E-ISSN:2456-3110

Research Article

Ekakushta

Journal of Ayurveda and Integrated Medical Sciences

2022 Volume 7 Number 9 October
Publisherwww.maharshicharaka.in

Management of Ekakushta vis-à-vis Chronic Plaque Psoriasis with Guduchi Kwatha and Karanja Taila - A Clinical Study

Saste D.1*, Mytrhey R.2
DOI: http://dx.doi.org/10.21760/jaims.7.9.2

1* Dhanwantari Saste, Post Graduate Scholar, Department of Post Graduate Studies in Kayachikitsa, Government Ayurveda Medical College, Mysuru, Karnataka, India.

2 R C Mytrhey, Professor and HOD, Department of Post Graduate Studies in Kayachikitsa, Government Ayurveda Medical College, Mysuru, Karnataka, India.

The prevalence of skin diseases in general population has varied from 7.86% to 11.16% in various studies. All the skin diseases in Ayurveda have been discussed under the umbrella of “Kushta”. Kushta is further divided into Mahakushta and Kshudrakushta. Ekakushta is considered as one among the Kshudrakushta and it is Vata-Kapha Pradhana Vyadhi having Lakshana like Aswedana, Mahavastu and Matsya Shakalavat Twacha. Psoriasis is one of the most intriguing and perplexing disorder of skin. It is a papulosquamous disorder of the skin, characterised by sharply defined erythematous plaque lesions. It is notoriously chronic and is well known for its cause or remission and exacerbation. Even though it is considered as an autoimmune disorder affecting the skin, it cannot always be treated as a somatic lesion, it is in fact multifactorial in origin and conditioned by various constitutional and environmental factors. A survey conducted by the National Psoriasis Foundation reports that, almost 75% of patients believe that psoriasis had moderate to large negative impact on their quality of life (QOL) with alterations in their daily activities. Guduchi Kwatha along with Karanja Taila which is specifically mentioned in Kushta Chikitsa, taken as intervention after the Virechana Karma.

Keywords: Mahakushta, Kshudrakusta, Ekakushta, Virechana, Psoriasis

Corresponding Author How to Cite this Article To Browse
Dhanwantari Saste, Post Graduate Scholar, Department of Post Graduate Studies in Kayachikitsa, Government Ayurveda Medical College, Mysuru, Karnataka, India.
Email: 		Dhanwantari Saste, R C Mytrhey, Management of Ekakushta vis-à-vis Chronic Plaque Psoriasis with Guduchi Kwatha and Karanja Taila - A Clinical Study. J Ayu Int Med Sci. 2022;7(9):13-20.
Available From
https://www.jaims.in/jaims/article/view/2070

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2022-08-29 2022-08-24 2022-08-31 2022-09-07 2022-09-14
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
Nil Nil Yes 17%

© 2022by Dhanwantari Saste, R C Mytrheyand 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].

Journal of Ayurveda and Integrated Medical Sciences 2022;7(9)13
Saste D et al: Ekakushta Chronic Plaque Psoriasis with Guduchi Kwatha Karanja Taila

Introduction

A person afflicted with psoriasis will suffer from social stigma, pain, discomfort, physical disability and psychological distress. Currently, the treatment modalities available for the management of psoriasis include topical steroid therapy, corticosteroids and photochemothrapy. Long term usage of topical glucocorticoids is often accompanied by loss of effectiveness and atrophy of the skin. Most of the treatment modalities have some limitations as they are only palliative. Hence psoriasis still remains a challenge for the management in contemporary system of medicine.

Considering the above reasons, it is relevant to search for an alternative management, which is effective and which gives long term remission.

Various Shodhana and Shaman Chikitsa have been mentioned in the Ayurvedic classics for the management of Kushta. So, to disintegrate the Samprapti and to increase the duration between relapse, a formulation which has not only Kushtaghna effect but which also works at the level of Dhatvagni countering Kapha and Vata Dosha is desirable. Hence the current study is taken up to assess and compare the clinical efficacy of Guduchi Kwatha after Samsarjana Karma of Virechana in the management of Ekakushta vis-à-vis chronic plaque psoriasis.

In the present study 20 cases of Ekakushta vis-à-vis chronic plaque psoriasis were registered.

Objective of the Study

To evaluate the efficacy of Guduchi Kwatha and Karanja Beeja Taila after virechana in Ekakushta vis-à-vis chronic plaque psoriasis.

