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<big>'''Abstract'''</big>

<big>'''Abstract'''</big>

<div style="text-align:justify;">This chapter deals with diagnosis of skin disease termed as Kushtha. The disease has variable manifestations on skin depending upon degree of involvement of three vitiated dosha and their effect on four vitiated factors i.e. rasa, rakta, mamsa and lasika (lymphatic system). On the basis of clinical manifestations and severity, kushtha is classified into seven major types, eleven minor types or innumerable types due to the permutation and combination of dosha predominance and involvement of particular quality of a dhatu and accretion of dosha at different sites. The etiopathology, prodromal symptoms (purvarupa), symptomatology of seven major types of kushtha (maha-kushtha), their dosha predominance, prognosis, complications and significance of early treatment are described in this chapter. </div>

<div style="text-align:justify;">This chapter deals with diagnosis of skin disease termed as Kushtha. The disease has variable manifestations on skin depending upon degree of involvement of three vitiated [[dosha]] and their effect on four vitiated factors i.e. [[rasa]], [[rakta]], [[mamsa]] and lasika (lymphatic system). On the basis of clinical manifestations and severity, kushtha is classified into seven major types, eleven minor types or innumerable types due to the permutation and combination of [[dosha]] predominance and involvement of particular quality of a [[dhatu]] and accretion of [[dosha]] at different sites. The etiopathology, prodromal symptoms (purvarupa), symptomatology of seven major types of kushtha (maha-kushtha), their [[dosha]] predominance, prognosis, complications and significance of early treatment are described in this chapter. </div>

'''Keywords''': ''Kushtha, Mandal, Kapala, Kakanak, Audambar, Rishyajihva, Pundareeka, Sidhma'', causes of skin diseases, discoloration of skin.  

'''Keywords''': ''Kushtha, Mandal, Kapala, Kakanak, Audambar, Rishyajihva, Pundareeka, Sidhma'', causes of skin diseases, discoloration of skin.  

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The pathology of skin diseases origin from the deranged physiology of seven factors connected to skin. They are ''vata, pitta'' and ''kapha'' ''doshas'' in aggravated state and ''dhatus'', namely, ''tvak'' (the word ''tvak'' represents skin. Since the skin is organ in which ''rasa dhatu'' is present, ''tvak'' word is used instead of ''rasa dhatu'' ), ''mamsa, shonita'' and ''lasika'' that get deranged due to aggravated ''dosha''. So seven type of kushtha are manifested by these seven morbid factors. Thus preliminary and manifested kushtha gradually afflicts the whole body. [3]

The pathology of skin diseases origin from the deranged physiology of seven factors connected to skin. They are ''[[vata]], [[pitta]]'' and ''[[kapha]]'' ''[[dosha]]s'' in aggravated state and ''[[dhatu]]s'', namely, ''tvak'' (the word ''tvak'' represents skin. Since the skin is organ in which ''[[rasa dhatu]]'' is present, ''tvak'' word is used instead of ''[[rasa dhatu]]'' ), ''[[mamsa]], shonita'' and ''lasika'' that get deranged due to aggravated ''[[dosha]]''. So seven type of kushtha are manifested by these seven morbid factors. Thus preliminary and manifested kushtha gradually afflicts the whole body. [3]

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=== Possible types of kushtha ===

=== Possible types of kushtha ===

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Variation in single ''dosha'' cannot cause kushtha. Even in kushtha with similar presentations, the clinical features in terms of sensation in skin, colour, site of skin lesion, other symptoms, and treatment may vary depending on the variation in vitiation of (qualities of) ''dosha''. Therefore there are seven or eighteen or innumerable types of kushtha. The variations in qualities of vitiated ''dosha'' lead to further differentiation in types of diseases, except in incurable conditions. As there might be innumerable types of kushtha leading to expansion of text, only seven types of kushtha are described here. [4]

