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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 3  |  Issue : 2  |  Page : 75-80

Management of xerosis cutis with cream of cashew shell oil: A case report


Department of Shalya Tantra, Amrita School of Ayurveda, Amrita Vishwa Vidyapeetham, Amritapuri, Kollam, Kerala, India

Date of Submission16-Jun-2020
Date of Acceptance28-Aug-2020
Date of Web Publication16-Oct-2020

Correspondence Address:
Dr. Rabinarayan Tripathy
Department of Shalya Tantra, Amrita School of Ayurveda, Amrita Vishwa Vidyapeetham, Amritapuri, Kollam, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JACR.JACR_36_20

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  Abstract 


Xerosis cutis is one of the common clinical conditions in clinical practice. Reduced skin hydration is the alarming characteristic of xerosis, that if ignored, can lead to insidious onset of cutaneous infections and chronic ulcers. Although various studies have been in vogue in this field, no standard method of treatment has yet been formulated. An abundantly available drug, cashew shell oil, has been used as a folklore practice in various parts of Kerala, for this condition. This case study is an attempt to evaluate the efficacy of cashew shell oil in cream form in the management of xerosis cutis of plantar surface. A 31-year-old female presented with the complaints of dry skin in the plantar region of the right foot with deep cracks, fissures, and flakes in the skin for two years. Diagnosis was done based on the clinical examination. Pre and post assessments were done based on DermaLab Combo parameters, namely hydration, transepidermal water loss (TEWL), skin pH, elasticity, temperature, skin color, videoscope, and Specified Symptom Sum Score system (scaling, roughness, redness, crack or fissure). Cashew shell oil cream was applied for a period of 30 days. Skin hydration levels improved and TEWL reduced after treatment. Skin pH, though raised during the period of intervention, came to normalcy by the end of treatment. There was improvement in skin viscoelasticity (VE), with reduced retraction time. The oil constituent being an antioxidant, reduces lipid peroxidation and protects from cell membrane damage, thus maintaining skin barrier function. Digital images evaluated using the DermaLab Combo parameters also depicted flaky dry skin being replaced by normal Stratum Corneum (SC) cells, with increased skin hydration. Cashew oil, though being a skin irritant, can be efficiently used in skin conditions, especially xerosis cutis, when administered in appropriate dose and formulation.

Keywords: Cashew shell oil, Padadari, skin hydration, transepidermal water loss, xerosis cutis


How to cite this article:
Jayaram J, Swathy S, Soumya M S, Raj S, Tripathy R. Management of xerosis cutis with cream of cashew shell oil: A case report. J Ayurveda Case Rep 2020;3:75-80

How to cite this URL:
Jayaram J, Swathy S, Soumya M S, Raj S, Tripathy R. Management of xerosis cutis with cream of cashew shell oil: A case report. J Ayurveda Case Rep [serial online] 2020 [cited 2020 Dec 2];3:75-80. Available from: http://www.ayucare.org/text.asp?2020/3/2/75/298293




  Introduction Top


Various occupational screening examinations have revealed that, approximately every third individual between the age of 16 and 70 years is affected by xerosis cutis. The prevalence increases with increasing age. Older individuals have been shown to develop xerosis cutis in 99.1% of cases.[1] Xerosis cutis of feet is a condition very much closer to Padadari mentioned under Kshudraroga by Acharya Sushruta. Here, Vata increased due to excessive walking produces cracks in the soles of feet. In Padadari, venepuncture, unction, and sudation should be done, followed by external application of a medicine in the form of ointment with bee wax as base.[2],[3]

