E-ISSN:2456-3110

Research Article

Kitibha Kushta

Journal of Ayurveda and Integrated Medical Sciences

2022 Volume 7 Number 7 August
Publisherwww.maharshicharaka.in

An open label single arm prospective clinical study on the combined effectiveness of Panchanimbakam Churna Vati and Pathyadi Lepa in Kitibha Kushta (Psoriasis)

Bhamini K.1*, L. Jadhav L.2, Joshi R.3
DOI: http://dx.doi.org/10.21760/jaims.7.7.5

1* Kalpana Bhamini, Post Graduate Scholar, Department of PG Studies in Kayachikitsa, Sri Dharmasthala Manjunatheshwara College of Ayurveda and Hospital, Hassan, Karnataka, India.

2 Lakshmiprasad L. Jadhav, Professor, Department of Kayachikitsa, Sri Dharmasthala Manjunatheshwara College of Ayurveda and Hospital, Hassan, Karnataka, India.

3 Rajouri Joshi, Post Graduate Scholar, Department of PG Studies in Kayachikitsa, Sri Dharmasthala Manjunatheshwara College of Ayurveda and Hospital, Hassan, Karnataka, India.

Kitibha Kushta is mentioned under Kshudra Kushta and is one among Ashtamahagada. There is nvolvement of Tridosha in all Kushta but predominance of Dosha makes types & manifestations of Kushta different. Psoriasis is one of most common skin disorders. It is papulosquamous disorder of skin characterized by sharply defined erythematosquamous lesions. It is chronic and is well known for its course of remission and exacerbation. Prevalence of psoriasis in adults varies from 0.44 to 2.8%, with a much lower prevalence in children. The combined formulations Panchanimbakam Churna Vati and Pathyadi Lepa, mentioned in Gadanigraha and Yogaratnakara respectively, are indicated for management of Kitibha Kushta. The combination collectively contains Kushtaghna Dravyas and has Katu, Tikta and Kashaya Rasa, Laghu, Ruksha Guna, and Ushna Veerya that are helpful in Samprapti Vighatana of Vata and Kapha dominant Kushta. Material and Methods: Among 30 registered participants, 25 completed treatment. They were administered with Panchanimbakam Churna Vati orally 3 gm per day before food and Pathyadi Lepa externally for 30 days. The Lakshanas and PASI score was assessed on 1st, 15th, and 30th. For Statistical analysis, subjective parameters were assessed by Cochran’s Q test followed by McNemar test, and objective parameters were assessed by Repeated Measures Anova and Paired T-Test. Results: There was statistically significant improvement in signs and symptoms of Kitibha Kushta (Psoriasis)(p<0.05). Conclusion: The combination of Panchanimbakam Churna Vati and Pathyadi Lepa, is effective in management of Kitibha Kushta (Psoriasis)

Keywords: Kitibha Kushta, Psoriasis, Panchanimbakam Churna Vati, Pathyadi Lepa

Corresponding Author How to Cite this Article To Browse
Kalpana Bhamini, Post Graduate Scholar, Department of PG Studies in Kayachikitsa, Sri Dharmasthala Manjunatheshwara College of Ayurveda and Hospital, Hassan, Karnataka, India.
Email: 		Kalpana Bhamini, Lakshmiprasad L. Jadhav, Rajouri Joshi, An open label single arm prospective clinical study on the combined effectiveness of Panchanimbakam Churna Vati and Pathyadi Lepa in Kitibha Kushta (Psoriasis). J Ayu Int Med Sci. 2022;7(7):35-39.
Available From
https://jaims.in/jaims/article/view/1983

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2022-06-28 2022-06-30 2022-07-07 2022-07-14 2022-07-21
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
Nil Nil Yes 19%

© 2022by Kalpana Bhamini, Lakshmiprasad L. Jadhav, Rajouri Joshiand Published by Maharshi Charaka Ayurveda Organization. This is an Open Access article licensed under a Creative Commons Attribution 4.0 International License https://creativecommons.org/licenses/by/4.0/ unported [CC BY 4.0].