Variation in single ''[[dosha]]'' cannot cause kushtha. Even in kushtha with similar presentations, the clinical features in terms of sensation in skin, colour, site of skin lesion, other symptoms, and treatment may vary depending on the variation in vitiation of (qualities of) ''[[dosha]]''. Therefore there are seven or eighteen or innumerable types of kushtha. The variations in qualities of vitiated ''[[dosha]]'' lead to further differentiation in types of diseases, except in incurable conditions. As there might be innumerable types of kushtha leading to expansion of text, only seven types of kushtha are described here. [4]

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=== Seven types of kushtha ===

=== Seven types of kushtha ===

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When ''vata'' and other ''doshas'' are aggravated and affect four vitiated ''dhatus'' such as ''twak'', and there is dominance of ''vata'' ''dosha'', then the disease is known as ''kapala kushtha''. Similarly ''dosha'' dominance with other six diseases are explained in the table below:

When ''[[vata]]'' and other ''[[dosha]]s'' are aggravated and affect four vitiated ''[[dhatu]]s'' such as ''twak'', and there is dominance of ''[[vata]]'' ''[[dosha]]'', then the disease is known as ''kapala kushtha''. Similarly ''[[dosha]]'' dominance with other six diseases are explained in the table below:

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Table 1: The major skin diseases and its dosha dominance.

Table 1: The major skin diseases and its [[dosha]] dominance.

{| class="wikitable"

{| class="wikitable"

! rowspan="1"| Skin diseases       

! rowspan="1"| Skin diseases       

! rowspan="1"| Dosha dominance         

! rowspan="1"| [[Dosha]] dominance         

|-  

|-  

! rowspan="1"| Kapala

! rowspan="1"| Kapala

! rowspan="1"| Vata

! rowspan="1"| [[Vata]]

|-

|-

| Udumbara ||  Pitta

| Udumbara ||  [[Pitta]]

|-

|-

| Mandala ||  Kapha

| Mandala ||  [[Kapha]]

|-

|-

| Rushyajihva || Vata-pitta  

| Rushyajihva || [[Vata]]-[[pitta]]

|-

|-

| Pundarika ||  Pitta-kapha

| Pundarika ||  [[Pitta]]-[[kapha]]

|-

|-

| Sidhma ||  Kapha-vata

| Sidhma ||  [[Kapha]]-[[vata]]

|-

|-

| Kakanaka || all doshas

| Kakanaka || all [[dosha]]s

|-

|-

|}

|}

*indulges in excessive oleation,  

*indulges in excessive oleation,  

Above causative factors lead to simultaneous aggravation of all the ''tridosha'', weakness in the skin etc. four ''dushyas''. Aggravated ''doshas'' lodge themselves in these weakened factors and after localization, further vitiate them and manifest kushtha. [6]

Above causative factors lead to simultaneous aggravation of all the ''tri[[dosha]]'', weakness in the skin etc. four ''[[dushya]]s''. Aggravated ''[[dosha]]s'' lodge themselves in these weakened factors and after localization, further vitiate them and manifest kushtha. [6]

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=== Premonitory signs of kushtha ===

=== Premonitory signs of kushtha ===

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The clinical manifestations of skin diseases are preceded by or associated with loss or excessive sweating (at the site of localization of vitiates ''doshas''), excess rough or excess smooth skin, discoloration, itching, pricking sensation, numbness, severe burning sensation, tingling sensation, goose bumps, xerosis on palpation, hot flashes, heaviness, swelling, if there is tenderness it indicates the possibility of suppurated, burnt, bitten, broken, injured and dislocated parts and even smaller ulcers become chronic, non healing.[7]

The clinical manifestations of skin diseases are preceded by or associated with loss or excessive sweating (at the site of localization of vitiates ''[[dosha]]s''), excess rough or excess smooth skin, discoloration, itching, pricking sensation, numbness, severe burning sensation, tingling sensation, goose bumps, xerosis on palpation, hot flashes, heaviness, swelling, if there is tenderness it indicates the possibility of suppurated, burnt, bitten, broken, injured and dislocated parts and even smaller ulcers become chronic, non healing.[7]

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=== Specific features of ''kapala kushtha'' ===

