E-ISSN:2456-3110

Case Report

Plaque Psoriasis

Journal of Ayurveda and Integrated Medical Sciences

2023 Volume 8 Number 11 November
Publisherwww.maharshicharaka.in

Effect of Panchatikta Ghrita Guggul and Mahamanjishthadi Kwath along with Virechan Karma in the management of Ek Kushtha (Plaque Psoriasis) : A Case Report

Saraf S1*, Nagpal S2, Shivhare S3, Sharma V4
DOI:10.21760/jaims.8.11.30

1* Shraddha Saraf, PG Scholar, Dept Of Kayachikitsa, Pt Khushilal Sharma Govt Auto Ayurveda College Institute, Bhopal, MP, India.

2 Swati Nagpal, Reader, Dept of Kayachikitsa, Pt Khushilal Sharma Govt Auto Ayurveda College Institute, Bhopal, MP, India.

3 Shwetal Shivhare, Reader, Dept of Kayachikitsa, Pt Khushilal Sharma Govt Auto Ayurveda College Institute, Bhopal, MP, India.

4 Vivek Sharma, Lecturer, Dept of Kayachikitsa, Pt Khushilal Sharma Govt Auto Ayurveda College Institute, Bhopal, MP, India.

Background: Psoriasis, an autoimmune disease, affects a vast number of peoples around the world. About 2% of the world population and 0.44-2.8% of the Indian population were affected by psoriasis in 2016-2017. Plaque psoriasis is the most common type of psoriasis that manifests as red scaly patches with white scales affecting body areas, including the scalp, elbows, knees, trunk, and buttocks. The Ayurvedic diagnosis is considered as Ekakushtha which is a Vata Kapha predominant Kshudrakushtha. Objective: The present study was intended to assess the efficacy of Virechan Karma as Shodhan procedure along with Panchatikta Ghrita Guggul and Mahamanjishthadi Kwath as Shaman drug in Ek Kushtha (psoriasis). Materials and Methods: Here an effort was made to treat a 21 years old male diagnosed case of Plaque Psoriasis since 1 year. He presents with complaints of red scaly patches with white scales on upper limbs, lower limbs and trunk with itching and burning. After a thorough examination, an Ayurvedic treatment plan was designed in the form of Panchakarma (Virechan Karma) and oral medication (Panchatikta Ghrita Guggul 250 mg twice and Mahamanjishthadi Kwath 10 ml twice daily). As the principle of treatment of all types of Kushtha is Sanshodhana along with Sanshamana drugs. In this study initially Virechana Karma was performed. Result: After Sanshodhana, Sanshamana drugs were given for 4 months, the symptoms such as itching, burning, eruption, scaly patches gradually decreased. PASI (Psoriasis area severity index) score was taken for assessment parameter showed significant improvement. The skin lesions of the patient was calculated by PASI score before starting the treatment was found to be 29.9 which decreased to 3.5 after 4 months. Conclusion: This case report showed that combined Ayurvedic modalities resulted in great improvement in overall condition of the patient and clinically safe and effective in the management of Ekkushtha (psoriasis).

Keywords: Ekakushtha, Psoriasis, PASI score, Ayurvedic management

Corresponding Author How to Cite this Article To Browse
Shraddha Saraf, PG Scholar, Dept Of Kayachikitsa, Pt Khushilal Sharma Govt Auto Ayurveda College Institute, Bhopal, MP, India.
Email: 		Saraf S, Nagpal S, Shivhare S, Sharma V, Effect of Panchatikta Ghrita Guggul and Mahamanjishthadi Kwath along with Virechan Karma in the management of Ek Kushtha (Plaque Psoriasis) : A Case Report. J Ayu Int Med Sci. 2023;8(11):187-192.
Available From
https://jaims.in/jaims/article/view/2757

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2023-09-13 2023-09-25 2023-10-05 2024-01-15 2023-10-21
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
None declared Nil Yes 23.85

© 2023by Saraf S, Nagpal S, Shivhare S, Sharma Vand 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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Shraddha Saraf et al. Management of Ek Kushtha (Plaque Psoriasis) : A Case Report

Introduction

Psoriasis is a common dermatologic disease, affecting up to 1% of the World’s population,[1] both males and females suffering equally.[2] Plaque psoriasis, the most common variant of psoriasis, makes up approximately 85 to 90 percent of all psoriasis cases.[3] Hyperactivity of T-helper cells is important in pathogenesis. Upregulation in the levels of inflammatory cytokines triggered by T-cells leads to psoriasis which also can be associated with an increased risk of psoriatic arthritis, lymphomas, cardiovascular risk, Crohn’s disease, and depression.[4]

The main abnormality in psoriasis is the increased epidermal proliferation due to excessive division of cells in the stratum basale and a shorter cell cycle. There is proliferation of subepidermal vasculature which is responsible for the Auspitz’s sign. Characteristic lesions are pink red, sharply demarcated papules and rounded plaques, covered by silvery scales. The most common areas involved are extensor body areas (elbow and Knees), gluteal cleft and scalp. Trunk is also commonly involved. Traumatized areas often involved Koebner phenomenon.