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Bhamini K et al: Panchanimbakam Churna Vati and Pathyadi Lepa in Kitibha Kushta

Introduction

Kushta is a condition in Ayurveda, where most skin diseases are discussed. Kitibha Kushta is one among the Kushta and is a Ashtamahagada.[1] It is mentioned under Kshudra Kushta. All Kushta have involvement of Tridosha and the type of Kushta depends on the predominance of particular Dosha. Acharya Charaka has described the involvement of Vata and Kapha in Kitibha Kushta and is compared with Psoriasis due to the maximum resemblance of its symptoms.

Psoriasis is a papulosquamous disorder of the skin characterized by sharply defined erythematosquamous lesions. It is chronic and is well known for its course of remission and exacerbation.[2]

Based on current evidence-based studies, the prevalence of psoriasis in adults varies from 0.44 to 2.8%, with a much lower prevalence in children. The global prevalence rate of psoriasis was 811 per 100,000 population, approximating 0.84% of the world population of about 64.6 million individuals. The incidence of new cases increased from 92 per 100,000 in 1990 to 99 in 2017.[3] Adults’ peak age at onset is in the third and fourth decade of life, with a slight male preponderance.

It has a substantial psychological and social impact on a person’s life. Even though various treatment modalities are available in the contemporary system of medicine including topical therapy, corticosteroids, cytotoxic drugs, and photochemotherapy, most of these treatment modalities have serious limitations. It’s important to note that they have substantial side effects when used for a longer period.

Material and Methods

Source of data

Tertiary Ayurveda hospital attached to Ayurveda medical college located in district headquarters in southern India.

Method of collection of data

Screening: Subjects were screened using a screening form and recruited participant’s data was collected using a prepared case report form (CRF) by incorporating all aspects of Kitibha Kushta (Psoriasis)

Diagnostic Criteria

Among screened patients, Kitibha Kushta (Psoriasis) was diagnosed based on Lakshana of Kitibha Kushta such as Shyava Varna, Kinakhara Sparsha, and Parushata.

Inclusion criteria

  • Participants with Kitibha Kushta with less than 5 years of chronicity
  • Participants aged between 18-60 years and of either gender.
  • Participants willing to participate in the study and ready to sign the informed consent.

Exclusion criteria

  • Participants with uncontrolled diabetes mellitus and essential hypertension.
  • Participants with impaired renal, hepatic, and cardiac function.
  • Pregnant and lactating women.

Ethical clearance and CTRI registration

Ethics clearance certificate was obtained from Institutional Ethics Committee.

The trial was registered on www.ctri.gov.in (2021/2/031318 dated 2nd February, 2021)

Study design

The study was an open label, single arm, prospective clinical trial in Kitibha Kushta (Psoriasis) (n=25) selected using convenience (non-random) sampling technique with pre and post-design conducted in tertiary Ayurveda hospital attached to Ayurveda medical college located in district headquarters in southern India.

Dosage and Drug Administration

Internal Medication

Panchanimbakam Churna Vati[4] : 2 tablets- 500mg each

Anupana : Warm water

External Application

Pathyadi Lepa[5] : Mixed with warm water

Duration : 30 days

Assessment : Day - 0, 15th, 30th day



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Bhamini K et al: Panchanimbakam Churna Vati and Pathyadi Lepa in Kitibha Kushta

Observations

In the present study total of 45 participants were screened, out of which 30 subjects were registered for the study, among them 25 subjects completed the study. Among 30 subjects maximum (n=9) were from the age group of 41-50 years and predominance of males (n=20).

25 subjects were from upper-middle-class group and majority of them (n=21) were from urban areas. Diet-wise distribution showed maximum (n=21) were following a mixed diet.

Results

McNemar test was run on subjective parameters and has shown significant improvement in symptoms like Shyava Varna, Kinakhara Sparsha and Parushata.

Results are placed at Paired t-Test was run on the objective parameter of PASI and showed significant improvement.

Effect of Panchanimbakam Churna Vati and Pathyadi Lepa on PASI score

Repeated measures ANOVA determined that the decrease in PASI score was statistically significant with p < 0.05. Post hoc tests using the Bonferroni correction 0.016 revealed that treatment elicited decrease in PASI score from 1st day - 30th day of treatment.

Table 1: McNemar test showing the combined effect of Panchanimbakam Churna Vati and Pathyadi Lepa on Shyava Varna.

