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Open Access Full Text Article                                                                  Review Article

Unani and Modern Perspective to Understanding and Managing Bahaq (Pityriasis Versicolor): A Comprehensive Review

Zaeema Qureshi ¹*, Mohammad Anzar Husain ², Altaf Husain Shah ³, Atoofa Khalid ⁴

¹P.G. Scholar, Department of Amraz-e-Jild Wa Tazeeniyat (Dermatology & Cosmetology), Hakim Syed Ziaul Hasan Government (Autonomous) Unani Medical College & Hospital, Bhopal, M.P., India, 462003.

² Professor, Department of Amraz-e-Jild Wa Tazeeniyat (Dermatology & Cosmetology), Hakim Syed Ziaul Hasan Government (Autonomous) Unani Medical College & Hospital, Bhopal, M.P., India, 462003.

³ Lecturer, Department of Mahiyatul Amraz (Pathology), Hakim Syed Ziaul Hasan Government (Autonomous) Unani Medical College & Hospital, Bhopal, M.P., India, 462003.

⁴ P.G. Scholar, Department of Amraz-e-Jild Wa Tazeeniyat (Dermatology & Cosmetology), Hakim Syed Ziaul Hasan Government (Autonomous) Unani Medical College & Hospital, Bhopal, M.P., India, 462003.

 

 

INTRODUCTION

Pityriasis versicolor (PV), also known as Tinea versicolor, is a common, mild, chronic, superficial and recurrent fungal infection of the stratum corneum caused by the lipophilic yeast Malassezia furfur^1,2,3. Patients with Pityriasis versicolor often have asymptomatic hypopigmented or hyperpigmented, finely scaled, round or oval macules or patches on the upper trunk, chest, back and shoulders that can spread to the neck, face and upper arms^4,5. The colour of skin lesions ranges from basically white to pink, fawn, to reddish brown¹. Patients occasionally complains itching, particularly when the disease is more extensive^4,5. The disease occurs throughout the world, but it is more common in humid and warm tropical areas. PV is more active during the summer season³. Skin discoloration that is related to the yeast's enzymatic activity and the bacterial colonization is temporary. However, in many cases, recurrence of the disease may occur despite adequate treatment, which adds to the effect on the quality of life of PV patients⁶. As a result, long-term maintenance treatments are frequently required³.

The diagnosis of pityriasis versicolor usually is simple. It is purely based on clinical presentation and barely requires a biopsy. However, in clinically unclear cases, extra noninvasive work-up (e.g., dermatoscopy, ultraviolet-induced fluorescence dermatoscopy, Wood's light examination or direct microscopy) can simplify the diagnostic process⁴.

In the unani system of medicine the term "pityriasis" is synonymous with "Bahaq" or "cheep"⁷. Renowned Unani physician Zakariyyā Rāzī stated that Bahaq is a frequent skin condition marked by hyperpigmentation and hypopigmentation as well as the development of skin scales⁸. According to Akbar Arzānī, there are two types of Bahaq: Bahaq Abyad, also called Cheep, is a mild hypopigmentation that appears on the skin superficially as small, round patches that appear suddenly and depart away quickly after applying detergent drugs locally^9,10. Bahaq Aswad is a skin condition marked by black discolouration and the development of scaly formations resembling wheat shell¹⁰. Hakeem Ajmal Khan and Ghulam Jilani, two well-known Unani Scholars from India from the similarly characterized Bahaq Abyad as an infectious or contagious disease marked by white-yellow patches on the trunk and neck accompanied by skin scaling. It may or could not be associated with itching^11,12,13,14.

METHODOLOGY

The author studied through unani medicinal books to find information about Bahaq. Important literatures of unani medicine were reviewed. Al-Qanoon fil Tib of Ibne Sina, "Moalijate Buqratiya" of Ahmad bin Rabban Mohd Tabri, "Al Hawi Al Kabeer" of Zakariyyā Rāzī, "Ghina Muna" of Abul M. H. Quamri, "Kitab al Taisir" of Ibn Zohar, "Kitabul Kulliyat" of Ibn Rushd, Tibbe Akbar of Hakim Akbar Arzani, Firdous al Hikmat, of Rabban Tabarī, Al Hawi of Zakariyyā Rāzī, Bayaz-e-Kabir and Zakhira Khawarizam Shahi for information on bahaq and unani treatment. Major scientific databases, including Pubmed and Science Direct, were searched."Bahaq and Unani," "Pityriasis versicolor” or “Tinea versicolor and Bahaq" and "Unani Medicines and Bahaq" were the search terms that were used. Searches for scientific evidence about the use of unani drugs in the treatment of Bahaq were conducted on the Internet using the same search engines and Google Scholar.

