AYUHOM

REVIEW ARTICLE
Year
: 2021  |  Volume : 8  |  Issue : 2  |  Page : 51--56

Therapeutics aspects of Apamarga Kshara (Herbomineral Formulation) in Ayurveda - A review


Pravin Jawanjal, Bishwajyoti Patgiri 
 Department of Rasa Shastra and Bhaishajya Kalpana, Itra, Gujarat Ayurved University, Jamnagar, Gujarat, India

Correspondence Address:
Pravin Jawanjal
Department of Rasa Shastra and Bhaishajya Kalpana, ITRA, Gujarat Ayurved University, Jamnagar, Gujarat
India

Abstract

Kshara is one of the dosage forms utilizes in Ayurveda. Apamarga Kshara is prepared from alkaline ash of herbs used in Ayurveda as local and internal therapeutics. In local therapeutics, it is used in the form of Ksharasutra and as Pratisrniya Kashara. It can be also administered for internal use termed as Paniya Khara. Apamarga Kshara is a herbomineral formulation commonly used in anorectal disorders. It is used in various ailments such as warts, polyp, renal disorders calculus, nasal diseases, ear diseases, and leukoderma. The Apamarga Kshara having properties of Ksharana (debridation), Bhedana (incision), Chhedana (excision), Shodhana (purification), Stambhana (haemostatic), and Ropana (healing). Apamarga Ksharodaka is an aqueous solution of Apamarga Kshara useful in the management of warts. Apamargakshara Taila is medicated oil prepared from Acyranthes aspera and sesame oil is indicated in-ear disorder. Hence, a review of the therapeutics aspects of Apamarga Kshara is selected for the study. The present review study aimed to analyze available information from the different databases and published literature to provide information about clinical studies and case reports of Apamarga Kshara. The published clinical data suggest the safety and efficacy of Apamarga Kshara.



How to cite this article:
Jawanjal P, Patgiri B. Therapeutics aspects of Apamarga Kshara (Herbomineral Formulation) in Ayurveda - A review.AYUHOM 2021;8:51-56


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Jawanjal P, Patgiri B. Therapeutics aspects of Apamarga Kshara (Herbomineral Formulation) in Ayurveda - A review. AYUHOM [serial online] 2021 [cited 2022 Oct 7 ];8:51-56
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Full Text



 Introduction



Kshara is a substance that causes Ksharana (perishing, decaying), Kshanana (cutting, falling, or destruction of diseased skin). Kshara is an acrid substance. Kshara are prepared from the dried plant ashes by a special process known as Kshara Kalpana.[1] Kshara is a product of the combination of multiple drug ingredients (Achyranthus aspera, lime stone, Plumbago zelanica, etc.). Hence, it has a pacifying effect on all three Dosha. (humor of the body.[2] Kshara is produced by drugs possessing Ushna Virya (hot temperament) as result, it is pungent in taste and nature. Kshara are alkaline prepared from the water-soluble ashes of herbs. Kshara is classified into two types: One is Pratisaraniya Kshara is for the external use and the other one is Paniya Kshara for the internal use.[3] The Pratisaraniya Kshara is classified into three types: mild, moderate, and intense.[4] As per Sushruta, the Kshara is obtained from herbs such as Euphorbia nerifolia Achyranthus aspera, Cassia fistula, Adhatoda vasica, Holarrhena antidysentrica, Sesamum indicum, Calotropis giganteo, etc., The Kshara has excision, incision, and scraping properties. Hence, Sushruta mentioned best in the instruments (Shastra) and their Anushastra (substitutes).[5] Apamarga (Achyranthes aspera L.) plant possesses lot of medicinal properties such as root powder is useful for preventing caries and cleansing teeth.[6] Aqueous extracts of A. aspera whole plant and Aqueous extracts of Achyranthes aspera leaves exhibit anti-inflammatory activity studied in albino mice using carrageenan induced left hind paw edema.[7] A. aspera showed marked antibacterial activity against Streptococcus mutans.[8] Ethanol extract of A. aspera exhibit Central Nervous System (CNS) depressant and significant anxiolytic activity in albino mice as compared to diazepam.[9]