Symptom BT 15th Day 30th Day N P Remark
Shyava Varna P A P A P A 25 >0.05 NS
25 0 24 1 20 5

BT- Before Treatment, N- Number of participants, P- Present, A- Absent, NS- Not Significant

Table 2: McNemar test showing the combined effect of Panchanimbakam Churna Vati and Pathyadi Lepa on Kinakhara Sparsha

Symptom BT 15th Day 30th DAY N P Remark
Kinakhara Sparsha P A P A P A 25 <0.05 S
25 0 23 2 9 16

BT- Before Treatment, N- Number of participants, P- Present, A- Absent, NS- Not Significant

Table 3: McNemar test showing the combined effect of Panchanimbakam churna Vati and Pathyadi Lepa on Parushata

Symptom BT 15th DAY 30th Day N P Remark
Parushata P A P A P A 25 <0.05 S
24 1 20 5 11 14

BT- Before Treatment, N- Number of participants, P- Present, A- Absent, NS- Not Significant

Table 4: Repeated measure ANOVA test showing the combined effectiveness of Panchanimbakam Churna Vati and Pathyadi Lepa on PASI Score

PASI Score N Mean Greenhouse-Geisser Greenhouse-Geisser error Df Remarks
Df F P
BT 25 13.368 1.252 21.397 <0.05 30.053 S
15th day 12.220
30th day 9.168

N- Number of participants, Df- Degree of freedom, F- Frequency, P- P value, S- Significant

Table 5: Pair wise comparison of PASI Score at different interval of treatment

Gross Score I Gross Score J Mean Difference (I- J) Std. error Sig. 95% confidence interval for difference Remarks
Lower Upper
BT 15th Day 1.148  0.350 <0.016 0.246 2.050 S
15th Day 30th day 3.052 0.702 <0.016 1.244 4.860 S
BT 30th day 4.200 0.840 <0.016 2.039 6.361 S

BT - Before Treatment, S - Significant

Discussion

Probable Mode of Action of Drug

Nimba, Khadira, Haritaki, Haridra and Karanja are Katu, Tikta in Rasa, and are Kapha Shamaka.

Sarshapa has Madhura Rasa and Saindhava Lavana has Snigdha Guna, which alleviates Vata. The comprehensive action of these ingredients is Vata- Kapha shamana.

Studies have shown that phenolic components of Nimba bark have antioxidant and immunomodulatory activity.

Nimba may have helped in the management of Psoriasis as its pathogenesis follows an autoimmune pathway.


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Bhamini K et al: Panchanimbakam Churna Vati and Pathyadi Lepa in Kitibha Kushta

jaims_1983_01.JPGImage 1: Before Treatment

jaims_1983_02.JPGImage 2: After Treatment

Nimba and Khadira has Laghu and Ruksha Guna and Tikta, Kashaya Rasa that act together as Kapha Shamaka. Nimba (Azadirachta indica) has a complex of various constituents including Nimbin, nimbidin, nimbolide, and limonoids, and such types of ingredients play role in diseases management through modulation of various genetic pathways and other activities.[6]

Khadira is recommended for all types of Kushta. It has immunomodulatory action that may activate

both cell-mediated as well as humoral immunity. Among various phytoconstituents present in Acacia catechu, catechins may contribute to its anti-inflammatory and antioxidant activities.[7]

The water extract of Acacia catechu showed inhibition of pro-inflammatory cytokine TNF-α and a significant increase in cytokine IL-10. IL-10 helps to control the secretion of pro-inflammatory cytokines by augmenting the proliferation of B cells, mast cells, and thymocytes.

Haritaki is Tikta Kashaya in Rasa, Laghu Ruksha Guna, Ushna Veerya and is Rasayana by Karma. It is mentioned in Bhavaprakasha as Varnya and Kushtahara.

A previous study showed that Terminalia chebula (Haritaki) exhibited potent anti-psoriatic effects via heme oxygenase (HO)-1-mediated inhibition of oxidative stress and NF-κB and the subsequent suppression of inflammation and keratinocyte proliferation.[8]

Bakuchi and Haridra are Katu Tikta in Rasa, Laghu, Ruksha in Guna, Ushna Veerya and has Katu Vipaka. It helps in balancing Vata and Kapha. It is Kushtaghna, Deepana, Paachana, Anulomana, and Vranashodhana by Karma.

