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Open Access Full Text Article                                                                       Review Article

Itrifal Shahtara for Eczema (Nar Farsi): A Comprehensive Review of Phytochemistry, Mechanisms, and Therapeutic Relevance

Madiha Akhtar ¹*, Munawwar Gauri ¹, S.M. Abbas Zaidi ², Mohammad Anzar Husain ¹, Saima Sharfuddin ³

1. Department of Amraze Jild wa Tazeeniyat, H.S.Z.H. Govt. Unani Medical College, Bhopal 
2. Department of Moalajat, H.S.Z.H. Govt. Unani Medical College, Bhopal 
3. Department of Ilaj bit Tadbeer, H.S.Z.H. Govt. Unani Medical College, Bhopal

 

 

Introduction

Skin disorders represent a major global health concern and are among the most prevalent conditions affecting individuals across all age groups. Beyond their physical manifestations, dermatological diseases often impose significant emotional and psychological distress, thereby adversely affecting quality of life. It has been estimated that skin diseases constitute nearly 34% of all occupational disorders worldwide, highlighting their substantial public health burden ¹.

Eczema, referred to as Nar Farsi in the Unani system of medicine, is a chronic inflammatory dermatosis characterized by intense pruritus and recurrent exacerbations. Clinically, it presents with a wide spectrum of manifestations including dryness, erythema, excoriation, exudation, fissuring, hyperkeratosis, lichenification, papulation, scaling, and vesiculation. These features arise from underlying pathological changes such as epidermal edema, acanthosis, hyperkeratosis, and inflammatory infiltration of lymphoid and histiocytic cells within the dermis ². Among these symptoms, pruritus is the most distressing and cardinal feature, often triggering a persistent itch–scratch cycle that severely interferes with sleep, daily functioning, and psychosocial well-being ¹. Globally, eczema affects approximately 2–10% of the population, with increasing prevalence observed in both developed and developing regions ³.

In Unani medicine, eczema is described under various terminologies such as Nar Farsi, Chajan, Akota, and Chambal. Classical Unani scholars have provided detailed clinical descriptions of the condition. Hakim Kabiruddin characterized eczema as a cutaneous disorder marked by intense burning sensations over the lesions, likening it to the sensation of fire ⁴. Similarly, Jurjani, in his renowned work Zakhira Khwarzam Shahi, described Nar Farsi as a skin disease associated with fluid-filled vesicles accompanied by severe burning and itching ⁵.

The extensive dermatological literature of Unani medicine, supported by centuries of empirical use, underscores the therapeutic potential of its herbal formulations in chronic skin disorders. Among these, Itrifal Shahtara is a classical polyherbal formulation traditionally prescribed for conditions associated with blood impurity, pruritus, and inflammatory dermatoses. It is attributed with Musaffi-i-dam (blood purifying), anti-pruritic, and emollient properties ⁶. The formulation comprises multiple medicinal plants known for their pharmacological activities relevant to the pathogenesis of eczema.

The present review aims to critically evaluate the therapeutic relevance of Itrifal Shahtara in the management of eczema by systematically analyzing the phytochemical composition and pharmacological actions of its individual constituents, and correlating these effects with contemporary understanding of eczema pathophysiology.

Pathophysiology of Eczema

According to classical Unani literature, eczema (Nar Farsi) is attributed to the presence of corrosive (Akkal), hot (Harr), and irritant (Lazih) substances within the body. These morbid materials are believed to circulate through the blood or arise from the pathological interaction of Harr (bilious and sanguineous humors) with Yabis Sawdawi Madda (dry melancholic humor), as well as the predominance of Haad Safra (irritant bile). This humoral imbalance results in inflammation, burning sensation, and pruritic cutaneous manifestations characteristic of eczema^7,8.

From the perspective of contemporary medicine, eczema is a multifactorial disorder resulting from a complex interplay between genetic predisposition, immune dysregulation, and epidermal barrier dysfunction. A positive family history significantly increases disease susceptibility. The Filaggrin gene (FLG), located on chromosome 1q21, plays a central role in maintaining the integrity of the stratum corneum. Loss-of-function mutations in FLG impair filaggrin synthesis, leading to defective barrier formation and reduced natural moisturizing capacity of the skin.

Immune dysregulation further contributes to disease pathogenesis, particularly through the predominance of T-helper 2 (Th2) mediated immune responses. This results in increased production of cytokines such as interleukins (IL-4, IL-13, and IL-31), which promote B-lymphocyte activation, hyper-eosinophilia, elevated serum IgE levels, and enhanced histamine release, culminating in inflammation and intense pruritus. IL-4 and IL-13 also suppress filaggrin expression, thereby aggravating epidermal barrier dysfunction, while IL-31 plays a direct role in itch signaling.