Materials and Methods

Materials: The Materials used in the study were:

  • Guduchi Kwatha[1] - contains only Guduchi
  • Karanja Beeja Taila[2] - contains only Karanja Beeja.

Source of drugs and method of preparation

Guduchi Kwatha was procured from a GMP certified S N pandit and son’s pharmacy. Karanja Beeja Taila was procured for the study from SN Pandit and sons Pharmacy (GMP Certified Unit), Shankar Matt, Main Road, Opposite to Nataraja Choultry, Mysuru.

Methods
Source of the data: Subjects were selected from the OPD and IPD of Government Ayurveda Medical College and Hospital, Mysuru and Government Hi-Tech Panchakarma Hospital - a teaching hospital, Mysuru and special was also conducted for the study.

Sample size: The study was completed on 20 subjects of Ekakushta vis-à-vis chronic plaque psoriasis. The selected subject’s detailed profile was prepared as per the proforma designed for the study.

Sampling method: It was an interventional study with pre, mid and post-test design.

Inclusion criteria

1. Subjects of all gender, between the age group of 18-60 years with the signs and symptoms of Ekakushta vis-à-vis chronic plaque psoriasis were selected for the study.

2. Both fresh cases and treated cases were included.

A. Fresh cases include freshly detected and untreated cases of Ekakushta vis-a-vis chronic plaque psoriasis.

B. Treated cases include already diagnosed as Ekakushta vis-a-vis chronic plaque psoriasis, who had voluntarily discontinued the treatment with the flush out period of 7 days.

Exclusion criteria

1. Subjects with K/C/O Diabetes mellitus (RBS->200mg/dl), K/C/O Hypertension (uncontrolled), Ischemic heart diseases and immune compromised subjects were excluded.

2. Subjects suffering from any other systemic disorder which may interfere with the intervention were excluded.

3. Pregnant and lactating women were excluded.

4. Chronic plaque psoriasis where in lesions with secondary severe infections was excluded.

Diagnostic Criteria: Diagnosis was made based on the Lakshana of Ekakushta and signs and symptoms of Chronic plaque psoriasis.

Lakshana of ekakushta are[3]

  • Aswedana (absence of perspiration, always dry in nature)

Journal of Ayurveda and Integrated Medical Sciences 2022;7(9)14
Saste D et al: Ekakushta Chronic Plaque Psoriasis with Guduchi Kwatha Karanja Taila
  • Mahavastu (large area involved, coin to palm shaped)
  • Matsyashakalavat Twacha (silvery scales)
  • Krishna Aruna Varna Mandalas (black or reddish brown skin lesions)
  • Abhraka Patra Sadrusha Twacha (scales resembling mica)

Symptoms of Chronic plaque psoriasis

  • Dry, raised, red skin lesions (plaques) covered with silvery scales.
  • Positive Auspitz sign.
  • Positive Candle grease sign
  • Positive Koebener phenomenon

Assessment criteria: To assess the effect of therapy, the Psoriasis Area and Severity Index score (PASI) scoring method was adopted.

PASI scoring was calculated before starting, during and after completion of the intervention and total percentage of improvement in “PASI” scoring was calculated to assess the effect of the treatment on this parameter.

Data was analysed by using contingency co-efficient table analysis. The assessment was done on the basis of severity of Itching, Erythema, Scaling and thickness in the affected area.

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 by four different Parameters i.e., Itching, Erythema, Scaling and Thickness.

Again, all these were measured separately for each skin section.

These were measured on a scale of 0 - 4, from none to maximum according to the following chart:

Table 2: Showing Severity Score

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

After figuring out all the scores, final “PASI” was calculated. Thus, PASI scoring was calculated before starting the intervention, after Samsarjana Krama and after the completion of the intervention and overall percentage in “P.A.S.I” scoring was calculated to assess the effect of the Intervention.

Overall assessment of clinical response

Complete remission - PASI score 0 after treatment.

Marked improvement - Reduction in PASI score >75%

Moderate improvement - Reduction in PASI score between 75% and 50%.

Minimal improvement - Reduction in PASI score <50%

Unchanged - No reduction in PASI score.

Assessment Schedule

  • Pre-test assessment was done before administering
  • Mid test assessment was done before administering Shamanoushadhi.
  • Post-test assessment was done after the completion of intervention (on 30th day)

Investigation: Necessary investigations were conducted in required cases to rule out other systemic diseases or complications.

