Ayurvedic management of Plaque Psoriasis - A Case Report

Prathviraj Puranik; K Suja; R Sharashchandra

Ayurvedic management of Plaque Psoriasis - A Case Report

Puranik P.¹, Suja K.^2*, Sharashchandra R.³

DOI:

¹ Prathviraj Puranik, Professor and HOD, Department of Kaumarabhrithya, Sri Dharmasthala Manjunatheshwara College of Ayurveda and Hospital, Udupi, Karnataka, India.

^2* K Suja, Final Year PG Scholar, Department of Kaumarabhrithya, Sri Dharmasthala Manjunatheshwara College of Ayurveda and Hospital, Udupi, Karnataka, India.

³ R Sharashchandra, Associate Professor, Department of Kaumarabhrithya, Sri Dharmasthala Manjunatheshwara College of Ayurveda and Hospital, Udupi, Karnataka, India.

Background: In Ayurveda almost all skin diseases are explained under Kushta Rogadhikara. Ekakushtha is a Raktapradoshaja, Vata–Kaphapradhana Tridoshaja Kshudrakushta. Psoriasis is a common chronic inflammatory skin condition typically characterized by raised, well defined, erythematous skin lesions of varying size that are surmounted by silvery-white scales. In India prevalence of Psoriasis varies from 0.44 to 2.88%. Aim: The aim was to evaluate the role of Ayurvedic treatment modalities in Ekakushta. Materials and methods: A 5 years old male child was apparently normal before 8 months gradually noticed flaky skin lesions over the foot with itching & peeling of skin & in the extensor surface of both elbows, pitting of nails. There were rough dry patches seen in the back, armpits, groins, forehead gradually seen over palms and foot which was treated with both Shamana and Shodhana Chikitsa. Shodhana was done by Snehapana with Mahatiktakagritha followed by Abhyanga with psora oil and Parisheka Sweda with Nimbakaranjapatra. Acchasnehapana was given and maximum quantity taken was 95ml. Virechana was given with 25g of Trivritleha[6] along with 30ml of Triphala Kashaya and he had 8 Vegas. Samsarjanakrama was done for 5 days. Patient was advised to consume Shamana Aushadis (internal medicines) for 15 days. Result: The study showed significant result with marked improvement in the Lakshanas.

Keywords: Psoriasis, Ekakushta, Virechana, Mahatiktakagritha, Trivritavaleha

Corresponding Author	How to Cite this Article	To Browse
K Suja, Final Year PG Scholar, Department of Kaumarabhrithya, Sri Dharmasthala Manjunatheshwara College of Ayurveda and Hospital, Udupi, Karnataka, India. Email:	Prathviraj Puranik, K Suja, R Sharashchandra, Ayurvedic management of Plaque Psoriasis - A Case Report. J Ayu Int Med Sci. 2022;7(10):270-275. Available From https://www.jaims.in/jaims/article/view/2057

Introduction

The skin acts as a barrier against mechanical, chemical and thermal injuries, penetration of toxins and infections and prevention of fluid and electrolyte imbalances. Psoriasis is a common chronic inflammatory skin condition, typically characterized by raised, well defined, erythematous skin lesions of varying size that are surmounted by silvery-white scales.^[7]The Etiology of Plaque psoriasis is the most common (>80%) subtype, is characterized by erythematous papules that coalesce to form plaques with sharply demarcated, irregular borders. There is a peak incidence during the late teens or early twenties. Psoriasis is multifactorial with an interaction of both genetic and environmental factors. There is a complex interplay of the vasculature, immune system and epidermis.^[8]Plaque psoriasis remains as a challenge to be treated. In Ayurveda, Ekakushta is treated with Shodhana and Shamana dual therapies. The nature of the disease is such that there is higher chance of remissions and exacerbations. Hence the disease needs to be managed by Shodhana and Shamanaaushadis.

Pathogenic factors of Eka Kushta

Dosha: Vata Kapha

Dusya: Twak, Rasa, Rakta

Agni: Samagni,

Ama: Jataragni and Dhatwagnijanya Ama (Srotorodha, Mala Sanga)

Srotas: Rasavaha, Raktavaha, Mamsavaha

Srotodushti: Sanga

Rogamarga: Bahya,

Rogaavastha: Chirakari,

Adhistana: Twak

Udbhavasthana: Amapakvasaya

Vyaktasthana: Pani, Paada, Twak

Sadhyaasadhyata: Asadhya

Case Report

Chief complaints: Patient complaints of itchy scaly patches in the soles of foot and palms and dry patches over forehead and nape of the neck since 8 months.