Xerosis cutis or dryness of epidermal layers of skin, attributed to the Stratum Corneum (SC), is characterized by decreased quality and quantity of hydrophilic substances and lipids.[4] With diminished hydration in cutaneous layers, the normal regulation of skin homeostasis is impaired.[5] Water molecules lost from the SC, though normal in small amounts, can be hazardous when increased beyond a limit. This can result in dysfunctional Natural Moisturizing Factors (NMFs) in the SC, which will further evoke loss of skin moisture. The NMF is responsible for preserving hydrated structures in conditions of compromised hydration.[6] The bi-lipid layer matrix of SC encasing layers of corneocytes, is periodically desquamated, thereby maintaining the normal texture of skin.[7] This empowers the skin barrier mechanism. It is due to the dysfunctional skin barrier that the skin undergoes dryness way beyond normal limits and is unable to prevent the excessive loss of moisture from SC. The skin barrier mechanism is also contributed by the acidic pH of skin, the sebum secretions, and the elasticity of skin. In xerosis cutis, the level of skin pH and elasticity varies. It has been found that, a normal cutaneous acidic level between 4 and 6 pH enables the skin to maintain normal lipid secretions.[6] Various intrinsic and extrinsic factors are responsible for the development of xerosis cutis. Use of soaps, exposure to cold, low humidity, repeated bathing, etc., are a few of the common etiology that enhances the loss of water from the SC.[7] The NMF in the corneocytes are responsible for the regulation of normal corneocyte desquamation. Xerosis cutis is a result of dysfunction of the NMF due to impaired desquamation of corneocytes, which is involved in reduced hydration of skin. Studies show that lower limbs, especially foot, are more affected than arms, trunk, and face.[4] Xerosis cutis of the plantar region can result in flaking of the plantar skin with heel cracks and fissures.

Although various studies have been undertaken for the evaluation and management of this condition, a satisfactory efficient remedy is not yet available. Cashew shell oil is an inexpensive and abundantly available drug, which can be a better choice than that of other classical formulations. With this background, the efficacy of cashew shell oil in cream form in the management of xerosis cutis is thought of. Cashew shell oil has been used as a folklore medicine since many years for plantar cracks and fissures due to xerosis cutis of plantar skin.[8] In Ayurveda, cashew is referred as a medicine for skin disorders, ulcers, and infectious conditions.[9]


  Case Report Top


A 31-year-old, non-hypertensive, non-diabetic female reported to the outpatient department in July 2019 with complaints of dry skin in the plantar region of the right foot with deep cracks, fissures, and flakes in the skin for two years. There was slight redness in the affected area. Detailed history and clinical examination revealed no significant family history, medical history, or conditions involving systemic diseases. On the basis of clinical history and examination, the condition was diagnosed as xerosis cutis. Other dermatological diseases were ruled out based on clinical observations. Plantar psoriasis which has similar symptoms of dry scaly skin was ruled out as the cardinal features such as erythematous sharply defined plaques and other features such as Auspitz's sign and candle grease sign characteristic of psoriasis were absent.[10] “Itch that rashes” is the main clinical feature of eczema. As such itching was absent in this case, eczema was excluded out.[11] Vipadika is a condition similar to Padadari. It is characterized by Pani-pada Sphutana (~fissure in the palm and soles) and Teevra vedana (~with severe pain). The Doshas involved in Vipadika are Vata and Kapha dosha.[12] Padadari is a Vata-predominant condition unlike Vipadika. Besides, severe pain is not a feature present in this case. Therefore, Vipadika can also be ruled out from the diagnosis. Hence, the present case was diagnosed as xerosis cutis based on physical examination and DermaLab Combo assessment including high-resolution images and Specified Symptom Sum Score (SRRC) system (scaling, roughness, redness, crack, or fissure).

Clinical findings

Inspection of the plantar skin revealed a dry scaly skin, with skin plaques, redness, cracks, and fissures, with palpation, roughness of the dry skin, cracks, and fissures felt.

Therapeutic intervention

Preparation of cream

Cashew shell oil was extracted by roasting method. The oil was converted into cream form with 50% concentration of oil and cream base (paraffin oil, paraffin wax, triethanolamine, stearic acid, and water). Methyl paraben and propyl paraben were added as preservatives. The aqueous and oil mixtures were heated to 80°C simultaneously to attain a homogeneous mixture of the contents. It was then added slowly and triturated continuously and manually to form emulsion with creamy consistency. The product was allowed to cool, and then collected and preserved in an air-tight container.

