Potential role of Unani medicinal plants in management of Kalaf(Chloasma): A review

*Corresponding Author:

Zareena Aquil
Central Research Institute of Unani Medicine
Hyderabad, Telangana State, India.
Telephone 55(98)981230696
e-mail zarzar.aquil@gmail.com

Received Date: December 11, 2018, Accepted Date: February 10, 2019, Published Date: February 18, 2019

Citation: Aquil Z, Khalid M, Uddin Q, et al. Potential role of Unani medicinal plants in management of Kalaf (Chloasma): A review. J Skin. 2019;3(1):1-2

Keywords

Kalaf; Melasma; Chloasma; Unani medicines

The term “Chloasma” has been taken from the word “chloazian” which means “green” and “melasma” from the Greek word “melas” meaning black [1]. Because the pigmentation is never green in look therefore melasm is the preferred term. It is basically a disorder of pigment metabolism which is exteriorly characterised by sharply demarcated, blotchy, and brown macular lesion usually symmetrical in distribution seen mostly on cheeks and forehead [2]. Although, melasma can affect any group of people but mostly seen in Asian and Hispanic females [2]. In Unani system of medicine, Kalaf is clinically like chloasma caused by charred melancholic blood parts that ooze out of capillaries and get accumulated beneath the skin [2].

Epidemiology

Melasma physiologically occurs in pregnant women that usually resolve spontaneously after delivery, but some traces may persist [2]. Similarly, about 10-20% of women taking oral contraceptive pills may develop melasma that may be a marker for other causes of elevated oestrogen level. Although, 90% of the patients are women, and the clinical-histological characteristics are same in both sexes [3]. According to Unani medicine, prolonged exposure to sun and heat, unhygienic conditions, consumption of saqeel, hot and raddi aghdia, consumption of alcohol and post-menopausal periods of women are some important factors which predispose to development of melasma [4].

Etiopathogenesis

The exact cause of melasma is unknown; even though, various different factors have been implicated in its etio-pathogenesis including genetic influences, exposure to UV radiation, pregnancy, oestrogen and progesterone therapies, thyroid dysfunction, cosmetics, phototoxic and anti-seizure drugs. Three main factors in the development of Melasma are female hormones, sun light exposure, and genetic predisposition [2].

According to Unani system of medicine, there are several causative factors implicated in its causation including prolonged exposure to excess abnormal external heat; Dam-e-Muharraq (charred blood), Sauda-e- Muharraq (charred melancholic blood), Ghiza-e-Kaseef (indigestible food), constant local pressure, pregnancy, liver diseases i.e. D?u‘f al-Kabid (liver atony) and S?ugh?r al-Kabid [5].

Classification

Three important types of chloasma have been described in modern pathology i.e., epidermal, dermal and mixed [6]. In Unani Medicine, following types have been mentioned attributed to their causative factors [7,5].

1. Kalaf-e-Rahmi: It occurs in pregnant women and the common sites of the lesion are forehead, face, and chest.

2. Kalaf-e-Zarbi: It results due to constant pressure over anypart of the body leaving a hyper-pigmented lesion.

3. Kalaf-e-Kabidi: It occurs as a manifestation of liver diseases and the common distribution is face, forehead, and hands.

4. Kalaf-e-Hurri: It occurs due to prolonged exposure to sun rays and the lesions are distributed on the exposed body parts.

Treatment

Conventional treatment includes mercury-containing compounds, hydroquinone, corticosterone (steroid hormone of corticosteroid), tretinoin, azelaic acid, laser treatment, and chemical peels. The efficacy of these treatment modalities is good and rapid, but some serious side effects are also associated with it such as erythema, skin peeling, and burning and stinging sensation [8].

In Unani system of medicine, various treatment approaches have been mentioned to treat melasma such as drug therapy; dietotherapy, and Ilajbit- Tadbeer. The commonly used medicinal plants in Kalaf exhibit different pharmacological properties such as Jaali (detergent), Qashir (scaling), stripper, lavage, Ghassaal (irrigator), Mubassir (vesicant), Muhammir (rubefacient), Raade-Mawaad (divergent) and Mughazzi (nutrient). Some of the important single drugs with their reported mechanisms of actions are delineated in Table 1.

Table 1: Some important Unani medicinal plants used in Melasma.

1. Tukhm-e-Turb (Rhaphanus sativum)

It contains vitamin C, pelargodinin-3-sophoroside-5-glucoside and caffeic acid. These constituents possess “antioxidative” activity [7].