Method of preparation of Apamarga Kshara in Rasatarangini,[10] Dravyaguna Vigyana[11] Ayurveda Sara Samgraha,[12] Sushruta Samhita,[13] and Sharngadhara Samhita,[14] are widely described. Quantitative micrometric microscopy revealed a greater number of crystals in Tikshna (intense) Apamarga Kshara (13/mm2) than Mridu (Soft) Apamarga Kshara (6/mm2).[15] Inductively coupled plasma-atomic emission spectrometer analysis revealed that Apamarga Kshara contains potassium, sodium, calcium, and magnesium are the main constituent.[16] Ksharasutra has property of excision or removal of unhealthy fibrous tissue in fissure termed as Ksharana property and makes the wound healthy known as Shodhana property.[17] Apamarga Kshara indicated in various disorders such as Arsha (piles), Kustha (skin disorders), Visha (poison) Dadru (fungal infection), Dushtavarna (nonhealing ulcers), Nadivrana (sinus), Mukharoga (mouth disorders), Arbuda (tumor), Bhagandar (fistula in ano), Krimiroga (worms infestation), Gara visha (artificial poison), Arochak (tastelessness), Udararoga (GIT disorders), Anaha (constipation), Agnimandya (loss of appetite), Ashmari (renal calculi), and Ajirna (indigestion).[18],[19]

In local therapeutics, it is used in the form of Apamarga Ksharasutra, Ksharodaka and as Pratisrniya kashara (alkaline preparation having Achyranthes aspera plant). Apamarga Ksharasutra is termed as medicated thread prepared using Apamarga. Ayurvedic pharmacopia of India described standard method of Ksharasutra preparation.[20] Ksharasutra contains Apamarga Kshara (Alkaline powder of Achyranthes aspera Linn.) Barbour linen thread no. 20, latex of Snuhi (Euphorbia nerifolia Linn.), and Haridra Churna (powder of Curcuma longa Linn.). Initial eleven coatings of latex of Snuhi were done and dried for a day. later on, seven coatings of Apamarga Kshara and latex of Snuhi were done. Finally, three coatings of latex of Haridra powder and Snuhi were done. After every coating, Ksharasutra were dried on the hangers. The need of current study was to elaborates patho-physiology of Apamarga Kshara in various ailments.

 Materials and Methods



Relevant published studies involving case reports and clinical trials of Apamarga Kshara were searched in the various database. The terms used “Apamarga Kshara,” “clinical trials,” “case reports,” and “Ksharasutra” in the English language. The data from studies regarding, clinical studies were collected and presented. Thirty-five research papers were found in PubMed indexed database. Ten research papers of clinical trials of Apamarga Kshara Sutra in anorectal disorders were found.

Aim

The aim of the present study was to develop robust data of Apamarga Kshara in various ailments.

 Discussion of Clinical Aspects



 Clinical trials of Apamarga Kshara sutra in anorectal disorders



Acharya Sushruta has recommended Kshara Karma as the most effective therapy for anorectal disorder.[21] Kshara invades into the cells of the lesion till the engorged tissue of the haemorrhoids mass destruction. During the cutting effect, there may be oozing of blood, which is ceased by the sclerosing effect of the Kshara by its coagulating property. The pressure made by the Kshara Sutra ligation creates mechanical strangulation of the blood vessels, which causes the local necrosis of haemorrhoids mass. Kshara Sutra ligation is surgical therapy effective as compare hemorrhoidectomy in the 2nd, 3rd, and 4th degrees of hemorrhoids.[22] Fistula in Ano can be treated by Kshara Sutra with a low reoccurrence rate and minimal loss of sphincter muscle.[23] The Apamarga kshara sutra is an effective treatment as compared to Snuhi Ksheera Sutra and Tilanala Kshara Sutra for fistula in ano.[24] Apamarga Kshara application is effective in the management of 1st and 2nd-degree internal piles as compared to sclerotherapy.[25] Apamarga Kshara Sutra Ligation is a useful form of treatment compared to Barron's rubber band ligation for Grades II and III internal hemorrhoids.[26] The Apamarga Kshara application was effective in internal piles of up to 2nd degree in comparison to Arshohara Vati (Herbomineral formulation) administration and infrared coagulation procedure.[27] The rate of Unit Cutting Time of Guggulu Chitrak Kshara Sutra is slightly higher than Snuhi Apamarga Kshar Sutra (Herbomineral formulation) in the management of fistula in ano.[28] In comparative study of Tankan Ksharasutra (Herbomineral formulation) and Apamarga Kaharasutra in the fistula in ano revealed that cutting time longer in Tankanksharasutra application as compared to Apamarga Kaharasutra.[29] In comparative study of Apamarga Kshara Sutra prepared by 7 and 21 coatings found that both were equally efficient in the management of Bhagandara [Table 1].[30] Apamarge kshar sutra was found to be more effective than Seton (surgical linen thread number 20) therapy in the management of Bhagandara.[31]{Table 1}

