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Neuropharmacological effect of methylphenidate on attention network in children with attention deficit hyperactivity disorder during oddball paradigms as assessed using functional near-infrared spectroscopy acne 8 year old boy cheap accutane 10mg with amex. Functional outcomes from a head-to-head, randomized, double-blind trial of lisdexamfetamine dimesylate and atomoxetine in children and adolescents with attention-deficit/hyperactivity disorder and an inadequate response to methylphenidate. Cardiovascular safety of medication treatments for attentiondeficit/hyperactivity disorder. Randomized, double-blind trial of guanfacine extended release in children with attention-deficit/hyperactivity disorder: morning or evening administration. Effects of neurofeedback versus stimulant medication in attentiondeficit/hyperactivity disorder: a randomized pilot study. Predicting acute side effects of stimulant medication in pediatric attention deficit/hyperactivity disorder: data from quantitative electroencephalography, event-related potentials, and a continuous-performance test. Combined methylphenidate and atomoxetine pharmacotherapy in attention deficit hyperactivity disorder. A 4-year follow-up study of attention-deficit hyperactivity symptoms, comorbidities, and psychostimulant use in a Brazilian sample of children and adolescents with attention-deficit/hyperactivity disorder. Baseline severity of parent-perceived inattentiveness is predictive of the difference between subjective and objective methylphenidate responses in children with attention-deficit/hyperactivity disorder. The metabotropic glutamate receptor subtype 7 rs3792452 polymorphism is associated with the response to methylphenidate in children with attentiondeficit/hyperactivity disorder. Catechol-O-methyltransferase Val158-Met polymorphism and a response of hyperactive-impulsive symptoms to methylphenidate: A replication study from South Korea. Iron Deficiency Parameters in Children and Adolescents with Attention-Deficit/Hyperactivity Disorder. Single- and multiple-dose pharmacokinetics of methylphenidate administered as methylphenidate transdermal system or osmotic-release oral system methylphenidate to children and adolescents with attention deficit hyperactivity disorder. Exercise improves behavioral, neurocognitive, and scholastic performance in children with attention-deficit/hyperactivity disorder. Methylphenidate does not improve interference control during a working memory task in young patients with attention-deficit hyperactivity disorder. Transcranial oscillatory direct current stimulation during sleep improves declarative memory consolidation in children with attentiondeficit/hyperactivity disorder to a level comparable to healthy controls. The pharmacological management of oppositional behaviour, conduct problems, and Aggression in children and adolescents with Attention-deficit hyperactivity disorder, oppositional defiant disorder, and conduct disorder: A systematic review and meta-analysis. Quantitative electroencephalography as a diagnostic aid for attention-deficit/hyperactivity disorder in children. Efficacy of cognitive retraining techniques in children with attention deficit hyperactivity disorder. Stimulant treatment and injury among children with attention deficit hyperactivity disorder: an application of the self-controlled case series study design. Minimizing adverse events while maintaining clinical improvement in a pediatric attention-deficit/hyperactivity disorder crossover trial with dextroamphetamine and methylphenidate. Clinical gains from including both dextroamphetamine and methylphenidate in stimulant trials. Randomized controlled trial of osmotic-release methylphenidate with cognitive-behavioral therapy in adolescents with attentiondeficit/hyperactivity disorder and substance use disorders. Is Physical Activity Causally Associated With Symptoms of Attention-Deficit/Hyperactivity Disorder. Reinforcement and Stimulant Medication Ameliorate Deficient Response Inhibition in Children with Attention-Deficit/Hyperactivity Disorder. Effectiveness of a cognitive-functional group intervention among preschoolers with attention deficit hyperactivity disorder: A pilot study. Methylphenidate normalizes fronto-striatal underactivation during interference inhibition in medication-naive boys with attention-deficit hyperactivity disorder. Safety of attention-deficit/hyperactivity disorder medications in children: an intensive pharmacosurveillance monitoring study.

