Healing Properties of Apamarga Kshara (Achyranthes aspera) in Ayurvedic Medicine: A Narrative Review

Apamarga Kshara is a traditional Ayurvedic powder formulation composed of the herb Apamarga (Achyranthes aspera) and processed alkaline materials. It is renowned in Ayurveda for its therapeutic properties and is used in various medicinal preparations to treat a range of health conditions. This blend holds promise in Ayurvedic medicine for its purported healing properties. A comprehensive analysis can shed light on its effectiveness and applications in holistic healthcare. ‘Kshara’ pertains to both ‘Paka’ (preparation) and ‘Vidhi’ (application). Its effectiveness among the sharper and auxiliary instruments is notable, as caustic alkali facilitates excision, incision, and scarification, helping to balance the three doshas and serving specific medical functions. Among the parasurgical techniques, Agni (cauterisation), Kshara (caustic alkali), and Jalauka (leeches) are all significant. However, Kshara is the most prominent because procedures such as excision and incision cannot be achieved with Agni and Jalauka. It is particularly used for targeted treatments, such as in the case of Arsha caused by Pitta dosha. The objective of present review is to compile data on the primary phytochemicals present in Apamarga Kshara and its pharmacological effects. Kshara, an Ayurvedic concoction featuring Apamarga (Achyranthes aspera) and processed alkaline substances, underscores its significance in Ayurvedic healing. The approach taken in present review involves a detailed analysis of the Sushruta Samhita. Acharya Sushruta detailed the properties of Apamarga Kshara, including its abilities to cut (Chedan), pierce (Bhedan), scrape (Lekhan), dry (Shoshan), and balance the three Doshas. Apamarga Kshar is particularly effective in managing digestive disorders, skin conditions, and urinary tract infections due to its ability to neutralise excess acidity and support detoxification. The preparation involves processing the ash of the plant with specific alkaline substances, resulting in a powerful remedy with diverse medicinal applications. Apamarga Kshar is particularly effective in managing digestive disorders, skin conditions, and urinary tract infections due to its ability to neutralise excess acidity and support detoxification.

Chemical, Dietary phytochemical, Plant bioactive compounds, Plant-derived, Phytonutrient

Kshara is a medicinal compound derived from the ashes of certain plants. It can be found in various forms such as solutions, powders, or crystals, all possessing alkaline properties. Understanding its efficacy could lead to enhanced healthcare practices rooted in traditional medicine. Acharya Sushruta extensively elaborated on Kshara in a dedicated chapter, a distinction not found in the works of other authors. The term “Kshara” is derived from its ability to cause tissue destruction, particularly affecting muscle and other bodily tissues [1]. According to Acharya Sushruta, Kshara is defined as a substance that possesses the properties of Ksharana and Kshanan, which refer to its ability to cause destruction or dissolution [1]. Acharya Sushruta elucidated that Kshara possesses properties such as Chedana (Excision), Bhedana (Penetrating), and Lekhana (Scraping), alongside its ability to maintain balance among the Tridoshas (Vaata, Pitta, and Kapha) within the body [1]. He extensively discussed Kshara within the domain of Shalya Tantra, considering its applications. The classification of Kshara can be based on its mode of administration, which includes Paneeya (ingestible) and Pratisaraneeya (applicable externally) [1]. In terms of concentration, namely Mrudu (mild), Madhyama (moderate), and Teekshna (strong), Acharya Sushruta outlined Kshara as a therapeutic tool, referred to as an Anushastra. It is recognised as one of the treatment methods for wounds (Vrana), being particularly effective in addressing various disorders such as persistent wounds (Dushta Vrana), fistula (Bhagandara), hemorrhoids (Arsha), and skin disorders like dermatitis (Charmakeela). Acharya Sushruta listed numerous ingredients for Kshara preparation, with Apamarga being one of them [2].

