Available online on 15.10.2021 at http://jddtonline.info

Journal of Drug Delivery and Therapeutics

Open Access to Pharmaceutical and Medical Research

Copyright   © 2021 The  Author(s): This is an open-access article distributed under the terms of the CC BY-NC 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited

Open Access  Full Text Article                                                                                                                                           Review Article 

Concept of Busoore Labaniya (Acne Vulgaris) and its Management In Light of Unani System of Medicine

Sultana Anjum ¹*  , Ayesha Tabasum ², Faisel Manzoor ³ , Mohammed Uwais Faisal ⁴ 

¹ PG Scholar, Dept. of Amraze Jild wa Tazeeniyat (Skin & Cosmetology), National Institute of Unani Medicine Bangalore (India) 560091

² PG Scholar, Dept. of Moalajat (Medicine), National Institute of Unani Medicine Bangalore (India) 560091

^{3 & 4} PG Scholar, Dept. Amraze Jild wa Tazeeniyat (Skin & Cosmetology), National Institute of Unani Medicine Bangalore (India) 560091

INTRODUCTION:

Skin disease is one of the most common human illnesses. It pervades all cultures, occurs at all ages, and affects between 30% and 70% of individuals.¹ According to different reports, the prevalence of skin diseases in the general population ranges from 7.86 percent to 11.16 percent. Skin diseases also have a substantial financial and psychological burden for the patients and their families.² Acne vulgaris is a virtually ubiquitous skin disorder in Westernized cultures, afflicting 79 percent to 95 percent of the teenage population.³ A study from the USA indicated that the prevalence by the mid-teens was virtually 100%.⁴ The global burden of acne is estimated to be 9.4% and it has been ranked as 8^th most prevalent disease all over the world.⁵ Globally around 85% of young adults aged 12-25 years, approximately 8% of adults aged 25-34 years, and 3% of adults aged 35-44 years old contain certain degree of acne.⁶ It affects approximately 40-50 million people in the United states per year, resulting in an annual cost of at least $ 2.5 billion in the United states, Acne accounts for ~0.3% of global disease burden and ~16% of the dermatologic disease burden.⁷ According to W.H.O: Acne is a skin condition that affects the pilosebaceous units in the face, neck, chest, and upper back. It first occurs at the start of puberty, when androgenic stimulation causes excessive sebum development and irregular follicular keratinization, as well as bacterial colonisation (Propionibacterium acnes) and local inflammation.⁸ Acne patients are more likely to have low self-esteem, low confidence, and social instability, all of which may lead to anxiety, depression, obsessive compulsive behavior, and suicidal ideation.⁹ it’s managed either pharmacologically or surgically in conventional medicines. For its treatment, pharmacological therapy involves topical and systemic therapy. Topical agents include benzoylperoxide, retinoids, azelaic acid, and clindamycin, while systemic treatment includes antibiotics (tetracycline, clotrimoxazole, ezithromycin), retinoids (isotretinoin), hormonal therapy (contraceptives), and anti-inflammatory medications. while surgical intervention includes incision and curettage of cysts.¹⁰ The long term use of these treatment modalities are often associated with certain side effects like erythema, irritation, peeling, burning, drying and bleaching of hair; use of isotretinoin has teratogenic effects and tetracycline causes gastrointestinal discomfort and diarrhea, etc.^11,12,13

MATERIAL AND METHODS

Unani classical books available in the National Institute of Unani Medicine library were reviewed for information related to busoore labaniya (Acne vulgaris)  such as Al-Qānūn, Mizanut-tib, Tibb-Akbar, Akseer Azam, Qarabadeen Azam wa Akmal, Haziq, Tarjuma Daqa-i-Qul Ilaaj, AlHawi, Kitabul Mukhtarat fittib, Tarjumae zakheera, Firdausul hikmat, Kitabul Taiseer, Kitabul Fakhir, Tazkira jaleel etc. Other published books and journals were also consulted for further details. 