There is no permanent cure for psoriasis, though in modern system of medicine coaltar preparations, calcipotriol, retinoid, corticosteroids and ultraviolet radiations are the local measure to manage Psoriasis. The systemic treatment commonly used is photo chemotherapy with PUVA, retinoids, methotrexate and cyclosporine - A and corticosteroids.[5] These medicines have been in wide use to control the symptoms with some success, but in long term cause a number of unpleasant side effects.

Ekakushtha is mentioned in all Ayurvedic classics under Kshudrakushtha and has predominance of Vata and Kapha Dosha.[6] The aetiologic factors of Kushtha described in Ayurved classics are Aharaj Nidan as Viruddha Aahara, excessive consumption of Drava, Snigdha, Guru Aahar, Navanna, Viharaj Nidan as Vega Dharana specially of vomiting. Indulgence in sinful act and ill Manovritti (negative mentality) are associated Mansik Nidan (mental factor) for causing the disease.[7] These causative factors are responsible for vitiation of Vata and Kapha Pradhan Tridosha. These Dosha through Tiryakvahini Siras proceed to Bahya Rogamarga i.e., Twacha, Rakta, Mamsa,

and Lasika and cause the symptoms of disease.[8] Acharya Charaka has mentioned the symptoms of Ekakushtha as Aswedanam, Mahavastu, and Matsyashakalopamam[9] and Acharya Sushruta described its symptoms as Krishna-Aruna Varnata.[10]

The goal of the treatment for the disease is to alleviate symptoms which interfere with the patient’s life both physically and socially. Repeated Samshodhana along with Samshamana is the main line of treatment. Both Antah Parimarjan and Bahiparimarjan therapies have been performed in Kushtha Roga to prevent further progression of this disease.

Case Presentation

A 21-year-old male patient, diagnosed with psoriasis for 1 year. He came to our hospital in May 2023 with following Chief Complaints of pink red lesions and rounded plaques with silvery scales on lower abdomen, lower back, elbows, forearms and forelegs. Itching and burning in rashes, with scaling on scratching.

History of Present Illness

The patient was asymptomatic before 1 year. After that he developed complaint of scaly rashes on his scalp then lower abdomen and lower back which gradually progressed and involved his both forelegs and both upper limbs. Gradually itching occurred in the rashes along with burning sensation, and scaling after scratching and patches widened. Lesions have no relation to seasonal variation and remained constant for whole year. He took allopathic medication for years which provided symptomatic relief till treatment continues, on discontinuity of the treatment again the symptoms aggravated. So, he came to our hospital for further treatment.

History of past illness

Patient has no significant past history of any chronic illness, trauma or Koebner’s phenomenon.

Family History: Negative for HTN, DM and any skin diseases.

Personal history

Diet - Mixed: prefer Amla, Lavana, Madhura Ahara, curd, pickles

Bowel - Frequency - 2/day, evacuation - Complete


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Stool consistency - Well formed

Appetite - normal

Micturition - Regular

Sleep - adequate

Allergy - Not yet detected

Addiction - Nil

On Examination

General condition was fair

Vitals were normal, afebrile

Central nervous system, cardiovascular system, respiratory system and gastrointestinal system examinations show no abnormality.

Prakriti - Pitta-Kapha

Integumentary system Examination

Lesion - erythematous papule then plaques of varying size, erythematous patches with white scales

Mode of spread - Centripetal

Colour - Erythematous papule and plaques covered with white scales - body erythematous patches with white scales - scalp

Size - Papule and plaques of varying size - body patches - scalp

Margination - Well demarcated - body

Surface - rough, dry with scales

Distribution - symmetrical, bilateral scattered

Auspitz sign - Present

Candle grease sign - Present

Diagnosis - On the basis of clinical history and examination the condition was diagnosed as Plaque Psoriasis.

Treatment protocol

Total duration - 4 months

1. Deepana Pachana with Lasunadi Vati 500 mg BD for 2 days.
2. Abhyantara Snehana with Panchtikta Ghrita for 5 days in increasing order from 30 ml to 180 ml followed by Mridu Snehana and Swedana for 2 days.

3. Virechana Karma - Then Virechan Karma was performed and Samsarjana Karma for 7 days was done before starting Samshamana drugs.