=== Specific features of ''kapala kushtha'' ===

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The incurable disease never give up its incurability (never become curable). The curable disease may sometimes become incurable due to misconduct (not following the diet and lifestyle regulations properly). The six (types of) kushtha are curable except ''kakanaka''. However if not treated properly, they may become incurable due to lack of timely management, improper management and constantly excess aggravation of ''doshas''. [9]

The incurable disease never give up its incurability (never become curable). The curable disease may sometimes become incurable due to misconduct (not following the diet and lifestyle regulations properly). The six (types of) kushtha are curable except ''kakanaka''. However if not treated properly, they may become incurable due to lack of timely management, improper management and constantly excess aggravation of ''[[dosha]]s''. [9]

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=== Complications of kushtha ===

=== Complications of kushtha ===

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If the curable diseases are neglected (not treated), then they are also afflicted with putrefaction of skin, muscle tissue, blood, lymph and ''swedaja krimi'' (maggots or micro-organisms). The ''krimi'' get nourishment from the decayed skin etc. and further vitiate ''doshas'' leading to variety of complications corresponding to individual ''doshas'' as follows:  

If the curable diseases are neglected (not treated), then they are also afflicted with putrefaction of skin, muscle tissue, blood, lymph and ''swedaja krimi'' (maggots or micro-organisms). The ''krimi'' get nourishment from the decayed skin etc. and further vitiate ''[[dosha]]s'' leading to variety of complications corresponding to individual ''[[dosha]]s'' as follows:  

   

   

*Due to ''vata'', blackish and downy red discoloration appears, roughness, dryness, piercing  pain, emaciation (atrophy), pricking  pain, tremors, horripilation, constriction, exhaustion, stiffness, numbness, ulceration and fissures;   

*Due to ''[[vata]]'', blackish and downy red discoloration appears, roughness, dryness, piercing  pain, emaciation (atrophy), pricking  pain, tremors, horripilation, constriction, exhaustion, stiffness, numbness, ulceration and fissures;   

*''Pitta'' causes burning sensation, sweating, moistening, putrefaction, discharge, suppuration and redness;  

*''[[Pitta]]'' causes burning sensation, sweating, moistening, putrefaction, discharge, suppuration and redness;  

*''Kapha'' causes whiteness, coldness, itching, immobility, heaviness, protuberance, unctuousness and coating, maggots eat up the skin etc. (skin, flesh, blood, lymph) vessels, ligaments  and cartilages. [10]

*''[[Kapha]]'' causes whiteness, coldness, itching, immobility, heaviness, protuberance, unctuousness and coating, maggots eat up the skin etc. (skin, flesh, blood, lymph) vessels, ligaments  and cartilages. [10]

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== Tattva Vimarsha (Fundamental Principles) ==

== Tattva Vimarsha (Fundamental Principles) ==

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*kushtha is the result of combined and simultaneous involvement of all the three ''dosha'' and subsequently vitiation of the four body constituents i.e. ''rasa'' (''twak'', or skin), ''mamsa''(muscle tissue), ''rakta''(blood), and ''lasika''(lymph).

*kushtha is the result of combined and simultaneous involvement of all the three ''[[dosha]]'' and subsequently vitiation of the four body constituents i.e. ''[[rasa]]'' (''twak'', or skin), ''[[mamsa]]''(muscle tissue), ''[[rakta]]''(blood), and ''lasika''(lymph).

*There can be infinite clinical presentations of kushtha (skin diseases) depending upon severity of combination of above mentioned vitiating factors.

*There can be infinite clinical presentations of kushtha (skin diseases) depending upon severity of combination of above mentioned vitiating factors.

*While diagnosing the severity of kushtha, the depth of lesion can be assessed according to involvement of skin, muscle, blood and lymph respectively. The treatment should be planned accordingly, targeting these constituents and should be based upon predominantly vitiated ''dosha''.  

*While diagnosing the severity of kushtha, the depth of lesion can be assessed according to involvement of skin, muscle, blood and lymph respectively. The treatment should be planned accordingly, targeting these constituents and should be based upon predominantly vitiated ''[[dosha]]''.  

