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Alteration in Asbāb-e-Sitta Ḍarūriyya (Six Essential Factors) for the Prevention of Buthūr Labaniyya (Acne Vulgaris): A Narrative Review of Unani and Contemporary Perspectives

Shaikh Mohammad Aatif Afzal ¹*, Momin Arshad Manzoor Ahmed ², Niyazi Abdullah Khizar ³, Mohd Tarique ⁴, Samira Khatoon Choudhary ⁵

¹ Department of Amraze Jild wa Tazeeniyat (Dermatology and Cosmetology) National Institute of Unani Medicine, Kottigepalya, Magadi Main Road, Bengaluru-91, Karnataka, India.

² Department of Tahaffuzi wa Samaji Tib (Preventive & Social Medicine) National Institute of Unani Medicine, Kottigepalya, Magadi Main Road, Bengaluru-91, Karnataka, India.

³ Department of Ilaj Bit Tadbeer (Regimenal Therapy), National Institute of Unani Medicine, Kottigepalya, Magadi Main Road, Bengaluru-91, Karnataka, India.

⁴ Department of Moalajat (Medicine), National Research Institute of Unani Medicine for Skin Disorders, Telangana State. 500038 Hyderabad

⁵ Department of Ilmul Qabalat wa Amraze Niswan (Gynaecology and Obstetrics) National Institute of Unani Medicine kottigepalya magadi main road Bengaluru -91 Karnataka, India

 

 

Introduction:

Acne vulgaris is a highly prevalent dermatological disorder that affects nearly all individuals at some point in life.¹ It is a chronic inflammatory condition of the pilosebaceous unit, most commonly manifesting during puberty. Clinically, acne presents with open and closed comedones, inflammatory papules, pustules, nodules, and cysts, and may resolve with residual scarring.² According to the World Health Organization (WHO), acne primarily involves the pilosebaceous units of the face, neck, chest, and upper back. Androgenic stimulation at the onset of puberty leads to increased sebum production, abnormal follicular keratinization, colonization by Propionibacterium species, and subsequent local inflammation.³ Globally, acne affects approximately 9% of the population, with prevalence increasing to nearly 85% among individuals aged 12–24 years.⁴ In India, the condition affects 72.3% of adolescents and 27% of adults.⁵

In Unani medicine, acne vulgaris is referred to as Buthūr Labaniyya, a term derived from Arabic words in which Buthūr denotes boils and Labaniyya signifies milk, reflecting the characteristic appearance of the lesions.⁶ Classical Unani texts describe Buthūr Labaniyya as Muhāsa or Kīl.⁷ Qarshī characterized the condition as a Mutāʿaddi (infectious) disorder of the skin, presenting with minute white eruptions over the face, cheeks, and nose that exude a cheesy material on pressure.⁸ Ibn Sīnā described similar lesions resembling condensed milk droplets over the cheeks and nose, while Ḥakīm Ajmal Khān reported the occurrence of erythematous facial eruptions that discharge viscous material and pus upon maturation.⁹

Eminent Unani scholars, including Zakariyya Rāzī, Ibn Hubal, Ibn Sīnā, Dā’ūd Antāki, and Hakīm Akbar Arzānī, attributed the development of these lesions to the accumulation of Mā’dda Sadīdiya (pus-like morbid matter) or excess Balgham-e-Fāsid (pathological phlegm), resulting in inflammatory cutaneous eruptions.^10,11 These humoral derangements are considered to arise from Fasād-i Dam (impure blood), Sū’-i-Mizāj Hār (abnormally hot temperament), poor hygiene, Ghayr Ṭabīʿī Daura-i Ṭamth (irregular menstruation), digestive dysfunctions, and alcohol consumption, all of which are recognized as contributory factors in acne pathogenesis.^7,12,13

Unani literature further identifies several predisposing and aggravating factors for Buthūr Labaniyya, including deranged temperament—particularly hot-moist or cold-dry Mizāj—improper dietary practices, inadequate personal hygiene, sedentary habits, disturbed sleep–wake rhythms, psychological stress, hormonal imbalance, and suppression of natural urges.^14–17 These factors are collectively encompassed within Asbāb-e-Sitta Ḍarūriyya, the six essential determinants of health that are fundamental for maintaining humoral equilibrium and preserving the functional integrity of Quwwat-e-Ṭabīʿa.¹⁷ Regulation of these essential factors therefore constitutes a comprehensive preventive and adjunctive approach in Unani medicine for the management of acne vulgaris, emphasizing lifestyle modification, disease prevention, and long-term therapeutic sustainability alongside conventional dermatological care.