It is widely described in Unani literature as an effective and potent medicine in treatment of chloasma either singly or with any appropriate drug. It possesses Ja?li (detergent) action that helps lighten the hyper-pigmentation [5,9,10,11].

2. Maghz-e-BadamTalkh (Prunus amygdalus)

It is a rich source of vitamins, minerals, fatty acids, carbohydrate, proteins, and antioxidants. Due to high protein content, it has the capacity to lighten the melasma lesions. Almonds also contain vitamin E that not only improves the complexion, but also nourishes the skin; thereby nourishing it i.e., it possesses Mughazzi (nutritive) property; hence, it has been vastly prescribed in treatment of chloasma [9,10].

3. Sandal Sufaid (Santalum album)

It is very effective in treating chloasma and can be used as a mufrad or with other compounds [5,12]. It has been found that α–santalol present in sandalwood inhibit tyrosinase, an essential enzyme for the synthesis of pigment melanin. This property helps in limiting the abnormal pigmentation associated with aging and exposure [12,13]. It contains raade-mawaad (divergent) and blood purifier activities [14]. The raade-mawaad (divergent) property of sandal safaid helps in diverting the fasid mawaad of chloasma from the site of lesion and hence helps in reducing the condition.

4. Aab-e-Lemun (Citrus lemon)

It has high amount of vitamin C, citric acid, polyphenols, trapenes and tannins that help reduce and removing the melasma pigmentation [15]. The citric acid of lemon acts as a jaali (detergent) and helps in peeling off the outer skin layer. It is very helpful in treating chloasma [5,11,16].

5. Gul-e-Surkh (Rosa damascena)

Rose contains high amount of vitamin C, a powerful antioxidant and phenolic compounds that prevent and treat the chloasma [17]. The rose water can help to prevent sunburn. It is described in various books of Unani as a very effective drug for chloasma as well as in other diseases [5,9].

6. Arad-e-Baqla (Vicia feba)

It contains proteins, magnesium, potassium, calcium, and vitamin C [18-28]. It has J?ali (detergent) action to treat chloasma [5,9,11].

7. Kaf-e-Dariya (Cuttlefish bone)

It contains chitin included in many cosmetic preparations. It exhibits Q?shir property, hence, used in Kalaf [5,11].

8. Husn-e-Yusuf (Laminaria hyperborea)

It is a potent hydrator, conditioner, and Mughazzi (nutritive) drug for skin. It also detoxifies skin through minerals and vitamins present in it. It is very useful in treatment of chloasma and has been described in various texts of Unani Medicine [5,11].

9. Khayar (Cucumis sativus)

The antioxidants and silica are abundantly present in cucumber that helps in gradual lightening of dark spot of chloasma [18-29].

10. Maweez (Vitis vinifera)

According to Unani literature, Maweez also has Musaffi (blood purifier)11 and J?ali activities that help lighten the dark spots of Kalaf [16].

11. Yasmeen (Jasminum officinalis)

The cicatrizant and collagen enhancing properties of Yasmeen make it an exceptional remedy for treating Kalaf. Applying paste of Yasmeen on chloasma can permanently cure the disease [5,11].

12. A’sl (Honey)

Honey is rich in antioxidants, enzymes and other nutrients that nourish, cleanse, and hydrate the skin. It possesses J?ali property hence; it is very effective in treatment of Kalaf. It can be used either as a single drug or with other appropriate medicines [5,11].

13. Zafr?n (Crocus sativa)

Zafr?n is a marvelous drug of Unani Medicine, and has multiple beneficial roles in various diseases. Paste of Zafr?n and Kaddu Kuhna (old bottle gourd) is applied on chloasma [11]. It also contains kaempferol which is a natural flavanol responsible for strong anti-oxidant property [30-33].

Future Research Prospects

Melasma is a complex disorder and various factors are involved in its pathogenesis, identification of which will help us in developing better, more efficacious treatment options with less side effects, ensuring longer periods of remission. There are various treatment modalities for melasma mentioned in Unani texts. But the research trend towards melasma has been very dismal, even though being a common cosmetic problem. Very few clinical trials have been conducted that have various limitations including small sample size, study design, and ethical concerns (Table 2).