*The varieties in vitiated qualities of ''doshas'' (like ''ruksha'' etc.) depend upon dietary and lifestyle causative factors. kushtha can be classified based upon the criteria like specific sensation in skin, change in color of skin (pigmentation), site of lesion, spread of lesion, clinical features.

*The varieties in vitiated qualities of ''[[dosha]]s'' (like ''ruksha'' etc.) depend upon dietary and lifestyle causative factors. kushtha can be classified based upon the criteria like specific sensation in skin, change in color of skin (pigmentation), site of lesion, spread of lesion, clinical features.

*Continuous exposure to change in temperature (thermal sensitivity), change in fluid volume and muscle mass inside body, incompatible dietary and lifestyle factors are main causative factors of kushtha. Similarly sudden changes in above factors may lead to acute condition of skin disease.  

*Continuous exposure to change in temperature (thermal sensitivity), change in fluid volume and muscle mass inside body, incompatible dietary and lifestyle factors are main causative factors of kushtha. Similarly sudden changes in above factors may lead to acute condition of skin disease.  

*If the curable kushtha are not timely treated, it leads to favorable environment to growth of micro-organisms. The micro-organisms grow on the vitiated ''twak, rakta, mamsa,'' and ''lasika'' leading to various severe skin lesions.  

*If the curable kushtha are not timely treated, it leads to favorable environment to growth of micro-organisms. The micro-organisms grow on the vitiated ''twak, [[rakta]], [[mamsa]],'' and ''lasika'' leading to various severe skin lesions.  

*The curable disease can become incurable due to improper management, exposure to causative factors and aggravation of ''dosha''.

*The curable disease can become incurable due to improper management, exposure to causative factors and aggravation of ''[[dosha]]''.

== Vidhi Vimarsha (Applied Inferences) ==

== Vidhi Vimarsha (Applied Inferences) ==

Three chapters are devoted to dermatological disorders, present chapter and [[Chikitsa Sthana]] chapter 7 ([[Kushtha Chikitsa]]) and 21([[Visarpa Chikitsa]]). The present chapter deals with seven types of kushtha, while in [[Kushtha Chikitsa]], all eighteen types have been described and have been given the name of ''Mahakushtha'' (major) and ''Kshudra kushtha'' (Minor). After reviewing the symptoms of seven major types it is clear that it covers a progressive disorder of skin leading to loss of organs and impaired sensation (sensory neuropathy). According to some commentators ''Kshudra kushtha'' is a  group of mild and localized skin diseases, which runs a chronic course.

Three chapters are devoted to dermatological disorders, present chapter and [[Chikitsa Sthana]] chapter 7 ([[Kushtha Chikitsa]]) and 21([[Visarpa Chikitsa]]). The present chapter deals with seven types of kushtha, while in [[Kushtha Chikitsa]], all eighteen types have been described and have been given the name of ''Mahakushtha'' (major) and ''Kshudra kushtha'' (Minor). After reviewing the symptoms of seven major types it is clear that it covers a progressive disorder of skin leading to loss of organs and impaired sensation (sensory neuropathy). According to some commentators ''Kshudra kushtha'' is a  group of mild and localized skin diseases, which runs a chronic course.

Most of the diseases are classified on the basis of ''dosha'' predominance. There is variable interplay of three ''dosha'' and four ''dushya'' in kushtha, which can present as seven types, eighteen types and innumerable types on the basis of symptoms, color, location, prognosis and treatment. (see chart).

Most of the diseases are classified on the basis of ''[[dosha]]'' predominance. There is variable interplay of three ''[[dosha]]'' and four ''[[dushya]]'' in kushtha, which can present as seven types, eighteen types and innumerable types on the basis of symptoms, color, location, prognosis and treatment. (see chart).

kushtha and ''visarpa'' - both the diseases have the same seven causative factors (three ''dosha'' and four ''dhatu'' type disorders), where kushtha is chronic and ''visarpa'' is acute and may be life threatening,  In ''visarpa'', ''rakta'' is dominant which makes it spread rapidly, treatment is bloodletting. In case of kushtha all seven factors are involved with little bit variation.

kushtha and ''visarpa'' - both the diseases have the same seven causative factors (three ''[[dosha]]'' and four ''[[dhatu]]'' type disorders), where kushtha is chronic and ''visarpa'' is acute and may be life threatening,  In ''visarpa'', ''[[rakta]]'' is dominant which makes it spread rapidly, treatment is bloodletting. In case of kushtha all seven factors are involved with little bit variation.