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Antibiotic prophylaxis for transrectal needle biopsy of the prostate: A randomized controlled study acne while breastfeeding order accutane 40 mg with mastercard. Antibiotic prophylaxis for transrectal biopsy of the prostate: A prospective randomized study of the prophylactic use of single dose oral fluoroquinolone versus trimethoprimsulfamethoxazole. Single-dose oral ciprofloxacin versus placebo for prophylaxis during transrectal prostate biopsy. Transrectal prostatic biopsy: the incidence of fever and sepsis after treatment with antibiotics. The problem of infection after prostatic biopsy: the case for the transperineal approach. A double-blind study of trimethoprim-sulfamethoxazole prophylaxis in patients having transrectal needle biopsy of the prostate. Efficacy and safety of fosfomycin-trometamol in the prophylaxis for transrectal prostate biopsy. Antimicrobial prophylaxis for transrectal ultrasound guided biopsy of prostate: A comparative study between single dose of Gentamicin vs. Antibiotic prophylaxis for transrectal prostate biopsy: A prospective randomized study of tosufloxacin versus levofloxacin. Antimicrobial prophylaxis for transrectal prostatic biopsy: A prospective study of ciprofloxacin vs piperacillin/tazobactam. Prospective assessment of the efficacy of single dose versus traditional 3-day antimicrobial prophylaxis in 12-core transrectal prostate biopsy. Reducing Infectious Complications Following Transrectal Ultrasound-guided Prostate Biopsy: A Systematic Review. Wearing shoes in endemic areas Mass de-worming of school aged children Sanitary 26. Distinguishing between transfusion related acute lung injury and transfusion associated circulatory overload Robert C. Brain natriuretic peptide can be useful in distinguishing cardiogenic from noncardiogenic pulmonary edema. As understanding of their pathogenesis improves, incidence, risk factors, differences, and possible preventive interventions are becoming clearer. Developing a thorough clinical profile including presenting signs and symptoms, fluid status, cardiac status including measurement of brain natriuretic peptide, and leukocyte antibody testing is the best strategy currently available to distinguish the two disorders. Determining the correct diagnosis is important because there are implications for the patient, the donor, and the other products associated with the involved donation [2]. The clinical features are similar, and there are no diagnostic tests that reliably discriminate. The fact that a patient could have both simultaneously only adds to the complexity [5,6,7]. Yet the therapy and management of the patient, and the implications for the donor of the two different reactions are completely different. Transfusion associated circulatory overload Despite the fact that circulatory overload has been a recognized complication of transfusion for decades, it still receives relatively little attention in the scientific literature [8]. During or within several hours of transfusion, patients develop respiratory distress, and may develop orthopnea, cyanosis, tachycardia, and hypertension. Rales can be identified on auscultation, and some patients may have jugular venous distention, an S3 on cardiac auscultation, or lower extremity edema. A chest radiograph can reveal cardiomegaly and interstitial infiltrates, but not all patients with heart failure will have these abnormalities [10]. It is common to infuse subsequent transfusions slowly, but no formal evidence exists that this is an effective intervention [9]. It has emerged as the leading cause of transfusion-related fatality reported to the United States Food and Drug Administration [14]. Recently transfused patients present with respiratory distress, hypoxemia, rales on auscultation, and diffuse bilateral infiltrates on chest radiograph.

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On the other hand skin care not tested on animals quality accutane 10mg, Sushruta Samhita mentioned the transfer of knowledge from Indra to Dhanvantari, along with Bhardwaj. The Indian Ayurvedic system has included herbals as one of its most powerful healing ingredients, which are recorded in the literature such as Vedas and Samhitas. Due to the availability of chemical analysis methods in the early 19th century, scientists started to extract and modify active compounds from the herbals, resulting in transition from raw herbs to synthetic pharmaceuticals. Thus people nowadays are shifting back to herbal drugs, which are originated from the nature and claim to be safer. Table 1 shows a few synthetic drugs used extensively which are derived from plants. Among