Table 2: Research Studies Conducted on Melasma in Unani medicine (Abbreviation: MASI; Melasma Area and Severity Index)

Hence, more randomized controlled trials are required to validate as well as evaluate their efficacy in melasma. Treatments consisting of fewer ingredients i.e., two to three drugs; may be easily evaluated with robust study designs. There is also needed to clarify the role of regimental procedures such as purgation and leech therapy as combination therapy to provide optimum results and prevent the relapses. Few future steps that may be considered while conducting trials on melasma are depicted diagrammatically (Figures 1 and 2).

Figure 1: Relative Comparison of Etiological Factors in Melasma (Abbreviation: OCP; Oral Contraceptive Pills)

Figure 2:Types of Melasma in Unani medicine.

Unani medicine has immense potential in curing melasma, but proper protocol development with robust study design including Black Box Design as the same is empowered with application of whole treatment regimes described in the classical texts. The basic problem faced in conducting research in Unani medicine like other traditional medical systems is evaluation of multi-drug regime as compared to conventional research framework, and while adopting this, the core concept of Unani medicine in melasma RCTs (Randomised Controlled Trials) is not fully adhered to. Hence, research organizations including WHO came up with black box design to implement the treatment regimes in phasic manner, but its acceptability within the scientific community of conventional medicine must be established. The same may be potentiated with employing newer measures like biomarkers to define the role of therapeutic measures (Figures 1-3).

Figure 3:Future Research Prospects.

Conclusion

Kalaf (chloasma) has been vastly discussed in Unani System of Medicine including its types, causes and treatment. The treatment modalities in Unani system of medicine are quite effective with no/ or minimal adverse effects. In addition to this, the Unani treatment is cost effective, economical and by far accessible.

Therefore, the efficacy and outcomes of different treatment modalities described in text should further be evaluated and validated by randomized clinical trials.