Clinical case reports of Apamarga Kshara Sutra in anorectal disorders

Apamarga Kshara Sutra is an effective and innovative therapeutic approach in the management of horse-shoe fistula.[32] A case report study revealed that nonspecific, complex, posterior, horse-shoe-shaped fistula-in-ano treated by Apamarga Kshara Sutra.[33] The case series of six patients have shown a remarkable effect of Ksharasutra application in fistula-in ano.[34] The clinical report revealed Kshara Sutra technique useful in the management of ano-rectal disorders. Kṣharasutra creates mechanical pressure on unhealthy tissue as it is tightly applied in the fistulous tract. It cuts tissue and augments the healing. Kṣhara acts as debridement agent and acts on pus pockets, unhealthy granulation, etc., This process of debridement and healing initiates from deeper tissues and travels toward periphery.[35] A case report suggests, in the low anal anterior fistula the tract was more than 10 cm which requires multiple sittings of Kshara Sutra and may require more than 4 to 5 months for complete healing.[36]

Clinical trials of Apamarga Ksharataila Uttarabasti (administration of drugs through urethral or vaginal orifice)

The study reported that Apamarga Ksharataila Uttarabasti is effective as compare to urethral dilatation in urethral stricture. Apamarga Kshara Taila has the properties of the Ksharana and Lekhana. Therefore, it may be result into the Ksharana and Lekhana of Mutramarga gata sansaktata.[37] Apamarga Kshara Taila Uttarbasti (n = 16) administered in the management of infertility w.s.r. tubal blockage, reported highly significant result 83.33% in Fimbrial block, 75% in the opening of fallopian tube, 76.92% in cornual block.[38] Apamarga Ksharataila (prepared from Acyranthes aspera and sesame oil) is used in ear disorders such as deafness, sound in ears, and Karna Purana (filling of ears with oil).[39] The study was reported the clinical assessment of a combination of Apamarga Kshara Basti (2 g Kshara in 10 ml of normal water) and Triphalaguggulu (herbal formulation) on 129 patients with bleeding piles in which 55 patients get marked relief [Table 2]. The use of Apamarga Kshara which is an astringent by nature immediately helps in stopping bleeding.[40]{Table 2}

Other therapeutic potential of Apamarga Kshara

A case series (n = 3) reported Apamargakshara Taila has tissue debridement properties in the management of nonhealing venous ulcers.[41] The combination of Pratisaraneeya Kshara along with Bilvādi Agada (antitoxic oral medicine) exhibit effectiveness in the management of Molluscum contagiosum. The Kshara possesses penetrating (Tikṣṇa) and hot (Uṣṇa) properties. These properties make it capable of infiltrating deep into papules, destroy the pathologic cells and hence preventing recurrence. Kshara acts as chemical cauterizing agent.[42] It cauterize the tissue by its corrosive properties.[43] Apamarga Kshara Sutra can be used in the management of nasal synechiae.[44] Kshara Sutra is a minimal invasive procedure and showed good potential in the treatment of Pilonidal sinus. The Apamarga Kshara Sutra helps lysis of tissues and in debridement, exerts anti-bacterial, antifungal, and anti-inflammatory.[45]

