. Hence, a further comparative study with other formulations and line of treatments can be encouraged.

GRAPHICAL ABSTRACT

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ACKNOWLEDGEMENTS

The authors are thankful to SDM College of Ayurveda & Hospital, Udupi for providing essential facility and support for the study.

ABOUT THE AUTHORS

Dr. Mohammed Faisal obtained his PhD in Dravyaguna Vignanam from Rajiv Gandhi University of Health Sciences, Bengaluru, Karnataka. Currently working as an assistant professor at Dept. of Dravyaguna Vignanam, SDM College of Ayurveda, Udupi, India. MF guided this clinical study and played a valuable role in accomplishing the study and paper.

Dr. Sreekant Vishnu Joshi pursed his BAMS. from KLE’s Sri BMK Ayurveda Mahavidyalaya, Belgaum in 2009. He was a former Post graduate scholar at Dept. of Dravyaguna Vignanam in SDM College of Ayurveda, Udupi, through 2013-16. Currently, he is working as a Deputy Dean for the proposed School of Ayurvedic Science and Research at Rai Technology University, Bengaluru, India. SVJ conducted this clinical study and played a vital contribution in completing the study and writing the article, under the valuable guidance of MF and TSB.

Dr. T Shridhara Bairy obtained in M.D. in Dravyaguna Vignanam from IPGT & RA, GAU, Jamnagar and then pursued his PhD in Botany from Mangalore University. He served as Professor and Head of the Dept. of Dravyaguna Vignanam at SDM College of Ayurveda, Udupi, India. TSB pioneered the idea of conducting this study and guided and encouraged both researchers very effectively from his vast experience in the field.

Notes

[4] Conflicts of interest CONFLICT OF INTEREST Nil

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Khare CP , author. Indian Medicinal Plants. 1 st. New Delhi: Springer (India) Private Limited; 2007. p. 278–9

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Vaidya BG , author. Nighantu Adarsha. Volume – I. 1 st. Varanasi: Chaukhambha Bharati Academy; 2009. p. 122–4

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Sastry JLN , author. Dravyaguna Vignanam. Volume – I. 1 st. Varanasi: Chaukhambha Orientalia; 2007. p. 122, 148

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Bhavamishra. Bhavaprakash Nighantu. 1 st. Chunekar KC , editor. Varanasi: Chouwkhambha Krishna Academy; 2010. p. 588