DESCRIPTION OF BUSOORE LABANIYA IN UNANI LITERATURE

Busoore Labaniya is a well known disease since Greco Arabic period and was described by various renowned Unani physicians Ibn Sina, Zakariya Razi, Raban Tabari, Ibn Hubl, Dau’d Antaki and Akbar Arzani in their treatises. In Classical Unani literature, there are various synonyms present of Acne vulgaris (Busoore Labaniya).i.e. Ru’khara in persian,¹⁴ Muhasa in hindi, ^14,15 Zirwan,¹⁴ Pimples in English, Keel, Muhase in Hindi, ¹⁶   Buthūr-i-Labaniyya, Duhniya in Arabic Muhāsa, Kīl, Funsi in Urdu, Mukhadushika in Sanskrit.¹⁷ Acne Vulgaris are whitish eruptions on the nose and face that represent milk droplets or frozen ghee (Roghan zard). They typically occur during adolescence.^14,15,18

Ibn Sina (980-1037 A.D.) depicts in his treatise “Al Qanoon Fil Tib”  the cause of Busoore Labaniya as Ma’dde Sadidiyah which is directed towards skin for expulsion along with ghaleez Bukharat.¹⁹

Hkm Ajmal Khan (1864- 1927) has mentioned in “Haziq” that this ailment is not troublesome but if it is left untreated it may ruin the beauty of body and face.²⁰

Akbar Arzani in his treatise “Mezan al Tib” has mentioned Khilt Balgham as the main cause of Basoore labaniya.¹⁵

Hkm Azam Khan (1315 A.D.) has mentioned that Busoore Labaniya is usually caused by Ma’dde Sadeedi.²¹

Ismail Jurjani has quoted in Zakhira Khawarzam Shahi that usually morbid substances (Ma’dah ba’d) are admixed with good humors that prevent from creating any obnoxious effect over body. Sometimes these good humors get excreted (Istifragh) from body thus leaving behind the morbid humors (Ma’dah ba’d). Body expels these morbid humors (Ma’dah ba’d) towards skin that causes warm (swelling) or busoor (eruptions) over skin surface.²²

Hkm Ajmal khan has also mentioned lack of proper personal hygiene, menstrual disorders and unhealthy dietary habits as its causes.²⁰

Dau’d Antaki (died 1599) “Tazkira ulal Albab” has revealed the cause of Busoore Labaniya as filthy Ma’de Balghamiyah.²³

Historical background

Acne is derived from the Greek word acme, which means "point or spot." While acne has been mentioned since the time of Eber's Papyrus, it was only after Fuch coined the word "Acne Vulgaris" that it received a clear definition. Acne's origin dates back to three well-known ancient civilizations: Egyptians, Greeks, and Romans.^24,25 In the sixth century AD, the term “acne” was first used by the Emperor Justinian’s physician, Aetius Amidenus. It was later translated from Greek into Latin, its origin is from the Greek acme, meaning peak, or whether acne was actually the original term. In 1842, Erasmus Wilson separated acne simplex (acne vulgaris) from acne rosacea.⁷ Acne cannot be regarded as a serious disease or measured in terms of life and death, but it has a nuisance value out of all proportion to its seriousness, affecting young people when they are most sensitive to any disfigurement. Fuchs classified acne as Acne Vulgaris, Acne Mentagra, and Acne Rosacea in 1840. This was the first time the word "Acne Vulgaris" was used, and it has persisted on to this day.²⁶

 In 1920, Revlon Corporation's Jack Breitbart invented benzoyl peroxide for the treatment of acne, which was more effective and smelled better than previous sulphur treatments.

In 1930, laxatives were in common use for treatment of acne.

In 1990, Laser therapy was first used to treat acne, and it is now a commonly used treatment because it removes both new and old marks left by acne, as well as active lesions.

In 2000, The blue/red therapy was developed along with laser therapy for easy treatment of acne. Micro-needling with derma roller has emerged as a new treatment modality for the treatment option of acne scars.