A case study suggests that Carmakila (Epidermal nevi) effectively cured by Pratisaraneeya kshara. It has penetrating, scraping, corrosive, and healing properties hence indicated in Carmakila.[46] Pratisaraneeya teekshna kshara may be responsible for coagulation of hemorrhoid plexus, results in the necrosis of tissue which is followed by fibrosis of plexus, adhesion of submucosal, mucosal coat causes prevention of further dilatation of veins. This factor causes radical obliteration of the hemorrhoids permanently. Pratisaraneeya teekshna kshara was found effective in internal hemorrhoid within 21 days of application.[47] In a case report, suggests Apamarga kshara, was found effective in the hypertrophied turbinate on local application. It produces shrinking effect on hypertrophied tissue by cauterisation. The submucosal hypertrophy and bogginess obliterate permanently by Apamarga kshara.[48] Apamraga Kshara Yoga (herbomineral formulation) is effective in vitiligo. Apamarga Kshara has Tikshna Guna so it can remove Ama, Kleda, and Kapha and also can clear Sroto Sanga[49] Apamarga Pratisaraniya Kshara for 30 days treatment in bleeding piles provided significant relief in slough, in pain by 100%, in the color of pile mass by 98.1%, in bleeding by 97.7%, in size of pile mass by 96.6%, in defecation 95.5, in tonicity of the anal canal by 95.2% noticed.[50] A clinical case study reported application of Apamarga Pratisaraneeya Kshara cured low anal fistula.[51] Umbilical granuloma was successfully treated with Apamarga Pratisaraneeya Kshara.[52] Case series suggests that warts can be treated with Subcutaneous intralesional Ksharodaka injection (aqueous solution of Achyranthes aspera) Kshara (alkaline ash of herbs).[53] Application of the Kshara Jala may be beneficial in plantar warts. Kshara sutra ligation may be beneficial in filiform warts.[54] Combined local application of Apamarga kshara and Jatyadi taila (Medicated oil) is more effective in cervical erosion.[55] Pratisaraneeya Kshara is better than rubber band ligation in management of large, broad-based piles.[56] In a single case study, Cervical polyp was removed successfully by Ksharasutra. Mechanical strangulation of the blood vessel and chemical cauterization may be probable actions of Ksharasutra.[57] The ten compounds were identified, namely myristic acid, dodecanol acid, neophytadiene, heptadecanoic acid, palmitic acid, linoleic acid, 3-7-dimethyl acid, elaidic acid, methyl eicos acid and, stearic acid in the methanolic extract of Apamarga Kshara. Apamarga Kshara has been found to be active against Trichomonas vaginalis (cervical erosion).[58] Joshi et al. a case study reported that local application of Apamarga Kshara Taila has effective in healing of diabetic wounds. Apamarga Kshara Taila has property of autolytic debridement of wound. It reduced excessive deposition of ketone bodies and helps in tissue debridement.[59],[60] Hiremath et al. a case study reported that Pratisaaraneeya Apamarga Kshara was effective in management of mucocele of lip.[61] Kumar et al. a case study suggested that Apamarga Kshara Sutra can be applied in Hydradenitis Suppurativa.[62] Bandekar Prerana S. a case studyrported that management of Hemangioma can be possible by application of Apamarga Kshara Sutra.[63]

 Conclusion



The present paper reveals the efficacy of different dosage form of Apamarga Kshara through case reports and clinical studies. The published clinical data suggest the safety and efficacy of Apamarga Kshara. Ano-Rectal disorders can be treated by Apamargakshara Kshara Sutra with a low reoccurrence rate and minimal loss of sphincter muscle. The cutting and healing of infected tract might be the possible mechanisms of action in anorectal disorders. Kshara. Sutra is a minimally invasive procedure which improves quality of life. It can be used in the management of pilonidal sinus, nasal synechiae, and Epidermal nevi. Pratisarniya Kshara is useful in the management of plantar warts, filiform warts, large, broad-based piles, hypertrophied turbinate, vitiligo, cervical erosion, Molluscum contagiosum, Umbilical granuloma. Apamarga Kshara Taila is indicated in-ear disorder and effective in urethral stricture. Apamarga Kshara has been proved reliable potent medicine in Ano-Rectal disorders, urethral stricture, uterine tubal blockage through clinical studies. The limitations of the clinical trials and case reports were the lack of a uniform reporting system in many studies Further clinical trials are required to evaluate a wide range of therapeutic aspects and to develops robust data of Apamarga Kshara in various ailments.