References

1. https://emedicine.medscape.com/article/1068640-overview. Accessed on 15-10-2018
2. Asia S, Tanveer AK. Clinical dermatology; Unani concept and management. New Delhi: S.R. Scientific Publication; 2010: 203-211
3. Frank CV, Gelber F, Klaus w, et al. Dermatology in general medicine.3rd ed. McGraw, UK. 1987;848-849
4. Khan HA. Hazique. Karachi: Madina Publishing Company; YNM: 550-551.
5. Ahmad HW, Moalajat vol 4, New Delhi: Qaumi Council Baraye Farogh Urdu Zaban; 2006: 30-35
6. Bagherani N, Gianfoldani S, Smoller B. ‘An Overview on Melasma’, Journal of Pigmentary Disorders 2015; 2 (10): 1-18.
7. Gutiérrez RMP and Perez RL. Raphanus sativus (Radish): Their Chemistry and Biology. TheScientificWorldJournal 2004; Vol- 4: 811–837 ISSN 1537-744X; DOI 10.1100/tsw.2004.131.
8. Thappa DM. Melasma (Chloasma): A review with current treatment option. Indian Journal of Dermatology 2004; 49 (4): 165-176.
9. Ghani AN, Khazain-ul-Advia. New Delhi: Idara Kitab-us- Shifa; 2011: 1275,324,1134,331,653
10. Rhazi AMBZ. Kitabul Mansoori, New Delhi: CCRUM; 1991: 199
11. Jafri SA, Siddiqee MY, Alhavi fit Tib. Vol- 23 part 2nd, Saba Publishers; 1994: 14-17
12. Aljamiul Mufradat Aladvia wal Aghzia vol- 3, New Delhi: CCRUM; 1999: 194
13. Moy RL, Levenson C. Sandalwood Album Oil as a Botanical Therapeutic in Dermatology. JClinAesthetDermatol 2017; 10 (10): 34-39.
14. Kauser H, Jahan N, Ahmed K, Aslam M, Ahmed P, Ahmed S. Unani perspective and recent studies of sandal safaid (santalum album linn.): A Review. World journal of pharmacy and pharmaceutical science July 2014; 3 (8): 2133-2145.
15. Tafseer MB, Latif A, Rauf A. LEEMU (Citrus lemon Linn.): A REVIEW. International Journal of Universal Pharmacy and Bio Sciences July-August 2016; 5(4): 141-146.
16. Tariq N.A. Taj-ul-Mufradat. New Delhi: Idara kitab-us-shifa; 2010: 120, 698.
17. Boskabady MH, Shafei MN, Saberi Z, Amini S. Pharmacological Effects of Rosa Damascena. Iranian Journal of Basic Medical Sciences July-Aug 201; 14(4): 295-307.
18. Alobaidi A.H, Hamad E.S, Kudair K.A, Alsamarai A.M, ‘Formulation of hypopigmentation creame and evaluation of its effect on skin pigment’ ,Our Dermatol Online 2014; 5(1): 9-13
19. Khan B.A, Akhtar N, Hussain I, Abbas K.A, Rasul A, ‘Whitening efficacy of plant extracts including hippophaerhamnoides and cassia fistula extracts on the skin of Asia patients with melasma’, Postepy Dermatol Alergol.2013 Aug;30(4):226-32.
20. Lukman M, Ulfa M, Syahruni R, Fatmawati. A, ‘Antityrosinase effect of botanicals; a review of medicinal plants cosmetic’. Journal of Chemical and Pharmaceutical Research, 2015, 7(5):716-722
21. Kanthraj G.R, ‘Skin lightening agents; New chemical and plant extracts-ongoing search for the holy grail’, Indian journal DermatolLeprol 2010; 76 (1): 3-6.
22. Clark A.K, Sivamani R.K, ‘Phytochemicals in the treatment of hyperpigmentation’, Dovepress Sept. 2016; Vol-6: 89-96
23. Mapunya M.B, Nikolova R.V, Lall N, Melanogenesis and anti tyrosinase activity of selected South African plants. Evidence based Complementary and Alternative Medicine 2012; 1-6. doi:10.1155/2012/374017
24. Sharma K, Joshi N, Goyal C. Critical review of Ayurvedic Varya herbs and their tyrosinase inhibition effect. Ancient Science of life 2015; 35 (1): 18-25.
25. Ghafari S, FahimiSh, SahranavardSh. Plants used to treat hyperpigmentation in Iranian traditional medicine; a review. Research journal of pharmacognosy 2017; 4(4): 71-85.
26. Wang Y et al, Preliminary screening of 44 plants extracts for anti-tyrosinase and antioxidant activities, Pak. J. Pharm. Sci. September 2015; 28 (5): 1737-1744.
27. Zaveri M, Patel A. preliminary screening of some selected plants for anti tyrosinase activity. International Journal of Institutional Pharmacy and Life Sciences January-February 2012; 2(1): 213-219.
28. Chemical composition of seeds and testa of Viciafaba L. Z LebensmUntersForsch. March 1995; 200 (3): 229-32.
29. Majoosi A.I.A. Kamil-al-sanah. New Delhi: Idarakitab-us-shifa; 2010:
30. Latif A, Zafar N, Abdullah. Randomised clinical trial of Unani formulations in chloasma/Melasma. Hippocratic journal of Unani medicine March 2012; 7(1): 19-31.
31. Gauri M, Ahmad T, Khan M.S, Ali S.J. Therapeutic evaluation of Unani herbal medicine for topical application (zimad of tukhme turb, tukhme karafs and sirka) in Melasma (Kalaf) – A single blind randomized controlled study. International Journal of Scientific Research December – 2015; 4 (12): 38-41.
32. Srivastava R, Ahmed H, Dixit RK, Dharamveer, Saraf S. A. Crocus sativusL: A comprehensive review. Pharmacogn Rev. Jul-Dec 2010; 4(8): 200–208.

*Corresponding Author:

Zareena Aquil
Central Research Institute of Unani Medicine
Hyderabad, Telangana State, India.
Telephone 55(98)981230696
e-mail zarzar.aquil@gmail.com

Received Date: December 11, 2018, Accepted Date: February 10, 2019, Published Date: February 18, 2019

Citation: Aquil Z, Khalid M, Uddin Q, et al. Potential role of Unani medicinal plants in management of Kalaf (Chloasma): A review. J Skin. 2019;3(1):1-2

Abstract

Kalaf (chloasma) is a brown macular hyper-pigmentation with well-defined scalloped symmetrical margins on cheeks, nose, forehead, and chin. The peak incidence is reported in the patients of 30-50 years of age. According to Unani system of medicine, Ghaleez Saudavi Bukharat (thick melancholic vapours) ascend towards the face and gets trapped beneath the skin; the dominance of abnormal black bile (Galba-e-Sauda) in the skin and blood are also involved in the disease pathogenesis. Vast body of literature is available in Unani Medicine for the treatment of melasma. Ancient Unani physicians such as Abu-al-Qasim Zohravi, ZakariyaRazi, IbnSina, Mohammad bin Tabri, and Ajmal Khan have described medicinal plants used for its treatment. The present review paper strives to explain the potential role of Unani medicinal plants used in the treatment of Kalaf