Prevention of Acne Vulgaris through Asbāb-e-Sitta Ḍarūriyya

Asbāb-e-Sitta Ḍarūriyya refers to six indispensable factors essential for human survival and health maintenance. Proper regulation of these factors enables the attainment and preservation of physical and mental well-being. These include Hawā-e-Muḥīṭ (atmospheric air), Makūl wa Mashrūb (food and drink), Ḥarkat wa Sukūn-e-Badnī (physical activity and rest), Ḥarkat wa Sukūn-e-Nafsānī (psychological activity and repose), Naum wa Yaqẓah (sleep and wakefulness), and Istifrāgh wa Iḥtibās (elimination and retention).¹⁸

1. Hawā-e-Muḥīṭ (Atmospheric Air)

In Unani medicine, Hawā-e-Muḥīṭ is recognized as a fundamental component of Asbāb-e-Sitta Ḍarūriyah, playing a crucial role in maintaining the balance of Akhlāṭ (humours) and Mizāj (temperament). Impure or polluted air is believed to disturb this balance by increasing internal heat and generating impurities, thereby predisposing individuals to dermatological disorders such as Buthūr Labaniyya. Maintenance of clean and balanced air is therefore considered essential for preserving skin health and systemic equilibrium.¹⁹

Contemporary dermatological research supports this classical concept. Airborne pollutants such as fine particulate matter (PM₂.₅ and PM₁₀), nitrogen dioxide (NO₂), and polycyclic aromatic hydrocarbons (PAHs) can adhere to the skin surface and penetrate follicular openings, triggering oxidative stress and inflammatory responses—key mechanisms involved in acne exacerbation. Exposure to particulate pollution activates inflammatory pathways, including aryl hydrocarbon receptor (AhR) signaling, leading to increased expression of pro-inflammatory cytokines such as IL-1α and IL-8, which are commonly elevated in acne lesions. Pollutants also alter sebum composition and reduce cutaneous antioxidants such as vitamin E and squalene, thereby compromising the skin barrier and promoting acne flares. Time-series studies have demonstrated that elevated ambient levels of PM₂.₅, PM₁₀, NO₂, and SO₂ are associated with increased acne-related outpatient visits and greater disease severity, highlighting air pollution as a modifiable risk factor in acne vulgaris.²⁰

Unani scholars emphasized preventive strategies to counter environmental harm. Rāzī advised residing in clean, well-ventilated environments and recommended fumigation with aromatic and medicinal substances such as Qust, Kundur, Mīʿa Sāʾila, ʿŪd, Ṣandal, Kāfūr, and Murr to purify indoor air.^21–23 These substances possess antiseptic and disinfectant properties, and modern studies have confirmed their antibacterial and antifungal activities.^24–29 Collectively, both Unani principles and contemporary dermatological evidence underscore the importance of clean atmospheric air in preventing and controlling exacerbations of acne vulgaris.

2. Makūl wa Mashrūb (Foods and Drinks)

After air, food and water constitute the most fundamental requirements for human survival. Adequate and balanced nutrition is essential for normal physiological functioning, and nutritional deficiencies or dietary imbalances can lead to various health disorders, including acne vulgaris. Diet plays a significant role in skin health, and accumulating evidence suggests that certain dietary patterns influence both the development and severity of acne. High-glycemic foods and certain dairy products have been associated with increased acne severity, potentially through hormonal and inflammatory mechanisms involving insulin and insulin-like growth factor-1 (IGF-1). In contrast, diets with a low glycemic load and rich in anti-inflammatory components—such as omega-3 fatty acids, fruits, vegetables, and antioxidants—may help reduce inflammation and regulate sebum production. Although the role of specific foods, including particular dairy products and chocolate, remains inconclusive and warrants further investigation, overall dietary balance appears beneficial in acne management.³⁰

From the Unani perspective, acne vulgaris—referred to as Busūr-e-Labaniyya—is attributed to the accumulation and outward movement of Ghalīẓ Bukhārāt (morbid humoral vapours) toward the skin. Improper diet and poor nutritional habits are believed to aggravate Sūʾ-i-Mizāj (deranged temperament), weaken Ṭabīʿat (vital force), and impair the body’s innate defense mechanisms, thereby predisposing individuals to cutaneous disorders. Consequently, Ilāj-bi’l-Ghizā (dietary regulation) is emphasized in Unani medicine as both a preventive and therapeutic approach, with moderation in food quality, quantity, and temperament considered essential for maintaining humoral balance and supporting natural healing processes.⁹