Samshamana therapy - For Samshamana therapy following medicines were used -

a) Panchatikta Ghrita Guggul 250 mg twice a day

b) Mahamanjisthadi Kwatha - 20ml twice a day

c) Psora oil for local application

Table 1: Line of treatment

DayTreatment
1st and 2nd day - Deepan and PachanDeepana Pachana with Lasunadi Vati 500 mg BD
3rd to 7th day - Abhyantar SnehpanaShodhnarth Snehpan with Panchatikta Ghrita, after complete digestion of previous day diet it was administered in higher dose every day in early morning depending upon Agni and Koshtha for a period 5 days, till the Samyak Snigdha Lakshan appears.
8th day - Abhyang and SwedanAbhyang with Marichadi oil, Sarvang Bashpa Svedan with Nimb Patra.
9th dayAbyang and Bashp Swedan
10th day - Virechan Yoga Virechan Karma with Trivrut Churna and Erand Tail (100ml).Total 18 Vega on administration ofVirechana Yoga, it was Kaphant Virechana, patient felt lightness in the body, Kshudha Pravritti.
11th to 14th day - Samsarjan KarmaSamsarjana Krama specific diet schedule was followed for 5 days according to Shuddhi.

Assessment: (Before Treatment)

PASI score: 29.9, Auspitz sign: Positive, Candle grease sign: Positive

PASI SCORE - PASI score in psoriasis which assesses and grade the severity of psoriatic lesions and patients’ response to treatment. Had a numeric score ranging 0 to 72. Score of 1 to 10 is considered moderate and above 10 is severe.

Lesion Score

Erythema (E)Induration(I)Scaling (S)No symptomsMildModerateMarkedVery marked
  0 1 2 3 4

Area score

Area01-9%10-29%30-49%50-69%70-89%90-100%
Score0123456



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Before treatment

Lesion ScoreHead (H)Trunk(T)Upper limb (UL)Lower limb (LL) including buttocks
Erythema(E)1333
Induration(I)2332
Scaling(S)2232
SUM: E+I=S5897
Percentage of affected area    
Area score3345
Sub Total:15243635
Sum × Area score    
Body area: subtotal × amount indicated15 x 0.124 x 0.336 x 0.235 x 0.4
Total1.57.27.214

PASI Score = H+T+UL+LL = 29.9

After Treatment

Lesion ScoreHead (H)Trunk(T)Upper limb (UL)Lower limb (LL) including buttocks
Erythema(E)1111
Induration(I)0111
Scaling(S)0001
SUM: E+I=S1223
Percentage of affected area    
Area score1112
Sub Total:1226
(Sum × Area score)    
Body area: subtotal × amount indicated1x 0.12x0.32x 0.26x 0.4
Total0.10.60.42.4

PASI Score = H+T+UL+LL = 3.5

Before Treatment

After Treatment

Results

The Patient had started improving during treatment, and all over recovery was done in 4 months. The patient's PASI score after treatment was 3.5. The candle grease sign was also negative after treatment.



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Discussion

Psoriasis is a common, chronic, recurrent inflammatory disease of the skin, characterized by circumscribed, erythematous, dry, scaly plaques of varying sizes. Plaque psoriasis or psoriasis vulgaris is the most prevalent one.

Here a case of Plaque Psoriasis has been discussed, which is best correlated to Ekakushtha. It is Raktapradoshaj Vyadhi, which is Vata-Kapha Pradhan and Tri-Doshaj. Since the skin diseases are caused by vitiation or aggravation of one or more Doshas, the line of treatment or selection of drugs is based on predominance of specific Dosha causing the ailment. Ayurveda classics explains Shodhan and Shaman Chikitsa for the management of Kushtha. Amongst the Shodhan, Virechan is the best Chikitsa for the Kushtha as it eliminates the Pitta and Kapha Dosha from the body.

In the present study Shodhan and Shaman Chikitsa was given to the patient. In Purva Karma, Deepan - Pachan was done with Lashunadi Vati which is Agnivardhak, Stimulates digestion and Amapachak. After that Snehapana was given with Panchtikta Ghrita for 5 days. Prior to Virechan Karma Abhyanga was done by Marichadi Tail which reduces the dryness, improves the blood circulation & reduces itching. Followed by Sarwanga Swedan it does the Dosha-Vilayana (liquefies the Doshas) and brings Shakhagat Doshas to Koshth to eliminate them. And thus, it does Srotoshodhan. As Kushtha is chronic and Bahudoshajanya both Sodhana and Samana therapies must be followed to provide long lasting results and a better life to patients.

Action of Snehapana

Panchatikta Ghrita has Shothahara (anti-inflammatory) property which helps provide relief from itching and irritation caused due to psoriasis. Its Pitta balancing and Snigdha (oily) properties help to control dryness which is also beneficial in psoriasis. Tikta Rasatmaka, Madhur Vipaki and Ushna Viryatmaka properties of Ghrita acts mainly on Kleda, Meda, Lasika, Rakta, Pitta and Kapha which helps in balancing the vitiated Dosha and Dhatu.