EPIDEMIOLOGY

Pityriasis versicolor occurs worldwide, but it is most typically encountered in tropical regions and has a greater incidence during the summer seasons^4,15,16. In tropical areas, the prevalence of PV may reach 50%, while in moderate and cold climates, it is considered to be between 1% and 4% (3). PV is most common in adolescents and young adults and is probably due to increased sebum production in these age groups. Although uncommon, the disease can affect both young children and the elderly (17-25). Rarely, newborns and infants have been reported to have Pityriasis versicolor⁴. PV is significantly more common in men than in women, likely due to higher sebaceous activity in men^24,26,27. About 17% of affected individuals have a positive family history of PV⁴. Pityriasis versicolor appears to be common in all races, but the change in skin pigmentation is more visible in dark-skinned people²⁶.

AETIOPATHOGENESIS

Modern Perspective:

Pityriasis versicolor is caused by dimorphic lipophilic and lipid-dependent yeasts in the genus Malassezia (previously known as Pityrosporum) which currently includes 19 species, including Malassezia globosa (M. globose), M. furfur and M. sympodialis. Other species included are M. restricta, M. obtuse, M. slooffiae, M. pachydermatis and M. japonica^3,4. These yeasts are common commensals on the skin surface^28,29. Skin colonisation increases with age, affecting 25% of children and nearly 100% of adults³⁰. When the saprophytic yeast or budding stage of the organism changes into the pathogenic hyphal or mycelial form, pityriasis versicolor develops. The fungal infection is limited to the stratum corneum. A hot and humid environment, hyperhidrosis, application of oily lotion or cream to the skin, mask wear, excessive lipid-containing sebaceous secretions, malnutrition, poor general health, use of oral contraceptives, pregnancy, diabetes mellitus, use of topical or systemic corticosteroids, Cushing disease, Helicobacter pylori infection, immune-deficiency and genetic predisposition are all risk factors for the conversion⁴. According to a recent study, the pathogenesis of pityriasis versicolor is unrelated to oxidative stress³¹. In pityriasis versicolor, hypo-pigmented lesions (more commonly seen in darker skin tones) are thought to be the result of melanocyte damage, lipid-like material accumulation in the stratum corneum that blocks ultraviolet light, small melanosomes and inhibition of tyrosinase by azelaic acid, a dicarboxylic acid produced by the Malassezia species involved. On the other hand, a thicker stratum corneum, more tonofilaments in the granulosum, large melanosomes and a hyperaemic inflammatory response triggered by Malassezia species can all lead to hyperpigmented lesions, which are more frequently observed in lighter skin tones⁴.The Malassezia species produces keratinase, which loosens the stratum corneum and leads to the formation of scales^32,33.

Unani Perspective

The aetiopathogenesis of Bahaq is described in classical literature of unani system of medicine such as “Firdaus-ul Hikmat,”  “Al Hawi al Kabeer,” “Moalijat-e-Buqratiya” and “Kitab al Taisir.” It is considered as a humoural disease⁷. The main cause is an imbalance in the quality and quantity of phlegmatic and melancholic humours ^7,34. When morbid humour accumulates beneath the skin, that area of the skin becomes hypopigmented or hyperpigmented, depending on the type of humour (melancholic or phlegmatic)^35,36,37,38. The faculty Quwwat Mughayyira (transformative faculty) plays a role in the accumulation of morbid humour that lies beneath the skin surface^10,39. It is speculated that this clinical condition may arise when the affected skin's Quwwat Mughayyira weakens and Quwwat Dafi‘a (expulsive faculty) becomes stronger^7,10,39.

The pathogenesis of this disease is explained in given schematic presentation below Fig. (1). Quwwat Mughayyira (transformative faculty) facilitates the conversion of nutrients into tissue. The affected part fails to get adequate tissue formation in clinical conditions due to the weakness of Quwwat Mughayyira ^10,37,39. Quwwat Mushabbiha (power of resemblance) is another bodily faculty that is necessary for skin's natural colouration. Usually, excessive metabolic products produced within the tissue are expelled out into the blood. This process is controlled by Quwwat Dafi'a. In this clinical state, these faculties do not perform normal functions, resulting in an imbalance in the quality and quantity of phlegmatic and melancholic humours. Several factors have also been identified as being directly or indirectly associated with the causation of this disease, including weakness of the Quwwat Mumayyiza (augmentative faculty) of the liver, Du'f al Tihal (functional weakness of the spleen), Du'f al- Mi'da (weakness of the stomach), intake of flatulence foods and malabsorption^40,41,42,43.