this, herbal formulation has gained great importance and rising global attention recently. In India, about 15,000 medicinal plants have been recorded, in which the communities used 7,0007,500 plants for curing different diseases. The discovery of herbals is further complemented with knowledge on the method of isolation, purification, characterization of active ingredients and type of preparation. The term "herbal drug" determines the part/parts of a plant (leaves, flowers, seeds roots, barks, stems and etc. Each and every part of the herbs are fully utilized for the different pharmacological action they may produce and made into a range of herbal preparations including Kwatha (Decoction), Phanta (Hot infusion), Hima (Cold infusion), Arka (Liquid Extract), Churna (Powders), Guggul (Resins and balsams), Taila (Medicated oil) and etc. Basically, it is the phytochemical constituent in the herbals which lead to the desired healing effect, such as saponins, tannins, alkaloids, alkenyl phenols, flavonoids, terpenoids, phorbol esters and sesquiterpenes lactones. A single herb may even contain more than one of the aforementioned phytochemical constituents, which works synergistically with each other in producing pharmacological action. Both in vitro and in animals;[17] clove oil and cinnamon leaf oil obtained from the dried flower buds of Syzygium aromaticum and leaves of Cinnamomoum zeylanicum respectively, contain eugenol as their main constituent and thus possess antimicrobial activities, i. The former two showed in vitro antibacterial action individually, Pharmacognosy Reviews July-December 2014 Vol 8 Issue 16 but not myrcene. However when mixed with any of the two components, myrcene enhanced their activity. Veerya (energy a herb releases when ingested) · It can be sheeta (cooling) or ushna (heating) · the former is said to be present in sweet, astringent and bitter herbs, which refreshes body, reduces irritation and inflammation; whereas the latter is obtained from sour, salty and pungent herbs that improves circulation, helps digestion and promotes sweating. Vipaka (Postdigestive effect) · There are three types of Vipaka: Madhura (sweet), Amla (sour) and Katu (pungent), each having different effects on the dosha. Prabhava (special and unique power of a herb that has variable action) · these herbs does not fit in the category of other herbs that present the same rasa, veerya or vipaka. Karma (therapeutic action) · these are classified as Deepana (Stimulant), Pachana (Digestive), Shodhana (Purification), Anuloman (Carminative) and Virechana (Purgative). Other than that, the doses, time of intake and Anupana (the carrier which the herbal medicines are prescribed with such as hot water, milk, honey, etc. In general, there are two types of Ayurvedic herbal formulations: Kasthoushadhies (pure herbal preparations) and Rasaushadhies (herbobiomineral metallic preparation), in which the latter contains minerals added for their therapeutic effect. This key traditional therapeutic herbal strategy exploits the combining of several medicinal herbs to achieve extra therapeutic effectiveness, usually known as polypharmacy or polyherbalism. For this, scientific studies have revealed that these plants of varying potency when combined may theoretically produce a greater result, as compared to individual use of the plant and also the sum of their individual effect. Certain pharmacological actions of active constituents of herbals are significant only when potentiated by that of other plants, but not evident when used alone. There are a few Ayurvedic herbs combinations to be cited here: Combination of ginger with black pepper and long pepper enhances their heating and mucousreducing effects; bitter and cold herbs are combined with warmer herbs (combination of neem and ginger) to positively offset any extreme effects. Pharmacodynamic synergism on the other hand, studies the synergistic effect when active constituents with similar therapeutic activity are targeted to a similar receptor or physiological system. Other than that, it is believed that multiplicity of factors and complications cause diseases in most of the cases, leading to both visible and invisible symptoms. Here, combination of herbals may act on multiple targets at the same time to provide a thorough relief. It is evident that better therapeutic effect can be reached with a single multiconstituent formulation. For this, a lower dose of the herbal preparation would be needed to achieve desirable pharmacological action, thus reducing the risk of deleterious sideeffects. Such incompatibility may be due to quantitative incompatibility, energetic incompatibility or functional incompatibility.