References

1Acharya S, Panda PK, Acharya G, Mohanty N, Nathsharma PK, Dash SC. A comparative clinical trial of chincha kshara and kadali kshara on amlapitta. Ayu 2011;32:494-9.
2Savrikar S, editor. Madhymakhanda. In: Sharangadhara of Sharangadhara Samhita. 1st ed., Vol. 2. Ch. 11. Delhi: Chaukhamba Sanksrit Pratishthan; 2020. p. 530-1.
3Jawanjal P, Patgiri B, Savrikar SS. Standard Manufacturing Procedure of Bhallataka Kshara (Herbo-mineral Prepation). BLDE Univ J Health Sci [Epub ahead of print] Available from: https://www.bldeujournalhs.in/temp/BLDEUnivJHealthSci000-2116639_055246.pdf.
4Dudhamal TS, Gupta SK, Bhuyan C, Singh K. The role of apamarga kshara in the treatment of arsha. Ayu 2010;31:232-5.
5Shastri A, editor. Shushruta Samhita of Sushruta, Sutrasthana12th ed.,;Ksharapakavidhi Chap. 11, Verse 3. Varanasi: Chaukambha Orientalia; 2001. p. 35.
6Mittal N, Joshi VK, Srivastava RK, Singh SP. Efficacy of ayurvedic drugs as compared to chlorhexidine in management of chronic periodontitis: A randomized controlled clinical study. J Indian Soc Periodontol 2018;22:28-33.
7Bhosale UA, Yegnanarayan R, Pophale P, Somani R. Effect of aqueous extracts of Achyranthes aspera Linn. on experimental animal model for inflammation. Anc Sci Life 2012;31:202-6.
8Yadav R, Rai R, Yadav A, Pahuja M, Solanki S, Yadav H. Evaluation of antibacterial activity of Achyranthes aspera extract against Streptococcus mutans: An in vitro study. J Adv Pharm Technol Res 2016;7:149-52.
9Bhosale UA, Yegnanarayan R, Pophale PD, Zambare MR, Somani RS. Study of central nervous system depressant and behavioral activity of an ethanol extract of Achyranthes aspera (Agadha) in different animal models. Int J Appl Basic Med Res 2011;1:104-8.
10Shastri K, editor. Rasa Tarangini of Sadanada Sharma, Taranga14. 11th ed., Ver. 59-61. New Delhi: Motilala Banarsidas; 2004. p. 337.
11Acharya YT. Dravyaguna Vigyana, Uttarardh, Adhyaya 2. 6th ed., Ver. 102-4. Nagpur: Shree Baidhyanath Ayurveda Bhavan Li; 2013. p. 61.
12Ayurved Sar Samgraha. Kshara-Lavan-Satva Prakarana; Anonymous. Alahabad: Hindi edition by Shree Baidhyanath Ayurveda Bhavan Limited; 2013. p. 697.
13Ambikadatta S, editor. Susruta Samhita of Acharya Susruta, Sutra Sthana; Ksharapaka Vidhi. 12th ed., Vol. 3., Ch. 11. Varanasi: Chaukhambha Sankrita Sansthan; 2010. p. 48.
14Savrikar S, editor. Madhymakhanda. In: Sharangadhara Samhita of Sharangadhara. 1st ed., Vol. 2., Ch. 11. Delhi: Chaukhamba Sanksrit Pratishthan; 2020. p. 530-1.
15Shrestha M, Harisha CR, Dudhamal TS, Kanakhara R. Comparative pharmacognostical analysis through quantitative micrometry and analytical study on mridu and tikshna apamarga kshara. Ayu 2018;39:159-64.
16Jadav HR, Galib R, Prajapati PK. Pharmaceutical standardization of apamarga kshara. J Ayurveda Integr Med 2015;6:290-4.
17Shastri A, Acharya Sushruta, Sushruta Samhita, Sutra Sthana. Ksharapaka Vidhi; 11/3. 12th ed. Varanasi: Chowkhambha Surabharati Sanshtan;. 2001. p. 34.
18Murthy KR. Acharya Vagbhata, Samhita of Astanga Hrdaya, Sutra Sthana 30/8-12, English Translation. 7th ed. Varanasi: Chowkhamba Krishnadas Academy; 2010. p. 344-5.
19Pushpalatha B, Kadam S, Bharathi K, Sakhitha KS. Preparation and physicochemical evaluation of mridu apamarga kshara. Int J Ayurveda Pharma Res 2019;7:16-20.
20Anonymous. Ayurvedic Pharmacopia of India. Part-II. Ksharsootra (Medicated Thread). 1st ed., Ch. 51. Delhi: Published by AYUSH, Govt. of India; 2001. p. 209-13.
21Vij A. Preparation of apamarga kshara and its role in surgical practice. Int J Herb Med 2016;4:28-30.