 

Weakened Quwwat Mughayyira (Transformative faculty)

Weakness of Quwwat Mushabbiha ( Power of resemblance)

Disturbance in conversion of nutrients

Accumulation of unaltered nutrients beneath the skin

Accumulation of morbid humours Beneath the skin

Excretion of morbid humours Towards skin

Strong Quwwat Dafi’a (Expulsive faculty)

  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Figure 1: Schematic representation of the pathogenesis of Bahaq according to unani scholars.

 

 

DIAGNOSIS

The diagnosis is typically clinical, based on the characteristic skin lesions (multiple hypopigmented or hyperpigmented, erythematous, centrally merging, oval to circular, finely scaling macules or patches and the 'evoked scale sign')⁴⁴. However, the various manifestations of Pityriasis versicolor can be perplexing to an inexperienced clinician. In difficult atypical cases, Wood's light, dermatoscopy and direct KOH microscopic examination may be helpful.

1.Wood’s lamp examination:

Examination of the lesion with a Woods lamp (filtered ultraviolet light with a 365 nm peak) may reveal golden-yellow, yellowish-green, or coppery-orange fluore-scence, while other lesions do not fluoresce^4,28.

2. Dermatoscopy :

Dermoscopy is a valuable diagnostic technique for pityriasis versicolor. Typical dermoscopic findings include changes in background pigmentation, a 'contrast halo' sign (a ring of hypopigmentation surrounding a hyperpigmented lesion or a ring of increased pigmentation surrounding a hypopigmented lesion)⁴. 

 

3. Direct KOH Microscopic Examination:

If necessary, a potassium hydroxide (KOH) preparation test can be done; scrapings from the lesion's borders soaked in 10-15% KOH reveal numerous short, stubby hyphae intermixed with clusters of spores (the so-called' spaghetti and meatballs' appearance)²¹.

MANAGEMENT OF PITYRIASIS VERSICOLOR (BAHAQ)

Treatment of pityriasis versicolor⁴

A. Topical antifungals 

1. Azoles (including  ketoconazole,  econazole,    eberconazole,  efinaconazole,  bifonazole,  luliconazole, clotrimazole,  miconazole,  sertaconazole,  sulconazole, oxiconazole,  fenticonazole,  tioconazole,  fluconazole and dapaconazole)

2. Ciclopiroxolamine

3.  Butenafine

4. Naftifine

5. Terbinafine

6. Non-specific topical antifungal medicines (such as selenium sulphide, zinc pyrithione, propylene glycol, Whitfield ointment, sulphur with salicylic acid and benzoyl peroxide) 

B. Oral antifungals 

1.  Fluconazole 

2.  Itraconazole

Oral antifungals 

Oral antifungal medications are typically used to treat severe, extensive, stubborn or recurrent pityriasis versicolor cases. Oral antifungal therapy is associated with higher costs, more adverse effects and probable drug-drug interactions; hence it is not recommended as the first-line treatment for pityriasis versicolor, particularly in children. 

Oral azole antifungals as itraconazole and fluconazole are the recommended systemic medications. Fatigue, malaise, headache, cutaneous eruption, pruritus, dyspepsia, nausea, vomiting, abdominal pain, diarrhoea, hypertension, congestive cardiac failure, thrombo-cytopenia, hypokalaemia, albuminuria, hypertri-glyceridemia and abnormal liver function are side effects of using oral antifungals⁴.

Usoole ̒Ilāj (Principles of Treatment) of Bahaq Abyaḍ:⁴⁷

• Tanqiyahe Balgham (Evacuation of phlegm).
• Topical application of Musakhkhin advia (calorific),  Jālī (detergent), Muḥammir (rubefacient) and Muḥallil (resolvent). 
• Ilāj bi'l Ghidhā (Dieto-therapy).

Tanqiyahe Balgham is performed in three steps;

• Munzijāte Balgham (phlegmatic concoctives)
• Mushilāte Balgham (phlegmatic purgatives) 
• Tabreed Badan (body refrigeration)^7,48.