History of Present illness

According to father, a 5 year old male child was apparently normal before 8 months gradually noticed flaky skin lesions over the foot with itching & peeling of skin. The lesions were raised with demarcated border & separated from one another. There was no smell or discharge. They consulted an allopathic physician and no improvement was seen. They consulted a homeopathic doctor & were under medication for 2 months. The lesions were also seen on the scalp specifically at the back of the head. There were rough patches seen in the back, armpits, and groins gradually seen over palms. Hence, they again consulted an allopathic physician and were diagnosed as psoriasis and was under medication. But there was regression of symptoms. Presently the lesions coalesce to form scales which are also present in the extensor surface of both elbows, forehead, soles, palms, foot, forehead and back along with itching and pain. For these complaints the patient was admitted in our hospital for better management.

History of Past illness

There is a h/o recurrent episode of RTI. Patient got admitted at the age of 3½ yrs due to breathing difficulty and was treated in modern hospital.

Family history: It is nuclear family. Mother is housewife and Father is a software engineer. Non consanguineous marriage. No family members have similar or contributing history.

Diet history: Mixed diet. Intake of milk 1 hour after intake of fish. Food includes rice in lunch, idli, dosa for breakfast. Virudhahara Sheela, Ativyayama was evident from history.

Dashavidha Pareeksha

Prakriti: Vata Kapha,

Vikirithi: Dosha - Vatakapha, Dushya: Twak, Rasa, Rakta,

Sara: Madhyama

Samhanana: Madhyama

Satva: Madhyama

Saatmya:Madhyama

Aharashakti: Madhyama

Vyayama Shakti: Madhyama

Pramana: Madhyama

Vaya: Bala.

Astasthana Pareeksha

Nadi: Prakrita, 102b/minute

Mala: Prakrita, regular once a day

Mutra: Prakrita, 4-5 times/day

Jihva: Anupalipta

Shabda: Prakrita

Sparsha: Anushnasheeta

Drik: Prakrita

Aakriti: Prakrita

Rogapareeksha

Nidana: Virudhahara Vihara
Purvarupa: Kharasparshatha, Twaksphutana
Rupa: Kandu, Toda, Bheda, Aswedana, Mahavastu, Matsyasakalopama
Upashaya: Moisturizing
Anupashaya: Playing in Mud, Intake of Virudhahara
Samprapti

Nidana → Vata Kaphadusti → Rasa Raktadushana → Sthanasamshraya in Paada, Hasta, Vankshana, Shiras → Kandu, Toda, Aswedana, Mahavastu, Matsyasakalopama → Eka Kusta

Lower limb

Inspection

Skin: Multiple scales of lesions with diffused margin on the soles of foot, over heels and central dependant part of soles. Bilaterally symmetrical lesions. No defined shape. Nail: pitting is present, Greyish discoloration at the tip of nails.

Palpation

Dry, rough lesions over the palms & heels. No raise in temperature. No local tenderness.

Upper limb

Inspection: Undefined shape and margins.

Palpation: Dry, unelevated lesions. Itching and pain was present.

Diagnostic Criteria

Diagnosis was made based on the Lakshanas of Ekakushta and signs and symptoms of plaque psoriasis.

Auspitz Sign - Positive,

Candle Grease Sign - Positive,

Koebner Phenomenon - Negative.