=== Causes of kushtha ===

=== Causes of kushtha ===

Environmental factors like diet and lifestyle, in the presence of genetic predisposition impair the immune system with increased susceptibility to secondary infection. ''Viruddhahara'' (incompatible foods) has similar effect through epigenetic mechanism.

Environmental factors like diet and lifestyle, in the presence of genetic predisposition impair the immune system with increased susceptibility to secondary infection. ''Viruddhahara'' (incompatible foods) has similar effect through epigenetic mechanism.

Early diagnosis is important and stages have been described for disease manifestation. ''Poorvarupa'' (prodromal symptoms) occur in the fourth stage of disease manifestation and if the disease is diagnosed at this level, early control and better treatment may be possible. Though in the stage of ''poorvarupa'' it may not be possible to diagnose the type/subtype of disease, however type of ''dosha'' can be decided and accordingly treatment can be started. (7)

Early diagnosis is important and stages have been described for disease manifestation. ''Poorvarupa'' (prodromal symptoms) occur in the fourth stage of disease manifestation and if the disease is diagnosed at this level, early control and better treatment may be possible. Though in the stage of ''poorvarupa'' it may not be possible to diagnose the type/subtype of disease, however type of ''[[dosha]]'' can be decided and accordingly treatment can be started. (7)

=== Classification of kushtha ===

=== Classification of kushtha ===

The ''mahakushtha'' has been classified under seven types as per their ''dosha'' predominance accordingly symptomatology of these has been described. All the body physiology and pathology is designated to a particular ''dosha'' thus the diseases are basically diagnosed on the basis of three ''dosha'' and their combinations. The color, texture, secretions, margins, and types of pain associated with these lesions, as wsell as their progression have been classified on the basis of three ''dosha''.

The ''mahakushtha'' has been classified under seven types as per their ''[[dosha]]'' predominance accordingly symptomatology of these has been described. All the body physiology and pathology is designated to a particular ''[[dosha]]'' thus the diseases are basically diagnosed on the basis of three ''[[dosha]]'' and their combinations. The color, texture, secretions, margins, and types of pain associated with these lesions, as well as their progression have been classified on the basis of three ''[[dosha]]''.

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=== Dosha specific variation in kushtha  ===

=== Dosha specific variation in kushtha  ===

Various Vedic texts on the subject have tried to classify all signs and symptoms on the basis of ''tridosha'' thus this serves a good tool to diagnose the lesions as per three ''doshas'' seen in the following table:

Various Vedic texts on the subject have tried to classify all signs and symptoms on the basis of ''tridosha'' thus this serves a good tool to diagnose the lesions as per three ''[[dosha]]s'' seen in the following table:

{| class="wikitable"

{| class="wikitable"

! rowspan="1"| Sr

! rowspan="1"| Sr

! rowspan="1"| Parikshya bhava( assessment parameter)

! rowspan="1"| Parikshya bhava( assessment parameter)

! rowspan="1"| vata

! rowspan="1"| [[vata]]

! rowspan="1"| pitta

! rowspan="1"| [[pitta]]

! rowspan="1"| kapha

! rowspan="1"| [[kapha]]

|-

|-

! rowspan="1"| 1

! rowspan="1"| 1

Prognostic criteria for curability or incurability has been given much importance. Text cautions that incurable will not leave its nature, however curable conditions can become incurable due improper treatment. With the availability of newer treatments and better diagnostic tools many syndromes which, were listed as incurable have become palliable. The management of leprosy is one example of change in the approach to management with the help of antibiotics, but, with limitations. The outcome of treatment can be significantly changed if the current antibiotic treatment is supplemented with Ayurvedic management.  