Additionally, disruption of the epidermal barrier leads to decreased ceramide levels, increased trans-epidermal water loss (TEWL), xerosis, and heightened skin permeability, which predispose patients to microbial colonization and recurrent flare-ups. Environmental and lifestyle factors such as allergens (pollens, food and contact allergens), psychological stress, and irritants further exacerbate disease severity and recurrence ⁹.

Management of Eczema

In Unani system of Medicine, the management of Nar Farsi is based on the principles of eliminating morbid humors, correcting humoral imbalance, and alleviating local symptoms. Therapeutic strategies include avoidance of known triggers and evacuation of corrosive, hot, and irritant substances through procedures such as Fas’d (venesection), Irsal-i-Alaq (leech therapy), and Hijama (cupping). Additional measures involve Tasfiya al-Dam (blood purification), administration of anti-pruritic medications, and the use of Mundij-i-Safra (bile-concoctive drugs) followed by Mus’hil (purgatives) to expel pathological humors from the body ^7,8.

In conventional medicine, the primary goal of eczema management is symptomatic control and prevention of disease exacerbations. Standard therapeutic approaches include the use of emollients to restore skin hydration, topical corticosteroids, calcineurin inhibitors such as tacrolimus, and systemic therapies including corticosteroids, methotrexate, cyclosporine, and ultraviolet (UV) phototherapy in severe or refractory cases. While these interventions are often effective in controlling acute symptoms, their long-term use is associated with significant adverse effects.

Prolonged exposure to corticosteroids and immunosuppressive agents may lead to complications such as skin atrophy, increased susceptibility to bacterial and viral infections, weight gain, alopecia, hypertension, osteoporosis, glaucoma, cataracts, growth retardation in children, menstrual irregularities, and organ toxicities including hepatotoxicity and nephrotoxicity. These limitations underscore the need for safer, well-tolerated, and sustainable therapeutic alternatives for long-term management of eczema ^10.

Methodology (Materials & Methods)

A comprehensive literature search was conducted to identify studies reporting the role of medicinal plants in the management of eczema. Electronic databases including PubMed, MEDLINE, Web of Science, Elsevier, Research Gate, Google Scholar, and Science Direct were systematically searched. In parallel, classical Unani medical texts available in the library of H.S.Z.H. Government Unani Medical College were reviewed to identify traditional formulations indicated for alleviating eczematous symptoms. Based on the frequency of citation in classical literature and the availability of contemporary scientific evidence, Itrifal Shahtara was selected for detailed evaluation. The phytochemical constituents of Itrifal Shahtara and their reported pharmacological activities relevant to eczema are summarized in Table 1.

Itrifal Shahtara and its Constituents                                                                                                  

Itrifal Shahtara is a classical Unani polyherbal formulation comprising eight medicinal ingredients: Shahtara (Fumaria officinalis), Post Halela Zard (Terminalia chebula), Post Halela Kabli (Terminalia chebula), Post Balela (Terminalia bellirica), Amla (Emblica officinalis), Barg-e-Sana Makki (Cassia augustifolia), Gul-e-Surkh (Rosa damascena), and Maweez Munaqqa (Vitis vinifera). These ingredients are combined in specific proportions and prepared in a semi-solid dosage form known as Itrifal, which has been used for centuries in Unani medicine for the management of various chronic ailments, including eczema.⁶

According to classical Unani literature, Itrifal Shahtara exhibits multiple therapeutic actions such as Musaffi-e-Khoon (blood purification), Dafa‘-e-Fasād-e-Khoon (correction of hemodynamic disturbances), Dafa‘-e-Ta‘affun (antiseptic), Mana‘wa Dafa‘-e-Ta‘diya (bacteriostatic and bactericidal), Qatil-e-Kirm-e-Shikam (anthelmintic), Nafi‘-e-Kharish (anti-pruritic), and Mudir-e-Baul (diuretic) properties ¹¹. These actions collectively support its traditional use in inflammatory and pruritic skin disorders.

Fumaria officinalis

Fumaria officinalis is a small herb belonging to the family Papaveraceae (Fumariaceae) and is widely distributed across Eastern Mediterranean regions. Traditionally, its aerial parts have been used in the treatment of inflammatory and painful conditions. In Unani medicine, its temperament is described as Murakkab-ul-Quwa, and it is regarded as a potent blood purifier, commonly prescribed for syphilis, pruritus, dermatophytosis, vesicular eruptions, and other skin ailments ¹².