Fernandes, in 2006, developed percutaneous collagen induction therapy with the derma-roller.²⁵

     Greco-Arabic (Unani) scholars have described ‘Busoore Labaniya’ in their legendary treatise.

• Ibn Sina (980-1037) also known as Avicenna in his legendary treatise ‘Al Qanoon Fil Tib’ (The Cannon of Medicine) has depicted the etiopathogenesis and clinical presentation of Busoore Labaniya.¹⁹
• Rabban Tabari (770-850 AD) described Sebaceous glands in detail in his legendary treatise ‘Firdous al Hikmah' (Paradise of Wisdom).²⁷
• Zakariya Razi (850-923 AD) also known as Rhazes explined treatment of Busoore Labaniya (acne) appearing over the face and nose in his prodigious text Al Hawi (The Virtuous Life)²⁸
• Ibn Hubl (1122-1213) transcribed in his treatise ‘Kitab al Mukhtarat Fil Tib’ (The selected or choice book in medicine) the clinical presentation and cause of Busoore Labaniya.²⁹ 
• Sabit Bin Qurrah (836-901 AD) has described in his treatise ‘Tajumae Zakheera’ various formulations for treatment of small eruptions (funsi) over the face.³⁰
• Abu Al Hassan Al Jurjani (12th century AD) in his monumental omnibus ‘Zakira Khawarzam Shahi’ (Thesaurus of the Shah of Khawarazam) has described the etiology of eruptions over the skin surface.²²
• Akbar Arzani (1772 AD) and Hkm Azam Khan (1813-1902 AD) have eloquently elucidated the clinical presentation of acne in their texts ‘Tibe akbar’, ‘Meezan al tib’ and ‘Akseer azam’.^14,15,18
• Dau’d Antaki (1541 AD died 1599) also referred as David of Antioch in his historic text ‘Tazkirah oolil albab’ has exposed the humoral cause of acne.²³

PATHOPHYSIOLOGY:

Busoore is a type of Waram (inflammation). The anomalies that occur in busoor are Su-i- mizaj, Su-i- tarkeeb, and Tafaruq-i- ittisal, and they are caused by Fasid Ma'dda, Az'a, Irregular diet, and Environmental facor.³¹ If any organ is unable to excrete out Fuzlat (waste material) from it or another organ, the Fuzlat is disposed of to the weak organ, and the weak organ is unable to dispose the waste as a result of Nutu or elevation arises in the organ. If this elevation does not rupture the skin or mucus membrane, then it is known as Waram, and if it crushes the elevation it is known as Busoor. Busoor which are on face and nose and are non-itching, then they are known as Labaniya.³² The causes of swelling are always external; Ṭabiyat (medicatrixnaturae) tries to eliminate the morbid material through the skin in the form of swellings and papules ^33,34 Ṭabīa̒t drives morbid material away from vital organs to the external ones to avoid any damage. If there is excess accumulation of vicious material in the body then Ṭabiat expels it towards skin, which leads to formation of Busoor and Awrām. If these are due to Quwwat-i-ṭabi‘ya (power of medicatrixnaturae), then severity is very less and easy to treat and if excessive deposition of morbid material is culprit, it is a vicious form of manifestation and very tough to be removed³⁵ As far as Unani system of medicine is concerned, most of the Unani physicians describe Busoore Labaniya in their treatises, and explain its etiopathogenesis on the basis of maddae sadidiya (Suppurative material). According to them, under favorable conditions latif bukharat (Vapors) of the body moves towards the surface of skin, where they condensed and transform into maddae sadidiya which could not be resolved due to its viscosity.¹⁹

SITES:

Acne is a polymorphic disease that primarily affects the face (99%) but also affects the back (60%) and chest (to a lesser extent) (15%). Acne affects 8% of 25-34 year olds and 3% of 30-44 year olds, despite the fact that it is typically an adolescent condition.¹³ Acne may appear on any hair-bearing skin, but some areas are more vulnerable than others. Larger sebaceous glands and hair follicles with small terminal hairs are found in these areas. The face, especially the cheeks, lower jaw, chin, nose, and forehead, is commonly affected. Back of neck, front of chest, back, and shoulders are other ‘favoured areas.' The scalp, however, is not involved.³⁶

CLINICAL FEATURES:

Disease commonly occurs at the age of 16–25 years on face, neck, shoulders, chest and back. Eruptions are red or white in color and size varies from a Dāna-i-khashkhāsh (poppy seeds) to a pea size.³⁹ These are small, with rigid base, pointed eruptions, and are red in color; after maturation, they excrete Kīl and pus.^37,39 On its tip, small amount of pus is there ³⁹. On pressing these eruptions, they excrete pus and something like solidified oil ¹⁸ leaving a pitting scar.³⁹  If Mawad is not excreted out, then it leaves a black spot.³⁹ If proper care and treatment is not taken, beauty of face and body become altered.²⁰ 

MANAGEMENT: 

In the Modern aspect, the treatment of acne vulgaris depends on its severity. mild acne treated by benzoyl peroxide, azelaic acid, topical retinoids, moderate acne treated by antibiotics, hormonal treatment, and severe acne treated by surgery and isotretinoin. 

General Measures:

Patients with acne are often depressed and may need sympathetic counseling and support.

1. Proper cleansing
2. Avoid use of cosmetics
3. Avoid picking of pimples
4. Avoid constipation
5. Diet rich in salads and fruits.¹⁶

Local Treatment:

Isotretinoin gel 0.05% applied once or twice daily

Adapalene gel 0.1% is a retinoid used for mild to moderate acne.

Tazarotene gel 0.1%, applied once daily

Systemic Treatment:

Topical antibiotics: Topical antibiotics are used in the treatment of mild to moderate inflammatory acne vulgaris The most commonly prescribed topical antibiotics are Erythromycin and clindamycin.⁴¹

Oral antibiotics: Oral antibiotics are indicated for the management of moderate to severe acne, which is resistant to topical treatment and covers large parts of the body surface.⁴¹ The oral antibiotics most commonly prescribed for acne include Doxycyclines, Minocycline, Macrolides, Clindamycin, Trimethoprim, Cotrimoxazole, and Quinolones all have efficacy in acne.^41,42

Hormonal Therapy: Hormonal therapy is an established second line treatment for female patients Indications of hormonal therapy in acne in girls and women include proven ovarian or adrenal hyperandrogenism, Hormonal therapies used in acne include antiandrogens, estrogens, OCs, low-dose glucocorticoids, or gonadotrophin-releasing hormone (GnRH) agonists.^7,41

Surgical Treatment: Comedo extraction, cryotherapy, Pulsed Dye Laser, Intralesional Steroid Therapy, Dermabrasion, chemical peels, Other Methods are Skin Needling (Percutaneous Collagen Induction herapy), Light and laser therapy, Dermal grafting, Silicone Gel, Soft Tissue Augmentation. ^10,43

USOOLE ILAJ:

1. Treatment of the main cause of disease ³⁷
2. Tanqiya of whole body. ^18,44
3. Tanqiya of Balgham from body.^15,44
4. Use of Mussafi Khoon advia.^14,44
5. Washing of face with Ja’ali advia.^14,21
6. Local application of Mujafif and Muhalil Advia.^14,19,38
7. Correction of digestion³⁹

ILAJ (Treatment):

It comprises of Ilaj Bil Tadbeer, Ilaj Bil Dawa, and Ilaj Bil Ghiza. 