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It may also occur in all skin types and racial groups acne 2nd trimester purchase accutane 30 mg amex, but appears more commonly to affect relatively fair-skinned individuals. Examination of 119 monozygotic twin pairs and 301 dizygotic twin pairs revealed an incidence of 21% among the monozygotic twins and 18% in dizygotic twins (16). A variety of such antigens within and between patients, however, seems more likely. Clinical Features Lesions generally develop symmetrically and affect only some sun-exposed areas of the skin, often those normally covered in winter, such as the V-area of the chest. The eruption typically begins each spring or early summer, on sunny vacations, or after recreational sunbed use (25), often moderating with continuing exposure. An attack may also be induced by outdoor activities in winter or by exposure through window glass (26,27). The eruption develops after minutes to hours (on vacation, sometimes days) of sun exposure and lasts for one to several days or occasionally weeks, particularly with continuing exposure. The tendency to develop the condition, however, often fades or ceases as summer or the vacation proceeds. In the absence of further exposure, all the lesions gradually subside completely without scarring over one to seven days, occasionally a week or two, or very rarely longer in severe cases. In a given patient, the eruption tends always to affect the same skin sites, although its distribution may gradually spread or recede overall. Associated systemic symptoms are rare, but shivesing, headache, fever, nausea, and a variety of other sensations are possible. The condition may be lifelong, but gradually improves over years in many patients: Over seven years, 64 of 114 patients (57%) reported steadily diminishing sun sensitivity, including 12 (11%) who totally cleared (29). Lesions vary widely between patients, but are generally pruritic, grouped, erythematous or skin-colored papules of varying size not infrequently coalescing into large, smooth or rough-surfaced plaques. Such subdivisions do not apparently relate to differences in disease pathogenesis. Differing morphologies may also occur at different skin sites in the same patient: diffuse facial erythema and swelling, for example, may accompany typical papular lesions at other sites. Rarely, covered sites may be mildly affected, due to radiation penetration through clothes. Acanthosis, spongiosis focal parakeratosis, and basal vacuolization can be present. Other common features are upper dermal and perivascular edema and endothelial cell swelling. Although the diagnosis is mainly clinical, provocative phototesting may be valuable in winter, if no lesions are present, to confirm the diagnosis. The best way to do this is by using repetitive irradiations on the V area of the neck or forearms for one to four consecutive days. Laboratory examinations are usually performed to exclude other dermatoses, such as erythropoietic protoporphyria and photosensitive lupus erythematosus. Patients with fully developed disease require topical corticosteroids, in some cases in the form of wet dressings, for several days. More severe attacks may be treated effectively with a short course of systemic (oral) corticosteroids (38). Prophylactic treatment consists of several approaches: avoidance of sunlight during the summer, the use of sunscreens with broadband filters, systemic treatment, and preventive phototherapy. Severely affected subjects suffering frequent attacks of their disease throughout the summer may require courses of prophylactic photo(chemo)therapy before the expected sun exposure in the early spring. Although these local effects may provide some barrier against photosensitivity, they probably do not suffice to explain the degree of protection induced in many patients. Thus other mechanisms may be involved, since photodermatoses do occur in dark-skinned subjects (39). The initial exposure and dose increments should be performed according to the guidelines outlined for psoriasis. Usually, brief symptomatic treatment with topical corticosteroids suffices (21,41,42).

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Minimizing inappropriate medications in older populations: A 10-step conceptual framework skin care 1006 buy accutane 5 mg online. Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written permission of the publisher. Rather than put a trademark symbol after every occurrence of a trademarked name, we use names in an editorial fashion only, and to the benefit of the trademark owner, with no intention of infringement of the trademark. However, in view of the possibility of human error or changes in medical sciences, neither the editors nor the publisher nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they disclaim all responsibility for any errors or omissions or for the results obtained from use of the information contained in this work. McGraw-Hill has no responsibility for the content of any information accessed through the work. To Katherine Tierney: a sister whose absolute commitment to her parents at the end of their lives provides a model for anyone fortunate enough to know her. To my father, Prem Saint, and father-in-law, James McCarthy, whose commitment to education will inspire generations. Learners at every level, and in many countries, remember them as crucial adjuncts to more detailed information about disorders of every type. Ideally, a Pearl is succinct, witty, and often colloquial; it is stated with a certitude suggesting 100% accuracy. Of course, nothing in medicine is so, yet a Pearl such as "If you diagnose multiple sclerosis over the age of fifty, diagnose something else" is easily committed to memory. Many have been changed since the previous editions, and we urge readers to come up with Pearls of their own, which may prove to be more useful than our own. The fourth edition, like its predecessors, uses a single page to consider each disease, providing the reader with a concise yet usable summary about most of the common diseases seen in clinical practice. For readers seeking more detailed information, a current reference has been provided for each disease. We have expanded the number of diseases from the previous edition and updated the clinical manifestations, diagnostic tests, and treatment considerations with the help of our contributing subject-matter experts. We hope that you enjoy this edition as much as, if not more than, the previous ones. No increased risk of valvular heart disease in adult poststreptococcal reactive arthritis. Survival in patients with severe aortic regurgitation and severe left ventricular dysfunction is improved by aortic valve replacement. Current status of stroke risk stratification in patients with atrial fibrillation. Curative catheter ablation in atrial fibrillation and typical atrial flutter: systematic review and economic evaluation. Surgery for severe mitral regurgitation and left ventricular failure: what do we really know? Adenosine versus intravenous calcium channel antagonists for the treatment of supraventricular tachycardia in adults. Risk factors for early pulmonary valve replacement after valve disruption in congenital pulmonary stenosis and tetralogy of Fallot. The prognostic significance of restrictive diastolic filling associated with heart failure: a meta-analysis. Eight-year outcomes of tricuspid annuloplasty using autologous pericardial strip for functional tricuspid regurgitation. Reference Guenther T, Noebauer C, Mazzitelli D, Busch R, Tassani-Prell P, Lange R. Severe community-acquired pneumonia in adults: current antimicrobial chemotherapy. Use of corticosteroids in acute lung injury and acute respiratory distress syndrome: a systematic review and meta-analysis. Asbestosis-related years of potential life lost before age 65 years-United States, 1968-2005. Addition of inhaled long-acting beta2-agonists to inhaled steroids as first line therapy for persistent asthma in steroid-naive adults and children. Empiric antibiotic coverage of atypical pathogens for community acquired pneumonia in hospitalized adults. Clinical and radiologic distinctions between secondary bronchiolitis obliterans organizing pneumonia and cryptogenic organizing pneumonia.