Munzijāte Balgham:

Asl-us-Soos muqashhar (Glycyrrhiza glabra Linn) 5gm, Parsiyaoshan (Adiantum capilusveneris) 7gm,  Anjeer zard (Ficus hispida Linn) 2 No., Gule Surkh (Rosa damascene) 7gm and Maweez munaqa (Vitis vinifera Linn) 9 No. The medicines are boiled, filtered and mixed with 46 gm Gulqand or 23 gm Sikanjabeen⁴⁹.

Mushilāte Balgham:

Aftimoon (Cascuta epithymum Linn) 20gm, Mastagi (Pistacia lentiscus) 12gm, Sana (Cassia angustifolia Vahl) 12gm and Haleela siyah (Terminalia chebula Retz) 40gm. Each medicine is powdered, mixed with shahad (honey) and used with an empty stomach in a quantity of 8 gms⁴⁸.

Mixture of Haleela kabuli (Terminalia chebula Retz) 7gm, Turbud (Operculina turpethum) 10gm and shahad (Honey) 10.5 gm per day dose⁷.

Tabreed Badan (body refrigeration):

Uses Mubarrid (Refrigerant) medicines to counteract the negative effects of Mushilāt on the intestines. Commonly used medicines are Sheera Unnab (Zizyphus jujube Linn), Loab-e-bahidana (Cydonia vulgaris), Loab-e-Aspaghol (Plantago ovata), Loab-e-resha khatmi (Althaea officinalis Linn), Arq Shahtara (Fumaria parviflora) and badiyan (Foeniculum vulgare Mill)⁴⁸.

Topical application: 

The following formulation is most commonly suggested for topical application in Bahaq in classical literature.

• Apply a mixture of Tukhme Panwar (Casiatora Linn) 3 gm, Babchi (Posoralia corylifolia Linn) 3gm and Tukhme Turb (Raphanus sativus Linn) 3gm to the affected area after mixing it with water⁴⁹.
• Applying a mixture of Nilofar (Nymphaea alba Linn.) and its root to the affected area eradicate Bahaq Abyaḍ ^35,48.
• Mixture of Sirka (vinegar) and Haldi (Curcuma longa Linn.) or only Sirka (vinegar)⁷.
• To make Shiyaf, Usara unsul (Urginea Scilla) is mixed with Khardil (Brassica nigra), Safsiyah and Gandhak (sulphur). Shiyaf should be mixed with arq payaz (Urgineascilla) and applied by massaging the affected area until it becomes red⁴⁸.

‘Ilāj bi'l Ghidhā (Dietotherapy):

Patients are recommended to take soft diets or easily digested foods (Latīf Ghidhā) and to restrict their intake of cold, moist foods in nature(mizāj), such as fish, fresh vegetables, fruits and fatty foods, as these may increase the production of phlegm. They are also advised to consume more hot, dry foods, such as goat and bird meat (Chakor and teetar), as well as spices like Siyah mirch (Piper nigrum), Zeera (Cuminum carvi Linn.) and Darchini (Cinnamomum zeyanicum)⁴⁷.

Usoole ‘Ilāj (Principles of Treatment) of Bahaq Aswad:

• Tanqiyahe Sawdā (Black Bile Evacuation).
• Topical application of Qawī Muḥallil advia (Resolvent) and Jālī (Detergent). 
• Ilāj bi'l Ghidhā (Dieto-therapy).

Tanqiyahe Sawdā has four steps. Faṣd (Venesection), the use of Munzijāte Sawdā (Melancholic Concoctives), Mushilāte Sawdā (Melancholic Purgatives) and Tabreed Badan (raising fluid flow in the body)^7,36,48.

Faṣd involves incising Warīd-e-Akhal (Median Cephalic Vein) to evacuate the morbid matter^7,36,39,48. 

Munzijāte Sawdā:

Gaozaban (Borago officinalis Linn.) 7 gm, Sapistan (Cordia dichotoma) 9 No., Unaab (Zizyphus jujube Linn.) 5 No., Asl-us-Soos muqashhar (Glycyrrhiza glabra Linn.) 5gm, Badranjboya (Melissa parviflora) 7gm, Badiyan (Foeniculum vulgare Mill) 7gm, Parsiyaoshan (Adiantum capilus-veneris) 7gm, Ustukhuddus (Lavandula stoechas Linn) 7gm and Shahtara (Fumaria parviflora) 7gm. 

All medications are soaked in water for the entire night, filtered and then mixed with Gulqand or Qand Safaid (sugar) in the morning⁴⁹.