Assessment Criteria

To assess the effect of therapy, the Psoriasis Area and Severity Index (P.A.S.I) scoring method was adopted.^[9]

Area: For each skin section, the amount of skin involved was measured as percentage of the skin of affected part of the body and then a score from 0-6 was assigned as follows:

Table 1: Showing Diseased Skin Grading

Coverage	Score
0	0
<10%	1
10-29%	2
30-49%	3
50-69%	4
70-89%	5
90-100%	6

The severity was measured with the help of four different parameters Itching, Erythema, Scaling, Thickness. These were measured for each skin section as per the following chart-

Table 2: Showing Severity Score

Severity	Score
None	0
Mild	1
Moderate	2
Severe	3
Very Severe	4

Overall Assessment of Clinical Response

Complete remission: 100% reduction in PASI score
Marked improvement:75-99% reduction in PASI score
Moderate improvement:50-74% reduction in PASI score
Mild improvement: 25-49% reduction in PASI score

Treatment given to the patient

Table 3: Shodhana Chikitsa

Procedure/drug	Dose	Duration
Mahatiktakagritha	25ml, 50ml, 65ml, 75ml, 85ml, 95ml.	6 days
Abhyanga with Psora oil	Q.S	3 days
Parisheka with Nimbakaranjapatra	Q.S	3 days
Virechana with Trivritleha with 30ml of Triphala Kashaya	25g	1 day

Samsarjana Krama was done for 5 days.

Table 4: Showing Samsarjana Krama

Day	Morning	Evening
1st	-	Peya
2nd	Peya	Vilepi
3rd	Vilepi	Akrithayusha
4th	Krithayusha	Akrithamamasarasa
5th	Krithamamsarasa	Normal diet

Shamana Chikitsa

Aragwadadhi Kashaya mixed with Mahamanjishtadi Kashaya 7.5ml bd

Mahatiktaka Gritha - 1tsp bd

Arogyavardhini Rasa - 1 tab bd

Jeevantyadi Yamaka (E/A)

Avipattikara Choorna - 2.5g with milk at bed time for 15 days

Observations and Results

Table 5: Showing PASI Score of Upper extremities

	BT	AT 30th day	1st FU 45th day
Area	2	1	1
Erythema	1	0	0
Induration	1	1	0
Desquamation	1	0	0
Itching	2	1	0

Table 6: Showing PASI Score of Lower extremities

	BT	AT 30th day	1st FU 45th day
Area	4	3	2
Erythema	3	2	0
Induration	3	2	1
Desquamation	4	3	1
Itching	3	2	1

Before treatment

After 1st Follow up

After 2nd Follow up

Discussion

Shodhana is the best line of management in the condition of Kushta. It is done in the condition of Bahudoshavastha. The Shodhana can be achieved by adopting the principle of Yatha Dosha Harana and Asanna Margaharana. In this condition, Virechana is adopted as nearest root of elimination of Doshas.

Mode of Action of Snehapana: Gritha is indicated in classics in the Kushtachikitsa. Snehapana pacifies Vata, brings softness in body parts, Mala stagnated gets loosened. Anulomagati of Vata.^[10]Mahatiktakagritha has Kapha Pitta Shamaka, Kushtagna property.

Mode of Action of Abhyanga: The rationality behind selection of Abhyanga is to bring the vitiated dosha to a suitable state, so that can be expelled out easily. Abhyanga mainly decreases scaling and dryness by its Snigdhaguna. Main ingredient of psora oil is Streekutaja. It is having Tikta Kashaya Rasa, Laghu, Rukshaguna and Sheetaveerya and thus Kapha Pitta Shamaka and Kushtaghna in action.^[11]The biomolecules that are present in this have the efficacy to accelerate the production of collagen in the human skin which provides a great solace from psoriatic lesions and modulates immune reaction.

Mode of Action of Parisheka Sweda

It is a method of Swedana. Swedana therapy liquefies the vitiated dosha and directs them towards Koshta. It decreases obstruction and increases Swedana. Parishekasweda ensures softening of the lesions and easy cleansing of scales. Nimba shows therapeutic role in enhancement of antioxidant activity, anti inflammatory activity.^[12] It reduces Kandu and Rukshata.

Mode of Action of Virechana: Virechana is Kaphanta. Ekakushta is Vatakaphapradhanavyadhi. Trivrit is considered as Sukhavirechanadravya. Trivrit is having Hepatoprotective, Anti-inflammatory activity etc.^[13]

Mode of Action of Shamana Aushadis

Aragwadadi Kashaya has most of the ingredients which are Kaphavatashamaka, Ushna Veerya and Katu Vipaka and Mahamanjistadi Kashaya has most of the ingredients which are Kaphapittashamaka, Raktaprasadaka, Kandughna and Kushtagna action.Most of the drugs are Kushtagna and anti inflammatory action as it inhibit T-cell proliferation.^[14]

Conclusion

Eka Kushta is a Vata Kaphaja Rakta Pradoshaja Vyadhi and one among the Kshudrakushta and it bears greater resemblance with plaque psoriasis. Shodhana followed by Shamana helps for complete cure from the signs and symptoms.