Apamarga, scientifically known as Achyranthes aspera Linn, is a wild perennial herb characterised by its height ranging from 30 to 90 cm and a branched taproot. Its stem is upright, herbaceous, and covered with fine hairs, while its leaves are petiolate, opposite, and semicircular with a pointed tip. The plant bears spikes with small green flowers arranged in a reflexed manner on long stalks. These flowers are bisexual, regular in shape, and give rise to indehiscent achenes enclosed within persistent perianths and bracteoles. Apamarga is widely distributed across India, thriving up to an altitude of 2100 feet, and is also found in the South Andaman Islands, typically growing as a weed along roadsides and in barren lands [1]. In today’s world, meeting the growing global demand requires advancements in Ayurvedic pharmaceutical science, including standardisation and quality control. While classical formulations are effective, they often come with certain drawbacks. To address these shortcomings, there is a necessity to transform them into more convenient, acceptable, and therapeutically effective forms. In this endeavor, the goal is to develop an ointment based on the composition of Apamarga Kshara Yoga (APK), aiming to create a product that is both efficient and user-friendly. APK Lepa is formulated with an equal proportion of Apamarga Kshara, derived from the alkaline substance of Achyranthes aspera Linn., and Manahshila, which is Arsenic Disulphide, finely ground with Gomutra, cow’s urine [3].

The present review is aimed to examine the healing properties of Apamarga Kshara, a blend of herbal and mineral components, within the context of Ayurvedic medicine. By evaluating both historical texts and contemporary research, the review seeks to provide a comprehensive understanding of Apamarga Kshara, thereby highlighting its relevance and importance in modern Ayurvedic practice. The present review explores the therapeutic potential of Apamarga Kshara in Ayurvedic medicine as it delves into the synergistic effects of its herbal and mineral components, shedding light on its healing.

Drug review: Apamarga, known scientifically as Achyranthes aspera Linn., belongs to the Amaranthaceae family. In the classical texts of Ayurveda, it is categorised under several therapeutic groups. According to Charaka, it falls into Shirovirechana, a group of herbs used for expelling doshas from the head and neck through treatments like nasya and dhoompana; Krumighna, herbs known for their antimicrobial and antiparasitic actions; and Vamanopaga, herbs used to support emesis therapy (vamana).

In Sushruta’s classification, it is listed under the Arkadi group. Commonly referred to as the Rough Chaff Tree or Prickly Chaff Flower in English, it is known as Aghada in Marathi and Latagira in Hindi [4].

The standard procedure for preparing Apamarga Kshara begins with the identification of the Apamarga (Achyranthes aspera Linn.) plant. This step ensures the correct species is used, followed by a thorough assessment of the sample based on Ayurvedic parameters such as taste (rasa), potency (virya), post-digestive effect (vipaka), and elemental composition (panchabhautikatwa). Various parts of the Apamarga plant, including the roots, bark, leaves, flowers, and fruit, are collected and then dried in the shade to preserve their medicinal properties. Each dried part is packed separately, ensuring roughly equal quantities of each.

The next stage involves burning the dried plant material completely until a greyish-coloured ash, free from impurities like mud, stones, and charcoal, is obtained. This ash is then mixed with six times its volume of distilled water, stirred with a glass rod, and left to settle overnight. The following morning, only the supernatant fluid is collected, and the dark-coloured sediment is discarded. This supernatant fluid is then filtered 21 times using a cotton cloth to obtain “gaumutra varna ksharjala.” The ksharjala is heated until all the water evaporates slowly over mild to moderate heat, with intermittent stirring for 3-4 hours, until it turns reddish-yellow (ishatrakta varna), indicating the formation of “mrudu kshar” or “sanvyuhim.”

The preparation continues with the creation of a pottali (small bundle) of shukti (conch shell ash), which is heated until red hot on a hot iron pan and then dipped into the mrudu kshara. This process is repeated with continuous heating and stirring until the mixture thickens and turns white, producing “madhyama kshara.” Finally, a paste of Chitrakmula, prepared in advance and weighing approximately one-tenth of the shukti, is added to the cooled madhyama kshara. This mixture is stirred thoroughly to ensure even distribution, resulting in the final product known as Tikshna Apamarga Kshara, a potent formulation used for various therapeutic applications in Ayurveda.