Keywords

Kalaf; Melasma; Chloasma; Unani medicines

The term “Chloasma” has been taken from the word “chloazian” which means “green” and “melasma” from the Greek word “melas” meaning black [1]. Because the pigmentation is never green in look therefore melasm is the preferred term. It is basically a disorder of pigment metabolism which is exteriorly characterised by sharply demarcated, blotchy, and brown macular lesion usually symmetrical in distribution seen mostly on cheeks and forehead [2]. Although, melasma can affect any group of people but mostly seen in Asian and Hispanic females [2]. In Unani system of medicine, Kalaf is clinically like chloasma caused by charred melancholic blood parts that ooze out of capillaries and get accumulated beneath the skin [2].

Epidemiology

Melasma physiologically occurs in pregnant women that usually resolve spontaneously after delivery, but some traces may persist [2]. Similarly, about 10-20% of women taking oral contraceptive pills may develop melasma that may be a marker for other causes of elevated oestrogen level. Although, 90% of the patients are women, and the clinical-histological characteristics are same in both sexes [3]. According to Unani medicine, prolonged exposure to sun and heat, unhygienic conditions, consumption of saqeel, hot and raddi aghdia, consumption of alcohol and post-menopausal periods of women are some important factors which predispose to development of melasma [4].

Etiopathogenesis

The exact cause of melasma is unknown; even though, various different factors have been implicated in its etio-pathogenesis including genetic influences, exposure to UV radiation, pregnancy, oestrogen and progesterone therapies, thyroid dysfunction, cosmetics, phototoxic and anti-seizure drugs. Three main factors in the development of Melasma are female hormones, sun light exposure, and genetic predisposition [2].

According to Unani system of medicine, there are several causative factors implicated in its causation including prolonged exposure to excess abnormal external heat; Dam-e-Muharraq (charred blood), Sauda-e- Muharraq (charred melancholic blood), Ghiza-e-Kaseef (indigestible food), constant local pressure, pregnancy, liver diseases i.e. D?u‘f al-Kabid (liver atony) and S?ugh?r al-Kabid [5].

Classification

Three important types of chloasma have been described in modern pathology i.e., epidermal, dermal and mixed [6]. In Unani Medicine, following types have been mentioned attributed to their causative factors [7,5].

1. Kalaf-e-Rahmi: It occurs in pregnant women and the common sites of the lesion are forehead, face, and chest.

2. Kalaf-e-Zarbi: It results due to constant pressure over anypart of the body leaving a hyper-pigmented lesion.

3. Kalaf-e-Kabidi: It occurs as a manifestation of liver diseases and the common distribution is face, forehead, and hands.

4. Kalaf-e-Hurri: It occurs due to prolonged exposure to sun rays and the lesions are distributed on the exposed body parts.

Treatment

Conventional treatment includes mercury-containing compounds, hydroquinone, corticosterone (steroid hormone of corticosteroid), tretinoin, azelaic acid, laser treatment, and chemical peels. The efficacy of these treatment modalities is good and rapid, but some serious side effects are also associated with it such as erythema, skin peeling, and burning and stinging sensation [8].

In Unani system of medicine, various treatment approaches have been mentioned to treat melasma such as drug therapy; dietotherapy, and Ilajbit- Tadbeer. The commonly used medicinal plants in Kalaf exhibit different pharmacological properties such as Jaali (detergent), Qashir (scaling), stripper, lavage, Ghassaal (irrigator), Mubassir (vesicant), Muhammir (rubefacient), Raade-Mawaad (divergent) and Mughazzi (nutrient). Some of the important single drugs with their reported mechanisms of actions are delineated in Table 1.

Table 1: Some important Unani medicinal plants used in Melasma.

1. Tukhm-e-Turb (Rhaphanus sativum)

It contains vitamin C, pelargodinin-3-sophoroside-5-glucoside and caffeic acid. These constituents possess “antioxidative” activity [7].

It is widely described in Unani literature as an effective and potent medicine in treatment of chloasma either singly or with any appropriate drug. It possesses Ja?li (detergent) action that helps lighten the hyper-pigmentation [5,9,10,11].