Action of Abhyanga with Marichyadi Tail

For the purpose of Abhyanga the Marichyadi Tail is used. The most of Dravyas of Marichyadi Tail

have properties like Katu, Tikta, Kashay Rasa and Ushna Virya which does the Shaman of Kapha and Vata Dosha. It has properties like Raktashodhan, Kushtaghna and Kandughna. Marichyadi Tail has antiseptic, antifungal, anti-inflammatory property. Hence it is effective in reducing the symptoms of Eka Kushtha.

Action of Virechan Karma

Virechana Karma is indicated in Kushtha, as it pacifies vitiated Pitta Dosha and also help in eliminating vitiated Kapha Dosha, also corrects Dushit Rakta Dhatu, causes Vatanulomana and Srotoshodhana. Due to Ushna, Tikshna, Vyavayi and Vikasi properties of Virechnopag drugs it helps in removal of all the toxins from the body thus burning sensation, inflammation, itching and pain were reduced.

Mode of action Panctiktaghrit Guggulu

Panctiktaghrit Guggulu consist of drugs like Giloy, Neem, Kantkari etc. which acts as an agent or a substance that inhibits the manifestation of immediate hypersensitivity. And help to reduce oxidative stress, by scavenging free radicals. Thus, Shodhana therapy along with Shaman Aushdhi completely expels the doshas out of the body and prevent the relapse of disease.

Mode of action of Manjisthadi Kwatha

Kushtha is a Santarpanottha Vyadhi as per Charak Samhita. Manjishthadi Kwath has contents like Manjishtha, Guduchi, Bakuchi, Nimb, Haridra, Patola etc., which helps in detoxification and purification of the blood. Thus, through its Rakta Prasadan property it helps in reliving plaque psoriasis.

Conclusion

Psoriasis being a chronic and often disfiguring condition causes a marked impairment in quality of life socially as well as mentally. In the present case the most common Plaque Psoriasis that is correlated with Eka-Kushtha was successfully treated with the Shodhana and Shamana Chikitsa. In all skin conditions mainly Katu, Kashaya, Tikta Aushadh should be given as Shamana. They all do Rakta Dhatu Shodhana. The patient was asked to avoid food, which is heavy to digest, sour food, milk and curd. Where there’s chronicity in disease, Shodhan is a must, because due to previous medicines


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which were taken by the patient, somewhat produces resistant or Avarana. For removal of that Shodhan is essential. Thus, it can be concluded that Virechana Karma followed by Shamana Aushadhi is highly effective in the management of psoriasis (Ek Kushtha).

References

1. Fauci AS, Braunwald E, Kasper DL, Hauser SL, Longo DL, Jameson JL, Loscalzo J. Harrison’s Principles of Internal Medicine. Vol 1. 17th ed. U.S.A.: McGraw Hill Companies; [Year of publication not provided]. p.315.

2. Goldman L, Schafer AI. Goldman’s Cecil Medicine. 24th ed. Elsevier Saunders; [Year of publication not provided]. Eczemas, photodermatoses, papulosquamous diseases. p.2517.

3. Griffiths CE, Barker JN. Pathogenesis and clinical features of psoriasis. Lancet. 2007;370(9583):263–271.

4. Boehncke WH, Schon MP. Psoriasis. Lancet. 2015;386:983–994.

5. Fitzpatrick TB, Johnson RA, Wolff K, Suurmond D. Fitzpatrick’s Dermatology in General Medicine. Vol 1. 7th ed. McGraw Hill Companies; [Year of publication not provided]. p.185.

6. Pandey PK, Chaturvedi G. Charak Samhita, Savimarsha Vidyotini-Hindi Vyakhya. Varanasi: Chaukhamba Sanskrit Sansthana; 2011. p.253.

7. Pandey PK, Chaturvedi G. Charak Samhita Poorvardh, Savimarsha Vidyotini-Hindi Vyakhya. Varanasi: Chaukhamba Sanskrit Sansthana; 2011. p.643.

8. Tripathi B. Ashtang Hridaya, Nirmala Hindi Tika. Varanasi: Chaukhamba Sanskrit Sansthana; 2010. p.369.

9. Pandey PK, Chaturvedi G. Charak Samhita, Savimarsha Vidyotini-Hindi Vyakhya. Varanasi: Chaukhamba Sanskrit Sansthana; 2011. p.252.

10. Shastri KA. Sushruta Samhita, Ayurveda Tatva Sandipika. Varanasi: Chaukhambha Sanskrit Sansthana; 2007. p.321.


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