In the Sushruta Samhita, a mixture containing Apamarga kshara, along with other herbs, combined with goat’s urine, is prescribed for the removal of urinary stones. Similarly, the Ashtang Hridaya mentions the same combination for treating gravel and stones. Chakradatta suggests applying a paste made from Apamarga root kshara and turmeric on Lingarsha. Furthermore, in subsequent texts, Apamarga kshara finds its way into numerous formulations aimed at treating various ailments [6].

Kshara is applied externally to treat wounds (vrana), inflammation of wounds (vranashotha), and matured external abscesses (pakva bahya vidradhi). Numerous research studies have investigated the efficacy of kshara application for conditions such as hemorrhoids (arsha), anal fissures (parikartika), and matured external abscesses [6-10].

The characteristics (Guna and Karma) of both Apamarga and Kshara [1] are detailed in [Table/Fig-1,2], respectively. Physicochemical properties of Apamarga and Kshara, including moisture, pH, specific gravity, ash content, and extract composition, are shown in [Table/Fig-3].

The plant’s ethanol extract was found to contain alkaloids and saponins. Analysis of the shoot revealed the presence of a novel aliphatic dihydroxyketone identified as 36,47-dihydroxyhenpentacontan-4-one, along with tritriacontanol. Furthermore, examination of the root identified oleanolic acid as the aglycone within the saponin fraction [11].

Apamarga Kshara, derived from Achyranthes aspera, exhibits anti-inflammatory and antimicrobial properties. It is traditionally used to treat digestive issues, wounds, and infections, which are explained in detail in [Table/Fig-4,5] [12].

Therapeutic applications of Apamarga Kshara for specific conditions Apamarga Kshara in managing stubborn wounds (Dushta Vrana):Apamarga Kshara’s efficacy lies in balancing Kapha Dosha, addressing issues like raised tissue, hardness, and itching in wounds. Sushruta explicitly recommends its use for such conditions [13]. In a clinical trial, Achyranthes aspera alkaline extract and trichloroacetic acid were compared for tympanic membrane perforation closure. The study found the extract effective in breaking fibrosis and promoting healing, comparable to trichloroacetic acid [1]. The application of Apamarga Kshara in treating Dushta Vrana, which translates to chronic or non healing wounds in Ayurveda, involves its specific therapeutic actions tailored to address this condition effectively. Here’s a different rendition: Apamarga Kshara plays a significant role in managing Dushta Vrana, persistent wounds resistant to healing. Its unique properties are harnessed to tackle the challenges posed by such stubborn wounds.

Antiseptic action:Apamarga Kshara exhibits potent antiseptic qualities that help cleanse the wound and prevent further infection. By targeting harmful microorganisms, it creates a conducive environment for healing.

Debridement: It aids in the removal of necrotic tissue or unhealthy debris from the wound bed, facilitating the growth of healthy granulation tissue. This process is crucial for promoting the regeneration of new skin layers.

Stimulating granulation tissue formation:Apamarga Kshara promotes granulation tissue formation, which is essential for wound healing. This tissue acts as a scaffold for the growth of new blood vessels and skin cells, ultimately leading to the closure of the wound.

Reducing inflammation: Chronic wounds often suffer from persistent inflammation, which can hinder the healing process. Apamarga Kshara’s anti-inflammatory properties help alleviate inflammation, thereby promoting a more conducive environment for healing.

Enhancing circulation: By improving local blood circulation to the wound site, Apamarga Kshara facilitates the delivery of oxygen and nutrients essential for tissue repair. This enhanced circulation accelerates the healing process in Dushta Vrana.

Analgesic effects: Chronic wounds may cause discomfort or pain. Apamarga Kshara’s analgesic properties provide relief from such symptoms, enhancing the patient’s comfort during the healing period.