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Shape & Size: Tears are mostly spheroidal or ovoid in shape and having a diameter of about 2 acne 2017 10 mg accutane with amex. Appearance: Tears are invariably opaque either due to the presence of cracks or fissures produced on the outer surface during the process or ripening. The fracture is usually very brittle in nature and the exposed surface appears to be glossy. Chemical Constituents Acacia was originally thought to be composed only of four chemical constituents, namely: (­) arabinose; (+) ­ galactose; (­)­rhamnose and (+) glucuronic acid. Lead Acetate Test: An aqueous solution of acacia when treated with lead-acetate solution it yields a heavy white precipitate. Borax Test: An aqueous solution of acacia affords a stiff translucent mass on treatment with borax. Blue Colouration due to Enzyme: When the aqueous solution of acacia is treated with benzidine in alcohol together with a few drops of hydrogen peroxide (H2O2), it gives rise to a distinct­blue colour indicating the presence of enzyme. Specific Test: A 10% aqueous solution of acacia fails to produce any precipitate with dilute solution of lead acetate (a clear distinction from Agar and Tragacanth); it does not give any colour change with Iodine solution (a marked distinction from starch and dextrin); and it never produces a bluish-black colour with FeCl3 solution (an apparent distinction from tannins). It is used extensively as a vital pharmaceutical aid for emulsification and to serve as a thickening agent. It is considered to be the gum of choice by virtue of the fact that it is quite compatible with other plant hydrocolloids as well as starches, carbohydrates and proteins. It is used in conjuction with gelatin to form conservates for microencapsulation of drugs. Persian tragacanth are exported from Iran and North Syria, whereas the Smyrna tragacanth from the Smyrna port in Asiatic Turkey. Collection the thorny shrubs of tragacanth normally grow at an altitude of 1000-3000 meters. As an usual practice transverse incisions are inflicted just at the base of the stem, whereby the gum is given out both in the pith and medullary rays. Thus, the absorption of water helps the gum to swell-up and subsequently exude through the incisions. The gummy exudates are duly collected and dried rapidly to yield the best quality white product. It usually takes about a week to collect the gum exudates right from the day the incisions are made; and this process continues thereafter periodically. The said two components may be separated by carrying out the simple filtration of a very dilute mucilage of tragacanth and are found to be present in concentrations ranging from 60-70% for bassorin and 30-40% for tragacanthin. Bassorin actually gets swelled up in water to form a gel, whereas tragacanthin forms an instant colloidal solution. It has been established that no methoxyl groups are present in the tragacanthin fraction, whereas the bassorin fraction comprised of approximately 5. When a solution of tragacanth is boiled with few drops of FeCl3 [aqueous 10% (w/v)] it produces a deep-yellow precipitate. Substituents/Adulterants Karaya gum which is sometimes known as sterculia gum or Indian tragacanth and is invariably used as a substitute for gum tragacanth. It is used as a pharmaceutical aid as a suspending agent for insoluble and heavy powders in mixtures. It is effectively employed as a binding agent for the preparation of tablets and pills. A substantial amount find its application in calico printing and in confectionary. Biological Source Karaya Gum is the dried exudate of the tree Sterculia urens Roxb; Sterculia villosa Roxb; Sterculia tragacantha Lindley and other species of Sterculia, belonging to the family: Sterculeaceae. It is obtained from Cochlospermum Geographical Source: gossypium, De Candolle or other species of cochlospermum Kunth ­family: Bixaceae. Preparation the gum is obtained from the Sterculia species by making incisions and, thereafter, collecting the plant excudates usually after a gap of 24 hours. The large irregular mass of gums (tears) which weigh between 250 g to 1 kg approximately are hand picked and despatched to the various collecting centres. The gum is usually tapped during the dry season spreading over from March to June. Each healthy fully grown tree yields from 1 to 5 kg of gum per year; and such operations may be performed about five times during its lifetime. In short, the large bulky lumps (tears) are broken to small pieces to cause effective drying.