Method of intervention

The patient was instructed to clean the affected area, make it dry, and apply the cream twice a day for a period of four weeks. The patient was advised to avoid the use of other products or soaps during the study period.

Diagnostic assessments

The outcome measures were assessed with DermaLab Combo. It is a multi-parameter skin analysis system operated by a wirelessly connected tablet PC. It can be freely configured with the parameters including hydration, TEWL, skin pH, elasticity, temperature, skin pigmentation, and videoscope image by using specific probes. Subjective criteria for assessment were based on the SRRC system by scoring the values for scaling, redness, roughness, cracks, and fissures, developed by the European group on efficacy measurement of cosmetics and other topical products.[13] Weekly assessment with DermaLab Combo and SRRC scoring system was done based on the above-mentioned parameters to estimate the pre- and post-levels of skin dryness.


  Timeline Top


A timeline of the events during the treatment period is shown in [Figure 1].
Figure 1: Timeline of events during the treatment period

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  Follow up and Outcome Top


The pre and post values [Table 1] showed increased skin hydration and decreased TEWL levels after the treatment duration of four weeks. The skin pH levels initially were normal and increased during the treatment period and again declined to normal pH of the skin by the end of four weeks. The viscoelasticity (VE) increased after treatment, but the elasticity values were rather not much affected. The melanin and erythema values increased during cream application and had returned to normal with the completion of treatment. Temperature variation before and after treatment, was negligible. The videoscope images [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6] showed gradual diminution of cracks and flakes to normal skin, even though the image clearly specified the pigmentation of the skin during the trial period. The scoring system based on scaling, redness, roughness, cracks, and fissures also showed periodic reduction of scores by the end of treatment [Table 2]. No adverse effects were found during the treatment period and follow-up.
Table 1: DermaLab Combo assessment values

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Figure 2: First assessment – Before treatment

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Figure 3: Second assessment – After one week of treatment

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Figure 4: Third assessment – After two weeks of treatment

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Figure 5: Fourth assessment – After three weeks of treatment

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Figure 6: Fifth assessment – After four weeks of treatment

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Table 2: Assessment based on the Specified Symptom Sum Score system

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  Discussion Top


Xerosis cutis causes plugging up of corneocytes on SC, leading to flakiness, callosity, cracking, fissuring, scales, tenderness, and pain. Xerosis cutis of feet is a condition very much closer to Padadari. In Padadari, venepuncture, unction, and sudation should be done, followed by external application of a medicine in the form of ointment with bee wax as base to maintain moisture and prevent further crack formation.[14]

The relationship between xerosis cutis and the values of hydration, TEWL, skin pH, elasticity, temperature has been established in various studies. The cutaneous barrier function is maintained by its water content. Furthermore, studies show that dermatological dysfunction results due to curtailed hydration levels of skin.[15] TEWL, a criterion which can be used to characterize barrier function of skin, is the amount of water molecules escaped from within the skin to the external environment.[16] As the skin dryness decreases, there is improvement in hydration levels of skin and reduction in TEWL.[16],[17] This indicates that the skin physiology has improved and its moisture levels are maintained after the trial period. By disseminating the plugged-up corneocytes, which are responsible for the loss of normal regulation of TEWL and hydration, the skin attains better moisturizing levels after the application of cashew shell oil cream. In addition, the cream, with both the drug and the cream bases being oil, can act as a barrier to reduce the TEWL. The skin being more lipophilic than hydrophilic,[18] can easily absorb the oil content in the drug and thus maintains its hydration. Cashew shell oil is a mixture of cardanol, cardol, and anacardic acid. It is found to accelerate wound healing.[19] The antibacterial and wound-healing activities of cashew nut shell liquid have been analyzed systematically. It has been found to accelerate wound closure in L929 cells.[8] Cardanol being an antioxidant reduces lipid peroxidation and protects from cell membrane damage, thus maintaining the skin barrier function and balancing TEWL and hydration.[5]