In summary, the utilisation of Apamarga Kshara in treating Dushta Vrana involves a comprehensive approach aimed at cleansing, promoting tissue regeneration, reducing inflammation, and enhancing overall wound healing. Its multifaceted actions make it a valuable therapeutic agent in managing chronic and non-healing wounds in Ayurveda [14].

Joshi FP and Dudhamal TS, concluded in a single case study that Apamarga Kshara Taila and Ayurvedic treatments effectively heal diabetic wounds, advocating further validation with more patients [15]. In a case series by Joshi F et al., three patients received Ayurvedic treatment, including Nadi Swedana, Panchavalkala Kwatha wash, Apamarga Kshara Taila dressing, oral medications, and a dietary regimen, resulting in complete wound healing [16].

For Apamarga Kshara in Arsha (Haemorrhoid) management: Relief from Arsha symptoms like rectal bleeding, itching, discharge, and pain can be achieved through Ksharapatan (Application of Pratisaraniya Kshara directly onto hemorrhoids) application. Kshara’s properties of tissue penetration, dissolution, and scraping contributed to shrinking piles. Gudadaha, a burning sensation, diminished as Kshara’s alkaline nature counteracted the acidic Pitta and Rakta doshas [17]. Sudarmi K and Dudhamal TS, aimed to assess the effectiveness of Apamarga Kshara, Infrared Coagulation (IRC), and Arshohara Vati (AV) in treating piles. Statistically significant improvements were observed in patients with 1^st and 2^nd degree piles. While the Apamarga Kshara Application (AKA) group showed significant reduction in bleeding and prolapse, the AV group notably relieved painful defecation and rectal discharge [7].

In a 2011 study by Gupta ML et al., 61 participants with hemorrhoids were randomly assigned to either Kshara sutra ligation (35 patients) or hemorrhoidectomy (26 patients). The results indicated that Kshara sutra ligation had superior outcomes compared to hemorrhoidectomy [8].

Shah B and Dudhamal TS, conducted an open-label trial involving 25 participants diagnosed with 1^st and 2^nd degree piles. The study compared the effectiveness of AKA to sclerotherapy, and after AKA, rectal bleeding stopped by week 2, while Sclerotherapy required three weeks (p<0.001). AKA’s quick hemostasis is attributed to Kshara’s properties, while Sclerotherapy’s slower effect involves intravascular coagulation. Both methods significantly relieved pain, reduced prolapse, discharge, and pile size, with AKA showing faster results [9].

Singh R et al., conducted a trial involving 20 participants diagnosed with hemorrhoids. Ten individuals were assigned to each group of Barron’s rubber band ligation and Kshar Sutra ligation. The study aimed to evaluate Barron’s rubber band ligation versus Kshara Sutra ligation. Results indicated that Kshar Sutra ligation showed more effectiveness compared to Barron’s rubber band ligation [10].

In a 2019 study by Sharma A et al., a trial was conducted involving 60 participants diagnosed with internal hemorrhoids to compare the application of Apamarga Kshara locally versus rubber band ligation. Results indicated that Apamarga Kshara showed superior efficacy compared to rubber band ligation, particularly in treating large, broad-based piles [18].

Apamarga Kshar as Ksharsutra in the Management of Bhagandara (Fistula-in ano): Apamarga Kshar is effectively used in Ksharsutra therapy for managing Bhagandara (fistula-in-ano). This Ayurvedic treatment involves a medicated thread that promotes drainage and healing, reduces infection, and minimises recurrence, providing a minimally invasive alternative to conventional surgical methods [19].

In a study by Kushwaha TK et al., Apamarga Kshar Sutra therapy offers effective healing of fistulous tracts with minimal complications. The healing time averaged seven weeks, shorter than Seton therapy’s 11 weeks, with a recurrence rate of 0.0% compared to Seton’s 13.33%. Itching, discharge, and tenderness significantly reduced, though pain and burning sensation temporarily increased [20]. Overall, Apamarga Kshar Sutra proved more competent and efficient in Bhagandara management as it cuts and heals the fistulous tract simultaneously [20].