Phytochemically, F. officinalis contains isoquinoline alkaloids with documented antibacterial and antioxidant activities, along with polyphenolic compounds such as caffeic acid, rosmarinic acid, and apigenin, and alkaloids including chelerythrine and fumaritine. Notably, the presence of fumaric acid esters (FAEs) has attracted scientific interest due to their established use in inflammatory dermatoses such as psoriasis. FAEs exert immunomodulatory effects by downregulating type-I cytokine secretion from T-helper lymphocytes, resulting in reduced interferon-gamma (IFN-γ) levels and inhibition of T-lymphocyte proliferation ¹³. The British Herbal Pharmacopoeia recognizes fumitory as a remedy for cutaneous eruptions and specifically recommends it for chronic eczema ¹⁴.

Triphala

Triphala is a well-known formulation in Unani medicine composed of the fruits of Terminalia chebula, Terminalia bellirica, and Emblica officinalis. It is a mandatory component of all Itrifal formulations and is widely used in dermatological conditions due to its antiviral, antibacterial, antifungal, antiallergic, and wound-healing properties.

 

 

Terminalia chebula

Terminalia chebula, belonging to the family Combretaceae, is native to India and Southeast Asia. Its fruit has been used for centuries as a traditional remedy for various chronic diseases. In Unani medicine, its temperament is described as cold and dry, and it is considered a blood purifier effective in chronic melancholic disorders such as leprosy and pruritus ¹⁵.

The fruit contains bioactive phytochemicals including phenolic acids and flavonoids such as ellagic acid, gallic acid, and chebulic ellagitannins, which confer anti-inflammatory, antioxidant, cytoprotective, hepato-protective, antiviral, and antiproliferative effects. Experimental studies have demonstrated that T. chebula extracts are effective in ameliorating symptoms of atopic dermatitis, a condition synonymous with eczema ¹⁶.

Unani scholars classify T. chebula into different types based on the stage of fruit maturation ¹⁷:

• Halela Siyah (Halela Hindi): Unripe fruit without seed; cold and dry temperament; used as a blood purifier in chronic skin conditions ¹⁵.
• Halela Zard: Yellow, ripened fruit containing seed.
• Halela Kabli: Fully mature, large fruit

Terminalia bellirica

Terminalia bellirica is a deciduous tree of the Combretaceae family, widely distributed in the Indian subcontinent. Its temperament is described as cold and dry ¹⁸. The plant exhibits astringent, laxative, antipyretic, anthelmintic, and antimicrobial properties, attributed to phytochemicals such as alkaloids, flavones, lignins, tannins, phenols, coumarins, terpenoids, and glycosides ¹⁹. Experimental evidence suggests that T. bellirica enhances immune function, delays aging processes, and improves resistance against pathogens ²⁰.

Emblica officinalis (Amla)

Emblica officinalis, belonging to the family Phyllanthaceae, is widely cultivated in tropical and temperate regions. In Unani medicine, it is described as having a cold and dry temperament and is commonly used in skin disorders such as eczema and dermatitis, possibly due to its Musakkin-e-Safra wa Khoon (bile and sanguine modulating) action ²¹.

The fruit is rich in ellagic acid, gallic acid, flavonoids, tannins, phenolic compounds, and vitamins, conferring anti-inflammatory, antioxidant, antifibrotic, antibacterial, antiproliferative, and antiallergic effects. Clinical studies have demonstrated that E. officinalis fruit extracts protect skin keratinocytes from inflammation and apoptosis, supporting its role in inflammatory dermatoses ²².

Cassia augustifolia

Cassia augustifolia, a member of the Fabaceae family, is distributed across subtropical and tropical regions including India, Africa, Saudi Arabia, Pakistan, and Mexico. It is traditionally used as a blood purifier, laxative, anti-inflammatory, and immune-enhancing agent ²³. In Unani medicine, it is considered to evacuate morbid phlegm, bile, and black bile (Mushil-e-Balgham, Safra, and Sauda) and has a hot and dry temperament.

The plant contains tannins, saponins, phenols, flavonoids, anthraquinones, astragalin, and kaempferol, which contribute to its anti-inflammatory, antioxidant, antiproliferative, and astringent effects. Several reviews have reported the efficacy of Cassia species in the management of atopic dermatitis ^24,25.