The normal skin pH is between 4 and 6. The acidity of skin is compromised in xerosis cutis.[4] In addition, studies reveal that an alkaline skin is specifically susceptible to cutaneous infections.[20] Increased skin pH during treatment reflects a chronic state of SC instability, which could be predisposing individuals to recurrences.[20] As the xerosis is relieved, the skin pH returns to normal levels. Normal skin is slightly acidic in nature as the acid mantle layer plays a significant role in maintaining the skin barrier function. pH has a role in lipid synthesis, differentiation, and desquamation of epidermal layers. The skin pH also regulates enzymes of ceramide metabolism such as β-glucocerebrosidase and acid sphingomyelinase enzymes. These ceramides are an important component of the lipid bi-layer matrix where corneocytes are embedded. Proteases such as chymotryptic enzyme and cathepsin D linked to epidermal differentiation and desquamation are under the control of pH.[7] Cashew shell oil being an acidic compound due to the presence of anacardic acid,[21] has a role here to reduce the alkalinity of the skin, thereby maintaining a normal skin barrier function. During the treatment period, it can be seen that the pH levels are raising and even fluctuating to alkaline pH. This is due to the fact that the accumulated layers of corneocytes are getting desquamated by the intervention, and this results in raised pH levels. It has been found that disruption of the physical barrier results in raised pH levels.[20] After the treatment, the skin pH levels attain normal acidity as the acid mantle layer functionality is maintained, thus regaining the skin barrier function.

Skin elasticity and VE though are closely related terms, the hydrated skin shows better variations in skin VE rather than skin elasticity. Elasticity is the immediate response of the skin contributed by thin elastin fibers. During the treatment, the clogged-up layers of corneocytes get desquamated and as a result the dry skin layer peels off. Thus, it reduces the elasticity values. VE refers to the bouncing property of the skin due to the quality of viscosity of close bound molecules. VE is provided by the fluids in the cutaneous layers and the thick fibers of cross-linking collagen and elastin proteins. It is the mechanism which protects the skin from minor wear and tear.[22] With the application of cashew shell oil cream, the water-binding property of SC increases, thereby raising the VE levels. In the present study, from the pre and post values, it is clear that the VE had increased after treatment and elasticity had slightly reduced after treatment. However, the reduced retraction time indicates the restoration of healthy skin layers [Table 1].

Previous studies on thermoregulation property of skin and its relationship with skin dryness reveal that xerosis is less likely to develop in higher temperatures. The cold stress test and the recovery time from cold stress show an indirect relation with the xerosis pathology. Skin carries out thermoregulation with the aid of sympathetic responses, providing timely vasodilation and vasoconstriction with higher and lower temperatures, respectively. Therefore, temperature has effect on skin physiology. In addition to this, cold-induced vasodilation, which occurs as a protective mechanism against ischemic damage, is found to be reduced with increasing age.[23] In the present study, there is no remarkable variation in the skin temperature during the trial period. However, the hot potency of the drug as described in Ayurveda can be incorporated here to hypothetically lay down a link with reversing skin dryness.

The scaling, roughness, redness, crack, and fissure values have reduced in this condition with the intervention. This is due to the improved desquamation of the SC layers which have been clogged up in piles due to xerosis cutis. With withering off of old corneocytes, the NMFs of SC become functional and regain their ability to regulate skin moisturization and thus improve the skin barrier function. This can lead to a well-balanced level of TEWL and skin hydration.


  Conclusion Top


Cashew oil, though being a skin irritant, can be efficiently used in skin conditions, especially xerosis cutis, when administered in appropriate dose and formulation. However, trials conducted on a larger population are required to assess the wide applicability of the drug in xerosis cutis. The pigmentation of the skin with the application of cashew shell oil cream, though temporary, needs to be furnished with better formulations which can mask the pigmenting effect of the drug. More studies on the action potential of the drug would enable addressing more dermal pathologies efficiently.

Declaration of patient consent

Authors certify that they have obtained patient consent form, where the patient/caregiver has given his/her consent for reporting the case along with the images and other clinical information in the journal. The patient/ caregiver understands that his/her name and initials will not be published and due efforts will be made to conceal his/her identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

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