1. Ilaj Bil Tadbeer:
2. Tanqiya of body and head by:
3. Fas’d of Sarar’o.¹⁴ and vessels of nose.¹⁴
4. Istefragh balgham from the body and brain¹⁸
5. Ishaal   ^14,18,38
6. Oral intake of decoction of Aftimoon.
7. Oral intake of Habe Qooqaya or Habe Ayaraj or Habe Sib’r.
8. Ilaj Bil Dawa:
9. It encompasses systemic therapy and topical therapy.
10. Istefragh balgham (evacuation of phlegm) is done by using Munzij (like Bekh Kasni, Asl us soos, Badiyan, Unnab)  and Mushil (like Turbud,Roghan bedanjir) therapy
11. Jali advia like Sandal safaid, Post sangtara, Haldi, Masoor etc.
12.  Muhallil advia are Khatmi, Methi, Alsi.

Systemic therapy: Unani physicians Ibn sina, Hkm Ajmal khan, Razi, Akbar Arzani mention in their treatise multiple preparations (nuskha) for Busoore labaniya.

• Joshanda for Mussafi Khoon advia as: Shahitra 4gms, Chraita 4gms, Sarfhooka 4gms, Gul Mundi 4gms, Unnab 5no, Shakar 6 gms.
• Formulations: Itriphal Shahitra at bed time in dosage of 7gms.
• Majoon Ushba 12 gms at bed time.²⁰
• Qurse Maveezi 2 in no. in morning and Mugarabi 2 in no. in evening with water.²⁰

 Topical therapy:

1. Formulations of Ub’tan: 
2. Magh’z Gungchi Safaid is mixed with Roghan Kunjad and applied over the face at night and washed next morning.¹⁴
3. Formulations of Zimad:
4. Saleekha along with Shah’d.¹⁴
5. Safeedah together with Roghan gul.¹⁴
6. Kharbaq 2 parts, Bekhe So’san 1 part admixed with Sirka.^18,28
7. Al’si, Gule Surkh, Kalonji together with Sirka.¹⁸
8. Formulations of Tila:
9. Murdarsang 3.5 gms, Sib’r Saqootri 17.5 gms, admixed with Roghan gul and Sirka. (Ratab eruptions)¹⁴
10. Khak’si, Sandal Surkh, Sandal Safaid together with Gulab.¹⁴
11. Shuneez mixed with Sirka.^28,38
12. Ilaj Bil Ghiza: 
13. Use of easily digestible foods viz. soups and chapatti.
14. Use of Vegetables possessing cold properties.
15. Use only Ghizā-i-Sāda (simple food items) like Turai (ridge gourd), Kaddu (pumkin), Palak (spinach), Shalgham (turnip), Mūng (green gram), Arhar (split red gram), mutton, etc.^37,39 
16. Regular intake of fruits i.e. oranges, pomegranates, apples and pears.
17. Avoid Raddi (waste), Fasid (Putrified) and badi (flatulent) agziyah like mash ki daal (black gram), matar (pea), gobhi (cauliflower)
18. Avoid to sharab intake.²⁰

RESULT AND DISCUSSION:

Despite the numerous successful therapies for acne vulgaris currently available but several patients struggle to respond adequately and experience side effects. Unani system of medicine contains successful and safe treatment of Acne vulgaris, so there is need to explore the Unani treatment of Acne vulgaris in general public for safe, economical and effective treatment. Mujaffif, Muhallil and Jali Advia are highly effective for the management of Busoore labaniya. Treatment is aimed at improving appearance, discomfort, and psychological wellbeing. It is an important disorder to treat, and it should not be dismissed as something trivial or purely cosmetic. Ghiza wa Parhez also play an important role in the management of Busoore labaniya.

Acknowledgement

Authors are thankful to library staff of NIUM for providing all kinds of literature related to this manuscript at the time of writing.

Conflict of Interest 

The authors report no conflict of interest.

Ethical Approval

It is not applicable.