Intervention: The interventions were as follows:

All the subjects were administered with Virechana Karma before starting the intervention as a pre requisite.

Shamanaushadhi was started after completion of Samsarjana Karma;

Guduchi Kwatha - 100 ml in two equally divided doses (50ml twice daily) was administered during morning and evening before food with the equal quantity of lukewarm water for 30 consecutive days.

Along with this Karanja Beeja Taila was used as an external application twice daily for 30 days.

Statistical Methods

The result was compared and analyzed statistically by using the following statistical methods:


  • Descriptive Statistics - Mean, Standard deviation, Frequency, Percent.

Journal of Ayurveda and Integrated Medical Sciences 2022;7(9)15
Saste D et al: Ekakushta Chronic Plaque Psoriasis with Guduchi Kwatha Karanja Taila
  • Inferential testing

1. Chi-square test

2. Repeated measures ANOVA

3. Contingency coefficient

All the statistical methods will be done using SPSS for windows.

Observation

21 subjects were registered for the study. Among them one subject was dropped out during the course of intervention. The study was completed in 20 subjects and observations are as follows;

Among 20 subjects, 1 subject belonged to age group of 18-30 years, 9 subjects were in 31-40 years of age group and 4 subjects belonged to 41-50 years of age group and 7 subjects were in between 50-60 years of age, 18 subjects were male and 3 subjects were females.

2 subjects were daily wage workers, 1 subject was student, 3 subjects were working in various factories, 2 subjects were homemakers, 6 subjects were farmers and 7 subjects were business men. Among 20 subjects, 2 had the chronicity less than 1 year, 16 subjects had the chronicity of 1-5 years, 3 subjects had the chronicity of 6-10 years. Among 20 subjects, 4 subjects were fresh cases and 17 subjects were treated by some other medications. Among 20 subjects, 2 subjects had family history of psoriasis and 19 subjects did not have any family history.

Results

Data was collected before Virechana, after Virechana and after completion of intervention. These were analyzed by using contingency- coefficient table analysis. Repeated measure ANOVA, descriptive statistics using SSPS and overall assessment with the help of chi-square test. In this study, the results were analyzed using PASI score in which the assessment was done on the basis of skin affected in each area by itching, erythema, scaling and thickness.

Total PASI of Head Region: Before Virechana, mean was 1.3750 with SD of 1.5586, after Virechana mean was 0.6600 with SD of 0.7351 and after the intervention, mean was 0.3650 with SD of 0.4145. Thus, the result of Total PASI of head is highly significant with the P value 0.000

Table 4: Total PASI of head region

PASI of head region Before Virechana After Virechana After Shamanaushadhi
Mean S.D Mean S.D Mean S.D
Group 1.3750 1.55863 .6600 .73513 .3650 .41457
Source DF Mean square F Sig
Change 2 16.672 41.760 .000

Total PASI of Upper Extremities: Before Virechana, mean was 8.0800 with SD of 3.03690, after Virechana mean was 4.5100 with SD of 2.2171 and after the intervention, mean was 2.2000 with SD of 1.67458. Thus, the result of Total PASI of Upper Extremities is highly significant with the P value 0.000

Table 5: Total PASI of upper extremities

PASI of upper extremities Before Virechana After Virechana After Shamanaushadhi
Mean S.D Mean S.D Mean S.D
Group 8.0800 3.03690 4.5100 2.21713 2.2000 1.67458
Source DF Mean square F Sig
Change 2 407.494 169.465 .000

Total PASI of Trunk: Before Virechana, mean was 8.3650 with SD of 6.44330, after Virechana mean was 3.9600 with SD of 3.34576 and after the intervention, mean was 2.2800 with SD of 2.19895. Thus, the result of Total PASI of Trunk is highly significant with the P value 0.000

Table 6: Total PASI of trunk region

PASI of trunk region Before Virechana After Virechana After Shamanaushadhi
Mean S.D Mean S.D Mean S.D
Group 8.3650 6.44330 3.9600 3.34576 2.2800 2.19895
Source DF Mean square F Sig
Change 1 3053.234 63.087 .000

Total PASI of Lower Extremities: Before Virechana, mean was 19.2000 with SD of 7.76931, after Virechana mean was 13.2800 with SD of 6.16626 and after the intervention, mean was 10.5000 with SD of 5.18764. Thus, the result of Total PASI of Lower Extremities is highly significant with the P value 0.001

Table 7: Total PASI of lower extremities region

PASI of lower extremities Before Virechana After Virechana After Shamanaushadhi
Mean S.D Mean S.D Mean S.D
Group 19.2000 7.76931 13.2800 6.16626 10.5000 5.18764
Source DF Mean square F Sig
Change 2 1112.820 95.184 .001

Journal of Ayurveda and Integrated Medical Sciences 2022;7(9)16
Saste D et al: Ekakushta Chronic Plaque Psoriasis with Guduchi Kwatha Karanja Taila

In the present study, out of 20 subjects, it was observed that 7 (35.0%) subjects showed marked improvement, 9 (45.0%) subjects showed moderate improvement and 4 (20.0%) subjects got minimal improvement.