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The skin remains of normal texture and there are usually no itching or other symptoms acne 5 weeks pregnant generic accutane 20mg on line. These patches are more obvious in sun-exposed areas including the hands, feet, arms, legs, face and lips, patches to appear are the armpits and groin and around the mouth, eyes, nostrils, navel and genitals. The colour of the skin is Pandura- Varna due to parakupita pitta vitiataed by rakta9. Acharya charaka has mentioned three varieties, namely Daruna, Aruna and Kilasa depending on Vitiation of dosha and involvement of dhatu. The principal of treatment are threefold in Ayurveda as Nidana Parivarjana, Apakarshana and Prakriti Vighata are to be followed while treating. Selection of any of them depends upon Roga Bala, Rogi Bala, Kala, Vaya, Agni, And vyadhi Avastha etc. When the morbid Dosha are more potent, the patient should be treated with Shodhana. Rakta Mokshana is to be done at every six months, Virechana is to be given at every one month; Vamana is to be given at every 15th day respectively10. This long term course of treatment is to eliminate vitiated Dosha and brings doshas in equilibrium state. The patient with Switra requires quick approach towards management, because it becomes Asadhya very quickly. Acharya Vagabhatta says that if the sinfulness of the person followed by Daana, Tapa etc. Apakarshana: Shodhana: Shodhana has its own important in this disease, Before shodhana Purvakarma (Snehana and Swedana) is must to get proper purification. The treatment should be started with snehapana with Tiktka Ghrita, Mahatiktka Ghrita12. Virechana is line of treatment for Pittaja and Raktaja Vyadhi and involvement of Rakta and Pitta are very clear in Switra. After Virechana the Vata Dosha increases in Koshtha so it is necessary to give again Snehapana13. If the number of patches is more and appears all over the body then Siravedha should done. Kshara prayoga: the conditions where Rakta Mokshana is contraindicated, Kshara is to be beneficial. Prakriti Vighatana: Shamana Therapy: Shamana includes local application and internal medication Lepana: Lepa should be applied after completion of the Shodhana 17. C & Abdul Khader: Switra Clinical Approach Through Ayurveda Hastimada along with Malati Koraka Kshara Nilotpala, Kushtha, Saindahva with Hastimutra Mulakabija, Avalguja with Gomutra Kakodumbara or Avalguja Chitraka with Gomutra Manashila with Mayurpitta Avalgunja Bija, Laksha,Gopitta, two types of Anjana, Pippali, Kalaloha Raja. Progression of this disease is rapid, so the management should be taken in proper time to arrest the pathogenises. Nidana Parivarjana, Apakarshana and Prakruti Vighatana are to be followed while treating. Ushna, tikshna, sara, sukshma guna and katu tikta pradhana rasa dravya should select to improve agni and helps to remove srotavarodha and sanga and drugs having Lekhana, Ropana and Varnya properties. Lekhana property is to form blister, Ropana for healing of blister and Varnya to enhance Melanogenesis. By activate the Bhrajaka pitta, bring equilibrium in doshas and dhatus and ultimately breaks the chain of samprapti of Switra (vitiligo) effectively. A person is made to undergo all shodhana procedures first, after patient is fully evacuated, samsrama karma is done as primary step of treated by giving malapu rasa (Kakodumbara) along with guda. The mixture should be given according to the bala rogi, after that he should be exposed to the sun. The blister should be pricked and remove the fluid, after all the blisters are opened, a kwatha prepared from bark of kakodumbara, priyangu, asana and shatapushpa should be given early in the mornings for 15 days or phanitham prepared from palasa can also be given. Khadira proyogas are useful, it has tikta, kashaya rasa, sheeta veerya properties, both Pitta and kapha dosha shamaka.


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