In Al-Qānūn fī al-Ṭibb, Ibn Sīnā emphasized that food is the primary source of humours and, therefore, a determinant of both health and disease. Consumption of a new meal before digestion of the previous one was considered harmful, as it could lead to indigestion, bloating, and formation of Khilṭ Fāsid (abnormal humour), a precursor to disease. Al-Rāzī further recommended consuming a single type of food per meal and in small quantities to facilitate proper digestion.⁸

Unani texts advise avoidance of Raddī (waste), Fāsid (putrefied), Bādī (flatulent), excessively oily and sweet foods, as well as items such as black gram, cauliflower, peas, alcohol, red meat, fried foods, brinjal, red lentils, hot spices, and red chilies, particularly those with Hārr (hot) and Qābiḍ (astringent) properties.^31–33 Excessive sun exposure is also discouraged.³²

A simple and balanced diet (Ghizā-i-Sāda) is recommended, including vegetables such as ridge gourd, pumpkin, spinach, turnip, green gram, and split red gram, along with light preparations such as simple shorba (Gravy), chapatti, and Bārid (cooling) vegetables. Fruits such as orange, pomegranate, apple, and pear are advised.^31,32,34 Adequate hydration and regular physical activity are additionally emphasized, as they may contribute to reducing the occurrence and severity of acne vulgaris.³⁵ 

 

 

Table 1: Unani Etiological Factors of Acne and Corresponding Dietary Recommendations

Unani Etiological Factor	Dietary Items to Avoid (Makūl wa Mashrūb )	Recommended Dietary Modifications (Makūl wa Mashrūb )	Rationale (Unani and Modern Perspective)
Hārr Aghziya (thermogenic / heat-producing foods)36	Spicy, fried, and excessively hot foods36	Cooling vegetables and light foods such as ridge gourd, pumpkin, spinach, turnip, green gram, and pigeon pea36	Reduces Shiddat-e-Harārat (excess internal heat) and restores humoral balance. Light foods improve digestion and reduce inflammatory responses.36
Fasād-e-Dam (impure blood), Sū-e-Hazm (indigestion), Qabd (constipation)36	Oily, flatulent foods; excessive sweets and alcohol36	Adequate hydration (water, buttermilk, coconut water), simple soups, and easily digestible staples.36	Improved digestion prevents accumulation of Āma (metabolic waste) and supports humoral equilibrium. Fibre and hydration are associated with reduced acne severity.36
Qillat-e-Dam (deficiency of blood) and Imtilā-e-Khūn (excess or congestion of blood)37	Excessive intake of fats, refined sugars, and alcohol.37	Fresh fruits (pomegranate, apple, orange), vegetables, and nutritionally balanced meals.37	Supports blood quality and nutrient sufficiency  reducing inflammation linked to acne pathogenesis.37
Sharāb (alcohol / intoxicants)37	Alcoholic and intoxicating beverages37	Water and herbal cooling drinks such as rose water and mint water37	Prevents humoral derangement caused by toxins and reduces exacerbation of acne lesions.37
Rutubāt-e-Zāʾidah (excess humidity), Harārat-e-Zāʾidah (excess heat), Tanaʾo (psychological stress)37	Processed foods, high–glycemic-index foods, and sugar-sweetened beverages38	Fresh fruits and vegetables rich in antioxidants38	Anti-inflammatory and antioxidant-rich diets counter oxidative stress and reduce acne risk.38
Fasād-e-Hawā (vitiated air / air pollution)37	No specific dietary restriction; supportive diet recommended38	Diet rich in anti-inflammatory and antioxidant foods38	Enhances cutaneous defense against environmental stressors. dietary antioxidants may mitigate pollution-induced inflammation.38
Maghziyyāt (oily, fatty, and sweet food items)37	Nuts such as peanuts and pistachios; sweet and oily desserts37	Moderate intake of lean proteins and simple legumes37	Restriction of excess fats supports balanced humors; Balanced macronutrient intake promotes skin health. 37

 

3. Ḥarkat wa Sukūn-e-Badanī (Physical Activity and Rest)