In a study by Anagha TS et al., thirty subjects participated in the study, divided into two groups. The trial group received treatment with Sarjarasa Apamarga Ksharasutra, while the control group was treated with Guggulu Apamarga Ksharasutra. The study indicates that Sarjarasa Apamarga Ksharasutra demonstrated significantly greater effectiveness in subjective assessments compared to Guggulu Apamarga Ksharasutra for the treatment of Fistula-in-ano. Moreover, no complications such as tissue death, narrowing, or loss of bowel control were observed following the use of Sarjarasa Apamarga Ksharasutra [21].

In a study conducted by Lobo SJ et al., 33 individuals diagnosed with fistula in ano were enrolled. The study comprised three treatment groups: 11 patients received Apamarga Kshara Sutra, 11 patients received Snuhi Ksheera Sutra, and another 11 patients received Tilanala Kshara Sutra. The effectiveness of Apamarga Kshara Sutra was evaluated in comparison to Snuhi Ksheera Sutra and Tilanala Kshara Sutra. In the findings, Group A showed significant improvement in pain and discharge, highly significant in itching, swelling, and wound size. Group B showed highly significant improvement in all symptoms. Group C showed significant improvement in itching, highly significant in other symptoms [22].

Savadi BS and Patel A conducted a trial involving 40 participants diagnosed with Fistula-in ano. Each group consisted of 20 individuals. The study compared the use of Tankana Ksharasutra (n=20) and Apamarga Kaharasutra (n=20). Results indicated that the duration of the cutting procedure was longer in Tankana Ksharasutra as criteria provided in the study compared to Apamarga Kaharasutra [23].

In 2018, Shankaraprasad K et al., conducted a trial involving 30 individuals diagnosed with Bhagandara. The study evaluated the effectiveness of Apamarga Kshara Sutra formulated with two groups: 7 and 21 coatings. Results indicated a significant decrease in pain, discharge, burning sensation, and itching among participants who underwent the treatment. In Group A, significant improvement was observed in pain and discharge, with highly significant results in itching, swelling, and wound size. In Group B, highly significant improvement was seen in all symptoms, including pain, discharge, itching, swelling, and wound size [24].

Regarding the use of Apamarga Kshara for application in Parikartika (Fissure-in ano), a study by Rathod AB observed that patients reported a notable reduction in symptoms, with a decrease in burning sensation by 87.5%, pain by 78.26%, spasms by 65%, and itching by 81.81%. Significant improvements were evident in all parameters, including burning sensation, pain, spasms, and itching [25].

In another study by Bhagat PJ et al., both groups-Kshara Application and Fissurectomy-experienced relief from symptoms like pain, bleeding, and spasm equally. However, fissurectomy showed better ulcer healing compared to Kshara application. While Kshara isn’t a substitute for fissurectomy, it effectively reduces symptoms and can be considered for patients unsuitable or unwilling for surgery [26].

Mode of Action of Apamarga Kshara when used as Kshar Sutra: The Ksharasutra comprises Apamarga Kshara, Snuhi Ksheera, Haridra Churna, and Mulethi powder, prepared according to the standardised method outlined in the Ayurvedic Pharmacopoeia of India [27]. Apamarga Kshara possesses various properties including excision, incision, debridement, hemostasis, purification, and healing. Its excision and incision abilities are particularly beneficial for removing the sentinel tag and fissure bed [28]. The Ksharasutra, when sutured at the fissure site, eliminates fibrotic tissue through its debridement action, effectively removing unhealthy fibrous tissue and debris. Additionally, its purification property aids in promoting wound healing and ensuring a healthy recovery [29]. Snuhi Ksheera, although slightly acidic, possesses antibacterial properties [30]. These ingredients not only prevent secondary infections but also promote wound cleanliness and accelerate healing due to their anti-inflammatory and antibacterial properties [31].