Reference

1. Acharya Y.T, editor, (1sted.) Ayurveda Deepika commentary of Chakrapanidatta on Charaka Samhita of Agnivesha, Chikitsasthana; Kushta chikitsa Adhyaya: Chapter 7, Verse 3 Varanasi: Chaukhambha Surabharati Prakashan,2008.

2. Acharya Y.T, editor, (1sted.) Ayurveda Deepika commentary of Chakrapanidatta on Charaka Samhita of Agnivesha, Chikitsasthana; Kushta chikitsa Adhyaya: Chapter 7, Verse 29 Varanasi: Chaukhambha Surabharati Prakashan,2008.

3. Gupta Piyush, Menon PSN, Ramji Siddarth, Lodha Rakesh. PG Textbook of Pediatrics. 2nd Ed. New Delhi: Jaypee Brothers Medical Publishers (P) Ltd; Vol 3, chap 48.14 ,2018. p. 3109.

4. https://www.medicinenet.com/psoriasis/article.htm

5. Acharya Y.T, editor, (1sted.) Ayurveda Deepika commentary of Chakrapanidatta on Charaka Samhita of Agnivesha, Chikitsa sthana; Kushta chikitsa Adhyaya: Chapter 7, Verse 150, Varanasi:Chaukhambha Surabharati Prakashan,2008.

6. Acharya Y.T, editor, (1sted.) Ayurveda Deepika commentary of Chakrapanidatta on Charaka Samhita of Agnivesha, Kalpa sthana; Syama Trivritkalpa Adhyaya: Chapter 7, Verse 23, Varanasi: Chaukhambha Surabharati Prakashan,2008.

7. Gupta Piyush, Menon PSN, Ramji Siddarth, Lodha Rakesh. PG Textbook of PEDIATRICS. 2nd Ed. New Delhi: Jaypee Brothers Medical Publishers (P) Ltd; Vol 3, chap 48.14,2018. p. 3109.

8. Gupta Piyush, Menon PSN, Ramji Siddarth, Lodha Rakesh. PG Textbook of PEDIATRICS. 2nd Ed. New Delhi: Jaypee Brothers Medical Publishers (P) Ltd; Vol 3, chap 48.14 ,2018. p. 3109.

9. PASI Calculator http://pasi.corti.li/

10. Acharya Y.T, editor, (1sted.) Ayurveda Deepika commentary of Chakrapanidatta on Charaka Samhita of Agnivesha,Siddhi sthana; Kalpanasiddhim Adhyaya: Chapter 1,Verse 7, Varanasi: Chaukhambha Surabharati Prakashan,2008.

11. Dr.Bulusu Sitaram, Bhavaprakasha of Bhavamisra; Guduchyadi varga: Verse 118, Varanasi: Chaukhambha Orientalia,Vol 1,2012.

12. Alzohairy MA. Therapeutics Role of Azadirachta indica (Neem) and Their Active Constituents in Diseases Prevention and Treatment. Evid Based Complement Alternat Med. 2016:7382506. doi: 10.1155/2016/7382506. Epub 2016 Mar 1. PMID: 27034694; PMCID: PMC4791507.

13. A Comprehensive Review on Trivrit (Trivrit operculina Turpenthum Syn. Ipomoea Turpethum), Kohli K.R., Nipanikar S.U., Kadbhane K.P.

14. Pandit Sharangdhar, Sharangdhar Samhita with english translation by K.R.Srikanta Murthy; 1st edition: Chapter 2, Madhyama Khanda Verse 137-142; Chaukhamba Orientalia Publication, Varanasi: 1984.

Manuscript Received	Review Round 1	Review Round 2	Review Round 3	Accepted
2022-09-22	2022-09-24	2022-10-01	2022-10-08	2022-10-15
Conflict of Interest	Funding	Ethical Approval	Plagiarism X-checker	Note
Nil	Nil	Yes	17%

Case Report

Plaque Psoriasis

Journal of Ayurveda and Integrated Medical Sciences