Balanced physical activity and rest are essential for maintaining humoral equilibrium. Moderate physical activity improves blood circulation, enhances metabolism, and facilitates the elimination of morbid matter, thereby supporting the health of the pilosebaceous unit. In contrast, excessive physical exertion generates excess heat and Yubūsat (dryness), which may aggravate acne lesions.^39,40

Classical Unani scholars such as Zakariyyā Rāzī, Ibn Sīnā, and Majūsī emphasized that excessive rest leads to increased Rutūbat (morbid wetness) and humoral stagnation, while excessive physical activity induces dryness; both extremes disturb Mizāj and predispose to disease.^41–43 In acne vulgaris, excessive rest may promote accumulation of morbid humours and obstruction of skin pores, whereas excessive physical activity increases heat and inflammation of the pilosebaceous unit. Therefore, maintaining an appropriate balance between rest and physical activity plays a significant role in the prevention and management of acne vulgaris.

4. Ḥarkat wa Sukūn-e-Nafsānī (Psychological Activity and Repose)

Psycho-emotional stress is a well-recognized etiological and aggravating factor in acne vulgaris. From a modern biomedical perspective, stress activates the hypothalamic–pituitary–adrenal (HPA) axis, resulting in increased secretion of corticotropin-releasing hormone (CRH), cortisol, and androgens. These hormonal changes stimulate sebaceous gland activity, promote follicular inflammation, and contribute to acne lesion formation.^44,45 Stress-associated neuropeptides, particularly substance P, further enhance sebaceous lipogenesis, mast-cell activation, and perifollicular neurogenic inflammation, thereby exacerbating inflammatory acne.⁴⁶

In Unani medicine, excessive Sukūn-e-Nafsānī (psycho-emotional disturbance) is considered a major cause of derangement of Mizāj, often leading to dominance of Burūdat (coldness) and Rutūbat (morbid moisture). Classical Unani physicians such as Ibn Nafīs, Ibn Sīnā, and Zakariyyā Rāzī described that persistent emotional disturbances weaken Quwwat-e-Hāḍima (digestive faculty) and Quwwat-e-Dāfiʿa (expulsive faculty), resulting in impaired metabolism and accumulation of Mādda-e-Fāsida (morbid matter).^42,47

When this morbid material is diverted toward the skin—particularly the basal follicles of Shaʿr (hair) and Ghadad-e-Duhniyya (sebaceous glands)—normal excretion becomes obstructed, leading to inflammatory eruptions. Unani texts further describe that excess Rutūbat increases the viscosity and stagnation of humours, predisposing the skin to Sudda (follicular obstruction) and Iltehāb (inflammation). Ibn Sīnā, in Al-Qānūn fī al-Ṭibb, stated that dominance of cold and moist temperament favors retention of waste material within cutaneous pores, resulting in Busūr-e-Labaniyya and Busūr-e-Wajh (facial eruptions), conditions closely resembling acne vulgaris.⁴¹

Unani medicine therefore emphasizes preservation of psychological equilibrium through Nafsiyātī Tadābīr, including environmental regulation, spiritual practices, recreation, positive companionship, and Riyāẓat-e-Nafsānī.^16,31,48 Herbs such as Zafran (Crocus sativus) and Gaozabān (Borago officinalis) are traditionally employed to calm the nervous system and strengthen mental faculties.³¹ Maintenance of psychological balance is thus regarded as essential for sustaining humoral harmony and preventing stress-induced exacerbation of acne vulgaris.

5. Naum wa Yaqẓah (Sleep and Wakefulness)

In Unani medicine, balanced Naum wa Yaqẓah is essential for preservation of Mizāj-e-Moʿtadil and cutaneous health. Adequate sleep provides repose to the Nafs and bodily faculties, strengthens Quwwat-e-Mudīrah, and preserves Ḥarārat-e-Gharīziyya, thereby facilitating proper digestion, metabolism, and elimination of waste materials. Classical Unani scholars, including Ibn Sīnā, Zakariyyā Rāzī, and ʿAlī ibn al-ʿAbbās Majūsī, emphasized that sound nocturnal sleep promotes Nuzj (maturation) of Akhlāṭ and prevents accumulation of Fuzūlāt, which otherwise predispose to Busūr-e-Wajh resembling acne vulgaris.^16,31,48,49