The comprehensive exploration of Apamarga Kshara reveals its multifaceted therapeutic potential in various medical conditions as described in Ayurvedic texts. Derived from plant ashes, it offers a natural approach to healing with its unique properties. Acharya Sushruta’s detailed exposition highlights its significance, outlining its role in balancing bodily doshas and promoting tissue repair. The application of Apamarga Kshara spans across different medical scenarios, ranging from digestive disorders to hemorrhoids, chronic wounds, and fistulas. Its diverse actions, including excision, incision, debridement, and healing, underscore its versatility in addressing a wide array of ailments. Additionally, its ability to maintain doshic balance within the body contributes to its efficacy in restoring health [32]. In contemporary pharmaceutical research, the development of formulations like Apamarga Kshara signifies an effort to enhance the accessibility and effectiveness of Ayurvedic remedies. By combining traditional knowledge with modern methods, such formulations aim to cater to the evolving healthcare needs of society. Moreover, studies evaluating the therapeutic efficacy of Apamarga Kshara in clinical settings underscore its potential as a viable treatment option. From managing chronic wounds to addressing anal fissures and fistulas, Apamarga Kshara demonstrates promising results, often comparable to conventional treatments. In conclusion, the profound understanding and application of Apamarga Kshara in Ayurveda offer a holistic approach to health and healing [33]. As scientific research continues to explore its potential, Apamarga Kshara remains a valuable asset in the realm of natural medicine, providing safe and effective solutions for various health concerns.

Apamarga Kshara, extensively explored in Ayurvedic texts and modern research, showcases versatile therapeutic benefits. Described meticulously by Acharya Sushruta and derived from plant ashes, it offers holistic healing for various ailments, from gastrointestinal issues to complex wounds. Its actions, including tissue repair and dosha balancing, highlight its efficacy in restoring health. Modern formulations like Apamarga Kshara blend traditional wisdom with scientific innovation to meet evolving healthcare needs. Clinical studies support its efficacy, making it a viable treatment option. As a valuable asset in natural medicine, ongoing research continues to unlock its potential, offering safe and sustainable solutions for diverse health concerns.

[1]. Acharya Sushruta, Sushruta Samhita Dalhana, Nibandhasangraha commentary, Yadavji Trikamji Acharya, Naarayana Ram Acharya, editors 2013 11(4)VaranasiChaukhambha Sanskrit Sansthan; Sutrasthana:45-47.  [Google Scholar]

[2]. Prakash Hegde L, Harini A, Text book of dravyaguna vijnana. Volume 2014 2New DelhiChaukhambha publications:43  [Google Scholar]

[3]. Sharma S, Rasa Tarangini. In: Shastri K, editor. Taranga 14, Verse 71 2004 New DelhiMotilala Banarsidas:339  [Google Scholar]

[4]. Susruta Samhita Vol. 1, Hindi Commentary by Kaviraja Ambikadutta Sastri, Chaukhambha Sanskrit Sansthan, Reprint 2012 :47,179,184,191,205  [Google Scholar]

[5]. Vij A, Preparation of Apamarga Kshara and its role in surgical practiceInternational Journal of Herbal Medicine 2016 4(3):28-30.  [Google Scholar]

[6]. Dixit SO, Angadi R, Renjal PU, Comparative pharmaceutical study of Apamarga Kshara prepared by Jala and GomutraJournal of Ayurveda and Integrated Medical Sciences 2016 1(2):24-30.Availalbe from: https://doi.org/10.21760/jaims.v1i2.3661  [Google Scholar]

[7]. Sudarmi K, Dudhamal TS, Comparative clinical study of Apamarga Kshara application, infrared coagulation and Arshohara Vati in the management of Arsha (1^st and 2^nd degree hemorrhoids)Ayu (An International quarterly Journal of research in Ayurveda) 2017 38(3-4):122-26.10.4103/ayu.ayu_94_17  [Google Scholar]  [CrossRef]