2. Maghz-e-BadamTalkh (Prunus amygdalus)

It is a rich source of vitamins, minerals, fatty acids, carbohydrate, proteins, and antioxidants. Due to high protein content, it has the capacity to lighten the melasma lesions. Almonds also contain vitamin E that not only improves the complexion, but also nourishes the skin; thereby nourishing it i.e., it possesses Mughazzi (nutritive) property; hence, it has been vastly prescribed in treatment of chloasma [9,10].

3. Sandal Sufaid (Santalum album)

It is very effective in treating chloasma and can be used as a mufrad or with other compounds [5,12]. It has been found that α–santalol present in sandalwood inhibit tyrosinase, an essential enzyme for the synthesis of pigment melanin. This property helps in limiting the abnormal pigmentation associated with aging and exposure [12,13]. It contains raade-mawaad (divergent) and blood purifier activities [14]. The raade-mawaad (divergent) property of sandal safaid helps in diverting the fasid mawaad of chloasma from the site of lesion and hence helps in reducing the condition.

4. Aab-e-Lemun (Citrus lemon)

It has high amount of vitamin C, citric acid, polyphenols, trapenes and tannins that help reduce and removing the melasma pigmentation [15]. The citric acid of lemon acts as a jaali (detergent) and helps in peeling off the outer skin layer. It is very helpful in treating chloasma [5,11,16].

5. Gul-e-Surkh (Rosa damascena)

Rose contains high amount of vitamin C, a powerful antioxidant and phenolic compounds that prevent and treat the chloasma [17]. The rose water can help to prevent sunburn. It is described in various books of Unani as a very effective drug for chloasma as well as in other diseases [5,9].

6. Arad-e-Baqla (Vicia feba)

It contains proteins, magnesium, potassium, calcium, and vitamin C [18-28]. It has J?ali (detergent) action to treat chloasma [5,9,11].

7. Kaf-e-Dariya (Cuttlefish bone)

It contains chitin included in many cosmetic preparations. It exhibits Q?shir property, hence, used in Kalaf [5,11].

8. Husn-e-Yusuf (Laminaria hyperborea)

It is a potent hydrator, conditioner, and Mughazzi (nutritive) drug for skin. It also detoxifies skin through minerals and vitamins present in it. It is very useful in treatment of chloasma and has been described in various texts of Unani Medicine [5,11].

9. Khayar (Cucumis sativus)

The antioxidants and silica are abundantly present in cucumber that helps in gradual lightening of dark spot of chloasma [18-29].

10. Maweez (Vitis vinifera)

According to Unani literature, Maweez also has Musaffi (blood purifier)11 and J?ali activities that help lighten the dark spots of Kalaf [16].

11. Yasmeen (Jasminum officinalis)

The cicatrizant and collagen enhancing properties of Yasmeen make it an exceptional remedy for treating Kalaf. Applying paste of Yasmeen on chloasma can permanently cure the disease [5,11].

12. A’sl (Honey)

Honey is rich in antioxidants, enzymes and other nutrients that nourish, cleanse, and hydrate the skin. It possesses J?ali property hence; it is very effective in treatment of Kalaf. It can be used either as a single drug or with other appropriate medicines [5,11].

13. Zafr?n (Crocus sativa)

Zafr?n is a marvelous drug of Unani Medicine, and has multiple beneficial roles in various diseases. Paste of Zafr?n and Kaddu Kuhna (old bottle gourd) is applied on chloasma [11]. It also contains kaempferol which is a natural flavanol responsible for strong anti-oxidant property [30-33].

Future Research Prospects

Melasma is a complex disorder and various factors are involved in its pathogenesis, identification of which will help us in developing better, more efficacious treatment options with less side effects, ensuring longer periods of remission. There are various treatment modalities for melasma mentioned in Unani texts. But the research trend towards melasma has been very dismal, even though being a common cosmetic problem. Very few clinical trials have been conducted that have various limitations including small sample size, study design, and ethical concerns (Table 2).

Table 2: Research Studies Conducted on Melasma in Unani medicine (Abbreviation: MASI; Melasma Area and Severity Index)

Hence, more randomized controlled trials are required to validate as well as evaluate their efficacy in melasma. Treatments consisting of fewer ingredients i.e., two to three drugs; may be easily evaluated with robust study designs. There is also needed to clarify the role of regimental procedures such as purgation and leech therapy as combination therapy to provide optimum results and prevent the relapses. Few future steps that may be considered while conducting trials on melasma are depicted diagrammatically (Figures 1 and 2).