Disturbances in sleep adversely affect skin function. Qillat-e-Naum (insufficient sleep) leads to Zoʿf-e-Aʿṣāb and Yubūsat, impairing cutaneous repair mechanisms and aggravating inflammatory acne lesions. Conversely, Kasrat-e-Naum (excessive sleep) induces Bārid-Ratb Mizāj, weakens digestion (Zoʿf-e-Hazm), and promotes accumulation of Mādda-e-Fāsida within the pilosebaceous unit, resulting in comedones and inflammatory eruptions.^16,48,49

Accordingly, Unani physicians recommend maintenance of a regular sleep–wake cycle, adequate nocturnal sleep, avoidance of heavy meals before bedtime, and restriction of excessive daytime sleep to preserve humoral equilibrium and prevent acne exacerbation.^16,31,48

6. Istifrāgh wa Iḥtibās (Elimination and Retention)

In Unani medicine, Istifrāgh wa Iḥtibās refers to the balanced elimination of waste materials from the body while retaining substances essential for physiological stability. This balance is crucial for maintaining Taʿādul-e-Akhlāṭ (humoral balance) and Mizāj-e-Moʿtadil (healthy temperament). Istifrāgh facilitates removal of excess or harmful matter, whereas Iḥtibās ensures conservation of vital fluids. Classical Unani physicians, including Ibn Sīnā and Zakariyyā Rāzī, emphasized that both accumulation of Mawād-e-Fāsida and excessive loss of essential fluids disturb temperament and predispose to disease, particularly disorders of the skin.

Physiological elimination occurs through urine, stool, sweat, and cutaneous secretions. Inadequate elimination leads to accumulation of Balgham and Sawdā, which, when diverted toward the skin and Ghadad-e-Duhniyya, result in facial eruptions and inflammatory lesions resembling acne vulgaris.^{41–43,50,51} Conversely, excessive Istifrāgh depletes vital fluids, induces Bārid-Yābis Mizāj, weakens Quwwat-e-Ṭabīʿa, and compromises skin resistance, thereby aggravating inflammatory acne.^45,50

Quwwat-e-Hāḍima (digestive faculty) plays a central role in this process, as weak digestion produces Ghalīẓ and Ghayr-Nājij Akhlāṭ, which accumulate as morbid matter and predispose to follicular obstruction and inflammation.^49,51 To restore balance, Unani physicians advocate Munzij wa Mushil therapy, along with Taʿarruq (sweating) and Ḥijāmah (cupping), to eliminate morbid material, purify blood, and prevent chronicity of disease.⁴¹

Modern evidence parallels these concepts, demonstrating that constipation, gut dysbiosis, and impaired elimination promote systemic inflammation, oxidative stress, and immune dysregulation, with increased levels of inflammatory mediators such as IL-6 and TNF-α, which contribute to sebaceous inflammation and acne pathogenesis.⁴⁶ Unani preventive measures therefore emphasize regular bowel habits, avoidance of suppression of natural urges, strengthening of digestion, adequate hydration, promotion of perspiration through moderate physical activity, and prevention of constipation to maintain humoral harmony and prevent acne vulgaris.^41,46,50

Conclusion

Acne vulgaris (Buthūr Labaniyya) is a multifactorial inflammatory disorder influenced by lifestyle, diet, environmental exposure, and psycho-emotional factors. In Unani medicine, the condition is attributed to humoral imbalance arising from derangement of Asbāb-e-Sitta Ḍarūriyah, which are fundamental to maintaining Mizāj and systemic equilibrium. This review demonstrates that regulation of these six essential determinants—Hawā-e-Muḥīṭ, Makūl wa Mashrūb, Ḥarkat wa Sukūn-e-Badnī, Ḥarkat wa Sukūn-e-Nafsānī, Naum wa Yaqẓah, and Istifrāgh wa Iḥtibās—offers a rational preventive and adjunctive approach in acne management. Integration of Unani principles with contemporary dermatological evidence highlights the importance of lifestyle modulation in reducing inflammation, restoring cutaneous homeostasis, and minimizing disease recurrence. Incorporation of Asbāb-e-Sitta Ḍarūriyah-based interventions alongside conventional therapy may provide a holistic, patient-centred strategy for the effective management of acne vulgaris.

Conflict of Interest: The authors declare no potential conflict of interest concerning the contents, authorship, and/or publication of this article.

Author Contributions: All authors have equal contributions in the preparation of the manuscript and compilation.

Source of Support: Nil

Funding: The authors declared that this study has received no financial support.

Informed Consent Statement: Not applicable. 

Data Availability Statement: The data supporting this paper are available in the cited references. 

Ethical approval: Not applicable.

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