22Gupta ML, Gupta SK, Bhuyan C. Comparative clinical evaluation of Kshara Sutra ligation and hemorrhoidectomy in Arsha (hemorrhoids). Ayu 2011;32:225-9.
23Panigrahi HK, Rani R, Padhi MM, Lavekar GS. Clinical evaluation of kshara sutra therapy in the management of Bhagandara (Fistula- in-Ano) – A prospective study. Anc Sci Life 2009;28:29-35.
24Lobo SJ, Bhuyan C, Gupta SK, Dudhamal TS. A comparative clinical study of snuhi ksheera sutra, tilanala kshara sutra and apamarga kshara sutra in Bhagandara (Fistula in Ano). Ayu 2012;33:85-91.
25Shah B, Dudhamal TS. Efficacy of apamarga kshara application and sclerotherapy in the management of arsha (1st and 2nd degree piles) – An open-labeled, randomized, controlled clinical trial. Ayu 2018;39:213-9.
26Singh R, Arya RC, Minhas SS, Dutt A. A comparative study of Barron's rubber band ligation with kshar sutra ligation in hemorrhoids. Int J Ayurveda Res 2010;1:73-81.
27Sudarmi K, Dudhamal TS. Comparative clinical study of apamarga kshara application, infrared coagulation and arshohara vati in the management of arsha (1st and 2nd degree hemorrhoids). Ayu 2017;38:122-6.
28Gond P, Kumar A, Rajeshwari PN, Choudhary PC, Kumar J; From the Proceedings of Insight Ayurveda 2013, Coimbatore. 24th and 25th May 2013. OA03.11. A comparative study of guggulu chitrak kshar – Sutra and snuhi apamarg kshar – Sutra in the management of fistula in ano. Anc Sci Life 2013;32 Suppl 2:S34.
29Patel A, Salimath M. A comparative clinical study on the effect of tankan ksharasutra and apamarga kaharasutra in the management of bhagandara (fistula in ano). Int J Health Sci Res 2019;9:225-31.
30Shankaraprasad K, Sharma M, Rakesh RN. Comparitive study of clinical effect of apamarga kshara sutra prepared by 7 and 21 coatings in bhagandara. J Ayurveda Integr Med Sci 2018;3:21-6.
31Singh B, Singh S, Rajput P. A clinical comparative study on the efficacy of apamarga kshara sutra and Seton therapy in the management of bhagandara WSR to fistula in ano. Bull Adv Sci Res 2015;1:13-20.
32Wali AA, Dongargaon TN, Shilpa MP, Toshikhane HD. Innovative approach in the management of horse-shoe fistula-in-ano with kṣārasūtra. Anc Sci Life 2015;34:162-6.
33Baria PB, Dudhamal TS. Two-staged surgical approach along with ksharasutra therapy in the management of complex, non-specific, posterior, horse-shoe-shaped fistula-in-ano: A case report. J Ayurveda Case Rep 2021;4:58-63.
34Nema A, Gupta SK, Dudhamal TS, Mahanta V. Transrectal ultra sonography based evidence of ksharasutra therapy for fistula-in-ano – A case series. J Ayurveda Integr Med 2017;8:113-21.
35Kurapati VK, Nishteswar K. Management of ano-rectal disorders by kṣārasūtra: A clinical report. Anc Sci Life 2014;34:89-95.
36Shindhe PS. Management of rare, low anal anterior fistula exception to Goodsall's rule with kṣārasūtra. Anc Sci Life 2014;33:182-5.
37Reddy KR. Clinical evaluation of apamarga-ksharataila uttarabasti in the management of urethral stricture. Ayu 2013;34:180-3.
38Rajput SS, Mata S, Dei P. Effect of apamarga kshara taila uttarbasti in the management of infertility w.s.r. to tubal blockage. IJAM 2015;6:51-8.
39Gohil H, Dhruve K, Prajapati PK. Role of media in the preparation of apamarga ksharataila. Ayu 2010;31:391-4.
40Mehra R, Makhija R, Vyas N. A clinical study on the role of ksara vasti and triphala guggulu in raktarsha (Bleeding piles). Ayu 2011;32:192-5.
41Joshi F, Dudhamal TS. Tissue debridement effect of apamarga kshara taila and adjuvant medications in the management of nonhealing venous ulcer: A case series. Med J DY Patil Vidyapeeth 2021;14:549-53.
42Kalasannavar SB, Sawalgimath MP. Molluscum contagiosum: A novel ayurvedic approach. Anc Sci Life 2013;33:49-51.