Figure 1: Relative Comparison of Etiological Factors in Melasma (Abbreviation: OCP; Oral Contraceptive Pills)

Figure 2:Types of Melasma in Unani medicine.

Unani medicine has immense potential in curing melasma, but proper protocol development with robust study design including Black Box Design as the same is empowered with application of whole treatment regimes described in the classical texts. The basic problem faced in conducting research in Unani medicine like other traditional medical systems is evaluation of multi-drug regime as compared to conventional research framework, and while adopting this, the core concept of Unani medicine in melasma RCTs (Randomised Controlled Trials) is not fully adhered to. Hence, research organizations including WHO came up with black box design to implement the treatment regimes in phasic manner, but its acceptability within the scientific community of conventional medicine must be established. The same may be potentiated with employing newer measures like biomarkers to define the role of therapeutic measures (Figures 1-3).

Figure 3:Future Research Prospects.

Conclusion

Kalaf (chloasma) has been vastly discussed in Unani System of Medicine including its types, causes and treatment. The treatment modalities in Unani system of medicine are quite effective with no/ or minimal adverse effects. In addition to this, the Unani treatment is cost effective, economical and by far accessible.

Therefore, the efficacy and outcomes of different treatment modalities described in text should further be evaluated and validated by randomized clinical trials.

References

1. https://emedicine.medscape.com/article/1068640-overview. Accessed on 15-10-2018
2. Asia S, Tanveer AK. Clinical dermatology; Unani concept and management. New Delhi: S.R. Scientific Publication; 2010: 203-211
3. Frank CV, Gelber F, Klaus w, et al. Dermatology in general medicine.3rd ed. McGraw, UK. 1987;848-849
4. Khan HA. Hazique. Karachi: Madina Publishing Company; YNM: 550-551.
5. Ahmad HW, Moalajat vol 4, New Delhi: Qaumi Council Baraye Farogh Urdu Zaban; 2006: 30-35
6. Bagherani N, Gianfoldani S, Smoller B. ‘An Overview on Melasma’, Journal of Pigmentary Disorders 2015; 2 (10): 1-18.
7. Gutiérrez RMP and Perez RL. Raphanus sativus (Radish): Their Chemistry and Biology. TheScientificWorldJournal 2004; Vol- 4: 811–837 ISSN 1537-744X; DOI 10.1100/tsw.2004.131.
8. Thappa DM. Melasma (Chloasma): A review with current treatment option. Indian Journal of Dermatology 2004; 49 (4): 165-176.
9. Ghani AN, Khazain-ul-Advia. New Delhi: Idara Kitab-us- Shifa; 2011: 1275,324,1134,331,653
10. Rhazi AMBZ. Kitabul Mansoori, New Delhi: CCRUM; 1991: 199
11. Jafri SA, Siddiqee MY, Alhavi fit Tib. Vol- 23 part 2nd, Saba Publishers; 1994: 14-17
12. Aljamiul Mufradat Aladvia wal Aghzia vol- 3, New Delhi: CCRUM; 1999: 194
13. Moy RL, Levenson C. Sandalwood Album Oil as a Botanical Therapeutic in Dermatology. JClinAesthetDermatol 2017; 10 (10): 34-39.
14. Kauser H, Jahan N, Ahmed K, Aslam M, Ahmed P, Ahmed S. Unani perspective and recent studies of sandal safaid (santalum album linn.): A Review. World journal of pharmacy and pharmaceutical science July 2014; 3 (8): 2133-2145.
15. Tafseer MB, Latif A, Rauf A. LEEMU (Citrus lemon Linn.): A REVIEW. International Journal of Universal Pharmacy and Bio Sciences July-August 2016; 5(4): 141-146.
16. Tariq N.A. Taj-ul-Mufradat. New Delhi: Idara kitab-us-shifa; 2010: 120, 698.
17. Boskabady MH, Shafei MN, Saberi Z, Amini S. Pharmacological Effects of Rosa Damascena. Iranian Journal of Basic Medical Sciences July-Aug 201; 14(4): 295-307.
18. Alobaidi A.H, Hamad E.S, Kudair K.A, Alsamarai A.M, ‘Formulation of hypopigmentation creame and evaluation of its effect on skin pigment’ ,Our Dermatol Online 2014; 5(1): 9-13
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