By this we can infer that Shamanoushadhi i.e., Guduchi Kwatha and Karanja Beeja Taila has good result in the management in Ekakushta vis-à-vis Chronic plaque psoriasis.

Discussion

Probable mode of action of Guduchi Kwatha

Coarsely powdered Guduchi was boiled in sixteen times of water until residual portion of liquid is reduced to one eighth of entire matter and was filtered.

Since it was used for the Shamana Karma, it was reduced to one eighth of the portion.

Biological Activities the major biological activities of Tinospora cordifolia summarized in the following manner[4]

Table 8: Major and sub groups of natural products present in different parts of Tinospora cordifolia and their biological activities.

Active Component Compound Part used Biological Activity (In Human being)
Alkaloids Berberine, Choline, Tembetarine, Magnoflorine, Tinosporin, Palmetine, Isocolumbin, Aporphine alkaloids, Jatrorrhizine, Tetrahydropalmatine, Stem and roots Anti-viral, Anticancer, anti-diabetes, Anti-inflammatory, immunomodulatory, improves psychiatric conditions
Steroids β–sitosterol, δ-sitosterol, 20 β-hydroxyecdysone, Ecdysterone, Makisterone A, Giloinsterol Shoot IgA neuropathy, glucocorticoid induced osteoporosis in early inflammatory arthritis, induce cell cycle arrest in G2/M phase and apoptosis through c-Myc suppression. Inhibits TNFα, IL-1 β, IL-6 and COX-2.
Aliphatic compound Octacosanol, Heptacosanol Nonacosan-15-one dichloromethane Whole plant Anti-nociceptive and anti- inflammatory. Protection against 6- hydroxydopamine induced parkinsonisms in rats. Down regulate VEGF and inhibits TFN-α from binding to the DNA

Immunomodulatory Activities[5]

T. cordifolia is well known for its immunomodulatory response. This property has been well documented by scientists. A large variety of compounds which are responsible for immunomodulatory and cytotoxic effects are 11- hydroxymuskatone, N-methyle-2-pyrrolidone, Nformylannonain, cordifolioside A, magnoflorine, tinocordioside and syringin. These natural compounds have been reported to improve the phagocytic activity of macrophages, enhancement in nitric acid production by stimulation of splenocyte, and production of reactive oxygen species (ROS) in human neutrophil cells.

Guduchi as a biologic in psoriasis

Biologic therapies for psoriasis utilize molecules that are designed to block specific molecular steps important in the pathogenesis of psoriasis.

TNF plays a central role in the pathogenesis of psoriasis, psoriatic arthritis, and a number of other disease states. TNF is released from cells as a soluble cytokine (sTNF) following cleavage from its cell surface-bound precursor (transmembrane TNF, tmTNF). Both sTNF and tmTNF are biologically active, and bind to either of the two distinct receptors: TNF receptor 1 (TNFR1, p55) and TNF receptor 2(TNFR2, p75). This leads to NF-kB activation (which promotes inflammation) and ⁄ or cell apoptosis.

In addition, tmTNF can itself act as a ligand (via a process of reverse signaling) to induce cell activation, cytokine suppression, or apoptosis of the tmTNF bearing cell.[6] 

Guduchi with its steroidal and aliphatic compounds inhibits TFN-α from binding to the DNA.

It also inhibits the IL-1 β, IL-6 thereby inhibiting the epidermal proliferation.

Hence Guduchi can be considered under the biologics which inhibits the TFN-α.

Probable mode of Action of Karanja Beeja Taila

Discussion on the action of Taila in general as an external application[7]

The keratin layer acts as a reservoir for a drug, hence Taila slowly diffuses into the deeper layer of the skin for many hours.