Rosa damascene

Rosa damascena, a perennial shrub of the Rosaceae family, is valued for both ornamental and medicinal purposes. Its temperament is described as Murakkab-ul-Quwa or cold and dry according to Unani physicians ²⁶. The flowers possess anti-inflammatory, antioxidant, antimicrobial, blood-purifying, astringent, antiallergic, and immunomodulatory properties due to the presence of phenols, flavonoids, tannins, folic acid, enzymes, and terpenoids. These properties make it useful in inflammatory skin disorders ²⁷.

Vitis vinifera

Vitis vinifera, belonging to the family Vitaceae, is native to the Mediterranean region and is one of the most widely consumed fruits globally. In Unani medicine, its temperament is described as hot and wet ²⁸. It contains flavonoids such as catechin, epicatechin, quercetin, kaempferol, ferulic acid, gallic acid, and vanillic acid, which confer antioxidant, tissue-protective, anti-inflammatory, anti-aging, and antimicrobial effects ²⁹. Clinical evidence indicates that V. vinifera exhibits protective effects against atopic dermatitis, further supporting its relevance in eczema management ³⁰.

Discussion

Eczema is a chronic, relapsing inflammatory dermatosis characterized by epidermal barrier dysfunction, immune dysregulation, oxidative stress, and persistent pruritus, all of which contribute to disease chronicity and impaired quality of life. Contemporary therapeutic approaches primarily focus on symptomatic control; however, their long-term use is limited by adverse effects, necessitating exploration of safer and multi-targeted therapeutic options. In this context, traditional Unani formulations such as Itrifal Shahtara offer a rational therapeutic approach due to their composite pharmacological actions.

The present systematic review critically analyzed the phytochemical composition and pharmacological activities of Itrifal Shahtara constituents, as summarized in Table 1, and correlated them with key pathogenic mechanisms of eczema. The formulation demonstrates a synergistic profile encompassing anti-inflammatory, immunomodulatory, antioxidant, anti-pruritic, antimicrobial, and skin barrier–supportive actions, which collectively address multiple pathological pathways involved in eczema.

Fumaria officinalis (Shahtara), the principal ingredient, contains fumaric acid esters and isoquinoline alkaloids that exhibit immunomodulatory and antioxidant effects. Fumaric acid esters are known to downregulate T-helper cell–mediated cytokine responses, particularly interferon-gamma, thereby modulating immune hyperactivity associated with eczema. This immunoregulatory effect directly aligns with the Th2-skewed immune response observed in eczematous skin.

The Triphala components—Terminalia chebula, Terminalia bellirica, and Emblica officinalis—contribute significantly to the anti-inflammatory and antioxidant potential of the formulation. Phenolic compounds such as ellagic acid, gallic acid, chebulic ellagitannins, and flavonoids present in these fruits have been shown to suppress inflammatory mediators, reduce oxidative stress, and enhance immune regulation. Experimental and clinical evidence supports their role in alleviating symptoms of atopic dermatitis by restoring immune balance and protecting keratinocytes from inflammatory damage.

Cassia augustifolia (Barg-e-Sana Makki) contributes a detoxifying and purgative action consistent with Unani principles of evacuating morbid humours. Its tannins, saponins, flavonoids, and anthraquinones exert anti-inflammatory, antioxidant, and antiproliferative effects, which may help reduce epidermal thickening and chronic inflammation observed in eczema.

Rosa damascena (Gul-e-Surkh) provides cooling, anti-inflammatory, and anti-allergic effects, attributable to its rich content of phenols, flavonoids, tannins, and terpenoids. These properties are particularly relevant in alleviating burning sensation, erythema, and hypersensitivity reactions commonly associated with eczema.

Vitis vinifera (Maweez Munaqqa) further enhances the formulation’s antioxidant and tissue-protective effects through bioactive flavonoids such as catechin, epicatechin, quercetin, and kaempferol. These compounds mitigate oxidative stress, improve microcirculation, and protect skin integrity, thereby supporting epidermal repair and reducing disease severity.

Collectively, the pharmacological actions identified in Table 1 demonstrate that Itrifal Shahtara targets multiple dimensions of eczema pathogenesis, including immune dysregulation, inflammation, oxidative damage, microbial susceptibility, and impaired skin barrier function. This multi-component, multi-target approach reflects both classical Unani therapeutic principles and modern biomedical understanding, supporting the formulation’s traditional use in chronic inflammatory skin disorders ³¹.