[8]. Gupta ML, Gupta SK, Bhuyan C, Comparative clinical evaluation of Kshara Sutra ligation and hemorrhoidectomy in Arsha (hemorrhoids)Ayu (An International quarterly Journal of research in Ayurveda) 2011 32(2):225-29.10.4103/0974-8520.92591  [Google Scholar]  [CrossRef]

[9]. Shah B, Dudhamal TS, Efficacy of Apamarga Kshara application and Sclerotherapy in the management of Arsha (1^st and 2^nd degree piles)-An open-labeled, randomized, controlled clinical trialAyu (An International quarterly Journal of research in Ayurveda) 2018 39(4):213-19.10.4103/ayu.AYU_147_18  [Google Scholar]  [CrossRef]

[10]. Singh R, Arya RC, Minhas SS, Dutt A, A comparative study of Barron’s rubber band ligation with Kshar Sutra ligation in hemorrhoidsInt J Ayurveda Res 2010 1(2):73-81.10.4103/0974-7788.64407  [Google Scholar]  [CrossRef]

[11]. Mali CV, Annapure SV, Ayurvedic approach in preparation of apamarga kshar, pharmaceutical study, its benefits and side effects-a literature reviewWorld Journal of Pharmaceutical Research 2018 7(16):560-67.10.20959/wjpr201816-13233  [Google Scholar]  [CrossRef]

[12]. Pal A, Gupta V, Tiwari G, Manigaunha A, A review on phyto-pharmacological aspects of Apamarg (Achyranthes aspera Linn.)Journal of Advanced Zoology 2023 44(S3):1222-32.Available from: https://doi.org/10.17762/jaz.v44iS-3.131010.17762/jaz.v44iS-3.1310  [Google Scholar]  [CrossRef]

[13]. Taylor M, Mcminn RM, Healing of experimental perforations of the tympanic membraneJ Laryngol Otol 1965 79:148-58.10.1017/s002221510006349014256265  [Google Scholar]  [CrossRef]  [PubMed]

[14]. Jawanjal P, Patgiri BJ, Therapeutics aspects of Apamarga Kshara (Herbomineral Formulation) in Ayurveda- A reviewAyuhom 2021 8(2):51-56.10.4103/AYUHOM.AYUHOM_57_21  [Google Scholar]  [CrossRef]

[15]. Joshi F, Dudhamal TS, Wound healing effect of Apamarga Kshara Taila and adjuvant drugs in the management of diabetic foot ulcer-A case reportAnnals of Ayurvedic Medicine 2020 9(4):320-27.  [Google Scholar]

[16]. Joshi FP, Dudhamal TS, Tissue Debridement effect of apamarga kshara taila and adjuvant medications in the management of nonhealing venous ulcer: A case seriesMedical Journal of Dr. DY Patil University 2021 14(5):549-53.10.4103/mjdrdypu.mjdrdypu_52_20  [Google Scholar]  [CrossRef]

[17]. Shastri Ambikadata, Sushruta Samhita, Ayurveda Tatva Sandipika Hindi CommentarySutrasthan 5 2001 11VaranasiChaukhamba Sanskrit Sansthan:34,37  [Google Scholar]

[18]. Sharma 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 haemorrhoidsJournal of Traditional and Complementary Medicine 2020 10(1):79-84.  [Google Scholar]

[19]. Hariprasad CP, Kumar A, Kumar M, Kumar M, Paswan SS, Rohit G, The efficacy of Ksharsutra, Fistulectomy and Ligation of Intersphincteric Fistula Tract (LIFT) procedure in management of Fistula in ano a prospective observational studyBMC Surg 2023 23(1):70Available from: https://doi.org/10.1186/s12893-023-01969-w  [Google Scholar]

[20]. Kushwaha TK, Yadav S, Yadav AK, Palasha kshara-sutra in the management of bhagandara wsr fistula-in-ano-a single case studyWorld Journal of Pharmaceutical Research 2022 1(2):2165-72.10.20959/wjpr20222-23082  [Google Scholar]  [CrossRef]