Journal of Ayurveda and Integrated Medical Sciences 2022;7(9)17
Saste D et al: Ekakushta Chronic Plaque Psoriasis with Guduchi Kwatha Karanja Taila

The Taila also acts as a lubricant which may help to reduce the fissure formation within the lesions and assists in maintaining flexibility and elasticity of the affected skin.

Study on the effect of oil has shown keratinocyte proliferation inhibition, retarding cell division to 90% level.

The formulation of Karanja are proven to be effective on chronic plaque psoriasis as it has Karanjin and pongapin.

Docking scores of karanjin and pongapin with different Studied receptors were found to be comparable to that of methotrexate, a known drug for treating psoriasis. Pongapin and Karanjin could be natural alternatives in curing psoriasis.[8]

Conclusion

Ekakushta is a Vata Kapha Pradhana Rakta Pradoshaja Vikara and one among the Kshudra Kushta which bears a greater resemblance with chronic plaque psoriasis.

There is no separate explanation mentioned in the classics regarding Nidana, Purvarupa and Samprapti of Ekakushta. In the present study, in most of the subjects Nidana of Kushta and genetic predisposition was observed. Majority of symptoms such as Matsya Shakalvat Twacha (silvery scaly lesions), Krishna Aruna Mandala (black or reddish-brown lesions), Mahavastu (extensive lesions), Abhraka Patra Sadrisha (like mica) were observed which is similar to that of chronic plaque psoriasis.

For the diagnosis of Ekakushta the features like candle grease sign, auspitz sign and koebner’s phenomenon were observed in subjects.

A clinical study was conducted using Guduchi Kwatha in the group consisting of 20 subjects with external application of Karanja Beeja Taila for 30 consecutive days. Intervention was started after Virechana Karma in both the groups. Guduchi Kwatha was effective in reducing erythema. Out of 20 subjects, it was observed that 7 (35.0%) subjects showed marked improvement, 9 (45.0%) subjects showed moderate improvement and 4 (20.0%) subjects got minimal improvement. No adverse effects of drugs were reported in the present study.

jaims_2070_01.JPGBefore Treatment
jaims_2070_02.JPGAfter Treatment
jaims_2070_03.JPGBefore Treatment
jaims_2070_04.JPGAfter Treatment

Reference

1. Sushruta Samhita, Nibandha Sangraha Commentary of Dalhanacharya and Nyayachandrika commentary of Gayadas. Edited by Vaidya Yadavji Tikamji Acharya, published


Journal of Ayurveda and Integrated Medical Sciences 2022;7(9)18
Saste D et al: Ekakushta Chronic Plaque Psoriasis with Guduchi Kwatha Karanja Taila

by Chowkambha Orientalia, Varanasi, 1992, Chikitsa sthana 10/14, P-451

2. Sushruta Samhita, Nibandha Sangraha Commentary of Dalhanacharya and Nyayachandrika commentary of Gayadas. Edited by Vaidya Yadavji Tikamji Acharya, published by Chowkambha Orientalia, Varanasi, 1992, Sutra sthana 45/115, P-206

3. Agnivesha Charaka Samhita, Ayurveda Dipika commentary of Chakrapanidatta revised by Charaka and Dridabala, Ed. By Vaidya Jadavji Trikamji Acharya,Chaukhamba Sanskrit Samsthana, Varanasi, 5th edition, 2011, chikitsa sthana 7/21 P-451.

4. Mittal J, Sharma MM, Batra A. Tinospora cordifolia: a multipurpose medicinal plant-A. Journal of Medicinal Plants. 2014;2(2).

5. Srivastava AK, Singh VK. Tinospora cordifolia (GILOY): A Magical Shrub. Asian Journal of Advances in Medical Science. 2021 Apr 20:22-30.

6. Tracey D, Klareskog L, Sasso EH, Salfeld JG, Tak PP. Tumor necrosis factor antagonist mechanisms of action: a comprehensive review. Pharmacology & therapeutics. 2008 Feb 1;117(2):244-79.

7. Cited by Dr.Chaitra B M, department of kayachikitsa govt. ayurveda medical college and hospital, mysuru. A comparative clinical study to evaluate the efficacy of Atarushadi kwatha and Karanja Arka in the management of Ekakushta vis-à-vis Chronic plaque psoriasis

8. Noor AA, Othman SN, Lum PT, Mani S, Shaikh M, Sekar M. Molecules of interest–Karanjin–A review.


Journal of Ayurveda and Integrated Medical Sciences 2022;7(9)19