Limitations

Most available evidence pertains to individual constituents rather than the formulation as a whole, and high-quality randomized controlled trials evaluating Itrifal Shahtara remain limited. Heterogeneity in study designs, dosages, and outcome measures precluded quantitative synthesis. Additionally, lack of standardized formulation protocols may affect reproducibility, underscoring the need for well-designed clinical trials.

 

Table 1: Components of Itrifal Shahtara

Unani Name (Component)	Scientific Name	Common / Vernacular Name	Mizaj (Temperament)	Part Used	Major Phytochemicals	Pharmacological Actions Relevant to Eczema	Ref.
Shahtara	Fumaria officinalis	Fumitory, Baqla-e-Mulk	Murakkab-ul-Quwa	Leaves	Fumaric acid esters, isoquinoline alkaloids, caffeic acid, rosmarinic acid, apigenin, fumaritine	Immunomodulatory, anti-inflammatory, antioxidant, antibacterial, skin pH regulation, anti-pruritic	11,12,13
Post Halela Zard / Kabli	Terminalia chebula	Harad, Halelaj	Cold & Dry	Fruit, bark	Gallic acid, ellagic acid, chebulagic acid, chebulinic acid, tannins, flavonoids	Anti-inflammatory, antioxidant, anti-fibrotic, antimicrobial, immunomodulatory	15,16,17
Post Balela	Terminalia bellirica	Bahera, Baheda	Cold & Dry	Fruit, bark	Ellagitannins (corilagin, chebulagic acid), phenolics	Anti-inflammatory, antioxidant, immunosuppressive, cytokine modulation	17,18,19,20
Amla	Emblica officinalis (Phyllanthus emblica)	Amlaj, Amrit Phal	Cold & Dry	Fruit	Gallic acid, ellagic acid, quercetin, luteolin, tannins, vitamin C	Anti-inflammatory, antioxidant, anti-allergic, keratinocyte protective, immunomodulatory	21,22
Barg-e-Sana Makki	Cassia augustifolia	Senna, Sana	Hot & Dry	Leaves	Anthraquinones, flavonoids, tannins, saponins, kaempferol, astragalin	Mild laxative, detoxifying, anti-inflammatory, antioxidant, astringent	23,24,25
Gul-e-Surkh	Rosa damascena	Rose, Gulab	Murakkab-ul-Quwa	Flowers	Phenols, flavonoids, tannins, terpenoids	Cooling, anti-inflammatory, anti-allergic, antimicrobial, soothing	26,27
Maweez Munaqqa	Vitis vinifera	Raisins, Zabeeb	Hot & Wet	Fruit	Catechin, epicatechin, quercetin, kaempferol, gallic acid, resveratrol	Antioxidant, anti-inflammatory, tissue protective, microcirculation enhancer	28,29,30

 

Figure 1: Actions of Itrifal Shahtara

 

 

Conclusion

The findings of this systematic review provide compelling evidence that Itrifal Shahtara possesses substantial therapeutic potential in the management of eczema through its synergistic, multi-targeted pharmacological actions. The formulation’s constituents exhibit well-documented anti-inflammatory, immunomodulatory, antioxidant, anti-pruritic, antimicrobial, and skin-protective properties that directly correspond to the core pathological mechanisms underlying eczema.

The integration of classical Unani concepts such as Musaffi-e-Khoon, evacuation of morbid humours, and temperament-based drug selection with contemporary pharmacological evidence highlights Itrifal Shahtara as a rational and holistic therapeutic option for long-term eczema management. Importantly, the favorable safety profile, historical usage, and affordability of Unani formulations further enhance their clinical relevance.

Despite encouraging experimental and clinical evidence supporting the individual constituents, high-quality randomized controlled trials evaluating Itrifal Shahtara as a composite formulation remain limited. Future research should focus on standardized formulation protocols, dose optimization, safety profiling, and well-designed clinical trials to establish its efficacy and facilitate broader clinical adoption.

In conclusion, Itrifal Shahtara represents a promising integrative therapeutic candidate for eczema, warranting further scientific validation to bridge traditional knowledge with evidence-based dermatological practice.

Acknowledgements: The authors are thankful to colleagues and senior faculty members for their valuable suggestions and academic guidance during the preparation of this review manuscript and the college for providing access to library facilities and online databases required for the preparation of this review article.

Author Contributions:  All the authors have accepted responsibility for the entire content of this manuscript.

Funding: None

Conflict of Interest: None

Informed Consent: Not applicable

Ethical Approval: Not applicable

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