REFERENCES:

1. Hay RJ, Johns NE, Williams HC et al. The Global Burden of Skin Disease in 2010: An Analysis of the Prevalence and Impact of skin conditions. J Invest Dermatol 2014; 134:1527-34. https://doi.org/10.1038/jid.2013.446

2. Jain S, Barambhe M.S, Jain J, Jajoo U.N, Pandey N. Prevalence of Skin Diseases In Rural Central India. A Community Based, Cross-Sectional, Observational Study. Journal of Mahatma Gandhi Institute of Medical Sciences. September 2016; 21(2):111-115. https://doi.org/10.4103/0971-9903.189537

3. Cordain L. et al. Acne vulgaris. A Disease of Western Civilization. Arch dermatomal. 2002; 138:1584-90. https://doi.org/10.1001/archderm.138.12.1584

4. Burns T, Breathnach S, Cox N, and Griffiths C. Rook's Textbook of Dermatology. 8th ed. Vol-II. UK: Wiley Blackwell; 2010: 17-43, 42.17-42.44.

5. Shams N, Niaz F, Zeeshan S, Ahmed S, Farhat S, Seetlani NK. Cardiff Acne Disability Index Based Quality of life in Acne Patients, Risk factors and Associations. J Liaquat Uni Med Health Sci.2018; 17(01):29-35. https://doi.org/10.22442/jlumhs.181710545

6. Sinha P, Srivastava S, Mishra N, Yadav NP. New Perspectives on Anti acne Plant Drugs Contribution to Modern Therapeutics. BioMed Research International Volume. 2014; 1-16. https://doi.org/10.1155/2014/301304

7. Bolognia JL, Schaffer JV, Cerroni L. Dermatology.Vol.1. 4th ed. USA: Elseivier; 2018: 588-601.

8. Om Prakash Katare et al. Acne. An Understanding of the Disease and its Impact on Life. Int. J. Drug Dev. & Res. 2012; 4(2):14-20.

9. Samanthula H, Kodali M. Acne and Quality of Life- A Study from a Tertiary Care Centre in South India. Journal of Dental and Medical Sciences. 2013; 6(3):59-62. https://doi.org/10.9790/0853-0965962

10. Fox L, Csongradi C, Aucamp M, Plessis J D, Gerber M. Treatment Modalities for Acne. Molecules 2016; 21:2-20. https://doi.org/10.3390/molecules21081063

11. Golwalla ASPI F. Golwalla S.A. Medicine for Students. 22nd ed. Mumbai: Dr. AF Golwalla Empress Court; YNM: 927-928.

12. Khanna N. Illustrated Synopsis of Dermatology and Sexually Transmitted Diseases. 5th edition. New Delhi: Elsevier, a division of Reed Elsevier India Private Limited; 2016: 120-130.

13. Lone A H, Habib S, Ahmad T, Anwar M. Effect of a Polyherbal Unani formulation in Acne Vulgaris: Journal of Ayurveda & Integrative Medicine. 2012; 3:180-83. https://doi.org/10.4103/0975-9476.104430

14. Khan A. Akseer Azam. Vol-4. Lucknow: Matab Munshi Naval Kishore; 1917: 450-1.

15. Arzani MA. Mizanut-tib. 4th Ed. New delhi: Idara Kitabul Shifa; 2002: 249.

16. Behh PN, Aggarwal A, Srivastava G. Practice of Dermatology, 9th Edn. New Delhi: CBS Publishers and Distributors; 2002; 408-09p.

17. Sultana et al. Buthūr-i-labaniyya (Acne vulgaris) With Special Reference to Unani Medicine: Review. Journal of AYUSH: 2015; 4(3): 1-6.

18. Arzani A. Tibe Akbar (Urdu Translation by Hussain M). Deoband: Faisal Publications; YNM: 722.

19. Ibne Sina Abu Ali. AL Qanoon (Urdu translation by Kantoori Sayed Ghulam Hasnain). Vol-II IV. New Delhi: Idara Kitab-ul-shifa; 2007:145-46:1432.