43Sharma SK, Sharma KR, Singh K. Kshara Sutra Therapy in Fistula-in-Ano and Other Anorectal Disorders. Rashtriya Ayurved Vidyapeeth (National Academy of Ayurveda): RAV Publication; 1994-95. p. 45.
44Sivabalaji K, Ali A, Bn A, Pv A, Tripathy R. Management of nasal synechiae with kshara sutra – A case report. J Ayurveda Integr Med 2021;12:540-3.
45Dwivedi AP. Management of pilonidal sinus by kshar sutra, a minimally invasive treatment. Int J Ayurveda Res 2010;1:122-3.
46Shindhe P, Kiran M. Carmakila: An effective management by kshara karma. J Ayurveda Integr Med 2013;4:181-3.
47Mahapatra A, Srinivasan A, Sujithra R, Bhat RP. Management of internal hemorrhoids by kshara karma: An educational case report. J Ayurveda Integr Med 2012;3:115-8.
48Kotrannavar VK, Angadi SS. Kshara application for turbinate hypertrophy. J Ayurveda Integr Med 2013;4:241-4.
49Jadav HR, Galib R, Prajapati PK. Clinical efficacy of apamarga kshara yoga in the management of shvitra (vitiligo). Ayu 2015;36:163-8.
50Pathak A, Yashawanth BN; From the Proceedings of Insight Ayurveda 2013, Coimbatore. 24th and 25th May 2013. OA03.02. The effect of kutaja pratisaraniya kshara in the management of ardra arshas. Anc Sci Life 2013;32 Suppl 2:S25.
51Kumar V, Kumar P. A clinical study of apamarga pratisaraneeya kshara in the management of bhagandara w.s.r. low anal fistula. Int J Dev Res 2018;8:20316-8.
52Tiwari LN, Vijayalaxmi M, Shailaja U, Bhandari M. Management of umbilical granuloma through chemical cauterization (Ksharakarma) – A case study. J Ayurveda Integr Med 2021;12:169-71.
53Gundeti MS, Reddy RG, Muralidhar JV. Subcutaneous intralesional ksharodaka injection: A novel treatment for the management of warts: A case series. J Ayurveda Integr Med 2014;5:236-40.
54Sekhar Namburi UR, prakash O.M, Babu G. A review on management of warts in Ayurveda. Ayu. 2011 Jan;32(1):100-2. doi: 10.4103/0974-8520.85739. PMID: 22131766; PMCID: PMC3215404.
55Gupta P, Sharma S. Clinical evaluation of the efficacy of kshara karma with apamarga kshara and jatyadi taila pichu in the management of cervical erosion (Karnini Yonivyapada). World J Clin Pharmacol Microbiol Toxicol 2015;1:43-9.
56Sharma A, Sahu M, Gupta SJ. A comparative study between rubber band ligation and local application of herbal caustic compound (pratisaraneeya kshara) in management of internal haemorrhoids. J Tradit Complement Med 2019;10:79-84.
57Chouksey M, Solanki S, Hetal Dave H. Review of research studies conducted on kshara karma in gynecology. Eur J Pharm Med Res 2020;7:335-7.
58Shaikh S, Aaqil H, Rizvi SM, Shakil S, Abuzenadah AM, Gupta P, et al. Comparative inhibition study of compounds identified in the methanolic extract of apamarga kshara against trichomonas vaginalis carbamate kinase (TvCK): An enzoinformatics approach. Interdiscip Sci 2016;8:357-65.
59Joshi F, Dudhamal TS. Wound healing effect of apamarga kshara taila and adjuvant drugs in the management of diabetic foot ulcer – A case report. Ann Ayurvedic Med 2020;9:320-7.
60Dudhamal TS. Clinical effect of apamarga kshara taila and adjuvant drugs in the management of diabetic wound – A case report. Healer 2021;2:106-10.
61Hiremath VR, Savadi B. Effect of pratisaaraneeya apamarga kshara in the management of jalarbuda w s r to mucocele of lip – A case study. Int J Res AYUSH Pharm Sci 2018;3:272-4.
62Kumar C, Fathima SA, Sharad K. Management of hydradenitis suppurativa by apamarga kshara sutra – A case study. J Ayurveda Integr Med Sci 2017;2:194-7.
63Bandekar PS. Management of hemangioma with ksharasutra – A case study. J Ayurveda Integr Med Sci 2021;6:275-8.