Mushilāte Sawdā: The following formulations have been recommended for use:

• Aftimoon (Cascuta epithymum Linn.), Ghariqoon (Agaricus alba Linn.), Haleela siyah (Terminalia chebula Retz), Bisfayej (Polypodium vulgaris), Ustukhuddus (Lavandula stoechas Linn.), Maweez (Vitisvinifera Linn.), Anjeer (Ficus hispida Linn.), kharbaq (Helleborus niger), Hujr-ul-Armani magsool (Boric powder) and Hajr-ul-Lajward (Lapis lazuli) are all drugs used in the form of decoction⁵⁰.
• Haleela kabuli (Terminalia chebula Retz), Aftimoon (Cascuta epithymum Linn.) and Haleela siyah (Terminalia chebula Retz) are all drugs taken in equal quantity, powdered and mixed with maweez (Vitis vinifera Linn.) to make Majoon⁵⁰.
• Amla (Emblica officinalis Gaertn), Kalonji (Nigella Sativa) and Haleela siyah (Terminalia chebula Retz) are all powdered in equal amounts and taken in a 12 gm dose in the morning and at night (39,48).
• Joshande Haleela siyah (Decoration of Terminalia chebula Retz), Joshande Aftimoon (Decoration of Cascuta epithymum Linn) and Ma-ul jubn (Whey)^7,9,39,49.

Tabreed Badan will be done to replenish the body's fluid, as Bahaq Aswad produces excess yabusat (dryness) in the body. Therefore, patients are recommended to take in plenty of fluids, especially water and fresh fruit. Some unani physicians recommended frequent Hammām (turkish bath) along with use of medications such as Loab-e-bahidana (Cydonia vulgaris), Loab-e Aspaghol (Plantago ovata), Loab-e-resha khatmi (Althaea officinalis Linn.) and Sheera Unnab (Zizyphus jujube Linn.) for tabreed ⁴⁸.

Topical application:

The following single and compound formulations in the form of Tila have been recommended for use, including;

• Aaqar qarha (Anacyclus pyrethrum DC) 4gm, Shitraj (Plumbago zeylanica Linn.) 4gm, Kharbaq (Helleborus  niger) 4gm and Gandhak (sulphur) 4gm, each drug is mixed with Sirka (vinegar) and apply to the affected area⁴⁸.
• Mix Post Bekh Kibr (Capparisspinosa) 12gm, Shitraj (Plumbagozeylanica Linn.) 20gm and Majeeth (Rubiacordifolia Linn.) 8gm in Sirka (Vinegar), apply it to the affected area and then wash it next day⁴⁸.
• Application of a mixture of Tukhme turb (Raphanus sativus Linn.) and Kundush (Centipeda minima) or Ma-ul Kibreet (Sulphur) to the affected area helps to remove Bahaq aswad completely^9,39,48.
• Wash the affected area with Booraq (Borax), then apply the mixture of Zareeq (Arsenic), Natron (Potassium carbonate) and Gandhak (Sulphur) under the sun^9,48.

Ilāj bi'l Ghidhā (Dietotherapy):

Patients are recommended to take foods that are easy to digest (Latīf Ghidhā). People should increase their intake of cold and moist foods and avoid from eating foods that cause the formation of black bile, which is the actual cause of disease^{7,9,36,37,39,48,50}. 

CONCLUSION:

Pityriasis versicolor is a frequent, chronic, relapsing dermatosis with a variety of clinical manifestations. Although the clinical presentation is typically used to make the diagnosis of PV. Bahaq (PV) has been extensively discussed in the unani system of medicine, regarding its concept, types, causes and treatments. The treatment methods are effective with little to no side effects. The treatment is based on the holistic approach of Munzij wa Mushil therapy, as well as topical application of Jali, Muhammir, Muhallil, Musaffi and Murakhi drugs such as Tila, zimad and roghan form. Contemporary medicines have been associated with adverse effects during the treatment of pityriasis versicolor, thus alternative and herbal treatments with favourable safety profiles are the best options for treating PV. Furthermore, the unani treatment is inexpensive, accessible and widely accepted and also unani medicine is preferred over contemporary medication in the treatment of resistant skin conditions. Hence, the efficacy and outcomes of the various therapeutic approaches discussed in the literature should be further evaluated and confirmed by randomized clinical trials.

Funding: There is no funding involve

Conflict of Interest: None

Acknowledgements: None

Ethical Statement: Not Applicable

Inform Consent: Not Applicable

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