[21]. Anagha T, Sweta K, Surendranath D, A randomized, controlled clinical study to evaluate the role of Sarjarasa Apamarga Ksharasutra in the management of Bhagandara w.s.r to fistula-in-anoJournal of Ayurveda and Integrated Medical Sciences 2022 7(6):28-34.Available from: https://doi.org/10.21760/jaims.7.6.5  [Google Scholar]

[22]. Lobo 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(1):85-91.10.4103/0974-8520.100319  [Google Scholar]  [CrossRef]

[23]. Savadi BS, Patel A, A comparative clinical study on the effect of Tankana Ksharasutra and Apamarga Ksharasutra in the management of Bhagandara (Fistula In Ano)Journal of Ayurveda and Integrated Medical Sciences 2018 3(6):50-55.Available from: https://doi.org/10.21760/jaims.v3i06.536  [Google Scholar]

[24]. Shankaraprasad K, Sharma M, Rakesh RN, Comparative study of clinical effect of Apamarga Kshara Sutra prepared by 7 and 21 coatings in BhagandaraJournal of Ayurveda and Integrated Medical Sciences 2018 3(3):21-26.Available from: https://doi.org/10.21760/jaims.v3i03.396  [Google Scholar]

[25]. Rathod AB, Preliminary clinical study to evaluate Jatyadi Ghrita suppository in the management of Parikartika with special reference to fissure-in-anoAyurlog: National Journal of Research in Ayurved Science 2019 7(4)Available from: https://doi.org/10.52482/ayurlog.v7i4.404  [Google Scholar]

[26]. Bhagat PJ, Sharma SU, Raut SY, Lakhapati AM, A comparative study on effect of kshara application against fissurectomy in Parikartika (Fissure in Ano)World Journal of Pharmacy and Pharmaceutical Sciences 2016 5(4):1522-32.10.20959/wjpps20164-6416  [Google Scholar]  [CrossRef]

[27]. Das N, Kalita B, A critical study of Ksharasutra preparation standardization and new developmentsInternational Journal of Ayurveda and Pharma Research 2018 Apr 25   [Google Scholar]

[28]. Yala K, A study on the Efficacy of Karaveera Pratisaraneeya Kshara Karma in Arshas WSR to Internal Haemorrhoids (Master’s thesis, Rajiv Gandhi University of Health Sciences (India))  [Google Scholar]

[29]. Meena RK, Dudhamal T, Gupta SK, Mahanta V, Comparative clinical study of Guggulu-based Ksharasutra in Bhagandara (fistula-in-ano) with or without partial fistulectomyAYU (An International Quarterly Journal of Research in Ayurveda) 2018 39(1):02-08.  [Google Scholar]

[30]. Sabale P, Bhimani B, Prajapati C, Sabalea V, An overview of medicinal plants as wound healersJournal of Applied Pharmaceutical Science 2012 2(11):143-50.10.7324/JAPS.2012.21127  [Google Scholar]  [CrossRef]

[31]. Negi PS, Jayaprakasha GK, Jagan Mohan Rao L, Sakariah KK, Antibacterial activity of turmeric oil: A byproduct from curcumin manufactureJ Agric Food Chem 1999 47(10):4297-300.Available from: https://doi.org/10.1021/jf990308d  [Google Scholar]

[32]. Goyal BR, Goyal RK, Mehta AA, PHCOG rev.: Plant review phyto-pharmacology of Achyranthes aspera: A reviewPharmacogn Rev 2007 1(1):143-50.  [Google Scholar]

[33]. Jadav HR, Galib R, Prajapati PK, Pharmaceutical standardization of Apamarga Kshara yogaJournal of Drug Delivery and Therapeutics 2015 5(6):31-34.10.22270/jddt.v5i6.1177  [Google Scholar]  [CrossRef]