20. Ajmal khan MH. Haziq. Karachi: Madeena Publication; 1983:550, 590-592.

21. Khan A. QarabadeenAzam wa Akmal. New Dehli: Aijaz Publishing house; 1996: 343-44.

22. Jurjani I. Zakheera Khwarzam Shahi, Vol-II X. Lucknow: Munshi Nawal Kishor; New Delhi. 1878: 6:13-16, 45-49.

23. Antaki D. Tazkirah Oolil Albab (Arabic). Vol-II. New Delhi: CCRUM, Ministry of Health and Family Welfare; 2010: 87.

24. History of Acne and Its Treatment. Best Acne Treatment http://www.bestacnetreatment.org/history-of-acne-and-its-treatment.

25. Mohiuddin AK. A Comprehensive Review of Acne Vulgaris. Journal of Clinical Pharmacy. 2019; 1(1):17-45. https://doi.org/10.15226/2378-1726/6/2/00186

26. Grant RNR. The Section of the History of Medicine. The History of Acne. Proceedings of Royal Society of Medicine.1951; 44:649-52. https://doi.org/10.1177/003591575104400802

27. Al-Tabri AHAR. Firdausul Hikmat (Urdu Translation). New Delhi: Idara Kitabul Shifa; 2017: 60-61,128.

28. Razi AMBZ. Al Hawi Fil Tib. (Urdu Translation by Hakeem M.Y. Siddiqui). Part-2. Vol-23. Saba Publishers Aligarh, AMU, Aligarh; 1994:36-37.

29. Baghdadi A.B.A.B.H. Kitabul Mukhtarat Fit-tib. Vol-IV. New Delhi: CCRUM; 2007: 188-189.

30. Qurrah S.I. Tarjumae Zakheera Sabit Ibne Qurrah (Urdu Translation by Hakeem S.A, Ali) Litho Colour Printers Aligarh, AMU, Aligarh; 1987: 33-34.

31. Ghulam Husnain. Kamil-us-sana. Vol.1. Part.1. New Delhi: (CCRUM. Dept. of AYUSH). Mahar Graphics New Delhi; 2010: 177-79.

32. Siddiqui MMH, Jafari SAH. Tarjuma Daqa-i-Qul Ilaaj. Deoband: Mukhtar Press; YNM:478-80: I.

33. Mazhar HS. The General Principles of Avicenna's Canon of Medicine. New Delhi: Idara Kitaabush Shifa. 2007; 147p.

34. Ibn Zohar Amam. Kitabul Taiseer. New Delhi: CCRUM. 1986: 193-94p.

35. Razi ABMBZ. Kitabul Fakhir Fit Tib. New Delhi: CCRUM. 2005; I (I): 37-38p.

36. Marks R. Roxburgh's common skin diseases. 17th Edition. London: Arnold publisher; 2003: 149-57. https://doi.org/10.1201/b13512

37. Jeelani G. Makhzane Hikmat. New Delhi: Ejaaz Publications. 1996; II: 689.

38. Ahmad Jaleel. Tazkira jaleel. New Delhi: Mahar Graphics; 2008: 429.

39. Qurshi HM. Jamiul Hikmat. New Delhi: Idara Kitabush Shifa. 2011; 994-95p.

40. Chandra Joshi B, Sundriyal A. Healing Acne with Medicinal Plants: An Overview. Inventi Journals (P) Ltd. 2017; (2):1-13.

41. Chaudhary MK, Chaudhary M. A Review on Treatment Options for Acne Vulgaris. World Journal of Pharmacy and Pharmaceutical Sciences.2016; 5(7):524-545.

42. Ray C, Trivedi P, Sharma V. Acne and Its Treatment Lines. International Journal of Research in Pharmaceutical and Biosciences. 2013; 3(1):1-16.

43. Fabbrocini G, Annunziata MC, Arco VD, Devita V, Lodi G, Mauriello MC et.al. Acne Scars, Pathogenesis, Classification and Treatment. Dermatology Research and Practice. 2010; 1-13. https://doi.org/10.1155/2010/893080

44. Khwaja RA. Tarjuma Sharah Asbab. New Delhi: CCRUM. 2010; IV: 236p.