Haridra is also called by the name of Vishothajita, which means it can act as an anti-inflammatory and help in decreasing the erythema of the skin. It improves the complexion and might have helped in treating Vaivarnya of skin.

Curcumin, a chemical compound found in Haridra is a non-competitive inhibitor of Phosphorylase kinase (PhK), a serine/threonine-specific protein kinase. A study was conducted previously and it showed that decreased levels of PhK in samples of plaques treated with curcumin 1% alcoholic gel as well as other traditional topical treatments were associated with decreased keratinocyte transferrin receptor (TRR) expression and severity of parakeratosis.[9] These observations may suggest that agents capable to inhibit PhK activity, such as curcumin, could be considered for the topical treatment of Psoriasis.

Karanja has Katu, Tikta, Kashaya Rasa, Laghu Teekshna Guna and Ushna Veerya and acts as Kapha and Vata Shamaka. It is Kushtaghna, Shothahara, and known as Kushtajita which means helpful in treating all types of skin disorders.

[10]


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Bhamini K et al: Panchanimbakam Churna Vati and Pathyadi Lepa in Kitibha Kushta

The free radical decimating property of Karanjin and Pongamin were experimentally studied. The scavenging effect of Karanjin (The highest activity of 95.60%) and Pongapin (68.05%) against nitric oxide. This study was found to be comparable to that of methotrexate, a known drug for treating Psoriasis and might also help in controlling the disease. Nitric oxide is the signaling molecule for keratinocyte growth and plays a pivotal role in this disease. These compounds were found to scavenge the excess nitric oxide from the psoriatic plaques. This study suggests that Karanja can a vital role in managing psoriasis.

Conclusion

Panchanimbakam Churna Vati in a dose of two tablets of 500mg thrice a day before food and Pathyadi Lepa application externally once a day for a period of one month showed significant results in subjective parameters like Shyava Varna, Kinakhara Sparsha and Parushata and also in objective parameters like PASI Score.

Reference

1. Sharma PV. Sushruta Samhita with Nibandhasangraha commentary of Dalhanacharya. Chaukambha Orientalia, Varanasi, 2002 (Reprint), Sutra Sthana33/5, p144

2. Rendon A, Schäkel K. Psoriasis Pathogenesis and Treatment. Int J Mol Sci. 2019;20(6):1475. Published 2019 Mar 23. doi:10.3390/ijms20061475

3. Dogra S, Mahajan R. Psoriasis: Epidemiology, clinical features, co-morbidities, and clinical scoring. Indian Dermatol Online J. 2016;7(6):471-480. doi:10.4103/2229-5178.193906

4. Sodhala. Pandeya, G Tripathi. Gadanigraha. Varanasi: Chaukambha Orientalia, Varanasi, 2002 (Reprint), Chikitsa Sthana33/5, p144

5. Suresh, B. S. (2005). Yogaratnakar: The "A" to "Z" classic on Ayurvedic formulations, practices & procedures, Sanskrit text with English translation and explanatory notes. Varanasi: Choukhamba Sanskrit Series Office.

6. Alzohairy MA. Therapeutics Role of Azadirachta indica (Neem) and Their Active Constituents in Diseases Prevention and Treatment. Evid Based Complement Alternat Med. 2016; 2016:7382506. doi:10.1155/2016/7382506

7. S. Ismail, M. Asad Immunomodulatory activity of Acacia catechu Indian J Physiol Pharmacol, 53 (1) (2009), pp. 25-33

8. An J, Li T, Dong Y, Li Z, Huo J. Terminalia Chebulanin Attenuates Psoriatic Skin Lesion via Regulation of Heme Oxygenase-1. Cell Physiol Biochem. 2016;39(2):531-43.

9. Heng MC, Song MK, Harker J, Heng MK. Drug-induced suppression of phosphorylase kinase activity correlates with resolution of psoriasis as assessed by clinical, histological and immunohistochemical parameters. Br J Dermatol. 2000 Nov;143(5):937-49. doi: 10.1046/j.1365-2133.2000.03767.x.

10. Ghosh A, Tiwari GJ. Role of nitric oxide-scavenging activity of Karanjin and Pongapin in the treatment of Psoriasis. 3 Biotech. 2018 Aug;8(8):338. doi: 10.1007/s13205-018-1337-5


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