Prognostic criteria for curability or incurability has been given much importance. Text cautions that incurable will not leave its nature, however curable conditions can become incurable due improper treatment. With the availability of newer treatments and better diagnostic tools many syndromes which, were listed as incurable have become palliable. The management of leprosy is one example of change in the approach to management with the help of antibiotics, but, with limitations. The outcome of treatment can be significantly changed if the current antibiotic treatment is supplemented with Ayurvedic management.  

After the fifth stage of the therapeutic intervention i.e. rupa (proper manifestation) if the disease is not managed properly or the intervention is ineffective the disease progresses further and produces symptoms of upadrava (complications). These symptoms and signs have again been classified on the basis of tri-dosha. As the rasa(twak), rakta, mamsa and lasika ( lymphatic tissue) are involved in the manifestation of kushtha, its progression to the deeper tissues like meda, asthi, majja and shukra will lead to complications. This includes permanent disfiguration of organs, loss of phalanges and infection of wounds by maggots causing severe damage to the tissues like bones. (verse 10-16)

After the fifth stage of the therapeutic intervention i.e. rupa (proper manifestation) if the disease is not managed properly or the intervention is ineffective the disease progresses further and produces symptoms of upadrava (complications). These symptoms and signs have again been classified on the basis of tri-[[dosha]]. As the [[rasa]](twak), [[rakta]], [[mamsa]] and lasika ( lymphatic tissue) are involved in the manifestation of kushtha, its progression to the deeper tissues like [[meda]], [[asthi]], [[majja]] and [[shukra]] will lead to complications. This includes permanent disfiguration of organs, loss of phalanges and infection of wounds by maggots causing severe damage to the tissues like bones. (verse 10-16)

If the symptomatology described by Charak and Dhatugata symptoms of Sushruta are compared, it is evident that the symptoms described for rasa dhatu represent poorvarupa. Rakta and mamsagata symptoms are listed as rupa of kushtha. The symptoms listed as medagata are the disfigurement of the organs, falling of limbs and flaring of skin lesions. The symptoms listed as asthigata kushtha are saddle nose, kerato- conjunctivitis, growth of maggots in lesions and loss of speech. This list of dhatugata kushtha described by Sushruta covers almost all the complications of leprosy. Thus taking into the consideration of Dhatugata stage of the disease further insight in the management of the disease as Sushruta has advised to increase the intensity of the treatment taking into the consideration of the dhatu involved.

If the symptomatology described by Charak and Dhatugata symptoms of Sushruta are compared, it is evident that the symptoms described for [[rasa dhatu]] represent poorvarupa. [[Rakta]] and mamsagata symptoms are listed as rupa of kushtha. The symptoms listed as medagata are the disfigurement of the organs, falling of limbs and flaring of skin lesions. The symptoms listed as asthigata kushtha are saddle nose, kerato- conjunctivitis, growth of maggots in lesions and loss of speech. This list of dhatugata kushtha described by Sushruta covers almost all the complications of leprosy. Thus taking into the consideration of Dhatugata stage of the disease further insight in the management of the disease as Sushruta has advised to increase the intensity of the treatment taking into the consideration of the [[dhatu]] involved.

Sushruta has explained the symptomatology on the basis of dhatugata stage of the dosha.[Sushruta Samhita Nidana Sthana 7/21-26] Rasa, lasika, rakta and mamsa are dushya, in this disease hence complications arise when the dosha proceed to the deeper dhatu, meda and majja.

Sushruta has explained the symptomatology on the basis of dhatugata stage of the [[dosha]].[Sushruta Samhita Nidana Sthana 7/21-26] [[Rasa]], lasika, [[rakta]] and [[mamsa]] are [[dushya]], in this disease hence complications arise when the dosha proceed to the deeper [[dhatu]], [[meda]] and [[majja]].

Samswedaja Krimi (Maggot/micro-organisms infestation with sweating) is a complication is to be kept in mind for treatment purpose.

Samswedaja Krimi (Maggot/micro-organisms infestation with sweating) is a complication is to be kept in mind for treatment purpose.